Albert Smith - AAA

Question 1

What does MEDIICAATION stand for and what does it relate to?

Answer 1

When trying to reach a diagnosis

Metabolic
Endocrine
Degenerative
Inflammatory-Infection
Congenital
Age related
Alcohol-Toxic
Injury-trauma
Oncological
Neoplastic

Question 2

DDx of generalized abdominal pain

Answer 2

1. Perforation
2. AAA
3. Acute Pancreatitis
4. Diabetes mellitus

Question 3

DDx of central abdominal pain

Answer 3

1. Early appendicitis
2. Subacute Obstruction
3. Acute gastritis
4. Acute pancreatitis
5. Ruptured AAA
6. Mesenteric
   thrombosis (Mesenteric venous thrombosis (MVT) is a blood clot in one or more of the major veins that drain blood from the intestine)

Question 4

DDx of epigastric pain

Answer 4

1. Peptic Ulceration DU /GU / Oesophagitis
2. Biliary Colic
3. Acute pancreatitis
4. AAA
5. Myocardial Infarction (inferior)

Question 5

DDx of RUQ pain

Answer 5

1. Gallbladder disease
2. Duodenal Ulcer
3. Acute pancreatitis
4. Pneumonia
5. Subphrenic abscess

Question 6

DDx of LUQ pain

Answer 6

1. Gastric Ulcer
2. Pneumonia
3. Acute pancreatitis
4. Spontaneous splenic
   rupture
5. Subphrenic abscess

Question 7

DDx of suprapubic pain

Answer 7

1. Acute urinary retention
2. UTIs
3. Cystitis
4. PID
5. Ectopic pregnancy
6. Diverticulitis

Question 8

DDx of RIF pain

Answer 8

1. Acute appendicitis
2. Mesenteric adenitis (young)
3. Perf DU
4. Diverticulitis
5. PID
   6.Salpingitis
6. Ureteric colic
7. Meckel’s diverticulum
8. Ectopic pregnancy
   • Crohn’s disease

Question 9

DDx of loin pain

Answer 9

1. Muscle strain
2. UTIs
3. Renal stones
4. Pyelonephritis
5. AAA

Question 10

DDx of LIF pain

Answer 10

1. Diverticulitis
2. Constipation
3. Irritable Bowel Syndrome
4. Pelvic Inflammatory
   Disease
5. Rectal Carcinoma
6. Ulcerative Colitis
7. Ectopic pregnancy

Question 11

Abdominal pain investigation options

Answer 11

1. Pregnancy test
2. Urine dipstick
3. Plain film (free air, obstruction, air-fluid, foreign bodies)
4. Ultrasound (role in trauma)
5. CT

Question 12

Mx steps for abdominal pain

Answer 12

1.ABC’
2. Supplemental oxygen
3. IV access
4. Fluid administration
5. Antiemetics
6. Analgesics
7. Urinary catheterisation
8. Antibiotics
9. Radiology…
10. Re-evaluation with results (Barium Meal, Blood
tests, Arterial Blood Gasses, ECG, radiology)

Question 13

Risk factors for AAA

Answer 13

1. ↑ Age
2. Male sex (x 4-8)
3. Smoking (x 6)
4. Family history (x 4)
5. Vascular disease
6. Hypertension
7. Hypercholesterolaemia
8. • Ethnicity
   • 50% decreased risk in black men
   • 90% decreased risk in Asian men
9. Genetic disorders: lysil oxidase deficiency
10. Connective tissue disorders
    • Marfan, Ehlers Danlos
11. Infective (Mycotic and inflammatory causes)

Question 14

Protective factors of AAA

Answer 14

1. Blacks and hispanics
2. Diabetes
3. Exercise 1 p/w
4. Fruit, veg and nuts

Question 15

Disease LOB Marfaans

Answer 15

Genetic disorder of connective tissue – tall with long
limbs and long thin fingers
• Autosomal dominant inheritance – Gene FBN1 which
encodes connective protein fibrillin – 1
• Varying penetrance – heart valves, aorta, lungs, eyes,
dura, skeleton, hard palate.
• Fibrillin 1
– A connective protein
– B binds transfroming growth factor beta (TGF-β).
TGF-β has deleterious effects on vascular smooth muscle
development and the integrity of extracellular matrix. Thus
excessive TGF-β weakens the tissues and causes Marfan’s

Question 16

Disease LOB Ehlers-Danlos syndrome

Answer 16

Group of inherited connective tissue disorders
caused by a defect in the synthesis of type V collagen.
• Typically affects joints, skin and blood vessels.
- Symptoms may include loose joints, stretchy skin,, poor wound healing and abnormal scar formation.
- These can be noticed at birth or in early childhood.
- Complications may include aortic dissection, joint dislocations, scoliosis, chronic pain, or early osteoarthritis.

Question 17

Pathophysiology of atherosclerosis

Answer 17

See notebook

Question 18

SS of AAA

Answer 18

1. Abdominal pain, back pain, loin pain
2. Pulsatile, expansile abdominal mass
3. 25% have associated femoral or popliteal aneurysms
4. <4cm AAA; clinical examination sensitivity 0.57
5. > 5cm AAA; clinical examination sensitivity 0.98

Question 19

Risk of AAA rupture per by size

Answer 19

– 4 cm.: 1 % / year
– 5 cm.: 4 %/ year
– 6 cm.: 10 % / year
– 7 cm.: 20 % / year
– 8 cm.: 40% / year
– 10cm.: 100% / year

Question 20

Most frequent misdiagnosis of AAA

Answer 20

1. Renal bleed
2. GI bleed
3. Diverticulitis
4. Back pain
5. MI
6. Motor vehicle accident
7. Sepsis

Question 21

AAA disease LOB

Answer 21

See notebook

Question 22

open surgery or EVAR

Answer 22

SEE SLIDE 54 OF mX OF aaa LECTURE (PANOS)

Question 23

Disadvantages of open repair

Answer 23

Clamping the aorta
• End-organ ischaemia
• Increased SVR (increased pre-load and after-load)
• Reperfusion injury (mediated by inflammatory cytokines)
Massive blood loss
• Transfusion-related coagulopathy

Question 24

Advantages of EVAR

Answer 24

• Avoids laparotomy

* Avoids aortic clamping

Question 25

Disadvantages of EVAR

Answer 25

* Wire trauma/access problems * Endoleak * Graft migration * Graft kinking/occlusion

Question 26

What are the distal branches of the abdominal aorta and what do they supply?

Answer 26

Abdo aorta splits into common iliac arteries which split into ext and int. iliac arteries Int. iliac supplies pelvis Ext. iliac continues downward to supply the leg and becomes the femoral artery

Question 27

Which parameters indicate that the fluid challenge has been successful (i.e. the patient responds positively to fluid)

Answer 27

Heart rate decreases Mean arterial pressure increases Arterial pulse pressure increases Urine output increases Lactate clearance increases Cardiac output or stroke volume increase

Question 28

When is it indicated to give blood glucose?

Answer 28

if < 3 mmol l-1 give glucose

Question 29

What is the significance of urine output in the sick patient?

Answer 29

Urine output is one of the few signs of end-organ perfusion In a sick patient catheterisation should be considered to allow measurement (and documentation) of hourly urine volume The weight is essential to get an accurate urine output.

Question 30

What is the difference between cholangitis and cholecyctitis?

Answer 30

Cholangitis: infection of the biliary tree, usually arising form a combination of biliary obstruction and presence of bacteria Cholecystitis: inflammation of the gallbladder, which results from obstruction of the cystic duct by gallstones in 90% of cases Clinical features: Cholangitis: Classic triad of fever (>90%), jaundice (65%) and RUQ pain (>40%), although all three occur in <20% of cases. Cholecystitis: Most have prior history of biliary colic (. Fever, nausea, vomiting often present, RUQ pain/guarding, palpable galbladder in 30% of cases. Jaundice suggests choledocholithasis or Mirizzi's syndrome (see defs below)

Question 31

What is biliary colic?

Answer 31

Biliary colic, also known as a gallbladder attack or gallstone attack, is when pain occurs due to a gallstone temporarily blocking the bile duct. Typically, the pain is in the right upper part of the abdomen, and it can radiate to the shoulder. Pain usually lasts from one to a few hours.

Question 32

Why is the sigmoid colon at highest risk of developing diverticula?

Answer 32

Sigmoid colon has the thinnest diameter therefore according the law of La Place it is subject to increase pressure (pressure is inversely proportional to diameter)

Question 33

Difference between diverticulosis and diverticulitits

Answer 33

Divertituclosis is outpuching of the colon without inflammation whereas diverticulsis in an inflamed diverticulosis - Diverticulosis may involve weaking of the vessel within the outpuching and can lead to painless bleeding however diverticulitis does not lead to bleeding as the vessel wall is scarred

Question 34

Outline a serious potential complication of diverticulosis

Answer 34

Vesicocolonic fistula - rupture of the diverticulosis causes a fistula to be formed in nearby strucutre e.g. the bladder The leads to fecal matter in the urine - nicht gut

Question 35

What are the features of mesenteric adentitis

Answer 35

- Usually preceded by viral or bacterial infection - Diffuse abdo pain > RIF pain - Can be indistinguishable from appendicitits - Children > adults - Precded by URT infection

Question 36

What is Meckels Diverticulaum

Answer 36

Diverticulum of all layers of the intestinal wall - mucosa, submucosa, muscularis and serosa As opposed to false diverticula which is just outpuching of the mucosa and submucosa Congenital remnant of the vetelline 2% population 2 feet from ileocecal valve 2 inches in length 2 x males most likely affect