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Abdo pain ** Flashcards

1
Q

AXR findings for bowel obstruction

A

air fluid levels
distended loops of bowel
free air
pneumonitis
bowel wall thickening
lumen narrowing
portal vein air
pleural effusions
gallstones
masses

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2
Q

CXR findings for bowel obstruction

A

free air under diaphragm
masses in chest
pleural effusions
widening mediastinum

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3
Q

Top 3 causes of SBO

A

Malignancy
Adhesions
Hernias

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4
Q

Top 3 causes of LBO

A

Cancer
Diverticulitis
Volvulus

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5
Q

Causes of paralytic ileus

A

Post Operative
Infection/Sepsis
Medications (opiates, anesthetics)
Electrolyte Disturbances (sodium, potassium, calcium)
Clostridium Difficile
Inactivity

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6
Q

causes of epigastric pain

A

Cardiac: aortic dissection, AAA, MI, pericarditis
GI: gastritis, PUID, mallory-weiss tear

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7
Q

causes of RUQ pain

A

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

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8
Q

causes of LUQ pain

A

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

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9
Q

causes of RLQ pain

A

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

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10
Q

causes of LLQ pain

A

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

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11
Q

causes of pelvic pain

A

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

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12
Q

causes of diffuse abdo pain

A

Peritonitis
Pancreatitis
Mesenteric ischemia
Pan-colitis
Ruptured AAA
Porphyria
DKA
Addison’s
Uremia
Hypercalcemia

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13
Q

Where do the following radiate to?
Ureteric obstruction
Biliary colic
Pancreas
AAA
Perf ulcer

A

ureteric obstruction -> ipsilateral testes or labia
biliary colic -> ipsilateral shoulder/ scapula
pancreas -> back
AAA -> back
perf ulcer -> RLQ

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14
Q

What ix to order for abdo pain, including ?mesenteric ischemia, Zollinger Ellison syndrome, endometriosis and ?obstruction

A

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

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15
Q

GERD Ix

A

Lifestyle Modifications Trial
Pharmacotherapy Trial
Barium Swallow
24 hour pH Monitoring
Gastroscopy
Acid Perfusion Test

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16
Q

GERD Red flags

A

Dysphagia
Weight Loss
Anemia
Early Satiety

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17
Q

Complications of GERD

A

Barrett’s - histologically - Metaplasia (Squamous to Columnar Epithelium
Esophaheal adenocarcinoma

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18
Q

RF for GERD

A

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

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19
Q

GERD Management

A

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

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20
Q

Sx PUD

A

Epigastric pain
Early satiety
Post prandial fullness
Bloating, N/V

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21
Q

Precipitating factors of PUD

A

Caffeiene, high fat, alcohol, smoking, NSAID/ ASA use, CCB

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22
Q

Ix for PUD

A

H pylori urea breath test, fecal antigen test or biopsy. Hold PPI for 2 weeks to prevent false positive

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23
Q

Management of PUD

A

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

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24
Q

Extraintestinal sx of UC

A

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

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25
Ix for UC
colonoscopy + biopsy, barium study, CT abdo
26
Lifestyle management of UC
Stop smoking Electrolyte, vitamin supplementation (Vit D, calcium, Mg, Zinc)
27
Crohns RF
smoking, Ashkenazi Jews
28
Crohns exacerbating factors
infection, smoking, NSAIDs
29
Ix for Crohns
endoscopy + biopsy, air contrast barium enema, US, MRI/ CT, CBC, CRP, B12, albumin
30
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
31
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
32
Primary vs secondary dysmenorrhea
Primary = pain during menses in absence of pelvic pathology Secondary = associated w/ pelvic pathology eg endometriosis
33
RF for dysmenorrhea
Smoking Poor social support Mood disorders
34
Causes of secondary dysmenorrhea
Endometriosis Adenomyosis Uterine myomas Cervical stenosis
35
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
36
Endometriosis RF
family hx, nulliparity, short menstrual cycle, diet high in red meat
37
Sx endometriosis
dysmenorrhea, deep dyspareunia, dyschezia, dysuria, chronic pelvic pain, infertility
38
Management of endometriosis
NSAIDs COCP continuously Progestin only (depo, pill, IUD) GnRH agonist (Dnaazol) Surgical: refractory pelvic pain, severe invasion, infertility
39
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
40
What are uterine fibroids?
Benign, hormone sensitive smooth muscle tumor
41
RF for fibroids
nulliparity, obesity, FH, HTN
42
Sx of fibroids
asymptomatic, abnormal uterine bleeding, pelvic pressure, bowel dysfunction, bladder sx
43
Complications of fibroids
IDA, infertility, miscarriage, fetal malpresentation
44
Management of fibroids
IUD GnRH agonist (leuprolide acetate) Selectie progesterone receptor modulators (ulipristal acetate) COCP POP Androgens (danazol) Uterine artery embolization Myomectomy Hysterectomy
45
What does a rigid abdo mean?
Perforated viscus
46
Pain out of proportion to exam?
ischemic bowel
47
Generalised pain that later localises
appendicitis
48
Waves of pain with other sx like hiccups/ N/V
bowel obstruction
49
Sx of appendicitis
fever, migratory pain periumbilical moving to RLQ, fever, anorexia, nausea
50
Complications of appendicitis
perforation, abscess, phlegmon
51
Management of appendicitis
laparoscopic surgery + ampicillin, gentamicin + metronidazole x24hrs
52
RF cholecystitis
obesity, multiparity, female gender, OCP, forties
53
Charcot’s triad
fever, RUQ pain, jaundice
54
Reynold’s pentad
fever, RUQ pain, jaundice, shock, confusion
55
Murphy’s sign
RUQ pain, severe, constant
56
Complications of cholecystitis
biliary obstruction, duodenal perforation, pancreatitis, ascending cholangitis, sepsis
57
Ix for cholecystitis + results
↑WBC, ↑conjugated bili, ↑ALT, ↑AST, ↑↑ALP, US (distended gallbladder, pericholecystic fluid, stone in cystic duct, thickened gallbladder wall)
58
Rx for cholecystitis
NPO, IVF, NG if persistent vomiting, ampicillin + gentamicin + metronidazole, lap chole
59
How to diagnose Primary biliary sclerosis
anti mitochondrial antibodies
60
Sx of diverticulitis
fever, LLQ pain, change in BMs, urinary sx, N/V
61
RF for diverticulitis
Increased Age Constipation Low Fibre Diet Obesity Sedentary Lifestyle
62
Complications of diverticulitis
abscess, fistula, obstruction, perforation
63
Ix for diverticulitis
CT or US if not available
64
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
65
RF for diverticulitis recurrence
young age, obesity, abscess
66
Prevention of diverticulitis
stop smoking, reduce meat, exercise, lose weight, reduce NSAID use
67
What Ix to avoid in diverticulitis?
Barium Enema (risk chemical peritonitis in acute diverticulitis) Colonoscopy/Sigmoidoscopy (risk of perforation in acute diverticulitis)
68
Causes of pancreatitis
gallstones, alcohol, tumors, scorpion stings, TB, mumps, SLE, surgery, hyperlipidemia, emboli, furosemide
69
Sx of pancreatitis
persistent epigastric pain, N/V, fever, jaundice
70
Complications of pancreatitis
abscess, pleural effusion, ARDS, ATN, pericardial effusion
71
Ix for pancreatitis
↑WBC, ↑lipase + amylase, ↑ALT, US, ERCP to r/o stone
72
Rx for pancreatitis
IVF, NPO, NG suction, analgesia, drain abscess, surgery if necrotic or acute biliary pancreatitis
73
Prognosis tool for pancreatitis
use Ranson’s criteria
74
Which Fat soluble vitamins absorption are affected by pancreatitis?
Vit A, D, E, K
75
Ix for renal stones
US + KUB XR
76
What abdo concerns do you get in neonates?
necrotising enterocolitis, malrotation, volvulus, incarcerated hernia, non-accidental trauma
77
What abdo concerns do you get in toddlers?
Meckles diverticulum, testicular torsion, intussusception, trauma
78
What abdo concerns do you get in 3-15y/o?
appendicitis, DKA, testicular torsion, constipation, functional pain
79
What abdo concerns do you get in the elderly?
cholecystitis, spontaneous bacterial overgrowth, appendicitis, large bowel obstruction, strangulated hernia, necrotising pancreatitis, infarcted bowel
80
What can make AAA worse?
Fluids
81
Sx of IBS
altered bowels, abdo pain, distension, mucus, dyspepsis
82
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
83
Exacerbating factors - IBS
alcohol caffeine fat fibre stress menstruation
84
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
85
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
86
Colorectal cancer sx
abdo pain, anemia, rectal bleeding, change in BMs, narrowing of stool diameter (ribboning), tenesmus (rectal cancer)
87
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
88
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
89
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)
90
Recommended diet for IBS
low FODMAP
91
FODMAP foods
oligosaccharides (wheat, legumes), disaccharides (milk, yogurt), monosaccharides (mangoes, honey), polyols (blackberries, lychee)
92
alarm features of abdo pain
wt loss, melena, age >55, palpable mass, GI blood loss
93
H pylori management
4 drugs, 14 days, PPI, bismuth, metronidazole, tetracycline
94
Prevention of Barrett’s
lifestyle, high dose PPI, ASA
95
Long term PPI risks
B12 deficiency, C diff, dementia, fractures
96
Management of ureteral stones <5mm + >5mm
<5mm = conservative management, tamsulosin if distal >5mm/ obstructive ureteral stones = timely decompression, refer to uro
97
ureteral stones imaging
XR + US KUB
98
pancreatitis RF
septra, flagyl, HCTZ, ACEi, progesterone, atorvastatin, estrogen, gallstones, alcohol
99
gallstone RF
female, forty, fertile, obese, OCP
100
Biologics for UC
Humira, Stelara, Entyvio
101
How to diagnose hiatus hernia?
Barium swallow or scope
102
How to diagnose GERD?
Barium swallow, med trial, scope
103
How to diagnose esophageal spasm?
Scope, barium swallow or nuclear medicine
104
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
105
Classification of GI ulcers
forrester

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