Abdominal Pain, IBS, GI Conditions

Question 1

red flag conditions for abdominal pain

Answer 1

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

Question 2

appendicitis overall best indicators signs and symptoms

Answer 2

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

Question 3

psoas sign definition

Answer 3

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

Question 4

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

Answer 4

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

Question 5

other signs and symptoms of appendicitis

Answer 5

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

Question 6

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

Answer 6

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

Question 7

bowel obstruction accounts for __% of abdominal pain cases

Answer 7

4% of abdominal pain cases

Question 8

proportion of large bowel obstructions vs small bowel obstructions

Answer 8

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

Question 9

etiology of large bowel obstruction

Answer 9

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

Question 10

volvulus definition

Answer 10

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

Question 11

etiology of small bowel obstruction

Answer 11

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

Question 12

stricture definition

Answer 12

an area of narrowing in the intestines

Question 13

signs and symptoms of bowel obstruction

Answer 13

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

Question 14

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

Answer 14

• 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

Question 15

investigations for LBO vs SBO

Answer 15

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

Question 16

prognosis of complete SBO

Answer 16

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

Question 17

late signs of strangulation in complete SBO

Answer 17

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

Question 18

prognosis of partial SBO

Answer 18

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

Question 19

prognosis of LBO

Answer 19

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

Question 20

typical cancers included in “abdominal malignancy”

Answer 20

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

Question 21

risk factors to consider for abdominal malignancy

Answer 21

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

Question 22

systemic symptoms of abdominal malignancy

Answer 22

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

Question 23

what are some cardiovascular origins of abdominal pain

Answer 23

abdominal aortic aneurysm
myocardial infarction
pericarditis
aortic dissection
mesenteric ischemia

Question 24

epidemiology for abdominal aortic aneurysm

Answer 24

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

Question 25

signs and symptoms of abdominal aortic aneurysm

Answer 25

- 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)

Question 26

orthostasis definition

Answer 26

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

Question 27

signs and symptoms of ACUTE mesenteric ischemia

Answer 27

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

Question 28

signs and symptoms of CHRONIC mesenteric ischemia

Answer 28

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

Question 29

investigations for acute and chronic mesenteric ischemia

Answer 29

acute: CT angiography chronic: ultrasonography

Question 30

urgent and emergent gynecological conditions presenting with abdominal pain

Answer 30

ectopic pregnancy ovarian torsion pelvic inflammatory diseease

Question 31

ectopic/extrauterine pregnancy definition

Answer 31

implantation of pregnancy outside of the uterus

Question 32

epidemiology for ectopic/extrauterine pregancy

Answer 32

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

Question 33

signs and symptoms of ectopic/extrauterine pregnancy

Answer 33

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

Question 34

prognosis for ectopic/extrauterine pregnancy

Answer 34

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

Question 35

investigations with ectopic/extrauterine pregnancy

Answer 35

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

Question 36

ovarian torsion definition

Answer 36

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

Question 37

epidemiology in ovarian torsion

Answer 37

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

Question 38

signs and symptoms of ovarian torsion

Answer 38

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

Question 39

investigations and prognosis of ovarian torsion

Answer 39

transvaginal ultrasound with doppler ovary and fallopian tube can be saved depending on duration and extent of ischemia/necrosis

Question 40

signs and symptoms in pelvic inflammatory disease

Answer 40

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

Question 41

prognosis of pelvic inflammatory disease

Answer 41

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

Question 42

investigations in pelvic inflammatory disease

Answer 42

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

Question 43

other causes of abdominal pain

Answer 43

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

Question 44

peptic ulcer disease definition

Answer 44

ulceration of the gastric or duodenal lining

Question 45

epidemiology of peptic ulcer disease

Answer 45

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

Question 46

risk factors for NSAID associated PUD

Answer 46

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

Question 47

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

Answer 47

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)

Question 48

prognosis for PUD

Answer 48

- 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!)

Question 49

indicators of massive hemorrhage vs more subtle bleeding

Answer 49

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

Question 50

investigations in peptic ulcer disease

Answer 50

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

Question 51

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

Answer 51

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

Question 52

cholecystitis definition

Answer 52

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

Question 53

signs and symptoms of cholecystitis

Answer 53

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

Question 54

Murphy's sign

Answer 54

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

Question 55

investigations in cholecystitis

Answer 55

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

Question 56

prognosis of cholecystitis

Answer 56

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

Question 57

risk factors for nephrolithiasis

Answer 57

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

Question 58

what is the recurrence of kidney stones at 5 years?

Answer 58

35-50% recurrence rate at 5 years

Question 59

signs and symptoms of nephrolithiasis

Answer 59

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

Question 60

dysuria definition

Answer 60

changes in urination, painful or difficult urination

Question 61

investigations in nephrolithiasis

Answer 61

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

Question 62

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

Answer 62

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

Question 63

prognosis in nephrolithiasis

Answer 63

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

Question 64

acute pancreatitis common causes

Answer 64

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

Question 65

signs and symptoms of acute pancreatitis

Answer 65

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)

Question 66

investigations in acute pancreatitis

Answer 66

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

Question 67

prognosis of acute pancreatitis

Answer 67

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

Question 68

chronic pancreatitis common cause

Answer 68

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

Question 69

signs and symptoms of chronic pancreatitis

Answer 69

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

Question 70

investigations for chronic pancreatitis

Answer 70

CT scan

Question 71

prognosis for chronic pancreatitis

Answer 71

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

Question 72

diverticulitis vs diverticulosis

Answer 72

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

Question 73

what population is most commonly affected by diverticular disease?

Answer 73

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

Question 74

signs and symptoms of diverticulitis

Answer 74

left lower quadrant tenderness may present with fever

Question 75

investigations for diverticular disease

Answer 75

abdominal CT scan

Question 76

prognosis for diverticular disease

Answer 76

potential complications: abscess peritonitis sepsis colonic obstruction fistula formation

Question 77

fistula definition

Answer 77

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

Question 78

potential causes of diarrhea in cases of abdominal pain with diarrhea

Answer 78

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

Question 79

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

Answer 79

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

Question 80

IBS criteria in ROME IV

Answer 80

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)

Question 81

describe the Bristol stool form scale

Answer 81

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

Question 82

alarm features with IBS-D

Answer 82

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

Question 83

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

Answer 83

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

Question 84

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

Answer 84

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

Question 85

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

Answer 85

patients 50+ years patients with alarm features

Question 86

when is SeHCAT testing recommended and for what patients?

Answer 86

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