Abdominal pain Flashcards
(112 cards)
1
Q
How does the patient describe her symptoms?
A
Bad abdominal pain Started last night Slowly getting worse Slept terribly Sharp Middle and top of tummy Laughing makes it worse Sudden onset Nothing like this before Stomach pain on and off for a year but not as bad as this Gets worse when she eats well Nausea - vomited once Tenderness in the right upper quadrant
2
Q
Does the patient have any health problems?
A
Borderline diabetes
Should loose weight and eat better
3
Q
What is found in the lifestyle history?
A
Works in a bank
Glass of wine most nights
3-4 bottles a week
4
Q
What is the doctors plan of action?
A
Examine
Run bloods
Painkiller
Explain what’s going on
5
Q
What does acute abdomen refer to?
A
Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology
6
Q
In who can pain free acute abdomen occur in?
A
older people
children
immunocompromised
last trimester of pregnancy
7
Q
What are some feature of acute abdominal pain?
A
Be located in any quadrant of the abdomen
Be intermittent, sharp or dull, achy, or piercing
Radiate from a focal site
Be accompanied by nausea and vomiting.
8
Q
What should immediate assessment focus on?
A
Distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively
9
Q
How is acute abdomen diagnosed?
A
History Physical examination Radiography Laboratory results OR Diagnostic laparoscopy
10
Q
In what can a laparoscopy be used therapeutically?
A
appendicitis, cholecystitis, lysis of adhesions, hernia repair, and many gynaecological causes of an acute abdomen.
11
Q
What can help stratify the risk of appendicitis in patients presenting with acute abdominal pain?
A
The Appendicitis Inflammatory Response (AIR) score
The Pediatric Appendicitis Risk Calculator (pARC)
12
Q
What is discourage in undiagnosed patients with acute abdomen?
A
Use of narcotic analgesia
because of concerns that symptoms would be masked, the examination hindered, and, therefore, the correct diagnosis missed
13
Q
Why can diagnosis be delayed in older people?
A
More co-morbidities
Dementia (issues communicating issues)
PNS dysfunction can alter perception of pain and temperature
14
Q
Why can diagnosis be delayed in pregnant women?
A
Enlargement of uterus displaces and compresses abdo organs
Physiological leukocytosis
Hesitancy to conduct radiographs
15
Q
What are common differentials for acute abdomen?
A
Adhesions
Incarcerated/strangulated hernia
Cholecystitis
Gastric ulcer
16
Q
What are uncommon differentials for acute abdomen?
A
Volvulus
Intussusception
Duodenal ulcer
Ruptured ovarian cyst
17
Q
What are the abdo causes of acute abdo (from common to less)?
A
Intestinal obstruction Peritonitis secondary to infection Haemorrhage Ischaemia Contamination by gastrointestinal contents
18
Q
What can cause abdominal haemorrhage?
A
ectopic pregnancy, ruptured aortic aneurysm
19
Q
What can cause abdominal ischaemia?
A
ovarian torsion, mesenteric ischaemia
20
Q
What processes can lead to contamination by GI contents?
A
perforated duodenal or gastric ulcer
21
Q
What causes obstructions?
A
Adhesions Hernia incarcerations Volvulus Gallstones Intussusception IBD Neoplasm Congenital abnormalities
22
Q
What can cause inflammation?
A
cholecystitis appendicitis acute pancreatitis acute diverticulitis Meckel diverticulitis UC Crohn's
23
Q
What should happen in females of child bearing age with acute abdomen?
A
should always have a pregnancy test to rule out ectopic pregnancy
24
Q
What are gynae causes of acute abdomen?
A
ruptured ovarian cyst, ovarian torsion, pelvic inflammatory disease, and endometriosis
25
What does Budd-Chiari syndrome involve?
Hepatic venous outflow obstruction and the abdominal pain may present with hepatomegaly and ascites
26
What can cause an abdominal wall haematoma?
```
Spontaneous
Trauma
Exercise
Coughing
Procedure
```
27
What are some abdominal infective diseases?
hepatic abscess or hepatitis
| gastroenteritis, infectious colitis, typhlitis
28
What is Fitz-Hugh Curtis syndrome?
a complication of pelvic inflammatory disease, comprises right upper quadrant abdominal pain associated with perihepatitis
29
What are the metabolic causes of acute abdomen?
Uraemia, diabetic ketoacidosis, Addisonian crisis, and hypercalcaemia
Inherited -
acute intermittent porphyria and hereditary Mediterranean fever.
30
What are the toxic causes of acute abdomen?
Heavy metal poisoning
| Narcotic withdrawal
31
What are the urological causes of acute abdomen?
Testicular torsion
Kidney stones
Pyelonephritis
32
What should be done while awaiting the results of lab tests?
Surgical consult
IV access
Vitals monitored and corrected
33
When should surgery be conducted with limited pre-op eval?
In patients exhibiting evidence of hypovolaemic shock with a known or suspected haemoperitoneum
34
What must be done if there is a potential haemorrhage?
Two large-bore IV lines
Typing and cross-matching
Fluid resus (2L isotonic)
Antifibrinolyitc? Tranexamic acid?
35
What is BP goal for AAA or aortic dissection?
Systolic 80-90
36
What can excess fluid replacement cause?
cause dilutional and hypothermic coagulopathy
lowers blood viscosity
increased perfusion pressure from the expanded volume can lead to secondary clot disruption
37
What should be done if a perforation, diverticulitis or appendicitis is suspected?
Broad-spec AB
As can lead to sepsis
Urinalysis and culture samples ideally done before
38
In who should you consider mesenteric ischaemia?
```
Pain disproportionate to the signs
Older
Smoking
PVD
AF
```
39
What is required for mesenteric ischaemia treatment?
Oxygen
Fluid
Empirical AB
Surgical and radiological consult
40
What are the key components in the history?
Time and onset
| Previous instances of similar pain
41
What indicated acute appendicitis?
Sudden-onset umbilical pain radiating to right iliac fossa
42
What is suggestive of a gastric ulcer?
Long-term epigastric pain
| sudden worsening may indicate perforation of the ulcer
43
What may indicate oesophageal perforation?
Sudden epigastric pain following vomiting
44
Epigastric pain?
```
Gastric ulcer
Pancreatitis
Perforated oesophagus
Mallory-Weiss tear
MI
```
45
LUQ pain?
```
Splenic infarct
Ruptured splenic artery aneurysm
Pyelonephritis
Kidney stones
Perforation
Malignancy (colon)
```
46
RUQ pain?
```
Cholelithiasis
Cholecystisis
Hepatitis
Hepatic abscess
Fitz-Hugh Curtis syndrome
Perforation
Malignancy
Kidney stones
Pyelonephritis
Acute api in pregnancy
```
47
LLQ pain?
```
Sigmoid volvulus
Diverticulitis
Crohn's
UC
Kidney stones
GI malignancy
Psoas abscess
Strangulated hernia
Gynae concerns
```
48
RLQ pain?
```
Api
Kidney stones
GI malignancy
Psoas abscess
Strangulated hernia
Gynae concerns
```
49
Persistent lateralised pain?
Ascending or descending colon
Kidney
Gallbladder
Ovary
50
Pain with radiation to the back?
pancreatitis, abdominal aortic dissection, or ruptured abdominal aortic aneurys
51
Right scapula pain?
Gallbladder disease, liver disease, or irritation of right hemidiaphragm
52
Left scapula pain?
Cardiac disease, gastric disease, pancreatic disease, splenic disease, or irritation of left hemidiaphragm
53
Testicular pain?
kidney stones or ureteral disease.
54
Associated systemic symptoms?
cholecystitis, a ruptured duodenal ulcer, gastric ulcer, appendicitis, acute mesenteric ischaemia, PID, acute diverticulitis, hepatic abscess, hepatitis, abdominal wall haematoma, or spider bites
55
Obstructive bowel process?
No recent bowel movement
56
What must you ask the patient?
```
Associated symptoms
Time of last bowel movement
Nature of last bowel movement
Type and time of last meal
Anorexia?
PMH
Last menstrual period/contraception
FH
Travel
```
57
What is important with the examination?
```
Vitals
PIPPA
Rigid abdomen
Distended
Guarding
Rebound tenderness
Murphy's sign
```
58
What is Murphy's sign?
Right upper quadrant tenderness with arrest of inhalation during palpation
59
What is a rectal examination conducted for?
presence of occult or frank blood, pain, or mass
60
What lab tests should be done?
FBC
Electrolytes
Urinalysis
Pregnancy test
61
What other lab tests can be done?
Metabolic panel
Coagulation studies
Serum amylase
Lactic acid levels
62
What imaging can be done?
```
AXT
Erect CXR
CT
USS
MRI
```
63
In who would a laparoscopy be considered?
Clinically stable
No indication for therapeutic surgical intervention
No apparent cause for their abdominal pain after non-invasive procedures
No relative or absolute contraindication to surgery.
64
What are the three diagnosis related to gallstones?
Biliary colic
Cholecystitis
Ascending cholangitis
65
What are the features of biliary colic?
Constant pain
Gallbladder neck is blocked by the stone
Muscle spasms against the stone cause dull RUQ pain
Nausea or vomiting
Triggered by fatty foods that trigger CCK release and gallbladder contraction
Symptoms for less than 6 hours
66
What are the features of cholecystisis?
```
Pain
Murphy's sign - when diaphragm flattens gallbladder hits hand and pain worsens
Fever
Gallstone blocks the cystic duct
Elevated WBCs and CRP
```
67
What are the features of ascending cholangitis?
Fever
Jaundice
Gallstone comes out of gallbladder and moves up blocking the hepatic duct
Elevated WBCs and CRP
Abnormal LFTs - raised bilirubin and alkaline phosphatase
68
What are the majority of gallstones?
Asymptomatic
| Incidental findings
69
What is the diagnosis of our patient and why?
Acute cholecystitis
| Normal LFTs
70
What is the investigation of choice for gallstones?
Abdo USS
71
How are gallstones formed?
High level of cholesterol in the bile
High bilirubin
Both cause crystallisation of bile
72
What are the risk factors for gallstone disease?
```
High fat diet
Female
Fat
Fair
Fourties
Fertile
OCP
Crohn's or IBS
Recent weight loss
```
73
What comprises bile?
```
98% water
Bile salts
Bilirubin
Electrolytes
Cholesterol
```
74
What affects the composition of gallstones?
Age
Diet
Ethnicity
75
What are the types of gallstones?
Cholesterol stones
Pigment stones
Mixed
76
What are the features of pigment stones?
```
Bilirubin breakdown products (from breakdown of RBCs)
Small
Dark
Numerous
From excess bile pigment production
```
77
Give an example of a condition that would cause pigment stones?
Haemolytic condition
78
What are the other complications of gallstones?
Acute pancreatitis
Gallstone Ileus
Gallbladder cancer
79
What are the characteristics of pancreatitis?
High amylase and lipase
80
What is gallstones ileus?
Small bowel obstruction secondary to gallstones
Large gallstone enters duodenum and causes blockage
Occurs of extended period of time
Hole forms between gallbladder and duodenum
81
What is the treatment for symptomatic cholecystisis?
Laparoscopic cholecystectomy
82
What is needed to obtain consent?
```
Provide all relevant info - tailor conversation to needs of patients
Diagnosis
Prognosis
Risks
Lifestyle
Explain treatment and benefit
How successful it is likely to be
Who's involved and potential follow ups
Allow patient time to reflect
Give copy of form
```
83
What is essential re the person giving consent?
Consent must be voluntary
| Patient must have capacity
84
What are the risks and complications of a laparoscopic cholecystectomy?
```
Bile leakage
Injury to bile duct
Injury to surrounding structures (liver, intestine, bowel and blood vessels)
Leaking of urine
Risk of converting to open surgery
```
85
What are some general surgical risks?
Infection
General anaesthetic (allergy?)
Chronic pain
86
How can we categorise complications?
General vs. Specific
| Early vs. Late
87
What are the early risks?
Wounds - keep dry and clean
88
What are some late risks?
Hernias
| Scar not healing properly
89
What is the biliary system?
series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine
90
What is the role fo the gallbladder?
component of the extrahepatic biliary system where bile is stored and concentrated
91
How is the gallbladder attached to the rest of the extrahepatic biliary system?
Via the cystic duct
92
What do hepatic lobules contain?
```
Central vein
Portal triads (bile duct, portal vein, hepatic artery)
```
93
What connects the peripheral vasculature to the central vein?
Epithelial lined sinusoids run between the hepatocytes and connect the peripheral vasculature to the central vein
94
What is the function of the canals of hering?
The bile produced by the hepatocytes is drained in the opposite direction of blood flow to the periphery of the lobule by small channels known as the Canals of Hering
95
What are the layers of the gallbladder wall?
Innermost mucosal layer (columnar epithelium with microvilli)
Lamina propia
Outer serosal layer
96
From what does the gallbladder develop?
Foregut
97
What happens at the 4th week of embryogenesis?
structure called the hepatic diverticulum appears. The hepatic diverticulum goes on to become the liver, extrahepatic biliary system, and a portion of the pancreas.
98
What happens at week 6 of embryogenesis?
The common bile duct and part of the pancreas rotate around the duodenum
99
Which cells are stimulated by fatty acids?
I-cells
Release CCK
CCK stimulates the smooth muscle of the gallbladder
CCK also signals the sphincter of Oddi to relax
100
Where are bile acids synthesised?
Liver from cholesterol pre-cursors
101
What is the RDS of bile acid production catalysed by?
cholesterol 7α—hydroxylase
102
What happens in the RDS?
The bile acids are conjugated to the amino acids glycine and taurine and become soluble bile salts.
103
Describe enterohepatic circulation
The bile salts are reabsorbed in the distal ileum of the small intestine and recycled back to the liver
104
Why does bile not being able to enter the duodenum cause jaundice?
the buildup of bilirubin
105
What is the most specific test to diagnose cholecystisis?
Hepatobiliary Iminodiacetic acid (HIDA) scan
106
What can cause acalculous cholecystitis?
Infection
Low perfusion
Biliary stasis
107
What drugs can increase risk of gallstone formation?
HRT
Somatostatin analogues
Fibrates
108
What are the main features of brown pigment stones?
Biliary tract infections
| More frequent in Asia
109
What are the main features of black pigment stones?
Mainly consist of calcium bilirubinate
| Found in haemolytic anaemia or ineffective haematopoesis in patients with CF
110
What are the three mechanisms of cholesterol stone formation?
Cholesterol supersaturation of bile
Gallbladder hypomotility
Kinetic, pro-nucleating protein factors
111
What is cholesterol supersaturation?
Precipitation of cholesterol occurs when cholesterol solubility exceeds the (cholesterol saturation index >1)
Cholesterol crystals occur at low phospholipid : cholesterol ratios
Multilammellar vesicles then fuse and may aggregate as solid crystals.
112
What are the main features of gallbladder hypomotility?
altered interdigestive gallbladder emptying
seen in several risk groups for cholesterol gallstones, e.g. patients with diabetes mellitus, and rapid weight loss
