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1
Q

Name causes of acute abdominal pain. (Note there are 16 of them!!)

A 
AAA
Perforation
Bowel obstruction
Acute appendicitis 
Acute pancreatitis 
Acute cholecystitis 
Cholangitis 
Biliary Colic
Obstructive jaundice 
Peptic ulcer disease
Diverticulitis 
Renal colic 
Ectopic pregnancy
PID
Miscarriage 
Ovarian cyst
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2
Q

AAA presentation & management

A
  • Abdo pain radiating to back, iliac fossa or groin
  • expansile mass
  • Rupture → grey turners/cullens from bleeding + acutely unwell (↓GCS, ↓BP, syncope)

Mgmt →
• Watch & wait if < 5.5cm
• Prophylactic surgery if >5.5cm
• Emergency surgery if rupture

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3
Q

Causes of perforated bowel?

A 
From previous GI condition: Diverticulitis
Ulcerative colitis
Crohn’s disease
Toxic megacolon
Strangulated hernia, which can result in poor blood flow to the intestines
Peptic ulcer disease
Forceful vomiting
Bowel Ischaemia

Trauma (knife wound, severe blow, swallowing sharp object)
Appendicitis

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4
Q

presentation of bowel perforation

A

severe sudden abs pain + pyrexia + vomiting + peritonitis +- bowel sounds

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5
Q

Investigations of bowel perforation

A

CXR: gas under diaphragm
ABG: acidotic
BLD: ↑WCC, ↓Hb, ↑Amylase, ↑lactate
urgent CT when stable

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6
Q

Mgmt bowel perforation

A

Oxygen, IV fluids, analgesia (morphine + cyclizine), cross match, IV Abx (co-amoxclav + metronidazole (cover anaerobes), NGT, surgery

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7
Q

Bowel obstruction causes

A

Obstruction:

  • adhesions secondary to intra-abdominal surgery
  • tumour
  • Crohn’s disease causing strictures
  • hernia

→ tingling bowel sounds

Post-op paralytic ileus:
- ↑surgical time, electrolytes imbalance (especially hyperkalaemia), hypothyroid, opiates,

→ no or sluggish bowel sounds

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8
Q

Presentation of bowel obstruction

A 
Colicky abdo pain - tender 
distended bowel 
tinkling bowe
constipation 
N&amp;V (bilious or faecal)
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9
Q

Inv of bowel obstruction

A

AXR →
• Dilated bowel loops (look at thickness of bowel, position and presence of valvulae commiventes or haustra)
• Bloods
• Contrast enema

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10
Q

Mgmt of bowel obstruction

A

DRIP AND SUCK
→ NGT, IV fluids & NBM
• Avoid pro kinetic drugs
• Surgery

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11
Q

Acute appendicitis CF

A

normally 10-20 years
• Central, colicky abdo pain → worse on movement, voluntary guarding
• N&V&D
• Mild fever + fatigue

Late →
• McBurney’s RIF pain → involuntary guarding, rigid abdomen
• Rovsings sign
• Swinging pyrexia

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12
Q

Acute appendicitis diagnosis

A

clinical
urine: ↑nitrates, ↑WCC
USS - 90% sensitive

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13
Q

Mgmt of acute appendicitis

A

NBM, IV fluids, analgesia
IV Abx: co-amoxiclav + metrondiazole
appendicectomy which can be performed via either an open or laparoscopic approach. Laparoscopic appendicectomy is now the treatment of choice

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14
Q

3 main causes of acute pancreatitis

A

gall stones, ethanol, trauma (GET)

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15
Q

CF of a. pancreatitis

A

Constant epigastric pain

  • radiates to the back
  • worse with alcohol
  • relieved by sitting forward
  • tenderness
  • abdonminal rigidity
  • Grey turners + Cullens sign
  • anorexia + vomiting (shock)
  • ↓ bowel sounds
  • NB: gallstone can give RUQ pain + shoulder tip pain
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16
Q

Invs of pancreatitis

A

↑ Amylase > 600 +- lipase
Bloods: ↑WCC/CRP, ↑glucose, ↓Ca, ↓Hb (if bleed)
AXR: retroperitoneal fluid + no psoas shadow (sentinel loop sign)

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17
Q

What scoring system is used to predict mortality from acute pancreatitis. What is a severe score

A

Modified Glasgow Score (> 3)

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18
Q

Mgmt pancreatitis

A

IV fluids, Oxygen, Analgesia
Catherter
NBM + NGT

HDU/ICU?
Gallstone - ERCP

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19
Q

Acute cholecystitis cause & CF

A

BG inflamed due to stone impaction at neck

• Constant colicky pain (biliary colic), radiates to R shoulder
• Worse on eating fatty foods
• RUQ tender 
• Murphy sign (RUQ pain on palpation)
• N,V,D + bloating 
• NOT peritonitic 
\+- obstructive jaundice
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20
Q

INV + Mgmt

A

Bloods: ↑WCC/CRP + deranged LFT
USS

Mgmt 
NBM
Analgesia 
Abx: Co-amoxiclav 
Urgent cholecystectomy
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21
Q

Acute (ascending cholangitis) cause

A

choledocholithasis causes biliary stasis in common bile duct leading to ascending bacterial infection from the bowel.

5 F’s: Fair, Fat, Forty, fertile, Female

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22
Q

Ascending cholangitis

A

Charcot’s triad
• Constant RUQ pain
• Fever
• Jaundice of skin + sclera

↑ inflammatory markers

→ risk of septic shock (hypotension + confusion

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23
Q

Investigations + Mgmt

A

Blood: WCC/CRP, bilirubin, LFT
Imaging
ERCP

Abx
Remove block: ERCP or shockwave lithotripsy or widened with stent or cholecystetectomy

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24
Q

Biliary colic

A

GB stones obstruct cystic duct
Causes RUQ pain, intermittent radiates to R. shoulder

→ worse in morning or after food

If obstructive → Dark urine + steatorrhoea (pale stones)

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25
Peptic ulcer disease CF
Dyspepsia (heartburn) Epigastric pain relieved by eating or drinking milk NB gastric worse on eating. Bleed→ haematemesis, SOB, drowsy, confused, fatigue Consider gastric cancer (wt loss, swallowing difficulty)
26
Investigations of peptic ulcer disease
* Upper GI endoscopy + biopsy | * H pylori test (Breath test, serology)
27
Mgmt
PPI Triple therapy if H Pylori - Amoxicillin + Clarithromycin + Lansoprazole Fluid rhesus if bleed Check NSAIDs
28
Diverticulitis description + CF
Outpouching of gut mucosa common in descending + sigmoid becomes inflammed Acutely symptomatic, L/R LQ pain, can be intermittent or constant → relieved by opening bowels Maybe a palpable mass + bloating, ↓BS, possible chance in bowel habit → PR bleeding? - bleeding can be sudden and painless, pass clots → Fever + Tachycardia → Anorexia N + V → Shock?
29
Invs/Mgmt
Bloods (G+S) /AXR/Colonscopy NBM + Analgesia + Abx
30
CF of renal colic
Sudden onset severe colicky loin pain, radiate to the groin, enlarged palpable kidney, tender • N&V • Sweaty & restless • Retention Sx
31
Invs
Urine: ↑blood, ↑nitrates Bloods: ↑creatinine, urea, K ↑Na KUB XR: 60% show Contrast CTKUB: 90%
32
Mgmt of kidney stones
``` Analgesia (Diclofenac, opioids) Tamsulosin (a-blocker) Antiemetic Shock wave lithotripsy Nephrostomy? ```
33
Ectopic pregnancy CF
``` Lower abdo or pelvic pain Vague → colicky → constant Adenexal mass Cervical os small uterus normal size cerival excitation Vaginal bleeding Hx ammonrhoea 6-8 weeks N&V → dizzy + syncope ```
34
Inv Ectopic
``` Pregnancy test: +ve → USS b-HCG: > 1000IU/ml: or rises >66% in 48 hours: IUP decline or slow rising = ectopic or MisC TV-USS → ectopic or MisC ```
35
Mgmt
ABCDE if haemorrhage • Methotexate (single dose then redo HCG at 7 days • Salpingostomy Rupture → syncope + shoulder tip pain
36
PID
Pelvic pain (constant or intermittent), deep dyspareunia, vaginal discharge + dysuria, irregular periods
37
Inv
G+C tests (endocervical = Vulvocaginal for NAAT + culture • Bloods ↑ WCC • USS if risk of ovarian access
38
Mgmt
Abx | • Ceftriaxone IM + doxycycline + metronidazole
39
Miscarriage
< 24 weeks, see antenatal notes * Pelvic pain * Uterine contractions * Bleeding * Offensive discharge if septic
40
Inv + Mgmt
* bHCG (<66% in 48hrs) * USS exclude ectopic + IU Admission: ABCDE Analgesia + Antiemtic • IM oxytocin • Anti-D
41
Ovarian cyst - What sort - CF
Low abdo pain or pelvic pain - Dull ache - Radiates to the back - Dyspareunia - Bleeding if rupture - Abdo mass - tender + peritonism if rupture
42
Inv + Mgmt
``` Pregnancy Test FBC Urinalysis: urinary signs USS CA125 ```
43
Mgmt
Analgesia (most cyst resolve spontaneously) Lapro-cystectomy if > 5cm Urgent Laparoscopy if ovarian torsion, rupture or bleed
44
What is more common anterior or posterior dislocation of the shoulder? How to tell the difference on X-RAY
Anterior is more common. Anterior → anterograde-inferior displacement posterior → abnormal symmetry of shoulder - "light bulb sing"
45
The different between Colle's fracture & Smith's fracture
Colles: more common, fall on outstretched hand, fracture bone breaks dorsally whilst radius moves ventrally Smith's: fall on flexed wrist, fracture moves ventrally and radius moves dorsally → check for pulses
46
Describe the difference between intracapsular, extra capsular trochanteric and extra-capusular subtrachanteric hip fractures
Intracapsular → involves femoral neck - risk of avascular necrosis • Hip appears externally rotated & shortened Ex trochanteric → between two trochanters Ex subtrochanteric → < 5cm of the lesser trochanter (proximal femoral shaft)
47
Shoulder examination
- Check pain - Inspection - 3 angles - Temperature - Assess for tenderness of joint at scapula - active movement: ab/ad + flex/ex + internal rotation/external - passive movement - rotator cuff → • initiate abduction (supra) • Painful arc • external rotation (infra+teres minor) - assess patient from behind pushing wall → winged scapula - watch patient reach behind back Finish: • Assess joint above & below (c-spine, elbow) • neurovascular status of upper limb • Appropriate imaging
48
Hip examination
``` pain assess gait trendelenburg inspection + temperature assess patient supine measure leg length 1) asis-medial 2) xiphisternum to medial malleolus both sides palpate - greater trochanter, a.s.i.s, hip joint active movement (hand under back) - flexion passive - flexion - internal + external rotation - abduction/adduction Prone → ``` - hip extension - thomas test finish: - joint above & below - spine & knee examination - neurovascular examination of lower limbs - imaging if indicated
49
Acute lower back pain differential
- AAA - Mechanical pain - nerve root pain - spinal pathology (caudal equina) - spinal cord compression
50
Investigate acute lower back pain
- Hx - PNS examination: tone, power, sensation, reflexes + special - Rectal examination - anal tone, assess blood - Palpate spine for tenderness - Asses gait - Abdo exam (AAA) → Urgent MRI - cauda equina or MSSC Urgent USS - AAA
51
Perineal injury causes
``` foot drop (loss of muscles in anterior comparement) loss of sensation over dorsum of foot ↓ proprioception of ankle joint ```
52
Name acute problems with urinary symptoms
``` Renal colic Testicular torsion UTI AKI Urinary retention ```
53
How would testicular torsion present?
Usually male around 12 years Sudden, acute pain, tender testicle which is swollen & red, N&V → Torted hydatid - gradual onset pain, with blue dot sign, hard mass above
54
Inv & mgmt of testicular torsion
Testicular & abdominal examination - feel both testies - Transilluminate the testies (hydrocele) Doppler USS → examin blood flow Compare both sides Mgmt → Emergency surgery within 6-12 hrs - Untwist and fix both testicles
55
AKI Diagnosis
>26 umol rise in creatinine over 48 hours 50% rise in serum creatinine over 7 days Urine output <0.5/ml/kg/hr for > 6hours (adult) 8 hours (child) > 25% fall in eGFR over 7d (child)
56
AKI general symptoms
* N, V, anorexia | * Dehydration, fatigue, ↓LOC, ↓UO
57
Nephrotic casuses + symptoms
Cause in adult: Glomerulonephritis Child: Minmal change disease * Periorbital swelling * Ascites * Oliguria + frothy urine * Abdo pain
58
HUS symptoms
• Haemoltyic anemia, thrombocytopenia, ARF | If D+ve → bloody diarrhoea
59
Inv of AKI
- Assess fluid status - Abdo exam (blot kidney + renal bruits - Urine dip + MSU + plasma osmolarity - Bloods: FBC, U+E, Creatinine, LFT, plasma osmolarity, clotting - ECG: Tall tented T wave: hyperkalaemia - Look at albuminuria
60
Mgmt AKI
ABCDE + treat cause - Catheter for UO - Regular creatinine monitor - Fluids - Hyperkalaemia → 10ml 10% calcium glucaonate (0.5ml/kg child), 10 units of act rapid insulin in 50ml 50% dextrose, 5mg salbutamol over 15 mins - metabolic acidosis → bicarbonate 8.3% 50-100mls over 30 mins - Pulmonary oedema → furosemide + o2 - Sepsis: BUFALO - HTN: Nitrate or diuretics - Review medications: remove neprotoxins, NSAIDS, gentamicin, ACEi
61
Describe urinary retention
More common in males, Male: Hx BPH/cancer/urethral stricture Female: retroverted uterus, atrophic urethritis, MS, pregnancy
62
CF urinary retention
Distended bladder + inability to urinate → oliguria → delirium ``` Abdo exam → suprapubic pain/discomfort → distended bladder → dull percussion over bladder → if prolapsed disc or cord compression → check LL power, reflexes, perianal sensation ```
63
Mgmt of urianry retention
• Urgent decompression → Urethral catheter * Post-bladder drainage * Monitor U+Es, fluids, UO * refer urology * Urgent MRI * Trial without catheter

ACC (7 decks)

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