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*Medicine: Gastrointestinal > Assessment of Abdominal Pain and Management of AAA > Flashcards

Assessment of Abdominal Pain and Management of AAA Flashcards

1
Q

What is the community prevalence of abdominal pain?

A
  • 15-20%
  • incidence increases in elderly
  • 25% consult their GP
  • 6-10% of A/E visits
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2
Q

What is important to remember when someone presents with abdominal pain?

A
  • Important to rule out serious pathology
  • Have a high index of suspicion regardless of who the person is
  • History, examination, targeted investigations
  • SOCRATES
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3
Q

What is important in the past medical history for adbdo pain?

A
  • similar episodes in the past?
  • other medical problems that inc/dec likelihood of problems (eg. diabetes mellitus and gastroporesis)?
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4
Q

What is important in past surgical history for abdominal pain?

A
  • previous surgery
  • adhesions
  • hernias
  • tumours
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5
Q

What is important in the drug history for abdominal pain?

A
  • Anitbiotics
  • NSAIDs - cause peptic ulcer disease so ask specifically about them
  • Acid blockers
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6
Q

What is important within the systemic review for abdominal pain?

A
  • Last menstrual period (for women)
  • Bleeding
  • Discharge
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7
Q

What is important to ask within the social hisotry for abdominal pain?

A
  • tobacco (every kind of vascular disease - aneurysms)
  • alcohol (pertinent for liver disease, tumours)
  • rec drugs
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8
Q

What is useful when looking at the general appearance of a patient complaining about abdominal pain?

A
  • Do they “look sick”?
  • mobile vs still - if moving around then most likely less worrisome
  • obvious pain or discomfort
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9
Q

What vital signs are looked at for abdominal pain?

A
  • Pulse
  • BP
  • Oxygen sats
  • Resp rate - a very useful and sensitive sign of a sick patient, raised resp rate is a cause for concern regardless of what they’re complaining of
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10
Q

What constitutes inspection during an abdominal examination?

A
  • distension
  • scars
  • bruises

indicate prev pathology, adhesions etc.

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11
Q

What is Cullen’s sign?

A

Bruising around the flanks or around the umbilicus, not due to trauma but can be due to blood collecting in those areas - sign of necrotizing pancreatitis or ruptured aneurysms - anything causing belly to fill with blood.

Unusual but not to be missed!

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12
Q

Describe palpation during the abdominal exam

A
  • often the most helpful part of exam
  • start away from most painful area first
  • looking at patient’s eyes to see their response
  • lighter and then deeper feel
  • tenderness vs pain
  • soft abdo = reassuring
  • rigid, hard abdo = concerning -> peritonitis -> guarding (can’t be faked)
  • looking for masses, lumps, pulsatile/mobile
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13
Q

What do bowel sounds normally sound like?

A

Rumbling tummy

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14
Q

What does absence of bowel sounds suggest?

A
  • Pathological
  • Probably an obstruction - no peristalsis going on
  • May develop tingling bowel sounds, may not
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15
Q

What additional exams should you do after an abdominal exam?

A
  • Pelvic
  • Rectal
  • Scrotal
  • Vaginal
  • Lungs
  • Heart
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16
Q

What causes generalised abdominal pain?

A
  • Peritonitis - going into CT scanner -> op theatre
  • Perforation -> pre-ceded by localised pain, can start off at site of perforation but then bc of release of gut contents, rapidly leads onto peritonitis -> generalised abdo pain
  • AAA
  • Acute pancreatitis
  • Diabetes Mellitus - gastroporesis
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17
Q

What causes central abdominal pain?

A
  • Early appendicitis
  • Small bowel obstruction
  • Acute gastritis
  • Acute pancreatitis
  • Ruptured AAA
  • Mesenteric thrombosis
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18
Q

What causes epigastric pain?

A
  • Duodenal ulcers / Gastric ulcers
  • Oesopgagitis
  • Acute pancreatitis
  • AAA
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19
Q

What causes right upper quadrant pain?

A
  • Gallbladder disease
  • Duodenal ulcers
  • Acute pancreatitis
  • Pneumonia
  • Subphrenic abscess
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20
Q

What causes left upper quadrant pain?

A
  • Gastric ulcers
  • Pneumonia (transmits inflammation across diaphraghm)
  • Acute pancreatitis
  • Spontaneous splenic rupture
  • Subphrenic abscess
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21
Q

What causes suprapubic pain?

A
  • Acute urinary retention
  • UTIs
  • Cystitis
  • Pelvic inflammatory disease (v common in younger women, chlamydia)
  • Ectopic pregnancy
  • Diverticulitis
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22
Q

What causes right iliac fossa pain?

A
  • Acute appendicitis
  • Mesenteric adenitis (common in young)
  • Perforated duodenal ulcer (pour bile out into lower abdo)
  • Diverticulitis
  • PID
  • Salpingitis
  • Ureteric colic
  • Meckel’s diverticulum
  • Ectopic pregnancy
  • Crohn’s disease
  • Biliary colic (low-lying gall bladder)
23
Q

What is a diverticulum?

A
  • abnormal sack/pouch formed in alimentary wall
  • colon has 2 layers (longitudinal, circular layers)
  • food/bolus can force inner muscular lining out through muscle
  • presence of diverticuli = diverticulosis = no consequence
  • if they start to cause symptoms (pain) -> diverticular disease
  • if these pouches become infected/inflammed -> diverticulitis
  • can cause pain and abscesses, occurs in old
24
Q

What causes loin pain?

A
  • Muscle strain
  • UTIs
  • Renal stones
  • Pyelonephritis
  • AAA

Beware of elderly man described with “renal colic” - check he doesn’t have ruptured AAA!

25
Q

What causes left illiac fossa pain?

A
  • Diverticulitis
  • Constipation
  • IBS
  • PID
  • Rectal Cancer
  • Ulcerative collitis
  • Ectopic pregnancy
26
Q

What are the most common causes of abdo pain for patients under 50?

A
  • Nonspecific abdo pain (40%)
  • Appendicitis (32%)
  • Cholecystitis (6%)
27
Q

What are the most common causes of abdo pain for patients over 50?

A
  • Cholecystitis (21%)
  • Nonspecific abdominal pain (16%)
  • Appendicitis (15%)
  • Bowel obstruction (12%)

Pancreatitis, diverticular disease, cancer, hernia and vascular problems are also much common in those over 50 than under 50!

28
Q

Name at least 3 extra-abdominal causes of abdominal pain

A
29
Q

What is ruptured AAA often misdiagnosed as?

A
  • Renal colic
  • Diverticulitis
  • Lumbar strain
30
Q

What are the boundaries of:

  • foregut
  • midgut
  • hindgut
A
  • foregut: becomes the oesophagus to first 2 sections of the duodenum and also gives rise to liver, gallbladder, pancreas, spleen and superior portion of pancreas. Supplied by celiac trunk, pain referred to epigastric region.
  • midgut: becomes lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, and first two-thirds of the transverse colon. Supplied by brances of superior mesenteric artery. Pain referred to umbilical region.
  • hindgut: gives rise to the last third of the transverse colon, descending colon, rectum, and upper part of the anal canal. Supplied by branches of inferior mesenteric artery. Pain is referred to suprapubic region.
31
Q

What investigations can be done for abdominal pain?

A
  • preg test in women of child bearing age
  • urine dipsticks
  • FBC, CRP, RFTs
  • ABG!!
  • Plain film x ray (if worried about perforation or obstruction)
  • Ultrasound - useful for polytrauma (fluid in belly) or ruptured AAA
  • CT - risk of radiation, use sparingly, useful for those who may need surgery
32
Q

When coming to manage abdominal pain, what do you start with?

A

ABCs…

  • A/B - supplemental oxygen
  • C - IV access, fluid admin, urinary cath
  • D - antiemetics, analgesics, antibiotics, radiology..
  • re-evaluation with results (blood tests, abg, ecg)

Move on step by step from each letter

33
Q

An 18 month old suddenly becomes inconsolable from abdominal pain while playing - what would you be worried about?

A
  • testicular torsion
  • intussusception
  • (trauma)
34
Q

A 20 year old man with 12 hours of diffuse crampy abdo pain that migrated to RLQ associated with vomiting - what could it be?

A

Appendicitis

35
Q

A 78 year old woman with a history of chronic steroid use with sudden sharp abdominal pain and percussion tenderness - what could it be?

A

Peptic ulcer disease - perforated, usually duodenal ulcer

36
Q

12 year old boy, 6 day history of vomiting and LIF pain. Isolated LIF percussion tenderness, BP 120/80, HR 100. Investigations?

A
  • White cell count - 20
  • CRP - 200
  • Nitrites in urine -> suggests UTI
37
Q

What is an arterial aneurysm?

A

An arterial aneurysm is defined by an increased vessel diameter of 50% or more than that of the non-dilated adjacent vessel

38
Q

Who are aneurysms common in? How common are they in the UK?

A
  • Inc incidence with age
  • 8% of men over 65 years
  • M:F = 6:1
  • 7th most common cause of male death in UK
39
Q

What are the biggest risk factors for AAAs?

A
  • Age (x7.73 75+)
  • Sex (male)
  • Smoking (> x7 for smokers vs non-smokers)
  • Fam history (x8 inc risk if affected sibling)
  • Ethnicity (caucasian)
  • Hypertension (x1.5)
  • High cholesterol
  • Genetic disorders
  • Connective tissue disorders (Marfan’s disease)
  • Infective (inflammatory causes)
40
Q

Does diabetes have an increased risk association with developing aneurysm?

A

No (0.65 risk)

41
Q

What is the 4 stage pathogenesis of AAAs?

A
  1. Trigger (genes, local haemo stress)
  2. Cellular migration (macrophages, neutrophils, T/B cells)
  3. Inflammatory infiltrate (inc chemokines, free radicals, MMPs)
  4. Collagen degradation (weakening media, dilation)
42
Q

Describe the progressive enlargement of an aneurysm

A
  • the bigger it gets, the more easily inflated it gets - like a balloon
  • on avg 0.2cm/year
  • larger it gets, greater risk of rupture
43
Q

What are the thresholds for elective intervention for AAA?

A
  • Men >65 years
  • AAA > 5.5cm (males)
  • AAA > 5.2cm (females)
  • New onset pain
  • Growth > 1cm/year
44
Q

What are symptoms of a AAA?

A
  • commonly none (75%)
  • otherwise abdominal pain, back pain, loin pain
  • rarely embolic symptoms
45
Q

What are signs of a AAA?

A
  • pulsatile, expansile abdominal mass
  • 25% have associated femoral or popliteal aneurysms
  • sensitivity much higher when >5cm
46
Q

What are the stats for a ruptured AAA?

A
  • catastrophic event
  • 75% die before reaching hospital
  • retroperitoneal rupture more likely to die
  • 40% in-hosp mortality for those reaching theatre
47
Q

What is the immediate management of a ruptured AAA?

A
  • ABC!!
  • supplemental oxygen
  • large bore IV access, urinary catheter
  • crossmatch blood (6-10 units + blood products)
  • you want a BP enough to perfuse their brain (not too high, otherwise will blow the hole) - permissive hypotension
  • imaging - CT
  • communicate with other specialties - anaesthetics, ICU
48
Q

Open imaging vs EVAR (Endovascular aneurysm repair): What determines whether EVAR is feasible?

A

Imaging

49
Q

When is it preferential to do open surgery over EVAR?

A

If the AAA is supra-renal

50
Q

What physiological impacts/insults does an open repair have?

A
  • clamping aorta
  • end-organ ischaemia (cutting off oxygen to rest of body)
  • increased SVR (inc pre-load + after-load)
  • reperfusion injury (mediated by inflammatory cytokines)
  • massive blood loss
  • can cause transfusion-related coagulopathy
51
Q

What are perioperative complications of open repair?

A
  • cardiovascular (MI)
  • respiratory (lower resp tract infections, acute resp distress syndrome)
  • CNS (stroke)
  • GI (abdominal compartment syndrome, ischaemic gut)
  • renal (AKI)
  • bleeding, distal limb ischaemia
  • wound infection
52
Q

What are late complications of open repair?

A
  • graft infection/anastomotic pseudoaneurysm
  • aorto-enteric fistula, small bowel obstruction
  • incisional hernia
53
Q

What does EVAR avoid?

A
  • avoids laparotomy
  • avoids aortic clamping
54
Q

What are complications of EVAR?

A
  • wire trauma/access problems
  • endoleak
  • graft migration
  • graft kinking/occlusion

*Medicine: Gastrointestinal (29 decks)

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