Chapter 8: Gastroenterology Flashcards by Sudharsan Madhavan

What are the life-threatening causes of abdo pain one must take note of?

1) Intra-abdominal
- Perforated viscus(PUD)
- AAA rupture
- Ischemic Bowel
- Pancreatitis
- Appendicitis
- Ectopic Pregnancy
- IO
- Peritonitis
- HBS sepsis
2) Extra-abdominal
- DKA
- AMI
- Basal lobe PE/pneumonia

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What are 3 indications of doing an AXR in ED?

1) Foreign Body(radio-opaque DO like iron)
2) IO(air-fluid level)
3) Ectopic Calcifications(AAA,pancreatitis, ureteric calculi)

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What is the mgmnt of pts with abdo pain?

1) Hemodynamically unstable pt:
-ABC and fluid resus with 1-2L of crystalloids(if AMI not suspected)
-Invg to order:
Bloods: FBC, U/E/Cr, LFT, GXM 2-4 units, CBG, Serum amylase, +-Blood cultures, +-cardiac enzymes
Imaging: CT AP, CXR(pneumoperitoneum), U/S HBS
Others: UPT(females), ECG, Urinalysis
-NBM
-IV antibiotics (Ceftriaxone 1g and Metronidazole 500mg) if suspecting intra-abdo sepsis.
-IV Analgesic

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What is the Alvarado Score for Acute Appendicitis?

Migration to RIF
Anorexia
N/V
Tenderness of RIF
Rebound pain
Elevated temp>37.3
Leukocytosis
Shift of leukocytes to left

Score>= 6 has 92% sensitivity.

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What other clinical features do you classically see in Appendicitis?

1) RLQ pain
2) Pain before vomiting
3) Body temp is rarely elevated beyond 39 degrees. Look for alternative dx in this case

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What invg and mgmnt would you do before definitive surgical rx?

1) ABC
2) IV line and fluid resus
3) Keep NBM
4) Send Bloods for invg: FBC, U/E/Cr, GXM 2-4 units and PT/PTT. (if still unsure of dx then CT Scan/UPT/Urinalysis)
5) Titrated IV analgesia+anti-emetics
6) Roc+Flagyl
7) Surgical consult

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What is the ddx of pancreatitis?

1) Ischemic bowel
2) Perforated viscus/PUD
3) AMI
4) AAA rupture
5) Acute cholangitis

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What are the causes of pancreatitis?

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps and other infections(CMV, VZV)
Autoimmune
Scorpion toxin and other toxins(Organophosphates)
Hypercalcemia/hyperTGs
ERCP
Drugs-
Sulfamethoxazole-trimethoprim(co-trimox)
Azathioprine
NSAIDs
Diuretics

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What are the clinical features of pancreatitis?

1) Severe epigastric pain, radiating to the back, worse on eating and drinking(alcohol), lean forward and curl up.
2) N/V
3) Ileus
4) Dehydration

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What invg will you do in pancreatitis?

1) Bloods:
- FBC(leukocytosis)
- U/E/Cr-assess dehydation
- LFT(elevated transaminases common if gallstone pancreatitis. But if Bil is high, may be choledocholithiasis)
- Amylase(Classically 3X normal levels but is not a marker of disease severity)
- Lipase

2) Imaging:
- AXR(sentinel loop sign, dilated prox bowel, L pleural effusion)
- CT

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What are clinical predictors of severity of pancreatitis?

-Ranson’s score but only done 48hr after initial dx

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What systemic cx is expected in pancreatitis?

1) Acidosis
2) ARDS
3) Renal failure
4) DIVC
5) Refractory hypotension

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How will you manage a pt with pancreatitis?

1) ABC and high flow O2
2) Keep NBM to rest pancreas
3) Aggressive fluid resus
4) Insert catheter
5) IV Analgesia(Parenteral opioids)
6) NG tube if severe ileus, refractory emesis
7) Call GS

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What are some red alert symptoms that suggest that gastric pain is more than just PUD?

1) LOW, LOA
2) Melena
3) Hematemesis
4) Anemia
5) Dysphagia
6) Palpable abdo mass

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What are the typical clinical symptoms of PUD?

1) Pain when pt is hungry, 1-3 hrs after a meal and may be nocturnal and relieved by food/antacids. Pain may radiate to the back.

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What are the typical RFs of PUD?

1) H.pylori

2) NSAIDS

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What is the mgmnt of patients with PUD?

1) Rule out life-threatening causes
2) Symptomatic Rx:
- MMT(Mist Magnesium trisilicate) 40-80ml and
- Anti-Spasmodic
- Oral PPI

2) Discharge with outpt referral to Gastro if:
- Pt>40yrs and dyspepsia
- Presence of red alert symptoms
- Presence of symptoms even after a trial of PPI

3) Advise: Upper abdo pain could be an early symptom of appendicitis and warn about the potential symptoms

What is biliary colic?

It is a constellation of symptoms when the gallbladder contracts against outlet obstruction due to an impacted stone in the Hartmann’s pouch. It is a CLINICAL DIAGNOSIS.

What are the clinical features of biliary colic?

1) Sharp, cramping, constant pain in bouts of 20-30min intervals
2) Radiates to the interscapular region
3) Often occurs at night
4) +-bloating/belching/malaise

What is the mgmnt of biliary colic?

1) Give analgesia(IM Pethidine, do not give NSAIDS until PUD has been excluded which is difficult without scope)
2) Avoid heavy meals
3) stick to low fat diet
4) If relief of symptoms, go for U/S HBS on a later date

What are the features of cholecystitis?

1) Steady, severe pain in the RHC + fever+-N/V, chills, anorexia
2) Positive Murphy’s sign
3) Anicteric

What invg will you do in a pt with cholecystitis?

1) Bloods:
-FBC
-U/E/Cr
-LFT(mild transaminitis)
-Amylase(concomitant pancreatitis)
2) Imaging:
U/S HBS

What are the sonographic features of cholecystitis?

1) Thickened gallbladder wall>4mm
2) Gallstones visualized in the pouch
3) Pericholecystic fluid
4) Sludge
5) Positive sonographic Murphy’s

How would you manage this pt with cholecystitis?

1) NBM
2) IV fluid resus
3) IV Analgesia
4) IV antibiotics(Roc+Flagyl)s

What are the common organisms in acute cholangitis?

1) E.Coli 2) Klebsiella(a/w endophthalmitis) 3) Enterococcus

What are some impt causes?

1) Stones(most common) 2) Post biliary intervention(high risk) 3) Tumour

What is Raynaud' pentad?

1) Fever 2) Jaundice 3) RHC pain 4) Hypotension 5) AMS

What is the ddx of cholangitis?

1) ACS 2) Basal pneumonia 3) Hepatitis/liver abscess 4) Pancreatitis

What invg are indicated in Acute Cholangitis?

1) FBC 2) U/E/Cr(dehydration) 3) LFT - ALP>>ALT/AST - Bilirubin high 4) Amylase 5) ABG 6) Lactate 7) GXM 2-4 units 8) DIVC screen 9) Blood Cultures

What other mgmnt is there for cholangitis?

1) ABC 2) IV fluids resus 3) Insert urinary catheter 4) IV antibiotics(RocFlagyl) and IV analgesia 5) Vasopressors 6) HD/ICU admission? 7) Definitive: ERCP

What are the causes of pyogenic liver abscess?

1) Intra-abdo infections - Appendicitis/Diverticulitis 2) Biliary obstruction/Instrumentation 3) Hematogenous spread - IE - IVDA 4) Hepatic trauma 5) Cyptogenic DM/Immunocompromised pts

What is the invg and definitive mgmnt of liver abscess?

``` Bloods: 1) FBC 2) LFT (Transaminitis) 3) Blood Cultures Imaging: 1) CXR/AXR -Elevation of hemi-diaphragm -Pleural effusion 2) U/S 3) CT ``` - IV antibiotics - Perc/Open Drainage

What are the classical quartet of symptoms in IO?

1) Abdo Pain 2) N/V-less in Large bowel IO 3) Constipation 4) Abdo distention-less in small bowel IO

What are some impt causes of IO?

``` 1)Mechanical: Extramural-Adhesions, Hernia, Volvulus Intramural- Strictures, malignancy Intraluminal- Gallstone ileus, Fecal impaction, FB 2) Functional: -Paralytic Ileus(post op, electrolytes, sepsis) -Pseudo-obstruction (OGLIVE syndome) -Toxic Megacolon ```

What are features suggestive of strangulation?

1) Constant pain 2) Fever 3) Peritonitis 4) Shock

What invg would you do for a pt with IO?

1) Bloods: FBC(anemia, leukocytosis), U/E/Cr-(dehydration, electrolytes), GXM (if impending op) 2) Imaging: -AXR: Dilated bowel loops, air-fluid levels, determine site and cause of IO, 3,6,9cm rule)

What is the mgmnt of IO?

1) ABC 2) Drip and Suck - IV Fluids and correct electrolyte abnormalities - NBM - Insert NG tube and allow passive drainage of fluids 3) Urinary Catheter 4) IV antibiotics (Roc+Flagyl)

What are the mgmnt principles of BGIT?

1) Identify shock and resus 2) Identify reversible causes of BGIT and correct 3) Identify physio derangements resulting from blood loss

What are common causes of BGIT?

Upper BGIT: - PUD - Mallory-Weis tear - Esophageal varices - Gastric CA - Dieulafoy lesion LBGIT: - Colorectal CA - Diverticulosis - Hemorrhoids - Torrential UBGIT - Inflammatory bowel disease - Bacterial enteritis(Shigella, Campylobactor) - Ischemic Bowel Disease - Angiodysplasias - Aortoenteric fistula(look for scar of previous AAA surgery) Dont forget COAGULOPATHY

What supportive mgmnt can you offer in BGIT?

1) ABC -Airway maintenance: Consider intubation if the hematemesis is copious. -O2>94% -Vitals signs monitoring including 12 lead ECG -2 peripheral IV lines 2) Invg: Bloods: GXM 2-4 units, FBC(check Hb), U/E/Cr, PT/PTT, LFT(if jaundiced), cardiac enzymes(if ECG changes) 3) Fluid resus 1 L crystalloids as temporary measure and order PCT blood transfx 4) Urinary Catheter 5) IV esomeprazole 80mg bolus and 8mg/h infusion 6) Emergent OGD

How about mgmnt for esophageal varices?

1) DO NOT INSERT NG TUBE 2) IV Somatostatin 250ug bolus followed by IV infusion 250ug/h 3) IV Antibiotics(ceftriaxone) 4) Sengstaken-Blackmore Tube 5) Emergent OGD