Murtagh - Abdominal pain cont. in the elderly and biliary pain Flashcards
perforated peptic ulcer
can cause acute abdominal pain both with an without history of prior peptic ulcer
acute surgical emergency
peak incidence of perforated peptic ulcer
45-55 years
which type of perforated peptic ulcer is more common
perforated duodenal ulcer is more common than gastric ulcer
perforated ulcers may come following a
heavy meal
clinical syndrome of perforated peptic ulcer
- prostration
- reaction (after 4 hours) - symptoms may improve
- peritonitis (after 4 hours) - severe pain
pain distribution of perforated peptic ulcer
clinical features of perforated peptic ulcer
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
patient with sudden onset severe pain, anxious and still, sweaty with deceptive improvement is likely to be
perforated peptic ulcer
signs of perforated peptic ulcer
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
perforated peptic ulcer on PR examination
pelvic tenderness
x-ray signs of perforated peptic ulcer
chest x-ray may show free air under diaphragm (in 75%)
what does the patient need to have done in order for free gas under the diaphragm to show up on the x-ray
they have to have sat upright for the 15 minutes prior to the scan
management of perforated peptic ulcer
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
ureteric colic
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
renal colic
not a true colic but a constant pain pain due to blood clots or a stone lodged at the pelvic-ureteric junction
maximum incidence of ureteric colic
maximum incidence 30-50 years
clinical features of ureteric colic
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
pain distribution of ureteric colic
a patient with intense loin to groin pain with microscopic haematuria is likely to have
ureteric colic
signs of ureteric colic
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
diagnosis of ureteric colic
urine mmicroscopy
plain x-ray
IVP
ultrasound
non contrast spiral KUB-CT
pain x-ray in ureteric colic may show
most stones - kidney, ureter, bladder - are radio opaque
if the diagnosis of ureteric colic is in doubt
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
why should you avoid high fluid intake in the ureteric colic patient
provokes distention of ureter and aggravates pain
avoid high fluid intake, especially if IV fluids
outcome for ureteric colic
most cases settle and the patient can go home when pain relief is obtained and an IVP arranged for the next day
the calculus causing ureteric colic is likely to pass spontaneously if
if its <5mm (90% of <4mm pass spontaneously)
what if the calculus is >5mm
intervention will usually be required by extracorporeal shock wave lithotripsy or surgery
when to refer the patient with ureteric colic
stone >5mm
high grade obstruction
gross hydronephrosis
fever/UTI
unremitting pain
stone fails to progress
type 2 diabetes
staghorn calculus
presence of solitary kidney
male to female ratio of urinary tract calculi
3:1
stereotyped patient who suffers form biliary pain
female, 40, fat, fair, fertile
can occur from adolescence to old age in both sexes
what causes biliary pain
produced by the contraction of the biliary tree upon an obstructing stone or inspissated bile
pain distribution of biliary pain
typical feature of biliary pain/colic
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
patient with severe pain, vomiting, pain radiation is likely to have
biliary colic
signs of biliary colic
patient is anxious and restless
localised tenderness (Murphy’s sign) over fungus of gall bladder (on transpyloric plane)
slight rigidity
diagnosis of biliary colic
abdominal ultrasound (to diagnose gallstones)/DIDA
helical CT
intravenous cholangiography is previous cholecystectomy
LFTs may show elevated bilirubin and alkaline phosphatase
biliary pain is usually precipitated by
a fatty meal
localised tenderness over the gallbladder is called
Murphy’s sign
LFTs for biliary pain may show
elevated bilirubin and alkaline phosphatase
management of biliary pain
pain relief - morphine or fentanyl or ketorolac
gallstone dissolution with ursodeoxycholic acid or lithotripsy (in those unable to have surgery)
cholecystectomy (main procedure)
the two main types of gallstone are
cholesterol and pigment (bilirubin)
acute cholecystitis may lead to
empyema, perforation, cholecystoenteric fistula
complications of gall stones
cholecystitis, obstructive jaundice, cholangitis, and acute pancreatitis (pancreatic duct obstruction)
acute cholecystitis occurs when
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
the causative organisms of acute cholecystitis are usually
aerobic bowel flora
eg. E. coli, klebsiella species and enterococcus faecalis
clinical features of acute cholecystitis
steady severe pain and tenderness
localised to right hypochondrium or epigastrium
nausea and vomtiing (bile) in bout 75%
aggravated by deep inspiration
signs of acute cholecystitis
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
diagnosis of acute cholecystitis
ultrasound: gallstones but not specific for cholecystitis
HIDA scan: demonstrates obstructed cystic duct - the usual cause
WCC and CRP: can be elevated
treatment for acute cholecystitis
bed rest
IV fluids
nil orally
analgesics
antibitotics
cholecystectomy
