GI Surgery - Acute Abdomen Flashcards
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
Causes of diffuse abdominal pain
Gastroenteritis/infectious colitis Mesenteric ischaemia Bowel obstruction Peritonitis IBS
–> Conditions that affect multiple parts of the gut
Causes of epigastric abdominal pain
Peptic ulcer disease GORD Gastritis Pancreatitis MI/Pericarditis
–> Foregut
Causes of umbilical abdominal pain
Early appendicitis
Ruptured aortic aneurysm
IBD (Crohn’s)
Diffuse pain causes (gastroenteritis, etc)
–> Midgut
Causes of suprapubic abdominal pain
UTI
Renal stones
Cystitis
Pelvic inflammatory disease
–> mostly renal in nature (some hindgut)
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
Causes of LUQ abdominal pain
Splenic abscess/infarct
Lower lobe pneumonia
Causes of epigastric pain (gastritis, gastric ulcer, pancreatitis, etc)
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
Causes of RIF abdominal pain
Appendicitis IBD (Crohn's) Inguinal hernia Renal stones Ectopic pregnancy Ovarian cyst/bleeding/torsion
Causes of LIF abdominal pain
Diverticulitis Colitis IBD (UC) Inguinal hernia Renal stones Ectopic pregnancy Ovarian cyst/bleed/torsion
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
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
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
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
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
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
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
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
