Acute abdomenal pain History

Station 1

• Onset• Duration• Site, radiation• Severity• Progression: continuous or ON&OFF, constant or increasing severity• Nature: burning, dull, sharp, colicky• Precipitating, aggravating, relieving factors• Associated symptoms: nausea, vomiting, anorexia, heartburn,

change in bowel habit, GI bleeding, jaundice, fever, wt loss• Risk factors: Hx of peptic ulcer disease (endoscopy, H.pylori Rx), IBD

(colonoscopy), Gastroenteritis (eating outdoor), previous abdominal operation (adhesions causing intestinal obs.)

Station 2

Q.Describe what you see?

Q.Give 3 causes?

Q.What are the investigations?

Q.How would you prepare the jaundiced patient for surgery?

• Describe? yellowish discoloration of the sclera (jaundice)

• Mention 3 causes:1. pre-hepatic: hemolytic disease2. Hepatic: hepatitis, cirrhosis3. Post-hepatic: CBD obstruction by stone, carcinoma

of head of pancreas, cholangiocarcinoma

Investigation :• CBC, U&E, LFT, Coagulation, Hepatitis• Remember Macrocytosis as a sign of alcoholism• In obstructive jaundice, the Alkaline Phosphatase will rise out of

proportion to the transaminases (These may be slightly up), and the bilirubin is conjugated.

• Hepatocellular jaundice is characterised by marked transaminase rise, and a mix of conjugated and unconjugated bilirubin.

• Prehepatic Jaundice is unconjugated (so not present in urine)• Ultrasound: if the CBD dilated the obs is extrahepatic, if not

dilated the obs is intrahepatic

How would you prepare the jaundiced patient for surgery?

• Basically this means correcting any coagulation abn with FFP and/or Vitamin K, and giving perioperative IV fluids to maintain a good urine output (Hepatorenal syndrome more likely in the dehydrated)

Jaundiced patient:Q.Take a history ?Q.what are the Finding on Examination?

Station 3

Hx: PD: age, gender, origin (for belharzia)• Onset, duration, how did the pt notice, previous episode• Associated symptoms: RUQ pain, nausea, vomiting, fever, rigors,

steatorrhea, dark urine, pale stool, itching, wt loss, anorexia, cirrhosis (hematemesis, melena, ascitis), anemia (fatigue, palpitations, SOB)

• Risk factors: hepatitis (IV drug abuse, BT, contact with jaundiced pt, recent travel, alcohol), GallBladder (previous Hx of stones, fertility, DM, crohn’s, ERCP, cholecystectomy), hemolytic disease (known blood disorder, we already asked abt BT), pancreatic CA (smoking)

• Medications: antiTB, OCPs, herbal• Family Hx: blood disorder, hepatitis, gall stones, malignancies

Jaundice P/E• Hands: Finger clubbing, Leukonechia, Palmar

erythema, Dupuytren’s, Asterixis• Skin: Bruising, Spider Naevi, itching• Face & Head: Jaundiced sclera. Constructional

apraxia, Foetor hepaticus.• Chest: Gynaecomastia• Abdomen: Enlarged liver or spleen, Ascites, Caput

Medusae. Remember to ascertain the nature of the liver edge, consistency, tenderness. Bruits etc astronomically rare.

• Legs: Peripheral pitting oedema from hypoalbuminaemia.

What are the DDx of RUQ pain?

Station 4

• Liver: Hepatitis, Liver abscess, Hepatocellular carcinoma (stretching liver capsule)

• Gallstone disease: biliary colick, cholecystitis, cholangitis

• Basal pneumonia (rt lower lobe)• pyelonephritis• Peptic ulcer disease• Pancreatitis• Colitis of hepatic flexure

Mention 4 symptoms in patient with acute pancreatitis?

Station 5

• Epigastric pain, radiating through to the back, releived by leaning forward

• Vomiting, nausea• Fever• Palpitations• fatigue

Cholecystitis HxExRx

Station 6

The pt will present with RUQ pain, so:• Onset, duration, site, radiation (Rt shoulder or inter-scapular region),

aggravating (fatty food, coffee, tea), relieving factors (analgesics), associated symptoms (fever, rigors, nausea, vomiting, usually no jaundice bcoz no CBD obstruction, if yes dark urine & pale stool & itching), nature (usually constant not colicky), severity

• Previous Hx of biliary colick, DM, blood disorder• Risk factors: female, 40’s, fatty, fertile, +ve family Hx, hemolytic

disease, ileal disease (Crohn’s) or resection• Exclude other DDx: hepatitis (IV drug abuse, BT, contact with jaundiced

pt, recent travel, alcohol, antiTB), basal pneumonia (cough,sputum), pyelonephritis (flank pain, dysuria, heamaturia), PUD (heartburn, epigastric pain, endoscopy), pancreatitis (pattern of pain, ERCP)

• Family Hx: blood disorder, hepatitis, gall stones

• Physical examination usually only shows subcostal tenderness and murphy’s sign. Rarely palpable. 5 F’s

• The investigation of cholecystitis is essentially the investigation of upper abdominal pain: CBC, U&E, AMYLASE, LFT’s, Erect Chest X-ray abdominal film, US abdomen, endoscopy.

• Treatment: admitssion, NPO, IVF, Abx (Cefuroxime), analgesics• Lap Cholecystectomy: if pt present within 72 hrs do it, if

present after 72 hrs do it after 6 wks (including 2 wks of Abx & spasmolytics)

• Cholangitis is Jaundice, Fever /Rigors, RUQ pain (Charcot’s triad).

What are the causes of Cirrhosis?

Station 7

Alcohol and viral Hepatitis are the first things to sayIf pressed:

Primary Biliary CirrhosisAutoimmune hepatitisHaemochromatosis and Wilson’s diseaseDrugs eg MethotrexateBudd-Chiari syndrome (Hen’s tooth), Congestive Cardiac failure.Alpha-1-antitrypsin deficiency

57 yr female , was treated by surgical inscesion of adenoCA in her rectum :

a) what are the exact operation?b) name the insecion?c) 4 complications ?

d)What does the arrow show?

Station 8

a) the exact operation :colostomy

b) name the insecion : midline

c) 4 complications?

d) the arrow shows :the stoma.

DDx of upper abdominal pain

Station 9

• Epigastric:Upper GI: Gastritis, Oesophageal reflux, Peptic Ulcer, Perforation of gastric or duodenal ulcer.Hepatobiliary: Biliary Colic, PancreatitisREMEMBER MYOCARDIAL INFARCTION

• Right HypochondriumHepatobiliary: Biliary Colic, Cholecystitis, Cholangitis, Hepatitis, Pancreatitis, Fitz-Hugh-Curtis syndrome.Upper GI: Peptic Ulcer, Perforation of UlcerOther Abdominal: Subphrenic abscess, Appendicitis, Renal ColicExtra-Abdominal: Right lower lobe pneumonia, Pulmonary embolus

Chronic vomiting Hx

الله شاء ان واضحة

Station 10