Gastrointestinal Exam 2 Flashcards
Sphincter of Odi
Between pancreas and duodenum
3 exoxrin pancreatic enzymes
Protease (trypsin and chymotrypsin)
Lipase
Amylase
Pancreatic delta cells
Secrete somatostatin
Endocrine cells more in the tail
Parts of pancreas damaged more with chronic versus acute pancreatitis
Acute - exocrine
Chronic - endocrine
MCC of acute pancreatitis
Gallstones, Alcohol, Idiopathic 20%
Alcoholic pancreatitis
May be due to acinar cell injury or stimulated contraction of sphincter of Oti
Presentation of acute pancreatitis
Epigastric pain radiating to the back
Improves leaning forward, worse lying down
N/V, sweating
PE findings for acute pancreatitis- 4
May have absent bowel sounds, epigastric tenderness, Jaundice, Mass
Cullen’s sign
Bruising around the umbilicus d/t acute pancreatitis
Gray Turner sign
Flank bruising d/t pancreatitis
Acute interstitial edematous pancreatitis
More common acute pancreatitis - intact blood flow
Necrotizing acute pancreatitis
Blood flow not intact - more severe
Labs for acute pancreatitis
Amylase and Lipase (more sensitive) 3x upper limit is diagnostic
Leukocytosis on CBC
Imaging for acute pancreatitis
Sentinel loop or colon cutoff sign on plain X-ray
US not useful
CT may show enlarged pancreas
Ranson’s Criteria- 5 At Admission and 6 after 48 Hours
Pancreatitis Prognosis
Admission:
Age >55
BG > 200mg/dL
Serum LDH >350
AST >250
WBC >16,000
Within 48 hours
HCT decrease >10%
BUN increase >5mg/dL
Serum calcium <8mg/dL
PaO2 <60mmHg
Base deficit >4mEq/L
Estimated fluid sequestration >6L
3+ predict a severe course
Mortality rate for Ranson’s Criteria
0-2 - 1%
3-4 - 16%
5-6 - 40%
7-8 - 100%
BISAP criteria for acute pancreatitis
BUN >25mg/dL
Impaired Mental Status
Systemic inflammatory response
Age >60
Pleural effusion
Treatment for acute pancreatitis
Admit
Rest Pancreas - NPO
IV fluids - early and aggressive
NO MORPHINE, Demerol for pain
Bed rest
Mild acute pancreatitis treatment as symptoms improve
Clear liquids and low fat first
Cholecystectomy if gallstone
Monitor for return of bowel sounds
Tx for severe acute pancreatitis
ICU, Treat complication, ABX if abcess - imepenem, Fluid resicitation, CT if not improving
Acute pancreatic fluid collection
Resolves spontaneously in 7 days
Chronic pancreatitis presentation
Slow irreversible loss
MCC = Alcoholism, smoking, autoimmune
Steady pain, worse after eating, DM and steatorrhea d/t enzyme loss
Can have an acute attack
Labs for chronic pancreatitis
Slightly elevated lipase and amylase could be normal
Check of autoimmune cause
Imaging for chronic pancreatitis
Calcifications on X-ray
CT is preferred
Ultrasound - honeycombing of the pancreas
Management of chronic pancreatitis
Low fat, stop smoking, alcohol
Pain management - careful with opioids
Treat complications
Puestow procedure
Pain relief for dilated duct - attach intestines to pancreas
Whipple procedure
Resection of part of the pancreas
Part of pancreas easier to resect
Head of the pancreas
Risk factors for pancreatic cancers (4)
Over 45
Late onset diabetes
Smoking
BRACA gene
Clinical presentation of pancreatic cancer
Gnawing insidious pain like gastritis
Painless jaundice with nontender palpable gallbladder = Courvasier’s sign
Sister Mary Joseph Nodule
Tumor marker for pancreas
CA-19-9
Imaging for pancreatic cancer
CT = First line
ERCP if uncertain CT
Pancrease staging
T1 and T2 confined to pancreas, others not
Surgery for pancreatic cancer
Exploratory laparoscopy followed by whipple procedure is suitable
Screening for pancreatic cancer
If 1st degree relative - get a CT 10 years before onset in the relative
ERCP
More invasive with sedation
Diagnostic AND therapeutic
MRCP
Like an MRI, less invasive
Only diagnostic
Triangle of Calot
Medial common hepatic duct
Inferior cystic duct
Superior-inferior surface of the liver
Landmark in cholecystectomy allowing for ligation of cystic duct and artery - need to protect common bile duct
CCK
Cholecystokinin - Stimulates gall bladder contraction and sphincter of Oti relaxation
Causes of gallstone formation
High cholesterol
High Billirubin
Sedentary Gall Bladder
Lifestyle changes to prevent cholelithiasis
Low carb or mediterranean diet
Caffeinated coffee
Asymptomatic cholelithiasis
Stones stay in the bottom of gall bladder and do not cause pain by blocking the duct
Presentation of cholelithiasis- Pain, Timing, Appearance
RUQ pain to right shoulder blade
After fatty meals
Dull with nausea and sweating
Not ill-appearing
Lab results for cholelithiasis
WNL
Abd exam with cholelithiasis
No peritoneal sx, no rebounds tenderness
Pretty benign
Imaging for cholelithiasis
Abd US is procedure of choice - RUQ
Could also use CT or XR
Treatment for cholelithiasis
NSAIDS for pain
Laparoscopic cholecystectomy
Don’t need to treat if asymptomatic
3 reasons for a prophylactic cholecystectomy
Calcified gall bladder
3cm or greater stones
Native American
Pregnancy and cholecystectomy
Try to wait until 2nd trimester
Need labor and delivery and NICU there
Intraoperative choleangiogram
Xray with catheter in bile duct to help with surgeon visualization - used to check for nicking of common bile duct
Treatment for cholelithiasys in those not candidates for surgery- 2 Pharm options
Urosodiol - Ursodeoxycholic acid
Bile salt PO
3 types of cholecystitis
Acute Calculus - due to gallstones and MC
Acute acalculous - Gallbladder stasis ischemia - major surgeries
Chronic cholecystitis - Episodic billiary cholic
Presentation of cholecystitis
Appear Ill - Unlike cholic
Pain with fatty meal lasting over 6 hours!!!
Peritoneal signs
Murphys sign
Cholecystitis - Inspiration stops with pressing down in RUQ
Lab findings in cholecystitis
Leukocytosis w/ Left shift
No elevation of liver enzymes
Imaging for acute cholecystitis
Thickening of gallbladder wall
Stones
Use an US
HIDA scan if inconclusive
HIDA scan
IV contrast that travels into bile ducts - look for transit time
Non-visualized gallbladder = Cholecystitis
Other diagnostic test for cholecystitis
CCK injection
Ejection fraction of gallbladder under 35
Complications of acute cholecystitis
Gangrene of gallbladder
Gallbladder perforation
Hydrops of gallbladder - distended
Mirizzi syndrome - Jaundice from common hepatic duct compression
Percelain gallbladder - calcified
Management of acute cholecystitis- 4
Abx for E coli - Pip and Taz or 2nd or 3rd gen chep or cipro and metro
NPO w/ NG tube
Demerol or NSAID for pain
Cholecystectomy w/in 24-48 hours
New treatment for acute cholecystitis
Cholecystotomy for drainage
Alternative if they can’t handle a cholecystecomy
-choledo-
Common bile duct
Choledocholithiasis presentation and cause
Gallstone in common bile duct - uncomplicated
RUQ pain up to scapula
Jaundice
Epigastric tenderness
Diagnosis for choledocholithiasis
Elevated liver enzymes with bilirubinemia
Treatment for choledocholithiasis
ERCP with spincterotomy and stent placement
with Cholecystectomy after
MRCP used first for low risk - just cholecytectomy if no stone
Cholangitis
Bacterial infection with stone in common bile duct
Triad of acute cholangitis
Charcot triad
RUQ pain
Fever
Jaundice
Reynolds Pentad
Add - Hypotension and Mental status changes
Labs and imaging for acute cholangitis
CBC leukocytosis
Liver enzymes
Prolonged PT
ERCP is the most accurate imaging - Diagnostic procedure of choice, will likely do an US first
Treatment for cholangitis
NPO, prep for surgery, IV fluids, Pain control
ERCP for stone extraction
ABX for cholangitis
Mild/Mod - Cipro and flagyl
Severe - Zosyn(Pip and Taz) and Flagyl
First line imaging for most billiary diseases
US
Primary sclerosing cholangitis
Related to UC and IBD
No cure
Leads to obstructive symptoms - fibrosis
Presentation of PSC
Jaundice
Pruritis
Hepatosplenomegaly
Lab finding for PSCA
Elevated LFTs
Increased P-ANCA antibodies (specific to injuries of billiary tree)
Imaging for PSCA
MRCP - ERCP if inconclusive
Beads on a string seen is indicative - Segmental fibrosis
Liver biopsy with “onion skinning” if those are inconclusive
Treatment for PSCA
No cure
Cipro for episodes
Immune suppressants and Ursodeoxycholic acid are being studied
ERCP with stent
Liver transplant
Resection of carcinoma - complication
Most deadly gallbladder cancer
Choleangiocarcinoma
3 common coexisting conditions with gallbladder carcinoma
Chronic infection - Salmonella
Gallbladder polyp
Calcification of gallbladder
Often invades liver
MC location of choleangiocarcinoma
Confluence of R/L hepatic ducts
PE findings of biliary tract cancer
RUQ tenderness
Courvoisier sign
Ascites
Diagnostic for Carcinoma of biliary tract
ERCP w/ biopsy or US guided biopsy
Tx for biliary tree cancer
Resect
Roux en Y if non-resectable to bypass bile duct -bile drains fromthe liver to the duodenum
Porta hepatis
Hepatic artery, Portal vein, and hepatic duct - between the four lobes
Unconjugated billirubin
Indirect bilirubin that has NOT been processed by the liver. made from protoporphyrin
Binds to albumin, lipid soluble
Conjugated bilirubin
Made by uridine glucuronyl transferase
Water soluble - has been processed by the liver
Goes to bile ducts
Fates of conjugated bilirubin
Goes to SI, urobilinogen sent to urine, cobilin sent to feces
Conjugated hyperbilirubinemia
Pale urine and stools as opposed to unconjugated hyperbilirubinemia
Post hepatic jaundice
3 factors not made in liver for clotting
III,IV, and VIII - not effected by liver disease
Gold standard to diagnose portal hypertension
Insert catheter to get pressure
ABCDE of portal hypertension
Ascites
Bleeding
Caput Medusae
Diminished liver function
Enlarged spleen
Hepatorenal syndrome
Liver failure leads to kidney failure - portal hypertension causes poor perfusion of kidneys
Hepatic encephalopathy
Due to ammonia buildup - ammonia can’t be made to urea
3 enzymes that assess for hepatic tissue damage
AST, ALT, LDH
ALT is the most specific to the liver
Elevated aminotranseferases indicating acute liver trauma
8-25x normal range
AST>ALT (ratio over two - chronic alcohol, under two non-alcoholic)
ALT>AST - Acute Liver Trauma
2 Liver enxymes to measure obstruction of the billiary tre
Alkaline phosphatase (4x elevation is cholestasis) AND Gamma-glutamyl transpeptidase
BOTH is indicative of obstruction
Also 5’-nucleotidase specific to the liver
Tests of hpatic synthetic function
Albumin levels
If other LFTs are normal consider malnutrition
PT time
See above note
Autoimmune hepatitis
Insidious onset to sudden attack presentation
Precipitated by viral illness, pregnancy, drug exposure
May have a history of autoimmune - Positive ANA, pANCA, anti-SLA
Liver biopsy for diagnosis
Treatment for autoimmune hepatitis
Prednisone long term
Azathioprine - second line
Liver transplant if they fail therapy
Drugs that can induce hepatitis
Acetominophe
Isoniazid
Tetracyclines
Labs and treatment for drug induced hepatitis
ALT > AST
May require a liver transplant
Acetominophen toxic doses for kids and adults
Adults - 4g (4000mg)
Kids - 80mg/kg
Stage one of acetominophen induced hepatitis
.5-24 hours - N/V, diaphoresis, pallor lethargy w/ normal labs
Stage two of acetominophen induced hepatitis
24-72 hours
Symptoms resolve but labs get worse
RUQ pain
PT and billirubin elevated
Stage three of acetominophen induced hepatitis
72-96
Jaundice, confusion
Elevated enzymes
Many die
Stage 4 of acetominopheni induced hepatitis
4 days to 2 weeks
Recovery
May have AKI
Symptoms and lab values begin to normalize
Diagnosis and treatment for acetominphen induced hepatitis
Measure acetominophen level with the blood
N-acetylcysteine (activated charcoal) if possible within 1-2 hours of ingestion - give if we don’t know when they took it
RiskFactors for Alcoholic liver disease
2 drinks per day for men, 1 per day for women
Fatty liver to alcoholic hepatitis to cirrhosis
50g daily for 10 years is the threshold
Often an incidental finding of labs in the fatty liver stage
ALT AST ratio of alcoholic liver disease
2:1 or greater AST to ALT ratio
Treatment for alcoholic liver disease
Abstinence from alcohol
Folic acid, zinc, thiamine
Prednisone for about a month
Glasgow alcoholic hepatitis score
Greater than 9 is an indication for steroid treatment
Non-alcoholic steatohepatitis
Fatty liver w/o alcohol us
Can still lead to cirrhosis
Fatty liver is without inflammation
RUQ discomfort - vague symptoms
Biopsy to diagnose
Treatment for non-alcoholic fatty liver disease- 5
Lifestyle modification
Hepatitis vaccines
Vitamin E, Thiazolidenediones, Metformin
Percent of NASH patients who progress to cirrhosis
20%
PE findings with cirrhosis- 7
Portal hypertension
Pruritis
Spider angiomas
ED,
Gyencomastia
Palmar erythemia
Jaundice - later in the disease
Labs and diagnostics for liver cirrhosis
Minimal elevations in liver enzymes early in the disease cours
DDx - Liver biopsy
FL - US of Liver
Treatment for cirrhosis- 6
TRANSPLANT
Avoid alcohol
Hepatitis vaccination
Spironolactose and Furosemide
TIPS - Shunt
Paracentesis
Bacterial peritonitis related to cirrhosis
Agent and Drug of Choice
MC w/ E. coli
Treat with cefotaxime
Treatment for hepatic encephalopathy
Reduce protein intake
Give lactulose
ABX - Rifamixin and Flagyl to reduce ammonia producing bacteria
Tx for cirrhosis clotting factor deficiencies
Give FFP, Ferrou sulfate for anemia
Tx for esophageal varices
Band, Ballon, Tamponade
Octreotide for bleeding
Beta blocker for maintainence
MELD score
Assesses for appropriateness for liver transplant
14 or higher qualifies for a liver transplant
Primary billiary cirrhosis
Chronic autoimmune destruction of the bile ducts
Common in women 40-60
Fatigue and itchiness are MC symptoms
Fat deposits in the fingers
Positive ANAD
Diagnosis- 2 and Tx - 3 for primary billiary cirrhosis
Elevated ALP and cholesterol
Baseline US biopsy not needed
Ursodeoxycholic acid is tx
CHolestyramine for itching
Liver transplant is definitive
Hepatitis A Etiology and Incubation
Fecal Oral route
Incubates for TWO weeks
No chronic carrier state
Hepatitis A presentation - 6
More severe in adults
Distaste for smoking
N/V/D
RUQ pain gets worse with movement
Jaundice and acholic stools
Hepatomegaly
Diagnosis of HAV
Jaundice with known risk for Hep A
Established by IgM anti HAV antibodies - peak during symptoms
ALT>AST
Imaging not indicated
Treatment for HAV
Symptomatic treatment - fluids and rest
Avoid alcohol
Prevent via handwashing and vaccination
3 antigens of Hepatitis B
HBcAg - Core antigen
HBeAg - Secreted BY the core
HBsAg - HBV surface antigen
Risk factors for HBV
Bloodborne
Sexual activity, mother to baby, healthcare workers, IVDU, incarceration, previous STD
Clinical presentationand incubation of Acute HBV
6 week to 6 month incubation
Recurrent fever
RUQ pain
Jaundice
Subsides in a few weeks
HBsAg
First to elevate - persists throughout clinical illness - presence for >6 months indicates chronic illness
anti-HBs
Indicates recovery when coupled with decline of HBsAg
Indicates vaccine response and immunity when no HBsAG is present
IgM anti HBc
One month after HBsAG is detected
Indicates declining acute hepatitis B
3-6 month persistence
Acute flares of chronic disease
IgG anti-HBC
Persists indefinitely
With Anti-HBs = recovery
With HBsAG = Chronic disease
HBeAG
Elevated with infectivity - helps us know how infectious it is
Appearance of antibody indicates reduction in infectivity
Parallelled by HBV DNA
Labs of acute hepatitis
ALT greater than AST - more marked than HAV
Txand Prophylaxis for HBV
Avoid alcohol and activity
Antiviral therapy only if chronic
HBIG for prophylaxis within 7 days of exposure and newborns with HBV positive mothers
Tx for chronic HBV
Can lead to hepatocellular carcinoma and cirrhosis
Nucleoside and nucleotide analogs - 1st line
Interferon treatment - 2nd line
Hepatitis C
IVDU, Sexually transmitted, Healthcare, often co-infected with HIV
Presentation and course of HCV
6-7 week incubation period
Often a mild presentation
Often becomes chronic
Anti-HCV antibodies - RNA indicates a CURRENT infection, only Ab’s indicate a past infection
Prevention for hepatitis C
No vaccine
Safe sex and needle use
Management for HCV
Harvoni - combo drug of ledipasvir/sofosbusir
HCV protease inhibitors and polymerase inhibitos for HCV
8 week course
Prevent viral replication
Hepatitis D
Only associated with Hepatitis B infection!!
Mainly in IVDU
Anti-HDV antibodies in serum
Hepatitis E
In non-US contries more often - fecal-oral
Most severe among young pregnant women
May be spread by swine
Test for IgM anti-HEV in serum
Treat with oral ribovirin to treat
Hemochromatosis
Autosomal recessive
Increased iron absorption from the duodenum and storage in the liver
Usually don’t present until older than 50
“bronze diabetes”
Diagnosis of hemochromatosis
Mild LFT elevationElevated serum Iron and serum ferritin
Test first degree family members
Genetic testing available
Treatment for hemocrhomatosis
Weekly phlebotomy for 2-3 years
Chelating agents if unable to tolerate phlebotomy - Defaroxamin
Liver transplant for cirrhosis
WIlson disease
Autosomal recessive disorder
Presents before age 40
Excessive absorption of copper and decreased excretion by the liver leading to low ceruloplasmin
Deposition of copper in liver and brain
Presentation of Wilson disease
Kayser Fleischer copper rings around iris - pathognomic
Parkinsonianism, Dysphagia
Personality changes
Labs for Wilson disease
Urine copper
Low serum ceruloplasmin levels
Liver biopsy to assess chronic hepatitis/cirrhosis
Five Treatments for Wilson disease
Restrict copper - nuts chocolate shellfish
Penicillamin - Drug of choice - Chelating agent and increases urinary excretion
B6 - antimetabolite of copper
Zinc promotes fecal copper excretion
Liver transplant if not caught early
Gilbert syndrome
Mild unconjugated hyperbilirubinemia
Familial
Reduced activity of glucuronyl transferase
Random outbreaks of jaundice
Bilirubin above 3mg/dL
Benign, educate about flare-ups
Crigler Najjar syndrome
Infantile jaundice
Glucuronyl transferase deficiency
Autosomal recessive
Rapid and severe
Does not go away after 2-3 weeks
Crigler Najjar Types
Type I - 20-50mg/dL
Type II <20mg/dL
High levels definitive for diagnosis
Treatment for crigler najjar syndrome
Phototherapy under fluorescent light
Plasmapheresis
Liver transplant - curative
Phenobarbital for type II
Dubin Johnson syndrome
Genetic
Conjugated bilirubin not sent to bile ducts
Intermittent jaundice and fatigue
Elevated conjugated bilirubin
Black liver
Benign - can be exacerbated by illlness or pregnancy
Rotor syndrome
Rare genetic disorder
Stored bilirubin leaks back into the blood stream
Inject dye for a transport study to differentiate from Dubin Johnson
Benign
Budd-Chiari syndrome
Hereditary or acquire hepatic venous outflow obstruction, RUQ Pain, jaundice, ascites
Budd-Chiari diagnosis
Doppler US
Can move on to an MRI
Tx for BC syndrome
Lovenox if clotting problem
TIPS - shunt
Pericentesis
Kernicterus
Crigler Najjar syndrome
Brain damage from high bilirubin levels in a baby’s blood
MC Hepatocellular carcinoma
Parenchymal cell carcinoma d/t cirrhosis
Lab findings for hepatocellular carcinoma
Alpha fetoprotein
CT/MRI for mass
Liver biopsy
Screening for hepatocellular cancer
Liver US Q 6 months
Carnett’s sign
If a patient’s pain on palpation worsens when flexing the abdominal muscles the pain is located in the abdomenal wall rather than the abdomen itself
Murphy’s sign
Inspiratory arrest during deep palpation of the RUQ - good indicator for Gallbladder inflammation
Rovsing sign
Indirect tenderness RLQ pain with LLQ palpation - indicates appendicitis
Psoas sign
Patient flexes the thigh against resistance of the examiner’s hand - on left side - Pain is indicative of appendicitis
Obturator sign
Flexion and internal and then external rotation of the thigh causes pain - appendicitis, diverticulitis, PID
Cough test
Indicative of peritoneal irritation
Volvulus
Torsion of segment of bowel
MC - sigmoid
Obstruction and strangulation - often in older adults 70+
Chronic constipation is a risk factor
Presentation of volvulus
Insidious onset of abdominal pain
Abdominal distension
Severe and colicky
Tympany on exam w/ tenderness
Fever and tachycardia after perforation
Diagnosis of volvulus
CT to establish diagnosis
Whirl pattern and bird beak appearance
Abdominal X-ray can also be performed
Treatment of volvulus
IV fluids
Endoscopic detorsion - advance scope through twisted segment
Elective resection if there is a risk of recurrence or major necrosis
Cecal volvulus
More rare than Sigmoid volvulus
Can be caused by violent coughing, tumor, or pregnancy
Presentation of cecal volvulus
Highly variable
Gradual onset of pain with N/V
Diagnosis of cecal colvulus
CT - first line
Whirlwind and birds beak
Coffee bean and comma sign with Abdominal X ray
Treatment for cecal volvulus
Can’t do endoscopic - must do open
Ileocecal detorsion if possible - if not possible cecopexy to anchor cecum to the wall
Intussusception
Bowel folds back into itself
6 months-3 years
more common in males and in the ileocolic area
Mostly idiopathic
Presentation of instussusception
Intermittent severe abdominal pain, 15-20 minute attacks
Current jelly stools
Sausage shaped mass in the right side of the abdomen
Tender and distended abdomen
Diagnosis and tx of instussusception
Utrasound is number 1 - coiled spring
Barium enema confirmatory- can be CURATIVE
Sonogrophy guided non-surgical reduction with saline or pneumatic reduction - air is less dangerous
Tx for intussusception if you suspect a perforation
Pneumatic reduction is better than barium
Presentation of appendicitis
MC between 10-30
MCC is a fecalith
Vague, colicky pain localizing the the RLQ within 12 hours
Pt can localize pain upon coughing
Rebound tenderness
McBurney’s point tenderness
Diagnosis of appendicitis
Mostly clinical
CT to confirm diagnosis
US can confirm but not exclude diagnosis
Management for appendicitis
Laparoscopic appendectomy
Hydration
Cefoxitin or Ampacillin-Sulbactam
Toxic megacolon
Complication of IBD or Crohns
Non-obstructive dilation of 6+ cm with systemic symptoms
Presentation of toxic megacolon
ABdominal pain and distension
Severe bloody diarrhea
Toxic appearing
Dehydrated
Recent travel, abx use, use of antimotility agents
Diagnosis of toxic megacolon
Radiographic evidence of colonic distension on CT or XR - CT preferred
PLUS 3 of:
Fever 100.4+
HR 120+
Leukocytosis over 10,500
Anemia
PLUS 1 of:
Dehydration
Altered mental status
Electrolyte disturbances
Hypotension
Most effected area in toxic megacolon
Transverse colon
Treatment for toxic megacolon
NG tube to decompress colon
Stop medications
PPI for stress ulcer prevention
Bowel rest - NPO
Serial CMP, BMP, Radiograph
Indications for surgery in toxic megacolon- 5
Surgery for perforation, necrosis, ischemia, hypertension, or compartment syndrome
Pharm for toxic megacolon
Amp, gent, metronidazole OR 3rd Gen Ceph w/ metronidazole
Corticosteroids
Acute mesenteric ischemia
Ischemia of the SMALL bowel
Occlusive or non-occlusive
MC in the SMA
Presentation of acute mesenteric ischemia
Abdominal pain out of proportion to findings
Severe, sudden, perumbilical
Fecalant breath odor
Labs and Dx for diagnosis for acute mesenteric ischemia
Metabolic acidosis - is indicative until proven otherwise
Mesenteric arteriography - dx of choice
CT/MRI are nonspecific
Tx for acute mesenteric ischemia
Opioids for pain control
Broad spectrum abx and NG tube
Anticoagulation and Nitroglycerin
Abdominal exploration d/t intestinal ischemia
MCC of upper GI bleeding
Peptic ulcer disease
MCC of lower GI bleed
Bleeding diverticulum
Presentation of GI bleed
Melena
Hematochezia
Coffee ground emesis
Blood y emesis
Weight loss suggests malignancy
Jaundice suggests liver problem
Things that can mimic GI bleeding
Iron or Bismuth - Melena
Beets - Hematochezia
Cefdinir - Red Stools
Division between upper and lower GI
Ligament of treitz
Risk factors for umbilical hernea
Pregnancies
Ascites
Obesity
Intra-abdominal hernia
Treatment for umbilical hernia
Surgical repair
Open or Mesh depending on size (open if larger)
Features of hernia associated with strangulation
Firm
Severe tenderness
Abdominal distension
Treatment of ventral hernia
Any hernia in abdominal area
Does not require surgery or is a poor surgical candidate or hernia is not emergent - can use an abdominal binder
X ray colors
Bone - White
Tissue - gray
Air - Black
Indication of air in the peritoneal cavity
Air UNDER the diaphragm - may be a bowel perforation or air expansion from laparoscopy
Feces on X ray
Soft tissue with opacities
Colors on US
Hypoechoic - Dense muscle and connective tissue
Hyperechoic - Bright - Air fat and gas
Anechoic - Fluid and blood filled structures appear more black
Contrast use for abdominal CT
IV - best for tumors, vascular abnormalities, urinary tract
Oral - Best for visualizing the bowel lumen, esophagus, stomach
Non-contrast - Best for evaluating stones
Pros/Cons of CT
Helps enhance and delineate between organs
Takes a while, renal failure can cause an allergic reaction or flushing
Barium swallow
Used with X ray
Continue images as it passes through the small bowel
Can also do a barium enema
MC complication of ERCP
Pancreatitis
