Abdominal Flashcards
(53 cards)
What is the initial approach to acute abdomen?
Assess for life-threatening causes
What are some RED FLAGS for abdominal pain?
Sudden onset of severe pain Pain that interrupts sleep Bilious vomiting Haematemesis, haematochezia Hypotension, tachycardia Pt. lying very still Pain writhing in pain Jaundice Guarding +/ rigidity Rebound tenderness Absent/tinkling bowel sounds Gross abdominal distension Pain out of proportion with abdo. findings High-risk pt. characteristics - age >50 - prev. abdo. surgery - hx of CAD +/ AF
What are some laboratory studies that should be considered when investigating abdominal pain, and why?
Blood gas analysis
- recurrent vomiting can cause hypochloraemic hypokalaemic metabolic alkalosis
- ischaemic bowel can cause metabolic acidosis (lactic acidosis)
Lactate
- elevated lactic indicates tissue hypoxia
- eg. hypotension/shock in pancreatitis
- eg. bowel infarction due to bowel obstruction/mesenteric ischaemia
Troponin
- consider checking in pt. with CAD RFs/hx
Serum glucose
FBE
- leucocytosis –> infection/inflammatory process (ie. acute appendicitis)
- Anaemia –> acute/acute on chronic blood loss
- Low HCT –> acute blood loss
- High HCT –> dehydration
Coags
- elevated INR –> onset of sepsis
- coagulopathy needs correcting prior to surgery
UEC
- evaluate renal function and electrolyte imbalances
LFTs
- cholestatic picture typical in choledocholithiasis, cholangitis, and gall stone pancreatitis
> cholestatic picture: ALP prominently ^, mild AST ^, ALT, conjugated hyperbilirubinaemia (dark wee, pale stools)
> hepatocellular picture: ALT and AST prominently ^, moderate ALP ^
Lipase/amylase
- 3x increase in lipase = diagnostic for acute pancreatitis
Blood type and screen
ESR/CRP
- consider if concern re inflammatory process (eg. peritonitis, IBD)
Urinalysis
- haematuria / nitrates / urinary crystals –> UTI / nephrolithiasis
- haematuria can be present in ruptured AAA
- mild pyuria may be present acute appendicitis
bHCG urine test
- all woman of reproductive age: consider ectopic pregnancy
Cultures (urine, blood)
- urine: if urinalysis indicates UTI
- blood: if suspected sepsis
What is the appropriate imaging to select if you are suspecting acute appendicitis?
Usually diagnosed clinically (ie. no imaging required)
Consider imaging in pt. with atypical presentations
U/S is less sensitive but is often performed in RLQ pain in order to reduce radiation exposure
- Most sensitive imaging, if necessary: CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute diverticulitis?
CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute pancreatitis?
U/S abdo
CT abdo w IV contrast (if U/S unequivocal OR pt. critically ill at presentation)
What is the appropriate imaging to select if you are suspecting nephrolithiasis?
U/S abdo and pelvis (preferred if presentation is typical: renal colic)
CT abdo pelvis w/o IV contrast (pref. if presentation is atypical/pt. >75yo)
What is the appropriate imaging to select if you are suspecting AAA in haemodynamically stable patient?
U/S abdo
CT/MRI angiography
What is the appropriate imaging to select if you are suspecting AAA in haemodynamically unstable patient?
NO IMAGING
Patient should go straight to the operating theatre
What is the appropriate imaging/Ix to select if you are suspecting ACS?
ECG
TTE
What is the appropriate imaging to select if you are suspecting haemorrhagic shock?
FAST scan (US of abdo looking for fluid/blood)
What is the appropriate imaging to select if you are suspecting a bowel perforation?
CT abdo pelvis w IV contrast Xray abdo (upright and supine) + CXR (upright)
What is the appropriate imaging to select if you are suspecting a small bowel obstruction?
CT abdo pelvis w IV contrast Xray abdo (upright and supine) + CXR (upright)
What is the appropriate imaging to select if you are suspecting acute diverticulitis?
CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute mesenteric ischaemia?
CT angiography of abdo
What is the classic presentation of acute mesenteric ischaemia and what other signs/sx might be present?
Classic: pain out of proportion abdo examination
Other: Blood diarrhoea, abdo distension and peritonitis
** when mesenteric ischaemia has progressed to bowel infarction (< 6 hrs) **
What are the life-threatening dx that must be excluded when a patient presents with acute abdomen?
Ruptured AAA Aortic dissection Ruptured ectopic pregnancy Mechanical bowel obstruction Acute mesenteric ischaemia Acute pancreatitis Acute cholangitis AMI
What investigations should be done if suspecting peptic ulcer dse?
FBE - anaemia if bleeding ulcer
Upper GI endoscopy - mucosal erosions/ulcers
Urea breath test - for H. pylori infection
What test is performed to identify H. pylori infection?
Urea breath test
What features might you expect to find on hx/examination in diverticulitis?
Fever
LLQ pain
Constipation
Tender mass in LLQ
What features might you expect to find on hx/examination in PUD?
Epigastric pain
Pain worse/better with eating: gastric ulcer/duodenal ulcer respectively
Hx of NSAID use
Signs of GI bleed
What might you expect to find on hx/ex in a mechanical bowel obstruction?
Colicky pain (pain may become constant if affected bowel loops become ischaemic) Obstipation/bloating Progressive N&V (late) Diffuse abdo. distension Tympanic abdo Collapsed rectum on DRE Tinkling bowel sounds Hx of abdo surgery (adhesions -> SBO)
What might you see on abdo xray in the case of a GI perforation?
Pneumoperitoneum
What features on hx/ex might you expect in the case of a GI perforation?
Diffuse abdo pain of sudden onset N&V Constipation/obstipation (due to ileus) Diffuse abdo guarding, rigidity, rebound tenderness Absent bowel sounds Loss of liver dullness on RUQ percussion
