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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
What is **Grey Turners Sign?**
**Ecchymosis of flank from fluid and blood in retropertioneum** **=\> acute pancreatitis**
26
What signs we will see on **XR** for **acute pancreatitis?**
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
What is diagnostic test is **NOT** **helpful in acute pancreatitis** because gas in bowel?
**US**
28
Other tests to run for **acute pancreatitis?**
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
How do we grade the **severity** of acute pancreatisi?
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
What does the ## Footnote HAPS (harmless acute pancreatitis score) predict?
Predicts non-severe course witth 98% accuracy if: - no abdominaal tenderness/guarding NL hemotocrit NL serum Cr
31
How do we use Ransoms Criteria to assess severity of acute pancreatitis
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
**_Acute Pancreatitis_** * Treatment?
* **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
**Acute Pancreatitis** Complications
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
What is this?
**Sentinal loop or localized ileus**
35
What is **emphysemematous pancreatitis?** ## Footnote **Treatment**
* Infected pancreas necoris with secondary gas formation. * Caused by (clostridium perfinges, enterobacter aerogenes, e. facellis) * Treatment: **Surgical debridmen**t + **ABX (imepenem or meropenem)**
36
What is a sign for **hypocalcemia**?
**Chvostek and Troussea Sign = fat necrosis**
37
What do we see on **XR** in **ARDS**?
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
Which is more accurate for measuring pancreatic source: **amylase** or **lipase**?
* Lipase * Amylase is elevated in other conditions: high intestinal obstruction: GE , mumps
39
\_\_\_\_\_\_\_\_\_\_\_\_ is most frequent cause of clinically apparent **chronic pancreatitis,** characterized by _______ damage to the pancrease and ultimately leads to \_\_\_\_\_\_\_\_\_\_\_.
**_Alcoholism_** * **Irreversible** * **Pancreatic exocrine** or **endocrine insufficiency**
40
**_Chronic pancreatitis_** H&P: * Cardinal symptom: \_\_\_\_\_\_\_\_\_\_ Dx
Sx: * Cardinal symptom: **pain** * **Steatorrhea** due to malabsorption caused by EPI (exocrine pancreas insufficiency) Dx: * **↓ fecal elastase (\<100 mcg/gram)**
41
**_Chronic Pancreatitis_** ## Footnote Dx
* **XR**: calcifications due to pancreaticolithiasis * **CT**: * Can show calcification not seen on plain film * Tumefactive chronic pancreatitis = concern for pancreatic cancer
42
What is the eiology for **Chronic Pancreatis?**
**_TIGAR-O_** ## Footnote * 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
* ________ should be **avoided**, if possible, in patients with **Chronic Pancreatitis.** * **Complications?** * **Main caue of death in people with Chronic Pancreatitis;.**
* **Tx: Opiods** * **Complications:** * **Brittle DM (80% of adults develop DM within 25 years after the clinical onset pancreatis).** * **Pancreatic CA** * **MCOD: Pancreatic carcinoma**
44
Name the 4 **Pancreatic Function Tests**
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
**Cystic Fibrosis, where mucus plugs lings and pancreas,** is a common cause of Chronic Pancreatitis. What are the symptoms seen in CF?
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
Pancreatic cancer is what type?
Adenocarcinoma
47
Symptoms of **pancreatic cancer?**
* **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
**Signs** of Pancreatic Cancer
1. Trousseau sign of Malignancy = **migratory thromboplebitis** (need to differentiate this from the other Trousseau signfor hypocalcemia) 2. **Courvoisier Sign** = palpable GB
49
What is HIGHLY lab finding is **HIGHLY SPECIFIC** for **PANCREATIC CANCER?**
**CA 19-9 (**Normal \<33-37 U/mL) in **absence** of biliary causes value \>100 U/mL
50
Risk factors for **Pancreatic CA:**
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
**PEPTIC ULCER DISEASE (PUD)** MCC occurs
1. **duodenal bulb** (duodenal ulcer, DU) 2. **stomach** (gastric ulcer, GU)
52
**_H&PE Peptic Ulcer Disease_** If uncomplicated?
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
Diagnostics of PUD
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
Complications of **PUD**?
**1. Ulcer on the posteiror wall o**f the duodenum or stomach may **perferate** into * pancrease * liver * biliary tree.
55
**_Duodenal Ulcers_** * Located: * Caused by: * Risk factors * Clinical features:
* **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
**_Gastric Ulcers_** ## Footnote Located: Caused by: (gastric acid secretion? Risk factors Clinical features:
* 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
What is a complication of PUD?
**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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