CSI 5 - Abdominal pain Flashcards
(130 cards)
1
Q
What does the term acute abdomen refer to?
A
The rapid onset of severe symptoms of abdominal pathology
2
Q
What is essential to diagnosis of acute abdomen?
A
- a comprehensive history and thorough physical examination are essential
- laboratory tests and imaging are used to support clinical assessment
3
Q
What are the key components of the history? (3)
A
- detailed evaluation of the pain (SOCRATES)
- type and time of last meal/other oral intake (information required if surgery is indicated)
- past medical and surgical history, medication use, and family history
4
Q
What can the location of the pain identify?
A
The organ involved
5
Q
What are some common locations of visceral pain? (5)
A
- gallbladder (right hypochondriac)
- stomach/pancreas (epigastric)
- renal (flanks)
- small bowel (umbilical)
- colon/uterine (hypogastric)
6
Q
What are some causes of pain that present suddenly and severe in onset? (3)
A
- perforated ulcer
- ruptured aortic aneurysm
- ureteral colic (may be constant)
7
Q
What are some causes of pain that present more colicky, crampy, and intermittent in nature? (4)
A
- biliary colic
- small bowel obstruction
- ureteral colic (kidney stones)
- colonic obstruction
8
Q
What are some types of pain that present gradually or more progressively? (7)
A
- cholecystitis
- hepatitis
- pancreatitis
- diverticulitis
- appendicitis
- tubo-ovarian abscess
- ectopic pregnancy
9
Q
What may epigastric pain relate to? (6)
A
- gastric ulcer/perforation (peptic/perforated ulcer)
- pancreatitis
- perforated oesophagus / oesophagitis
- Mallory-Weiss tear
- cholelithiasis (also considered)
- myocardial infarction (also considered)
10
Q
What may left upper quadrant pain relate to? (4)
A
- splenic infarct/ruptured splenic artery aneurysm
- pyelonephritis
- kidney stones
- perforation/malignancy of the colon
11
Q
What may right upper quadrant pain relate to? (8 + 1)
A
- cholelithiasis
- cholecystitis
- hepatitis
- hepatic abscess
- Fitz-Hugh Curtis syndrome
- perforation/malignancy of the colon
- pyelonephritis
- kidney stones
- (acute appendicitis in pregnant women due to displacement by enlarging uterus)
12
Q
What may left lower quadrant pain relate to? (11)
A
- sigmoid volvulus (typically older)
- diverticulitis
- Crohn’s disease
- ulcerative colitis
- kidney stones
- gastrointestinal malignancy
- psoas abscess
- incarcerated/strangulated hernia
- gynaecological concerns - ovarian torsion/cyst rupture, ectopic pregnancy, PID
- situs inversus (less common)
- midgut malrotation (less common)
13
Q
What may right lower quadrant pain relate to? (6)
A
- appendicitis
- kidney stones
- GI malignancy
- psoas abscess
- incarcerated/strangulated hernia
- gynaecological concerns - ovarian torsion/cyst rupture, ectopic pregnancy, PID
14
Q
What may periumbilical pain relate to? (4)
A
- appendicitis (may radiate to right lower quadrant)
- acute mesenteric ischaemia
- leaking/ruptured abdominal aortic aneurysm
- small bowel obstruction
15
Q
What may persistent lateralised pain relate to? (4)
A
- ascending/descending colon
- kidney
- gallbladder
- ovary
16
Q
What kind of pain may a perforated viscus cause?
A
Generalised pain
17
Q
What do we ask about the onset and time course of the pain? (3)
A
- time of onset?
- sudden or gradual?
- how is it changing over time?
18
Q
What is sudden onset pain typical of? (7)
A
- perforated ulcer
- oesophageal tear/rupture
- nephrolithiasis
- biliary colic
- acute cholecystitis
- pancreatitis
- appendicitis
19
Q
What kind of pain does diverticulitis usually cause?
A
Persistent pain
20
Q
What do previous instances of similar pain suggest?
A
A recurrent condition (e.g. cholecystitis, pancreatitis, diverticulitis), with increasing frequency and severity indicating disease progression
21
Q
What do we ask about the character of the pain?
A
Elicit whether pain is intermittent, sharp, dull, achy or piercing
22
Q
What does sharp, localised pain usually indicate?
A
Parietal peritoneum is irritated
23
Q
What does dull, poorly localised pain felt in the midline usually indicate?
A
Visceral pain
24
Q
What is the pain of kidney/ureteric stones like?
A
Characteristically severe, with the patient unable to find a comfortable position
25
What is the pain from adhesions and incarcerated/strangulated hernias like?
Intermittent and colicky
26
What is the pain of an abdominal aortic dissection like?
Severe, sharp, or tearing in the thorax or abdomen
27
What can the presence and pattern of radiation of pain suggest?
Potential aetiology
28
Where does the pain of renal colic frequently radiate?
From the flanks downwards into the groin (loin-->groin)
29
What can pain with radiation to the back indicate? (3)
- pancreatitis
- abdominal aortic dissection
- ruptured AAA
30
What can right scapula pain indicate? (3)
- gallbladder disease
- liver disease
- irritation of right hemidiaphragm (e.g. right lower lobe pneumonia)
31
What can left scapula pain indicate? (5)
- cardiac disease
- gastric disease
- pancreatic disease
- splenic disease
- irritation of left hemidiaphragm
32
What can scrotal/testicular pain indicate? (2)
- kidney stones
- ureteral disease
33
What can pain associated with cholecystitis and cholelithiasis be exacerbated by?
Exacerbated by eating, especially fatty food
34
What can pain associated with appendicitis be exacerbated by?
Movement
35
What does pain made worse by food suggest?
Gastric ulcer
36
What does pain relieved by eating that worsens after a few hours suggest?
Duodenal ulcer
37
What does prior surgery increase the likelihood of?
Obstruction secondary to adhesions
38
What can cardiovascular disease predispose to?
Aortic aneurysm
39
What can atrial fibrillation predispose to?
Mesenteric ischaemia
40
What order should the physical examination of acute abdomen be performed in?
- (measure vital signs: BP, temperature, pulse rate)
- inspection - general assessment of how ill the patient appears
- auscultation - chest and abdomen
- percussion
- palpation
- other important examinations: rectal, pelvic, scrotal
41
What signs on inspection indicate haemorrhagic pancreatitis? (2)
- Cullen's sign - periumbilical discolouration
- Grey-Turner's sign - bruising of the flanks
42
When is rebound tenderness (or more generally examination evidence of peritoneal irritation) present?
Present not only in appendicitis and diverticulitis but with any condition where there is irritation of the parietal peritoneum
43
What is Murphy's sign?
Right upper quadrant tenderness with arrest of inhalation during palpation - may be present with cholecystitis
44
What is often present in ectopic pregnancy?
Palpable adnexal mass with/without tenderness, and vaginal bleeding on speculum examination
45
What laboratory tests are done for all patients with acute abdomen? (4)
- FBC
- serum electrolytes panel
- urinalysis
- pregnancy test (all women of reproductive age)
46
What laboratory test finding is the hallmark of acute pancreatitis?
Significantly elevated serum lipase and amylase (more than 3x normal)
47
What imaging tests are done for acute abdomen? (7)
- plain abdominal X-ray
- erect chest X-ray (if perforation suspected)
- CT of abdomen
- ultrasound
- MRI
- fluoroscopy
- endoscopy
48
What can epigastric pain indicate? (4)
- oesophagitis
- peptic ulcer
- perforated ulcer
- pancreatitis
49
What can right hypochondriac pain indicate? (6)
- gallstones
- cholangitis
- hepatitis
- liver abscess
- cardiac causes
- lung causes
50
What can left hypochondriac pain indicate? (3)
- spleen abscess
- acute splenomegaly
- spleen rupture
51
What can umbilical pain indicate? (4)
- appendicitis (early)
- mesenteric lymphadenitis
- Meckel diverticulitis
- lymphomas
52
What can left/right lumbar pain indicate? (2)
- ureteric colic
- pyelonephritis
53
What can hypogastric pain indicate? (4)
- testicular torsion
- urinary retention
- cystitis
- placental abruption
54
What can right iliac pain indicate? (6)
- appendicitis
- Crohn's disease
- caecum obstruction
- ovarian cyst
- ectopic pregnancy
- hernias
55
What can left iliac pain indicate? (5)
- diverticulitis
- ulcerative colitis
- constipation
- ovarian cyst
- hernias
56
What is the progression of gallstones like? (4)
(cholelithiasis) --> biliary colic --> acute cholecystitis --> choledocholithiasis --> ascending cholangitis
57
What is biliary colic (from cholelithiasis)?
**Gallstones stuck in cystic duct temporarily** (so when CCK stimulates contraction of gallbladder post-prandially this causes pain) - usually resolves itself, **no inflammation** yet
58
What are the features of biliary colic/cholelithiasis? (4)
- epigastric, RUQ abdominal pain
- steady pain
- often after eating
- radiates to scapula
59
What is acute cholecystitis?
Gallstones stuck in cystic duct causes inflammation of the cystic duct and bile gets trapped in the gallbladder, inflammation +/- infection (phospholipase A secretion, prostaglandin release)
60
What are the features of acute cholecystitis? (5)
- severe epigastric, RUQ abdominal pain
- radiates to scapula
- fever, nausea, vomiting
- positive Murphy sign (inspiratory pause)
- emphysematous cholecystitis (diabetic elderly male) - due to inflammation, bacteria produce gas, collects in GB wall
61
What is Murphy's sign?
- when palpating RUQ upon inhalation, gallbladder is felt
- as gallbladder is inflamed and inhalation means diaphragm pushes both liver and gallbladder down
- seen in acute cholecystitis
62
What is choledocholithiasis?
Gallstone gets trapped in common bile duct (instead of cystic duct)
63
What is ascending cholangitis?
Inflammation and infection of the biliary tree due to obstruction of bile flow - inflammation reaches CBD
64
What are the features of ascending cholangitis? (4)
- Charcot triad
- Reynolds pentad
- hepatomegaly
- icterus (jaundice)
65
What is Charcot's triad?
- abdominal pain (RUQ)
- jaundice
- fever
66
What is Reynold's pentad?
- Charcot's triad (abdominal pain, jaundice, fever)
- confusion
- hypotension
67
What are the factors for gallstone formation? (3)
- cholesterol supersaturation
- gallbladder hypomotility
- nucleation (kinetic factors)
68
How does cholesterol supersaturation contribute to stone formation?
- cholesterol only slightly soluble in aqueous media but soluble in bile through mixed micelles with bile salts and phospholipids, mainly phosphatidylcholine (lecithin)
- supersaturation of cholesterol occurs when cholesterol concentration exceeds concentration at which it remains soluble
- can result in formation of multilamellar vesicles that may then fuse and aggregate as solid cholesterol crystals
- crystals can grow in size to form stones
69
How does gallbladder hypomotility contribute to stone formation?
- supersaturated bile often found in healthy individuals
- assumed that microcrystals formed are effectively flushed from gallbladder during postprandial contractions
- impaired gallbladder motility is commonly seen in several gallstone risk groups - diabetes mellitus, rapid weight loss
70
How does nucleation (kinetic factors) contribute to stone formation?
- formation of microcrystals in supersaturated bile is modulated by kinetic protein factors - promote crystallisation of cholesterol
- in vitro studies using model bile systems have described several nucleation-inhibitory or nucleation-promoting proteins
- mucin (glycoprotein mixture secreted by biliary epithelial cells) has consistently been defined as a nucleation-promoting protein in gallbladder sludge
71
What is the composition of bile? (4)
- water (97-98%)
- bile salts (0.7%)
- fats (0.5%) - cholesterol
- bilirubin (0.2%)
72
What are the three types of gallstones?
- cholesterol stones (80-90%)
- bilirubin stones (pigment stones)
- mixed
73
What are the risk factors for gallstones? (5)
- obesity (increased cholesterol in bile --> C stones))
- haemolytic anaemia (increased bilirubin supersaturation --> BR stones)
- hyperlipidaemia (increased hepatic cholesterol secretion --> C stones)
- Crohn's disease (reduced bile acid absorption in terminal ileum --> supersaturation)
- female sex (oestrogen associated with cholesterol metabolism --> C stones)
74
What are the 5Fs (risk factors for stones?
- female
- fat
- forty
- fertile
- fair
75
Do gallstones show up on X-ray?
99% do not
76
What are some complications of gallstones? (5)
- gallstone pancreatitis (stuck in pancreatic duct = autodigestion, tissue damage, inflammation)
- acute cholecystitis
- gallstone ileus
- biliary fistula
- Mirizzi's syndrome
77
What is Mirizzi's syndrome?
- rare complication of gallstones
- large gallstone gets stuck in cystic duct
- compresses common hepatic duct externally
- results in obstruction and jaundice
- looks like cholangitis but gallstone is in cystic duct
78
How do fistulas form?
- stones cause inflammation, ulceration and damage
- this penetrates the wall
- inflammation comes into contact with underlying tissue
- large hole called fistula appears between two tissues, and stone can leak through
79
What is gallstone ileus?
Large stone passes down intestines (fistula) and becomes stuck in narrow ileocaecal valve --> pain, constipation, nausea and vomiting
80
90% of the time that gallstones occur are they symptomatic or asymptomatic?
Asymptomatic
81
What makes up valid consent? (3)
- informed consent (what, risks+benefits, alternatives)
- capacity (understand, retain, weigh up, communicate)
- voluntary (no coercion)
82
How can complications of a laparoscopic cholecystectomy be divided?
- early complications
- general
- site-specific
- delayed complications
- general
- site-specific
83
What are the general early complications of a laparoscopic cholecystectomy? (3)
- bleeding (excessive bleeding during or after surgery)
- infection (e.g. surgical site infections)
- DVT
84
What are the site-specific early complications of a laparoscopic cholecystectomy? (2)
- organ injury (damage to adjacent organs may occur during procedure)
- adhesion formation (development of scar tissue between abdominal organs can lead to complications)
85
What are the general delayed complications of a laparoscopic cholecystectomy? (2)
- hernia (weakening of the abdominal wall through surgery can lead to hernias, where organs protrude through the incision site)
- wound complications (issues with wound healing e.g. dehiscence or keloid formation)
86
What are the site-specific delayed complications of a laparoscopic cholecystectomy? (2)
- adhesive bowel obstruction (adhesions between organs can lead to bowel obstruction)
- chronic pain (some patients experience persistent abdominal pain due to nerve damage or other factors related to surgery)
87
Where does the gallbladder lie?
Right upper quadrant of the abdomen, affixed to the undersurface of the liver at the gallbladder fossa
88
What does dysfunction in the physiology of the gallbladder most commonly result in?
Gallstones
89
What do many gallbladder pathologies ultimately warrant?
Surgical intervention, and thus cholecystectomy (removal of gallbladder) is one of the most common surgical procedures
90
Describe the drainage of bile produced by hepatocytes?
- bile drained in the opposite direction of blood flow to the periphery of the lobule by small channels known as the Canals of Hering
- they are lined by simple cuboidal epithelium
- ultimately drain into the bile ductule of the portal triad --> drains into the bile duct
91
What are the three layers of the gallbladder wall?
- innermost mucosal layer - columnar epithelium with microvilli
- lamina propria - smooth muscle
- outer serosal layer
92
What is the hepatic diverticulum?
Becomes the liver, extrahepatic biliary system and a portion of the pancreas
93
Where does the common bile duct merge with the main pancreatic duct?
Ampulla of Vater in the pancreas
94
What is the leading cause of pancreatitis?
Gallstone that becomes lodged in the ducts of the pancreas
95
What does stimulation of the small intestine by fatty foods and proteins cause?
Gallbladder to empty bile into duodenum
96
What is the function of the gallbladder?
- store and concentrate bile, which is released into the duodenum during digestion
- bile - alkaline fluid continuously produced by the liver, primary function is to aid in digestion and absorption of lipids as they are not soluble in water
97
How is CCK released?
- specialised enteroendocrine cells called I-cells located in duodenum and jejunum
- I-cells stimulated by fatty acids and amino acids released from stomach --> CCK released
98
What are the two main functions of CCK pertaining to the gallbladder?
- stimulate smooth muscle of gallbladder to contract and release bile into biliary tree
- simultaneously signal the muscular sphincter of Oddi to relax
99
What stimulates release of bile into duodenum? (2)
- meal --> CCK release from I-cells (hormonal)
- meal --> ACh from vagus nerve (neural)
100
What is the flow of bile after leaving the gallbladder?
- flows down CBDs --> ampulla of Vater --> major duodenal papilla
- flow through papilla controlled by opening and closing of sphincter of Oddi
- not stimulated by CCK = gallbladder relaxes and fills with bile
101
What does CCK do outside of the gallbladder?
Stimulates pancreatic secretions necessary for digestion and delays further emptying of stomach
102
What inhibits release of CCK?
Somatostatin (turns off digestion)
103
Bile acids in the liver are conjugated into what two amino acids which are now bile salts?
Glycine and taurine
104
What nature of bile salts allows them to act as emulsifiers?
- amphipathic nature
- hydrophilic portions interact with water = soluble
- negatively charged = repels from other bile salts and keeps lipids small and easy to digest
- hydrophobic portions keep lipids contained in centre
105
What colour is bilirubin?
Yellow
106
What is unconjugated (indirect) bilirubin conjugated with in the liver?
Glucuronate via the enzyme UDP-glucuronosyltransferase
107
What breakdown products of bile give urine and faeces their colour?
- urobilin --> yellow urine
- stercobilin --> brown faeces
108
When bile cannot enter the duodenum, what happens?
Jaundice as there is a buildup of bilirubin which causes yellowing of skin, eyes and mucous membranes as well as alcoholic stools
109
What is the initial choice to diagnose most disorders of gallbladder?
Abdominal ultrasound - non-invasive, effectively evaluate stones, sludge and signs of inflammation (stones, GB distension, GB wall thickening, pericholecystic fluid)
110
Why is a CT done during an emergency department visit and why is it not always used?
Evaluates abdominal pain and is very accurate when diagnosing gallbladder disease but exposes the patient to radiation
111
What is the most sensitive and specific diagnostic test to confirm cholecystitis?
Hepatobiliary iminodiacetic acid (HIDA) scan AKA cholescintigraphy - radionuclide scan where tracer given intravenously and taken up by hepatocytes
112
An ejection fraction of what in the gallbladder is considered abnormal and indicative of functional gallbladder disease?
<35% (EF tested by administering CCK)
113
If there is increased ALT, ALP and AST, what organ is obstructed by the gallstone?
Liver
114
If there is increased lipase and amylase what organ is obstructed by the gallstone?
Pancreas
115
In cholecystitis, what is the effect on gamma-glutaryltransferase?
Increased - found in both hepatocytes and epithelial cells of gallbladder
116
What % of stones do cholesterol stones account for?
80%
117
What kind of stones are pigmented stones divided into?
Brown and black stones (black composed of calcium bilirubinate and more likely to be seen on radiography)
118
What are black and brown stones formed secondary to?
- black stones secondary to haemolysis
- brown stones secondary to infection
119
What is the difference between cholelithiasis, biliary colic and choledocholithiasis?
- cholelithiasis - gallstones in gallbladder
- biliary colic - stone lodged in cystic duct
- choledocholithiasis - gallstone lodged in common bile duct
120
What is biliary colic characterised by?
RUQ pain in response to fatty meals as the lipids stimulate the secretion of CCK which causes painful contractions against the stone
121
What is the difference in clinical findings between cholecystitis and biliary colic?
Acute cholecystitis has prolonged abdominal pain with associated fever and leukocytosis
122
What increases the risk of cancer during cholecystitis?
Resultant scarring and calcification due to chronic cholecystitis
123
What can acalculous cholecystitis (inflammation without stones) result from? (3 + 3)
- infection
- low perfusion
- biliary stasis
- (dehydration)
- (TPN)
- (vasculitis)
124
How do somatostatin analogues e.g. octreotide increase the risk of gallstones forming?
Block release of CCK --> formation of biliary sludge and reduced gut motility
125
How can fibrates lead to increased gallstone formation?
Block the rate-limiting enzyme 7-alpha-hydroxylase --> increased cholesterol and decreased bile production
126
How can hormone replacement therapies containing oestrogen contribute to gallstone formation?
Oestrogen increases level of cholesterol --> cholesterol supersaturation
127
What effect does bile acids sequestrants have on cholesterol levels in the body?
They prevent reabsorption of bile acids in the ileum and lead to lower cholesterol levels as the body is forced to use it as a substrate to produce new bile acids
128
Once gallstones form, is the risk of developing symptomatic gallstone disease higher or lower in those with efficient gallbladder emptying?
Higher - more likely to be lodged in cystic duct or common bile duct and cause symptoms due to impeded flow etc
129
How do we differentiate between biliary colic, acute cholecystitis and ascending cholangitis?
- biliary colic: RUQ pain, no fever, no jaundice
- acute cholecystitis: RUQ pain, fever, no jaundice
- ascending cholangitis: RUQ pain, fever, jaundice (Charcot's triad)
130
How do you treat acute cholecystitis? (4)
- analgesia and fluids
- consider Abx
- early/delayed cholecystectomy (mainly laparoscopic)
- percutaneous cholecystostomy (if deemed unfit for surgery)
