GI/GEN - Acute Abdomen (CONDITIONS) Flashcards
Biliary Colic
Risk Factors for Gallstones
Clinical Features
Bedside Investigations
Imaging
Management
1.) Risk Factors for Gallstones
- 5Fs: female, fertile, fat, fair forty
- increasing age, FH, diabetes (metabolic syndrome), oral contraception
- sudden weight loss: eg after obesity surgery
- loss of bile salts: e.g. ileal resection, terminal ileitis seen in Crohn’s
2.) Clinical Features - sudden, dull, colicky pain in RUQ
- pain can last for hours and can also radiate to the epigastrium, back, and shoulders (interscapular region)
- can be associated with nausea and vomiting
- may occur after fatty meals (↑CCK –> contraction)
- no signs of inflammation
3,) Bedside Investigations - bloods, urinalysis
- WCC and CRP normal due to no inflammation
- raised ALP (obstruction) normal ALT and bilirubin
- amylase/lipase to check for evidence of pancreatitis
- urinalysis (inc hCG) to exclude renal or gynae issues
4.) Imaging - USS, MRCP
- 1°biliary USS: looking for stones, gallbladder wall thickness, bile duct dilation
- MRCP (if USS inconclusive): defects in the biliary tree
5.) Management
- analgesia: paracetamol +/- NSAIDs +/- opiates
- lifestyle: low fat diet, weight loss, increased exercise
- definitive: elective laparoscopic cholecystectomy within 6 wks
Acute Cholecystitis
Clinical Features
Bedside Investigations
Imaging
Management
1.) Clinical Features - constant pain in RUQ/epigastrium w/ inflammatory signs e.g. fever, lethargy
- tender in RUQ,
- positive Murphy’s sign: arrest of respiration due to severe pain on inhalation
- NO jaundice
2.) Investigations - bloods, urinalysis
- ↑WCC and ↑CRP due to inflammation
- ↑ALP (obstruction), normal ALT and bilirubin
- amylase/lipase to check for evidence of pancreatitis
- urinalysis (inc hCG) to exclude renal or gynae issues
3.) Imaging - USS, HIDA MRCP
- 1°biliary USS: stones, gallbladder wall thickness, bile duct dilation
- 2°cholescintigraphy (HIDA scan): gallbladder not visualised due to cystic duct obstruction
- 3°MRCP (USS inconclusive): defects in the biliary tree
- CT scans are poor at visualising the biliary tree and gallbladder
4.) Management
- analgesia, antibiotics, antiemetics
- definitive: 1°ERCP, 2°PTC (percutaneous transhepatic cholangiography)
- lap cholecystectomy w/in 3-7days, complication can be a stone in the CBB causing RUQ and jaundice
- percutaneous cholecystectomy if not fit for surgery
Ascending Cholangitis
What is it?
Clinical Features
Investigations/Imaging
Management
1.) What is it? - biliary outflow obstruction + infection
- aetiology: occlusion of the biliary tree (common causes: gallstones, ECRP, cholangiocarcinoma)
2.) Clinical Features - constant pain in RUQ
- Charcot’s triad: pain in RUQ, fever, jaundice
- Reynolds pentad: Charcot’s + hypotension, confusion
- pruritus due to bile accumulation
- pale stools/dark urine (obstructive jaundice)
3.) Investigations/Imaging
- routine bloods: ↑WCC/CRP, ↑ALP +/- GGT, ↑bilirubin
- blood cultures: E.coli is the most common cause
- biliary USS: bile duct dilation (>6mm), gallstones
- ECRP (gold): diagnostic and therapeutic
4.) Management
- sepsis 6 (patients may present w/ sepsis)
- endoscopic biliary decompression via ERCP or PTC (percutaneous transhepatic cholangiography) after 24-48 hours to relieve any obstruction
Acute Pancreatitis
Diagnostic Triad
Causes/Risk Factors (IGETSMASHED)
Bedside Investigations
Glasgow Score (PANCREAS)
Management
1.) Diagnostic Triad - 2/3 needed
- Sx: severe acute onset of burning epigastric pain (blockage of the pancreatic duct), worse when supine and may radiate to the back, can cause severe N+V
- Ix: amylase x3 upper limit of normal
- radiological evidence (CT, ultrasound or MRI)
- other signs: jaundice, abdo tenderness w/ guarding, ↓bowel sounds, Cullen’s and Grey Turner signs,
2.) Causes/Risk Factors - I GET SMASHED
- Idiopathic, GALLSTONES, ETHANOL, Trauma
- Steroids, Mumps, Autoimmune, Scorpion venom,
- Hyperlipidaemia, Hypercalcaemia, Hypothermia
- ERCP: occurs within 6hrs of the procedure
- Drugs: NSAIDs, steroids, azathioprine, mesalazine, diuretics, sodium valproate, pentamidine, didanosine
3.) Bedside Investigations
- bloods + amylase, albumin, BG
- coagulation screen and blood type
- ABG if SATS are low, VBG for lactate
4.) Glasgow Score - determines severity, (PANCREAS)
- PaO2 (<8kPa), Age (<55), Neutrophils (>15)
- Calcium (<2mM), Renal Function (urea >16)
- Enzyme (↑LDH/AST), Albumin (<32), Sugar (> 10mM)
- >2 score suggestive of organ failure
- >3 or more in the first 48hrs suggests severe attack and requires admission to HDU
- Ranson score is an alternative: it estimates the mortality of patients based on initial and 48-hour lab values
5.) Management
- aggressive IV fluids (Hartmann’s) because lots of third space losses due to endothelium release
- IV morphine pump (PCA, patient-controlled analgesia)
- catheter to monitor fluid output
- encourage enteral feeding (esp PO): moves bacteria through GI tract to ↓ the risk of pancreatic tissue infection
- NO ANTIBIOTICS
6.) Complications
- fluid collections (ascites), pseudocysts, abscesses
- pancreatic necrosis, haemorrhage
- acute respiratory distress syndrome
- DIC, hyper/hypoglycaemia
Acute Diverticulitis
Signs and Symptoms
Risk Factors
Investigations
Hinchey Classification
Management
1.) Signs and Symptoms - abdominal pain (usually LLQ)
- PR bleed (haematochezia), constipation, N+V, fever
- bloating/distension, palpable mass
- severe: ↓bowel sounds, signs of peritonitis
- colovaginal fistula (complication): vaginal passage of faeces or flatus
- colovesical fistula (complication): pneumaturia (frothy urine, air bubbles) or faecaluria (brown/faeces in urine)
- diverticular disease: bloating, change in bowel habit (constipation or diarrhoea), intermittent abdo pain (LLQ)
2.) Risk Factors
- age (>50s), smoking, obesity, low fibre diet, NSAIDs
- FH, CT disease (e.g. Marfan’s, Ehlers Danlos)
3.) Investigations
- PR: can detect a pelvic abscess
- CT-AP: colonic mural thickening, pericolic fat stranding in the sigmoid colon
- flexible sigmoidoscopy
- AVOID colonoscopy due to pain and risk of perforation
4.) Hinchey Classification - stages diverticular perforations which determines management
- 1: localised pericolic abscess, 2: large mesenteric abscess, 3: free perforation, 4: faecal peritonitis
5.) Management
- diverticulitis flares: manage w/ PO Abx at home, if no improvement within 72hrs, admission to hospital for IV ceftriaxone + metronidazole
- NBM+IV fluids: saline, 3L/24hrs (maintenance)
- IV abx: tazocin OR co-amoxiclav + metronidazole
- analgesia: paracetamol, avoid NSAIDs and opioids
- abscesses: CT-guided drainage
- perforation/peritonitis: Hartmann’s procedure (sigmoidectomy + end colostomy)
GI Perforation/Peritonitis
Aetiology
Clinical Features
Investigations
Management
1.) Aetiology
- inflammatory: PEPTIC ULCERS, DIVERTICULITIS, cholecystitis, Meckel’s diverticulum, toxic megacolon
- ischaemic: mesenteric ischemia, obstructing lesions
- traumatic: iatrogenic, blunt trauma, direct rupture (e.g. excessive vomiting –> oesophageal perforation)
2.) Clinical Features
- rapid onset of sharp pain, N/V, malaise, lethargy
- rigid abdomen, guarding, ↓bowel sounds
- rebound or percussion tenderness
- lay completely still, shallow breaths, ↑HR, ↓BP
- thoracic perforation: pain (neck/chest) radiating to the back, worse on inspiration, resp sx, N/V
3.) Investigations
- routine bloods: ↑WCC, ↑CRP, ↑amylase
- urinalysis: exclude renal and tubo-ovarian pathology
- eCXR: pneumoperitoneum, 70% sensitivity
- CT (gold): identify and locate free air in the abdomen
- AXR: Rigler’s sign (?double walled bowel) suggests free air in the peritoneal cavity, Psoas sign (obscured psoas muscles)
4.) Management - will often need surgical intervention
- NBM + IV fluids (resus), analgesia, consider NG tube
- broad-spectrum IV antibiotics
- surgical: omental patch (perforated peptic ulcer), Hartmann’s procedure (perforated diverticulae)
- localised peritonitis may be treated conservatively
Small Bowel Obstruction
Clinical Features
Investigations/Imaging
Management
1.) Clinical Features
- N/V –> colicky abdominal pain –> distension
- absolute constipation (last)
- tympanic sounds, tinkling (increased) bowel sounds
- abdominal tenderness but no guarding or rebound tenderness unless bowel has become ischaemic
2.) Investigations/Imaging
- routine bloods: inc G/S (may need surgery)
- VBG: ischaemia/high lactate, metabolic derangement
- AXRs (initial): >3cm dilation, central, valvulae conniventes (mucosal folds cross the full width of the bowel). may see fluid levels
- CT w/ IV contrast better than AXRs
- eCXR: to exclude perforation
- water-soluble contrast study for adhesions (if it doesn’t reach the colon in 6hrs, they need surgery)
3.) Management - ‘drip and suck’
- NBM + NG tube to decompress the bowel
- IV fluids (inc K+): gross dilatation –> ↑peristalsis –> secretion of fluids into the bowel (‘third spacing’)
- catheter to monitor fluid balance
- analgesia and anti-emetics
- laparotomy +/- stoma: for ischaemia/perforation, closed loop obstruction or patients who don’t improve after 48hrs
Large Bowel Obstruction
Clinical Features
Investigations/Imaging
Management
1.) Clinical Features
- absolute constipation –> colicky abdominal pain
- abdominal distension –> N/V (last)
- tympanic sounds, tinkling bowel sounds
- abdominal tenderness but no guarding or rebound tenderness unless bowel has become ischaemic
2.) Investigations/Imaging
- routine bloods: inc G/S (may need surgery)
- VBG: ischaemia/high lactate, metabolic derangement
- CT w/ IV better than AXRs (determines cause)
- AXRs: bowel >6cm (colon) or >9cm (caecum), peripheral location, haustra lines visible (mucosal folds DO NOT cross the full width of the bowel)
- eCXR: to exclude perforation
3.) Management - ‘drip and suck’
- NBM + NG tube to decompress the bowel
- IV fluids (inc K+): gross dilatation –> ↑peristalsis –> secretion of fluids into the bowel (‘third spacing’)
- catheter to monitor fluid balance
- analgesia and anti-emetics
- laparotomy +/- stoma: for ischaemia/perforation, closed loop obstruction or patients who don’t improve after 48hrs
Acute Appendicitis
Pathophysiology
Clinical Features
Differentials
Management
General Advice Post-Appendicectomy
1.) Pathophysiology - inflammation of the appendix due to infection trapped in the appendix by obstruction at the point where the appendix meets the bowel
- obstruction: faecolith, impacted stool, lymphoid hyperplasia, appendiceal/caecal tumour (rare)
- peak incidence is in patients aged 10 to 20 years
- complications: perforation/peritonitis, appendix mass or abscess
2.) Clinical Features - diagnosis can be made clinically
- poorly localised umbilical pain –> severe RIF
- mild fever, N+V, loss of appetite (hamburger sign)
- tenderness at McBurney’s point (1/3 ASIS -> umbilicus)
- Rosving’s sign: palpation of LIF –> pain in RIF
- inflammation: pain on right knee flexion, Psoas sign
- rebound tenderness and percussion tenderness both suggest peritonitis caused by a ruptured appendix
3.) Differentials
- mesenteric adenitis, Meckel’s diverticulum
- gynae: ectopic (< 40s need a pelvic US), ovarian cyst,
- caecal cancer: over 40s need CT scan
4.) Management
- bloods (raised WCC), urinalysis, pregnancy test
- imaging: abdo/pelvic USS in children, women <40, pregnant/breastfeeding women, CT-AP for >40s
- appropriate analgesia
- prophylactic IV bs-Abx (Co-Amox) until theatre
- first-line treatment is a laparoscopic appendectomy
5.) General Advice Post-Appendicectomy
- home in 1-2 days if the appendix doesn’t rupture
- avoid driving, drinking alcohol, operating machinery for up to 2 days after surgery
Crohn’s Disease (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-30/60-80), smoking, FH of IBD
- white European, appendicectomy
2.) Clinical Features - episodic abdominal pain and chronic diarrhoea which may contain blood or mucus
- pain can be anywhere but most common in RLQ
- malaise, malabsorption, weight loss
- oral aphthous ulcers, perianal disease, mass in RIF
- extra-intestinal features
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- stool sample, faecal calprotectin
- proctisigmoidoscopy to for perianal fistulae
4.) Imaging
- colonoscopy (gold): gross pathological changes
- CT-AP: for bowel obstruction, perforation, fistulae
- MRI: enteric fistulae and peri-anal disease
Ulcerative Colitis (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-25/55-65), FH of IBD
- smoking is a protective factor (reduces risk)
2.) Clinical Features - bloody diarrhoea
- change in bowel habits: PR bleed, mucus discharge, ↑frequency, urgency of defecation, tenesmus
- dehydration, malaise, low-grade fever, anorexia
- abdominal pain for complications: toxic megacolon, perforation, fulminant colitis, peritonitis
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- LFTs deranged in patients on medical treatment
- clotting can be deranged in severe attacks
- stool sample, faecal calprotectin
4.) Imaging
- colonoscopy (gold): gross pathological changes
- flexible sigmoidoscopy may be sufficient
- acute exacerbations: AXR or CT for complications
Renal/Ureteric Colic
Pathophysiology
Clinical Features
Investigations
Imaging
Initial Management
1.) Pathophysiology - renal or ureteric stones usually due to over-saturation of urine
- types: calcium (80%), urate (9%), cystine, struvite (stag horn, associated with proteus infection)
- common locations: PUJ, pelvic brim, VUJ
- demographics: male, <65s
2.) Clinical Features - sudden onset, severe colic pain
- radiating from the flank to pelvis (‘loin to groin’)
- tenderness is not common with renal colic
- haematuria (90% of cases), N/V, restlessness
- most rule out AAA
3.) Investigations
- urine dip and culture: haematuria, rule out infection
- calcium and urate levels
- FBC+CRP (associated infection), U+Es (AKI)
- clotting (if percutaneous intervention planned)
4.) Imaging
- 1°CT-KUB (non-contrast): high sensitivity+specificity
- USS only detects renal stones and hydronephrosis
- AXRs only detects radiopaque stones (not urate)
5.) Initial Management
- stones in lower ureter or <5mm can pass spontaneously within 4 weeks of initial symptom onset
- fluids: reverse dehydration from N/V and ↓intake
- analgesia: PR/IM diclofenac (relaxes the ureters)
- inpatient admission criteria: AKI, uncontrollable pain, infected stone, large stones (>5mm)
Pseudomembranous Colitis
CAPSULE - GI 31
Post Op/Paralytic Ileus
Kaka
Volvulus
Risk Factors
Clinical Features
Investigations/Imaging
Management
1.) Sigmoid Volvulus - most common form of volvulus (80%) –> large bowel obstruction
- torsion of the (sigmoid) colon around it’s mesenteric axis (sigmoid mesocolon) resulting in compromised blood flow and closed loop obstruction
- risk factors: ↑age, male, chronic constipation, previous abdominal operations, neurological conditions (e.g. Parkinson’s, DMD), psychiatric conditions (e.g. schizophrenia)
- clinical features: large bowel obstruction
2.) Caecal Volvulus - rarer form of volvulus (20%) –> small bowel obstruction
- occurs in those without a retroperitoneal caecum (developmental failure)
- risk factors: pregnancy, adhesions
- clinical features: small bowel obstruction
3.) Investigations/Imaging
- sigmoid volvulus: AXR (LBO + coffee bean sign), CT (whirl sign)
- caecal volvulus: AXR (SBO)
4.) Management - regular LBO/SBO management including:
- sigmoid: decompression by sigmoidoscopy and insertion of a flatus tube OR surgery (Hartmann’s or laparotomy) if ischaemic, perforated, or failed decompression
- caecal: usually operative, a right hemicolectomy is often needed
