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120 Cards in this Set
- Front
- Back
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What features of history for acute abdominal pain are red flags? |
Collapse at toilet - points to intra-abdominal bleeding Lightheadedness Ischaemic heart disease Progressive vomiting, pain and distension Menstrual abnormalities Malignancy |
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What features on examination are red flags for acute abdominal pain? |
Allow and sweating Hypotension Atrial fibrillation or tachycardia Fever Prostration Rebound tenderness and guarding Decreased urine output |
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What are the 3 most common causes of acute abdominal pain in general practice? |
1. Acute appendicitis 2. Colic abdominal pain - ureteric or biliary 3. Mesenteric adenitis (when children included in study) |
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Colicky midline umbilical abdominal pain (severe) + vomiting + distension = |
SBO |
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Midline lower abdominal pain + distension + vomiting = |
LBO |
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What is the common pattern with pain and vomiting in the acute abdomen with a surgical cause? |
The pain nearly always precedes the vomiting |
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What should be considered in a elderly person with arteriosclerotic disease or in patients with partial fibrillation presenting with severe abdominal pain or following an MI? |
Mesenteric artery occlusion |
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What is the common diagnosis for up to 1/3 of all presentations (acute and chronic) of abdominal pain? |
Non-specific - no cause is found |
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What are the most likely causes of acute abdominal pain (excluding trauma)? |
Acute gastroenteritis Acute appendicitis Mittelschmerz/ dysmenorrhoea Irritable bowel sundrome |
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What serious disorders not to be missed should be considered in acute abdominal pain? |
Cardiovascular: - MI, ruptured AAA, dissecting aneurysm aorta, mesenteric artery occlusion Neoplasia: - LBO or SBO Severe infections: - acute salpingitis, peritonitis, ascending cholangitis, intra-abdominal abscess Pancreatitis Ectopic pregnancy SBO/ strangulated hernia Sigmoid volvulus Perforated viscus |
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How does early appendicitis typically present? |
Central abdominal pain that shifts to the RIF 4-6 hours later Characteristic march of symptoms: pain -> anorexia + nausea -> vomiting |
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What specific areas of history questioning should be explored in abdominal pain aside from SOCRATES? *Think associated symptoms/ causes |
Anorexia, nausea or vomiting Micturition Bowel function Menstruation Drug intake |
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What general examination aside from that of the abdomen should be performed? |
General appearance Oral cavity Vitals - temp, HR, BP, RR Chest - check heart and lungs for upper abdominal pain (esp. if absent abdominal signs) Abdomen - inspection, auscultation, palpation and percussion |
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What specific examinations of the abdomen should you consider with abdominal pain? |
Inguinal region (including hernial orifices) and femoral arteries Rectal examination - mandatory Vaginal exam - for suspected problems of the fallopian tubes, uterus or ovaries Thoracolumbar spine - if referred spinal pain suspected UA - white cells, red cells, glucose, ketones and porphyrins Special tests - Murphy sign (acute cholecystitis); iliopsoas or obturator signs |
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What does guarding indicate? What does rebound tenderness indicate? |
Guarding - peritonitis Rebound tenderness - peritonial irritation (bacterial peritonitis, blood) |
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What is the patient pain indicator? |
Finger pointing sign - indicates focal peritoneal irritation vs. Spread palm sign - indicates visceral pain |
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What are some causes of a silent abdomen? |
Diffuse sepsis Ileus Mechanical obstruction (advanced) |
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What does hypertympany indicate? |
Mechanical obstruction |
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What blood tests could you consider ordering in acute abdominal pain? |
FBC - anaemia with chronic blood loss Blood film - abnormal red cells with sickle cell disease WCC - infection ESR - raised with cancer, Chrohns, abscess CRP - diagnosis and monitoring infection and inflammation LFTs - hepatobiliary disorder Lipase - pancreatitis (>3x normal in acute) |
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What other tests (other than blood or radiological) could you consider in acute abdominal pain? |
Urine B-hcg (can also do serum) - for suspected ectopic Urine analysis - blood: ureteric colic (stone or blood clot), urinary infection - white cells: UTI, appendicitis (bladder irritation) - bile pigments: gall bladder disease - porphobilinogen: porphyria - ketones: DKA Faecal blood - mesenteric artery occlusion, intussusception, colon cancer, diverticulitis, Crohns disease and ulcerative colitis ECG |
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What radiological tests can be considered for acute abdominal pain? |
Plain xray abdomen CXR - air under diaphragm -> perforated ulcer USS IVP Contrast enhanced x-rays e.g. gastrografin meal for ddx of bowel leakage CT scan ERCP MRI scan |
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What might you be looking for/ find on a plain abdominal X-ray? |
Kidney/ ureteric stones (70% opaque) Biliary stones (10-30% opaque) Air in biliary tree Calcified aortic aneurysm Marked distension sigmoid -> sigmoid volvulus Distended bowel with fluid level -> bowel obstruction Enlarged caecum with large bowel obstruction Blurred right psoas shadow -> appendicitis A sentinel loop of gas in LUQ -> acute pancreatitis |
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What might you be looking for/ find on an USS scan of the abdomen? |
Good for hepatobiliary system, kidneys and female pelvis - Gallstones - Ectopic pregnancy - Pancreatic pseudocyst - Aneurysm aorta/ dissecting aneurysm - Hepatic metastases and abdominal tumours - Thickened appendix - Paracolic collection |
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What might you be looking for/ find on CT scan of the abdomen? |
Excellent survey of abdominal organs including masses and fluid collection - Pancreatitis (acute/ chronic) - Undiagnosed peritoneal inflammation (best) - Trauma - Diverticulits - Leaking AAA - Retroperitoneal pathology - Appendicitis (esp. with PO contrast) |
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What invasive procedures can you refer a patient with abdominal pain for? |
Endoscopy upper GIT Sigmoidoscopy Colonoscopy |
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What conditions tend to cause pain in the RUQ? |
Biliary colic Chilecystits Ascending cholangitis Acute heptitis |
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What conditions tend to cause epigastric pain? |
Gastritis Perforated ulcer Cholecystitis Pancreatitis MI (referred) Lower lobe pneumonia (referred) |
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What conditions tend to cause LUQ pain? |
Kidney colic UTI Splenic infarct/ rupture |
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What conditions tend to cause periumbilical pain? |
SBO Appendicitis (early) Ruptured AAA Mesenteric artery occlusion |
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What conditions tend to cause RIF pain? |
Appendicitis Crohns disease Meckel's diverticulitis Renal/ ureteric colic Mesenteric adentitis |
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What conditions tend to cause lower abdominal pain? |
LBO |
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What conditions tend to cause LIF pain? |
Diverticulitis Ureteric colic |
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What conditions tend to cause suprapubic pain? |
Ruptured ectopic Acute PID Ruptured ovarin cyst Torsion of ovary |
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What conditions tend to cause groin pain? |
Torsion of testis Check hernial orifices with SBO |
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What are the 3 most common causes of acute abdominal pain in children? |
Infant colic Gastroenteritis (all ages) Mesenteric adentitis |
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What are 3 serious causes of abdominal pain in children? |
Intussusception (peaks at 6-9 months) Acute appendicitis (mainly 5-15 years) Bowel obstruction |
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What are some common pitfalls that are missed in the diagnosis of acute abdominal pain in children? |
Child abuse Constipation Torsion of testes Lactose intolerance Peptic ulcer Infections: mumps, tonsillitis, pneumonia (esp. RLL), EBM, UTI Adnexal disorders in females e.g. ovarian |
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What are the typical clinical features of infant colic? |
2-16 weeks old Prolonged crying - at least 3 hours Crying worse around 10 weeks of age Crying during late afternoon and early evening Occurence at least 3 days per week Child flexing legs and clenching fists because of the 'stomach ache' Normal physical examination |
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What management options can you provide for parents with a child with infant colic? |
Reassurance Use gentleness (subdued lighting, soft music, quiet feeding times) Avoid quick movements Make sure abby is not hungry If breastfed, express water foremilk before putting baby to breast Provide demand feeding Make sure baby is burped Provide comfort from a dummy or pacifier Cuddle and carry the baby around e.g. use sling Mother to get rest Do not worry about leaving a crying child for 10 mins or so after 15 minutes of trying consolation Can use simethicone (infancol wind drops) in severe cases |
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Pale child + severe colic + vomiting = |
Acute intussusception |
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What are the typical clinical features of a child with intussusception? |
Male babies > female Age 3 months - 2 years Sudden-onset of acute pain with shrill cry - about every 15 mins for 2-3 mins Vomiting Lethargy Pallor with attacks Intestinal bleeding: red current jelly (60%) |
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What signs might you find in a child with intussusception? |
Pale, anxious, unwell Sausage-shaped mass in RUQ esp. during attacks Signe de dance (emptiness in RIF to palpation) Alternating high-pitched active bowel sounds with absent sounds Rectal exam +/- blood |
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What investigations can you use to diagnose intussusception? |
USS Oxygen or barium enema (with caution) for diagnosis and rx |
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What treatment options are there for intussusception? |
Hydrostatic reduction by air or oxygen from the "wall" supply (preferred) or barium enema Surgical intervention |
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What is a common cause of colicky abdominal pain in children caused by a drug? |
Cigarette smoking Other drugs e.g. marijuana, cocaine and heroin can also cause |
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What are the typical features of acute appendicitis in children? |
10-12 years old Mildline pain, shifts to right Nil preceding respiratory illness Anorexia, nausea and vomiting - ++ Usually pale Temperature usually normal or mild increase Tender in RIF, guarding +/- rigidity Rectal exam - invariably tender Psoas and obturator tests - usually positive FBC - leucocytosis |
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What are the typical features of mesenteric adentitis? |
Younger child Pain is RIF but can be midline Usually had URTI or tonsillitis preceding May have anorexia, nausea or vomiting Usually flushed Temperature usually high Tender in RIF, minimal guarding, no rigidity Often tender in rectum but usually less than appendicitis Psoas and obturator tests usually negative FBC - lymphocytosis |
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What size is abnormal for an abdominal aorta? When does a AAA become dangerous? |
>30mm is abnormal Significant size up to 50mm >50mm - requires operation > 60mm - high risk of rupture (dangerous) |
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What investigations can help to define a AAA? |
USS - good for screening CT - clearer imaging MRI scan - best definition |
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What should happen with all AAA regardless of size? |
Referral! |
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Intense pain + pale and 'shocked' + back pain = |
Ruptured AAA |
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What causes acute intestinal ischaemia? |
Superior mesenteric artery occlusion - embolus or thrombus |
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Anxiety and prostration + intense central pain + profuse vomiting +/- bloody diarrhoea = |
Mesenteric arterial occlusion |
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What signs might you find in a patient with mesenteric arterial occlusion? |
Localised tenderness, rigidity and rebound over infarcted bowel (later finding) Absent bowel sounds (later) Shock (later) Tachycarida - ? AF |
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What investigations should you considering mesenteric artery occlusion? |
CRP - elevated Xray abdo - thumb printing due to mucosal oedema on gas-filled bowel CT - best defintion Mesenteric arteriography - if embolus suspected Laparotomy - common way to diagnose |
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What is the management of mesenteric artery occlusion? |
Surgical |
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Localised RIF pain + a/n/v + guarding = |
acute appendicitis |
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What is the psoas sign (acute appendicitis)? |
Pain on resisted flexion of right leg or on hip extol or on elevating right leg (due to irritation of psoas esp. with retrocaecal appendix |
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What is the obturator sign (acute appendicitis)? |
Pain on flexing patients right thigh at the hip with knee bent and then internally rotating the hip |
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What is an unusual sign that might be present in adults with appendicitis? |
Furred tongue and halitosis |
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What is Rovsing sign (acute appendicitis)? |
Tenderness in RIF while palpating in LIF |
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When is appendicitis most likely to occur in pregnancy? |
Second trimester |
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If perforated appendix what antibiotics should be given to a patient? |
Cefotaxime Metronidazole |
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Colicky central pain + vomiting + distension = |
SBO |
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What are the main causes of SBO? |
Outside obstruction e.g. adhesions - commonest cause, previous laparotomy Strangulation in hernia or pockets of abdominal cavity - may lead to "closed loop" obstruction Lumen obstructions e.g. foreign body, trichobezoar, gallstones, intussusception, malignancy |
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Name 7 clinical features of SBO? |
Severe colicky epigastric and periumbilical (mainly) pain Spasms last about 1 minute Spasms every 3-10 minutes (according to level) - the more proximal the obstruction, the more sever the pain Vomiting Absolute constipation (nil after bowel emptied) No flatus Abdominal distension |
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What signs might be seen in SBO? |
Visible peristalsis, loud borborygmi Abdomen soft (except with strangulation) Tender when distended Increased sharp, tinkling bowel sounds Dehydration PR: empty rectum, may be tender Check hernial orifices |
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What investigations can you consider for SBO? |
Xray: plain erect flim - step ladder fluid levels (4-5 for diagnosis) in 3-4 hours Gastrografin follow-through for precise diagnosis with caution +/- CT scan |
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What management is there for SBO? |
Admission to hospital IV fluids Bowel decompression with NG tube Laparotomy or hernia repair |
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Name 5 differences between SBO and LBO |
1. Frequency of pain: SBO 3-5 mins, LBO 6-10 mins 2. Intensity of pain: SBO +++, LBO + 3. Vomiting: SBO - early, frequent, violent with gastric juices then green, LBO - later, less severe, faeculent content (later) 4. Dehydration and degree of illness: SBO - marked, LBO - less prominent 5. Distension: SBO - minimal, LBO - marked |
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Colicky pain + distension +/- vomiting = |
LBO |
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What is the most common cause of LBO? |
Colon cancer (75%) * Can occur with diverticulitis or volvulus of the sigmoid colon (10%) or caecum |
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Who is sigmoid volvulus more common in? |
Older men - Sudden and severe onset |
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What investigations should you consider for LBO? |
Xray: distension of large bowel with separation of austral markings, esp. caecal distension - Sigmoid volvulus shows a distended loop - Gastrografin enema confrims diagnosis |
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What management options are there for LBO? |
Drip + suction Surgical referral |
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Sudden severe pain + anxious, still, 'grey', sweaty + deceptive improvement = |
Perforated peptic ulcer |
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What should you ask about in someone you suspect has a perforated peptic ulcer? |
Drugs - NSAIDs and H2-receptor antagonists Recent heavy meal Sudden-onset severe epigastric pain Continuous pain but lessens for a few hours Radiation to 1 or both shoulders (uncommon) or RLQ Hiccough - a common late symptom |
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What investigations should you consider if you suspect perforated peptic ulcer? |
CXR: may show free air under diaphragm (need to sit up right for 15 mins prior CT scan - accurate * limited Gastrografin meal can confirm diagnosis |
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What are the 4 traps to avoid when dealing with a patient with sudden onset abdominal pain? |
1. Beware of easing of pain as peritoneal fluid accumulates 2. Elderly puts may have minimal pain 3. Painless perforation can occur with steroids 4. Avoid giving morphine or pethidine until diagnosis confirmed |
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Where is a peptic ulcer most likely to perforate? |
Duodenum |
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What are the management options for a perforated peptic ulcer? |
Pain relief Drip and suction - immediate NG Broad-spectrum abs Immediate laparotomy after resusitation Conservative rx may be possible (e.g. later presentation and Gastrografin swallow indicates sealing of perforation ) |
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Intense pain (loin) -> groin + microscopic haematuria = |
Ureteric colic |
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Where does the following pain usually suggest a stone is lodged? Loin? Kidney/ ureteric colic? Strangury? |
Loin pain - stone in kidney
Kidney/ ureteric colic - ureteric stone Strangury - stone in bladder |
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What are the clinical features of ureteric colic? |
30-50 years old (average) M>F Intense colicky pain: in waves, each lasting 30 seconds with 1-2 mins respite Begins in loin and radiates around the flank to the groin, thigh, testicle or labia Usually lasts <8 hours +/- vomiting |
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What signs might you see in a patient with ureteric colic? |
Restless: may be writhing in pain Pale, cold and clammy Tenderness at costovertebral angle +/- abdominal and back muscle spasm Smokey urine due to haematuria |
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How do you diagnose ureteric colic? |
Urine: microscopy +/- dip (negative does not exclude calculus) Plain x-ray: 75% radio-opaque IVP: confrims opacity, level of obstruction, kidney function and any anatomical abnormalities USS: may locate calculus but will exclude obstruction Non-contrast CT: gold standard (97% sensitive, 96% specific) |
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What medications can you give for ureteric colic? |
Morphine 5-10mg IV state then titrate to effect + Metoclopramide 10mg IM OR Fentanyl 50-100 mcg IV then titrate Then further pain relief with indomethacin suppositories (max 2 per day) OR Diclofenac injection 50mg TDS for 1 week |
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What non-pharmacological management can you consider for ureteric colic? |
Avoid high fluid intake - provokes distension of ureter Can go home once pain settles and have IVP next day Strain urine to obtain calculus and send off for analysis |
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When is a calculus likely to pass spontaneously? |
<5mm (90% <4mm pass spontaneously) |
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What follow up do patients with ureteric colic require? |
Analysis of stone Repeat IVP if evidence of obstruction for > 3 weeks Search for cause of stone e.g. hyperparathyroidism, hypercalcaemia, hyperoxaluria and UTI If develop fever indicates obstructed infected kidney |
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When should you refer a patient with ureteric colic? |
Stone > 5mm in diameter High-grade obstruction Gross hydronephrosis Fever UTI Unremitting pain Stone fails to progress T2DM Presence of solitary kidney |
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How common is recurrence of urinary tract calculi? |
75% (most within 2 years) |
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What is the percentages/ types of urinary stones? |
Calcium oxalate - 75-80% Uric acid - 7% Cystine - rare Infected calculi (struvite) Mg+, NH4+, PO4- (5%) |
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What investigations should you consider in a patient with recurrent urinary calculi? |
Serum EUCs Serum calcium, phosphate, uric acid, magnesium Serum alkaline phosphatase Urine - microbiology and culture (at least 2 consecutive 24 hour urine samples) Stone analysis IVP |
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What dietary advice should be given to patients with recurrent urinary calculi? |
Drink at least 2L of water per day - most important Minimise foods with oxalate or uric acid - Oxalate foods e.g. chocolate, coffee, cola drinks, rhubarb, tea - Uric acid foods e.g. beer, red wine, red meat, organ meats Avoid milk in tea - calcium precipitates oxalate Restrict salt intake Reduce animal protein to 1 major meat meal per day Add citrate-containing fruit juices to diet including grapefruit, apple and orange juice Eat a healthy diet of vegetables and fruit with high fibre content |
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Severe pain + vomiting + pain radiation = |
Biliary colic |
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What is the stereotypical patient with biliary colic? |
Female 40's Fat Fair Fertile |
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What are the typical clinical features of biliary colic? |
Acute onset severe pain Post-prandial or at night (often wakes 2-3am) Constant pain (not colicky) Lasts 20 mins to 2-6 hours Maximal RUQ/ epigastrium May radiate to tip of right shoulder or scapula Painful episode builds to a crescendo for about 20 mins Some relief by assuming flexed posture +/- nausea and vomiting with considerable retching |
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What specific signs might you find in a patient with biliary colic? |
Localised tenderness (Murphy sign) over funds of gallbladder (on transpyloric plane) |
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What tests can you consider for diagnosis of biliary colic? |
Abdo USS Helical CT Intravenous cholangiography if previous cholecystectomy LFTs - may show elevated bilirubin and alkaline phosohatase |
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What management options are there for biliary pain? |
Pain relief - morphine 10-15mg IM q4hly PRN + hyoscine 20mg IM or pO OR morphine 2.5-5mg IV stat then titrate or fentanyl 50-100mcg IV stat then titrate Gallstone dissolution or lithotripsy (in those unable to have surgery) Cholecystectomy (main procedure) |
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What are the 2 main types of gallstones? |
Cholesterol Pigment (bilirubin) |
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How often is acute cholecystitis associated with gallstones? |
Over 90% of cases * usually past hx of biliary pain |
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What are the most common causative organisms of acute cholecystisis? |
Aerobic bowel flora e.g. e. coli, klebsiella species, enterococcus faecalis |
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What are the clinical features of acute cholescystisis? |
Steady severe pain and tenderness Localised to right hypochondium or epigastrium Nausea and vomiting (bile) in about 70% Aggravated by deep inspiration |
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What are the signs of acute cholecystitis? |
Patient tends to lie still Localised tenderness over gall bladder (Murphy postive) Muscle guarding Rebound tenderness Palpable gallbladder (approx. 15%) Jaundice (approx. 15%) +/- Fever |
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How do you diagnose acute cholecystitis? |
USS: gallstones but not specific HIDA scan: demonstrates obstructed duct - the usual cause WCC and CPR - can be elevated |
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What is the treatment for acute cholecystitis? |
Bed rest IV fluids NBM Analgesics Abx - if evidence of sepsis use amoxy/ amp 1g IV QID plus gent 4-6mg/kg IV daily - change to Augmentin DF PO BD when afebrile Cholecystectomy |
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Severe pain + nausea and vomiting + relative lack of abdominal signs = |
Acute pancreatitis |
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What are the common causes of acute pancreatitis? |
Alcoholism (35%) Gallstone disease (40-50%) Commonly precipitated by fatty foods and etoh |
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What are the typical clinical features of acute pancreatitis? |
Sudden onset of sever constant epigastric pain but onset can be steady Lasts hours or a day or so May radiate to back Pain may be relieved by sitting forwards Nausea and vomiting Sweating and weakness |
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What signs might be found in a patient with acute pancreatitis? |
Patient is weak, pale, sweating and anxious Tender in epigastrium Lack of guarding, rigidity or rebound Reduced bowel sounds (may be absent if ileus) +/- abdo distension Fever, tachycardia +/- shock |
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What investigations might you consider in the diagnosis of acute pancreatitis? |
WCC - leucocytosis Serum lipase CRP - elevated Serum glucose increased, calcium decreased LFTs: ? obstructive pattern Plain x-ray: may be sentinel loop CT scan - esp. for complications USS - better for detecting cysts and unsuspected gallstones |
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What management options are there for acute pancreatitis? |
Admission NBM NG suction (if vomiting) IV fluids ANalgesia May require ERCP if obstructive LFTs |
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Acute pain + left-sided radiation + fever = |
Acute diverticulitis |
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What are the typical features of acute diverticulitis? |
Acute onset of pain in LIF Pain increased with walking and change of position Usually associated with consitpation |
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What signs might be seen in a patient with acute diverticulitis? |
Tenderness, guarding and rigidity in LIF Fever May be inflammatory mass in LIF |
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What investigations can you consider in a patient with acute diverticulitis? |
FBC - leucocytosis Elevated ESR Pus and blood in stools Abdo USS CT scan (best) Erect CXR Erect and supine abdo X-ray |
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What treatment options can you consider for acute diverticulitis? |
Admission NBM - dry and suction Analgesia Abx - mild cases: Augment duo TDS for 5-7 days or metronidazole + cephlexin - severe cases: amp 2g IV QID + gent 5-7mg/kg IV BD or metronidazole and ceftriaxone 1g IV/ day Surgery for complications Screening colonoscopy after acute episode |
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What are the red flags in chronic abdominal pain? |
Older patient Nocturnal pain or diarrhoea Progressive symptoms Rectal bleeding Fever Anaemia Weight loss Abdominal mass Faecal incontinence or urgency (recent onset) |
