Gastroenterology COPY Flashcards
What is dyspepsia?
Describes a range of upper gastrointestinal tract including epigastric pain/burning, nausea, heartburn and fullness
What is dysphagia?
Difficulty swallowing
Where are they vomiting centres located in the brain?
Medulla
Nausea and vomiting are most commonly associated with the GI system with concurrent abdominal pain.
But in the absence of abdominal pain, pathology of what other systems may cause nausea/vomiting?
Central nervous system (e.g. raised ICP)
Excess alcohol
Drugs (e.g. chemotherapy agents)
Metabolic disease (uraemia, diabetic ketoacidosis)
Persistent nausea/vomiting with no other symptoms may also be ________ in nature
Functional
Causes of dysphagia may be divided into what categories related to aetiology
Disorders of mouth and tongue
Oesophageal motility disorder
Extrinsic lesions (e.g. mediastinal glands or goitre)
Intrinsic lesions (strictures, foriegn body)
What is the definition of diarrhoea?
Increased amount of loose stool (stool weight >250g/day)
What is steatorrhoea?
Passage of pale, bulky and foul-smelling stools
What is the pathophysiology of steatorrhoea?
Fat malabsorption due to pancreatic/biliary pathology leads to increased fat in the stools.
Name a faecal marker of inflammation
Faecal calprotectin
Endoscopy is an essential investigation in the diagnosis of GI pathology. It can look at different parts of the GI tract. Name a few types of endoscopy
(6)
Oesophagogastroduodenoscopy (a.k.a. gastroscopy) Sigmoidoscopy (flexible or rigid) Colonoscopy ERCP Endoscopic ultrasound Capsule endoscopy
What is PET scanning used for in the investigation of GI pathology?
Staging of oesophageal, gastric and colorectal cancers
Outline the different types of contrast studies
Barium swallow - outline oesphagus
Barium meal - outline stomach and duodenum
Barium follow-through - outline small intestine
Outline the function of oesophageal physiology testing
Probes lowered into the oesophagus via the nose to measure:
- 24-hour monitoring of pH
- Volume reflux of gastric contents
What is oesophageal manometery?
Used for the investigation of oesophageal motility disorders
What is the most common type of non-infectious mouth ulcers?
Recurrent apthous ulcer
What are recurrent apthous ulcers?
Recurrent episodes of self-limiting, painful ulcers (rarely on the palate)
What treatment, if any, is indicated for recurrent apthous ulcers?
Topical corticosteroids for symptomatic relief
How does squamous cell carcinoma present in the oral cavity?
Painless ulcer, usually on the lateral borders of the tongue or floor of the mouth
If a patient presents with oral white patches in the mouth, what is the most impotant distinction to make in the history?
Are they transient or persistent
What is the most likley diagnosis with transient white oral patches?
Oral candida
What is the most likley diagnosis with persistent white oral patches?
Leucoplakia
What is leucoplakia?
Persisteny white patches in the oral cavity most storngly associated with smoking or alcohol consumption.
They are premalignant changes
What is glossitis?
Inflammation of the tongue.
Smooth, sore and red.
Most stongly assocaited with B12, folate or iron deficiency
What is the cause of a hairy black tongue?
Proliferation of chromogenic microorganisms causing stainig of elongated filiform papillae
Causes include heavy smoking
Gum bleeding is most commonly caused by what condition?
Gingivitis (inflammatory condition of the gums associated with denta plaque)
What is GORD?
Gastro-oesophageal reflux disorder
Reflux of gastric acid, pepsin, bile and duodenal back into the oesophagus
What is the pathophysiology of GORD?
GORD prevalence and severity is influenced by many factors.
Primarily due to overcoming the lower oesophageal sphincter
What physiological property of the lower oesophageal sphincter (LOS) prevents GORD in most people?
LOS remains clonsed until the swallowing reflex is triggered causing Transient Lower Oesophageal Sphincter Relaxations (TLOSRs) to allow transmission of foodstuffs/liquids.
What are the symptoms of GORD?
Dydpesia (heartburn)
Regurgitation
Odynophagia (painful swallowing)
Outline the investigations of GORD
Simple cases are diagnosed clinically
Any patient over the age of 55 with concurrent alarm symptoms (weight loss, dysphagia, haematemesis etc.) will undergo investigation e.g. OGD or pH monitoring
How is GORD treated?
First line - conservative measures (weight loss, avaoidance of triggers e.g. alcohol)
Second line - simple antacids/proton-pump inhibitors/H2-receptor antagonists
Third line - Surgery (Nissan Fundoplication)
Outline two complications of untreated GORD
Peptic stricture
Barrett’s Oesophagus - pre-malignant metaplasia
What is achalasia?
Condition of unknown aetiology characterised by oesophageal aperistalsis and impaired relaxation of the LOS
What are the clinical features of achalasia?
Long history of dysphagia of both liquids and solids with potential association with regurgitation
What investigations might you order in the suspected case of achalasia and why?
Chest X-ray - may see dialtion of oesphagus
Barium swallow - shows aperistalsis (bird beak sign)
CT scan - exlcude cancer
How is achalasia managed?
Medical - nitrates e.g. nefidipine (20mg sublingually)
Surgeical - Endoscopic balloon dilatation or surgical division of the LOS (Hellers cardiotomy)
What is a hiatus hernia?
When part of the stomach herniates through the oesophageal hiatus of the diaphragm
What are the two types of hiatus hernia?
Sliding (most common) - no serious complications
Para-oesophageal - serious risk of gastric volvulus and haemorrhage
What are the two most common types of oesophageal cancer?
Sqaumous cell and adenocarcinoma
Extremely rarely primary small cell
What is the precursor to adenocarcinoma of the oesophagus?
Barrett’s metaplsia
What are the typical clinical features of oesophagela malignancy?
Progressive dysphagia
Weight loss
Chest pain caused by food impaction/local infiltration
How is oesophageal malignancy investigated?
Diagnosis is by gastroscopy and biopsy
Initial staging is done by CT scan of chest and abdomen
Furhter assessment for metastesis is done by PET scna
How is oesophageal malignancy treated?
Surgical resection provides best chance of cure. Often combined with pre-operative chemotherapy with or without neo-aduvant radiotherapy
Palliation may be given in terminal cases including stenting to relieve symptoms of dysphagia
Gastric acid is secreted by what cell in the stomach?
Parietal cells
What hormone signals the release of gastric acid from parietal cells?
Histamine (also in turn under control from acetylcholine and gastrin)
What hormone is inhibitory to the secretion of histamine and gastrin?
Somatostatin
What is H. Pylori?
Gram-negative urease-producing spiral-shaped bacterium found mainly in the gastric antrum
What serious pathologies are at least in part attributed to H. Pylori infection?
Chronic gastritis, peptic ulcer disease, gastric cancer, gastric B cell lymphoma
How is H. Pylori infection diagnosed?
Non-invasive - serrology, breath test or stool antigen
Invasive - anteral biospy or rapid urease (CLO) test
How is H. Pylori infection managed?
Eradication is indicated in all symptomatic patients with PPI-based triple therapy e.g.
Omeprazole (20mg), metronidazole (400mg) and clarithromycin (500mg) all twice per day
What is a peptic ulcer?
An ulcer of the mucosa in or adjacent to an acid-bearing area. Most occur in the proximal stomach or the proximal duodenum
What are the clinical features of peptic ulcer disease?
Burning epigastric pain is typical
Nausea, heartburn and flatulence
What are the most common complications of peptic ulcer disease?
(3)
Perforation
Painless haemorrhage
Gastric outflow obstruction
How is peptic ulcer disease treated?
H.pylori is tested for (non-invasive method preferred) and eradicated if present
If not sufficient then PPI treatment is commenced
Unless there are complications, surgery is rarely needed
What is the most likely cause of a non-H. Pylori peptic ulcer?
NSAID or aspirin overuse
What type of ulcer is most likely to perforate?
Duodenal ulcers perforate more often than gastric ulcers
List the ALARM symptoms
Dysphagia Weight loss Vomiting GI bleeding (haematemesis or melaena) Epigastric mass
List some other causes of gastritis other than H. Pylori infection
Autoimmune gastritis
Viral gastritis
Duodeno-gastric reflux
What is autoimmune gastritis?
Immune-mediated destruction of gastric parietal cells leading to perniscious anaemia
What are the histological diffferences between acute and chronic gastritis?
Acute - neutrophil invasion
Chronic - mononuclear (mostly lymphocytes), macroghages and plasma cell infiltration
What anatomical region of the stomach do gastric tumours most commonly arise?
The antrum
What are the clinical features are common for gastric cancer?
Pain siminlar to peptic ulcer disease
Nausea, anorexia and weight loss are common in more advanced disease
What findings may be present on examination in a case of gastric cancer?
Palpable epigastric mass
Palpable Virchow’s node (left supraclavicular fossa)
Skin manifestations (dermatomyositis and acthanosis nigrans)
What common sites of metastasis occurin gastric cancer?
Peritoneum and liver
How is gastric cancer investigated?
Gastroscopy and biospy for diangosis
CT/PET scan for staging
How is gastric cancer treated?
Surgical resection with aduvant chemotherapy
Palliative chemotherapy may be offered with inoperable pathology
Whatis the most common histological type of gastric cancer?
Adenocarcinoma
What is haematemesis?
Vomiting blood
What is malaena?
The passage of black tarry stools indicative of altered blood from a bleed proximal to the jejenum
How does acute massive upper GI bleed present?
Fresh rectal bleeding and shock
How is acute upper GI haemorrrhage managed in the immediate setting?
Two large-bore (16 gauge) IV cannulas
Group, save and cross match at least 4L of blood
What evidence suggesting a large GI bleed may be found on examination?
Blood pressure <100mmHg systolic >100 bpm Cold extremities Slow capillary refill Haemoglobin <100g/L
How is a persons risk for a recurrent or life-threatening bleed?
Using the Rockall Score
What is a Mallory-Weiss tear?
Linear mucosal tear at the oesophagogastric junction
How are bleeding oesophageal varices treated?
Banding or glue sclerotherapy
What are the most common causes of massive lower GI bleeding?
DIverticular disease or ischaemic colitis
List some common causes of colonic GI bleeding
Haemorrhoids
Anal fissure
Neoplasms
Diverticular disease
List some common causes of small intestine GI bleeding
Neoplasms
Ulcerative disease: Crohn’s disease, NSAIDs
How does chronic GI bleeding present?
Iron deficiency anaemia
What investigations are indicated in the case of chronic GI bleed? And why perform them?
Exclusion of malignancy with OGD and colonoscopy
What are the typical presenting symptoms of small bowel disease? (4)
Diarrhoea, steatorrhoea, abdominal pain/discomfort, anorxia
What is coeliac disease?
Autoimmune condition characterised by inflammation of jejunal mucosa when exposed to gluten (contained in wheat, rye and barley) when goes into remission on exclsuion of gluten from the diet
What is the toxic molecule in gluten to patients with coelia disease?
alpha-gliadin
What are the microscopic findings of an acute attack coeliac disease?
Villous atrophy and crypt hyperplasia
What investigations are indicated for coeliac disease?
IgA tissue transglutaminase (serological test)
Distal duodenal biospies
Blood count (mild anaemia is common)
How is coeliac disease managed?
Life-long gluten free diet and correction of any vitamin deficiencies
What is the most common malignant compliction of coeliac disease?
Intestinal T-cell lymphoma
What are the symptoms and signs of coeliac disease?
Non-specific symptoms of malaise and tiredness
Symptoms of small bowel disease (diarrhoea, steaorrhoea, abdominal pain/discomfort etc.)
Dermatitis herpetiformis
What is dermatitis herpetiformis?
Itchy, symmetrical eruption of vesicles and crusts with deposition of granular IgA on the extensor surfaces of the body.
How is dermatitis herpetiformis trested?
Dapsone and a gluten-free
What conditions predispose someone to developing Coeliac disease?
Type-1 Diabetes
Irritable bowel syndrome
Downs Syndrome
What is Whipple’s disease?
A rare disease caused by infection with the Tropheryma whipplei bacterium
What are the clinical features of Whipple’s disease?
Steatorrhoea Abdominal pain Fever Lymphadenopathy Arthritis
How is Whipple’s disease diagnosed?
Small bowel biopsy showing acid-Schiff (PAS)-positive macrophages
How is Whipple’s disease treated?
Co-trimoxazole for one year
How does tuberculosis of the gut arise?
Reactivation of the primary disease caused by mycobacterium tuberculosis
What is the most common site of TB of the gut?
The iliocaecal valve
How does the treatment for TB of the gut differ from pulmonary disease?
Same regimen but extended for one year
What is Meckel’s Diverticulum?
A diverticulum projects from the wall of the ileum approx. 60cm from the ileocaecal valve
How does Meckel’s Diverticulum present?
Lower GI bleeding, perforation, inflammation and/or obstruction
How is Meckel’s Diverticulum treated?
Surgical excision
Intestinal ischaemia is a very serious pathology which is most commonly caused by what underlying disease processes?
(3)
Artheroma, vasculitis or profound shock
What is the presentation fo ischaemic bowel?
Severe abdominal pain with very little to find on abdominal examination
Name the autosomal dominant condition causing mucocutaneous pigmentation and GI polyps
Peutz-Jeghers Syndrome
What are carcinoid tumours?
Tumours originating from enterochromaffin (serotonin producing) cells
What is carcinoid syndrome?
Term applied to the symptoms that arise from the production of serotonin, kinins and histamine
What are the clinical features of carcinoid syndrome?
Flushing, wheezing, diarrhoea, abdominal pain and right-sided cardiac valvular fibrosis causing stenosis and regurgitation
How is carcinoid syndrome diagnosed?
High levels of 5-hydroxyindoleacetic acid in the urine
How is carcinoid syndrome treated?
Inhibition of tumour products with somatostatin analogues (e.g. octreotide)
Surgical resection of tumour
What is inflammatory bowel disease?
A group of chronic systemic disease involving inflammation of the intestine and includes: ulcerative colitis, Crohn’s disease and intermediate colitis
What stuctures are affected by ulcerative colitis?
Only the colon
What structures are affected by Crohn’s disease?
Can affect any part of the GI tract from the mouth to the anus
What is indeterminate colitis?
Disorder with features of both ulcerative colitis and Crohn’s disease
Outline the macroscopic features of ulcerative colitis
Limited to the colon
Begins in rectum and extends proximally and continuously
Red mucosa (eaily bleeds/ulcerates)
Outline the microscopic features of ulcerative colitis
Mucosal non-granulomatous inflammation with goblet cell deplpetion and crypt abscess formation
Outline the macroscopic features of Crohn’s disease
Can affect any part of the GI tract
Oral and perianal evolvement is common early
Discontinous involvement (skip lesions)
Ulceration and fissures giving ‘cobblestone appearance’
Outline the microscopic features of Crohn’s disease
Transmural inflammation
Granulomata (50% of cases)
How does Crohns disease usually present? Describe both colonic and perianal disease
Colonic disease - diarrhoea, bleeding and pain related to defaecation
Perianal disease - anal tags, fissures, fistulae and abscess formation
What is the clinical presentation of ulcerative colitis?
Diarrhoea, often containing blood and mucus
Ulcerative colitis can have several different patterns of clinical course. Describe three common patterns.
Persistent diarrhoea
Relapses/remissions
Severe fulminant colitis
As a systemic pathology, IBD can manifest outside of the bowel. List five extra-intestinal manifestations of IBD
Uveitis Arthralgia Erythema nodosum Gallstones Oxalate stones
The severit of IBD is calculated by the UC Severity Index. It meausures six variables to distinguish between mild and severe relapses of UC. What are the six variables?
Blood diarrhoea Fever Tachycardia Erythrocyte Sedimentation Rate Anaemia Serum albumin
What biochemical investigations are potentially useful in the diagnosis of IBD?
Blood tests (normochromic normocytic anaemia, B12 deficiency, ESR, CRP, albumin) Liver biochemistry may be abnormal
What imaging is indicated for investigation and monitoring of IBD?
Rigid/flexible sigmoidoscopy (to establish diagnosis)
Colonoscopy (measure extent of disease)
Small bowel imaging (in Crohn’s disease)
Ultrasound (useful in detection of abscesses)
How is IBD managed medically?
5
Oral 5-ASAs - used in mild disease only
Steroids - used in mild/severe disease
Liquid enteral nutrition (elemental/polymeric) - helps induce remission
Thiopurines - used to maintain remissions (methotrexate used if intolerant)
Anti-TNF (infliximab) - used to induce remission when other modalities have failed
What is the major concearn of therapy with thiopurine durgs?
Bone marrow suppression
What are the indications for surgery to manage IBD?
Failure of medical treatment
Complications
Failure to thirve in children
What complications are possible in IBD?
Toxic megacolon Bowel perforation Colorectal cancer Haemorrhage Obstruction
What different approaches to surgery are taken in Crohn’s disease and ulcerative colitis respectively?
Crohn’s disease - resection kept to a minimum as relapse is inevitable
Ulcerative colitis - colectomy offers “curative” treatment
Outline the options for surgery in ulcerative colitis
Colectomy with ileoanal anatomosis (pouch formation)
Panproctocolectomy with ileostomy (requires stoma)
What is microscopic colitis?
Symptomatic colitis with normal appearance of mucosa
How many litres of water enter the gastrointestinal tract per day on average? How much passes the ileocaecal valve and how much is then reabsorped in the colon?
9L enter the GI tract
1500mls pass the IC valve
1350mls are absorped
As a rule of thumb, what is an approx. definition of constipation?
Infrequent passage of approx. <3 stools per week
List five potential causes of constipation
Non-exhaustive list:
Pregnancy Poor fibre intake Immobility IBS Hypercalcaemia Opiate useage Spinal cord lesions Intestinal obstruction
What is faecal incontinence?
Recurrent and uncontrolled passage of flatus/stool
What factors does faecal continence depend on?
Cognition Stool volume Stool consistency Integrity of anal sphincters Integrity of puborectalis muscle Integrity of pedundal nerve
What is the most common cause of faecal incontinence?
Faecal impaction (overflow diarrhoea)
How can labour and anal surgery cause faecal incontinence?
Anal sphincter tear and/or pedundal nerve trauma
What types of comorbidities can cause reduced anal sensation?
Diabetes mellitus
Multiple sclerosis
Dementia
Spinal cord injuries
What is diverticular disease?
Pouches of mucosa extrude through the colonic muscular wall
What is meant by the term diverticulosis?
The presence of diverticula
What is meant by diverticulitis?
Implies inflammation which occurs when faeces obstruct the neck of the diverticulum
What is the cause of diverticular disease?
Not fully understood but thought that a low-fibre diet is partly responsible in the west.
How does diverticular disease present?
Usualy asymptomatic and found incidentally but can present with pain and contipation (due to lumenal narrowing) or bleeding
How may masssive diverticulitis present?
Left iliac fossa pain and fever
What are the complications of diverticulitis?
Perforation (leading to abscess formation)
Fistula formation
How is acute diverticulitis diagnosed?
CT abdomen or sometimes ultrasound
How are acute attacks of diverticulitis managed?
Antibiotics (cephalosporins and metronidazole)
What is megacolon?
Describes a number of conditions in which the colon is dilated
What is the most common cause of megacolon?
Chronic constipation
Describe the blood supply of the colon
From the superior and inferior mesenteric arteries
What areas of the colon are most susceptible to ischaemia and why?
Watershed areas such as the caecum and splenic flexure
What does it mean to be a watershed area?
An area receiveing blood from two overlapping distal arteries
What demongraphic of people are most likely to develop ischaemic colitis?
Elderly patients with underlying atheroscelrosis
What is the presentation of ischaemic colitis?
Abdominal pain and rectal bleeding (occaisionally shock)
What is the treatment of ischaemic colitis?
Symptomatic
Surgery may be required to remove gangrene, perforation or stricture
What is a polyp?
An abnormal growth of tissue projecting into the intestinal lumen from the normally flat mucosal surface
What type of histological tissue are most polyps?
Most polyps are adenomas
Polpys may be precursors to what serious pathology?
Colorectal cancer
What are some less common histological types of polyp? (3)
Hyperplastic, inflammatory, hamartomatous
The risk of a polyp developing into malignancy are determed by what variables? (5)
Size (>1cm)
Sessile (greater risk) or pedunculated
Increasing dysplasia
Villous atrophy (greater risk) or tubular
Multiple (greater risk) or isolated polyp
What is the average age of diagnosis of CRC?
60-65 years old
Colon cancer has a strong genetic component which can lead to a variety of distinct pathologies. Describe the two most common familial CRC syndromes
- HNPCC (Lynch’s syndrome) - accelerated progression from adenoma to CRC (onset in fourth decade)
- Familial adenomatous polyposis - numerous polyps with 100% progression to CRC usually in young adulthood
How does CRC spread?
Direct invasion and later invasion of blood and lymphatics
Where are tumours of colon most likely to occur?
Left side of the colon
What are the most common symptoms of CRC?
Rectal bleeding Stenosis Alteration in bowel habit Colicky abdominal pain Hepatomegaly (in liver metastesis)
How does carcinoma of the caecum/right colon usually present?
Iron deficiency anaemia and/or right iliac fossa mass
What investigations are indicated in the case of suspected CRC?
Colonic examination (colonoscopy, CT colonography, barium enema)
Blood tests (FBC, LFTs, CEA tumour biomarker)
Radiology (PET scan)
Faecal occult blood test (used in screening)
How is CRC managed?
Surgical resection with end-to-end anastomosis
Limited liver mets can be treated sometimes with lobular resection
What are the two most common cause of acute diarrhoea?
Infection or dietary indiscretion
What investigations are indicated in the case of acute diarrhoea?
Stool cultures (x3 ova, parasites and cysts)
Flexible cystoscopy
Colonic biopsy if no diagnosis is reached
What is the mainstay treatment of acute diarrhoea?
Maintain hydration
Anti-diarrhoeal agents
Antibiotics for specific indications
What is the definition of chronic diarrhoea?
Diarrhoea lasting more than 14 days
What is the difference between organic and functional causes of chronic diarrhoea?
Organic causes (frequent passage of faeces of stool weight >250g)
Functional causes (frequent passage of small volume stools with weight <250g)
What investigation is good at distinguishing organic from functional causes of diarrhoea?
Faecal calprotectin
What are the four mechanisms of diarrhoea?
Osmotic
Secretory
Inflammatory
Motility
Describe the mechanism of osmotic diarrhoea
Large quanitities of un-absorbed hypertonic fluid which draws fluid into the intestinal lumen
Describe the mechanism of secretory diarrhoea
Active secretion of intestinal fluid with decreased absorption
Describe the mechanism of inflammatory diarrhoea
Damage to the intestinal lumen lead to loss offluid and blood
Describe the mechanism of motility diarrhoea
Abnormal frequency rather than true diarrhoea
Name a few causes of motility diarrhoea
Post-vagotomy
Diabetic autonomic neuropathy
What are functional bowel disorders?
Symptoms that occur in the absence of any demonstrable abnormalities in the digestion and absorption of nutrients, fluid and electrolytes and no strutural abnormalities of the GI tract
Name some mechanisms which may contribute to functional bowel disorders
Altered bowel habit
VIsceral hypersensitivity
Psychological factors
What are some potential medical treatment options for functional bowel disorders?
Low-dose amitriptyline
What chronic gastrointestinal symptoms are more suggestive of a functional origin?
Nausea alone Vomiting alone Belching Bloating Passage of mucous per rectum
Name some specific functional bowel disorders
Functional oesophageal disorder
Functional dyspepsia
Irritable bowel syndrome
List some symptoms of functional oesophageal disorder
Globus sensation (feeling of a lump in the throat persisting between meals)
Regurgitation
Midline chest pain
List some symptoms of functional dyspepsia
Epigastric pain
Early society
Bloating
Nausea
How is functional dyspepsia treated?
Reassurance and lifestyle changes (reducing fat, coffee, alcohol etc.)
Prokinetic agents e.g. metoclopramide
Eradication of H. pylori may help
Describe irritable bowel syndrome
Crampy, abdominal pain relieved by defaecation or passage of wind
Outline the subtypes of IBS
IBS-c (constipation), IBS-d (diarrhoea) and IBS-m (mixed picture)
How is IBS diagnosed?
Diagnosis of exclusion
In young patients: FBC, CRP, coeliac serology
Patient s over age 50 need colonoscopy to exclude other pathology
How is IBS treated?
Reassurance
Discussion of diet and lifestyle (try FODMAP diet and increase dietary fibre)
Smooth muscle relaxants
Low-dose amitriptyline or citalopram
Psychologial interventions (CBT, hyponotherapy)
What kind of medical conditions may present as an acute abdomen?
Diabetic ketoacidosis
Myocardial infarction
Pneumonia
What serious pathology may present with apparent colickly pain and must be considered in the over 50’s patient?
Leaking abdominal aortic aneurysm
Give a differrntial diagnosis of a surgical acute abdomen
Intestinal obstruction (small bowel or coloninc) Intestinal perforation Ruptured peptic ulcer disease Abdominal aortic aneurysm Gynaecological (ruptured ectopic pregnancy) Acute pancreatitis Acute appendicitis Calculi in a hollow viscus (tube)
Outline a systematic history to help diangose the underlying pathology of acute abdomen
Onset (sudden or gradual)
Site (upper or lower abdominal, iliac fossae, back pain etc.)
Pain (intermittent or constant)
