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Acute Abdomen and GI Bleeding
Malik, SEM4, ROSSU
Terms in this set (78)
What is Acute Abdomen?
The sudden appearance of symptoms and signs of intra-abdominal diseases usually treated by surgery. Timely treatment is mandatory, and mortality rates are higher in pediatric, geriatric, and unstable patients.
Relate Emergency Surgery and Planned Surgery in Acute Abdomen:
Emergency surgery has higher morbidity and mortality than planned surgery
What are the causes of Acute Abdomen?
1. Cause cannot be determined in most of the cases
2. Second common cause is Acute Appendicitis
What are the common presenting features of Acute Abdomen?
Pain, nausea, vomiting, shock and disorientation.
PAIN is the most outstanding feature.
Discuss the importance of Radiology in Acute Abdomen:
Abdominal X-Ray AXR- is good in conditions like intestinal obstruction, perforative peritonitis, they are often inconclusive and non-specific.
CT and US provide excellent pre-operative information.
What are the causes of Diffuse Abdominal Pain?
1. Acute Pancreatitis
2. Early Appendicitis
3. Diabetic Ketoacidosis
5. Intestinal Obstruction
6. Mesenteric Ischemia
What are some Upper-Right Abdominal Pain causes?
Biliary Tract Disease, Perforated Peptic Ulcer
What is Acute Cholecystitis?
Obstruction of the cystic duct in which there is a production of distension and acute inflammation of the Gall Bladder. There is NOT infection of the Gall Bladder.
What are the clinical features of Acute Cholecystitis?
There is Acute Pain in RUQ or epigastrium that may radiate to the right shoulder or scapula. There is Nausea, vomiting, and anorexia.
Murphy's Sign is pathognomonic. There are HYPOactive bowel sounds.
What dos a positive HIDA scan mean?
The Gallbladder is not usually visualized within 4 hours of dye injection. (It is usually excreted within 1 hour)
What is the Tx of Acute Cholecystitis?
Prepare for surgery and perform cholecystectomy
What is Choledocholithiasis?
Stone in the Common Bile Duct. There is the Charcot's Triad!
What is the Charcot's Triad?
Pain, Jaundice and Fever
What is the "gold standard" of Dx Choledocholithiasis?
ERCP which will also remove the stone. Followed by Sphincterotomy and stent replacement.
What are the complications of Choledocholithiasis?
Ascending cholangitis, Acute pancreatitis, liver failure, and biliary cirrhosis
Discuss Perforated Peptic Ulcer:
Acute severe abdominal pain, signs of peritonitis, hemodynamic instability. If not operated on it can progress to sepsis and death
Discuss Dx of Perforated Peptic Ulcer:
1. Chest XR shows free gas under the diaphragm
2. CT is the most sensitive test and shows free abdominal air
Discuss acute pancreatitis:
Autodigestion of pancreas from prematurely activated pancreatic enzymes resulting in acute inflammation.
Commonly seen in patients with gall stone disease and alcoholics.
What are the clinical features of Acute Pancreatitis?
Epigastric abdominal pain radiating in the back.
It gets worse in the supine position and after taking food.
There is fever, hypotension, tachycardia, and leukocytosis. There is decreased abdominal sounds.
Grey Turner's Sign!
What is Grey Turner's Sign?
Bruising of the flanks seen in Acute Pancreatitis.
What is Cullen's sign?
Cullen's sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus.
What is used to diagnose Acute Pancreatitis?
1. Serum Amylase and Lipase
2. Liver Function Tests
3. Abdominal X-Ray and Ultrasound
4. CT is the most accurate test for diagnosis and complications
5. ERCP with specific indication
What are the complications of Acute Pancreatitis?
4. Adult Respiratory Distress Syndrome
6. Ascites and pleural effusion
What is the Tx of Acute Pancreatitis?
1. IV Fluid
2. Pain Control
3. Naso-gastric tube if required
What are the most common problems in Upper Left Abdominal Pain?
Gastric and Splenic Disorders
What are the most common Lower Right Abdominal Pain causes?
2. Crohn's Disease
3. Meckel's Diverticulitis
What is Diverticular Disease?
A primarily lower left abdominal pain disease in which colonic diverticuli are caused by increased intra luminal pressure in the colon. The inner colonic layer bulges out through the focal weak areas of the colonic wall, usually an area of vessel penetration. It is a false diverticulum.
Usually in Sigmoid Colon and may be genetic.
Constipation is precipitating factor.
What is the investigation of choice if Diverticular DIsease?
What are the complications of Diverticulitis?
Bowel obstruction, pericolic abscess, perofration, peritonitis, fistula formation
What are the investigations involved therein with Diverticulitis?
CT abdomen and pelvis with oral and IV contrast. It may show
swollen, edematous bowel wall and abscess
When is barium enema and colonoscopy contraindicated?
Acute Diverticulitis due to risk of perforation!
What is the treatment of Diverticulitis?
IV antibiotics, IV fluids. If symptoms are prolonged more 3-4 days, surgical resection may be performed.
What is Mittelschmerz?
Mittelschmerz is one-sided, lower abdominal pain that occurs in women at or around the time of an egg is released from the ovaries (ovulation).
It is a cause of lower abdominal pain.
What is Melena?
Tarry stool due to presence of blood altered by the intestinal enzymes and bacteria acting on hemoglobin.
There has to be a bleeding loss of at least 60ml and last for at least 10-14 hours.
It is usually not an emergency.
What does Hematemesis and Melena both present indicate?
Upper GI tract hemorrhage bleeding proximal to the Ligament of Treitz.
At what volume can rapid hemorrhage produce systemic sign?
What does orthostatic hypotension indicate?
20% or more reduction in blood volume.
What does blood loss >40% indicate?
The patient may develop shock. Central Venous Pulse may be 0 and all pressure recordings are low.
What are causes of severe GI bleeding?
Rupture of Esophageal Varices, Peptic Ulcer Disease, Diverticulitis, Angiodysplasia, Ischemic Colitis, Meckel's diverticulum
A gastric ulcer in which severe bleeding ensues indicates which artery has been compromised?
Left Gastric Artery
A duodenal ulcer in which severe bleeding ensures, indicates which artery has been compromised?
What is non-bilious projectile vomiting most commonly associated with?
What should be done first in a patient when the hemoglobin is low?
CBC and reticulocyte count
Discuss Occult Blood Tests
Can detect colorectal cancer. It requires multiple stool examination.
A false positive can be due to gum bleeding and some food like horse radish, red meat, turnips, wtithin 3 days of the test.
False positives can also be due to oxidizing drums, iron, and colchicum
What is a Curling Ulcer?
An acute peptic ulcer due to a severe burn
What is a Snail Tract Ulcer?
A syphilitic ulcer
What is a Rodent Ulcer?
(This is skin cancer) Basal cell carcinoma is a slow-growing form of skin cancer.
What is an Apthous Ulcer?
This is a Canker Sore
What is a Cushing's Ulcer?
A Cushing ulcer is a gastric ulcer produced by elevated intracranial pressure
What is the difference between posterior and anterior duodenal ulcers?
Duodenal ulcers are never malignant, but anterior ulcers may perforate
Discuss outcomes and prognosis of Gastric Ulcers:
1/3 of patients with bleeding, adherent clot or blood vessels seen in endoscopy require emergency surgery.
1/3 of patients will rebleed within 1-2 years.
What are the classic signs of a 1-cm benign gastric antral ulcer?
Gross appearance is classic for a benign ulcer in
1) it is relatively small,
2) the mucosa surrounding the ulcer base does not appear tumefactive
3) the radiating rugal folds extend nearly all the way to the margins of the base.
Biopsy of gastric ulcer is a must.
What are the criteria for Malignant Gastric Ulcers?
It MUST be biopsied, but even then it is not 100% accurate. These reports may provide false reassurance.
Discuss Ruptured Esophageal Varices:
Treatment is based on local therapy to varices and reduction of portal pressure.
Renal failure is associated with worse prognosis and increased risk of bleeding
What has been shown to decrease bleeding?
Ventilation and PEEP.
Beware transfusions because they increase portal pressure.
What is the management of Esophageal Varices?
Urgent Endoscopy and consider intubation for airway protection in patients with massive bleeding.
What should be given to patients with known or suspected varices awaiting endoscopy?
Terlipressin or Octreotide
If Octreotide or Terlipressin with the Endoscopic treatment down work, what should be done?
Balloon tamponade and consider Esophageal transection.
What is Mallory Weiss Syndrome?
Upper GI bleeding from tears in the mucosa at the junction of the stomach and esophagus. It is usually caused by Severe Vomiting.
It is often associated with alcoholism
Discuss Symptoms and Gastric Cancer:
Stomach cancer is often asymptomatic or causes only non-specific symptoms in early stages. By the time real symptoms occur, the cancer has generally metastasized to other parts of the body. This is why it has a bad prognosis
What are the early symptoms of Gastric Cancer?
Ingestion, burning sensation (heartburn) loss of appetite, especially meat
What are the late symptoms of Gastric Cancer?
Abdominal pain or discomfort in the upper abdomen. Nausea, vomiting, diarrhea, constipation, weight loss, weakness, fatigue, bloating after meals.
SEVERE BLEEDING IS UNCOMMON.
1. Krukenberg Tumor
2. Bulmer's Shelf
3. Sister Joseph's Nodule
4. Virchow's Node, Troisier's sign
5. Trousseau's Sign (Fleeting thrombophlabitis)
7. Gastric Obstruction
What is Krukenberg Tumor?
Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract (stomach cancer here)
What is Bulmer's Shelf?
Blumer's shelf is a finding felt in rectal examination that indicates that a tumor has metastasized to the Pouch of Douglas.
What is Sister Joseph's Nodule?
refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.
What is Trosier's Sign?
This is Virchow's Node, a left supraclavicular lymph node enlargement
What is Trousseau's Sign?
medical sign found in certain cancers that is associated with venous thrombosis and hypercoagulability. It is also referred to as Trousseau syndrome and is distinct from the Trousseau sign of latent tetany. It is more commonly referred to as Trousseau's Syndrome within the research data.
What are the most common cause of Lower GI Bleeding?
What are Piles?
Where is the most common location of an anal fissure?
Discuss Ulcerative Colitis:
Starts in the rectum. There is frequent watery or bloody diarrheas sometimes with pus and mucus.
There is relapse and remission and it affects the mucosa and submucosa.
Severe cases affect the deeper layers.
What is seen in Ulcerative Colitis Investigations?
Granular Mucosal Pattern in Xray or Fine Bumpy pattern due to pseudopolyms
What are the complications in Ulcerative Colitis?
Anemia, fever, severe hemorrhage, hypoproteinemia, acute dilation, perfoation
Relate Ulcerative Colits and the Probability of Colon Cancer:
The possibility of cancer increases if there is an early age of onset, the length of the colon is involved, and if the disease is more active
What is the gold standard for screening for colorectal cancer?
What are the clinical features of Colon Cancer?
1. Suprapubic colicky pain (if constant disease is likely to be advanced)
2. Alteration of bowel habit
3. Palpable lump
4. Abdominal Distention
5. Presentation of right sided colon cancer shows weakness, anemia, and lump abdomen
Identify "Apple Core" appearance of Colon Cancer:
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