GASTRO/GENSURG
LIST OF DIFFERENTIALS
PromptDifferentials of sudden onset abdo pain
ResponseIschaemic bowel
AAA
Aortic dissection
Renal colic
Perforated viscous
Pancreatitis
Bowel obstruction
Biliary colic
AAA
Aortic dissection
Renal colic
Perforated viscous
Pancreatitis
Bowel obstruction
Biliary colic
PromptEpigastric pain differentials + features
ResponsePancreatitis
- History of alcohol binge/excess, pain radiating to back
- Soft abdo, epigastric tenderness, relieved sitting up
- Elevated lipase
- Murphies positive/RUQ peritonism
- Thickened GB wall >3mm +/- pericholecystic fluid on USS
- Known CBD stones at cholangiogram
- Jaundice, Fever, RUQ tenderness
- Often with soft abdomen
- Obstructed CBD on USS (>4mm or age/10mm) with loss of tapering
- Recent risks - steroids/NSAIDS
- Peritonism
- Pulsatile mass in epitastrium
- Aneurysm on bedside USS, free fluid on CTA abdomen
- Radiation to R arm/jaw, exertional, history of IHD
- Soft non tender abdomen
- STEMI on ECG
- Known procoagulant state, AF
- Soft abdomen
PromptLIF pain differentials and clinical features
ResponseRuptured ectopic
- Sudden onset, adnexal mass on examination - hCG positive, U/S shows complex adnexal mass and empty uterus
- Sudden or staggered onset, adnexal tenderness. Doppler ultrasound no flow
- Colicky pain, blood on urine dip, renal tract U/S
- Gradual onset of pain, may be guarding, CT abdo
Prompt“Constipation” - concerning Differentials and CT findings
ResponseIschaemic colitis - Gas in intestinal wall (Pneumatosis intestinalis) or portal vein (Pneumatosis portalis)
Toxic megacolon - colon dilated >6cm diameter
Sigmoid volvulus - Volvulus lacking haustra and end pointing to pelvis
Acute diverticulitis - segmental bowel wall thickening or presence of abscess
(free gas in abdomen - pneumoperitoneum - more of a complication of the above rather than a diagnosis in itself - justify well and use once only)
Toxic megacolon - colon dilated >6cm diameter
Sigmoid volvulus - Volvulus lacking haustra and end pointing to pelvis
Acute diverticulitis - segmental bowel wall thickening or presence of abscess
(free gas in abdomen - pneumoperitoneum - more of a complication of the above rather than a diagnosis in itself - justify well and use once only)
PromptGastric outlet syndrome causes
ResponseMalignant
- Adenocarcinoma
- GIST
- Lymphoma
- Metastasis
- duodenal/peptic ulcer disease
- Pancreatic pseudocyst
- Gastric varices
- Gtanulomatous disease (Crohns, sarcoid, TB)
- Gallstones (Bouveret syndrome)
- Strictures (eg from caustic ingestion)
- Gastric antral web
- Gastric vovulus
- Gastric Bezoar (Rapunzel syndrome)
PromptConsiderations when deciding non operative management of old people with abdominal disasters
ResponseConfirm advanced care directive with NOK/EPOA
Adjust obs/AMP - avoid met calls
NBM/IV fluids
Medications
Adjust obs/AMP - avoid met calls
NBM/IV fluids
Medications
- Antiemetics
- Analgesia - subcutaneous opioids
- Tripple antibiotics - cover coliforms and anaerobes