8 - Abdominal catastrophes

Question 1

What is the cause and consequence of a bowel obstruction?

Answer 1

Caused by strangulated hernias

Results in hypovolemic shock due to fluid loss

Question 2

What is blood loss into retroperitoneum caused by?

Answer 2

Ruptured abdominal aortic aneurysm

Question 3

What is cholangitis?

Answer 3

Infection of the billary tract caused by gallstones or stents

Question 4

Why does parietal peritoneum/diaphragm pain radiate to the shoulder tip?

Answer 4

Diaphragm supplied by phrenic nerve which has its roots at c3-5 at shoulder tip

Question 5

What is visceral referred pain?

Answer 5

Visceral pain fibres follow sympathetic fibres back to spinal cord that gave preganglionic sympathetic fibres
CNS perceives visceral pain as coming from area supplied by spinal cord segment

Question 6

What causes visceral pain?

Answer 6

Inflammation
Ischaemia
Abnormal muscle contraction - colic

Question 7

Where is gastric and duodenal pain referred to?

Answer 7

Foregut structures so pain felt in epigastric

Question 8

Where is gall bladder pain referred to?

Answer 8

Foregut structure so pain felt in epigastric

Irritates parietal peritoneum, referring pain to tip of scapula

Question 9

Where is splenic pain reffered to?

Answer 9

Left lumbar region, anterior and posterior

Question 10

Where is appendicitis pain referred to?

Answer 10

Early: Midgut structure so pain in umbilicus
Later: Inflammation irritates parietal

Question 11

Where is pancreatic and abdominal aorta pain referred to?

Answer 11

Hindgut structures so pain in suprapubic area

Question 12

Where is small intestine colic pain referred to?

Answer 12

Hindgut structure so pain in suprapubic area

Question 13

Where is large intestine colic pain referred to?

Answer 13

Hindgut structure so pain in suprapubic area

Question 14

Where is ureteric colic pain referred to?

Answer 14

Right ASIS to pubic symphysis and right iliac region (back)

Patients roll around on floor in pain

Question 15

Where is peritonitis pain referred to?

Answer 15

Pain all over abdomen and shoulder tips

Question 16

How does bowel obstruction lead to hypovolaemic shock?

Answer 16

Increased secretion into small intestine
Decreased reabsorption
Accumulation of fluid as isotonic water removed from ECF
Vomit up, more space for fluid to be sequestered
Check for raised haematocrit

Question 17

What causes bleeding into the gut?

Answer 17

Vom blood and melaena:
Oesophageal varices (dilated veins)
Peptic ulcer
Bright red bleed from rectum: Diverticular disease

Question 18

What has occured in a bleeding peptic ulcer?

Answer 18

Posterior duodenal ulcer has eroded into gastroduodenal artery

Question 19

What causes melaena?

Answer 19

Alteration of blood by digestive enzymes, usually due to oesophageal varices or peptic ulcer

Question 20

Why does urea rise in oesophageal and gastric bleeds?

Answer 20

Bleed means large protein ends up in small intestine

Liver converts protein to urea, while creatinine levels stay normal

Question 21

What causes retroperitoneal bleeding?

Answer 21

Ruptured abdominal aortic anuerysm

Anticoagulated patients tearing retroperitoneal veins

Question 22

Describe the typical presentation of AAA

Answer 22

Sudden onset severe abdominal and back or loin pain

Shock symptoms

Question 23

Describe the typical presentation of ruptured ectopic pregnancy

Answer 23

Reproductive age
Lower abdominal pain and left shoulder tip pain on lying down
Vaginal bleeding
Collapse

Question 24

What happens in a posterior perforation of a gastric ulcer?

Answer 24

Allows gastric contents to enter lesser sac, so fluid can enter greater sac via epiploic foramen
Leads to chemical peritonitis

Question 25

What are the consequences of perforated diverticular disease?

Answer 25

Faeces in peritoneal cavity
Peritoneal sepsis
Septicemia

Question 26

What is pneumoperitoneum and what does it indicate?

Answer 26

Air in peritoneum, under diaphragm leading to peritonitis

Indicates perforated viscus

Question 27

What causes bowel obstructions?

Answer 27

Small bowel:
Adhesions from previous surgery 
Femoral/inguinal hernia 
Volvulus (intestine twists on itself and mesentery) 
Carcinomaof caecum 
Large bowel:
Carcinoma 
Sigmoid volvulus
Diverticular disease (affects lumen)

Question 28

What are the metabolic effects of bowel obstruction?

Answer 28

Vomiting - lose H and Cl - metabolic alkalosis

Renal compensation for metabolic alkalosis is to preserve H+ at the expense of K - hypokalaemia

Question 29

How does acute pancreatitis lead to dehydration?

Answer 29

Pancreas autodigested by proteases from retroperitoneum
Fluid sequestration in retroperitoneum
Vomiting

Question 30

What serum analysis indicates acute pancreatitis?

Answer 30

Raised serum amylase

Question 31

What causes acute gut ischaemia?

Answer 31

Embolism due to atrial fibrillation

Question 32

What is the typical presentation of acute gut ischaemia?

Answer 32

Severe abdominal pain
Tenderness over affected area
Very high white blood cell count

Question 33

What is acute cholangitis and what causes it?

Answer 33

Infection in bile ducts
Caused by gall stone obstructing the bile duct, leading to jaundice and billary stasis, leading to secondary infection by E Coli

Question 34

Describe the typical presentation of acute cholangitis?

Answer 34

Jaundice
Fever
Right upper quadrant pain
Hypotension