Murtagh - Abdominal pain cont. biliary pain

Question 1

in a patient with acute pancreatitis, there may be a past history of

Answer 1

previous attacks or alcoholism, or gallstone disease

Question 2

acute pancreatitis is commonly precipitated by

Answer 2

fatty foods and alcohol, mumps, hypertriglyceridaemia and come antidiabetic medications e.g. gliptins

Question 3

pain distribution of acute pancreatitis

Answer 3

Question 4

typical clinical features of acute pancreatitis

Answer 4

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

Question 5

pain of acute pancreatitis may be relived by

Answer 5

sitting forwards

Question 6

patient with severe pain, nausea and vomtiing and relative lack of abdominal signs is likely to have

Answer 6

acute pancreatitis

Question 7

signs of acute pancreatitis

Answer 7

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

Question 8

WCC for acute pancreatitis will show

Answer 8

leukocytosis

Question 9

CRP for acute pancreatitis will be

Answer 9

elevated

Question 10

other labs for acute pancreatitis

Answer 10

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

Question 11

imaging for acute pancreatitis

Answer 11

plain x-ray, may be sentinel loop
CT scan (especially for complications)
ultrasounds better for detecting cysts and unsuspected gall stones

Question 12

management for acute pancreatitis

Answer 12

admit
bed rest, nil orally, nasogastric suction of vomiting, IV fluids and analgesics (morphine)
may require ECRP if obstructive LFTs

Question 13

what sort of analgesia will the patient with acute pancreatitis require

Answer 13

2.5-5mg IV morphine or fentanyl 50-100mcg IV statim then titrate to effect

Question 14

clinical features of chronic pancreatitis

Answer 14

pain is milder but more persistent
may be epigastric pain boring through to the back
symptoms may relapse and worsen

Question 15

chronic pancreatitis should be investigated with

Answer 15

investigate with CT scan and ultrasound and faecal elastase
MRCP is the most sensitive imaging study

Question 16

problems with diagnosing chronic pancreatitis

Answer 16

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

Question 17

acute diverticulitis

Answer 17

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

Question 18

how many patients with diverticular disorder will get diverticulitis

Answer 18

less than 10%

Question 19

pain distribution of diverticulitis

Answer 19

Question 20

clinical features of acute diverticulitis

Answer 20

acute onset of pain in the left iliac fossa
pain increased with walking and change of position
usually associated with constipation

Question 21

signs of acute diverticulitis

Answer 21

tenderness, guarding, and rigidity in LIF
fever
may be inflammatory mass in LIF

Question 22

investigations for acute diverticulitis

Answer 22

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

Question 23

complications of acute diverticulitis

Answer 23

bleeding (can be profuse, especially in the elderly)
perforation (high mortality)
abscess
peritonitis
fistula (bladder, vagina, small bowel)
instestinal obstruction

Question 24

treatment for acute diverticulitis

Answer 24

admit
rest the gIT: nil orally, drip and suction
analgesics
antibiotics
surgery for complications
screening colonoscopy after acute episode

Question 25

peritonitis

Answer 25

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

Question 26

investigations for peritonitis

Answer 26

peritoneal fluid culture and CT scan

Question 27

management for peritonitis

Answer 27

surgical intervention usually required
antibiotics
spontaneous bacterial peritonitis can occur in any patient with ascites

Question 28

abdominal stitch

Answer 28

sharp, stabbing pain in the epigastric of hypochondrium regions of the abdomen, usually during running

Question 29

the sufferer of a stitch should

Answer 29

stop and walk - don’t run
apply deep massage to the area with the palms of three middle fingers
perform slow or deep breathing

Question 30

chronic or recurrent abdominal pain

Answer 30

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

Question 31

investigations for chronic or recurrent abdominal pain

Answer 31

ultrasound, CT, endoscopy, MRI, laparoscopy

Question 32

red flags in abdominal pain for organic disease

Answer 32

older patient
nocturnal pain or diarrhoea
progressive symptoms
rectal bleeding
fever
anaemia
weight loss
abdominal mass
recent onset faecal incontinence or urgency

Question 33

chronic appendicitis

Answer 33

recurrent episodes of subacute inflammation of the appendix

Question 34

diagnosing chronic appendicitis

Answer 34

a laparoscopy performed during or soon after an attack is diagnostic

Question 35

adhesions

Answer 35

no evidence that adhesions are painful apart from complications such as bowel obstruction

Question 36

clinical features of peptic ulcer (gastric or duodenal)

Answer 36

usually central epigastric pain
burning pain
received by antacids or food or milk

Question 37

what precipitates pain from peptic ulcer

Answer 37

usually 2-3 hours after meals or wakes from sleep
inconsistent relationship to eating