Gill revision Flashcards
Inflammation pain vs obstruction pain in tummy?
Inflammation –> throbbing
Obstruction –> colic
Patient moving around –> colic
Patient lying still –> inflammation
Tenderness to percussion
Peritonism
Appendicitis march of events
1st Pain, usually epigastric or umbilical
2nd Anorexia, nausea, or vomiting
3rd Tenderness – somewhere in the abdomen or pelvis
4th Fever
5th Leucocytosis
McBurneys
1/3rd of way between ASIS and tummy button
Perforated appendice
Generalised pain and guarding with peritonism
Iliopsoas test for appendicitis?
Stretching the iliopsoas can elicit pain
Retrocaecal or pelvic appendix may require what?
May require rectal examination –> this may be the only way to elicit pain and point of tenderness
Remember that the appendix can be in loads of really weird places
RECTAL EXAMINATION ESSENTIAL IN ANY APPENDICITIS
Cell origin of oesophagus cancers?
Squamous cell
Adenocarcinomas in the lower third of the oesophagus are usually gastric in origin or have developed in Barrett’s oesophagus
Where do oesophageal carcinomas spread to?
Liver, lungs, bone and lymph glands
Dysphagia without weight loss?
Achalasia
Degeneration of the ganglion cells of Auerbach’s mesenteric plexus?
Achalasia
Confirming diagnosis of oesophageal carcinoma?
Endoscopy with biopsy
barium swallow will demonstrate irregular stricture
Primary investigation for achalasia?
Barium swallow
-proximal oesophagus is dilated and tortuous and merges into a smooth cone shaped narrowed segment above the gastro-oesophageal junction
Treatment for achalasia
Surgery –> Heller’s cardiomyotomy
Balloon dilatation
A low grade fever with tenderness and guarding over McBurneys point?
Acute appendicitis
Complications of appendicitis?
Perforation
Appendix mass
Gallstones risk factors
Age > 40 Female High fat diet Obesity Pregnancy Hyperlipidaemia Five “Fs” Bile salt loss (Crohn’s) Diabetes Dysmotility of GB Prolonged fasting TPN
Biliary colic
Stone impacts in cystic duct Gradual build-up pain in RUQ Radiates to back / shoulder May last 2-6 hours Associated with indigestion / nausea
Severe acute epigastric pain differentials
Biliary colic Peptic ulcer disease Oesophageal spasm Myocardial infarction Acute pancreatitis
Treatment for acute cholecystitis
IV antibiotics and IV fluids
Nil by mouth
US to confirm diagnosis
Urgent cholecystectomy** (asap)
Interval cholecystectomy (drainage of fluid then removal of gallbladder)
Cholecystitis
Inflammation of the gallbladder
Cholangitis
Infection of the common bile duct
Complications of gallstones
Stone may migrate into CBD:
Jaundice
Cholangitis
Acute Pancreatitis
Gallstone Ileus
Diagnosis of common bile duct pathology (e.g. if gallstones have passed into common bile duct)
Itch, nausea, anorexia
Jaundice
Abnormal LFTs
ERCP:
ES + stone removal
Surgical Exploration: CBD (Open vs Lap)
Gallstone ileus
Small bowel obstruction –
gallstone impacted in distal ileum .
Fistula gallbladder + duodenum - Large gallstone passes into small intestine.
Moves down SB causing intermittent colic
Present with distal SB obstruction.
Acute pancreatitis
Alcohol / gallstones
10% mortality AP
Autodigestion of peri-pancreatic tissues by activated enzymes
Cholecystectomy during INDEX admission
ERCP / ES if frail
Treatment for gallstone ileus
Treatment:
Urgent Laparotomy – SB enterotomy to remove stone
Interval cholecystectomy in 3 months.
Clinical presentation of cholangiocarcinoma?
Clinical Presentation: Usually late !
- Jaundice; Weight loss; anorexia; lethargy - 50% lymph node metastases - 20-30% peritoneal metastases at diagnosis
Staging of cholangiocarcinoma?
Staging / Assessment:
Duplex Ultrasound
(Spiral CT / ERCP / PTC)
MRI / MRCP/ MRA
Treatment for cholangiocarcinoma?
Surgical resection: Bile duct and liver resection
Palliation: insertion of biliary stent
Cholangiocarcinoma
Cancer of the bile ducts
Cholangiocarcinoma grading
I) confined to confluence II) below the confluence IIIa) extended into right hepatic duct IIIb) extended into left hepatic duct IV) extension into left and right hepatic duct
Bilirubin
Obstructive jaundice
-Urobiligen is not present in obstructive jaundice
What should you perform in all women presenting with acute abdomen?
Always perform urinary bHCG to exclude pregnancy in ALL women of childbearing age, however unlikely this is!
What do urea and creatinine show?
Hydration and renal status
What does prothrombin time show?
Synthetic function of liver e.g. CBD stone
Hydronephrosis
When one or both kidneys become stretched and swollen as a result of build up of urine in kidneys
Investigation for AAA
Ultrasound
Investigation for perforation or pancreatitis?
CT
Investigation for pancreatitis?
CT
Investigation for obstructive jaundice?
ERCP
What would you use a water soluble contrast swallow to investigate?
Oesophageal rupture
-it will show contrast in mediastinum
Grey-turners sign
Bruising in the flanks (last rib –> top of hip)
Acute pancreatitis
Cullen’s sign
Cullen’s sign is yellow blue discolouration of the skin around the umbilicus. It was first reported in ruptured ectopic pregnancy but is more commonly associated with severe, acute pancreatitis.
(looks like a bug bruise around the tummy button)
Causes for immediate surgery (<1hour)
Bleeding, perforation, incarceration, ectopic pregnancy
Causes for urgen surgery (<24 hours)
Appendicitis, uncomplicated bowel obstruction
Scheduled surgery >24 hours
Cholecystitis, adhesive SBO
Tests you should definitely do in acute abdomen?
urinalysis, bHCG, and PR
