Gastroenterology: Acute Presentations

Question 1

What are the causes of bleeding in the abdomen in an acute abdomen?

Answer 1

• Abdominal Aortic Aneurysm
• Ruptured Ectopic Pregnancy
• Bleeding Gastric Ulcer
• Trauma

Question 2

What are the features of a patient who presents with bleeding in an acute abdomen?

Answer 2

Hypovolaemic shock which presents with:

• Tachycardia
• Hypotension
• Pale and clammy
• Patients are cool to touch with a thread pulse

Question 3

What are the causes of a perforated viscus in an acute abdomen presentation?

Answer 3

• Peptic Ulceration
• Small or Large bowel obstruction
• Diverticular Disease
• Inflammatory Bowel Disease

Question 4

What are the features of a perforated viscus in an acute abdomen presentation?

Answer 4

• Patient often lay completely still, not to move their abdomen and look unwell. Different to renal colic where patient move around a lot
• Tachycardic and Potential hypotension
• Completely rigid ‘washboard’ abdomen with percussion tenderness
• Involuntary guarding – patient involuntarily tenses their abdominal abdomen when you touch the abdomen
• Reduced or absent bowel sounds – suggests the presence of a paralytic ileus

Question 5

What are the causes of an Ischaemic Bowel in an acute abdomen presentation?

Answer 5

• Thrombus-in-situ
• Embolism
• Non-occlusive cause
• Venous occlusion and congestion

Question 6

What are the features of an Ischaemic Bowel in an acute abdomen presentation?

Answer 6

• Severe pain out of proportion to the clinical sign. Patient will often complain of diffuse and constant pain associated with nausea and vomiting. Patient may find it difficult to localise the pain
• Often acidaemic with raised lactate and physiologically compromised
• Take out any potential embolic sources such as AF, heart murmur and valvular replacement surgery

Question 7

What are the features of a colic?

Answer 7

• Abdominal pain that crescendos to become completely severe and goes away completely. Typically, either ureteric obstruction or bowel obstruction
• Biliary colic is not a true colic as the pain does not go away completely, instead getting periodically better and worse

Question 8

What are the features of peritonism?

Answer 8

• Localised inflammation of the peritoneum usually due to inflammation of a viscus that then irritates the visceral peritoneum.
• Pain starts in one place before localising to another area or becoming generalised. Classic example is acute appendicitis

Question 9

What are the general laboratory tests in an Acute Abdomen?

Answer 9

Urine dipstick – for signs of infection or haematuria ±MC&S. Include a pregnancy test for all women of reproductive age.

ABG – useful in bleeding or septic patients, especially for the pH, pO2, pCO2, and lactate for signs of tissue hypoperfusion, as well as a rapid haemoglobin.

Routine bloods (FBC, U&Es, Liver Function, CRP, amylase)

• Consider measuring serum calcium in suspected pancreatitis.
• Do not forget a group & save (G&S) if the patient is likely to need surgery soon.
• Amylase 3x greater than the upper limit is diagnostic of pancreatitis. Any raised value lower than this may also be due to another pathology such as perforated bowel, ectopic pregnancy or diabetic ketoacidosis

Blood cultures – if considering infection as a potential diagnosis

Question 10

What are the imaging of Acute Abdomen?

Answer 10

ECG to exclude myocardial infarction

Ultrasound

• Kidneys, ureters and bladder. For suspected renal tract pathology
• Biliary tree and liver for suspected gallstone disease
• Ovaries, Fallopian Tubes and Uterus for suspected tubo-overian pathology

Radiology

• An erect chest X-ray for evidence of bowel perforation
• CT imaging often depending of suspected underlying diagnosis

Question 11

How is an acute abdomen managed?

Answer 11

• IV access, NBM, Analgesia +/- antiemetics, Imaging, VTE prophylaxis, Urine dip, Bloods
• Consider urinary catheter and/or nasogastric tube if necessary
• Start IV fluid and monitor fluid balance