Surgical Presentations of Abdominal Disease Flashcards
Where does gall bladder pain tend to radiate?
Through to the back and right
What structures cause pain in the upper three zones?
Gall bladder
Stomach and duodenum
Pancreas
Where does gastric and duodenal pain radiate?
Straight through to the back
Where does pancreatic pain radiate to?
Through to the back and left
What causes throbbing pain?
Inflammation
What sort of pain does obstruction cause?
Colic
How does a patient suffering colic pain tend to act?
They move around
If the patient is lying still, what sort of pathology may be occurring?
Inflammation
If the abdomen is moving with respiration, there is general peritonitis. True or false?
False.
If there is tenderness to percussion, what term is used?
Peritonitis
What are the diagnostic conditions for anorexia nervosa?
- Significant weight loss (BMI < 17.5)
- Weight loss is self induced (Avoiding fatty food, calorie counting)
- Core psychopathology (Body image distortion)
- Widespread endocrine abnormality
What endocrine abnormalities can result due to anorexia?
Amenorrhoea
Loss of sexual interest
Elevated GH/cortisol
Abnormalities of insulin secretion
What are the two types of anorexia?
Restricting type
Binge eating/Purging type
What is the aetiology of anorexia and bulimia?
Socio-cultural pressures (family dysfunction)
Personal vulnerability
Sexual maturity
What is factitious disorder?
Intentional feigning
Either physical or psychiatric
Munchausen Syndrome
What is malingering?
Deliberate exaggeration of symptoms
What are the types of antidepressants and what do they do?
Tricyclics - enhance mono amine activity in the brain
Selective Serotonin Reuptake Inhibitors - Stimulate 5HT3 receptors
What bowel sounds are present in obese patients?
None
When is the plain AXR useful?
In obstruction
In colitis
In perforation
What is the gold standard of radiological imaging of the abdomen?
CT
How is a sigmoid Volvulus managed?
Decompressed with a rigid sigmoidscope
What is the classification of Diverticulitis?
Hinchey Classification
- Para colic abscess
- Pelvic abscess
- Purulent abscess
- Faecal peritonitis
What is Hartmann’s procedure?
Remove sigmoid
Leave rectum
Bring out colostomy
How do haemorrhoids present?
Painless bleeding
Fresh, bright red blood, not in stool, on toilet paper
Perianal itchiness
No other symptoms
What investigations can be done in a patient with haemorrhoids?
PR exam
Rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy (Age above 50)
Treatment of haemorrhoids?
Slcerosation therapy (5% phenol in almond oil) Rubber band ligation Open haemorrhoidectomy Stapled haemorrhoidectomy HALO/THD procedure
What part of the rectum prolapses in a partial prolapse?
Anterior mucosa
How does a rectal prolapse present?
Protruding mass (especially during defaecation)
PR bleeding and mucus
Poor anal tone
Management of complete rectal prolapse?
Bulking agent and education on manual reduction Delormes procedure Perineal rectopexy Abdominal rectopexy Anterior resection
Where are anal fissures typically located?
In the midline posteriorly
What is the presentation of an anal fissure?
Severe acute anal pain (often following constipation)
Pain lasts for 30 mins after defaecation
Bright rectal bleeding
What is the treatment of anal fissures?
Dietary advice Stool softeners Pharmacological sphyncterotomy Lateral sphyncterotomy Botox
Where does the bowel dilate in obstruction: Proximally or Distally?
Proximally
What is the typical presentation of an upper small bowel obstruction?
Acute Hours of onset Large volume of vomit - Gastric secretions - Pancreatic secretions - Biliary secretions
What is the presentation of a distal small bowel of large bowel obstruction?
Colicky abdo pain
Distension
(Faeculent vomiting)
What are the general symptoms of bowel obstruction?
Vomiting
Pain
Constipation
Distension
If vomit contains semi-digested food with no bile, where is the obstruction?
Gastric outlet
If there is copious bile in the vomitus, where is the obstruction?
Upper small bowel
What is the character of vomitus in a distal obstruction?
Thicker
Brown
Foul-smelling
When is back flow of accumulated colonic contents prevented?
If the ileocaecal valve remains competent
What is a ‘closed loop obstruction’?
A caecum that progressively dis tends with swallowed air
Eventually may rupture
What happens to the muscle of the bowel wall if obstruction is chronic?
It hypertrophies
What are the signs of dehydration?
Dry mouth
Loss of skin turgor and elasticity
What is the appearance of dilated bowel in an AXR?
Lie in a central position
Have valvulae coniventes
What is the AXR appearance of a distended large bowel?
Lies in anatomical position
Has haustra coli
Management of intestinal obstruction?
NG tube (decompress stomach)
Nil by mouth
Blood sample
IV fluids
Examples of mechanical obstruction?
ADHESIONS or BANDS Incarnated hernia Volvulus Tumour Strictures Bolus Intussusception
What type of obstruction do inflammatory strictures tend to cause?
Incomplete
What may cause a bolus obstruction?
Food
Impacted faeces
Impacted gallstone
Trichobezoar
What is Intussusception?
Segment of bowel wall becomes ‘telescoped’ into the segment distal to it
When is cholecystitis or biliary colic pain often exacerbated?
By eating
What is the first line investigation in cholecystitis or biliary colic?
Ultrasound
How do we further clarify cholecystitis or biliary colic?
MRCP and/or ERCP
What is the ideal method of imaging in suspected pancreatitis and when is it best performed?
CT (to evaluate complications)
1 week following symptom onset
What is the investigation of choice in perforation?
ERECT CXR
How do we investigate appendicitis?
Ultrasound
What investigation is used in diverticulitis?
CT
What symptoms may prompt the idea of a urological cause of abdominal pain?
Associated urinary symptoms
Haematuria
What might prompt you to consider vascular causes of abdominal pain?
Sudden onset
Back pain
Hypotension
If a patient has a distended abdomen and a bowel source if suspected, what is the first line investigation?
AXR
If a patient has a distended abdomen and a fluid cause is suspected what is the first line investigation?
Ultrasound
How is haematemesis investigated?
Endoscopy
Allows intervention or biopsy
What method of contrast may be given in a patient who is suffering from haematemesis?
IV (for CT scan)
What radiological investigations are done in a patient with a change in bowel habit?
Barium enema
CT virtual colonography
When is a small bowel MRI used?
In small bowel Crohn’s
In large bowel Crohn’s with suspected small bowel involvement
What scan can be used to localise active inflammation in known IBD?
Radio-labelled White cell scan
How does cirrhosis appear on ultrasound?
Small volume of ascites
Nodular contour and course echotexture
How do liver metastases appear on an ultrasound?
Hypoechoic
Solid
Varying size
‘Target’ appearance
How does ischaemic colitis appear histologically?
Crypt withering
Pink smudgy lamina propria
Fewer chronic inflammatory cells
Explosive fibrinopurulent exudate on surface
Pseudomembranous colitis
Thickened basal membrane with a patchy appearance and intrepithelial inflammatory cells
Collagenous colitis
Telangectasia
Bizarre stromal cells
Radiation colitis
