1. ACUTE ABDOMEN Initial assessment & diagnosis Mr R Ved Surgical CT1 UHW

3. Acute abdomen - History Pain SOCRATES Pain SOCRATES Vomiting Vomiting Bowel habit Bowel habit Urinary symptoms Urinary symptoms Appetite / Weight loss Appetite / Weight loss Gynae History Gynae History

4. History Pain: Pain: Site Site Onset Onset Character Character Radiation Radiation Alleviating factors Alleviating factors Temporal factors Temporal factors Exacerbating factors Exacerbating factors Severity Severity

5. History Vomiting Vomiting Onset / Frequency / Blood Onset / Frequency / Blood Bowels Bowels Change in bowel habit Change in bowel habit Blood / Colour change Blood / Colour change Urinary symptoms Urinary symptoms OBGYN Hx in women OBGYN Hx in women

6. History Past Medical History Past Medical History Surgery Surgery Other medical conditions e.g. Crohn’s Disease, Diabetes Other medical conditions e.g. Crohn’s Disease, Diabetes Drug, family & social history: Medication (NSAIDS / Steriods), familial bowel cancer, smoking, ETOH Drug, family & social history: Medication (NSAIDS / Steriods), familial bowel cancer, smoking, ETOH

7. Examination 1) A-B-C (DEF) 1) A-B-C (DEF) 2) Chest & abdominal examination 2) Chest & abdominal examination

8. Examination

9. Blood: FBC, U&E, LFT, Amylase, blood cultures Blood: FBC, U&E, LFT, Amylase, blood cultures Urine: Dipstick + Preg. Test Urine: Dipstick + Preg. Test Radiographs: Erect chest +/- abdomen (if not pooping or farting = ‘absolute constipation’) Radiographs: Erect chest +/- abdomen (if not pooping or farting = ‘absolute constipation’) Other imaging (USS/CT) Other imaging (USS/CT) Investigations

10. Management Resuscitation Resuscitation ABC(DEF) ABC(DEF) Definitive treatment Definitive treatment A) Conservative (IV fluids / antibiotics, ?NG tube?, good urine output) B) Surgical procedure

11. Practise MCQ 1 47 yrs old obese woman presents with RUQ & epigastric pain & vomiting for 24hrs. She is haemodynamically stable, but in pain. On examination she has RUQ tenderness only. Her WCC is 17 (4-12) but other blood tests & radiographs are normal. What is the most likely diagnosis? 47 yrs old obese woman presents with RUQ & epigastric pain & vomiting for 24hrs. She is haemodynamically stable, but in pain. On examination she has RUQ tenderness only. Her WCC is 17 (4-12) but other blood tests & radiographs are normal. What is the most likely diagnosis? A. Ruptured AAA B. Diverticulitis C. Acute cholecystitis D. Acute appendicitis Answer: C

12. Acute cholecystitis RUQ pain RUQ pain Prev/currently stimulated by fatty foods Prev/currently stimulated by fatty foods Radiation to back esp. tip of scapula/shoulder Radiation to back esp. tip of scapula/shoulder Pyrexia, tachy, RUQ tender on insp. (Murphy’s sign) - Infected GB = cholecystitis Pyrexia, tachy, RUQ tender on insp. (Murphy’s sign) - Infected GB = cholecystitis - Pain alone = biliary colic - Pain alone = biliary colic Middle age women (4 Fs) Middle age women (4 Fs) Gallstones – IV fluids + antiobx  USS abdomen Gallstones – IV fluids + antiobx  USS abdomen

13. Differential diagnoses Peptic ulceration – unstable Peptic ulceration – unstable Hepatitis - LFTs Hepatitis - LFTs Pancreatitis – Amylase (x5) Pancreatitis – Amylase (x5) Right basal pneumonia – resp exam + CXR Right basal pneumonia – resp exam + CXR Ascending cholangitis – Jaundice, LFTs Ascending cholangitis – Jaundice, LFTs AAA – Unstable, expansile mass, back pain AAA – Unstable, expansile mass, back pain

14. Practise MCQ 2 A 44 yr old obese, alcoholic man presents with epigastric pain. He has crippling osteoarthritis. His HR is 110, BP 98/77. He has epigastric guarding & rebound tenderness. His stool was very dark on DRE. His WCC is 17 (4-12) & amylase is normal. His erect CXR is booked. What investigation is most important to carry out next? A 44 yr old obese, alcoholic man presents with epigastric pain. He has crippling osteoarthritis. His HR is 110, BP 98/77. He has epigastric guarding & rebound tenderness. His stool was very dark on DRE. His WCC is 17 (4-12) & amylase is normal. His erect CXR is booked. What investigation is most important to carry out next? A. Abdominal radiograph B. Blood gas + lactate C. Urine dipstick D. Ultrasound abdomen Answer: B

15. Perforated peptic ulcer History History Sudden onset Sudden onset Severe upper abdominal pain Severe upper abdominal pain PHx Dyspepsia / Peptic ulcer PHx Dyspepsia / Peptic ulcer Medication: NSAIDS, steroids Medication: NSAIDS, steroids Smoking, ETOH Smoking, ETOH burns, trauma (Curling’s & Cushing’s ulcers) burns, trauma (Curling’s & Cushing’s ulcers)

16. Perforated peptic ulcer Examination Examination Tachycardia/haemdynamic instabiltiy Tachycardia/haemdynamic instabiltiy Temperature Temperature Guarding/Rebound tenderness Guarding/Rebound tenderness Generalised peritonitis Generalised peritonitis

17. Investigation Blood tests Blood tests Amylase: Normal/slightly elevated (<5x) Amylase: Normal/slightly elevated (<5x) Lactate + ABG = mandatory Lactate + ABG = mandatory Erect CXR Erect CXR Free gas under diaphragm Free gas under diaphragm

18. Perforated peptic ulcer - Management Resucitation – ABC Resucitation – ABC If stable after resus  CT If stable after resus  CT Still unstable  Emergency surgery/endoscopy Still unstable  Emergency surgery/endoscopy Laparotomy & repair of ulcer Laparotomy & repair of ulcer H Pylori eradication- triple therapy H Pylori eradication- triple therapy

19. Differential diagnoses – perf. PU Ascending cholangitis – jaundice, LFTs Ascending cholangitis – jaundice, LFTs Pancreatitis - Amylase Pancreatitis - Amylase GORD – stable, no melaena GORD – stable, no melaena Hepatitis – LFTs, signs of CLD Hepatitis – LFTs, signs of CLD AAA – Unstable, expansile mass AAA – Unstable, expansile mass

20. Practise MCQ 3 An 84 yr old woman presents with lower abdominal pain & fevers. She has chronic constipation. She has no urinary symptoms. HR is 90, temp 38°, other obs are normal. She has suprapubic & left iliac fossa tenderness. DRE was unremarkable. Her WCC is 17 (4-12) & amylase is normal. Urine dipstick showed Leukocytes +1. Her erect CXR normal. What is the most likely diagnosis? An 84 yr old woman presents with lower abdominal pain & fevers. She has chronic constipation. She has no urinary symptoms. HR is 90, temp 38°, other obs are normal. She has suprapubic & left iliac fossa tenderness. DRE was unremarkable. Her WCC is 17 (4-12) & amylase is normal. Urine dipstick showed Leukocytes +1. Her erect CXR normal. What is the most likely diagnosis? A. UTI B. Ruptured AAA C. Pancreatitis D. Diverticulitis Answer: D

21. Diverticulitis History LIF pain LIF pain Common 60yrs+ Common 60yrs+ Diarrhoea / constipation Diarrhoea / constipation PR bleeds PR bleeds Generalised peritonitis if perforated Generalised peritonitis if perforated

22. Diverticulitis Examination Examination Tachycardia/haemodynamic instability Tachycardia/haemodynamic instability Temperature Temperature LIF/generalised peritonitis LIF/generalised peritonitis Mass Mass PR blood PR blood

23. Differential diagnosis Urinary Tract Infection – no LUTs & only +1 leuk = normal in females >65 Urinary Tract Infection – no LUTs & only +1 leuk = normal in females >65 Gastroenteritis – D&V, ill contacts Gastroenteritis – D&V, ill contacts IBD – usually younger, PR mucus/blood IBD – usually younger, PR mucus/blood Sigmoid carcinoma – need to exclude  elective endoscopy Sigmoid carcinoma – need to exclude  elective endoscopy AAA – expansile mass, back pain AAA – expansile mass, back pain

24. Practise MCQ 4 An 18 yr old female presents with right iliac fossa pain, urinary frequency and dysuria. She has no PMH Her HR is 100, BP 95/77. She has RIF tenderness over McBurney’s point. Her WCC is 17 (4-12) & amylase is normal. Her erect CXR is booked. What investigation is most important to carry out next? An 18 yr old female presents with right iliac fossa pain, urinary frequency and dysuria. She has no PMH Her HR is 100, BP 95/77. She has RIF tenderness over McBurney’s point. Her WCC is 17 (4-12) & amylase is normal. Her erect CXR is booked. What investigation is most important to carry out next? A. CT abdo-pelvis B. LFTs C. Urine dipstick + ßHCG D. Ultrasound abdo-pelvis Answer: C

25. Appendicitis History& examination History& examination RIF pain (central ache moving to sharp RIF) RIF pain (central ache moving to sharp RIF) Nausea /Anorexia/vomiting. Diarrhoea +/- LUTs, tender RIF, rovsing’s +, generalised peritonitis Nausea /Anorexia/vomiting. Diarrhoea +/- LUTs, tender RIF, rovsing’s +, generalised peritonitis Invx Invx Urine dip + PT Urine dip + PT Inflammatory markers (WCC/CRP) Inflammatory markers (WCC/CRP) USS-AP (assess for OCA) USS-AP (assess for OCA) CT if equivocal CT if equivocal

26. Differential diagnosis Ruptured ectopic pregnancy - PT Ruptured ectopic pregnancy - PT UTI (pyelonephritis) – flank pain, dipstick UTI (pyelonephritis) – flank pain, dipstick Ovarian cyst rupture – mid cycle, mild inflamm. response Ovarian cyst rupture – mid cycle, mild inflamm. response Pelvic inflammatory disease – Hx of STI, RUQ pain, vaginal discharge, dyspareunia, pelvic examination Pelvic inflammatory disease – Hx of STI, RUQ pain, vaginal discharge, dyspareunia, pelvic examination Mesenteric adenitis (young) – dx of exclusion Mesenteric adenitis (young) – dx of exclusion Terminal ileitis (IBD, tropical infections) – PMH, bowel syx, foreign travel/contacts Terminal ileitis (IBD, tropical infections) – PMH, bowel syx, foreign travel/contacts

27. Practise MCQ 5 A thin 80 yr old female presents with sudden central abdominal pain. Her PMH includes CVA x 2, AF, osteoperosis and MI x 1. HR is 112, BP 95/77. She has severe central abdominal pain & a large mass is easily palpable. You feel that it’s pulsatile. Her pedal pulses are just palpable. Her WCC is 17 (4-12) & amylase is normal. Her erect CXR is booked. What is the most likely diagnosis? A thin 80 yr old female presents with sudden central abdominal pain. Her PMH includes CVA x 2, AF, osteoperosis and MI x 1. HR is 112, BP 95/77. She has severe central abdominal pain & a large mass is easily palpable. You feel that it’s pulsatile. Her pedal pulses are just palpable. Her WCC is 17 (4-12) & amylase is normal. Her erect CXR is booked. What is the most likely diagnosis? A. Perforated appendicitis B. Perforated PU C. Ruptured AAA D. Mesenteric ischaemia Answer: D

28. Gut Ischaemia Definition Definition Inadequate blood supply to the bowel/GI tract Inadequate blood supply to the bowel/GI tract Causes Causes Embolus Embolus Thrombus Thrombus

29. Acute Ischaemia History: History: Elderly pts Elderly pts Severe, non localised abdominal pain Severe, non localised abdominal pain PR bleeding PR bleeding PHx of Recurrent pain after eating – ‘gut claudication’ PHx of Recurrent pain after eating – ‘gut claudication’ Atherosclerosis- CV Hx Atherosclerosis- CV Hx

30. Acute Ischaemia Examination: Possible findings: Possible findings: Fever Fever Hypotension / shock Hypotension / shock Diffuse tenderness Diffuse tenderness Abdominal distention Abdominal distention Absent bowel sounds Absent bowel sounds

31. Investigations WCC raised – 90% WCC raised – 90% Arterial Lactate elevated Arterial Lactate elevated Arterial blood gases - Metabolic Acidosis (hypotension/shock  hypoxia  lactic acidosis) Arterial blood gases - Metabolic Acidosis (hypotension/shock  hypoxia  lactic acidosis)

32. Ischaemia - Investigations AXR: AXR: “Thumbprinting” of wall of colon “Thumbprinting” of wall of colon CT (angiogram) CT (angiogram)

33. Management Resuscitation: Resuscitation: (Mesenteric angiogram +/- anticoagulants) (Mesenteric angiogram +/- anticoagulants) Surgery: Surgery: ASAP, unless futile ASAP, unless futile Segmental ischaemia  bowel resection Segmental ischaemia  bowel resection Embolectomy/bypass Embolectomy/bypass Palliative Care Palliative Care

34. Differential diagnoses AAA – Unstable, expansile (not just pulsatile) mass, back pain, absent leg pulses AAA – Unstable, expansile (not just pulsatile) mass, back pain, absent leg pulses Peptic ulceration – epigastric pain, vomiting Peptic ulceration – epigastric pain, vomiting Pancreatitis – Amylase (x5) Pancreatitis – Amylase (x5) Ascending cholangitis – Jaundice, LFTs Ascending cholangitis – Jaundice, LFTs Appendicitis - Appendicitis -

35. Summary – Acute abdomen Wide variety of causes Wide variety of causes Accurate history is key Accurate history is key Examination – consider site of symptoms Examination – consider site of symptoms Use investigations to confirm diagnosis Use investigations to confirm diagnosis Management – resuscitate (early) then treat cause Management – resuscitate (early) then treat cause