526 Gastro and Hepatic Flashcards
what are the three signs most predictive of appy
pain that starts in epigastrum or periumbilical
migration of pain to right lower quadrant
abdominal rigidity
true or false, appendictis most often results in a left shift
true
what other blood tests should be ordered when diagnosing appendicitis
CBC and lytes, HCG, amylase, lipase, CRP, urinalysis, sickeldex
what differential should be considered for a possible appendicitis in african americans
sickle cell anemia
what are the most common causes of bowel obstructions
adhesions, hernias and tumors
bowel obstruction type pain that increases in severity, localizes and becomes constant is indicative of what
strangulated obstruction - requires urgent surgery
how does the presention of a bowel obstruction differ from the presentation of an ileus
ileus - bowel sounds or usually decreased or absent and in obstruction they are usually hyperactive at the beginning
how do bowel sounds progress throughout the progression of a bowel obstruction
initially hyperactive with high pitched tinkling sounds but then absent with progression
true or false, it is possible to diagnose a small bowel obstruction with plain radiography
true
what is the diagnostic of choice for bowel obstruction
CT
what would an abdominal xray show for a bowel obstruction
free air (if there is perforation)
distended bowel proximal to the obstruction
air-fluid levels
how would xray results differ in a SUPINE radiograph for an ileus and an obstruction
ileus - distended bowel loops in large and small intestine
obstruction - distending bowel loops proximal to obstruction, and decreased bowel distal to obstruction
duodenal or gastric ulcers are more likely to perforate
duodenal
what is the most common presenting symptoms of perforated peptic ulcer
abrupt severe abdo pain in epigastrum and then throughout abdo followed by peritoneal signs
severe abdo pain with hematemesis that improves after 6-12 hours but then is followed by worsening illness if common of what condition
perforated peptic ulcer
boardlike abdo rigidity, tachycardia, hypotension and fever or indicative of what condition
perforated peptic ulcer
how is perforated peptic ulcer diagnosed
finding of pneumoperitoneum on an upright abdo xray
what is the most common cause of primary spontaneous bacterial peritonitis
cirrhosis
what is secondary peritonitis
spillage of gastro or GU contents into peritoneal speace
what is the most common pathogen in primary peritonitis
E coli
what should be suspected in a patient with fever, abdo pain and tenderness with rigidity and leukocytosis
peritonitis
systemic symptoms with peritoneal signs in a patient with ascites or cirrhosis is likely from
peritonitis
what empiric antibiotics are chose for primary peritonitis
3rd or 4th gen cephalosporin or quinolone
why would a patient with cirrhotic ascites be prescribed low dose antibiotics for a prolonged time
to prevent a peritonitis
a patient with cirrhosis would have an increased or decreased systemic response to a peritonitis
decreased, signs may only be subtle
what is the typical presentation of a AAA
severe abdo pain to the flank, low back or groin that radiates into the back
when is screening for AAA recommended
men 65-75 with history of smoking
if time allows, what is the standard for evaluation of a AAA
CT scan
what is the most common misdiagnosis for AAA
MI
a nonpainful abdominal mass that englarged with increasing intra abdominal pressure or with standing if characteristic of what
aymptomatic hernia
what are the characteristics of an incarcerated hernia
painful enlargement of previous hernia
cannot be manipulated through fascial defect
n/v symptoms of bowel obstruction
what are the characteristics of a strangulated hernia
symptoms of incarcerated
systemic toxicity
pain and tenderness persist after reduction of incarcerated hernia
at what age would you consider sending a child for repair of an umbilical hernia
2-4 years
what is an incarcerated hernia
unable to be reduced
how might the skin appear for a strangulated abdominal hernia
erythematous or dusky
should you reduce an abdominal hernia with erythema or dusky skin
no, needs emergent surgical consult
what maneuver should be preformed when evaluating for a hernia
valsalva
what location of hernia have high risk for strangulation and should be surgically repaired
femoral
what are the two common causes PUD
NSAID and H. pylori
sharp, aching, gnawing pain in the epigastrum occuring 2-5 hours after eating or waking from night is characteristic of what
PUD
true or false: the pain of PUD is usually relieved with eating food
true
how long must a patient be off PPI before completing the stool antigen test for H pylori
14 days
what is the pros and cons to a serologic H pylori test
pro: does not need to stop PPI
con: unable to determine if previous or active infection
what diagnostic provides the most accurate diagnosis for PUD
endoscopy
what condition should be considered for a patient with PUD that does not respond to lifestyle modification and pharmacotherapy
zollinger-ellison syndrome - excess acid production
true or false: new onset dyspepsia in a patient older than 50 requires immediate physician consult
true
cimetidine, famotidine, and nizatidine are all what class of medication and are used to treat what abdominal disorder
histamine 2 receptor antagonists (H2RAs) for PUD
what is the course prescribed for H2RAs for PUD
4-6 weeks for healing then maintainence at bedtime for 1 year
when might you consider prostaglandin therapy for PUD? what medication is used for prevention?
patients with PUD who cannot stop taking NSAIDs
misoprostol
what is the recommended treatment for H pylori
PPI + clarithromycin +amox
OR
PPI + clarithromycin + metronidaxzole
for up to 14 days
pain in the RUQ radiating into the scapula 1-2 hours after a fatty meal is indicative of what condition
gallbladder stones
how can you treat an acute attack of cholelithiasis pain with no signs of infection
buscopan
gravol
toradol
if no resolution in 6-8 hours transfer to hospital
what diagnostic imaging would you order for recurrent gallbalder colic
abdo ultrasound
true or false: the number of gallbladder stones seen on an US will determine need for surgery
false, surgical treatment is determined by presentation, frequency of attack and other risk factors
what medications may increase risk for gallbladder disease
estrogen, oral contraceptives, thiazides, diuretics
what are the 3 types of gall stones
cholesterol, bilirubin (or pigmented), and mixed
how do gallstones cause diarrhea and jaundice
bile cant be extreted which causes jaundice and lack of bile means fat cant be broken down so it pulls more water into the large intestines
what is acalculous cholecystitis and when is it acute vs chronic
cholecystitis in the abscence of stones
acute <1 month
chronic >3 months
what is the difference between cholelithiasis and cholecystitis
cholecystitis develops similar to cholelithiasis but lasts longer than 4-6 hours
Cholelithiasis= presence of stones
Cholecystitis = inflammation of gallbalder
what is the charcot triad and what is it indicative of
right upper quadrant pain
fever
jaundice
seen when stone is lodged in common bile duct causing cholangitis
true or false: patients with acute acalculous cholecystitis are usually sicker and require hospitalizaiton
true
true or false: cholecystitis will not have muscle guarding or rigidity
false
a patient with tender RUQ, (+) murphys, and jaundice may have what condition
cholecystitis
what imaging is used to definitively diagnose cholecystitis
ultrasound
true or false: oral hydration is preferred over IV for initial management of symptomatic gallbladder disease
false, oral hydration is contraindicated during this time
what is ursodeoxycholic acid and when is it used
it is a treatment to decrease the pain with biliary disease and help with gallstone dissolution
for mild symptoms, with small stones and normal gallbladder function
what is choledocholithiasis
presence of gallstones in the common bile duct
if gallstones found incidentially on imaging are not symptomatic do they still require surgical intervention
no
what is the most common cause of pancreatitis
gall stones
what are the causes of pancreatitis (I GET SMASHED)
iatrogenic
gallstones
ETOG
trauma
steroids
mumps
autoimmune
scorpion bites
hypertriglycerides/hypercalcemia
ERCP
drugs
a patient with constant epigastric pain that radiates to the back, worse with lying flat, with n/v and jaundice may have what
pancreatitis
how is the epigastric pain from pancreatitis different from the epigastric pain of PUD
PUD is intermittent, pancreatitis is constant
what GI disorder puts the patient at risk for developing DIC
pancreatitis
what would you expect to see of the following labs for a pancreatitis:
CRP, BUN, GFR,
CRP increased
BUN increased
GFR decreased
triglycerides 3x the upper limit is diagnostic of what condition
pancreatitis
what would you expect to see with bili, AST and ALT in pancreatitis
all elevated
what is initial treatment for pancreatitis? what is definitive treatment
initially fluids then ERCP or cholecystecomy
true or false: pancreatitis is treated with anitbiotics
false, only if an abcess forms afterwards
what is the difference between chlelithiasis and cholecystitis
cholelithiasis is formation of gall stones in gall bladder
cholecystitis is inflammation of the gallbladder
what is the difference between cholelithiasis and choledocholithiasis
cholelithiasis is formation of stones in gallbladder
choledocholithiasis is formation of stones in the common bile duct
what is cholangitis
a complication of bile stones where infection develops in the bile duct
will biliary colic have fever, increased WCC, and jaundice
no
how can you differentiate biliary colic, cholyecystitc and cholangitis based on symptomology
biliary colic = RUQ only
cholecystitis = RUQ and fever
Cholangitis = RUQ, fever and jaundice (charcots triad)
which strands of viral hepatitis cause acute hepatitis
B, C, D
when is hepatitis considered viral
presence of virus at least 6 months after initial exposure
how many weeks after exposure would you expect to see symptoms of hepatitis
4 weeks
true or false: patients with hepatitis are not conatgious when they are asymptomatic
false
what liver disease is associated with metabolic disorder
NASH
which viral strain of hepatitis is most likely to cause haundice
B
what are symptoms of cirrhosis
jaundice
ascites
edema
easily bruised
fatigue
encephalopathy
upper GI bleeding
spider telangiectasia, parotid enlargement, gynecomastia and palmar erythema is more common in what condition
alcoholic hepatitis
which serum levels will you look for in the acute phase of hepatitis
increased AST and ALT, bili
what condition would cause equal proportions of direct and indirect bili with bili in the urin
hepatitis
what treatment suggestions might you make for NAFLD
diet, exercise, weight loss, Vit. E
malabsorption causing soulte rich molecules to enter the colon is what kind of diarrhea
osmotic
diarrhea that starts postprandial and ends with fasting is osmotic or secretory
osmotic
secretory or osmotic diarrhea is most common
secretoy
diarrhea caused by compromise of the absorptive fuction of the gut is what kind
secretory
celiac and diabetes cause what kind of diarrhea
secretory
what is the abx of choice to treat C diff
metronidazole or vanco for 10-14 days
when should you suspect bacterial casues of diarrhea
when the presentation suggests inflammatory (fever, pain, tenesmus, large volume, blood or mucuos)
how long does travellers diarrhea usually last
3-7 days
although travellers diarrhea is usually self limiting, what bx may be prescibred
cipro or azithro
when are diagnostics needed for travellers diarrhea
persists past 1 week or symptoms of inflammatory diarrhea
when would you presscribe an abx for travellers diarrhea
symptoms last more than 2 days and assocaited with high fever
osmotic or stimulant laxatives are first line treatment for constiptaion
osmotic
PEG is an osmotic or stimulant laxative
osmotive
Senna is an osmotic or stimulant laxative
stimulant
what is the chain of advancing treatment for consitpation
- lifestyle
- bulk forming agents
- stool softeners
- osmotic laxatives
- stimulant laxatives
- secretagogues
