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Adult Primary Care > Gastrointestinal Disorders > Flashcards

Gastrointestinal Disorders Flashcards

1
Q

New pt presents with acute abdominal pain. What steps will you take to quickly r/o physical deterioration or shock?

A

IMMEDIATELY assess BP. Inspect and gently palpate the abdomen, noting rigid, board-like abdomen, severe rebound tenderness, or involuntary guarding

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2
Q

Rigid, board-like abdomen, suspect….

A

peritonitis

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3
Q

Type of GI pain that is dull and poorly localized

A

visceral

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4
Q

Type of GI pain that is sharp, localized, and worse with movement

A

parietal

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5
Q

Type of GI pain that is severe, comes and goes, patient often squirming

A

colic

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6
Q

Order of examination for the GI system

A

Inspection, Auscultation, Percussion, Palpation

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7
Q

Female of reproductive age presents with acute abdominal pain. You should always order this lab

A

urine HCG (pregnancy test)

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8
Q

Sudden severe abdominal pain, consider these differential diagnoses….

A

appendicitis, intestinal perforation, mesenteric infarction, dissected aorta, ruptured aortic aneurysm, ectopic pregnancy, ruptured ovarian cyst

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9
Q

Medical term for gall stones and gall bladder inflammation

A

cholelithiasis, cholecystitis

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10
Q

Hopkins Pearl: GI pain followed by vomiting, think….

A

acute surgical abdomen

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11
Q

Hopkins Pearl: GI pain after vomiting, think….

A

acute medical abdomen

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12
Q

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

A

False - do not give pain medications until after a thorough evaluation, as you could mask important s/s

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13
Q

Hopkins Pearl: GI pain, high fever, lethargy, chills, think…..

A

shock or peritonitis

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14
Q

Hopkins Pearl: GI pain exaggerated by movement, think….

A

peritonitis

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15
Q

Hopkins Pearl: GI pain in rigid, immobile patient, think….

A

peritonitis

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16
Q

Hopkins Pearl: GI pain in the restless, writhing patient, think….

A

biliary (bile duct) or renal colic

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17
Q

True or false: xrays are highly diagnostic in acute abdominal pain

A

False - xrays are diagnostic only 50% of the time

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18
Q

True or false: Abdominal pain without associated symptoms is rarely a serious medical or surgical problem (Hopkins Pearl)

A

True

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19
Q

Uncommon cause of abdominal pain that is more common in the elderly, keep this on your radar….

A

cancer

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20
Q

Most common cause of acute RLQ pain requiring surgical intervention

A

appendicitis

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21
Q

Appendicitis: Overview

A

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

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22
Q

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

A

appendicitis

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23
Q

Signs used to rule out appendicitis (5)

A

Rovsings, Psoas, Obturator, McBurney’s, Markel

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24
Q

Rovsing’s sign

A

pressure on the LLQ produces pain on RLQ

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25
Q

Psoas sign

A

straight R leg raise produces pain in RLQ

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26
Q

Obdurator sign

A

supine pt with knee 90 degrees, adduct leg produces pain in RLQ

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27
Q

McBurney’s sign

A

rebound tenderness at specific point in RLQ

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28
Q

Markel sign

A

stand on toes then drop to heels, produces pain in RLQ

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29
Q

Labs and diagnostic tests in appendicitis work up

A

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.)

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30
Q

Most helpful diagnostic tools in appendicitis workup

A

History & physical is how you make a diagnosis. CT and abdominal US would be most useful to visualize

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31
Q

Primary care management of diagnosed appendicitis

A

refer to the ER, do not give your patient narcotics because they mask developing symptoms that may indicate a complication (such as perforation)

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32
Q

(4) predominant risk factors for cholecystitis

A

female, obese, pregnant, aging

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33
Q

Cholecystitis (inflammation of the gall bladder) is usually caused by….

A

cholelithiasis (gall stones) - specifically, cholesterol stones. Bile contains cholesterol in solution, when the bile contains more cholesterol, it crystallizes and leads to stone formation.

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34
Q

Your female pt just gave birth and is here for postpartum visit, experiencing RUQ pain. Suspect….

A

cholecystitis (gall bladder inflammation)

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35
Q

Hopkins Pearl: RUQ pain in diabetic pt is ______ until proven otherwise

A

cholecystitis (gall bladder inflammation)

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36
Q

Complications of cholecystitis if left untreated (3)

A

gangrene, abscess, perforation

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37
Q

Cholecystitis pain can refer to….

A

middle of the back, infrascapular region

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38
Q

Physical assessment technique to rule out cholecystitis

A

Murphy sign

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39
Q

Murphy sign

A

sharp CESSATION of breath when you press in on the RUQ

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40
Q

DIAGNOSE: Colicky abdominal pain, indigestion, nausea, low grade fever, mild jaundice. On physical exam, sharp cessation of breathing when palpating for the liver

A

Cholecystits

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41
Q

Gold standard diagnostic test for cholecystitis

A

ultrasound

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42
Q

True or false: Your pt has abdominal pain highly suspicious for cholecystitis. You should order a CT scan to confirm

A

False - while CT is an option, Ultrasound is the gold standard for diagnosis

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43
Q

Lab results expected with cholecystitis

A

On CBC, elevated WBCs. On CMP, elevated AST, ALT, alk phos, and bilirubin

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44
Q

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….

A

ECG

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45
Q

Primary care treatment for cholecystitis

A

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

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46
Q

Diverticulosis vs. Diverticulitis

A

Diverticulosis is the presence of intestinal diverticula (outpouchings) which are asymptomatic when uninflamed. Diverticulosis occurs with painful inflammation of the diverticular mucosa

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47
Q

Most common locations of diverticular disease (2)

A

descending and sigmoid colon (LLQ)

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48
Q

Primary risk factor for diverticulosis

A

low fiber diet

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49
Q

DIAGNOSE: LLQ pain with blood in stool, fever, rebound tenderness, and guardign

A

diverticulitis

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50
Q

Most sensitive test for diverticulitis

A

CT with oral contrast

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51
Q

Possible diagnostic tests for working up diverticulitis

A

CT with oral contrast (most sensitive), barium enema, abdominal xray, CBC

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52
Q

Management of asymptomatic diverticulosis

A

high fiber diet, daily fiber supplementation with psyllium

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53
Q

Mildly symptomatic diverticulitis management patient with known diverticulosis

A

Rest, oral antibiotics, clear liquid diet

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54
Q

Acute, severely symptomatic diverticulitis management

A

hospitalization and IV antibiotics, hydration, analgesia, bowel rest and possible NG tube

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55
Q

Acute pancreatitis: Overview

A

Inflammation of the pancreas and surrounding tissue. Inflammation results in the breakdown and release of pancreatic enzymes which autodigest the tissue.

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56
Q

Mortality from pancreatitis is significantly increased by….

A

inflammation beyond the pancreas (mortality rate 10-50%)

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57
Q

Clinical course of mild acute pancreatitis

A

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

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58
Q

Clinical course of severe acute pancreatitis

A

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)

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59
Q

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

A

Acute pancreatitis

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60
Q

Primary diagnostic lab in acute pancreatitis

A

serum amylase (elevated up to 3x normal)

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61
Q

Diagnostic tests and labs for acute pancreatitis

A

serum amylase and lipase (expect elevation), WBC elevation, C-reactive protein elevation (with pancreatic necrosis).

CT scan or ultrasound (if gallstone pancreatitis is suspected)

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62
Q

Acute pancreatitis management in primary care

A

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

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63
Q

Chronic pancreatitis: Overview

A

Progressive inflammatory process leading to irreversible fibrosis of the pancreas with destruction and atrophy of exocrine and endocrine glandular tissue.

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64
Q

Causes 70-80% of chronic pancreatitis cases in industrialized countries

A

Alcoholism

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65
Q

2 findings characteristic of chronic pancreatitis

A

hypersecretion of protein without increase in ductal bicarb (HCO3), inflammation

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66
Q

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

A

chronic pancreatitis

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67
Q

Diagnostic workup for chronic pancreatitis

A

labs to determine pancreatic function (amylase, lipase, fasting blood sugar), 72-hr stool analysis (demonstrating malabsorption, fecal fat), abdominal xray

68
Q

Management of chronic pancreatitis

A

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

69
Q

Medical term for the layterm “stomach flu”

A

acute gastroenteritis

70
Q

Gastroenteritis: Overview

A

Inflammation of the stomach and intestine.

71
Q

Causative agents of acute gastroenteritis

A

bacteria, virus, parasite, injury to bowel mucosa, poisons, drugs

72
Q

Causative agents of chronic gastroenteritis

A

food allergies, food intolerance, stress, lactase deficiency

73
Q

Most common viral organisms that cause acute gastroenteritis (2)

A

rotavirus, norwalk virus

74
Q

In which 2 populations are gastroenteritis a medical emergency, r/t dehydration risk

A

children, older adults

75
Q

DIAGNOSE: Nausea, vomiting, diarrhea, fever, abdominal pain and cramping, borborygmus. Upon examination, ill-appearing but otherwise normal physical exam, abdominal pain rated 5/10

A

gastroenteritis

76
Q

Signs of dehydration (4)

A

dizziness, tachycardia, dry mucus membranes, hypotension

77
Q

Diagnostic workup for gastroenteritis

A

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)

78
Q

When should you get a stool culture in suspected gastroenteritis (3)

A

fever >101.3F, severe diarrhea, bloody stools

79
Q

Fecal leukocytes suggest….

A

bacterial infection

80
Q

Difference between dyspepsia and heartburn

A

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)

81
Q

Common causes of dyspepsia (4)

A

medications, alcohol, giardiasis, H pylori

82
Q

Most common cause of heartburn

A

GERD

83
Q

Priority complication of GERD

A

Barrett’s esophagitis (pre-cancerous)

84
Q

GERD: Overview

A

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.

85
Q

DIAGNOSE: Pt presents with heartburn, regurgitation, water brash, sour taste, belching, coughing, and hoarseness. Physical exam unremarkable. Hemoccult positive for microscopic blood in stool.

A

GERD

86
Q

Hopkins Pearl: Any patient who presents with odynophagia, they need….

A

EGD (esophagogastroduodenoscopy) - upper endoscopy procedure

87
Q

When to refer your GERD pt to a specialist

A

dysphagia, odynophagia, GI bleeding, iron deficiency anemia, unintentional weight loss, early satiety, vomiting

88
Q

Precipitating or aggravating factors for GERD

A

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

89
Q

Test of choice for documenting type and extent of tissue damage in GERD

A

upper endoscopy with biopsy

90
Q

GERD vs. PUD pain

A

PUD pain usually relieved by food, GERD pain worsened by food

91
Q

Cholelithiasis pain is more common after meals high in….

A

fat

92
Q

Lifestyle modifications for GERD

A

weight loss, small frequent meals, avoid high-fat meals, avoid aggravating foods, quit smoking, avoid tight clothing around waist, sleep with HOB elevated

93
Q

Pharmacotherapy for GERD

A

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

94
Q

Criteria for PUD

A

penetrates the muscularis mucosa and is >5mm in diameter

95
Q

(3) main causes of PUD

A

H pylori, NSAIDs/aspirin, acid hypersecretion

96
Q

Duodenal ulcers usually come with impaired secretion of….

A

bicarbonate (HCO3)

97
Q

Hopkins Pearl: Primary care management of dysphagia and odynophagia

A

automatic referral

98
Q

DIAGNOSE: Pt reports of burning, gnawing abdominal pain after meals and worse a night, localized to the same spot. Physical exam unremarkable

A

PUD

99
Q

Duodenal vs. Gastric ulcers and food

A

Duodenal are aggravated by food. Gastric are relieved by food

100
Q

Gold standard for diagnosing PUD

A

Upper GI endoscopy (with biopsy for H Pylori testing)

101
Q

Priority non-pharm recommendation for managing PUD

A

smoking cessation

102
Q

Drug of choice for managing PUD

A

PPI (heal 90% of gastric ulcers in 8 weeks and duodenal ulcers in 4 weeks)

103
Q

Pharmacotherapy for H pylori

A

3 drug combo - two abx and a PPI

104
Q

When to refer for PUD

A

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.

105
Q

When to refer your pt with diarrhea

A

Hospitalize if unable to maintain hydration and volume depleted - particularly in elderly. Refer to GI specialist if bloody or purulent diarrhea (concern for IBD)

106
Q

Category of constipation: low fiber or suppression of defecation

A

simple

107
Q

Category of constipation: slowed transit time, IBS, diverticular disease

A

disordered motility

108
Q

Category of constipation: medications, chronic laxative use, immobility

A

secondary

109
Q

Non-pharm treatment for constipation

A

Increase dietary fiber to 25-35g/day, increase fluids, exercise, toilet hygiene

110
Q

Melena

A

black, tarry stools positive for occult blood

111
Q

Most common cause of melena

A

upper GI bleeding

112
Q

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

A

IBS

113
Q

IBS rarely presents for the first time in patients older than….

A

50yo

114
Q

Up to 33% of folks develop IBS after….

A

bacterial gastroenteritis

115
Q

Chronic immunological disease resulting in intestinal inflammation only of the colon, resulting in friability, erosions, and bleeding

A

ulcerative colitis

116
Q

Chronic immunological disease resulting in intestinal inflammation of any or all of the bowel as well as any portion of the GI tract

A

crohn’s disease

117
Q

Type of bowel obstruction resulting from a mechanical blockage (i.e., tumor, fecal impaction)

A

simple

118
Q

Type of bowel obstruction when its results from a disruption in motility (i.e., paralytic ileus)

A

functional

119
Q

DIAGNOSE: Sudden onset of colicky abdominal pain with dehydration, abdominal distention, and high pitched hyperactive bowel sounds

A

bowel obstruction

120
Q

Diagnostic test for bowel obstruction

A

xray

121
Q

One of the few abdominal conditions that an xray is most helpful for

A

bowel obstruction

122
Q

Primary care management of a bowel obstruction

A

hospitalization and immediate referral to surgeon

123
Q

External vs. Internal hemorrhoids origin

A

External hemorrhoids originate from the inferior hemorrhoidal plexus. Internal from the superior hemorrhoidal plexus

124
Q

DIAGNOSE: Abrupt, intense pain after defection associated with a perianal lump. Pruritis, and frank rectal bleeding

A

Hemorrhoids

125
Q

Primary care management of hemorrhoids

A

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

126
Q

Types of groin hernias (3)

A

indirect inguinal (most common), direct inguinal, femoral

127
Q

Types of ventral hernias (3)

A

epigastric, umbilical, incisional

128
Q

All patients with _______ hernias require surgical consultation

A

abdominal

129
Q

Post-surgical patient education for groin hernia

A

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

130
Q

Types of colorectal polyps (3)

A

hyperplastic, adenomatous, submucosal

131
Q

Type of colorectal polyp that is neoplastic

A

adenomatous

132
Q

Diet characteristics at high risk for colorectal cancer

A

high in fat, red meat, refined carbs, low in plant fiber

133
Q

Screening for colorectal cancer includes

A

colonoscopy

134
Q

Inflammation of the bladder is called….

A

cystitis

135
Q

Inflammation of the bladder wall is called….

A

interstitial cystitis

136
Q

DIAGNOSE: Dysuria, urinary frequency, low back pain and suprapubic pain, cloudy foul-smelling urine

A

Lower UTI

137
Q

Diagnostic test for lower UTI

A

clean-catch, midstream urine sample for urinalysis

138
Q

Urinalysis of UTI patient may exhibit:

A

cloudy appearance, alkalkine pH, hematuria, nitrates, leukocyte esterase, sediments of WBCs mucus and bacterial overgrowth

139
Q

UA result indicative of infection

A

> 100,000 organisms/mL

140
Q

Gold standard laboratory confirmation of UTI

A

urine culture

141
Q

Lower vs. Upper UTI differentiation

A

Lower UTI does not exhibit signs of sepsis (fever, chills, flank and CVA tenderness)

142
Q

Mainstay over lower UTI treatment

A

antibiotics

143
Q

Hopkins Pearl: If pt continually coming in with UTI symptoms that does not bear out with culture, suspect…

A

interstitial cystitis (does not respond to abx)

144
Q

How often should an indwelling catheter be changed

A

Q4-6 weeks

145
Q

Patient education when to notify provider with UTI

A

flank pain, hematuria, or lack of response to antibiotics

146
Q

Patient education with UTI self-management

A

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.

147
Q

Medical term for kidney stones

A

nephrolithiasis

148
Q

Majority of kidney stones form from….

A

calcium oxalate or calcium phosphate (65-85% of cases)

149
Q

Type of kidney stone found predominantly in women and associated with UTIs

A

struvite stones

150
Q

DIAGNOSE: Sudden onset of colicky abdominal pain, nausea, diaphoresis, dysuria, hematuria, and weakness. ON exam, found to have abdominal guarding and CVAT

A

kidney stone

151
Q

Diagnostic testing options for nephrolithiasis

A

urinalysis, CBC, “blood chemistry”. You can do a KUB xray to ID where the stone is located

152
Q

Diagnosis of renal stones is confirmed by….

A

urinalysis positive for blood, followed by renal visualization with xray or US

153
Q

Primary care management of kidney stones

A

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

154
Q

Preventative recommendations for kidney stones

A

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)

155
Q

Most common predisposing factor for ectopic pregnancy

A

PID

156
Q

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.

A

Ectopic pregnancy

157
Q

Most common cause of PID

A

chlamydia

158
Q

Essential diagnostic tests to r/o ectopic pregnancy (2)

A

serum HCG, pelvic US

159
Q

PID is described as an ________ infection

A

ascending

160
Q

Priority complication if PID ascends intra-abdominally

A

perihepatitis (Fitz-Hugh-Curtis syndrome)

161
Q

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….

A

infection

162
Q

Minimum CDC criteria for diagnosing PID (4)

A

lower abdominal pain, adnexal tenderness, CMT, absence of a competing diagnosis

163
Q

DIAGNOSE: Pt presents with lower abdominal pain, fever, cervical inflammation with yellowish discharge, CMT, adnexal tenderness.

A

PID

164
Q

Lab tests in the workup of PID

A

blood HCG (r/o ectopic preg), CBC, HIV, gonorrhea/chlamydia culture, wet prep for BV or trich

165
Q

Diagnostic test for PID

A

pelvic US

Adult Primary Care (6 decks)

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