Acute abdomen

Question 1

What is biliary colic

Answer 1

This is the most common presentation. Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant and typically lasts for more than 30 minutes, but less than eight hours.

It is often severe, and may be associated with nausea and vomiting, but is not associated with fever, or abdominal tenderness.

Question 2

What is acute cholecystitis

Answer 2

Inflammation of the gallbladder. It usually happens when a gallstone blocks the cystic duct.

Question 3

Symptoms of acute cholecystitis

Answer 3

Classical symptoms and signs are similar to biliary colic, but in addition other classical features are fever and tenderness in the right upper quadrant.

Question 4

Features of obstructive jaundice

Answer 4

Yellowish discolouration of the skin, dark urine and pale stools.

Question 5

Features of cholangitis

Answer 5

Typical features, referred to as Charcot’s triad, are diagnostic: fever (often with rigors), jaundice, and upper quadrant abdominal pain.

Question 6

What is cholangitis

Answer 6

Infection and inflammation of the biliary tree

Question 7

Features of gallstone pancreatitis

Answer 7

Constant epigastric pain radiating through to the back, and profuse vomiting.

Question 8

IX for suspected gallstone disease

Answer 8

Abdominal ultrasound
LFTs
MRCP if ultrasound has not detected common bile duct stones

Question 9

Management of asymptomatic gallstones found in a normal gallbladder and normal biliary tree

Answer 9

Reassure them that they do not need treatment unless they develop symptoms.

Explain that asymptomatic gallstones are very common.

Prophylactic treatments aimed at preventing future complications are not recommended (such as prophylactic cholecystectomy) as the risk of complications from surgical treatment outweighs the potential risk of developing complications from the stones.

Question 10

When might prophylactic cholecystectomy be considered in asymptomatic gallstones found in a normal gallbladder and normal biliary tree

Answer 10

People with a partially calcified ‘porcelain’ gallbladder.

Question 11

Management of asymptomatic gallstones found in the CBD

Answer 11

Offer referral for bile duct clearance and laparoscopic cholecystectomy — although they are asymptomatic, there is a significant risk of developing serious complications such as cholangitis or pancreatitis.

Question 12

Management of symptomatic gallstones

Answer 12

Emergency admission if systemically unwell

Surgical referral

Consider laparoscopic cholecystectomy

Question 13

When is percutaneous cholecystectomy advised for gallstones

Answer 13

To manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful

Question 14

Advice regarding diet to help prevent biliary pain

Answer 14

low-fat diet

Question 15

advice for people with symptomatic gallstones

Answer 15

Avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed, but they do not need to avoid this food and drink after surgery.

Seek further advice if eating or drinking triggers existing symptoms or causes new symptoms to develop after they have recovered from having their gallbladder or gallstones removed.

Question 16

What sign is suggestive of acute cholecystitis

Answer 16

Murphy’s sign

Question 17

What is Murphy’s sign

Answer 17

Place a hand in RUQ and apply pressure

Ask the patient to take a deep breath in

The gallbladder will move downwards during inspiration and come in contact with your hand

Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 18

What might an abdominal ultrasound scan show in acute cholecystitis

Answer 18

Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder

Question 19

Mx of acute cholecystitis

Answer 19

Nil by mouth
IV fluids
Antibiotics (as per local guidelines)
NG tube if required for vomiting

ERCP to remove stones in CBD

Cholecystectomy within 72 hrs of symptoms if required

Question 20

Complications of acute cholecystitis

Answer 20

Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation

Question 21

What is gallbladder empyema

Answer 21

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder

Question 22

Mx of gallbladder empyema

Answer 22

Cholecystectomy (to remove the gallbladder)

Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

Question 23

Two main causes of ascending cholangitis

Answer 23

Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)

Infection introduced during an ERCP procedure

Question 24

Most common organisms in ascending cholangitis

Answer 24

Escherichia coli
Klebsiella species
Enterococcus species

Question 25

Acute mx of ascending cholangitis

Answer 25

``` Nil by mouth IV fluids Blood cultures IV antibiotics (as per local guidelines) Involvement of seniors and potentially HDU or ICU ```

Question 26

Diagnosis of cholangitis

Answer 26

Abdominal ultrasound scan CT scan Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic ultrasound

Question 27

Option for patients who are not suitable for ERCP or where ERCP has failed

Answer 27

Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction.

Question 28

What are most gallstones made of

Answer 28

Cholesterol

Question 29

Definition of cholelithaisis

Answer 29

gallstone(s) are present

Question 30

Definition of choledocholithiasis

Answer 30

gallstone(s) in the bile duct

Question 31

Definition of biliary colic

Answer 31

intermittent right upper quadrant pain caused by gallstones irritating bile ducts

Question 32

Risk factors for gallstones

Answer 32

The risk factors for gallstones can be remembered with the four F’s mnemonic: F – Fat F – Fair F – Female F – Forty

Question 33

Presentation of biliary colic

Answer 33

Severe, colicky epigastric or right upper quadrant pain Often triggered by meals (particularly high fat meals) Lasting between 30 minutes and 8 hours May be associated with nausea and vomiting

Question 34

Why is it important to avoid fatty foods in gallstones

Answer 34

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Question 35

Key complications of ERCP

Answer 35

Excessive bleeding Cholangitis Pancreatitis

Question 36

Mx of asymptomatic gallstones

Answer 36

Asymptomatic patients with gallstones may be treated conservatively, with no intervention required.

Question 37

Incision in open cholecystectomy

Answer 37

right subcostal “Kocher” incision

Question 38

What is post-cholecystectomy syndrome

Answer 38

involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time

Question 39

Symptoms of post-cholecystectomy syndrome

Answer 39

``` Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence ```

Question 40

What can ischaemia to the lower gi tract result in

Answer 40

acute mesenteric ischaemia chronic mesenteric ischaemia ischaemic colitis

Question 41

Predisposing factors to bowel ischaemia

Answer 41

``` Age AF(mesenteric ischaemia) Endocarditis,malginancy CVS - HTN, smoking, diabetes Cocaine - ischaemic colitis ```

Question 42

Common features of bowel ischaemia

Answer 42

``` Abdo pain Rectal bleeding Diarrhea Fever Bloods may show WBC raised with lactic acidosis ```

Question 43

What is acute mesenteric ischaemia typically caused by

Answer 43

Typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery

Question 44

Characteristic feature of acute mesenteric ischaemia

Answer 44

The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.

Question 45

Mx of acute mesenteric ischaemia

Answer 45

Urgent surgery usually

Question 46

Characteristic feature of chronic mesenteric ischaemia

Answer 46

Colickly, intermittent abdominal pain occurs

Question 47

Where is ischaemic colitis more likely to occur

Answer 47

'watershed' areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Question 48

What is ischaemic colitis

Answer 48

Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage

Question 49

IX in ischaemiac colitis

Answer 49

'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage

Question 50

Mx of ischaemic colitis

Answer 50

Usually supportive - surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage

Question 51

Bowels typically affected in mesenteric ischaemia vs ischaemic colitis

Answer 51

Mesenteric - small bowel Ischamic colitis - large bowel

Question 52

LFTs in acute cholecystitis and what might deranged LFTs indicate

Answer 52

Typically normal Deranged LFTs may indicate Mirizzi syndrome - a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct

Question 53

What can be used if diagnosis is uncertain in acute cholecystitis after ultrasound

Answer 53

cholescintigraphy (HIDA scan) may be used technetium-labelled HIDA (hepatobiliary iminodiacetic acid) is injected IV and taken up selectively by hepatocytes and excreted into bile in acute cholecystitis there is cystic duct obstruction (secondary to odema associated with inflammation or an obstructing stone) and hence the gallbladder will not be visualised

Question 54

Factors which increase risk of gallstone formation

Answer 54

``` Increasing age Family history. Sudden weight loss Loss of bile salts - eg, ileal resection, terminal ileitis(from crohn's) Diabetes Oral contraception ```

Question 55

Symptoms of IBS

Answer 55

``` Diarrhoea Constipation Fluctuating bowel habit Abdominal pain Bloating Worse after eating Improved by opening bowels ```

Question 56

Diagnosis of IBS

Answer 56

Normal FBC, ESR and CRP blood tests Faecal calprotectin negative to exclude inflammatory bowel disease Negative coeliac disease serology (anti-TTG antibodies) Cancer is not suspected or excluded if suspected

Question 57

General advice for IBS

Answer 57

Adequate fluid intake Regular small meals Reduced processed foods Limit caffeine and alcohol Low “FODMAP” diet (ideally with dietician guidance) Trial of probiotic supplements for 4 weeks

Question 58

1st line medication for iBS

Answer 58

Loperamide for diarrhoea Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

Question 59

2nd line medication for IBS

Answer 59

Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)

Question 60

3rd line medication for IBS

Answer 60

SSRIs antidepressants

Question 61

Genes associated with coeliac disease

Answer 61

HLA-DQ2 | HLA-DQ8

Question 62

Signs and symptoms of coeliac disease

Answer 62

``` Chronic/intermittent diarrhoea Nausea/vomiting Fatigue Recurrent abdominal pain Sudden/unexpected weight loss IDA ```

Question 63

Complications of coeliac disease

Answer 63

``` Anaemia Hyposplenism Osteoporosis Lactose intolerance Subfertility ```

Question 64

Cancer associated with coeliac disease

Answer 64

enteropathy-associated T-cell lymphoma of small intestine

Question 65

Mx of rectal prolapse

Answer 65

Gentle digital pressure(sedation and local perianal anaesthesia) Treat precipitants(constipation/diarrea) Surgical referral for irreducible prolapse Subcutaneous circumanal rubber ring may be fitted in elderly where surgery is not appropriate