(11) Abdomen tables Flashcards
GERD:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of the lower esophageal sphincter; Helicobacter pylori may be present
Location: chest or epigastric
Quality: heartburn, regurgitation
Timing: After meals, especially spicy
foods
Aggravating Factors: Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
Relieving Factors: Antacids, proton pump inhibitors;
avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers
Associating Symptoms/Setting: Wheezing, chronic cough, shortness of breath, hoarseness, choking
sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esophageal cancer
Peptic Ulcer Disease:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the muscularis mucosa; H. pylori infection present in 90% of peptic ulcers
Location: epigastric, may radiate straight to the back
Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike; No symptoms in up to 20%
Timing: Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
Aggravating Factors: variable
Relieving Factors: Food and antacids may bring relief
(less likely in gastric ulcers)
Associating Symptoms/Setting: Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer); dyspepsia is more common in the young (20–29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30–60 yrs
Gastric Cancer:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Adenocarcinoma in 90%–95%, either
intestinal (older adults) or diffuse
(younger adults, worse prognosis)
Location: increasingly in “cardia” and GE junction; also in distal stomach
Quality: variable
Timing: Pain is persistent, slowly progressive;
duration of pain is typically
shorter than in peptic ulcer
Aggravating Factors: Often food; H. pylori infection
Relieving Factors: Not relieved by food or antacids
Associating Symptoms/Setting: Anorexia, nausea, early satiety, weight
loss, and sometimes bleeding; most
common in ages 50–70 yrs
Acute Appendicitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Acute inflammation of the appendix
with distention or obstruction
Location: Poorly localized periumbilical pain,
usually migrates to the right lower
quadrant
Quality: Mild but increasing, possibly
cramping; Steady and more severe
Timing: Lasts roughly 4–6 hrs, depending
on intervention
Aggravating Factors: Movement or cough
Relieving Factors: If it subsides temporarily,
suspect perforation of the
appendix.
Associating Symptoms/Setting: Anorexia, nausea, possibly vomiting,
which typically follow the onset of
pain; low fever
Acute Cholecystitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Acute inflammation of the gallbladder with distention or obstruction
Location: Right upper quadrant or epigastrium; may radiate to right shoulder or interscapular
area
Quality: steady, aching
Timing: Gradual onset; course longer
than in biliary colic
Aggravating Factors: Jarring, deep breathing
Relieving Factors: none
Associating Symptoms/Setting: Anorexia, nausea, vomiting, fever;
no jaundice
Biliary Colic:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Sudden obstruction of the cystic duct
or common bile duct by a gallstone
Location: Epigastric or right upper quadrant;
may radiate to the right scapula and
shoulder
Quality: Steady, aching; not colicky;
Usually last longer than 3 hrs
Timing: Rapid onset over a few min, lasts
one to several hrs and subsides
gradually; often recurrent
Aggravating Factors: Fatty meals but also fasting;
often precedes cholecystitis,
cholangitis, pancreatitis
Relieving Factors: none
Associating Symptoms/Setting: Anorexia, nausea, vomiting, restlessness
Acute Pancreatitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Intrapancreatic trypsinogen activation
to trypsin and other enzymes, resulting
in autodigestion and inflammation
of the pancreas
Location: Epigastric, may radiate straight to the back or other areas of the abdomen;
20% with severe sequelae of organ
failure
Quality: usually steady
Timing: Acute onset, persistent pain
Aggravating Factors: Lying supine; dyspnea if pleural
effusions from capillary leak syndrome;
selected medications,
high triglycerides may exacerbate
Relieving Factors: Leaning forward with trunk
flexed
Associating Symptoms/Setting: Nausea, vomiting, abdominal distention,
fever; often recurrent; 80%
with history of alcohol abuse or
gallstones
Chronic Pancreatitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Irreversible destruction of the pancreatic
parenchyma from recurrent inflammation
of either large ducts or small ducts
Location: epigastric, radiating to back
Quality: severe, persistent, deep
Timing: Chronic or recurrent course
Aggravating Factors: Alcohol, heavy or fatty meals
Relieving Factors: Possibly leaning forward with
trunk flexed; often intractable
Associating Symptoms/Setting: Pancreatic enzyme insufficiency,
diarrhea with fatty stools (steatorrhea)
and diabetes mellitus
Acute Diverticulitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Acute inflammation of colonic diverticula,
outpouchings 5–10 mm in diameter,
usually in sigmoid or descending
colon
Location: LLQ
Quality: may be cramping at 1st then steady
Timing: often gradual onset
Aggravating Factors: none
Relieving Factors: analgesia, bowel rest, antibiotics
Associating Symptoms/Setting: Fever, constipation. Also nausea,
vomiting, abdominal mass with
rebound tenderness
Acute Bowel Obstruction:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Obstruction of the bowel lumen, most
commonly caused by (1) adhesions or
hernias (small bowel), or (2) cancer or
diverticulitis (colon)
Location: Small bowel: periumbilical or upper abdominal; Colon: lower abdominal or generalized
Quality: cramping
Timing: Paroxysmal; may decrease as
bowel mobility is impaired
Paroxysmal, though typically
milder
Aggravating Factors: Ingestion of food or liquids
Relieving Factors: none
Associating Symptoms/Setting: Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction); obstipation develops (early); vomiting late if at all; prior symptoms of underlying cause
Mesenteric Ischemia:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Occlusion of blood flow to small
bowel, from arterial or venous thrombosis
(especially superior mesenteric
artery), cardiac embolus, or hypoperfusion;
can be colonic
Location: May be periumbilical at first, then diffuse; may be postprandial,
classically inducing “food fear”
Quality: Cramping at first, then
steady; pain disproportionate
to examination findings
Timing: Usually abrupt in onset, then
persistent
Aggravating Factors: underlying cardiac disease
Relieving Factors: none
Associating Symptoms/Setting: Vomiting, bloody stool, soft distended
abdomen with peritoneal
signs, shock; age >50 yrs
Pancreatic Cancer:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Predominantly adenocarcinoma (95%); 5% 5-yr survival
Location: If cancer in body or tail, epigastric, in either upper quadrant, often radiates to the back
Quality: steady, deep
Timing: Persistent pain; relentlessly progressive illness
Aggravating Factors: smoking, chronic pancreatitis
Relieving Factors: Possibly leaning forward with trunk flexed; often intractable
Associating Symptoms/Setting: Painless jaundice, anorexia, weight loss; glucose intolerance, depression
Oropharngeal Dysphagia:
Timing
Aggravating Factors
Associated Symptoms/Conditions
Timing: acute or gradual onset & variable course, depending on underlying disorder
Aggravating Factors: attempts to start swallowing process
Associated Symptoms/Conditions: aspiration into the lungs or regurgitation into the nose w/ attempts to swallow; from motor disorders affecting the pharyngeal muscles such as stroke, bulbar palsy, or other neuromuscular conditions
Esophageal Dysphagia (mechanical narrowing): Mucosal rings and webs
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent
Aggravating Factors: solid food
Relieving Factors: regurgitation of the bolus of food
Associated Symptoms/Conditions: usually none
Esophageal Dysphagia (mechanical narrowing): Esophageal stricture
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may become slowly progressive
Aggravating Factors: solid foods
Relieving Factors: regurgitation of the food bolus
Associated Symptoms/Conditions: long history of heartburn and regurgitation
Esophageal Dysphagia (mechanical narrowing): Esophageal cancer
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: may be intermittent at first, progressive over months
Aggravating Factors: solid foods w/ progression to liquids
Relieving Factors: regurgitation of food bolus
Associated Symptoms/Conditions: pain in chest and back, weight loss - especially late in course of illness
Motor Disorders: Diffuse esophageal spasm
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver, sometimes nitroglycerin
Associated Symptoms/Conditions: chest pain that mimics angina pectoris or MI and lasts min to hrs, possibly heartburn
Motor Disorders: Scleroderma
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may progress slowly
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver
Associated Symptoms/Conditions: heartburn, other manifestations of scleroderma
Motor Disorders: Achalasia
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may progress
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver
Associated Symptoms/Conditions: regurgitation often at night when lying down with nocturnal cough, possibly chest pain precipitated by eating
Acute Diarrhea: Secretory Infection (non-inflammatory)
process characteristics of stool timing associated symptoms setting/person @ risk
process: infection by virus, preformed bacterial toxins, cryptosporidium, rotavirus, Giardia lamblia
characteristics of stool: watery, w/o blood, pus, mucus
timing: few days
associated symptoms: N/V, periumbilical pain, temp normal or slightly elevated
setting/person @ risk: travel, food source, epidemic
Acute Diarrhea: Inflammatory Infection
process characteristics of stool timing associated symptoms setting/person @ risk
process: colonization of invasion of intentional mucosa
characteristics of stool: loose to watery, often w/ blood, pus, or mucus
timing: acute illness of varying duration
associated symptoms: lower abd cramping pain and often rectal urgency, tenesmus, fever
setting/person @ risk: travel, contaminated food or water, frequent anal intercourse
Drug-induced Diarrhea
process characteristics of stool timing associated symptoms setting/person @ risk
process: action of many drugs (Mg antacids, Abs, chemo, laxatives)
characteristics of stool: loose to watery
timing: actor, recurrent, chronic
associated symptoms: nausea, usually little to no pain
setting/person @ risk: prescribed or OTC meds
Chronic Diarrhea: Irritable Bowel Syndrome
process characteristics of stool timing associated symptoms setting/person @ risk
process: altered motility ot secretion from liminal and mucosal irritants that change mucosal permeability; immune activation, and colonic transit, including maldigested carbs, fats, excess bile acids, gluten intolerance, enteroendocrine signaling, and changes in microbiomes
characteristics of stool: loose, 50% w/ mucus; small-moderate volume; small hard stools w/ constipation; may be mixed patten
timing: worse in am, rarely at night
associated symptoms: cramps lower abdominal pain, abd distention, flatulence, nausea; urgency, pain relieved w/ defecation
setting/person @ risk: young-middle aged, women
Chronic Diarrhea: fecal impaction/motility disorders
process characteristics of stool timing associated symptoms setting/person @ risk
process: partial obstruction by impacted stool only allowing passage of loose feces
characteristics of stool: loose, small volume
timing: variable
associated symptoms: campy abd pain, incomplete evacuation
setting/person @ risk: older adults, immobilized/institutionalized pts, medications
Chronic Diarrhea: cancer of sigmoid colon
process characteristics of stool timing associated symptoms setting/person @ risk
process: partial obstruction by malignant neoplasm
characteristics of stool: may be blood streaked
timing: variable
associated symptoms: change in usual bowel habits, cramps lower abd pain, constipation
setting/person @ risk: >55y/o
Ulcerative Colitis
process characteristics of stool timing associated symptoms setting/person @ risk
process: mucosa; inflammation typically extending proximally from rectum to varying lengths of colon, w/ microulcerations and if chronic inflammatory polyps
characteristics of stool: frequent, eatery, often contain blood
timing:onset typically abrupt, often recurrent, persistent, may awaken at night
associated symptoms: cramping w/ urgency, tenesmus, fever, fatigue, weakness, abd pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema nodosum
setting/person @ risk: young adults, Ashkenazi Jew, altered CD+ T cell Th2 response (increased colon CA risk)
Crohn Disease of small bowel or colon
process characteristics of stool timing associated symptoms setting/person @ risk
process: Chronic transmural inflammation of the bowel wall, with skip pattern involving the terminal ileum and/ or proximal colon (and rectal sparing); may cause strictures
characteristics of stool: Small, soft to loose or
watery, with bleeding
if colitis, obstructive
symptoms, if enteritis
timing: More insidious
onset; chronic or
recurrent
associated symptoms: Crampy periumbilical, right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, fever, and/ or weight loss; perianal or perirectal abscesses and fistulas; may cause small or large bowel obstruction
setting/person @ risk: Often teens or young adults, but also adults of middle age; more common in Ashkenazi Jewish descendants; linked to altered CD4+ Tcell helper Th1 and 17 response; increases risk of colon cancer
Chronic Diarrhea: malabsorption syndrome
process characteristics of stool timing associated symptoms setting/person @ risk
process: Defective membrane transport or absorption of intestinal epithelium (Crohn, celiac disease, surgical resection); impaired luminal digestion (pancreatic insufficiency); epithelial defects at brush border (lactose intolerance)
characteristics of stool: Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet (steatorrhea)
timing: Onset of illness
typically insidious
associated symptoms: Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein)
setting/person @ risk: Variable, depending
on
cause
Chronic Diarrhea: osmotic - lactose intolerance
process characteristics of stool timing associated symptoms setting/person @ risk
process: intestinal lactase deficiency
characteristics of stool: watery diarrhea of large volume
timing: follow the ingestion of milk and milk products; relieved by fasting
associated symptoms: crampy abd pain, abd distention, flatulence
setting/person @ risk: African Americans, native Americans, Hispanics (lower risk in Caucasians)
Chronic Diarrhea: abuse of osmotic purgatives
process characteristics of stool timing associated symptoms setting/person @ risk
process: laxative habit, often surreptitious
characteristics of stool: watery diarrhea of large volume
timing: variable
associated symptoms: often none
setting/person @ risk: persons w/ anorexia or bulimia
Chronic Diarrhea: secretory diarrhea
process characteristics of stool timing associated symptoms setting/person @ risk
process: Variable: bacterial infection, secreting
villous adenoma, fat or bile salt malabsorption,
hormone-mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide)
characteristics of stool: watery diarrhea of large volume
timing: variable
associated symptoms: Weight loss, dehydration, nausea, vomiting, and cramping, abdominal pain
setting/person @ risk: Variable
depending on cause
Constipation: inadequate time or setting for the defecation reflex
Process
Associated Setting/Symptoms
Process: Ignoring the sensation of a full rectum
inhibits the defecation reflex
Associated Setting/Symptoms: Hectic schedules, unfamiliar
surroundings, bed rest
Constipation: False Expectations of Bowel Habits
Process
Associated Setting/Symptoms
Process: Expectations of “regularity” or more
frequent stools than a person’s norm
Associated Setting/Symptoms: Beliefs, treatments, and advertisements
that promote the use of laxatives
Constipation: Diet Deficient in Fiber
Process
Associated Setting/Symptoms
Process: decreased fecal bulk
Associated Setting/Symptoms: Other factors such as debilitation and
constipating drugs may contribute
Irritable Bowel Syndrome:
Process
Associated Setting/Symptoms
Process: Functional change in frequency or form
of bowel movement without known
pathology; possibly from change in
intestinal bacteria.
Associated Setting/Symptoms: Three patterns: diarrhea—predominant, constipation—predominant, or mixed. Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance)
