Clin - Abdominal Pain Flashcards
top 5 ddx for RUQ pain
1) gallbladder
2) duodenal ulcer
3) hepatitis
4) pancreatitis
5) budd-chiari syndrome
essentials of diagnosis for acute cholecystitis (4)
1) steady, severe pain
2) RUQ or epigastric pain
3) N/V
4) fever and leukocytosis
cause of acute cholecystitis
90% of cases due to gallstones in the cystic duct
10% due to acute illness, fasting, hyperalimentation (artificial supply of nutrients), vasculitis, gallbladder CA
sx of acute cholecystitis
- acute attacks after fatty meals
- RUQ tend
- tea-colored urine and/or acholic stools
- guarding and rebound tend.
lab results acute cholecystitis
- leukocytosis
- bilirubinemia
- elevated AST
- elevated ALP and GGT
- elevated serum amylase
imaging results acute cholecystitis
X-ray: radiopaque gallstones
HIDA scan: obstructed cystic duct
US: wall thickening, sonographic murphy sign, gallstones
complications of acute cholecystitis
1) gangrene of gallbladder (from splanchnic vasoconstriction and intravascular coagulation)
2) emphysematous cholecystitis
essentials of diagnosis for choledocholithiasis (3)
1) biliary pain w/ or w/o jaundice
2) N/V
3) stones in common bile duct
sx choledocholithiasis
1) recurring attacks severe RUQ pain
2) chills and fever
3) jaundice
lab results choledocholithiasis and ascending cholangitis
- striking increase in serum aminotransferase levels
- hyperbilirubinemia
- leukocytosis
- slow rise in alk phos and GGT
- elevated serum amylase
imaging results choledocholithiasis
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
procedure of choice for high suspicion of common bile duct stone (choledocholithiasis)
ERCP w/ sphincterotomy and stone extraction
complication of choledocholithiasis
can lead to acute ascending cholangitis
essentials of diagnosis for ascending cholangitis
fever followed by hypothermia and gram negative shock, jaundice, and leukocytosis
what are charcot triad and reynold pentad and what dz process are they associated with
charcot triad: RUQ pain, fever, and jaundice
reynold pentad: charcot triad, AMS, and hypotension
ascending cholangitis
what organisms are most likely to cause ascending cholangitis
E. coli, klebsiella, enterococcus
what is biliary dyskinesia and what are its sx
symptomatic functional disorder of the gallbladder (not due to stone or infection)
episodes of RUQ pain with nausea that limits activities of daily living
how to diagnose biliary dyskinesia
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
tx biliary dyskinesia
supportive care, low fat diet, cholecystectomy
causes of acute hepatitis
1) viral, bacterial, rickettsial, parasitic
2) drugs
3) ischemia
4) budd-chiari syndrome
5) idiopathic
sx acute hepatitis
- fever, malaise, myalgia, arthralgia, fatigued, anorexia, N/V/D
- maybe acholic stools
- jaundice
- RUQ pain over liver
diagnostic tests for acute hepatitis
- viral serology
- CBC, CMP
- PT/INR
- acetominophen level
tx/management of acute hepatitis
- supportive (some are self limited)
- anti-virals
- stop offending meds
- gastric lavage
- antibiotics
- liver transplant
what defines chronic hepatitis
a group of disorders characterized by a chronic inflammatory reaction in the liver for at least 6 months
sx chronic hepatitis
- fatigue, malaise, anorexia, low grade fever
- jaundice
diagnostic tests for chronic hepatitis
- CBC, CMP, coag studies
- biopsy for histological classification
- serum fibroSure and/or US elastography can look for fibrosis (cirrhosis)
how is chronic hepatitis classified
Grade: histologic assessment of necrosis and inflammatory activity
stage: reflects level of dz progression, based on degree of fibrosis
most frequent cause of chronic pancreatitis
alcoholism
compare manifestations of exocrine and endocrine pancreatic insufficiency
exocrine: malaborption (steatorrhea)
endocrine: DM
sx chronic pancreatitis
- chronic or intermittent epigastric pain (cardinal sx)
- steatorrhea (malabsorption)
- weight loss, anorexia
- N/V/constipation
- flatulence
lab values in chronic pancreatitis
- elevated lipase and amylase
- may have elevated alk phos and bilirubin
- sugar in the urine (glycosuria)
- excess fecal fat
- low B12
- DECREASED FECAL ELASTASE
lab values in autoimmune pancreatitis
elevated IgG4 and ANA
imaging results in chronic pancreatitis
x-ray: calcifications (pancreaticolithiasis in 30% pts)
CT: calcifications, ductal dilation, tumefactive chronic pancreatitis
ERCP: (most sensitive) duct dilation, stones, strictures, pseudocysts
what CT finding in chronic pancreatitis warrants concern for pancreatic CA
tumefactive chronic pancreatitis
mnemonic for classifications of chronic pancreatitis
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)
tx for chronic pancreatitis
- pain control, supportive
- pancreatic enzyme supplementation
- low fat diet, NO ALCOHOL
- NO OPIOIDS
over 80% of pts w/ chronic pancreatitis develop _____ within 25 years
brittle diabetes mellitus
complications of chronic pancreatitis
- DM
- pseudocysts or abscesses
- jaundice
- bile duct stricture
- pancreatic insufficiency
- osteoporosis
- pancreatic CA
what is Budd-Chiari Syndrome
occlusion of flow to the hepatic v. or IVC
factors that predispose pts to Budd-Chiari Syndrome
75% pts: hereditary and acquired hypercoagulable states 50% pts: polycythemia vera Other: - mutation in gene encoding JAK2 - factor 5 leiden
sx Budd-Chiari Syndrome
RUQ pain and tenderness, ascites, hepatosplenomegaly, jaundice
complications of Budd-Chiari Syndrome
- hepatocellular carcinoma
- bleeding varices
- hepatic encephalopathy
- hepatopulmonary syndrome
imaging results in Budd-Chiari Syndrome
- occlusion/absence of flow in hepatic veins or IVC
- prominent caudate liver lobe
Direct Venography: “spider web” patterns of caval webs
screening test of choice in Budd-Chiari Syndrome
contrast enhanced US (CEUS)
- also can do color or pulsed-doppler US
tx Budd-Chiari Syndrome
- symptomatic tx
- anticoag in some cases
- liver transplant in some
top 8 ddx for epigastric pain
1) dissecting/ruptured aortic aneurysm
2) PUD
3) hiatal hernia
4) GERD
5) gastritis
6) esophagitis
7) pancreatitis
8) cholecystitis
describe how the size of an aneurysm affects its risk of rupture
risk of rupture increases with size
5 year risk for aneurysms <5cm –> 1-2%
5 year risk for aneurysms >5cm –> 20-40%
sx non-ruptured abdominal aneurysm
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
sx of ruptured abd aneurysm
acute pain and hypotension –> medical emergency
screening by US for abdominal aneurysms is recommended for what pts
men age 65-75 who have ever smoked
siblings or offspring of people w/ abd aneurysms
describe an aortic dissection and its sx
circumferential tear of intima of aorta often in right lateral wall of ascending aorta
atypical CP, widened mediastinum, vascular abnormalities
top 4 ddx for LUQ pain
1) gastric ulcer
2) gastritis
3) pancreatitis
4) perforated subdiaphragmatic viscus
top 6 ddx for RLQ
1) appendicitis
2) ectopic pregnancy
3) ovarian torsion
4) IBD (CD > UC)
5) Ogilvie syndrome
6) meckel’s diverticulum
etiology of appendicitis
initiated by obstruction of the appendix by a fecalith, inflammation, foreign body, or neoplasm
describe the atypical presentation of appendicitis in retrocecal appendicitis
pain remains less intense and poorly localized, abd tenderness may be in the right flank
describe the atypical presentation of appendicitis in pelvic appendicitis
pain in lower abd on left with urge to urinate or defecate
- no abd tenderness
- tenderness evident on pelvic or rectal exam
describe the atypical presentation of appendicitis in appendicitis in the elderly
diagnosis of sx is often delayed b/c pts present with minimal, vague sx and mild abd tenderness
describe the atypical presentation of appendicitis in appendicitis in pregnancy
may present with pain in RLQ, periumbilical area, or right subcostal area owing to displacement of appendix by uterus
lab and imaging results in appendicitis
- moderate leukocytosis with neutrophilia
- microscopic hematuria and pyruia
- CT and US are helpful
complications of untreated appendicitis
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
causes of ectopic pregnancies
conditions that prevent migration of fertilized ovum to uterus
- hx of infertility
- PID
- ruptured appendix
- prior tubal surgery
sx ectopic pregnancy
SEVERE LOWER QUADRANT PAIN (right or left)
- 6-8 weeks after LNMP
- sudden onset, does not raidate
- backache
- abd distention and paralytic ileus
diagnostic test for ectopic pregnancy
- positive pregnancy test
- no intrauterine pregnancy on US
sx ovarian torsion
sudden-onset, severe, unilateral lower abd pain that may develop after episodes of exertion
- N/V in 70% cases
- maybe fever
diagnosis and tx of ovarian torsion
transvaginal US w/ doppler
surgical emergency
where do the majority of ovarian torsions occur
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
what is Ogilvie Syndrome
spontaneous massive dilation of cecum or right colon without mechanical obstruction
sx Ogilvie Syndrome
- abd distention
- absent bowel movements
- abd tenderness
- normal or decreased bowel sounds
diagnostic tests for Ogilvie Syndrome
x-ray or CT: looking for colonic dilation confined to cecum and proximal colon
(upper limit of normal for cecal size is 9 cm)
tx for Ogilvie Syndrome
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
top 6 ddx for LLQ pain
1) diverticulitis
2) ischemic colitis
3) ectopic pregnancy
4) ovarian torsion
5) IBD (UC > CD)
6) colon CA
sx diverticulitis
LLQ acute abd pain, fever, N/V, constipation
diagnostic tests for diverticulitis
CBC showing leukocytosis
CT w/ CONTRAST
ENDOSCOPY CONTRAINDICATED
tx for diverticulitis in pts:
1) who recover w/ medical therapy in 4-6 weeks
2) inpatient
3) outpatient
4) recurrent cases
1) barium enema or colonoscopy to exclude CA
2) IV fluids, NPO, antibiotics 7-10 days
3) antibiotics, clear liquid diet
4) surgical resection
top 5 ddx for periumbilical abd pain
1) early appendicitis
2) mesenteric artery ischemia
3) ruptured aortic aneurysm
4) bowel obstruction
5) IBD
sx of chronic mesenteric ischemia
“abdominal angina”
- dull, crampy, periumbilical pain 15-30 mins after a meal lasting for several hours
- “food fear”
- weight loss
imaging of choice in chronic mesenteric ischemia
mesenteric arteriography
diagnosis for intestinal obstructions
plain radiographs or CT
tx adhesions
- NG tube decompression and fluid resuscitation
- urgent laparotomy for lysis of adhesions
sx acute small bowel obstruction
N/V, obstipation, distention
- minimal abd tenderness
- decreased or absent bowel sounds (high pitched tinkling bowel sounds)
imaging of choice for SBO
plain abd radiography (KUB/abd series) or CT
tx SBO
nasogastric tube to suction
top 7 ddx for diffuse abd pain
1) IBS
2) mesenteric artery ischemia
3) peritonitis
4) intestinal obstruction
5) IBD
6) toxic megacolon
7) constipation
etiology of primary bacterial peritonitis
most commonly due to cirrhosis (due to alcoholism) and preexisting ascites
common organisms that cause primary bacterial peritonitis
enteric gram (-) bacilli like E. coli
gram (+) like strep, enterococci, and pneumococci
sx primary bacterial peritonitis
acute onset of abd pain or signs of peritoneal irritation
some pts have malaise, fatigue, encephalopathy
80% patients have FEVER
diagnostic test for primary bacterial peritonitis
peritoneal fluid is sampled and contains > 250 PMNs/microliter
etiology of secondary peritonitis
bacteria contaminate the peritoneum as a result of spillage from intraabdominal viscus
common organisms that cause secondary bacterial peritonitis
mixed flow in which gram (-) bacilli and anaerobes predominate
sx secondary bacterial peritonitis
pts lie motionless w/ knees drawn up to avoid stretching the nerve fibers of the peritoneal cavity
coughing or sneezing causes severe, sharp pain
diagnostic test for secondary bacterial peritonitis
radiographic studies to find source of peritoneal contamination or immediate surgical intervention
tx secondary peritonitis
antibiotics
surgical intervention often needed
describe toxic megacolon and its etiology
total or segmental nonobstructive colonic dilatation plus systemic toxicity
complication of UC or C. diff
diagnosis for toxic megacolon
enlarged dilated colon on abd imaging accompanied by severe systemic toxicity
