CA-lecture facts Flashcards
what are GI complaints difficult to evaluate? 3
- frequently benign
- often nonspecific
- occasionally serious
what are the majority of visits to the ED for?
stomach and abdominal pain, cramps, or spasms
what is often required to make a specific diagnosis for abdominal complaints?
imaging
what drives the evaluation of pain?
location
what do the pain receptors in the abdomen respond to?
4
2
- mechanical stimuli-stretch, distention, traction, compression torsion
- chemical stimuli-inflammation or ischemia
what are the 3 types of pain?
- visceral
- parietal
- referred
visceral pain
dull, aching, can be colicky, poorly localized and arises from distention of hollow organs
ex: bowel obstruction
parietal pain
sharp, very well localized
arises from paritoneal irritation
Ex: appendicitis
refferred pain
aching, perceived to be near body surface
EX: cholecystitis referred to right scapula
what is the key to formulating the dif Diagosis list?
location of the pain is KEY!!!!
so have them point to the area that hurts
what are the 5 organs in RUQ?
- liver/gallbladder
- pylorus/duodenum
- head of pancreus
- ascending/transverse colon
- right kidney/adrenal
what are 5 organs in the right lower quadrant?
- right kidney/ureter
- cencum/appendix
- ovary/fallopian tube
- spermatic cord
- uterus/bladder
what are 6 organs in the upper left quadrant?
- liver (left lobe)
- spleen
- stomach
- body of pancreus
- descending/transverse colon
- left kidney/adrenal
what are the 5 organs in the LLQ?
- left kidney and ureter
- sigmoid/descending colon
- ovary/fallopian tube
- spermatic cord
- uterus/bladder (if enlarged)
what are 2 key things that can be reasons for pain in the left upper quadrant?
- myocardial infarction
- splenic rupture
what is 1 key thing that can appear in the RLQ?
- ectopic pregnancy
- appendicitis (starts periumbilically)
what is 1 important thing that can appeare in the left lower quadrant?
- ectropic pregnancy
- diveriticularis can be midline too
what are 4 things tht can appeare as epigastric pain?
- myocardial infarction
- reptured aortic aneurysm
- esophagitis
- PUD
what is 1 imporant thing you can see in the periumbilical area?
- ruptured aortic aneurysm
what is 1 important thing that can be in the suprapubic area?
- ectopic pregnancy
what are 2 important things that can cause diffuse pain?
- mesenteric ischemia
- peritonitis
what are 2 things that are key patterns for pain in RUQ?
- cholecystitis
- hepatitis
pain radiating to the back suggests…
pancreatitis
pain radiating to the R shoulder indicates….
cholecystitis
pain radiating to the groin suggests…
renal colic
steady, rapid increase in pain suggests…
pancreatitis
several days pf pain prior to presentations suggestsion
diverticulitis
sudden, abrupt onset, severe pain suggests…
appendix rupture
aortic dissection
buring or gnawing pain suggests….2
GERD
PUD
colicky may suggest….3
- gastroenteritis
- bowel obstruction
- nephrolithiasis
high intensity pain could suggest….
biliary or renal colic
mesenteric infarcation
lower intensity pain coud suggest
gastroenteritis
pain with empy stomache
AND
pain relieved with eating could suggest
PUD
pain with any movement
AND
COUGH PAIN
AND
relief with lying on back and not moving could suggest.
peritonitis
pain worse with eating any fatty food could suggest…
cholecystitis
pain relieved with sitting up and leaning forward could suggest
pancreatitis
what do you need to exclude in all women of childbearing age presenting with abdominal pain?
PREGANCY!!
what are 3 vital signs that are important to note in abdominal complaints?
- temp (infection)
- HR
- orthostatic BP (GI blood loss or dehydration)
what are 3 things that can cause increased 3rd spacing of fluid and intravascular volume depletion or overt shock?
- bowel obstruction
- peritonitis
- bowel infarction
what do you want to look at the eyes for?
scleral icterus
what do you look at the skin for? seen in?
jaundice
- hepatitis
- cholgangitis
how often do normal bowel sounds occur?
what do they sound like?
5-10 seconds
clicks and gurgles
how long should you listen for bowel sounds?
2 minutes!! must listen for this long to say that they have NO BOWEL SOUNDS
if high pitched bowel sounds…suspect
small bowel obstruction
what are 4 things that can cause decreased bowel sounds?
- peritonitis
- ileus
- mesenteric
- narcotic use
what are 2 things that can cause friction rub?
- splenic infarction
- hepatitic metastasis
what are 4 places you listen for bruits?
what are 6 organs that are usually not palpable?
- stomach
- spleen
- gallbladder
- duodenum
- pancreas
- kidneys
what are two things you should suspect if the pt has rebound tenderness “guarding”?
- peritonitis
- appendicitis
spleen palpation
kidney palpation
what are 4 tests you do for appendicitis?
- McBurneys point
- Rovsings sign
- psoas sign
- obturator sign
what is the test you do for gallbladder disease?
murphys sigh
what are two tests you do for ascites?
- shifting dullness
- fluid wave
McBurneys point
for appendicitis
rovsing’s sign
appendicitis
if you deep press in RLQ and then lift up they haverebound pain as you lift up
psoas sign
appendicitis
pain with pushing down
obturator sign
appendicitis
pain with this motion
murphys sign
gallbladder/cholecystitis
slide hand under right rib while breathing out and causes pain
shifting dullness
ascites
fluid wave
acities
push on one side and see if you feel wave on other side
what is this?
caused by?
caput medusa
varicose veins of the liver
spider angiomata
little telangestasis that is indicative of liver disease
what are 2 signs that are can be indicative of liver disease?
- spider angiomata
- caput medusa
***what do you need to consider in any patient over 50 years old with pain out of proportion to PE findings**
mesenteric ischemia
what are 5 conditions that are more common in elderly?
- cholecystitis
- diverticulitis
- mesenteric ischemia
- small bowel obstruction
- ruptured aortic aneurysm
if woman has adnexal pathology, what should you think of?
- ovarian cyst
- torsion
- neoplasm
when presentation would you consider for ectopic pregnancy?
vaginal bleeding 6-8 weeks after LMP
what are two things you need to do in all women of childbearing age who present with abdominal pain?
- HCG
if postitive
- transvaginal US
what is the HCG level know as the discriminatory zone that allows you to see gestational sac of the IUP on US?
1,500
what are 4 sxs other than pain that children can present with?
- vomiting
- fever
- irritibaility
- lethargy
what does stillness in a child indicate?
irritation of the peritoneum like appendicitis
what does writhing for a comfortable positions suggest in a child?
obstruction or renal colic
what are 2 symptomatic reliefs for abdominal pain?
- opoid analgesia
- antiemetics (zofran)
amylase
pacreatitis if lipase not avaliable
lipase
pancreatitis
coagulation studies
GI bleeding
end stage liver dxs
coagulopathy
electrolytes
dehydration
metabolic disorder
glucose
diabetic ketoacidosis
pacreatitis
plain radiograph
3 indications
flat and upright views
screening for obstruction “dilated looks of
sigmoid volvus perforation (free air)
severe constapation
US
2 preferences
preferred for:
- biliary tract-cholecystitis
- GYN-ectopic pregnancy
CT
pros?
cons?
pros: sensitive and specific
cons: delay in surgery, radiation, cost and must check creatine with contrast
patients with unclear diagnosis at end of the visit shoud…
reevalation within 12 hours
and return if sxs change with increased pain, fever, vomiting, syncope, bleeding etc
what should you make sure to document?
pertinent negatives
what should you make sure to do for the radiologist?
provide clinical information
what are the majority of abdominal plain view films?
AP view
on a xray, how dose gas appeare?
black
on a xray, how does fat appeare?
dark grey
on a xray, how dose soft tissue or fluid appeare?
light grey
on a xray how does bone/calcification appeare?
white
on a xray how does metal appear?
intense white
pelvic phelboliths is…..
calcificaiton within the mesentary
this is normal finding
what is wrong with this?
the marking of L isn’t right…..it was marked on the wrong side by looking at the anatomy (look at the heart and the somach)
how large is the diametere of the SI?
2.5-3 cm
how large is the diameter of the LI?
3-5 cm
what are 6 things you should look at when examining the bone?
Cortical Outline
Joint and Disc Space
Trabecular Pattern
General Bone Density
Lysis, Fracture, Sclerosis
Epiphyseal Lines
conventional CT scan
how are the scans taken?
what must patient do?
scan taken slice by slice
after each scan it stops and move to the next place
requires the pt to hold still without movement
ON THE WAY OUT AS A MEHTOD FOR CT
spiral/helical CT
HOW ARE THE IMAGES TAKEN?
CONTINUOUS SCAN taken in spiral fashion
DUH, hence the name
MUCH FASTER PROCESS AND IMAGES ARE CONTINUOUS
REPLACING THE CONVENTIONAL CT SCANNERS
IT ROTATES AROUND THE PATIENT AND PRODUCES A BLOCK IMAGE IN ONLY A SECOND
housefield units
what are they?
scale?
allows radiologist to differntiate between different types of tissues on CT, measure of density
air-1000 units (minimum)
water=0
bone +1000
the numerical number allows the radiologist to determine the type of tissue/fluid it is
explain the difference between clotting blood and free running blood on a hemmorage using housefield units?
clotting: 45-70 HU
free: 20-45 HU
what are two rxns you worry about when giving contrast for CT?
what is the new type less likely to do this?
anaphylaxsis-bronchospasm/laryngeal edema
renal failure
**injections can make patient feel warm, or even severe pain**
non-ionic options are less likely to cause severe allergic rxns but $$$
what is the insoluble powerd that is suspecnded in water that is used as a common radiocontrast for the gastrointestinal tract during CT?
alternative?
barium sulfate
alternative: water soluble iodine
what can prevent the risk associated with giving contrast dye?
good hydration
what do you withhold before a CT scan?
metformin
**want to insure if person does get renal failure they don’t have this in their system because it can cause a toxic accumlation if their kidneys can’t filter it out**
LACTIC ACIDOSIS
when reading CT how should it be done?
head to toe
superficial to deep
Shifting dullness test to assess for ascites
After percussing border of tympany and dullness w/ patient supine, ask patient to turn onto one side then percuss and mark borders again
In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top
Fluid wave test to assess for ascites
Ask patient or assistant to press edges of both hands firmly down the midline of abdomen. While you tap one flank sharply w/ your fingertips, feel on the opposite flank for a “wave” transmitted through the fluid
An easily palpable “wave” suggests ascites
McBurney’s point
tenderness to assess for appendicitis
Find point (lies 2” from ASIS on an imaginary line drawn to umbilicus)
Positive if tender w/ guarding, rigidity and rebound tenderness
Rovsing’s sign
to assess for appendicitis
Press deeply and evenly in LLQ then quickly withdraw your fingers
Positive if pain in RLQ during left-sided pressure
Psoas sign
to assess for appendicitis
Place hand just above patient’s right knee and ask patient to raise thigh against your hand
Positive if pain increases
Obturator sign
to assess for appendicitis
Flex patient’s right thigh at hip, w/ knee bent, and rotate leg internally at hip (swing lower leg laterally)
Positive if right-sided pain
Murphy’s sign
to assess for acute cholecystitis
Hook your left thumb or fingers of your right hand under costal margin of RUQ and ask patient to take deep breath
Positive if sharp increase in pain w/ sudden stop in inspiratory effort or wincing. Less pronounced pain may indicate liver inflammation
Ventral hernia assessment
(umbilical or incisional)
Ask patient to raise the head and shoulders off the table
Bulge of hernia will usually appear
Mass in abdominal wall assessment
Ask patient either to raise the head and shoulders off the table or bear down
Mass in abdominal wall remains palpable
what are the four liver enzymes you check for liver function?
- aspartate aminotransferase (AST)
- alanine aminotransferase (ALT)
- gamma-glutamyl transpeptidase (GGT)
- alkaline phosphatase
what are the 3 things you check for liver function?
- albumin
- bilirubin, total and direct
- prothrombin time
what would you expect to see for LFTs with hepatocellular damage? 2 examples?
increased ALT/AST
increased alkaline phosphate
what would you expect to see on LFTs with cholestasis?
increases ALT/AST, increase alkphos
what would you expect to see for labs with jaundice?
increased total bilirubin…but can’t differentiate wb etween hepatocellular damage or cholestasis
what does low albumin suggest?
chronic procress
what does a prolonged PT/INR suggest?
significant hepatocellular damage
what should these values of AST to ALT ratios make you think of?
AST:ALT
2:1 …
4x greater
25x normal
50x normal
2:1 alcohol liver disease, cirrohosis
x4 greater nonalchoholic fatty liver disease
25x greater hepatitis, toxin related
50x greater ischemic hepatopathy
unconjugated indirect Bilirubin
how is this produced?
2 things cause increase?
3 sxs?
a product of RBC break down when the cell dies, naturally or not naturally
if increased:
1. hemolytic anemia
2. imparied bilirubin uptake and storage
S&S:
- mild jaundice
- stool and urine abnormal
- splenomegaly (in hemolysis)
conjugated direct bilirubin
where is this made?
what do increased levels come from?
3 S&S?
becomes conjugated in the liver
if this accumulates i nthe blood it means tha:
1. liver isn’t functioning
2. billiary obsruction causing it to backup into blood
S&S
- jaundice, pruritis
- dark urine, light colored stool
- RUQ pain (hepatomegaly)
inclass activity:
bowel obstruction
2 key word findings
imaging 1st and second
dilated loops of bowel on xray standing and supine
**air fluid levels on xray**
if need surgery, do ct
mesenteric ischemia
when does pain occur?
3 KEY FINDINGS
TEST
- worst 10-30 mins after eating with pain out of proportion to exam
TEST: CT ANGIOGRAM
**focal and segmental bowel wall thickening with gas infiltration into the liver**
cholecystitis
IN CLASS
3 tests to check/order
Tests:
- CBC
- MURPHYS SIGN with guarding
test- color flow US
stones (doppler)
acute cholangitis
4 tests to check?
how to tx?
Tests:
- CBC
- LFT hyperbilirubin
3. increase alkaline phosphatase
4.2 blood cultures
ECRP for DX and TX
what is the earliest indicator of acute infection for hepatits B?
hepatitis B surface antigen
when does hepatitis A IgM antibody typically develop?
2-3 weeks after being infected
when is a unique time hepatitis B IgM core antibody can occur, outside of initial infection
in hepatitis flares in people with chronic hep B
what is important to keep in mind regarding the hepatitis C antibody?
you can’t distinguish between active or previous infection
hepatitis
test you want to check? 1 finding?
2 sxs?
hepatitis panel
LFTs in 1,000s
jaudice
itchy
check glucose
PUD
how to describe the pain?
3 tests, which absolute?
urease breath test
fecal stool antigen
endoscopy NEEDED
BURNING OR GNAWING
how do you test for H. pylori if there is no acute bleed?
- upper endoscopy with bx
others;
urease breth test
fecal stool antigen
how do you test for H. pylori if presence of acute upper GI bleed?
urea breath test
pancreatitis
<span>where does pain go?</span>
<span>2 tests?</span>
<span>2 findings?</span>
epigastic pain that radiates to back
1.amylase/lipase
2. abdominal CT
“heterogenous with multiple colors or FAT STRANDING”
appendicitis
pain location
3 positive findings
test and tx?
periumbilical FOLLOWED BY RLQ
postiive:
ROVSINGS
PSOAS
MCBURNEYS
CT AND REMOVE
diverticularis
type of pain?
3 tests?
LLQ with progressive pain
CBC
GUIAC TEST
CT
