Murtagh - Abdominal pain Flashcards
inflammatory causes of acute abdomen
inflammatory bowel disease
appendicitis
cholecystitis
hepatitis
pancreatitis
salpingitis (Fallopian tubes)
diverticulitis
causes of acute abdomen caused by perforation
perforated duodenal ulcer
perforated gastric ulcer
faecal peritonitis
biliary peritonitis
appendicitis
obstructive causes of acute abdomen
biliary colic
acute small bowel obstruction
acute large bowel obstruction
ureteric colic
acute urinary retention
intestinal infarction
heamorragic causes of acute abdomen
ruptured ectopic pregnancy
ruptured spleen or liver (haemoperitoneum)
ruptured ovarian cyst
ruptured abdominal aortic aneurysm
causes of acute abdomen related to torsion (ischaemia)
sigmoid volvolus
torsion ovarian cyst
torsion of testes
what is the most likely cause of severe colicky midline umbilical abdominal pain with distension and vomiting
SBO
what is the most likely cause of midline lower abdominal pain with distention and vomiting
large bowel obstruction
name something that must be considered in an elderly patient presenting with severe abdominal pain with a background of arteriosclerotic disease or AF, or following MI
mesenteric artery occlusion
‘probability diagnosis’ for acute abdominal pain
acute gastroenteritis
acute appendicitis
mittelschmerz/dysmenorrhea
irritable bowel syndrome
biliary colic/renal colic
serious cardiovascular disorders ‘not to be missed’ for acute abdomen presentation
myocardial infarction
ruptured AAA
dissecting aneurysm aorta
mesenteric artery occlusion/ischaemia
severe infections ‘not to be missed’ in acute abdomen presentations
acute salpingitis
peritonitis/spontaneous bacterial peritonitis
ascending cholangitis
intra-abdominal abscess
other ‘serious disorders not to be missed’ for acute abdomen
pancreatitis
ectopic pregnancy
small bowell obstruction/strangulated hernia
sigmoid volvolus
perforated viscus
neoplasia (large or small bowel obtstruction)
pitfalls often missed in acute abdomen
acute appendicitis
myofascial tear
pulmonary causes - pneumonia or pulmonary embolism
faecal impaction (elderly)
herpes zoster
rare causes of acute abdomen
porphyria
lead poisoning
henoch-schonlein purpura
haemochromatosis
haemoglobinuria
Addison disease
seven masquerades checklist for acute abdomen
depression
diabetes (ketoacidosis)
drugs (especially narcotics)
anaemia (sickle cell)
endocrine disorder (thyroid storm, Addison)
spinal dysfunction
UTI (including urosepsis)
for acute abdomen - is the patient trying to tell me something?
consider munchausen syndrome, sexual dysfunction and abdominal stress
probability diagnosis of chronic abdomen
irritable bowel syndrome
diverticular disease
mittelschmerz/dysmenorrhea
peptic ulcer/gastritis
serious disorders not to be missed in chronic abdomen
cardiovascular - mesenteric artery ischaemia or AAA
neoplasia
- bowel/stomach cancer
- pancreatic cancer
- ovarian tumours
severe infections
- hepatitis
- recurrent PID
pitfalls often missed for chronic abdomen
adhesions
appendicitis
food allergies
lactase deficiency
constipation/faecal impaction
chronic pancreatitis
crohns disease
endometriosis
diverticulitis
rare causes of chronic abdomen
tropical infections eg. hydatids, melioidoses, malaria, strongyloides
uraemia
lead poisoning
porphyria
sickle cell anaemia
hypercalcaemia
Addisons disease
seven masquerades checklist for chronic abdomen
depression
drugs
andocrine disorder (Addisons disease)
spinal dysfunction
UTI
for chronic abdomen - is the patient trying to tell me something?
consider hypochondriasis, anxiety, sexual dysfunction, munchausen syndrome
misdiagnosis of ectopic pregnancy may cause
rapid hypovolaemic shock
misdiagnosis of ruptured AAA may cause
rapid hypovolaemic shock
misdiagnosis of gangrenous appendix may cause
peritonitis/pelvic abscess
misdiagnosis of perforated ulcer may lead to
peritonitis
misdiagnosis of obstructed bowel may lead to
gangrene
what is a common cause of acute abdomen in children
mesenteric adenitis
red flags to ask about in history taking for the acute abdominal pain patient
collapse on the toilet
lightheadedness
ischameic heart disease
progressive vomiting pain, distention
menstural abnormalities
malignancy
lack of flatus
signs to look out for in the acute abdomen presenting patient
pallor and sweating
hypotension
atrial fibrillation or tachycardia
fever
prostration
rebound tenderness and guarding
decreased urine output
early appendicitis presents typically as
centraal abdominal pain that shifts to the right iliac fossa some 4-6 hours later
can cause diarrhoea with abdominal pain, especially if a pelvic appendix
in what populations might appendicitis present atypically
elderly, in children, pregnancy and in those taking steroids
disaccharidase deficiencies
eg. lactase deficiency
associated with cramping and abdominal pain, which may be severe
follows hours after the ingestion of milk and is accompanied by the passage of watery stool
how might herpes zoster present
in the elderly patient with unilateral abdominal pain in the dermatomal distribution
causes of abdominal pain, frequency and dysuria other than UTI
cause could also be diverticulitis, pelvic appendicitis, salpingitis or a ruptured ectopic pregnancy
drugs to consider as a cause of abdominal pain
alcohol
antibiotics
aspirin
corticosteroids
cytotoxic agents
tricyclic antidepressants
iron preparations
nicotine
NSAIDs/COX-2 inhibitors
sodium valproate
phenytoin
for a patient with AF you should consider
mesenteric artery obstruction
for a patient with tachycardia you should consider
sepsis and volume depletion
for a patient with taahypnoea you should consider
sepsis, pneumonia, acidosis
for a patient with pallor and shock you should consider
acute blood loss
for a patient with absent bowel sounds you should consider
diffuse sepsis, ileum, mechanical obstruction (advanced)
for distension, you should consider
six Fs
fat, fluid, flatus, faeces, fetus, frightening growths
for hypertympany, you should consider
indicates mechanical obstruction
haemoglobin may identify
anaemia with chronic blood loss
eg. peptic ulcer, cancer, oesophagitis
blood film may indicate
abnormal red blood cells with sickle cell disease
WCC may indicate
leucocytosis with appendicitis
acute pancreatitis
mesenteric adenitis
cholecystitis (especially with empyema)
pyelonephritis
ESR indicates
raised with cancer, crohns disease, abscess, but non-specific test
CRP may indicate
preferable to ESR
use in diagnosing and monitoring infection, inflammation eg. pancreatic
liver function tests may indicate
hepatobiliary disorder
serum amylase and/or lipase may indicate
if raised to greater than three times the normal upper level then pancreatitis is most likely
also raised partially with most intra-abdominal disasters (e.g. ruptured ectopic pregnancy, perforated peptic ulcers, ruptured empyema of gall bladder, ruptured aortic aneurysm)
faecal elastase may indicate
chronic pancreatitis
pregnancy tests may indicate
for susppected ectopic
urina and serum bHCG
blood in urine sample may indicate
ureteric colic (stone or blood clot), urinary infection
white cells in urine sample may indicate
urinary infection, appendicitis (bladder irritation)
bile pigments in urine sample may indicate
gall bladder disease
porphobilinogen in the urine sample may indicate
porphyria
(add ehrlich aldehyde agent)
ketones in the urine sample may indicate
diabetic ketoacidosis
air in the urine sample is called
pneumaturia
pneumaturia may indicate
fistula (eg. diverticulitis, other pelvic abscess, pelvic cancer)
faecal blood may indicate
mesenteric artery occlusion, intussusception (recurrant jelly), colon cancer, diverticulitis, crowns disease and ulcerative colitis
what might you look for on an x-ray abdomen
- kidney/ureteric stones (70% opaque)
- biliary stones (10-30% opaque)
- air in the biliary tree
- calcified aortic aneurysm
- marked distension sigmoid - sigmoid volvolus
- distended bowel with fluid level: bowel obstruction
- enlarged caecum with large bowel obstruction
- blurred right psoas shadow: appendicitis
- coffee bean sign: volvulus
- a sentinel loop of gas in left upper quadrant (LUQ): acute pancreatitis
a distended bowel with fluid level on x-ray indicates
bowel obstruction
a blurred high psoas shadow on x-ray indicates
appendicitis
a coffee bean sign on x-ray indicates
volvolus
a sentinel loop of gas in the upper left quadrant indicates
acute appendicitis
what are you looking for on a chest x-ray
perforated ulcer
an ultrasound is most useful for
hepatobiliary system,
kidneys and female pelvis
what should you look for on an ultrasounds
gallstones
ectopic pregnancy
pancreatic pseudocyst
aneurysm aorta/dissecting aneurysm
hepatic metastases and abdominal tumours
thickened appendix
parabolic collection
an ultrasound might be affected by
gas shadows
a CT scan is good for
gives good survey of abdominal organs including masses and fluid collection
what are you looking for on CT scan
pancreatitis (acute and chronic)
undiagnosed peritoneal inflammation (best)
trauma
diverticulitis
leaking aortic aneurysm
retroperitoneal pathology
appendicitis (especially with oral contrast)
ERCP might show
bile duct obstruction and pancreatic disease
a contrast enhanced x-ray might be useful for
e.g. gastrograffin meal
diagnosis of bowel leakage
HIDA or DIDA nuclear sign is used for
diagnosis of acute cholecystitis
this is useful when US is unhelpful
other investigations for abdominal presentations
IVP
barium enema
MRI
ECG
endoscopy upper GI
sigmoidoscopy and colonoscopy
what does this stuff look like on plain x-ray?
early severe vomiting indicates
severe obstruction of the GIT
what is colicky pain
rhythmic pain with regular spasms of recurring pain building to a climax and then fading
what is true colic?
true colic is ureteric colic
biliary colic and kidney colic are not ‘true colics’
epigastric pain usually arises from
usually arises from the disorders of the embryologic foregut
eg. oesophagus, stomach and duodenum, hepatobiliary structures, pancreas and spleen
if the pain moves from the epigrastrium to the right
gall bladder and liver
if the pain moves from the peigastrium to the left
spleen
periumbilical pain usually arises from
usually arises from disorders of the embryologic midgut
supreppubic pain usually arises from
disorders of the embryologic hindgut
pain from visceral mechanoreceptors
triggered by intestinal distention or tension on mesentery or blood vessels
diffuse and poorly localised pain
pain from parietal peritoneal nociceptors
triggered by mechanical, thermal and chemical stimuli
pain is experienced directly at the site of insult
