CSI 17 - Acute Abdomen Flashcards
in what demographics can a pain free acute abdomen occur in?
Old people
Children
Immunocompromised
Last trimester of pregnancy
After the initial diagnostic procedures (Hx, Exams Ixs, labs, etc), what other pathways or methods may you use to help determine cause of an acute abdomen IF the symptoms doesn’t neccesitate immediate surgery
Further abdo exams by a physician with more xp
Diagnostic laparoscopy
what conditions can laparascopy be used therapeutically
- Appendicitis
- Cholecystitis
- Lysis of adhesions
- Hernia repair
- many gynaecological causes of an acute abdo
what diagnostic algorithms or tools can help to further stratify risk of appendicitis
Appendicitis Inflammatory Response (AIR) score
Novel Pediatric Appendicitis Risk Calculator (pARC)
Need further prospective studies to evaluate clinical use
How has the attitude of narcotic analgesia changed over time regarding it’s use in patient’s with an acute abdomen
Before: it was discouraged as they thought it would mask the symptoms or exam findings and hence miss diagnosis
Now: evidence shows it doesn’t hinder management and improves pt comfort.
Fentanyl or one of it’s analouges is a useful agent used due to it’s potency and short half life
Give reasons as to why old people present atypically with abdo pain
They have long standing co-morbidiites hence cannot mount the appropriate physiological response (due to comorbidities or meds treat it).
Deteriorating CNS or PNS
- CNS- dementia and hence can’t communcate symptoms effectively
- PNS - alter perception of pain/temperature
Give reasons as to why pregnant people present atypically with abdo pain.
Explain any response needed?
Pregnancy have different physiology and hence making diagnosis very difficult.
Enlarged uterus compress abdo organs and there’s laxity of abdo walls: makes it difficult to localise pain and can blunt peritoneal signs
Pregnant people mauy have mild physiological leukocytosis (this finiding is non-specific in women with acute abdo).
Concerns about imaging (CT or Xrays)
what is the amount/threshold of radiation that hasn’t been linked to maternal or foetal defects?
less than 5 rads
what are the abdominal sources/causes of an acute abdomen?
From most common to least common
Intestinal Obstruction
Peritonitis secondary to infection
Inflammatory conditions that present with peritonism
Haemorrhage (e.g. ectopic pregnancy)
Ischaemia (Mesenteric ischaemia or ovarian torsion)
Processes associated with contamination of GI contents (e.g. perforated duodenal ro gastric ulcer)
What should you do if you see a pt with peritonitis secondary to infection?
what is needed?
Surgical emergency- LAPARATOMY
Don’t wait for diagnostic studies
what are the causes of obstruction (leading to an acute abdomen)
Adhesions (most common)
Incarceration of hernia (2nd msot common) and most common in people without prior abdo surgery
Volvulus, Gallstones, Intussuception
Congential anatomical abnormalities
Cancer
IBD
Inflammation may be an aetiology for an acute abdomen.
Give causes of inflammtion
Cholecystitis,etc
Diverticulitis
Meckel’s diverticulitis
IBD- pain due to inflammation itself or secondary obstruction
Perforation may be an aetiology for an acute abdomen.
Give causes of perforation
Gasstric or duodenal ulcers
Boerhaave’s syndrome and
Mallory weiss tear
Can lead to oesophageal laceration and GI haemorrhage
what are the gynacological causes of an acute abdomen
Ectopic pregnancy hence always do a pregnancy test for women in child bearing age
Others are:
- Ruptured overian cyst
- Ovarian torsion
- Pelvic inflammatory diseases
- Endometriosis
what are the vascular causes of an acute abdomen.
Explain any relevant details
Haemorrhage caused by
- ruptured AAA
- Abdo aortic dissection
- ruptured splenic artery aneurysm
Ischeamic:
- AMI or ischeamic colitis
- splenic infarct
- Vaso-occlusive episoded of sickle cell crisis
Budd chiari syndrome - stop hepatic venous outflow and hence lead to hepatomegaly and ascites
Abdo wall haemtoma
- occur spontaneously or
- secondary to trauma , coughong, exercise or procedure
State and explain the infective causes of an acute abdomen
Psoas abscess- due to tuberculosis abcess spreading from lumbar vertebrae to psoa
Hepatitis/hepatic abcess
gastroenterirtis, infectious colitis
Typhilitis (neutropenic enterocolitis)
Fitz-Hugh syndrome: complication of pelvic inflammatory disease
- you hsve RUQ pain associated with perihepatitis
what are the metabolic causes of acute abdomen
Uraemia
Diabetic ketoacidosis
Addisonian crisis
Hypercalcaemia
Genetic:
- Acute intermittent porphyria
- Hereditary Meditteranean fever
state what toxic substances can cause an acute abdomen
Heavy metal poisoning - caused by medical/environmental/occupational exposure to, mercury, lead, or arsenic.
Narcotic withdrawal from opioids may result in abdominal cramping pain.
what are the urological and other causes of acute abdomen
Urology
- In men, testicular torsion should be considered.
- In both men and women: kidney stones and pyelonephritis
Other
Radiation enteritis and spider bites
what are the general urgent considerations for pt with an acute abdoment
Whilst waiting for routine labs, consult a surgeon; it’s more efficient
IV access should be obtained and monitor vital signs
Correct any abnormalities (with fluids or blood products)
what should you consider for a pt exhibiting evidence of hypovolaemic shock with a known or suspected haemoperitoneum
Get to surgery ASAP (with limited pre-op evaluation)
Those with ongoing haemorrhage:
- Give 2 large bore IV lines
- Urgent typing and cross-mathcing of blood is needed
- Fluid resuscitation
Initial resuscitation involves:
- 2L of isotonic fluids
- O negative uncross-matched blood can be given until cross-matched blood can be given
- Maybe give antifibrinolytic like tranexamic acid
what should you consider regarding FLUIDs for a pt exhibiting evidence of aortic dissection or ruptured AAA?
Explain why
Careful fluid management (aim SBP to bebetween 80 and 90) or even lower if mentation is intact
This is becauses aggressive fluid replacment can lead to more bleeding via:
- hypothermic and dilutional coagulopathy
- Lowering blood viscosity
- Increased perfusion pressure FROM FLUID expands volume and lead to sendoary clot disruption
what should you consider APART FROM FLUIDs for a pt exhibiting evidence of aortic dissection or ruptured AAA?
Explain why
O2
multiple peripheral or centraL venous access
Urgent blood typing and cross-matching
Routing labs tests
Vascular surgery consultation
Prophylactic Abx
what should you consider if a perforated viscus, appendicitis or cholecystitis is suspected
i.e what measures should you take quickly?
Give Broad spectrum Abx: contents of GI can lead to sepsis
Urine MCS and dip stick
Blood tests
what should you consider for a pt that is female of childbearing age.
what should you do now?
Preg test - exclude ectopic preg
if ectopic is suspected give 2 large bore IV cannulae (incase it ruptures)
Blood type and cross matching should be considered
Urgent gynaecological consultation is needed
what should you consider If a patient reports abdominal pain disproportionate to the signs on physical examination,
what disgnois should you think of and what should you offer
Consider mesenteric ischeamia esp in old ppl with Hx of:
- Smoking
- Peripheral vascular diseases
- A-fib
Offer:
- O2
- Fluid resuscitation
- Broad spectrum Abx
- Urgent surgical and Interventional radiologist consultation needed
what are the common differentials for an acute abdomen?
*The list is not exhaustive but you should already the know the ones not listed*
Gastrointestinal malignancy
Hepatic abscess
Fitz-Hugh Curtis syndrome
Mallory-Weiss tear
Abdominal wall haematoma
Hereditary Mediterranean fever
Typhlitis (neutropenic enterocolitis
Narcotic withdrawal
Infectious colitis
what are the uncommon causes of an acute abdomen.
*Again list is not exhausitve, the others are too niche that you would guess them in the SBA*
- Volvulus
- Intussusception
- Duodenal ulcer
- Ruptured ovarian cyst
- Ovarian torsion
- AMI/ ishcameic colitis
- Hypercalcaemia
- Aortic dissection
- Ruptured AAA
- DKA
what does long standing epigastric pain suggest?
Gastric ulcer
A sudden worsening suggests perforation
what does sudden epigastric pain following vomiting and/or OGD suggests?
Oesophageal perforation
what does it suggest for areas of the pain in the diagram that present gradually or more progressively
If a pt has similar pain before but now it’s come back, what does it suggest?
This may suggest a recurrent condition, such as cholecystitis, pancreatitis or diverticulitis, with increasing frequency and severity indicating disease progression.
what does RUQ pain signify
Cholelithiasis, cholecystitis, hepatitis, hepatic abscess,
Fitz-Hugh Curtis syndrome,
Perforation or malignancy of the colon,
Pyelonephritis, or kidney stones.
Acute appendicitis in a pregnant woman due to displacement by the enlarging uterus.
what does LLQ pain indicate?
Sigmoid volvulus (typically older patients), diverticulitis, IBD kidney stones, gastrointestinal malignancy,
Psoas abscess,
incarcerated / strangulated hernia,
gynaecological concerns,:
- ovarian torsion or cyst rupture,
- ectopic pregnancy, or pelvic inflammatory disease (PID).
what are the causes of periumbilical pain?
Appendicitis before radiating
Acute mesenteric ischeamia
Leaking or ruptured AAA
Small bowel obstruction
What does persistent lateralised pain indicate?
condition associated with ascending or descending colon, kidney, gallbladder or ovary.
what does the diagram show about radiation
what does referred pain to the follwoing indicate?
Right scapula
Left scapula
Scrotal/Testicular pain
Right scapula:
- Gallbladder disease, liver disease,
- irritation of right hemidiaphragm (e.g., right lower lobe pneumonia)
Left scapula:
Cardiac disease, gastric disease, pancreatic disease, splenic disease, or irritation of left hemidiaphragm.
Scrotal or testicular pain:
- Usually from loin to groin: kidney stones or ureteral disease
*
what are other important information to consider when a pt presents with abdominal pain
Character: Aortic diseection is a sharp, tearing pain.
Other associated symptoms like fever, chills, N&Vomiting shows:
- Cholecystitis , etc
- spider bites, abdominal wall haematoma
Time of last bowel movement: important for construction
Nature of recent stool
Time and type of last meal or oral intake
Presence of anorexia:
- Appendicitis
- radiation enteritis
- hepatic abscess
PMHx, FHx, SHx, DHx
last menstrual period
what are the clinical features/cause of biliary colic
Dull RUQ pain
Symptoms last for LESS than 6 hrs (more likely to be constant)
No inflammation: blood tests is normal
Trigger by fatty food; stimulate CCK causes contraction of gall bladder
Nausea and vomiting
Normally caused by blockage of gallstones in the cystic duct or neck of gallbladder causing muscular contraction
what are the clinical features/cause of acute cholangitis
Biliary outflow obstruction and infection of bile ducts (bacterial)
Gallstones may be found in CBD
CLINICAL SIGNS:
- Jaundice
- Severe pain
- Rigors and fever
- Tachycardic, febrlle and hypotensive
- Raised WCC, CRP, ALP
- Raised LFTs (raised BR and others)
Charcot’s triad (Jaundice, rigors/fever and RUQ pain)
Very high mortality
Reynold’s Pentad: if they have shock and altered mental status
Obstruction of bile from liver or gallbladder and infection (bacterial)
what investigation is used to see gallstones?
what will you see
USS
99% of gallstones don’t show up on AXR and CTs aren’t used
Features seen on USS:
- Hyperechoic echoing and posterior acoustic shadowing
what is the composition of bile and how does gallstones form?
what are the types of gallstones
Bile mainly made of water (98%). Others are BR, Cholesterol, bile salts and electrolytes
Gallstones result from supersaturation of bile, can differ in sizes.
The composition differs from age, diet and ethnicity.
Gallstone Crystallisation could be either from cholesterol (majority) or bilirubin (pigment) or both
what are the features of cholesterol stones and give relavant risk factors
Cholesterol gallstones normally found alone, and can be yellow or dark green or brown colour.
They are large.
RF are:
- poor diet and
- obesity due to excess cholesterol
what are the features and RF of pigment stones and mixed stones
Pigment stone:
- made up of bilirubin breakdown products.
- They are small, darker and numerous.
- It can be from excess bile pigment production.
- Can be black or brown
Black pigment: made up of calcium bilirubinate and more likely seen on X-ray
Brown: occur secondary to infectiojn
RF: haemolytic anaemia (for black pigment stones esp)
Mixed stones: combo of pigment and cholesterol , and bile salts
what are the different locations of gallstones that can cause
- Acute cholecystitis
- Bilairy colic
- Ascending cholangitis
- Pancreatitis
Gallstones in neck of gallbladder or cystic duct you get cholecystitis
Hartman’s pouch can also cause it
Impacted stone with inflammation gives you cholecystitis
Gallstone found in CBD with infection causes ascending cholangitis
Gallstone in the neck of gallbladder or cystic duct can also cause bilary colic
Gallstone in pancreatic duct causes acute pancreatitis
Explain the pathophysiology of Gallstone Ileus
Gallbladder lies adjacent to duodenum
It is small bowel obstruction secondary to gallstones.
Overtime wall of gallbladder is eroded due to chronic inflammation and lead to fistula formation b/w gallbladder and duodenum (this occurs over a long time)
It occurs when gallstone enters duodenum and causes the blockage of small bowel.
Gallstone enters ileocaceal valve and cause small bowel obstruction
It takes TIME
Explain and outline the procedure for a laparoscopic chiolecystectomy
You must have knowledge of the procedure to obtain valid consent
Explain diagnosis to them and all the effects
Make sure they have capacity. Give them time
Treatment options:
- Include do nothing
- Tell them all available
- You cam recommend to pt but don’t force it
Purpose of treatment- needs to be written on consent form.
Tell risk:
- Different people have varying tolerance for risk
- Different risk are different for different people
what 3 mechanisms are important in the formation of cholesterol gall bladder stones
Cholesterol supersaturation
Gallbladder hypomotility
Kinetic, pro-nulceating protein factors
Explain the mechanism of how kinetic factors can lead to formation of cholesterol gallstones
Formation of microcrystals in supersaturated bile is modulated by kinetic protein factors.
A number of inhibitory or promoting proteins have been described.
Mucin, a glycoprotein mixture that is secreted by biliary epithelial cells is the crystallization promoting protein in gallbladder sludge.
