GI: The Acute Abdomen Flashcards
What is an acute abdomen?
Someone who becomes acutely unwel and in whom symptoms and signs are ciefly related to the abdomen
What clinical syndromes can present in an acute abdomen?
- Ruptured organ
- General/local Peritonitis
- Colic
- Bowel obstruction
What are surgical causes of an acute abdomen?
- Appendicitis
- Acute cholecystitis
- Peptic ulcer perforation
- Urinary retention
- Acute pancreatitis
- SBO
- Trauma
- Urinary stones
- LBO
- Acute diverticulitis
- Malignancy
- Medical disorders - DKA, penumonia, MI, IBS
- Vascular conditions - AAA
- Gynae conditions
What are features of someone with a ruptured organ?
- Shock - leading sign
- Abdominal swelling
- History of trauma
- Mild peritonism
What are gynaecological causes of acute abdomen?
- Ruptured ectopic pregnancy
- Ruptured functional ovarian cyst
- Torsion/rupture of ovarian cyst
- Acute salpingitis
What are features of localised peritonitis?
- Pain
- Tenderness
What are signs of generalised peritonitis?
- Prostration
- Fever
- Shock
- Lying still
- Positive cough test
- TEnderness +/- rebound/percussion pain
- Board-like abdominal rigidity
- Guarding
- No bowel sounds - due to paralytic ileus
What type of peritonitis always requires laparotomy?
Generalised peritonitis
What are the main insults which can cause generalised peritonitis?
- Infection
- Chemical irritation - leackage of gut contents
What microorganisms are most commonly implicated in peritonitis?
- E. coli
- Bacteriodes
What are routes of infection for peritonitis?
- Perforation of the GI tract
- Female genital tract
- Penetration of abdominal wall
- Haematogenous spread
What is the pathophysiology of generalised peritonitis?
Generalised peritonitis represents failure of localisation and occurs when contamination is too rapid, contamination persists, or an abscess ruptures.
The peritoneal cavity becomes acutely inflamed, with production of an inflammatory exudate that spreads throughout the peritoneum, leading to intestinal dilatation and paralytic ileus.
What is the difference between perforation and secondary inflammatory disease in terms of onset of peritonitis?
- Perforation - rapid onset
- Inflammatory disease - less rapid onset, preceded by other features of disease
What investigations would you consider doing in someone with features of peritonitis?
Standard Acute abdomen investigations
- Bedside - NEWS, urine output, consider ECG, urine dip + cultures, BHCG
- Bloods - FBC, U+E’s, LFTs, CRP, Serum albumin, Amylase/Lipase, consder ABG and blood cultures if septic, INR, G+S
Specific peritonitis investigations
-
Imaging
- Urgent CT/MRI
- Erect CXR
-
Consider
- Abdo US - detect abscess/fluid
- Consider ascitic tap - if significant fluid accumulation
- Consider Gastrografin - look for leaks/perforations
What are causes of peritonitis?
- Inflammation of organ +/- perforation
- Perforation of a hollow viscus
- Postoperative complication - anastamotic leak
- Ischaemia
- Haemoperitoneum
- Trauma
What are symptoms of peritonitis?
- Severe abdominal pain aggravated by motion
- Nausea + vomiting
- Hot and sweaty
- Loss of appetite
What general investigations would you consider doing in someone with an acute abdomen before focussing on diagnostic investigations?
-
Bedside
- Monitoring - NEWS, urine output
- Tests - Urinalysis/urine culture, Urine/serum BHCG
- Bloods - U+E’s, FBC, Amylase, LFT, CRP, Lactate, INR, G+S, blood culture if pyrexial
How would you manage peritonitis?
ABCDE
Standard acute abdomen
- Bed rest
- Consider NG
- IV fluids - consider catheter
- Analgesia and antiemetics
- VTE prophylaxis - TEDS + LMWH
- If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds
Peritonitis specific
- 2 wide bore cannulas
- Consider antibiotics
- Surgical repair - may need laparotomy
What are medical causes of acute abdomen?
- IBS
- MI
- Gastroenerritis
- DKA
- HSP
- Infection - Pneumonia, Pneumococcal peritonitis, TB, Malaria, Typhoid, cholera
- Thyroid storm
- Prophyria
- Sickle-cell crisis
- Phaeochromocytoma
What is the following?
Rigler’s sign - when the air is present on both sides of the intestine, i.e. when there is air on both the luminal and peritoneal side of the bowel wall. It is a sign of perforation
What antibiotics would you use to manage peritonitis?
3-7 days
- IV gentamicin + metranidazole +/- amoxicillin (co-trimoxazole if penicillin allergic)
- Oral Metranidazole + doxycycline/Co-trimoxazole
What is important about the early management of an acute abdomen?
Early surgical consultation
If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature in their suprapubic area, what might you consider as a cause?
Colonic obstruction
If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature over the umbilicus, what might you consider as a cause?
Small bowel obstruction
If someone presented with an acute abdomen with sudden severe pain in their umbilical region which spread into their groin and genitalia, what might you consider as a cause?
Ruptured Aortic Aneurysm
If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature over the right subcostal area, what might you consider as a cause?
Biliary colic
If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature from loin to groin, what might you consider as a cause?
Kidney stones
If someone presented with an acute abdomen with sudden severe pain in their epigastric region, what might you consider as a cause?
Perforated ulcer
If someone presented with a prgressive pain in their epigastric region that was relieved by sitting forward, what might you consider as a cause?
Pancreatitis
If someone presented with a progressive pain right subcostal region, what might you consider as a cause?
- Cholcystitis
- Hepatitis