assessment and management of acute abdomen (osce stop)

© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

Table 1: Assessment and management of the acute abdomen

Peritonitis Ruptured AAA Renal colic Appendicitis Gallstones Acute pancreatitis Gastritis / peptic ulcer

Diverticulitis Bowel obstruction Ectopic pregnancy

Common differentials

Perforated viscus ↘Peptic ulcer ↘Colonic tumour ↘Gallbladder ↘Appendix ↘Spleen ↘AAA ↘Ectopic

SBP

Other peritonitiscauses

Pyelonephritis

Biliary colic

Meckel’sdiverticulum

Crohns

Mesenteric adenitis

Ovarian cyst rupture/ torsion/ haemorrhage Ectopic pregnancy

Biliary colic Intermittent RUQ pain Exacerbated by fatty food

Cholecystitis Continuous RUQ pain Murphy’s +ve Tender + guarding RUQ

CBD stones Jaundice RUQ pain

Cholangitis Jaundice Fever/rigors RUQ pain

Acute pancreatitis (See column)

Gastritis

Cholecystitis

Pancreatitis

Cholecystitis

Diverticular cyst

Diverticulosis

Mesenteric ischaemia

IBS

Ovarian cyst rupture/ torsion/ haemorrhage

Gasteroenteritis Appendicitis

Pelvic inflammatorydisease

Meckel’s diverticulum

Crohns

Mesenteric adenitis

Ovarian cyst rupture/ torsion/ haemorrhage

Classical history Severe generalisedabdominal pain

Elderly

Severe generalisedabdominal pain

Back pain

Reduced GCS/collapse

Spasms of loin to groinpain (excruciating)

Nausea and vomiting

Cannot lie still

Young patient

Periumbilical pain

Moves to RIF

Anorexia

Severe epigastric/ centralpain

Radiating to back

Relieved by sitting forwards

Vomiting

Epigastric pain

Related to meals

Elderly

LIF pain

Guarding

Pyrexia

Vomiting + abdo pain + no bowel motions

Increasing iliac fossa/pelvic pain

6 weeks pregnant/ not using contraception

May have spotting

Classical examination

No movement withrespiration

Guarding

Firm, peritoniticabdomen

Reboundtenderness

Severe pain to light palpation

Percussion tenderness

Hypotension

Peritonitis

Expansile mass

Soft non-tender abdomen

May be renal angle tenderness

Tender RIF

Worse at McBurneyspoint

Guarding/ localperitonitis

Rosvings +ve

Epigastric tenderness

Tachycardia

Fever

Shock

Grey-Turner’s and Cullens sign’s (rare)

Tender epigastrium

Soft abdomen

Tender LIF

Guarding/ localperitonitits

PR (confirm noCA/abscess)

Distended, tender abdomen

Tinkling bowel sounds

Tenderness RIF/LIF

Guarding

Adnexial tenderness

Cervical excitation

Standard investigations

Bloods (inc. FBC, U&E, LFT, CRP, amylase, INR, G&S) + blood culture if pyrexial

Urine dip ± culture

Urine βHCG

Specific investigations

Erect CXR (if anysuspicion)

Urgent CTabdo/pelvis

None usually

CT only if stable

CT KUB None if very likely

USS abdo/pelvis if gynae differentials

Abdominal USS No imaging needed to confirm if very likely

CT abdo if diagnosticuncertainty

Apache II / Glasgow score↘ABG required↘Calcium

Confirm cause ↘USS abdo (exclude gallstones in all) ↘Triglycerides ↘Immunoglobulins

Gastroscopy & biopsy

Flexible sigmoidoscopy AXR

Then CT abdo/ pelvis

Serum βHCG + trend

Transvaginal USS

Vaginal swabs

General management

IV fluids

Analgesia (paracetamol IV/PO, codeine PO, tramadol PO, morphine IV/IM/SC) & anti-emetics

Clexane + anti-embolism stockings

If may require surgery: ↘NMB

↘Check INR and G&S ↘Stop warfarin/aspirin/diabetic medications

Management 2 wide-bore IV cannulae

Urgent laparotomy& repair

2 wide-bore IV cannulae

Aim for permissive hypotension (SBP 100)

Activate ‘massive haemorrhage protocol’ e.g. 10U

Urgent open repair (/ EVAR if stable)

Diclofenac analgesia

Smooth muscle relaxants (nifedipine/tamsulosin)

ABx (e.g. cef) if infection

Pelvic stone ↘<2cm – ESWL ↘>2cm – PCNL

Ureteric stone ↘<5mm - conservative ↘<1cm – ESWL ↘>1cm - uteroscopy

Urgent laparoscopy/appendicectomy

Biliary colic

OPT Cholecystectomy Cholecystitis

ABx (ciprofloxacin)

Cholecystectomy (hot/6w) CBD stone

Continuous IVI (prevent hepato-renal syndrome)

ERCP Cholangitis

IV ABx (e.g. cipro/tazocin)

Treat cause

Supportive Mx

NBM ± NG tube

Lots of IV crystalloids e.g.1L every 4h (third space sequestration)

Stop causative meds

No ABx unless proveninfection

Treat cause

ITU + oxygen may be required

PPI (omeprazole PO/ pantoprazole IV)

Gastroscopy

H Pylori eradication

NBM

Bowel antibiotics (Cef + Met)

NBM

Wide-bore NG tube(free drainage)

IV fluid hydration

Laparoscopy/ laparotomy depending on cause

2 wide-bore IV cannulae

Laparoscopy (or methotrexate if uncomplicated)

Other important conditions not covered: volvulus; acute mesenteric ischaemia; strangulated hernia; ovarian cyst/ torsion; salpingitis; PID. Medical causes of acute abdominal pain: MI; pneumonia; sickle cell crisis; gastroenteritis; DKA; pyelonephritis; IBD/ IBS

Assessment and Management of the Acute Abdomen