exam 4: GI

Question 1

Diffuse pain could mean
1
2
3
4
5
6

Answer 1

1. Inflammatory bowel disease (IBD),
2. Irritable bowel syndrome (IBS)
3. gastroenteritis
4. AAA
5. bowel obstruction
6. ischemic bowel

Question 2

Epigastric pain could mean
1
2
3
4

Answer 2

1. MI
2. peptic ulcer disease (PUD), 3. biliary disease
3. pancreatitis

Question 3

Right upper quadrant
pain could mean
1
2
3

Answer 3

1. hepatitis

2. gallbladder (biliary) disease, 3. renal disease (pyleo or renal stone)

Question 4

Left upper quadrant pain could mean
1
2

Answer 4

1 - spleen

2- renal disease

Question 5

Periumbilical pain could mean
1
2

Answer 5

1. early appendicitis

2. small bowel disease

Question 6

Left lower quadrant: pain could mean
1
2
3
4

Answer 6

1 diverticulitis (can be diffuse)
2 PID
3 ovarian cyst
4 ectopic pregnancy

Question 7

Right lower quadrant pain could mean
1
2
3
4

Answer 7

1 appendicitis
2 PID
3 ovarian cyst
4 ectopic pregnancy

Question 8

___ sign: RUQ pain on deep inspiration: seen with inflamed gallbladder. May also be elicited by palpating the RUQ as they take a deep breath.

Answer 8

Murphey’s sign

Question 9

__ sign: Palpation of the left lower quadrant causes pain in the right lower quadrant. Seen with appendicitis

Answer 9

Rovsing sign

Question 10

___ test: Pain felt in the right lower quadrant on internal rotation of the right hip. Seen with appendicitis.

Answer 10

Cope Obturator Test

Question 11

___ sign: Extension of the right hip causes pain in the right lower quadrant. Seen with appendicitis.

Answer 11

Iliopsoas sign

Question 12

Signs of peritoneal irritation
1.
2.

Answer 12

Guarding:

   voluntary: usually symmetric, muscles more tense on inspiration, usually doesn’t hurt to rise from supine to sitting position (using abdominal muscles), lessens with distraction.
  involuntary: aysmmetrical, rigidity present on inspiration and expiration, rising to sitting position greatly increases pain, doesn’t change with distraction

Rebound tenderness: slowly compress abdomen, then quickly release pressure, pain increases.

Question 13

Imaging:
___: may detect renal stones, look for stool in colon, free air in perforation, dilated loops of bowel in obstruction

Answer 13

KUB

Question 14

_____look for gallstones, ovarian cysts or ectopic pregnancy, hydronephrosis due to renal stone, high specificity for appendicitis but not as sensitive as CT.

Answer 14

Abdominal Ultrasound

Question 15

___ most sensitive test for diagnosing acute abdominal pain. Useful for appendicitis, abscesses, AAA, diverticulitis, bowel obstruction, tumors. Renal CT for renal stones

Answer 15

CT

Question 16

___Anorexia, periumbilical pain that later migrates to RLQ, anorexia, nausea &vomiting usually after onset of pain, prefers to remain still
WBC may be normal or slightly elevated

Answer 16

Appendicitis

Question 17

___Pain is colicky, located in the epigastrium or RUQ with radiation to the flanks & occasionally the R shoulder.
Classic pain occurs within 1 hour after eating a large meal, lasts for several hours, & is followed by a residual aching that can last for days.
May have anorexia, nausea, vomiting & fever

Answer 17

CHOLELITHIASIS/ Cholecystitis

Question 18

___Abrupt onset of severe epigastric pain that may radiate to the back.
Nausea, vomiting, sweating & anxiety.
Pain is ↑ with movement or lying supine and patient prefers to sit up and lean forward.

Answer 18

Pancreatitis

Question 19

Gastroenteritis:

1. ___ cause: large volume, watery stool, no blood, Lasts 1-2 days, associated N/V, crampy abd pain, fever, malaise, dehydration in young children

Answer 19

viral

Question 20

Gastroenteritis:

1. ___ : variable from mild symptoms to severe, may have bloody diarrhea. C. difficile may occur up to 8 weeks after exposure to antibiotics, esp. Clindamycin or fluoroquinolines, with watery diarrhea and cramps
2. ____ watery diarrhea which may be prolonged, cramps

Answer 20

1. Bacterial

2. Parasitic

Question 21

___
-Mild to moderate aching abd pain, usually in LLQ, constipation or loose stools, N&V may occur, usually symptoms are mild and pts do not seek medical attention until several days after onset.

-Low-grade fever, LLQ tenderness, palpable mass, stool for occult blood +, mild-moderate ↑ WBC

Answer 21

Diverticulitis

Question 22

GERD work-up Patients < ___y/o without alarm symptoms may be treated empirically without further testing.
Patients with alarm symptoms or poor response to empiric therapy should be referred for upper GI endoscopy

Answer 22

under 55

Question 23

___Heartburn is the typical symptom. Usually occurs 30-60min after meals and with reclining. Burning chest pain and regurgitation are common. Pain may be relieved by antacids.
Most have no structural defects
Non-GI symptoms include asthma, chronic cough, laryngitis, sore throat or non-cardiac chest pain and sleep disturbance.

Answer 23

GERD

Question 24

___Dyspepsia: described as gnawing, hunger-like, burning pain in epigastric area. Pain may awaken patient. Symptoms wax and wane. May have relief with food intake or antacids and return of pain 2-4 hr later. Up to 60% NSAID-induced PUD have no symptoms.

Answer 24

Peptic Ulcer Disease

Question 25

A ___ infant is defined as one who is healthy and well fed but cries for more than 3 hrs. a day, for more than 3 days a week, and for more than 3 weeks. Characterized by severe & paroxysmal crying that occurs mainly in the late afternoon. Infant’s knees are drawn up & its fists are clenched. A behavioral sign that begins in the first few weeks and peaks at age 2-3 months. In 30-40% of cases, it continues into the 4th and 5th months.

Answer 25

colicky

Question 26

___ Most common cause of intestinal obstruction in the first 2 yrs of life. Presents as a thriving infant aged 3-12 months with paroxysmal, colicky pain, draws up knees and screams. Vomiting & diarrhea occur soon afterward in 90% of cases and bloody BMs with mucus appear within the next 12 hrs. (currant jelly stools). Prostration and fever supervene. Abd is tender and becomes distended. A sausage-shaped mass may be palpated in the upper mid abdomen. Barium or air enema is diagnostic and therapeutic. Prognosis relates to the duration before reduction.

Answer 26

Intussusception

Question 27

___Hernias – affects full-term African American children more often; most close spontaneously within 1st yr of life and majority close by the 5th year; Large defects and those persisting after age 4 are repaired surgically; in adults umbilical hernias need repair because of the high risk of incarceration and strangulation.

Answer 27

Umbilical

Question 28

___hernias – account for 75% of abdominal hernias. In children these hernias are congenital, but can be acquired from obesity, chronic cough, ascites, chronic constipation with straining, and lifting heavy objects.

Answer 28

Inguinal

Question 29

___healthy infant suddenly refuses to eat, vomits bile, and becomes inconsolable, and develops abdominal distention. This usually occurs during the first 3 weeks of life. Diagnosis: UGI shows the malrotation and it can be further confirmed with a BE. Treatment: Surgery

Answer 29

Malrotation

Question 30

___Vomiting begins 2-4 wks of age and rapidly becomes projectile after every feeding. It starts at birth in 10% of infants and onset may be delayed in premature infants. Vomitus may be blood streaked. Infant appears hungry, eats frequently, & eventually has constipation, dehydration, wt loss, & is fretful. After feeding, upper abdomen may be distended Prominent gastric peristaltic waves may be seen In some infants, an olive-sized mass can be felt on deep palpation in the right upper abdomen.

Answer 30

Pyloric Stenosis

Question 31

___Symptoms usually begin around 4-6 yrs of age. Symptoms include intestinal dilatation, bloating, increased flatulence, pain and eventually diarrhea. Symptoms appear 2 hrs. after ingestion of milk or products, sometimes as long as 12 hrs. after. Often confused with cow’s milk intolerance, which occurs in infancy and has symptoms of blood in the stools and often manifestations of allergies such as eczema, hives and asthma.

Answer 31

Lactose Intolerance

Question 32

___Acute onset of unilateral lower quadrant pain which usually is continuous and crampy with some degree of vaginal bleeding and a low-grade fever. Positive pregnancy test Ultrasound fails to reveal intrauterine pregnancy Emergent referral to OB

Answer 32

Ruptured Ectopic Pregnancy

Question 33

___Mid-cycle pain caused by irritation of the peritoneum due to spillage of fluid from the ruptured follicular cyst at time of ovulation. Sudden onset of localized unilateral lower quadrant pain, which persists for a few minutes to as long as 8 hrs. Rarely mimics the abdominal findings of appendicitis, torsion or rupture of ovarian cyst, or ectopic pregnancy. Anovulatory cycles can lead to a normal follicular cyst growing large over several cycles and causing considerable pain on rupture.

Answer 33

Mittelschmerz

Question 34

``` MISCELLANEOUS Causes of Abdominal Pain 1 2 3 4 ```

Answer 34

Dissecting aortic aneurysm Acute pyelonephritis Splenic infarction or rupture Acute mesenteric vascular occlusion and related conditions

Question 35

NONSURGICAL CONDITIONS SIMULATING ACUTE ABD PAIN

Answer 35

``` Metabolic conditions: Diabetes mellitus (ketoacidosis) Hyperthyroidism Hypercalcemia/Hyperkalemia Familial mediterranean fever Pneumonias Sickle Cell Crisis Papillary necrosis of the kidney Herpes zoster Hemolytic uremic syndrome Henoch-Schonlein purpura ```

Question 36

___Anorexia, periumbilical pain that later migrates to RLQ, anorexia, nausea &vomiting usually after onset of pain, prefers to remain still WBC may be normal or slightly elevated

Answer 36

Appendicitis

Question 37

___Pain is colicky, located in the epigastrium or RUQ with radiation to the flanks & occasionally the R shoulder. Classic pain occurs within 1 hour after eating a large meal, lasts for several hours, & is followed by a residual aching that can last for days. May have anorexia, nausea, vomiting & fever

Answer 37

CHOLELITHIASIS/ Cholecystitis

Question 38

___Abrupt onset of severe epigastric pain that may radiate to the back. Nausea, vomiting, sweating & anxiety. Pain is ↑ with movement or lying supine and patient prefers to sit up and lean forward.

Answer 38

Pancreatitis

Question 39

Gastroenteritis: 1. ___ cause: large volume, watery stool, no blood, Lasts 1-2 days, associated N/V, crampy abd pain, fever, malaise, dehydration in young children

Answer 39

viral

Question 40

Gastroenteritis: 1. ___ : variable from mild symptoms to severe, may have bloody diarrhea. C. difficile may occur up to 8 weeks after exposure to antibiotics, esp. Clindamycin or fluoroquinolines, with watery diarrhea and cramps 2. ____ watery diarrhea which may be prolonged, cramps

Answer 40

1. Bacterial | 2. Parasitic

Question 41

___ -Mild to moderate aching abd pain, usually in LLQ, constipation or loose stools, N&V may occur, usually symptoms are mild and pts do not seek medical attention until several days after onset. -Low-grade fever, LLQ tenderness, palpable mass, stool for occult blood +, mild-moderate ↑ WBC

Answer 41

Diverticulitis

Question 42

GERD work-up Patients < ___y/o without alarm symptoms may be treated empirically without further testing. Patients with alarm symptoms or poor response to empiric therapy should be referred for upper GI endoscopy

Answer 42

under 55

Question 43

___Heartburn is the typical symptom. Usually occurs 30-60min after meals and with reclining. Burning chest pain and regurgitation are common. Pain may be relieved by antacids. Most have no structural defects Non-GI symptoms include asthma, chronic cough, laryngitis, sore throat or non-cardiac chest pain and sleep disturbance.

Answer 43

GERD

Question 44

___Dyspepsia: described as gnawing, hunger-like, burning pain in epigastric area. Pain may awaken patient. Symptoms wax and wane. May have relief with food intake or antacids and return of pain 2-4 hr later. Up to 60% NSAID-induced PUD have no symptoms.

Answer 44

Peptic Ulcer Disease

Question 45

A ___ infant is defined as one who is healthy and well fed but cries for more than 3 hrs. a day, for more than 3 days a week, and for more than 3 weeks. Characterized by severe & paroxysmal crying that occurs mainly in the late afternoon. Infant’s knees are drawn up & its fists are clenched. A behavioral sign that begins in the first few weeks and peaks at age 2-3 months. In 30-40% of cases, it continues into the 4th and 5th months.

Answer 45

colicky

Question 46

___ Most common cause of intestinal obstruction in the first 2 yrs of life. Presents as a thriving infant aged 3-12 months with paroxysmal, colicky pain, draws up knees and screams. Vomiting & diarrhea occur soon afterward in 90% of cases and bloody BMs with mucus appear within the next 12 hrs. (currant jelly stools). Prostration and fever supervene. Abd is tender and becomes distended. A sausage-shaped mass may be palpated in the upper mid abdomen. Barium or air enema is diagnostic and therapeutic. Prognosis relates to the duration before reduction.

Answer 46

Intussusception

Question 47

___Hernias – affects full-term African American children more often; most close spontaneously within 1st yr of life and majority close by the 5th year; Large defects and those persisting after age 4 are repaired surgically; in adults umbilical hernias need repair because of the high risk of incarceration and strangulation.

Answer 47

Umbilical

Question 48

___hernias – account for 75% of abdominal hernias. In children these hernias are congenital, but can be acquired from obesity, chronic cough, ascites, chronic constipation with straining, and lifting heavy objects.

Answer 48

Inguinal

Question 49

___healthy infant suddenly refuses to eat, vomits bile, and becomes inconsolable, and develops abdominal distention. This usually occurs during the first 3 weeks of life. Diagnosis: UGI shows the malrotation and it can be further confirmed with a BE. Treatment: Surgery

Answer 49

Malrotation

Question 50

___Vomiting begins 2-4 wks of age and rapidly becomes projectile after every feeding. It starts at birth in 10% of infants and onset may be delayed in premature infants. Vomitus may be blood streaked. Infant appears hungry, eats frequently, & eventually has constipation, dehydration, wt loss, & is fretful. After feeding, upper abdomen may be distended Prominent gastric peristaltic waves may be seen In some infants, an olive-sized mass can be felt on deep palpation in the right upper abdomen.

Answer 50

Pyloric Stenosis

Question 51

___Symptoms usually begin around 4-6 yrs of age. Symptoms include intestinal dilatation, bloating, increased flatulence, pain and eventually diarrhea. Symptoms appear 2 hrs. after ingestion of milk or products, sometimes as long as 12 hrs. after. Often confused with cow’s milk intolerance, which occurs in infancy and has symptoms of blood in the stools and often manifestations of allergies such as eczema, hives and asthma.

Answer 51

Lactose Intolerance

Question 52

___Acute onset of unilateral lower quadrant pain which usually is continuous and crampy with some degree of vaginal bleeding and a low-grade fever. Positive pregnancy test Ultrasound fails to reveal intrauterine pregnancy Emergent referral to OB

Answer 52

Ruptured Ectopic Pregnancy

Question 53

___Mid-cycle pain caused by irritation of the peritoneum due to spillage of fluid from the ruptured follicular cyst at time of ovulation. Sudden onset of localized unilateral lower quadrant pain, which persists for a few minutes to as long as 8 hrs. Rarely mimics the abdominal findings of appendicitis, torsion or rupture of ovarian cyst, or ectopic pregnancy. Anovulatory cycles can lead to a normal follicular cyst growing large over several cycles and causing considerable pain on rupture.

Answer 53

Mittelschmerz

Question 54

``` MISCELLANEOUS Causes of Abdominal Pain 1 2 3 4 ```

Answer 54

Dissecting aortic aneurysm Acute pyelonephritis Splenic infarction or rupture Acute mesenteric vascular occlusion and related conditions

Question 55

NONSURGICAL CONDITIONS SIMULATING ACUTE ABD PAIN

Answer 55

``` Metabolic conditions: Diabetes mellitus (ketoacidosis) Hyperthyroidism Hypercalcemia/Hyperkalemia Familial mediterranean fever Pneumonias Sickle Cell Crisis Papillary necrosis of the kidney Herpes zoster Hemolytic uremic syndrome Henoch-Schonlein purpura ```