Murtagh - Abdominal pain cont. biliary pain Flashcards
in a patient with acute pancreatitis, there may be a past history of
previous attacks or alcoholism, or gallstone disease
acute pancreatitis is commonly precipitated by
fatty foods and alcohol, mumps, hypertriglyceridaemia and come antidiabetic medications e.g. gliptins
pain distribution of acute pancreatitis
typical clinical features of acute pancreatitis
sudden onset of severe constant deep epigastric pain but onset Cana be steady
lasts hours or a day or so
pain may radiate to the back
pan may be relieved by sitting forwards
nausea and vomiting
sweating and weakness
pain of acute pancreatitis may be relived by
sitting forwards
patient with severe pain, nausea and vomtiing and relative lack of abdominal signs is likely to have
acute pancreatitis
signs of acute pancreatitis
patient is weak, pale, sweating and anxious
tender in epigastrium
lack of guarding, rigidity or rebound
reduced bowel sounds (may be absent if ileus)
+/- abdominal distension
fever, tachycardia, +/- shock
WCC for acute pancreatitis will show
leukocytosis
CRP for acute pancreatitis will be
elevated
other labs for acute pancreatitis
serum lipase (preferred as more sensitive and specific) or serum amylase
serum glucose will be elevated
calcium will be low
blood gasses for pulmonary complications
LFTs may show obstructive pattern
imaging for acute pancreatitis
plain x-ray, may be sentinel loop
CT scan (especially for complications)
ultrasounds better for detecting cysts and unsuspected gall stones
management for acute pancreatitis
admit
bed rest, nil orally, nasogastric suction of vomiting, IV fluids and analgesics (morphine)
may require ECRP if obstructive LFTs
what sort of analgesia will the patient with acute pancreatitis require
2.5-5mg IV morphine or fentanyl 50-100mcg IV statim then titrate to effect
clinical features of chronic pancreatitis
pain is milder but more persistent
may be epigastric pain boring through to the back
symptoms may relapse and worsen
chronic pancreatitis should be investigated with
investigate with CT scan and ultrasound and faecal elastase
MRCP is the most sensitive imaging study
problems with diagnosing chronic pancreatitis
patient with this problem is often labelled as gastritis, ulcer or neurotic because of the indeterminate nature of the pain
malabsorption and diabetes may result from pancreatitis and weight loss and steatorrhoea become prominent features
acute diverticulitis
the patient with acute diverticulitis is usually over 40 years of age, with long-standing, grumbling, left sided abdominal pain and constipation, but acan have irregular bowel habit
how many patients with diverticular disorder will get diverticulitis
less than 10%
pain distribution of diverticulitis
clinical features of acute diverticulitis
acute onset of pain in the left iliac fossa
pain increased with walking and change of position
usually associated with constipation
signs of acute diverticulitis
tenderness, guarding, and rigidity in LIF
fever
may be inflammatory mass in LIF
investigations for acute diverticulitis
FBE: leucocytosis
elevated ESR
pus and blood in stools
abdominal ultrasound/CT scan (especially - can detect fistula, abscess, or perforation)
erect chest x-ray
erect and supine abdominal x-ray
complications of acute diverticulitis
bleeding (can be profuse, especially in the elderly)
perforation (high mortality)
abscess
peritonitis
fistula (bladder, vagina, small bowel)
instestinal obstruction
treatment for acute diverticulitis
admit
rest the gIT: nil orally, drip and suction
analgesics
antibiotics
surgery for complications
screening colonoscopy after acute episode
peritonitis
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
investigations for peritonitis
peritoneal fluid culture and CT scan
management for peritonitis
surgical intervention usually required
antibiotics
spontaneous bacterial peritonitis can occur in any patient with ascites
abdominal stitch
sharp, stabbing pain in the epigastric of hypochondrium regions of the abdomen, usually during running
the sufferer of a stitch should
stop and walk - don’t run
apply deep massage to the area with the palms of three middle fingers
perform slow or deep breathing
chronic or recurrent abdominal pain
consider conditions such as pancreatic cancer, ovarian cancer, small bowel tumours, mesenteric ischaemia, chron’s disease, metabolic disorders such as lactase deficiency, and rarer conditions
investigations for chronic or recurrent abdominal pain
ultrasound, CT, endoscopy, MRI, laparoscopy
red flags in abdominal pain for organic disease
older patient
nocturnal pain or diarrhoea
progressive symptoms
rectal bleeding
fever
anaemia
weight loss
abdominal mass
recent onset faecal incontinence or urgency
chronic appendicitis
recurrent episodes of subacute inflammation of the appendix
diagnosing chronic appendicitis
a laparoscopy performed during or soon after an attack is diagnostic
adhesions
no evidence that adhesions are painful apart from complications such as bowel obstruction
clinical features of peptic ulcer (gastric or duodenal)
usually central epigastric pain
burning pain
received by antacids or food or milk
what precipitates pain from peptic ulcer
usually 2-3 hours after meals or wakes from sleep
inconsistent relationship to eating
