Beruflich Dokumente
Kultur Dokumente
Semester 12 2009
SELECT INVESTIGATIONS
appropriate to the situation
Remember
epigastric pain may relate to pathology above the diaphragm
Colicky pain
Hollow viscus obstruction/spasm
Constant pain
Inflammation
Radiation
Shoulder tip/back/loin to groin
Clotting
Ultrasound
Cheap Non-invasive No preparation Useful in biliary, renal and gynaecological problems.
Case 1
23 male presents with 24 hr history of abdominal pain Pain initially periumbilical and localises to right iliac fossa Temp 37.4 pulse 80 with tenderness guarding and rebound in RIF
Case 1
Haematology
Biochemistry Microbiological Imaging Special
WCC
?? U/S Laparoscopy +/Appendicectomy
Case 1 Management
Consent for appendicectomy
Laparoscopic/open
Antibiotics
Aerobic and anaerobic cover Duration of antibiotics???
Appendicitis
Essentially a clinical diagnosis
Pain RIF tenderness WCC > 12000
Ultrasound and CT
Useful when clinical doubt
Female Atypical history
Appendicitis
Essentially a clinical diagnosis
Pain RIF tenderness WCC > 12000
May masquerade as
Gastroenteritis Urinary tract infection Pelvic inflammatory disease (PID) Ovarian pathology (Torsion of testis)
Ultrasound and CT
Useful when clinical doubt
Female Atypical history
Appendicitis symptoms
Associated symptoms:
Nausea, vomiting, anorexia. Pain precedes vomiting.
Alleviating factors:
Lying still
Aggravating factors:
Moving, coughing, walking, palpation of abdomen.
Beware:
likely to be classic in the young, the elderly, pregnant women,
The most consistent symptoms/signs are anorexia, RLQ tenderness, rebound tenderness.
1 1 1
2 1 1
2
1 10
Case 2
18 year old female presents with right sided abdominal pain mid cycle. She is tender in the right iliac fossa with guarding and slight rebound Differential includes ovarian pathology, ectopic pregnancy and appendicitis
Case 2
Haematology
Biochemistry Microbiological Imaging Special
WCC
Pregnancy test Ultrasound Laparoscopy
Case 2 Management
Observe Investigate
U/S
If not resolving
Laparoscopy
Case 2 Ultrasound
Imaging of appendicitis
CT
Sensitivity 85-100%
Beware radiation in young women
US
Sensitivity 74-100% Dedicated units
Sensitivity 89% Specificity 95% PPV 86% NPV 96%
Case 3
35 Y male presents with sudden onset of severe abdominal pain with assoc. shoulder tip pain. O/E distressed lying still tachcardia normotensive
Case 3
Haematology Biochemistry
Microbiological Imaging Special Erect chest ?CT
WCC ?Lipase
Case 3
FBE
Hb 13.9 WCC 15000
Case 3 Management
Analgesia Antibiotics N/G tube I/V fluids DVT prophylaxis Theatre
Case 4
54 year old female otherwise well Hysterectomy 15 years previously 24hrs
Colicky abdominal pain Vomiting Distension
Case 4
Haematology
Biochemistry Microbiological Imaging Special
WCC
U&E Supine and erect ?CT -
Case 4
Case 4 Management
Analgesia I/V fluids N/G tube Observation Issues
Signs of strangulation
???Repeat analgesia
Failure to resolve
Laparotomy/laparoscopy
Case 4
Laparotomy if signs of strangulation
CONSTANT PAIN Fever Leucocytosis
Non resolution
CT useful
Case 4b
Case 4b
Diagnosis
LBO
Issues
Pseudo-obstruction Mechanical
Competent ileocaecal valve?
Caecal size
Case 4 Management
Mechanical
Stent Hartmanns Colostomy Primary resection
Pseudo
Decompress
Rectal tube Colonoscopy
Pharmacologial
Neostigmine
Case 5
A 43 year old man who is in excellent general health presents with a 2 hour history of severe right loin which radiates to the groin. There is no abdominal tenderness but the patient is visibly distressed.
Case 5
Haematology
Biochemistry Microbiological Imaging Special MSU Plain XR / U/S/ CT KUB
Case 5 Imaging
Management
Analgesia Image Observe Urological intervention if not resolved
Case 6
HISTORY:75 year old man presents with severe epigastric pain radiating to the back.He as no significant past history.
CLINICAL FINDINGS:Normotensive. Tachycardia. Moderate epigastric tenderness. Absent bowel sounds.
Case 6
What is the differential diagnosis?
Pancreatitis Cholecystitis PPU Leaking AAA
Case 6
Haematology
Biochemistry Microbiological Imaging Special
Y
Y N Y N
Case 6 RESULTS
Hb 14 WCC 20.4 urea 15.3 creatinine 0.17 amylase 1435 bilirubin 35 alk phos 250 LDH 250 Ca 1.99
Amylase
Produced in pancreas and salivary glands Normal <200 IU/l Rises with many causes of acute abdominal pain Amylase greater than 1000 IU/l generally considered to be diagnostic of pancreatitis
75% specificity 60% sensitivity
Pancreatitis Trauma to pancreas Perforated ulcer Ischaemic bowel Ectopic pregnancy Pelvic inflammatory disease Abdominal aortic aneurysm Parotitis
Amylase - pancreatitis
Levels rise in first 6-24 hrs Normalise over 5-7 days Can be normal Peak within 48 hrs One piece of information which should be combined with clinical findings and other laboratory findings.
Lipase
Technically more difficult assay but newer assays now making lipase more readily available Originates from pancreas Increases in 4-8 hrs of onset Peaks at 24 hrs Decrease over 8-14 days Increase less frequently associated with non pancreatic abdominal pain
More sensitive and specific than amylase at twice upper limit of normal
Pancreatitis - issues
Establish diagnosis Assess severity
If severe to ICU
Define aetiology
Biliary/alcohol
Case 6 Management
Analgesia I/V fluids
?CVC
SELECT INVESTIGATIONS
appropriate to the patient