Week 10 Flashcards
What is visceral pain ?
Pain originating from the organs
What is somatic pain ?
Pain originating from tissues like the skin, skeleton, muscles or tendons
What general issues can cause visceral pain ?
- contraction
- distention (stretch)
- tension
- ischaemia
Name the type of visceral pain associated with gall stones….
Biliary colic
What types of stimuli can trigger somatic pain ?
Activation of the pain receptors in tissues
- temperature
- force
- vibration
- swelling
Is visceral pain…
A) sharp and localised ?
B) dull and localised ?
C) dull and poorly localised ?
Dull and poorly localised
Where is visceral pain from the foregut structures felt ?
The epigastrium
Where is visceral pain from the midgut structures felt ?
The periumbilical region
Where is visceral pain from the hind gut structures felt ?
The hypogastric region
What does the term ‘distended abdomen’ mean ?
Abdomen that is greater in size than normal
(need to ask patient what normal is)
What does the term ‘tympanic abdomen’ mean ?
Distended abdomen (air), like a balloon
(similar to bloated)
What does the term ‘tender abdomen’ mean ?
Abdominal pain is present in response to touch/pressure
What does the term ‘soft abdomen’ mean ?
No peritonism (inflammation), even though pain might be present
What does the term ‘peritonitic’ mean ?
Inflammation of the peritoneum by a noxious substance
What does the term ‘rebound tenderness’ mean ?
Pain when releasing pressure from palpation
sign of peritonism
What does the term ‘guarding’ mean ?
Involuntary tensing of abdominal wall muscle on palpation
sign of local peritonism if in one quadrant only
What does the term ‘rigid abdomen’ mean ?
Involuntary guarding in all 4 quadrants
sign of general peritonitis
Which cell type in the stomach secretes hydrochloric acid ?
Parietal cells
Which cell type in the stomach secretes pepsinogen ?
Chief cells
Which cell type in the stomach secretes the hormone gastrin ?
G cells
Which cell type in the stomach secretes alkaline mucus to protect the stomach lining ?
Mucous cells
What are the functions of the exocrine pancreas ?
Secretion of digestive enzymes, water and ions into the duodenum
- lipase hydrolyses triglycerides into monoglycerides and fatty acids
- elastases break down elastin
- chymotrypsinogen is converted into chymotrypsin that breaks down proteins into amino acids
In which part of the digestive tract is trypsinogen activated/converted into trypsin ?
Duodenum
What in the skeletal system could cause acute upper abdominal pain ?
- lower rib fractures/issues
- back pain can radiate forwards
What in the endocrine system could cause acute upper abdominal pain ?
Diabetic ketoacidosis
What in the nervous system could cause acute upper abdominal pain ?
Back pain that gets referred forwards depending on nerve involvement
What in the integumentary (skin) system could cause acute upper abdominal pain ?
Skin rashes e.g shingles
you would expect to see this on examination
What in the obstetrics system could cause acute upper abdominal pain ?
Pre-eclampsia, especially if associated with vomiting
What in the digestive system could cause acute upper abdominal pain ?
Stomach…
- peptic ulcers
- gastritis
- perforation
- cancer
Duodenum ….
- perforation
Pancreas…
- acute pancreatitis
Gallbladder/biliary system…
- biliary colic
- acute cholecystitis
Small bowel…
- IBS
What in the urinary system could cause acute upper abdominal pain ?
Renal colic pain can radiate upwards
usually pain felt in loin/groin region
What in the haematological system could cause acute upper abdominal pain ?
Rar
Pain from splenomegaly causes by haematological malignancies
- splint infarction
- trauma to spleen
What in the respiratory system could cause acute upper abdominal pain ?
Acute lower lobe pneumonia
What in the cardiovascular system could cause acute upper abdominal pain ?
- ruptured abdominal aortic aneurysm
- MI (atypical presentation)
What is ecchymosis ?
The medical term for bruises
What does Cullen’s sign look like ?
A bruise below the bellybutton
periumbilical ecchymosis
What does Grey-Turner’s sign look like ?
Bruises in either flank
What is Murphy’s sign ?
Pain in RUQ from local peritonism from acute cholecystitis
What is Rovsing’s sign ?
Pain felt in right iliac fossa when the left side is palpated
sign of acute appendicitis
What does Caput Medusae look like ?
Swollen veins (varices) in the abdomen around the belly button
occur with portal hypertension from liver cirrhosis
What condition might present with Murphy’s sign ?
Acute cholecystitis
What condition might present with Rovsing’s sign ?
Acute appendicitis
What condition might present with Caput Medusae ?
Liver cirrhosis
(Portal hypertension)
What can both Cullen’s sign and Grey-Turner’s sign indicate ?
Internal haemorrhage due to…
- acute pancreatitis
- splenic rupture
- perforated peptic ulcer disease
What can acute pancreatitis cause/lead to ?
- systemic inflammatory response syndrome (SIRS)
- renal failure (acute kidney injury)
- respiratory failure (acute respiratory distress syndrome)
- death in severe cases
What is the criteria for diagnosing acute pancreatitis ?
At least 2 of the following…
- abdominal pain (acute, persistent, epigastric pain radiating to the back)
- serum lipase/amylase levels higher than 3x upper limit of normal
- radiological evidence of pancreatitis (CT/MR)
Which pancreatic cells release lipase and amylase ?
Acinar cells in the inflamed pancreas
Which is the more sensitive bio marker of acute pancreatitis…
A) amylase ?
B) lipase ?
Lipase
Which has the higher specificity as a bio marker for acute pancreatitis …
A) amylase ?
B) lipase ?
The have the same specificity of 99%
What does the sensitivity of a test/investigation mean ?
The true positive rate
How many patients the test correctly identifies as having the disease/condition
What does the specificity of a test/investigation mean ?
The true negative rate
How many patients the test correctly identifies as not having the disease/condition
Which test can detect acute pancreatitis up to 8-14 days post-onset…
A) amylase ?
B) lipase ?
Lipase
How many hours after onset of acute pancreatitis do
A) amylase levels peak ?
B) lipase levels peak ?
Amylase peaks between 12 and 72hrs after onset
Lipase peaks at 24hrs after onset
How quickly can levels of
A) amylase …
B) lipase …
Return to normal after onset of acute pancreatitis ?
A) amylase returns to normal 3 days after onset
B) lipase returns to normal between 8 and 14 days after onset
Which test is better overall for diagnosing acute pancreatitis…
A) amylase ?
B) lipase ?
Lipase
What are the 3 levels when assessing the severity of acute pancreatitis ?
- mild
- moderate severe
- severe
What classifies as mild acute pancreatitis ?
No organ failure or local/systemic complications
What classifies as moderate severe acute pancreatitis ?
- transient organ failure (e.g AKI) resolving within 48 hrs
- may have a local complication (e.g a peripancreatic collection)
What classifies as severe acute pancreatitis ?
Persistent/multi organ failure
What are the 2 types of acute pancreatitis ?
- interstitial oedematous pancreatitis
- necrotising pancreatitis
Which type of acute pancreatitis is more common …
A) interstitial oedematous ?
B) necrotising ?
Interstitial oedematous pancreatitis
(90-95% of acute pancreatitis cases)
What happens in interstitial oedematous pancreatitis ?
Pancreatic parenchyma is inflamed/oedematous
What happens in necrotising pancreatitis ?
Necrosis of pancreatic parenchyma and/or peripancreatic tissue
May become infected
What are the potential subtypes/complications associated with interstitial oedematous pancreatitis ?
- acute peripancreatic fluid collection (APFC)
- pseudocyst
What are the potential subtypes/complications associated with necrotising pancreatitis ?
- acute necrotic collection (ANC)
- walled off necrosis (WON)
What are the causes of acute pancreatitis?
Idiopathic
Gallstones
Ethanol
Trauma
Steroid use
Mumps
Autoimmune/family Hx/genetics
Scorpion sting
Hypercalcaemia + hypertriglyceridaemia
Endoscopic retrograde cholangiopancreatography (ERCP)
Drugs/medications
What investigations would you perform in the case of suspected acute pancreatitis ?
- Lipase/Amylase
- U+Es
- LFTs
- Lactate
- FBC
- chest X-ray (to rule out differentials e.g pneumonia or visceral perforation)
What blood results would you expect to see in the case of acute pancreatitis ?
- Lipase/amylase higher than 3x the upper limit of normal
- raised WCC
- raised CRP
- raised creatinine
- raised urea suggests AKI
- low albumin
normal LFTs and no jaundice rules out cholangitis
What CXR results would you expect to see in the case of acute pancreatitis ?
Normal
air under diaphragm would suggest gastric/visceral perforation
When would you perform a CT for a patient with suspected acute pancreatitis ?
5-7 days after admission as this is when local complications would start to develop
After bloods and CXR indicate acute pancreatitis, what is the next most appropriate investigation?
Abdominal ultrasound (USS) to identify if gallstones are the cause
a CT is indicated for a diagnosis if the bloods etc were unclear
What would be the initial management of a patient with acute pancreatitis ?
- analgesics
- antiemetics (NG tube if vomiting)
- VTE prophylaxis
- fluid balance (IV fluids and catheter)
When should an urgent upper GI endoscopy be ordered?
- patients with dysphasia (swallowing issues)
Or
- patients over 55 with weight loss and either upper abdo pain, reflux or dyspepsia
What does dyspepsia mean ?
Indigestion
feelings of burning, belching, bloating or barfing after eating
What are the risk factors for GORD ?
- smoking
- alcohol
- stress
- pregnancy
- hiatus hernia
- trigger foods
- medications that reduce the tone of the LOS e.g NSAIDS and beta-blockers
What is the first line management for people with GORD, where cancer is not suspected ?
Proton-pump inhibitors e.g omeprazole, esomeprazole, lansoprazole…
Or upper GI endoscopy for patients who don’t respond to the meds
Are there surgical options for GORD management ?
Yes, where meds and lifestyle management have failed
Called a Nissen fundoplication
What is a Nissen fundoplication ?
A surgical management for GORD when other methods have failed
Wrap the stomach fungus around the lower oesophagus to reinforce the LOS
What are the potential complications resulting from untreated GORD ?
- Barrett’s Oesophagus
- oesophagitis
- chronic cough
- recurrent chest infections * due to gastric aspirate in the lungs*
- benign stricture
What is oesophagitis ?
Inflammation in the lower oesophagus
How does unresolved GORD lead to a chronic cough ?
Stomach acid can reach the larynx at night when laid flat
What is the metaplastic change that occurs in Barrett’s Oesophagus?
Stratified squamous cells of oesophagus change to columnar cells like in the stomach
squamous —> columnar
What factors would constitute surgery in the case of GORD ?
- unresolved by meds and lifestyle changes
- desire to stop meds e.g cos of side effects…
- presence of a hiatus hernia
What are the red flag symptoms (ALARMS) in patients presenting with dyspepsia ?
Dyspepsia = indigestion
Anaemia (lethargy, breathlessness)
Loss of weight
Anorexia (loss of appetite)
Recent onset/progressive symptoms
Mallena and haematemesis (black stool and red vomit)
Swallowing difficulty (dysphagia)
What age group are gastric cancers most commonly seen in ?
75+
What is the most common hydrological type of gastric cancer ?
Adenocarcinoma
less common:
- squamous cell carcinoma
- non-Hodgkin lymphoma
- gastrointestinal stromal tumours (GIST)
- neuroendocrine tumours (NETs)
What are the main risk factors for gastric adenocarcinoma ?
- 75+
- male
- H.pylori infection
- FAP (familial adenomatous polyposis)
- ethnicity (black, Hispanic, Asian)
- smoking
- alcohol
- poor diet
- obesity
What do the TNM stages refer to in the case of gastric adenocarcinoma?
T = how far the tumour has grown into the gastric wall
N = lymph node spread
M = metastatic spread
What does T2 stage indicate in gastric adenocarcinoma ?
T2 = invasion into muscularis propria
What does N2 stage indicate in gastric adenocarcinoma ?
Spread into 3-6 regional lymph nodes
What is the 5-year survival rate of…
A) stage 3 gastric adenocarcinoma ?
B) stage 4 gastric adenocarcinoma ?
Stage 3 = 25%
Stage 4 <1%
What TNM grades classify stage 3 gastric adenocarcinoma ?
T2, N1-3, M0
Or
T4a, N1-3, M0
Stage 4 involves metastasis
When does a cancer grading become stage 4 ?
When metastasis is involved
What is the investigation pathway required in cases of gastric adenocarcinoma ?
- upper GI endoscopy (as per NICE guidelines)
- minimum of 6 biopsies during endoscopy
- CT thorax, abdo + pelvis (for initial staging)
- discussion at MDT
- perioperative chemotherapy (if tumour is resectable)
What is the management for gastric adenocarcinoma ?
