The Acute Abdomen + Peritonitis Flashcards
What is peritonitis
Inflammation of the peritoneum
What is primary
No cause found at laparotomy
What is secondary peritonitis
Underlying disease
What is localised
Certain part of abdomen
e.g. abscess, cholecystitis
What is generalised
Affects whole abdomen
>2 quadrants
Tenderness diffuse and inflammation widespread
Often due to rupture
What causes peritonitis
Inflammation / obstruction \+- perforation of - GI / biliary / female tract - Ulcer / gall bladder / appendix / IBD / malignancy Perforation of abdominal wall Rupture or organ - ectopic / aorta / spleen Haematogenous spread of infection Post-op - anastomotic leak Ischaemia Kidney / liver failure PD
How does peritonitis present
Sudden severe abdominal pain Lying still Vomiting Fever Loss of appetite No urine High temp / RR / HR Shock Absence of bowel sounds
How does colic present to peritonitis
Pace about
Peritonitis lie still as don’t want fluid to track (prostration)
What are signs of peritonitis
Guarding Rebound tenderness Percussion tenderness - use to localise Rigid abdomen No bowel sounds
What are bowel sounds like in obstruction
High pitched
How do you investigation peritonitis
Urine dip in all abdo pain Bloods - FBC, U+E, LFT, CRP, amylase, BG VBG = quick result - Lactate - mesenteric ischaemia ? - Biochemical / sig electrolyte - Acidotic Urine and serum hCG to exclude ectopic if female + abdominal pain ECG to exclude cardiac Blood culture if spiking temp
Imaging Erect CXR for free air AXR USS CT abdo Gastrograffin Laparoscopy
What is CI
Endoscopy
What does CXR show
Gas under diaphragm - pneumoperitoneum
Suggests perforation
What is USS / CT used for
Show abscess
Fluid collection
What is Gastrograffin useful for
Detect anastomotic leak/ perforation
How do you deal with peritonitis
ABCDE NBM IV access with largest as possible - Analgesia - Fluid if unstable - Anti-emeitc - Ax Bloods - G+S Resuscitate Ensure tissue perfusion and oxygenation SEPSIS 6 Catheter NBM if surgery NG tube if vomiting and suspect obstruction Imaging
How do you sort out the tissue
Drain abscess
Surgery - repair peritoneum
Treat cause
What are complications of peritonitis
Abscess formation Localized ileus Sepsis Septic shock Adhesions
When does peritonitis not localise
Contamination too rapid
Abscess ruptures
Immunocompromised
What is the acute abdomen
Severe abdo pain which results in patient being referred for urgent surgical opinion
What are emergencies/. difficult to Dx conditions
Mesenteric ischaemia Acute pancreatitis Leaking/ ruptured AAA Peritonitis after ruptured appendix Always think as may cause mild signs
Pancreatitis
Causes peritonitis signs but does not require laparotomy to Dx
How does AAA present
Retroperitoneal back pain
Shock
Sudden collapse
Why is appendix rupture difficult
Unusual distribution of pain
What is somatic / parietal pain pain
Arise from abdominal wall
Peritoneum irritated
Intercostal nerves supply
Localised pain which tracks where fluid goes
What is visceral pain
Arise for organ / gut Insensitivite to mechanical or thermal Sensitive to distension / ischaemia / spasm Autonomic Poorly differentiate
What are signs of rupture
Shock
Abdo swelling
Peritonitis signs
What suggests abscess
Swinging fever
Swelling
Increased WCC
What will be seen on examination
Guarding
Rebound tenderness
What should you do prior to surgical referral n acute abdomen
Hx - SOCRATES Urine dip + MSSU Urine bHCG for ectopic Bloods GROUP AND SAVE OR X-MATCH ABG for oxygen VBG for electrolyte and lactate Blood culture ECG for diseases above diaphragm Imaging
What bloods and why
FBC - bleeding (Hb) / WCC U+E - kidney function LFT CRP Amylase / lipase - any inflammation in pancreas Lactate - mesenteric ischaemia Glucose Calcium - pancreatitis severity INR / clotting - liver function / coag prior to procedures
Why is it important to do ECG
Diseases above diaphragm
What imaging
USS abdo / pelvis = 1st line - Need full bladder and fasted AXR - Erect CXR CT if time often diagnostic CT angio CT-KUB
What do you do USS
Abscess
Gall stone
Dilatation of biliary tree
Gynae issue
What is AXR useful for and erect CXR
Obstruction
Show dilatation of bowel loop
Erect CXR may show gas under diaphragm indicative of perforation
When is CT angio indicated
If bruit suggest aneurysm
CT KUB
If suspect renal stone
How do you treat
SURGEY
What do you do before surgery
ABCDE Resuscitate - shock compounds anaesthesia unless blood lost faster than can replace e.g. aneurysm / trauma IV access NBM if scan / surgery Fluid If needed Catheterise for fluid balance X-match and transfuse Analgesia Anti-emetic IV Ax if evidence of infection Thrombo-prophylaxis - Dalteparin NG aspiration if evidence of obstruction Nutrition
What is seen on a CT scan if perforation
Air between abdominal wall and skin
Same as hernia
What are common causes of acute abdomen
Acute appnedicitis Obstruction Urinary tract Biliary tract Trauma Malignancy Perforated ulcer / gall stone Pancreatitis
Surgical Sleeve
Hepatobiliary Upper GI Lower GI Urology Gynae Infection Metaboli Trauma Vascular
What causes epigastric pain
Gastritis Peptic ulcer Biliary colic Pancreatitis Perforation Diseases above diaphragm
What diseases above diaphragm
Inferior MI PE DKA Poisin Pneumonia- L lower lobe
What should you do for diseases above
CXR
ECG
Blood glucose
What causes umbilical pain
Chrons Small bowel obstruction Appendicits Adhesions Malignancy Mesenteric ischaemia Ruptured AA
What causes hypogastriac pain
COnstipation Diverticulitis COlon cancer Volvulus Gina / testicular / ovarian
What causes RLQ / LLQ pain
Appendicits Ruptured ectopic Renal stone Pyelonephrititis Cholecystitis Hernia Mesenteric adenitis Perforation Diverticulitis Testicular / ovarain torsion PID
What causes LUQ pain
Ruptured spleen Ruptured AA Pyelonephritis Pneumonia Renal colic
What causes RUQ pain
Appendicits Pneumonia Acute cholecystitis Cholangitis Choledohcolithathis Biliary colic Ulcers Hepatitis Pyelonephritis Renal colic
What causes abdominal distension
Pregnancy Obstruction Volvulus Ascites Retention Ovarian cancer Constipaiton
When is obstruction likely
Surgery Hx due to adhesions
Cancer
When is ascites likely
Alcohol
CF
Stomach / liver
What are 5Fs
Fat Faeces Flatus Fetus Fluid
What is most likely cause of shock in surgical patient
Hypovolaemia from blood loss
Check UO, GCS and CRT as measure of perfusion
What do you do if anastomotic leak
Emergency surgery
Why do you want lactate
Sepsis
What gives definite Dx
CT abdo pelvis
If suspect triple A then CT angio
