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