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GI 2 Exam 1 > DSA 6: RUQ and Epigastric Pain > Flashcards

DSA 6: RUQ and Epigastric Pain Flashcards

1
Q

what are the 4 main concerns on DDx for RUQ and epigastric pain?

A
  1. gallbladder disease
  2. hepatitis
  3. pancreatitis
  4. PUD
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2
Q

positive sign: deep inspiration or cough during palpation of RUX produces increased pain or inspiratory arrest

A

Murphy’s sign

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3
Q

what are the two major types of gallstones?

A
  • cholesterol (80%)

- calcium bilirubinate (<20%)

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4
Q

what is the best diagnostic tool for cholelithiasis?

A
  • *RUQ ultrasound/hepatobiliary US**

- NOTE: stones seen as “acoustic shadow””

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5
Q

what are the risk factors of gallstones?

A
  • family hx
  • female
  • fair
  • fate
  • fertile
  • forty
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6
Q

what are the protective factors for gallstones?

A
  • low carb diet
  • physical activity
  • cardiorespiratory fitness
  • consumption of caffeine (in women)
  • ligh intake of Mg and polyunsaturated/monosat fat (in men)
  • ASA, NSAIDs
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7
Q

calculous gallstones (>90% of cases) impacted in **cystic duct*

  • can be acalculous stones
  • large fatty meal -> acute attack
  • bilirubinemia
  • sometime jaundice is present, suggesting choledocolithiasis (bile duct obstruction)
A

acute cholecystitis

- dx: RUQ abd US

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8
Q

what is a severe complication of acute cholecystitis to keep in mind?

A
  • *emphysematous cholecystitis** (air lining the gallbladder)
  • secondary infection with a gas-forming organism
  • requires urgent cholecystectomy!
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9
Q

what is the procedure of choice for dx and therapy for choledocolithiasis?

A

ERCP with sphincterotomy and stone extraction (can be done in same operation)

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10
Q

what is Charcot’s triad?

A
  1. RUQ pain
  2. fever/chills
  3. jaundice
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11
Q

what is the Reynold pentad? when does it present?

A

Charcot triad + altered mental status and hypotension

  • ascending cholangiitis (infection of biliary tract as result of obstruction, leads to invasion of bacteria from duodenum)
  • is very similar to choledocholithiasis, but will have positive blood cultures for E. Coli, Klebsiella, or Enterococcus
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12
Q

what are the top 2 causes of pancreatitis?

A
  1. alcoholism

2. gallstones

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13
Q

RUQ pain (similar to biliary colic), nausea, but normal ultrasound of gallbladder (no stones, sludge, microlithiasis, wall thickening or dilation)

A

biliary dyskinesia

- consider Rome III dx criteria for functional gallbladder

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14
Q 
HIDA scan (radionucleotide scan - nuclear medicine Technetium Tc99m)
what are normal and abnormal findings?
A
  • normal: gallbladder visualized within 1 hour of injection, tracer also seen in small bowel
  • abnormal: GB NOT seen -> stone in cystic duct of cholecystitis
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15
Q

cholecystokinin stimulated hepatobiliary iminodiacetic scan (CCK-HIDA)
- what is considered abnormal and warrants cholecystectomy?

A

an ejection fraction of less than 35-38% (should be much high with presence of CCK)

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16
Q

what is a porcelain gallbladder?

A

chronic inflammation shows an incidental calcified lesion

- most likely seen on plain X-ray

17
Q

what is courvoisier’s gallbladder?

A

enlarged, palpable non-tender gallbladder with jaundice

- associated with cancer of the head of the pancreas

18
Q

heavy alcohol use

  • biliary tract: gallstones <5mm
  • epigastric abdominal pain: constant, **boring”” pain straight through to the back
  • edema/anasarca (d/t THIRD spacing)
  • positive Cullen or Grey Turner sign
  • LIPASE 3X above normal
  • CT changes consistent with pancreatitis
A

acute pancreatitis

19
Q

plain radiograph shows:

  • calcified gallstones
  • sentinel loop
  • colon cutoff sign (gas filled segment of transverse colon abruptly ending at the area of pancreatic inflammation)
A

acute pancreatitis

20
Q

when should a rapid bolus IV contract-enhanced CT be avoided in acute pancreatitis?

A

if pt has kidney issues! (serum Creatinine >1.5 mg/dL)

21
Q

3 or more of the following predict a severe course complicated by pancreatic necrosis with sensitivity of 60-80%

  • over 55 y/o
  • WBC > 16x10^3
  • blood glucose >200
  • serum lactate DH >350
  • aspartate aminotransferase (250)
A

Ranson criteria

22
Q

what is the most important treatment of acute pancreatitis?

A
  • *IV FUILDS**
  • acute pancreatitis is very dehydrating (d/t third spacing)
  • **1/3 of total 72 hour volume administered within 24 hours of presentation
23
Q

what are the complications of acute pancreatitis?

A
  • fluid collection (pleural effusion)
  • infection (needs to be removed)
  • pseudocysts
  • ARDS
24
Q

what does a sentinel loop of bowel often signal?

A

the presence of an adjacent irritative/inflammatory process -> acute pancreatitis

25
Q

colon cut-off sign, Cvostek and Trousseas signs (for hypocalcemia) seen in what?

A

acute pancreatitis

26
Q

bilateral diffuse fluffy infiltrates

  • normal cardiac size
  • complication of acute pancreatitis
A

ARDS

27
Q

what is the most frequent cause of clinically apparent chronic pancreatitis?

A

alcoholism

28
Q

first event initiates an inflammatory process that results in injury and later fibrosis

A

SAPE (sentinel acute pancreatitis event)

29
Q
  • *PAIN** is cardinal symptom
  • steatorrhea
  • hx of alcohol abuse
  • elevated lipase
  • decreased fecal ELASTASE (<100mcg)
A

chronic pancreatitis

30
Q

what is the TIGAR-O mnemonic?

- used for chronic pancreatitis

A
  • toxic-metabolic (alcoholic)
  • idiopathic
  • genetic
  • autoimmune (IgG4 hypergammaglobulinemia)
  • recurrent
  • obstructive
31
Q

what is the treatment for acute pancreatitis?

A

supportive

  • pain control, but avoid opioids if possible
  • low fat diet, NO ALCOHOL
32
Q

what are complications of chronic pancreatitis?

A
  • brittle diabetes mellitus (over 80% develop DM within 25 years after onset of chronic pancreatitis)
  • pancreatic cancer (main cause of death)
33
Q

what is the main pancreatic function test McGowan wants us to know?

A
  • *fecal elastase**

- will be low in pancreatic insufficiency (<100mcg/gram stool)

34
Q

pt presents with PAINLESS JAUNDICE

  • or they have mild-epigastric pain that radiates to the back, hurts the most at night laying down, relieved with bending forward
  • elevated CA 19-9 (>100 is highly specific for pancreatic malignancy!)
  • Trousseau sign of malignancy (different than test for hypocalcemia, this one is recurrent vessel inflammation that occurs sporadically over body)
A

pancreatic cancer

35
Q

coffee ground emesis, hematemesis, melena, or hematochezia

  • EDG with biopsy (to exclude malignancy)
  • detection of H. pylori via fecal antigen test
A

PUD

36
Q

burning gnawing epigastric pain

  • 60 min-3 hours after meal
  • nocturnal
  • relieved by food
A 
duodenal ulcer (up to 95% caused by H. pylori!)
- gastric acid HYPERsecretion
37
Q

can be asymptomatic

  • burning pain worse with food -> food aversion
  • nausea/anorexia
  • need to perform endoscopy with biopsy to rule out malignancy
A

gastric ulcer

  • chronic NSAID use is risk factor
  • H. pylori in up to 75%
  • gastric acid secretory rates usually normal or reduced
38
Q

pneumoperitoneum (below diaphragm) and pneumomediastinum (above diaphragm) are two types of what?

A

perforated viscus

- can happen in PUD, or with any hollow organ

GI 2 Exam 1 (22 decks)

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