Exam 2 - GI problems (need to know) Flashcards
Gallbladder disease risk factors
- Native American
- Over age 40
- Female
- Family history
- Diet
- Medications (estrogen, OCP, thiazide)
- Obesity
- Rapid weight loss
- History of gastric bypass surgery
Acute versus chronic cholecystitis
Acute: less than 1 month
Chronic: longer than 3 months
Symptomatic cholelithiasis symptoms
Presents as biliary colic
- Intermittent or steady RUQ abdominal pain
- Radiates to right posterior shoulder within one hour of eating a large meal with high fat content
- Pain lasts 1-6 hours
- Nausea and vomiting
Charcot triad for cholelithiasis
- RUQ pain
- Fever
- Jaundice
Cholecystitis patient presentation
- Recurrent, mild to moderate RUQ and epigastric abdominal pain
- Nausea and vomiting
- Pain may radiate to right shoulder; worse after eating fatty foods
- Fever
- Loss of appetite
Cholecystitis physical exam findings
- Positive Murphy’s sign (inability to take a deep breath because of discomfort during palpation beneath right costal margin)
Cholangitis patient presentation
Same as cholecystitis plus
- Jaundice
- Altered mental status
- Shock/sepsis
Diagnostic labs for cholecystitis and cholangitis
- CBC with diff
- Urinalysis
- LFT
- Pancreatic enzymes
- BUN and creatinine (renal function and electrolyte balance)
- CMP
- hCG if childbearing age
Gold standard imaging for gallstones
Abdominal ultrasound
Pharmacologic treatment of symptomatic gallbladder disease
Isotonic IV rehydration and correction of electrolyte imbalances
Pharmacologic treatment for uncomplicated cholelithiasis
- Antispasmodic
- Antiemetic
- NG tube for stomach decompression with protracted vomiting
- NSAIDs, narcotics for pain control
When are ursodeoxycholic acid and/or chenodeoxycholic acid indicated for gallstone dissolution?
- Patients with mild symptoms
- Stone size <0.5-1 cm
- Normal gallbladder function
What is the gold standard treatment for symptomatic gallbladder disease?
Laparoscopic cholecystectomy
Gallbladder disease patient education
- Lifestyle and diet modifications (especially if obese)
- Complications include blockage of common bile duct → symptomatic gallbladder disease requires surgery
Volume repletion rate for mild dehydration (pediatrics)
50 mL/kg over 4 hours
Volume repletion rate for moderate dehydration (pediatrics)
100 mL/kg over 4 hours
Volume repletion rate for severe dehydration (pediatrics)
NS or LR IV 20 mL/kg bolus
Pyloric stenosis risk factors
- Preterm
- Male
- Caucasian first born male
Pyloric stenosis - HPI
- Regurgitation and non projectile vomiting during first few weeks of life
- Projectile, non bilious vomiting at 2-3 weeks of life
- Insatiable appetite with weight loss, dehydration, constipation
Pyloric stenosis - physical exam findings
- Weight loss
- Non bilious vomiting immediately after feeding
- “Olive” shaped mass in epigastrium to right of midline
Imaging indicated for pyloric stenosis
Ultrasound
Pyloric stenosis management
Surgical intervention (pyloromyotomy) indicated after correcting fluid and electrolyte imbalances
GI specialist referrals are indicated when…
- Suspected GI bleed
- Bowel obstruction
- Orthostatic vital sign changes
- Jaundice
- Positive pregnancy test
- Severe localized or unilateral lower abdominal pain
- Any indication of peritoneal irritation
Appendicitis HPI
- Epigastric or periumbilical pain
- Pain migration to RLQ
- Abdominal rigidity
- N/V, anorexia
Appendicitis physical exam findings
- Abdominal tenderness with cough
- Signs of peritoneal irritation (guarding, rebound tenderness, obturator sign, psoas sign)
Abnormal presentations of appendicitis
- Pain better when lying down
- “Bump” sign - pain when driving over speed bump while driving
- Markle sign - pain with jumping
What is McBurney’s point?
Sign of appendicitis
- Tenderness in RLQ between the umbilicus and anterosuperior iliac spine
What is Rovsings sign?
Sign of appendicitis
- RLQ pain with palpation of LLQ
Appendicitis diagnostic testing
- History and physical exam findings
- Elevated WBC count
- hCG (females)
- Serum amylase and lipase
- CRP
- Urinalysis
First line imaging for appendicitis (when diagnosis of abdominal pain is unclear)
CT abdomen/pelvis with contrast
Is pharmacologic therapy indicated for appendicitis?
- Perioperative
- Perforated appendix
- Suspected septicemia
- Scheduled laparoscopic surgery
True/false: Immediate surgical referral or transfer to the ER is indicated for suspected appendicitis
Appendicitis treatment
- Appendectomy within 24 hours of symptom onset
- NPO, IV fluid, electrolyte repletion
Small bowel obstruction clinical manifestations
- Intermittent and crampy abdominal pain
- Vomiting, constipation
- Abdominal distention
- Hyperactive bowel sounds
- Fever
What relieves abdominal pain related to small bowel obstructions?
- Vomiting
- Intestinal tube decompression
- Passage of intestinal contents through a partial obstruction
Concerning signs that warrant urgent referral to surgery (small bowel obstruction)
- Pain that progresses in severity, localizes, becomes constant
- Localized tenderness
- Abdominal guarding
- Rebound tenderness
- Rigidity
Imaging for small bowel obstruction
Abdominal CT scan with contrast if abdominal infection or mechanical obstruction suspected
Small bowel obstruction labs
- Elevated WBC
- Electrolyte abnormalities
- Elevated hematocrit, creatinine, BUN (dehydration)
- hCG
Non pharmacologic management of small bowel obstruction
- Restriction of oral intake
- IV fluid therapy
- Electrolyte and acid-base correction
- NG tube for gastric decompression
Pharmacologic management of small bowel obstruction
Antiemetics for systemic relief
Are antibiotics indicated for small bowel obstructions?
Not indicated, but IV broad spectrum antibiotics can be used for strangulated bowel or adjunct to surgery
Is a small bowel obstruction a medical emergency?
Yes - urgent laparotomy required if patient does not respond to supportive care, advanced illness, ischemia, or perforation
Signs of ischemic bowel
- Fever
- Severe and continuous pain
- Hematemesis
- Peritoneal signs
- Hypotension
- Gas in bowel wall or portal vein
- Abdominal free air
- Acidosis
Do peptic ulcer perforations occur more often with duodenal or gastric ulcers?
Duodenal ulcers
Causes of peptic ulcers
- H. pylori infection
- Medications (aspirin, bisphosphonates, NSAIDs, potassium chloride)
- Gastric malignancy
- Tobacco abuse
Peptic ulcer clinical manifestation
- Abrupt onset of severe abdominal pain followed by peritoneal signs
- Pain begins in epigastrium and spreads throughout the abdomen with radiation to scapular areas
- Coffee-ground emesis
- Hematemesis or melena
- Hematochezia
- Decreased perception of pain within 6-12 hours after perforation
Peptic ulcer physical exam findings
- Board-like abdominal rigidity
- Gastric ulcer: pain after eating
- Duodenal ulcer: pain between meals
Imaging to diagnose peptic ulcers
Chest x-ray → pneumoperitoneum
Confirmed with endoscopy
Peptic ulcer labs
- CBC with diff
- Serum electrolytes - BUN, creatinine, amylase
- H. pylori
- Stool for occult blood
- hCG
Non pharmacologic management of peptic ulcer disease
- IV fluid resuscitation
- Correct electrolyte abnormalities
- Continuous NG suction for decompression
Pharmacologic management for peptic ulcer disease
- IV PPI and broad spectrum antibiotics
- Transfusion if hemorrhage
Indications for referral and hospitalization for peptic ulcer disease
- Uncontrolled bleeding
- Hemodynamically unstable
- Signs of peritonitis
- Free extravasation of contrast material on upper GI studies
Peptic ulcer disease patient education
- Older adults at higher risk due to increased use of NSAIDs, aspirin, warfarin, bisphosphonates
- Long term tobacco and alcohol use increases risk
Alarming symptoms that might suggest gastric cancer
- Unintentional weight loss
- Early satiety
- Dysphagia or odynophagia
- GI bleed
- Iron deficiency anemia
- Persistent vomiting
- Palpable abdominal mass
- Adenopathy
- Consider EGD in patients >50 years or family history of GI malignancy
True/false: An immediate hospital referral is indicated for suspected peritonitis
True
What is the most common cause of primary spontaneous bacterial peritonitis in adults?
Cirrhosis complicated by variceal hemorrhage and ascites
What is the most common cause of secondary peritonitis?
Spillage of GI or GU microorganisms into the peritoneal space
- Most often the result of peritoneal dialysis, perforated viscus, penetrated wounds
Peritonitis clinical manifestation
- High fever, chills
- Acute abdominal pain that is diffuse, localized, or referred
- N/V/D/C
Peritonitis physical exam findings
- Abdominal distention and rigidity
- Decreased bowel sounds
- Diffuse abdominal tenderness
- Rebound tenderness and guarding
- Fever, tachycardia, tachypnea, hypotension
What findings would make the provider suspect a diagnosis of peritonitis?
- Fever
- Abdominal pain
- Tenderness
- Leukocytosis
What initial imaging and lab work could be collected in the primary care setting for suspected peritonitis?
- Chest and abdominal x-ray
- CBC w/ diff
- Serum electrolyte with BUN and creatinine
What diagnostic study is needed for confirmatory diagnosis of peritonitis?
Laparotomy
On what basis should the provider diagnose spontaneous bacterial peritonitis if the patient has cirrhosis?
- Clinical appearance
- Presence of ascites
- Ascitic fluid analysis
Requires paracentesis in hospital setting
Non pharmacological management of peritonitis
- Fluid resuscitation
- Careful monitoring of VS and fluid balance
- NG tube
Pharmacologic management of primary bacterial peritonitis
Empiric antibiotic therapy until culture results available
- 3rd or 4th generation cephalosporin
- Quinolone
Pharmacologic management of secondary bacterial peritonitis
- May require surgical intervention
- Metronidazole + carbapenem
Abdominal aortic aneurysm risk factors
- Male
- Family history
- Advanced age
- Caucasian
- Smoker
- Hypertension
- Atherosclerosis
True/false: Most aortic aneurysms are asymptomatic until they rupture
True
Abdominal aortic aneurysm clinical presentation
Rupture causes sudden onset severe abdominal pain that may be confined to the flank, low back, or groin with radiation to the back
Abdominal aortic aneurysm physical exam findings
- Abdominal distention
- Pulsations (painful) felt directly over mass and displace examining fingers laterally - near xiphoid process and umbilicus
- Aortic bruit
- Diminished or absent peripheral pulses
Screening recommendations for abdominal aortic aneurysms
Men ages 65-75 with positive history of smoking
Are diagnostic tests indicated for the diagnosis of abdominal aortic aneurysms?
Additional diagnostics (other than screening) not required → immediate hospital referral for resuscitation and therapy in OR
What imaging would be indicated if abdominal aortic aneurysm diagnosis is in doubt?
CT scan - determine extent of aneurysm
Angiography - preoperatively to demonstrate aortic and vascular anatomy and renal vessel involvement
Abdominal aortic aneurysm symptom triad
- Hypotension
- Shooting back or abdominal pain
- Pulsatile abdominal mass
Diverticular disease risk factors
- Low fiber diet
- Aspirin and NSAID use
- Lack of exercise
- Obesity
- Consumption of red or processed meats
- Smoking
Diverticulosis symptoms
- Intermittent abdominal pain
- Bloating
- Excessive flatulence
- Irregular defecation
- Urinary dysfunction, anorexia, N/V, heartburn
What imaging techniques can diagnose diverticulosis?
Colonoscopy, CT san
Diverticulosis patient education
- Goal of 30-35 g/day of fiber
When is hospitalization indicated for diverticulitis?
- Fever above 101.3
- Signs of peritonitis
- Suspected abscess
- Intestinal obstruction
- Sepsis
- Hypovolemia
Diverticulitis clinical presentation
- LLQ abdominal pain
- Fever
- Leukocytosis
Diverticulitis physical exam findings
- LLQ tenderness + guarding and rigidity
- Mild distention
Diverticulitis diagnostic imaging
CT scan w/ contrast → bowel wall thickening, pericolic fat stranding, pericolic fluid
- Colonoscopy (4-6 weeks after acute episode has resolved)
Diverticulitis labs
- CBC w/ diff
- CRP
- Urinalysis
- BUN and creatinine in older patients and patients with renal insufficiency
Are antibiotics indicated for uncomplicated diverticular disease?
No, but necessary to avoid sepsis in acute diverticulitis
If antibiotics are used to treat uncomplicated diverticulitis, which should be prescribed?
- Bactrim + metronidazole
- Amoxicillin-clavulanate potassium
- Ciprofloxacin + metronidazole
Outpatient management of diverticulitis
- Bowel rest (clear liquids and follow up in 48-72 hours)
- Increased fluid intake
- Oral antibiotics to cover colonic flora
External versus internal hemorrhoids
External → distal to dentate line, sensitive to touch, temperature, stretch
Internal → proximal to dentate line, painless
Hemorrhoid patient education
- Increase dietary intake of fiber
- Topical corticosteroids
- Increase fluid intake
- Avoid straining and prolonged time on the toilet
Do most anal fissures occur in the posterior or anterior midline?
Posterior
If an anal fissure is not in the posterior midline, what other causes does this indicate?
- STD
- TB
- HIV
- Ulcerative colitis
- Crohn disease
- Malignant neoplasm
First line treatment of anal fissures
- Increase dietary fiber
- Stool softeners
- Sitz baths
Gold standard treatment of chronic anal fissures
Lateral internal sphincterotomy (LIS)
What diarrheal findings would prompt immediate medical evaluation?
- Fever
- Significant abdominal pain
- Bloody stool
- Dehydration
- Unintentional weight loss
- Family history of colorectal cancer
What is osmotic diarrhea?
Includes malabsorptive disorders and results from ingested, solute-rich molecules leaving the vascular space and entering the colon
What is secretory diarrhea?
Most common → watery stool as the absorptive function of the gut is compromised
What symptoms would prompt the provider to collect a stool sample for c. diff with consideration of IBD?
- Temperature above 102
- Blood diarrhea
- Abdominal pain
- 6+ unformed stools in 24 hour period
- Profuse watery diarrhea
- Dehydration
If diarrhea continues for 2+ weeks and suspected cause is non infectious, what conditions would the provider suspect as the cause?
- Colitis
- Diverticulitis
- Pancreatitis
- IBS and IBD
