Murtagh - Abdominal pain cont. in the elderly

Question 1

abdominal aortic aneurysm

Answer 1

may be asymptomatic until it ruptures
or may present with abdominal discomfort and pulsatile mass noted by the patient

Question 2

screening for abdominal aortic aneurysm

Answer 2

tends to be a family history
ultrasound screening is appropriate in all families in first degree relates over 50 years

Question 3

risk of rupture in abdominal aortic aneurysm is related to

Answer 3

diameter of the AAA and the rate of increase in diameter

Question 4

normal diameter of the aorta

Answer 4

10-30mm
aneurysm is anything greater than 30mm
refer if it is above 40mm
operate if above 50mm

Question 5

best investigations for AAA

Answer 5

ultrasound is good for screening, obesity can be a problem
CT scan provides clearer imaging, helical/spiral scan is the investigation of choice
MRI scan provides best definition

Question 6

typical pain distribution of ruptured abdominal aortic aneurysm

Answer 6

Question 7

mesenteric artery occlusion

Answer 7

acute intestinal ischaemia arises from superior mesenteric artery occlusion from either an embolus or a thrombosis in an atherosclerotic artery
another cause is an embolus from atrial fibrillation
necrosis of the intestine soon follows if intervention is delayed

Question 8

what happens if mesenteric artery occlusion is missed?

Answer 8

necrosis of the intestine

Question 9

clinical features of mesenteric artery occlusion

Answer 9

abdominal pain - gradually becomes intense
patients develop a fear of eating
profuse vomiting
watery diarrhoea - blood in one third of patients
patient becomes confused

Question 10

what is the likely diagnosis of a patient with anxiety and prostration + intense central pain + profuse vomiting +/- bloody diarrhoea

Answer 10

mesenteric arterial occlusion

Question 11

signs of mesenteric artery occlusion

Answer 11

localised tenderness, rigidity and rebound over infarcted bowel (later finding)
absent bowel sounds (later finding)
shock (develops later)
tachycardia (may be arterial fibrillation and other signs of atheroma)

Question 12

what investigations should you do for mesenteric artery occlusion

Answer 12

CRP may be elevated intestinal alkaline phosphatase
X-ray (plain) shows ‘thumb printing’ due to mucosal oedema on gas-filled bowel
CT scanning gives the best definition which mesenteric arteriography is performed is embolus is suspected
commonly only diagnosed at laparotomy

Question 13

pain distribution of mesenteric artery occlusion

Answer 13

central

Question 14

management of mesenteric artery occlusion

Answer 14

early surgery may prevent gut necrosis but massive resection of necroses gut may be required as a life saving procedure
early diagnosis is essential

Question 15

mesenteric venous thrombosis

Answer 15

can occur but usually in patients with circulatory failure

Question 16

inferior mesenteric artery occlusion

Answer 16

less severe are survival is more likely than superior

Question 17

acute retention of urine

Answer 17

acute retention of urine of 600+mL usually causes severe abdominal pain
may not be apparent in the senile or demented patient

Question 18

possible causes of acute retention of urine

Answer 18

enlarged prostate or prostatitis
bladder neck obstruction by feacal loading or other pelvic masses
anticholinergic drugs
neurogenic causes such as multiple sclerosis, spinal injury and diabetes

Question 19

management of acute retention of urine

Answer 19

perform a rectal examination and empty the rectum of any impacted feacal material
catheterise with a size 14 Foley catheter to relieve obstruction and drain (give antibiotic cover)
have catheter in situ and seek urology consult
send specimen for MCU

Question 20

if the acute urine retention is drug induced

Answer 20

withdraw drug
leave catheter for 48 hours
remove and give trial of prazosin 0.5mg bd or terazosin

Question 21

patient comfort/care with acute retention of urine

Answer 21

may be worth giving analgesics
may be helpful to ambulate patient and attempt voiding by standing up to the sound of running water
a hot bath may also provide a simple solution

Question 22

what should you check for for a patient with acute retention of urine

Answer 22

check for prostate cancer or renal impairment
perform neurological examination of lower limbs and perianal area

Question 23

feacal impaction is typically encountered in

Answer 23

aged, bedridden, debilitated patient

Question 24

acute appendicitis in the elderly

Answer 24

usually a condition of young adults
symptoms can vary due to different positions of the appendix

Question 25

typical pain distribution of acute appendicitis

Answer 25

Question 26

clinical features of acute appendicitis

Answer 26

maximum incidence 20-30 years initial pain is central abdominal (sometimes colicky) increasing severity then continuous shifts and localises to RIF within 6 hours may be aggravated by walking (causing a limp) or coughing sudden anorexia nausea and vomiting a few hours after the pain starts +/- diarrhoea or constipation

Question 27

signs of acute appendicitis

Answer 27

patient looks unwell flushed at first, then pale furred tongue and halitosis may be febrile tenderness in RIF, usually at McBurney point local rigidity and rebound tenderness guarding +/- superficial hyperaesthesia +/- psoas sign +/- obturator sign rovsing sign

Question 28

psoas sign

Answer 28

pain on resisted flexion of right leg, on hip extension or on elevating right leg due to irritation of psoas especially with retrocaecal appendix

Question 29

obturator sign

Answer 29

pain on flexing patients right thigh at the hip with the knee bent and then internally rotating the hip )due to irritation of internal obturator muscle)

Question 30

rovsing sign

Answer 30

rebound tenderness in RIF while palpating in LIF

Question 31

acute appendicitis on PR examination

Answer 31

anterior tenderness to high, especially if pelvic appendix or pelvic peritonitis

Question 32

acute appendicitis in a retrocaecal appendix

Answer 32

pain and rigidity less and may be no rebound tenderness loin tenderness possitive psoas test

Question 33

acute appendicitis in pelvic appendix

Answer 33

no abdominal rigidity urinary frequency diarrhoea and tenesmus very tender PR obturator tests usually positive

Question 34

how does acute appendicitis present differently in the elderly

Answer 34

pain often minimal and eventually manifests as peritonitis can stimulate intestinal obstruction

Question 35

investigations for acute appendicitis

Answer 35

blood cell count shows leucocytosis with a left shift urea and electrolytes to assess hydration prior to surgery CRP - elevated plain x-ray ultrasound CT scan laparoscopy b-HCG

Question 36

what might plain x-ray show for acute appendicitis

Answer 36

may show local distension, blurred psoas shadow and fluid level in caecum

Question 37

what might ultrasound show for acute appendicitis

Answer 37

thickened appendix affected by gas shadow

Question 38

what might CT scan show for acute appendicitis

Answer 38

accurate and allows you to see other causes, especially in the female pelvis

Question 39

for small bowel obstruction, symptoms will depend on

Answer 39

the level of the obstruction the more proximal, the more severe the pain

Question 40

differences between high and low small bowel obstruction

Answer 40

Question 41

main causes of small bowel obstruction

Answer 41

outside obstructions (eg. adhesions is the commonest cause, previous laparotomy), strangulation in hernia or pockets of abdominal cavity - this may lead to 'closed loop' obstruction lumen obstructions (e.g. foreign body, trichobezoar, gallstones, intussusception, malignancy)

Question 42

clinical features of small bowel obstruction

Answer 42

spasms last about 1 minute spasms every 3-10 minutes (according to level) vomiting absolute constipation no flatus abdominal distension

Question 43

typical pain distribution of small bowel obstruction

Answer 43

Question 44

a patient with colicky central pain, vomiting and distension is likely to have

Answer 44

small bowel obstruction

Question 45

signs of small bowel obstruction

Answer 45

patient weak and sitting forward in distress visible peristalsis, loud borborygmi abdomen soft (except with strangulation) tender when distended increased sharp, tinkling bowel sounds dehydration rapidly follows, especially in children and the elderly

Question 46

rectal exam for the patient with small bowel obstruction

Answer 46

empty rectum may be tender note: check all hernial orifices, especially umbilicus

Question 47

imaging for the patient with small bowel obstruction

Answer 47

x-ray: plain erect film confrims diagnosis, 'step ladder' fluid levels in 3-4 hours. gastrograffin follow through for precise diagnosis with caution. it can cause severe diarrhoea but may be therapeutic in adhesive obstruction +/- CT scan (especially if extrinsic causation

Question 48

management of the patient with small bowel obstruction

Answer 48

IV fluids and bowel decompression with nasogastric tube laparotomy or hernia repair

Question 49

the cause of large bowel obstruction is commonly

Answer 49

cause is commonly colon cancer, especially on the left side

Question 50

causes of large bowel obstruction

Answer 50

commonly colon cancer diverticulitis volvulus of the sigmoid colon and caecum

Question 51

sigmoid volvolus

Answer 51

more common in older men and has a sudden and severe onset

Question 52

clinical features of large bowel obstruction

Answer 52

sudden-onset colicky pain (even with cancer) each spasm lasts less than 1 minute usually hypogastric midline pain vomiting may be absent (or late) absolute constipation (obstipation) no flatus

Question 53

typical pain distribution of large bowel obstruction

Answer 53

Question 54

signs of large bowel obstruction

Answer 54

increased bowel sounds, especially during pain distension may be early and marked local tenderness and rigidity

Question 55

large bowel obstruction on PR exam

Answer 55

empty rectum may be rectosigmoid cancer or blood check for faecal impaction

Question 56

large bowel obstruction on x-ray

Answer 56

distension of large bowel with separation of haustral markings, especially caecal distension - sigmoid volvulus shows a distended loop and coffee bean sign - gastrograffin enema confirms diagnosis