Differentials of acute abdominal pain Flashcards
Which areas do you need to consider with abdominal pain?
Structures above and below the diaphragm
What is peritonitis?
Inflammation of the peritoneum
What causes peritonitis?
- Peptic ulcer
- Tumour
- Gallbladder
- Appendix
- Spleen
- AAA
- Ectopic
- Spontaneous Bacterial Peritonitis
What is the classical Hx of peritonitis?
Severe generalised abdominal pain
What are the classical examination findings of peritonitis?
- Rebound and percussion tenderness
- Later on, distention of abdomen
- Guarding
- No abdominal movement with respiration
- Severe pain to light palpation
What investigations would you order for peritonitis and what would they show?
- Erect CXR: air under diaphragm
* CT abdo/pelvic: reveals cause
What is the management for peritonitis?
Urgent laparotomy and repair
What is the classical Hx of ruptured AAA?
- Elderly
- Severe generalised abdominal pain
- Back pain
- Reduced GCS/collapse
What are the classical examination findings of ruptured AAA?
- Shock
- Peritonitis
- Expansile mass
What investigations would you order for ruptured AAA and what would they show?
- USS abdomen if freely available
- CT only if stable
- Don’t delay theatre
What is the management for ruptured AAA?
- Aim for permissive hypotension (SBP–100)
- Activate ‘massive haemorrhage protocol
- Urgent open repair
What is appendicitis?
Inflammation of the appendix
What is the classical Hx of appendicitis?
- Young patient
- Periumbilical pain initially
- Moves to RIF
- Anorexia, nausea
What are the classical examination findings of appendicitis?
- Tender RIF
- Worse at McBurney’s point
- Guarding/local peritonitis
- Rovsing’s +ve
What investigations would you order for appendicitis and what would they show?
- Clinical diagnosis
- USS abdo/pelvis if gynae differentials
- Inflammatory markers: raised
- Urine: beta-HCG: rule out ectopic
What is the management for appendicitis?
- Appendicectomy
- Antibiotics
- Nil by mouth
What are gallstones?
Presence of solid concretions in the gallbladder.
Symptoms are caused if a stone obstructs the cystic, bile or pancreatic duct.
What is biliary colic?
Blockage of bile duct
What is cholecystitis?
Inflammation of gallbladder
What is cholangitis?
Inflammation of bile duct system
What is acute pancreatitis?
A disorder of the exocrine pancreas. It is associated with acinar cell injury with local and systemic inflammatory responses.
What is cholelithiasis?
Formation of gallstones
What is the classical Hx of biliary colic?
- Intermittent RUQ pain
- Radiation of pain to right scapula
- Exacerbated by fatty food
- Cannot sit still
What is the classical examination signs of cholecystitis?
- Continuous RUQ pain
- Murphy’s +ve
- Tender and guarding RUQ
What is the classical Hx of common bile duct (CBD) stones?
- Jaundice
* RUQ pain
What is the classical Hx of cholangitis?
- Jaundice
* RUQ pain
What is the classical Hx of acute pancreatitis?
- Severe epigastric/ central pain
- Radiating to back
- Relieved by sitting forwards
- Vomiting
- Hx of possible cause: gallstones, alcohol, trauma, surgery, medications
What are the classical examination findings of acute pancreatitis?
- Epigastric tenderness
- Tachycardia
- Fever
- Shock
- Guarding
- Grey-Turner’s and Cullen’s signs
- Reduced or absent bowel sounds
What investigations would you order for gallstones and what would they show?
• LFTs: obstructive picture if CBD stones/cholangitis
Rise in ALT, AST «_space;rise in alk phos
• Inflammatory markers: raised in cholecystitis/cholangitis
• Abdominal USS
What investigations would you order for acute pancreatitis and what would they show?
- Amylase or lipase: raised
- LFTs: deranged
- CT abdo if diagnostic uncertaincy
- Apache II / Glasgow score
- ABG required
- Calcium
- Confirm cause
- USS abdo (exclude gallstones)
- Triglycerides
- Immunoglobulins
What is the management for acute pancreatitis?
- Supportive management
- IV crystalloids
- Stop causative meds
- No antibiotics unless proven infection
- Treat cause
- ITU may be required
- Analgesia
- Consider - antiemetic
What is the management for biliary colic?
- Analgesia
* OPT cholecystectomy
What is the management for cholecystitis?
- Antibiotics (ciproflocacin or cephalosporin)
* Cholecystectomy
What is the management for CBD stone?
- Continuous IVI (prevent hepato-renal syndrome)
* ERCP