GI/GEN - Acute Abdomen (GENERAL)

Question 1

Bedside Investigations

Bloods
Urinalysis
ABG/VBG
ECG
CXR
Others

Answer 1

1.) Bloods and Cultures

2. ) Urinalysis - urine dipstick
   - ?UTI (+leucocytes and nitrites)
   - also include pregnancy test (separate)
   - 24 hour urine collection, urinary PCR
3. ) ABG/VBG
   - ABG: pH, PaO2, PaCO2, HCO3-,
   - VBG: lactate (signs of ischaemia, dehydration, excessive vomiting)
4. ) ECG/ECHO
   - suspected MI or PE, heart failure
   - undergoing major surgery

5.) CXR - cardiorespiratory symptoms

6. ) Others
   - MRSA/COVID swabs, peak flow, bladder scan
   - sickle cell test: FH or afro-caribbean descent

Question 2

The Blood Test

Main Bloods (FBC, CRP, LFTs, U/Es)
Coagulation Screen
Blood Typing x2
Others

Answer 2

1. ) Main Bloods
   - FBC (bleeding, infection), CRP (inflammation, for progress), LFTs (liver/biliary tree), U/Es, (eGFR, electrolyte disturbance, contrast CT)
2. ) Coagulation Screen - clotting factors
   - PT/INR, aPTT, bleeding time, thrombin time
   - also assesses synthetic function of the liver
   - deranged coagulation needs correcting pre-surgery
3. ) Blood Typing - group and save/crossmatch
   - G/S: determines blood group but no blood issued so used if blood loss is not anticipated
   - crossmatch: emergency, mixes donor’s w/ patients’ to see reaction, if successful can be used for patient
   - O- blood given if no time to identify blood type
4. ) Others
   - amylase, albumin, D-dimer, troponin, BNP, TFTs
   - toxicology screen, serial mast cell tryptase levels

Question 3

Bedside Interventions

Oxygen
Fluids/NBM
Medication
NG Tube
Catheter

Answer 3

1.) Oxygen

2. ) Fluids/NBM
   - NBM+otherwise well requires maintenance fluids
   - fluid resuscitation if haemodynamically unstable
3. ) Medication - The 4 As
   - antibiotics: check local guidlines or broad spectrum
   - analgesia: paracetamol, NSAIDs, opioids
   - anti-emetics: ondansetron +/- cyclizine
   - anti-spasmodics: e.g. dicyclomine
4. ) NG Tube
   - reduces intrabdominal pressure and also prevents aspiration in patients with lots of vomiting
5. ) Catheter - measure urinary output
   - for haemodynamically unstable patients
   - also used for urinary retention

Question 4

Acute Abdominal Pain Locations

Epigastrium (8), RUQ (5), LUQ (2)
Peri-Umbilical/Central (5), R/L Flanks (3)
Hypogastrium (4), RLQ (6), LLQ (7)

Answer 4

1. ) Epigastrium
   - biliary colic, acute cholecystitis, pancreatitis
   - oesophagitis, gastritis, gastroduodenal ulcers
   - myocardial infarction, lower lobe pneumonia
2. ) RUQ
   - biliary colic, acute cholecystitis, ascending cholangitis
   - hepatitis, liver abscess
3. ) LUQ
   - splenic abscess/rupture/infarct
   - acute mesenteric ischemia (splenic flexure)
4. ) Peri-Umbilical/Central
   - appendicitis (early), AAA, mesenteric ischaemia
   - DKA, sickle cell crisis
   - can overlap with epigastric pain
5. ) R/L Flanks
   - pyelonephritis, renal colic
   - acute mesenteric ischemia (left sided)
6. ) Hypogastrium
   - UTI, urinary retention, testicular torsion, hernia
7. ) RLQ
   - acute appendicitis, IBD (Crohn’s), inguinal hernia
   - ectopic pregnancy, ovarian cyst/torsion/cancer, PID
8. ) LLQ
   - diverticulitis, volvulus, IBD (UC), inguinal hernia
   - ectopic pregnancy, ovarian cyst/torsion/cancer, PID

Question 5

5 associated symptoms w/ abdominal pain

Nausea/Vomiting 
Fever
Change in Bowel Habits
Stools
Others x5

Answer 5

1. ) Nausea/Vomiting - any inflammatory condition
   - more pronounced in acute pancreatitis
   - bilous and early suggests upper GI problems
   - faeculent and late/delayed suggests distal GI
2. ) Fever - suggests infection
   - could also be widespread inflammation in the peritoneum (peritonitis)
3. ) Change in Bowel Habits
   - frequency, consistency, tenesmus, waking overnight to open bowels, urgency, incontinence
   - diarrhoea: gastroenteritis, IBD
   - constipation: obstruction (large>small)
4. ) Stools
   - haematochezia (distal GI), melaena (upper GI)
   - pale stools (dysfunction in biliary system)
   - steatorrhoea (exocrine pancreatic insufficiency)
5. ) Others
   - bleeding: haematemesis or PR bleeding
   - bloating, weight loss,
   - urinary: dysuria, haematuria
   - gynae: discharge, dyspareunia, LMP, pregnancy?

Question 6

General Scoring Systems

POSSUM
NELA
scoring system

Answer 6

1. ) POSSUM - risk of morbidity and mortality for general surgical patients
2. ) NELA - mortality risk within 30 days of emergency abdominal surgery