WEEK 11 - Central/Lower Abdominal Pain Flashcards
(95 cards)
1
Q
Draw the IVC and its branches
A
2
Q
Draw the aorta and its branches
A
3
Q
A
4
Q
On a AXR, which of the following features suggest bowel obstruction?
- caecum diameter >9cm
- small bowel diameter >3cm
- Rigler’s sign (double wall)
- thumbprinting
- colon diameter >6cm
A
Caecum diamter >9cm
Small bowel diameter >3cm
Colon diameter >6cm
5
Q
What organs will give you CENTRAL abdominal pain?
A
- Intra-abdominal structures (Midgut)
- Retroperitoneal structures (Duodenum, Pancreas, Aorta)
- Abdominal wall (Hernia, Muscle, skin)
- Referred pain: (from the Back, base of lung, inferior heart)
- Rarely medical causes (Diabetic Ketoacidosis, Porphyria)
6
Q
What are the mid gut structures?
A
From the opening of the bile duct to 2/3rd of Transverse colon. (Distal Duodenum, Jejunum, ileum, caecum, Appendix, Ascending colon, Proximal 3/3rd of Transverse colon)
7
Q
Pain from the foregut (Oesophagus, stomach, Liver, biliary, pancreas and proximal duodenum) transmits pain via the _______ ________ nerves and received branches from the __-___ thoracic sympathetic ganglia. Pain from these structures is perceived in the _______ region.
A
- greater splanchnic
- T5-T8
- epigastric
8
Q
Pain from the midgut (distal duodenum, jejunum, ileum, cecum, appendix, ascending colon, and proximal 2/3 of transverse colon) transmits pain via the ______ _______ nerves and received branches from the ___-___ thoracic sympathetic ganglia. Pain from these structures is perceived in the ________ region.
A
- lesser splanchnic
- T10-T11
- umbilical
9
Q
Pain from the hindgut (the distal half of the transverse colon, descending colon, sigmoid colon, and the proximal third of the rectum) transmits pain via the _______ ________ nerves and received branches from the __-__ lumbar sympathetic ganglia. Pain from these structures is perceived in the ___________ region.
A
- lesser splanchnic
- L1-L2
- hypogastric
10
Q
Give any possible diagnoses for the description of the pain:
Continuous abdominal pain radiating to the back
A
Symptomatic abdominal aortic aneurysm (AAA)
Pancreatitis
11
Q
Give any possible diagnoses for the description of the pain:
Colicky abdominal pain that is now constant
A
Bowel obstruction with/without hernia
Irritable Bowel Syndrome
12
Q
Give any possible diagnoses for the description of the pain:
Colicky abdominal pain associated with diarrhoea
A
Gastroenteritis
Inflammatory Bowel Disease
13
Q
Give any possible diagnoses for the description of the pain:
Central abdominal pain that shifted to the right iliac fossa
A
Appendicitis
Rarely perforated Duodenal Ulcer
14
Q
Give any possible diagnoses for the description of the pain:
Sudden severe pain radiating to the back, flank and/or groin
A
Abdominal aortic aneurysm (AAA) until proven otherwise
Renal colic
15
Q
Give any possible diagnoses for the description of the pain:
Severe generalised pain with shoulder tip pain
A
Diaphragm irritation by free fluid / blood within the abdomen
16
Q
Describe acute appendicitis
A
Classic central (visceral) abdominal pain that localises to the RIF when the inflamed appendix irritates the peritoneum locally
17
Q
Describe symptomatic abdominal aortic aneurysm (AAA)
A
Central abdominal pain, no link to food, palpable pulsatile/expansile mass especially if tender
18
Q
Describe a duodenal perforation
A
Usually have a background of epigastric pain and a clear relationship to eating. Duodenal perforation can cause ‘high’ central abdominal pain and leak of duodenal content will track a cross the root of the mesentery into the RIF localising the pain to that side
19
Q
What is associated with left vs right colon tumours
A
Malignancy symptoms depend on the site and are associated with a level of bowel obstruction
Left — change in bowel habits
Right — anaemia
20
Q
Describe small bowel ischaemia
A
Usually sudden severe pain ‘out of proportion to clinical findings’
21
Q
Describe inflammatory bowel disease (IBD)
A
Usually young ish age group, bloody diarrhoea and systemic symptoms
22
Q
Complicated hernia: The patient might present with the symptoms of _________ pain of incarceration or just symptoms of bowel obstruction caused by trapped loop of bowel within hernia ___.
A
- localised
- sac
23
Q
What does colicky pain that becomes constant suggest?
A
That a partial obstruction of a hollow viscus (bowel, bile duct, ureter etc) has become complete — needs urgent intervention to prevent perforation/major complication
24
Q
What do pyrexia, localised tenderness and guarding suggest?
A
An infection or inflammatory process in one organ (appendix, GB, bowel etc)
25
_________ usually points to the possible organ but it can also suggest progression of the disease
Radiation
26
_______, ______ and _________ are more related to the bowel obstruction but remember that inflammatory causes can also cause localised ileus giving a similar (but less severe) picture.
Nausea, vomiting and distention
27
Femoral hernias can be very subtle but always remember looking for them especially in __________
Elderly females
28
What is McBurney’s point?
Classical point of maximum tenderness in appendicitis, corresponding to the position of the base of appendix. 1/3rd the line between Anterior Superior iliac Spine to umbilicus.
29
What is the appendix attached to?
Caecum
30
What is an abdominal aortic aneurysm (AAA)?
Dilation of the abdominal aorta, with a diameter of more than 3cm
Often the first time patients become aware of an aneurysm is when it ruptures, causing life-threatening bleeding into the abdominal cavity. The mortality of a ruptured AAA is around 80%.
31
AAA RFs
- men are affected significantly more often and at a younger age than women
- increased age
- smoking
- HTN
- FHx
- existing CV disease
32
Screening for AAA?
All men in England are offered a screening ultrasound scan at age 65 to detect asymptomatic AAA. Early detection of an AAA means preventative measures can stop it from expanding further or rupturing.
Women are not routinely offered screening, as they are at much lower risk. The NICE guidelines (2020) say a routine ultrasound can be considered in women aged over 70 with risk factors such as existing cardiovascular disease, COPD, family history, hypertension, hyperlipidaemia or smoking.
Patients with an aorta diameter above 3cm are referred to a vascular team (urgently if more than 5.5cm).
33
AAA presentation
Most patients with AAA are asymptomatic. It may be discovered on routine screening or when it ruptures
Other ways it can present include:
- non-specific abdominal pain
- pulsatile and expansile mass in the abdomen when palpated with both hands
- as an incidental finding on an AXR, USS or CT scan
34
How are AAAs diagnosed?
- US is the usual initial investigation for establishing the diagnosis
- CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm
35
How are AAAs classified?
The severity of the aortic aneurysm depends on the size:
- normal : less than 3cm
- small aneurysm : 3-4.4cm
- medium aneurysm : 4.5-5.4cm
- large aneurysm : above 5.5cm
36
AAA : The Public Health England (updated 2017) screening and surveillance programme recommends what follow up scans?
- yearly for patients with aneurysms 3-4.4cm (small)
- 3 monthly for patietns with aneurysms 4.5-5.4cm (medium)
37
AAA: NICE recommends elective repair for patients with what?
Any of:
- symptomatic aneurysm
- diameter growing more than 1cm per year
- diameter above 5.5cm
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Elective surgical repair involves inserting an artificial “graft” into the section of the aorta affected by the aneurysm.
What are the 2 methods for inserting the graft?
- open repair via laparotomy
- endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
39
What are the rules surrounding driving and AAA?
Gov.uk (April 2021) advise that patients must:
1. Inform the DVLA if they have an aneurysm above 6cm
2. Stop driving if it is above 6.5cm
3. Stricter rules apply to drivers of heavy vehicles (e.g., bus or lorry drivers)
40
What does a ruptured aortic aneurysm present with?
- severe abdominal pain that may radiate to the back or groin
- haemodynamic instability (hypotension and tachycardia)
- pulsatile and expansile mass in the abdomen
- collapse
- loss of consciousness
It is a SURGICAL EMERGENCY
41
What is permissive hypotension?
Refers to the strategy of aiming for a lower than normal blood pressure when performing fluid resuscitation. The theory is that increasing the blood pressure may increase blood loss
42
What can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients?
CT angiogram
43
What are common ruptured AAA misdiagnoses?
- renal colic 24%
- diverticulitis 13%
- GI bleed 13%
- MI 9%
- muscular or mechanical back pain 9%
44
Clinical examination picks up what % of AAA?
Only 40-50%
(difficult in obese people)
False positive in thin individuals (transmitted pulse vs expansile mass)
45
Where should you examine pulses in suspected AAA?
All limbs
People with AAA can have other aneurysmal arteries especially in the popliteal
46
Shock and 1 leg vs 2 leg ischaemia?
- ruptured AAA causes generalised shock state and BILATERAL leg iscahemia
- if patient presents with shock and one leg ischaema, think of dissection or significant peripheral vascular disease (PVD)
47
Always suspect ruptured AAA in who?
Men above 60 years old with first presentation of renal colic
48
What should you suspect until proven otherwise in patients with GI bleeding and a past history of aortic surgery?
Aorto-enteric fistula
49
What is a hernia?
A protrusion of an organ through its containing wall and into a different cavity. Can be acquired or congenital
50
What are the commonest abdominal wall hernias in order of frequency?
1. Inguinal
2. Umbilical/paraumbilical
3. Femoral
4. Incisional (through any previous surgical scar)
5. Epigastric or midline
Rare: spigelian, obturaotr, lumbar and gluteal
51
What are the 2 types of inguinal hernias?
Direct and indirect
52
Describe a direct inguinal hernia
the leading area of weakness is the posterior wall of the inguinal canal, where viscera herniates anteriorly through Hesselbach’s triangle and not into scrotum
53
Describe an indirect inguinal hernia
The leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside spermatic cord, and can exit the canal through the superficial inguinal ring and into the scrotum
54
What is a reducible hernia?
The hernia can be manually pushed back (or ‘reduced’) into the abdominal cavity
55
What is an irreducible hernia?
The hernia sac and it’s content cannot be pushed back into the abdomen
56
What is a strangulated hernia?
The ‘neck’ of the sac is quite tight leading to cut off the blood supply to the organ that herniated
57
What is an incarcerated hernia?
The contents are fixed in the sac with adhesions. The hernia is irreducible but the organ within the sac is not compromised, but is at risk of strangulation
58
What is an obstructed hernia?
The bowel loop trapped within the sac causes bowel obstruction. With further oedema it can become strangulated
59
_____________ hernias can be very subtle but always remember looking for them especially in elderly females. They are more likely to cause obstruction as 3 of the 4 borders of the _______ canal are ligaments and so have very laxity to stretch.
- femoral
- femoral
60
Microcytic anaemia could point towards what, an important differential of RIF pain?
Caecal cancer
61
What is a sentinel loop?
a short segment of adynamic ileus close to an intra-abdominal inflammatory process. The sentinel loop sign may aid in localising the source of inflammation. For example, a sentinel loop in the upper abdomen may indicate pancreatitis, whilst one in the right lower quadrant may be due to appendicitis.
62
What is the gold standard treatment option for acute appendicitis?
Appendicectomy
63
What are 3 complications of appendectomy that a patient needs to be counselled on?
- conversion to open surgery
- postoperative wound infection or intra-abdominal collection
- bleeding
Other common postoperative complications can include pain/discomfort, a postoperative ileus, lower-respiratory tract infections/pneumonias, deep vein thrombosis (DVT) and pulmonary embolism. Longer term complications can include adhesions (leading to intestinal obstruction) and an incisional hernia.
64
What is the marker for ovarian cancer?
CA-125
65
Who should be urgently referred (2ww) for suspected ovarian cancer?
If physical exam identifies any of:
- ascites
- pelvic or abdominal mass (which is not obviously uterine fibroids)
66
Ovarian cancer urgent investigation:
Arrange CA125 and/or ultrasound tests in women (especially if 50 or over) who persistently or frequently (particularly more than 12 times per month) experience what?
- persistent abdominal distention (bloating)
- early satiety and/or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- new onset symptoms suggestive of IBS (as IBS rarely presents for the first time in women of this age)
67
Consider CA125 and/or ultrasound tests if a woman reports any of what?
- unexplained weight loss
- fatigue
- changes in bowel habit (though colorectal cancer is a more common malignant cause)
68
Which of the following prompt urgent referral for investigation of colorectal cancer?
- age 50 and over with unexplained rectal bleeding
- any age with a rectal or abdominal mass
- age 60 and over with Fe def anaemia
- age 40 and over with unexplained weight loss and abdominal pain
All
69
Symptoms and signs of a strangulated hernia?
(Occurs when a section of herniated bowel becomes trapped and ischaemic)
Causes acute, severe pain and would be detectable on examination as a non-reducible mass in the groin or anterior abdominal wall
70
What is Giardia?
Parasitic infection
Found worldwide, esp in areas of poor sanitation and unsafe water (think of travel Hx)
Can cause chronic diarrhoea along with abdominal discomfort and bloating
71
What is IBD?
Ulcerative colitis and Crohn’s disease are both IBDs
- UC affects the colon only
- Crohn’s can affect any part of the digestive system, from the mouth to the anus
Exact cause unknown
They can affect people of any age but most commonly present between ages of 15 and 40
Symptoms and signs – Symptoms can include a combination of abdominal pain and bloating, bloody diarrhoea, weight loss and extreme tiredness
72
What is IBS?
a common functional disorder of the bowel. The cause is not completely understood but is thought to be related to the way the bowel and the brain interact, causing increased sensitivity of the bowel to normal stimuli and abnormal motility.
can occur at any age but is mostly commonly diagnosed between ages of 20 and 40. Women are twice as likely to be affected as men.
73
What are signs and symptoms of IBS?
Hormonal fluctuations during the menstrual cycle can affect symptoms, they are often worse during the progesterone dominant premenstrual phase. Emotional stress is a recognised trigger and it can also occur after an episode of gastroenteritis. Symptoms vary and can include diarrhoea, constipation, or alternation between both, abdominal pain, diurnal bloating, mucus in the stool and tiredness.
74
What is diverticulitis?
Diverticula are small bulges or pouches in the lining of the large intestine. They are usually incidental findings on scans or colonoscopy and occur with advancing age. The presence of asymptomatic diverticula is called diverticulosis.
75
What are signs and symptoms of diverticulitis?
Diverticulitis occurs when the pouches become infected or inflamed, causing severe pain, often in the left lower quadrant, bloating, fever and bloody diarrhoea. It is much less likely in a young person, especially a young female. It would also likely cause more severe pain, worsening over several days, rather than ongoing colicky pain for weeks.
76
What is coeliac disease?
This is an autoimmune condition triggered by sensitivity to gluten, a protein found in cereals such as wheat, barley and rye. Repeated exposure to gluten causes inflammation of the small intestine.
Symptoms and signs – Symptoms include abdominal pain, bloating, tiredness, diarrhoea or constipation, anaemia, weight loss and skin rashes – specifically dermatitis herpetiformis.
77
How does a bowel obstruction present?
- acutely
- accompanied by constipation and poss vomiting
- unwell pateint
78
What is lactose intolerance?
Pathophysiology – This is caused by a deficiency of the enzyme lactase, produced in the small intestine. It breaks down the sugar lactose, found in dairy products.
Symptoms and signs – Symptoms usually occur about 30 minutes after eating dairy products and include diarrhoea, crampy abdominal pains, bowel gas and bloating.
Epidemiology – Primary lactase deficiency is most common in adults of African, Asian, Hispanic and American Indian descent. Secondary lactase deficiency can also occur as a result of other conditions affecting the function of the small intestine, including Crohn’s disease and after a severe episode of gastroenteritis. A dietary history should identify this as a potential cause of Maria’s symptoms.
** It is important to note that lactose intolerance and an allergy to cow’s milk protein are separate conditions. Cow’s milk protein allergy is a sensitivity to the proteins found in dairy products, not the sugar lactose. It is most common in babies and children and can manifest with gastrointestinal symptoms along with skin rashes and even anaphylaxis in the most severe cases.
79
What is bile acid diarrhoea?
Pathophysiology – This is an under-recognised condition which is frequently overlooked leading to a misdiagnosis of irritable bowel syndrome with predominant diarrhoea. Bile acids are produced in the liver, stored in the gallbladder and secreted into the small intestine after meals. They are mostly reabsorbed in the ileum and returned to the liver in a cycle known as enterohepatic circulation. When they are not adequately reabsorbed, chronic diarrhoea along with bloating and cramping pain can result. Conditions affecting the terminal ileum can cause this problem, however sometimes there is no obvious cause.
Epidemiology – It is thought to affect 1 in 100 people in the UK.
Investigations – The gold standard investigation is a nuclear medicine test called the SeHCAT scan. An artificial bile acid is swallowed and an initial scan determines how much is present in the body. A further scan a week later shows how much of the original amount has been retained via the enterohepatic circulation. It is important to recognise, as it is very treatable.
Treatment – Treatment includes a low fat diet and bile acid sequestrants, drugs that bind to bile acids in the small intestine and prevent irritation in the colon.
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What is the principle way to distinguish between IBS and IBD?
Faecal calprotectin — marker of bowel inflammation
IBS - normal result
IBD - elevated faecal calprotectin even if CRP is normal
81
What is anaemia common ion?
Coeliac disease and IBD
82
What are 2 antibodies formed in response to eating gluten, and a positive result from a blood test is suggestive of coeliac disease and should prompt referral to a gastroenterologist for consideration of a confirmatory duodenal biopsy
Tissue transglutaminase antibody (tTGA) or endomysial antibody (EMA)
83
What is this describing?
This is an invasive test with a small risk of bowel perforation. It is extremely useful in investigation of suspected malignancy, as it allows direct visualisation and tissue biopsy. Maria has no red flags for colorectal malignancy at present. It may also be indicated if there is a strong suspicion of inflammatory bowel disease, but it would not be one of the initial investigations requested in primary care at this stage.
Colonoscopy
84
Describe barium enema
Barium liquid is radiopaque and inserted via the rectum, to outline the bowel wall so that it is visible on xray. It can be helpful in identifying structural pathology of the bowel. It is less frequently used now, and almost never as a first line investigation with CT scanning and colonoscopy preferred. It would not be a first line investigation for abdominal pain and diarrhoea in a young patient.
85
What is this showing?
A barium enema study showing colonic diverticulosis
86
When is CT scan of the abdomen and pelvis used?
This involves significant radiation exposure in a young woman of child bearing age. It is a very useful test in an unwell patient presenting with an acute abdomen, to quickly identify structural pathology requiring emergency surgical intervention It is also useful in diagnosing and staging cancers. CT virtual colonoscopy can be used to investigate bowel symptoms if the patient is not fit for, or does not agree to, colonoscopy. However it is inferior to colonoscopy.
87
What 4 things are recommended for IBS as first line management?
- loperamide
- reducing caffeine intake
- reducing intake of fizzy drinks
- regular exercise
88
What is loperamide?
an anti-motility drug, used as the first line in treatment of diarrhoea associated with irritable bowel syndrome. It is an opioid-receptor agonist and acts on the μ opioid receptors in the colon, decreasing the tone of the smooth muscle in the intestinal wall. Importantly it hardly crosses the blood brain barrier so has no central effects unless taken in overdose.
89
What drugs are recommended as second line treatment for IBS, if antispasmodics and loperamide or laxatives have not helped?
Low dose tricyclic antidepressants — should be made clear they are being used in a far lower dose as visceral painkillers and not as antidepressants. The effect may take a few weeks to appear.
90
What should be considered for the treatment of irritable bowel syndrome in people who have not responded to pharmacological treatments after twelve months?
Hypnotherapy
(However it is not widely available in the NHS)
91
An obstructing femoral hernia
92
Serum beta human chorionic gonadotropin
Determining pregnancy status in a female of child-bearing age is mandatory in the assessment of abdominal pain. The diagnosis is an ectopic pregnancy until proven otherwise.
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Ruptured AAA
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Crohn’s disease
95
Toxic megacolon
