Week 11 - Case One Flashcards

1
Q

what does an AAA refer to

A

the dilation of the abdominal aorta with a diameter of more than 3cm

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2
Q

often, when is the first time a patient becomes aware of an aneurysm

A

when it ruptures, causing life-threatening bleeding into the abdominal cavity

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3
Q

what is the mortality rate of a ruptured AAA

A

80%

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4
Q

what are the risk factors for an AAA

A

Men are affected significantly more often and at a younger age than women
Increased age
Smoking
Hypertension
Family history
Existing cardiovascular disease

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5
Q

what is the screening programme for an AAA

A

all men in England are offered a screening ultrasound scan at the age of 65 to detect asymptomatic AAA

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6
Q

are women offered screening

A

not routinely offered screening as they are at much lower risk.

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7
Q

what do the NICE guidelines say about screening women

A

the NICE guidelines say a routine ultrasound can be considered in women over 70 with risk factors such as existing cardiovascular disease, COPD, family history, hypertension, hyperlipidaemia or smoking

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8
Q

what aortic diameter counts to refer people to the vascular team

A

patients with an aortic diameter above 3cm are referred and are referred urgently if more than 5,5cm

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9
Q

what is the presentation of AAA

A

most patients are asymptomatic. it may be discovered on routine screening or when it ruptures

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10
Q

what are the other ways it can present

A

non-specific abdominal pain

pulsatile and expansile mass in the abdomen when palpated with both hands

as an incidental finding on an abdominal X-ray, ultrasound or CT scan

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11
Q

what is the usual investigation for establishing a diagnosis of AAA

A

an ultrasound

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12
Q

why is a CT angiogram sometimes given

A

gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm

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13
Q

what are the four classifications of aneurysm

A

Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm

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14
Q

what can the risk of AAA progression be reduced by

A

treating reversible risk factors;
stop smoking
healthy diet and exercise
optimising the management of hypertension, diabetes and hyperlipidaemia

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15
Q

what screening and surveillance programme is recommended by Public Health England

A

yearly for patients with aneurysms 3-4.4cm

3 monthly for patients with aneurysms 4.5-5.4cm

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16
Q

the NICE guidelines recommend elective repair for patients with what symptoms

A

Symptomatic aneurysm
Diameter growing more than 1cm per year
Diameter above 5.5cm

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17
Q

what is involved in elective surgical repair

A

inserting an artificial graft into the section of the aorta affected by the aneurysm

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18
Q

what are the two methods used to insert this graft

A

open repair via a laparotomy
endovascular aneurysm repair (EVAR) using a scent inserted via the femoral arteries

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19
Q

what does gov.uk advise that patients MUST do - concerning driving

A

Inform the DVLA if they have an aneurysm above 6cm
Stop driving if it is above 6.5cm
Stricter rules apply to drivers of heavy vehicles (e.g., bus or lorry drivers)

20
Q

how does a ruptured AAA present

A

Severe abdominal pain that may radiate to the back or groin
Haemodynamic instability (hypotension and tachycardia)
Pulsatile and expansile mass in the abdomen
Collapse
Loss of consciousness

21
Q

what is permissive hypotension

A

strategy of aiming for a lower than normal blood pressure when performing fluid resuscitation

the theory is that increasing the BP may increase blood loss

22
Q

what should happen to a haemodynamically unstable patient with a suspected AAA

A

should be transferred directly to theatre.

surgical repair should not be delayed by getting imaging to confirm the diagnosis.

23
Q

what can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients

A

CT angiogram

24
Q

what is the difference between a true and false aneurysm

A

a true aneurysm - the wall of the artery forms the wall of the aneurysm

a false aneurysm - other surrounding tissues form the wall of the aneurysm

25
Q

where are AAA usually found

A

in the infrarenal part of thr aorta

26
Q

what are the features of pain in an AAA

A

epigastric pain radiating to the back. pain may also be present in the groin, illiac fossa or testicles

27
Q

what is a common feature of a thoracic aortic aneurysm

A

BP may be different in each arm

28
Q

what is the mechanism of referred pain

A

pain of visceral origin is referred to the site on the skin that follows the dermatome rule.

beware of overlapping dermatomes from borderline structures between foregut and midgut. (pancreatic and duodenal in particular)

29
Q

what are the possible diagnoses for colicky abdominal pain that is now constant

A

bowel obstruction with/without hernia

irritable bowel syndrome

30
Q

what are the possible diagnoses for colicky abdominal pain associated with diarrhoea

A

gastroenteritis

inflammatory bowel disease

31
Q

Give any possible diagnoses for the description of the pain:

Central abdominal pain that shifted to the right iliac fossa

A

Appendicitis
Rarely perforated Duodenal Ulcer

32
Q

Give any possible diagnoses for the description of the pain:

Sudden severe pain radiating to the back, flank and/or groin

A

Abdominal aortic aneurysm (AAA) until proven otherwise
Renal colic

33
Q

Give any possible diagnoses for the description of the pain:

Severe generalised pain with shoulder tip pain

A

Diaphragm irritation by free fluid / blood within the abdomen

34
Q

what does colicky pain that becomes constant suggest

A

that there is a partial obstruction of the hollow viscus, that has become complete and needs urgent intervention to prevent perforation/major complication

35
Q

what does pyrexia, localised tenderness and guarding suggest

A

an infection or inflammatory process in one organ

36
Q

what does radiation usually point to

A

the possible organ but it can also suggest the progression of the disease

37
Q

what are nausea, vomiting and distension related to

A

the bowel obstruction but rememeber that inflammatory causes can also cause localised ileus giving a similar but less severe picture

38
Q

what is McBurney’s point

A

classical point of maximum tenderness in appendicitis, corresponding to the position of the base of the appendix.

1/3rd of the line between anterior superior iliac spine to umbillicus

39
Q

what is the definition of a hernia

A

defined as a protrusion of an organ through its containing wall and into a different cavity

40
Q

what is the most common abdominal wall hernia

A

inguinal

41
Q

what are direct hernias

A

the leading area of weakness is the posterior wall of the inguinal canal, where viscera herniates anteriorly through Hesselbach’s triangle and not into scrotum

42
Q

what are indirect hernias

A

the leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside spermatic cord, and can exit the canal through the superficial ring and into the scrotum

43
Q

what are the other four types of hernia

A

Umbilical / paraumbilical

Femoral (Below the inguinal ligament, inferior and lateral to the pubic tubercle)

Incisional (through any previous surgical scar)

Epigastric or midline hernias, where there are natural areas of weakness due to the ‘criss-crossing’ of fibres that form the linea alba

44
Q

what is a sentinel loop

A

a short segment of adynamic ileus close to an intra-abdominal inflammatory process.

the sentinel loop may aid in localising the source of inflammation.

45
Q
A