Presentations Flashcards
what are the most common causes of severe intra-abdominal bleeding and what signs indicate this
ruptured AAA
ruptured ectopic pregnancy
bleeding gastric ulcer
trauma
these patients typically go into hypovolaemic shock; tachycardia, hypotension, pale and clammy on inspection and cool to touch
sings and symptoms of hypovolaemic shock
tachycardia
hypotension
pale and clammy on inspection
cool to touch
what is peritonitis and what is broadly the most common cause
inflammation of the peritoneum
most commonly caused by perforation of an abdominal organ
what are some causes of perforation in the abdomen
peptic ulceration
small or large bowel obstruction
diverticular disease
inflammatory bowel disease
signs and symptoms of generalised peritonitis
lay completely still and look very unwell
tachycardia and potential hypotension
rigid abdomen with percussion tenderness
involuntary guarding (tensing of abdo muscles when palpating the abdomen)
reduced or absent bowel sounds (paralytic ileus)
any patient who presents with severe acute abdomen pain out of proportion to the clinical signs is immediately suspected to have what
ischaemic bowel
what do patients with ischaemic bowel usually complain of
diffuse severe constant abdo pain - however examination is often unremarkable
what laboratory tests are required in all cases of acute abdominal pain
urine dipstick - infection or haematuria
pregnancy test for women of reproductive age
ABG - useful in bleeding and septic patients; pH, pCO2, pO2, lactate (tissue hypoperfusion) and haemoglobin levels
routine bloods - include amylase (pancreatitis) and group and save (surgery)
blood cultures - ?infection
imaging and tests required for all acute abdo pain cases
ECG and CXR - ?cardiac pathology or ?free air in abdomen
USS KUB (KUB = kidney, ureters, bladder)
USS of liver and biliary tree
Transvaginal USS - ?tubo-ovarian pathology
CT abdomen
basic management for all cases of acute abdo pain (and severe acute malaise in general) prior to any definitive action
IV access, NBM status, analgesia, anti-emetics, initial imaging, VTE prophylaxis, urine dip and routine bloods, catheter or NG tube if required, resus fluids
what is biliary colic
RUQ pain, intermittent in nature and worse after eating
what are oesophageal varices
dilations of the porto-systemic venous anastamoses in the oesophagus
what are some emergency causes of haematemesis
oesophageal varices
gastric ulceration
what is the most common cause (60%) of haematemesis cases
gastric ulceration
how does gastric ulceration cause haematemesis
ulceration can result in erosion into the blood vessels supplying the upper GI tract - most commonly on the lesser curve of the stomach or posterior duodenum
what is a mallory-weiss syndrome tear and what is the most common history
tear in the epithelial lining of the oesophagus - history of severe or recurrent vomiting followed by minor haematemesis
what are some causes of oesophagitis
GORD
infection (most commonly candida)
ingestion of toxic substances
medications
what are some non-emergency causes of haematemesis
mallory-weiss tear
oesophagitis
gastritis
gastric malignancy
investigations into haematemesis
FBC and VBG + group and save
definitive investigation is oesophagogastroduodenoscopy (OGD)
erect CXR if perforated peptic ulcer is suspected - in such a case pneumoperitoneum may be seen
CT abdomen with IV contrast can also be useful if endoscopy is contraindicated
if a patient presents with haematemesis and upon investigation is found to have air in the peritoneum on eCXR - what is the most likely diagnosis
perforated peptic ulcer
definitive management of peptic ulcer disease
first line; A to E + IV cannulas, start fluid resus and crossmatch blood
OGD needed to visualise
definitive; adrenaline injections and cauterisation of the bleeding followed by high dose IV PPI therapy to reduce acid secretion, and finally H.pylori eradication therapy if necessary
definitive management of oesophageal varices
first line; active resus + blood + prophylactic abx
definitive; endoscopic banding, vasopressors to reduce splanchnic blood flow and reduce bleeding
what plain film radiographic sign may indicate a perforated gastric ulcer
subdiaphragmatic free gas
what are some mechanical causes of dysphagia
oesophageal or gastric malignancy
benign oesophageal strictures
pharyngeal pouch
foreign body
extrinsic compression
what are some neuromuscular causes of dysphagia
post-stroke
achalasia
myasthenia gravis
diffuse oesophageal spasm
what are red flag symptoms for dysphagia
weight loss
sensation of food becoming stuck
hoarse voice
referred ear or neck pain
investigations into dysphagia
OGD + biopsy if relevant
routine bloods
what is the blood supply to the inferior third of the oesophagus
left gastric artery
what is the most common neuromuscular cause of acute dysphagia in a 70 year old male
stroke
what is Gastric Outlet obstruction
describes a mechanical obstruction of the proximal GI tract, occurring at some point between the gastric pylorus and the proximal duodenum, resulting in an inability to empty the stomach
what are some causes of gastric outlet obstruction
gastric or small bowel malignancy
peptic ulcer disease - causing stricture of stomach/duodenum
stricture following surgery
pancreatic cyst
bouveret syndrome
what is Bouveret syndrome
gastric outlet obstruction secondary to a gallstone impacted at the pylorus or proximal duodenum
occurs in patients with a cholecystoduondenal fistula
clinical features of gastric outlet obstruction
epigastric pain
vomiting post eating
early satiety
often no change in bowel habit initially
dehydrated due to persistent vomiting and obstruction - also tachycardic and hypotensive (hypovolaemic)
investigations into gastric outlet obstruction
routine bloods - FBC, CRP, U&Es, clotting, group and save
CT abdo with IV contrast + endoscopy (following decompression of stomach)
what is the main first line step in managing gastric outlet obstruction
decompress the stomach via NG tube
then start on IV PPI therapy
most common causes of small bowel obstruction
adhesions and herniae
most common causes of large bowel obstruction
malignancy, diverticular disease and volvulus
what are the cardinal signs of bowel obstruction
abdominal pain - colicky or cramping in nature (secondary to peristalsis)
vomiting - early in proximal obstructions and late in distal obstructions
abdominal distension
absolute constipation - early in distal obstructions but late in proximal obstructions
what are characteristic signs that an obstructed bowel is becoming ischaemic
guarding and rebound tenderness
percussion tenderness
tinkling bowel sounds indicate what?
bowel obstruction
laboratory tests into suspected bowel obstruction
routine bloods - important to monitor for electrolyte changes
VBG - check lactate (high = sign of ischaemia)
imaging for a suspected bowel obstruction
gold standard = CT abdo pelvis with IV contrast
AXR still used in some settings
what are the AXR findings that would indicate small bowel vs large bowel obstruction
small bowel = dilated >3cm, central location, valvulae conniventes visible (lines completely crossing the bowel)
large bowel = dilated >6cm, peripheral location, haustral lines visible (lines not completely crossing the bowel - go Halfway as they are Haustra)
management of bowel obstruction
conservative; IV fluids, urinary catheter, analgesia, NBM and insert NG tube to decompress the bowel (non-surgical treatment only suitable in those with no signs of ischaemia or strangulation)
surgical; laparotomy and possible stoma (indicated in those with signs of ischaemia or closed bowel obstruction)
what measurement in an ABG is most indicative of bowel ischaemia
high lactate levels
causes of gastrointestinal perforation
diverticulitis
peptic ulcer disease
GI malignancy
iatrogenic e.g. routine endoscopy
trauma
foreign body
appendicitis
mesenteric ischaemia
bowel obstruction
clinical features of GI perforation
pain - rapid onset and sharp in nature
systemically unwell - malaise, vomiting and lethargy
signs of sepsis
signs of peritonism - rigid abdomen, guarding, etc.
imaging in suspected GI perforation
gold standard = CT scan
management of GI perforation
broad spectrum abx, NBM, NG tube, IV fluids and analgesia
surgery - identify, manage and washout
what artery provides the blood supply to the ascending colon
superior mesenteric artery
what is malaena
black tarry stools occurring as a result of upper GI bleeding - usually have a very offensive smell
what is the most common cause of malaena
peptic ulcer disease
common causes of maleana
peptic ulcer disease
oesophageal varices
upper GI malignancy
gastritis, oesophagitis, mallory-weiss tear
investigations into malaena
routine bloods + group and save
ABG - pH and lactate
OGD - definitive investigation in most cases of malaena
CT abdo with IV contrast - if contraindications to OGD
how does a drop in haemoglobin and rise in urea:creatinine ratio indicate upper GI bleed
digested Hb produces urea as a by-product and is readily absorbed by the intestine; therefore urea levels increase
what is the role of somatostatin analogues in variceal bleeding
reduces splanchnic blood flow to the GI tract - thereby reducing bleeding
what is haematochezia
passage of fresh blood via the rectum caused by bleeding from the lower GI tract
what are some common causes of acute lower GI bleeding
diverticular disease
ischaemic or infective colitis
haemorrhoids
malignancy
angiodysplasia
crohn’s disease
ulcerative colitis
what is the most common cause of lower GI bleeding
diverticulosis
what first line examination is essential in any patient presenting with haematochezia
DRE
investigations into haematochezia
routine bloods - baseline
group and save - surgery
stool cultures - ?infection
unstable patients require CT angiogram - to identify location of bleed
stable patients require flexible sigmoidoscopy - to exclude left colonic malignancy
what investigations are required in stable vs unstable patients with haematochezia
stable = flexible sigmoidoscopy
unstable = CT angiogram
what is the blood supply to the ileum
superior mesenteric artery
what is the first line investigation in an haemodynamically unstable patient presenting with haematochezia
CT angiogram
