DSA 5: Abd Pain, Fatigue, Wt. Loss Flashcards
What is the Tx/management of diverticlitis
in pt recover w/ medical therapy - perform barium enema or colonoscopy in 4-6 wks to exclude CA
empiric therapy - inpatient: IV fluids, NPO clear liquids then low residue diet; ABx 7-10 days
outpatient: ABx, clear liquid diet –> low residue diet
SRG resection - refractory/recurrent cases
What is intestinal obstruction?
Sxs, Dx, Tx?
MCC: peritoneal adhesions- laparotomy, intra-abd infxn, ischemia & peritonitis (increased risk)
Sxs: colicky abd pain, N/V (feculent vomiting), abd distention, absence of flatus/stool
Dx: x-ray or CT scan - dilated bowel & air-fluid lecels w/ decompressed bowel distal to the site of obstruction
Tx: NG tube decopression & fluid resuscitation, urgent laparotomy for lysis of adhesions must be performed before bowel ischemia develops
What is the DDx for RLQ pain
Appendicitis
Ectopic Pregnancy
Ovarian torsion
IBD
Ogilvie syndrome
Meckel’s diverticulum
What is an aortic aneurysm dissection
circumferential or less common, transerve tear of the intima
ofton along R. lateral wall of ascending aorta where hydraulic shear stress is high
& pulsatile aortic flow disect along elastic lamellar plates & creasr false lumen
=atypical chest pain, widened mediastium, VS abnormalities
emergency!
what is the DDx for diffuse abd pain
IBS
mesenteric A ischemia
peritonitis
intestinal obstruction
IBD
toxic megacolon
constipation
What is the Tx/management of acute colonic pseudo-obstruction (ogilvie syndrome)
conservative if no/minimal abd tenderness, no fever, leukocytosis, cecal diameter < 12 cm
underlying illness treated appropriately
NGT & rectal tube placed
discontinue- reduce intestinal motility (opiods, anticholinergics, Ca channel blockers)
asscess cecal size every 12 hrs
intervention should be considered in pt w/ no improvement/clinial deterioration after 24-48 hr conservative therapy; dilation > 10 cm; if > 12 cm - give neostigmine- unless contraindicated, colonoscopic decompression if neostigmine fails, SRG if colonoscopy is unsuccessful
What are characterisitics of toxic megacolon
potentially lethal complication of (IBD: ulcerative colitis) or infectious colitis (C.Diff)
characterized by total/segmental nonobstructive colonic dilatation plus systemic toxicity
Dx: in all pts presenting with abd distension & acute/chronic diarrhea
Dx = clinical, based on finding of enlarged dilated colon on abd imaging accompanied by severe systemic toxicity
What are characteristics of chronic mesenteric ischemia
“Abd angina”: dull, crampy periumbilical pain 15–30 min after meal & lasting for several hours (pt’s develop food fear); weight loss; occasionally diarrhea.
Evaluate with mesenteric arteriography for possible bypass graft surgery
What are the Hx/PE findings in ectopic pregnancies
- severe RLQ & LLQ pain almost every case- w/ general clinical signs 6–8 weeks after the last normal period
- =sudden onset, stabbing, intermittent, no radiation, backaches
- 2/3 pts Hx of abnormal period; maybe infertile
- blood leak from tubal ampulla over a couple days & accumulate in peritoneum
- slight/persistent vaginal spotting & pelvic mass palpated, abd distention & mild paralytic ileus
- Orthostatic signs and fever
What is secondary peritonitis
Bacteria contaminate peritoneum–> spillage from an intra-abd viscus
Microbio: mixed flora; gram (-) bacilli and anaerobes predominate esp if contaminating source is colonic
Initial Sxs - localized/vague; –> infxn spread to peritoneal cavity, pain increases; pts lie motionless, w/ knees drawn up to avoid stretching nerve fibers of the peritoneal cavity Coughing/sneezing- severe, sharp pain; marked voluntary & involuntary guarding of anterior abd M, tenderness (w. rebound) and fever
Dx radiograph to find source of contamination/immediate surgical intervention usually part of the initial diagnostic evaluation Abd taps done only to exclude hemoperitoneum in trauma cases
Tx: Antibiotics aimed at the inciting flora
Surgical intervention is often needed
what is the Hx/PE finding, Dx and Tx of acute small bowel obstruction
N/V (feculent), obstipation, disentation
minimal abd tenderness, decreased/absent bowel sounds
caused by adhesion- multiple abd SRGs = RF, diverticulitis, crohn dz
high pitched tinkling bowel sounds
Dx: plain abd radiograph (KUB/abd series) or CT scan - dilated loops of small bowel, air fluid levels
Tx: NGT to suction, supportive, SRG if NGT isnt helpful
What is the DDx for RUQ pain
Duodenal Ulcers
GB prob
hepatits
pancreatitis
budd-chiari syndrome
What are the risk factors for Aortic Aneurysms to rupture
what is the presentation
increase risk w/ size of aneurysm: 20-40% if > 5cm diameter; mean age 65-75 who has ever smoked (Abd US- useful serial documentation & screening for high risk pt)
commonly no sxs & detected on routine exam= palpabe, pulsitile, expansive, nontender mass OR incidental finding on abd imaging
as it expands –> painful which is usually sign of rupture & = emergency; MC acute rupture = w/o prior warning =life-threatening
acute pain & hypotension = emergency
what are Hx/PE findings of ovarian torsions
Fever; N/V (70%) ; sudden-onset, severe, unilateral, lower abd pain may develop after episodes of exertion
PE: tenderness w/ guarding, unilateral adnexal tenderness on bimanual examination & presence of a latero-uterine mass
What is the DDx for periumbilical/suprapubic pelvic
early appendicitis
mesenteric A ischemia
ruptured aortic aneurysm
bowel obstruction
IBD
What is the DDx for unintentional wt. loss
CA
Malabs syndrome
IBD
poor dentition
loss of 5-10% of body weight over 6 months should prompt further evaluation
What are characteristics of acute mesenteric ischemia
Periumbilical pain out of proportion to tenderness
N/v, distention, GI bleeding, altered bowel habits
Abd x-ray - bowel distention, air-fluid levels, thumbprinting (submucosal edema) or normal
CT angiography of abd & pelvis w/ IV contrast: test of choice to see vasculature–> celiac & mesenteric arteriography recommended in all cases following hemodynamic resuscitation
Peritoneal signs -> infarcted bowel requiring surgical resection (Laparotomy indicated to restore intestinal blood flow obstructed by embolus/thrombosis or to resect necrotic bowel
Postop anticoag indicated in mesenteric venous thrombosis, controversial in arterial occlusion.++
What is the DDx for epigastric pain
Dissecting/Rupture Aortic Aneurysm
PUD
Hiatal hernia
GERD
Gastritis
Esophagitis
Pancreatitis
Cholecystitis
What is the DDx for LUQ pain
Gastric ulcer
Gastritis
Perforated subdiaphragmatic viscus
Pancreatitis
What is important Hx and typical PE findings for appendicitis
tenderness/localized rigidity; begin w/ vague, colicky periumbical/epigastric pain & w/i 12 hrs localizes to RLQ (worsens w/ cough/walking)
anorexia, constipation, N/V, low-grade fever (if high = something else or perforation)
PE: tenderness (McBurney’s Point);
peritoneal signs:
- psoas sign: pain on passive extension of right hip
- obturator sign: pain w/ passive flexion & IR of right hip
- heel strike
- rebound tenderness
What is the etiology, Dx, Tx & complications fo ectopic pregnancies
=98% tubal; Hx of infertility, PID, ruptured appendix & prior tubal SRG
USA- undiagnosed/undetected MCC maternal death in 1st
no intrauterine preg on transvaginal US w/ beta-hCG > 2,000
Tx: SRG, med
complication: shock in about 10% often after pelvic exam; maternal death
What is primary (spontaneous) bacteral peritonitis
MC: pts with cirrhosis
Pathogenesis: hematogenous spread to ascitic fluid in pts w/ liver dz & altered portal circulation compromise the liver’s filtration function
Microbio: Enteric gram (-) bacilli - E. coli or gram (+) - MC = streptococci, enterococci, and pneumococci (single organism is typically isolated)
If polymicrobial infxn including anaerobes is identified –> think 2dary
peritonitis
acute-onset abd pain/signs of peritoneal irritation vs nonspecific & nonlocalizing manifestations (e.g., malaise, fatigue, encephalopathy), Fever (~80% of pts)
Dx: peritoneal fluid - contains >250 PMNs/μL; culture yield is improved if a 10-mL of peritoneal fluid is placed directly into blood culture bottles
Blood cultures should be performed bc bacteremia = common
Prevention: 70% pts recurrence w/i 1 yr. Prophylaxis w/ fluoroquinolones or Bactrim
Tx: 3rd-gene cephalosporin (e.g., ceftriaxone) or piperacillin/tazobactam constitute appropriate empirical tx
What is the etiology, Hx/PE, Dx and complication of diverticulitis
macroscopic inflam –> Inflam alone –> microperforation w/ localized paracolic inflam –> macroperforation w/ abscess/generalized peritonitis
LLQ pain, fever, N/V, constipation at 1st and then loose stools
PE: mild LLQ tenderness w thickened, palpable sigmoid & descending colon (small mass)
CT w/ contrast; leukocytosis; endoscopy CONTRAINDICATED - risk of perforation
complication: pericolic abscess, perforation, fistula, liver abscess, stricture
What is the etiology, Hx/PE and Dx for acute colonic pseudo-obstruction (ogilvie syndrome)
Spontaneous massive dilation of cecum/ R colon w/o mechanical obstruction
abd distention; plain film radiograph - colonic dilation
absent BM but 40% continue to pass flatus/stool; abd tenderness w/ some gaurding/rebound tendernus
signs of peritonitis IF perforation
Dx: X-ray/CT- demonstrate colonic dilation; upper limit of normal for cecal size = 9 cm; cecal diameter > 10-12 cm, associated w/ increased risk of colonic perdoration; dilated appearance of colon - raise concern of distal colonic mechanical obstruction due to malignancy, volvulus or fecal impaction
What is the etiology, Dx, Tx & complications for appendicitis
10-30 yr old; initiated by obstruction of the appendix by fecalith, inflam, foreign body or neoplasm
Dx: Mod leukocytosis w/ neutrophilia; microscopic hematuria & pyuria, Abd US & CT = diagnositc
Tx: SRG: appendectomy (before 21 yo = protective against UC); broad spectrum ABx w/ gram (-)/anaerobic
complications: perforation (untreated, gangrene w/i 36 hrs) = persistant pain for 36 hrs, high fever, diffuse abd tenderness/peritoneal findings, palpable mass or marked leukocytosis
What are important Hx & PE findings for unintentional weight loss
how to you Dx
Hx: GI symp should be obtained, including difficulty eeating, dysgeusia (distrorted sense of taste), dysphagia, anorexia, nausea & change in bowel habits; HAVE TO ASK ABOUT DENTITION
PE: Weigh them,ascess dentition; All men - rectal examination - prostate; all women - pelvic exam; both should have testing of stool for ocult blood
Dx: Before extensive evaluation its imp to confirm wt loss has occurred (up to 50% of claims of weight loss cannot be substantiated)
what is the DDx for LLQ pain
diverticulitis
ischemic colitis
ectopic pregnancy
ovarian torsion
IBD
colon CA
what is the DDx in fatigue (in relation to GI)
Occult GIB
CA
IBS
Chronic liver disease
Malnutrition/malabsorption: Celiac, Chronic Pancreatitis/Pancreatic insufficiency/Cystic fibrosis, Bile Salt Malabsorption, Whipple Disease
(MANY other DDx)
what are atypical presentations for appendicitis
due to variable locations:
rectrocecal appendix: less intense & poorly localized, psoas sign (+)
pelvic appendix: pain in lower abd (LEFT) - urge to urinate/defecate, obturator sign (+), tender w/ pelvic/rectal exam
elderly - minimal, vague, mild abd tenderness
pregnancy- RLQ, periumbilical area, right subcostal area bc displacemtn of appendix by uterus
What are the etiology, Dx, Tx and complications of ovarian torsion
- Adnexal pathology - acute, maybe bc rupture, bleeding/torsion of cysts ; almost always associated w/ ovarian enlargement
- nearly 70% of torsions on R. side, due to increased length of utero-ovarian ligament on the R & sigmoid on the L, limit space for movement
- RF: pregnancy bc enlarged corpus leutrum, presence of large ovarian cysts/tumors, chemical induction of tulation, tual ligation
Dx: transvaginal US w/ doppler is the primary diagnostic modality for susspected torsion; ovary > 4 cm due to cyst, tumor, edema = MC ultrasonographic findings associated w/ torsion
Tx: ovarian torsion = SRG emergency
complication- loss of ovarian fxn
what are Sxs of meckel’s diverticulitis
how do you Dx/Tx
presention - rule of 2’s
adult - intestinal obstruction, rectal bleeding, intussusception, perforation or diverticular inflam
Dx- technetium-99m scan
Tx: SRG resection
