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Maddy - GI II Exam I - some pharm > Clin - Abdominal Pain > Flashcards

Clin - Abdominal Pain Flashcards

1
Q

top 5 ddx for RUQ pain

A

1) gallbladder
2) duodenal ulcer
3) hepatitis
4) pancreatitis
5) budd-chiari syndrome

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2
Q

essentials of diagnosis for acute cholecystitis (4)

A

1) steady, severe pain
2) RUQ or epigastric pain
3) N/V
4) fever and leukocytosis

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3
Q

cause of acute cholecystitis

A

90% of cases due to gallstones in the cystic duct

10% due to acute illness, fasting, hyperalimentation (artificial supply of nutrients), vasculitis, gallbladder CA

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4
Q

sx of acute cholecystitis

A
  • acute attacks after fatty meals
  • RUQ tend
  • tea-colored urine and/or acholic stools
  • guarding and rebound tend.
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5
Q

lab results acute cholecystitis

A
  • leukocytosis
  • bilirubinemia
  • elevated AST
  • elevated ALP and GGT
  • elevated serum amylase
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6
Q

imaging results acute cholecystitis

A

X-ray: radiopaque gallstones

HIDA scan: obstructed cystic duct

US: wall thickening, sonographic murphy sign, gallstones

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7
Q

complications of acute cholecystitis

A

1) gangrene of gallbladder (from splanchnic vasoconstriction and intravascular coagulation)
2) emphysematous cholecystitis

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8
Q

essentials of diagnosis for choledocholithiasis (3)

A

1) biliary pain w/ or w/o jaundice
2) N/V
3) stones in common bile duct

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9
Q

sx choledocholithiasis

A

1) recurring attacks severe RUQ pain
2) chills and fever
3) jaundice

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10
Q

lab results choledocholithiasis and ascending cholangitis

A
  • striking increase in serum aminotransferase levels
  • hyperbilirubinemia
  • leukocytosis
  • slow rise in alk phos and GGT
  • elevated serum amylase
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11
Q

imaging results choledocholithiasis

A

ERCP: most direct and accurate, tells you cause, location, and extent of obstruction

US and CT: dilated bile ducts

Radionuclide: impaired bile flow

helical CT, MRI: bile duct stones

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12
Q

procedure of choice for high suspicion of common bile duct stone (choledocholithiasis)

A

ERCP w/ sphincterotomy and stone extraction

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13
Q

complication of choledocholithiasis

A

can lead to acute ascending cholangitis

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14
Q

essentials of diagnosis for ascending cholangitis

A

fever followed by hypothermia and gram negative shock, jaundice, and leukocytosis

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15
Q

what are charcot triad and reynold pentad and what dz process are they associated with

A

charcot triad: RUQ pain, fever, and jaundice

reynold pentad: charcot triad, AMS, and hypotension

ascending cholangitis

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16
Q

what organisms are most likely to cause ascending cholangitis

A

E. coli, klebsiella, enterococcus

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17
Q

what is biliary dyskinesia and what are its sx

A

symptomatic functional disorder of the gallbladder (not due to stone or infection)

episodes of RUQ pain with nausea that limits activities of daily living

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18
Q

how to diagnose biliary dyskinesia

A

ROME III diagnostic criteria

also association of pain w/ nausea and vomiting, radiation of pain to infrascapular region, pain what wakes pt up in the night

labs and imaging will be normal

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19
Q

tx biliary dyskinesia

A

supportive care, low fat diet, cholecystectomy

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20
Q

causes of acute hepatitis

A

1) viral, bacterial, rickettsial, parasitic
2) drugs
3) ischemia
4) budd-chiari syndrome
5) idiopathic

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21
Q

sx acute hepatitis

A
  • fever, malaise, myalgia, arthralgia, fatigued, anorexia, N/V/D
  • maybe acholic stools
  • jaundice
  • RUQ pain over liver
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22
Q

diagnostic tests for acute hepatitis

A
  • viral serology
  • CBC, CMP
  • PT/INR
  • acetominophen level
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23
Q

tx/management of acute hepatitis

A
  • supportive (some are self limited)
  • anti-virals
  • stop offending meds
  • gastric lavage
  • antibiotics
  • liver transplant
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24
Q

what defines chronic hepatitis

A

a group of disorders characterized by a chronic inflammatory reaction in the liver for at least 6 months

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25
Q

sx chronic hepatitis

A
  • fatigue, malaise, anorexia, low grade fever

- jaundice

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26
Q

diagnostic tests for chronic hepatitis

A
  • CBC, CMP, coag studies
  • biopsy for histological classification
  • serum fibroSure and/or US elastography can look for fibrosis (cirrhosis)
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27
Q

how is chronic hepatitis classified

A

Grade: histologic assessment of necrosis and inflammatory activity

stage: reflects level of dz progression, based on degree of fibrosis

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28
Q

most frequent cause of chronic pancreatitis

A

alcoholism

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29
Q

compare manifestations of exocrine and endocrine pancreatic insufficiency

A

exocrine: malaborption (steatorrhea)
endocrine: DM

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30
Q

sx chronic pancreatitis

A
  • chronic or intermittent epigastric pain (cardinal sx)
  • steatorrhea (malabsorption)
  • weight loss, anorexia
  • N/V/constipation
  • flatulence
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31
Q

lab values in chronic pancreatitis

A
  • elevated lipase and amylase
  • may have elevated alk phos and bilirubin
  • sugar in the urine (glycosuria)
  • excess fecal fat
  • low B12
  • DECREASED FECAL ELASTASE
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32
Q

lab values in autoimmune pancreatitis

A

elevated IgG4 and ANA

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33
Q

imaging results in chronic pancreatitis

A

x-ray: calcifications (pancreaticolithiasis in 30% pts)

CT: calcifications, ductal dilation, tumefactive chronic pancreatitis

ERCP: (most sensitive) duct dilation, stones, strictures, pseudocysts

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34
Q

what CT finding in chronic pancreatitis warrants concern for pancreatic CA

A

tumefactive chronic pancreatitis

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35
Q

mnemonic for classifications of chronic pancreatitis

A

T: toxic-metabolic (alcoholism)

I: idiopathic (smoking is risk factor)

G: genetic (CFTR, SPINK1, PRSS2, PSTI)

A: autoimmune (Celiac dz, Hypergammaglobuminemia - IgG4)

R: recurrent (in 36% pts w/ acute pancreatitis)

O: obstructive (strictures, stone, tumor)

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36
Q

tx for chronic pancreatitis

A
  • pain control, supportive
  • pancreatic enzyme supplementation
  • low fat diet, NO ALCOHOL
  • NO OPIOIDS
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37
Q

over 80% of pts w/ chronic pancreatitis develop _____ within 25 years

A

brittle diabetes mellitus

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38
Q

complications of chronic pancreatitis

A
  • DM
  • pseudocysts or abscesses
  • jaundice
  • bile duct stricture
  • pancreatic insufficiency
  • osteoporosis
  • pancreatic CA
39
Q

what is Budd-Chiari Syndrome

A

occlusion of flow to the hepatic v. or IVC

40
Q

factors that predispose pts to Budd-Chiari Syndrome

A 
75% pts: hereditary and acquired hypercoagulable states
50% pts: polycythemia vera
Other: 
- mutation in gene encoding JAK2 
- factor 5 leiden
41
Q

sx Budd-Chiari Syndrome

A

RUQ pain and tenderness, ascites, hepatosplenomegaly, jaundice

42
Q

complications of Budd-Chiari Syndrome

A
  • hepatocellular carcinoma
  • bleeding varices
  • hepatic encephalopathy
  • hepatopulmonary syndrome
43
Q

imaging results in Budd-Chiari Syndrome

A
  • occlusion/absence of flow in hepatic veins or IVC
  • prominent caudate liver lobe

Direct Venography: “spider web” patterns of caval webs

44
Q

screening test of choice in Budd-Chiari Syndrome

A

contrast enhanced US (CEUS)

  • also can do color or pulsed-doppler US
45
Q

tx Budd-Chiari Syndrome

A
  • symptomatic tx
  • anticoag in some cases
  • liver transplant in some
46
Q

top 8 ddx for epigastric pain

A

1) dissecting/ruptured aortic aneurysm
2) PUD
3) hiatal hernia
4) GERD
5) gastritis
6) esophagitis
7) pancreatitis
8) cholecystitis

47
Q

describe how the size of an aneurysm affects its risk of rupture

A

risk of rupture increases with size

5 year risk for aneurysms <5cm –> 1-2%

5 year risk for aneurysms >5cm –> 20-40%

48
Q

sx non-ruptured abdominal aneurysm

A

commonly produces no sx and is usually detected on routine examination as a palpable, pulsatile, expansive, nontender mass
- can expand and cause pain in chest, lower back, scrotum

49
Q

sx of ruptured abd aneurysm

A

acute pain and hypotension –> medical emergency

50
Q

screening by US for abdominal aneurysms is recommended for what pts

A

men age 65-75 who have ever smoked

siblings or offspring of people w/ abd aneurysms

51
Q

describe an aortic dissection and its sx

A

circumferential tear of intima of aorta often in right lateral wall of ascending aorta

atypical CP, widened mediastinum, vascular abnormalities

52
Q

top 4 ddx for LUQ pain

A

1) gastric ulcer
2) gastritis
3) pancreatitis
4) perforated subdiaphragmatic viscus

53
Q

top 6 ddx for RLQ

A

1) appendicitis
2) ectopic pregnancy
3) ovarian torsion
4) IBD (CD > UC)
5) Ogilvie syndrome
6) meckel’s diverticulum

54
Q

etiology of appendicitis

A

initiated by obstruction of the appendix by a fecalith, inflammation, foreign body, or neoplasm

55
Q

describe the atypical presentation of appendicitis in retrocecal appendicitis

A

pain remains less intense and poorly localized, abd tenderness may be in the right flank

56
Q

describe the atypical presentation of appendicitis in pelvic appendicitis

A

pain in lower abd on left with urge to urinate or defecate

  • no abd tenderness
  • tenderness evident on pelvic or rectal exam
57
Q

describe the atypical presentation of appendicitis in appendicitis in the elderly

A

diagnosis of sx is often delayed b/c pts present with minimal, vague sx and mild abd tenderness

58
Q

describe the atypical presentation of appendicitis in appendicitis in pregnancy

A

may present with pain in RLQ, periumbilical area, or right subcostal area owing to displacement of appendix by uterus

59
Q

lab and imaging results in appendicitis

A
  • moderate leukocytosis with neutrophilia
  • microscopic hematuria and pyruia
  • CT and US are helpful
60
Q

complications of untreated appendicitis

A

gangrene and perforation develop within 36 hours and can cause abscesses

can also cause septic thrombophlebitis of portal vein system w/ high fever, chills, bacteremia, jaundice

61
Q

causes of ectopic pregnancies

A

conditions that prevent migration of fertilized ovum to uterus

  • hx of infertility
  • PID
  • ruptured appendix
  • prior tubal surgery
62
Q

sx ectopic pregnancy

A

SEVERE LOWER QUADRANT PAIN (right or left)

  • 6-8 weeks after LNMP
  • sudden onset, does not raidate
  • backache
  • abd distention and paralytic ileus
63
Q

diagnostic test for ectopic pregnancy

A
  • positive pregnancy test

- no intrauterine pregnancy on US

64
Q

sx ovarian torsion

A

sudden-onset, severe, unilateral lower abd pain that may develop after episodes of exertion

  • N/V in 70% cases
  • maybe fever
65
Q

diagnosis and tx of ovarian torsion

A

transvaginal US w/ doppler

surgical emergency

66
Q

where do the majority of ovarian torsions occur

A

on the right side due to increased length of utero-ovarian ligament on the right and the sigmoid on the left, limiting space for movement

67
Q

what is Ogilvie Syndrome

A

spontaneous massive dilation of cecum or right colon without mechanical obstruction

68
Q

sx Ogilvie Syndrome

A
  • abd distention
  • absent bowel movements
  • abd tenderness
  • normal or decreased bowel sounds
69
Q

diagnostic tests for Ogilvie Syndrome

A

x-ray or CT: looking for colonic dilation confined to cecum and proximal colon
(upper limit of normal for cecal size is 9 cm)

70
Q

tx for Ogilvie Syndrome

A

first step approach: conservative tx

place NG tube and rectal tube

discontinue any drugs that reduce intestinal mobility, such as opioids, anticholinergics, and CCBs

assess cecal size via radiograph every 12 hours

71
Q

top 6 ddx for LLQ pain

A

1) diverticulitis
2) ischemic colitis
3) ectopic pregnancy
4) ovarian torsion
5) IBD (UC > CD)
6) colon CA

72
Q

sx diverticulitis

A

LLQ acute abd pain, fever, N/V, constipation

73
Q

diagnostic tests for diverticulitis

A

CBC showing leukocytosis

CT w/ CONTRAST

ENDOSCOPY CONTRAINDICATED

74
Q

tx for diverticulitis in pts:

1) who recover w/ medical therapy in 4-6 weeks
2) inpatient
3) outpatient
4) recurrent cases

A

1) barium enema or colonoscopy to exclude CA
2) IV fluids, NPO, antibiotics 7-10 days
3) antibiotics, clear liquid diet
4) surgical resection

75
Q

top 5 ddx for periumbilical abd pain

A

1) early appendicitis
2) mesenteric artery ischemia
3) ruptured aortic aneurysm
4) bowel obstruction
5) IBD

76
Q

sx of chronic mesenteric ischemia

A

“abdominal angina”

  • dull, crampy, periumbilical pain 15-30 mins after a meal lasting for several hours
  • “food fear”
  • weight loss
77
Q

imaging of choice in chronic mesenteric ischemia

A

mesenteric arteriography

78
Q

diagnosis for intestinal obstructions

A

plain radiographs or CT

79
Q

tx adhesions

A
  • NG tube decompression and fluid resuscitation

- urgent laparotomy for lysis of adhesions

80
Q

sx acute small bowel obstruction

A

N/V, obstipation, distention

  • minimal abd tenderness
  • decreased or absent bowel sounds (high pitched tinkling bowel sounds)
81
Q

imaging of choice for SBO

A

plain abd radiography (KUB/abd series) or CT

82
Q

tx SBO

A

nasogastric tube to suction

83
Q

top 7 ddx for diffuse abd pain

A

1) IBS
2) mesenteric artery ischemia
3) peritonitis
4) intestinal obstruction
5) IBD
6) toxic megacolon
7) constipation

84
Q

etiology of primary bacterial peritonitis

A

most commonly due to cirrhosis (due to alcoholism) and preexisting ascites

85
Q

common organisms that cause primary bacterial peritonitis

A

enteric gram (-) bacilli like E. coli

gram (+) like strep, enterococci, and pneumococci

86
Q

sx primary bacterial peritonitis

A

acute onset of abd pain or signs of peritoneal irritation

some pts have malaise, fatigue, encephalopathy

80% patients have FEVER

87
Q

diagnostic test for primary bacterial peritonitis

A

peritoneal fluid is sampled and contains > 250 PMNs/microliter

88
Q

etiology of secondary peritonitis

A

bacteria contaminate the peritoneum as a result of spillage from intraabdominal viscus

89
Q

common organisms that cause secondary bacterial peritonitis

A

mixed flow in which gram (-) bacilli and anaerobes predominate

90
Q

sx secondary bacterial peritonitis

A

pts lie motionless w/ knees drawn up to avoid stretching the nerve fibers of the peritoneal cavity

coughing or sneezing causes severe, sharp pain

91
Q

diagnostic test for secondary bacterial peritonitis

A

radiographic studies to find source of peritoneal contamination or immediate surgical intervention

92
Q

tx secondary peritonitis

A

antibiotics

surgical intervention often needed

93
Q

describe toxic megacolon and its etiology

A

total or segmental nonobstructive colonic dilatation plus systemic toxicity

complication of UC or C. diff

94
Q

diagnosis for toxic megacolon

A

enlarged dilated colon on abd imaging accompanied by severe systemic toxicity

Maddy - GI II Exam I - some pharm (23 decks)

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