Surgical Assessment Workbook

!!!Assessment of the Acute Abdomen

The Key Principles: Explained

!For Cardiff University Medical Undergraduates

!Version 1 - 2014

!1CREATED BY: DR DAFYDD LOUGHRAN

Introduction This workbook gives you the power to understand the

principles of surgical assessment.

This short interactive workbook will get you thinking as a surgeon. It gives you the tools to understand the key anatomy, physiology and clinical information to give you a flying start on your surgical placement.

Guide

Understanding the principles will make your life in medical school and beyond much easier. To get you thinking you’ll see tasks throughout the book with the following symbols:

!Do you understand? If not, think about it, create your own understanding, then discuss it with a friend. !

! Get together as a group and discuss the principle. Use each others’ understanding and jot down the key points. !! Recommended further reading. !

Time to test your understanding. !! Create a memory cue. Stick a post-it on your toaster, make an presentation and watch it in a toga, make a mind-map and stick it on your ceiling. Make it memorable. !

Answers to key questions and tasks can be found on page 19…but you’ll learn much more if you attempt the tasks without them. No prizes for a tidy workbook!


Learning

Objectives

Understand the differences between clinical presentations

Link prior scientific knowledge with clinical understanding

Develop a common framework for assessment

Score ≥8/10 in the post workbook quiz

Content !Presenting symptoms 4

!Pain - the Socrates approach 5

Anatomy - the basics 5

Biliary Duct Anatomy 10

!Vomiting 11

Vomiting centres 11

Haematemesis 12

!Lower GI Pathology 13

Appendicitis 13

PR Bleeding 14

!Constipation & Obstruction 15

Small Bowel Obstruction 15

!Hernias, Incisions & Stomas 16

!Urinary retention 17

Single Best Answers 18

!Task answers 19

!Reflection & Evaluation 20


Symptom Presentation !There are only a few key symptoms that you need to understand to diagnose the vast majority of cases on the surgical wards. !The aim is to understand the key principles behind each symptom, and use this as a framework for the assessment of any patient with an acute abdomen. !!!!!!!

!Jot down some initial thoughts on what would be important to ask regarding these symptoms, and why the answer may be clinically relevant.

!!!!!!!!!!!!!!!!!


Pain

Vomiting

Diarrhoea

Constipation

Urinary symptoms

Questions Clinical relevance?

Pain:

Vomiting:

Diarrhoea:

Constipation:

Urinary:

Pain - the SOCRATES approach !What is pain? !Why is some pain different to others? ! ite - the site usually gives us a good idea of where the problem is. Fill in the following and compare with the answers.

!!!

Take note of where the organs lie in relation to the 9 anterior quadrants. !

Look again at the anterior and lateral images. What are the implications of the organs’ position on the lateral image on site and radiation of the pain? Which organs may pose a diagnostic challenge?


S

Find out the names of the 9 abdominal quadrants and annotate the image.

Annotate the following 13 on both anterior and lateral diagrams: liver, gall bladder, pancreas, kidneys, oesophagus, stomach, small & large intestine, appendix, bladder, aorta, and ovaries & uterus in females.

Although the site gives us a good idea, it’s not an exact science. For diagnostic reasons we often think of the abdomen as 4 quadrants. Below are the 13 most important causes of abdominal pain. Link them to the quadrants where they may cause pain. Remember some causes may present in more than one quadrant.

! nset - the pattern of onset gives us clues as to what type of pathology is occurring.

!Get together and discuss which of the following are linked, and come up with a list of diagnoses which may present each way.

!!!!!

!!!!!!


Appendicitis Cystitis

Diverticulitis Biliary Colic

Pancreatitis Duodenal Ulcer

Cholecystitis & Cholangitis Renal & Ureteric Colic

GORD & Gastritis Urinary Retention

Small Bowel Obstruction Ruptured AAA

Ectopic or gynae pathology & consider MI’s, pneumonia & PE’s.

O

Seconds to minutes !Progressive over hours to days !

Wave-like pattern

Obstructive !Inflammatory !

Arterial

Rupture or blockage leading to acute symptoms in dependant organs.

Development of cytokine response and cell necrosis.

Contraction of smooth muscle meeting resistance.

Seconds / Minutes Hours / Days Wave-like pattern

haracter - is the pain “stabbing”, “aching”, “cramping” ! Here’s a highly recommended short article discussing the different types of pain: http://www.wellcome.ac.uk/en/pain/microsite/science3.html ! In summary hollow organs have nociceptors which lead to pain in the presence of distension, irritation and inflammation. The following give classic pain characters for common pathologies: !

!!7CREATED BY: DR DAFYDD LOUGHRAN

Ureteric & Biliary ColicDull aching pain as the ducts, ureters or gall bladder distend, followed by severe sharp pain when there is contraction against the obstruction.

Gut InflammationInfection and inflammation of the gut leads to distention and oedema of the gut wall leading to constant aching pain. Severe tenderness may be evident on palpation.

Bowel Obstruction

May not present with any pain, only the classic symptoms of distention, absolute constipation*, nausea, and tinkling bowel sounds**. If pain does occur it is usually cramping in character as the bowel peristalsis meets resistance.

C

* Absolute constipation refers to there being no faeces OR FLATUS being passed - an important differentiator between simple constipation and bowel obstruction.

** Audio clips of different bowel sounds: http://tinyurl.com/3wn9fmf

adiation - when pain is felt away from the affected organ. !Recall from the Wellcome Trust paper why pain radiation occurs.

The following classic examples can be valuable clues in our assessment:

Get together and take a history from each other. Actors, choose one of the following to simulate:

From To Suggestive of

Epigastric Central Back Aortic Aneurysm/ Dissection

Pancreatitis

Loin/Flank Groin Ureteric colic

Right upper quadrant/Any area Shoulder tip Shoulder tip pain suggests diaphragmatic irritation. This

could be due to inflamed structures nearby the diaphragm, or

PERITONITIS


R

Periton (-of the peritoneum) itis (-inflammation)

The peritoneum is the membrane that lines the abdominal cavity. Peritonitis occurs due to infection on damage to an organ in the abdomen such as a perforated ulcer or appendix, or a ruptured ectopic pregnancy. It is an emergency and needs rapid management. !Signs of peritonitis: ! • Systemic inflammatory response syndrome - tachycardia,

tachypnoea, abnormal temperature, raised inflammatory markers.

• Severe pain and tenderness throughout abdomen • Abdominal guarding - non-voluntary tensing of muscles

to guard inflamed organs. • Rebound tenderness - removing the palpating hand

quickly causes more pain than palpating the abdomen.

Renal colic Small bowel obstruction Appendicitis Biliary colic

ssociations - does the pain occur with nausea, vomiting, diarrhoea, constipation, urinary symptoms, or gynaecological symptoms? ! iming - Has the pain happened before? How long does it usually last? ! !!!!!!!!! !! xacerbating and relieving factors - !!! ! everity - a subjective measure usually scored as a 1-10 rating. ! Patients’ assessment of the severity of their pain can vary considerably, can you think of ways of objectively assessing pain?


A

TRenal colic has 3 phases, timings can vary considerably but for the typical patient:

Onset - reaches peak within around 2 hours

Constant - persists for around 3 hours

Relief - decrease in symptoms over around 2 hours

Biliary colic generally causes 1-5 hours of constant dull pain.

Patients more comfortable moving around.

Onset a couple of house following fatty meal.

Associated nausea and vomiting.

E

S

Gastric & duodenal ulcers can often be differentiated by relation to eating. Gastric ulcers are worse during eating as gastric cid is produced as food is in the stomach. Duodenal ulcers are relieved during eating as the pyloric sphincter closes so then acid doesn’t reach the duodenum.

!Pancreatitis is classically exacerbated by lying flat

Biliary Pathology !

Annotate the diagram with the anatomical names. !Biliary pathology leads to symptoms in 2% of the population every year. The key conditions are: !!!!!!!

Complete the following definitions: !

Biliary Colic = Pain following impaction of a ………. in the …….. duct.

Acute Cholecystitis = ……………. of the gallbladder following obstruction of the

………. duct by a gallstone.

Ascending Cholangitis = Infection of the ………. system due to a stone in the

common ……. duct.

Acute Pancreatitis = Sudden inflammation of the pancreas most commonly due to

…………… or …………… .

Read the following article and describe how you will differentiate between acute cholecystitis and ascending cholangitis when assessing a patient:

http://tinyurl.com/nb2vkab

!!!!


Biliary colic

Acute cholecystitis

Ascending Cholangitis

Acute Pancreatitis

Vomiting !Remind yourself of what causes vomiting:

!!!

!!

!!!

!Different drugs affect the vomiting pathways at different areas, so it’s important to consider the most likely cause of vomiting when commencing anti-emetics.

!Many drugs list nausea and vomiting as a possible side effect but it’s incidence varies from drug to drug. Come up with a top 5 list of drug classes that can cause vomiting:

!!!!!!


Pain, smells, emotions

Toxins & Drugs

Pharynx & Stomach stimuli

Higher centres

Chemoreceptor trigger zone (CTZ)

Nucleus of the solitary tract

Vomiting centreVomiting

…are you on any of the following?

☑ ️

☑ ️

☑ ️

☑ ️

☑ ️

Any cause of severe abdominal pain can cause vomiting, but there are some conditions that are particularly prone. Think about:

• Bowel obstruction - especially in the presence of abdominal distention and constipation.

• Biliary colic - pain lasting a few hours, typically following fatty foods.

• Gastro Oesophageal Reflux Disease / Hiatus hernia - retrosternal burning worse on lying flat.

• Pancreatitis - epigastric pain with radiation through to back. Elevated amylase on blood tests.

Haematemesis is …….. …….! !

You are working your first day as a Foundation Doctor and a nurse calls you to see a 40 year old man on the Surgical unit because of haematemesis. How will you assess this patient?

!Mid-Point Recap

Flick back through the previous pages and jot down on these post-it notes any questions you’d like answered. Your tutor will see if the group

have common questions and tailor a teaching session to these: !!!!!


THE ANSWER IS ALWAYS

ABCDE!!

A = Is the airway patent, if not

B = Is there an issue with their breathing

C = Are there any concerns about their circulation

D = Is there a new disability (confusion, drowsy)

E = Exposure - rashes, burns

(and DEFG - Don’t Ever Forget Glucose)

S OR T !I T

And no matter how senior you are. Always call for help early!

Here Are Your Top 3 Causes Of Haematemesis !

Oesophageal varices - often 2ary to portal hypertension

Gastric ulcer - often due to NSAID’s/aspirin/steroids

Duodenal ulcer - often due to NSAID’s/aspirin/steroids

Lower GI Pathology !Annotate the diagram and remind yourself of the function of each part of the bowel: ! Human Physiology. Pocock, Richards & Richards. Part 10

!!!!!!!Appendicitis Appendicitis is an inflammation of the appendix that 6% of the population develop at some point. It is often caused by faeces becoming trapped in the appendix, leading to swelling and inflammation. The treatment is an appendicectomy (-ectomy = to remove).


Duodenum Jejunum Ileum Colon

Together describe a classic case of severe appendicitis using SOCRATES, other symptoms, findings from an observation chart, blood results, and any other features that may point towards the diagnosis…

!PR (per-rectum) Bleeding !Fresh PR bleeding is bright red & likely due to rectal or anal pathology such as haemorrhoids, fissures, or rectal cancer. !Dark stools with blood mixed in is called melaena and is likely to originate from higher in the GI tract. Remember melaena is not the diagnosis, only the finding, and it has the same differential diagnoses as haematemesis. !The key to safe it’s safe assessment and management is to consider whether the patient is haemodynamically stable. Consider whether the BP is dropping? Is the heart rate climbing? Is the Hb dropping? If yes then call for help & start fluid resuscitation.


S

O

C

R

A

T

E

S

Other features

!

Temp

Heart Rate

BP

Resp rate

Hb

WBC

CRP

Differential diagnoses Alvardo’s scoring system for Appendicitis:

M igratory pain (1) A norexia - recent ↓ appetite (1) N ausea (1) T enderness (2) R ebound tenderness (1) E levated temperature (1) L eukocytosis - high WBC (2) S hift to left in leukocytes (1) Score: 0-4 = not appendicitis 5-6 = doubtful diagnosis >7 = likely appendicitis

Constipation and Obstruction !As a junior doctor you'll be asked relentlessly to review patients' constipation. Sometimes some laxatives will work a treat, but other times it's exactly what the patient didn't need... !

Key question: What's normal for you? !A chat with some friends might reveal that what you thought was 'normal' might be very different to other people. Some are regular as clockwork, some not, some once every other day, some 3 times a day. If possible, have a chat with some friends and come to a decision about what's 'normal'.

!So never forget to ask about any previous operations as any abdominal operation leads to adhesions, and always check for any hernias. !Large bowel obstructions are less common but are usually due to a colorectal cancer or a volvulus, which is an abnormal twisting of the sigmoid or caecum. !

Common causes of not opening bowels

Opioid treatment (morphine, oramorph, codeine)

Immobility due to hospitalisation

Post-operative ileus - the bowels tend to be very inactive for a few days after the peritoneum is opened

Small Bowel Obstruction - more common than large bowel obstruction due to narrow small bowel


Small Bowel Obstruction - Classic signs

Abdominal distention

Nausea & vomiting

Tinkling bowel sounds

Absolute constipation (see page 7)

Commonest causes of

SMALL bowel obstruction are:

!Adhesions Hernias Tumours

Virtually the only occasion when a plain abdominal radiograph is justified is to assess for bowel obstruction. Compare the following two radiographs and annotate them with the classic findings in small bowel obstruction.

!!

Hernias, Incisions & Stomas Annotate the following:

Hernias Stomas !!!!!

Incisions !

!


Normal plain abdominal radiograph Small bowel obstruction

Multiple dilated loops of gas filled bowel, due to obstruction further down

Valvulae conniventes - lines seen across entire bowel wall, seen in small bowel only. Large bowel has haustra that only partially cross the bowel.

………… - small bowel comes out with a spout.

………… - large bowel comes out flush with skin.

1.

2.

3.

4.

5.

1.

2.

3.

4.

Urinary Retention !Retention is defined as the inability to pass urine. A normal bladder can hold 400-500ml, and any volume beyond this should be considered retention if the patient is unable to pass urine. !As the bladder lies low in the pelvis it is usually not palpable. A palpable bladder is dull to percussion and usually suggests retention. If there is any doubt bladder scanners (ultrasound) are available on most wards and give an estimated current bladder volume.

!

Causes of Urinary Retention

Bladder outflow obstruction - including benign prostatic hyperplasia, prostate cancer and urethral strictures

Medications - including anti-depressants, and botox injections into the bladder for urge incontinence

Constipation

Clot retention - from haematuria

Spinal cord disease

Recent catheterisation


Voiding !Bladder compliance is important in maintaining normal urination patterns. Normally due to detrusor compliance the pressure within the bladder remains stable until there is around 300-400ml in the bladder. This ensures that there is no urge to urinate until that point, and allows unimpeded entry of urine into the bladder. Beyond this point an urge to micturate if felt and there is central control of voiding via the pontine micturition centre in the pons. This then inhibits motor neurons to the external urethral sphincter and pelvic floor muscles, while stimulating parasympathetic innervation of the detrusor, leading to voiding.

Single Best Answers Aim for 8/10 to show you’re ready for the wards. Some questions require further reading.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!


1. The appendix is most commonly located in the:

A. Epigastrium

B. Right upper quadrant

C. Right iliac fossa

D. Left flank

E. Suprapubic region

!2. Which of the following diagnoses most commonly causes pain

radiating from the epigastrium through to the back?

A. Acute Pancreatitis

B. Diverticulitis

C. Appendicitis

D. Renal Colic

E. Gastro-Oesophageal Reflux Disease

!3. Identify one pathology associated with improvement following eating.

A. Biliary Colic

B. Acute Cholecystitis

C. Ureteric Colic

D. Duodenal ulcer

E. Small Bowel Obstruction

!4. One of the following is due to a stone in the common bile duct.

A. Biliary Colic

B. Acute Cholangitis

C. Mirizzi Syndrome

D. Gallstone Ileus

E. Ascending Cholangitis

!5. The most common cause of melaena is:

A. Internal Haemorrhoids

B. Peptic Ulcer

C. Rectal cancer

D. Angiodysplasia

E. Mallory Weiss tear

!!

6. Which of the following is one of the 2 most common causes of small

bowel obstruction?

A. Post-operative Ileus

B. Opioid use

C. Bowel Cancer

D. Adhesions

E. Gallstone Ileus

!7. Which of the following is NOT a recognised risk factor for

urinary retention?

A. Benign Prostatic Hyperplasia

B. Spinal Cord Compression

C. Clot Retention

D. Constipation

E. Bladder instability

!8. A 13-year old girl presents with central abdominal pain radiating to

the right iliac fossa. Which of the following would NOT be a suitable

investigation?

A. Urine dipstick

B. Pelvic ultrasound

C. Serum inflammatory markers

D. Abdominal radiograph

E. Pregnancy test

!9. Which of the following classically presents with radiation from loin to

groin?

A. Acute Cholecystitis

B. Acute Hepatitis

C. Splenic Rupture

D. Ureteric Colic

E. Pyelonephritis

!10. Which of the following is NOT suggestive of peritonitis?

A. Abdominal guarding

B. Systemic inflammatory response syndrome

C. Rebound tenderness

D. Hyperactive bowel sounds

E. Hypotension

!!!

!!

!

!

!!!

!


9 Quadrants

AnswersAnterior Lateral Differentials

Biliary tractBiliary Colic = Pain following impaction of a gallstone

in the cystic duct.

Acute Cholecystitis = Inflammation of the gallbladder

following obstruction of the cystic duct by a gallstone.

Ascending Cholangitis = Infection of the biliary

system due to a stone in the common bile duct.

Acute Pancreatitis = Sudden inflammation of the

pancreas most commonly due to gallstones or alcohol.

Page

5 & 6

Page

10

Ascending Cholangitis:

Reynold’s Pentad =

Jaundice

Fever

RUQ pain

Shock

Altered mental status

}Charcot’s triad

Page

11

…are you on any of the following?

☑ ️ Opioids

☑ ️ Anticholinergics

☑ ️ Antibiotics

☑ ️ Cytotoxics

☑ ️ Anti epileptics

☑ ️ Digoxin

}

}gastric stasis

chemical effect

Page

12Haematemesis is vomiting blood!

Page

13

GI Tract

Page

14Page

16

Hernias

1. Umbilical

2. Epigastric

3. Incisional

4. Inguinal

5. Femoral

Incisions

1. Kocher (for open cholecystectomies)

2. Midline (for diagnostic laparotomies)

3. McBurney (for appendicectomies)

4. Pfannenstiel (for caesarian sections)

Stomas - RIF = ileostomy (due to total colectomy)

LIF = colostomy (due to resection of distal colon)

Single Best Answers - your target was 8 or more.

1 = C, 2 = A, 3 = D, 4 = E, 5 = B, 6 = D, 7 = E, 8 = D, 9 = D, 10 = D.

Feedback Please answer the following questions fully and return to your Placement Supervisor.

!1. Were the learning objectives fulfilled?

No Yes

1 2 3 4 5

!2. Did you find the learning style engaging and beneficial? Please add comments.

No Yes

1 2 3 4 5

…………………………………………………………………………………..

!3. How would you rate the appropriateness of the topics discussed? Please add comments.

Irrelevant Exactly what I needed

1 2 3 4 5

…………………………………………………………………………………..

!4. How would you rate the complexity of the topics discussed? Please add comments.

Too simple Way over my head

1 2 3 4 5

…………………………………………………………………………………..

!5. Would you recommend this workbook to peers?

No Definitely

1 2 3 4 5

!6. Give the 3 topics covered that enhanced your understanding the most.

…………………………………… ……………………………………

……………………………………

!7. Suggest 3 topics that either were not covered or needed further clarification.

…………………………………………………………………………… ……………………………………………………………………………

……………………………………………………………………………


Documents

Surgical Assessment Workbook