Acute abdomen and critically ill ptnt recognition

Question 1

example of abdominal pathology presenting with inner thigh pain?

Answer 1

obturator hernia= Howship-Romberg sign

Question 2

example of abdominal pathology presenting with shoulder tip pain?

Answer 2

subdiaphragmatic irritation by free blood or pus e.g. ruptured ectopic pregnancy, =Kehr’s sign
acute cholecystitis

Question 3

why does an obstructed small bowel present initially with central abdominal colic?

Answer 3

small bowel= midgut structure, so pain referred to periumbilical area as viscus receives AN innervation which is poorly localised, in contrast to involvement of parietal peritoneum receiving somatic innervation which allows pain to be localised.
colicky as viscus overactivity in attempt to relieve obstruction.

Question 4

why might vomiting not occur at all in large bowel obstruction?

Answer 4

ileo-caecal valve prevents vomiting

Question 5

when does vomiting occur in small bowel obstruction and describe it

Answer 5

early and prominently
proximal obstruction= green vomitus as bile brought up
distal obstruction= more brown as faecal matter contained.

Question 6

what does abdominal distension indicate in SBO?

Answer 6

obstruction has been of relatively long duration

Question 7

symptoms of ectopic pregnancy?

Answer 7

acute abdominal pain, possibly shoulder tip pain, missed menstruation with vaginal bleeding

Question 8

sign on inspection of abdomen indicating peritonitis?

Answer 8

abdomen doesn’t move with respiration, it is rigid-board like rigidity

Question 9

why is it important to note old scars on abdominal inspection in cases of suspected SBO?

Answer 9

may indicate cause of SBO to be adhesions

Question 10

exception to acute abdomen presenting with tenderness on palpation?

Answer 10

acute mesenteric infarction- causes exceptional pain but few signs

Question 11

ultimate investigation for acute abdominal pain dependent on clinical picture?

Answer 11

laparotomy

Question 12

contrast presentation of peritonitis with biliary, intestinal or renal colic

Answer 12

peritonitis= lie still
colic= rolling around in agony

Question 13

sign visible on supine AXR (occasionally erect CXR) which indicates bowel perforation?

Answer 13

Rigler’s sign= bowel wall clearly defined as free intra-abdominal gas next to gas filled bowel loop.

Question 14

what should AF with abdominal pain always prompt thoughts of?

Answer 14

mesenteric ischaemia

Question 15

classical clinical triad of acute mesenteric ischaemia?

Answer 15

acute severe abdominal pain- central and constant, or around RIF (almost always involves small bowel)
no adominal signs
rapid hypovolaemia, leading to SHOCK

degree of illness far out of proportion with clinical signs

Question 16

investigations for acute mesenteric ischaemia?

Answer 16

increase HB due to plasma loss
WCC increase
Us and Es-baseline for surgery, check for renal disease prior to contrast use in CT angio
modestly raised amylase
raised serum lactate
persistent metabolic acidosis on ABG- HCO3- low
ECG-AF, or evidence of prev MI e.g. pathological Q waves
gasless abdomen on AXR early on, later may be evidence of paralytic ileus with multiple fluid levels and as in mesenteric vein or in bowel wall. thumb printing may be present, espec. if ischaemia of large bowel.
CT angio-absence of contrast medium in mesenteric arteries, or evidence of aortic dissection
laparotomy- nasty necrotic bowel

Question 17

main life-threatening complics secondary to acute mesenteric ischaemia?

Answer 17

septic peritonitis-bowel perforation*?

progression of SIRS into multi-organ dysfunction syndrome, mediated by bacterial translocation across dying gut wall

Question 18

tment of acute mesenteric ischaemia?

Answer 18

resuscitation with IV fluids, Abx- gentamicin and metronidazoe, SC LMWH
in very early stages, percutaneous endovascular restoration of mesenteric b.flow by balloon angioplasty, suction embolectomy, thromobolysis and stenting may be successful
laparotomy-pale or gangrenous bowel with poor peristalsis, absence of pulsating vessels in mesenteric arteries, dead bowel MUST be resected before attempts to restore b.supply, then end to end anastomosis or bring out the 2 ends as stomas to skin surface if bowel viability in doubt.
2nd look laparotomy 24hrs after anastomosis to assess bowel viability and carry out further resections
embolectomy catheters-if fail, can do SMA end arterectomy with a patch graft or some sort of bypass

Question 19

2 potential watershed areas in arterial supply of colon?

Answer 19

splenic flexure- were SMA and IMA meet at marginal artery, or Griffith’s point
at origin of superior rectal artery- Sudeck’s point

Question 20

diagnoses patients with non-specific abdo pain (NSAP) are commonly discharged from hosp with?

Answer 20

dyspepsia
mesenteric adenitis
dysmenorrhea
constipation
gastroenteritis

Question 21

symptoms and signs of NSAP?

Answer 21

acute onset abdo pain, usually in RIF though may be diffuse
no vomiting or anorexia- assoc. with acute appendicitis
rarely systemic signs e.g. tacycardia, fever, flushing
no signs of peritonism or peritonitis
symtoms usually self-limiting

Question 22

DD for NSAP in women with no discrete abdominal signs?

Answer 22

endometriosis

Question 23

which people should not be diagnosed as having NSAP?

Answer 23

elderly- as likely some pathology to account for pain, and even if no cause found, they should be followed up in OPC.

Question 24

sign on examination of patient with acute appendicitis where palpating LLQ increase pain felt in RLQ?

Answer 24

Rovsing’s sign

Question 25

signs on examination of peritonitis ptnt?

Answer 25

``` prostration board like rigidity guarding shock lying still +ve cough test tenderness +/- rebound/percussion pain no bowel sounds ```

Question 26

signs of suspected abscess formation?

Answer 26

swelling swinging fever raised WCC raised CRP if so, do USS or CT look for sentinel loop on plain AXR= single loop of dilated bowel adjacent to inflammation, indication of localised ileus e.g. in cholecystitis, pancreatitis, appendicitis or diverticulitis.

Question 27

ABG is important for diagnosis of which condition causing acute abdomen?

Answer 27

acute mesenteric ischaemia

Question 28

PLAN for acute abdomen?

Answer 28

``` treat shock crossmatch 2U blood, or group and save blood culture, then antibiotics- cefuroxime and metronidazole analgesia IVI- 0.9% saline plain AXR CXR if peritonitic or >50 ECG if >50 consent NBM for 2h pre-op ```

Question 29

classes of hypovolaemia due to blood loss where blood is also given with crystalloid fluids?

Answer 29

class III and IV

Question 30

blood loss in class IV hypovolaemia?

Answer 30

``` >40% (>2L) pulse >140bpm BP decreasing and PP decreasing respirations >35/min negligible urine output lethargic ```

Question 31

in surgical abdomen, does pain or vomiting tend to come first?

Answer 31

pain

Question 32

general signs of acute appendicitis?

Answer 32

``` fever 37.5-38.5 degrees C tachcardia furred tongue kying still coughing hurts foetor with or without flushing shallow breaths RIF= guarding, rebound and percussion tenderness, PR painful on R side if low lying pelvic appendix ```

Question 33

symptoms of acute appendicitis?

Answer 33

periumbilical pain ,omving to RIF anorexia vomiting poss, pain precedes vomiting constipation, sometimes diarrhoea

Question 34

special tests in acute appendicitis?

Answer 34

rovsing's sign= pain in RIF > LIF when LIF pressed psoas sign= pain on hip extension if retrocaecal appendix cope sign= pain on flexion and internal rotation of R hip in appendix closely related to obturator internus

Question 35

why might pain be felt in R shoulder in acute cholecystitis?

Answer 35

inflamed GB irritates diaphragm inervated by phrenic nerve- C3-C5, so referred pain.

Question 36

percussion note if obstruction?

Answer 36

resonant

Question 37

properties of bowel sounds if peritonitis, and if obstruction?

Answer 37

reduced or absent in peritonitis | high pitched and tinkling if obstruction

Question 38

what might ptnt do to relieve pain in acute pancreatitis?

Answer 38

sit forwards

Question 39

prognosis in acute mesenteric ischaemia?

Answer 39

POOR of those that develop SB infarction, 70-80% die small number survive left with short bowel syndrome requiring IV nutritional support for wks, mnths or rest of life