JM Chapter 24 Flashcards
Colicky midline umbilical abdominal pain (severe) - vomiting - distension =
small bowel obstruction (SBO).
Midline lower abdominal pain - distension - vomiting
large bowel obstruction
(LBO).
be considered in an older person with
arteriosclerotic disease or in those with atrial fibrillation presenting with severe
abdominal pain or following myocardial infarction
Mesenteric artery occlusion
Atrial fibrillation:
mesenteric artery obstruction
Tachycardia:
sepsis and volume depletion
Tachypnoea:
sepsis, pneumonia, acidosis
Pallor and ‘shock’:
acute blood loss
Causes of a ‘silent abdomen’:
diffuse sepsis, ileus, mechanical obstruction (advanced).
If distension,
fat, fluid, flatus, faeces, fetus, frightening growths.
Hypertympany indicates
mechanical obstruction.
anaemia with chronic blood loss
Investigation?
Possible diagnosis
haemoglobin
Possible diagnosis:
peptic ulcer, cancer, oesophagitis)
abnormal red cells
Investigation?
Possible diagnosis
blood film-
sickle-cell disease
-leucocytosis with appendicitis (75%),^ acute pancreatitis, mesenteric adenitis (first day)
Investigation?
Possible diagnosis
WCC
cholecystitis (especially with empyema), pyelonephritis
ESR- raised with cancer,
Crohn disease, abscess (but non-specific)
use in diagnosing and monitoring infection, inflammation (e.g.
pancreatic). Preferable to ESR
Investigation
C-reactive protein (CRP)
hepatobiliary disorder
Investigation
liver function tests
urine:
blood:
ureteric colic (stone or blood clot), urinary infection
urine
WBCS
Urinary infection
appendicitis
urine
bile pigments:
gall bladder disease
urine
porphobilinogen:
porphyria (add Ehrlich aldehyde reagent)
urine
ketones
diabetic Ketoacidosis
Urine
air
(pneumaturia): fistula (e.g. diverticulitis, other pelvic abscess, pelvic cancer)
urine
faecal blood-
mesenteric artery occlusion, intussusception (‘redcurrant jelly’), colorectal
cancer, diverticulitis, Crohn disease and ulcerative colitis
plain X-ray abdomen:
marked distension sigmoid
sigmoid volvulus
distended bowel with fluid level
plain X-ray abdomen:
bowel obstruction
blurred right psoas shadow
plain X-ray abdomen
appendicitis
plain X-ray abdomen
‘coffee bean’ sign
volvulus
plain X-ray abdomen
a sentinel loop of gas in left upper quadrant (LUQ)
acute pancreatitis
plain X-ray abdomen
chest X-ray: air under diaphragm
perforated ulcer
plain X-ray abdomen
70% opaque
kidney/ureteric stones
plain X-ray abdomen
only 10-30% opaque
biliary stones-
shows bile duct obstruction and pancreatic disease
ERCP:
diagnosis of acute cholecystitis (good when US unhelpful)
HIDA nuclear scan-I
Typical sites of acute abdominal pain
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.
Intussusception
DxT pale child + severe ‘colic’ + vomiting
acute intussusception
Signs
acute intussusception
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
Diagnosis
acute intussusception
Ultrasound
Enema using oxygen or barium (with caution) used for diagnosis and treatment
Treatment?
acute intussusception
Hydrostatic reduction by air or oxygen from the ‘wall’ supply (preferred) or barium enema
arises from superior mesenteric artery occlusion from either an
embolus or a thrombosis in an atherosclerotic artery.
Acute intestinal ischaemia
Mesenteric artery occlusion
Mesenteric artery occlusion
Clinical features
Central periumbilical abdominal pain - gradually becomes intense. Patients develop a fear of
eating
Profuse vomiting
Watery diarrhoea- blood in one-third of cases (eventually)
DxT anxiety and prostration + intense central pain + profuse vomiting +
bloody diarrhoea -
mesenteric arterial occlusion
Investigations
mesenteric arterial occlusion
CRP may be elevated intestinal alkaline phosphatase.
X-ray (plain) shows ‘thumb printing’
Clinical features
mesenteric arterial occlusion
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
Signs
mesenteric arterial occlusion
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)
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.
Rupture of aneurysm
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,
Acute retention of urine
Management
Acute retention of urine
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.
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
Acute appendicitis
Signs of acute appendicitis
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
the gold standard management of Acute Appendicits
Immediate referral for surgical removal-
the gold standard management of Acute Appendicits, If perforated,
Cefotaxime
and Metronidazole.
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).
SBO
Clinical Features of SBo
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)
X-ray: plain erect film confirms diagnosis- stepladder’ fluid levels (4-5 for diagnosis)
SBO
Management
SBO
IV fluids and bowel decompression with nasogastric tube
Laparotomy or hernia repair
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
LBO
What’s the Confirmatory test for LBO
Gastrogaffin enema
Management of LBO
Drip and suction
Surgical referral
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
Perforated Peptic ulcer
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
Signs and tests (typical of peritonitis)
Perforated Peptic ulcer
MANAGEMENT OF perforated Peptic Ulcer
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)
DxT intense pain (loin) - groin + microscopic haematuria
ureteric
colic
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
ureteric
colic
Diagnosis of Ureteric Colic
Management of Ureteric Colic
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.
Biliary pain
DxT severe pain + vomiting + pain radiation
biliary colic
What is the mainprocedure for Biliary Colic
LAPAROSCOPIC CHOLECYSTECTOMY
What are the 2 main types of gallstones
Cholesterol
Pigment (bilirubin)
What is the causative organisms of the Acute cholecystitis
E coli
KLEBSIELLA
Enterococcus faecalis
CLINICAL FEATURES OF Acute Cholecystitis
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
Diagnosis of Acute Cholecystitis
Ultrasound: gallstones but not specific for cholecystitis
HIDA scan: demonstrates obstructed cystic duct- the usual cause
WCC and CRP: can be elevated
Treatment of Acute Cholecystitis
Bed rest
IV fluids
Nil orally
Analgesics
Antibiotics
Cholecystectomy
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%).
Acute pancreatitis
DxT severe pain + nausea and vomiting + relative lack of abdominal
signs -
acute pancreatitis
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.
Autoimmune pancreatitis
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.
Chronic pancreatitis
most sensitive imaging study -
Chronic pancreatitis
MRCP
Management of Chronic Pancreatitis
Use paracetamol for pain.
Give pancreatic enzyme supplements (e.g. pancrelipase) for malabsorption
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
Acute diverticulitis
DXT acute pain + left-sided radiation + fever
acute diverticulitis
Tx of Acute diverticulitis in severe cases
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.
Peritonitis
Peritonitis
Investigation
peritoneal fluid culture and CT scan.
Peritonitis
Treatment
IV cephalosporins or amoxi/ampicillin + gentamicin + metronidazole.
Surgical intervention is usually required.
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
Abdominal ‘stitch’
If an elderly person presents with intense acute abdominal pain, inadequately
relieved by strong parenteral injections, likely causes include
mesenteric artery
occlusion,
acute pancreatitis and ruptured or dissecting aortic aneurysm
if the person is woken (e.g. at 2-3 am)
with abdominal pain
Consider
gallstones and duodenal ulcer
person with abdominal pain, tenderness and
rigidity and deep sighing respiration
Consider
diabetic ketoacidosis
