MedEd acute abdomen Flashcards
who is most likely to get acute appendicits?
10-20 y/o
how does appendicits present?
periumbilical pain that moves to RIF
nausea and vomiting
low grade fever
what is murphys triad used to diagnose?
appendicits
what triad is used to diagnose appendicits?
murphys triad
what is murphys triad?
abdominal pain that moves from the umbilicus to the RIF
nausea and vomitting
low grade fever
what signs are seen in appendicitis and what do you see?
rovsings sign- palpation of the LIF will cause referred pain in the RIF
psoas sign- extension of the hip causes pain
obturator sign- internal rotation of the flexed thigh causes pain
percussion rebound tenderness and guarding
mc burney’s sign- pain at mcburneys point 1/3 of the way from ASIS to umbilicus
how is appendicitis managed?
make patient NBM
give fluid if there are signs of shock
abx
laparoscopic appendectomy
what are complications of appendicitis?
rupture which can cause peritonitis
abscess which will require drainage
what is diverticular disease?
herniation of mucosa and submucosa through muscle layer of the colonic wall
what is the difference between diverticular disease and diverticulosis?
diverticulosis= presence of diverticula but asymptomatic
diverticular disease= presence of diverticula but symptomatic
where along the colon does herniation occur in diverticular disease?
in between bands of tenia coli
where are diverticula never found?
in the rectum
what are RF for diverticular disease?
low fibre diet
age over 50
obesity
out of diverticulosis and diverticular disease which is worse? why?
diverticular disease because it is symptomatic
how des diverticulitis present?
LIF pain
fever
tachycardia
abdo distention
whats the difference between diverticular disease and diverticulosis?
both are symptomatic but diverticulosis is severe symptoms due to diverticula getting very inflammed or infected
what imaging is done for diveritcular disease and what do you see?
GS: colonoscopy to visualise the diverticula
Barium enema: sawtooth appearance
CT- can confirm diagnosus
how is diverticular disease managed?
you can’t reverse growth but you can slow progression- high fibre diet, hydration, reduce weight, stop smoking
what analgesics should you avoid in diverticular disease and why?
opioids because it will make them more constipated
what are complications of diverticular disease?
diverticulitis abscess perforation peritonitis fistulas and stricture formation
what happens to fluid when there is an intraluminal pressure due to bowel obstruction?
third spacing because fluid is squeezed out
what part of the bowel is most likely to get obstructed?
small bowel
what is strangulation in bowel obstruction?
compromised blood supply which can lead to ischaemia and gangrene
what are the most common causes of small v large bowel obstruction?
small bowel obstruction= mainly from adhesions from surgery
large bowel obstruction= mainly from malignancy
what is the most common cause of small bowel obstruction?
adhesions from surgery
what is the most common cause of large bowel obstruction?
malignancy
what are signs and symptoms of bowel obstruction?
severe colicky pain abdo distention tinkling bowel sounds bilious vomitting constipation
what is the main imaging for bowel obstruction?
supine abdominla x ray
on abdo x ray how do you differentiate between small and large bowel obstruction?
small bowel= vulvae coniventae are seen which are lines that go all the way across the bowel
large bowel= haustra which go halfway across the bowel
what are vulvae coniventae, how do you spot them and in what are they seen?
they are lines that go all the way across the bowel and help identify small bowel obstruction
what is the difference between vulvae coniventae and haustra and where is each seen on an abdo x ray?
vulvae coniventae= lines on the small bowel that go all the way across
haustra= lines on the large bowel that only go halfway across
how is bowel obstruction managed?
conservative: NDM, NG tube to decompress bowels, IV fluids, urinary catheter and analgesia
if acute and theres evidence of strangulation/ichaemia then do a laparotomy
how is bowel obstruction secondary to adhesions managed?
conservatively- NMD, NG tube to decompress bowel
then check in 24 hrs
what is volvulus?
rotation of a loop of bowel around the axis of its mesentery that results in obstruction and ischaemia
what part of the bowel is most commonly affected in volvulus?
most commonly the sigmoid colon
sometimes the caecum
what are RF for volvulus?
long sigmoid colon long mesentery mobile caecum chronic constipation adhesions
what are signs and symptoms of volvulus?
severe colicky pain constipation absent or tinkling bowel sounds vomitting abdo distention and tenderness signs of dehydration
what is seen on abdo x ray in volvulus?
coffee bean sign
how is volvulus managed?
if sigmoid colon then sigmoidoscopy and detorsion, there is a high rate of recurrence and if so surgery may be needed
if caecum them colonoscopy cannot be done due to risk of detorsion so surgery is done
describe how acute pancreatitis arises
when a apcnreas is inflammed calcium build up in it
this causes release of enzymes like lipase and amylase
this damages local structures and causes systemic signs
what is the most common cause of pancreatitis in women vs men?
women= gallstones men= alcohol
what electrolyte imbalance can cause pancreatitis?
hypercalcaemia
what drugs can cause pancreatitis?
sodium valproate, steroids, thiazides and azathioprine
what are signs and symptoms of acute pacreatitis?
severe epigastric pain that radiates to the back- relieved by sitting forward and worse when lying down
nausea and vomitting
fever
hypovolemia
what are the 2 signs of acute pancreatitis and where are they found?
cullens sign= periumbilical bruising
grey turners sign= flank bruising
how do you remember which way around grey turners and cullens sign is?
cullens= bella cullen from twilight had a really fucked up baby and a baby is in the tummy so cullens sign= tummy/perumbilical bruising
grey turners sign= flank bruising
what are grey turners and cullens signs a sign of?
acute pancreatitis
what ix are done for acute pancreatitis? what will you see
amylase lipase- 3x higher than normal
CT abdo GS to confirm diagnosis
ALP +bilirubin to check for gallstones
Ca/triglyceride levels
what is GS imaging for acute pancreatitis?
CT abdomen
how high are amylase and lipase in acute pancreatitis? what must you be careful to remember?
3x normal
the level of enzyme does not correspond to the severity of the pancreatitis
out of amylase and lipase which is more sensitive for pancreatitis?
lipase
describe glasgow/ PANCREAS score
PaO2= <8kpa/60 mmHg Age >55 Neutrophils- high WBC Calcium <2 mmol/L Renal function- urea >16 mmol/L Enzymes- high AST/ALT or LDH Albumin <32g/L Sugar- glucose >10 mmol/L
how is acute pancreatitis managed?
analgesia IV fluids NG tube Control blood sugar abx if infected treat cause
if acute pancreatitis is caused by gallstones how is this managed?
ERCP with sphincterotomy
cholecystectomy
remove nectrotic tissue
what is a predictor of pancreatitis severity? what is not
heamatocrit is a good indicator of severity
enzymes (amylase/lipase) ARE NOT good severity predictors
what is peritonitis?
inflammation of the peritoneal lining of the abdominal cavity
what is the difference between primary and secondary generalised peritonitis?
primary is due to bacterial infection without an obvious source
secondary is due to a pre existing abdominal condition
what are signs and symptoms of peritonitis?
nausea and vomitting
acute onset severe abdomen pain that is generalised at first and then becomes localised
reduced bowel sounds (due to paralytic ileus)
signs of sepsis
gaurding and rebound tenderness
washboard rigidity
what is seen on ascitic tap in SBP?
neutrophil count over 250
what is seen on erect CXR in peritonitis?
air under the diaphragm
what is SBP?
spontaneous infection of ascitic fluid not originating from an obvious place in the abdomen eg hole in intestines or collection of pus
how is peritonitis managed?
conservative: IV fluids, abx, NG tube
primary generalised/septic= broad spectrum abx
localised/secondary generalised= treat cause, may need surgery (necrosectomy and peritoneal lavage)
what is a hernia and what are the 2 common types?
usually inguinal or femoral
it is a protrusion of contents through areas of weakness in the wall that contains them
what are the causes of hernia?
anything that increases intra abdominal pressure eg pregnancy chronic cough constipation weakened abdo muscles
where are femoral vs inguinal hernias located? how do you remember this
femoral= inferior and lateral to the pubic tubercle (remember because the femoral vein goes below/inferior and is lateral to the pubic tubercle)
inguinal= superior and medial to the pubic tubercle
what are the borders of hesselbach’s triangle?
lateral border of rectus abdominis
inferior epigastric vessels
inguinal ligament
what type of hernia is related to hesselbach’s triangle and how?
direct inguinal hernia
what anatomical triangle does a direct inguinal hernia protrude through?
hesselbach’s triangle
in what gender are inguinal hernias more common?
males
describe anatomically where an direct vs indirect inguinal hernia starts and ends
direct= in through a hole in the back of the inguinal canal and out through superficial inguinal ring indirect= in through deep inguinal ring and out through superficial inguinal ring
in what gender is femoral hernia more common in and how do you remember?
females because femoral and female both start with an f
how do you remember the positioning of inguinal v femoral hernia?
femoral artery is below and lateral to pubic tubercle and so is the hernia
inguinal= intimate to it extends towards the genitalia therefore it is superficial and medial to the pubic tubercle
what is an incarcerated hernia?
when the contents of a hernia are stuck inside by adhesions
what is a strangulated hernia?
when the blood supply to the hernia is cut off
how are inguinal or femoral hernias managed?
conservative- weight loss
elective repair- mesh repair where stent is placed over the defect where the hernia protruded from
obstructed/strangulated- emergency laparotomy
how are incarcerated/strangulated hernias repaired?
via emergency laparotomy
how dies intestinal ischaemia arise?
obstruction of a mesenteric vessel leading to bowel ischaemia and necrosis
what are RF for intestinal ischaemia?
increasing age
AF
other causes of emboli eg endocarditis, malignancy
cardiovascular disease RF eg hypertension, diabetes, hyperlipidaemia
