Exam 2 - GI problems (need to know) Flashcards
1
Q
Gallbladder disease risk factors
A
- Native American
- Over age 40
- Female
- Family history
- Diet
- Medications (estrogen, OCP, thiazide)
- Obesity
- Rapid weight loss
- History of gastric bypass surgery
2
Q
Acute versus chronic cholecystitis
A
Acute: less than 1 month
Chronic: longer than 3 months
3
Q
Symptomatic cholelithiasis symptoms
A
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
4
Q
Charcot triad for cholelithiasis
A
- RUQ pain
- Fever
- Jaundice
5
Q
Cholecystitis patient presentation
A
- 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
6
Q
Cholecystitis physical exam findings
A
- Positive Murphy’s sign (inability to take a deep breath because of discomfort during palpation beneath right costal margin)
7
Q
Cholangitis patient presentation
A
Same as cholecystitis plus
- Jaundice
- Altered mental status
- Shock/sepsis
8
Q
Diagnostic labs for cholecystitis and cholangitis
A
- CBC with diff
- Urinalysis
- LFT
- Pancreatic enzymes
- BUN and creatinine (renal function and electrolyte balance)
- CMP
- hCG if childbearing age
9
Q
Gold standard imaging for gallstones
A
Abdominal ultrasound
10
Q
Pharmacologic treatment of symptomatic gallbladder disease
A
Isotonic IV rehydration and correction of electrolyte imbalances
11
Q
Pharmacologic treatment for uncomplicated cholelithiasis
A
- Antispasmodic
- Antiemetic
- NG tube for stomach decompression with protracted vomiting
- NSAIDs, narcotics for pain control
12
Q
When are ursodeoxycholic acid and/or chenodeoxycholic acid indicated for gallstone dissolution?
A
- Patients with mild symptoms
- Stone size <0.5-1 cm
- Normal gallbladder function
13
Q
What is the gold standard treatment for symptomatic gallbladder disease?
A
Laparoscopic cholecystectomy
14
Q
Gallbladder disease patient education
A
- Lifestyle and diet modifications (especially if obese)
- Complications include blockage of common bile duct → symptomatic gallbladder disease requires surgery
15
Q
Volume repletion rate for mild dehydration (pediatrics)
A
50 mL/kg over 4 hours
16
Q
Volume repletion rate for moderate dehydration (pediatrics)
A
100 mL/kg over 4 hours
17
Q
Volume repletion rate for severe dehydration (pediatrics)
A
NS or LR IV 20 mL/kg bolus
18
Q
Pyloric stenosis risk factors
A
- Preterm
- Male
- Caucasian first born male
19
Q
Pyloric stenosis - HPI
A
- 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
20
Q
Pyloric stenosis - physical exam findings
A
- Weight loss
- Non bilious vomiting immediately after feeding
- “Olive” shaped mass in epigastrium to right of midline
21
Q
Imaging indicated for pyloric stenosis
A
Ultrasound
22
Q
Pyloric stenosis management
A
Surgical intervention (pyloromyotomy) indicated after correcting fluid and electrolyte imbalances
23
Q
GI specialist referrals are indicated when…
A
- 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
24
Q
Appendicitis HPI
A
- Epigastric or periumbilical pain
- Pain migration to RLQ
- Abdominal rigidity
- N/V, anorexia
25
Appendicitis physical exam findings
* Abdominal tenderness with cough
* Signs of peritoneal irritation (guarding, rebound tenderness, obturator sign, psoas sign)
26
Abnormal presentations of appendicitis
* Pain **better** when lying down
* “Bump” sign - pain when driving over speed bump while driving
* Markle sign - pain with jumping
27
What is McBurney's point?
Sign of appendicitis
* Tenderness in RLQ between the umbilicus and anterosuperior iliac spine
28
What is Rovsings sign?
Sign of appendicitis
* RLQ pain with palpation of LLQ
29
Appendicitis diagnostic testing
* History and physical exam findings
* Elevated WBC count
* hCG (females)
* Serum amylase and lipase
* CRP
* Urinalysis
30
First line imaging for appendicitis (when diagnosis of abdominal pain is unclear)
CT abdomen/pelvis with contrast
31
Is pharmacologic therapy indicated for appendicitis?
* Perioperative
* Perforated appendix
* Suspected septicemia
* Scheduled laparoscopic surgery
32
True/false: Immediate surgical referral or transfer to the ER is indicated for suspected appendicitis
33
Appendicitis treatment
* Appendectomy within 24 hours of symptom onset
* NPO, IV fluid, electrolyte repletion
34
Small bowel obstruction clinical manifestations
* Intermittent and crampy abdominal pain
* Vomiting, constipation
* Abdominal distention
* Hyperactive bowel sounds
* Fever
35
What relieves abdominal pain related to small bowel obstructions?
* Vomiting
* Intestinal tube decompression
* Passage of intestinal contents through a partial obstruction
36
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
37
Imaging for small bowel obstruction
Abdominal CT scan with contrast if abdominal infection or mechanical obstruction suspected
38
Small bowel obstruction labs
* Elevated WBC
* Electrolyte abnormalities
* Elevated hematocrit, creatinine, BUN (dehydration)
* hCG
39
Non pharmacologic management of small bowel obstruction
* Restriction of oral intake
* IV fluid therapy
* Electrolyte and acid-base correction
* NG tube for gastric decompression
40
Pharmacologic management of small bowel obstruction
Antiemetics for systemic relief
41
Are antibiotics indicated for small bowel obstructions?
Not indicated, but IV broad spectrum antibiotics can be used for strangulated bowel or adjunct to surgery
42
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
43
Signs of ischemic bowel
* Fever
* Severe and continuous pain
* Hematemesis
* Peritoneal signs
* Hypotension
* Gas in bowel wall or portal vein
* Abdominal free air
* Acidosis
44
Do peptic ulcer perforations occur more often with duodenal or gastric ulcers?
Duodenal ulcers
45
Causes of peptic ulcers
* H. pylori infection
* Medications (aspirin, bisphosphonates, NSAIDs, potassium chloride)
* Gastric malignancy
* Tobacco abuse
46
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
47
Peptic ulcer physical exam findings
* Board-like abdominal rigidity
* Gastric ulcer: pain after eating
* Duodenal ulcer: pain between meals
48
Imaging to diagnose peptic ulcers
Chest x-ray → pneumoperitoneum
Confirmed with endoscopy
49
Peptic ulcer labs
* CBC with diff
* Serum electrolytes - BUN, creatinine, amylase
* H. pylori
* Stool for occult blood
* hCG
50
Non pharmacologic management of peptic ulcer disease
* IV fluid resuscitation
* Correct electrolyte abnormalities
* Continuous NG suction for decompression
51
Pharmacologic management for peptic ulcer disease
* IV PPI and broad spectrum antibiotics
* Transfusion if hemorrhage
52
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
53
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
54
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
55
True/false: An immediate hospital referral is indicated for suspected peritonitis
True
56
What is the most common cause of primary spontaneous bacterial peritonitis in adults?
Cirrhosis complicated by variceal hemorrhage and ascites
57
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
58
Peritonitis clinical manifestation
* High fever, chills
* Acute abdominal pain that is diffuse, localized, or referred
* N/V/D/C
59
Peritonitis physical exam findings
* Abdominal distention and rigidity
* Decreased bowel sounds
* Diffuse abdominal tenderness
* Rebound tenderness and guarding
* Fever, tachycardia, tachypnea, hypotension
60
What findings would make the provider suspect a diagnosis of peritonitis?
* Fever
* Abdominal pain
* Tenderness
* Leukocytosis
61
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
62
What diagnostic study is needed for confirmatory diagnosis of peritonitis?
Laparotomy
63
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
64
Non pharmacological management of peritonitis
* Fluid resuscitation
* Careful monitoring of VS and fluid balance
* NG tube
65
Pharmacologic management of primary bacterial peritonitis
Empiric antibiotic therapy until culture results available
* 3rd or 4th generation cephalosporin
* Quinolone
66
Pharmacologic management of secondary bacterial peritonitis
* May require surgical intervention
* Metronidazole + carbapenem
67
Abdominal aortic aneurysm risk factors
* Male
* Family history
* Advanced age
* Caucasian
* Smoker
* Hypertension
* Atherosclerosis
68
True/false: Most aortic aneurysms are asymptomatic until they rupture
True
69
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
70
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
71
Screening recommendations for abdominal aortic aneurysms
Men ages 65-75 with positive history of smoking
72
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
73
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
74
Abdominal aortic aneurysm symptom triad
* Hypotension
* Shooting back or abdominal pain
* Pulsatile abdominal mass
75
Diverticular disease risk factors
* Low fiber diet
* Aspirin and NSAID use
* Lack of exercise
* Obesity
* Consumption of red or processed meats
* Smoking
76
Diverticulosis symptoms
* Intermittent abdominal pain
* Bloating
* Excessive flatulence
* Irregular defecation
* Urinary dysfunction, anorexia, N/V, heartburn
77
What imaging techniques can diagnose diverticulosis?
Colonoscopy, CT san
78
Diverticulosis patient education
* Goal of 30-35 g/day of fiber
79
When is hospitalization indicated for diverticulitis?
* Fever above 101.3
* Signs of peritonitis
* Suspected abscess
* Intestinal obstruction
* Sepsis
* Hypovolemia
80
Diverticulitis clinical presentation
* LLQ abdominal pain
* Fever
* Leukocytosis
81
Diverticulitis physical exam findings
* LLQ tenderness + guarding and rigidity
* Mild distention
82
Diverticulitis diagnostic imaging
CT scan w/ contrast → bowel wall thickening, pericolic fat stranding, pericolic fluid
* Colonoscopy (4-6 weeks after acute episode has resolved)
83
Diverticulitis labs
* CBC w/ diff
* CRP
* Urinalysis
* BUN and creatinine in older patients and patients with renal insufficiency
84
Are antibiotics indicated for uncomplicated diverticular disease?
No, but necessary to avoid sepsis in acute diverticulitis
85
If antibiotics are used to treat uncomplicated diverticulitis, which should be prescribed?
* Bactrim + metronidazole
* Amoxicillin-clavulanate potassium
* Ciprofloxacin + metronidazole
86
Outpatient management of diverticulitis
* Bowel rest (clear liquids and follow up in 48-72 hours)
* Increased fluid intake
* Oral antibiotics to cover colonic flora
87
External versus internal hemorrhoids
External → distal to dentate line, sensitive to touch, temperature, stretch
Internal → proximal to dentate line, painless
88
Hemorrhoid patient education
* Increase dietary intake of fiber
* Topical corticosteroids
* Increase fluid intake
* Avoid straining and prolonged time on the toilet
89
Do most anal fissures occur in the posterior or anterior midline?
Posterior
90
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
91
First line treatment of anal fissures
* Increase dietary fiber
* Stool softeners
* Sitz baths
92
Gold standard treatment of chronic anal fissures
Lateral internal sphincterotomy (LIS)
93
What diarrheal findings would prompt immediate medical evaluation?
* Fever
* Significant abdominal pain
* Bloody stool
* Dehydration
* Unintentional weight loss
* Family history of colorectal cancer
94
What is osmotic diarrhea?
Includes malabsorptive disorders and results from ingested, solute-rich molecules leaving the vascular space and entering the colon
95
What is secretory diarrhea?
Most common → watery stool as the absorptive function of the gut is compromised
96
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
97
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
