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G.I. > Abdomen: Masses, Pain & Acute abdomen > Flashcards

Abdomen: Masses, Pain & Acute abdomen Flashcards

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1
Q

Masses in the abdomen can be caused by… (6Fs)

A 
> Fat
> Faeces
> Flatus
> Foetus
> Fluid
> Fatal growth (Fucking big tumour)
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2
Q

History of PC

A

Does it change when lying down?

Is it tender?

Duration?

Blood loss, gynae symptoms, vomiting, urinary symptoms. bowel habit, weight loss, anorexia.

Where are they in their menstrual cycle?

Any previous operations?

Jaundice

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3
Q

PMHx/ Comorbidities/ Social hx/ FHx

A

Diabetes
Heart and lung disease

Medication
Allergies

not fit = no operation

Smoking, alcohol

FHx of cancer

PREGNANCY!!!

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4
Q

What is a key question to ask (if female)?

A

Are the pregnant???

If they don’t know –> pregnancy test

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5
Q

Abdominal examination - Inspection

A 
Contour
SHape
Pulsations
Prominent veins
Scars
Rashes
Colour
other lesions?
Breathing

Ask to cough and stand up - hernia.

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6
Q

Abdo exam - Palpation

A 
Systematic
Tender area last
light then deep palpation
liver, spleen, kidneys
Hernial orifices 
PR exam
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7
Q

Mass on examination & percussion

A

Is it:

Tender
Fixed --- bad
Hard
Smooth edge/craggy
Moves on respiration
Pulsatile

Percussion//

for organs
fluid or solid?
Ascites - able to shift fluid around?

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8
Q

Auscultation

A

Bowel sounds

Bruit

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9
Q

Investigations

A

> CT**

    • delineates mass and anatomy
    • biopsy

> Erect CXR

    • air under diaphragm
    • lung metastases

> Supine Abdominal Xray

    • dilated small bowel loops
    • dilated large bowel loops
  • calcification of aorta

> Ultrasound (transabdo/transvaginal)
– over major organs

> Sigmoidoscopy/colonoscopy/ upper GI endoscopy
ERCP
Laparoscopy

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10
Q

What does air under the diaphragm indicate?

A

Something has burst/perforated

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11
Q

What is the gold standard investigation for an abdominal mass patient

A

CT scan

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12
Q

What should go at the top of differential diagnoses?

A

Life threatening things - what could cause the patient to die right in front of me?

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13
Q

What does sudden onset epigastric pain radiating to the back indicate?

A

AAA rupture

retroperitoneal

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14
Q

Abdominal aortic aneurysm - Ix and exam

A

CT scan

Pulsatile epigastric mass, feel for detail pulses

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15
Q

Renal mass

A

May be ballotable.

Ultrasound scan, CT

has to be large to be able to feel it.

Hx - renal failure. weight loss.

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16
Q

Pancreatic Mass

A

Hx - weight loss, non tender, alcohol

ERCP, CT , biopsy

LATE PRESENTATION

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17
Q

Colorectal Cancer

A

VERY COMMON.

Hx - altered bowel habit, PR bleeding, weight loss, anaemia

Small bowel obstruction, localised mass

CT & colonoscopy

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18
Q

Gynaecological

A

Arise from the pelvis.

May seem large, superior border is palpable. Inferior border is difficult to palpate.

Transvaginal ultrasound

CT SCAN

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19
Q

If you cannot get below a mass in the pelvic area, what may this indicate?

A

It is gynaecological in nature.

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20
Q

Sister Mary Joseph Node

A

Palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.

Indicates wide spread disease

Very poor outcomes.

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21
Q

Should you give pain medication to patients who have just come in with pain?

A

Yes.

Then you will have a calmer patient to talk to and get a clearer history from

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22
Q

What causes a shift in pain from umbilicus to the right iliac fossa?

A

Appendicitis

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23
Q

What kind of pain could laughing or coughing cause exacerbate?

A

Peritonitis

Guarding
Shallow breathing

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24
Q

Pain

A 
Site
Time and mode of onset
Severity
Nature
Progression
The end
Duration
Relieving / exacerbating factors
Radiation

what did your pain prevent you from doing?

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25
SOCRATES
``` Site Onset Character Radiation Associations Time Exacerbating/relieving factors Severity ```
26
Shifting vs spreading pain
Spreading pain - radiates, spreads from a focal point Shifting - pain moves from one place to another
27
History - time
1. last Wednesday 2. Wed 3rd April 2013 3. Wed 3rd April 2013, (5 days ago) 4. Wed 3/4/2013 (5 days ago), at 1 am 5. Wed 3/4/2013 (5 days ago) at 1 am, woke him up from sleep Precise
28
Kids with appendicitis commonly do not want to..?
Walk around
29
Any pain that "annoys" the diaphragm
Gives shoulder tip pain | c3,4,5 keeps the diaphragm alive
30
Before an abdo exam of a patient with abdo pain, what should you give?
IV morphine. Be as gente as possible Site of maximal tenderness
31
If a kid presents with abdominal pain, what could you ask them to do?
Push out their tummy and then suck it as far in as they can . If they can, there is probably not much wrong
32
Ureteric colic - what should not be used?
Morphine - worsens the condition as it raises ureteric pressure
33
Examination - applying painful stimuli
DO NOT DO REBOUND TENDERNESS 1. Take a deep breath in 2. Puff up your tummy 3. suck your tummy in 4. give me a gentle cough 5. give me a big cough 6. Percuss - start furthest away from painful site 7. Lightly palpate while distracting
34
Tenderness to percussion
Peritonism
35
Abdominal guarding
Peritonitis
36
Diverticulitis - common area of pain?
Left iliac fossa
37
Very sick
Extreme pain and tenderness High pulse rate Low blood pressure ABCs Analgesia early
38
McBurney's Point (appendicitis)
Locality of greatest sensitiveness to pressure About 1/3rd of the way between anterior superior iliac spine and umbilicus.
39
Perforated appendix - what kind of pain?
Generalised pain and guarding with peritoneum
40
Where does the appendix almost always perforate?
Tip or base
41
Iliopsoas Test
Indicates that the appendix is retrocoecal in orientation
42
Appendicitis in pregnancy
The appendix can change position during all stages of pregnancy. However most of the time it does not and it presents the same as normal appendicitis
43
What is an acute abdomen?
Less than 10 days Causing severe morbidity or threat to life.
44
Munchausen Syndrome & Drug Seekers
> Common acute abdomen admission > Seem genuine > Drug seekers not usually IVDU > HIGHLY manipulative > Tend to have clustering of admissions relating to stress
45
Acute abdomen - symptoms
Abdominal pain// > visceral > parietal > extra-abdominal Location Radiation Associated symptoms// - nausea/vomiting - burping - heartburn/ indigestion - change in bowel habit - PR blood/mucous
46
Acute abdomen - vague pain that suddenly localises
-
47
Vomiting
``` > Colour of vomit > Green or foodstuff (bile) > Projectile > Blood > Coffee grounds ```
48
Acute abdomen - constipation
> Means different things to people > Clarify > Laxative use?
49
Acute abdomen - signs O/E
``` > Pain > Localised peritonism > Generalised peritonitis > Guarding > Rebound tenderness > Press in LIF, pain in RIF ``` - moribund - Unwell? - moving or still - holding abdomen - scars
50
Bowel obstruction auscultation
Tinkling sounds
51
Erythema ab igne
Hot water bottle rash | exposure to heat
52
Cullen's sign
Superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus
53
Grey turner
Bruising of the flanks Retroperitoneal haemorrhage could be pancreatitis
54
Initial Investigations - Acute Abdomen
> Bloods > AMYLASE > AMYLASE > ABGs > AXR, erect CXR > Erect CXR is first line and useful if abnormal; pre-op investigation GOLD STANDARD - CT
55
Gold standard investigation for acute abdomen?
CT scan
56
Ultrasound
Very useful in RUQ & RIF pain Useful in kids Women with pelvic pain
57
Acute abdomen - key things to look for
Look for and exclude: > pancreatitis > symptomatic AAA Look at plain AXR & CXR
58
Perforated Duodenal Ulcer - treatment
``` Resuscitate Abx Theatre (or not) Patch repair Eradicate H pylori PPI ```
59
Colonic emergencies
``` Obstruction Volvulus Acute diverticulitis Toxic colitis Perforations ```
60
Colonic emergencies - management
> Volvulus --- decompress using a rigid sigmoidoscope > Malignant obstruction --- stent or operate > Diverticulitis --- spectrum from abx to hartmann's > Typhilitis --- abx or operate
61
Classification of diverticulitis
Hinchey Classification I - para colic abscess II - pelvic abscess III - purulent peritonitis IV - facecal peritonitis
62
Hartmann's procedure
Remove sigmoid colon Leave the rectum Bring out colostomy
63
Peritonitis leads to...
death esp. faecal peritonitis

G.I. (20 decks)

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