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MBBS IV - Junior Clerkship WCS > JC53 (Surgery) - Lower and diffuse abdominal pain, Peritonitis, Abdominal emergencies > Flashcards

JC53 (Surgery) - Lower and diffuse abdominal pain, Peritonitis, Abdominal emergencies Flashcards

1
Q

3 physiological origins of abdominal pain

A

Visceral pain

Parietal

Referred pain

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2
Q

Visceral abdominal pain

Origin and innervation

Cause

Site

Character

A

Origin and innervation: Visceral peritoneum innervated bilaterally by autonomic nerves

Cause: Stretching, inflammation, ischaemia

Site: Midline in upper (foregut), central (midgut) or lower abdomen (hindgut)

Character: Dull, poorly localized

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3
Q

Parietal abdominal pain

Origin and innervation

Cause

Site

Character

A

Origin and innervation: Parietal peritoneum innervated unilaterally by somatic nerves

Cause: Irritation (inflammatory or mechanical)

Site: Well-localized over irritated area

Character: Sharp, severe

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4
Q

Referred abdominal pain

Origin and innervation

Cause

Site

Character

A

Origin and innervation: Innervation shared by both somatic nerves and visceral organs

Cause: same as visceral pain - Stretching, inflammation, ischaemia

Site: Well-localized in a distant area

Character: Sharp

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5
Q

Causes of RLQ pain

A

Ileum: ileitis (Crohn’s disease, Yersinia), Meckel’s diverticulitis

Caecum/Rt colon: acute appendicitis, diverticulitis, caecal ischaemia, colitis (infective, IBD, radiation), CA colon/caecum

O/G: torsion/ruptured of ovarian cysts, ectopic pregnancy

Urological: ureteric colic, testicular torsion

Others: strangulated inguinal/femoral hernia, mesenteric adenitis

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6
Q

Causes of LLQ pain

A

Sigmoid colon/Lt colon: colitis (infective, IBD, radiation), diverticulitis, CA Lt colon/sigmoid

O/G: torsion/rupture of ovarian cyst, ectopic pregnancy, PID

Urological: ureteric colic, testicular torsion

Others: strangulated inguinal/femoral hernia

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7
Q

Ddx peri-umbilical pain

A

Small bowels: small bowel obstruction, gastroenteritis, early appendicitis, mesenteric ischaemia, IBD

Retroperitoneal: ruptured AAA, pancreatitis

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8
Q

Ddx hypogastric/ suprapubic area pain

A

Large bowels: large bowel obstruction, colorectal CA

Urological: AROU, bladder stones, cystitis/UTI

O/G: PID, degenerating fibroid, adenomyosis/endometriosis, ectopic pregnancy

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9
Q

Ddx diffuse/ non-specific abdominal pain

A

Bowels: gastroenteritis, constipation, uncomplicated bowel obstruction

Peritoneum: generalized peritonitis, intra-abdominal haemorrhage, ruptured viscus\

Medical causes: DKA, hypercalcemia, herpes zoster, anaphylaxis, porphyria

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10
Q

Ddx Right flank pain

A

Kidney: pyelonephritis, renal infarct, obstructive uropathy (hydronephrosis), renal stone, RCC

(Biliary)

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11
Q

Ddx Left flank pain

A

Kidney: pyelonephritis, renal infarct, obstructive uropathy (hydronephrosis), renal stone, RCC
(Splenic

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12
Q

Ddx RUQ pain

A

Liver: hepatitis, hepatomegaly, liver abscess
Biliary: cholangitis, cholecystitis, cholelithiasis, choledocholithiasis
Thoracic: pneumonia, pleural effusion
Others: subphrenic abscess

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13
Q

Ddx epigastric pain

A

Oesophagus: oesophagitis, GERD, Boerhaave’s syndrome
Stomach: gastritis, peptic ulcer, gastric volvulus, gastric outlet obstruction, CA stomach
Pancreas: pancreatitis, CA pancreas
Thoracic: MI, pericarditis
(Hepatobiliary)
Others: rAAA,

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14
Q

Ddx LUQ pain

A

Spleen: rupture, infarct, splenomegaly
Pancreas: pancreatitis
Thoracic: pneumonia, pleural effusion, MI

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15
Q

Most common causes of acute, severe abdominal pain

A
  • *1.Inflamed viscus**
  • Appendicitis
  • Ileitis
  • Colitis
  • Diverticulitis
  • *2. Perforated viscus**
  • Peptic ulcer
  • Ischaemic bowel
  • *3. Obstructed viscus**
  • IO, strangulation
  • (Ureteric colic)
  • (Biliary colic)
  • *4. Infarcted viscus**
  • Mesenteric ischemia
  • Ischemic colitis
  • *5. Intra-abd or retroperitoneal haemorrhage**
  • Ruptured AAA
  • Ruptured spleen
  • Ectopic pregnancy
  • *6. Extra-GI causes**
  • Pleurisy
  • MI
  • DKA…
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16
Q

Ddx the following S/S with abdominal pain

Signs of local inflammation (early) or generalized peritonitis (late):

  • Pain, tenderness, guarding, rebound tenderness
  • ↓bowel sounds
  • Tachycardia, fever
A

Inflamed viscus

  • Appendicitis
  • Ileitis
  • Colitis
  • Diverticulitis
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17
Q

Ddx the following S/S with abdominal pain

Colicky pain, vomiting, distension, absolute constipation

Local/generalized peritonitis

A

Obstructed viscus
- IO: Luminal obstruction or strangulation

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18
Q

Ddx the following S/S with abdominal pain

Local/generalized peritonitis Signs of hypovolemic shock (late)

A

Infarcted viscus

  • Mesenteric ischemia
  • Ischemic colitis
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19
Q

Ddx the following S/S with abdominal pain

Signs of generalized peritonitis

Cullen’s sign, Grey Turner’s sign, shifting dullness, shoulder pain

Signs of hypovolemic shock (early)

A

Intra-abd or retroperitoneal haemorrhage

  • Ruptured AAA
  • Ruptured spleen
  • Ectopic pregnancy
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20
Q

Ddx acute abdomen by onset/ duration of second, minutes or over hours

A

Within seconds:
→ Infarction, eg. MI, mesenteric occlusion
→ Haemorrhage, eg. ruptured AAA
→ Perforation, eg. PPU

Within minutes:
→ Inflammatory, eg. acute appendicitis, pancreatitis, diverticulitis
→ Colic, eg. biliary colic, ureteric colic, IO
→ Ischaemia, eg. mesenteric ischaemia, strangulated IO, volvulus

Over hours:
→ Inflammatory, eg. appendicitis, cholecystitis
→ Obstruction, eg, non-strangulated IO, urinary retention
→ Mechanical, eg. ectopic pregnancy, perforating tumours

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21
Q

Differentiate causes and character of constant vs colicky vs stretching abdominal pain

A

Constant pain due to inflammation, infiltration, ischaemia or infarction
→ Severe, persistent, made worse by local or general movement

Colicky pain due to hyperperistalsis against obstruction
→ Waxing and waning gripping pain
→ Intestinal obstruction/ureteric colic: with periods of complete cessation (true colic)
→ Biliary colic: severe, constant with painful exacerbations but no complete pain-free periods

Stretching pain due to prolonged obstruction to outflow of hollow viscus
→ Constant stretching pain but not colicky

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22
Q

Ddx the following abdominal pain radiation patterns

  • Back
  • Right Shoulder tip
  • Right Scapular spine
  • Loin to groin
  • Testicles to flank
  • Flank
A

Radiation:
□ Back: pancreatitis, AAA, aortic dissection, posterior stomach/duodenal ulcer
□ R Shoulder tip: haemoperitoneum (eg. ruptured ectopic, splenic ruptured)
□ R Scapular spine: gallbladder
□ Loin to groin: renal colic
□ Testicles to flank: testicular pain
□ Flanks: pyelonephritis, retroperitoneal haematoma, AAA

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23
Q

Outline history taking approach to acute abdomen

A
  1. Onset/ duration/ progression
  2. Quality: constant/ colicky/ stretching
  3. Site and radiation
  4. Severity
  5. Exacerbating and relieving factors
  6. Associated symptoms: Screen UGI, LGU, Urology, vascular and O/G pathologies
  7. PMH: Risk factors for IO, Perforation, AAA, LMP…etc
  8. Drug history
  9. Social and family history
  10. Menstrual and sexual history
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24
Q

First-line investigations and rationale for acute abdomen

Bedside

Bloods

Imaging

A

Bedside: Urinalysis (UTI, stones), pregnancy test (ectopic preg.)

Blood count: RBC for chronic bleed, WBC for infection

LFT: hepatic vs obstructive jaundice

RFT: Hydration status, HypoK + HypoCl for chronic vomiting, HypoK + HypoCa for ileus, Cr for scans

Amylase: acute pancreatitis

ABG: Metabolic acidosis + lactate for ischemia, Metabolic alkalosis for vomit

Clotting profile, T/S for transfusion prep and surgery

Imaging:

Erect CXR (free gas under diaphragm for perforation)

Erect and supine AXR (IO, air-fluid levels, coffee bean sign, stones, sentinel loop sign, pancreatic calcification)

USG: Gallstones, cholecystitis

CT Contrast: mesenteric ischemia, retroperitoneal leaks or stones

Endoscopy

25
Q

Acute appendicitis

Pathology

Demographic

Pain character

Associated S/S

A

Pathology: Unknown, likely obstruction by faecolith, lymphoid hyperplasia, stricture, carcinoid tumour

Demographic: young adults and teenagers

Pain:

  • Begins as vague ‘colicky’ paraumbilical pain
  • Shifts to Rt iliac fossa and becomes more severe, constant and localized after a few hours-days

S/S:

  • Anorexia (~75%) before onset of pain
  • Nausea, vomiting after onset of pain
  • Fever often after 6h
  • Generalized peritonitis if progressed
  • Retrocaecal (64%) → RLQ, flank pain
    Pelvic (32%) → bladder (dysuria, frequency), large bowel (diarrhoea) S/S
26
Q

Acute appendicitis

Signs: general, abdomen

A

General:

  • Unwell, low-grade pyrexia
  • Tachycardia
  • Fetor oris (halitosis)
  • Limited lower abd resp movt

Abdomen:

  • RLQ tenderness and guarding (max over McBurnley’s point)
  • Tenderness at Flank (retrocaecal), RUQ (subhepatic)
  • ± RLQ tender mass (Indistinct, dull on percussion)
27
Q

Acute appendicitis

4 special signs elicited for confirmation

Main mode of diagnosis

A

Specific signs:

  • Rovsing’s sign = pressure on Lt iliac fossa cause pain in Rt iliac fossa
  • Cough sign = Rt iliac fossa pain on coughing due to localized peritonitis
  • Obturator sign = RIF pain on internal rotation of flexed Rt hip due to spasm of obturator internus
  • Psoas sign = RIF pain on Rt hip flexion due to inflamed retrocaecal appendix is lying on psoas muscles

Mostly clinical Dx, USG or CT may be helpful

28
Q

Mesenteric adenitis

  • Pathology, causative agents
  • Demographic
  • Pain
  • Associated S/S
A

Inflammation of mesenteric LNs (common mimic of acute appendicitis)

Causative agents:

  • B-hemolytic streptococcus, E. coli, Streptococcus viridans, Yersinia,
  • Coxsackievirus, Rubeola, Adenovirus

Demographic: usu. children

Pain: central abd pain but can cause RLQ pain

Associated S/S:

  • Preceding URTI (high fever, sore throat) and cervical LN enlargement
  • Pain may move at lateral decubitus position when glands move over with mesentery
29
Q

Acute diverticulitis

Pathology

Demographic

Pain character

Associated S/S

A

Pathology: Inflammation and microperforation of colonic diverticula at mucosal herniations, mostly at sigmoid colon

Demographic: 50-70y, Westerners

Pain:

  • Gradual onset of mild intermittent lower abd pain
  • Shift to L/R iliac fossa and becomes more severe and constant

Associated S/S:

  • Fever, tenderness and guarding
  • Nausea, poor appetite, constipation (vomiting and diarrhea are RARE)
  • Dysuria, ↑frequency
30
Q

Acute diverticulitis

Specific Signs

Preceding S/S

Complications

A

Specific signs:

  • Lie still, pyrexia, tachycardia
  • Iliac Fossa tenderness and guarding
  • ±IF mass tender sausage-shaped dull on percussion
  • Reversed Rovsing’s sign: pressure on Rt side of abdomen may induce pain on left
  • PR may show pain

Preceding S/S:

  • Hx of diverticular disease, flatulence, distension, L/RIF pain

Complications

  • localized abscess, purulent peritonitis or fecal peritonitis
31
Q

Acute diverticulitis

Main mode of Dx

Treatment

A

CT confirms diagnosis and assesses severity

Tx:

  • Antibiotics
  • Image-guided drainage
  • Laparoscopy and lavage (purulent peritonitis)
  • Laparotomy and bowel resection (Fecal peritonitis)
32
Q

Ileitis

Causes

Main mode of Dx

Presentation

A

Causes:

  • Crohn’s disease
  • TB
  • Radiation enteritis
  • Bacterial infection: Campylobacter, Yersinia, Salmonella

Main mode of Dx:

  • Incidental finding of inflamed terminal ileum during operations

Presentation:

Crohn’s ileitis (commonest)

  • Episodic colicky abdominal pain
  • Watery, fatty or inflammatory (less common) diarrhoea
  • Malabsorptive features
  • ± subacute/acute IO (fibrotic strictures)
  • ± RLQ mass
33
Q

Merkel’s diverticulum

Pathology

Demographic

Pain

associated S/S

A

Pathology:

  • Remnant of vitelline duct adhered to umbilicus, 2 inches long, 2 feet from ileocaecal junction
  • ectopic gastric or pancreatic mucosa cause inflammation at site, cause bleeding, perforation, volvulus or intussusception

Demographic: 2% population, usually present at 2 years old

Pain:

  • Central abdominal pain - ectopic mucosa cause ulceration or bleeding
  • Colicky abdominal pain - act as head of intussusception causing IO or volvulus

Associated S/S:

  • Highly similar to acute appendicitis
34
Q

Merkel’s diverticulum

Main mode of diagnosis

Treatment

A

Main mode of diagnosis: CT scan/ incidental finding during appendicectomy

Treatment:

Antibiotic coverage + diverticulectomy/ small bowel resection

35
Q

Testicular torsion

Demographic

Pain character

Associated S/S

Specific sign on exam

Treatment

A

Demographic: 10-15

Pain character: Severe pain in testes and groin +/- radiation to loin

Associated S/S: preceding vague abdominal pain

Specific sign on exam: Tender and high-lying testicles

Treatment: Surgical emergency

Surgical exploration +/- Orchidopexy, Orchidectomy

36
Q

Ectopic pregnancy and abdominal pain

Pathology

Demographics

Pain character

Associated S/S

Complications

A

Pathology: Tubal pregnancy ± rupture into abdominal cavity at 6 weeks

Demographics: Female in child-bearing age, previous PID, ectopic preg.

Pain character: Sudden onset severe lower abdominal pain on side of ectopic pregnancy

Associated S/S : Preceded by a few days of mild abd pain

Complications:

  • Generalized Peritonitis
  • Hypovolemic shock (fainting, collapse) if ruptured
  • Shoulder tip pain if blood collects beneath the diaphragm
37
Q

Ectopic pregnancy and abdominal pain

Main mode of diagnosis

Treatment

A

Dx: Ultrasound

Tx:

Large bore IV cannula and resuscitation

Urgent laparoscopy and salpingotomy/ salpingectomy

38
Q

Pelvic inflammatory disease

Pathology

Demographics/ risk factors

Pain character

Associated S/S

A

Pathology: Salpingitis and associated infection of adnexa supporting tissue from ascending vaginal infection (e.g. chlamydia, gonorrhoea…)

Demographics/ risk factors: Sexually active female under 40y, history of IUCD, STD, gynaecological procedures

Pain character: Gradual onset of constant lower abd pain ± radiation into back

Associated S/S:

  • Preceded by a few months of menstrual irregularities and dysmenorrhoea
  • purulent yellow-white vaginal discharge by a few days
  • dysuria and urinary frequency
  • dyspareunia
39
Q

Pelvic inflammatory disease

Signs (general, abdominal, genital)

Treatment

A

General Signs:

High fever (38-39.5oC)
Lower abd tenderness, guarding

Vaginal exam:

  • Yellow-white introital discharge
  • Adnexal tenderness on bimanual palpation
  • Chandelier sign - painful cervical excitation**
  • Pus discharge from cervical canal in speculum examination

Treatment:

  • Antibiotics
  • Drainage of tubovarian abscess
40
Q

Torsion/ ruptured ovarian cyst

Pathology

Pain character

Associated symptoms

Main mode of diagnosis

Treatment

A

Pathology: Ovarian cyst complication

Pain character: Sudden severe unilateral lower abd pain during agitating movement (eg. exercise)

Associated symptoms:

  • S/S of intra-abdominal bleeding
  • ± S/S of hypovolemic shock
  • ± lower abd tenderness and guarding

Main mode of diagnosis: USG or CT

Treatment: Laparoscopy ovarian cystectomy/ oophorectomy

41
Q

Ureteric colic

Pathology

Pain character

Associated S/S

Signs

A

Pathology: Obstruction in ureter due to ureteric stones

Pain character:

  • Severe, gripping true colic radiating down from renal angle, parallel to inguinal ligament into groin
  • Alleviate by rolling around bed or walking around

Associated S/S:

  • Autonomic symptoms (sweating, N/V)
    Gross or microscopic haematuria

Signs

  • May have renal angle tenderness
    Urinalysis shows gross or microscopic haematuria
42
Q

Large bowel obstruction

Common Causes

S/S

A

Common causes:

  • Colon cancer
  • Volvulus
  • Diverticular stricture
  • Pseudo-obstruction

S/S:

  • Cramping pain
  • Vomiting
  • Abdominal distension
  • Constipation
43
Q

Outline list of physical exams for suspects large bowel IO

A

General:

  • Hydration status (3rd space loss)
  • Tachycardia and hypotension (Hypovolemia)

Abdominal:

  • Peritoneal signs/ localized tenderness
  • Hernial orifices (hernia incarceration)
  • Bowel sounds and percussion: Resonance over distended bowel, High-pitched tinkling BS, absent BS
  • Rectal examination (impaction, mass)
44
Q

Outline first-line investigations for large bowel IO

A

Full bloods

Imaging:

  • Plain abdominal X-ray
  • Abdominal CT with contrast
  • Contrast study: e.g. Gastrografin follow-through enema
45
Q

Distinguishing features of large and small bowel on X-ray

A

Xray:

Small bowel = central with valvulae conniventes

Large bowel = Peripheral with haustations

46
Q

Treatment of large bowel IO

(basic, surgical)

A

Diet:

  • Nil Per Oral
  • IV fluid resuscitation: secure IV access
  • NG tube decompression if IO

Definitive surgical treatment:

  • Colonic stenting
  • Endoscopic decompression
  • Bowel resection
  • Stoma
47
Q

Ischemic bowel

Causes of ischemia

A

Thromboembolism

Venous occlusion

Non-obstructive mesenteric ischaemia

Chronic mesenteric ischemia (e.g. chronic anaemia, vasopressor use…etc)

Mechanical (volvulus, hernia)

48
Q

Ischemic bowel

Demographics

Pain character

Associated S/S

Signs on PE

Complications

A

Demographics: Elderly, with history of AF or IHD

Pain character: Constant, severe, non-specific abdominal pain

Associated S/S: Rectal bleeding or bloody diarrhea, colic

Signs on PE:

  • Lie still, pale, sweating, tachycardia
  • Rarely peritoneal signs

Complications:

  • Metabolic acidosis, renal failure, ileus, shock, death
49
Q

Peritonitis

Classification by location, underlying causes

Classification by primary, secondary and tertiary

A

Location:

Localized vs generalized/ diffuse

Underlying causes:

e.g. Spontaneous bacterial peritonitis, Chemical peritonitis

□ Primary peritonitis: not a/w 1o pathology → bacteria often from haematogenous dissemination
□ Secondary peritonitis: secondary to pathological process in abdominal viscera, commonly perforated viscus
□ Tertiary peritonitis: persistent peritonitis after treatment, immunocompromised state or opportunistic infection of peritoneum

50
Q

Peritonitis

Pathogenesis of hypovolemia and systemic shock

A

inflamed peritoneum becomes oedematous, hyperaemic and covered w/ fibrinous exudates → resulting in
□ Sequestration of large amount of protein-rich fluid
□ Septicaemia and endotoxaemia
□ Hypovolaemia and shock

51
Q

Peritonitis

S/S - General and abdominal

A

General:

  • Fever, tachycardia (often early), tachypnoea
  • Septic shock
  • Features of visceral inflammation
  • Malaise, anorexia, nausea

Abdominal:

Peritoneal irritation:
- Burning pain: initially localized and later spread, often ↑ w/ movement and coughing
- Peritoneal signs: tenderness, rebound tenderness, guarding, rigidity
Paralytic ileus:
- Abdominal distension
- Absent bowel sounds (paralytic ileus)

52
Q

List causes of primary bacterial peritonitis

Typical pathogens

Risk factors

A
  • Spontaneous bacterial peritonitis
  • Tuberculous peritonitis
  • Peritonitis associated with Chronic Ambulatory Peritoneal Dialysis

Typical pathogens: normally monomicrobial (secondary = polymicrobial)

  • Strep. pneumoniae
  • Group A streptococcus
  • Enteric organisms

Risk factors:

  • Ascites
  • Malnutrition
  • Intra-abdominal malignancies
  • Immunosuppression
  • Splenectomy, Chronic liver disease. CKD
53
Q

Outline all metrics of peritoneal fluid analysis

A

Appearance: serous, blood-stained, purulent, bile-stained, feculent → ‘E’ OT if bile-stained (HBP/SB perf) or feculent (LB perf)

Cell count: neutrophil >500/μL in peritonitis

Biochemistry:

  • ↓Glc, ↑protein, ↑LDH cf serum → indicates bacterial inf’n
  • ↑amylase → indicates perforated GI tract from pancreatitis
  • ↑Cr compared to serum → indicates perforated urological tract/ urine leak

Microbiology: Gram stain, culture (aerobic, anaerobic, AFB, fungal)

54
Q

Tuberculous peritonitis

S/S

Mode of investigation and diagnosis

A

S/S:

  • Non-specific: low-grade fever, weight loss
  • Insidious onset of abdominal pain
  • Rare/ minimal peritoneal signs

Dx:

  • Laparoscopy and biopsy of peritoneum
  • AFB smear not reliable (false negatives)
55
Q

Acute secondary bacteria peritonitis (most prevalent peritonitis**)

Causes

A

Severe inflammation of abdominal organ - e.g. diverticulitis, cholecystitis, appendicitis

Perforation of GIT - spontaneous, trauma, iatrogenic

Anastomotic leak - chemical peritonitis by gastric juice/ bile/ pancreatic secretions/ urine/ blood

Ischemia of abdominal organs

56
Q

Acute secondary bacterial peritonitis

Causative agents

A

POLYMICROBIAL (cf monomicrobial in primary bacterial peritonitis)

Gram negative, enterobacteria: (most common)

  • E.coli. Enterobacter, Proteus, Psudomonas

Gram positive:

  • Streptococcus, Enterococcus

Anaerobes

  • Bacteroides
57
Q

Complications of peritonitis

A

Septicemia, endotoxemia

Hypovolemia and shock

Sequestration of protein rich fluid in peritoneum

58
Q

Treatment of acute secondary bacterial peritonitis

A

Supportive: IV fluid resuscitation, NG tube, Foley catheter, O2, pain relief

Broad-spectrum Abx: usually 2G ceph (eg. cefuroxime (Zinacef)) + metronidazole (Flagyl)

Definitive treatment:

Drainage for stable, localized pathologies, eg. percutaneous drainage of abscess, ERCP for biliary

Surgical emergency: Laparoscopy for PPU repair, cholecystectomy, bowel resection, appendicectomy/ exploratory laparotomy

59
Q

Why does peritonitis present late in elderly

A

Poor detailed history

Confused or demented

Peritoneal signs may be mild

MBBS IV - Junior Clerkship WCS (131 decks)

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