Murtagh - Abdominal pain cont. in the elderly Flashcards
abdominal aortic aneurysm
may be asymptomatic until it ruptures
or may present with abdominal discomfort and pulsatile mass noted by the patient
screening for abdominal aortic aneurysm
tends to be a family history
ultrasound screening is appropriate in all families in first degree relates over 50 years
risk of rupture in abdominal aortic aneurysm is related to
diameter of the AAA and the rate of increase in diameter
normal diameter of the aorta
10-30mm
aneurysm is anything greater than 30mm
refer if it is above 40mm
operate if above 50mm
best investigations for AAA
ultrasound is good for screening, obesity can be a problem
CT scan provides clearer imaging, helical/spiral scan is the investigation of choice
MRI scan provides best definition
typical pain distribution of ruptured abdominal aortic aneurysm
mesenteric artery occlusion
acute intestinal ischaemia arises from superior mesenteric artery occlusion from either an embolus or a thrombosis in an atherosclerotic artery
another cause is an embolus from atrial fibrillation
necrosis of the intestine soon follows if intervention is delayed
what happens if mesenteric artery occlusion is missed?
necrosis of the intestine
clinical features of mesenteric artery occlusion
abdominal pain - gradually becomes intense
patients develop a fear of eating
profuse vomiting
watery diarrhoea - blood in one third of patients
patient becomes confused
what is the likely diagnosis of a patient with anxiety and prostration + intense central pain + profuse vomiting +/- bloody diarrhoea
mesenteric arterial occlusion
signs of mesenteric artery occlusion
localised tenderness, rigidity and rebound over infarcted bowel (later finding)
absent bowel sounds (later finding)
shock (develops later)
tachycardia (may be arterial fibrillation and other signs of atheroma)
what investigations should you do for mesenteric artery occlusion
CRP may be elevated intestinal alkaline phosphatase
X-ray (plain) shows ‘thumb printing’ due to mucosal oedema on gas-filled bowel
CT scanning gives the best definition which mesenteric arteriography is performed is embolus is suspected
commonly only diagnosed at laparotomy
pain distribution of mesenteric artery occlusion
central
management of mesenteric artery occlusion
early surgery may prevent gut necrosis but massive resection of necroses gut may be required as a life saving procedure
early diagnosis is essential
mesenteric venous thrombosis
can occur but usually in patients with circulatory failure
inferior mesenteric artery occlusion
less severe are survival is more likely than superior
acute retention of urine
acute retention of urine of 600+mL usually causes severe abdominal pain
may not be apparent in the senile or demented patient
possible causes of acute retention of urine
enlarged prostate or prostatitis
bladder neck obstruction by feacal loading or other pelvic masses
anticholinergic drugs
neurogenic causes such as multiple sclerosis, spinal injury and diabetes
management of acute retention of urine
perform a rectal examination and empty the rectum of any impacted feacal material
catheterise with a size 14 Foley catheter to relieve obstruction and drain (give antibiotic cover)
have catheter in situ and seek urology consult
send specimen for MCU
if the acute urine retention is drug induced
withdraw drug
leave catheter for 48 hours
remove and give trial of prazosin 0.5mg bd or terazosin
patient comfort/care with acute retention of urine
may be worth giving analgesics
may be helpful to ambulate patient and attempt voiding by standing up to the sound of running water
a hot bath may also provide a simple solution
what should you check for for a patient with acute retention of urine
check for prostate cancer or renal impairment
perform neurological examination of lower limbs and perianal area
feacal impaction is typically encountered in
aged, bedridden, debilitated patient
acute appendicitis in the elderly
usually a condition of young adults
symptoms can vary due to different positions of the appendix
typical pain distribution of acute appendicitis
clinical features of acute appendicitis
maximum incidence 20-30 years
initial pain is central abdominal (sometimes colicky)
increasing severity then continuous
shifts and localises to RIF within 6 hours
may be aggravated by walking (causing a limp) or coughing
sudden anorexia
nausea and vomiting a few hours after the pain starts
+/- diarrhoea or constipation
signs of acute appendicitis
patient looks unwell
flushed at first, then pale
furred tongue and halitosis
may be febrile
tenderness in RIF, usually at McBurney point
local rigidity and rebound tenderness
guarding
+/- superficial hyperaesthesia
+/- psoas sign
+/- obturator sign
rovsing sign
psoas sign
pain on resisted flexion of right leg, on hip extension or on elevating right leg due to irritation of psoas especially with retrocaecal appendix
obturator sign
pain on flexing patients right thigh at the hip with the knee bent and then internally rotating the hip )due to irritation of internal obturator muscle)
rovsing sign
rebound tenderness in RIF while palpating in LIF
acute appendicitis on PR examination
anterior tenderness to high, especially if pelvic appendix or pelvic peritonitis
acute appendicitis in a retrocaecal appendix
pain and rigidity less and may be no rebound tenderness
loin tenderness
possitive psoas test
acute appendicitis in pelvic appendix
no abdominal rigidity
urinary frequency
diarrhoea and tenesmus
very tender PR
obturator tests usually positive
how does acute appendicitis present differently in the elderly
pain often minimal and eventually manifests as peritonitis
can stimulate intestinal obstruction
investigations for acute appendicitis
blood cell count shows leucocytosis with a left shift
urea and electrolytes to assess hydration prior to surgery
CRP - elevated
plain x-ray
ultrasound
CT scan
laparoscopy
b-HCG
what might plain x-ray show for acute appendicitis
may show local distension, blurred psoas shadow and fluid level in caecum
what might ultrasound show for acute appendicitis
thickened appendix
affected by gas shadow
what might CT scan show for acute appendicitis
accurate and allows you to see other causes, especially in the female pelvis
for small bowel obstruction, symptoms will depend on
the level of the obstruction
the more proximal, the more severe the pain
differences between high and low small bowel obstruction
main causes of small bowel obstruction
outside obstructions (eg. adhesions is the commonest cause, previous laparotomy), strangulation in hernia or pockets of abdominal cavity - this may lead to ‘closed loop’ obstruction
lumen obstructions (e.g. foreign body, trichobezoar, gallstones, intussusception, malignancy)
clinical features of small bowel obstruction
spasms last about 1 minute
spasms every 3-10 minutes (according to level)
vomiting
absolute constipation
no flatus
abdominal distension
typical pain distribution of small bowel obstruction
a patient with colicky central pain, vomiting and distension is likely to have
small bowel obstruction
signs of small bowel obstruction
patient weak and sitting forward in distress
visible peristalsis, loud borborygmi
abdomen soft (except with strangulation)
tender when distended
increased sharp, tinkling bowel sounds
dehydration rapidly follows, especially in children and the elderly
rectal exam for the patient with small bowel obstruction
empty rectum
may be tender
note: check all hernial orifices, especially umbilicus
imaging for the patient with small bowel obstruction
x-ray: plain erect film confrims diagnosis, ‘step ladder’ fluid levels in 3-4 hours.
gastrograffin follow through for precise diagnosis with caution. it can cause severe diarrhoea but may be therapeutic in adhesive obstruction
+/- CT scan (especially if extrinsic causation
management of the patient with small bowel obstruction
IV fluids and bowel decompression with nasogastric tube
laparotomy or hernia repair
the cause of large bowel obstruction is commonly
cause is commonly colon cancer, especially on the left side
causes of large bowel obstruction
commonly colon cancer
diverticulitis
volvulus of the sigmoid colon and caecum
sigmoid volvolus
more common in older men and has a sudden and severe onset
clinical features of large bowel obstruction
sudden-onset colicky pain (even with cancer)
each spasm lasts less than 1 minute
usually hypogastric midline pain
vomiting may be absent (or late)
absolute constipation (obstipation)
no flatus
typical pain distribution of large bowel obstruction
signs of large bowel obstruction
increased bowel sounds, especially during pain
distension may be early and marked
local tenderness and rigidity
large bowel obstruction on PR exam
empty rectum
may be rectosigmoid cancer or blood
check for faecal impaction
large bowel obstruction on x-ray
distension of large bowel with separation of haustral markings, especially caecal distension
- sigmoid volvulus shows a distended loop and coffee bean sign
- gastrograffin enema confirms diagnosis
