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Junior Surgery- GI > The Acute Abdomen > Flashcards

The Acute Abdomen Flashcards

1
Q

What is an acute abdomen?

A

Someone who becomes acutely unwel and in whom symptoms and signs are ciefly related to the abdomen

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2
Q

What are surgical causes of an acute abdomen?

A
  1. Appendicitis
  2. Acute cholecystitis
  3. Peptic ulcer perforation
  4. Urinary retention
  5. Acute pancreatitis
  6. SBO
  7. Trauma
  8. Urinary stones
  9. LBO
  10. Acute diverticulitis
  11. Malignancy
  12. Medical disorders
  13. Vascular conditions
  14. Gynae conditions
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3
Q

What are features of someone with a ruptured organ?

A
  • Shock - leading sign
  • Abdominal swelling
  • History of trauma
  • Mild peritonism
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4
Q

What are gynaecological causes of acute abdomen?

A
  • Ruptured ectopic pregnancy
  • Ruptured functional ovarian cyst
  • Torsion/rupture of ovarian cyst
  • Acute salpingitis
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5
Q

What are features of localised peritonitis?

A
  • Pain
  • Tenderness
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6
Q

What are signs of generalised peritonitis?

A
  • Prostration
  • Fever
  • Shock
  • Lying still
  • Positive cough test
  • TEnderness +/- rebound/percussion pain
  • Board-like abdominal rigidity
  • Guarding
  • No bowel sounds - due to paralytic ileus
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7
Q

What type of peritonitis always requires laparotomy?

A

Generalised peritonitis

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8
Q

What are the main insults which can cause generalised peritonitis?

A
  • Infection
  • Chemical irritation - leackage of gut contents
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9
Q

What microorganisms are most commonly implicated in peritonitis?

A
  • E. coli
  • Bacteriodes
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10
Q

What are routes of infection for peritonitis?

A
  • Perforation of the GI tract
  • Female genital tract
  • Penetration of abdominal wall
  • Haematogenous spread
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11
Q

What is the pathophysiology of generalised peritonitis?

A

Generalised peritonitis represents failure of localisation and occurs when contamination is too rapid, contamination persists, or an abscess ruptures.

The peritoneal cavity becomes acutely inflamed, with production of an inflammatory exudate that spreads throughout the peritoneum, leading to intestinal dilatation and paralytic ileus.

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12
Q

What is the difference between perforation and secondary inflammatory disease in terms of onset of peritonitis?

A
  • Perforation - rapid onset
  • Inflammatory disease - less rapid onset, preceded by other features of disease
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13
Q

What investigations would you consider doing in someone with features of peritonitis?

A

Standard Acute abdomen investigations

  • Bedside - NEWS, urine output, consider ECG, urine dip + cultures, BHCG
  • Bloods - FBC, U+E’s, LFTs, CRP, Serum albumin, Amylase/Lipase, consder ABG and blood cultures if septic, INR, G+S

Specific peritonitis investigations

  • Imaging
    • Urgent CT/MRI
    • ​Erect CXR
    • Consider
      • Abdo US - detect abscess/fluid
      • Consider ascitic tap - if significant fluid accumulation
      • Consider Gastrografin - look for leaks/perforations
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14
Q

What are causes of peritonitis?

A
  • Inflammation of organ +/- perforation
  • Perforation of a hollow viscus
  • Postoperative complication - anastamotic leak
  • Ischaemia
  • Haemoperitoneum
  • Trauma
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15
Q

What are symptoms of peritonitis?

A
  • Severe abdominal pain aggravated by motion
  • Nausea + vomiting
  • Hot and sweaty
  • Loss of appetite
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16
Q

What general investigations would you consider doing in someone with an acute abdomen before focussing on diagnostic investigations?

A
  • Bedside
    • Monitoring - NEWS, urine output
    • Tests - Urinalysis/urine culture, Urine/serum BHCG
  • Bloods - U+E’s, FBC, Amylase, LFT, CRP, Lactate, INR, G+S, blood culture if pyrexial
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17
Q

How would you manage peritonitis?

A

ABCDE

Standard acute abdomen

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Peritonitis specific

  • 2 wide bore cannulas
  • Consider antibiotics
  • Surgical repair - may need laparotomy
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18
Q

What are medical causes of acute abdomen?

A
  • IBS
  • MI
  • Gastroenerritis
  • DKA
  • HSP
  • Infection - Pneumonia, Pneumococcal peritonitis, TB, Malaria, Typhoid, cholera
  • Thyroid storm
  • Prophyria
  • Sickle-cell crisis
  • Phaeochromocytoma
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19
Q

What is the following?

A

Rigler’s sign - when the air is present on both sides of the intestine, i.e. when there is air on both the luminal and peritoneal side of the bowel wall. It is a sign of perforation

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20
Q

What antibiotics would you use to manage peritonitis?

A

3-7 days - AMG protocol

  • IV gentamicin + metranidazole +/- amoxicillin (co-trimoxazole if penicillin allergic)
  • Oral Metranidazole + doxycycline/Co-trimoxazole
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21
Q

What is important about the early management of an acute abdomen?

A

Early surgical consultation

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22
Q

If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature in their suprapubic area, what might you consider as a cause?

A

Colonic obstruction

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23
Q

If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature over the umbilicus, what might you consider as a cause?

A

Small bowel obstruction

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24
Q

If someone presented with an acute abdomen with sudden severe pain in their umbilical region which spread into their groin and genitalia, what might you consider as a cause?

A

Ruptured Aortic Aneurysm

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25
Q

If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature over the right subcostal area, what might you consider as a cause?

A

Biliary colic

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26
Q

If someone presented with an acute abdomen with colicky, crampy pain of an intermittent nature from loin to groin, what might you consider as a cause?

A

Kidney stones

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27
Q

If someone presented with an acute abdomen with sudden severe pain in their epigastric region, what might you consider as a cause?

A

Perforated ulcer

28
Q

If someone presented with a prgressive pain in their epigastric region that was relieved by sitting forward, what might you consider as a cause?

A

Pancreatitis

29
Q

If someone presented with a progressive pain right subcostal region, what might you consider as a cause?

A
  • Cholcystitis
  • Hepatitis
30
Q

If someone developed pain over their umbilicus which spread to RIF, what might you consider as a diagnosis?

A

Appendicitis

31
Q

If someone developed progressive pain in their LIF, what might you consider as a diagnosis?

A

Diverticulitis

32
Q

What is the differential for RUQ pain?

A
  1. Acute cholcystitis
  2. Duodenal ulcer
  3. Hepatitis
  4. Congestive hepatomegal
  5. Pyelonephritis
  6. Appendicitis
  7. Pneumonia
33
Q

What is the differential diagnosis for epigastric pain?

A
  1. Pancreatitis
  2. MI
  3. Peptic ulcer
  4. Acute cholecystits
  5. Perforated oesophagus
34
Q

What would your differential diagnosis be for LUQ pain?

A
  1. Ruptured spleen
  2. Gastric ulcer
  3. Aortic aneurysm
  4. Perforated colon
  5. Pyelonephritis
  6. Pneumonia
35
Q

What would be your differential diagnosis for umbilical pain?

A
  1. Intestinal obstruction
  2. Acute pancreatitis
  3. Early appendicitis
  4. Mesenteric thrombosis
  5. Aortic Aneurysms
  6. Diverticulitis
36
Q

What would your differential diagnosis be for someone with LLQ pain?

A
  1. Sigmoid diverticulitis
  2. Salpingitis
  3. Tubo-ovarian abscess
  4. Ruptured ectopic pregnancy
  5. Strangulated hernia
  6. Perforated colon
  7. Crohn’s Disease/UC
  8. Renal/ureteric stones
37
Q

What are causes of RLQ pain?

A
  1. Appendicits
  2. Salpingitis
  3. Tubo-ovarian abscess
  4. Ruptured ectopic pregnancy
  5. Strangulated hernia
  6. Mesenteric adenitis
  7. Meckel’s Diverticulitis
  8. Perforated caecum
  9. Psoas Abscess
  10. Crohn’s Disease
  11. Renal/ureteric stones
38
Q

What general measures would you take when managing someone with an acute abdomen?

A

Don’t rush to theatre - anaesthesia compounds shock

  • ABCDE
    • Bed rest
    • Volume status and IV fluids - consider catheter and NG tube
    • Analgesia - paracetamol, codeine, tramadol, morphine
    • VTE prophylaxis - TEDS and LMWH
    • Consider taking BCs/giving Antibiotics
    • If surgery required - NBM, Check INR + G&S, stop antiplatelet, anticoag, diabetic meds
39
Q

What is always important to exclude in a female presenting with an acute abdomen?

A

Pregnancy +/- ectopic

40
Q

What is the following?

A

Pneumoperitoneum - air in the peritoneal space

41
Q

What are causes of the following?

A

Pneumoperitoneum

  • Bowel perforation
  • Gas-forming infection - C. perfringens
  • Iatrogenic causes - laparoscopic surgery
  • Per vaginum
  • Interposition of bowel between live rna diaphragm - Chilaiditi sign
42
Q

What are the objectives of surgery in someone with peritonitis?

A
  • Peritoneal lavage of abdominal cavity
  • Specific treatment for causative problem
43
Q

What mnemonic can be used to remember the causes of acute abdomen?

A

Medic Curses A Mop

  • Mesenteric adenitis
  • Enteritis
  • Diverticulitis
  • Ischaemic colitis
  • Cholecystitis
  • Ulcers
  • Renal colic
  • Salpingitis
  • Ectopic pregnancy
  • Small bowel obstruction
  • Appendicitis
  • Meckel’s diverticulum
  • Ovarian cyst
  • Pancreatitis
44
Q

What specific investigations would you perform for someone with anacute abdomen thought to be caused by peritonitis?

A

Standard investigations, plus:

  • Erect CXR
  • Urgent CT abdo/pelvis
45
Q

What specific investigations would you perform for someone with anacute abdomen thought to be caused by ruptured AAA?

A

Standard investigations, plus:

  • Bedside USS
  • CT angiography
46
Q

How would you manage a ruptured AAA?

A

ABCDE

Standard acute abdomen:

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia (careful administration - will make hypotenisive) and antiemetics
  • VTE prophylaxis - Consider TEDS but NO!!! LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific AAA management

  • 2 wide bore cannula
  • Permissive hypotension (Aim SBP 90-100) - THIS IS MOST IMPORTANT ASPECT OF MANAGEMENT PRIOR TO GETTING THEM TO SURGERY/BLOOD PRODUCT REPLACEMENT!!
  • Major haemorrhage protocol
  • Urgent repair
    • Endovascular if stable
    • Open if unstable
47
Q

What specific investigations would you consider doing in someone with suspected renal colic?

A

Standard investigaitons, plus:

  • X-ray KUB
  • CT KUB
48
Q

How would you manage someone with renal colic?

A

ABCDE

General management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • Diclofenac
  • IV fluids/hydration
  • Removal method (depending on size)
  • Ureteric stent/nephrostomy - if obstructed
49
Q

How would remove a renal stone that was < 1cm?

A

Smooth muscle relaxant - tamsulosin

50
Q

How would you go about removing a renal stone of between 1-2cm?

A

Ureteroscopy/ESWL

51
Q

How would you remove a renal stone >2cm?

A

Percutaneous nephrolithotomy

52
Q

What sepcific investigations would you consider doing in someone with suspected appendicitis?

A

Standard investigations, plus:

  • None if very likely
  • Consider Abdo USS
  • Consider CT for complications
53
Q

How would you manage someone with suspected appendicitis?

A

ABCDE

Standard measures

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific measures

  • Urgent laparoscopic appendicectomy
54
Q

What specific investigations would you consider doing for someone with suspected gallstone related disease?

A

Standard investigations, plus:

  • Abdo USS
  • CT - if perc. drainage/cholecystostomy required
55
Q

How would you manage biliary colic?

A

ABCDE

Standard management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • Outpatient cholecystectomy
  • Analgesia
  • Fat-free diet
56
Q

How would you manage cholecystitis?

A

ABCDE

Standard management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • Antibiotics
  • Cholcystectomy (if moderate to severe)
    *
57
Q

What specific investigations would you consider doing in someone with acute pancreatitis?

A

Standard investigations, plus:

  • Amylase/lipase
  • CT abdo if uncertain
  • ApacheII/Glasgow Criteria
  • Confirm cause
    • Abdo USS
    • Triglycerides
    • Immunoglobulins
58
Q

How would you manage CBD stone?

A

ABCDE

Standard management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • Continuous IV fluids
  • ERCP
59
Q

How would you manage Cholangitis?

A

ABCDE

Standard management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • IV Antibiotics
  • Treat the cause
    • Biliary decompression - ERCP +sphincterectomy + drainage
    • Biliary decompression - Choledocotomy/Cholecystectomy
60
Q

How would you manage someone with acute pancreatitis?

A

ABCDE

Standard acute abdo management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific acute pancreatitis management

  • Supportive
  • Aggressive fluid resus - titrate to UO
  • NBM until nausea/pain improve - enteric feeding if prolonged
  • ABx if proven infection, gas on CT or raised procalcitonin
  • Treat cause/stop meds
  • Consider ICU
61
Q

What specific investigations would you consider doing in someone with suspected peptic ulcer/gastritis?

A

Standard investigations, plus:

  • OGD +/- biopsy
62
Q

What specific investigations would you consider doing in someone with suspected diverticulitis?

A

Standard investigation, plus:

  • Consider CT abdo/pelvis (if needed)
63
Q

How would you manage someone with diverticulitis?

A

ABCDE

Standard acute abdomen management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific diverticulitis management

  • Clear fluids, then build up over 2-3 days
  • Antibiotics
64
Q

What specific investigations would you consider doing in someone with suspected bowel obstruction?

A

Standard investigations, plus:

  • AXR, followed by CT abdo/pelvis
  • Gastrograffin studies - SBO
65
Q

How would you manage someone with bowel obstruction?

A

ABCDE

Standard acute abdomen management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific obstruction management

  • NBM
  • Wide bore NG tube
  • IV fluid hydration
  • Laparoscopy/laparotomy
66
Q

What specific investigations would you consider doing for someone with a suspected ectopic pregnancy?

A

Standard investigations, plus:

  • Serial BHCG
  • Transvaginal USS
67
Q

How would you manage someone with suspected ectopic pregnancy?

A

ABCDE

Standard acute abdo management

  • Bed rest
  • Consider NG
  • IV fluids - consider catheter
  • Analgesia and antiemetics
  • VTE prophylaxis - TEDS + LMWH
  • If surgery required - NBM, G+S + INR, Stop anticoag/antiplatelets/diabetic meds

Specific management

  • 2 wide bore cannulas
  • Laparoscopic salpingostomy/salpingectomy, or methotrexate if uncomplicated
  • Anti-D prophylaxis

Junior Surgery- GI (43 decks)

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