A MEDED LECTURE ACUTE ABDO - PowerPoint Presentation

1. A MEDED LECTUREACUTE ABDO Mehmet Ergisime717@ic.ac.uk

2. SBA 1A 17-year-old female presents to the emergency department with peri-umbilical pain. The pain is sharp in nature, is exacerbated by coughing and came on gradually over the past 12 hours. On examination, she is unable to stand on one leg comfortably and experiences pain on hip extension. The is no rebound tenderness or guarding. A urine pregnancy test is negative, and her temperature is 37.7. Bloods reveal a leucocytosis that is predominantly neutrophils. What is the Dx?Inguinal herniaAcute appendicitisLower urinary tract infectionAcute mesenteric ischaemia Diverticulitis

3. SBA 1A 17-year-old female presents to the emergency department with peri-umbilical pain. The pain is sharp in nature, is exacerbated by coughing and came on gradually over the past 12 hours. On examination, she is unable to stand on one leg comfortably and experiences pain on hip extension. The is no rebound tenderness or guarding. A urine pregnancy test is negative, and her temperature is 37.7. Bloods reveal a leucocytosis that is predominantly neutrophils. What is the Dx?Inguinal herniaAcute appendicitisLower urinary tract infectionAcute mesenteric ischaemia Diverticulitis

4. AppendicitisInflammation of appendix Most common cause of surgical emergencyMainly found in 10-20 y/o age groupDefinitionAetiologyCause of inflammation is obstruction of the opening of the appendixFaecolith (poop rock)Lymphoid hyperplasia (kids)Filarial wormsIndigested seedsAetiologyEpidemiology

5. MURPHY’S TRIADLow-grade feverAbdo painUmbilicus  R iliac fossaN+VSymptomsAppendicitisA 17-year-old female presents to the emergency department with peri-umbilical pain. The pain is sharp in nature, is exacerbated by coughing and came on gradually over the past 12 hours. On examination, she is unable to stand on one leg comfortably and experiences pain on hip extension. The is no rebound tenderness or guarding. A urine pregnancy test is negative, and her temperature is 37.7. Bloods reveal a leucocytosis that is predominantly neutrophils.

6. Percussion & rebound tenderness, guardingSignsAppendicitisPain at McBurney's point 1/3rd of way from ASIS to umbilicus On examination, she is unable to stand on one leg comfortably and experiences pain on hip extension. The is no rebound tenderness or guarding. A urine pregnancy test is negative, and her temperature is 37.7. Bloods reveal a leucocytosis that is predominantly neutrophils.

7. Make patient NBMGive fluids if signs of shockAntibiotics Laparoscopic appendectomy ManagementAppendicitisRupture  peritonitisAbscess (requires drainage)Complications

8. SBA 2A 65-year-old man comes to the emergency department because of blood in his stools for the last few days. He denies fever, chills, nausea, or vomiting, and says that his bleeding is painless. His last colonoscopy was five years ago and only showed several colonic diverticula, but no colonic polyps or cancer. His temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 15/min, and blood pressure is 120/80 mm Hg. Rectal examination does not show any abnormalities. What is the Dx?DiverticulitisDiverticulosisColonic polypsCrohn’s diseaseUlcerative colitis

9. SBA 2A 65-year-old man comes to the emergency department because of blood in his stools for the last few days. He denies fever, chills, nausea, or vomiting, and says that his bleeding is painless. His last colonoscopy was five years ago and only showed several colonic diverticula, but no colonic polyps or cancer. His temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 15/min, and blood pressure is 120/80 mm Hg. Rectal examination does not show any abnormalities. What is the Dx?DiverticulosisDiverticulitisColonic polypsCrohn’s diseaseUlcerative colitis

10. Diverticular DiseaseHerniation of mucosa and sub-mucosa through muscle layer of colonic wallVery common – 60% in industrialised countries will develop a diverticulumDefinitionDiverticulum: 1 outpouchingDiverticula: multiple outpouchings Diverticulosis: presence of outpouching but ASxDiverticular disease: diverticulosis WITH SxDiverticulitis: inflammation + infection of outpouching TerminologyEpidemiologyPsuedo: muscle layer does NOT OutpouchTrue: muscle layer DOES Outpouch

11. Diverticular DiseaseLow fibre diet  increase intra-luminal pressure to move stoolAge >50 y/o Obesity Taeniae coli (muscle that runs along the colon)  present in bands  herniation of the mucosa occurs in between these bandsRisk factors Aetiology WEST: L side of colon (descending colon + sigmoid)NEVER found in the rectum

12. FeverTachycardiaAbdo distentionL iliac fossa pain Diverticulitis (Sx)Diverticular DiseaseA 65-year-old man comes to the emergency department because of blood in his stools for the last few days. He denies fever, chills, nausea, or vomiting, and says that his bleeding is painless. His last colonoscopy was five years ago and only showed several colonic diverticula, but no colonic polyps or cancer. His temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 15/min, and blood pressure is 120/80 mm Hg. Rectal examination does not show any abnormalities. DiverticulosisASxMay have blood in stools

13. Barium enemaSaw-tooth appearance of lumenColonoscopyCT FBC High WCCHigh CRPInvestigationsDiverticular Disease

14. Can’t reverse growth, can only treat to prevent progression Increase fibre in diet, fluid hydration, weight reduction, exercise, stop smokingIf uncomplicated diverticulitis: ABx If complicated diverticulitis: IV ABx, IV fluids, analgesiaCT-guided drainage of abscess if presentAnalgesia caution: You don’t want to give a constipating analgesic (i.e. many opioids, particularly morphine) as this also raises intra-luminal pressureLaxatives post-surgery (osmotic, NOT stimulant)ManagementDiverticular DiseaseDiverticulitisAbscessPerforationPeritonitisFistula formationStrictures/obstructionComplications

15. SBA 3A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination. What is the Dx?DiverticulitisAppendicitisSmall bowel obstruction PeritonitisLarge bowel obstruction

16. SBA 3A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination. What is the Dx?DiverticulitisAppendicitisSmall bowel obstruction PeritonitisLarge bowel obstruction

17. Bowel ObstructionObstruction that can affect small intestine (SI) or large intestine (LI)DefinitionAetiology of SxBowel obstruction ↓Stasis of luminal contents and gas proximal to the obstruction↓Increased intraluminal pressure↓Abdominal distention + dehydration and hypovolaemia + vomiting↓Compression of vessels can cause ischaemia and gangrenePartial (some contents can pass – Sx less severe) Complete (total obstruction – Sx progress rapidly)Simple Strangulated (compromised blood supply  ischaemia + gangrene)Small intestine (80%)CausesLarge intestineMAIN: surgery  adhesionsMAIN: malignancy (90%)

18. Vomiting (bilious)Constipation / obstipationSevere Colicky PainSymptoms and signsBowel ObstructionAbdo distentionTinkling bowel soundsA man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination. What is the Dx?

19. Supine AXRBowel Obstruction SMALL bowel obstruction3-5cm dilationVulvulae coniventae (all the way across)LARGE bowel obstruction>5cm dilationHaustra (don’t go all the way across)

20. Conservative: NBM + NG tube (decompress bowel), IV fluids, urinary catheter, analgesiaIf acute obstruction / strangulation / ischaemic bowel signs: laparotomy If SI obstruction secondary to adhesion: conservative Mx – contrast enema within 24 hours to check ManagementBowel Obstruction DehydrationPerforation  PeritonitisGangrene of bowel wall (if strangulation) Complications

21. VolvulusRotation of a loop of bowel around the axis of its mesentery that results in bowel obstruction and potential ischaemiaSigmoid colon - 65% Caecum - 30%DefinitionLong sigmoid colonLong mesentery Mobile caecum Chronic constipation AdhesionsParasitic infections Neonates: malrotationRisk factors

22. VomitingConstipationSevere Colicky PainSymptoms and signsVolvulusAbdo distention + tendernessAbsent/Tinkling bowel soundsSigns of dehydration

23. Abdominal X-ray VolvulusCoffee bean sign

24. Sigmoid volvulusSigmoidoscopy with detorsion If no suspicion of ischaemia or perforation 75-95% successRecurrence 84% - need to do surgery after detorsion to preventCaecal volvulusColonoscopy and detorsion not done – risk of perforation Need to perform surgery ManagementBowel Obstruction

25. SBA 4A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. His temperature is 37.9ºC (100.2˚F), pulse is 105/min, respirations are 18/min, and blood pressure is 115/75 mmHg. The patient appears very pale, and his abdomen is extremely tender to palpation. Amylase and lipase are raised. What is the Dx?Acute pancreatitisDiverticulitisPeritonitisSmall bowel obstruction Large bowel obstruction

26. SBA 4A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. His temperature is 37.9ºC (100.2˚F), pulse is 105/min, respirations are 18/min, and blood pressure is 115/75 mmHg. The patient appears very pale, and his abdomen is extremely tender to palpation. Amylase and lipase are raised. What is the Dx?Acute pancreatitisDiverticulitisPeritonitisSmall bowel obstruction Large bowel obstruction

27. Acute PancreatitisAcute inflammation of the pancreas - reversible DefinitionAetiologyCalcium build up in inflamed pancreas ↓Release of enzymes (amylase, lipase, protease)↓Enzymes damage local structures and cause systemic Sx/signsCausesI GET SMASHEDIdiopathic Gallstones (Females)Ethanol (Males)TraumaSteroidsMumps/EBV/HIVAutoimmuneScorpion venomHypercalcaemia/hyperlipidaemiaERCPDrugs (sodium valproate, steroids, thiazides, azathioprine)

28. Hx of causePainSevereEpigastricRadiates to backWorse lying down (better whilst sitting)Symptoms and signsAcute Pancreatitis N+VFeverSx of hypovolaemiaA 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. His temperature is 37.9ºC (100.2˚F), pulse is 105/min, respirations are 18/min, and blood pressure is 115/75 mmHg.

29. Cullen’s sign2 unique signsAcute Pancreatitis Grey-Turner’s sign

30. CT abdo USSIx for causeALP + bilirubin (gallstones)Ca/triglyceride levels Amylase / lipasex3 higher than normalInvestigationsAcute Pancreatitis

31. Modified Glasgow / PANCREAS ScoreAcute Pancreatitis

32. General TxAnalgesiaIV fluids and electrolytesOxygen support NG tubeControl blood sugarABx if infected necrotic tissueManagementAcute PancreatitisComplicationsTx of cause Gallstones: ERCP (with sphincterotomy), cholecystectomy Necrotic tissue: necresectomy Acute kidney injury (from hypovolaemia or toxins)Septic shockAcute lung injury / ARDSPancreatic necrosisPancreatic abscessPseudocystsAscitesChronic pancreatitis

33. PeritonitisInflammation of peritoneal lining of abdo cavity Localised to one part, or generalisedDefinitionLocalised peritonitisAppendicitis Cholecystitis DiverticulitisSalpingitis AetiologyPrimary generalised peritonitisBacterial infection, without obvious sourceRF: cirrhosis, ascites, nephrotic syndromeRARE – seen in younger, F ptsE. coli and gram -ve bacteria generally Staph aureus – particularly in post-operative casesSecondary Generalised PeritonitisBacteria from pre-existing abdo conditionCould be due to spillage of bowel contents, bile and blood (perforated peptic ulcer, diverticulitis, cholecystitis, appendicitis)

34. Signs of septic shockPainSudden onsetSharp Worse on movementGeneralised  localisedSymptoms and signsPeritonitisGuardingRebound tendernessWashboard rigidityN+VReduced bowel soundsParalytic ileus

35. If ascites: ascitic tap (neutrophils >250 if SBP)Blood cultures (infection)High WCC, CRPInvestigationsPeritonitisErect CXRAir under diaphragm

36. Conservative: IV fluids, IV ABx, NG tubeLocalised/secondary generalised: Treat the cause, may require surgery (appendectomy) or simply ABxPrimary generalised/sepsis: broad spectrum ABxIf infected/necrotic tissue: necresectomyPeritoneal lavageManagementPeritonitisComplicationsSeptic shock Respiratory failure Multiorgan failure Paralytic ileus Wound infection Abscesses Adhesions

37. Hernia (in general)Protrusion of abdominal contents through congenital/acquired areas of weakness in the wallDefinition (hernia in general)2 main types: inguinal (more common) and femoral Due to increase in intra-abdominal pressure:Chronic coughSmoking causing coughConstipationPregnancyWeight-lifting Weakened abdominal musclesCausesIrreducible: if they cannot be pushed back into the right placeIncarceration: contents of the hernia sac are stuck inside by adhesionsObstruction: when bowel contents can’t pass through GI herniaStrangulated: blood supply cut-off, so you get ischaemia of the herniaTerminology

38. Hernia (in general)LocationInguinalSuperomedial to the pubic tubercle FemoralInfero-lateral to the public tubercle

39. Inguinal HerniaAbnormal protrusion of a peritoneal sac through a weakness of the abdominal wall in the inguinal region Definition2 types, which both emerge at the superficial inguinal ringTypesDirectIndirectProtrusion of the hernial sac directly through a weakness in the posterior wall of the inguinal canal Through Hesselbach's triangle Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal

40. Inguinal HerniaHesselbach's Triangle3 bordersLateral border of rectus abdominisInferior epigastric vesselsInguinal ligamentCommonx9 more common in MEpidemiologyCongenital Acquired - due to increased intra-abdominal pressure along with muscle and transversalis fascia weakness Aetiology

41. Femoral HerniaAbdominal contents pass through a naturally occurring weakness called the femoral canalDefinitionFar less common than inguinalMore common in FEpidemiology

42. Pain if incarcerated/strangulated Typically ASx, other than presence of lump in the groinAsk pt to cough if the hernia is not visible at firstCheck if it is irreducible Symptoms and signsInguinal and Femoral HerniaInguinal: lump extends towards genitalia (medially)Femoral: lump is more lateral

43. Lifestyle changes: diet if overweight, limit increase in abdo pressureIf uncomplicated: elective repairMesh repair - hernia is surgically reduced and a mesh is inserted to reinforce the defect where the hernia protruded throughLaparoscopic If obstructed/strangulated: emergency laparotomyManagementInguinal and Femoral HerniaComplicationsIncarceration Strangulation Bowel obstructionSurgical complications

44. SBA 5A 67-year-old male presents to the emergency department complaining of severe generalised abdominal pain, which hasn't improved despite morphine. His medical history includes hypertension, type 2 diabetes, abdominal aortic aneurysm (3.9cm) and atrial fibrillation. He currently takes warfarin, metformin, gliclazide and amlodipine. He smokes 30 cigarettes per day. What is the Dx?Acute pancreatitisAppendicitisDiverticulitisAcute mesenteric ischaemiaRupture of aortic aneurysm

45. SBA 5A 67-year-old male presents to the emergency department complaining of severe generalised abdominal pain, which hasn't improved despite morphine. His medical history includes hypertension, type 2 diabetes, abdominal aortic aneurysm (3.9cm) and atrial fibrillation. He currently takes warfarin, metformin, gliclazide and amlodipine. He smokes 30 cigarettes per day. What is the Dx?Acute pancreatitisAppendicitisDiverticulitisAcute mesenteric ischaemiaRupture of aortic aneurysm

46. Intestinal IschaemiaObstruction of a mesenteric vessel leading to bowel ischaemia and necrosisUncommonMore common in elderlyDefinitionEpidemiologyIncreasing ageAtrial fibrillation - particularly for mesenteric ischaemiaOther causes of emboli: endocarditis, malignancyCardiovascular disease risk factors: smoking, hypertension, diabetesCommon RF

47. Intestinal IschaemiaAcute mesenteric ischaemiaArterialAlmost always involves small bowelAffects superior mesenteric artery (75%)Arterial thrombosis (35%) or embolism (35%) – atrial fibrillation, endocarditisVenousVenous thrombosisNon-occlusiveDue to hypoperfusion – shock, heart failure, volvulusTypesChronic mesenteric ischaemiaUsually due to a low flow state Likely to have Hx of vascular diseaseRareIschaemia colitisInflammation of the colon caused by decreased colonic blood supplyUsually follows low flow state in inferior mesenteric arteryThrombus/embolus, hypovolaemia, hypercoagulable stateHis medical history includes hypertension, type 2 diabetes, abdominal aortic aneurysm (3.9cm) and atrial fibrillation. He currently takes warfarin, metformin, gliclazide and amlodipine. He smokes 30 cigarettes per day.

48. Diarrhoea Abdo painColicky, intermittentSymptoms and Signs (common)Intestinal IschaemiaRectal bleedingFever

49. CTVBG Raised lactate (acidosis)Investigations Intestinal IschaemiaThumbprint on barium enema for ischaemic colitis

50. Acute mesenteric ischaemiaFluid resuscitationABx to prevent bacterial translocationHeparin/thrombolyticNeeds urgent surgery Chronic mesenteric ischaemiaSurgery to prevent ongoing risk of infarctionStent insertion to revascularize Ischaemic colitisConservative Mx: Fluids resuscitation, ABxSurgery if conservative fails, or if perforation and/or peritonitisManagementIntestinal IschaemiaComplicationsPerforationPeritonitisMulti-organ dysfunction syndromeGangreneIntestinal obstruction

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52. SBA 7An 8-year-old boy presents with classical appendicitis pain, that has migrated from the umbilicus to the right iliac fossa within the last 12 hours. When the doctor palpates the left iliac fossa, the boy feels pain in the right iliac fossa. What is the name of this eponymous sign?McBurney’s signRovsing’s signPsoas signKernig’s sign Cope sign

53. SBA 7An 8-year-old boy presents with classical appendicitis pain, that has migrated from the umbilicus to the right iliac fossa within the last 12 hours. When the doctor palpates the left iliac fossa, the boy feels pain in the right iliac fossa. What is the name of this eponymous sign?McBurney’s signRovsing’s signPsoas signKernig’s sign Cope sign

54. SBA 8A 64-year-old man comes to the emergency department because of a 2-day history of uncontrollable nausea, vomiting, and generalized abdominal pain. His temperature is 36.8°C (98.2°F), pulse is 112/min, respirations are 20/min, and blood pressure is 104/64 mm Hg. Physical examination shows a distended abdomen with decreased bowel sounds that is tympanitic to percussion. An abdominal radiograph is obtained and is shown below. Which of the following is the most common underlying cause of the patient's symptoms?AdhesionsTumourStrangulated herniaIntussusceptionAdhesions

55. SBA 8A 64-year-old man comes to the emergency department because of a 2-day history of uncontrollable nausea, vomiting, and generalized abdominal pain. His temperature is 36.8°C (98.2°F), pulse is 112/min, respirations are 20/min, and blood pressure is 104/64 mm Hg. Physical examination shows a distended abdomen with decreased bowel sounds that is tympanitic to percussion. An abdominal radiograph is obtained and is shown below. Which of the following is the most common underlying cause of the patient's symptoms?AdhesionsTumourStrangulated herniaIntussusceptionAdhesions

56. SBA 9A 70-year-old man who is known to have atrial fibrillation presents with abdominal pain and rectal bleeding. A diagnosis of ischaemic colitis is suspected. Which part of the colon is most likely to be affected?Hepatic flexureDescending colonSplenic flexureAscending colonRectum

57. SBA 9A 70-year-old man who is known to have atrial fibrillation presents with abdominal pain and rectal bleeding. A diagnosis of ischaemic colitis is suspected. Which part of the colon is most likely to be affected?Hepatic flexureDescending colonSplenic flexureAscending colonRectum

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