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
2
Q
What are surgical causes of an acute abdomen?
A
- Appendicitis
- Acute cholecystitis
- Peptic ulcer perforation
- Urinary retention
- Acute pancreatitis
- SBO
- Trauma
- Urinary stones
- LBO
- Acute diverticulitis
- Malignancy
- Medical disorders
- Vascular conditions
- Gynae conditions
3
Q
What are features of someone with a ruptured organ?
A
- Shock - leading sign
- Abdominal swelling
- History of trauma
- Mild peritonism
4
Q
What are gynaecological causes of acute abdomen?
A
- Ruptured ectopic pregnancy
- Ruptured functional ovarian cyst
- Torsion/rupture of ovarian cyst
- Acute salpingitis
5
Q
What are features of localised peritonitis?
A
- Pain
- Tenderness
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
7
Q
What type of peritonitis always requires laparotomy?
A
Generalised peritonitis
8
Q
What are the main insults which can cause generalised peritonitis?
A
- Infection
- Chemical irritation - leackage of gut contents
9
Q
What microorganisms are most commonly implicated in peritonitis?
A
- E. coli
- Bacteriodes
10
Q
What are routes of infection for peritonitis?
A
- Perforation of the GI tract
- Female genital tract
- Penetration of abdominal wall
- Haematogenous spread
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.
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
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
14
Q
What are causes of peritonitis?
A
- Inflammation of organ +/- perforation
- Perforation of a hollow viscus
- Postoperative complication - anastamotic leak
- Ischaemia
- Haemoperitoneum
- Trauma
15
Q
What are symptoms of peritonitis?
A
- Severe abdominal pain aggravated by motion
- Nausea + vomiting
- Hot and sweaty
- Loss of appetite
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
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
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
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
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
21
Q
What is important about the early management of an acute abdomen?
A
Early surgical consultation
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
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
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
25
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?
Biliary colic
26
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?
Kidney stones
27
If someone presented with an acute abdomen with sudden severe pain in their epigastric region, what might you consider as a cause?
Perforated ulcer
28
If someone presented with a prgressive pain in their epigastric region that was relieved by sitting forward, what might you consider as a cause?
Pancreatitis
29
If someone presented with a progressive pain right subcostal region, what might you consider as a cause?
* **Cholcystitis**
* **Hepatitis**
30
If someone developed pain over their umbilicus which spread to RIF, what might you consider as a diagnosis?
Appendicitis
31
If someone developed progressive pain in their LIF, what might you consider as a diagnosis?
Diverticulitis
32
What is the differential for RUQ pain?
1. **Acute cholcystitis**
2. **Duodenal ulcer**
3. **Hepatitis**
4. **Congestive hepatomegal**
5. **Pyelonephritis**
6. **Appendicitis**
7. **Pneumonia**
33
What is the differential diagnosis for epigastric pain?
1. **Pancreatitis**
2. **MI**
3. **Peptic ulcer**
4. **Acute cholecystits**
5. **Perforated oesophagus**
34
What would your differential diagnosis be for LUQ pain?
1. **Ruptured spleen**
2. **Gastric ulcer**
3. **Aortic aneurysm**
4. **Perforated colon**
5. **Pyelonephritis**
6. **Pneumonia**
35
What would be your differential diagnosis for umbilical pain?
1. **Intestinal obstruction**
2. **Acute pancreatitis**
3. **Early appendicitis**
4. **Mesenteric thrombosis**
5. **Aortic Aneurysms**
6. **Diverticulitis**
36
What would your differential diagnosis be for someone with LLQ pain?
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
What are causes of RLQ pain?
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
What general measures would you take when managing someone with an acute abdomen?
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
What is always important to exclude in a female presenting with an acute abdomen?
**Pregnancy +/- ectopic**
40
What is the following?
**Pneumoperitoneum** - air in the peritoneal space
41
What are causes of the following?
Pneumoperitoneum
* **Bowel perforation**
* **Gas-forming infection** - C. perfringens
* **Iatrogenic causes** - laparoscopic surgery
* **Per vaginum**
* **Interposition of bowel between live rna diaphragm** - Chilaiditi sign
42
What are the objectives of surgery in someone with peritonitis?
* **Peritoneal lavage of abdominal cavity**
* **Specific treatment for causative problem**
43
What mnemonic can be used to remember the causes of acute abdomen?
Medic Curses A Mop
* **M**esenteric adenitis
* **E**nteritis
* **D**iverticulitis
* **I**schaemic colitis
* **C**holecystitis
* **U**lcers
* **R**enal colic
* **S**alpingitis
* **E**ctopic pregnancy
* **S**mall bowel obstruction
* **A**ppendicitis
* **M**eckel's diverticulum
* **O**varian cyst
* **P**ancreatitis
44
What specific investigations would you perform for someone with anacute abdomen thought to be caused by peritonitis?
Standard investigations, plus:
* **Erect CXR**
* **Urgent CT abdo/pelvis**
45
What specific investigations would you perform for someone with anacute abdomen thought to be caused by ruptured AAA?
Standard investigations, plus:
* **Bedside USS**
* **CT angiography**
46
How would you manage a ruptured AAA?
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
What specific investigations would you consider doing in someone with suspected renal colic?
Standard investigaitons, plus:
* **X-ray KUB**
* **CT KUB**
48
How would you manage someone with renal colic?
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
How would remove a renal stone that was \< 1cm?
Smooth muscle relaxant - tamsulosin
50
How would you go about removing a renal stone of between 1-2cm?
Ureteroscopy/ESWL
51
How would you remove a renal stone \>2cm?
Percutaneous nephrolithotomy
52
What sepcific investigations would you consider doing in someone with suspected appendicitis?
Standard investigations, plus:
* **None if very likely**
* **Consider Abdo USS**
* **Consider CT for complications**
53
How would you manage someone with suspected appendicitis?
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
What specific investigations would you consider doing for someone with suspected gallstone related disease?
Standard investigations, plus:
* **Abdo USS**
* **CT** - if perc. drainage/cholecystostomy required
55
How would you manage biliary colic?
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
How would you manage cholecystitis?
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
What specific investigations would you consider doing in someone with acute pancreatitis?
Standard investigations, plus:
* **Amylase/lipase**
* **CT abdo if uncertain**
* **ApacheII/Glasgow Criteria**
* **Confirm cause**
* Abdo USS
* Triglycerides
* Immunoglobulins
58
How would you manage CBD stone?
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
How would you manage Cholangitis?
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
How would you manage someone with acute pancreatitis?
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
What specific investigations would you consider doing in someone with suspected peptic ulcer/gastritis?
Standard investigations, plus:
* **OGD +/- biopsy**
62
What specific investigations would you consider doing in someone with suspected diverticulitis?
Standard investigation, plus:
* **Consider CT abdo/pelvis (if needed)**
63
How would you manage someone with diverticulitis?
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
What specific investigations would you consider doing in someone with suspected bowel obstruction?
Standard investigations, plus:
* **AXR, followed by CT abdo/pelvis**
* **Gastrograffin studies** - SBO
65
How would you manage someone with bowel obstruction?
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
What specific investigations would you consider doing for someone with a suspected ectopic pregnancy?
Standard investigations, plus:
* **Serial BHCG**
* **Transvaginal USS**
67
How would you manage someone with suspected ectopic pregnancy?
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**
