Gastroenterology (The Acute Abdomen) Flashcards
(48 cards)
1
Q
history for acute abdomen
A
1) Presenting complaint
Pain: SOCRATES
Associated symptoms:
- N+V
- haematemesis
Have they been able to eat and drink?
- When was the last time?
Systemic symptoms
- fever
- weight loss
- rash or itching
- changes to bowel habbits
- rectal bleeding
- passing urine
- feartures of anaemia
**2. PMH **
- IBD
- AF- mesenteric ischaemia
- CVD- AAA
- Any trauma
- Any previous surgery
3. Medication history
- Peptic ulcer- NSAIDs, aspirin, bisphosphonates, corticosteroids, SSRIs
- Pancreatic: corticosteroids, azathioprine, thiazides, sulfonamides, furosemid, oestrogens and tetracyclines
** 3. Family history**
- Is anyone else in the family experiencing similar symptoms?
- Is there a family history of anything similar?
4. Social
- Do they smoke and/or drink?
- If so, how much and how long?
- Excessive alcohol consumption can predispose to pancreatitis
- Have they travelled anywhere recently?
- May predispose patients to infections such as gastroenteritis
2
Q
In women of childbearing age…
A
a gynaecological and obstetric history is essential
Any woman of childbearing age should be considered pregnant until proven otherwise:
The ‘four Ps’ can help:
- PV bleeding?
- Any unusual PV bleeding (e.g. intermenstrual, postcoital etc.)
- PV discharge?
- Any unusual PV discharge?
- Pelvic pain?
- Use SOCRATES
- Pregnancy?
- Are they pregnant?
- When was their last menstrual period?
- Any previous gynaecological surgery?
- Any previous ectopic pregnancies?
- Do they use any hormonal contraceptives?
3
Q
epigastric pain
A
- Oesophageal perforation (e.g. Boerhaave’s syndrome)
- Mallory-Weiss tears
- Pancreatitis
- Peptic ulcer disease and perforation
- Gallstones
- Myocardial infarction
4
Q
LUQ pain
A
- Splenic problems (e.g. splenic rupture)
- Pyelonephritis
- Left-sided pneumonia
5
Q
Right upper quadrant (RUQ) pain:
A
- Biliary colic
- Acute cholecystitis
- Ascending cholangitis
- Acute pancreatitis
- Hepatitis
- Right-sided pneumonia
6
Q
Left lower quadrant (LLQ) pain:
A
- Acute diverticulitis
- Sigmoid volvulus
- Ulcerative colitis
7
Q
Right lower quadrant (RLQ) pain:
A
- Appendicitis
- Crohn’s disease
8
Q
Periumbilical pain:
A
- Appendicitis
- Acute mesenteric ischaemia
- Ruptured abdominal aortic aneurysm
9
Q
Unilateral pain (may be restricted to upper or lower quadrants):
A
- Renal stones
- Pyelonephritis
- Ectopic pregnancy
- Ovarian torsion
- Ovarian cyst rupture
- Incarcerated or strangulated hernias
- Psoas abscess
10
Q
Central abdominal pain radiating to the right lower quadrant suggests:
A
Appendicitis
11
Q
Central abdominal pain radiating to the back – suggests:
A
- Pancreatitis
- Ruptured abdominal aortic aneurysm
- Aortic dissection
12
Q
RUQ pain may radiate to the back/right shoulder – suggests:
A
- Biliary colic
- Cholecystitis
- Hepatitis
- Right lower lobe pneumonia irritating the right hemidiaphragm
13
Q
LUQ pain may radiate to the back/left shoulder – suggests:
A
- Myocardial infarction
- Acute pancreatitis
- Splenic disease
- Left lower lobe pneumonia irritating the left hemidiaphragm
14
Q
Loin-to-groin pain – suggests
A
renal colic and renal stones
15
Q
Exacerbating and relieving factors may give some clues:
A
- Gastric ulcers – pain classically worsened when eating
- Duodenal ulcers – pain classically relieved with eating
- Biliary colic – classically worse after eating a fatty meal
16
Q
investigations for the acute abdomen
A
- FBC
- UE
- Urinalysis
- LFT
- CRP
- Pregnancy test
- Serum amylase
- Serum lactate- acute mesenteric ischaemia
- Abdomial x-ray
- Erect chest x-ray - may show free air under the diaphragm
- Abdominal US, CT, endoscopy
- Laparoscopy
17
Q
Oesophageal perforation
A
- There may be a history of vomiting/retching followed by chest/epigastric pain
- Subcutaneous neck emphysema may be present
- A chest x-ray may show a widened mediastinum or free mediastinal air
18
Q
Mallory-Weiss tears
A
- There may be a history of repeated vomiting/retching/coughing
- Patients may have epigastric pain
- Small streaks of bright red blood may be coughed up
- Signs of anaemia may be present – postural hypotension, pallor, syncope, tachycardia
19
Q
Perforated peptic ulcer
A
- Presents as acute-onset severe epigastric pain
- There may be a history of drugs such as NSAIDs, corticosteroids, aspirin, or selective serotonin reuptake inhibitors (SSRIs)
- Features of upper GI bleeding such as haematemesis and melaena may be present
- There may be a history of peptic ulcer disease:
- Gastric ulcers – epigastric pain worse when eating
- Duodenal ulcers – epigastric pain that improves when eating
- Tachycardia and fever may be present
- Abdominal rigidity, guarding, or rebound tenderness may be present
- A chest x-ray may show free air under the diaphragm
20
Q
Appendicitis
A
- Acute-onset constant, severe, central abdominal pain that classically moves to the RLQ
- Anorexia is commonly seen
- More common in children and young adults
- Fever and tachycardia may be present
- Rovsing’s sign may be present – palpating the LLQ elicits pain in the RLQ
- FBC may show leukocytosis
21
Q
Acute diverticulitis
A
- Acute-onset colicky LLQ pain
- Generally seen in older patients (>50 years)
- Diarrhoea is often seen, which may be bloody
- There may be a long history of constipation
- Fever may be present
- LLQ tenderness may be present
- FBC may show leukocytosis
22
Q
Crohn’s disease
A
- Patients are generally <50 years old
- A history of chronic diarrhoea may be present
- There may be associated fatigue, weight loss, and fever
- An ileocaecal (right lower quadrant) mass may be present on exam
- Oral ulcers and perianal disease (e.g. skin tags, fistulae, abscesses etc.) may be present
- Anaemia may be seen
- ESR/CRP may be elevated
- Faecal calprotectin may be positive
23
Q
Ulcerative colitis
A
- Patients are generally <50 years old
- A history of chronic diarrhoea may be present – more commonly bloody than in Crohn’s disease
- Faecal urgency and tenesmus may be present
- Extra-intestinal features (e.g. joint pain) may be present
- Anaemia may be seen
- ESR/CRP may be elevated
- Faecal calprotectin may be positive
24
Q
Intestinal obstruction
A
- Patients may have a history of previous abdominal surgery, which may predispose them to adhesions causing an obstruction. There may be a history of malignancy, which can cause obstruction
- Patients generally have severe nausea and vomiting, which may be bilious in small bowel obstruction
- Constipation and an inability to pass flatus may be present
- Abdominal sounds may be faint or absent, tinkling may be seen
- Diffuse abdominal tenderness may be seen
- An abdominal x-ray may show dilated bowel loops or air-fluid levels
25
Biliary colic
* Causes colicky RUQ epigastric pain that is classically provoked when eating fatty meals
* Patients are generally stable and do not have abnormal blood tests, although some derangements may be seen
* Abdominal ultrasound may show gallstones
26
Acute cholecystitis
* Causes RUQ pain that may radiate to the right shoulder
* Patients may have a history of biliary colic
* Murphy’s sign may be positive – RUQ tenderness causing the arrest of inspiration during palpation
* Fever may be present
* FBC may show leukocytosis
* LFTs may show derangements
* CRP may be elevated
27
Acute cholangitis
* Causes RUQ pain
* Charcot’s triad may be present – fever, pain, and jaundice
* Hypotension and confusion may be present – in combination with Charcot’s triad, this is known as Reynolds’ pentad
* FBC may show leukocytosis
* LFTs may show derangements
* CRP may be elevated
28
Acute pancreatitis
* Causes acute-onset severe epigastric or mid-abdominal pain that classically radiates to the back
* Relieved by leaning forward
* There may be a history of specific causes such as biliary colic, alcohol misuse, or certain drugs
* Pain may be severe on palpation
* Flank bruising may be seen (Grey-Turner’s sign) or periumbilical bruising (Cullen’s sign)
* FBC may show leukocytosis
* Serum lipase/amylase is 3 times the upper limit of normal
29
Acute viral hepatitis
* RUQ pain is present
* Hepatosplenomegaly may be seen
* Jaundice and ascites may be seen
* Risk factors for its development may be present (e.g. unprotected sexual intercourse)
* Liver function tests are deranged
* Hepatitis serology and antigens are generally positive
30
Budd-Chiari syndrome
* Generally seen in female patients in their 30-40s with risk factors for a hypercoagulable state, such as contraceptive use, postpartum, myeloproliferative disorders etc.
* May present with a classic triad of ascites, abdominal pain, and hepatomegaly
* FBC may be abnormal if a myeloproliferative disorder is present
31
Renal colic
* Acute-onset severe loin pain that radiates to the groin
* Patients may be agitated or restless due to the pain
* Costovertebral angle tenderness may be seen
* A urine dipstick may be positive for blood, leukocytes, and/or nitrites
* U&Es may be deranged
32
Acute pyelonephritis
* Presents with severe loin pain that may radiate to the grain
* There is generally fever, nausea, and vomiting
* Dysuria may be present
* Costovertebral angle tenderness may be seen
* A urine dipstick is generally positive for nitrates, along with blood or leukocytes
* Urinalysis, Gram staining, and cultures may identify the underlying pathogen
33
Hydronephrosis
* May present similarly to renal stones with colicky loin-to-groin pain
* Patients may be hypotensive and tachycardic
* There may be a history of urinary retention and its causes
* Costovertebral angle tenderness may be seen
* U&Es may show derangements
34
Urinary retention
* Generally presents with suprapubic tenderness
* There may be features of an underlying cause (e.g. some drugs, such as tricyclic antidepressants, benign prostatic hyperplasia etc.)
35
Testicular torsion
* Presents with sudden-onset testicular pain that may have associated nausea or vomiting
* Typically seen in adolescents and young adult males
* The affected testis may be retracted upwards and erythematous
* Elevation of the testis does not ease the pain (negative Prehn’s sign)
* The cremasteric reflex may be absent
36
Ectopic pregnancy
* Severe sudden-onset unilateral pain in the LLQ or RLQ with associated vaginal bleeding
* There is usually a 6-8-week period of amenorrhoea
* An adnexal mass may be felt during a pelvic examination
* Rebound tenderness may be seen if a ruptured ectopic pregnancy is seen
* Shoulder tip pain may be seen when passing urine or opening the bowels due to peritoneal bleeding
* Pregnancy tests are essential to rule out ectopic pregnancy
37
Ovarian torsion
* Severe sudden-onset unilateral pain in the LLQ or RLQ
* There may be a history of trauma or exercise
* Nausea and vomiting may be seen
* Unilateral severe adnexal tenderness may be seen during a pelvic examination
* In severe cases, there may be abdominal rigidity, guarding, or rebound tenderness
* A pregnancy test is negative
38
Ovarian cyst rupture
* May present similarly to ovarian torsion with sudden-onset severe unilateral pain in the LLQ or RLQ
* There may be a history of trauma or exercise
* Light vaginal bleeding may be seen
39
Pelvic inflammatory disease
May be seen in patients who have or have risk factors of sexually-transmitted infection (e.g. Chlamydia or gonorrhoea)
May also occur following the insertion of an intrauterine device
Menstrual irregularities, abnormal vaginal discharge, and fever may be seen
Cervical excitation or adnexal tenderness may be present on examination
40
Ruptured abdominal aortic aneurysm
* Severe central abdominal pain that may radiate to the back
* Patients may be haemodynamically unstable and be hypotensive/tachycardic and may have reduced consciousness
* There may be a history of cardiovascular disease
* An expansile and pulsative mass may be felt on abdominal palpation, however, this may be limited due to severe pain
41
Mesenteric ischaemia
* Presents with acute-onset central abdominal pain
* Patients classically have atrial fibrillation or other cardiovascular diseases
* There may be a history of post-prandial abdominal pain (intestinal angina)
* Pain is generally out of proportion to examination findings
* Hypotension and tachycardia may be present
* An abdominal x-ray may show free air, dilated bowel loops, or bowel wall thickening
* A chest x-ray may show free air under the diaphragm
* Serum lactate may be elevated, and an arterial blood gas may show metabolic acidosis
42
Infective gastroenteritis
* There may be a history of travelling and carrying out activities that may predispose them to infection (e.g. eating street food or staying in places with unsanitary conditions)
* Other family members may be affected
* Patients may be dehydrated
* FBC may show leukocytosis
* Increased urea in proportion to creatinine suggests dehydration
* Stool cultures may identify the underlying pathogen
43
Strangulated hernia
* There may be a history of an intermittently painful abdominal lump
* Pain, fever, increased size, or localised tenderness may be seen
* Features of bowel obstruction or features of bowel ischaemia (e.g. bloody diarrhoea) may be seen
44
Psoas abscess
* Presents with flank pain and patients may limp
* Fever, nausea, and vomiting may be seen
* There may be risk factors present, such as Crohn’s disease, diverticulitis, endocarditis, or intravenous drug use
* Pain with active hip flexion and passive extension may be seen
* FBC may show leukocytosis
* CRP may be elevated
45
Spontaneous bacterial peritonitis
* Presents with acute-onset abdominal pain and fever in patients with a history of ascites
* Nausea and vomiting may be seen
* Paracentesis analysis may show increased neutrophil counts and may identify the underlying causative organism
46
Diabetic ketoacidosis
* Features are generally acute and patients may have abdominal pain
* There may be associated nausea and vomiting, and reduced consciousness
* There may be a history of polyuria and polydipsia
* A triggering stressor may precede the event, such as pneumonia and urinary tract infections
* Kussmaul’s breathing may be seen (deep and gasping hyperventilation)
* Signs of hypovolaemia may be seen such as tachycardia, hypotension, delayed capillary refill time
* The patient’s breath may smell like acetone
* Serum glucose is elevated
* U&Es may show low sodium and high potassium
* Urinalysis is positive for glucose and ketones and may be positive for nitrites if an infection is present
* Arterial blood gases show metabolic acidosis
47
Addisonian crisis
* There may be general abdominal pain, nausea, vomiting, and weight loss
* Postural hypotension, dizziness, and syncope may be present
* Skin hyperpigmentation may be seen
* Fevers may be present
* Hyponatraemia and hyperkalaemia may be seen
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