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  5. Oorzaken van ziekten 3.2 (GK03.4)

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Summary Thema 7: alle matrixen!
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  • Oorzaken van ziekten 3.2 (GK03.4)
  • Institución
  • Rijksuniversiteit Groningen (RuG)

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Información del documento

  • 18 de abril de 2023
  • 22
  • 2022/2023
  • Resumen

Temas

  • acute abdominale pijn
  • peritonitis
  • obstructie
  • coma metabolisch
  • coma neurologisch
  • coma intoxicaties

Escuela, estudio y materia

  • Rijksuniversiteit Groningen (RuG)
  • Geneeskunde
  • Oorzaken van ziekten 3.2 (GK03.4)
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Week 5: Peritonitis
Diagnosis Cholecystitis Cholecystolithiasis Ulcer disease Pancreatitis Perforation of GI Appendicitis Diverticulitis
organ
Definition Inflammation of the Gallstones = most Most commonly in the Often due to alcohol Results in generalised Most common cause Inflamed diverticula –
gallbladder – often due common cause of stomach or duodenum abuse (40%) or peritonitis of the acute abdomen can perforate:
to cholecystolithiasis biliary tract disease – sometime gallstones (40%) peritonitis
Often begins with oesophagus
physical and chemical
inflammation – later
bacterial infection
Tests Patient is systemically Exclude Test for H. pylori: History Increased leucocytes + Clinical suspicion + Most common site =
unwell: fever and haematological and Stool antigen test Investigations: CRP ultrasound or CT scan sigmoid/descending
tachycardia liver abnormalities – Serum anti-H. pylori  Pancreatic Free air in the Point of McBurney = colon
Increased blood test for CRP, IgG enzymes in abdomen on X-ray or where the appendix Mild left iliac fossa
inflammatory markers FBC, liver enzymes and Hydrogen breath test plasma CT scan comes out of the tenderness
Tenderness in RUQ – pancreatic enzymes Endoscopic biopsies  CRP caecum – localised Faecal loading
more marked in Establish if gallstones with urease testing  Plasma lipase peritonitis Endoscopy = to
inspiration are present – Endoscopy esophago-  ALAT Tenderness to confirm diagnosis and
Tender, inflammatory ultrasound gastro-duodenoscopy  Liver function palpation exclude malignancy
gallbladder mass may Assess integrity and or gastroscopy – tests Fever: 37.5-38.5 CT or contract enema
be palpable patency of the bile gastritis  Ultrasound of the Guarding = to diagnose abscess
Murphy sign = pain at duct system and the Biopsies is to gallbladder Board-like rigidity
the RUQ when the pancreatic duct: distinguish benign Severe pancreatitis Rebound tenderness =
doctor palpates the  Non-jaundiced: from malignant + H. criteria (3): Blumberg’s sign
gallbladder while the intraoperative pylori  >55 yrs or >75 yrs Systemic toxicity:
patient holds his/her cholangiography Contrast radiography = for gallstone  Fever
breath  Jaundice: MRCP – effectiveness of gastric  Leucocytosis  Malaise
Increased liver no results: ERCP emptying – barium  High blood sugar  Tachycardia
enzymes or endoscopic meal  High LDH  Leucocytosis
Attack lasts more than sphincterotomy  High ASAT When in doubt: admit
24h or papillotomy During next 48 hrs: the patient – monitor
70%: a pathogen can  Endoscopic  >10% haematocrit every few hours
be cultured ultrasound = to  Increased plasma
Ultrasound = to assess lower end urea
support diagnosis of the common  Hypocalcaemia
bile duct +  Low PaO2
ampulla + head of  Metabolic
the pancreas acidosis
 Increased fluid
sequestration
Clinical Charcot’s triad: Epigastrium or RUQ Epigastric pain Severe abdominal pain At first: localised At first: poorly Chronic, grumbling
presentation  Pain in RUQ pain Severe retrosternal Often radiates to the peritonitis = when localised and central diverticular pain: low-
 Ever Intermittent and acute pain + dysphagia = back small perforation pain = visceral pain grade recurrent
 Jaundice pain: colicky pain oesophagus Vomiting becomes an After 12-24 hours: pain inflammation  bowel
Decreased RR and Jaundice = when the Exacerbation by acidic Restlessness – keeps intraabdominal localised to the spasm  episodic
consciousness stone obstructs the or spicy food = changing position abscess + NO faecal affected area: diarrhoea and

, common bile duct stomach Distended, tender spillage RLQ/right iliac fossa constipation
Steatorrhea Relieved by food = abdomen – NO Generalised peritonitis Exacerbation by Acute peritonitis =
Hypocoagulopathy = duodenum – coming guarding = due to chemical muscle movement local extension of
due to reduced vitamin back when hungry = Absent bowel sounds and/or bacterial Nausea diverticular
K uptake hunger pain Jaundice irritation Vomiting inflammation –
Nausea Anorexia Minimal or rapidly  Hypovolaemia Local peritonitis: pericolic tissues and
Vomiting Weight loss resolving abdominal  Toxaemia guarding and rebound peritoneum:
Pain is often triggered Chronic anaemia signs: abdominal  Sepsis = when tenderness  Left iliac fossa
by fat meals Abdominal fullness distension, tenderness, infection is Tachycardia pain
Pain radiates to the and bloating guarding and absent present Fever  Systemically ill
back Weight gain = with bowel sounds  Rigid and tender Facial flush patient: pyrexia
Upper abdominal duodenal ulcers – pain Severe: abdomen Perforation: and tachycardia
tenderness often comes at night:  Severe toxaemia  Absent bowel generalised peritonitis  Mild left iliac
relieved by bland and shock sounds and systemic toxicity fossa tenderness
foods and milk  Generalised  Obvious local
Perforation = localised peritonitis peritonitis
or generalised  ARDS = early Pericolic abscess:
peritonitis: severe complication  Swinging fever
abdominal pain and  Persistent pain
shock and tenderness
Haemorrhage: massive  Incomplete
haematemesis and obstruction
melaena  Septicaemia
Intermittent  Purulent
symptomatic episodes diarrhoea
Patient Cause = often Women are affected Risk factors: Causes: Causes: Age: <40 – esp. 10-20 Main cause = too low
obstruction by stones 4x more  Bad diet  Affected more  Perforation of an yrs  rare <10 fibre intake
or stenosis (e.g. due to Predisposing factors:  Stress  Idiopathic ulcer Cause = obstruction Females are affected
pancreatic tumour) –  Pregnancy  H. pylori –  Gallstones  Perforation of the with faeces – common more than males
stasis of bile –  Obesity infection is often  Ethanol small bowel – due in low fibre diets
ascending infection  Diabetes acquired in  Trauma to something
from the duodenum childhood  Steroids sharp and
 Alcohol = erosion  Mumps distension
of the mucosal  Autoimmune  Transmural
wall  Scorpion/snakes inflammation of
 NSAIDs –  Hyperlipidaemia the bowel:
blockage of COX1 and appendicitis,
 Smoking – hypercalcaemia diverticulitis and
elevated gastrin  ERCP Crohn’s
 Elevated gastrin  Drugs  Transmural
inflammation of
other organs:
salpingitis and
cholecystitis
 Rupture of colon
due to
constipation =

, often fatal faecal
peritonitis
Typical onset Acute Chronic Chronic Acute Acute Acute Acute
>50 years >40 years Duodenal = 30-50 Alcoholic = <44 Any age 10-20 years >50 years
Stomach = >60 Gallstones = >45
History Systemically unwell + Women + Epigastric pain + History of gallstones or Local peritonitis – First poorly localised + History of constipation
palpable inflammatory epigastrium/RUQ pain triggered by alcohol + severe severe pain and then pain in RLQ + + mild tenderness of
gallbladder mass + + colicky pain + spicy/acidic food + abdominal pain guarding and patient systemically the left iliac fossa +
RUQ tenderness esp. triggered by fat meals hunger pain radiating to the back + tenderness + unwell + young patient grumbling pain +
upon inspiration jaundice generalised peritonitis erratic bowel
– shock and sepsis movements
Treatment Acute cholecystectomy Normally surgery: Control predisposing Mild attacks: Surgical emergency – Preference = Take out Sigmoid
within a few days after cholecystectomy – or aggravating cause:  Fluid resuscitation treat on clinical laparotomy – view of colon:
the attack gold standard =  Lifestyle  Analgesia suspicion the adjacent structures  Hartmann
ABs: when the patient laparoscopy  Stop aspirin or  Treat Local peritonitis: treat In women always procedure = make
has bacterial infection Only laparotomy with NSAIDs predisposing the underlying laparoscopy a stoma
ERCP with papillotomy unexpected difficulties  Stress factors problem Resuscitation  Anastomosis of
= to relieve obstruction or complications Elimination of H. Severe attacks: Generalised Antibiotic prophylaxis: the colon to the
If patient is not fit for pylori: omeprazole +  ARDS – peritonitis: metronidazole rectum
surgery: antibiotics ventilatory 1. Fluid resuscitation (anaerobic) + Lifestyle: high-fibre
chenodeoxycholic acid (clarithromycin + support 2. High dose if IV sometimes diet
– 50% recurrence after amoxicillin) –  Supportive ABs cephalosporin ABs
2 years eradication of often measures: O2, 3. Urgent (aerobic)  2 hrs IV fluids = to rest the
Side effects: long-term within 1 fluids and laparotomy before surgery bowel
 Severe diarrhoea week nasogastric tube Conservative = in suppository
 Hepatic damage Diminishing irritant  CRP patients unfit for Peritoneal toilet = if
Indications for surgery effects of acid-pepsin: measurements surgery: pus or faeces were
= symptomatic antacids  Regular liver  Nasogastric found
gallstones or gallstones Administration of enzyme tests to aspiration
that could become mucosal protective test for biliary  IV fluids
symptomatic in the agents: sucralfate obstruction  Gastric acid
future Reduction in acid  Renal function suppression
Relief jaundice before secretion: tests  ABs
surgery by endoscopic  H2 receptor  NO ABs
sphincterotomy = blocking agents =  Endoscopic
stone extraction and cimetidine and surgery for
bile duct stenting ranitidine gallstones
 Proton-pump
inhibitors:
omeprazole
 Surgical
vasectomy = rare
Partial gastrectomy =
removal of affected
tissue
Correction of
secondary anatomic

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