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Countdown to finals: Acute Abdomen

Rah Chowdhury & Chris Mumford 17th January 2012

Outline.

Common causes Investigations Basic management Cases A few things they like to put in finals Quiz

DEFINITION: Abdominal pain

A short history (less than 48hours) Presenting as an emergency With no history of trauma

R upper quadrant Acute cholecystitis Duodenal ulcer Hepatitis Cholangitis RLL pneumonia

Epigastrium Peptic ulcer disease Acute cholecystitis MI Pancreatitis

L upper quadrant Gastric ulcer Splenic infarct/injury Pancreatitis L pneumonia Central/paraumbilical Early appendicitis S.bowel obstruction Pancreatitis Ischaemic bowel Aortic aneurysm Diabetic ketoacidosis L lower quadrant (LIF) Diverticulitis Sigmoid volvulus Inflammatory bowel Ectopic pregnancy Pyelonephritis Renal/ureteric calculi PID/ ovarian cyst

R lower quadrant (RIF) Appendicitis Ectopic pregnancy Ovarian cyst PID Pyelonephritis Renal/ureteric calculi Perforated peptic ulcer Caecal volvulus
Mesenteric adenitis Incarcerated hernia Psoas abscess

Suprapubic/pelvic UTI Urinary retention Gynae causes

General approach
1)

History and examination Investigations basic and specific Management F1

2)

3)

History

Previous episodes Pain Nausea/Vomiting Distension Bowel habit Haematemesis/ melaena Appetite/weight loss PV bleeding Vascular risk factors Family history Collateral history

Examination

General Hands, neck, face Inspection Palpation Percussion Auscultation Endpoints: Stool sample, Hernias, PR, Urine, External genitalia (SHRUG)

Investigations Basic
1) 2) 3) 4)

5)
6)

Urine: dip, culture, pregnancy test Bloods ABG CXR AXR ECG

Bloods FBC U&E LFT CRP Amylase Clotting Lactate G&S

Special OGD/Colonoscopy/FlexiSig Abdominal USS CT abdomen/pelvis

Basic management
ABC
Airway: Patent? Maintaining? Breathing: Resp rate, SATs, auscultate, ABG, CXR Circulation: HR, BP, CRT, auscultate, ECG, fluid challenge Disability: GCS, pupils, BM, Temperature Examination: Abdominal, other relevant

What investigations do I need?

Case 1

History

22 year old female Central abdominal pain for 2/7, now moved to RIF. Had a temperature today. Vomited x2, bowels open normally, not eating. No PMH of note. Penicillin allergic.

Case 1

Examination

Tender +++ in right iliac fossa, guarding. Not distended. Bowel sounds absent. Obs

T 38.9oC HR 110 BP 116/85 RR 16 SpO2 100% on room air.

Case 1- Differential Diagnosis


Appendicitis. Ectopic pregnancy/torted ovarian cyst. PID. Pyelonephritis/renal colic. Subacute strangulated hernia. Perforated gastric/duodenal ulcer.

Case 1 Investigation and Management.

Investigations

Bloods FBC, U&E, CRP, G+S. ECG. Pregnancy test +/- swabs + urine dip. Is imaging indicated? ABC Analgesia Antibiotics Appendicectomy- call your seniour!!!

Management

Case 2

History

18 year old male, first week of university. 24 hour history of severe gnawing central abdominal pain. Vomited x 3. Feels sweaty and shivery, normal bowel opening. No PMH of note. No known drug allergies.

Case 2

Examination

Not visibly jaundiced, no stigmata of chronic liver disease. Abdomen soft, tender ++ epigastrically. No mass/organomegaly/hernia. Bowel sounds present. Temp 37.9oC, HR 100, BP 93/68, SaO2 94% on RA, RR 28.

Obs

Case 2 Differential Diagnosis


Acute pancreatitis. Perforated peptic ulcer. Ischaemic bowel. Severe gastroenteritis. Diabetic ketoacidosis. Testicular torsion.

Case 2 Investigation

Bloods FBC, U&E, CRP, LFT, amylase, G+S, clotting, LDH, cultures. CXR and AXR. ECG. ABG. Is further imaging useful?

Case 2 Management

ABC NG tube. IV fluid resuscitation (3rd space losses). Analgesia. Oxygen. Antiemetic. Catheter and fluid balance. PPI depends on centre. Placement Modified Glasgow Score.

Modified Glasgow Score


A Age > 55 yr G Glucose > 10 mmol/L L LDH > 600 UI/L A Albumin < 32 g/L S Serum Urea > 16 mmol/L S Serum ALT > 100 IU/L C Ca2+ < 2.0 mmol/L O pO2 < 8.0 kPa W WCC > 15 x109/L

Modified Glasgow Score


A Age G Glucose L LDH A Albumin S Serum Urea S Serum ALT C Ca2+ O pO2 W WCC

> 55 yr > 10 mmol/L > 600 UI/L < 32 g/L > 16 mmol/L > 100 IU/L < 2.0 mmol/L < 8.0 kPa > 15 x109/L

18 8 120 34 20 154 1.7 8.5 24

GET SMASHED

G Gallstones E Ethanol (Alcohol) T Trauma S Steroids M Mumps and other viruses A Autoimmune S Scorpion venom H Hypertriglyceridaemia, hypercalcaemia E ERCP D Drugs Azothioprine, tetracyclines.

Case 3

History

64 year old male. Presented with vomiting and abdominal distension for 48 hours. Bowels last opened 7 days ago. No fever/rigors, recent weight loss of 1 stone over 4 months. PMH hypertension, osteoarthritis. NKDA.

Case 3 - Examination

No stigmata of liver disease, not jaundiced. Abdomen distended, slightly tender, no guarding. No evidence of ascites. No organomegaly/palpable mass. No hernia. Bowel sounds active. PR empty rectum. Obs stable.

Case 3 - Investigation

Bloods FBC, U&E, LFT, CRP, G+S, clotting, electrolytes. Abdominal and chest radiographs. ABG if unwell. ECG. +/- CT abdomen and pelvis. +/- flexible sigmoidoscopy.

Bowel obstruction

Causes

Hernia Adhesions Obstructing tumour Stricture (stoma/IBD) Volvulus/intussusception Bezoar/foreign body Pseudo-obstruction Faecal impaction Small bowel vs. large bowel.

Abdominal film

Case 3 management

ABC Drip and Suck. IV fluids to replace 3rd space loss. Conservative management where possible. May require stenting or laparotomy if malignant or not resolving.

Case 4

History

80 year old male. Had PR bleed 4 hours ago. Large volume of fresh blood independent of stool. Stopped spontaneously in A&E. Pain in LIF for 2 days. Feeling hot, had 8 episodes of loose stool. No weight loss, no loose stool. PMH STEMI 3 months ago. Type 2 DM, COPD, CKD. NKDA, on aspirin and prasugrel.

Case 4

Examination

Tender ++ in left iliac fossa. Some guarding. Not distended. No organomegaly. Firmness in LIF. No hernia. Bowel sounds normal. PR fresh blood, hard stool in rectum, no palpable mass.

Obs

Stable, temperature 37.6oC.

Case 4 - Differential Diagnosis


Diverticulitis Tumour Haemorrhoids Upper GI bleed/peptic ulcer. Colonic polyp AV malformation/varices.

Investigation

Bloods FBC, U&E, CRP, LFT, clotting, crossmatch, cultures. ECG. Chest and abdominal x-rays. Flexible sigmoidoscopy/colonoscopy.

Case 4 - Management

ABC IV fluids +/- blood transfusion. Reverse anticoagulation (senior decision). Antibiotics Interventional radiology/surgery if severe.

QUESTIONS THEY LIKE TO ASK IN FINALS

Question 1

What are both of these signs called? (2) What do they classically indicate (1)

Question 2

A. What is the name of this sign? B. What does it indicate C. How many are needed to indicate the answer to part B.

Question 3

What a and b (2) What is the difference between a and b?


b.

a.

Question 4.

What abnormality is seen on this radiograph? (1 mark) Give two causes for this abnormality (2 marks)

Question 5

What is the diagnosis? (1 mark) What is the immediate treatment? (1 mark)

Question 6

What is the name of this clinical sign? (1 mark)

Question 1

What are both of these signs called? (2)

Grey Turners and Cullens sign

What do they classically indicate (1)

Acute pancreatitis (together necrosis)

Question 2

A. What is the name of this sign?

Spider naive Liver disease

B. What does it indicate

C. How many are needed to indicate the answer to part B.

More the 5 (women may have more if on oestrogen therapy or pregnant).

Question 3

What a and b (2)

Naso-gastric tubes A- Fine bore tube feeding B- Ryles tube for draining (drip and suck)
b.

What is the difference between a and b?


a.

Question 4.

What abnormality is seen on this radiograph? (1 mark) Air under diaphragm Give two causes for this abnormality (2 marks) Bowel perforation, recent laparoscopy, vigorous sex, water-skiing

Question 5

What is the diagnosis? (1 mark) Sigmoid volvulus What is the immediate treatment? (1 mark) Insertion of sigmoidoscope and flatus tube

Question 6

What is the name of this clinical sign? (1 mark) Riglers sign

Thankyou

Any Questions?