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Ok, great. So let's start the session. So today we're gonna talk about acute abdomen. Um So acute abdomen is something that you're gonna come across for the rest of your life really as a doctor. And it's one of the most common presentations in an emergency department. Um Let's start talking about what an acute abdomen is. So acute abdomen is basically what the name says. It's an, it's a abdomen which something acute has happened to. In really silly terms. It's a essentially any conditions that whether that be medical surgical gynecological that causes abdominal pain and requires intervention like um analgesia fluid surgery. Anything that causes acute pain in the tummy is what ca is an acute ab is what we call an acute abdomen. So there's many, many, many causes of an acute abdomen. I found this diagram really, really helpful because it sort of anatomically divides up the different regions of the abdomen and depending on the sort of anatomical region in it and the structures in that region, it gives you a pretty good idea of what might be going on. So for instance, if you're getting pain in the right iliac fossa, I think this is the right side in the right iliac fossa, um right iliac fossa, pain, just think about what lies underneath the iliac fossa. Um You have your ascending large bowel, you have your appendix, you have the cecum, you have the ileum, you can have an ovary, you can have uh you have your ureters. Um your kidneys are just on top of your right leg fossa. So you can just ana anatomically correlate what's in the abdominal region. And if something is giving you pain in that abdominal region, think about the anatomy and you can decide you can come up on a diagnosis like that. Um So this diagram is really helpful to tell you what it is there. Um I would look at this picture on your own time and sort of create a mental model of what the anatomy is everywhere and what sort of symptoms can occur according to it. Oh, no. My friend just told me that the slides aren't changing. That's really frustrating. Sorry. Um Let me, can you guys see the slide now? Can you see God? Have I just been chatting? Um How about, can you see the slide that I'm talking about now? Um Is the slide the one with the anatomical regions? OK. Fine. Let's just do it like this. II won't like start a slideshow then. Um I don't know how I can change that anyways. So for those of you who missed it all, I'm saying is that usually this diagram is really helpful with telling you what um regions of the abdomen can cause pain. So just use your anatomy knowledge to correlate what's happening. So if this pain in the right iliac fossa, think about the structures in the right iliac fossa, you've got the ascending colon, you've got the cecum, you've got the ilium, you've got the um appendix, you've got ovaries, you have the ureter. So think about things that can affect those structures and that's, that will probably give you your diagnosis. So, if someone's got pain in their right iliac fossa, so um they might have inflammation of the appendix, they might have inflammation of the cecum, they might have inflammation of the ovary. So this is a really good system for you to uh find out what exactly is the cause of their pain. But it's never as simple as that as we all know in medicine. So these are the causes of an acute abdomen, anatomically region wise, um then causes. So now let's talk about system wise, causes of um acute abdomen. So as we know, and there's a lot, lots of systems in the um in the abdomen, you've got your gastrointestinal, you've got your urological system, you've got uh gynecological system. It can uh so there's a variety of things that can happen in the, that are there in the abdomen. So let's just think about it system wise. So what are things that can go wrong with your gut, whether that be a large bowel or your small bowel, uh things like a perforation, um, appendicitis and ulcer ischemia, inflammatory bowel disease. So, these are all conditions that affect the gut. Another, the other thing that's in your abdomen is your liver. So, what sort of things affect the liver, hepatitis clots in the portal venous system, uh, things that affect the gallbladder, cholangitis, cholecystitis, um your pancreas, pancreatitis, spleen can be a splenic rupture. So those are the primary things in your abdomen. Then let's talk about the urological conditions commonly caused your commonly occurring urological conditions that can cause acute abdomen. You can get uti cystitis, pyelonephritis, um colic urinary retention if everybody just um minds popping in what sort of year they are they a medical student? Are they a physician associate student? Um And I can, we can talk more about things because I appreciate some of you might be not be in your clinical years and may not have come across these terms before. And if any questions just pop it into the chat. Um then let's then the other system that's is your gynecological system. So things like ectopic pregnancies, malignancy, torsion of ovaries, fibroids, ovarian cyst ruptures. Um So those are gynecological things that can cause an acute abdomen vascular. So things to do with the arteries and the veins in the body. So what can cause um issues in the veins and arteries in the body that causes acute abdomen. Um, a abdomina, abdominal aortic aneurysm rupture. So that's when an aneurysm in the a abdominal aorta can rupture. And that's life threating mes andric ischemia. That's essentially ischemia of the bowel. And ischemic colitis is ischemia causing inflammation of the bowel. So obviously, you have the system based cau causes, you've got the anatomical causes, but then there's medical causes as well. So things that not that are not in the abdomen, but still cause pain. So, diabetic ketoacidosis is one big thing that can cause abdominal pain. Um and heart attacks, mis the pain can radiate down. And in women and diabetic people, you can get silent mis which basically they'll present with a bit of reflux, a bit of epigastric pain and, but they're actually having an M I it doesn't always present. So classically sickle cell crisis and Addison's disease are two other things that are good to have as differentials if you can't identify an immediate cause of an acute abdomen. So how, what so patients come in? They've got a really painful abdomen. Um What are you gonna do about it? How are you going to assess this abdomen? How are you going to get to a diagnosis? And honestly, in acute abdomen, 95% of the diagnosis is in your history and your exam. Um So, and sometimes you don't even need a scan to tell you what is causing the pathology and scans are simply um for completion sake rather than anything else. So, um 90% of it is in your history and your uh exam. So, what sort of things do you want to ask in your history? Um So if someone's coming with abdominal pain, the first thing you want to do is a good Socrates, a good Socrates will save you in most situations in an acute abdomen. So let's talk about. So, sight, sight really matters as I was talking about earlier with the anatomical correlation. So if someone's got right iliac fossa pain, you're immediately thinking appendicitis. If someone's got epigastric pain, what's in the epigastrium? The pancreas, the fungus on the stomach, the diaphragm, your lung bases. So you can start thinking maybe if it's epigastric pain and the pancreas is there, maybe it's pancreatitis if it's in uh if it, it might be stomach pain, so it might be a a stomach ulcer, it might be acid reflux. It can be, it can even be pneumonia related pain in the epigastrium. So it's really, really important that you delineate which exact region of the abdomen, the pain is um then severity. So um I mean, pain is subjective. You never for diff a pain of one pe people can experience the pain of one with a lifethreatening condition, take it with a pinch of salt, but usually classically, what we see is a 10 out of 10 pain means um it's something really, really serious. So you need to start thinking about things like ischemia, perforations or aneurysm ruptures anybody who comes in and tells you with, they've got a, a pain in their tummy and it's a 10 out of 10. You should take them really seriously and think about what is the most dangerous thing, what is the thing that could kill them? And it's usually a perforation or ischemia that kills people or an aneurysm rupture. So, always have that in the top of your differential. Um not just top of your differential, always rule them out early and have a high suspicion for the these things because these are the things that kill patients than um character. So character of the pain can tell you a lot of things. So essentially we're going through all of these things so that you can make a mental model of like what different conditions present like. And if somebody comes to you and gives you a pattern of the disease, you can easily tell them like, yeah, that's acute abdomen that, that seems more like pancreatitis or that seems more like an ectopic rupture. So it's really important to get your head into sort of pattern recognition, knowing like what disease is present like in mental models. So, um things like aching pain would be like um uh would be usually you think of colic maybe constipation. Um Usually the the maybe um colic constipation inflammation uh usually present as aching pain, burning pain is really, really characteristic for high acid production. So things like reflux ulceration is really characteristic of. But pain, stabbing pain, stabbing pain is it happen? I think stabbing pain is quite nonspecific to be fair. It can mean anything but usually, um, renal colic can be stabbing pain like and if it's like cramping pain that comes on and comes off, think about your bowels twisting together. So it's cramping. And if there's like an object that's stopping the bowel from moving, it's going to like cramp, cramp, cramp. And then if the object will move past and then the bowels will relax. And that's what we call like colicky pain. So that can happen with IBS. If there's an obstruction, the bowels like twisting around the obstruction for things to move past. So, um, cramping pain is really typical for things like obstruction, ibs colic. And then, um, the next one progression of the pain. So is, is the pain constant. Does it come and go if it comes, does it last for minutes, does it last for hours? Um So if it's constant pain, think about ulcers, inflammation. If it comes and goes, it's more likely to be colicky. So, biliary, colic, renal colic. Um And the next thing is you wanna think about radiation. So, where is the pain going? Is it going to the back? If it's back, epigastric pain associated with radiation to the back is a very classic pancreatitis picture because the pancreas is, is in the retroperitoneum. So, pain and inflammation of the pancreas can radiate to the back. Um, if it's going to the scapula, that's usually to do with the gallbladder. So if someone's got like right upper Cordran tendinous with scapular pain, think about gallbladder or ectopic pregnancies because of how the nerve roots work is referred pain. Um, if the pain is going from sort of the groin to um, the scrotum or um, whatever it in there, yeah, low to groin pain. So low to groin pain is basically, is going from the kidney down to the scrotum area or the um basically down below. So if it's a kidney stone, imagine the ureter is trying to like squeeze out the kidney stone. So, and then the ureter starts with the kidney ends at the urethra. So you get pretty classic low into groin pain, which is like very twisty, very crampy. It comes and goes. And um that's a very classic picture for Ureteric colic. Um And then lo to run pain can also be testicle torsion. And that's really important thing that you need to make sure that you've ruled out. Um it's a bit easier to rule out in women than in men. But um testicle pain is really important. Um Just realize you can't see the bottom bit of my slides. And then, so what makes the pain worse? What makes the pain better? So if the pain is worse with movement, it's usually peritonitis. So because the peritoneum is really, really inflamed in peritonitis. So even slight movement can inflame the periton peritoneum. So usually people with peritonitis, you'll be seeing they'll be lying really still not moving, looking really unwell. Um But if they're moving around a lot, um it's likely to be colic cause they're trying to get themselves comfortable by moving around and if the pains worsened with food, it's usually likely to be ulcers. Um Right. Um Next one, so a good Socrates can honestly give you the diagnosis of an acute abdomen. Um Then as you continue to take your normal medical history, you take a past medical history. You ask if they've had any previous surgery, why do we think asking about surgery is important? Well, number one is if they've got like, let's say a subtotal colectomy, it's unlikely they have a ischemic colitis because they don't have any colon. If they've had an, their appendix removed, it's like unlikely to be appendicitis. So it's really important to know what abdominal organ organs they really need. They really have. Um especially with women who've had Cesarean sections. It's really important to ask women if they've had cesarean sections or not, they're of childbearing age because what the thing that we worry about with surgery is adhesions because in surgery essentially you're going in, you're roughing up the abdomen. So it gets really inflamed. So, adhesions can form easily and cause obstructions infections. Um, if they've had surgery recently they might have an infection. So it's really important to ask about their last surgical history, trauma for obvious reas reasons if there's a rupture or if there's a perforation is really important to ask about trauma. If, if they've had a car accident, they might have fallen and ruptured their aortic aneurysm drug history is really important because um things like nsaids, Ibuprofen, uh naproxen, they can cause inflammation of the gi tract and that can lead to ulceration and potentially perforation and even gi bleeds. So, it's really important. You ask whether they've taken any Ibuprofen, recently opioids can cause constipation. So, morphine, oxyCODONE, um those cause constipation. So someone's come in who's complaining of uh painful abdomen and taking lots of constipate, uh la uh sorry opioids. They can be quite constipated a lot that can cause obstruction, bowel obstruction or that might cause abdominal pain. And then social history is really important. Travel history is important because you, if they've traveled anywhere, you want to rule out any infective causes if they've been to some tropical destinations, um people can get infective colitis and eventually ischemic colitis. You want to ask about um diet because diet actually plays a really big part in um cholecystitis and um peptic ulcers. So, if you have like a really spicy high fat diet, you're more prone to things like gallstones. Uh peptic ulcers, alcohol is really important to us because it can affect the, it can cause gastritis because alcohol is quite irritating to your gi tract. It can cause pancreatitis. Alcohol is the most common cause of pancreatitis with gallstones. Um, it can cause Hepati hepatitis liver cirrhosis. So it's really important to ask about alcohol and smoking as well because of malignancy. And if they're going for surgery, you want to ask about their smoking history because they might not be fit enough, their lungs might not be strong enough for them to proceed on to surgery. And then, so examination, let's think about what we'll see on our exam. So we've taken a really good history. We should have sort of a viable different list of differentials. Now. And now we're going to examine them to add to our history and start either creating a more extensive diagnosis, differential list or ruling out differentials. So, if a patient, if you, so a lot can be told by just looking at the patient. So if they're lying completely, still think about peritonitis, um, as we spoke earlier because of the peritoneum being really inflamed and any movement irritates it. If they're moving around a lot, they're colicky. And if somebody is punched forward and bending over, it's very classic for pancreatitis. Ok. Let's talk about, um, abs. So what sort of abs would you see on a patient who's come in with an acute abdomen? Um, so let's do it systematically BP, you could see high BP because of the pain, low BP, low BP is a lot more concerning than high BP. Um, low BP is where, um, you need to start thinking about things like bleeds, abscesses, perforations, um, peritonitis, let's talk about temperature. High temperatures means it's usually there's an infective process going on. So, things like abscesses in infective colitis, um, respirate. Um, well, I don't think it's of much significance but if it's very high or very low, be concerned as you would with anybody. Um Heart rate, if they're tachycardic, it could mean that they, they might have had a perforation, they might have ruptured something, they might have had uh aneurysm rupture. So it's really important to um check their heart rate and oxygen saturations as well. Um Right, let's talk about just general examination findings. You might find things like conjunctival pallor means if they're really anemic, then maybe there's a like long term gi bleed going on cyanosis means that really peripherally shut do shut down. So I would be really concerned in a patient who's got cyanosis because it means they've had like a gi bleed or a perforation. So the the circulations aren't great and they become hypo jaundice is a good sign of um cholangitis. The classic trial for cholangitis is right up quadrant pain, jaundice and high temperature signs of dehydration. The prob possibly not eating and drinking enough because they're in pain. Um And lymphadenopathy is a good com good indication of um infective processes inspection. So you wanna check how, if every time they breathe in, deeply out out they're in pain. If that, that if they are, like, wincing every time they're taking a deep breath in or breathing out, it's probably that it's likely to be peritoneal. Yeah. If they have, they got abdominal distension, if they've got abdominal distension, they might have free gas in the abdomen means something's per perforated. If they got visible peristalsis, the bowels working really hard to push out an obstruction. Sorry. Hi. Um Yeah, sorry, I'm still at the hospital. So a few interruptions. Um, any masses, any like obvious masses that could be abscesses, hernias, um malignancy and scars, um also are a good indication of any previous surgeries. Um It's good to get them to cough to see if any hernias are protruding and that would give a quick diagnosis as well. And then the next thing is deep palpation. You can look for organomegaly, you can look for. Um uh Yeah, so organomegaly is quite good in the palpation. If they've got like hepatitis or malignancy or splenomegaly, that would start raising your red flags and superficial palpation. That's the most important actually. So every time you palpate an abdomen, obviously, you're looking for the site of the pain. That's the most important. But the other most important thing is to rule out peritonitis. So if they've got rebound, tende, if they've got really uncharacteristic tenderness where it's so painful, they can't even tolerate superficial palpation, I would be really concerned and means the patient is probably quite unwell if they call rebound tenderness. So, rebound tenderness is essentially when, um, when you press down and then when you press up the action of the abdomen, sort of bouncing back up is really, really painful. That means they're incredibly peritoneal means that the peritoneum is really, really inflamed. And um, that's usually a surgical emergency and then if they're guarding, so when they tense up their abdominal muscles, uh that means they're guarding and they're quite rigid. So those are all really concerning signs for peritonitis. Um I realized we've talked about peritonitis so much. But does anybody really know what peritonitis is? Um I'm asking all these questions but I can't see anybody or I can't hear anyone. So I'm just answering the questions myself as well. But peritonitis is essentially inflammation of the peritoneum and inflammation of the peritoneum can cau can be caused by various things. So like most commonly is when there's a, if there's a bacterial infection in the abdomen, it can cause peritonitis. If there's malignancy spreading to the peritoneum, it can cause peritonitis if there's a perforation somewhere in the, in the gut and the fecal matter has leaked onto the peritoneum that can cause inflammation. So, those are various things that can cause peritonitis and peritonitis is usually a bad sign. Um And then percussion. So if the percussion is really tym tympanic, that means there's usually an intestinal obstruction because, um, there's lots of free air in the abdomen and if it's dull, it means there's fluid usually like ascites or retention in the bladder. Auscultation means if it's quiet, um, you really worry about obstruction, you worry about bowel ischemia. Um, and if it's really loud, so if it's hyperresonant, it can mean it's intestinal obstruction. Um, I just realized I've got about 40 minutes left and about 50 sides to go through. So I'll go through them quickly. Now, um let's talk about some important signs you could see on abdomina, uh abdominal examination. Um These are quite high yield things. So if you remember how these signs present, MC Qs can ask you these things like a patients come in, they found to have some bluish periumbilical discoloration. Uh What diagnosis do you think it is then, you know, it's associated with like retro toenail hemorrhage, which is associated with pancreatitis. So, colon sign is basically when they've got some bruising uh by the umbilic umbilicus, sinus, severe left shoulder pain. Mcburney sinus. If you press on the mcburney's point between the aces and the umbilicus, there's quite a lot of tenderness. Um Murphy sinus. When you uh do, when you press down on the right upper quadrant, they take a deep breath in and when they're taking a deep breath out, it's really painful. It's usually cholecystitis. Um Gray turn sign is when there's disc r of the flank. So that's also because of that peritoneal hemorrhage from um pancreatitis. Ro swing sign is when you press on the right lower quadrant. Uh, no, when you press on the left, lower quadrant, you get right lower quadrant pain because of the widespread inflammation. So we'll upload these slides later on. Um, these signs are quite good to know investigations. So you, these are the investigations you do routinely on somebody who's got an acute abdomen, full blood count, things like a high white cell count which show infection and inflammation. Um low low hemoglobin could indicate a bleed urea and electrolytes. If the renal function is really poor, it might indicate renal kidney issues. So things like urinary colic pyelonephritis, liver function test if the ast and the alt is really elevated, it's prob usually hepatic, it's a hepatic cause of abdominal issues. But if the ALP is elevated, it's usually a post hepatic cause. So, like cholecystitis can cause the raised alp cholangitis can cause the raised alp and raised bilirubin crp is vital because an elevated crp uh can really tell you a lot about the extent of and severity of inflammation. Um urinalysis is quite good because blood or blood in the urine could show pyelonephritis, leukocytes and nitrates in the urine could show infection in the like a uti abdominal x-ray is really good. It show it can, it's quite good to show things like obstruction or constipation. And a chest X ray is quite good because a, an erect chest X ray is really good at showing um pneumoperitoneum. Basically, that means that uh there's free air in the diaphragm because the bowels ruptured and now there's air in the peritoneum. And you can see that on a chest X ray ct and ultrasound as well. So these are, this is sort of the basic way on how, what sort of differentials we can have, what sort of diagnosis can happen, which is going through a case. Um I'm hoping this will be a little bit more interactive. Um I'm just gonna see, um, read out the cases and if you could just put in the chart, what do you think it is? That would be really good, Baba I realize we're the only people here. Oh, ok. So there's a, let's just go through the cases. So there's a 24 year old man with a one day history of abdominal pain. He's got pain on his, uh his pain was generalized first and now it's in the lower right abdomen and radiates to his right groin. He vomited twice a day. He denies any fevers, any diarrhea, uh any other complaints. He's got a normal past medical, past surgical history, quite fit and healthy. So, I mean, immediately as soon as we hear right quadrant abdominal pain, it's sort of classic, isn't it? With appendicitis? So that's already like the top differential in my mind, we can easily rule out gynecological issues because he's a male. Um, the other stuff you could think about is testicular torsion, I suppose in a young man or hernias. So, on a physical examination, his temperature is fine. His heart rate is fine. His BP is fine. His respirate is 18 and his oxygen is 100% on room air and he looks a bit uncomfortable, a bit pale. And then on abdominal examination, it's soft, it's non distended. It's tender to palpation in right lobe in the right co low cord with mild guarding and he's got hyperactive bowel sounds and a normal testicular exam. So top differentials at this point are seem, I mean, we ruled out testicle torsion and ruled out any hernial stuff. So it's most likely to be appendicitis and given the lack of like past medical history, we don't think it's like an IBD flare. We don't think it's DKA. So I think appendicitis is uh pretty classic. So there you go. It's appendicitis, periumbilical pain, loss of appetite, nausea, vomiting, pain, localizing to the right lower quadrant. Uh These are all classic signs of appendicitis treatment of appendicitis. So, CT S are quite uh good to show us appendicitis. It can show pericecal inflammation, abscess, um fluid collection, localized fat stranding. These are all quite common finding for appendicitis. So, if you see here, this is the cecum and this is this little bit is the appendix, I guess. So you can see. Well, it's not very clear here but you can see a bit of an abscess area of hypodensity over here. So that makes us think it's probably appendicitis as well. So the diagnosis of high white cell counts, the diagnosis of appendix is appendicitis is usually clinical. We don't really need any scans to tell us that it's appendicitis. Um, but a CT scan can help confirm it in cases. The treatment is for them to be nail by mouth. IV fluids, antibiotics, uh painkillers and eventually an appendectomy case number two. So you've got a 68 year old lady with two days of left lower quadrant abdominal pain, diarrhea, fevers and chills, nausea, vomited at home once or past medical history of hypertension, diverticulosis and past surgical history is negative. Um So she got left lower quadrant pain, diarrhea fever chills and she's got a past medical history of diverticulosis. So, essentially what diverticulosis is is out pouching of the bowel. Um It can happen with age poor diet, chronic constipation and diverticulitis is infection of diverticulosis, which is basically an infection of the outpouching of the bowels. Um So with diverticulitis, it's pretty common to have diarrhea, fevers, chills, vomiting. Um So what do we let's go temperature? Fine, heart rate is fine. BP is ok. Her abs are fairly non exciting. Generally, she looks a little bit uncomfortable, a little bit pale, probably from the pain cardiovascularly. She's fine, normal heart sounds no edema in the leg, normal pulses. Abdomen is soft, she is moderately tender on her left lower quadrant and apr examination shows normal tone and just brown stool. So, what are differentials at this point? I mean, with a lady with fevers, diarrhea and a past history of diverticulosis, I think it's quite obvious that it's probably diverticulitis. So there you go, that's the diagnosis of diverticulitis. The risk factor for diverticulitis usually includes diverticula. So the out pouchings, increasing age and features of it include discomfort in the left, lower quadrant change in bowel habits, urinary symptoms. Um It can also cause paralytic ileus. So that's basically when the bowel becomes paralyzed or small bowel obstruct. Uh No. So, uh physical exam will show a low fever, localized tenderness rebound guarding. Um, as you can see on the slides, um, diverticulitis is pretty easy to manage. You just give antibiotics, um, make sure there's no abscess and, um, they usually recover quite well and you can offer, um, laxatives to help keep this, um, stool smooth. So you can see here, I think, hm, you can see lots of free gas. Oh, here, that's the bowel. Um, so, oh, here, I think you can see some pericolic fat stranding around here, um, thickened bowel wall over here and you can see an abscess as well. Um, so, um, it just make sure that the diverticulitis doesn't proceed to an abscess because that can be life threatening because of perforation and sepsis. So, the treatment is usually fluids we need to collect any electrolyte abnormalities because with the diarrhea, you can lose electrolytes, um, antibiotics and sometimes surgery as well to um, remo, remove the bit of the bowel with severe divertic colitis. Um Next one, next case, this is a 46 year old man with who's got a history of alcohol abuse. He's got a three day history of severe upper abdominal pain, vomiting and subjective features. And his past medical history is fairly unexciting on his observations. His BP is a bit low and he's tacking. So he, he seems a bit unwell now. So we're like a little bit concerned about him generally. He, so he looks quite ill. He appears to be in a, a lot of pain. Um um cardiovascular tachycardic, heart valves are not um notable pulse is fine, lungs, clear abdomen is quite distended and he's got tenderness in the epigastric region with guarding and his pr exam, there's no blood in his stool. What do we think our main differential is? So man excess alcohol history, epigastric pain, some guarding a bit tachycardic. Um I think it's quite classic for pancreatitis. Pancreatitis can make people sick very quickly and very easily. So it's always good to have it in your differential list. So we have this pancreatitis, a good pneumonic to remember the causes of pancreatitis is I get smashed. Um But the most common causes of pancreatitis is alcohol and gallstones. So, in this man who's got like a pretty big alcohol history. I think we can safely say that it's probably what's called his pancreatitis. Um, the classic features of pancreatitis are epigastric pain that radiates to back severe severe. It's really severe nausea and vomiting. The physical findings are low grade fevers, tachycardia, hypotension, you can get atelectasis and pleural effusion in quite severe cases. Peritonitis is usually a late finding. So, um, that means they're really, really unwell ileus is basically uh paralysis of the bowel colon sign as we talked about earlier, bruising around the umbilicus and gray turner sign is blue discoloration of the flanks. The easy way to remember, colon sign is colon is just one word. So it's just one bruise above the umbilicus and gray turner is two words. So it's on both flanks. That's how I remembered it. Uh pancreatitis, how do we diagnose it? So, lipase is the most sensitive, but lipase tests are really expensive to run. So most hospitals won't run lipase. So amylase is the next best thing. Um Amylase is not specific but it, if it's three times the upper limit of normal, we usually can pretty safely say they've got pancreatitis. A CT scan is quite um can be helpful but it doesn't always tell us if they've got pancreatitis or not. Um An MRI might be more sensitive. So, treatment is they have to be nail by mouth, you have to give them IV fluids. Um You, we don't usually give antibiotics. And if it's mild pancreatitis, they can, we can just give them fluids, analgesia. But if it's severe pancreatitis with hemodynamic unstability, they usually need admission. Right. Case four, how many cases do we have left? We've got quite a few left. Ok. We'll always through them. We got about 20 minutes more. So, 70 year old male with a history of coronary artery disease on aspirin with severe several days of dull upper abdominal pain and now with worsening pain in the entire abdomen, some relief with food until today. Now, worse after eating lunch, right. So that's quite helpful. His history because we can sort of make a his make a diagnosis purely from the history itself. Um We don't really need anything more to be honest with, with that history, we know he's got coronary artery disease and he's on aspirin. So maybe we can also start thinking about is this more? Is, could this be a vascular issue? Could this be an abdominal aorta aneurysm rupture rupture, but it doesn't really quite fit because the pain has been going on for several days. Um And the pain is getting better with food. Um And now it's worse actually after food, um an abdominal aortic aneurysm rupture would be sudden and would be quick. They'd start having stabbing pain in the middle of the abdomen and it's like unbearable pain. So it's unlikely that this is, it's something vascular. But with the history of coronary artery disease, aspirin. It is like a consideration for sure. I mean, he's a classic 72 year old man, hypertension, heart failure. He's had an appendectomy in the past. Um, he's on aspirin, furosemide me beta blockers. Um, he's a smoker. He doesn't drink alcohol, doesn't use drugs. Um, on examination, we find that his temperature is ok. He's a bit high heart rates. Ok. BP is quite low. Um, so we're just a bit worried now that his BP is a bit low and he seems to be a thin elderly male looks ill. His abdomen is quite distended and diffusely tender to palpation with rebound tenderness and guarding. So now we're really concerned about him. So it's clearly peritonitic. What pains can cause peritonitis, perforations, ruptures infection. So, what could um the key factor in this case is that it's worse with food now. So, um, so it's because it's worse with food, we can immediately start thinking about maybe a peptic ulcer disease. And the answers to this case is a peptic ulcer disease couldn't have been. Um, so peptic ulcer disease is basically an ulcer of the um stomach or the duodenum. Um, it can be caused by a variety of things. H Pylori is a big risk factor. NSAID, smoking, hereditary. It's got very classic sort of burning epigastric pain and it's usually worse with food. Um So, and if the patient's peritinic with it, it usually means they perforated the ulcer. So the ulcers in basically really friable material. So it can easily perforate it. So what's the diagnosis? Uh Rectal exam is quite good because it can tell you if there's any melena. That means the ulcer has been bleeding, full blood count for hemoglobin. Um The gold standard diagnosis for peptic ulcer disease is an OGD and the treatment is tobacco. Uh the treatment is not tobacco. The treatment is to avoid tobacco, don't have tobacco, which of peptic ulcer disease. Um, avoid nsaids, avoid aspirin and give high dose PPI and have they got any of these features? If they're more than 45 years of age, they've got weight loss, they've got anemia. Um We worry that it might be malignancy related as well. So let's have a look at this X ray of this gentleman who's come in with um peptic ulcer disease. He's really peritinic. He's really hypotensive. What do you think is going on here? What just stands out at the chest X ray? So, as you can clearly see, there's lots of air in the diaphragm. So we know he's definitely perforated something. So, um, so we think now that he's perforated his peptic ulcer and now he's got free air in the diaphragm. So it's really important to get a chest X ray in your patients. Perforated peptic ulcer is an abrupt onset of severe epigastric pain. Um And it usually needs oxygen IV fluids, um, abdominal X rays, antibiotics and it requires a general surgical review, right? So now let's do something a bit different. We finally got a female presenting to Ed. Any time a woman presents to hospital with abdominal pain and is in childbearing age, you always, always, always need to ask her last menstrual period and do a pregnancy test because you'd be surprised how many of these things that could be gynecological. So, we've got a 35 year old lady. She's come to Ed with nausea and vomiting. She was seen yesterday since yesterday. She's got some generalized abdominal pain. Um, she's not got any fevers. She's lost her appetite a bit. She last opened her bowels two days ago. Medically, she's not, nothing really. Um, exciting has happened to her surgically. She's had a hyster hysterectomy for fibroids and she denies any alcohol, tobacco or drugs on the exam. She's temperature is ok. Heart rate is fine. BP is fine. Respirate is ok. Oxygen is ok. She's a bit obese. She's vomiting. Um, her cardiovascular exam is ok. Lungs are clear abdomen. She's like moderately distended. She's got mild tenderness to palpation all over her tummy. She's got hypoactive bowel sounds and no rebound regarding. So she's coming in with vomiting. Her appetite is poor. She's got like tummy pain everywhere and her b like her bowel sounds aren't that great. So, what do we think? The biggest thing is, what do you think is causing her? It could be something gynecologically related if we do a pregnancy test. We could really, we could rule out things like an ectopic pregnancy. Um If we do a, um the other things that might cause things like ovarian rupture or ovarian torsion, but to have generalized abdominal pain with nausea and vomiting doesn't really fit with hypoactive bowel sounds, doesn't really fit with the gynecological cause. So she's kindly, they've done a really, they've done a chest x abdominal x-ray for her. So that's really helpful. Um And the abdominal X ray sort of gives it away immediately as to what it is. So we, we can safely say that this is a bowel obstruction. If you look closely, you'll see the, the bowel loops are really, really dilated. Essentially, that happens because something is obstructing the passage of things in the bowel and all the gas is building up. So they become huge and that's why the tummy is really distended. So this is pretty classic bowel obstruction. Um bowel obstruction can be mechanical. That means when there's a physical cause. So like adhesions, a hernia, if there's a malignancy or it can be non mechanical. So, um things like ileus where there's an electrolyte disturbance causing the uh gut to stop moving properly, that's non mechanical. So the clinical features are crampy, intermittent pain, periumbilical or diffuse use in inability to have bowel movements or pus nausea, vomiting, bloating, they feel really full and physical findings are distension, tympani on percussion. So it's like really high pitched percussion sounds and the bowel sound really sounds like tingling because there's so much of air in the abdomen. So we've covered bowel obstruction. The diagnosis is, I mean, bloods may not be really exciting in somebody with bowel obstruction. If they got really high white cells really high CRP, maybe. Now they've perforated the bowel because the obstruction is stretching the bowel. But uh the best thing is an abdominal X ray. It will show like lots of dilated large bowel loops. Ct scan can tell you the cause of obstruction. So, is it an adhesion? Is it infection or malignancy? Treatment of bowel obstruction is, um, you need to make sure they're not perforated. That's the biggest thing. Um, the treatment is usually you put an energy tube that decompresses all the gas in the bowel and then you need to treat the cause of the obstruction. So, if it's constipation, you need to give them laxatives. If it's malignancy, maybe they need surgical opinion. So, the first thing to do is rule out any um, perforations, then put an NG tube in start fluids, keep the nail by mouth and get surgical opinion. Ok. Case six. So this is a 48 year old obese female with a one day history of abdominal pain after eating and it doesn't radiate. It's intermittently cramping, no diarrhea. Other than it's, she seems pretty ok. Other than this intermittent cramping, abdominal pain. So every time somebody comes cramping, abdominal pain. We talked about how cramping usually means there's a colic like intermittent cramping pain is usually colicky. So, um on examination, fairly unexciting, she's quite obese. Um she's got tenderness in her right upper quadrant and positive Murphy sign. Um and non distended abdomen, normal bowel sounds. So, what are we thinking about her here? She's got right upper quadrant pain, Murphy sign positive. That's a dead giveaway for acute cholecystitis. So, acute cholecystitis usually happens in um there's a really cheeky um way to remember it, which is four fs so female fat fair. And what was the other female doctor? And I can't remember the other f to be honest. Um If I remember, I'll let you guys know. Um So this woman, we know that she's, she's a woman, she's a bit obese. So her risk factors are quite high. So, classic features of uh acute cholestasis is right, upper quadrant or epigastric pain. It goes to the shoulders, it's dull and achy, you can get nausea, poor appetite fevers and the examination is epigastric or right upper quadrant pain Murphy sign and the patient appears quite ill if this peritonitis again, this proliferation and the treatment is um you can see elevated alp S and elevated bilirubin, as I said before, um the sort of first line diagnose is uh ultrasound, which can show things like a thickened gallbladder, wall, pericholecystic fluid gallstones and a Hida scan, which can be more specific. So, treatment is usually acute cholecystitis. The gallbladder needs to come out within six weeks if it's an acute episode. Um, so a cholecystectomy fluids, anusia antibiotics is usually the treatment for acute cholecystitis. Ok. Not long left. Now. Um, we've got a 34 year old male with a four day, his four hour history of sudden onset left flank pain, nausea and vomiting with no prior history of similar symptoms. You've got no fevers, no chills and with some difficulty urinating and no hematuria and he feels the urgency to urinate but he can't. And po other medical issue is fairly unexciting. So, left lung pain, nausea, vomiting, um with difficulty urinating. Um What sort of differentials are we thinking of? So it's probably likely to be urological. If he's got left flank pain, he's finding it difficult to urinate. Um It might probably be urological. So, on our examination, his observed he's a bit tachycardic, he's a bit hypertensive, that's probably from the pain. He's ring around stretching in pain. Um and he's a bit tachycardic. So it seems like he's quite uncomfortable, seems a bit colicky with all this moving around and all of that. So the answer to this is renal colic. So that's basically when kidney stones are trying to pass, you can get renal colic. Um So it has very classic loin to groin pain. Um It's acutely comes on, it's um you can get nausea and vomiting. Um You don't usually get fever with it. And on the abdominal examination, you can find like, um, patients will be unable to sit still. Um, classic investigations. CT Kub S are the best for renal colic. It can tell you about kidney stones. Um, and the treatment is, um, if there's a stone, it needs to be removed. Fluids, analgesia, um, antibiotics, urology. So, we've covered a lot of acute abdominal cases. Now, we've covered obstruction, ulceration, cholecystitis. Um, you colic uh diverticulitis. And we've talked about a lot of other things as well. So if you guys have any questions, feel free to put them in the chat, we'll upload these slides on and we'll put a recording as well for your, uh, more for your learning. Um, hopefully you found that useful. We'd really appreciate if you filled out a feedback form and sent to us. Thank you so much. Ok.