Clinical Correlations Flashcards
Which sx are red flags that will require further elucidation and work up?
Dysphagia, odynophagia, hematemesis, melena, unintentional weight loss, persistent vomiting, constant/severe pain, unexplained iron deficiency anemia, palpable mass, lymphadenopathy, FHx of upper GI cancer
What can cause abdominal pain the RUQ?
Cholecystitis, hepatitis, pneumonia, kidney stones
Gallbladder*
Which conditions can cause pain in the epigastric region?
Pancreatitis, PUD/GERD
What can cause pain in the LUQ?
Gastritis, PUD
What can cause pain the RLQ?
Appendicitis
What can cause pain in the LLQ?
Diverticulitis
What is visceral pain?
Caused by stimulation of the visceral pain fibers
Secondary to distention, stretching or contracting of hollow organs, stretching the capsule of solid organs or organ ischemia
Not localized
What is parietal (somatic) pain?
Caused by stimulation of the somatic pain fibers
Secondary to inflammation in the parietal peritoneum
Localized
Aggravated by movement/coughing and alleviated by remaining still
What to ask when someone has nausea and vomiting?
Appearance? Blood? Coffee grounds? Food? Feculent?
How often? Projectile?
What is oropharyngeal dysphagia?
Trouble initiating swallowing
Associated with neurological, metabolic, structural disorders or infections
What are the two types of esophageal dysphagia?
Due to mechanical obstruction or motility disorder
What questions are important to ask with esophageal dysphagia?
Solids, liquids or both?
Progressive or not?
Constant vs intermittent?
Which labs are used for GI/abdominal work up?
CBC, comprehensive metabolic panel (chem 12), basic metabolic panel (chem 7), urinalysis, pregnancy test
Others: lipase/amylase, Pt/Ptt (liver failure), fractionated bilirubin
What is in a CBC with diff?
Percentage and absolute differential counts of specific cell types (PMN, lymph, basophils, eosinophils, monocytes)
Diff = percentages
Regular = counts
What is tested in a basic metabolic panel?
Na, K, Cl, CO2 (bicarb), BUN, creatinine, glucose
What is tested in a comprehensive metabolic panel?
Albumin:globulin ratio (A:G), albumin, alkaline phosphatase, AST, ALT, total bilirubin, total globulin, total protein
What are examples of plain films of the abdomen?
Acute abdominal series and KUB
What is an acute abdominal series?
Single view chest XR and a flat upright XR of the abdomen
Good for initial screening but not good for diagnostic
What is a KUB?
Single flat plate (supine) XR of the abdomen
Limited diagnostic benefit
What is a barium esophpgraphy (barium swallow)?
Differentiate b/w mechanical lesions and motility disorders
More sensitive for detecting subtle esophageal narrowing due to rings, achalasia, and proximal esophageal lesions
What is an upper endoscopy (EGD)>
Study of choice for imaging of upper GI tract like heartburn, dysphagia, structural abnormalities
Diagnostic and therapeutic - direct visualization, allows biopsy of mucosal abnormalities or normal appearing mucosa, and allows for dilation of strictures
What are colonoscopies used for?
Screening test, lower GI bleeds, undifferentiated LAP
What are ultrasounds used for?
Good for imaging fluid filled structures like gallbladder, fast scan for trauma, bladder, kidneys, aorta and vessels, heart
Limited by air and fat
What is an endoscopic retrograde cholangiopancreatography (ERCP)?
Invasive way to visualize the hepatobiliary and pancreatic ducts
Can provide intervention: diagnostic and therapeutic techniques
What is MRCP used for?
Diagnosing gall stones
What is HIDA (hepatobiliary iminodiacetic acid scan)?
Nuclear scan that tests for dysfunctional gall bladder
HIDA + CCK -> check gall bladder ejection fraction, if low then biliary dyskinesia
Which imagining technique will give you the most information about abdominal pathology?
CT scan
How are GERD, gastritis and PUD similar?
Similar pathophysiology, diagnostic work up and tx
Describe GERD
Very common in the western world
Classic sx: heartburn (pyrosis) and regurgitation/reflux
Diagnosis can often be based on clinical sx alone in pts with classical sx such as heartburn and regurgitation
Can perform an upper endoscopy
How is GERD treated?
Lifestyle modification (weight loss if obese, elevate head of bed, eliminate triggers, avoid alcohol and smoking) Antacids, surface agents, H2 blockers, proton pump inhibitors
Describe peptic ulcer disease
Very common
Two major risk factors: H pylori and NSAIDs
Sx: upper abdominal pain, primarily epigastric but can also be in RUQ and LUQ, may be present initially as GI bleed or perforation
Most common cause of UGI bleed
Describe a gastric ulcer
Located typically in the lesser curvature of the antrum of the stomach
Sx: sharp and burning epigastric pain, worsens wihtin 30mins-1.5hour after eating
Tx: proton pump inhibitor, eradicate H pylori
Describe duodenal ulcers
Located in the proximal duodenum; multiple ulcers or ulcers distal to 2nd portion of duodenum
Sx: gnawing epigastric pain; worsens 3-5 hours after eating; may be temporarily relieved by food/eating
Tx: proton pump inhibitor, eradicate H pylori
Describe H pylori
Most prevalent chronic bacterial disease known
Associated with many types of GI pathology including PUD, chronic gastritis, gastric adenocarcinoma, gastric mucosa, associated lymphoid tissue (MALT) lymphoma, and duodenal ulcers*
Describe the pathophysiology of H pylori
Bacterial urease hydrolyzes gastric luminal area to form ammonia that helps neutralize gastric acid and form a protective cloud around the organism enabling it to penetrate the gastric mucous layer
What are some diagnostic tests for H pylori?
Urea breath test (great first line and generally used to confirm eradication of H pylori)
Fecal antigen test (first line; confirms eradication)
Have pt stop proton pump inhibitor medication 14 days before fecal and breath tests or high chance of a false negative test
What is 90% of the time secondary to UGIB?
Melena (black tarry stools)
Hematochezia is usually due to what?
Lower GI bleed
Red blood in stool
What is an UGIB?
Any GI bleed originating proximal to ligament of Treitz
Esophagus, stomach or duodenum
(Can be caused by PUD)
What is a LGIB?
Any GI bleed originating distal to the ligament of Treitz
Jejunum, ileum, colon, rectum
What is strongly associated with a number of causes of GI bleeding?
Alcohol abuse
What are the 3 options for presentation of gall stones (cholelithiasis/cholecystitis)?
Asymptomatic (most often)
Classic presentation = biliary colic (episodic to constant RUQ pain, worse after eating greasy foods)
Complications of gallstone disease (ex. pancreatitis)
Describe pancreatitis
Pathophysiology: inflammatory condition of the pancreas
Risk factors include gallstones, alcohol abuse, hypertriglyceridema, multiple others
What is the classic presentation for appendicitis?
RLQ abdominal pain, anorexia, nausea/vomiting, +/- fever
Usually starts with visceral pain (vague nonspecific)
The pain migrates and becomes localized in the RLQ and ends with somatic pain (sharp and localized) in the RLQ
What is the diagnostic work up for appendicitis?
CBC, comprehensive metabolic panel, UA, pregnancy test
Imaging on case by case basis
Describe diverticulitis/diverticulosis
Diverticulosis: prevalence is age dependent (age 60) (presence of diverticulum)
Diverticulitis: develops after diverticulosis (erosion of diverticular wall)
Abdominal pain which Localizes to the LLQ, nausea/vomiting, +/- fever
Describe achalasia (BP)*
Uncommon
Results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall, leads to failure of relaxation of the lower esophageal sphincter accompanied by a loss of peristalsis in the distal esophagus
Primary or secondary achalasia
Describe primary achalasia
Loss of NO producing inhibitory neurons in the myenteric plexus
Progressive dysphagia for solids and foods; regurgitation of undigested food
Birds beak with barium swallow study
Esophageal manometry confirms diagnosis (complete absence of normal peristalsis and incomplete lower esophageal sphincter (ES) relaxation (and LES stays closed) with swallowing)
What is Chagas’ disease (secondary achalasia)?*
Esophageal dysfunction indistinguishable from primary achalasia
Caused by the parasite Trypansoma Cruzi (protozoan disease)
Causes other systemic sx (causes swelling of the site/chagoma and a romana sign)
Describe Zollinger-Ellison syndrome (ZES)**
Very uncommon
Caused by secretion of gastrin by duodenal or pancreatic NE tumors (gastrinomas)
Consider when intractable ulcer/recurrent ulcer disease/severe ulcer disease, ulcers in atypical locations, ulcer associated with diarrhea, steatorrhea, weight loss, nausea/vomiting
Elevated fasting gastrin level and positive secretin stimulation test
Describe the parasympathetic levels of viscerosomatics
Upper portion: esophagus through transverse colon (OA, AA, vagus N)
Lower portion: descending colon, sigmoid rectum (S2-4 (pelvic Splanchnic N))
Describe the sympathetic levels of viscerosomatics
Appendix T12 Esophagus T2-8 Stomach T5-9 Liver T6-9 Gallbladder T6-9 SI T5-9; T9-12 Colon T9-L2 Pancreas T5-11
