GI - Lower and diffuse abdominal pain, Peritonitis, Abdominal emergencies Flashcards

Question

Acute appendicitis Pathology Demographic Pain character Associated S/S

Answer 1

Pathology: Unknown, likely obstruction by faecolith, lymphoid hyperplasia, stricture, carcinoid tumour Demographic: young adults and teenagers Pain: * Begins as vague ‘colicky’ paraumbilical pain * Shifts to Rt iliac fossa and becomes more severe, constant and localized after a few hours-days S/S: * Anorexia (~75%) before onset of pain * Nausea, vomiting after onset of pain * Fever often after 6h * Generalized peritonitis if progressed * Retrocaecal (64%) → RLQ, flank pain Pelvic (32%) → bladder (dysuria, frequency), large bowel (diarrhoea) S/S

Answer 2

General: * Unwell, low-grade pyrexia * Tachycardia * Fetor oris (halitosis) * Limited lower abd resp movt Abdomen: * RLQ tenderness and guarding (max over McBurnley’s point) * Tenderness at Flank (retrocaecal), RUQ (subhepatic) * ± RLQ tender mass (Indistinct, dull on percussion)

Answer 3

Specific signs: * Rovsing’s sign = pressure on Lt iliac fossa cause pain in Rt iliac fossa * Cough sign = Rt iliac fossa pain on coughing due to localized peritonitis * Obturator sign = RIF pain on internal rotation of flexed Rt hip due to spasm of obturator internus * Psoas sign = RIF pain on Rt hip flexion due to inflamed retrocaecal appendix is lying on psoas muscles Mostly clinical Dx, USG or CT may be helpful

Answer 4

Inflammation of mesenteric LNs (common mimic of acute appendicitis) Causative agents: * B-hemolytic streptococcus, E. coli, Streptococcus viridans, Yersinia, * Coxsackievirus, Rubeola, Adenovirus Demographic: usu. children Pain: central abd pain but can cause RLQ pain Associated S/S: * Preceding URTI (high fever, sore throat) and cervical LN enlargement * Pain may move at lateral decubitus position when glands move over with mesentery

Answer 5

Pathology: Inflammation and microperforation of colonic diverticula at mucosal herniations, mostly at sigmoid colon Demographic: 50-70y, Westerners Pain: * Gradual onset of mild intermittent lower abd pain * Shift to L/R iliac fossa and becomes more severe and constant Associated S/S: * Fever, tenderness and guarding * Nausea, poor appetite, constipation (vomiting and diarrhea are RARE) * Dysuria, ↑frequency

Answer 6

Specific signs: * Lie still, pyrexia, tachycardia * Iliac Fossa tenderness and guarding * ±IF mass tender sausage-shaped dull on percussion * Reversed Rovsing’s sign: pressure on Rt side of abdomen may induce pain on left * PR may show pain Preceding S/S: * Hx of diverticular disease, flatulence, distension, L/RIF pain Complications * localized abscess, purulent peritonitis or fecal peritonitis

Answer 7

CT confirms diagnosis and assesses severity Tx: * Antibiotics * Image-guided drainage * Laparoscopy and lavage (purulent peritonitis) * Laparotomy and bowel resection (Fecal peritonitis)

Answer 8

Causes: * Crohn's disease * TB * Radiation enteritis * Bacterial infection: Campylobacter, Yersinia, Salmonella Main mode of Dx: * Incidental finding of inflamed terminal ileum during operations Presentation: Crohn’s ileitis (commonest) - Episodic colicky abdominal pain - Watery, fatty or inflammatory (less common) diarrhoea - Malabsorptive features - ± subacute/acute IO (fibrotic strictures) - ± RLQ mass

Answer 9

Pathology: * Remnant of vitelline duct adhered to umbilicus, 2 inches long, 2 feet from ileocaecal junction * ectopic gastric or pancreatic mucosa cause inflammation at site, cause bleeding, perforation, volvulus or intussusception Demographic: 2% population, usually present at 2 years old Pain: * Central abdominal pain - ectopic mucosa cause ulceration or bleeding * Colicky abdominal pain - act as head of intussusception causing IO or volvulus Associated S/S: * Highly similar to acute appendicitis

Answer 10

Main mode of diagnosis: CT scan/ incidental finding during appendicectomy Treatment: Antibiotic coverage + diverticulectomy/ small bowel resection

Answer 11

Demographic: 10-15 Pain character: Severe pain in testes and groin +/- radiation to loin Associated S/S: preceding vague abdominal pain Specific sign on exam: Tender and high-lying testicles Treatment: Surgical emergency Surgical exploration +/- Orchidopexy, Orchidectomy

Answer 12

Pathology: Tubal pregnancy ± rupture into abdominal cavity at 6 weeks Demographics: Female in child-bearing age, previous PID, ectopic preg. Pain character: Sudden onset severe lower abdominal pain on side of ectopic pregnancy Associated S/S : Preceded by a few days of mild abd pain Complications: * Generalized Peritonitis * Hypovolemic shock (fainting, collapse) if ruptured * Shoulder tip pain if blood collects beneath the diaphragm

Answer 13

Dx: Ultrasound Tx: Large bore IV cannula and resuscitation Urgent laparoscopy and salpingotomy/ salpingectomy

Answer 14

Pathology: Salpingitis and associated infection of adnexa supporting tissue from ascending vaginal infection (e.g. chlamydia, gonorrhoea…) Demographics/ risk factors: Sexually active female under 40y, history of IUCD, STD, gynaecological procedures Pain character: Gradual onset of constant lower abd pain ± radiation into back Associated S/S: * Preceded by a few months of menstrual irregularities and dysmenorrhoea * purulent yellow-white vaginal discharge by a few days * dysuria and urinary frequency * dyspareunia

Answer 15

General Signs: ``` High fever (38-39.5oC) Lower abd tenderness, guarding ``` Vaginal exam: * Yellow-white introital discharge * Adnexal tenderness on bimanual palpation * Chandelier sign - painful cervical excitation\*\* * Pus discharge from cervical canal in speculum examination Treatment: * Antibiotics * Drainage of tubovarian abscess

Answer 16

Pathology: Ovarian cyst complication Pain character: Sudden severe unilateral lower abd pain during agitating movement (eg. exercise) Associated symptoms: * S/S of intra-abdominal bleeding * ± S/S of hypovolemic shock * ± lower abd tenderness and guarding Main mode of diagnosis: USG or CT Treatment: Laparoscopy ovarian cystectomy/ oophorectomy

Answer 17

Pathology: Obstruction in ureter due to ureteric stones Pain character: * Severe, gripping true colic radiating down from renal angle, parallel to inguinal ligament into groin * Alleviate by rolling around bed or walking around Associated S/S: * Autonomic symptoms (sweating, N/V) Gross or microscopic haematuria Signs * May have renal angle tenderness Urinalysis shows gross or microscopic haematuria

Answer 18

Common causes: * Colon cancer * Volvulus * Diverticular stricture * Pseudo-obstruction S/S: * Cramping pain * Vomiting * Abdominal distension * Constipation

Answer 19

General: * Hydration status (3rd space loss) * Tachycardia and hypotension (Hypovolemia) Abdominal: * Peritoneal signs/ localized tenderness * Hernial orifices (hernia incarceration) * Bowel sounds and percussion: Resonance over distended bowel, High-pitched tinkling BS, absent BS * Rectal examination (impaction, mass)

Answer 20

Full bloods Imaging: * Plain abdominal X-ray * Abdominal CT with contrast * Contrast study: e.g. Gastrografin follow-through enema

Answer 21

Xray: Small bowel = central with valvulae conniventes Large bowel = Peripheral with haustations

Answer 22

Diet: * Nil Per Oral * IV fluid resuscitation: secure IV access * NG tube decompression if IO Definitive surgical treatment: * Colonic stenting * Endoscopic decompression * Bowel resection * Stoma

Answer 23

Thromboembolism Venous occlusion Non-obstructive mesenteric ischaemia Chronic mesenteric ischemia (e.g. chronic anaemia, vasopressor use…etc) Mechanical (volvulus, hernia)

Answer 24

Demographics: Elderly, with history of AF or IHD Pain character: Constant, severe, non-specific abdominal pain Associated S/S: Rectal bleeding or bloody diarrhea, colic Signs on PE: * Lie still, pale, sweating, tachycardia * Rarely peritoneal signs Complications: * Metabolic acidosis, renal failure, ileus, shock, death

Answer 25

Location: Localized vs generalized/ diffuse Underlying causes: e.g. Spontaneous bacterial peritonitis, Chemical peritonitis □ Primary peritonitis: not a/w 1o pathology → bacteria often from haematogenous dissemination □ Secondary peritonitis: secondary to pathological process in abdominal viscera, commonly perforated viscus □ Tertiary peritonitis: persistent peritonitis after treatment, immunocompromised state or opportunistic infection of peritoneum

Answer 26

inflamed peritoneum becomes oedematous, hyperaemic and covered w/ fibrinous exudates → resulting in □ Sequestration of large amount of protein-rich fluid □ Septicaemia and endotoxaemia □ Hypovolaemia and shock

Answer 27

General: * Fever, tachycardia (often early), tachypnoea * Septic shock * Features of visceral inflammation * Malaise, anorexia, nausea Abdominal: Peritoneal irritation: - Burning pain: initially localized and later spread, often ↑ w/ movement and coughing - Peritoneal signs: tenderness, rebound tenderness, guarding, rigidity Paralytic ileus: - Abdominal distension - Absent bowel sounds (paralytic ileus)

Answer 28

* Spontaneous bacterial peritonitis * Tuberculous peritonitis * Peritonitis associated with Chronic Ambulatory Peritoneal Dialysis Typical pathogens: normally monomicrobial (secondary = polymicrobial) * Strep. pneumoniae * Group A streptococcus * Enteric organisms Risk factors: * Ascites * Malnutrition * Intra-abdominal malignancies * Immunosuppression * Splenectomy, Chronic liver disease. CKD

Answer 29

Appearance: serous, blood-stained, purulent, bile-stained, feculent → ‘E’ OT if bile-stained (HBP/SB perf) or feculent (LB perf) Cell count: neutrophil \>500/μL in peritonitis Biochemistry: - ↓Glc, ↑protein, ↑LDH cf serum → indicates bacterial inf’n - ↑amylase → indicates perforated GI tract from pancreatitis - ↑Cr compared to serum → indicates perforated urological tract/ urine leak Microbiology: Gram stain, culture (aerobic, anaerobic, AFB, fungal)

Answer 30

S/S: * Non-specific: low-grade fever, weight loss * Insidious onset of abdominal pain * Rare/ minimal peritoneal signs Dx: * Laparoscopy and biopsy of peritoneum * AFB smear not reliable (false negatives)

Answer 31

Severe inflammation of abdominal organ - e.g. diverticulitis, cholecystitis, appendicitis Perforation of GIT - spontaneous, trauma, iatrogenic Anastomotic leak - chemical peritonitis by gastric juice/ bile/ pancreatic secretions/ urine/ blood Ischemia of abdominal organs

Answer 32

POLYMICROBIAL (cf monomicrobial in primary bacterial peritonitis) Gram negative, enterobacteria: (most common) * E.coli. Enterobacter, Proteus, Psudomonas Gram positive: * Streptococcus, Enterococcus Anaerobes * Bacteroides

Answer 33

Septicemia, endotoxemia Hypovolemia and shock Sequestration of protein rich fluid in peritoneum

Answer 34

Supportive: IV fluid resuscitation, NG tube, Foley catheter, O2, pain relief Broad-spectrum Abx: usually 2G ceph (eg. cefuroxime (Zinacef)) + metronidazole (Flagyl) Definitive treatment: Drainage for stable, localized pathologies, eg. percutaneous drainage of abscess, ERCP for biliary Surgical emergency: Laparoscopy for PPU repair, cholecystectomy, bowel resection, appendicectomy/ exploratory laparotomy

Answer 35

Poor detailed history Confused or demented Peritoneal signs may be mild