Exam 3 Flashcards
Red flags for abdominal pain
fever, chills, leukocytosis with increases neutrophils and bands on the differential, and rebound tenderness
Abdominal pain lasting >6 hours or the pain wakes up the patient at night
New onset constipation >50 years old
RUQ pain
cholecystitis, RLL pneumonia, acute hepatitis
LUQ pain
Gastritis, pancreatitis, MI, LLL pneumonia
RLQ pain
Appendicitis, ectopic pregnancy, ovarian cyst, diverticulitis, endometriosis
LLQ pain
Diverticulitis
GI imaging for plain flat/upright
Ileus, bowel obstruction, perforation
GI imaging fo abdominal US
gallbladder, pelvic organs, appendix, kidneys, liver
GI imaging CT
Acute abdominal pain, diverticulitis
GI imaging MRI
Hepatocellular carcinoma, metastatic disease
GI imaging EGD
Upper GI
GI imaging colonoscopy
Lower GI
Lower abdominal pain in females
Can indicate gynecologic problem–ovarian cyst, ectopic pregnancy
Causes of acute abdominal pain
Appendicits, cholecystitis, diverticulitis, small bowel obstruction, perforated peptic ulcer, peritonitis, ruptured ectopic pregnancy, PID, ruptured AAA, hypercalcemia, superior mesenteric artery syndrome, acute intermittent porphyria
3 s/s most predictive of acute appendicitis
Pain that starts in the epigastrium or periumbilical area, migration of the pain to the RLQ, and abdominal rigidity
McBurney point
Appendicitis
Rovsing sign
RLQ pain elicited by palpating left lower quadrant
Obturator sign
Passive rotation of the right leg with the patient supine and right hip and knee flexed
Psoas sign
Supine patient raises straightened right leg against resistant
Perioperative antibiotics for appendicitis
Metronidazole and ceftizoxime
intermittent and crampy abdominal pain, vomiting, obstipation, abdominal distention, hyperactive bowel sound and fever; pain usually relieved by vomiting, intestinal tube decompression or passage of intestinal contents through partial obstruction
Small bowel obstruction
distended tympanic abdomen with peristaltic rushes and high pitched tinkling sounds initially but may be absent as disorder progresses; diffuse midabdominal tenderness common; localized tenderness, abdominal guarding, rebound tenderness and rigidity concerning signs
Small bowel obstruction
abrupt onset of severe abdominal pain followed rapidly by peritoneal signs; pains begin in the epigastrium and spread rapidly throughout the abdomen with frequent early radiation of pain to the scapular areas
Perforated peptic ulcer
Diagnosis of perforated peptic ulcer
Detection of pneumoperitoneum on upright abdominal or chest x ray
high fever, acute abdominal pain that can be diffuse, localized or referred; tenderness, N/V, diarrhea or constipation
abdominal distention, rigidity, decreased bowel sounds, diffuse abdominal tenderness, rebound tenderness, guarding
Peritonitis
Antibiotics for peritonitis
3rd or 4th generation cephalosporin or quinolone
Decline in leukocyte count after 24-48 hours after antimicrobial therapy
abdominal, flank, or back pain with radiation to the back
Pulsatile painful mass palpated in the abdomen, aortic bruit
Ruptured aortic aneurysm
Risk factors for cholesterol stones
female, obesity, pregnancy, aging, drug induced, cystic fibrosis, rapid weight loss, spinal cord injury, ileal disease, DM, sickle cell anemia
biliary colic with intermittent or steady, right upper quadrant abdominal pain that radiates to the right posterior shoulder within an hour of eating any type of large meal, specifically high fat
Cholecystitis/cholelithiasis
Drugs that increase risk of cholelithiasis
Fibric acid derivatives, contraceptives, steroids, estrogen, progesterone, sandostatin, ceftriaxone
RUQ tenderness and guarding and rigidity, distended gall bladder, hypoactive bowel sounds, positive murphy sign, jaundice, dehydration
Cholecystitis
Cirrhosis
End stage consequence of progressive hepatic fibrosis affecting normal liver function; serious, irreversible disease which is the result of exposure to persistent toxins and resulting in liver failure and death
autoimmune destruction of the intrahepatic bile ducts and eventual development of cirrhosis and liver failure
Primary biliary cirrhosis
jaundice, spider angiomata, gynecomastia, ascites, splenomegaly, palmar erythema, digital clubbing, and asterixis may be presenting signs; liver may be nodular, firm, enlarged or shrunken and spleen may be enlarged; fluid wave and increased abdominal girth if ascites is present
Cirrhosis
Tx of cirrhosis
Immunizations: pneumococcal, flu, hep A and B
Eliminate NSAID and alcohol
Antiviral for Hepatitis
Prevention of GI bleeding in cirrhosis
Administer a beta blocker (propranolol), consult with gastroenterologist, monitor PT and platelet count
Constipation
<3 bowel movements per week + passage of hard or lumpy stools, sensation of straining, feeling of incomplete evacuation, use of manual maneuvers to aid defecation
Alarm symptoms constipation
sudden change in bowel habits, weight loss >10 pounds, blood in stool, anemia, family history of colon cancer or inflammatory bowel disease, constipation resistant to treatment >50 years old
Chronic constipation differential
low dietary fiber, fundamental constipation, IBS, fecal impaction, anal fissure, hemorrhoids, drug induced, bowel tumors
First line constipation meds
Bulking agents
Psylliym, methylcellulose, polycarbophil
Stool softeners
Docusate sodium, mineral oil
Osmotic laxatives
Magensium hydroxide, PEG, lactulose, sorbitol
Stimulant laxative
Senna, bisacodyl
Osmotic diarrhea
Lactase deficienc, magneisum sulfate, small bowel injury
Secretory diarrhea
Bacterial enterotoxins such as E Coli, laxative abuse, bile salt malabsorption, endocrine tumors
Treatment of C diff
Metronidazole or vancomysin
Treatment of IBD diarrhea
Sulfasalazine or mesalamine + steroid
Risk factors for diverticulitis
Consumption of red or processed meats, obesity, smoking, low fiber diet
Diverticulosis
asymptomatic or symptomatic presence of noninflamed multiple colonic diverticula: outpouching or mucosa through colon wall
may have flattened or ribbon like to hard pellet stools; may have alternating diarrhea and constipation, bouts of steady or crampy pain mainly in left lower quadrant and abdominal distention
Diverticulitis
complicated disease associated with inflammation in or more of the diverticula with possible resultant perforation leading to abscess or fistula formation
mild to moderate, colicky to steady, aching abdominal pain usually present in the left lower quadrant accompanied by fever and leukocytosis; may be loose stools or constipation and may be N/V
Treatment of diverticulitis
May have spontaneous resolution
Clear liquids, limit physical activity
Oral abx: Bactrim + metronidazole OR augmentin or Cipro + metronidazole
Short term low fiber diet
Treatment of choice for GERD
Prescription PPI
Prevents acid production at the final juncture of the histamine, gastrin and acetylcholine pathways
-Prazole
Barrett esophagus
Infrequent, pre-malignant condition associated with chronic >5 years esophageal injury resulting from reflux
Patches of normal gray-white stratified squamous cell mucosa of the esophagus change into the light pink columnar epithelium
Hepatitis A
caused mostly by contaminated food or water; risk factors include crowded conditions (prisons, nursing homes, daycares)
Transmitted by fecal oral route but can be detected in blood
Can be excreted in feces 2 weeks before symptoms
Hepatitis C
Risk factors: IV drug use, sex with IV drug user, tattooing, body piercing, alcohol use
Nonalcoholic fatty liver disease
Associated with metabolic syndrome–abdominal obesity, hyperlipidemia, and diabetes
anorexia, fatigue, myalgias, nausea, fever, headaches, arthralgias, vomiting and abdominal pain; jaundice is rare
Hepatitis
most accurate test to determine amount of inflammation and scarring in the liver
Biopsy
Chronic inflammation of the lining of the colonic mucosa and the submucosal layer; beginning in the rectum and may involve the entire colon or only part of the colon (Worse in the rectum)
4-10 bowel movements per day; small to large amountso f blood and mucous; abdominal pain, impaired nutrition
Ulcerative colitis
Smoking protective
Friability, erosions and bleeding
All layers of the intestinal tract wall are affected; can occur in segments of the GI tract (patchy)
Diarrhea with blood intermittently, steatorrhea, abdominal cramping and pain
Crohn Disease
Fistulas can occur
Smoking makes worse
abdominal pain (diffuse or localized to the right or left lower quadrants); spasms, urgency and fecal incontinence may be reported with active rectal inflammation; stools loose or watery and may have blood
Inflammatory bowel disease
1st line for IBD
Mesalamine, sulfasalazine (5-aminosalicylic acid)
Medications for IBS
Antispasmodics–dicyclomine (bentyl)
Anti-diarrheals, anti-constipation, antidepressant
Cornerstones of antiemetic therapy
5-HT3 recepto blockers: ondansetron and dolasteron
Treatment of generalized N/V
Bismuth subsalicylate, metoclopramide, prochlorperazine, promethazine
Treatment of nausea associated with chemo
Serotonin blockers (ondansetron), dopamine receptor blockers (phenothiazines), cannabinoids, benzos
Treatment of motion sickness
Antihistamine/anticholinergic
Diphenhydramine, meclizine, promethazine, scopolamine
Ranson criteria
For acute pancreatitis
if >7 there is 100% mortality
Most common cause of pancreatitis
Gallstones
ABC causes of acute pancreatitis
Alcohol, autoimmune, arteritis, biliary, congenital, drugs, ERCP, eosinophila, formation of tumors, genetic, hyperlipidemia, hypercalcemia, idiopathic infections
sudden onset of sharp, poorly localized abdominal pain that radiates to the back
Pancreatitis
patient usually reluctant to take a deep breath due to severe abdominal pain; pain worse in supine position; abdominal distention due to leakage of fluid into the retroperitoneum; rebound tenderness are late signs
Pancreatitis
Diagnostics for pancreatitis
Serum amylase and lipase
Rise 6-12 hours after onset of symptoms
Management of acute pancreatitis
Early IV hydration
Pain treated with opioid–demerol
Clear fluids when pain-free
Causes of chronic pancreatitis
Chronic alcoholism, duct obstruction from tumors, hypercalcemia, hyperlipidemia, genetics, autoimmune
abdominal pain epigastric with potential referral to upper back, anterior chest or flank; N/V may accompany the pain; pain intensifies with alcohol or fatty food; weight loss, diarrhea and steatorrhea due to fat
Pancreatitis
2 types of PUD
NSAID or H Pylori
epigastric pain (sharp, burning, aching, gnawing pain) or dyspepsia; pain usually relieved by food or antacids or have pain with eating
PUD
1st line therapy for PUD
Antisecretory therapy
Discontinue NSAID or COX-2 inhibitors
H2 blockers for PUD
Cimetifine, famotidine, nizatidine, ranitidine
PPI for PUD
Omeprazole, lansoprazole, rabeprazole, esomeprazole
Prostaglandin therapy for PUD
Misoprostol only available agent for NSAID induced gastric ulcer
H Pylori treatment
- Omeprazole + Clarithromycin, then omeprazole
- Ranitifine bismuth + Clarithromycin, then ranitidine
- Bismuth subsalicylate + Metronidazole + Tetracycline + ranitidine
- Lansoprazole, amoxicillin, and clarithromycin
1st line treatment for fever
Acetaminophen
Differentials for lymphadenopathy CHICAGO
Cancers, hypersensitivities, infection, connective tissue disease, atypical lymphoproliferative disorders, granulomatous lesions, other
fever, chills, headache, malaise, myalgia, loss of appetite
dry cough, nasal congestion with clear discharge and sore throat
Influenza
4 treatments of flu
Amantadine, rimantadine, zanamivir, oseltamivir
Most common cause of acute diarrhea
Norovirus
Most common organism for travelers diarrhea
E Coli
Abx for travelers diarrhea
Cipro or azithromycin
Treatment of C Diff
Oral metronidazole or oral vancomycin