GI Surgery - Acute Abdomen Flashcards by Guy Kirkpatrick

Acute Abdomen

Rapid onset of severe symptoms that may indicate life-threatening intra-abdominal pathology often requiring urgent surgical intervention.
The most common presentation, and the presentation you will be given, is abdominal pain <48 hours.
Patients with an acute abdomen tend to deteriorate within this time

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Causes of diffuse abdominal pain

Gastroenteritis/infectious colitis
Mesenteric ischaemia
Bowel obstruction
Peritonitis
IBS

–> Conditions that affect multiple parts of the gut

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Causes of epigastric abdominal pain

Peptic ulcer disease
GORD
Gastritis
Pancreatitis
MI/Pericarditis

–> Foregut

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Causes of umbilical abdominal pain

Early appendicitis
Ruptured aortic aneurysm
IBD (Crohn’s)
Diffuse pain causes (gastroenteritis, etc)

–> Midgut

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Causes of suprapubic abdominal pain

UTI
Renal stones
Cystitis
Pelvic inflammatory disease

–> mostly renal in nature (some hindgut)

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Causes of RUQ abdominal pain

Hepatitis
Biliary Colic (cholelithiasis)
Cholecystitis
Cholangitis
Lower lobe pneumonia
Causes of epigastric pain (e.g. pancreatitis etc)

–> Mostly foregut organs in RU abdomen

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Causes of LUQ abdominal pain

Splenic abscess/infarct
Lower lobe pneumonia
Causes of epigastric pain (gastritis, gastric ulcer, pancreatitis, etc)

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Causes of flank abdominal pain

Renal stones
Pyelonephritis
Hydronephrosis
Causes of suprapubic pain (UTI/Cystitis)

-> Flank pain is usually renal in nature
-> Same on both sides

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Causes of RIF abdominal pain

Appendicitis
IBD (Crohn's)
Inguinal hernia
Renal stones
Ectopic pregnancy
Ovarian cyst/bleeding/torsion

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Causes of LIF abdominal pain

Diverticulitis
Colitis
IBD (UC)
Inguinal hernia
Renal stones
Ectopic pregnancy
Ovarian cyst/bleed/torsion

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Abdominal Scars

Subcostal/Kocher's
Right Paramedian
Midline
Nephrectomy/Loin
Gridiron
Laparoscopic
Left Paramedian
Transverse suprapubic/Pfannenstiel
Inguinal hernia

(google image abdominal scars)

Subcostal/Kocher's
• Choleocystectomy
Right Paramedian
• Laparotomy
Midline
• Laparotomy
Nephrectomy/Loin
• Renal surgery
Gridiron
• Appendectomy
Laparoscopic
• Choleocystectomy
• Appendectomy
• Colectomies
Left Paramedian
• Anterior rectal resection
Transverse suprapubic/Pfannenstiel
• Hysterectomy
• Other pelvic surgery
Inguinal hernia
• Hernia repair

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Victoria is a 55 year woman person who presents to A and E with generalized abdominal pain which has been getting worse over the last 3 hours. She is most comfortable lying still, is continually complaining of pain and is not amused. On examination her abdomen is rigid and there is tenderness, especially on percussion.

Gastritis
Inflammatory bowel disease
Peritonitis
Pyelonephritis
Ruptured abdominal aortic aneurysm

Peritonitis

Generalised abdo pain
Lying still
Abdomen rigid
Tenderness
Percussion

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Peritonitis Presentation and Rx

Inflammation of the peritoneum. By far most common cause is GI perforation

Presentation:
Abdominal guarding (diffuse rigid abdomen)
Rebound tenderness - pain is greater on release (on palpation)
Patient completely still

Rx treat cause

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Julius is a 72 year old Italian man is brought in to the urgent care centre by his adopted son, Augustus. He claims to have developed central abdominal pain which radiates to the back. He has a history of hypertension and has smoked 1 pack a day for the last 40 years.

Diverticulitis
GI perforation
Peritonitis
Pancreatitis
Ruptured abdominal aortic aneurysm

Ruptured abdominal aortic aneurysm

Radiates to back
HTN
Smoked

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Abdominal aortic aneurysm

Presentation/Ix/RF

An aortic aneurysm is a permanent localised dilatation of the aorta to greater than 150% of its normal diameter

Presentation:
Palpable pulsatile abdominal mass
If ruptured: 
Intermittent/continuous abdominal pain which radiates to the back
Hypotensive shock

Ix: Abdominal US
RF: Smoking, HTN

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Cleo is a 21 year old North African student who was found collapsed in her apartment by her boyfriend Mark. She is brought to A&E and is pale, pyrexic, tachycardic and has a low blood pressure. Her boyfriend says that she has been suffering from abdominal pain for the last 24h. This initially started in her “stomach” but later moved to her “hip.” Mark is afraid Cleo may have been bitten by her pet snake.

Caecal volvulus
GI perforation
Pancreatitis
Poisoning
Ruptured abdominal aortic aneurysm

GI perforation (secondary to appendicitis)

Collapsed
Pale
Tachycardic
Low BP
Moved to her hip

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GI Perforation

Presentation/RF

Perforation of the bowel will result in free air in the abdomen. Clinical manifestations depend somewhat on the organ affected and what is released.

Presentation:
Generalised acute abdominal pain
\+signs of peritonitis (guarding, board-like rigidity, percussion pain)
Lying still
Shock and reflex tachycardia
No BS

RF:
Peptic ulcer disease
Trauma
Appendicitis
Diverticulitis
Volvulus
IBD

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GI Perforation

Ix/Rx

Ix:
Erect CXR - check for pneumoperitoneum (gas within the peritoneal cavity)
Abdo XR - check for pneumoperitoneum. Rigler’s sign.
Although if an option, choose an abdominal CT as more accurate.

Rx:
Emergency surgery

Rigler’s sign

If there is free intra-abdominal gas adjacent to a gas filled loop of bowel, then both sides of the bowel wall are well-defined.

Ögedei is a 55 year old Mongolian actor who presents found drunk outside a theatre with an empty bottle of wine, and was brought to you in A&E. He is having trouble communicating with you but you believe that he has abdominal pain. You do some bloods and find that his AST/ALT are 2x the normal limit and he has a very high amylase level. When you take his blood pressure, Ögedei complains of pain and slaps you. You are no longer his F1.

Appendicitis
Alcoholic hepatitis
Cholecystitis
GI perforation
Pancreatitis

Pancreatitis

Drunk
Wine
Very high amylase level
BP
Ogedei complains of pain

Acute vs Chronic Pancreatitis

Acute pancreatitis is an isolated fully reversible attack.

Chronic pancreatitis is a progressive, non-reversible condition.

Causes of pancreatitis

GET SMASHED

Gall stones
Ethanol
Trauma
Steroids
Mumps
Autoimmune - chronic
Scorpion venom
Hyperlipidaemia
ERCP
Drugs

Acute Pancreatitis

Presentation

Nausea and vomiting
Anorexia
Epigastric pain - may radiate to back or sides

Signs of hypocalcaemia:
Chvostek’s sign: Facial muscle spasm when facial nerve is tapped.
Trousseau’s sign: Carpopedal spasm when blood pressure cuff is applied.

If late-stage necrotising pancreatitis:
Grey-Turner and Cullen’s signs

Acute Pancreatitis Ix/Rx

Investigations:

Bloods...
FBC - raised neutrophils
Raised serium amylase (3x normal)
Raised serium lipase
Slightly raised AST/ALT

Abdominal Ultrasound
possibly followed by AXR/ACT if unsure

CXR

–> Determine severity using modified Glasgow Scale

Rx:
Admission to hospital, even ICU
Analgesia
Nutritional support and ion (Ca/Mg) replacement
If gallstones –> ERCP or cholecystectomy

Isabella is a 29 year old Spanish teacher who is presenting with pain in the lower abdomen. She has had some tummy pain which lasted all day, and has felt both nauseous and has lost her appetite. She claims this is due to some Mexican food her friend Colombo brought her. The pain is now worse and has moved lower down which is why she has come to see you. On examination she has a temperature of 38oC and there is pain on palpation of both the right and left iliac fossa. ``` Appendicitis Bowel obstruction Ectopic pregnancy Renal stones Urinary tract infection ```

Appendicitis ``` Tummy pain Nausea Lost appetite Moved lower down Temp RandL IF ```

Acute appendicitis | Presentation and RF

Inflammation of the appendix. Aetiology is unclear, but it is thought to be due to obstruction usually due to a faecolith. Presentation: Colicky epigastric pain which shifts to the RIF. Usually after 6h or so, due to irritation of the peritoneum. Fever Nausea and vomiting Anorexia Rosvig's sign: Palpation of the LIF results in pain in the RIF RF: Low dietary fibre (? increased risk of faecolith)

Acute appendicitis Ix/Rx

Ix: FBC (raised neutrophils) Urinary pregnancy test. If positive, do an US --> may reveal an ectopic pregnancy that presents similarly. Abdominal and pelvic CT scan Erect CXR. If perforation is suspected and there are signs of peritonitis. Rx: NBM Appendicectomy performed asap Adjunct antibiotics - ceftriaxone/metronidazole If perforation suspected: IV fluids and emergency surgery

Akbar is a 75 year old Indian drummer who loves playing music. He didn’t want to come in initially but was persuaded by his good friend Birbal. Akbar has developed pain in the left hip. He has had intermittent constipation for the last 3 months and now feels a little bloated. On examination there is some guarding in the left iliac fossa. Full blood count suggests neutrophilia and the registrar orders a CT scan. ``` Caecal volvulus Crohn’s disease Diverticulitis Sigmoid volvulus Ulcerative colitis ```

Diverticulitis ``` Constipation Bloated Guarding in LIF Neutrophilia CT ```

Diverticulum: Diverticulosis: Diverticular disease: Diverticulitis:

Diverticulum: Single outpouchin of gut wall Diverticulosis: Presence of diverticula Diverticular disease: Presence of diverticula which cause symptoms Diverticulitis: Inflammation of diverticulum.

Diverticular disease management

Dietary modification | Fibre supplementation

Acute diverticulitis | Aetiology and Presentation

Diverticular disease is a common incidental finding - 90% are asymptomatic. If the diverticula become inflamed --> diverticulitis Aetiology: Unknown. Theorised due to faecal impaction at neck of diverticula ``` Presentation: Guarding Tenderness in LLQ Bloating Altered bowel habit (constipation) Nausea and Flatulence ```

Acute diverticulitis RF/Ix/Management/Complications

RF: Low fibre diet Age > 50 Obesity Ix: FBC (raised neutrophils) Erect CXR CT abdomen Rx: Oral antibiotics + analgesia + low-residue diet ``` Complications: Perforation Abscess Fistula Haemorrhage ```

Elizabeth is a 70 year old woman who has presented with abdominal pain and vomiting over the last 12h. Her abdomen is distended and the vomit is green in nature. Elizabeth has been very constipated lately. Whenever she was able to pass stool it has been bloody. ``` Bowel Obstruction Crohn's Disease Diverticulitis Peptic Ulcer Disease Ruptured Aortic Aneurysm ```

Bowel obstruction, possibly due to bowel malignancy ``` Abdo pain Vomiting Green Constipated Bloody ```

Bowel Obstruction | Presentation and Aetiology

``` Presentation: Profuse vomiting (usually small bowel obstruction) --> may be bilious Abdominal pain Abdominal distension Failure to pass stool or flatus ``` Aetiology: Outside of the bowel - post operative surgical adhesion, strangulated hernia, volvulus Within the bowel wall - Bowel malignancy, Crohn's disease Inside of the bowel lumen - Gall stone ileus

Bowel Obstruction | Ix and Rx

Ix: Abdo XR - there will be gaseous distension of the bowel very apparent on Xray Erect Chest XR Rx: Pre-operative treatment: NBM, IV fluids, Nasogastric decompression (Drip and suck)

Napoleon is a 45 year old short, angry Frenchman who has presented with acute abdominal pain which started very suddenly. He is very cross because he is desperate to pass gas but it only results in more pain. On examination he is tachycardic, pale and has a distended abdomen. You do an abdominal X ray and are unable to interpret it. Your friendly reg says “oh that’s easy, that’s a coffee bean sign.” ``` Caecal volvulus GI perforation Diverticulitis Sigmoid volvulus Toxic megacolon ```

Sigmoid volvulus (+ bowel obstruction) Started very suddenly Desperate to pass gas Distended abdomen Coffee bean sign

Sigmoid and caecal volvulus | Presentation/Ix

Volvulus: rotation of the gut on its mesenteric axis Usually affecting the caecum or sigmoid colon Presentation: Abrupt bowel obstruction Ix: Abdo XR. Enormously dilated oval gas shadow on the left side which may be looped in on itself to give the typical "bent inner tube" sign.

Sigmoid volvulus distinguishing

Coffee bean sign. Twisting is at the left iliac fossa

Caecal volvulus distinguishing

Embryo sign. Twisting is at the right iliac fossa

Justinian is a 47 year old lawyer who has suffered from biliary colic for the last 6 months. In the last 12h he has recently developed a fever and epigastric pain which noticeably radiates to the back. He was referred to AandE by the GP. What is the most appropriate initial investigation. ``` Abdominal CT Abdominal USS ECG FBC Serum amylase ```

Serum amylase (he has signs of pancreatitis and gall stones is a risk factor)

Genghis is a 72 year old soldier who has grown obese in his old age. For the last 2 days he has had left iliac fossa pain. He has had constipation for the last 6 months, has felt bloated and is passing gas a lot. His wife harps on about how poor Genghis’s diet is; all he eats is horse meat from Tesco. His previous CT scan revealed numerous diverticulae. How would you like to manage this patient? ``` Analgesia Laparotomy Laxatives Oral antibiotics Surgical resection ```

Oral antibiotics (treatment for diverticulitis)

Donald is an 70y old orange politician who presents with abdominal pain, distension, and an inability to pass wind. He has spent the last 3 weeks building a wall because no one else will. What is the most appropriate management? ``` Check if he has insurance Nil-by-mouth and prepare for surgery Oral antibiotics and analgesia Pneumatic reduction Who cares ```

NBM and prepare for surgery (probable bowel obstruction)

Gynaecological causes of acute abdomen

``` Ovarian cyst Ovarian torsion Ectopic pregnancy Pelvis inflammatory disease Labour ```

Urology causes of acute abdomen

Urolithiasis (renal stones) | Pyelonephritis/cystitis