GastroIntestinal/Nutritional Flashcards
Biliary Colic,
Acute Cholecystitis,
Acute Cholecystitis, Acute Cholangitis,
Acute Hepatitis,
Causes of RUQ abdominal pain
Splenomegaly, Splenic infarct,
Splenic abscess,
splenic rupture
Causes of LUQ abdominal pain
Acute myocardial infarction, acute pancreatitis, chronic pancreatitis, peptic ulcer disease, GERD
Causes of epigastric abdominal pain
Appendicitis, diverticulitis, nephrolithiasis, pyelonephritis, cystitis,
Causes of lower abdominal pain
Patient will present as → a 49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level.
Acute/Chronic Cholecystitis
What is the most specific test for acute cholecystitis?
HIDA
PE findings include: RUQ pain, guarding, and +Murphy’s sign
Cholecystitis
Precipitated by fatty meals. Class pt = Fertile+ Fat+ Forty
Cholecystitis
Ultrasound = 1st line imagine procedure
Radionuclide scanning (HIDA) = Gold Standard
DX for cholecystitis
What is the procedure of choice for uncomplicated acute and chronic cholecystitis?
Lap Chole
What are the complications of acute cholecystitis?
Abscess perforation, choledocholithiasis, cholecystenteric fistula formation, gallstone ileus,
Labs usually associated with acute cholecystitis?
Increase WBC. May have slight elevation in alk phos, LFTs, amylase
Burning pain or discomfort in the upper chest and midchest, possibly involving the neck and throat, usually occurs after eating or at night and may worsen when lying down
heartburn and dyspepsia
Standard workup for this prior to surgical procedure includes:
Endoscopy with biopsy (gold standard)
Manometry
24 hour ambulatory pH probe testing
barium esophagography
Heartburn and dyspepsia
lifestyle modifications and acid suppression therapy is standard treatment for the classic presentation
Heartburn and dyspepsia
histamine H2 receptor antagonist -> PPI for mild or intermittent sx
tx for heartburn and dyspepsia
Triple therapy PPI+ clarithromycin + amoxicillin +/- metronidazole
tx for H. pylori infection
fundoplication if failed medical management or complications
surgical tx for heartburn/ dyspepsia
Patient will present as → a 37-year-old male complaining of rapid onset of severe mid-epigastric pain with radiation to the back after eating a large meal. The pain lessens when the patient leans forward or lies in the fetal position. Physical exam shows a low-grade fever, epigastric tenderness, diminished bowel sounds, and bruising of the flanks.
Acute/chronic pancreatitis
superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus
Cullen’s sign
bruising of the flanks, the part of the body between the last rib and the top of the hip
Grey Turner’s sign
The classic triad = pancreatic calcification, steatorrhea, and diabetes mellitus
Chronic pancreatitis
Abdominal CT is the diagnostic test of choice
Sentinel loops on X-Ray
(look for diminished bowel sounds as part of the exam question)
ERCP is the most sensitive
Dx for acute and chronic pancreatits
circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)
pancreatic pseudocyst (complication of acute pancreatitis)
Prochlorperazine 5 to 10 mg IV or
Droperidol 0.625 mg IV
rescue antiemetics for PONV
If the patient is hungry and can eat, you should seriously question the diagnosis of what surgical condition?
appendicitis
patients with acute hematemesis is indicative of what?
Upper GI bleed
Symptoms that suggest the bleeding is severe include orthostatic dizziness, confusion, angina, severe palpitations, and cold/clammy extremities.
hematemesis
IV access or transfusion for pts that remain hemodynamically unstable
tx for hematemesis
Patient will present as → a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient’s mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.
Appendicitis
1st sx is crampy or “colicky” pain around the navel. Usually a marked reduction in or total absence of appetite
appendicitis
Patient will present as → a 65-year-old female with diffuse abdominal pain and vomiting. She has not had a bowel movement in three days. PE reveals high-pitched, hyperactive bowel sounds, tympany to percussion, no rebound tenderness, and a temperature of 100.4 F. Abdominal radiograph reveals distended loops of bowel with a step ladder pattern of differential air-fluid levels.
Small bowel obstruction
Intussusception is the most common cause of this in children.
Smal bowel obstruction
decompression with a NGT. Surg if mechanic obstruction is suspected
small bowel obstruction
Where is the most common location of a large bowel obstruction?
Sigmoid colon
What finding on abdominal x-ray should make you think of bowel obstruction?
Air fluid levels
Patient will present as → a young mother who brings her 12-month-old daughter to your office reporting that she has had recurrent “belly aches” for the past two weeks. The child experiences sudden, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. These episodes are interspersed with periods of no complaints. The mother also reports that she has seen her squatting with her knees to her chest, which seems to relieve her of her symptoms. She describes her stool as bloody with mucus, almost as though it were a currant jelly. On physical examination, you note abdominal distention and tenderness along with a sausage-shaped abdominal mass in the RUQ.
Intussuception
what type of stool is pathognomonic for intussusception?
currant jelly stool
An abdominal x-ray will reveal a “Crescent sign” or a “Bull’s eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen.
Intussusception
Ultrasound shows “target sign”
Intussusception
Air or barium enema may be curative for children; if not, surgery is needed.
Adults generally require surgery
tx for Intussusception
What is the gold standard for confirming the dx of intussusception in children?
Barium enema (both diagnostic and therapeutic)
what is the diagnostic test of choice for esophageal webs?
barium swallow
esophageal webs + dysphagia + iron deficiency anemia
Plummer-Vinson syndrome
Patient will present as → a 62-year-old man with a history of alcoholism complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years. In addition he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness.
esophageal cancer
smoking and alcohol consumption is associated with which kind of esophageal cancer?
Squamous cell CA (most common world wide)
Barrett’s esophagus is associated with which kind of esophageal cancer?
Adenocarcinoma (most common in the US)
What is the dx test of choice for esophageal cancers?
Upper endoscopy with biopsy. (CT scans for staging)
tx for esophageal cancer?
esophageal resection. (endoscopic screening recommended for pts with Barrett’s Q3-5 years)
Adenocarcinoma of the esophagus most likely occurs in which part of the esophagus?
Lower third
Patient will present as → a 43-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.
Cholelithiasis and choledocholithiasis
gallstones in the gallbladder (no inflammation)
cholelithiasis
cystic duct obstruction by gallstones
cholecystitis
gallstones in the biliary tree – associated with ductal dilation and biliary colic or jaundice. Stones in the common bile duct
Choledocholithiasis
biliary tract infection secondary to obstruction by gallstones
Cholangitis
What age should adults be screened for colorectal cancer according to USPSTF?
45 to 75
This presents as painless rectal bleeding and a change in bowel habits
colorectal carcinoma
A barium enema with classically show this for colorectal carcinoma
“apple core” lesion
definitive diagnosis for colorectal carcinoma
colonoscopy and biopsy
What are the colonoscopy guidelines for screening with increased risk factors such as adenomatous polyps or colon cancer in a 1st degree relative?
age 40 or 10 years younger for earliest diagnosis in the family
Whats the recommended age for screening if you have a hx of Crohn’s disease of UC?
Any age
Patient will present as → a 68 year old man who presents to the ED with unintentional weight loss and bloody stool. He reports that he experiences abdominal pain/fullness on occasions for the past 20 years. On PE, he is guaiac positive. There is a supraclavicular lymphadenopathy noted along with Sister Mary Joseph’s node. Labs show low hemoglobin levels.
gastric cancer
How do you dx gastric cancer?
EGD and biopsy
What will CBC show for gastric cancer?
microcytic/hypochromic anemia
How do you treat gastric cancer?
surgical removal of the stomach. Gastrectomy is only curative tx.
What are risk factors for gastric cancer?
fm hx of gastric cancer, gastric ulcers, H. Pylori, pernicious anemia (vitamin B12 anemia)
Patient will present as → a 6-week-old first-born baby boy with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region at the lateral edge right upper quadrant. Labs show blood pH 7.47 and potassium of 3.2 mmol/L. On a barium upper GI series report, the radiologist states a “string sign” is present.
pyloric stenosis
what is most likely dx if Infants feed well for first 2-3 weeks of life then presents with nonbilious vomiting after most or every feeding
pyloric stenosis
A string sign on barium swallow should make you think of what diagnosis?
pyloric stenosis
what is the tx for pyloric stenosis?
pyloromyotomy (ramstedt procedure)
what is the most common cause of massive lower GI bleeding?
diverticulitis
This disease presents as painless rectal bleeding, particularly in an elderly patient.
Diverticulosis
What will a CT scan show for diverticular disease?
Fat stranding and bowel wall thickening
What is the outpatient tx for colonic diverticulitis?
pain control and a liquid diet. If ABX needed, can use cipro and metronidazole
What is a complication of gallstones with symptoms secondary to an infected obstruction of the common bile duct (E.coli is the #1 cause)
cholangitis
the presenting sx associated with ascending cholangitis include
fever, right upper quadrant pain, and jaundice (Charcot’s triad)
Reynolds pentad includes what? and what is it a sx of?
Hypotension
Confusion
Right upper quadrant pain
Jaundice
Fever
What is a good initial test for ascending cholangitis and what will it show?
US. biliary dilation or stones
In patients with Charcot’s triad and abnormal liver tests, proceed directly to which test to confirm the diagnosis and provide biliary drainage?
ERCP
Patient will present as → a 52-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks.
hepatic carcinoma
What tumor marker may be used for liver cancer?
alpha-fetoprotein
What type of tumor is an aggressive tumor that often occurs in the setting of chronic liver dz and cirrhosis
hepatocellular carcinoma
What are some sx of pancreatic carcinoma?
weight loss, epigastric and pain, clay-colored stools.
What tumor marker can be used to follow pancreatic cancer?
CA 19-9
What is Courvoisier’s sign?
nontender, palpable gallbladder (may indicate pancreatic neoplasm)
What is the treatment for pancreatic carcinoma?
Whipple procedure
Patient will present as → a 68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable non-tender gallbladder and clay-colored stool. Labs show total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150.
pancreatic carcinoma
What are the types of hiatal hernias?
Sliding hiatal hernia - type 1 (accounts for > 90 percent)
Paraesophageal hiatal hernia - type 2 (accounts for <5 percent)
What is the surgery for type 1 hiatal hernia?
Nissen fundoplication
A colonoscopy that shows cobblestone or skip lesions should make you think of what diagnosis?
Crohn’s disease
Which inflammatory bowel disease is limited to the mucosa and submucosa?
Ulcerative colitis
What are some radiographic findings of Crohn’s disease?
String sign of the terminal ileum
What are some radiographic findings of Ulcerative colitis?
Tubular (lead pipe) appearance
This presents with bloody puss-filled diarrhea, rectal/LQ pain, fever, urgency
Ulcerative colitis
This presents with and pain, weight loss, non-bloody diarrhea, oral mucosal aphthous ulcers.
Crohn’s disease
Where does Crohn’s disease most commonly present?
terminal ileum
What will an antibody test show for Crohn’s disease?
+Anti-Saccharomyces cerevisiae antibodies (ASCA)
What will an antibody test show for Ulcerative Colitis
Antineutrophil cytoplasmic antibodies (p-ANCA)
A patient on sulfasalazine (anti inflammatory) for an inflammatory bowel disease should be supplemented with what vitamin?
Folate
Is surgery curative for Crohn’s or ulcerative colitis?
UC
What is the maintenance medication for IBD?
Sulfasalazine
serum bilirubin of > 2.5 mg/dl is a sign of what?
Jaundice
What are the 4 cardinal signs of strangulated bowel?
fever, tachycardia, leukocytosis, localized and pain
Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery
Small bowel obstruction
Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly
large bowel obstruction
What is the most common cause of large bowel obstruction?
colorectal cancer
What is a classic radiographic finding of SBO?
dilated loops of small intestine, air fluid levels, bowel stacking
What is a “coffee bean sign” indicative of
volvulus (loop of intestine twists around itself causing a bowel obstruction
Patient will present as → a 45-year-old man with severe rectal pain when he defecates, lasts for several hours and subsides until the next bowel movement. He has been constipated for the past 6 months and when he does have a bowel movement the stool is covered with bright red blood. A sentinel pile (thickened mucosa) is noted on physical exam.
Anal fissure
Patient will present as → a 47-year-old man with severe rectal pain when he defecates. He has a fever of 102.2 F (39 C). On exam there is perianal swelling, redness and tenderness. A palpable mass is felt at the anal verge.
rectal abscess
Patient will present with → perianal drainage, perirectal abscess, recurrent perirectal abscess, “diaper rash,” itching
rectal fistula
What is a risk factor for an increased incidence of duodenal and gastric ulcers, as well as a decrease in rate of healing?
cigarette smoking
food classically causes pain for this type of ulcer
gastric ulcer
food classically decreases pain for this type of ulcer
duodenal ulcer
duodenal and gastric ulcers are most commonly caused by what?
H. pylori infections
What is the most accurate dx test for PUD?
Upper endoscopy
tx for H. Pylori
PPI + Amoxicillin 1g PO BID + Metronidazole or Clarithromycin 500 mg PO BID
What is more painful, internal or external hemorrhoids?
external hemorrhoids
What causes more bleeding, internal or external hemorrhoids?
internal hemorrhoids
This involves protrusion of the stomach through the diaphragm via the esophageal hiatus. It can cause symptoms of GERD; acid reduction may suffice, although a surgical repair can be used for more serious cases.
Hiatal (diaphragmatic) hernia
This type of hernia occurs when there is weakening in the anterior abdominal wall and may be either incisional or umbilical
Ventral hernia
This hernia is associated with vertical incisions, especially with obesity
Incisional hernia
This hernia is very common, generally is congenital, and appears at birth. Many resolve on their own and rarely require intervention. Refer to surgery if hernia persists >2 years of life.
umbilical hernia
This hernia goes through a passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
Indirect inguinal hernia (most common)
this hernia goes though a passageof intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum
Direct inguinal hernia
Patient will present as → a 24-year-old man with ulcerative colitis receives Lomotil for excessive diarrhea and develops fever, abdominal pain and tenderness, and a massively dilated colon on abdominal x-ray.
toxic megacolon
a complication of inflammatory bowel disease, such as ulcerative colitis and, more rarely, Crohn’s disease, and of some infections of the colon, including Clostridium difficile infections, which have led to pseudomembranous colitis.
Toxic Megacolon
plain-film radiography will show colonic dilation > 6 cm
toxic megacolon
At least three of the following for a dx: Fever (>101.50F),
Heart rate > 120/min,
Neutrophilic leukocytosis (>10.5 x 109/L)
and Anemia.
toxic megacolon
