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Flashcards in Acute Abdomen Deck (87)
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1
Q

What is the definition of an acute abdomen?

A

Recent or sudden onset of unexpected signs or symptoms, including abdominal pain.

Potential for life-threatening infection or fluid/blood loss

2
Q

Reminder: what are the features of visceral pain?

A

Stimulation of receptors in smooth muscle by:

  • ischaemia
  • distension/stretching
  • tension

Often colicky.

Conducted by ANS.

Poorly localised to midline.

Associated with malaise, N&V, and sweating.

3
Q

Reminder: what are the features of somatic pain?

A

Stimulation of pain receptors in parietal peritoneum.

Conducted by segmental somatic nerves.

Accurately localised.

Usually overrided by the early visceral component.

5
Q

Give some examples of causes of generalised and localised peritonitis.

A

Generalised peritonitis:

  • perforated viscus
  • primary infective peritonitis
  • rupture of cyst

Localised peritonitis:

  • appendicitis
  • cholecystitis
  • pancreatitis
  • diverticulitis
  • abscesses
  • salpingitis/ruptured ectopic pregnancy
6
Q

Give some examples of causes of ischaemia in the acute abdomen.

A
  • mesenteric angina
  • splenic infarction
  • torsion of ovarian cyst/testicle/omentum
  • tumour necrosis (hepatoma, fibroid)
7
Q

Give some examples of extra-abdominal causes of acute abdomen.

A

Thoracic: pleurisy, pneumonia, IHD, oesophageal disease

Neurological: herpes zoster, spinal arthritis, radiculopathy from tumours, tabes dorsalis, abdominal epilepsy

Metabolic: diabetes mellitus (DKA), chronic renal failure, porphyria, acute adrenal insufficiency

Toxins: snake/insect bites, lead poisoning, strychnine

Other: peptic ulcer, IBD

8
Q

What are the key questions for assessing the acute abdomen?

A

Severity

Character:

  • ?colicky
  • sharp, severe, well localised or dull, vague, deep

Location:

  • ?localised to quadrant
  • ?midline
  • ?radiation of pain

Aggravating/relieving factors:

  • diffuse peritonitis
  • colic due to bowel obstruction

Urinary features:

  • frequency
  • urgency
  • pain
  • haematuria

Gynae features:

  • last menstrual period
  • discharge

GI features:

  • appetite
  • N&V
  • distension
  • bowel habit changes
  • weight loss
  • blood/mucus in stool

History of trauma

Past medical and surgical history:

  • clotting/blood disorders
  • cancer (abdo. mets)
  • previous abdominal surgery (adhesions)
  • previous surgery (?anaesthesia reaction)

Medications/allergies

FHx:

  • bowel cancer
  • hereditary disorders
  • anaesthetic problems

SHx:

  • alcohol (detox, gastritis, cancer, liver disease)
  • recreational drugs
  • smoking (cancer, increased coagulation, peptic ulcers)
  • diet
  • occupation
  • carers
  • living arrangement
  • exercise

Systems r/v:

  • cancer
  • cardiorespiratory
  • GU (?pregnancy)
  • urinary (?UTI)

Last meal: Nil by mouth

9
Q

Compare the differentials of acute abdomen according to timeframe.

A

Sudden (secs):

  • perforation/rupture of AAA/duodenal ulcer
  • MI
  • acute mesenteric occlusion

Rapidly accelerating (min):

  • biliary colic
  • ureteric colic
  • small bowel obstruction

Gradual (hrs):

  • inflammatory
  • obstructive
  • mechanical
10
Q

What are the time limits for nil by mouth?

A

Food - 6hrs
Breast milk - 4hrs
Clear liquids - 2hrs (non-fizzy to prevent reflux and regurgitation)

11
Q

What are the features of acute abdomen caused by malignancy?

A

Intermittent pain lasting >48hrs

Alteration of bowel habit

Mass felt

Weight loss

Abdominal distension

12
Q

What are the features of acute abdomen caused by intestinal obstruction?

A

Colicky severe pain

No aggravating factors

Vomiting/constipation (depending on level of obstruction)

Abdominal distension

High pitched bowel sounds

Previous surgery

13
Q

What are the features of acute abdomen caused by a perforated viscus?

A

Sudden onset of pain

Constant severe pain

Pain aggravated by moving/coughing

Diffuse tenderness

Silent, rigid abdomen

14
Q

What are the key examinations in an acute abdomen?

A
  • ABCDE
  • bedside: vomit bowls, IVs, Abx
  • general: appearance (unwell, pain, consciousness), vital signs (obs chart, EWS)
  • abdo. inspection: distension, discolouration (rashes, Grey Turner’s/Cullen’s, erythema ab igne), scars, visible peristalsis, masses (hernias, tumours, varices)
  • abdo. palpation: light (?tenderness), deep (?masses), guarding/rigidity (peritonitis), palpable masses, hernial orifices, rebound tenderness (peritonitis releasing stretches peritoneum)
  • abdo. percussion
  • abdo. auscultation: bowel sounds (peritonitis causing ileus has no bowel sounds, obstruction has tinkling bowel sounds)
  • PR +/- PV, testicles: PID, testicular torsion, indirect inguinal hernia, bowel obstruction, rectal bleeding
  • systems r/v: cardiorespiratory, vascular
15
Q

What are the key investigations in an acute abdomen?

A
  • Bedside: BM, urinalysis, pregnancy test, temperature, spO2, BP +/- stool samples +/- ECG
  • FBC: anaemia, infection
  • Clotting: DIC (sepsis), drugs, liver pathology
  • G&S: identify blood type and cross-match
  • U&Es: hypokalaemia (vomiting), renal function
  • amylase (serum/urinary): pancreatitis
  • ABG: acid-base balance, lactate
  • CRP
  • CXR: bowel perforation
  • AXR: obstruction (dilated bowel)
  • US
  • contrast studies
  • CT scan: perforation
  • laparoscopy/(exploratory) laparotomy
16
Q

What is the general management of an acute abdomen?

A
  • NBM
  • IV fluids (dehydration)
  • ?frequency of observations
  • tubes: catheter (monitor fluid output), NG (vomiting, obstruction)
  • thromboprophylaxis: TEDs, dalteparin (VTE assessment)
  • analgesia (IV morphine)
  • antiemetics
  • ?Abx
  • theatre workup (bloods, ECG, put on theatre list)
17
Q

Reminder: what are the different regions of the abdomen according to the digestive tract?

A

EPIGASTRIC:
Stomach —> 2nd part of duodenum
Liver/biliary tree
Pancreas & spleen

PERIUMBILICAL:
2nd part of duodenum —> proximal 2nd-3rd of transverse colon

SUPRAPUBIC:
Distal transverse colon to anal verge

18
Q

What is the aetiology of acute appendicitis?

A
1/400 incidence 
Peak incidence 15-25yrs 
Majority of appendices are retrocaecal (63%)
- 33% vermiform 
- pre- and post-ileal 
- subcaecal 
- paracaecal
19
Q

Describe the pathophysiology of acute appendicitis.

A

Causes of lumen obstruction:

  • faecolith
  • foreign body
  • tumour
  • trichobezoar
  • worms
  • trauma
  • lymphadenitis

Inflammation —> increased intraluminal pressure/onbstruction —> lymphoid swelling, decreased venous drainage, thrombosis, bacterial invasion —> abscess —> gangrene —> perforation —> peritonitis

20
Q

What are the signs and symptoms of acute appendicitis?

A
  • severe constant pain; starts as diffuse periumbilical pain and then moves to McBurney’s point
  • fever
  • unwell; flushed
  • anorexia
  • N&V
  • lymphadenopathy (mesenteric adenitis)
  • diarrhoea
21
Q

Constrat the prevalence of diagnoses of acute abdomen.

A
  • nonspecific (34%)
  • mesenteric adenitis = children following infection
  • acute appendicitis (28%)
  • acute cholecystitis/biliary colic (10%)
  • peptic ulcer perforation/bleeding (4%)
  • small bowel obstruction (4%)
  • gynaecological cause (4%) = ovarian cyst rupture/torsion, PID, ectopic, dysmenorrhoea
  • acute pancreatitis (3%)
  • renal/ureteric colic (3%)
  • malignant disease (2%)
  • acute diverticulitis (2%) = usually left-sided (sigmoid) but can be right-sided if bowel is long and looping
  • dyspepsia (1%)
  • IBD = “fat-wrapping” around affected bowel
22
Q

What is the scoring system for acute appendicitis diagnosis?

A

MANTRELS

Migratory pain +1
Anorexia +1
Nausea +1
Tenderness (RIF) +2
Rebound tenderness +1
Elevated temp. +1
Leucocytosis +2
Shift to left (blood film; indicates neutrophilia) +1

7 or above indicates acute appendicitis diagnosis

23
Q

What is Rovsing’s sign?

A

Light palpation of LIF causes pain in the RIF caused by displacement of appendix against peritoneum.

Specific to appendicitis

24
Q

What is psoas sign?

A

Patient lies on left side —> hyperextend right thigh —> abdo. pain as iliopsoas contracts

e.g. inflamed appendix lying near iliopsoas, extrapelvic abscess

25
Q

What are some of the investigations which may be appropriate in acute appendicitis?

A

BEDSIDE: BP, bpm, spO2, urine dip. (leucocytes)

BLOODS:

  • U&Es: dehydration
  • FBC: thrombocytosis, leucocytosis, anaemia
  • pregnancy
  • CRP
  • INR
  • G&S
  • blood culture

IMAGING:

  • CXR: ?perforation
  • US: if female to check repro. tracts before op.
  • abdo. CT
  • AXR: ?bowel obstruction
26
Q

What are the sepsis six?

A
  1. Deliver high flow O2
  2. Take blood cultures
  3. Empirical IV Abx
  4. Measure serum lactate & FBC
  5. IV fluid resuscitation
  6. Commence accurate urine output measurement
27
Q

What is the management of acute appendicitis?

A
  • ABCDE: 3.0-3.5l of Hartmann’s/saline over 24hrs
  • book OR for open/diagnostic lap +/-/appendicectomy
  • anaglesia: morphine, IV paracetamol
  • NBM
  • DVT prophylaxis: dalteparin
  • ?Abx: can complicate diagnosis unless sepsis is diagnosed
  • monitoring
  • senior review
  • laparoscopy
28
Q

When is an open appendicectomy indicated?

A
  • suspicion of adhesions
  • young (small abdomen)
  • difficult access
  • surgeon incapable of lap. appendicectomy
29
Q

Should the appedix be removed in an appendicectomy if it looks normal?

A

Yes

  • prevent future appendicitis
  • microscopic inflammation
30
Q

Give some extramural causes of intestional obstruction.

A
  • adhesions, fibrous bands
  • herniae (internal and external)
  • compression by tumour e.g. ovarian, peritoneal metastases
31
Q

Give some intramural causes of intestinal obstruction.

A
  • IBD
  • tumours e.g. adenocarcinoma, lymphoma, carcinoid
  • structures e.g. IBD, colitis, surgery (anastomosis), diverticular, ischaemia
  • volvulus
  • intussusception (adults: adhesions, strictures; babies: Henoch-Schonlein purpura, enlarged lymph nodes)
32
Q

Give some intraluminal causes of intestinal obstruction.

A
  • faecal impaction
  • swallowed foreign bodies
  • bezoars
  • gallstone ileus
33
Q

What are the most common causes of small intestinal obstruction?

A

Adhesions (50%-75%) = fibrous tissue usually resulting from prev. surgery causes “kinks” in bowel

Hernias (7%-25%)

  • femoral = high risk of strangulation (sharp, tough, borders —> venous swelling —> incarceration)
  • inguinal = low risk of strangulation
34
Q

Give some causes of functional obstruction of the intestines.

A
  • paralytic ileus following surgery/electrolyte imbalance
  • pseudocolon: elderly, mental disorders, electrolyte imbalance
  • Hirschsprung’s disease
35
Q

What are the less common causes of small intestinal obstruction?

A

Primary malignancy: GIST, carcinoid syndrome, lymphoma, caecal carcinoma

Seconday malignancy: ovarian, colorectal, stomach; causes multiple level obstruction (surgery not indicated —> permanent ileostomy)

Volvulus around fibrous band adhesion —> closed-loop —> fluid moves in —> distension

Mesenteric infarction

Gallstone ileus

Intussusception

36
Q

What are the signs and symptoms of small intestinal obstruction?

A
  • colicky abdo. pain (rolling around, paroxysms every 4-5min) which progresses to constant pain (lying still)
  • (faeculant) vomiting
  • late absolute constipation
  • failure to pass flatus
  • abdo. distension
  • visible peristalsis
  • visible hernias, scars
  • high-pitched, tinkling bowel sounds
  • dehydration
  • sepsis: tachycardia, hypotension, fever,
37
Q

What are some investigations which may be appropriate in small intestinal obstruction?

A

BEDSIDE:

BLOODS:

  • U&Es: vomiting
  • LFTs: ?gallstone ileus, ?metastases
  • FBC: ?anaemia, WCCs
  • clotting
  • G&S
  • ABG
  • serum amylase: ?pancreatitis
  • lactate: ?sepsis, ?necrotic bowel

IMAGING

  • AXR
  • erect CXR
  • MRI: ?Crohn’s
  • CT scan
  • barium meal

note: normal X-ray does not exclude (fluid-filled small bowel due to obstruction not visible on X-ray)

38
Q

What is the management of small intestinal obstruction?

A
  • resuscitation: 0.9% saline/Hartmann’s fluid boluses (10-20ml/kg)
  • NG tube placement
  • catheterise
  • conservative: adhesional obstruction resolves 60%-70% of the time
  • surgical: non-adhesional obstruction, adhesional obstruction with evidence of bowel ischaemia e.g. fever, marked tenderness, failure of resolution, imaging shows perforation
39
Q

What are the most common causes of large intestinal obstruction?

A

Colorectal carcinoma (65%)

Diverticular disease (20%)

  • acute diverticulitis
  • chronic: fibrotic diverticular strictures
  • pericolic abscess
  • ischaemic colitis causing strictures
  • IBD causing strictures

Volvulus (10%)

40
Q

Reminder: what are diverticula? Give some examples of true and false diverticula.

A

Outpouchings of hollow or fluid-filled structures (tend to occur where blood vessels pierce wall)

TRUE: invovle all layers of the structure
- Meckel’s diverticulum

FALSE: do not involve all layers of the structure

41
Q

What are the signs and symptoms of large intestinal obstruction?

A
  • colicky abdo. pain (longer paroxysms than small bowel) which progresses to constant in peritonitis
  • early absolute constipation
  • failure to pass flatus
  • rectal examination may reveal mass
  • visible peristalsis
  • high-pitched, tinkling bowel sounds
  • dehydration
  • signs of sepsis: tachycardia, hypotension, fever,
42
Q

What are some appropriate investigations in large bowel obstruction?

A

BEDSIDE:

BLOODS:

  • U&Es: vomiting
  • LFTs: ?gallstone ileus, ?metastases
  • FBC: ?anaemia, WCCs
  • clotting
  • G&S
  • ABG
  • serum amylase: ?pancreatitis
  • lactate: ?sepsis, ?necrotic bowel

IMAGING

  • AXR
  • erect CXR
  • MRI: ?Crohn’s
  • CT scan
  • barium meal

note: normal X-ray does not exclude (fluid-filled small bowel due to obstruction not visible on X-ray)

43
Q

What is the management of large intesintal obstruction?

A
  • resuscitation: 0.9% saline/Hartmann’s fluid boluses (10-20ml/kg)
  • catheterise
  • conservative: sigmoid volvulus resolves in 90%
  • surgical: resectionof infarcted bowel/stenting (not possible in complete obstruction; usually used palliatively in tumours)
44
Q

What is the aetiology, presentation, and examination findings in pelvis sepsis?

A

Aetiology: after acute appendicitis, salpingitis, diverticulitis, anaestomotic dehiscence

Presentation: pelvic discomfort, diarrhoea, tenesmus, fever, lassitude, sweats, rigors, pyrexia

DRE: +/- tender, boggy swelling high in pelvis

45
Q

Describe the characteristics of biliary colic.

A

Caused by transient obstruction of the cystic duct by a gallstone.

RUQ/epigastric pain (colicky - every 10-30min - but never goes away completely)

Abrupt onset, possibly exacerbated by (fatty) food

Associated with nausea and vomiting

No associated systemic response

Elevated ALP and bilriubin

Cessation spontaneous or post-analgesia

46
Q

Describe the characteristics of acute cholecystitis.

A

Same cause as biliary colic but associated with inflammation and involvement of the parietal peritoneum.

Localised tenderness with localised peritonism (+ve Murphy’s sign)

Associated with a systemic response i.e. leucocytosis, pyrexia

47
Q

Describe the aetiology of gallstones.

A

80% asymptomatic.
Up to 30% of pop. may have gallstones.
8% of males and 17% of females (fiar, fat, female, fertile, forty)

48
Q

Give examples of some distant complications of acute cholecystitis.

A
  • choledocholithiasis: stones within common bile duct; presents with elevated bilirubin and cholangitis
  • cholangitis: infected bile —> Charcot’s triad (fever, RUQ pain, jaundice)
  • Reynold’s pentad: Charcot’s triad + mental obtundation + shock
  • pancreatitis: deranged LFTs and elevated amylase
49
Q

Give examples of some local complications of acute cholecystitis.

A
  • mucocoele: failure to relieve cystic duct obstruction causes gallbladder necrosis
  • empyema: same as above but with more infection
  • gangrene
  • perforation
  • fistula: into duodenum/colon (gallstone ileus)
  • Mirizzi syndrome: external compression of common bile duct by stone impacted in Hartmann’s pouch
50
Q

Give examples of causes of pre-hepatic jaundice.

A

Unconjugated bilirubin elevated

  • haemolysis
  • Gilbert’s syndrome: reduced liver uptake of unconjugated bilirubin
  • Crigler-Nagler syndrome: reduced conjugation of bilirubin due to enzyme defect
51
Q

Give examples of causes of hepatic jaundice.

A
  • viral hepatitis
  • alcoholic hepatitis
  • drug induced
  • cirrhosis
52
Q

Give examples of causes of post-hepatic jaundice.

A

Conjugated bilribuin elevated

  • gallstones
  • biliary stricture
  • sclerosing cholangitis
  • autoimmune pancreatitis associated sclerosing cholangitis
  • congenital choledochal cysts
  • malignancy
53
Q

What history, examinations, and investigations are appropriate in post-hepatic jaundice?

A

Hx:

  • abdo. pain
  • fever
  • itching
  • alcohol
  • drugs

O/E:

  • abdo. masses
  • hepatomegaly
  • splenomegaly
  • stigmata of liver disease
  • ascites
  • caput medusae
Ix: 
BLOODS:
- FBC
- U&Es
- LFTs: elevated  in liver damage 
- ALP: elevated 
- bilirubin: elevated 

IMAGING:

  • US abdomen to confirm (if -ve: hepatitis serology, autoimmune screen)
  • CT (periampullary)
  • MRCP
54
Q

What is the management of post-hepatic jaundice?

A

CBD stones: ERCP, lap./open exploration

Benign strictures: hepaticojejunostomy

Autoimmune: steroids, ERCP and balloon dilatation of dominant stricture

Malignancy: resection (10%-20%) or palliative

55
Q

Reminder: what are the endocrine and exocrine enzymes released by the pancreas.

A

Endocrine:

  • insulin
  • glucagon
  • somatostatin
  • pancreatic polypeptide

Exocrine:

  • trypsinogen
  • HCO3-
  • amylase
  • prolipase
  • chymotrypsinogen
56
Q

What is the presentation of pain due to acute pancreatitis?

A

Constant epigastric pain, maximal intensity several hours after onset

50% radiate to back

Aggravated by movement, relieved by sitting up, worst when flat (inflamed pancreas resting on spine)

Associated with nausea and vomiting

57
Q

What are the causes of acute pancreatitis?

A

I GET SMASHED

Idiopathic 
Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps 
Autoimmune 
Scorpion/spider bite 
Hyperlipidaemia 
ERCP 
Drugs e.g. azathioprine, metronidazole
58
Q

What are the indications for ERCP?

A
  • choledocholithiasis in high risk patients (recent cholangitis, recent acute pancreatitis, abnormal LFTs)
  • acute pancreatitis due to biliary obstruction, sphincter of Oddi dysfunction, idiopathic
  • diagnosis of pancreatic/biliary malignancy
  • palliative procedures e.g. drainage
  • dilatation of benign strictures
59
Q

What are the examination findings in acute pancreatitis?

A
  • epigastric tenderness
  • abdo. distension
  • fever
  • tachycardia
  • Grey-Turner’s/Cullen’s sign (3%)
  • jaundice
60
Q

What are the appropriate investigations in acute pancreatitis?

A

BLOODS:

  • FBC
  • U&Es
  • LFTs
  • amylase
  • lipase
  • calcium
  • ABG

IMAGING:

  • CXR/AXR: exclude perforation, sentinel loop
  • US abdo.: rule out gallstones, check for pseudocysts
  • CT: assess for pancreatic necrosis
61
Q

What are some differentials for acute pancreatitis?

A
  • perforated duodenal ulcer
  • mesenteric infarction
  • MI
  • AAA
  • cholecystitis/cholangitis
62
Q

How is acute pancreatitis scored?

A
Glasgow scale (Imrie): PANCREAS
PaO2 < 8.0kPa (+1)
Age > 55yrs (+1)
Neutrophils > 15 x 10^9 (+1)
Calcium < 2.0 (+1)
Urea > 16 (+1) 
LDH > 600 (+1)
Albumin < 32 (+1) 
Glucose > 10 (+1) 

2< severe pancreatitis likely
(also Balthazar score)

63
Q

Outline the management of acute pancreatitis.

A
  • IV fluids
  • catheter: monitor urine output
  • correct eletrolytes
  • can eat and drink
  • etOH withdrawal prophylaxis if appropriate
  • identify and treat cause
  • +/- Abx
  • +/- ERCP
  • central line if necessary
64
Q

Give some examples of complications of acute pancreatitis.

A

SYSTEMIC

  • SIRS/shock
  • pulmonary insufficiency
  • hypocalcaemia/magnesium/albumin
  • DIC

LOCAL

  • pancreatic necrosis
  • pancreatic abscess
  • pancreatic pseudocyst
  • pancreatic ascites
  • pancreatic fistulae
  • pancreatic duct stricture
  • pancreatic haemorrhage
65
Q

Give some examples of complications of ERCP.

A
  • pancreatitits (2%-9%)
  • infection
  • bleeding
  • perforation of duodenum
  • failure to remove gallstone
  • stent occlusion
  • pancreatic duct obstruction
  • pseudocyst formation
66
Q

Outline the causes and presentation of chronic pancreatitis.

A

Causes:

  • alcohol
  • trauma
  • pancreas divisum (single pancreatic duct splits)
  • familial

Presentation: recurrent/persistent abdominal pain with evidence of exocrine or endocrine pancreas insufficiency

67
Q

What are the examination findings and investigations in suspected chronic pancreatitis?

A

O/E:

  • recurrent epigastric pain radiating to back
  • anorexia
  • weight loss
  • steatorrhoea
  • diabetes
  • naroctic abuse

Ix:

  • radiological evidence of calcification, fibrosis of pancreas, duct dilatation
  • faecal elastase
68
Q

What is the management of chronic pancreatitis?

A
  • Creon to counteract exocrine dysfunction
  • opiate analgesia & coeliac axis block
  • give up alcohol
  • diabetic control
  • ERCP and pancreatic duct stenting
  • resection
  • drainage
69
Q

Give some differentials for pain in the epigastric region.

A
  • acute/chronic peptic ulceration
  • acute cholecystitis
  • perforated peptic ulcer
  • acute pancreatitis
  • IBS
  • gastric volvulus
  • Boerhaave’s syndrome
  • ruptured AAA
  • Curtis-Fitz-Hugh syndrome
  • acute hepatitis
  • liver mets
  • spleen infarction
  • acute appendicitis
  • MI
  • pericarditis
  • pre-eclampsia
  • gastric carcinoma
  • pancreatic cyst/tumour
70
Q

Give some differentials for pain in the right hypochondrium.

A
  • MI
  • pericarditis
  • lower lobe pneumonia
  • PE
  • pleurisy
  • cholecystitis
  • pre-eclampsia
  • HELLP syndrome
  • duodenal ulcer
  • retrocaecal appendicitis
71
Q

Give some differentials for pain in the left hypochondrium.

A
  • MI
  • pericarditis
  • lower lobe pneumonia
  • PE
  • pleurisy
  • splenic rupture
  • splenic abscess
  • acute splenomegaly
  • oesophagitis
  • gastritis
  • peptic ulcer
  • oesophageal/gastric cancer
72
Q

Give some differentials for pain in the umbilical region.

A
  • small bowel obstruction
  • large bowel obstruction
  • intestinal infarction/ischaemia
  • small bowel volvulus
  • small bowel perforation
  • intussusception
  • Crohn’s
  • AAA
  • mesenteric adenitis
  • Meckel’s diverticulum
  • mesenteric ischaemia/infarction
  • acute pancreaitis
  • pancreatic cyst/tumour
  • lymphoma
  • lymph mets
73
Q

Give some differentials for pain in the right lumbar region.

A
  • AAA rupture/dissection
  • renal calculi
  • pyelonephritis
  • renal tumour
  • retrocaecal appendicitis
  • diverticulitis
  • ovarian cyst/torsion/rupture
  • cholecystitis
  • retroperitoneal haemorrhage
  • mesenteric ischaemia
74
Q

Give some differentials for pain in the left lumbar region.

A
  • AAA rupture/dissection
  • renal calculi
  • pyelonephritis
  • renal tumour
  • diverticulitis
  • ovarian cyst/torsion/rupture
  • pancreatitis
  • retroperitoneal haemorrhage
  • mesenteric ischaemia
75
Q

Give some differentials for pain in the hypogastric region.

A
  • distended bladder
  • IBS
  • UTI
  • constipation
  • diverticulitis
  • IBD
  • large bowel obstruction
  • colon tumour
  • ectopic pregnancy
  • PID
  • ovarian cyst/torsion/rupture
  • ovulation pain (Mittelschmerz)
  • endometriosis
  • miscarriage
  • labour
  • placental abruption
76
Q

Give some differentials for pain in the right iliac fossa.

A
  • constipation
  • acute appendicitis
  • Meckel’s diverticulitis
  • mesenteric adenitis
  • Crohn’s (terminal ileum)
  • acute gastroenteritis
  • intussusception
  • colon/caecal carcinoma
  • solitary caecal diverticulum
  • acute sigmoid diverticulitis
  • TB
  • actinomycosis
  • Yersinia pestis
  • pseudo-TB
  • testicular torsion
  • perforated peptic ulcer
  • hernias
  • ovarian cyst/torsion/rupture
  • endometriosis
  • PID
  • ureteric calculus
  • ectopic pregnancy
  • ovulation pain (Mittelschmerz)
  • pyelonephritis/cystitis
77
Q

Give some differentials for pain in the left iliac fossa.

A
  • IBS
  • diverticulitis/pericolic abscess
  • large bowel obstruction/perforation
  • colon carcinoma +/- pericolic abscess
  • IBD
  • ectopic pregnancy
  • PID
  • endometriosis
  • ovulation pain (Mittelschmerz)
  • ischaemia
  • Crohn’s colitis
  • toxic colon
  • testicular torsion
  • ureteric colic/pyelonephritis
  • hernia
  • constipation
78
Q

Contrast cholangitis and asc. cholangitis.

A

Cholangitis = bile stasis above obstruction —> superimposed infection of biliary tract

Asc. cholangitis = propagation of biliary infection proximally into intrahepatic ducts —> liver abscess

79
Q

What is Borchardt’s triad?

A

Sudden onset epigastric pain + intractable retching + passing NG tube difficult = indicates gastric volvulus (giant hiatus hernia req.)

80
Q

Which flank should Grey-Turner’s sign be?

A

Haemorrhagic pancreatitis —> LEFT

Intraperitoneal haemorrhage e.g. AAA —> RIGHT

81
Q

Describe the features of carcinoid syndrome.

A

Carcinoid tumour (tumour on liver/beyond portal system, otherwise 5-HT would be metabolised by liver e.g. small intestine, appendix, proximal large bowel) secreting 5-HT.

Causes symptoms of flushing, diarrhoea, abdo. pain, palpitations, hypotension, wheezing

82
Q

What are the six Fs of abdominal distenstion?

A

Fat, Fluid, Faeces, Flatus, Foetus, Fibroids

83
Q

Give some examples of causes of GI haemorrhage.

A

COMMON (80%):

  • acute peptic ulceration
  • gastric erosions
  • chronic peptic ulceration

UNCOMMON (5%): oesophageal varices

OTHER:

  • bleeding disorders
  • Meckel’s diveritculum
  • jejunal diverticulum
  • intussusception
  • angiodysplasia
  • Peutz-Jegher’s syndrome = hereditary intestinal polyposis
  • Osler-Rendu-Weber syndrome = hereditary haemorrhagic telangiectasia
  • oesophagitis
  • GIST tumours
  • gastric adenocarcinoma
  • Mallory-Weiss tear
  • aortic-enteric fistula
  • haemobilia
  • Dieulafoy syndrome = large torturous arteriole in stomach wall
  • Henoch-Schonlein purpura
84
Q

What is the cause and presentation of empyema of the gallbladder?

A

Complication of acute cholecystitis.

  • fever
  • pain
  • tender mass under liver, moves with palpation

Treat by cholecystectomy

85
Q

Contrast the conservative and urgent management of a cholecystitis.

A

CONSERVATIVE = send home after pain subsides, book for elective lap. cholecystectomy in 6-8wks

URGENT = acute attacks, biliary peritonitis

86
Q

What is acanthosis nigricans?

A

Thickened, hyperpigmented skin, predominantly on flexures, warty/velveted appearance

Young/obese = increased insulin (pseudo-acanthosis nigricans)
Older = malignancy (esp. GI)
Hyperandrogenism in females

87
Q

Contrast true and pseudo macroglossia.

A

TRUE = definitve histological findings

  • primary: hypertrophy/plasia e.g. hypothyroidisim, lymphangioma, haemangioma, Down’s, idiopathic, metabolic, amylodosis
  • secondary: infiltration of normal tissue with anomalous elements

PSEUDO = relative enlargement of tongue secondary to small mandible with no definitive histological findings

88
Q

What is Light’s criteria for exudate?

A

TRANSUDATE EXUDATE
Clear Cloudy
Lower specific gravity Higher specific gravity
Lower protein content Higher protein content
Higher albumin content Lower albumin content
Lower cholesterol content Higher cholesterol content