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GI II Exam 1 > DSA: RUQ and Epigastric Abdominal Pain > Flashcards

DSA: RUQ and Epigastric Abdominal Pain Flashcards

1
Q

What organs can cause RUQ/epigastric abdominal pain?

A
  1. Gallbladder
  2. Liver
  3. Pancrease
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2
Q

DDx for RUQ/Epigastric Pain

A
  1. Gallbladder Disease
    1. Acute cholecystitis
    2. Choledocholithiasis
    3. Asending cholangitis
    4. Biliar dyskensia
  2. Hepatitis
  3. Pancreatitis
    1. Acute
    2. Chronic
  4. PUD
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3
Q

What is Murphys Sign and what does it indicate?

A
  • Palpate the RUQ and have a patient take a deep breath in => pain + or stops breathing in due to pain =>
      • Murphys => Acute cholecystitis
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4
Q

There are 2 major types of gallstones:

  1. Cholesterol (80%), made up of mostly _______
  2. Pigment (20%), made up up mostly __________
A
  1. Cholesterol
  2. Calcium bilirubinate
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5
Q
  • What is a sign/sx of Cholelithiasis?
  • Dx:
A

Symptoms: (occur when obstruction occurs)

  1. Biliary colic: severe steady ache in the RUQ/epigastrium that begins suddenly, 30-90 minutes after food => right shoulder
  2. N/V

Dx:

  1. ​Ultrasound; but only 10% are radio-opaque
    1. ​Stones + acoustic shadow they cast are seen.
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6
Q

_________ stones tend to form in the bile duct due to bacterial infections; accounting for 30-90% of gallstones in Asian population.

A

Brown pigment stones

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7
Q

Risk factors for Gallstones

A
    1. DM, glucose intolerance, insulin resistance
    1. NA> Mexicans
    1. M>W if they have cirrhosis or hep C
    1. Crohns
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8
Q

Protective factors for Gallstones

A
  1. Low carb diet
  2. PA
  3. Caffeine in W
  4. High Mg and poly/mono unsaturated fats in M
  5. High fiber/statins
  6. ASA and NSAIDS
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9
Q

In acute calculous cholecystitis, gallstones get stuck in the _______, causing inflammation of the GB (where)?

In acute acalculous cholecystitis, what is the cause?

A
  • acute calculous cholecystitis,
    • Cystic duct
    • Behind the obstruction
  • acute acalculous cholecystitis
    • ​True cholecystitis + no stones in an acute illness (ICU patients)
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10
Q

Diagnosing Acute Cholecystitis,

A
  1. HIDA scan (Hepatic iminidiacetic acid scan), a Tc hepatobilliary imaging
    1. Show obstructed cystic duct
  2. RUQ abdominal US
    1. => GB thickl; perichloeycystic fluid; sonographic Murphy sign
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11
Q

Serious complications of Acute Cholecystitis

A
  1. Emphysematous cholecystitis => secondary infection with a gas forming organism.
    1. Patient will have to have and URGENT cholecystectomy.
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12
Q

Choledocholithiasis = _____

Essentials of Diagnosis:

Diagnosis and treatment:

A

Choledocholithiasis = Stones in the common bile duct

  • Biliary pain +/- jaundice
  • ECRP with sphinecterotomy and stone extraction or stent replacement
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13
Q

Ascending Cholangitis =

Symptoms:

Labs/Dx:

A
  • Inflammation of the bile duct, usually caused by an obstruction => bacteria ascending from duodenum (first part of the small intestine)
  • Symptoms
      1. Charcot triad: RUQ pain + fever (& chills) + jaundice
    • 2 Reynold pentad: Charcot triad + AMS (confusion) + hypotension.
      • => ACUTE SUPPURATIVE CHOLANGITIS => pus in biliary duct => ENDOSCOPIC MRGNC
    • blood cultures:
      • E.coli
      • enterococcus
      • Kliebsiella
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14
Q

What indicated acute suppurative cholantitis and what must be done about it?

A
  • => pus in biliary duct
  • Reynolds triad: Charcot triads + AMS (confusion) + hypotension
  • Endoscopic MRGNC
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15
Q

BILIARY DYSKINESIA = Symptomatic functional disorder of the gallbladder

  • Hx/PE:
  • Dx:
A
  • Hx/PE (sim to biliary coli)
    • Episodes of RUQ pain, limits activities of daily living
    • Nausea w pain
  • Dx
    1. US is NL (no stones, thickening, dilation)
    2. Rome III diagnostic criteria for functional gallbladder = NL liver enzymes, conjugated bilirubin, and amylase/lipase.
    3. HIDA scan= radionucleotide scan
      • NL GB seen in 1 hour of injection, tracer also seen in small bowel
    • Abnormal GB not seen => stone in cystic duct or cholecystitis
      • (CCK) stimulated hepatobiliary iminodiaceticscan (CCK-HIDA)
      • Abnormal ejection fraction < 35-38% => choleycystectomy
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16
Q

Chronic Cholecystitis

  • Dx:
  • Complication of dx
  • Treatment
A

Porcelain gallbladder- incidental calcified lesion => at risk of gallbladder cancer (Poor prognosis)

  • Seen on plain XR
    • (or KUB-kidney/ureter/bladder x-ray/thoracic or lumbar spine x-ray)
  • Tx: Cholecystectomy
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17
Q

What is Courvoisiers GB?

A
  • Enlarged, palpable non-tender GB with jaundice associated with cancer of the head of the pancreas
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18
Q

ACUTE HEPATITIS

  • Etiology
  • Hx/PE
  • Dx:
A
  • Etiology
    • Viral, bacterial, ricketssial, parasitic
    • Drugs
    • Ischemia (shock)
  • Hx/PE
    • Acholic stools
    • RUQ pain with tenderness over liver ***
    • jaundice + hepatomegaly
  • Dx:
    • CBC & CMP (AST/ALT, bilirubin, ALK, albumin and renal function)
    • PT/INR
    • Acetiminophen levels using Rumack Matthew Nomogram ( = increase = increase risk)
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19
Q

What is Acetiminophen levels using Rumack Matthew Nomogram used to test for?

A

Acute hepatitis

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20
Q

Most common causes of acute pancreatitis?

A
  1. Gallstones less than or equal to 5mm
  2. Heacy EtOh use
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21
Q

Acute Pancreatitis

  • Symptoms
  • Dx
A
  1. Constant, boring epigastric pain that raidates straight through back => L shoulder
  2. RUQ pain/dyspepsia/GB diseases
  3. Cullen or Grey Turner sign

Dx (2/3)

  1. Epigastric pain
  2. Lipase (and amylase) 3x the ULN
  3. CT changes that insit pancreatitis.
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22
Q

What do you see on the following test for acute pancreatitis?

  1. CBC
  2. CMP/BMP
  3. CMP
  4. Lipid panel
  5. Other
A
  1. CBC
    1. Leukocytosis
    2. High HCT; if above 44% => hemoconcentration => pancreatic necrosis
  2. CMP/BMP
    1. Hyperglycemia
    2. High BUN/Cr
  3. CMP
    1. Hyperbilirubinemia
    2. High ALP, ALT (>150 = think biliary etiology)
    3. Hypocalcemia => fat necrosis/saponifcation (<7 with NL abumin = tetany and poor prognosis)
  4. CRP
    1. >150 at 48 hours = severe pancreatitis
  5. Lipid panel
  6. Other
    1. Proteinuria
    2. Granular casts in urine
    3. Glycosuria
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23
Q

Which of the following labs indicates:

    1. Acute pancreatitis d/t bilary etiology
    1. Pancreas necrosis
    1. Fat necrosis (saponification)
    1. Severe pancreatitis
A
    1. Acute pancreatitis d/t bilary etiology
      * ALT levels are >150
  • 2. Pancreas necrosis
    • Cr is >1.8 at 48 hours
    • ↑ Hct (>44%) = hemoconcentration
  • 3. Fat necrosis (saponification)
    • Hypocalcemia (<7 with NL albumin)
    1. Severe pancreatitis
      * CRP >150 at 48 hours
24
Q

What is Cullens sign?

A

Ecchymosis of umbilicis from retroperiteum fluid and bleeding

=> acute pancreatitis

25
Q

What is Grey Turners Sign?

A

Ecchymosis of flank from fluid and blood in retropertioneum

=> acute pancreatitis

26
Q

What signs we will see on XR for acute pancreatitis?

A
  1. Sentinel loop: segment of SI filled with air, most common in LUQ
  2. Colon cuttoff sign:
    1. Segment of gas filled transverse colon that abruptly ends where pancreas inflammtion begins
    2. Focal linear atelectasis of the lower lobe of the lungs with or without pleural effusion
27
Q

What is diagnostic test is NOT helpful in acute pancreatitis because gas in bowel?

A

US

28
Q

Other tests to run for acute pancreatitis?

A
  1. Rapid-bolus IV constrast-enhanced CT
    1. Avoid when serum Cr is >1.5 mg
  2. Perfusion CT( PCT)
    1. Focuses on the perfusion of the pancreas
29
Q

How do we grade the severity of acute pancreatisi?

A
  1. Ranson Criteria
  2. APACHE II (>8 = high mortality)
  3. BISAP (beside index for severity in acute pancreatitis)
    1. ​BUN>25 mg/dl
    2. Imparied mental status
    3. SIRS
    4. Age >60
    5. Pleural effusion
      1. Scale from 1-5; mortality is up to 27 if 5.
  4. HAPS (harmless acute pancreatitis score)
  5. CT Grade of Severity Index for Acute Pancreatitis
30
Q

What does the

HAPS (harmless acute pancreatitis score) predict?

A

Predicts non-severe course witth 98% accuracy if:

  • no abdominaal tenderness/guarding

NL hemotocrit

NL serum Cr

31
Q

How do we use Ransoms Criteria to assess severity of acute pancreatitis

A

AT ADMISSION (GEORGIA LAW)

  1. Glucose >200
  2. Age >55
  3. LDH >350
  4. AST >250
  5. WBC >16K

48 hours AFTER admission C & HOBBS

  1. Calcium <8
  2. Hemocrit drop >10%
  3. PaO2 <60mmHg
  4. Base deficit >4
  5. BUN increase >5
  6. Sequestion of fluid >6L
32
Q

Acute Pancreatitis

  • Treatment?
A
  • TREAT THE CAUSE
  • If mild:
    • Fluid resuscitation (LOTS); IV; double edged sword because aggressive fluids can lead to increased pain and possibility of ARDS
  • Severe
    • ICU
33
Q

Acute Pancreatitis

Complications

A
  1. Depletion of intravascular volume
    1. 3rd spacing => fluid moves from intravascular space => pancreatic islet
    2. Prerenal azotemia
  2. Pleural effusion
  3. Necrosis/infection => needs debridment HIGH MORTALITY
  4. Pseudocyts
  5. ARDS
34
Q

What is this?

A

Sentinal loop or localized ileus

35
Q

What is emphysemematous pancreatitis?

Treatment

A
  • Infected pancreas necoris with secondary gas formation.
  • Caused by (clostridium perfinges, enterobacter aerogenes, e. facellis)
    • Treatment: Surgical debridment + ABX (imepenem or meropenem)
36
Q

What is a sign for hypocalcemia?

A

Chvostek and Troussea Sign = fat necrosis

37
Q

What do we see on XR in ARDS?

A
  1. Bilateral diffuse fluffly infiltrates
  2. NL cardiac size
  3. Tracheostomy tube
  4. Left subclavian central line going inside the R atrium
  5. EXG wires
38
Q

Which is more accurate for measuring pancreatic source: amylase or lipase?

A
  • Lipase
  • Amylase is elevated in other conditions: high intestinal obstruction: GE , mumps
39
Q

____________ is most frequent cause of clinically apparent chronic pancreatitis, characterized by _______ damage to the pancrease and ultimately leads to ___________.

A

Alcoholism

  • Irreversible
  • Pancreatic exocrine or endocrine insufficiency
40
Q

Chronic pancreatitis

H&P:

  • Cardinal symptom: __________

Dx

A

Sx:

  • Cardinal symptom: pain
  • Steatorrhea due to malabsorption caused by EPI (exocrine pancreas insufficiency)

Dx:

  • ↓ fecal elastase (<100 mcg/gram)
41
Q

Chronic Pancreatitis

Dx

A
  • XR: calcifications due to pancreaticolithiasis
  • CT:
    • Can show calcification not seen on plain film
    • Tumefactive chronic pancreatitis = concern for pancreatic cancer
42
Q

What is the eiology for Chronic Pancreatis?

A

TIGAR-O

  • Toxic-metabolic (Alcohol = 45-80%)
  • Idiopathic
    • early onset (23YO) or late onset (62YO)
  • Genetics (<30 YO)
    • Cystic Fibrosis => mutation in CFTR
  • Autoimmune
    • Hypergammaglobuminemia (IgG4)
  • Recurrent

Obstructive

43
Q
  • ________ should be avoided, if possible, in patients with Chronic Pancreatitis.
  • Complications?
  • Main caue of death in people with Chronic Pancreatitis;.
A
  • Tx: Opiods
  • Complications:
    • Brittle DM (80% of adults develop DM within 25 years after the clinical onset pancreatis).
    • Pancreatic CA
  • MCOD: Pancreatic carcinoma
44
Q

Name the 4 Pancreatic Function Tests

A
  1. ↓ Trypsinogen (<20 ng/mL) => steatorrhea
  2. ↓ Fecal elastase (< 100 mcg/gram stool)
  3. Pancreatic malasorption (enzyme secretion is <5-10%, takes >5 years to develop)
  4. Stimulation (CCK/secretin)
45
Q

Cystic Fibrosis, where mucus plugs lings and pancreas, is a common cause of Chronic Pancreatitis.

What are the symptoms seen in CF?

A
  1. Fatigue
  2. Thick, Sticky Mucus
  3. ↓ absorption of vitamins and enzymes
  4. Abdominal
  5. Rectal prolapse
  6. Steatohea
  7. Meconium Ileus in Newborns
46
Q

Pancreatic cancer is what type?

A

Adenocarcinoma

47
Q

Symptoms of pancreatic cancer?

A
  • Painless jaundice, N/V fatigue, WL, steatorrhea
  • If there is pain => it is typically mid-epigastric pain that radiates to the back, hurts the most at night (lying flat on back and relieved with bending forward)

*

48
Q

Signs of Pancreatic Cancer

A
  1. Trousseau sign of Malignancy = migratory thromboplebitis (need to differentiate this from the other Trousseau signfor hypocalcemia)
  2. Courvoisier Sign = palpable GB
49
Q

What is HIGHLY lab finding is HIGHLY SPECIFIC for PANCREATIC CANCER?

A

CA 19-9 (Normal <33-37 U/mL) in absence of biliary causes value >100 U/mL

50
Q

Risk factors for Pancreatic CA:

A
  1. Smoking
  2. Obesity
  3. Male
  4. African American
  5. >65 yo
  6. Diabetes Mellitus
  7. Chronic pancreatitis
  8. Liver cirrhosis (alcohol)
  9. Family history
51
Q

PEPTIC ULCER DISEASE (PUD) MCC occurs

A
  1. duodenal bulb (duodenal ulcer, DU)
  2. stomach (gastric ulcer, GU)
52
Q

H&PE Peptic Ulcer Disease

If uncomplicated?

A
  1. Epigastric pain the is gnawing, dull, aching or hunger-like
  2. GI bleeding: coffee ground emesis, hematemsis, melana or hematochezia

If uncomplicated;

  • PE is NL, but mild, localized, epigastric tenderness to deep palpation may be present & hyperactive bowel sounds
53
Q

Diagnostics of PUD

A
  1. EGD with biopsy to exclude malignancy
  2. Nasogastric lavage to test for blood
    1. if (-); does not exclude active bleeding from a DU
  3. Detect H. Pylor
    1. Stop PPIs 14 days before fecal and breath tests due to a risk of false (-)
      1. Fecal antigen test
      2. Urea breath test
      3. Upper endoscopy with gastric biopsy using Wartharin Stary Silver stain
54
Q

Complications of PUD?

A

1. Ulcer on the posteiror wall of the duodenum or stomach may perferate into

  • pancrease
  • liver
  • biliary tree.
55
Q

Duodenal Ulcers

  • Located:
  • Caused by:
  • Risk factors
  • Clinical features:
A
  • Located: anterior wall of proximal duodenum
  • Caused by: 90-95% H.Pylori: increased gastrin => gastric acid HYPERSECRETION
  • Risk factors: Glucocorticoids and NSAIDS
  • Clinical features:
    • Asyx
    • Dyspepsia, burning, gnawing** epigastric pain 60-3 hours AFTER meals
      • @ night
      • Relived by food
56
Q

Gastric Ulcers

Located:

Caused by: (gastric acid secretion?

Risk factors

Clinical features:

A
  • Located: Lesser curvature of the antrum stomach
  • Caused by: 75% care caused by H. Pylori
    • => Gastric acid secretory rates are NL/reduced
  • Risk factors: Smoking****, Chronic NSAIDS/Sallicylate
  • Clinical features:
    • Asx
    • Dyspepsia, burning epigastric pain, that is WORSE within 30 minutes of eating => FOOD EVERSION
57
Q

What is a complication of PUD?

A

Perforated viscus occurs in any hollow organ that perforates

  • (esophagus, stomach, intestine, uterus, bladder)
  • DO: NPO, IV ABX, Pre-op labs, surgery consult
  • EMERGENCY SURGERY
  • Dx:
    • CT or XR: Free air under diaphragm or air in mediastiunum
      • Pneumoperitoneum-below diaphragm
      • Pneumomediastinum-above diaphragm

GI II Exam 1 (19 decks)

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