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
