Murtagh - Abdominal pain cont. in the elderly and biliary pain

Question 1

perforated peptic ulcer

Answer 1

can cause acute abdominal pain both with an without history of prior peptic ulcer
acute surgical emergency

Question 2

peak incidence of perforated peptic ulcer

Answer 2

45-55 years

Question 3

which type of perforated peptic ulcer is more common

Answer 3

perforated duodenal ulcer is more common than gastric ulcer

Question 4

perforated ulcers may come following a

Answer 4

heavy meal

Question 5

clinical syndrome of perforated peptic ulcer

Answer 5

1. prostration
2. reaction (after 4 hours) - symptoms may improve
3. peritonitis (after 4 hours) - severe pain

Question 6

pain distribution of perforated peptic ulcer

Answer 6

Question 7

clinical features of perforated peptic ulcer

Answer 7

sudden onset severe epigastric pain
continuous pain but lesses for a few hours
epigastric pain at first, and then generalised to the whole abdomen
pain may radiate to one or both shoulders (uncommon) or right lower quadrant
nausea and vomiting (delayed)
hiccough is common late symptom

Question 8

patient with sudden onset severe pain, anxious and still, sweaty with deceptive improvement is likely to be

Answer 8

perforated peptic ulcer

Question 9

signs of perforated peptic ulcer

Answer 9

patient lies quietly (pain aggravated by movement and coughing
pale, sweating or ashen at first
board like rigidity
guarding
maximum signs at point of perforation
no abdominal distension
contraction of abdomen (forms a shelf over lower chest)
bowel sounds reduced (silent abdomen)
shifting dullness may be present
pulse, temperature and BP usually normal at first
tachycardia (later) and shock later (3-4)
breathing is shallow and inhibited by pain

Question 10

perforated peptic ulcer on PR examination

Answer 10

pelvic tenderness

Question 11

x-ray signs of perforated peptic ulcer

Answer 11

chest x-ray may show free air under diaphragm (in 75%)

Question 12

what does the patient need to have done in order for free gas under the diaphragm to show up on the x-ray

Answer 12

they have to have sat upright for the 15 minutes prior to the scan

Question 13

management of perforated peptic ulcer

Answer 13

pain relief
drip and suction (immediate nasogastric tube)
broad - spectrum antibiotics
immediate laparotomy after resuscitation conservative treatment may be possible (e.g. later presentation and gastrograffin swallow indicates sealing of perforation

Question 14

ureteric colic

Answer 14

severe true colic due to stone movement, dilatation and ureteric spasm
intense colicky pain - in waves, each lasting 30 seconds with 1-2 minutes respite

Question 15

renal colic

Answer 15

not a true colic but a constant pain pain due to blood clots or a stone lodged at the pelvic-ureteric junction

Question 16

maximum incidence of ureteric colic

Answer 16

maximum incidence 30-50 years

Question 17

clinical features of ureteric colic

Answer 17

intense colicky pain - in waves, each lasting 30 seconds with 1-2 minutes respite
begins in loin and radiates around the flank to the groin, thigh, testicle and labia
usually lasts <8 hours
+/- vomiting

Question 18

pain distribution of ureteric colic

Answer 18

Question 19

a patient with intense loin to groin pain with microscopic haematuria is likely to have

Answer 19

ureteric colic

Question 20

signs of ureteric colic

Answer 20

patient restless - may be writhing in pain
pale, cold and clammy
tenderness at costovertebral angle
+/- abdominal and back muscle spasm
smoky urine due to haematuria

Question 21

diagnosis of ureteric colic

Answer 21

urine mmicroscopy
plain x-ray
IVP
ultrasound
non contrast spiral KUB-CT

Question 22

pain x-ray in ureteric colic may show

Answer 22

most stones - kidney, ureter, bladder - are radio opaque

Question 23

if the diagnosis of ureteric colic is in doubt

Answer 23

especially if narcotic addiction is suspected
get the patient to pass urine the the presence of an examiner and test for haematuria
while awaiting the passage of urine, an indomethacin suppository may be tried for pain relief

Question 24

why should you avoid high fluid intake in the ureteric colic patient

Answer 24

provokes distention of ureter and aggravates pain
avoid high fluid intake, especially if IV fluids

Question 25

outcome for ureteric colic

Answer 25

most cases settle and the patient can go home when pain relief is obtained and an IVP arranged for the next day

Question 26

the calculus causing ureteric colic is likely to pass spontaneously if

Answer 26

if its <5mm (90% of <4mm pass spontaneously)

Question 27

what if the calculus is >5mm

Answer 27

intervention will usually be required by extracorporeal shock wave lithotripsy or surgery

Question 28

when to refer the patient with ureteric colic

Answer 28

stone >5mm
high grade obstruction
gross hydronephrosis
fever/UTI
unremitting pain
stone fails to progress
type 2 diabetes
staghorn calculus
presence of solitary kidney

Question 29

male to female ratio of urinary tract calculi

Answer 29

3:1

Question 30

stereotyped patient who suffers form biliary pain

Answer 30

female, 40, fat, fair, fertile
can occur from adolescence to old age in both sexes

Question 31

what causes biliary pain

Answer 31

produced by the contraction of the biliary tree upon an obstructing stone or inspissated bile

Question 32

pain distribution of biliary pain

Answer 32

Question 33

typical feature of biliary pain/colic

Answer 33

acute onset severe pain
post-prandial or at night (often wakes 2-3am)
constant pain
lates 20 minutes to 2-6 hours
maximal at RUQ or epigastrium
may radiate to tip of right shoulder or scapula
painful episode builds to a crescendo for about 20 minutes, may recede or last for hours
some relief by assuming flexed posture
+/- nausea and vomiting with considerable retching
often a history of biliary pain (may be mild) or jaundice
often precipitated by a fatty meal

Question 34

patient with severe pain, vomiting, pain radiation is likely to have

Answer 34

biliary colic

Question 35

signs of biliary colic

Answer 35

patient is anxious and restless
localised tenderness (Murphy’s sign) over fungus of gall bladder (on transpyloric plane)
slight rigidity

Question 36

diagnosis of biliary colic

Answer 36

abdominal ultrasound (to diagnose gallstones)/DIDA
helical CT
intravenous cholangiography is previous cholecystectomy
LFTs may show elevated bilirubin and alkaline phosphatase

Question 37

biliary pain is usually precipitated by

Answer 37

a fatty meal

Question 38

localised tenderness over the gallbladder is called

Answer 38

Murphy’s sign

Question 39

LFTs for biliary pain may show

Answer 39

elevated bilirubin and alkaline phosphatase

Question 40

management of biliary pain

Answer 40

pain relief - morphine or fentanyl or ketorolac
gallstone dissolution with ursodeoxycholic acid or lithotripsy (in those unable to have surgery)
cholecystectomy (main procedure)

Question 41

the two main types of gallstone are

Answer 41

cholesterol and pigment (bilirubin)

Question 42

acute cholecystitis may lead to

Answer 42

empyema, perforation, cholecystoenteric fistula

Question 43

complications of gall stones

Answer 43

cholecystitis, obstructive jaundice, cholangitis, and acute pancreatitis (pancreatic duct obstruction)

Question 44

acute cholecystitis occurs when

Answer 44

calculus becomes impacted in the cystic duct and inflammation develops
very common in the elderly
the acute attack is often precipitated by a large or fatty meal

Question 45

the causative organisms of acute cholecystitis are usually

Answer 45

aerobic bowel flora
eg. E. coli, klebsiella species and enterococcus faecalis

Question 46

clinical features of acute cholecystitis

Answer 46

steady severe pain and tenderness
localised to right hypochondrium or epigastrium
nausea and vomtiing (bile) in bout 75%
aggravated by deep inspiration

Question 47

signs of acute cholecystitis

Answer 47

patient tends to lie still
localised tenderness over gall bladder (positive Murphy’s sign)
muscle guarding
rebound tenderness
palpable gall bladder (approximately 15%)
jaundice (approximately 15%)
+/- fever

Question 48

diagnosis of acute cholecystitis

Answer 48

ultrasound: gallstones but not specific for cholecystitis
HIDA scan: demonstrates obstructed cystic duct - the usual cause
WCC and CRP: can be elevated

Question 49

treatment for acute cholecystitis

Answer 49

bed rest
IV fluids
nil orally
analgesics
antibitotics
cholecystectomy