Acute abdominal pain Flashcards
(75 cards)
1
Q
How does ruptured AAA present?
What are some signs on examination of ruptured AAA?
A
Presentation of ruptured AAA
- sudden onset severe pain radiating to back, abdomen, groin
- collapse
Signs on examination
-rigid abdomen and PULSATILE, EXPANSILE MASS
-shock-low BP, high HR, poor perfusion (absent femoral pulses)
-signs of ecchymosis (bleeding under skin)
• Cullen’s sign
• Grey-Turners sign
2
Q
What size dilatation is a AAA categorised as?
When is unruptured AAA big enough to be operated on?
A
AAA is a permanent dilatation >3cm
<5.5cm = watch and wait
-regular USS monitoring
(3-4.5 do yearly USS
(4.5-5.5 do 3 monthly USS)
-modify risk factors (stop smoking, control HTN (ACEi), DM, chol (statin), Aspiring potentially)
> 5.5cm OR >1cm/yr OR symptoms = surgery
- endovascular stent repair
- or laparotomy with prosthetic graft
3
Q
What is most common site for AAA?
A
Infrarenal (just below kidneys)
4
Q
Risk factors for AAA?
A
- Over 50 years old (age related changes in elastin + collagen + smooth muscle)
- Male(screened)
- Risk factors for developing atheroma in the aorta:
- Hypertension
- Smoking
- Male
- Hyperlipidaemia
- Obesity
- Genetics
- Marfan’s
- Collagen disorders(Elher’s Danos syndrome)
- Syphilis
5
Q
Investigations for AAA?
A
Investigations for AAA
- Urgent USS is diagnostic for AAA - but if it has already ruptured should not waste time doing this
- USS, ECG AND BLOODS: • FBC • group and save and a cross match for 10U or more • amylase • LFTs • Us and Es • Clotting
6
Q
How should you manage AAA rupture?
A
AAA management
-CALL THEATRE ASAP (vascular surgeon with experienced anaesthetist)
ABCDE
- High flow oxygen 15L/min via non rebreathe mask
- 2 wide bore cannulas in antecubital fossa
- Bloods - emergency cross matching 10U, FBC, clotting, amylase, U+Es, LFTs
- Give fluids in major hypovolaemia but avoid excess(aim for systolic <100)
-IV morphine(prevent tachycardia and hypertension)- IV antiemetics - 50mg cyclizine
-IV prophylactic antibiotics -METRONIDAZOLE AND CEFUROXIME
7
Q
Symptoms of appendicitis?
A
symptoms appendicitis
- INITIAL GENERALISED abdo pain which localised to the RIF just a few hours later
- Nausea and vomiting
- Anorexia
- Constipation or diarrhoea
- Frequent urination (irritation-can mimic UTI)
8
Q
Signs of acute appendicitis? What are: Rovsigns sign Copes sig/obturator Psoas sign
A
Signs of acute appendicitis
- Tachycardia, tachypnoea, pyrexia
- Tenderness at McBurney’s point (2/3rds umbilicus to ASIS)
- Guarding (localised peritonitis)
- Rovsigns sign -pain in RIF when pressing on LIF
- Cope/obturator sign - pain on flexion and internal rotation of R thigh
- Psoas sign- get patient to lie on LHS and extend their right leg> PAIN
9
Q
What causes acute appendicitis?
What should some differentials for acute appendicitis be?
A
appendicitis CAUSES
- infected faecolith
- gut microorganisms arrive
- causes immune cells to kick off
- inflammation
appendicitis DIFFERENTIALS
- diverticulitis
- gastroenteritis
- acute flare of IBD
- ectopic pregnancy
- ovarian cyst
- mesenteric ischemia (always think about this)
10
Q
What investigations should be done in acute appendicitis?
A
Appendicitis investigations
- mainly clinical
- CRP!!!!!!
Bedside
- urinalysis -can be normal (rule out UTI). It is abnormal 50% of the time because bladder is close to appendix- white cells (inflammation)
- pregnancy test (rule out ectopic)
Bloods
- CRP!!
- FBC (increased neutrophils)
- Us Es/LFTs/amylase/crossmatch
Imaging
-not required clinical is enough
can do CT or USS if unsure
11
Q
How should we manage acute appendicitis in ED?
A
Appendicitis management
• Obtain IV access and resuscitate if necessary
• Commence fluids if dehydrated
• Antibiotics (metronidazole and cefuroxime) (guidelines)
• IV analgesia and anti-emetics
• Refer to general surgeons for prompt laparoscopic appendectomy
12
Q
What causes cholecystitis?
A
- Stone or sludge obstruction of the neck of the gall bladder
- Causing INFLAMMATION of the gall bladder
13
Q
What are some signs and symptoms of cholecystitis?
A
Symptoms of cholecystitis
- Continuous epigastric or RUQ pain
- May radiate to right shoulder
- Worse when eating (especially fatty foods)
- Vomiting
Signs
- Fever- the presence of fever distinguishes from just biliary colic
- local peritonism- tender o/e with possible GB mass with guarding and some rigidity
○ MURPHY’S SIGN 2 fingers over RUQ and ask patient to breath in . (only +ve if the same test in the LUQ does not cause pain)
14
Q
What is the most common cause of cholecystitis?
A
Gall stones
15
Q
What investigations should be done in a patient with potential cholecystitis?
A
Cholecystitis investigations
- FBC (high WCC)
- LFTs (marginal elevation of ALP, bili and ALT possible - but highly elevated levels might be more suggestive of bile tract obstruction)
- USS might show thick walls and shrunken GB, might see stones and might see a dilated CBD
16
Q
How should we initially manage cholecystitis in ED?
A
Cholecystitis management
- NBM
- analgesia
- IV fluids
- IV antibiotics (guidelines) (cefuroxime)
Refer for laparoscopic cholecystectomywithin 7 DAYS
17
Q
What is ascending cholangitis and how does it differ from cholecystitis?
Treatment for cholangitis?
A
Cholangitis -This is similar to cholecystitis PLUS JAUNDICE -It's bad! likely septicaemia! -Infection of the gall bladder -CHARCOT'S TRIAD: •RUQ pain •Fever and rigors •Jaundice
Treatment
-antibiotics (cefuroxime and metronidazole) (guidelines)
18
Q
What are some symptoms and signs in a patient with a bowel obstruction?
A
- Vomiting, nausea, anorexia.
If the obstruction is long-term then the faecal contents behind the obstruction might start to ferment and this can cause FAECAL VOMITING - Constipation
- Colic
- Abdominal distension
o/e distension, rigidity, absent or tinkling bowel sounds
19
Q
What difference will there be between the presentation in patients with small and large bowel obstructions?
A
Small bowel
- central distention (less severe than large bowel)
- bilous vomiting will be predominant early symptom
- colic pain +++
Large bowel
- flank distention
- constipation is early sign
- more constant pain
20
Q
What are some common causes of bowel obstruction? (dynamic and adynamic) give examples of both
A
Dynamic -> mechanical obstruction •hernias •fecal impaction •volvulus •adhesions •TB
Adynamic -> paralytic ileus (inactivity of the bowel)
•recent abdo surgery
• electrolyte imbalance e.g. loss of K+ after surgery or hypercalceamia
•spinal injury
•pseudo obstruction
21
Q
How would you approach a patient presenting with ?Bowel obstruction in ED
A
Bowel obstruction managment (emergency)
- ABCDE approach
- ABDO EXAM and end pieces
- stool
- hernia-femoral more likely to cause obstruction
- rectal exam (1st line)
- urine-cathertise
- BLOODS
- FBC
- UsEs
- LFT
- clotting
- group and save (surgery)
- glucose
- amylase
- calcium,
- Imaging:
- AXR -bigger than 3 (small),6, (caecum) 9 (large)
- CXR erect (pneumoperitomium))
22
Q
What specific treatment can be done for bowel obstruction?
A
Bowel obstruction treatment
ABCDE management
-Drip and suck
-IV fluids
-NG ryles tube (reduce contamination of peritonium)
-IV antibiotics
-Correct electrolytes
-Analgesia and antiemetic (if necessary)
-Catheter (monitor fluid input AND output)
-PPI
-Refer to surgery (exploratory laparotomy for patients that are haemodynamically unstable or signs of ischaemia/necrosis)
23
Q
What is diverticulosis/diviticular disease/diverticulitis?
In which diverticula does diverticulitis most often occur?
What are some complications of diverticulitis?
A
Increase in lumen pressure>out pouching
Diverticulosis= asymptomatic
Diverticular disease=symptomatic
Diverticulitis (infected)
In the diverticula of the descending/sigmoid colon (LIF)
Complications of diverticulitis
- abscess (swinging fever, WCC)
- perforation -surgery
- haemorrhage
- fistulae
24
Q
What are some common symptoms of acute diverticulitis?
What are some common signs on examination would you see?
A
Acute diverticulitis
- SEVERE PAIN IN THE LEFT ILIAC FOSSA (normally relieved by defecation)
- Fever
- Nausea
- Altered bowel habit
- Flatulance
Examination • Febrile • Tachycardia (pain) • Tenderness and guarding in LIF • Localised or generalised peritonism • Diarrhoea ± Bleeding (melaena)
25
What investigations should be done in patients with diverticulitis?
What score should you use to classify severity?
BLOODS:
•FBC (wcc raised)
•ESR and CRP raised
IMAGING
- CT abdo with IV contrast (can also look for abcess)
- Erect CXR to look for perforation
- Can also do USS: thickened bowel walls and pericolic collections
Hinchey score – severity classification
26
How should diverticulitis be managed in the ED?
What investigation must you AVOID in acute diverticulitis?
Acute diverticulitis
- Mild attacks an be treated as an outpatient with oral co-amoxiclav
- If they are in considerable abdo pain or cant tolerate oral fluids consider admission for IV fluids, IV co-amoxiclav and analgesics (NBM)
DO NOT DO A COLONOSCOPY IN AN ATTACK OF DIVERTICULITIS (risk of perf)
27
What are risk factors for ectopic pregnancy?
What are some clinical features of ectopic pregnancy?
Ectopic pregnancy
RISK FACTORS
- endometriosis
- intrauterine contraceptive devise
- pelvic inflammatory disease
- pelvic surgery/edhesions
- PMH ectopic
- IVF
- progesterone only pill
FEATURES
- Collapse/syncope
- Recurrent lower abdominal pain (haemorrhage may cause pain to radiate to shoulder)
- Vaginal bleeding
- Missed period
28
What investigations should be done with suspected ectopic pregnancy?
What investigation should be AVOIDED?
Ectopic pregnancy
-Trans-vaginal USS
- Urine pregnancy test and serum bHCG in blood
-Bloods: FBC, crossmatch to determine rhesus status
think about other causes (UsEs, LFT, amylase, Ca, glucose)
Do not do bimanual examination in ectopic pregnancy
29
How should we manage ectopic pregnancy?
Ectopic pregnancy
- Fluid resuscitation if shocked
- Depends on size and certain factors (B-hCG and FHR)
- Refer to gynaecology
- Watch and wait while measuring Hcg OR Methotrexate (if diagnosed later) OR surgery (heamodynamically unstable)
30
How might a miscarriage present?
Miscarriage presentation
- Acute vaginal bleeding with or without pain/cramping.
- Sometimes bleeding can be profuse and cause hypotension/collapse/faintness
31
What might cause a miscarriage?
Miscarriage causes
- Might be spontaneous or might be repeated (infertility)
- Chromosomal abnormalities of fetus
- Uterine malformations (fibroids or cervical changes) - this is more likely to be the cause if the miscarriage is in the second or third trimester
- Drugs (isotretinoin)
- Trauma
32
What investigations should be done in a patient with potential miscarriage?
```
Investigations post miscarriage
1st line: pregnancy test
2nd line: USS (determine if unteruterine)
3rd line:
Intrauterine: look at cervix (see if open)
Not seen in uterus: beta hcg levels
-suboptimal rise=ectopic
-declining=miscarriage
```
Others
- FBC, Rhesus status
- Pelvic examination
33
How should miscarriage be managed in the ED?
- Resuscitate if needed
- Treat pain
- Refer to gynaecology and obstetrics for examination
- Counselling
34
How might an ovarian cyst present in an acute setting?
- Lower abdominal pain, can be a dull ache or a sharp pain
- May radiate lower back
- Exacerbated by intercourse
- Bloating or swelling in the abdomen
- Urinary symptoms if pressing on bladder
- Very heavy/irregular periods
-Difficulty getting pregnant
Ruptured cysts
• Severe sudden sharp pain
• Vomiting
• Vaginal bleeding
• Shock
35
What are some important causes of ovarian cyst?
Cysts are either:
FUNCTIONAL
- very common and form as part of the menstrual cycle
- usually these are harmless, short-lived and asymptomatic
PATHOLOGICAL
- much less common
- they are an abnormal growth and while the majority are benign some can be cancerous
- can be associated with endometriosis/PCOS
36
What investigations should be done in people with suspected ovarian cyst?
Investigations for ovarian cyst
- Pregnancy test (blood and urine) to exclude ectopic
- USS
- CA125 for ovarian cancer (high levels doesn’t necessarily mean cancer)
- Urinalysis to exclude UTI
37
How should we initially manage ovarian cyst in the ED?
```
Ovarian cyst management
-Resuscitation if shocked
-No treatment required in most cases
- If the woman is post-menopausal then she might have a slightly higher risk of cancer and so might suggest monitoring over a year
- Consider surgeon referral (lap cystectomy) if ovarian cysts are:
• Large >5cm
• Symptomatic
• Cancerous
• Signs of torsion
```
38
What are some clinical features of acute pancreatitis?
Signs on examination?
Initially: -severe epigastric pain (relived by sitting forward) with nausea and vomiting
Then: pain radiates to back (involvement of peritoneum)
Signs O/E:
- Tachycardia + hypotension (fluid shift)
- Mild fever
- Jaundice if gallstones is cause (may have RUQ pain)
- Epigastric tenderness/local peritonism (rigidity/guarding )
- GREY-TURNER'S (flank) or CULLEN'S (central)
- Oliguria
- Hypocalceamia (lipase breaks down fat that bind to free calcium)
39
What actually is acute pancreatitis?
What are some causes of acute pancreatitis?
Acute pancreatitis
- Self-perpetuating pancreatic inflammation (enzyme-mediated auto-digestion)
- Odema and fluid shift (to gut, peritoneum, retroperitoneum) → HYPOVOLAEMIA (worsened by vomiting)
```
GET SMASHED
G - Gall stones (38%)
E - Ethanol (35%)
T - Trauma
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion venom
H - Hyperlipidaemia, hypercalcaemia, hypothermia
E - ERCP and emboli
D - Drugs
```
40
What investigations should we do in someone in whom we're suspecting acute pancreatitis?
```
ACUTE PANCREATITIS
Bloods
-ABG (critically ill patient)
-FBC (↑WCC)
-UsEs (↑Urea)
-LFT and clotting
-↑CRP (marker of severe)
-↑Amylase (3x upper limit-can also be normal)_
-↑Lipase (more specific and sensitive)
-↑Glucose
-↑lactate (
-Ca2+ ( may be ↑)
```
Imaging
-CT (standard- rule out pnuemoperitoneum)
-AXR
(no psoas shadow-high retroperitoneal fluid)
(sentinel loop sign-solitary air-filled dilatation)
-CXR (rule out other causes e.g. bowel perf)
-USS (if gallstones)
Sentinel loop sign (solitary air-filled dilatation) indicates gall stone ileus
3. MRCP – determine if gall stone obstructing CBD
41
How should we initially manage someone with acute pancreatitis in the ED?
Acute pancreatitis is managed by surgeons
1. Stabalise
- Admit to ward and monitor vital signs
- IV access (FLUIDS FLUIDS FLUIDS)
- If vomiting, NBM (NJ tube)
- Analgesia (IM pethidine-avoid morphine-sphincter of oddi contraction)
- Antibiotics if necrotic
2. Treat cause
- hypercalceamia
- gallstones (ERCP to relive obstruction within 72 hours. call general surgery for cholecystectomy)
3. Now what?
- Glasgow imrie score within 48 hours (assess severity)
- 3+ then transfer to ICU
42
What are some clinical features of someone presenting with peptic ulcer disease ?
```
PUD: *Sharp, easily located epigastric pain*
(50% assymptomatic)
S-Epigastric, can easily point to where it is
O-
C-sharp
R-
A
-heart burn
-taste changes (more metallic)
-bloating/early satiety
ALARMS
-Anemia (tiredness, palpitations)
-Loss of weight
-Anorexia
-Recent onset
-Melena/heamatemisis(not a lot)-may relieve.
-Swalling problems
T-
E
-food RELIEVES DUODENAL
-food EXACERBATES GASTRIC
S-
```
43
What are some important causes of peptic ulcer disease?
Duodenal ulcer is the most common
1. Helicobacter pylori - bacteria which produces ammonia to neutralise stomach acid which is toxic to epithelial cells
2. DRUGS: NSAIDs, steroids SSRIs
Others
- Smoking
- Alcohol
- Stress
- Aggravating food
- Elderly (gastric)
44
What investigations should we do in patients with peptic ulcer disease?
(what is diagnostic -wat do you do for it)
BEDSIDE
-ECG to rule out cardiac pain
BLOODS
- FBC (↓Hb – indicates anaemia, refer)
- Us and Es
SPECIAL TESTS -
1. Non-invasive H.Pylori test
- 1st line is carbon urea breath test
- or stool antigen
2. Endoscopy (if DYSPHAGIA or 55+ with ALARMS signs)
- DIAGNOSTIC: Upper GI endoscopy (∆) – exclude malignancy and determine extent of oesophagitis
- Stop PPI 2 wks before
- Multiple Biopsies and histology (H.Pylori CLO)
- recheck after treatment to see if malignant
45
How should we manage peptic ulcer disease initially?
1. Stop drugs (NSAIDS)/lifestyle and review in 4 weeks
2. If no improvement then check for H pylori
-If H pylori -ve then give PPI (4 weeks)
-If H pylori +ve with NSAID use> PPI first then irradication
- If H pylori +ve and no NSAID use> TRIPPLE THERAPY
•PPI + amoxicillin, + either clarithromycin/metronidazole
for 1 week
(if pen allergic, give PPI, metronidazole and clarithromycin
* *in ED just test for H pylori (skip step 1)
* *only irradiate H pylori twice-if still +ve seek expert advice
46
What are some clinical features of PID?
What is a sign on examination?
This is an inflammation of the upper part of the female reproductive tract (ovaries, fallopian tubes, uterus and surrounding pelvis)
- Pelvic and lower abdominal pain
- New or different discharge
- Pain during sex
- Painfull/irregular periods
- Dysuria
On examination
-cervical motion tenderness
47
What are some important causes of PID?
```
90% associated with sexually transmitted infections:
- Gonorrhoea
- Chlamydia
- Bacterial vaginosis increases the risk of developing PID
Organisms
• Chlamydia trachomatis
• Neisseria gonorrhoea
• Mycoplasma hominis
• Ureaplasma urealyticum
```
48
What investigations should we do in patients with PID?
- FBC (high WCC)
- Pelvic exam
- Pregnancy test
- Swabs of cervix and vagina> look for STIs
- Urinalysis-exclude UTI
- USS (abbess)
49
How should we consider managing PID?
- Gynaecological review
- Pain killers
- Empirical antibiotics
50
What is pathophysiology of renal colic?
| What are some clinical features of renal colic?
REAL COLIC
- intermittent severe pain in flank/loin/groin (testes-not not tender)
- ureteric peristalsis
Symptoms
- suprapubic pain
- anorexia
- nausea and vomiting
- sweating
urine problems
-change in smell/ colour (heamaturia)/amount (anuria/dysuria)
51
What is the most likely cause of renal colic?
Kidney stones (haematuria and raised inflammatory markers)
52
What investigations should we do in someone with renal colic?
Bloods
- FBC (wcc)
- UsEs
- CRP
- Calcium
Urine
- urine dip (blood and leucocytes due to inflammation)
- pregnancy test
Urgent Imaging within 24 hours
- CT non contrast
- if young or pregnant do KUBUSS
53
How should we consider managing a patient with renal colic in ED?
< 5mm stones
- NSAIDS (PO diclofenac or IV ketorolac)
- Fluids- important to keep pt hydrated-help to pass stones
- AB if infection
>5mm
- alpha blocker to relax (tamsulosin)
- or surgical treatment
54
What are some clinical features of urinary tract infections?
-suprapubic pain (loin/flank pain>pylonephritis)
- URINARY SIGNS:
○ Urgency
○ Frequency
○ Feeling of incomplete emptying
○ Haematuria
○ Dysuria
○ Smelly urine
- Fever, rigors and tenderness are also suggestive of an upper UTI
- Confusion in the elderly-easily missed
55
What are some important causes of UTIs?
- Very common in women, especially those who are sexually active
- Common in the elderly
- Gram negative organisms: E.col
○ Consider immunocompromisation in pt not in high risk group
56
What investigations should we consider in someone with a UTI?
- Urine dip and culture
- Pregnancy test
- Bloods: FBC, U+;E
57
How can we manage a UTI in the ED?
- Antibiotics (follow guidelines, trimethoprim, nitrofurantoin, pivmecillinam)
○ Cefuroxime if UUTI
- Encourage high intake oral fluids, IV if pt is unwell
58
What is binary colic?
How does it present?
Investigations?
Treatment?
Bilary colic
-Gallstones temporarily obstruct cystic duct, then are passed into common bile duct
-Will cause RUQ and might have some jaundice. However no fever as the GB is NOT inflamed
```
-Investigations (rule out other conditions)
○Urinalysis
○ Bloods
○CXR
○ECG
```
```
-Treatment
○NBM
○analgesia
○IV fluids
○elective laparoscopic cholecystectomy
```
59
How would liver enzymes look in obstructive jaundice (post hepatic)
Obstructive jaundice/ post hepatic jaundice
- ALP +++
- GGT+++
- Unconjugated bilirubin+ Conjugated bilirubin+++
- ALT and AST normal or +
60
Complications of peptic ulcer disease?
Complications of peptic ulcer disease
- UPPER GI BLEED if erosion of vessels(Haematemesis/Melaena)
- PERFORATION-can cause acute abdomen (epigastric pain → generalised rigidity (CXR – pnuemoperitoneum)
PYLORIC STENOSIS– due to scarring of the duodenum
Weight loss + Projectile Vomiting
61
What is the severity score for acute pancreatitis?
| How does this effect your managment?
```
Acute pancreatitis
-Do the Glasgow imrie score within 48 HOURS (assess severity)
P- PaO2 <8
A- >55
N- Neutrophilia >15x109
C- Calcium <2mmol
R- Renal function urea >16
Enzymes -LDH (>600) and AST (>200)
A-Albumin <32
Sugar (blood glucose >10mmol)
```
-If 3+ then transfer to ICU
62
Complications of acute pancreatitis? (early and late-3)
```
Complications of acute pancreatitis
EARLY
-shock (FLUIDS)
-renal failure (FLUIDS)
-sepsis
-DIC
-ARDS (acute lung injury due to systemic illness)
```
LATE
1. Pseudocyst (mass and persistent high amylase)-cystogastrostomy if symptoms dont resolve
2. Pancreatic abscess-infected pseudocyst (drain)
3. Necrotising pancreatitis: Imipenem if > 30% necrosis
63
Complications of diverticulitis? (how do you treat)
Complications of diverticulitis
1. Haemorrhage (sudden and painless)
→ Transfusion
2. Abscess- swinging fever, ↑↑WCC/Neut, localising signs e.g. boggy rectal mass
→ antibiotics – Co-Amoxiclav
→ image guidedpercutaneous drainage (rectally)
3. Perforation - Ileus, peritonitis ± shock
→ Laparotomy w/ Hartmann’s procedure (temporary colostomy + partial colectomy)
64
Differential for aneurysm?
Pseudoaneurysm/false aneurysm
| -blood vessel wall is injured and the leaking blood collects in the surrounding tissue
65
What would you see on x-ray for bowel obstruction?
How do you know if small/large bowel?
Dilated bowel
- Small bowel dilatation if >3cm
- Large bowel dilatation if >6cm
- Cecal dilatation if > 9cm
* no gas distal
* *multiple fluid levels is abnormal
* **riglers sign(both sides of bowel wall can be seen)= perf and pneumoperitoneum
Small bowel obstruction - valvulae conniventes are visible (lines completely cross the bowel)
Large bowel obstruction - haustral lines visible (just on edges)
66
What are some causes of small bowel obstruction?
- ADHESIONS most common (prior abdo surgery, TB)
- Incarcerated hernias
- Crohn's disease
67
What are some causes of large bowel obstruction?
- TUMOURS most common e.g. colon carcinoma
- Constipation
- Volvulus
- Diverticular stricture
68
How can you tell the difference between mechanical and functional bowel obstruction?
'functional' or dynamic:
- absent bowel sounds
- pain tends to be less
mechanical/dynamic:
-bowel sounds tinkling
69
Best imaging for determining cause of bowel obstruction?
CT scan (with IV contrast)
70
What is a simple/closed loop/strangulated bowel obstruction and how can you tell difference?
Simple: just one obstruction point, no vascular compromise
Closed loop: obstruction at 2 points (sigmoid volvulus-risk of perf)
Strangulated: compromised blood supply
- PERITONISM!!! (sharper more localised pain)
- ILLER THAN YOU'D EXPECT
- ↑WCC
71
How can you tell the difference between functional and mechanical bowel obstruction?
'functional' or dynamic:
- absent bowel sounds
- painless
- no flatus (large amount of gas in rectum)
mechanical/dynamic: bowel sounds tinkling
72
What can be done for palliative treatment for obstructive large bowel malignancys?
Endoscopic stenting – useful in palliative + elderly pts.
73
What would you see on imaging for sigmoid volvulus (2 different images)
CT abdo-pelvis with IV contrast - dilated sigmoid colon with 'whirl sign'
AXR - coffee-bean sign arising from LIF
74
What is sigmoid volvulus?
| Who does it normally occur in?
Large bowel twists on mesentery- can cause strangulated obstruction
(tends to occur in elderly, comorbid, constipated patient)
75
Treatment of sigmoid volvulus?
- Flatus tube/sigmoidoscopy to decompress
| - If that doesnt work: sigmoid colectomy
