WEEK 1: Understanding Abdominal Pain

Question 1

Define the following terms.

1. Abdomen
2. Pain
3. Tenderness
   4.Acute
4. Surgery
5. A Surgeon

Answer 1

Abdomen
The abdomen is the part of the body between the chest and the pelvis. It contains various organs, including the stomach, liver, intestines, and kidneys.

Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Tenderness
Tenderness refers to a sensation of pain or discomfort when pressure is applied to a specific area of the body.

Acute
In medical terminology, “acute” refers to a condition or symptom that has a sudden onset and is of short duration.

Surgery
Surgery is a medical procedure that involves the manual or instrumental manipulation of body tissues to diagnose, treat, or prevent a disease or injury.

A Surgeon
*A surgeon is a medical professional who specializes in performing surgical procedures.

*A Surgeon is a physician who can operate when it is indicated and in the better interest of the patient.

Question 2

Is Pain Always Bad, Undesirable?

Answer 2

Pain is not always bad or undesirable. While pain is often associated with negative experiences and discomfort, it serves an important purpose in our bodies. Here are some key points to consider:

1. Pain is a protective mechanism that alerts us to potential harm or injury. It acts as a warning signal, signaling that something is wrong in our body and needs attention.
2. Pain can help us identify and address underlying health issues. It can be an indicator of an injury, infection, or disease, prompting us to seek medical attention and treatment.
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3. Pain can also be instrumental in our healing process. It can guide us to take necessary precautions and avoid further damage to the affected area.

Question 3

ACUTE ABDOMEN ≠ PERITONITIS

Define the 2 terms.

Answer 3

1. Acute Abdomen:
   Any sudden non-traumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary.

The term “acute abdomen” refers to the sudden onset of severe abdominal symptoms that may necessitate surgical intervention or requiring urgent medical attention.

Patients with an acute abdomen often present with:

*Severe abdominal pain: This pain can be sudden in onset and may be localized or diffuse.
*Nausea and vomiting.
*Changes in bowel habits: These changes can include diarrhea or constipation/obstipation

2. Peritonitis:
   Peritonitis refers to inflammation of the inside lining of the abdomen (the peritoneum).

Symptoms of peritonitis include:
*Constant abdominal pain or pain that worsens upon gentle touch or pressure.

Question 4

Acute abdomen is not the same as operative abdomen.

Define operative abdomen.

Answer 4

The term “operative abdomen” refers to the surgical exploration and intervention within the abdominal cavity.

It involves opening the abdomen (laparotomy) to access and visualize the abdominal organs for diagnostic or therapeutic purposes.

Abdominal surgery can be performed for various reasons, such as removing diseased organs or tissues, repairing injuries, treating abdominal infections, or addressing other conditions affecting the abdominal cavity.

Question 5

Define Acute and chronic.

Answer 5

ACUTE
The term “acute” refers to a condition or symptom that has a sudden onset and is of short duration. It typically describes a condition that occurs suddenly and is severe in nature.

Acute conditions often require immediate attention or intervention.

CHRONIC
On the other hand, the term “chronic” refers to a condition or disease that persists or recurs over a long period of time.

Chronic conditions develop gradually and may worsen over time. They are characterized by their long-lasting nature and often require long-term medical care.

Question 6

When it comes to describing pain, there are different terms used to characterize its qualities. Two of these terms are “sharp pain” and “dull pain.”

Describe the 2 types of pain.

Answer 6

Sharp pain: Sharp pain is often described as a sudden, intense, and piercing sensation.

It can be felt as a stabbing or cutting pain. Sharp pain is typically associated with acute conditions or injuries, such as a muscle strain, a cut, or a broken bone.
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Dull pain: Dull pain is usually a bearable but long-term pain. It is often described as a steady, aching pain.

Dull pain can be persistent and may last for an extended period of time. It is commonly associated with chronic conditions, such as arthritis or muscle tension.

Question 7

Define surgery according to Mark M. Ravitch.

Answer 7

Surgery = Hand + Work

Surgery is not an act or a room.

Surgery is an art, a science, a system of thought, a tradition.

Question 8

We are physicians who think, not “just” technicians who perform manual tasks and procedures

Define medicine according to Sir William Osler, 1849-1919.

Answer 8

“Medicine is a science of uncertainty and an art of probability.”

Question 9

YOU SEE WHAT YOU LOOK FOR, YOU DIAGNOSE WHAT YOU KNOW- Ronald Belsey

Question 10

When preparing for entry to the operating theater, there are several important components to consider.

State them.

Answer 10

1. History: Prior Operations, Medications, Co-morbidities, Performance-status, etc.
2. Physical Examination
3. Investigations
   -Lab
   -Imaging

Question 11

Outline items to consider when having acute abdomen prior to surgery.

Answer 11

Other Items to Consider:
History: Weight Loss
Medications
Prior colonoscopy or EGD PMI: ? HIV, IBD

Physical: BMI/Weight SpO2

Investigations:
Hgb SS
HCG
INR

Any items specific to the concerns or diff dx at hand.

Confinement = last delivery

Question 12

Diagnosis precedes treatment. Explain.

Answer 12

Diagnosis involves the process of identifying a disease or condition based on signs, symptoms, medical history, and various diagnostic tests. It is through the diagnostic process that healthcare professionals can determine the underlying cause of a patient’s symptoms and establish a specific diagnosis.

Once a diagnosis is made, treatment decisions can be based on the identified condition. Treatment plans are tailored to address the specific disease or condition, taking into account factors such as the severity of the condition, the patient’s overall health, and any potential risks or contraindications.

Question 13

What is visceral peritoneum?

Discuss innervation of viscera and pain.

Answer 13

The visceral peritoneum is a layer of the peritoneum, a serous membrane that lines the abdominal cavity and covers the abdominal organs.

It is the inner layer of the peritoneum that directly covers the organs, providing them with a protective covering.

The visceral peritoneum is not innervated, meaning it lacks sensory nerve fibers. However, the sub-mesothelial tissue beneath the visceral peritoneum is innervated by the autonomic nervous system.
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1. Autonomic Innervation:

The autonomic nervous system (ANS) is responsible for regulating involuntary bodily functions, including those of the internal organs.

The autonomic innervation of the abdominal and pelvic viscera involves both the sympathetic and parasympathetic branches of the ANS.

The sympathetic nerves arise from the thoracic and lumbar regions of the spinal cord, while the parasympathetic nerves originate from the cranial nerves and the sacral region of the spinal cord.

These autonomic nerves provide motor innervation to the abdominal and pelvic organs and also carry sensory information from these organs back to the central nervous system.
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2. C Fibers:
C fibers are a type of unmyelinated nerve fibers that transmit sensory information related to pain and temperature.

They are part of the general visceral afferent (GVA) fibers, which conduct sensory impulses from the internal organs, glands, and blood vessels to the central nervous system.

C fibers are involved in the transmission of slow, dull, and poorly localized pain sensations. In the context of visceral pain, C fibers play a role in the perception of diffuse and poorly defined pain that is often felt in the midline of the body
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3. Midline:
In the context of visceral pain, the term “midline” refers to the central region of the body.

Visceral pain is often perceived as a diffuse, dull pain that is not well localized and is frequently referred to the midline region of the abdomen or upper sternum.

This means that the pain is felt in the central area of the body, rather than in a specific location.

Question 14

Discuss parietal peritoneum.

Answer 14

The parietal peritoneum is the outer layer of the peritoneum, a serous membrane that lines the abdominal cavity and covers the abdominal organs.

Unlike the visceral peritoneum, which covers the organs, the parietal peritoneum lines the internal surface of the abdominal and pelvic walls.

It is innervated by both somatic and visceral afferent nerves.
Sensitive branches from the lower intercostal nerves and upper lumbar nerves provide innervation to the parietal peritoneum.

Microscopically, a dense network of unmyelinated and myelinated nerve fibers can be found throughout the parietal peritoneum

1. Somatic Innervation:
   Somatic innervation refers to the innervation of structures related to the body wall, including the parietal peritoneum.

The parietal peritoneum receives somatic innervation from spinal nerves T10 through L1. This somatic innervation allows for the sensation of pain, pressure, touch, and temperature, which can be localized. Pain from the parietal peritoneum is well-localized and can be perceived as sharp.

2. C and A Delta Fibers:
   C fibers and A delta fibers are types of nerve fibers involved in transmitting sensory information related to pain.

C fibers are unmyelinated and transmit slow, dull, and poorly localized pain sensations.

Delta fibers are myelinated and transmit sharp, well-localized pain sensations.

Both C fibers and A delta fibers are involved in the perception of pain from the parietal peritoneum. Noxious stimuli to the parietal peritoneum are perceived as localized, sharp pain.

3. Focal:

In the context of the provided search results, the term “focal” is not directly related to the parietal peritoneum or its innervation.
However, it is important to note that pain from the parietal peritoneum is typically well-localized, meaning it is felt in a specific area rather than being diffuse or generalized

Question 15

Compare Visceral pain and Somatic pain (parietal).

Answer 15

1. Visceral pain
   -Dull, aching and vague
   -Poorly localized
   -Non-lateralizing
   -Assoc with nausea, emesis, sweating and pallor
2. Somatic pain (parietal)
   -Sharp, lancing, more intense
   -Precisely localized
   -Lateralizes

Question 16

Visceral afferent nerves (autonomics) accompany major arteries and are stimulated by distension, stretching and ischemia yielding midline symptoms.

Describe the innervation and the type of pain in the following parts.

Answer 16

Foregut celiac plexus epigastric
Midgut SMA afferents periumbilical
Hindgut IMA/lumbar hypogastric

1. Foregut:
   The celiac plexus, which is a network of nerves located around the celiac artery, provides autonomic innervation to the organs derived from the foregut.

These include the distal esophagus, stomach, proximal duodenum, pancreas, liver, biliary system, spleen, and adrenal glands.

Stimulation of the visceral afferent nerves in this region can yield symptoms in the epigastric area

2. Midgut:
   The superior mesenteric artery (SMA) afferents provide autonomic innervation to the organs derived from the midgut.

These include the distal duodenum, jejunum, ileum, cecum, appendix, ascending colon, and proximal transverse colon.

Stimulation of the visceral afferent nerves in this region can yield symptoms in the periumbilical area.
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3. Hindgut:

The inferior mesenteric artery (IMA) and lumbar afferents provide autonomic innervation to the organs derived from the hindgut.

These include the distal transverse colon, descending colon, sigmoid colon, rectum, upper anal canal, bladder, external genitalia, and gonads.

Stimulation of the visceral afferent nerves in this region can yield symptoms in the hypogastric (lower abdominal) region.

Question 17

Discuss Somatic/Parietal Pain.

Answer 17

An inflammatory process stimulates the afferent pain receptors of the parietal peritoneum.

Somatic peripheral nerves correspond to dermatomes.

Question 18

Describe referred pain.

State where the pain originating from the following will bw felt at.

C4
T6-8
T10

Answer 18

Pain felt in 2 entirely separate and anatomically distinct areas that share a common embryological origin and therefore a common afferent innervation.

C4 diaphragm shoulder
T6-8 liver, biliary tree subscapular
T10 kidney, ureter flank, groin

Question 19

An “acute abdomen” is not necessarily an emergent or urgent surgical condition.

Name ten diseases than can mimic an operative abdomen?

Answer 19

“Diseases which may simulate the acute abdomen”, Ch 21. Cope’s

Diabetes Herpes zoster
Typhoid Fever Renal Disease
Malaria Periarteritis nodosa
Tuberculosis Retroperitoneal Dz.
Pleurisy/Pneumonia (AAA, dissections, etc.)
Acute cardiac disease Pelvic Infections/Inflm.
Osteomyelitis spine Hgb SS—Sickle Crisis
Tabes Dorsalis

Question 20

Describe physical exam of the abdomen.

Answer 20

The Abdomen as a Cylinder:Chest, Back, Abdominal Wall, Pelvis, Hips

Expose: Nipples to Femoral Triangles
*Observe
*Auscultate
*Ask to cough
*Percuss
*Palpate—Remember the Beagle

Rectal Exam; Pelvic Exam

Question 21

Define algorithm according to Al-khuwarizmi BD ~ 825CE, Arab mathematician.

Answer 21

A procedure for solving a mathematical problem in a finite number of steps.

Question 22

Surgical Causes of Acute Abdominal Pain.

Where can abdominal pain originate from?

Answer 22

Can originate from:
*Peritoneal source:
The peritoneum is a continuous membrane that lines the abdominal cavity and covers the abdominal organs.

*Hollow viscus: Hollow viscera are organs with a hollow lumen, such as the stomach, intestines, gallbladder, bladder, and rectum. Distension or stretching of these organs can stimulate visceral afferent nerves and result in visceral pain.

*Solid viscera: Solid viscera are organs that are primarily solid in nature, such as the liver, pancreas, spleen, adrenals, and kidneys.

*Pelvic organ.
Pelvic Organ: Pelvic organs, including the uterus, bladder, and reproductive organs, can also be a source of visceral pain. Pain originating from these organs can be referred to the hypogastric (lower abdominal) region

Question 23

Outline the causes of abdominal pain.

Answer 23

*Inflammation
*Mechanical obstruction
*Vascular disturbance (ischemia)

Question 24

Outline Unique Circumstances of Abdominal Pain.

Answer 24

Pregnant patient
Critically ill “medical” patient
Immune compromised patient

Question 25

Outline Location of Pain: Diffuse.

Answer 25

Peritonitis
Pancreatitis
Early appendicitis
Gastroenteritis
Ruptured aneurysm
Intestinal obstruction
Colitis
Mesenteric vascular insufficiency
Sickle cell crisis

Question 26

Discuss Location of Pain: Periumbilical or Central Abdomen.

Answer 26

Acute appendicitis (early)
Small bowel obstruction
Acute gastroenteritis
Acute pancreatitis (early)

Question 27

Outline Location of Pain: RUQ.

Answer 27

-Biliary tract
-Hepatitis (infectious vs. passive congestion)
-Peptic ulcer disease
-Pancreatitis
-(Retrocecal) appendicitis
-Pneumonia or Pleurisy
-Myocardial infarct
-Renal/ureteral disease

Question 28

Outline Location of Pain: LUQ.

Answer 28

Gastritis
Pancreatitis
Pneumonia or pleurisy
Splenic disease (rupture, infarct, aneurysm)
Renal disease

Question 29

Outline Location of Pain: RLQ

Answer 29

Appendicitis
Inflammatory bowel disease
Bowel obstruction
Cholecystitis
Ectopic pregnancy
Ovarian torsion
PID
Renal disease
Perforated duodenal ulcer

Question 30

Outline Location of Pain: LLQ.

Answer 30

Diverticulitis: Diverticulitis is a condition characterized by the inflammation or infection of small pouches called diverticula that form in the wall of the large intestine (colon).

Bowel obstruction

Ruptured ectopic pregnancy

Ovarian disease: torsion, ruptured cyst

Ruptured aneurysm

Renal disease: pyelonephritis, stone

Endometriosis

Question 31

Define ileus.

Define Adynamic ileus.

Answer 31

Hippocrates, Galen and their successors felt that almost all serious abdominal conditions which progressed to a fatal termination were obstructions of the bowels and given the name ileus (eilos), the iliac passion (passio iliaca), and later miserere mei (“Have compassion on me”).

Adynamic Ileus = non-contractility of the bowel secondary to electrolyte abnormalities, pharmacologic agents, recent operation, spine injury, etc.

Question 32

BEWARE CONSTIPATION

Constipation rarely produces a genuine acute abdomen.

Define constipation.

State things which should never be administered until the possibility of bowel obstruction has been excluded.

Answer 32

Constipation is a condition characterized by infrequent or difficult bowel movements.

It is generally defined as having three or fewer bowel movements per week, with the passage of small amounts of hard, dry stool.

Common symptoms of constipation include discomfort, bloating, and a feeling of incomplete evacuation.

Enemas, laxatives, and cathartics

Enemas: An enema involves introducing liquid into the rectum and lower colon to stimulate bowel movements. The liquid can help soften the stool and promote its passage. Enemas may be used for constipation relief, to empty the bowels before medical procedures, or to administer medication.

Laxatives: Laxatives are medications or substances that help resolve constipation by promoting bowel movements. They work by increasing the frequency of contractions in the large intestine or by softening the stool. Laxatives can be classified into different types, such as bulk-forming laxatives, osmotic laxatives, stimulant laxatives, and stool softeners. Each type works in a specific way to alleviate constipation.

Cathartics: Cathartics are substances that accelerate defecation, similar to laxatives. They can stimulate the intestines and increase motility, leading to the evacuation of the colon. Some substances can function as both laxatives and cathartics, depending on the dosage.

Question 33

After initial assessment (by physician and surgeon), analgesics for pain relief should not be withheld.

In moderate doses, analgesics neither obscure useful physical findings nor mask their subsequent development.

Define analgesics.

Answer 33

Analgesics, also known as pain relievers or painkillers, are a group of drugs or substances used to alleviate or reduce pain without causing a loss of consciousness.

Question 34

“The trend is away from operation without clinical judgment.”

Expalin the phrase.

Answer 34

However, based on the snippets provided, it can be inferred that clinical judgment is an essential aspect of healthcare practice.

Clinical judgment refers to the ability of healthcare professionals to make informed decisions and assessments based on their knowledge, experience, and critical thinking skills.

It involves the integration of various factors, such as patient history, physical examination findings, diagnostic tests, and evidence-based guidelines, to arrive at a diagnosis or treatment plan.

The phrase “the trend is away from operation without clinical judgment” suggests that there is a shift in healthcare practice towards emphasizing the importance of clinical judgment in decision-making, particularly in the context of surgical interventions.

This may imply that surgical interventions should not be solely based on technical considerations but should also take into account the clinical judgment of healthcare professionals, considering factors such as the appropriateness of the procedure for a particular patient, potential risks and benefits, and alternative treatment options.

Question 35

“There is no condition that can’t be made worse by an operation.”
Explain the phrase above.

Answer 35

The phrase “There is no condition that can’t be made worse by an operation” suggests that any medical condition has the potential to be exacerbated or worsened by a surgical procedure.

While surgery is often performed to improve or treat certain medical conditions, it is not without risks.

Complications can arise during or after surgery, which may lead to a worsening of the patient’s condition.

Question 36

Malius est anceps quamnullum experire remedium.

It is better to try a doubtful remedy than to leave a patient to a certain death.
Z. Cope
A History of the Acute Abdomen

Explain the phrase above.

Answer 36

The phrase “Malius est anceps quam nullum experire remedium” translates to “It is better to try a doubtful remedy than to leave a patient to a certain death.”

This statement emphasizes the importance of exploring potential treatment options, even if they may carry some uncertainty or risk, rather than accepting a dire outcome without attempting any intervention.

The idea behind this phrase is that when faced with a severe or life-threatening condition, it is often preferable to take action and try different remedies, even if their effectiveness is uncertain, rather than passively accepting a certain negative outcome. It highlights the value of exploring all possible avenues for treatment and not giving up hope.

Question 37

Some people can die without the benefit of an operation.

Alfred Blalock

Explain the phrase above.

Answer 37

It is true that some people can die without the benefit of an operation. The decision to undergo surgery is complex and involves weighing the potential risks and benefits. In certain situations, surgery may not be a viable option or may carry significant risks that outweigh the potential benefits. Here are a few reasons why some individuals may not undergo surgery

1. Advanced age and frailty:
   Older adults who are frail or have multiple underlying health conditions may be at higher risk for complications during and after surgery. In such cases, the risks associated with surgery may outweigh the potential benefits, and alternative treatment options or palliative care may be considered.
2. Terminal illness:
   In cases where a person has a terminal illness with a limited life expectancy, surgery may not be recommended as it may not significantly improve the overall quality or length of life. In these situations, the focus may shift towards providing comfort and symptom management through palliative care.
3. Patient preference:
   Some individuals may choose not to undergo surgery due to personal beliefs, cultural or religious reasons, or a desire to explore alternative therapies. Patient autonomy and informed decision-making play a crucial role in determining whether or not to proceed with surgery.
4. Inoperable conditions:
   There are certain medical conditions or anatomical abnormalities that may be deemed inoperable due to their complexity, location, or associated risks. In these cases, alternative treatment options or supportive care may be recommended.

Question 38

Imminent demise is not an operative indication.

Alfred Blalock

Explain the phrase above.

Answer 38

The phrase suggests that the mere presence of an imminent or impending death should not be the sole determining factor for deciding whether or not to perform an operation.

In other words, the fact that a patient’s condition is deteriorating rapidly or that death is imminent should not automatically exclude them from being considered for surgical intervention.

Blalock’s statement implies that medical professionals should carefully evaluate each individual case and consider various factors, such as the potential benefits, risks, and overall prognosis, when deciding whether or not to proceed with an operation.

It emphasizes the importance of clinical judgment and a comprehensive assessment of the patient’s condition rather than solely relying on the immediacy of the impending death.

Question 39

The disastrous consequences of dichotomous thought. Stephen J. Gould

Explain the phrase above.

Answer 39

The phrase “The disastrous consequences of dichotomous thought” is attributed to Stephen J. Gould, a prominent American paleontologist, evolutionary biologist, and science writer.

The phrase suggests that adopting a dichotomous or binary way of thinking can lead to negative or harmful outcomes.

Dichotomous thinking refers to the tendency to view things in terms of strict opposites or mutually exclusive categories, such as right/wrong, good/bad, or black/white.

This type of thinking oversimplifies complex issues and fails to acknowledge the nuances and complexities that exist in the real world.

Gould’s statement implies that when we approach complex topics or problems with a dichotomous mindset, we may overlook important nuances, alternative perspectives, or potential solutions.

This can lead to misunderstandings, polarization, and the inability to fully grasp the complexity of the subject at hand.

Question 40

Don’t let the skin stand between you and the diagnosis.Don Meier

Explain the phrase above.

Answer 40

The phrase “Don’t let the skin stand between you and the diagnosis” suggests that one should not allow superficial or surface-level factors to hinder the process of reaching a proper medical diagnosis.

It emphasizes the importance of looking beyond the external appearance or initial impressions when evaluating a patient’s condition.

In a medical context, this phrase encourages healthcare professionals to thoroughly examine and investigate a patient’s symptoms, rather than solely relying on superficial observations.

It reminds medical practitioners not to dismiss or overlook potential underlying conditions based solely on the appearance of the skin or other external factors.

Question 41

Outline Major Causes of An Acute Abdomen at PMH or SSA

Answer 41

1. Appendicitis: Simple vs. Complicated

Appendicitis refers to the inflammation of the appendix, a small organ located in the lower right abdomen.

*Simple appendicitis: In simple appendicitis, the inflammation is confined to the appendix without any complications such as perforation or abscess formation. It typically presents with symptoms like abdominal pain, nausea, vomiting, and fever.

*Complicated appendicitis: Complicated appendicitis refers to cases where the inflammation has progressed to more severe stages.
This can include complications like perforation (rupture) of the appendix, abscess formation, or the spread of infection to the surrounding tissues. Complicated appendicitis may require more aggressive treatment, such as surgical intervention and antibiotic therapy.

2. Perforated PUD: GU vs. DU
   Perforated peptic ulcer disease (PUD) refers to the development of a hole or perforation in the lining of the stomach (gastric ulcer) or the upper part of the small intestine (duodenal ulcer). The location of the ulcer determines whether it is classified as a gastric ulcer (GU) or a duodenal ulcer (DU).

*Gastric ulcer (GU): A gastric ulcer is an ulcer that develops in the lining of the stomach. If a gastric ulcer perforates, it means that it has created a hole or rupture in the stomach lining.

*Duodenal ulcer (DU): A duodenal ulcer is an ulcer that forms in the upper part of the small intestine called the duodenum. If a duodenal ulcer perforates, it means that it has created a hole or rupture in the duodenal lining.

3. Bowel Obstruction: SBO vs. LBO

Bowel obstruction refers to a blockage that prevents the normal flow of intestinal contents through the digestive tract. It can be classified as small bowel obstruction (SBO) or large bowel obstruction (LBO) based on the location of the blockage.

*Small bowel obstruction (SBO): SBO occurs when there is a blockage in the small intestine, which is the portion of the digestive tract that connects the stomach to the large intestine.
Common causes of SBO include adhesions (scar tissue), hernias, tumors, or inflammation.

*Large bowel obstruction (LBO): LBO occurs when there is a blockage in the large intestine, which includes the colon and rectum.
Causes of LBO can include colorectal cancer, volvulus (twisting of the intestine), or impacted feces.

The symptoms of bowel obstruction can include abdominal pain, bloating, constipation, vomiting, and inability to pass gas or stool.
Treatment for bowel obstruction may involve relieving the blockage through non-surgical or surgical interventions, depending on the underlying cause and severity of the obstruction.

4. Perforated Typhoid Ulcer of the Ileum (SSA)
   Perforated typhoid ulcer of the ileum refers to a complication of typhoid fever, a bacterial infection caused by Salmonella typhi.

Typhoid fever primarily affects the gastrointestinal tract and can lead to the development of ulcers in the small intestine, particularly in the ileum (the last part of the small intestine).

If a typhoid ulcer perforates, it means that it has created a hole or rupture in the intestinal wall. This can result in the spread of bacteria into the abdominal cavity, leading to a serious condition called peritonitis.

Perforated typhoid ulcer of the ileum requires urgent medical attention and often surgical intervention to repair the perforation and treat the infection.

Question 42

Describe the following, why they are done and the information obtained from them in Acute abdomen.

Answer 42

1. Upright PA Chest X-ray (CXR):
   Purpose: To rule out free air in the abdominal cavity.

Information obtained: This view is more sensitive for detecting pneumoperitoneum (free air under the diaphragm). Sometimes chest pathology can present as abdominal pain, so the erect PA chest radiograph helps in identifying such cases1.

Note: In the UK, the erect abdominal radiograph has virtually disappeared from clinical practice due to limited impact on management1.

2. Upright Abdominal X-ray:
   Purpose: To assess air-fluid levels within the abdomen.

Information obtained: This view allows visualization of gas-fluid levels and free gas in the abdominal cavity. It helps evaluate conditions such as ascites, perforation, intra-abdominal masses, ileus, or postoperative complications2.

3. Supine Abdominal X-ray (KUB):
   Purpose: To differentiate between obstruction and ileus by examining gastrointestinal air/water levels.

Information obtained: The width of bowel loops is most visible in this view, providing an estimate of bowel distention3.

4. Left Lateral Decubitus Abdominal X-ray (used when the patient cannot tolerate an upright position):

Purpose: To evaluate intraperitoneal free gas.

Information obtained: This view is most sensitive for detecting free gas within the peritoneal cavity

Question 43

Upright X-ray: An upright X-ray of the abdomen is taken with the patient standing or sitting upright. This position allows for the visualization of gastric or small bowel air-fluid levels. It can help identify conditions such as bowel obstruction or gastrointestinal perforation.

Flat X-ray: A flat X-ray of the abdomen is taken with the patient lying flat on their back in the supine position. This position allows for the visualization of the valvulae conniventes, which are the characteristic mucosal folds in the small intestine. The appearance of the valvulae conniventes can resemble stacked coins and can provide information about the normal anatomy and potential abnormalities in the small intestine.
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KUB X-ray: KUB stands for Kidneys, Ureters, and Bladder. A KUB X-ray is a plain frontal supine radiograph of the abdomen. It is often supplemented by an upright PA view of the chest (to rule out air under the diaphragm or thoracic etiologies presenting as abdominal complaints) and a standing view of the abdomen (to differentiate obstruction from ileus by examining gastrointestinal air/water levels). However, despite its name, a KUB X-ray is not typically used to investigate pathology of the kidneys, ureters, or bladder
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Question 44

Small Bowel vs. Large Bowel

Discuss Valvulae conniventes

Answer 44

Valvulae conniventes = Kerckring folds = plicae circulares

These are large valvular flaps or folds of the mucous membrane that project into the lumen of the small intestine. They are present throughout the small intestine, starting from the second part of the duodenum, and gradually decrease in size distally in the ileum, eventually disappearing entirely in the distal ileal bowel loops.

The valvulae conniventes, Kerckring folds, or plicae circulares play an important role in increasing the surface area of the small intestine for efficient absorption of nutrients. They contribute to the amplification of the absorptive surface area, along with other structural features such as villi and microvilli

The appearance of the valvulae conniventes on abdominal radiographs, barium studies, or CT scans can be characteristic and resemble stacked coins
. This appearance is due to the presence of these folds in the small intestine.

Question 45

Discuss haustra.

Answer 45

The haustra (singular haustrum) of the colon are the small pouches caused by sacculation (sac formation), which give the colon its segmented appearance.

Think “stalactites, stalagmites” in a cave.

Question 46

Discuss sigmoid volvulus.

Answer 46

The Sigmoid Volvulus is a condition where the sigmoid colon (a part of the large intestine) twists on its mesentery, leading to obstruction.

Radiographic Features:

*Coffee Bean Sign: This is a specific radiological finding seen on abdominal radiographs. It appears as a large, dilated loop of the colon with a few gas-fluid levels. The “coffee bean” shape results from the twisted sigmoid colon.

*Frimann-Dahl Sign: Three dense lines converge toward the site of obstruction.

Question 47

Discuss Cecal Volvulus

Answer 47

Cecal volvulus is a condition characterized by an axial twist of the terminal ileum, ascending colon, and cecum around the mesenteric pedicle.

Question 48

Discuss Complex volvulus or Ileosigmoid knotting

Answer 48

Ileosigmoid knotting, also known as compound volvulus or double volvulus, is a rare and life-threatening cause of intestinal obstruction.

In this condition, the ileum (the last part of the small intestine) wraps around the base of the sigmoid colon and forms a knot.