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Y4 GI / Surgery > The Acute Abdomen > Flashcards

The Acute Abdomen Flashcards

1
Q 
Match the sign to the diagnosis: 
Cullen's sign
Grey Turner's sign
Murphy's sign
Rosvig's sign
A

Cullen’s sign pancreatitis
Grey Turner’s sign pancreatitis
Murphy’s sign gallbladder
Rosvig’s sign appendicitis

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2
Q

Pain exacerbated by coughing/moving is caused by what type of pain?

A

Parietal pain

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3
Q

Pain where you’re unable to stay still is caused by what type of pain?

A

Visceral pain

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4
Q

What causes tinkling bowel sounds?

A

Complete small bowel obstruction

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5
Q

Is referred pain always ipsilateral?

A

Yes

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6
Q

Does parietal or visceral pain cause guarding rebound tenderness?

A

Parietal pain

visceral non-tender

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7
Q

What is absolute constipation?

A

Not passing wind

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8
Q

What colour is fresh bile?

A

Golden yellow

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9
Q

What drug can be used to reverse warfarin? how long does it take? what can be done if you need it asap?

A

Vitamin K
PO takes few days
IV takes 6hr
ASAP: FFP or factor 7

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10
Q

Name 4 causes of LLQ pain

A 
Ruptured ectopic
Ovarian cyst/torsion
Diverticulitis
Renal stone
Crohn's / UC
Strangulated hernia
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11
Q

Name 4 causes of RLQ pain

A 
Ruptured ectopic
Ovarian cyst/torsion
Diverticulitis
Appendicitis
Renal stones 
Crohn's 
Strangulated hernia
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12
Q

Name 4 causes of epigastric pain

A 
Pancreatitis
MI
PUD
Gastritis / reflux 
AAA
Diaphragmatic hernia
Acute cholecystitis
Cholecystitis
AAA
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13
Q

Name 4 causes of RUQ pain

A 
Acute cholecystitis
RLL pneumonia
Duodenal ulcer
Hepatitis
Appendicitis
Renal stone
Pyelonephritis
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14
Q

Name 4 causes of LUQ pain

A 
LLL pneumonia
AAA
Pyelonephritis
Pancreatitis
Renal stone
Gastric ulcer
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15
Q

Name 4 causes of central abdominal pain

A 
Intestinal obstruction
Pancreatitis
Early appendicitis
AAA
Diverticulitis
Ischemic bowel
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16
Q

What basic investigations should you do for the acute abdomen?

A 
Bloods: FBC, CRP, U+E, lactate, amylase, cardiac enzyme, G&S, crossmatch
ECG 
Urinalysis
bHCG 
erect CXR
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17
Q

What type of imaging is 1st line when investigating the acute abdomen?

A

CT
If suspect obstruction: AXR
US useful in RUQ pain / women with pelvic pain / kids

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18
Q

What basic Mx would you give for the acute abdomen whilst awaiting Ix results?

A 
IV morphine
IV paracetamol
Antiemetic
Oxygen if low
IV fluid
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19
Q

In the management of the acute abdomen, most patients require resuscitation before surgery, except which?

A

Ischemic gut / faecal peritonitis

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20
Q

What is absolute constipation?

A

Not passed wind

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21
Q

A peritonitic patient is likely to stay still or move about?

A

Stay still

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22
Q

What would be see on urine dipstick in pyelonephritis?

A

Nitrites, protein, leukocytes

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23
Q

What is free air under the diaphragm a sign of?

A

Perforation

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24
Q

Abdominal XR has the radiation equivalent of how many CXR?

A

50

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25
Q

What type of imaging is used for the acute abdomen in pregnant women?

A

MRI

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26
Q

Sudden onset abdo pain + shock = what (until proven otherwise)

A

AAA

or bowel perforation, inferior MI, acute ischemic bowel

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27
Q

Is the normal location of the appendix intraperitoneal or retroperitoneal?

A

Retroperitoneal

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28
Q

Where is the pain located in appendicitis?

A

Perriumbilical central pain that shift to RIF
(periumbilical since pancreas is a midgut organ, shifts as irritates parietal peritoneum)
(ask patient to point to where the pain started and where it is now)

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29
Q

How can you assess for peritonism in appendicitis?

A

Ask kid to jump, ask adult to cough

If kids can jump, probably not appendicitis

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30
Q

What is the relevance of puritanism in appendicitis?

A

If peritonitic - need surgery

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31
Q

What is the name of the scoring system used in paediatrics for appendicitis?

A

ALVARADO

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32
Q

What is Rosvig’s sign?

A

Press LIF, PTx feels more pain in RIF

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33
Q

Where is McBurney’s point and what is its relevance?

A

1/3 distance from umbilicus - ASIS

Where tenderness maximal in appendicitis

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34
Q

Bad breath halitosis in a child with acute abdominal pain is a sign of what?

A

Appendicitis

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35
Q

What age has the highest incidence of appendicitis? When is the second peak?

A

10-20yr

2nd peak in 60s

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36
Q

Appendicitis can occur at any age, true or false

A

True

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37
Q

What effect does appendicitis have on:

  • Temperature
  • HR
  • WCC
  • CRP
  • LFTs
  • U+Es
  • bHCG
A
  • Low grade fever
  • Mild >HR
  • Mild >WCC
  • > CRP
  • Normal LFTs
  • Normal U+Es
  • Normal bHCG
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38
Q

What imaging is first line for suspected appendicitis in men, fertile women, pregnant women and non-fertile women and children?

A 
Men - CT
Pregnant women - MRI
Fertile women - US then CT
Children - US
Non-fertile women - CT
(US fertile women is to exclude ovarian causes, not to see appendicitis)
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39
Q

In males under 40yr, if appendicitis is very strongly suspected is CT still required before LAP?

A

Yes - NICE says CT before LAP

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40
Q

In males over 40yr, what is in the differential for appendicitis?

A

Perforated caecal tumour
Atypical diverticulitis
Ischemic bowel

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41
Q

What is a faecolith?

A

Stone of hard poo

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42
Q

Are antibiotics given for appendicitis?

A

Yes

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43
Q

What are the 5 Ps for causes of ileus?

A 
Post intra-abdo surgery
Low potassium
Peritonitis
Pelvic/spinal fracture
Parturition childbirth
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44
Q

How is bowel obstruction classified?

A

Structural mechanical v paralytic ileus

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45
Q

What are the 3 types of mechanical AKA structural bowel obstruction?

A

External compression
Wall compression
Something in lumen

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46
Q

What is the commonest and 2nd commonest cause of small bowel obstruction?

A

1st adhesion

2nd hernia

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47
Q

What cause of bowel obstruction can’t be diagnosed in a virgin abdomen?

A

Adhesion

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48
Q

What is the commonest and 2nd commonest cause of large bowel obstruction?

A

1st malignancy

2nd volvulus

49
Q

What is a stricture? Name 2 causes

A

Narrowing of the lumen
Due to inflammation
Crohn’s / diverticular

50
Q

In bowel obstruction, why is the there abdominal distension? Why is there colicky pain? Why is there nausea?

A

Distension - proximal bowel dilates + swells full of fluid/gas
Colicky pain - increased motility / peristalsis
Nausea - electrolyte imbalance + dehydration

51
Q

What does bowel distal to the obstruction do?

A

Carries on as normal until empty - then contracts and becomes immobile

52
Q

Where are the 2 types of volvulus?

A

Caecal / sigmoid

Both small bowel obstruction

53
Q

What is the management of sigmoid volvulus?

A

Decompress during rigid sigmoidoscope

54
Q

What is the AXR appearance of volvulus?

A

Coffee bean

55
Q

“Strands pulling parts of bowel together” is the description of what?

A

Adhesion

56
Q

What is gallstone ileus?

A

Causes mechanical small bowel obstruction
Complication of cholecystiis
Not a true ileus
Gallstone stuck at ileocaecal valve

57
Q

Early distension / constipation is a sign pf small or large bowel obstruction?

A

SBO late distension, late constipation

LBO early significant distension, early constipation

58
Q

In small or large bowel obstruction is there early or large bilious vomiting?

A

Small bowel early bilious vomit

Large bowel late bilious then faeculent vomit

59
Q

What cause of acute abdomen causes tympanic percussion?

A

Bowel obstruction

60
Q

In a patient with acute bowel obstruction, change in the character/severity of pain (colicky > constant) suggests what?

A

Complication: ischemic, perforation, sepsis

61
Q

What is the normal size of bowel on AXR?

A

Small bowel 3cm
Large bowel 6cm
Caecum 9cm

62
Q

What is seen on ABG in bowel obstruction?

A

Late metabolic acidosis

63
Q

What imaging is done for bowel obstruction?

A

AXR + contrast CT

64
Q

What is the conservative Mx of bowel obstruction?

A 
Analgesia
IV fluids with potassium
NG tube (suck intestinal decompression)
Catheter
NBM 
('Drip and suck')
65
Q

What are the indications for surgery in bowel obstruction?

A 
Strangulation
Closed loops
Haemodynamically unstable
Perforation 
Ischaemia
No improvement after 72hr conservative Mx
66
Q

What drug is contraindicated in bowel obstruction?

A

Metoclopramide pro-kinetic perforation risk

67
Q

Gas is produced by _____ metabolism of gut organism

A

Anaerobic

68
Q

What are signs of dehydration that can be seen on bloods?

A

High haematocrit
High lactate
High urea/creatinine

69
Q

How does the clinical presentation of ileus differ from mechanical bowel obstruction?

A

Continuous non-colicky abdo pain

70
Q

What is the management of ileus?

A

Conservative NG tube

71
Q

What is the relevance of an incompetent ileocecal valve in bowel obstruction?

A

Incompetent valve good since it spreads the pressure

72
Q

Which type of IBD is more associated with strictures and why?

A

Crohn’s since transmural inflammation

73
Q

Where in the GIT are diverticulum most common?

A

Sigmoid

74
Q

What is a diverticula? What is the aetiology?

A

Outpouching of got wall

Due to lack of dietary fibre; high intraluminal pressure; mucosae herniate through muscle layers of gut at weak points

75
Q

What is diverticulosis, diverticular disease and diverticulitis?

A

Diverticulosis = diverticula present (most asymptomatic incidental finding)
Diverticular disease = symptomatic
Diverticulitis = inflamed diverticula

76
Q

What is the presentation of diverticular disease?

A

Altered bowel habit +- left sided pain

77
Q

What classification system is used in diverticulitis?

A

Hinchey

grades 1-4

78
Q

What is the presentation of diverticulitis?

A

Fever
Altered bowel habit
LHS pain/tender
>HR

79
Q

How is diverticulitis diagnosed?

A

CT
(Avoid colonoscopy in the acute setting due to perforation risk)
(If first presentation arrange outpatient colonoscopy)

80
Q

What is the management of diverticlar disease?

A

High fibre diet +- antispasmodic PO mebeverine

81
Q

What is the management of diverticulitis?

A

Empirical IV ABx

82
Q

A complication of diverticulitis is an abscess, how is this diagnosed? Who drains it?

A

CT

Interventional radiologists

83
Q

What is a Hartmann’s procedure?

A

Remove sigmoid
Bring out colostomy
Reverse in younger PTx

84
Q

What surgical procedure is done for perforation in diverticulitis?

A

Hartmann’s procedure

85
Q

Define a fistula

A

Abnormal connection between 2 epithelialized surfaces

86
Q

What type of fistula can cause bubbles in urine, brown urine and frequent UTIs?

A

Colovesical
(Surgical mx)
(Comp of diverticulitis)

87
Q 
Aetiology of pancreatitis
50% -
25% -
15% -
10% -
A

50% gallstone
25% alcohol
15% other
10% idiopathic

88
Q

What is the aetiology of pancreatitis using the pneumonic?

A 
I idiopathic
G gallstone
E ethanol 
T trauma
S steroids
M mumps / malignancy
A autoimmune
S scorpion
H hypertriglycerideaemia / hypercalcemia
E ERCP
D drugs: diuretics, azathioprine
89
Q

Pain in pancreatitis

  • Severe or mild
  • Constant or colicky
  • Radiates where?
  • Worse in what position?
  • Better in what position?
  • Tender or non-tender?
A 
Severe constant
Radiates to back (since retroperitoneal)
Worse in supine position lying down
Relief sitting upright / leaning forward
Tender
90
Q

What signs on the abdomen can be seen in severe pancreatitis?

A

Cullen’s + Grey Turner’s

91
Q

What is the diagnosis criteria for acute pancreatitis?

A

2/3 of: amylase >300 + abdo pain typical of apppendicitis + CT findings

92
Q

When do you CT scan acute appendicitis?

A

If unclear Dx OR if no improvement at 48hr (to look for comp/necrosis) OR if suspect necrotizing (severe)

(if amylase >3X upper limit normal don’t need CT scan - can diagnose)

93
Q

What is the role of US in appendicitis?

A

US everyone

look for comp / causes

94
Q

In pancreatitis, if US finds gallstones, what scan is done next?

A

MRCP

Then ERCP or cholecystectomy with bile duct exploration

95
Q

What is an index cholecystectomy?

A

Means within 1wk of admission - in the same admission

96
Q

What is the Mx of mild pancreatitis?

A

Analgesia
Antiemetic
Fluid resuscitation - lots 4-6L in 24hr to maintain fluid volume
(Mild pancreatitis usually responds by 48hr)

97
Q

What is the Mx of severe pancreatitis?

A 
Analgesia
Fluid resuscitation
HDU/ICU for pulmonary/renal monitoring
Correct electrolyte derangement
CT to rule out necrosis
Prophylactic ABx if necrosis
Surgical drainage if infected
TPN / enteric nutrition
98
Q

A complication of pancreatitis ‘capsulated fluid collection around a non-necrotic pancreas that lasts more than 4 weeks’ describes what?

A

Pancreatic pseudocyst

99
Q

Is amylase specific to pancreatitis?

A

No

100
Q

Is amylase a severity / prognostic indicator in pancreatitis?

A

No

101
Q

‘Interstitial edematous’ and ‘acute necrotizing’ are both types of pancreatitis - which is the commonest type of pancreatitis? How can you differentiate them?

A

Interstitial edematous commonest type

Differentiate by CT

102
Q

Are antibiotics given to all patients with pancreatitis?

A

No only if necrotising

If necrotic IV amox + metron + gent

103
Q

Gallstone pancreatitis typically has a raised ALP + Bn, true or false

A

True

Alcoholic pancreatitis typically has low MCV

104
Q

Who is more at risk for chronic pancreatitis - alcoholic acute pancreatitis or gallstone pancreatitis?

A

Alcoholic - longstanding pancreatic insult

105
Q

In chronic pancreatitis there is exocrine pancreas insufficiency - what is the management of this?

A

Creon enzyme replacement

106
Q

Chronic bowel ischemia ‘angina of the gut’ is caused by what disease process? Is causes pain triggered by what?

A

Atherosclerosis

Triggered by eating

107
Q

In acute ischemic bowel, SB usually dies and LB usually lives - why is this?

A

LB supplied by marginal A collaterals can maintain perfusion

108
Q

In ischemic bowel, pain is said to be ________

A

Pain out of proportion of clinical findings

109
Q

What is the management of ischemic bowel?

A 
Theatre ASAP
(Remove dead gut, resect nonviable intestines)
110
Q

What blood test in the acute abdomen should alert suspicion of ischaemic bowel?

A

High lactate

111
Q

What investigation is done for diagnosis in ischaemic bowel?

A

CT angiogram

112
Q

The caecal squelch sign is assoicated with what cause of the acute abdomen

A

Mesenteric adenitis

- but googled it and can’t find this on the internet ???

113
Q

What antibiotics are given for intra-abdominal sepsis, and what bugs are they against?

A

Amoxicillin (strep, enterococcus)
Gentamicin (coliforms)
Metronidazole (anaerobes)

114
Q

What is Mittelschmerz?

A

Pain associated with ovulation

115
Q

Mesenteric adenitis

  • what age range
  • viral or bacterial
  • pyrexic or apyrexic
A

Kids
Viral (often history of recent viral illness)
High fever

116
Q

Name 2 causes of toxic megacolon

A

C diff

UC

117
Q

Hirschsprung’s disease

  • Diarrhea or constipation
  • What colour vomit
  • Missing what
A

Constipation
Green bile vomit
Missing parasympathetic plexus

118
Q

Can renal or gallstones be seen on AXR?

A

Renal

not gallstones

119
Q

What questions should you ask in a history for PR bleeding?

A 
Every stool or once
How much blood
Colour of blood
Mixed with stool
Pain with defecation
On blood thinners
Loose or hard stool
How often pass stool 
Weight loss

Y4 GI / Surgery (11 decks)

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