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Chings Notes > JM Chapter 24 > Flashcards

JM Chapter 24 Flashcards

1
Q

Colicky midline umbilical abdominal pain (severe) - vomiting - distension =

A

small bowel obstruction (SBO).

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2
Q

Midline lower abdominal pain - distension - vomiting

A

large bowel obstruction
(LBO).

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3
Q

be considered in an older person with
arteriosclerotic disease or in those with atrial fibrillation presenting with severe
abdominal pain or following myocardial infarction

A

Mesenteric artery occlusion

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4
Q

Atrial fibrillation:

A

mesenteric artery obstruction

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5
Q

Tachycardia:

A

sepsis and volume depletion

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6
Q

Tachypnoea:

A

sepsis, pneumonia, acidosis

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7
Q

Pallor and ‘shock’:

A

acute blood loss

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8
Q

Causes of a ‘silent abdomen’:

A

diffuse sepsis, ileus, mechanical obstruction (advanced).

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9
Q

If distension,

A

fat, fluid, flatus, faeces, fetus, frightening growths.

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10
Q

Hypertympany indicates

A

mechanical obstruction.

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11
Q

anaemia with chronic blood loss
Investigation?
Possible diagnosis

A

haemoglobin

Possible diagnosis:
peptic ulcer, cancer, oesophagitis)

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12
Q

abnormal red cells
Investigation?
Possible diagnosis

A

blood film-
sickle-cell disease

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13
Q

-leucocytosis with appendicitis (75%),^ acute pancreatitis, mesenteric adenitis (first day)
Investigation?
Possible diagnosis

A

WCC

cholecystitis (especially with empyema), pyelonephritis

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14
Q

ESR- raised with cancer,

A

Crohn disease, abscess (but non-specific)

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15
Q

use in diagnosing and monitoring infection, inflammation (e.g.
pancreatic). Preferable to ESR
Investigation

A

C-reactive protein (CRP)

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16
Q

hepatobiliary disorder
Investigation

A

liver function tests

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17
Q

urine:
blood:

A

ureteric colic (stone or blood clot), urinary infection

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18
Q

urine
WBCS

A

Urinary infection
appendicitis

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19
Q

urine
bile pigments:

A

gall bladder disease

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20
Q

urine
porphobilinogen:

A

porphyria (add Ehrlich aldehyde reagent)

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21
Q

urine
ketones

A

diabetic Ketoacidosis

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22
Q

Urine
air

A

(pneumaturia): fistula (e.g. diverticulitis, other pelvic abscess, pelvic cancer)

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23
Q

urine
faecal blood-

A

mesenteric artery occlusion, intussusception (‘redcurrant jelly’), colorectal
cancer, diverticulitis, Crohn disease and ulcerative colitis

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24
Q

plain X-ray abdomen:
marked distension sigmoid

A

sigmoid volvulus

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25
Q

distended bowel with fluid level
plain X-ray abdomen:

A

bowel obstruction

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26
Q

blurred right psoas shadow
plain X-ray abdomen

A

appendicitis

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27
Q

plain X-ray abdomen
‘coffee bean’ sign

A

volvulus

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28
Q

plain X-ray abdomen
a sentinel loop of gas in left upper quadrant (LUQ)

A

acute pancreatitis

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29
Q

plain X-ray abdomen
chest X-ray: air under diaphragm

A

perforated ulcer

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30
Q

plain X-ray abdomen
70% opaque

A

kidney/ureteric stones

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31
Q

plain X-ray abdomen
only 10-30% opaque

A

biliary stones-

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32
Q

shows bile duct obstruction and pancreatic disease

A

ERCP:

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33
Q

diagnosis of acute cholecystitis (good when US unhelpful)

A

HIDA nuclear scan-I

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34
Q

Typical sites of acute abdominal pain

A
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35
Q

child aged between
3 months and 2 years presenting with sudden onset of severe colicky abdominal pain,
coming at
intervals of about 15 minutes and lasting for 2-3 minutes.

A

Intussusception

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36
Q

DxT pale child + severe ‘colic’ + vomiting

A

acute intussusception

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37
Q

Signs
acute intussusception

A

Pale, anxious and unwell
Sausage-shaped mass in right upper quadrant (RUQ) anywhere between the line of colon and
umbilicus, especially during attacks (difficult to feel)
Signe de dance (i.e. emptiness in RIF to palpation)
Alternating high-pitched active bowel sounds with absent sounds
Rectal examination: + blood + hard lump

38
Q

Diagnosis
acute intussusception

A

Ultrasound
Enema using oxygen or barium (with caution) used for diagnosis and treatment

39
Q

Treatment?
acute intussusception

A

Hydrostatic reduction by air or oxygen from the ‘wall’ supply (preferred) or barium enema

40
Q

arises from superior mesenteric artery occlusion from either an
embolus or a thrombosis in an atherosclerotic artery.

A

Acute intestinal ischaemia
Mesenteric artery occlusion

41
Q

Mesenteric artery occlusion

Clinical features

A

Central periumbilical abdominal pain - gradually becomes intense. Patients develop a fear of
eating

Profuse vomiting

Watery diarrhoea- blood in one-third of cases (eventually)

42
Q

DxT anxiety and prostration + intense central pain + profuse vomiting +
bloody diarrhoea -

A

mesenteric arterial occlusion

43
Q

Investigations
mesenteric arterial occlusion

A

CRP may be elevated intestinal alkaline phosphatase.

X-ray (plain) shows ‘thumb printing’

44
Q

Clinical features

mesenteric arterial occlusion

A

Central periumbilical abdominal pain - gradually becomes intense.

Patients develop a ‘fear of
eating’

Profuse vomiting

Watery diarrhoea- blood in one-third of cases (eventually)

Patient becomes confused

45
Q

Signs
mesenteric arterial occlusion

A

Localised tenderness, rigidity and rebound over infarcted bowel (later finding)

Absent bowel sounds (later)

Shock develops later
Tachycardia (may be atrial fibrillation and other signs of atheroma)

46
Q

real surgical emergency in an elderly person who presents with acute abdominal and
perhaps back pain with associated circulatory collapse

The patient often
collapses at toilet because they feel the need to defecate and the resultant Valsalva manoeuvre
causes circulatory embarrassment.

A

Rupture of aneurysm

47
Q

common cause of an enlarged prostate or prostatitis, it can also result from bladder neck
obstruction by faecal loading or other pelvic masses or anticholinergic drugs. It is often
precipitated by extreme cold or an excess of alcohol. Neurogenic causes include multiple
sclerosis, spinal injury and diabetes

volume of 600+ mL usually causes severe lower abdominal pain,

A

Acute retention of urine

48
Q

Management
Acute retention of urine

A

Perform a rectal examination and empty rectum of any impacted faecal material

Catheterise with size 14 Foley catheter to relieve obstruction and drain (give antibiotic cover)

Have the catheter in situ and seek a urological opinion.

Send specimen for MCU.

49
Q

shifts and localises to RIF within 6 hours

may be aggravated by walking (causing a limp) or coughing

sudden anorexia

nausea and vomiting a few hours after the pain starts

+ diarrhoea and constipation

A

Acute appendicitis

50
Q

Signs of acute appendicitis

A

Tenderness in RIF, usually at McBurney point

Local rigidity and rebound tenderness

Guarding

+ Superficial
hyperaesthesia

t Psoas sign: pain on resisted flexion of right leg, on hip extension or on elevating
right leg (due to -
Iritation of psoas especially with retrocaecal appendix)

+ Obturator sign: pain on the examiner flexing patient’s right thigh at the hip with the knee
bent and then internally rotating the hip (due to irritation of internal obturator muscle)

Rovsing sign: rebound tenderness in RIF while palpating in LIF

PR: anterior tenderness to right, especially if pelvic appendix or pelvic peritonitis

51
Q

the gold standard management of Acute Appendicits

A

Immediate referral for surgical removal-

52
Q

the gold standard management of Acute Appendicits, If perforated,

A

Cefotaxime
and Metronidazole.

53
Q

Outside obstruction (e.g. adhesions commonest cause, previous laparotomy), strangulation in
hernia or pockets of abdominal cavity
may lead to a ‘closed loop
obstruction.

Lumen obstructions (e.g. foreign body, trichobezoar, gallstones, intussusception, malignancy).

A

SBO

54
Q

Clinical Features of SBo

A

Severe colicky epigastric and periumbilical (mainly) pain

Spasms every 3-10 minutes (according to level), lasting about 1 minute

Vomiting

Absolute constipation (nil after bowel emptied)

No flatus

Abdominal distension (esp. if lower SBO)

55
Q

X-ray: plain erect film confirms diagnosis- stepladder’ fluid levels (4-5 for diagnosis)

A

SBO

56
Q

Management
SBO

A

IV fluids and bowel decompression with nasogastric tube

Laparotomy or hernia repair

57
Q

Increased bowel sounds, especially during pain

Distension early and marked

Local tenderness and rigidity

PR: empty rectum; may be rectosigmoid cancer or blood. Check for faecal impaction

X-ray: distension of large bowel with separation of haustral markings, especially caecal
distension

A

LBO

58
Q

What’s the Confirmatory test for LBO

A

Gastrogaffin enema

59
Q

Management of LBO

A

Drip and suction
Surgical referral

60
Q

sudden-onset severe epigastric pain

continuous pain but lessens for a few hours

epigastric pain at first, and then generalised to whole abdomen

pain may radiate to one or both shoulders (uncommon) or right lower quadrant

nausea and vomiting (delayed)

hiccough is a common late symptom

A

Perforated Peptic ulcer

61
Q

Patient lies quietly (pain aggravated by movement and coughing)

Pale, sweating or ashen at first

Guarding, board-like rigidity

Maximum signs at point of perforation
No abdominal distension

Shifting dullness may be present

X-ray: chest X-ray may show free air under diaphragm (in 75%) -need to sit upright for prior
15 minutes

A

Signs and tests (typical of peritonitis)
Perforated Peptic ulcer

62
Q

MANAGEMENT OF perforated Peptic Ulcer

A

Pain relief

Drip and suction (immediate nasogastric tube)

Broad-spectrum antibiotics

Immediate laparotomy after resuscitation

Conservative treatment may be possible (e.g. later presentation and Gastrografin swallow
indicates sealing of perforation)

63
Q

DxT intense pain (loin) - groin + microscopic haematuria

A

ureteric
colic

64
Q

Restlessness: may be writhing in pain

Maximum incidence 30-50 years (M> F

Intense colicky pain: in waves, each lasting 30 seconds with 1-2 minutes respite

Begins in loin and radiates around the flank to the groin, thigh, testicle or labia

Usually lasts <8 hours

+ Vomiting

Loin pain

Smoky urine due to hematuria

A

ureteric
colic

65
Q

Diagnosis of Ureteric Colic

A
66
Q

Management of Ureteric Colic

A
67
Q

Abdominal pain can be produced by contraction of the biliary tree upon an obstructing stone or
inspissated bile (sludge). Although the stereotyped higher-risk person is female, 40, fat, fair and
fertile, it can occur from adolescence to old age and in both sexes.

A

Biliary pain

68
Q

DxT severe pain + vomiting + pain radiation

A

biliary colic

69
Q

What is the mainprocedure for Biliary Colic

A

LAPAROSCOPIC CHOLECYSTECTOMY

70
Q

What are the 2 main types of gallstones

A

Cholesterol
Pigment (bilirubin)

71
Q

What is the causative organisms of the Acute cholecystitis

A

E coli
KLEBSIELLA
Enterococcus faecalis

72
Q

CLINICAL FEATURES OF Acute Cholecystitis

A

Steady severe pain and tenderness

Localised to right hypochondrium or epigastrium

May be referred to the right infrascapular area

Anorexia, nausea and vomiting (bile) in about 75%

Aggravated by deep inspiration

Patient tends to lie still

Localised tenderness over gall bladder (positive Murphy sign)

Muscle guarding

Rebound tenderness

Palpable gall bladder (approximately 15%)
Jaundice (approximately 15%)

+ Fever

73
Q

Diagnosis of Acute Cholecystitis

A

Ultrasound: gallstones but not specific for cholecystitis

HIDA scan: demonstrates obstructed cystic duct- the usual cause

WCC and CRP: can be elevated

74
Q

Treatment of Acute Cholecystitis

A

Bed rest

IV fluids

Nil orally

Analgesics

Antibiotics

Cholecystectomy

75
Q

It is commonly precipitated by fatty foods and
alcohol, mumps, hypertriglyceridaemia and some antidiabetic medications, e.g. gliptins.

There may be a past history of previous attacks or a past history of
alcoholism (35%) or gallstone disease (40-50%).

A

Acute pancreatitis

76
Q

DxT severe pain + nausea and vomiting + relative lack of abdominal
signs -

A

acute pancreatitis

77
Q

This IgG4-related disorder presents with abdominal pain, jaundice and weight loss.

Diagnosis is
by a pancreatic mass or enlargement on imaging and serology (IgG4).

Treatment is with
corticosteroids.

A

Autoimmune pancreatitis

78
Q

epigastric pain boring through to the back.

Weight loss and steatorrhoea become prominent features.

The person
with this problem is often labelled as ‘gastritis’, ‘ulcer or even ‘neurotic` because of the
indeterminate nature of the pain.

Malabsorption and diabetes may result from this.

A

Chronic pancreatitis

79
Q

most sensitive imaging study -
Chronic pancreatitis

A

MRCP

80
Q

Management of Chronic Pancreatitis

A

Use paracetamol for pain.

Give pancreatic enzyme supplements (e.g. pancrelipase) for malabsorption

81
Q

usually over 40 years of age, with longstanding,

Typical clinical features are:

acute onset of pain in the left iliac fossa

pain increased with walking and change of position

usually associated with constipation

A

Acute diverticulitis

82
Q

DXT acute pain + left-sided radiation + fever

A

acute diverticulitis

83
Q

Tx of Acute diverticulitis in severe cases

A
84
Q

Can be generalised due to intra-abdominal sepsis following perforation of a viscus, e.g. peptic
ulcer, appendix, diverticulum,

Typical signs are as for perforated peptic ulcer.

A

Peritonitis

85
Q

Peritonitis
Investigation

A

peritoneal fluid culture and CT scan.

86
Q

Peritonitis
Treatment

A

IV cephalosporins or amoxi/ampicillin + gentamicin + metronidazole.

Surgical intervention is usually required.

87
Q

experience of a sharp, stabbing pain in the epigastric or
hypochondrium regions of the abdomen, usually during running.

The sufferer should:
stop and rest, then walk- don’t run

apply deep massage to the area with the palps (fleshy tips) of the middle three fingers

perform slow or deep breathing

A

Abdominal ‘stitch’

88
Q

If an elderly person presents with intense acute abdominal pain, inadequately
relieved by strong parenteral injections, likely causes include

A

mesenteric artery
occlusion,
acute pancreatitis and ruptured or dissecting aortic aneurysm

89
Q

if the person is woken (e.g. at 2-3 am)
with abdominal pain
Consider

A

gallstones and duodenal ulcer

90
Q

person with abdominal pain, tenderness and
rigidity and deep sighing respiration
Consider

A

diabetic ketoacidosis

91
Q
A

Chings Notes (39 decks)

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