Abdo pain ** Flashcards
AXR findings for bowel obstruction
air fluid levels
distended loops of bowel
free air
pneumonitis
bowel wall thickening
lumen narrowing
portal vein air
pleural effusions
gallstones
masses
CXR findings for bowel obstruction
free air under diaphragm
masses in chest
pleural effusions
widening mediastinum
Top 3 causes of SBO
Malignancy
Adhesions
Hernias
Top 3 causes of LBO
Cancer
Diverticulitis
Volvulus
Causes of paralytic ileus
Post Operative
Infection/Sepsis
Medications (opiates, anesthetics)
Electrolyte Disturbances (sodium, potassium, calcium)
Clostridium Difficile
Inactivity
causes of epigastric pain
Cardiac: aortic dissection, AAA, MI, pericarditis
GI: gastritis, PUID, mallory-weiss tear
causes of RUQ pain
Hepatobiliary: biliary colic, cholecystitis, cholangitis, hepatitis, appendicitis
Genitourinary: nephrolithiasis, pyelonephritis, mass, ischemia
Cardiopulmonary: RLL PNA, CHF (causing hepatic congestion), MI, pericarditis, pleuritis
Other: shingles, costochondritis
causes of LUQ pain
Pancreatic: pancreatitis, tumor
GI: gastritis, PUD, mallory-weiss tear
Splenic: rupture, infarct, abscess, aneurysm
GU: nephrolithiasis, pyelonephritis, mass, ischemia
Cardiopulmonary: aortic dissection, AAA, MI, pericarditis, LLL PNA
causes of RLQ pain
GI: appendicitis, Crohns, TB, intusseception, mesenteric lymphadenitis, diverticulitis, volvulus, hernia
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones
causes of LLQ pain
GI: diverticulitis, cancer, fecal impaction, proctitis, volvulus
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones
causes of pelvic pain
GI: appendicitis, Crohns, TB, intusseception, mesenteric lymphadenitis, diverticulitis, volvulus, hernia, cancer, fecal impaction, proctitis
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones
causes of diffuse abdo pain
Peritonitis
Pancreatitis
Mesenteric ischemia
Pan-colitis
Ruptured AAA
Porphyria
DKA
Addison’s
Uremia
Hypercalcemia
Where do the following radiate to?
Ureteric obstruction
Biliary colic
Pancreas
AAA
Perf ulcer
ureteric obstruction -> ipsilateral testes or labia
biliary colic -> ipsilateral shoulder/ scapula
pancreas -> back
AAA -> back
perf ulcer -> RLQ
What ix to order for abdo pain, including ?mesenteric ischemia, Zollinger Ellison syndrome, endometriosis and ?obstruction
CBC, U+Es, ex lytes, LFTs, lipase, CRP, glucose, urinalysis, bHCG
3 view abdo ?obstruction = >3 air fluid levels in upright AXR
CT angio for mesenteric ischemia
Gastroscopy/ colonoscopy
Urea breath test for H pylori
Fasting serum gastrin levels for Zollinger Ellison syndrome
Stool samples for ova + parasites
Diagnostic laparoscopy for endometriosis
GERD Ix
Lifestyle Modifications Trial
Pharmacotherapy Trial
Barium Swallow
24 hour pH Monitoring
Gastroscopy
Acid Perfusion Test
GERD Red flags
Dysphagia
Weight Loss
Anemia
Early Satiety
Complications of GERD
Barrett’s - histologically - Metaplasia (Squamous to Columnar Epithelium
Esophaheal adenocarcinoma
RF for GERD
Obesity
Alcohol Use
Smoking
Diet (high fat foods, chocolate, mint, citrus, spicy foods, caffeine…)
Hiatal Hernia
Delayed Gastric Emptying/Clearance
Pregnancy
Medications (anticholinergics, nitrates, calcium channel blockers, NSAIDS, bisphosphonates)
Scleroderma
GERD Management
Wt loss, reduce alcohol + caffeine, elevating head of bed, stop smoking
Antacids
H2 Blockers
Proton Pump Inhibitors - try PPI holiday annually. Unlikely to respond to surgery if not responding to PPI
Bariatric surgery if obesity is a factor
Sx PUD
Epigastric pain
Early satiety
Post prandial fullness
Bloating, N/V
Precipitating factors of PUD
Caffeiene, high fat, alcohol, smoking, NSAID/ ASA use, CCB
Ix for PUD
H pylori urea breath test, fecal antigen test or biopsy. Hold PPI for 2 weeks to prevent false positive
Management of PUD
Stop smoking
Lifestyle: eat smaller, more frequent meals, reduce alcohol, avoid spicy food, maintain ideal weight
Negative H pylori: PPI x4 weeks for duodenal ulcers, 8 weeks for gastric
Positive H pylori: PPI BID + amox 1000mg BID + clarithromycin 500mg BID + metronidazole 500mg BID x 2 weeks
NSAID induced - lower/ stop NSAID and ASA use, consider using alternatives like Tylenol. 4-6 weeks PPI for duodenal ulcers or 6-8 wks for gastric ulcers
Physiological stress induced (often in ICU) - prophylaxis with PPI or H2 blockers during ventilation
Extraintestinal sx of UC
Flares: peripheral arthritis of large joints, episcleritis, apthous ulcers, erythema nodosum
Continuous: ankylosing spondylitis (pain in SI joint), uveitis (serious, needs optho consult), primary sclerosing cholangitis (check LFTs)
Gallstones, ureteric obstruction as a complication
Ix for UC
colonoscopy + biopsy, barium study, CT abdo
Lifestyle management of UC
Stop smoking
Electrolyte, vitamin supplementation (Vit D, calcium, Mg, Zinc)
Crohns RF
smoking, Ashkenazi Jews
Crohns exacerbating factors
infection, smoking, NSAIDs
Ix for Crohns
endoscopy + biopsy, air contrast barium enema, US, MRI/ CT, CBC, CRP, B12, albumin
Complications of Crohns
Urinary calculi
Liver problems
Cholelithiasis
Epithelial problems
Retardation of growth
Arthralgias
Thrombophlebitis
Vit deficiency
Eyes
Colorectal carcinoma
Obstruction
Leakage (perforation)
Iron deficiency
Toxic megacolon
Stricture/ fistulae
Crohns management
Stop smoking
Electrolyte, vitamin supplementation (Vit D, calcium, Mg, Zinc)
Assess for depression, anxiety and stress and treat accordingly
Check med adherence
Iliocolonoscopy 8 years after sx onset for cancer screening
Keep vaccines UTD and screen for hepatitis and TB before starting immunosuppressants
Influenza
Refer to GI for immunosuppressants
Functional sx: loperamide, anti-spasmodics, neuropathic agents, Tylenol, 5-ASA (sulfasalazine)
Colon only: prednisone
Terminal ileum/ right colon: budesonide
Then
1) thiopurine +/-
2) biologics eg infliximab
3) methotrexate
Primary vs secondary dysmenorrhea
Primary = pain during menses in absence of pelvic pathology
Secondary = associated w/ pelvic pathology eg endometriosis
RF for dysmenorrhea
Smoking
Poor social support
Mood disorders
Causes of secondary dysmenorrhea
Endometriosis
Adenomyosis
Uterine myomas
Cervical stenosis
Management of dysmenorrhea
Lifestyle:
Exercise
Heated pads
Ginger
Non hormonal:
Tylenol
NSAIDs
COCP continuous
Progestin IUD, depo or POP
Surgical:
Uterine nerve ablation (fertility preserving)
Endometrial ablation
Hysterectomy
Endometriosis RF
family hx, nulliparity, short menstrual cycle, diet high in red meat
Sx endometriosis
dysmenorrhea, deep dyspareunia, dyschezia, dysuria, chronic pelvic pain, infertility
Management of endometriosis
NSAIDs
COCP continuously
Progestin only (depo, pill, IUD)
GnRH agonist (Dnaazol)
Surgical: refractory pelvic pain, severe invasion, infertility
DDx for dysmenorrhea
Endometriosis
Adenomyosis
Pelvic Inflammatory Disease
Fibroids
Endometrial Polyps
Intrauterine Device
Cervicitis
Cervical Stenosis
Chronic Pelvic Pain Syndrome
Ovarian Cysts
Cystitis
Interstitial Cystitis
Pelvic Malignancy
What are uterine fibroids?
Benign, hormone sensitive smooth muscle tumor
RF for fibroids
nulliparity, obesity, FH, HTN
Sx of fibroids
asymptomatic, abnormal uterine bleeding, pelvic pressure, bowel dysfunction, bladder sx
Complications of fibroids
IDA, infertility, miscarriage, fetal malpresentation
Management of fibroids
IUD
GnRH agonist (leuprolide acetate)
Selectie progesterone receptor modulators (ulipristal acetate)
COCP
POP
Androgens (danazol)
Uterine artery embolization
Myomectomy
Hysterectomy
What does a rigid abdo mean?
Perforated viscus
Pain out of proportion to exam?
ischemic bowel
Generalised pain that later localises
appendicitis
Waves of pain with other sx like hiccups/ N/V
bowel obstruction
Sx of appendicitis
fever, migratory pain periumbilical moving to RLQ, fever, anorexia, nausea
Complications of appendicitis
perforation, abscess, phlegmon
Management of appendicitis
laparoscopic surgery + ampicillin, gentamicin + metronidazole x24hrs
RF cholecystitis
obesity, multiparity, female gender, OCP, forties
Charcot’s triad
fever, RUQ pain, jaundice
Reynold’s pentad
fever, RUQ pain, jaundice, shock, confusion
Murphy’s sign
RUQ pain, severe, constant
Complications of cholecystitis
biliary obstruction, duodenal perforation, pancreatitis, ascending cholangitis, sepsis
Ix for cholecystitis + results
↑WBC, ↑conjugated bili, ↑ALT, ↑AST, ↑↑ALP, US (distended gallbladder, pericholecystic fluid, stone in cystic duct, thickened gallbladder wall)
Rx for cholecystitis
NPO, IVF, NG if persistent vomiting, ampicillin + gentamicin + metronidazole, lap chole
How to diagnose Primary biliary sclerosis
anti mitochondrial antibodies
Sx of diverticulitis
fever, LLQ pain, change in BMs, urinary sx, N/V
RF for diverticulitis
Increased Age
Constipation
Low Fibre Diet
Obesity
Sedentary Lifestyle
Complications of diverticulitis
abscess, fistula, obstruction, perforation
Ix for diverticulitis
CT or US if not available
Rx for diverticulitis
Bowel rest, clear fluids then high fibre diet, abx if comorbid conditions (cipro 500mg BID + flagyl 500mg BID x7/7). If severe, NPO, NG, suction. Surgery if unstable w/ peritonitis, abscess
RF for diverticulitis recurrence
young age, obesity, abscess
Prevention of diverticulitis
stop smoking, reduce meat, exercise, lose weight, reduce NSAID use
What Ix to avoid in diverticulitis?
Barium Enema (risk chemical peritonitis in acute diverticulitis)
Colonoscopy/Sigmoidoscopy (risk of perforation in acute diverticulitis)
Causes of pancreatitis
gallstones, alcohol, tumors, scorpion stings, TB, mumps, SLE, surgery, hyperlipidemia, emboli, furosemide
Sx of pancreatitis
persistent epigastric pain, N/V, fever, jaundice
Complications of pancreatitis
abscess, pleural effusion, ARDS, ATN, pericardial effusion
Ix for pancreatitis
↑WBC, ↑lipase + amylase, ↑ALT, US, ERCP to r/o stone
Rx for pancreatitis
IVF, NPO, NG suction, analgesia, drain abscess, surgery if necrotic or acute biliary pancreatitis
Prognosis tool for pancreatitis
use Ranson’s criteria
Which Fat soluble vitamins absorption are affected by pancreatitis?
Vit A, D, E, K
Ix for renal stones
US + KUB XR
What abdo concerns do you get in neonates?
necrotising enterocolitis, malrotation, volvulus, incarcerated hernia, non-accidental trauma
What abdo concerns do you get in toddlers?
Meckles diverticulum, testicular torsion, intussusception, trauma
What abdo concerns do you get in 3-15y/o?
appendicitis, DKA, testicular torsion, constipation, functional pain
What abdo concerns do you get in the elderly?
cholecystitis, spontaneous bacterial overgrowth, appendicitis, large bowel obstruction, strangulated hernia, necrotising pancreatitis, infarcted bowel
What can make AAA worse?
Fluids
Sx of IBS
altered bowels, abdo pain, distension, mucus, dyspepsis
How do you diagnose IBS?
Rome criteria for dx: recurrent abdo pain weekly w/ associated sx: related to defecation, change in frequency or form of stool
Exacerbating factors - IBS
alcohol
caffeine
fat
fibre
stress
menstruation
Rx for IBS
FODMAP, increase fibre
Constella
Ibsrela
Constipation: linaclotide, SSRIs, lactulose, PEG, GI referral
Diarrhea: amitryptiline
Pain + bloating: anti-spasmodics like hyosciamine or peppermint oil
Colorectal cancer RF
age >50, IBD, personal hx of colorectal or polyps, 1st degree relative with colorectal cancer, known genetic predispositions like familial adenomatous polyposis, Lynch syndrome, low physical activity, diet low in fibre/ fruits/ vegs, alcohol + tobacco use, obesity
Colorectal cancer sx
abdo pain, anemia, rectal bleeding, change in BMs, narrowing of stool diameter (ribboning), tenesmus (rectal cancer)
What to assess in annual review of UC
Assess for depression, anxiety and stress and treat accordingly
Check med adherence
Iliocolonoscopy 8 years after sx onset for cancer screening
Keep vaccines UTD and screen for hepatitis and TB before starting immunosuppressants
Medical therapy for UC, inc functional sx rx
Functional sx: loperamide, anti-spasmodics, neuropathic agents, Tylenol, 5-ASA (sulfasalazine) for Crohns only in colon
Corticosteroids for flares (oral budesonide 1st, prednisone 2nd line)
Thiopurine + Anti-TNF TOGETHER for induction + remission
Immunomodulators for severe disease (TNF antagonists (infliximab)), fistulas/ abscesses = surgery
Signs associated w/ appenditicis
pain on McBurneys point (tenderness ⅓ from ASIS)
Rovsing’s sign (palpation of left abdo causes pain in McBurneys point)
psoas sign (pain on flexion of hip against resistance)
obturator sign (flexion then rotation of right hip causes pain)
Recommended diet for IBS
low FODMAP
FODMAP foods
oligosaccharides (wheat, legumes), disaccharides (milk, yogurt), monosaccharides (mangoes, honey), polyols (blackberries, lychee)
alarm features of abdo pain
wt loss, melena, age >55, palpable mass, GI blood loss
H pylori management
4 drugs, 14 days, PPI, bismuth, metronidazole, tetracycline
Prevention of Barrett’s
lifestyle, high dose PPI, ASA
Long term PPI risks
B12 deficiency, C diff, dementia, fractures
Management of ureteral stones <5mm + >5mm
<5mm = conservative management, tamsulosin if distal
>5mm/ obstructive ureteral stones = timely decompression, refer to uro
ureteral stones imaging
XR + US KUB
pancreatitis RF
septra, flagyl, HCTZ, ACEi, progesterone, atorvastatin, estrogen, gallstones, alcohol
gallstone RF
female, forty, fertile, obese, OCP
Biologics for UC
Humira, Stelara, Entyvio
How to diagnose hiatus hernia?
Barium swallow or scope
How to diagnose GERD?
Barium swallow, med trial, scope
How to diagnose esophageal spasm?
Scope, barium swallow or nuclear medicine
ROME criteria for dyspepsia
postprandial fullness
early satiety
epigastric pain
epigastric burning
severe enough to interfere with the usual activities and occur at least 3 days per week over the last 3 months with an onset of at least 6 months in advance
Classification of GI ulcers
forrester
