Eval associated with GI conditions

Question 1

Murphy’s Sign

Answer 1

Cessation of inspiration during right upper quadrant examination (Acute cholecystitis)

Question 2

Cullen’s Sign

Answer 2

Periumbilical bluish discoloration (Retroperitoneal hemorrhage, Pancreatic hemorrhage, AAA rupture)

Question 3

Grey Turners Sign

Answer 3

Bluish discoloration of the flanks (Retroperitoneal hemorrhage, Pancreatic hemorrhage, AAA rupture)

Question 4

Kehr’s Sign

Answer 4

Severe left shoulder pain (Splenic rupture, Ectopic pregnancy rupture)

Question 5

Carnett’s Sign

Answer 5

Increased pain when a supine patient tenses the abdominal wall by lifting the head and shoulders off the examination table

Question 6

McBurney’s Sign

Answer 6

Tenderness located midway between the anterior superior iliac spine and umbilicus

Question 7

Cutaneous Hyperesthesia

Answer 7

Localized pain in the right lower quadrant elicited by gently picking up a fold of abdominal skin between your thumb and index finger

Question 8

Rosving’s Sign

Answer 8

Pain in the right lower quadrant during left-sided pressure (i.e., referred rebound tenderness)

Question 9

Obturator Sign

Answer 9

Pain with flexed right hip rotation (retroperitoneal Inflammation)

Question 10

Psoas Sign

Answer 10

Pain when raising a straight leg against resistance (Retroperitoneal Inflammation)

Question 11

Rebound Tenderness

Answer 11

Pain induced or increased by the rapid withdrawal of the palpating hand
Secondary to rapid movement of inflamed peritoneum
Associated with peritoneal inflammation – not specific to one disorder over another

Question 12

Referred Rebound Tenderness

Answer 12

As with rebound tenderness, associated with peritoneal inflammation
On withdrawal of palpating hand, pain elicited in other location
Area of ‘referred’ pain may be source of problem

Question 13

Referred Pain

Answer 13

Symptomatic pain in areas that are remote from the diseased organ
Result of visceral and afferent neurons from different anatomic regions converging at the same spinal cord segment
Example: Right subscapular pain with cholelcystitis.

Question 14

Mnemonic for Retroperitoneal Viscera

Answer 14

S = Suprarenal glands (i.e., adrenal glands)
A = Aorta/IVC
D = Duodenum (second and third segment)
P = Pancreas (tail is intraperitoneal)
U = Ureters
C = Colon (only ascending and descending)
K = Kidneys
E = Esophagus
R = Rectum

Question 15

Jaundice

Answer 15

Indication of altered bilirubin metabolism from a variety of causes – not just specific to acute hepatitis

Question 16

Spider Telangiectasias

Answer 16

Vascular arborizations that blanch on pressure and can be found on the face, upper part of the back, thorax, and upper part of the arms and thought to be related to systemic excess of estrogen combined with portosystemic shunting from cirrhosis

Question 17

Butterfly Sign

Answer 17

Area of hypopigmentation between the scapulae relative to surrounding skin and related to cholestasis (not to be confused with the facial sign of the same name associated with systemic lupus erythematosis) - Hypopigmentation likely due to patient not being able to scratch the affected area with surrounding skin changes in areas being scratched.

Question 18

Muehcke’s Lines

Answer 18

White horrizontal lines on the nails indicative of hypoalbuminemia

Question 19

Azure Lunulae

Answer 19

Sky blue discoloration of the nails and a green hue on the skin from the accumulation of copper associated with Wilson’s disease

Question 20

Peptic Ulcer Disease

Answer 20

Most peptic ulcers are associated with colonization with H Pylori

Histologic examination of gastric mucosal biopsies
Very sensitive and specific for H Pylori
Most commonly performed when patient undergoing EGD

Question 21

Serology testing for Peptic Ulcers

Answer 21

Serology: relatively inexpensive and relatively convenient, but not helpful to assess whether H. pylori has been eradicated with antibiotics

Question 22

Stool Antigen Testing for Peptic Ulcers

Answer 22

Significantly more accurate than serology

Capable of detecting H. pylori infection 1 week after PPIs are discontinued

Question 23

Carbon-13 (13C)–urea breath testing for Peptic Ulcers

Answer 23

Significantly more expensive than stool or blood testing

Becomes negative as soon as H Pylori eradicated (but recommended to still wait 4-6 weeks post-treatment)

Question 24

Charcots Triad

Answer 24

Fever with rigors, RUQ pain, and jaundice

Associated with bacterial cholangitis

Question 25

Reynolds Pentad

Answer 25

Charcot’s triad plus altered mental status and hypotension (S&S of Septic Shock)
Associated with septic shock accompanying bacterial cholangitis

Question 26

Evaluations for digestive conditions often include the following labs

Answer 26

CBC
LFTs
Amylase
Lipase
Coagulation Profiles
UA
Pregnancy Testing

Question 27

Urine pregnancy testing

Answer 27

Beta-hCG; always check level on fertile female patient for pregnancy & ectopic pregnancy

Question 28

Why check both ALT and AST

Answer 28

ALT is considered more specific to the liver
AST is also present in skeletal and cardiac muscle and is commonly elevated in cases of muscle injury or inflammation
AST:ALT ratio >2 is commonly attributed to the effects of long-term alcohol use

Question 29

Common Hepatic Causes

Answer 29

Alcohol Use
Cirrhosis
Chronic Hep B
Chronic Hep C
Steatohepatitis (NASH)
Medications/Toxins
Acute Viral Hepatitis

Question 30

Lactic Dehydrogenase (LDH)

Answer 30

Primarily reflects tissue damage
Can order LD-Isoenzymes to assist in identifying source - Heart, Liver, Kidney,
Liver conditions associated with increased LD may include (but are not limited to): Cirrhosis, Hepatitis, Hepatic Necrosis

Question 31

ALP is sensitive to what?

Answer 31

ALP sensitive to fasting vs. non-fasting state

Question 32

What would you do if the cause is unknown

Answer 32

If causes unknown, consider ordering Alk Phos Isoenzymes

Question 33

Elevated ALP and GGT is suggestive of what?

Answer 33

Elevated ALP and GGT suggestive of cholestastasis but bilirubin not elevated until late in disease course

Check antimitochondrial antibody (AMA) to rule-out primary biliary cirrhosis.

Question 34

What if you have a middle-aged female patient with chronic pruritus, fatigue, and dry mouth with the above lab abnormalities

Answer 34

Consider a diagnosis of primary biliary cirrhosis

Consider abdominal ultrasound and cholangiogram

Consider ordering an antimichondrial titer (AMA)

Question 35

Steatohepatitis Testing

Answer 35

Liver biopsy is the gold standard for definitive diagnosis

Markedly elevated AST and ALT (e.g. >10 fold) rarely related to steatohepatitis

Question 36

Celiac Disease

Answer 36

There is no universally accepts testing format; however, the noted serologic testing and biopsy is very sensitive and specific when patients on “normal diet”

Many providers would initiate gluten free diet trial prior to biopsy

Instead of tTG could order Endomysial Antibody (EMA), IgA or IgG but more labor intensive

Question 37

What is the gold standard test for Wilson’s Disease

Answer 37

Gold diagnosis = Liver Biopsy
Often other lab testing can be indeterminate!

patient with neurological or psychiatric symptoms typical of Wilson’s disease and who is positive for KF rings dg via slit lamp exam does not necessarily need further work-up

Question 38

Videofluoroscopic swallowing study and barium esophagram

Answer 38

Efficient and effective noninvasive means of excluding significant pathologic changes in patients with dysphagia (e.g., strictures, masses)
Barium studies not effective for evaluation of cell changes associated with Barrett’s Esophagus

Question 39

Esophagogastroduodenoscopy (EGD)

Answer 39

Better than upper GI tract barium series at identifying erosions, ulcers, polyps, and masses
EGD with Biopsy test of choice for suspected Barrett’s Esophagus

Question 40

Ultrasonography

Answer 40

Useful for imaging solid organs and fluid-filled structures but limited by its inability to penetrate gas-filled structures (e.g. overlying bowel gas may obscure underlying structures)
Test of choice to identify Cholelithiasis and Cholecystitis