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gi/gu ii exam 1 > DSA 5: Abd Pain, Fatigue, Wt. Loss > Flashcards

DSA 5: Abd Pain, Fatigue, Wt. Loss Flashcards

1
Q

What is the Tx/management of diverticlitis

A

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

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2
Q

What is intestinal obstruction?

Sxs, Dx, Tx?

A

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

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3
Q

What is the DDx for RLQ pain

A

Appendicitis

Ectopic Pregnancy

Ovarian torsion

IBD

Ogilvie syndrome

Meckel’s diverticulum

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4
Q

What is an aortic aneurysm dissection

A

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!

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5
Q

what is the DDx for diffuse abd pain

A

IBS

mesenteric A ischemia

peritonitis

intestinal obstruction

IBD

toxic megacolon

constipation

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6
Q

What is the Tx/management of acute colonic pseudo-obstruction (ogilvie syndrome)

A

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

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7
Q

What are characterisitics of toxic megacolon

A

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

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8
Q

What are characteristics of chronic mesenteric ischemia

A

“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

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9
Q

What are the Hx/PE findings in ectopic pregnancies

A
  1. severe RLQ & LLQ pain almost every case- w/ general clinical signs 6–8 weeks after the last normal period
  2. =sudden onset, stabbing, intermittent, no radiation, backaches
  3. 2/3 pts Hx of abnormal period; maybe infertile
  4. blood leak from tubal ampulla over a couple days & accumulate in peritoneum
  5. slight/persistent vaginal spotting & pelvic mass palpated, abd distention & mild paralytic ileus
  6. Orthostatic signs and fever
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10
Q

What is secondary peritonitis

A

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

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11
Q

what is the Hx/PE finding, Dx and Tx of acute small bowel obstruction

A

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

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12
Q

What is the DDx for RUQ pain

A

Duodenal Ulcers

GB prob

hepatits

pancreatitis

budd-chiari syndrome

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13
Q

What are the risk factors for Aortic Aneurysms to rupture

what is the presentation

A

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

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14
Q

what are Hx/PE findings of ovarian torsions

A

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

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15
Q

What is the DDx for periumbilical/suprapubic pelvic

A

early appendicitis

mesenteric A ischemia

ruptured aortic aneurysm

bowel obstruction

IBD

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16
Q

What is the DDx for unintentional wt. loss

A

CA

Malabs syndrome

IBD

poor dentition

loss of 5-10% of body weight over 6 months should prompt further evaluation

17
Q

What are characteristics of acute mesenteric ischemia

A

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.++

18
Q

What is the DDx for epigastric pain

A

Dissecting/Rupture Aortic Aneurysm

PUD

Hiatal hernia

GERD

Gastritis

Esophagitis

Pancreatitis

Cholecystitis

19
Q

What is the DDx for LUQ pain

A

Gastric ulcer

Gastritis

Perforated subdiaphragmatic viscus

Pancreatitis

20
Q

What is important Hx and typical PE findings for appendicitis

A

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:

  1. psoas sign: pain on passive extension of right hip
  2. obturator sign: pain w/ passive flexion & IR of right hip
  3. heel strike
  4. rebound tenderness
21
Q

What is the etiology, Dx, Tx & complications fo ectopic pregnancies

A

=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

22
Q

What is primary (spontaneous) bacteral peritonitis

A

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

23
Q

What is the etiology, Hx/PE, Dx and complication of diverticulitis

A

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

24
Q

What is the etiology, Hx/PE and Dx for acute colonic pseudo-obstruction (ogilvie syndrome)

A

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

25
Q

What is the etiology, Dx, Tx & complications for appendicitis

A

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

26
Q

What are important Hx & PE findings for unintentional weight loss

how to you Dx

A

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)

27
Q

what is the DDx for LLQ pain

A

diverticulitis

ischemic colitis

ectopic pregnancy

ovarian torsion

IBD

colon CA

28
Q

what is the DDx in fatigue (in relation to GI)

A

Occult GIB

CA

IBS

Chronic liver disease

Malnutrition/malabsorption: Celiac, Chronic Pancreatitis/Pancreatic insufficiency/Cystic fibrosis, Bile Salt Malabsorption, Whipple Disease

(MANY other DDx)

29
Q

what are atypical presentations for appendicitis

A

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

30
Q

What are the etiology, Dx, Tx and complications of ovarian torsion

A
  • 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

31
Q

what are Sxs of meckel’s diverticulitis

how do you Dx/Tx

A

presention - rule of 2’s

adult - intestinal obstruction, rectal bleeding, intussusception, perforation or diverticular inflam

Dx- technetium-99m scan

Tx: SRG resection

gi/gu ii exam 1 (16 decks)

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