Exam 3 GI Diagnostics Flashcards
RLQ Pain differential dx
- acute appendicitis
- mesenteric adenitis
- right renal colic
- torsed right testis
- chron’s
- gynecologic causes?
acute appendicitis clues
RLQ pain
shift of pain, anorexia, localized tenderness
mesenteric adenitis pain
RLQ pain
fever, inconstant signs
renal colic
RLQ pain or LLQ pain
colicky pain, hematuria
torsed testis
RLQ pain/LLQ pain
tender swollen testis, usually young age
chron’s disease
RLQ pain
recurrent, several day hx
LLQ pain differential dx
- diverticular disease
- acute urinary retention
- UTI
- inflammatory bowel disease
- large bowel obstruction
- left renal colic
- torsion of testis
diverticular disease clues
LLQ pain
elderly pt, recurrent
acute urinary retention pain
LLQ pain
palpable bladder, difficulty passing urine
UTI clues
LLQ pain
dysuria, frequency
inflammatory bowel disease clues
LLQ pain
recurrent attacks, diarrhea (+/- mucus, blood)
large bowel obstruction clues
LLQ pain
colicky pain, constipation
differential dx- LUQ and epigastric pain
- splenic rupture
- fractured ribs
- pancreatitis
- gastritis/ PUD
- PNA
splenic rupture clues
RUQ/ epigastric pain
hx of trauma or splenic disease
fractured ribs clues
LUQ/RUQ
hx of trauma, gross deformity, extreme tenderness on palpation
pancreatitis clues
LUQ/epigastric pain
hx of etoh, hx of similar event, elevated labs
gastritis/ PUD clues
LUQ/epigastric pain
recurrent, relationship to meals, relationship to posture
pna clues
LUQ/epigastric pain
fever, CXR findings, bronchial breathing
differential dx RUQ
- biliary colic, acute cholecystitis
- acute hepatitis
- right pyelonephritis
- CHF
- retrocecal appendicitis
- R LLQ PNA
biliary colic, acute cholecystitis clues
RUQ pain
recurrent attacks, tender over gallbladder
acute hepatitis clues
ruq pain
etoh hx, jaundice, meds
right pyelnophritis
RUQ pain
dysuria, fever, CVA tenderness
CHF clues
RUQ pain
edema, dyspnea, elevated JVP
retrocecal appendicitis clues
RUQ pain
shift of pain, tenderness
right LL pna clues
RUQ pain
fever, tachypnea, bronchial breathing
if female is childbearing age and having abd pain, do what
- ask location of pain
- do pregnancy test
never miss dx of ectopic pregnancy
c diff toxin assay
gram + spindle shaped anaerobic bacterium
produces toxins- toxins produce bloating, diarrhea, bleeding and necrosis of bowel wall
transmitted from person to person by oral - fecal route
tests for c diff dx
stool sample
presence of toxins a and b determined in lab by ELISA (enzyme linked immunoabsorbant assay)
test specific for each toxin- A and B
c diff stool sample should be ordered for any pt with diarrhea/bloating, who:
- is hospitalized, in nursing home, or recently dc from hospital or SNF
- pts on ATBs or who are immunocompromised esp at risk
- bloody diarrhea
Is c diff test specific
yes
how is c diff spread
by spores that are ingested - spores remain dormant on surfaces for a long time - the oral fecal rout accounts for spread of the disease
symptoms of c diff infection
bloating, gas, diarrhea, rectal bleeding
what is test for c diff and how is it performed
ELISA test done for c diff toxins a and b in stool
what is best way to limit spread of c diff
regular hand washing and thorough cleaning of all surfaces with a cleanser containing bleach
esophagogastroduodenoscopy aka EGD aka upper endoscopy
Flexible fiber optic tube to directly visualize the esophagus, stomach and the first part of the duodenum
as with cscope, lumen is viewed directly, smaples and bx can be obtained
EGD prep
NPO
conscious sedation used, so pt needs someone to drive them home after EGD
recommendations for appropriate EGD
older patients (esp those w/ symptoms or unexplained wt loss)
those with positive fecal occult blood tests
history or documented hematemesis or bloody stool
weight loss
trouble swallowing
early satiety
not necessary to EGD on all pts with complaints or disorders r/t esophagus or stomach if:
- under age of 55 (CA less likely)
- not anemic from blood loss in GI tract
- no s/s of obstruction or perforation of stomach (acute abdomen)
treatment can be initiated based on H&P and if tx fails, pt can be referred***
when to refer pt to egd?
New symptoms over age 55, bleeding, anemia, unexplained weight loss in an older person especially, patients with emergent sysptoms of possible obstruction or perforation, swallowing difficulties, and when treatment for GERD or dyspepsia fails to alleviate symptoms.
what would you tell pt before EGD?
explain sedation procedure (check allergies and reactions to sedation in the past), someone must accompany the patient to drive them home after the procedure, NPO after midnight but may take meds if can do so at least 60 min prior to procedure (take with a glass of water)
What limits the sensitivity and specificity of the EGD?
Skill of the endoscopist, and technical factors making it difficult to visualize the entire mucosa of the esophagus, stomach and duodenum.
helicobacter pylori
gram - bacterium
associated with duodenal and gastric ulcers
can cause erosive gastritis and esophagitis
ASA and NSAIDs can also cause ulceration and gastritis
what re 2 main causes of PUD and gastritis
h pylori, asa, nsaids
tests for h pylori
blood for antibodies, urea breath test, stool for bacterial antigen, biopsy (urease test, microscopic examination and culture)
What are the two best tests for H pylori if a biopsy is not obtained? Why?
stool for antigen and urea breath test bc less invasive
endoscope for h pylori
is gold standard but not first lign
fresh stool for h pylori
tested for presence of h pylori antigen
urea breath test for h pylori
breath analyzed for co2 content
co2 produced by breakdown of urea by urease secreted by organism
blood test for antibodies for h pylori
can detect immunoglobins made by hosts immune system to parts of h pylori organism
caution against this bc if pt ever had h pylori antibodies they would be present, false positive
pts without alarm symptoms- bleeding, perforation, obstruction
may be evaluated and treated as outpatient based on results for h pylori
use urea breath test or stool test
h pylori tx
triple/quadruple tx- 2 ATB and ppi
symptomatic treatment for PUD
PPI or H2 blocker
if h pylori tests are negative and symptoms recur after tx, do what
pt referred for egd
protein, blood values
6-8.5 g/dl
blood proteins have 2 components
- albumin (60% of blood protein)
carries meds and hormones throughout body. helps with tissue growth and healing - globulins (40% of blood protein)
group of proteins. some made by liver. others by immune system. help fight infection and transport nutreints
albumin value
3.5 - 5 g /dl
albumin fx
maintains oncotic pressure, keeps excess fluid from seeping into tissues
transports amino acid nutrients to cells
when albumin low, what happens
oncotic pressure in vascular system is reduced and fluid leaks into surrounding tissues
accounts for edema in pts with low albumin
uses for albumin
Measure of nutrition Post-op patients Liver disease Various cancers Chronic diseases Renal disease Burn victims Pregnancy
reduced albumin levels from
- malnutrition
- renal disease
- advanced cirrhosis
- meds- ie estrogen and po contraceptives, can reduce albumin while total protein may remain WNL
- p/o esp GI surgery and recovery prolonged
- burns
where is albumin made
liver
where is globulin made
reticuloendothelial cells
stool tests
- culture and sensitivity
- ova and parasites
- WBCs
stool tests
Toxigenic infectious agents take over the normal flora or inflame the mucosa of the bowel
bacteria, virus, parasitic infections
most common cause of gastroenteritis in US
viruses
bacteria organism causing gastroetneritis
e coli, campylobacter, shigella, salmonella
stool culture
a stool sample is collected in a cup or on a swab to send to the microbiology lab for culture and sensitivity
In the lab, the specimen is placed on various culture media to grow the suspected bacteria.
stool sample continued
examined under the microscope for ova and parasites - may reveal evidence of a parasitic GI infestation
Stool for ova and parasites should be fresh, i.e. not sit around all night to be brought for testing the next day
Stool for WBCs may be collected with a swab.
gi disease caused by virus, bacteria, and parasites causes
diarrhea, maybe bloody
bleeding
bloating
n/v
recommendations for stool sample
Only unusual situations should trigger testing.
Most cases of viral illness are self-limited and require no testing.
When symptoms last longer than 1 - 2 days without stopping or patients are very ill with dehydration stool should be sent for culture and sensitivity.
Low grade symptoms for a week or more or they have traveled to under-developed countries or have drank unfiltered Rocky Mountain stream water send stool for ova and parasites.
if stool sample negative the first time and causative agent is strongly suspected, what to do
repeat test
WBC in stool sample
helpful when trying to decide if causative organism is viral or bacterial and stool cx is pending
WBC more plentiful wen pt has symptoms from bacterial disease, will not occur in viral disease
positive stool cx is diagnostic for
E coli, shigella, salmonella, toxigenic E coli or campylobacter
positive stool for ova and parasites requires
consideration of appropriate pharmacologic tx
When would you order a stool test for bacterial culture and sensitivity?
Unexplained lower GI tract symptoms (diarrhea, bloating, gas, bleeding) not abating in 24 to 48 hours
When would you order a stool test for ova and parasites?
For lower GI symptoms (gas, bloating, loose stools or diarrhea) lasting longer than 1 - 2 weeks especially if there has been travel to countries where parasites are endemic or if the patient has been hiking in the Rocky Mountains (giardia)
What is the purpose of ordering a semi-quantative test for stool white blood cells?:
To help decide between a viral and a bacterial etiology of lower GI symptoms
What is important for patient to know about collecting a stool sample for ova and parasites?
stool must be in lab while still warm
List the indications for colonoscopy:
Screening (disease detection), bleeding, weight loss in older adult especially, unexplained diarrhea, bloating, gas or symptoms not responding to treatment, abdominal pain, change in stool size, constipation (maybe if severe and unresponsive to stool softeners and periodic laxatives).
DX ca with bx
diagnose bleeding in the lower GI tract - diverticuli, ulcerative colitis, Crohn Disease, polyps, fissures, etc
What function does blood urea play?
Formed in the liver as a breakdown product of proteins, it is transported to the kidney for excretion
what causes elevated BUN
Blood in the gut, dehydration, renal disease
when there is large amount of protein to digestion
under what circumstances might BUN be low
chronic liver failure
bun normal range
7 - 30 mg/dl
what happens to bun with inadequate hydration
BUN is not excreted as well by kidney, BUN increases (dehydration)
usual ratio of BUN to Cr
10 to 1
the longer the blood in GI tract, what happens to bun/cr ratio
it is higher with longer amount of time
celiac disease
digestive disease that damages small intestine and interferes with absorption of nutrients of food
ppl cannot tolerate gluten, protein in wheat, rye, and barely
gluten found in many foods, meds, vitamins, lip balms
when ppl with celiac disease eat foods or used products containing gluten what happens
immune system responds by damaging or destroying villi lining in small intestine
villi does what
normally allows nutreints from food to be absorbed through walls of small intestine into blood stream
w/o healthy villi, person becomes malnourished
celiac dx
Bloodwork- anti-tissue transglutaminase antibodies plus an IgA antibody (tTG-IgA)
positive in about 98% of patients with celiac disease who are on a gluten-containing diet
Intestinal BX- small intestine; through endocope (EGD)
a biopsy of the small intestine is the only way to diagnose celiac disease
