Eval associated with GI conditions Flashcards
Murphy’s Sign
Cessation of inspiration during right upper quadrant examination (Acute cholecystitis)
Cullen’s Sign
Periumbilical bluish discoloration (Retroperitoneal hemorrhage, Pancreatic hemorrhage, AAA rupture)
Grey Turners Sign
Bluish discoloration of the flanks (Retroperitoneal hemorrhage, Pancreatic hemorrhage, AAA rupture)
Kehr’s Sign
Severe left shoulder pain (Splenic rupture, Ectopic pregnancy rupture)
Carnett’s Sign
Increased pain when a supine patient tenses the abdominal wall by lifting the head and shoulders off the examination table
McBurney’s Sign
Tenderness located midway between the anterior superior iliac spine and umbilicus
Cutaneous Hyperesthesia
Localized pain in the right lower quadrant elicited by gently picking up a fold of abdominal skin between your thumb and index finger
Rosving’s Sign
Pain in the right lower quadrant during left-sided pressure (i.e., referred rebound tenderness)
Obturator Sign
Pain with flexed right hip rotation (retroperitoneal Inflammation)
Psoas Sign
Pain when raising a straight leg against resistance (Retroperitoneal Inflammation)
Rebound Tenderness
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
Referred Rebound Tenderness
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
Referred Pain
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.
Mnemonic for Retroperitoneal Viscera
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
Jaundice
Indication of altered bilirubin metabolism from a variety of causes – not just specific to acute hepatitis
Spider Telangiectasias
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
Butterfly Sign
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.
Muehcke’s Lines
White horrizontal lines on the nails indicative of hypoalbuminemia
Azure Lunulae
Sky blue discoloration of the nails and a green hue on the skin from the accumulation of copper associated with Wilson’s disease
Peptic Ulcer Disease
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
Serology testing for Peptic Ulcers
Serology: relatively inexpensive and relatively convenient, but not helpful to assess whether H. pylori has been eradicated with antibiotics
Stool Antigen Testing for Peptic Ulcers
Significantly more accurate than serology
Capable of detecting H. pylori infection 1 week after PPIs are discontinued
Carbon-13 (13C)–urea breath testing for Peptic Ulcers
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)
Charcots Triad
Fever with rigors, RUQ pain, and jaundice
Associated with bacterial cholangitis
Reynolds Pentad
Charcot’s triad plus altered mental status and hypotension (S&S of Septic Shock)
Associated with septic shock accompanying bacterial cholangitis
Evaluations for digestive conditions often include the following labs
CBC LFTs Amylase Lipase Coagulation Profiles UA Pregnancy Testing
Urine pregnancy testing
Beta-hCG; always check level on fertile female patient for pregnancy & ectopic pregnancy
Why check both ALT and AST
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
Common Hepatic Causes
Alcohol Use Cirrhosis Chronic Hep B Chronic Hep C Steatohepatitis (NASH) Medications/Toxins Acute Viral Hepatitis
Lactic Dehydrogenase (LDH)
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
ALP is sensitive to what?
ALP sensitive to fasting vs. non-fasting state
What would you do if the cause is unknown
If causes unknown, consider ordering Alk Phos Isoenzymes
Elevated ALP and GGT is suggestive of what?
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.
What if you have a middle-aged female patient with chronic pruritus, fatigue, and dry mouth with the above lab abnormalities
Consider a diagnosis of primary biliary cirrhosis
Consider abdominal ultrasound and cholangiogram
Consider ordering an antimichondrial titer (AMA)
Steatohepatitis Testing
Liver biopsy is the gold standard for definitive diagnosis
Markedly elevated AST and ALT (e.g. >10 fold) rarely related to steatohepatitis
Celiac Disease
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
What is the gold standard test for Wilson’s Disease
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
Videofluoroscopic swallowing study and barium esophagram
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
Esophagogastroduodenoscopy (EGD)
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
Ultrasonography
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
