Acute Abdo

Question 1

What should always be suspected in unexplained abdo pain + hypotension

Answer 1

AAA

Question 2

What are the signs of a ruptured AAA?

Answer 2

Sweating, inc HR, absent femoral pulses, mottled skin in lower body, tender pulsative mass, sudden collapse

Question 3

Abdo signs of ruptured AAA

Answer 3

Abdominal bruir

Grey turner’s sign

Question 4

What is the pathophysiology of AAA?

Answer 4

degradation of the elastic lamellae + smooth muscle loss

Question 5

What is the most common site of AAA?

Where is blood most likely to haemorrhage?

Answer 5

Below the renal arteries

Blood into the retroperitoneum

Question 6

In an unruptured AAA, when would surgery be considered?

Answer 6

Aneurysm >5.5cm diameter or expansible of >1cm

Question 7

How is unruptured AAA monitored?

Answer 7

Regular USS (if <4.4cm then every 2 years, if >4.5 then every 3 months) + BP control

Question 8

ABCDE management of suspected AAA rupture

Answer 8

1. Oxygen
2. venous access
3. bloods: including coagulation screen + crossmatch
4. IV analgesia (morphine)
   IV anti-emetic (cyclizine)
5. IV fluids
6. IMMEDIATE BEDSIDE USS
7. urinary catheter, radial arterial line, ECG

Question 9

IV fluids in AAA rupture

Answer 9

Treat major hypovolaemia until systolic >90 (if passing urine then minimal fluid needed before theatre)

Question 10

What is the emergency surgical management of AAA?

How can this be done?

Answer 10

Stenting!!
Endovascular (through femoral)
Open (expose aorta, clamp + repair)

Question 11

Describe the classic pattern of appendicitis pain

Answer 11

Pain in the epigastric region, worsens in first 24 hours, then migrates to RIF (becomes constant + sharp)

Question 12

What can make pain in appendicitis worse?

think adults + children

Answer 12

Movement (e.g. cough)

Hopping

Question 13

Abdo exam in appendicitis

Answer 13

Tenderness
Guarding at RIF
Rebound tenderness

Question 14

Where is McBurney’s point?

Answer 14

2/3 from umbilicus to ASIS

Question 15

Presentation of appendicitis

Answer 15

Pain!!

Anorexia, N+V, facial flushing, fever, inc HR

Question 16

What is rovsing’s sign in appendicitis?

Answer 16

Palpation of LLQ increases pain over RQ

Question 17

Signs of perforation in appendicitis

Answer 17

Inc HR

Sudden relief of pain

Question 18

Signs of abscess formation in appendicitis

Answer 18

Pyrexia

Palpable abdo mass

Question 19

Signs of peritonitis

Answer 19

Vomiting, high fever, severe pain, absent bowel sounds

Question 20

Risk factors for appendicitis

Answer 20

Age 10-20
Male
Frequent abx
Smoking

Question 21

Two bedside tests in appendicitis to rule out differentials

Answer 21

Pregnancy test

Urinalysis

Question 22

ABCDE for appendicitis

Answer 22

IV access
IV opioid + anti-emetic
Pre-op abx: cefuroxime + metronidazole

Question 23

Define the following:
Cholecystitis
Biliary colic
Cholangitis

Answer 23

Cholecystitis: gallstone impaction + acute inflammation of the GB

Biliary colic: ‘gallstone attack’, gallstone temporarily blocks the cystic duct

Cholangitis: inflammation of the biliary tract

Question 24

Most common GS problems

Answer 24

Biliary colic (56%)
Cholecystitis (36%)

Question 25

Features of biliary colic

Answer 25

Short-lived, recurrent episodes of epigastric/ right hypochondrial pain RADIATES TO THE BACK

Question 26

Features of cholecystitis

Answer 26

``` Hypochondrial pain radiating to the RUQ Vomiting Fever Murphy's sign Palpable mass? ```

Question 27

What is murphy's sign?

Answer 27

local peritonism, particularly on inspiration

Question 28

Features of chonalngitis (charcot's triad)

Answer 28

Abdo pain Jaundice Fever

Question 29

5 F's (RFs for gallstones)

Answer 29

Female, fair, fat, female + forty

Question 30

Other RFs for gallstones

Answer 30

Sudden weight loss Loss of bile salts (e.g. ileal resection) OCP Poor diabetes control

Question 31

RFs specific for cholangitis

Answer 31

Pregnancy | Hyperlipidaemia

Question 32

Which imaging is the best way of detecting gallstones? | What may it show?

Answer 32

USS Stones, thickened GB wall, pericholecystic fluid

Question 33

Why isn't ERCP 1st line?

Answer 33

More invasive + v expensive!

Question 34

Management of biliary colic

Answer 34

NBM Analgesia IV fluids Elective removal

Question 35

Management of acute cholecystitis

Answer 35

NBM IV analgesia + anti-emetic IV abx Laparascopic cholecystectomy

Question 36

What abx are given in acute cholecystitis?

Answer 36

IV cefuroxime (1.5g/ 8 hours)

Question 37

Management of cholangitis

Answer 37

Abx (cefuroxime + metronidazole) Prompt treatment - may become septic!! Definitive: endoscopic biliary decompression ERCP to clear any obstruction

Question 38

What is diverticulitis?

Answer 38

Inflamed + infected diverticula (protrusions of mucosa through muscular wall of the colon)

Question 39

What are uncomplicated and complicated diverticulitis

Answer 39

Uncomplicated: localised inflammation, does not extend to peritoneum Complicated: abscess, peritonitis, fistula, obstruction or perforation

Question 40

Risk factors for diverticulitis

Answer 40

Lack of dietary fibre (low stool bulk, slow transit time. high intraluminal pressure) Smoking, obesity, genetics

Question 41

If diverticulitis is uncomplicated/ mild, how can it be managed?

Answer 41

Can be managed in primary care Co-amoxiclav + metronidazole Analgesia

Question 42

In emergency diverticulitis, what is the management?

Answer 42

Analgesia IV fluids Refer to surgeon (NBM) Broad spec abx (cefuroxime + metronidazole)

Question 43

Emergency diverticulitis: what should you advise re the urge to pass stools

Answer 43

Avoid if possible, as may cause another bleed