Abdominal pain Flashcards
A Crohn’s patient presents with abdominal pain, relieved by hip flexion. What complication do they have?
Psoas abscess - sinus tracks from bowel to psoas (posterior abdominal wall) - flexion relaxes psoas
What is shown on USS in acute gallstone obstruction? What do the LFTs do?
Dilated ducts
- Not always dilated
Alk Phos usually normal
ALT initially very high, drops rapidly
Remember to ask about rigors
What are the differentials of abdo pain based
Diffuse
- peritonitis
- referred pain
- pneumonia
- discitis
- herpes zoster
- Colitis
How does ischaemic colitis present
- typically occurs in >60 yr olds with atheroslcerotic disease or low flow states
- in younger people, more likely related to vasculitis or hypercoagulable states
- Abdo pain
- tenderness may be present in left side of abdomen
- In severe cases where necrosis and perforation have occurred –> peritonitis
- Blood stools
Describe how the vascular anatomy affects colitis presentation
- SMA - right colon (caecum to splenic flexure)
- IMA - left colon (splenic flexure to rectum)
- Watershed areas
- Splenic flexure - griffiths point
- rectosigmoid junction - Sudeck point
- low flow states and non-occlusive vessel disease are most common and typically lead to ischaemic colitis in watershed areas
- Complete vascular occlusion can produce involvement of the entire vascular teritory
What are the key ix to confirm a dx of ischaemic colitis
- Contrast enhanced CT
- bowel wall thickening, usually uniform and segmental
- Submucosal oedema
- Bowel dilatation
- Pericolic fluid
- Pneumoperitoneum
- vascular occlusion
How do you treat ischaemic colitis
- Anticoag or thrombolysis
- Percutaneous vascular intervention in acute mesenteric artery occlusion
- Surgical resection if peritonitis, perforation, sepsis, massive haemorrhage
What is an important potential emergency complication of IBD
IBD - can form fistulas, strictures or post-operative adhesions that can cause acute or subacute obstruction.
Intestinal fibrostensosis is frequent and debilitating of Crohn’s (rare in UC), can cause small bowel obstruction and lead to repeated resection.
What is your work up for acute abdo
- FBC, UE, LFT, CRP, amylase
- DRE
- Abdo XR
- CXR - pneumoperitoneum
- ECG - atypical MI
- Urine, stool cultures
- USS abdo - good for pancreatitis
- CT angiogram
- CT abdo
What are the most common causes of mechanical bowel obstruction
Small bowel
- adhesions (60%)
- Hernias
- Intussusception (paediatric)
Large bowel
- malignancy
- Volvulus
What is the pathological progression of bowel obstruction
NB) fluid resuscitation is often under-estimated in small bowel obstruction
How are peptic ulcers defined
Break-in the mucosal lining of stomach or duodenum of > 5mm
- smaller than this or without obvious depth = erosions
What are the risk factors for the development of peptic ulcers?
- H pylori infection
- NSAIDs
- Age
- risk increases with age and peaks in fifth to seventh decades
What is the presentation of peptic ulcer disease
-
CHRONIC or RECURRENT epigastric pain
- associated with eating (and often worse at night)
- duodenal ulcers tend to cause a more consistent pain
- duodenal ulcer radiates to back as a result of penetration of ulcer posteriorly into pancreas
- uncommon
- N&V
- weight loss
- sx of anaemia
- GI bleed
How do you ix ?Peptic ulcer
- H pylori urea breath test or stool antigen
- OGD
- FBC
