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PCM3 Final > CIS GI Case 1 > Flashcards

CIS GI Case 1 Flashcards

1
Q

Where do brown pigment stones form in the gallbladder?

A

Tend to form in bile ducts as a result of bacterial infection
May account for 30-90% gallstones in Asian populations

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2
Q

What are the risk factors for gallstones?

A

(Cholesterol stones unless stated otherwise)
Family history, fair, fat, female, fertile, forty
American Indians>Mexican Americans>non-Hispanic whites>African Americans
Obesity
Rapid weight loss (after bariatric surgery)
DM, glucose intolerance, insulin resistance
High intake of carbohydrates
Hypertriglyceridemia
*M>W when they have cirrhosis and hepatitis C
Crohn disease (pigment stones)
Prolonged fasting (5-10 days) -> biliary sludge
Pregnancy
HRT/oral contraceptives

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3
Q

What are protective factors against gallstones?

A

Low carbohydrate diet
Physical activity
Cardiorespiratory fitness
Consumption of caffeinated coffee (in women)
High intake of Mg and polyunsaturated and monounsaturated fats (in men)
High fiber diet and statin therapy
ASA and NSAIDs

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4
Q

What is ascending cholangitis? What are the lab changes and causes?

A

Infection of biliary tract secondary to bile duct obstruction or bile stasis

Lab changes: hyperbilirubinemia, leukocytosis, transaminitis, alkaline phosphatase elevation

Causes: choledolithiasis, pancreatic/biliary neoplasm, postoperative strictures, choledocal cysts

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5
Q

What are the organisms involved in ascending cholangitis?

A

Colonic-ascend from duodenum

Gram-negative (most common to less): E. Coli, Klebsiella pneumoniae, enterobacter

Gram-positive: enterococcus species (10-20%)

Anaerobes: Bacteroides fragility and clostridia as part of mixed infection

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6
Q

What is Charcot’s triad?

A

Jaundice
Fever (>102F)
RUQ pain

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7
Q

What is Reynold’s Pentax?

A

Charcot’s Triad
Mental status changes
Hypotension

Associated with significant morbidity and mortality

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8
Q

What is the treatment of ascending cholangitis?

A 
Urgent ERCP (within 12-24 hours)
-Sphincterotomy (cut sphincter of Oddi slightly) with stone removal or stent placement

Antibiotics geared toward colonic bacteria (aerobes and anaerobes)

Supportive care like IVF (treating sepsis and shock)

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9
Q

Describe first choice empiric antibiotic therapy for gram-negative and anaerobic pathogens

A

Monotherapy with beta-lactate/beta-lactamase inhibitor:
Ampicillin-sulbatum (3g IV q6h)
Piperacillin-tazobactam (3.375 or 4.5g IV q6h)
Ticarcillin-clavulante (3.1g IV q4h)

Combination third generation cephalosporin PLUS metronidazole
Ceftriaxone (1g IV q24h or 2g IV q12h for CNS infections)
PLUS metronidazole (500 mg IV q8h)

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10
Q

Describe alternative empiric regimens for gram-negative and anaerobic pathogens

A

Combination fluoroquinolone plus metronidazole
Ciprofloxacin (400 mg IV q12h) OR levofloxacin (500 or 750 mg IV once daily)
PLUS metronidazole (500 mg IV q8h)

Monotherapy with carbapenem
Imipenem-cilastatin (500 mg IV q6h)
Meropenem (1g IV q8h)
Doripenem (500 mg IV q8h)
Etrapenem (1g IV once daily)
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11
Q

What labs should be ordered?

A

AST/ALT, alk phos, fractionated bilirubin, amylase/lipase (pancreatitis from choledocholithiasis vs post-ERCP pancreatitis)
Pre-procedure INR
Follow up on blood cultures and bile cultures that were ordered and are pending

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12
Q

What are some possible complications status post (s/p) ERCP?

A

Pancreatitis
Ascending cholangitis
Less commonly: hemophilia, perforation, bile leaks

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13
Q

What is Mirizzi syndrome?

A

Common hepatic duct obstruction caused by extrinsic compression from impacted stone in cystic duct
May be presence of a cholecystoenteric fistula because when stone is impacted in the cystic duct, it can result in narrowing of common hepatic duct, which can lead to cholecystenteric fistula, thus providing exit route for gallstones

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14
Q

Describe basics of TNF alpha inhibitors

A

Treatment of inflammatory conditions like RA and IBD
Targeted strategy and quality of life improving for many of pts.
Annual screening: PPD, hepatitis panel, dermatology exam, continue follow up with GI or rheum
Lab screening: CBC with differential, CMP every 2 months
They are injected or infused. Injection/infusion site reaction possible

Other possible side effects

  • Infections: bacterial (particularly pneumonia, cutaneous possible), zoster, tuberculosis, opportunistic infections
  • Cutaneous reactions: dermatological conditions (psoriasis, eczema, SLE, lichen planes)
  • malignancy (lymphoma and skin cancer)
  • induction of autoimmunity
  • -autoimmune hepatitis
  • -drug-induced SLE
  • -psoriatic skin lesions
  • -inflammatory eye disease
  • -interstitial lung disease
  • -multiple sclerosis
  • -sarcoidosis
  • -dermatomyositis (DM)/polymyositis (PM)
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15
Q

Describe diaphragmatic excursion

A

Determine distance between level of dullness on full expiration and level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm)

Normal excursion = 3-5.5 cm

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16
Q

Describe transmitted voice sound tests: bronchophony, egophony, whispered pectoriloquy

A

If abnormally located bronchovesicular or bronchial breath sounds are heard (pneumonia, consolidations, effusions), assess transmitted voice sounds

Pt says “99”
Normally, sounds transmitted through healthy lungs are muffled and indistinct (can also palpate for tactile fremitus while pt is speaking)
Bronchophony: spoken words become louder and clearer

Pt says “ee”
Normally, hear muffled long E sound
Egophony: “ee” sounds like “A.” “A” has nasal bleating quality and should be localized
Note: in pts with fever and cough, presence of bronchial breath sounds and egophony more than triples likelihood of pneumonia

Pt whispers “99” or “1,2,3”
Normally, whispered voice is faint and indistinct or not heard at all
Whispered pectoriloquy: whispers are heard louder and clearer during auscultation

17
Q

Describe Grey Turner sign, Cullen sign, Rebound tenderness, guarding, and rigidity

A

Grey Turner Sign: flank ecchymosis secondary to hemorrhage

Cullen sign: ecchymosis around umbilicus (periumbilical) secondary to hemorrhage

Rebound tenderness: pain upon removal of pressure, rather than application of pressure to abdomen
Tests for peritoneal inflammation

Guarding: voluntary versus involuntary

Rigidity: Abdomen is hard, involuntary reflex

18
Q

Describe Rovsing’s sign, McBurney’s point, Murphy sign, and Courvoisier’s sign

A

Rovsing’s sign: pain in RLQ during left-sided pressure
Referred rebound tenderness seen in appendicitis

McBurney’s point: rebound tenderness or pain 1/3 distance from ASIS to umbilicus
May suggest appendicitis/peritoneal irritation

Murphy Sign: palpate deeply under right costal margin during inspiration and observe for pain and/or sudden stop in inspiratory effort
Tests for acute cholecystitis or cholelithiasis

Courvoisier’s sign: enlarged non-tender gallbladder secondary to pancreatic disease or cancer

19
Q

Describe the OS levels in the GI system:

Sympathetic: esophagus, stomach, liver, gallbladder, small intestine, colon, pancreas, appendix

Parasympathetic: upper portion and lower portion

A 
Sympathetic:
Esophagus: T2-8
Stomach: T5-9
Liver: T6-9
Gallbladder: T6-9
Small intestine: T9-11
Colon: T10-L2
Pancreas: T5-11
Appendix: T12
Parasympathetic:
Upper portion (esophagus through transverse colon): OA, AA (vagus n)
Lower portion (descending colon, sigmoid, rectum): S2-S4 (pelvic splanchnic n)
20
Q

Describe special tests involved in GI exam: iliopsoas muscle test, obturator muscle test, Lloyd punch/kidney punch/costovertebral angle (CVA) tenderness, heel strike

A

Iliopsoas muscle test: Pt flexes hip against doc resistance
Positive: increased abdominal pain
Suggests irritation of psoas muscle from inflammation of appendix

Obturator muscle test: flex pt’s right thigh at hip with knee bent and rotate leg internally at hip
Positive: right hypogastric pain
Suggests irritation of obturator muscle from inflamed appendix

Lloyd punch/Kidney punch/CVA tenderness: gently tapping area of back overlying kidney (CVA) produces pain
Suggests infection around kidney (perinephric abscess) or pyelonephritis or renal stone

Heel strike: pt supine. Doc strikes pt’s heel
Pain upon striking could indicate appendicitis

21
Q

When do you suspect choledocholithiasis on ultrasound?

A

When common bile duct is >6 mm

Normal in non-elderly with intact gallbladder: 3-6 mm
Elderly or post cholecystectomy: up to 10 mm

22
Q

What do you have to consider when giving biliary pt opioids?

A

NSAIDs are preferred, but opioids can be given if NSAIDs are contraindicated or pain is uncontrolled

All opioids increase sphincter of Oddi pressure, so clinical concern is it would worsen underlying problem and more pain

  • Morphine in particular was historically avoided because of this.
  • insufficient data to suggest morphine (opioids) should be avoided

Opioids slow digestive tract as well, causing possible ileus and constipation

23
Q

What is systemic inflammatory response syndrome (SIRS)?

A

Response is manifested by 2 or more of the following conditions:
Temperature >38C (100.4F) or <36C (96.8F)
Heart rate >90 beats/min
Respiration rate >20 breaths/minute or PaCO2 <32 mm HG
White blood cell count > 12,000/uL, <4000/uL, or >10% immature (band) forms

24
Q

Describe sepsis, severe sepsis, and septic shock

A

Sepsis: systemic response to infection defined by 2 or more SIRS criteria as result of infection

Severe sepsis: sepsis associated with organ dysfunction, hypoperfusion, or hypotension

Septic shock: sepsis-induced hypotension despite adequate fluid resuscitation along with presence of perfusion abnormalities

25
Q

What is multiple organ dysfunction syndrome (MODS)?

A

Presence of altered organ dysfunction in acutely ill pt

26
Q

What are RLQ pain differentials?

A 
Ascending cholangitis
Choledocholithiasis
Cholecystitis (calculous/acalculous)
Adhesions/fistula
Biliary dyskinesia
Pregnancy/ectopic pregnancy
Primary sclerosing cholangitis (men with UC)
Duodenal ulcer/gastric ulcer
Hepatitis: multiple causes, viral or autoimmune, hepatotoxicity from Humira (adalimummab) among the top
Retrocecal appendicitis
Right-sided diverticulitis
PID: Fitz Hugh Curtis
Pneumonia
MSK
Right-sided colon cancer

PCM3 Final (5 decks)

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