Gastroenterology (The Acute Abdomen) Flashcards
history for acute abdomen
1) Presenting complaint
Pain: SOCRATES
Associated symptoms:
- N+V
- haematemesis
Have they been able to eat and drink?
- When was the last time?
Systemic symptoms
- fever
- weight loss
- rash or itching
- changes to bowel habbits
- rectal bleeding
- passing urine
- feartures of anaemia
**2. PMH **
- IBD
- AF- mesenteric ischaemia
- CVD- AAA
- Any trauma
- Any previous surgery
3. Medication history
- Peptic ulcer- NSAIDs, aspirin, bisphosphonates, corticosteroids, SSRIs
- Pancreatic: corticosteroids, azathioprine, thiazides, sulfonamides, furosemid, oestrogens and tetracyclines
** 3. Family history**
- Is anyone else in the family experiencing similar symptoms?
- Is there a family history of anything similar?
4. Social
- Do they smoke and/or drink?
- If so, how much and how long?
- Excessive alcohol consumption can predispose to pancreatitis
- Have they travelled anywhere recently?
- May predispose patients to infections such as gastroenteritis
In women of childbearing age…
a gynaecological and obstetric history is essential
Any woman of childbearing age should be considered pregnant until proven otherwise:
The ‘four Ps’ can help:
- PV bleeding?
- Any unusual PV bleeding (e.g. intermenstrual, postcoital etc.)
- PV discharge?
- Any unusual PV discharge?
- Pelvic pain?
- Use SOCRATES
- Pregnancy?
- Are they pregnant?
- When was their last menstrual period?
- Any previous gynaecological surgery?
- Any previous ectopic pregnancies?
- Do they use any hormonal contraceptives?
epigastric pain
- Oesophageal perforation (e.g. Boerhaave’s syndrome)
- Mallory-Weiss tears
- Pancreatitis
- Peptic ulcer disease and perforation
- Gallstones
- Myocardial infarction
LUQ pain
- Splenic problems (e.g. splenic rupture)
- Pyelonephritis
- Left-sided pneumonia
Right upper quadrant (RUQ) pain:
- Biliary colic
- Acute cholecystitis
- Ascending cholangitis
- Acute pancreatitis
- Hepatitis
- Right-sided pneumonia
Left lower quadrant (LLQ) pain:
- Acute diverticulitis
- Sigmoid volvulus
- Ulcerative colitis
Right lower quadrant (RLQ) pain:
- Appendicitis
- Crohn’s disease
Periumbilical pain:
- Appendicitis
- Acute mesenteric ischaemia
- Ruptured abdominal aortic aneurysm
Unilateral pain (may be restricted to upper or lower quadrants):
- Renal stones
- Pyelonephritis
- Ectopic pregnancy
- Ovarian torsion
- Ovarian cyst rupture
- Incarcerated or strangulated hernias
- Psoas abscess
Central abdominal pain radiating to the right lower quadrant suggests:
Appendicitis
Central abdominal pain radiating to the back – suggests:
- Pancreatitis
- Ruptured abdominal aortic aneurysm
- Aortic dissection
RUQ pain may radiate to the back/right shoulder – suggests:
- Biliary colic
- Cholecystitis
- Hepatitis
- Right lower lobe pneumonia irritating the right hemidiaphragm
LUQ pain may radiate to the back/left shoulder – suggests:
- Myocardial infarction
- Acute pancreatitis
- Splenic disease
- Left lower lobe pneumonia irritating the left hemidiaphragm
Loin-to-groin pain – suggests
renal colic and renal stones
Exacerbating and relieving factors may give some clues:
- Gastric ulcers – pain classically worsened when eating
- Duodenal ulcers – pain classically relieved with eating
- Biliary colic – classically worse after eating a fatty meal
investigations for the acute abdomen
- FBC
- UE
- Urinalysis
- LFT
- CRP
- Pregnancy test
- Serum amylase
- Serum lactate- acute mesenteric ischaemia
- Abdomial x-ray
- Erect chest x-ray - may show free air under the diaphragm
- Abdominal US, CT, endoscopy
- Laparoscopy
Oesophageal perforation
- There may be a history of vomiting/retching followed by chest/epigastric pain
- Subcutaneous neck emphysema may be present
- A chest x-ray may show a widened mediastinum or free mediastinal air
Mallory-Weiss tears
- There may be a history of repeated vomiting/retching/coughing
- Patients may have epigastric pain
- Small streaks of bright red blood may be coughed up
- Signs of anaemia may be present – postural hypotension, pallor, syncope, tachycardia
Perforated peptic ulcer
- Presents as acute-onset severe epigastric pain
- There may be a history of drugs such as NSAIDs, corticosteroids, aspirin, or selective serotonin reuptake inhibitors (SSRIs)
- Features of upper GI bleeding such as haematemesis and melaena may be present
- There may be a history of peptic ulcer disease:
- Gastric ulcers – epigastric pain worse when eating
- Duodenal ulcers – epigastric pain that improves when eating
- Tachycardia and fever may be present
- Abdominal rigidity, guarding, or rebound tenderness may be present
- A chest x-ray may show free air under the diaphragm