Senior Surgery > Emergency Medicine Flashcards
Abdo Pain > Acute abdomen
DDx RUQ Pain (7)
Cholecystitis Hepatitis Pyelonephritis Rt pneumonia Duodenal ulcer Appendicitis Congestive hepatomegaly
Abdo Pain > Acute abdomen
DDx Epigastric Pain (4)
Inferior MI
Perforated oesophagus
Cholecystitis
Peptic ulcer
Abdo Pain > Acute abdomen
DDx LUQ Pain (6)
Aortic aneurysm Ruptured spleen Gastric ulcer Lt pneumonia Pyelonephritis Perforated colon
Abdo Pain > Acute abdomen
DDx LLQ Pain (6)
Intestinal obstruction Acute pancreatitis Early appendicitis Mesenteric thrombosis Aortic aneurysm Diverticulitis
Abdo Pain > Acute abdomen
DDx Left middle zone Pain (9)
Sigmoid diverticulitis Salpingitis Tubo-ovarian abscess Ruptured ectopic pregnancy Incarcerated hernia Perforated colon Crohn's disease Ulcerative colitis Renal/ureteral stone Ovarian cyst accident
Abdo Pain > Acute abdomen
DDx RLQ Pain (11)
Appendicitis Salpingitis Tubo-ovarian abscess Ruptured ectopic pregnancy Renal/ureteric stone Incarcerated hernia Mesenteric adenitis Meckel's diverticulitis Crohn's disease Perforated caecum Psoas abscess
Signs of peritonitis
Lying still
Rosving’s sign (palpation in the LIF causing pain in the RIF)
Rebound tenderness
Rising pulse
Basic prehospital/emergency department care of suspected acute abdomen
Keep patient nil by mouth Oxygen IV fluids Blood (group and save and crossmatch) Nasogastric tube Analgesia (morphine) Antiemetic Antibiotics Surgical/Gynae review Admit for surgery
Abdo Pain > Acute abdomen
> Cholecystitis
- Cause
- Questions in history
- Investigations
- Management
Cholesterol stones are most common - solitary and radiolucent
Can get biliary colic (gallstone impacting cystic duct) or cholecystitis (GB distends with subsequence necrosis and ischaemia of mucosal wall)
Biliary colic - pain starts suddenly in epigastrium or RUQ, radiates to back, constant, N & V
Cholecystitis similar but jaundice may occur, Murphy’s sign (2 fingers over RUQ ask pt to breathe in - pain and arrest of inspiration, must be negative in LUQ)
Bilous vomit
WCC up in cholecystitis and liver enzymes mildly abnormal, CXR, ECG, Ultrasound best for stones and shows thickened GB wall in cholecystitis, ERCP good for CBD stones and can be therapeutic too
Most patients can be managed initially at home - morphine. Admit if pain >24h or fever, IV ABx in hospital.
Surgically, laparoscopic cholecystectomy, if pt unfit can do purcutaneous cholecystotomy (drainage)
Consider biliary stent if stones irretrievable
Abdo Pain > Acute abdomen
> Appendicitis
- Cause
- Questions in history
- Investigations
- Management
Often occurs when the appendix becomes blocked, often by stool, a foreign body, or cancer. Blockage also occurs from infection
Pain (early = perimbulical, moves to RIF) Exacerbated by movement and coughing. Nausea, vomiting, anorexia, low grade pyrexia may be present, rising pule - peritonitis, tenderness, guarding, rebound tenderness in the RIF, Psoas test (extend the hip and abduct the thigh)
Leukocytosis, left shift of neutrophils, negative urinalysis, negative preg test, CRP may be raised, US may help to rule out other things, CT more specific - enlarged appendix, appendiceal wall thickening, peri-appendiceal fat stranding, appendiceal wall enhanement
Perforation in young women may lead to impaired fertility later
Hospital admission, laparoscopic appendectomy, Abx alternative to surgery in simple cases, IV flujids, opiate analgesia
Abdo Pain > Acute abdomen
> Ruptured spleen
- Cause
- Questions in history
- Investigations
- Management
Can occur from severe direct blow or blunt trauma. Increased risk in infectious mononucleosis, lymphomia, haemolytic anaemia, malaria (due to splenomegaly)
Pain under rib cage, left shoulder pain, BP drop symptoms (blurred vision, confusion, light-headedness, fainting, signs of shock (pale, clammy, nausea, anxiety)
CT with contrast to diagnose
Splenectomy but sometimes conservative, blood transfusions, can trial arterial embolisation if trying to save the spleen
Abdo Pain > Acute abdomen
> Intestinal obstruction
- Cause
- Questions in history
- Investigations
- Management
Ileus = non-mechanical obstruction
Paralytic ileus = inactivity of the bowel
Small intestinal obstruction - adhesions (main), strangulated hernia, malignancy, volvulus
Large intestinal obstruction - colorectal malignancies
Sigmoid/caecal volvulus - Rotation of gut on mesenteric axis (psych)
Presents with nausea, vomiting, dysphagia, abdominal pain, failure to pass bowel movements, patient may be generally toxic and unwell
Signs = abdominal distention, tympany, high pitched/tinkling bowel sounds, check hernial orifices - femoral hernia is at high risk of obstruction
Normal bloods + creatinine, group and cross match (major surgery may be required) Water soluble contrast enema X ray may be useful in low level obstruction, non contrast CT, can use MRI and US too
If uncomplicated, can manage conservatively - fluid resuscitation, electrolyte replacement, intestinal decompression, bowel rest
Laparotomy if diagnosis is unclear, endoscopic stenting
Abdo Pain > Acute abdomen
> Acute pancreatitis
- Cause
- Questions in history
- Investigations
- Management
(Pancreatic pseudocyst)
Common causes: Gallstones and alcohol consumption account for most cases
Ask about alcohol consumption, sudden onset severe upper abdominal pain with comiting, in LUQ radiating to back, can encircle abdomen, tends to decrease steadily over 72 hrs
Signs - hypothermia, mild pyrexia, hyperlipidaemia, jaundice, abdo tendernesss
Serum amylase (2/3 times more than normal), lipase is more sensitive and specific
Can use CRP for prognosis
Can use bilirubin to indicate gallstones
Plain erect abdo x-ray to exclude other things, CT with contrast may be diagnostic
If it is mild, may be managed on general ward, give adequate pain relief (morphine usually contraindicated - possible spastic effect on sphincter of Oddi), IV fluids, NBM, NG tube, ABx if necessary, when bloods start normalising - oral fluids then solids
If severe, ITU or HDU, if significant pancreatic necrosis - IV antibiotics, enteral nutrition, can use ERCP for patients with cholangitis or biliary obstruction, surgery only required if infection or necrosis - open surgical debridement, catheter draining
Can lead to pancreatic pseudo cyst (cyst containing pancreatic juices - can rupture or haemorrhage, required surgery)
Abdo Pain > Acute abdomen
> Diverticulitis
- Cause
- Questions in history
- Investigations
- Management
Can lead to complications -
perforation, abscess, fistula, stricture/obstruction
Presents with LLQ pain but ocassionaly RLQ pain (particularly Asians), may be intermittent or constant and associated with changed bowel habits, may pass blood if their is diverticular bleeding
Colonoscopy, sigmoid colonoscopy is best for fresh-ish blood/ young patients because minimally invasive, haemotynics, barium enema, CXR (pneumoperitoneum)
Hospital admission if pain cannot be managed by paracetamol, hydration, rectal bleeding may require transfusion, broad spectrum ABx, Mesalazine if recurrent, indications for surgery are purulent or faecal peritonitis, uncontrolled sepsis, fistula, obstruction, inabilty to exclude carcinoma
May do a primary anastamosis if there is a bleed or a colon resection if serious peritonitis
Abdo Pain > Acute abdomen
> Ectopic pregnancy
- Cause
- Questions in history
- Investigations
- Management
Implantation of ovum outside of the uterus, may rupture
RIF pain, abdo pain, N & V, shoulder tip pain, lightheadedness, PV bleeding, pasage of tissue, fainting, pregnancy symptoms, LMP, Hx STI, ectopic, coil
Signs - pelvic/abdo tenderness, adnexal tenderness, rebound tenderness, cervical tenderness
Do pregnancy test, TVUS, hCG if PUO and woman clinically stable - take 48 hrs apart to moniter
Admit, anti-D prophylaxis, early pregnancy unit, may manage conservatively if levels are falling and patient is clinically well, may use methotrexate if small pregnancy, hCG <1500, surgical if women cannot return for follow-up and do not fulfil these criteria - salpingotomy if risk of infertility otherwise salpingectomy
