Approach to pt with abd pain - GI Exam Flashcards
1
Q
Acute Abdomen
A
medical jargon that refers to any acute condition within the abdomen that requires immediate medical or surgical attention.
2
Q
Approach to the Patient With Abdominal Pain
A
- Note the patient’s age, gender and past medical history, precipitating factors, location of the pain, radiation and associated symptoms.
3
Q
Types of Abdominal Pain (3)
A
- Visceral Pain (colic pain)
- Parietal Pan
- Referred Pain
4
Q
Visceral Pain (colic pain):
A
source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Cramping not well localized.
5
Q
Parietal Pain
A
Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.
6
Q
Referred Pain
A
From a distant sight
7
Q
Gall badder pain referred to?
A
right shoulder
8
Q
Spleen pain referred to?
A
Left shoulder
9
Q
Pancreas or aorta pain referred to?
A
back
10
Q
_____of the pain is one of the best determinants of the diagnosis.
A
location
11
Q
Melena
A
= Black tarry stools
- 50-60 ml of blood in the stomach can produce melena
- Above the “Ligament of Treitz” (very general rule)
12
Q
Hematochezia
A
- Blood unchanged by passage through the gut usually at the level of the colon or lower
- Blood in the bowel is a cathartic
13
Q
Blood mixed with stool suggests _____, blood outside the stool suggests_____.
A
upper colon…… sigmoid or rectum
14
Q
Jaundice
A
Staining of tissue and body fluids with bilirubin
15
Q
Jaundice - Signs and Symptoms (5)
A
- Yellow skin
- Scleral yellowing
- Pruritus = generalized itching all over
- Urine color – darken urine from conjugated
- Acholic feces – malodorous, gray to light colored stools
16
Q
Unconjugated hyperbilirubinemia
A
Unconjugated bilirubin being produced at a rate exceeding the maximal rate of liver conjugation and excretion or decreased conjugation.
17
Q
Unconjugated hyperbilirubinemia Etiologies (6)
A
- Hemolysis
- Red cell defects – sickle cell
- Ineffective erythropoiesis
- Deficient hepatic uptake
- Deficient hepatic conjugation – - hepatitis
18
Q
Conjugated Hyperbilirubinemia
A
Impaired excretion of conjugated bilirubin from hepatocytes in the bile canaliculi or obstruction of biliary flow.
19
Q
In Conjugated Hyperbilirubinemia Serum alkaline phosphatase is…..
A
elevated out of proportion to the transaminases
20
Q
Conjugated Hyperbilirubinemia Etiologies (2)
A
- Intrahepatic cholestasis – hepatocellular disease, drugs, sepsis, primary biliary cirrhosis
- Extrahepatic obstruction – gallstones, biliary carcinoma, sclerosing cholangitis, parasites, pancreatic cancer, pancreatitis
21
Q
Ascites
A
An increase accumulation of peritoneal fluid by any one or more of several mechanisms:
- Transudation of fluid from portal hypertension
- Lymphatic obstruction
- Decreased plasma oncotic pressure
- Peritoneal inflammation – peritonitis
22
Q
Ascites 4 signs of free Fluid
A
- Bulging flanks
- Tympany at the top of the abdomen
- Fluid wave
- Shifting dullness
23
Q
Ascites Most Common Differentials (3)
A
- Cirrhosis (80-85%)
- Malignancy (10%)
- Congestive heart failure (3%)
24
Q
Fluid wave
A
Place patient’s or assistant’s hand in midline. Tap on one flank and palpate with the other hand. An easily palpable impulse suggests ascites.
25
Shifting dullness
percuss the patient on their
back and then their side. Note where the sound
changes from tympany to dull and the shift of the
sound when the patient is turned to the side.
26
The physical examination of the abdomen and rectum includes: (6)
- Inspection
- Auscultation
- Percussion
- Palpation
- Rectal examination
- Special techniques
27
Adequate exposure of the abdomen =
Xiphoid to the pubis
28
Inspection of the Abdomen (5)
1. Must adequately expose the abdomen
2. Skin - scars, striae, superficial veins
3. Umbilicus – hernia, “Caput medusa”
4. Contour – flat, scaphoid, protuberant
5. Pulsations or peristalsis
29
Auscultation of the Abdomen
1. Listen for bowel sounds before palpation and percussion.
- All 4 quadrants
- RLQ – best place to listen
2. Listen for bruits in the
midline between the
xiphoid and umbilicus.
Femoral arteries B/L.
30
Normal bowel sounds =
high pitched “tinkle” about every 3-5 seconds.
31
Absent Bowel Sounds =
No bowel sounds after 2 minutes
32
Borborygmi
- Increased, hyperactive bowel sounds,
- Low pitched rumbling
- Hyperperistalsis
33
Abdominal bruits
A soft sound made by disrupted arterial flow through a narrowed artery. causes a "hissing sound"
34
Location of aortic bruits
between the umbilicus and xiphoid
35
Location of Renal artery bruits
just lateral to the aorta
36
Location of Femoral Artery Bruits
along the inguinal ligament
37
4 common causes of Abdominal Bruits
1. aorta
2. Renal arteries
3. Illiac arteries
4. Femoral arteries
38
Percussion of the Abdomen helps evaluate the presence of: (4)
- Gaseous distention
- Fluid
- Solid masses
- Size and location of the liver and spleen
39
Percussion
- Percuss all 4 quadrants
| - Best done with the patient in the supine position
40
Tympany
- Most common percussion note.
| - Presence of gas in the stomach and small bowel.
41
Percussion of the liver
- Percuss along the right mid-clavicular line from top to bottom.
- Resonant (lungs) to dull (liver) to tympanic (intestine)
42
Normal sized liver
43
Hepatomegaly liver size
> 10 cm
44
Abdominal palpation is usually divided into the following segments: (6)
- Light palpation
- Deep palpation
- Liver palpation
- Spleen palpation
- Kidney palpation
- Rebound palpation
45
Technique for light palpation
- Detect tenderness and areas of muscular spasm or rigidity.
- Palpate all 4 quadrants.
- Use finger tips with a gentle motion.
46
Technique for deep palpation
- Used to evaluate organ size, abnormal masses, aorta, deep pain etc.
- One hand placed on top of the other.
47
Rebound Tenderness is used to evaluate
peritoneal tenderness and inflammation
48
Rebound Tenderness Technique
1. In the suspected area of the abdomen, slowly, gently and deeply palpate.
2. Then, quickly remove the palpating hand.
If the patient experiences pain = “+ rebound tenderness”.
49
Rovsing’s sign
= referred rebound tenderness.
Press on the LLQ and release, positive if pain in the RLQ.
50
DDX for Peritonitis (5)
1. Spontaneous bacterial peritonitis
2. Secondary bacterial peritonitis
- Appendicitis
- Diverticulitis
- Perforated PUD/ Perforated bowel
- Cholecystitis
Pancreatic ascites
3. PID
4. Ectopic pregnancy
5. Fitz-Hugh-Curtis syndrome
51
Technique for palpation of the liver
1. Place left hand under the right 11th and 12th rib.
2. Right hand in the RUQ
3. Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.
4. Can repeat the maneuver.
52
Technique for palpation of the liver
| “Hooking Technique”
1. Stand near the patient’s head .
2. With both hands “hook” your fingers around the lower right costal margin.
3. Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.
53
DDX for Hepatomegaly ( 11)
1. Hepatitis
- Viral
- Bacterial
- Protozoal
- Alcoholic
- Toxic
2. Fatty liver
3. Cirrhosis
4. Congestive heart failure
5. Hepatocellular carcinoma or 6. metastatic cancer
7. Leukemia or lymphoma
8. Autoimmune disease
9. Infiltrative disease
10. Sickle cell disease
11. Glycogen storage disease
54
Liver Function Tests
Bilirubin
Albumin
PT
55
______ are Released d/t inflammation,
| tissue damage or obstruction
ALT
AST
ALP
56
General Approach to liver enzymes in extra-hepatic diseases
Alk Phos - very elevated
| ALT/AST - slightly elevated
57
General Approach to liver enzymes in Hepatic Disease
Alk Phos - slightly elevated
| ALT/AST - very elevated
58
Technique for palpation of the spleen
1. Place left hand under the 11th and 12th ribs.
2. Place right hand in the LUQ under the costal margin.
3. Instruct the patient to breath deeply as the examiner gently presses inward and upward.
4. Repeat the maneuver for deeper palpation.
--> The spleen is normally not palpated in normal conditions.
59
DDX for Splenomegaly (9)
1. Infections
- Mononucleosis – EBV
- Cytomegalovirus – CMV
- HIV
- Malaria
- Histoplasmosis
2. Leukemia/Lymphoma
3. Extramedullary hematopoiesis
4. CHF
5. Polycythemia vera/thrombocytosis
6. SLE
7. RA – Felty’s syndrome
8. Metastatic disease
9. Amyloidosis
60
Palpation of the Aorta
- Press firmly and deep in the upper abdomen with two hands.
| - Normal aorta is 2.5 to 3.0 cm wide.
61
Aortic aneurysm
– pathologic dilatation of the aorta.
- Can be associated with a bruit.
- Assessed with an ultra sound or CT scan.
62
Technique for palpation of the kidneys
“Sandwich method”
1. Place a hand above and below the costal margins just lateral to the midline.
2. Deep and gentle palpation attempt to palpate the lower pole of each kidney.
3. The kidneys are normally not palpated under normal conditions.
63
Percussion of the kidneys,
| a.k.a. CVA tenderness (Lloyd's Sign)
- With a fist, gently hit the area over the costovertebral angle on each side of the spine.
- Pain over a kidney may indicate an inflammatory or infectious process of the kidney.
- The examiner may also place a flat hand over the CVA and strike the hand.
64
DDX for CVA Tenderness
1. Nephrolithiasis
2. Pyelonephritis
3. Renal cell carcinoma
4. DJD
5. Pneumonia – lower lobe
6. SLE
7. Perinephric abscess
8. AAA
9. Glomerulonephritis
65
Every abdominal examination should conclude with a ___
DRE
66
DRE Pt position (3)
1. Patient on their back – Modified Lithotomy
2. Lying on left side – a.k.a. – Sims’ Position
3. Standing, bent over the exam table
67
DRE Inspection
- Spread the buttocks
- Sacrococcygeal and perianal areas
- Anus and rectum
Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors
68
Palpation or Digital Rectal Examination (DRE)
1. Inform the patient of what is going to happen.
2. Lubricate your gloved index finger.
3. Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
4. Slowly insert the finger as the sphincter relaxes as far as possible.
5. Rotate your hand to palpate as much of the rectal surface as possible.
6. Gently withdraw the glove and note the color
of the fecal material and test for occult blood.
Note: nodules, irregularities, masses, tenderness,
induration.
69
Patients with a positive FOBT (fecal occult blood test) ____. The study of choice is _____. ____ are acceptable alternatives.
require a through evaluation for CRC (colorectal cancer)...... Colonoscopy.... Sigmoidoscopy and air contrast barium
enema
70
Common causes of anal warts
1. Condyloma acuminata - HPV
| 2. Condylomata lata – syphilis
71
Procidentia
A Complete Rectal Prolapse
72
Appendicitis Etiology
Obstruction of the appendiceal lumen. Fecal or foreign matter, tumors or lymphomas.
73
Appendicitis history (4)
- Pain starts peri-umbilical then shifts to the right lower quadrant.
- Nausea and vomiting
- Anorexia = one of the most common symptoms
- Fever
74
Appendicitis PE (5)
- RLQ pain and RLQ rebound tenderness
- Decreased or absent bowel sounds
- Rovsing’s sign
- Psoas sign
- Obturator sign
Always do a rectal examination and a pelvic exam on a female.
75
Psoas sign
turn patient on left side and extend the right leg to check for psoas muscle inflammation
76
Obturator sign
place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
77
Appendicitis Diagnostic Work Up (7)
1. CBC – moderate leukocytosis with left shift.
2. Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
3. Plain x-ray – rarely helpful.
4. Ultrasound – enlarged and thick walled appendix.
5. CT scan – most sensitive. 90 – 98% sensitive. Test of choice
6. Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
7. BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.
78
Acute Cholecystitis Etiology
Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.
79
Acute Cholecystitis History (6)
1. RUQ postprandial pain. Biliary colic pain.
2. Pain radiating to the right shoulder.
3. Nausea and vomiting.
4. Anorexia
5. Obesity
6. Fever
80
Acute Cholecystitis The 5 “f’s”
female, fat, fertile, fair, flatulent.
81
Acute Cholecystitis Physical Examination
- RUQ pain and RUQ rebound tenderness.
- Decreased or absent bowel sounds.
- Abdominal distention.
- Murphy’s sign
- Diagnostic Triad = RUQ pain, fever and leukocytosis.
82
Murphy’s sign
RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
83
Acute Cholecystitis Diagnostic Triad
1. RUQ pain,
2. fever
3. leukocytosis.
84
Acute Cholecystitis Diagnostic Work Up (6)
1. CBC – leukocytosis with left shift
2. Serum bilirubin – can be mildly elevated.
3. AST/ALT – can be elevated.
4. Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
5. HIDA scan – radionuclide biliary scan.
6. CT scan
85
Acute Pancreatitis Etiology (5)
- Alcohol use
- Obstruction – gallstones, cancer
- Hyperlipidemia
- Drugs and medications
- Infection
86
Acute Pancreatitis History
- Acute onset
- Nausea/vomiting
- Pain radiating to the back
- Constant pain
87
Acute Pancreatitis Physical Examination (6)
- Low grade fever
- Hypotension
- Decreased or absent bowel sounds
- Epigastric tenderness
- Turner’s sign
- Cullen’s sign
88
Acute Pancreatitis Diagnostic workup (7)
- Amylase and lipase (most specific)
- Glucose & Calcium
- Abd film
- Ultrasound/CT Scan/MRI
- ERCP
- CBC
- Liver function
89
Turner’s sign
discoloration around the flanks [looks like bruises]
90
Cullen’s sign
discoloration around the umbilicus D/T Hemorrhagic pancreatitis
