GI - The Acute Abdomen Flashcards
- Definition of acute abdomen
- What is the aim of initial assessment?
Sudden onset of severe abdominal pain of less than 24 hours duration with no Hx of trauma. It has a large number of possible causes and so a structured approach is required.
-Determine if pt has acute surgical problem : does it need immediate/prompt surgical intervention and/or urgent medical therapy
Name 4 possible aetiologies of pain in acute abdo
- Pain due to inflammation (peritonitis)
- Pain due to obstruction of hollow viscous (colic)
- Referred pain (compression of nerve root- eg Rovsing’s sign)
- Pain in a specific organ or mass (hepatitis, cholecystitis)
Name at least 2 things which can cause pain in the 9 regions of abdo
- RUQ: gallstones, gallbladder related disease, hepatitis/hepatic cyst
- Epigastrium: peptic ulcer/perforation/pancreatitis/cholecystitis, myocardial infarction
- LUQ and Peri-umbellical: Early appendicitis, SBO, gastro-enteritis
- LUQ and RUQ: pneumonia
- R and L flank: ureteric colic, pyelonephritis
- Peri-umbellical: SBO, LBO, appendicitis, AAA
- RIF: appendicitis, caecal obstruction, ectopic pregnancy, ovarian cyst, Crohn’s of terminal ileum
- Suprapubic area: cystitis, urinary retention, testicular torsion
- LIF: diverticulitis, constipation, UC, ectopic pregnancy and ovarian cyst
Female patients-
What important gynae questions are needed for Hx?
- Sexual Hx
- Date of LMP (heavy, regular, pus, discharge)
- If active: pain? contraceptive?
- PV: cervix (hard= pregrancy), masses?
Presentations requiring urgent surgery: Bleeding
- Main Dx?
- What happens to pts if untreated?
- AAA = most serious cause of intra abdo bleed
- Other causes: ruptured ectopic, bleeding gastric ulcer and trauma
- Pts will go into hypovolaemic shock (hypotensive, pale, clammy, thready pulse)
Presentations requiring urgent surgery: perforated viscus
- Main causes?
- What does perforation lead to?
- Peptic ulceration, SBO/LBO, diverticular disease, IBD
- Leads to Peritonitis
What does a pt with peritonitis look like?
- Pts lay still, look unwell and don’t move abdo
- Tachycardic and hypotensive
- Rigid ‘‘washboard abdo’’
- involuntary guarding
- Reduced/absent bowel sounds
Presentations requiring urgent surgery: ischaemic bowel
- What does the pt look like?
- pH status?
- Pain?
- Pt with severe pain out of proportion with clinical signs has ischaemic bowel until proven otherwise
- Often acidaemic with raised lactate
- Diffuse and constant pain but examination can often be otherwise unremarkable
Less acute abdo presentation: Colic
- What is it?
- Possible Dx?
- Abdominal pain that crescendos to become v severe and then completely goes away
- Dx: ureteric obstruction or bowel obstruction
- Biliary colic: not true colic b/c pain never goes away - waxes/wanes
What is peritonism?
- Localised inflammation of peritoneum
- usually due to inflammation of a viscus that then irritates the visceral (and subsequently, parietal), peritoneum.
- classic in acute appendicitis
Acute Abdo- Ix - labs
- FBC, U&E, CRP, LFT, Amylase/Lipase
- Lactate
- Clotting + Group and save
- AXR
- eCXR
- Urine dipstick
- Pregnancy test
- US: abd/pelvis to assess for tubo-ovarian pathology, free fluid and appendicitis
- CT: assess for appendicitis, collection, perf, IBD, Ca
Acute Abdo- Mx (general structure)
- Assess pt ABCDE
- Analgesia
- Resuscitate (IV fluids)
- If septic/suspect sepsis then start protocol
- Catheterise
- NBM
- Book and consent
What Ix (imaging) do you do on a pregnant pt with RIF pain?
- Gynae referral to rule out gynae cause
- MRI scan
- Low resolution CT
Hx: A 76yr woman was admitted through the A&E with 24hr hx of epigastric pain radiating to the back and relieved by sitting forward.
-Dx?
Dx: -Life threatening: Perforation (?Gastric/Duodenal) Ruptured Aneurysm Mesenteric infarct Ascending Cholangitis
-Worrying: Intestinal obstruction
Pancreatitis
Cholecystitis
**was pancreatitis
How do you assess severity of pancreatitis?
Glasgow system [0-2 Mild/Mod] (>3 Severe)
- PaO2 <8.0
- Age >55
- Neutophils (WCC > 15 x 10^9/L)
- Ca2+ <2.0 mmol
- Renal (Urea > 16 mmol/L)
- Enzymes ( LDH>600IU/L or AST>100IU/L)
- Albumn <32g/L
- Sugar BM >10
Outline basic pancreatitis Mx
Assess ABCDEs
Analgesia
Resuscitate (IV fluids)
Catheterise (if high risk or in shock)
What is aetiology of pancreatitis?
I GET SMASHED
- Idiopathic
- Gall Stones
- Ethanol
- Trauma
- Steroids
- Mumps/Malignancy
- Autoimmune
- Scorpion stings
- Hypercalcaemia/hyperTAG
- ERCP
- Drugs
Pancreatitis: Ix - imaging and others
- USS abdo: check for cholecystitis, gallstones, CBD dilation, carcinoma of head of pancreas
- MRCP scan
- ERCP (endoscopy retrograde cholangpancreatography) can cause acute pancreatitis
Emergency intervention (surgical) for deteriorating ascending cholangitis pt
- Percutaneous transhepatic cholangiogram
- ERCP
- Laparoscopuc cholecystostomy
- Lasparoscopic/open cholecystectomy
Case: A 75yr old man who presents with Rectal Bleeding, Abdominal pain
-Differential for rectal bleeding?
- Haemorrhoids
- Diverticulitis
- Colitis (Ischaemic/ Inflammatory/infective)
- Malignancy
- Peptic ulcers
- Angiodysplasia
Red flags in rectal bleeding
Bowel habit Weight loss Night sweats Abdominal pain Family history of cancer(bowel) Anaemia
What Ix (non blood) would you order for pt with PR bleeding?
- CT scan: assess for Collection, Diverticular perforation, Colitis, underlying malignancy
- Endoscopy: flexisig or colonoscopy (not acute)
What Ix (non blood) would you order for pt with PR bleeding in whom you suspect malignancy?
- Need staging CT scan (Chest/Abdomen/Pelvis)
- Need to address patient expectations/wishes
- Assess patient fitness for intervention
