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CMS150 > Abdominal Pain, IBS, GI Conditions > Flashcards

Abdominal Pain, IBS, GI Conditions Flashcards

1
Q

red flag conditions for abdominal pain

A

appendicitis
bowel obstruction
abdominal malignancy
cardiovascular origins of abdominal pain
gynecological: Pelvic inflammatory disease, ectopic pregnancy, ovarian torsion

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2
Q

appendicitis overall best indicators signs and symptoms

A

right lower quadrant pain
migrating pain from periumbilical area to right lower quadrant
fever
psoas sign
pain before vomiting/pain unrelieved by vomiting
rebound tenderness
abdominal rigidity
anorexia

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3
Q

psoas sign definition

A

elicits pan and discomfort when hip is flexed either active or passively

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4
Q

rebound tenderness in appendicitis
definition
is it a sign for anything else?

A

coincides with McBurney’s point
applying pressure to McBurney’s point will cause pain and rebound tenderness is pain that occurs when removing your fingers from McBurney’s point
also a sign of peritonitis

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5
Q

other signs and symptoms of appendicitis

A

abdominal pain may be poorly localized initially
can have LUQ pain in early appendicitis
McBurney’s point painful on palpation

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6
Q

investigations (which are best for diagnosing) and prognosis of appendicits

A

abdominal CT scan (LR+ 24, LR- 0.08)
ultrasound indicated in pregnancy

prognosis: emergency! may progress to ischemia, necrosis, perforation of bowel (leading to sepsis)
>50% of people with appendicits who do not receive treatment die

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7
Q

bowel obstruction accounts for __% of abdominal pain cases

A

4% of abdominal pain cases

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8
Q

proportion of large bowel obstructions vs small bowel obstructions

A

large bowel obstruction: 24%
small bowel obstruction: 76%

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9
Q

etiology of large bowel obstruction

A

most to least common:
cancer
sigmoid or cecal volvulus
diverticular disease
extrinsic compression from metastatic cancer
other causes (12%)

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10
Q

volvulus definition

A

a loop of intestine that twists around itself and the mesentery that supports it can cause a disruption in the natural flow of your bowels

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11
Q

etiology of small bowel obstruction

A

most to least common:
postsurgical adhesions (70%)
malignant
hernia
IBD with stricture
radiation

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12
Q

stricture definition

A

an area of narrowing in the intestines

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13
Q

signs and symptoms of bowel obstruction

A

intermittent pain at first, that later becomes more constant
bowel sounds may diminish and become absent. Can first see an increase in bowel sounds because the bowels increase their efforts to pass the contents before being obstructed completely
constipation, absence of bowel movements of flatus
abdominal distention
pain decreases after vomiting
colic
previous abdominal surgery

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14
Q

what COMBINED signs and symptoms are best for confirming large or small bowel obstruction

A
  • distention associated with increased bowel sounds, vomiting, constipation, or prior surgery
  • increased bowel sounds with a history of prior surgery
  • increased bowel sounds with vomiting
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15
Q

investigations for LBO vs SBO

A

LBO: CT scan (LR+ 10), barium enema for LBO (LR+ 48, LR- 0.04)
SBO: radiography, ultrasound, CT scan
generally CT scan is used most often

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16
Q

prognosis of complete SBO

A

20-40% progress to bowel strangulation and infarction
clinical signs do not allow for identifying strangulation prior to infraction
50-75% of patient admitted require surgery

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17
Q

late signs of strangulation in complete SBO

A

fever
leukocytosis
metabolic acidosis
these suggest infarction and at this point, the patient has a complete obstruction

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18
Q

prognosis of partial SBO

A

rarely progress to strangulation or infarction
able to pass stool or flatus; or if doing barium enema will be able to see flow of contrast around the obstruction
resolves spontaneously without surgery in 65-80% of cases

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19
Q

prognosis of LBO

A

most will resolve with treatment
surgical emergency if bowel perforation or bowel ischemia occur

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20
Q

typical cancers included in “abdominal malignancy”

A

colorectal cancer
gynecological cancers
pancreatic cancer
gall bladder or bile duct cancer
gastric cancer
liver cancer

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21
Q

risk factors to consider for abdominal malignancy

A

personal or family history of cancer
lifestyle factors - smoking, mediation, drug use
age - depends on the type of cancer
consult certain cancer screening criteria specific to each cancer type

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22
Q

systemic symptoms of abdominal malignancy

A

unintentional weight loss (36% of cancer diagnoses)
loss of appetite
significant night sweats
symptoms waking patient from sleep (ex. diarrhea)

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23
Q

what are some cardiovascular origins of abdominal pain

A

abdominal aortic aneurysm
myocardial infarction
pericarditis
aortic dissection
mesenteric ischemia

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24
Q

epidemiology for abdominal aortic aneurysm

A

M > F (7.6% vs 1.3%)
strong family history of AAA increases prevalence of 8.3% in women

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25
Q

signs and symptoms of abdominal aortic aneurysm

A
  • pulsatile abdominal mass with ruptured AAA - very limited sensitivity in patients with rupture and large girth
  • asymptomatic (most to least common)
    abdominal pain
    flank or back pain
    abdominal mass on careful exam
    hypotension or orthostasis
    syncope (fainting)
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26
Q

orthostasis definition

A

another term for orthostatic hypotension;
a decrease in BP that happens soon after standing or sitting up

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27
Q

signs and symptoms of ACUTE mesenteric ischemia

A

abdominal pain intensity out of proportion to exam is a classic finding (absent in up to 25% of cases)
vomiting
diarrhea
prior history of intestinal angina

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28
Q

signs and symptoms of CHRONIC mesenteric ischemia

A

recurrent postprandial abdominal pain (in first hour, diminishing 1-2 hours later)
food fear, weight loss due to food aversion
history of tobacco use
peripheral vascular disease
CAD
hypertension
abdominal pain (epigastric or periumbilical)
diarrhea

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29
Q

investigations for acute and chronic mesenteric ischemia

A

acute: CT angiography
chronic: ultrasonography

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30
Q

urgent and emergent gynecological conditions presenting with abdominal pain

A

ectopic pregnancy
ovarian torsion
pelvic inflammatory diseease

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31
Q

ectopic/extrauterine pregnancy definition

A

implantation of pregnancy outside of the uterus

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32
Q

epidemiology for ectopic/extrauterine pregancy

A

female patients of childbearing age
ectopic implantation occurs in approx. 2% of first trimester pregnancies

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33
Q

signs and symptoms of ectopic/extrauterine pregnancy

A

severe lower quadrant pain
sudden onset of pain: stabbing, intermittent, does not radiate
at least 2/3 of patients have history of abnormal menstruation
spotting (slight vaginal bleeding)
pelvic adnexal mass palpable via bimanual pelvic exam

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34
Q

prognosis for ectopic/extrauterine pregnancy

A

repeat tubal pregnancy in 10% of cases
mortality rate if treated before rupture is low (<1/100,000)

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35
Q

investigations with ectopic/extrauterine pregnancy

A

serum beta hCG (pregnancy test) levels generally lower than with an intrauterine pregnancy - levels plateau instead of increasing
pelvic ultrasound

36
Q

ovarian torsion definition

A

ischemia or necrosis of the ovary usually due to the presence of a cyst or mass

37
Q

epidemiology in ovarian torsion

A

can occur in patients of any age
can occur in pre-menarchial patients (20% of cases)
higher risk in pregnancy (20% of of cases)

38
Q

signs and symptoms of ovarian torsion

A

almost 70% of torsions occur on the R side
sudden onset, severe, unilateral, lower abdominal pain
patient may also have gradual onset and be mild or intermittent
nausea and vomiting
abdominal tenderness, guarding on palpation
presence of latero-uterine mass
close to 30% of bilateral adnexal tenderness of bimanual pelvic exam

39
Q

investigations and prognosis of ovarian torsion

A

transvaginal ultrasound with doppler

ovary and fallopian tube can be saved depending on duration and extent of ischemia/necrosis

40
Q

signs and symptoms in pelvic inflammatory disease

A

lower abdominal pain
chills and fever
menstrual disturbances
purulent cervical discharge
cervical and adnexal tenderness

41
Q

prognosis of pelvic inflammatory disease

A

about 20% of women with PID become infertile
40% can develop chronic pain
1% of women who conceive have an ectopic pregnancy
can resolve spontaneously

42
Q

investigations in pelvic inflammatory disease

A

CRP
ESR
endocervical culture - Neisseria gonorrhoeae or Chlamydia trachomatis - tests for STIs

43
Q

other causes of abdominal pain

A

peptic ulcer disease
cholecystitis
cholelithaisis
nephrolithiasis
acute and chronic pancreatitis
diverticular disease
autoimmune conditions
infectious gastroenteritis
functional disorders

44
Q

peptic ulcer disease definition

A

ulceration of the gastric or duodenal lining

45
Q

epidemiology of peptic ulcer disease

A

most ulcers are secondary to NSAID use, H.pylori infection, or both
peptic ulcers develpo in 1-10% of patients infected with H.pylori
ulcer disease develops in 25% of persons who take NSAIDs regularly

46
Q

risk factors for NSAID associated PUD

A

history of prior PUD
age >65
high dose NSAID therapy
concomittant use of aspirin (low or high dose), corticosteroids, or anticoagulants
concurrent H. pylori infection

47
Q

signs and symptoms of peptic ulcer disease
how do NSAID-associated and non-NSAID associated ulcers differ in presentation?

A

60% of NSAID associated ulcers are asymptomatic
25% of non-NSAID associated ulcers are asymptomatic
less than 1/3 of patients with epigastric discomfort have PUD
unintentional weight loss (10-20 lbs is common, could lose more than 20 lbs)

48
Q

prognosis for PUD

A
  • the first sign of PUD could be a life-threatening complication - hemorrhage or perforation (over 50% of cases)
  • bleeding (massive hemorrhage or occult, chronic, subtle bleeding with iron deficiency anemia)
  • perforation (EMERGENCY!)
49
Q

indicators of massive hemorrhage vs more subtle bleeding

A

larger hemorrhage: hematemesis, melena, hematochezia
occult, chronic, subtle bleeding: iron deficiency anemia, harder to see

50
Q

investigations in peptic ulcer disease

A

screen for H.pylori infection - urea breath test, stool antigen test, blood test (antibodies)
imaging - EGD (endoscopy) only recommended for over 60 years or if alarm features present

51
Q

methods of screening for H.pylori infection and how they differ

A

urea breath test: measure exhaled CO2 and H.pylori makes urease and so measured CO2 will be higher than normal if H. pylori infection is present

stool antigen test: can see if patient has active H. pylori infection

blood test: for antibodies, cannot distinguish between past and current H. pylori infections

52
Q

cholecystitis definition

A

inflammation of the gall bladder and/or bile ducts, usually secondary to cystic duct obstruction

53
Q

signs and symptoms of cholecystitis

A

murphy’s sign
right upper quadrant pain
fever
jaundice
nausea, vomiting

54
Q

Murphy’s sign

A

palpate under right subchondral margin while the patient inhales
positive sign if patient stops inhalation suddenly (inspiration arrest) due to pain

55
Q

investigations in cholecystitis

A

elevated leukocytes (>10,000)
ultrasound
cholelithiasis - gall stones present in 84-99% of cases
does not usually have a significant increase in lipase or liver biochemical tests

56
Q

prognosis of cholecystitis

A

if untreated, necrosis, infection and gangrene can occur
it doesn’t get to this point because people are in so much pain they go to emergency care

57
Q

risk factors for nephrolithiasis

A

men affected 2-3x more than women (consume more protein and have higher sodium intake, protective effects of endogenous estrogen, no protective effect of exogenous estrogen/estrogen therapy seems to increase risk)
positive family history increases risk

58
Q

what is the recurrence of kidney stones at 5 years?

A

35-50% recurrence rate at 5 years

59
Q

signs and symptoms of nephrolithiasis

A

rapid onset of excrutiating back and flank pain that may radiate to the abdomen or groin
pain may be associated with nausea, vomiting, dysuria, urinary frequency
abdominal tenderness
hematuria may or may not be present

60
Q

dysuria definition

A

changes in urination, painful or difficult urination

61
Q

investigations in nephrolithiasis

A

non contrast renal CT is most accurate
determine composition of stones to prevent recurrence: urine culture, pH, chemical analysis of retreived stones; serum calcium; multiple 24 hour urine analysis

62
Q

types of kidney stones (5)
which type is most common

A

calcium oxalate stones 75%
calcium phosphate stones (CaPO4) 5%
uric acid stones 5-10%
struvite stones (MgNH4PO4) 5-15%
other: cystine or indinavir stones

63
Q

prognosis in nephrolithiasis

A

ureteral obstruction
pyelonephritis
sepsis
acute kidney injury is rare, occurring in patients with bilateral obstruction or obstruction of a solitary functioning kidney

64
Q

acute pancreatitis common causes

A

alcohol abuse - binge drinking
and choledocholithiasis - obstruction of common bile duct
account for 80% of cases
15-25% are idiopathic, possibly due to microlithiasis or sphincter of Oddi dysfunction

65
Q

signs and symptoms of acute pancreatitis

A

low grade fever
pain may radiate to back and may be exacerbated in the supine position
nausea and vomiting usually present
rebound is rare on presentation; guarding is common
periumbilical bruising = Cullen sign
retroperitoneal bruising -> flank bleeding = Grey Turner sign (rare but valuable clue)

66
Q

investigations in acute pancreatitis

A

blood tests - liver enzymes will be affected
lipase 3x Upper Limit of Normal
ALT or AST elevated > 100 IUs
AST or ALT <50 IU make acute pancreatitis unlikely
imaging - transabdominal ultrasound to determine if gallstones of common bile duct dilation is present

67
Q

prognosis of acute pancreatitis

A

can lead to chronic pancreatitis
tends to be a sudden inflammatory reaction that is reversible

68
Q

chronic pancreatitis common cause

A

usually is secondary to recurrent acute pancreatitis, primarily from alcohol abuse

69
Q

signs and symptoms of chronic pancreatitis

A

chronic, disabling, mid-epigastric postprandial pain
pain may radiate to the back and be relieved by sitting forward
abdominal bloating
unintentional weight loss and diarrhea
weight loss secondary to anorexia and malabsorption with steatorrhea

70
Q

investigations for chronic pancreatitis

A

CT scan

71
Q

prognosis for chronic pancreatitis

A

pancreatic cancer develops in 4% of patients
diabetes may develop due to concomitant destruction of pancreatic islet cells
not reversible due to structural changes like fibrosis and calcification

72
Q

diverticulitis vs diverticulosis

A

diverticulosis - presence fo out-pouching in large intestine
diverticulitis - acute inflammation of out pouching of large intestine
both are considered diverticular disease

73
Q

what population is most commonly affected by diverticular disease?

A

ages 85+, then ages 60+
mean age of onset is 63 yo

74
Q

signs and symptoms of diverticulitis

A

left lower quadrant tenderness
may present with fever

75
Q

investigations for diverticular disease

A

abdominal CT scan

76
Q

prognosis for diverticular disease

A

potential complications:
abscess
peritonitis
sepsis
colonic obstruction
fistula formation

77
Q

fistula definition

A

when there is an abnormal connection between 2 body parts that shouldn’t be there, due to internal injury or surgery
ex. fistula between the intestine and the skin

78
Q

potential causes of diarrhea in cases of abdominal pain with diarrhea

A

infectious - bacterial, viral, parasitic
antibiotic side effect
autoimmune/inflammatory - ulcerative colitis, crohn’s disease, celiac disease
endocrine - hyperthyroid or bile acid malabsorption
dietary - food intolerances or sensitivities
functional GI disorders

79
Q

disorders of gut-brain interaction
(DGBI) definition AND potential processes involved (4)

A

bi-directional connection between our gut and brain. what affects our brain affects our digestion and vise versa

potential processes:
impaired gut motility
altered microbiome
visceral hypersensitivity
mucosal layer alterations

80
Q

IBS criteria in ROME IV

A

recurrent abdominal pain on average 1 day/week in the last 3 months followed by 2 or more of:
- related to defecation
- associated with a change in frequency of stool
- associated with a change in form/appearance of stool
symptom onset at least 6 months prior to diagnosis (this part is debatable)

81
Q

describe the Bristol stool form scale

A

types 1-7 ranging from more solid to watery
- type 1 is constipation, type 7 is diarrhea
- type 3 or 4 is ideal - like a sausage that is smooth or has cracks on surface

82
Q

alarm features with IBS-D

A

unintentional weight loss
nocturnal diarrhea
tenesmus
passing of bright red blood in stool - hematochezia
high-volume of diarrhea or high volume of bowel movements
suspicion of malnutrition
family history of colorectal cancer

83
Q

is blood testing recommended in patients with suspected IBS-D?

A

NO. it’s recommended to use a symptom based approach, exclude alarm features, then do specific testing

84
Q

is fecal calprotectin evaluation recommended in patients suspected with IBS-D?

A

Yes. IBD falls under autoimmune category with is different from IBS, so we would treat it differently and would want to know if the patient has IBD instead of IBS

85
Q

when is colonoscopy recommended for patients with suspected IBS-D or functional diarrhea?

A

patients 50+ years
patients with alarm features

86
Q

when is SeHCAT testing recommended and for what patients?

A

in all patients with unexplained chronic diarrhea, testing is recommended to exclude the diagnosis of bile acid diarrhea

CMS150 (6 decks)

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