Gastrointestinal/Nutrition Flashcards by Heather White

A 25-year-old man presents to the ED with 5 days of watery, foul-smelling diarrhea. He recently returned from a trip where he hiked and camped on the Inca Trail to Machu Picchu. He would not always purify his water since he was high in the mountains and assumed it was clean. He reports abdominal bloating and cramping with flatulence and smelly diarrhea. What is the best treatment for this patient?
Azithromycin 1 g orally for one dose
Incorrect

A) Ciprofloxacin 500 mg orally twice a day for 3 days
B) Tinidazole 2 g orally for one dose
C) Trimethoprim-sulfamethoxazole DS one tab orally twice a day for 10 days
D) Azithromycin 1g orally for one dose

Tinidazole 2 g orally for one dose

This patient, who just returned from an international camping trip where he did not adequately purify his water, most likely is returning with Giardia lamblia infection. Giardia is a flagellated protozoan parasitic infection that is waterborne and foodborne and is frequently found in international travelers.

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What is the most common cause of Clostridioides difficile infection (CDI)?

What is the hallmark symptom?

Antibiotic use, particularly clindamycin, fluoroquinolones, and broad-spectrum beta-lactams.

Watery diarrhea, often with a foul odor

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What diagnostic test is most commonly used to confirm CDI?

What is the first line treatment?

Stool polymerase chain reaction (PCR) for C. difficile toxin genes

Oral vancomycin

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Which infection control measure is critical for preventing CDI transmission in healthcare settings?

Contact precautions and handwashing with soap and water (not alcohol-based sanitizer)

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What is the most common cause of appendicitis?

Obstruction of the appendiceal lumen, often by a fecalith (hardened stool), lymphoid hyperplasia, or less commonly by tumors or foreign bodies.

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What is the classic initial symptom of appendicitis?

Periumbilical pain that later migrates to the right lower quadrant (RLQ) as the inflammation progresses.

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What is McBurney’s point?

It is a point located two-thirds of the distance from the umbilicus to the anterior superior iliac spine (ASIS). Tenderness at this point is a classic sign of appendicitis.

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What is the most common complication of untreated appendicitis?

Perforation, which can lead to peritonitis or an intra-abdominal abscess.

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Which physical exam sign suggests appendicitis if the patient experiences pain upon passive extension of the right hip?

Psoas Sign

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What is the typical sequence of symptoms in acute appendicitis?

Periumbilical pain → anorexia → nausea/vomiting → RLQ pain

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What imaging modality is most commonly used to diagnose appendicitis in adults?

CT scan of the abdomen and pelvis with contrast

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What is the treatment for uncomplicated appendicitis?

Appendectomy

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What are the typical laboratory findings in acute appendicitis?

Leukocytosis with a left shift (increased neutrophils), but normal labs do not rule out appendicitis

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What is the most common cause of emergent abdominal surgery in the United States?

Acute appendicitis

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Can you have an abnormal urinanalysis with appendicitis?

Yes, mild hematuria and pyuria are common in appendicitis w/ pelvic inflammation, resulting in inflammation of the ureter

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What are the preoperative medications and preperation for an appendectomy?

Rehydration with IV fluids (LR)
Preoperative antibiotics with anaerobic coverage

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A 32-year-old pregnant female presents with right lower quadrant pain, nausea, and vomiting. On physical exam, she has tenderness in the RLQ, and a positive psoas sign. Ultrasound is non-diagnostic. What is the most appropriate next step in management?

A) MRI of the abdomen
B) CT scan of the abdomen with contrast
C) Immediate laparoscopic appendectomy
D) Exploratory laparotomy

MRI of the abdomen

In pregnant patients, MRI is preferred for diagnosis of appendicitis if ultrasound is non-diagnostic, as CT should be avoided due to radiation risks. Surgery is indicated if imaging confirms appendicitis.

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A 15-year-old boy presents with diffuse abdominal pain and fever for 2 days. He now has sharp pain in the right lower quadrant, along with nausea and vomiting. On exam, he has rebound tenderness and guarding in the RLQ. His WBC count is 18,000/mm³. What is the most likely complication if his condition is left untreated?

A) Bowel obstruction
B) Appendiceal perforation
C) Pancreatitis
D) Intussusception

Appendiceal perforation

Untreated appendicitis commonly leads to perforation, which may cause peritonitis or an abscess.

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What is the first step in treating cholysistitis?

Fluid resuscitation

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Patients with acute cholecystitis should be given fluids and IV antibiotics. What are the three most common bugs to cause cholecystitis?

What antibiotics are typically used?

E. coli
Klebselia
Entercococus faecialis

IV ceftriaxone or cipro plus mitronidazole or zosyn

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What is Murphy’s sign?

Acute RUQ pain/tenderness with palpation with inspiration associated with cholecystitis

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What is Boas Sign?

Referred pain to the right subscapular area due to phrenic nerve irritation in cholecystitis

Describe Grey-Turner’s Sign?

Flank ecchymosis often related to pancreatitis

What lab tests are used to evaluate the patient with an acute abdomen?

CBC with differential, chem-10, lipase, type and screen, urinalysis, LFT’s

A 36-year-old woman presents with a painful bulge in her right groin. She reports that the pain worsened over the past 24 hours and is now constant. On physical exam, a tender mass is palpated below the inguinal ligament. The mass is not reducible, and there is tenderness to palpation. What is the most appropriate next step in management? A) Observation with close follow-up B) Emergent hernia repair C) CT scan of the abdomen and pelvis D) Manual reduction and discharge home

Emergent hernia repair ## Footnote This patient likely has a femoral hernia, which occurs below the inguinal ligament. Femoral hernias have a high risk of incarceration and strangulation, requiring emergent surgery to prevent bowel ischemia and necrosis.

A 68-year-old man with a history of chronic back pain presents with an acute onset of black, tarry stools and is vomiting blood. His chronic back pain is managed with diclofenac and ibuprofen. On exam, he is hypotensive, tachycardic, and dyspneic. A stool guaiac test is positive. Laboratory studies demonstrate an elevated blood urea nitrogen-creatinine ratio. Which of the following is the most common cause of the suspected diagnosis? A) Diverticulosis B) Esophageal varices C) Mallory-Weiss tear D) Peptic ulcer disease

Peptic Ulcer Disease

What two symptoms are highly suggestive of upper gestational tract bleeding? | What defines upper GI bleeds?

* Melana (black, tarry, liquid stools) * Hematemesis | Bleeds occuring above the ligament of Trietz

What is the most common cause of melana?

Peptic Ulcer Disease

A 4-week-old male infant presents to the ED with his parent for a 4-day history of projectile vomiting. The parent says the infant is constantly fussy and hungry but vomits after every feeding. Physical exam reveals dry mucous membranes and a small, hard, mobile mass in the right upper quadrant. A pediatric surgeon is consulted and agrees with the initial ED assessment. Which of the following is the most likely diagnosis? A) Intussusception B) Pyloric stenosis C) Rotavirus infection D) Wilms tumor

Pyloric Stenosis

What is the most common cause of pyloric stenosis in adults?

Chronic Ulcer Disease

What is Rovsing's Sign?

RLQ pain with palpation of LLQ

What is Obturator Sign?

RLQ pain with internal rotation of the hip

Which of the following is the most common symptom of appendicitis in children? A. Constipation B. Vomiting C. Right lower quadrant pain D. High fever

Right lower quadrant pain

A 10-year old child presents with periumbilical pain that later localizes to the right lower quadrant. What is the most likely diagnosis?

Appendicitis

What is the most common complication of appendicitis in pediatric patients?

Peritonitis

Which imaging study is preferred initially for diagnosing appendicitis in children?

Abdominal Ultrasound

A 9-year-old female presents with a 24-hour history of abdominal pain that initially started around the navel but has now localized to the right lower quadrant. She has vomited twice and reports a decrease in appetite. On examination, she has a fever of 37.8°C (100°F) and tenderness in the right lower quadrant with guarding. What is the next best step in management? A. Administer IV fluids and observe B. Order an ultrasound of the abdomen C. Schedule for immediate surgery D. Start broad-spectrum antibiotics

Order an ultrasound of the abdomen

What is the most common cause of toxic megacolon? A) Ulcerative colitis B) Crohn's disease C) Ischemic colitis D) Infectious colitis

Ulcerative colitis ## Footnote Toxic megacolon most commonly arises as a complication of inflammatory bowel disease, particularly ulcerative colitis.

Which imaging modality is preferred for diagnosing toxic megacolon? A) CT scan B) Abdominal X-ray C) MRI D) Ultrasound

Abdominal x-ray ## Footnote Abdominal X-ray typically shows colonic dilation greater than 6 cm, which is characteristic of toxic megacolon

A 35-year-old male with a 10-year history of ulcerative colitis presents to the emergency department with severe abdominal pain, distension, and fever. His vital signs show a heart rate of 120 bpm, BP of 90/60 mmHg, and a temperature of 102°F. Physical exam reveals marked abdominal tenderness with decreased bowel sounds. An abdominal X-ray shows a dilated colon greater than 7 cm. What is the next best step in management? A) Start broad-spectrum antibiotics and IV fluids B) Perform an immediate total colectomy C) Administer corticosteroids and monitor D) Place a nasogastric tube and start bowel rest

Start broad-spectrum antibiotics and IV fluids ## Footnote Initial management of toxic megacolon includes aggressive fluid resuscitation and broad-spectrum antibiotics. Surgery may be needed if there is no improvement with medical management.

A 28-year-old female with a history of Crohn’s disease presents with fever, tachycardia, and severe abdominal pain. She reports passing fewer bowel movements than usual over the last 24 hours. Abdominal X-ray reveals dilation of the colon consistent with toxic megacolon. What complication is this patient at greatest risk for if her condition is not promptly treated? A) Perforation B) Stricture formation C) Fistula development D) Malabsorption

Perforation ## Footnote The major complication of toxic megacolon is perforation, which can lead to peritonitis and septic shock

A 27-year-old woman presents with vomiting and 10/10 right lower extremity pain. The symptoms started suddenly 1 hour ago when she was lifting weights. The pain is constant and worsening. She has no significant medical or surgical history, but she noticed a painless mass below her right inguinal crease 1 month ago. Her vital signs are T 37.1°C, HR 107 bpm, BP 141/92 mm Hg, RR 23/min, and SpO2 99%. Her BMI is 22 kg/m2. On examination, she is diaphoretic and pale, and there is a right-sided erythemic mass protruding inferior and lateral to the pubic tubercle. The mass is hot, firm, pulseless, and exquisitely tender to palpation. What is the best way to diagnose this condition? A) Clinical exam B) CT of the abdomen and pelvis with IV contrast C) Hernia sac laparoscopy D) Ultrasound of the abdomen and pelvis | What is the treatment?

Clinical Exam | Strangulated hernias are surgical emergencies

Which serum marker is most specific for the diagnosis of acute pancreatitis?

Lipase

What is the most appropriate initial imaging study for suspected acute pancreatitis? A) Abdominal ultrasound B) Abdominal CT scan C) Abdominal X-ray D) MRI

Abdominal ultrasound ## Footnote Abdominal ultrasound is typically the first imaging study used to identify gallstones as a potential cause of acute pancreatitis

A 50-year-old male with a history of heavy alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting. His lipase and amylase levels are elevated. What complication is he at greatest risk for during the first 48 hours of hospitalization? A) Pancreatic abscess B) Pseudocyst formation C) Sepsis D) Acute respiratory distress syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) ## Footnote Severe acute pancreatitis can lead to systemic complications such as ARDS, especially in the early stages

A 40-year-old woman presents to the emergency department with right upper quadrant pain. On exam, she is afebrile but has right upper quadrant tenderness. Laboratory testing reveals an alkaline phosphatase of 640 U/L, AST of 204 U/L, and ALT of 220 U/L. The common bile duct measures 9 mm on transabdominal ultrasound, and the gallbladder is present. Which of the following is both diagnostic and therapeutic for the most likely diagnosis? A) Endoscopic retrograde cholangiopancreatography B) Endoscopic ultrasound C) Magnetic resonance cholangiopancreatography D) Right upper quadrant abdominal ultrasound

Endoscopic retrograde cholangiopancreatography

A 40-year-old woman presents to the emergency department with an acute onset of epigastric pain, nausea, fever, and vomiting. On exam, an inspiratory arrest is noted during deep palpation of the right upper quadrant of the abdomen. Laboratory studies demonstrate leukocytosis with a left shift. Her ultrasound image is shown above. Which of the following is the initial intervention indicated for this patient? A) Administration of intravenous fluids B) Outpatient antibiotic therapy C) Refer to surgery for cholecystectomy D) Refer to surgery for cholecystostomy

Administration of intravenous fluids ## Footnote Once the diagnosis of acute cholecystitis is made, administration of intravenous fluids is the next step in management, followed by broad-spectrum intravenous antibiotics, bowel rest, analgesics, and correction of electrolyte abnormalities. Definitive treatment is with laparoscopic cholecystectomy within the first 72 hours.

What disease is associated with the classic triad of fever, right upper quadrant pain, and jaundice?

Acute cholangitis

A 62-year-old woman presents to the ED with acute onset of upper abdominal pain radiating to the back and shoulders. She has had similar pain in the past but it is usually relieved with over-the-counter medications. She has a history of osteoarthritis, diabetes, and obesity. She is diaphoretic on arrival with a BP of 95/42 mm Hg, HR of 115 bpm, RR of 18/min, T of 38.6°C (101.5°F), and SpO2 of 98% on room air. She has diffuse upper abdominal tenderness with localized guarding. A portable chest X-ray shows free air under the diaphragm (pneumoperitoneum). Fluid resuscitation and pain control is ordered. What is the most likely diagnosis? A) Chronic pancreatitis B) Perforated peptic ulcer C) Cholecystitis D) Necrotizing enterocolitis

Perforated peptic ulcer ## Footnote This patient presents with classic symptoms of perforation, including sudden, severe epigastric pain that radiates to the chest, back, or shoulders and is refractory to usual medications. Signs of sepsis (fever, hypotension, and tachycardia) may also develop due to bacterial translocation and peritoneal contamination.

What is the typical presentation of diverticulosis? | What is the treatment?

Painless bright red blood per rectum | Bowel rest (no solids), IV fluids, monitoring CBC for anemia

What is the most likely cause of black stools in a patient who treats pain with NSAIDs?

Gastritis or gastric ulcers secondary to NSAID overuse

Without a spleen, patients are at risk for severe sepsis from encapsulated organisms. What are the most common bugs that lead to sepsis in asplenic patients?

* Streptococcus pneumoniae * Neisseria meningitidis * Haemophilus influenzae

A 32-year-old man presents to the emergency department with diarrhea for 4 days. It began after he returned from a multi-day hunting and camping trip. His stools are malodorous and greasy, and he notices a sulfuric smell when he belches. He also reports abdominal discomfort. You diagnose giardiasis. Which of the following is the first-line treatment for the patient's condition? A) Albendazole B) Ciprofloxacin C) Rifaximin D) Tinidazole

Tinidazole ## Footnote Tinidazole 2 grams orally as a single dose is a primary treatment for Giardia infection. Patients should be counseled to avoid lactose-containing foods, as acquired lactose intolerance can occur in up to 40 percent of cases and can take weeks or months to resolve

Fever, right upper quadrant pain, and jaundice suggest what pathology?

Ascending cholangitis