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2. Anorexia, nausea, vomiting Flashcards

1
Q

2 general mechanisms for nausea and vomting

A

neurological

peripheral

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2
Q

neurological cause for nausea and vomiting

A

Stimulation of the area postrema, which ‘senses’ noxious chemical agents (e.g., poisons, chemotherapy agents, digoxin) and subsequently stimulates the vagal nuclei, which evokes nausea and co-ordinates the emesis reflex.
Diseases of the central nervous system (CNS) such as infections or brain tumours stimulate CNS structures and elicit nausea and vomiting, ultimately through vagal pathways.

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3
Q

peripheral causes for nausea and vomtiing

A

Diseases and disorders that originate in peripheral organ systems, such as the gastrointestinal tract, stimulate vagal or spinal afferent nerves that connect with the vagal sensory (tractus solitarius) and vagal efferent motor nuclei. Ultimately, cortical centres where nausea is perceived and the efferent pathways that mediate vomiting are stimulated.
Tumours, infections, and drugs in the periphery may cause local dysfunction in a variety of organ systems that is sensed as nausea that, when severe, evokes vomiting.

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4
Q

gastritis Hx

A

use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food; may be aggravated by recent stress or anxiety

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5
Q

gastritis O/E

A

tenderness to palpation in the epigastrium or normal examination

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6
Q

gastritis Ix

A

upper gastrointestinal endoscopy:
gastritis; antral mucosal biopsies may reveal H pylori infection, which requires antibiotic therapy; may confirm aetiology such as eosinophilic gastritis
Helicobacter pylori antibody:
positive

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7
Q

GORD Hx

A

typical: heartburn and regurgitation; atypical: minimal epigastric burning or regurgitation; nausea predominates; morning nausea common

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8
Q

GORD O/E

A

tenderness in the epigastrium on palpation or normal examination

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9
Q

GORD Ix

A

upper gastrointestinal endoscopy:
may be normal or reveal oesophageal inflammation ranging from erythema to frank ulceration (not required for diagnosis)
24-hour oesophageal pH study:
confirms acid reflux if endoscopy normal

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10
Q

diagnosis of GORD made based on

A

history, endoscopy, or 24 hour pH study

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11
Q

peptic ulcer disease Hx

A

use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food

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12
Q

peptic ulcer disease O/E

A

tenderness to palpation in the epigastrium or normal examination

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13
Q

peptic ulcer disease Ix

A

Helicobacter pylori antibody:
positive
upper gastrointestinal endoscopy:
reveals gastritis, gastric ulcer, duodenal ulcer, or duodenitis; antral mucosal biopsies reveal H pylori infection, which requires antibiotic therapy

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14
Q

acute gastroenteritis Hx

A

diarrhoea; abdominal pain; low-grade fever in viral disease; high-grade fever with toxicity in bacterial aetiology

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15
Q

acute gastroenteritis O/E

A

diffuse abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)

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16
Q

acute gastroenteritis labs

A

serum electrolytes:
low sodium and potassium
stool culture:
may identify microbial agent; usually unrevealing (most cases are viral in origin)

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17
Q

food poisoning Hx

A

diarrhoea, abdominal pain; symptoms develop within 24 hours of a meal; symptoms may improve or persist for weeks leading to chronic disease

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18
Q

food poisoning O/E

A

epigastric tenderness; lower abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)

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19
Q

food poisoning labs

A

serum electrolytes:
low sodium and potassium
stool culture:
may reveal Campylobacter, Salmonella, Shigella

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20
Q

migraine Hx

A

recurrent nausea and/or vomiting in the presence of headache and disturbed vision

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21
Q

migraine O/E

A

no neurological findings but abdomen may be tender due to vomiting/retching

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22
Q

migraine Ix

A

no initial test:
clinical diagnosis
CT head:
may exclude alternate diagnosis
MRI head:
may exclude alternate diagnosis

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23
Q

benign paroxysmal positional vertigo Hx

A

brief, sudden, episodic vertigo

normal neurological exam

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24
Q

benign paroxysmal positional vertigo Ix

A

Dix-Hallpike manoeuvre:
positive

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25
Q

stroke Hx

A

transient nausea, loss of vision, instability, dizziness

focal neurological deficits

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26
Q

Stroke Ix

A

CT head:
oedema or infarct in brainq

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27
Q

hypercalcaemia Hx

A

alterations of mental status, abdominal pain, constipation, muscle pains, polyuria, headache

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28
Q

hypercalaemia Ix

A

calcium:
elevated; >2.63 mmol/L (>10.5 mg/dL)
parathyroid hormone:
suppressed (non-hyperparathyroid diagnoses such as malignancy) or elevated (hyperparathyroidism)

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29
Q

hypothyroidism Hx

A

fatigue; cold intolerance; dyspepsia

hair loss; dry skin; delayed reflexes; goitre

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30
Q

hypothyroidism Ix

A

thyroid-stimulating hormone:
elevated in primary hypothyroidismMore
T4 (serum free thyroxine):
low or normalMore

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31
Q

T4 in hypothyroidism

A

Low free T4 with an elevated thyroid-stimulating hormone is diagnostic of primary hypothyroidism. However, free T4 may be normal in subclinical hypothyroidism, despite a mildly elevated thyroid-stimulating hormone.

32
Q

gastric outlet obstruction Hx

A

history of peptic ulcer disease; vomitus is yellow gastric juice or may contain blood; upper abdominal pain is prominent

33
Q

gastric outlet obstruction O/E

A

epigastric tenderness and/or distension; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

34
Q

gastric outlet obstruction Ix

A

upper gastrointestinal series:
gastric distension
upper gastrointestinal endoscopy:
reveals the site and cause of obstruction (strictures and cancers can be biopsied)
CT abdomen:
reveals the site of obstruction or free air under the diaphragm indicating perforation

35
Q

small bowel obstruction Ix

A

bilious vomiting; peri-umbilical location of pain

36
Q

small bowel obstruction O/E

A

peri-umbilical tenderness; abdominal distension; bowel sounds high pitched or absent; rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

37
Q

small bowel obstruction Ix

A

acute abdominal x rays:
air fluid levels in small bowelMore
CT abdomen:
reveals site of obstruction or free air under the diaphragm indicating perforation

38
Q

colonic obstruction Hx

A

lower abdominal pain with or without distension; faeculent vomitus

39
Q

colonic obstruction O/E

A

tenderness and/or distension in lower abdomen; bowel sounds may be absent; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

40
Q

colonic obstruction Ix

A

acute abdominal series:
distended colon proximal to site of obstruction; air fluid levels in small bowel
CT abdomen:
reveals site of colonic obstruction; free air under the diaphragm indicating perforation
colonoscopy:
may reveal mucosal lesion that may narrow the bowel lumen

41
Q

choledocholithiasis Hx

A

right upper quadrant (RUQ) or epigastric pain, postprandial symptoms

RUQ tenderness; may have jaundice

42
Q

choledocolithiasis Ix

A

abdominal ultrasound:
stones in gallbladder or bile duct`

43
Q

cholecystitis Hx

A

history of prior biliary colic; right upper quadrant (RUQ) pain; may have fever or referred right shoulder pain

44
Q

cholecystitis O/E

A

may have positive Murphy sign (right subcostal tenderness, worse after deep inspiration); may have tender RUQ mass; possible jaundice

45
Q

cholecystitis Ix

A

CBC:
elevated WBC count
LFTs:
cholestatic pattern
ultrasound RUQ:
may show thickened gallbladder wall with calculi or pericholecystic fluid collection

46
Q

post-GI surgery Hx

A

previous surgery (fundoplication, oesophagectomy, gastrojejunostomy [Bilroth I or II], or bariatric operation); epigastric discomfort; bloating; regurgitation after oesophagectomy with early satiety

47
Q

post Gi surgery O/E

A

epigastric tenderness; tender scars, positive Carnett’s sign (occurs when a combination of pressure on the scar and flexion of the head clearly exacerbates the patient’s typical pain)

48
Q

post Gi surgery Ix

A

upper endoscopy:
mechanical obstruction at site of surgery, mucosal abnormalities, or normal
gastric emptying study:
gastroparesis or normal
electrogastrogram:
gastric dysrhythmia or normal

49
Q

severe constipation Hx

A

constipation; altered bowel habits; abdominal pain; pain on defecation

tender abdomen; palpable abdominal mass

50
Q

severe constipation Ix

A

acute abdominal series:
dilated loops of bowel; faecal loading in right colon

51
Q

IBS Hx

A

altered bowel habits (alternating constipation and diarrhoea), bloating, abdominal pain and distension, stress-related symptoms

52
Q

IBS O/E

A

normal in most patients; abdominal tenderness in some cases

53
Q

IBS Ix

A

no initial test:
diagnosis of exclusion
acute abdominal series:
dilated loops of bowel
colonoscopy:
may demonstrate alternate diagnosis such as inflammatory bowel disease or neoplasm

54
Q

cyclic vomiting syndrome Hx

A

onset in childhood; migraine common; symptom-free weeks

normal

55
Q

cyclic vomiting syndrome Ix

A

solid-phase gastric emptying study:
>50% retained at 2 hours; >10% retained at 4 hours
electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmia
endoscopy:
normal

56
Q

gastric dysrhythmias Hx

A

nausea, early satiety, fullness worse after meals

normal

57
Q

gastric dysrhythmias Ix

A

electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmias
endoscopy:
normal (excludes mucosal disease)
gastric emptying study:
normal (excludes gastroparesis)

58
Q

gastroparesis Hx

A

nausea, early satiety, fullness, and vomiting of undigested food; all symptoms are worse after ingestion of meals; history of diabetes or Parkinson’s disease

59
Q

gastroparesis O/E

A

succussion “splash” rarely detected; weight loss, orthostatic hypotension

60
Q

gastroperesis Ix

A

solid-phase gastric emptying study:
>50% retained at 2 hours; >10% retained at 4 hours
non-digestible capsule test:
diagnosis is confirmed if capsule not emptied within 5 hours after it is ingested
electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmia
endoscopy:
no evidence of mucosal inflammation

61
Q

bacterial peritonitis Hx

A

abdominal pain; nausea or vomiting ranges from mild to severe; fever low grade to severe; recent abdominal surgery

rigid abdomen with rebound tenderness

62
Q

bacterial peritonitis Ix

A

acute abdominal series:
air under diaphragm indicates perforation
CT abdomen:
air under diaphragm, ascites; thickened bowel wall, intra-abdominal fluid or masses

63
Q

anorexia nervosa Hx

A

abnormalities in body image, depression, amenorrhoea, or psychosocial dysfunction

64
Q

anorexia nervosa O/E

A

cachexia; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension), signs of malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema)

65
Q

anorexia nervosa Ix

A

solid-phase gastric emptying study:
gastroparesis
electrogastrogram:
tachygastria, bradygastria, mixed dysrhythmia

66
Q

bulimia nervosa Hx

A

abnormalities in body image, depression, other psychosocial dysfunction

67
Q

bulimia nervosa O/E

A

normal examination; possible signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension) and malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema); may have teeth enamel erosion from repeated vomiting

68
Q

bulimia nervosa Ix

A

solid-phase gastric emptying study:
normal
electrogastrogram:
normal

69
Q

drug induced Hx

A

symptoms not related to eating or bowel movements; onset days to weeks after starting the medicine; symptoms recur 3 to 4 days after re-initiation of medicine (e.g., chemotherapy agents); causative medications include non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, anti-arrhythmics, opioids, chemotherapy, oestrogen/progesterone, theophylline, digoxin, lubiprostone, metformin, exenatide
epigastric tenderness may be present with NSAIDs

70
Q

nephrolithiasis Hx

A

flank pain, may radiate to groin; dysuria
costovertebral angle tenderness

71
Q

nephrolithiasis Ix

A

urinalysis:
microscopic or gross haematuria
noncontrast CT abdomen:
size and location of stones

72
Q

uraemia Hx

A

existing renal disease or diabetes; fatigue, anorexia, weight loss; severe cases may have muscle cramps, pruritus, mental and visual disturbances; increased thirst

73
Q

uraemia O/E

A

oedema; sallow skin; pallor; occult gastrointestinal bleed; hypertension

74
Q

uraemia Ix

A

24-hour urine creatinine clearance:
<10 to 20 mL/minute
renal profile:
hyperkalaemia; acidosis; hypocalcaemia; hyperphosphataemia
ultrasound kidneys:
large kidneys in hydronephrosis, obstructions; small kidneys in chronic irreversible damage
CT abdomen:
size and morphology of the kidneys, lymph nodes

75
Q

idiopathic functional dyspepsia/post prandial distress syndrome

A

vague epigastric discomfort, early satiety, and prolonged fullness
no initial test:
diagnosis of exclusion
upper gastrointestinal endoscopy:
excludes structural lesions or inflammation

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