Gastrointestinal Disorders Flashcards
New pt presents with acute abdominal pain. What steps will you take to quickly r/o physical deterioration or shock?
IMMEDIATELY assess BP. Inspect and gently palpate the abdomen, noting rigid, board-like abdomen, severe rebound tenderness, or involuntary guarding
Rigid, board-like abdomen, suspect….
peritonitis
Type of GI pain that is dull and poorly localized
visceral
Type of GI pain that is sharp, localized, and worse with movement
parietal
Type of GI pain that is severe, comes and goes, patient often squirming
colic
Order of examination for the GI system
Inspection, Auscultation, Percussion, Palpation
Female of reproductive age presents with acute abdominal pain. You should always order this lab
urine HCG (pregnancy test)
Sudden severe abdominal pain, consider these differential diagnoses….
appendicitis, intestinal perforation, mesenteric infarction, dissected aorta, ruptured aortic aneurysm, ectopic pregnancy, ruptured ovarian cyst
Medical term for gall stones and gall bladder inflammation
cholelithiasis, cholecystitis
Hopkins Pearl: GI pain followed by vomiting, think….
acute surgical abdomen
Hopkins Pearl: GI pain after vomiting, think….
acute medical abdomen
True or false: When someone comes in with severe abdominal pain, give them pain medications right away so that you are able to more comfortably asses them
False - do not give pain medications until after a thorough evaluation, as you could mask important s/s
Hopkins Pearl: GI pain, high fever, lethargy, chills, think…..
shock or peritonitis
Hopkins Pearl: GI pain exaggerated by movement, think….
peritonitis
Hopkins Pearl: GI pain in rigid, immobile patient, think….
peritonitis
Hopkins Pearl: GI pain in the restless, writhing patient, think….
biliary (bile duct) or renal colic
True or false: xrays are highly diagnostic in acute abdominal pain
False - xrays are diagnostic only 50% of the time
True or false: Abdominal pain without associated symptoms is rarely a serious medical or surgical problem (Hopkins Pearl)
True
Uncommon cause of abdominal pain that is more common in the elderly, keep this on your radar….
cancer
Most common cause of acute RLQ pain requiring surgical intervention
appendicitis
Appendicitis: Overview
Appendicitis is inflammation of the appendix caused by an obstruction and/or infection. When the lumen is obstructed, it becomes distended, impairing venous blood flow and leading to tissue necrosis. When left untreated, bacterial continue to proliferate and perforation can occur. Its classic presentation includes initial visceral periumbilical pain that moves to parietal RLQ pain over 24 hours
DIAGNOSE: Acute onset of mild, colicky periumbilical pain that is vague at first but then localizes to the RLQ over the course of a day. On physical exam, found to be hypertensive and tachycardic with a mildly elevated temperature
appendicitis
Signs used to rule out appendicitis (5)
Rovsings, Psoas, Obturator, McBurney’s, Markel
Rovsing’s sign
pressure on the LLQ produces pain on RLQ
Psoas sign
straight R leg raise produces pain in RLQ
Obdurator sign
supine pt with knee 90 degrees, adduct leg produces pain in RLQ
McBurney’s sign
rebound tenderness at specific point in RLQ
Markel sign
stand on toes then drop to heels, produces pain in RLQ
Labs and diagnostic tests in appendicitis work up
Labs are not diagnostic, but may be useful in painting full clinical picture. A CBC usually reveals mild-moderate leukocytosis (10,000-20,0000)
Urinalysis may show microscopic hematuria or pyuria in 25% of cases.
A urine HCG should be taken to r/o ectopic pregnancy.
Xray is not very helpful early on, but may demonstrate changes as progresses.
Most helpful would be a CT of the abdomen (to r/o other causes) and an abdominal ultrasound (visualize inflammed appendix). A diagnostic laparoscopy could be done in female patients to r/o other pelvic conditions (PID, ectopic, etc.)
Most helpful diagnostic tools in appendicitis workup
History & physical is how you make a diagnosis. CT and abdominal US would be most useful to visualize
Primary care management of diagnosed appendicitis
refer to the ER, do not give your patient narcotics because they mask developing symptoms that may indicate a complication (such as perforation)
(4) predominant risk factors for cholecystitis
female, obese, pregnant, aging
Cholecystitis (inflammation of the gall bladder) is usually caused by….
cholelithiasis (gall stones) - specifically, cholesterol stones. Bile contains cholesterol in solution, when the bile contains more cholesterol, it crystallizes and leads to stone formation.
Your female pt just gave birth and is here for postpartum visit, experiencing RUQ pain. Suspect….
cholecystitis (gall bladder inflammation)
Hopkins Pearl: RUQ pain in diabetic pt is ______ until proven otherwise
cholecystitis (gall bladder inflammation)
Complications of cholecystitis if left untreated (3)
gangrene, abscess, perforation
Cholecystitis pain can refer to….
middle of the back, infrascapular region
Physical assessment technique to rule out cholecystitis
Murphy sign
Murphy sign
sharp CESSATION of breath when you press in on the RUQ
DIAGNOSE: Colicky abdominal pain, indigestion, nausea, low grade fever, mild jaundice. On physical exam, sharp cessation of breathing when palpating for the liver
Cholecystits
Gold standard diagnostic test for cholecystitis
ultrasound
True or false: Your pt has abdominal pain highly suspicious for cholecystitis. You should order a CT scan to confirm
False - while CT is an option, Ultrasound is the gold standard for diagnosis
Lab results expected with cholecystitis
On CBC, elevated WBCs. On CMP, elevated AST, ALT, alk phos, and bilirubin
If you have a patient at high risk for cardiac disease (diabetic, tobacco use) and they have abdominal pain near their chest, you are never wrong to do an….
ECG
Primary care treatment for cholecystitis
Referral to surgical evaluation. Recommend low-fact diet and weight loss, shock wave lithotripsy or stone dissolution medication for treatment. Consider transitioning to a lower-estrogen birth control option or alternative methods of menopausal symptom reduction than HRT
Diverticulosis vs. Diverticulitis
Diverticulosis is the presence of intestinal diverticula (outpouchings) which are asymptomatic when uninflamed. Diverticulosis occurs with painful inflammation of the diverticular mucosa
Most common locations of diverticular disease (2)
descending and sigmoid colon (LLQ)
Primary risk factor for diverticulosis
low fiber diet
DIAGNOSE: LLQ pain with blood in stool, fever, rebound tenderness, and guardign
diverticulitis
Most sensitive test for diverticulitis
CT with oral contrast
Possible diagnostic tests for working up diverticulitis
CT with oral contrast (most sensitive), barium enema, abdominal xray, CBC
Management of asymptomatic diverticulosis
high fiber diet, daily fiber supplementation with psyllium
Mildly symptomatic diverticulitis management patient with known diverticulosis
Rest, oral antibiotics, clear liquid diet
Acute, severely symptomatic diverticulitis management
hospitalization and IV antibiotics, hydration, analgesia, bowel rest and possible NG tube
Acute pancreatitis: Overview
Inflammation of the pancreas and surrounding tissue. Inflammation results in the breakdown and release of pancreatic enzymes which autodigest the tissue.
Mortality from pancreatitis is significantly increased by….
inflammation beyond the pancreas (mortality rate 10-50%)
Clinical course of mild acute pancreatitis
Hits suddenly and improves within 48-72 hours. Does not involve other organs and self-limiting. May not be diagnosed, pt assumes was food poisoning
Clinical course of severe acute pancreatitis
Often associated with complications and multisystem organ failure including hemodynamic instability, shock, renal failure, and respiratory compromise. Can be life-threatening, particularly with secondary gram-negative sepsis (100% mortality rate unless able to surgically debride)
DIAGNOSE: Abrupt, deep, epigastric pain persisting hours to days with intense sharp, boring, constant pain that is refractory to large doses of narcotics. It is aggravated by activity and improves when patient is seated and leaning forward. On physical exam, patient has tachycardia, tachypnea, abdominal tenderness with guarding
Acute pancreatitis
Primary diagnostic lab in acute pancreatitis
serum amylase (elevated up to 3x normal)
Diagnostic tests and labs for acute pancreatitis
serum amylase and lipase (expect elevation), WBC elevation, C-reactive protein elevation (with pancreatic necrosis).
CT scan or ultrasound (if gallstone pancreatitis is suspected)
Acute pancreatitis management in primary care
Severe pancreatitis should be referred to gastroenterologist or surgeon, may require hospitalization. Will be managed with fluid replacement, pain control, NPO and/or NG tube with introduction of clear fluids when pain free and amylase/lipase return to normal. Daily electrolyte and hemodynamic monitoring
Chronic pancreatitis: Overview
Progressive inflammatory process leading to irreversible fibrosis of the pancreas with destruction and atrophy of exocrine and endocrine glandular tissue.
Causes 70-80% of chronic pancreatitis cases in industrialized countries
Alcoholism
2 findings characteristic of chronic pancreatitis
hypersecretion of protein without increase in ductal bicarb (HCO3), inflammation
DIAGNOSE: Intractable abdominal pain to LUQ that is dull and constant, aggravated by food and alcohol intake. Subsequent anorexia and weight loss, malabsorption and diarrhea
chronic pancreatitis
Diagnostic workup for chronic pancreatitis
labs to determine pancreatic function (amylase, lipase, fasting blood sugar), 72-hr stool analysis (demonstrating malabsorption, fecal fat), abdominal xray
Management of chronic pancreatitis
Refer to a specialist for co-management. Recommend abstinence from alcohol, low-fat diet (<50g/day), pancreatic enzyme supplementation. May need narcotic analgesia and eventual surgery
Medical term for the layterm “stomach flu”
acute gastroenteritis
Gastroenteritis: Overview
Inflammation of the stomach and intestine.
Causative agents of acute gastroenteritis
bacteria, virus, parasite, injury to bowel mucosa, poisons, drugs
Causative agents of chronic gastroenteritis
food allergies, food intolerance, stress, lactase deficiency
Most common viral organisms that cause acute gastroenteritis (2)
rotavirus, norwalk virus
In which 2 populations are gastroenteritis a medical emergency, r/t dehydration risk
children, older adults
DIAGNOSE: Nausea, vomiting, diarrhea, fever, abdominal pain and cramping, borborygmus. Upon examination, ill-appearing but otherwise normal physical exam, abdominal pain rated 5/10
gastroenteritis
Signs of dehydration (4)
dizziness, tachycardia, dry mucus membranes, hypotension
Diagnostic workup for gastroenteritis
History and physical are typically all that are required for diagnosis. If symptoms are not resolving as expected, there is severe diarrhea or systemic symptoms, bloody stools, or you suspect protozoan infection (i.e., recent travel), then you will do further workup. This will likely include stool. May include blood cultures for systemic symptoms. Beyond this, other tests would likely be ordered by specialist (bowel biopsy, antibody tests, ELISA, flexible sigmoidoscopy)
When should you get a stool culture in suspected gastroenteritis (3)
fever >101.3F, severe diarrhea, bloody stools
Fecal leukocytes suggest….
bacterial infection
Difference between dyspepsia and heartburn
Dyspepsia includes epigastric discomfort, post-prandial fullness, belching, bloating, nausea, dysphagia and abdominal burning. Heartburn is characterized by extreme retrosternal burning pain that can be difficult to distinguish from angina pectoris, and that occasionally radiates (back, arms, jaw)
Common causes of dyspepsia (4)
medications, alcohol, giardiasis, H pylori
Most common cause of heartburn
GERD
Priority complication of GERD
Barrett’s esophagitis (pre-cancerous)
GERD: Overview
GERD is a condition in which stomach contents reflux into the esophagus, causing retrosternal burning. Reflux results from increased intra-abdominal pressure (from food, from pregnancy, etc.), decreased sphincter tone, and inappropriate lower esophageal sphincter relaxation. The normal squamous epithelium of the esophagus undergoes metaplastic changes from exposure to columnar epithelium, a tissue that is more resistant to acid but is pre-malignant and 40x more at risk for esophageal cancer.
DIAGNOSE: Pt presents with heartburn, regurgitation, water brash, sour taste, belching, coughing, and hoarseness. Physical exam unremarkable. Hemoccult positive for microscopic blood in stool.
GERD
Hopkins Pearl: Any patient who presents with odynophagia, they need….
EGD (esophagogastroduodenoscopy) - upper endoscopy procedure
When to refer your GERD pt to a specialist
dysphagia, odynophagia, GI bleeding, iron deficiency anemia, unintentional weight loss, early satiety, vomiting
Precipitating or aggravating factors for GERD
Reclining after eating, eating a large meal, alcohol, chocolate, caffeine, decaf coffee, fatty or spicy food, constrictive clothing, heavy lifting, peppermint or spearmint, garlic, citrus fruit, tomato products, certain medications
Test of choice for documenting type and extent of tissue damage in GERD
upper endoscopy with biopsy
GERD vs. PUD pain
PUD pain usually relieved by food, GERD pain worsened by food
Cholelithiasis pain is more common after meals high in….
fat
Lifestyle modifications for GERD
weight loss, small frequent meals, avoid high-fat meals, avoid aggravating foods, quit smoking, avoid tight clothing around waist, sleep with HOB elevated
Pharmacotherapy for GERD
H2 blockers. If no improvement, step up to a PPI. Continue for 6 weeks and then re-evaluate. An 8-week course of a PPI daily is 80% effective, 2x daily is 95% effective. Maintenance therapy is often necessary for severe erosive esophagitis
Criteria for PUD
penetrates the muscularis mucosa and is >5mm in diameter
(3) main causes of PUD
H pylori, NSAIDs/aspirin, acid hypersecretion
Duodenal ulcers usually come with impaired secretion of….
bicarbonate (HCO3)
Hopkins Pearl: Primary care management of dysphagia and odynophagia
automatic referral
DIAGNOSE: Pt reports of burning, gnawing abdominal pain after meals and worse a night, localized to the same spot. Physical exam unremarkable
PUD
Duodenal vs. Gastric ulcers and food
Duodenal are aggravated by food. Gastric are relieved by food
Gold standard for diagnosing PUD
Upper GI endoscopy (with biopsy for H Pylori testing)
Priority non-pharm recommendation for managing PUD
smoking cessation
Drug of choice for managing PUD
PPI (heal 90% of gastric ulcers in 8 weeks and duodenal ulcers in 4 weeks)
Pharmacotherapy for H pylori
3 drug combo - two abx and a PPI
When to refer for PUD
No improvement of a duodenal ulcer in 2 weeks, refer to gastroenterology for endoscopy. If suspect gastric ulcer, refer to gastro for endo r/t higher incidence of cancer. FUP is necessary for anyone not responding to tx.
When to refer your pt with diarrhea
Hospitalize if unable to maintain hydration and volume depleted - particularly in elderly. Refer to GI specialist if bloody or purulent diarrhea (concern for IBD)
Category of constipation: low fiber or suppression of defecation
simple
Category of constipation: slowed transit time, IBS, diverticular disease
disordered motility
Category of constipation: medications, chronic laxative use, immobility
secondary
Non-pharm treatment for constipation
Increase dietary fiber to 25-35g/day, increase fluids, exercise, toilet hygiene
Melena
black, tarry stools positive for occult blood
Most common cause of melena
upper GI bleeding
DIAGNOSE: Pt presents with diffuse abdominal pain, discomfort relieved by defecation, frequent stools (>3 per day), passing mucus, feelings of straining, urgency, and incomplete evacuation
IBS
IBS rarely presents for the first time in patients older than….
50yo
Up to 33% of folks develop IBS after….
bacterial gastroenteritis
Chronic immunological disease resulting in intestinal inflammation only of the colon, resulting in friability, erosions, and bleeding
ulcerative colitis
Chronic immunological disease resulting in intestinal inflammation of any or all of the bowel as well as any portion of the GI tract
crohn’s disease
Type of bowel obstruction resulting from a mechanical blockage (i.e., tumor, fecal impaction)
simple
Type of bowel obstruction when its results from a disruption in motility (i.e., paralytic ileus)
functional
DIAGNOSE: Sudden onset of colicky abdominal pain with dehydration, abdominal distention, and high pitched hyperactive bowel sounds
bowel obstruction
Diagnostic test for bowel obstruction
xray
One of the few abdominal conditions that an xray is most helpful for
bowel obstruction
Primary care management of a bowel obstruction
hospitalization and immediate referral to surgeon
External vs. Internal hemorrhoids origin
External hemorrhoids originate from the inferior hemorrhoidal plexus. Internal from the superior hemorrhoidal plexus
DIAGNOSE: Abrupt, intense pain after defection associated with a perianal lump. Pruritis, and frank rectal bleeding
Hemorrhoids
Primary care management of hemorrhoids
Recommend oral analgesia (acetaminophen or NSAIDs), sitz baths, bulk-forming laxatives, increase fiber slowly (25-35g/day), topical hydrocrotisone cream for pruritis. Last option would be to refer for excision
Types of groin hernias (3)
indirect inguinal (most common), direct inguinal, femoral
Types of ventral hernias (3)
epigastric, umbilical, incisional
All patients with _______ hernias require surgical consultation
abdominal
Post-surgical patient education for groin hernia
SURGERY: Return to normal activities in 1 week, avoid heavy lifting or contact sports for 4-6 weeks
LAPAROSCOPIC REPAIR: resume all activities as soon as 2 days post-procedure
Types of colorectal polyps (3)
hyperplastic, adenomatous, submucosal
Type of colorectal polyp that is neoplastic
adenomatous
Diet characteristics at high risk for colorectal cancer
high in fat, red meat, refined carbs, low in plant fiber
Screening for colorectal cancer includes
colonoscopy
Inflammation of the bladder is called….
cystitis
Inflammation of the bladder wall is called….
interstitial cystitis
DIAGNOSE: Dysuria, urinary frequency, low back pain and suprapubic pain, cloudy foul-smelling urine
Lower UTI
Diagnostic test for lower UTI
clean-catch, midstream urine sample for urinalysis
Urinalysis of UTI patient may exhibit:
cloudy appearance, alkalkine pH, hematuria, nitrates, leukocyte esterase, sediments of WBCs mucus and bacterial overgrowth
UA result indicative of infection
> 100,000 organisms/mL
Gold standard laboratory confirmation of UTI
urine culture
Lower vs. Upper UTI differentiation
Lower UTI does not exhibit signs of sepsis (fever, chills, flank and CVA tenderness)
Mainstay over lower UTI treatment
antibiotics
Hopkins Pearl: If pt continually coming in with UTI symptoms that does not bear out with culture, suspect…
interstitial cystitis (does not respond to abx)
How often should an indwelling catheter be changed
Q4-6 weeks
Patient education when to notify provider with UTI
flank pain, hematuria, or lack of response to antibiotics
Patient education with UTI self-management
Finish the full course of antibiotics. Increase fluid intake to 8 8-oz glasses of water. Wear cotton underclothes, avoid harsh soaps and scented feminine hygiene products, use condoms, empty bladder frequently and completely, take showers instead of baths.
Medical term for kidney stones
nephrolithiasis
Majority of kidney stones form from….
calcium oxalate or calcium phosphate (65-85% of cases)
Type of kidney stone found predominantly in women and associated with UTIs
struvite stones
DIAGNOSE: Sudden onset of colicky abdominal pain, nausea, diaphoresis, dysuria, hematuria, and weakness. ON exam, found to have abdominal guarding and CVAT
kidney stone
Diagnostic testing options for nephrolithiasis
urinalysis, CBC, “blood chemistry”. You can do a KUB xray to ID where the stone is located
Diagnosis of renal stones is confirmed by….
urinalysis positive for blood, followed by renal visualization with xray or US
Primary care management of kidney stones
Referral to urology. Recommend increasing fluid intake (8 8-oz glasses of water per day), pain management (NSAIDs promote relaxation of ureteral smooth muscle), warm compresses to the lower back. Monitor UOP and strain urine for passed stones. Avoid OTC medications containing phosphorus, vitamin D, and calcium. Promote vitamin B6 and magnesium
Preventative recommendations for kidney stones
Avoid caffeine, beer, wine, oxalate-rich foods (beets, black tea, chocolate, lamb, nuts, rhubarb, spinach), eliminate milk and cola, limit intake of purine-rich foods (organ meats)
Most common predisposing factor for ectopic pregnancy
PID
DIAGNOSE: History of amenorrhea and irregular vaginal bleeding. Now presents with pelvic pain, nausea, vomiting. On physical exam, found to have tenderness on palpation with palpable adnexal mass.
Ectopic pregnancy
Most common cause of PID
chlamydia
Essential diagnostic tests to r/o ectopic pregnancy (2)
serum HCG, pelvic US
PID is described as an ________ infection
ascending
Priority complication if PID ascends intra-abdominally
perihepatitis (Fitz-Hugh-Curtis syndrome)
Hopkins Pearl: Anytime you have a female on birth control pills who has been on them without breakthrough bleeding…. and now she presents with breakthrough bleeding, suspect….
infection
Minimum CDC criteria for diagnosing PID (4)
lower abdominal pain, adnexal tenderness, CMT, absence of a competing diagnosis
DIAGNOSE: Pt presents with lower abdominal pain, fever, cervical inflammation with yellowish discharge, CMT, adnexal tenderness.
PID
Lab tests in the workup of PID
blood HCG (r/o ectopic preg), CBC, HIV, gonorrhea/chlamydia culture, wet prep for BV or trich
Diagnostic test for PID
pelvic US
