General surgery (1) (The acute abdomen, common presentation and history) Flashcards
define the acute abdomen
A sudden onset of severe abdominal pain developing over a short time period
- It has a large number of possible causes and so a structured approach is required.
initial assessment of the acute abdomen
Is the patient critically unwell- end-of-bed-o -gram and observations?
- Yes?
- Call for help early
- Start initial management steps early
presentations requiring urgent intervention
- bleeding
- perforated viscus
- ischaemic bowel
less acute presentations
- colic
- peritonism
causes of bleeding
- Most serious cause is AAA
- Ruptured ecotopic pregnancy
- Bleeding gastric ulcer
- Trauma
presentation of bleeding
- hypovolaemic shock
- Tachycardia
- Hypotension
- Pale
- Clammy
- Cool to touch
perforated viscus cause
perforation (peptic ulceration, obstruction, diverticular disease and IBD)
presentation of perforated viscus
peritonism (diff to peritonism)
- Lie completely still
- Look unwell
examintion of perforated viscus
- Tachycardia and potential hypotension
- Rigid abdomen and percussion tenderness
- Involuntary guarding
- Reduced or absent bowel sounds
ischaemic bowel presentation
- Presentation
- Severe pain out of proportion to the clinical signs
- Acidaemic with raised lactate and physiologically compromised
- Diffuse and constant pain
- Definitive diagnosis- CT with IV contrast
colic
- Abdominal pain that crescendos and then goes away completely
cause of colicky pain
- Biliary colic
- Ureteric colic
- Bowel obstruction
peritonism
presentation of peritonism
- Diff to peritonitis
- Localised inflammation of peritoneum- usually due to inflammation of viscus that irritate visceral peritoneum
e.g. acute appendicitis (pain migrates from umbilical region to the RIF
types of abdominal pain
visceral
somatic
visceral pain
(originating from organs)- vague pain felt in midline (autonomic)
- Results from stimulation of receptors in smooth muscle
- By ischaemia, distension/stretching, tension (often colicky)
- Conducted by autonomic nerves
- Poorly localised midline pain
- Associated with malaise, nausea, vomiting and sweating
- Example: appendicitis
somatic pain
(body wall)- localised, specific pain
Referred
- Biliary tract pain
- Diaphragmatic irritation e.g with gall stones
differential diagnosis fo acute abdomen related to extra-abdominal organs
cardiac, resp, gynaecological, testicular
common causes of the acute abdomen
- Appendicitis
- Cholecystitis and biliary colic
- Diverticulitis
- Obstruction
- Pancreatitis
- Gynae pathology renal/urology pathology
Differential diagnosis of acute abdomen based on located
investigations for the acute abdomen
laboratory tests
imaging
laboratory tests
The investigations in all cases of the acute abdomen share the same generic outline:
-
Urine dipstick – for signs of infection or haematuria ±MC&S.
- Include a pregnancy test for all women of reproductive age
- Arterial Blood Gas – 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 level
-
Routine bloods – FBC, U&Es, LFTs, CRP, amylase*
- Do not forget a group & save (G&S) if the patient is likely to need surgery soon
- Blood cultures – if considering infection as a potential diagnosis
*Any 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
imaging
Following assessment, initial imaging may help to further help focus the diagnosis if still unclear:
- An erect chest plain film radiograph (eCXR) – for evidence of free abdominal air e.g. pneumoperitoneum or lower lobe lung pathology
-
Ultrasound
- Kidneys, ureters, and bladder (‘KUB’) – can check for hydronephrosis and cortico-medullary differentiation
- Biliary tree and liver – can check for the presence of gallstones, gallbladder thickening, or duct dilatation
- Transvaginal – for suspected tubo-ovarian pathology
- CT imaging of the abdomen, often best discussed with a senior depending on the suspected underlying diagnosis if required
In the emergency setting, every patient with abdominal pain should have electrocardiogram to exclude cardiac pathology, as referred pain
management of the acute abdomen
Depends largely on the cause. However, a good initial management plan includes core points, regardless of the underlying aetiology.
These include:
- Intravenous access
- Nil-by-mouth (NBM) status set
- Analgesia +/- antiemetics
- Imaging
- VTE prophylaxis
- Urine dip
- Bloods
- If the patient is unwell, consider a urinary catheter and/or nasogastric tube if necessary,
- Intravenous fluids and monitor fluid balance.
cause of generalised peritonitis
- Perforated viscus
- Primary infective peritonitis
- Rupture of cyst
cause of localised peritonitis
- Appendicitis
- Cholecystitis
- Pancreatitis
- Diverticulitis
- Abscesses
- Salpingitis/ruptured ectopic
causes of motility disorders
- Spasms
- Irritable colon, uterine contractions
- Obstruction
- Intestinal, ureteric, biliary
causes of ischameic
- Mesenteric angina
- Splenic infarction
- Torsion of ovarian cyst, testicle, omentum
- Tumour necrosis
presentation of ruptured AAA
- Sharp and tearing
- Radiates to the back
thoracic pain causes
- Lung disease
- Ischaemic heart disease
- Oesophageal disease
neurological diseases
- Herpes zoster
- Spinal arthritis
- Radiculopathy from tumours
- Tabes dorsalis (form of neurosyphilis, which is a complication of late stage syphilis infection)
- Abdominal epilepsy
metabolic causes of acute abdomen
- DM
- Chronic renal failure
- Porphyria
- Acute adrenal insufficiency
causes of acute abdomen: toxins
- Snake and insect bites
- Lead poisoning
e.g. scorpion skin- pancreatitis
broad categories of common surgival presentation
- Abdominal pain
- Perforation
- UGI
- Perforated duodenal ulcer
- LGI
- Perforated diverticular disease
- Perforated tumour
- Iatrogenic
- UGI
- Obstruction
- GI bleeding
- Hernias
- HPB emergencies
- Abscesses (inc perianal abscess)
GI perforation
- Presenting features
- Haemodynamically unstable
- Sharp constant pain
- Vomiting
- Fever
- Examination findings
- GI exam
- Investigations
- CT
- Blood gases
- Management
- IV fluids
- Antibiotics
- Oxygen if needed
- Surgery (not very often)
- Dependent on performance status of the patient
- UGI perforation e.g. DU are genrally close
- LGI perforation e.g. due to diverticular disease generally resected
- Mortality and morbidity high
bowel obstruction presentation
- Colicky pain
- Abdominal distention
- Vomiting
- Not opening bowels
causes of bowel obstruction an be split into
- Within the tube
- Constipation
- Foreign body
- Within the wall of the tub
- Tumours
- Stricture
- Connective tissue disorder e.g. Hirshsprungs, achalasia
- Outside
- Adhesions/strictures
- Tumour
- Twists
- Hernias
- Intra-abdominal malignancy
causes of small bowel obstruction
- Adhesions (50-75%)
- Hernia (7-25%)
- Tumours (7-14%)
causes of large bowel obstruction
Large bowel
- Colorectal (65%)
- Diverticular disease (20%)
- Sigmoid volvulus (10%)
Clinical signs of obstruction
- Distension
- Visible hernia/scars
- High pitched, tinkling bowel sounds
- Dehydration
- Tachycardia
- Hypotension
- Fever
- Tenderness
management of obsturction
- NBM, NGT
- IVI, catheter
- Analgesic
- A definitive diagnosis – AXR + CT
- Definitive management
SBO on AXR
- Central
- SB lines up as a ladder
- Lines go right across
Hernia
A condition in which part off an organ is displaced and protrudes through the wall of the activity containing it
common hernias
- Inguinal
- Umbilical
- Femoral
- Incisional
complications of hernias
- Obstruction
- Strangulation
presenation of hernia
- Tender, painful, non-reducible lump
- Skin erythema
- Systemic upset
- Abdominal distension/vomiting
HPB emergencies
- Biliary colic
- Cholecystitis
- Choledocholithiasis
- Ascending cholangitis
- Pancreatitis
- Gallstone ileus
general HPB themes
- Imaging modality
- MRCP
- Role of urgent/early surgery in gallstone disease
- ERCP
GI history taking: introduction
- Wash your hands and don PPE if appropriate.
- Introduce yourself to the patient including your name and role.
- Confirm the patient’s name and date of birth.
- Explain that you’d like to take a history from the patient.
- Gain consent to proceed with history taking.
GI history taking: PC
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
- Can you tell me more?
GI history taking: HPC key GI symptoms
nausea, vomiting, abdominal pain, distension, weight loss and jaundice
GI history taking: HPC- exploring symptoms
Use SOCRATES to explore symptoms
Site
Ask about the location of the symptom:
- “Where is the pain?”
- “Can you point to where you experience the pain?”
Onset
Clarify how and when the symptom developed:
- “Did the pain come on suddenly or gradually?”
- “When did the pain first start?”
- “How long have you been experiencing the pain?”
Character
Ask about the specific characteristics of the symptom:
- “How would you describe the pain?” (e.g. sharp, dull ache)
- “Is the pain constant or does it come and go?”
Radiation
Ask if the symptom moves anywhere else:
- “Does the pain spread elsewhere?”
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom:
- “Are there any other symptoms that seem associated with the pain?” (e.g. fever in intrabdominal infection, vomiting in bowel obstruction)
Time course
Clarify how the symptom has changed over time:
- “How has the pain changed over time?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
- “Does anything make the pain worse?” (e.g. GORD is worsened by lying flat)
- “Does anything make the pain better?” (e.g. GORD is improved with antacid medication)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
- “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
- If the symptom is weight loss, try to quantify the amount of weight the patient has lost over a specific time period.
GI history taking: Upper GI symptoms
- Jaundice: yellowing of the skin/sclera and dark urine. Causes include hepatitis, liver cirrhosis and biliary obstruction (e.g. gallstone, pancreatic cancer).
- Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.
- Vomiting: a common symptom of many gastrointestinal disorders including infections (e.g. gastroenteritis), gastro-oesophageal reflux disease (GORD), pyloric stenosis (projectile non-bilious vomiting), bowel obstruction (typically bilious), gastroparesis (e.g. secondary to diabetes), pharyngeal pouch and oesophageal stricture (vomit containing undigested food).
- Haematemesis: the vomiting of blood which can be fresh red in colour (e.g. Mallory-Weiss tear, oesophageal variceal rupture) or coffee ground in appearance (e.g. gastric or duodenal ulcer).
- Gastro-oesophageal reflux: backflow of the stomach’s contents into the oesophagus secondary to lower oesophageal sphincter incompetence. Patients typically describe epigastric discomfort which is burning in nature.
- Dysphagia: difficulty swallowing which may affect solid food, liquids or both depending on its severity (e.g. oesophageal cancer).
- Odynophagia: pain during swallowing which may be associated with oesophageal obstruction (e.g. stricture) or infection (e.g. oesophageal candidiasis).
GI history taking: lower GI symptoms
Lower gastrointestinal symptoms include:
- Abdominal pain: may be localised (e.g. right iliac fossa in appendicitis) or generalised (e.g. spontaneous bacterial peritonitis).
- Abdominal distension: associated with a wide range of gastrointestinal pathology including ascites, constipation, bowel obstruction, organomegaly and malignancy.
- Constipation: causes include dehydration, reduced bowel motility (e.g. autonomic neuropathy) and medications (e.g. opiates, ondansetron, iron supplements).
- Diarrhoea: causes include infection (e.g. C.difficle), irritable bowel syndrome, inflammatory bowel disease, medications (e.g. laxatives), constipation (with overflow) and malignancy.
- Steatorrhoea: the presence of excess fat in faeces causing them to appear pale and be difficult to flush. Causes of steatorrhoea include pancreatitis, pancreatic cancer, biliary obstruction, coeliac disease and medications (e.g. Orlistat).
- Malaena: dark, tar-like sticky stools containing digested blood secondary to upper gastrointestinal bleeding (e.g. peptic ulcer).
- Haematochezia: fresh red blood passed per rectum which may be caused by haemorrhoids, anal fissures and lower gastrointestinal malignancy.
GI history taking: systemic symptoms
- Systemic: fevers, weight change, fatigue
- Cardiovascular: chest pain, oedema, syncope, palpitations
- Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
- Genitourinary: oliguria, polyuria, dysuria, urinary frequency
- Neurological: visual changes, motor or sensory disturbances, headache, confusion
- Musculoskeletal: chest wall pain, trauma
- Dermatological: rashes, skin lesions, jaundice
GI history taking: family history
cancers etc
GI history taking: past medical history
ask about previous GI issues and surgeries
are they being seen by a doctor for anything regularly
GI history taking: drug history
- any daily medication
- any pain medication
- any over counter
- how good are thye at taking it
GI history taking: allergies history
any allergies- what kind of response
GI history taking: social history
- General context
- Travel history
- Smoking
- Alcohol
- Recreational drug use
- Gambling
- Diet
- Exercise
- Sexual history
