medical causes of abdominal pain Flashcards
sx to ask about in an abdominal pain Hx
SOCRATES
site - upper or lower
- epigastic - stomach, duodenum, pancreas
- LLQ - sigmoid colon = diverticulum
- RLQ - appencitis, crohn’s
Waves, colicky (muscular tube contracting repeatedly due to obstruction of the tube) or constant.
All time or come and go – freq and duration
Associated sx – vom/diarrhoea etc
inflammatory GI causes of abdo pain
gastroenteritis
appendicitus
gastritis
oesophagitis
diverticulitis
crohn’s
UC
GI obstructive causes of abdo pain
hernia
intissesception
volvulus
post-surgical adhesions
tumour
severe constipation
haemorrhoids
vascular GI causes of abdo pain
embolism
thrombosis
haemorrhage
SCD - thrombotic type sx
abdominal angina - mesenteric ischemia
blood vessel compressiuon - coeliac artery compression syndrome
superior mesenteric artery syndrome
digestive GI causes of abdo pain
peptic ulcer
lactose intolerance
coeliac disease
allergies
bile system causes of abdo pain
inflammatory - cholecystitis, cholangitis
obstruction - cholelithiasis, tumours
liver causes of abdo pain
hepatitis
abscess
pancreatic cause of abdo pain
pancreatitis
renal and urological inflammatory causes of abdo pain
pyelonephritis
bladder infection
indigestion
onstruction causes of renal and urological abdo pain
kidney stones
urolithiasis
urinary retention
tumours
renal and urological vascular causes of abdo pain
left renal vein entrapment
gynae causes of abdo pain
inflammatory - pelvic inflammatory disease
mechanical - ovarian torsion
endocrinological - menstruation, mittelschmerz
tumours - endometriosis, fibroids, ovarian cyst, ovarian cancer
pregnancy - ruptured ectopic pregnancy, threatened abortion
abdominal wall causes of abdo pain
muscle strain or trauma
muscular infection
neurogenic pain - herpes zoster (dermatomal), radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrem (ACNES), tabes dorsalis
referred pain in abdo
from thorax - pneumonia, PE, IHD, pericarditis
from spine - radiculitis
from genitals - testicular torsion (also to the back)
metabolic disturbance cause of abdominal pain
uraemia
DKA
porphyria
C1- esterase inhibitor deficiency
adrenal insufficiency
lead poisening
BV cause of abdo pain
aortic dissection
AAA
mesenteric ischemia
immune system cause of abdo pain
sarcoidosis
vasculitis
familial mediterranean fever
idiopathic cause of abdo pain
IBS - effects 20% of the population, most common cause of recurrent and intermittent abdo pain
dyspepsia
range of sx from upper GIT - >4wks - upper abdo pain ot discomfort, heartburn, gastric refluc, nausea or vomiting
related to eating
epidemiology fo dyspepsia
majority of GI GP consultations are related to dyspepsia
2% of population consult dr about dyspepsia annulay
£600 million on prescription drugs and GI endoscopy for dyspepsia/yr
major conditions to identify in dyspepsia
severe (stricturing) oesophagitis
peptic ulcer disease
oesophageal cancer
gastric cancer
?barretts oesophagus
Ix for dyspepsia
if sx and no red flag (<50, not anaemic, no dysphagia) - H pylori test and eradication
endoscopy is definite Ix
Barrett’s – surveillance – squamous -> columnar metaplasia -> dysplasia -> cancer - endoscopy and relatively few people transform
definition of diarrhoea
passage of 3 or more loose or liquid stools /day. or more frequent than normal for person
faecal weight of more tha 200g/day
acute <2wks
chronic >4wks
definitions irrelevant - pt have own idea - need accurate Hx
hx for diarrhoea
frequency
consistency
presence of blood and mucus
associated features - pain, vomiting and fever
BO at night - suggests significant physical cause, less inIBS
urgency - colitis - rectal inflammation - rush as soon as stool is in the rectum
does it flush - malabsorption – steatorrhea – if not absorbing fat its difficult to flush
bristol stool chart
mechanisms of diarrhoea
secretory - cholera toxin make gut pump out a lot of salt and water into lumen -> dehydrated
osmotic eg hypolactasia, drugs, malabsorption – suck water into lumen, lactase deficiency – don’t break down lactose – osmotically active = suck water in. lactulose (osmotic laxative), bile acid malabsorptipn - bile salt in colon osmotically active = watery diarrhoea
exudative - secretion of exudate into lumen, associated with inflammation in the mucosa. eg IBD/severe infection
abnormal motility - IBS push things through too fast. If problem with motility too slow – bacterial overgrowth from the stasis = diarrhoea – osmotically active and water. Previous surgery
mixed
what is overflow diarrhoea
become so constipated that they get overflow diarrhoea – liquid squeeze around the constipated stool
what is dysentry
diarrhoea assiciated with the passage of frank blood - associated with fever, abdo pain and vomiting
mainly infective:
- bacillary dysentry due to shigella, salmonella, yersinia, campylobacter or e coli
- amoebic dysentry - entamoeba histolytica - hard to dx (need hot stool sample to see cysts)
causes of diarrhoea
Viral is the most common
Giardia – upper small bowel and causes malabsorption = sig wht loss – if biopsy don’t see any changes – need to catch the giardia
Coeliac – gluten enteropathy
Bacterial overgrowth
Microscopic colitis – only see when take biopsy. Routinely take biopsy
Thyrotoxicosis – increased sweating, tachy
NSAIDs – can cause small bowel problems
Addisons sometimes
Gastrinoma – similar path to ZE
GI infections causing diarrhoea
short hx
precipitating event - food, contact, travel
associated feaures - fever, crampy abdo pain, vom
dysentry if severe
multiple stool samples needed to detect bacterial infection
viral difficult to dx - electron microscopy
Mx - rehydration and AB (ciprofloxacin)
clostridium difficile diarrhoea
can cause pseudomembranous colitis
associated with AB use, wipe out normal microbiome and c diff take over - more in healthcare
cause mortality, esp in elderly
Mx - rehydration and AB (metronidazole or vancomycin)
if resistant - faecal microbial transplantation
colectomy if evidence of dilation or perforation
what is malabsorption
failure to absorb nutrients from the bowel
- failure to secrete digestive enzymes - pancreatic disease
- failure to absorb through the gut wall - mucosal disease
- abnormal luminal env preventing absorption - structural abnormalities, surgery, stricture
single or combined nutrient abnormality
clincal features of malabsorption
diarrhoea
steatorrhea if fat absorption
pale, bulky, offensive stools
difficult to flush
malabsorption w/o diarrhoea suggests intestinal cause
wht loss
lethargy, anorexia, abdo discomfort/bloating
hypoalbuminaemia, hypocalcaemia, vitamin deficiencies
mx of malabsorption
document the malabsorption
- stool sample for fat globules
- 3 day faecal fat estimation
- FBC - B12, folate, Fe, ferritin
- clotting - PT (vit K def)
- albumin, ca, phos, ALP
establish site of amalabsorption
establish underlying cause
institute treatment
what malabsorption does pancreatitis/pancreatic cancer cause
fat
ca
B12
what malabsorption does coeliac disease cause
iron
B12
folate
fat
ca
what malabsorption dose crohn’s disease form
b12
bile salts
what malabsorption does infective/post-infective causes form
fat
folate
what type of malabsorption does bacterial overgrowth form
combined
causes of malabsorption
biliary obstruction
tropical sprue
parasites
short bowel
resection - gastric, pancreatic, terminal ileal
rare - CF, lymphoma, Whipple’s, thyrotoxicosis, ZE, amyloidosis, mesenteric ischemia, mastocytosis
non-invasive tests to determine whether malabsorption is intestinal or pancreatic
faecal elastase - have to have moderately severe pancreatic malabsorption for it to be +ve
CT scanning/ERCP
trial of therapy
tTG, anti-endomysial Ab, reticulin, gliadin Ab’s
tests for intestinal causes of malabsorption
tissue transglutaminase - coeliac, specific
IgA Ab - some people deficient so miss dx in these people
becomes -ve on gluten free diet
jejunal/distal duodenal biopsy gold standard dx for coeliac
lactulose breath test - less commonly performed
barium follow through/small bowel MRI - structural abnormality, crohn’s
jejunal diverticulosis - bacterial overgrowth
crohn’s - B12 def
SeHCAT scan - assess bile salt malabsorption - high negative predictive value
what is lactulose breath test
give 50g of lactulose
unabsorbed sugar fermented by bacteria to hydrogen - absorbed into circulation and exhaled
30mls end expiratory air is collected at 20 min intervals for 3hrs and analysed for hydrogen
>20ppm is abnormal and suggests bacterial overgrowth
commonest causes of malabsorption
chronic pancreatitis
coeliac disease
crohn’s disease
post-infective
what are IBD
chronic relapsing inflammatory disorders of teh GIT
UC or crohn’s
also include - microscopic colitis, behcet’s disease, systemic vasculitis
need to distinguish from infections
microscopic colitis
common
dont need surgery
no risk of cancer
behcet’s
recurrent oral and genital ulcer
in gut in 20% cases
in turkey and fertile crescent
ddx of UC
amoebic olitis
ddx of crohn’s
yersinia
TB
ddx of crohn’s and UC
behcet’s
vasculitis
sx of inflammation in colon
bleeding
mucus
urgency
diarrhoea (constipation if just rectum involved)
sx of small bowel inflammation
abdo pain
wht loss
tiredness/lethargy
diarrhoea
abdo mass because of loop of matted bowel
sx of perianal inflammation
anal pain
leakage
difficulty passing stool
extra-intestinal sx of IBD
arthrits - axial = ankylosing spondylitis, peripheral
skin - erythema nodosum, pyoderma gangrenosum
eyes - anterior uveitis, episcleritis/iritis
liver - PSC, autoimmune hepatitis
pyoderma gangrenosum
this is sterile
how do you dx active IBD
stool cultures
inflammatory markers
fecal calprotectin
rectal biopsy
bloods - malabsorption, Hb
ddx
- infection - amoebic, yersina/c diff
- appendicitis
- bacterial overgrowth
- bile salt malabsorption
acute severe colitis
consequence of IBD or pseudomembranouse colitis from c diff
systemically unwell
diarrhoea
truelove and witts criteria
- BO >6x/day
- tachycardia
- pyrexia >37.5
- anaemia
problem with toxic megacolon
risk of perf
= peritonitis
= death
Mx of acute severe colitis
admit
ACR
is there colonic dilatation or evidence of perf = surgeons
resus
IV hydrocortisone
IV AB
monitor FBC, ESR and CRP dauily
if no better at 3-4 days - infliximab
if no better at 5-7 - colectomy
if acute deterioration - colectomy
toxic megacolon
such substantial inflammation in colonic wall = failure of peristalsis – gas dilates = toxic megacolon
