CIS GI Case 1 Flashcards
Where do brown pigment stones form in the gallbladder?
Tend to form in bile ducts as a result of bacterial infection
May account for 30-90% gallstones in Asian populations
What are the risk factors for gallstones?
(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
What are protective factors against gallstones?
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
What is ascending cholangitis? What are the lab changes and causes?
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
What are the organisms involved in ascending cholangitis?
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
What is Charcot’s triad?
Jaundice
Fever (>102F)
RUQ pain
What is Reynold’s Pentax?
Charcot’s Triad
Mental status changes
Hypotension
Associated with significant morbidity and mortality
What is the treatment of ascending cholangitis?
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)
Describe first choice empiric antibiotic therapy for gram-negative and anaerobic pathogens
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)
Describe alternative empiric regimens for gram-negative and anaerobic pathogens
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)
What labs should be ordered?
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
What are some possible complications status post (s/p) ERCP?
Pancreatitis
Ascending cholangitis
Less commonly: hemophilia, perforation, bile leaks
What is Mirizzi syndrome?
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
Describe basics of TNF alpha inhibitors
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)
Describe diaphragmatic excursion
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
Describe transmitted voice sound tests: bronchophony, egophony, whispered pectoriloquy
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
Describe Grey Turner sign, Cullen sign, Rebound tenderness, guarding, and rigidity
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
Describe Rovsing’s sign, McBurney’s point, Murphy sign, and Courvoisier’s sign
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
Describe the OS levels in the GI system:
Sympathetic: esophagus, stomach, liver, gallbladder, small intestine, colon, pancreas, appendix
Parasympathetic: upper portion and lower portion
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)
Describe special tests involved in GI exam: iliopsoas muscle test, obturator muscle test, Lloyd punch/kidney punch/costovertebral angle (CVA) tenderness, heel strike
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
When do you suspect choledocholithiasis on ultrasound?
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
What do you have to consider when giving biliary pt opioids?
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
What is systemic inflammatory response syndrome (SIRS)?
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
Describe sepsis, severe sepsis, and septic shock
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
What is multiple organ dysfunction syndrome (MODS)?
Presence of altered organ dysfunction in acutely ill pt
What are RLQ pain differentials?
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
