Aquifer 2 - GI Flashcards
What categories are on the differential for abdo pain and vomiting?
GI
Cardiovascular
GU
Name 8 GI causes of upper abdo pain and vomiting (11 listed)
Gastritis
Gastroenteritis
Gastric outlet obstruction
Peptic ulcer disease
Pancreatitis
Cholecystitis
Cholangitis
Hepatitis
Small bowel obstruction
Appendicitis
Spontaneous bacterial peritonitis
Name 3 cardiovascular causes of upper abdo pain and vomiting (4 listed)
Acute coronary syndrome
Angina
Mesenteric ischemia
Vasculitis
Name 4 GU causes of upper abdo pain and vomiting (6 listed)
Pyelonephritis
Nephrolithiasis
Pelvic inflammatory disease Ectopic pregnancy (if pre-menopausal) Endometriosis (if pre-menopausal) Ruptured ovarian cyst (if pre-menopausal)
What is a single-question screen for unhealthy alcohol use?
“How often do you have four (five for men) or more drinks on one occasion?”
What is a three question screen for unhealthy alcohol use?
“How often do you have a drink containing alcohol?”
“How many standard drinks containing alcohol do you have on a typical day when you are drinking?”
“How often do you have six or more drinks on one occasion?”
(This test has slightly increased sensitivity compared to the single-item screening; CAGE has poor sensitivity)
What pain symptoms are typical of involvement of parietal peritoneum?
Constant and severe pain
Pain worse with movement
When should you not assess rebound tenderness?
When there is peritoneal tenderness on palpation
there would def be rebound tenderness but putting pt through that would be unnecessary and inhumane
What are the characteristics of pain due to inflammation of the parietal peritoneum?
- localized pain over inflamed area
- worsening pain with movement (pt stays still, resists exam)
- may have rigidity (involuntary guarding) due to abdo muscle spasm over inflamed peritoneum
What are the characteristics of pain due to obstruction of a hollow viscera?
- deep, poorly localized pain
- tempo: varies – eg colicky in SBO, constant in biliary tree obstruction
- pt is often restless, attempting to find comfortable position
- typically causes anorexia
Why is parietal pain localized, and visceral pain not?
Parietal peritoneum is innervated by somatic nerves (type A delta fibers) that terminate in the thalamus
The viscera are innervated by Type C sensory fibers. These axons terminate in the brainstem, which results in deeper, poorly localized pain.
What are the characteristics of pain due to ischemia?
Worsening Sx and progressive pain severity in a pt with vascular, thrombotic, or embolic risk factors
Can be sudden and intense, or develop slowly over days (depending on vessels and structures affected)
Viscera that are deprived of blood will inevitably cause pain.
What are the characteristics of referred pain?
Poorly localized
Pain from major diseases of the heart, lungs, and testicles can be referred to the abdomen: must evaluate to r/o
In what time frame after last drink does alcoholic hallucinosis occur?
24-72h
What are the signs of early alcohol withdrawal?
agitation sleep disturbances tremor tachycardia hypertension nausea No signs of delirium.
When do the signs of early alcohol withdrawal peak?
24-36 hours after last drink
What are the SSx of alcoholic hallucinosis?
visual, auditory, or tactile hallucinations but with otherwise intact sensorium and normal vital signs.
What are the signs of delirium tremens?
Autonomic hyperactivity: tachycardia, hypertension, diaphoresis, low grade fever
Tremulousness
Clouded sensorium and disorientation
When does delirium tremens occur?
48-96h after last drink
What is the mortality rate of delirium tremens?
Up to 5%
Why approach a pt from the right for physical exams?
- JVP more visible
- R kidney lower than L
- R hand better positioned to palpate apical impulse
What should be done for cholecystitis, ABO, or abdo organ perforation?
Surgical consult
What is the management of uncomplicated pancreatitis?
isotonic IV fluids, pain control, and a soft, low fat diet as tolerated
Should you keep a pancreatitis pt NPO?
No
Formerly patients with mild pancreatitis were kept NPO for several days until symptoms resolved however more recent trials have shown that a PO diet is safe.
When should you do a surgical consult for pancreatitis?
complicated pancreatitis:
- impacted gallstone that can’t be extracted with ERCP
- pancreatic abscess
- necrotic pancreatitis
- symptomatic pancreatic pseudocyst
How long should surgical intervention for pancreatitis be delayed, and why?
Up to 4 weeks in stable patients
To allow liquefaction of the contents and the development of a fibrous wall around the necrosis
When should you use prophylactic Abx in pancreatitis?
Some studies have shown benefit with increasing severity of illness, organ dysfunction, and worsening pancreatic necrosis
Clearly not indicated for mild cases
When should empiric Abx be used in pancreatitis?
Patients who appear to have infection complicating a severe pancreatitis course
e.g. infected pseudocyst, pancreatic abscess
What imaging is indicated for acute pancreatitis?
RUQ US – to look for impacted gallstones and CBD dilatation
What imaging/tests are not routinely indicated for uncomplicated acute pancreatitis, and when might you consider these studies?
Abdo XR: screens for free air (bowel perforation)
CT abdo pelvis: not necessary for Dx; consider if concern for abscess or necrosis
ERCP: not routine; consider if evidence of an impacted gallstone on the other imaging studies
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography
Directly cannulates the Ampulla of Vater and injects radio-opaque dye into the duct to outline an obstruction
What is MRCP?
Magnetic resonance cholangiopancreatography
Noninvasive imaging test using MRI technology to detect obstruction of the biliary tree and pancreatic duct.
Slightly less sensitive than ERCP, but much less risky for patients
Pt presents with upper abdo pain, vomiting, & fever, with Hx of unhealthy alcohol use. Name 6 things on your DDx.
Gastritis
PUD
SBO
Cholecystitis
Pancreatitis
Spontaneous bacterial peritonitis
