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SURGERY > GENERAL - GI > Flashcards

GENERAL - GI Flashcards

1
Q

Overweight patient with burning retrosternal pain

  • worse with bending, tight clothes, lying flat at night
  • better with OTC antacids and H2 blockers

Diagnosis?

A

GERD

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2
Q

How to diagnose GERD

A

Clinical:
– if typical signs/symptoms & response to antacids, H2 blockers, PPIs

pH monitoring

    • if atypical signs/symptoms
    • to confirm correct Dx of refractory GERD before surgery
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3
Q

Treatment of GERD

A
  • OTC antacids, H2 blockers, PPIs

- surgery (Nissen fundiplication, resection)

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4
Q

Potential consequences of GERD

A 
Peptic esophagitis 
--> 
Barrett esophagus 
= metaplasia (stratified squamous --> simple columnar w/goblet cells)
--> 
Adenocarcinoma :(
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5
Q

Surgery for GERD: Indications

A
  • refractory disease (Nissen fundiplication)

- ulcerations, stenosis, or severe dysplasia (Resection)

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6
Q

Woman with dysphagia to liquids more than solids, improved after sitting straight for a time, with occasional regurgitation of undigested food. Megaesophagus seen on CXR.

  1. Diagnose.
  2. Next steps (Dx, Tx)
A
  1. Achalasia
    - more common in women
    - unique dysphagia to liquids more than solids
    - improved swallow w/straight sitting due to weight of fluid overcoming sphincter tone
  2. Dx: Barium swallow; Manometry definitive
    Tx: endoscopic balloon dilation
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7
Q

Male African American patient with history of alcohol abuse presenting with progressive dysphagia (first to noticed choking on meats, then soft foods, now even has trouble swallowing saliva). Has smoked 1ppd for 20 years.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Squamous cell carcinoma of esophagus
    - Risk factors: male, Af. Am., EtOH, smoking
    - Progressive dysphagia, solids to liquids (eventually even saliva)
  2. Dx: endoscopic biopsy (barium swallow first if concern for perforation)
    Tx: CT to assess operability; Surgery and/or Palliative care
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8
Q

Overweight patient with PMHx of long-standing refractory GERD presenting to progressive dysphagia from solids to liquids.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Adenocarcinoma of esophagus
    - Risk factor: long standing GERD
  2. First, confirm Dx of GERD with pH monitoring.
    Dx: endoscopic biopsies (barium swallow 1st if concern for perforation)
    Tx: CT to determine operability; Surgery and/or Palliative
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9
Q

Patient with long term history of bulimia presents with painful emesis of bright red blood.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Mallory Weiss Syndrome
    = laceration of esophageal mucosa at G-E junction after prolonged foreceful retching (often 2/2 bulimia, alcohlism, hyperemesis gravidarum)
  2. Dx: endoscopy
    Tx: endoscopic photocoagulation if needed (often resolves spontaneously in 24-48hrs; rarely fatal)
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10
Q

Patient with long term history of alcoholism presents after several days of binge drinking. He appeas very sick and has been vomiting forcefully. He is found to have fever and leukocytosis. After an hour in the ED, he develops sudden hematemesis as well as continuous severe wrenching epigastric/low sternal pain.

  1. Diagnosis
  2. Diagnostic steps
  3. Treatment
A
  1. Boerhaave Syndrome
    = full-thickness esophageal rupture after prolonged forceful vomiting (assoc’d w/bulimia, alcoholism, ulcer)
    -very sick appearance with fever and leukocytosis followed by sudden onset of epigastric/low sternal pain and continuous hematemesis
  2. CXR: mediastinal or free peritonial air; SQ emphysema; widened mediastinum

CT: esophageal wall thickening; mediastinal widening; air/fluid in pleural spaces, retroperiotoneum, or less sac

Contrast swallow (Gastrograffin 1st; barium if neg.)

***DON’T SCOPE: increases perforation, mediastinal free air

  1. Immediate Abx & Emergent surgical repair
    High mortality: 100% untreated, 25% treated
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11
Q

A patient is resting in the recovery room after an upper endoscopy. He suddenly begins vomit up bright red blood and complain of severe low sternal and epigastric pain. The physician rushes to his bed and notices that he appears very ill, with palpable emphysema of his lower neck.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Instrumental esophageal perforation
    = most common cause of esophageal perf
  2. Dx: Contrast swallow (1st Gastrograffin, Barium if neg.)
    Tx: Prompt surgical repair
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12
Q

An elderly man presents with anorexia and early satiety. He has vague epigastric distress and occasional throws up bloody emesis. His wife says he has lost significant weight in the past couple months.

  1. Diagnosis
  2. Diagnostic steps
  3. Tx
A
  1. Gastric adenocarcinoma vs. Gastric lymphoma
  2. Endoscopic biopsies
3.
Adenocarcinoma
-- CT to assess operability
-- Surgery
Lymphoma
-- Chemo & Radiation
-- +/- Surgery if concern for perf as tumor melts w/above tx
-- *can reverse low-grade lymphomatoid transformation (MALTOMA) by treating H. pylori
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13
Q

Patient with Hx of laparoscopic appendectomy years ago presents with colicky abdominal pain and protracted vomiting, with concern that his belts no longer fit. He has not had a bowel movement in 2 days. On exam, the nurse noticed high-pitched bowel sounds, but later in the day the doctor did not appreciate any bowel sounds at all.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Mechanical small bowel obstruction
    - risk factors: adhesions from prior laparotomy
    - s/sx colicky abd pain, protracted vomiting, no BMs or flatus, distension if low blockage, high-pitched bowel sounds progressing to no bowel sounds
  2. Dx: Abd XR: dilated small bowel loops with air-fluid levels
    Tx:
    1st: NPO, NG suction, IVF –> may spontaneously resolve
    2nd: Surgery indicated for
    -signs of strangulation
    -failure of 24hr conservative tx if complete obstruction
    -failure of few days of conservative tx if partial obstruction
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14
Q

A patient presents due vomiting and a lack of BMs x4days. He has had colicky abdominal pain which today became constant. On exam, his abdomen is rigid and diffusely tender with significant guarding. It is found that he has a fever and leukocytosis.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Strangulated small bowel obstruction
    - signs of small bowel obstruction (colicky pain, no BMs, protracted vomiting) progressing to constant pain, fever, leukocytosis, and periotoneal signs
    - at risk for peritonitis and sepsis
  2. Dx:
    Besides clinical s/sx…
    Abd XR: dilated small bowel loops with air-fluid levels alon

Tx: Emergent surgery

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15
Q

A patient presents with vomiting and no BMs x 1 week. He has had colicky abdominal pain which this morning became constant. On exam, his abdomen is rigid and diffusely tender with significant guarding. An outpouching is found in his groin area, which cannot be pushed back in. It is found that he has a fever and leukocytosis.

  1. Diagnosis
  2. Next steps (Dx, Tx)
A
  1. Incarcerated hernia causing mechanical small bowel obstruction and strangulation
    - irreducible hernia + sx of strangulated hernia (vomiting, no BMs/flatus, constant pain, fever, leukocytosis, periotoneal signs)
  2. Dx: Besides clinical s/sx, Abd XR showing dilated small bowel loops with air-fluid levels
    Tx: Emergent surgery
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16
Q

A patient presents with diarrhea and abdominal pain as well as wheezing. The doctors notices significant JVD and facial flushing. Blood tests after the attack are normal.

  1. Likely Diagnosis
  2. Dx
  3. Tx
A
  1. Carcinoid syndrome
    = small bowel carcinoid tumor + liver mets or liver failure (only symptomatic after liver can no longer inactivate the serotonin secreted by the tumor)
  2. Dx:
    - 24hr urine collection for 5-hydroxyindoleacetic acid (HIAA) [high concentrations in blood only during attack]
    - Octreoscan or other imaging to locate tumor/mets
  3. Tx:
    - Surgical resection
    - +/- radiation, chemo, symptomatic tx (octreotide)
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17
Q

Young woman presents to the ED complaining of anorexia, nausea/vomiting, and vague periumbilical pain for a couple hours. When the doctor visits a little later, the pain has become more sharp and severe and has moved lower and to the right. On exam, the doctor notes abdominal tenderness, guarding, and rebound only on the right and below the umbilicus. The patient is found to have a slight fever and mild leukocytosis with a left shift.

  1. Likely Diagnosis
  2. Dx
  3. Tx
A
  1. Classic Acute Appendicitis
  2. Dx: CT abdomen (could consider US first)
  3. Tx: Emergent appendectomy
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18
Q

After his annual physical, an elderly patient is diagnosed with hypochromic anemia of unknown cause. He has always refused health screening tests outside of blood tests.

  1. Likely Diagnosis
  2. Dx
  3. Tx
A
  1. Rt-sided colon cancer
    - typically presents as anemia of unknown cause in elderly
  2. Dx:
    Fecal testing shows 4+ occult blood.
    Colonoscopy/biopsy diagnostic
  3. Tx: Surgery (right hemicolectomy)
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19
Q

An elderly man presents due to painless bloody bowel movements. At his wife’s prompting, he reluctantly admits he has noticed his stool has become flatter-appearing and that he has felt somewhat constipated.

  1. Likely Diagnosis
  2. Dx
  3. Tx
A
  1. Left-sided colon cancer
    - presents with blood-coated stool of narrowed caliber +/- constipation
  2. Dx:
    Flexible proctosigmoidoscopy and biopsies
    Full colonoscopy before surgery (r/out synchronous second primary)
    CT to assess operability
  3. Tx: Surgical resection (+/- pre-op chem/RXT)
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20
Q

Colonic polyps - arrange in order of descending order of probability for malignant transformation:

  • Familial multiple inflammatory polyps
  • Hyperplastic polyps
  • Adenomatous polyp
  • Peutz-Jeghers syndrome polyps
  • Familial polyps
  • Juvenile polyps
  • Villous adenoma
  • Isolated Inflammatory polyps
A

High likelihood of malignant transformation to low:

  • Familial polyps
  • Familial multiple inflammatory polyps
  • Villous adenoma
  • Adenomatous polyp

Non-malignant:

  • Juvenile polyps
  • Peutz-Jeghers syndrome polyps (hamartomas)
  • Isolated Inflammatory polyps
  • Hyperplastic polyps
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21
Q

Potential for malignant transformation or not?

Hyperplastic polyps

A

No! Not pre-malignant.

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22
Q

Potential for malignant transformation or not?

-Familial multiple inflammatory polyps

A

Yes! 2nd most likely to transform.

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23
Q

Potential for malignant transformation or not?

-Isolated Inflammatory polyps

A

No! Not pre-malignant.

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24
Q

Potential for malignant transformation or not?

-Peutz-Jeghers syndrome polyps

A

No! Not pre-malignant.

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25
Q

Potential for malignant transformation or not?

-Adenomatous polyp

A

Yes! 4th (least) most likely to transform.

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26
Q

Potential for malignant transformation or not?

- Familial polyps

A

Yes! Most likely to transform.

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27
Q

Potential for malignant transformation or not?

-Villous adenoma

A

Yes! 3rd most likely to transform.

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28
Q

Potential for malignant transformation or not?

-Juvenile polyps

A

No! Not pre-malignant.

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29
Q

Indications for surgery in treatment of chronic ulcerative colitis (CUC)

A

Primarily medically managed

Surgery to remove affected colon (always w/rectum) indicated if:

  • over 20yrs (high incidence of malignant degeneration)
  • severe interference w/nutritional status
  • need for high-dose steroids or immunosuppressants
  • development of toxic megacolon (abd pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on XR w/gas w/in colon wall)
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30
Q

An patient was recently treated with PCN allergy was recently treated for pneumonia. She developed profuse watery diarrhea as well as abdominal cramps. She was found to have a fever and leukocytosis.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Pseudomembranous enterocolitis
    - 2/2 bacterial overgrowth in patients recently on antibiotics
  2. Dx: ID toxins in stool (C. diff toxins A & B)
    * Stool Cx often takes too long and pseudomembranes may not be seen on endoscopy
  3. Tx:
    - D/c offending Abx
    - Begin metronidazole (alternative: PO Vancomycin)
    - Do NOT use anti-diarrheals
    - Emergent colectomy if unresponsive to tx with WBC >50,000 and serum lactate >5
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31
Q

Which bacteria and antibiotics are most implicated in pseudomembranous enterocolitis?

A
  1. Bacteria: Clostridium difficile

2. Clindamycin 1st described; Cephalosporins now most common; Any antibiotic can do it.

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32
Q

Diagnosis of anorectal cancer

A
  • Presentation may suggest specific benign process (hemorrhoids, fissure etc.)
  • R/out with rectal exam and proctosigmoidoscopy
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33
Q

Two patients with hemorrhoids:
Pt 1: Painful
Pt 2: No pain but bleeding

Internal or external? Treatment?

A

Pt 1: Internal hemorrhoids

  • bleed but not pain UNLESS prolapsed (–> pain, itch)
  • tx with rubber band ligation

Pt 2: External hemorrhoids

  • painful
  • conservative tx; surgery if fails
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34
Q

Young woman presents with exquisitely painful defecation with blood-streaked stools. The pain has lead to avoidance of BMs and constipation. She will not allow anal exam in the office but accepts an exam under anesthesia.

  1. Mostly likely diagnosis
  2. Dx
  3. Tx
A
  1. Anal fissure
    - exquiste pain w/defecation, blood-streaked stool
    - fear of pain so intense that they avoid BMs (–> constipation) and refuse anal exam
    - usually caused/perpetuated by tight sphincter
  2. Dx: may require anal exam under anesthesia (fissure usually posterior & mid-line)
  3. Tx: To relax sphincter…
    - Stool softeners
    - CCBs (topical diltiazem ointment 2% TID) x6wks (80-90% success)
    - Topical nitroglycerin
    - Local injection of botulinum toxin (50% success rate)
    - Forceful dilation
    - Lateral internal sphincterotomy
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35
Q

Young woman was diagnosed with an anal fissure which was refractory to conservative treatment. She underwent surgical interventions but the wound only worsened.

  1. Likely diagnosis
  2. Tx
A
  1. Crohn disease
    - starts with fissure, fistula, or small ulcerations
    - fails to heal/worsens after surgery (area usually heals well and quickly due to excellent blood supply; if not, Crohn’s)

Tx:

  • Surgery should NOT be done in anal Crohn’s dz
  • Treat Crohn’s dz medically
  • Fistula, if present, may be drained with seton stitches
  • Infliximab (Remicade) helps healing
36
Q

A patient presents with exquisite pain around his rectum that prevents him from sitting and having BMs. The nurse reports that he is febrile. On physical exam, the physician notes a warm, red, painful area of induration lateral to the anus, in between the rectum and ischial tuberosity.

  1. Likely diagnosis
  2. Tx
A
  1. Ischiorectal (perirectal) abscess
    - r/out cancer by exam
  2. Tx: I & D (r/out cancer by exam during procedure)
    * WATCH severe diabetics closely (may proceed to horrible necrotizing soft tissue infection)
37
Q

A patient who recently had an ischiorectal abscess drained presents with fecal soiling and occasional discomfort in the perineal area.

  1. Likely diagnosis
  2. Likely physical exam findings
  3. Other Dx steps
  4. Tx
A
  1. Fistula-in-ano
    - fistula forming after drainage of ischiorectal abscess, with permanent tract formed via epithelial migration from anal crypts (where abscess originated) and from perineal skin (where drainage was done)
    - -> fecal soiling, occasional perineal discomfort
  2. PE:
    - opening(s) lateral to the anus
    - +/- palpable cord-like tract
    - +/- expressible discharge
  3. Other Dx: r/out necrotic & draining tumor
  4. Tx: Fistulotomy (open up the fistula tract)
38
Q

A young HIV+ male presents with the complaint of rectal bleeding and pressure. He has also noticed a lump near his anus for the past few months. He mentioned that he also thinks he has a hernia, as he can feel a bulge in his groin area that he hadn’t felt before, though he reports no recent heavy lifting or trauma to the area. His family physician, who has followed this patient since adolescence, is concerned because the patient began sexual activity at an early age with other males.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Squamous cell carcinoma of the anus
    - common in HIV+ individuals as well as those practicing receptive sexual practices
    - fungating mass grows out of anus
    - inguinal node mets often felt
  2. Dx: Biopsy
  3. Tx: Nigro chemoradiation protocol (90% success) followed by surgery for residual tumor (rarely required)
39
Q

From where does most GI bleeding originate (upper or lower GI)?
From whence does the rest most commonly arise?
What is the least common source?

A
  • UPPER (3/4 cases)
  • 1/4 from colon or rectum
  • very few from jejunum & ileum
40
Q

What is the dividing landmark between upper & lower GI?

A

Upper GI: Tip of the nose to the ligament of Treitz (suspensory ligment from duodenum/jejunum to left diaphragm)

41
Q

DDx of colonic bleeding

A

-angiodysplasia
-polyps
-diverticulosis
-cancer
all more common in old people
(when young people have GI bleed, likely not colonic; likely upper GI)

42
Q

Sources of bleeding per rectum in young vs. old person

A
  • Overall, upper GI most common source at all ages.
  • Colon sources & hemorrhoids are increasingly common with age, but bleeding in an old person could come from anywhere.
  • In young person, upper GI source are overwhelming most likely.
43
Q
  1. Source of hematemesis (upper vs lower GI)

2. Initial workup

A
  1. Always UPPER GI source
    * also true when blood recovered from NG tube in person complaining of blood per rectum
  2. Initial workup:
    Upper GI endoscopy (look at mouth & nose first!)
44
Q
  1. Source of melena

2. Initial workup

A
  1. Melena = digested blood, therefore originates high enough to undergo digestion (UPPER GI)
  2. Initial workup: upper GI endoscopy
45
Q
  1. Source of bright red blood per rectum

2. Initial workup

A
  1. May be from anywhere! (including upper GI with rapid transit)
  2. Initial workup:
    1st aspirate gastric content via NG tube
    - If blood retrieved, UPPER GI source –> upper endoscopy
    - If no blood retrieved & fluid is white (no bile), nose to pylorus source ruled out; BUT duodenum & lower GI still possible sources –> upper endoscopy 1st, then other studies (anoscopy, colonoscopy…)
    - If no blood retrieved but fluid is green (bile-tinged), upper GI excluded & there is not need for an upper endoscopy
46
Q

Work up of lower GI bleed

A

1) Rule out upper source w/NG tube +/- upper endoscopy.
2) ANOSCOPY: rule out bleeding hemorrhoids

3) Rule out colonic sources:
* Colonoscopy not helpful in active bleed (obscures view)
- ANGIOGRAM: If fast bleeding (>2ml/min or 1 unit/4hr)
- -> may allow angiographic coagulation
- COLONOSCOPY: If slow bleeding (

47
Q

Patient presents with history of blood per rectum, but currently none is found. What is the best initial workup?

A
  • If young patient: upper endoscopy 1st

- If old patient, upper & lower endoscopy at same time

48
Q

Blood per rectum in child

1) Cause
2) Work up
3) Tx

A

1) Meckel diverticulum
= diverticulum in distal ileum present at birth
= vestigial remnant of omphalomesenteric duct (aka vitelline duct or yolk stalk)

2) Technetium scan
- looking for ectopic gastric mucosa present in some

3) Surgical resection

49
Q

Stress ulcers

1) Presentation
2) Dx
3) Tx / Prevention

A

1) Massive upper GI bleed in the stressed, multiple trauma, or complicated post-op patient
2) Dx: Endoscopy

3)
Tx :Angiographic embolization
Prevent: Maintain gastric pH >4

50
Q

DDx of Acute Abdominal Pain

broad categories & specific examples

A
  • Perforation (most common: peptic ulcer perf)
  • Obstruction (stones in ureteral, cystic, or common duct)
  • Inflammatory process (pancreatitis, diverticulitis)
  • Ischemic process (ischemic bowel)
51
Q

Patient presents with severe constant generalized abdominal pain that began suddenly. He is reluctant to move and very protective of his abdomen. On exam, he has impressive abdominal tenderness, guarding, and rebound pain. No bowel sounds are appreciated.

1) Likely broad category of acute abdominal pain & most likely specific cause
2) Dx
3) Tx

A

1) Perforation, likely due to perforated peptic ulcer
2) Dx confirmed by upright XR showing free air under the diaphragm
3) Tx: Emergency surgery

52
Q

Overweight 44yo G5P6 female presents with sudden onset of colicky abdominal pain in the RUQ along with nausea and vomiting. She says it is not usually the time of the month she gets cramps, plus the pain is worse and different than usual cramps. She is shifting constantly in her ED bed, trying to find a comfortable position when the physician walks in. He notes severe tenderness to palpation in the RUQ but no where else. Labs show high alk phos.

  1. Likely broad category of acute abd pain & most likely specific cause
  2. Dx
  3. Tx
A
  1. Obstruction, likely due to blockage of bile ducts (cystic, common) by gallstone
    - Risk factors: Fat, forty, fertile, female; Mex-Am or Native Am
    * Other obstructive acute abd pain may be due to ureter obstruction, with same sudden onset of colicky pain but different location & radiation
  2. Dx:
    High serum alkaline phosphatase
    US: dilated ducts, non-dilated gallbladder full of stones
    ERCP: confirm dx… and tx
  3. Tx:
    - Supportive (NSAIDs or opioids +/- nausea meds +/- IVF)-
    - ERCP –> sphincterotomy, remove common duct stone
    - Cholecystectomy afterwards
53
Q

Middle-aged woman presents with gradual onset of slowly worsening abdominal pain for the past 10 hours. The pain is constant. The patient can’t describe where the pain began, but she said it eventually located to her left lower abdomen. She is found to have a fever and leukocytosis. On exam, she has moderate tenderness and guarding over her LLQ.

  1. Likely broad category of acute abd pain & most likely specific cause
  2. Dx
  3. Tx
A
  1. Inflammatory, likely due to acute diverticulitis
    - may sometimes palpate tender mass
    - DDx in women: tubal or ovarian process
  2. Dx: CT diagnostic
  3. Tx:
    NPO, IVF, Abx
    Emergency surgery if no improvement with above tx
    -radiologically guided percutaneous drainage of abscess
    -resection if needed
    Elective surgery if at least 2 attacks
54
Q

Elderly patient with PMHx of AFib and recent MI presents with severe acute abdominal pain as well as rectal bleeding.

  1. Likely broad category of acute abd pain
  2. Next steps (Dx/Tx)
A
  1. Ischemic, most likely mesenteric ischemia
    - usually elderly
    - usually Hx of AFib or recent MI (clot breaks off and lodges in superior mesenteric artery)
    - in elderly, often acute abdomen is less impressive
    - only condition mixing acute pain with GI bleeding
    - may develop acidosis and sepsis
  2. Dx/Tx: Early arteriogram and embolectomy
55
Q

Patient presents with with ascites as well as mild generalized abdominal pain with peritoneal signs but equivocal physical findings. He has fever and leukocytosis.

  1. Likely diagnosis
  2. Dx
  3. Txx
A
  1. Suspect primary peritonitis (i.e. spontaneous infection arising in peritoneum, not 2/2 to other source)
  2. Dx: Culture of ascitic fluid
    - > single organism (rather than multiple organism found in more common forms of acute abdomen)
  3. Tx: Abx (NOT surgery)
56
Q

Child presents with nephrosis and ascites, and is found to have fever and leukocytosis.

  1. Suspected diagnosis
  2. Dx
  3. Tx
A
  1. Primary peritonitis (i.e. spontaneous infection arising in peritoneum, not 2/2 to other source)
  2. Dx: Culture of ascitic fluid
    - > single organism (rather than multiple organism found in more common forms of acute abdomen)
  3. Tx: Abx (NOT surgery)
57
Q

Approach to generalized acute abdomen

A
  1. R/out primary peritonitis (clinical, ascites culture)
  2. R/out mimickers
    - –MI with EKG
    - –Lower lobe PNA with CXR
    - –PE with clinical picture and/or tests
  3. R/out things that specifically do not require surgery
    - –Pancreatitis (amylase, lipase)
    - –Urinary stones (CT abdomen)
  4. Exploratory laparotomy is the diagnosis/treatment of generalized acute abdomen of other etiology
58
Q

Patient with a history of alcoholism presents with severe sudden epigastric pain that developed within a couple hours. The pain is constant and radiates through to the back. He also complains of nausea, vomiting, and retching. Physical exam demonstrates tenderness in the upper abdomen.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Acute pancreatitis (inflammatory cause of acute abdomen)
  2. Dx:
    Serum (12-48hrs) or urinary (3-6 day) amylase/lipase
    CT if unclear from labs
  3. Tx:
    NPO, NG suction, IVF
59
Q

Patient presents after sudden onset of colicky flank pain radiating to his inner thigh and scrotum. He has urgency and frequency as well. UA show microhematuria.

  1. Likely diagnosis
  2. Dx
A
  1. Ureteral stones
    - radiates from flank to inner thigh and scrotum/labia
    - occasional other urinary sxs (urgency, frequency)
  2. Dx: UA: microhematuria; CT diagnostic
60
Q

An elderly patient with a history of constipation is brought in from the nursing home due to constipation, abdominal pain and severe severe distention that has been progressing for days. He has not had any recent BMs or flatus. This morning, he began to vomit and his pain became constant and severe. On exam, his abdomen is distended, tympanic, and tender. Abdominal XR shows huge air-filled loop in the RUQ that taper down toward the LLQ in the shape of a “parrot’s beak”

  1. Likely diagnosis
  2. Next dx steps
  3. Tx
A
  1. Sigmoid volvulus
    - seen in elderly, especially with history of constipation and institutionalization
    - severe distention and obstructive signs
    - develops over days
    - may lead to perforation and/or peritonitis (fever, tachycardia & hypotension, peritoneal signs)
  2. Dx:
    XR diagnostic, with remarkable distended loop in RUQ tapering to a point in the LLQ (“parrot’s beak”)
  3. Tx:
    Proctosigmoidoscopy with old rigid instrument resolves acute problem; rectal tube left in.
    Elective sigmoid resection if recurrent.
61
Q

A patient with a PMHx of hepatic cirrhosis is at her annual physical and admits symptoms of vague RUQ discomfort as well as unintended weight loss in the past few months. Blood tests are positive for alpha-fetoprotein.

  1. Likely dx
  2. Dx
  3. Tx
A
  1. Primary hepatoma (hepatocellular carcinoma)
    - seen only in cirrhotics in the US
    - vague RUQ discomfort + weight loss
  2. Dx:
    Specific blood marker: alpha-fetoprotein
    CT: location & extent
  3. Tx: Resection if possible
62
Q

A patient who was is being treated for colon cancer presents with vague RUQ discomfort. He is found to have rising carcinoembryonic antigen (CEA) levels and elevated LFTs.

  1. Likely diagnosis
  2. Next steps to Dx
  3. Tx
A
  1. Mets to liver
    - common site for metastases due to rich dual blood supply
    - outnumbers primary liver cancer by 20:1 in US
  2. Dx
    - May be suspected due to rising CEA levels in person who had colon cancer
    - May be seen on CT if follow-up for treated primary cancer is under way
  3. Tx:
    - Resection if slow growing primary tumor and mets confined to one lob
    - Radioablation also a possibility
63
Q

Young woman who has been on OCPs for many years complains of RUQ pain. On US, a small mass is noted in her liver.

  1. Likely diagnosis & risks
  2. Dx
  3. Tx
A
  1. Hepatic adenoma
    - strongly associated with prolonged OCP use
    - tendency to rupture and bleed massively inside abdomen
  2. Dx:
    May be found US (often incidentally)
    CT diagnostic
  3. Tx: Surgery (emergency if rupture)
64
Q

An 45yo overweight Mexican-American female has been having intermittent colicky RUQ pain for a week. She then developed tenderness in the RUQ and fever. She feels her skin looks more yellow than usual. In the ED, she if found to have leukocytosis.

  1. Likely initial diagnosis 1 week ago
  2. Possible complications that have developed
  3. Dx
  4. Tx
A
  1. Cholelithiasis/cholecystits
  2. Ascending cholangitis and/or Pyogenic liver abscess
  3. Dx:
    US or CT
    –dilated thickened ducts for ascending cholangitis
    –possible e/o gallstones hinting at cause (though can’t visualize duct stones)
    –liver abscess
  4. Tx:
    Percutaneous drainage of abscess
    IVF, Abx for ascending cholangitis; ERCP emergently or after some improvement on Abx
65
Q

A Mexican immigrant presents with abdominal pain. He is found to have fever, leukocytosis and a tender liver.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Amebic liver abscess
    - favors men
    - “Mexico connection” (i.e. visited, immigrant…)
  2. Dx: US or CT scan
    Definitive dx by serology (takes weeks)
    (ameba does not grow in the pus)
  3. Tx: Metronidazole (empiric)
    * percutaneous draining seldom required; only if no improvement on metronidazole
66
Q

Etiologies of jaundice

A

Hemolytic
Hepatocellular
Obstructive

67
Q

Hemolytic jaundice

  1. Level of bilirubin elevation (low, medium, high)
  2. Type of bilirubin elevated- Direct (conjugated), Indirect (unconjugated), or both
  3. Other findings
  4. Further work up
A
  1. Low level (bilirubin 6-8, NOT 35-40)
  2. Only unconjugated (indirect) bili elevated
  3. No bile in urine
  4. Work up to determine cause of hemolysis
68
Q

Hepatocellular jaundice

  1. Type of bilirubin elevated- Direct (conjugated), Indirect (unconjugated), or both
  2. Other findings
  3. Further work up
A
  1. Both direct (conjugated) and indirect (unconjugated) hyperbilirubinemia
  2. Very high transaminases, mildly elevated alk phos
  3. Serologies to determine cause of hepatitis (most common cause)
69
Q

Obstructive jaundice

  1. Type of bilirubin elevated- Direct (conjugated), Indirect (unconjugated), or both
  2. Other findings
  3. Causes
  4. Further work up
A
  1. Both direct (conj) and indirect (unconj) bili elevation
  2. Modestly elevated transaminases, Very high alk phos
  3. Causes of obstruction: Gallstones, Malignancies
  4. US: biliary duct dilation and…
    - –stones in gallbladder indicating unseen stone in ducts & chronic irritation of gallbladder preventing its dilation
    - – malignant obstruction causing large, thin-walled, distended gallbladder (Courvoisier-Terrier sign)
70
Q

Types of malignancies causing obstructive jaundice

A
  1. Obstructive jaundice caused by tumor
    - -adenocarcinoma of pancreas head
    - -adenocarcinoma of ampulla of Vater
    - -cholangiocarcinoma arising in common duct itself
71
Q

Work up for malignancies causing obstructive jaundice

A

US: large dilated gallbladder

CT: Visual pancreatic cancers causing obstruction (larger)
–> percutaneous biopsy

ERCP: if CT negative (cancer too small to visualize)

  • -endoscopy (“E”) to visualize ampullary cancer
  • -cholangiogram (“C”): to visualize cholangiocarcinoma of common duct (“apple core”) or small pancreatic cancers

Endoscopic US: alternative

72
Q

Patient presents with jaundice, anemia, and stool positive for blood. She has noticed significant unintended weight loss over a couple months.

  1. Likely diagnosis
  2. Next step for workup
A
  1. Ampullary cancer causing obstructive jaundice & anemia
    - bleeds into lumen like any other mucosal malignancy
    - obstructs biliary flow by virtue of its location
  2. Endoscopy
73
Q

Prognosis for different causes of malignant obstructive jaundice:

  • Pancreatic adenocarcinoma
  • Ampullary adenocarcinoma
  • Common duct cholangiocarcinoma
A

Pancreatic cancer
–Seldom cured, even after Whipple procedure (pancreatoduodenectomy)

Ampullary cancer & cancer of lower end of common duct
- Somewhat better prognosis (40% cure)

74
Q

Medical student performs ultrasound on her friend for practice and incidentally finds gallstones in her gallbladder. The friend denies any RUQ pain, nausea, vomiting, or other symptoms associated with the stones.

  1. Diagnosis
  2. Tx
A
  1. Asymptomatic gallstones (incididental finding)

2. LEAVE ALONE

75
Q

Overweight female patient presents with colicky RUQ pain that radiates to her right shoulder as well as belt-like to her back. She also complains of nausea and vomiting. She has felt pains like this before, which lasted about 10 minutes after having eaten at her favorite diner. She receives a shot of Toradol and the pain improves quickly. On exam, there local tenderness in RUQ but no distention, guarding, or rebound tenderness.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Biliary colic
    - when stone temporarily occludes cystic duct
    - no peritoneal signs, usually self-limited, triggered by fatty meals
  2. Confirm with US
  3. Elective cholecystectomy
76
Q

A middle-aged woman has had several episodes of RUQ pain with nausea/vomiting that have stopped on their own after ~20 minutes. Today she again had such an episode, but the pain became constant and she has been feeling feverish. She is found to have fever, leukocytosis, and RUQ pain with guarding. LFTs are fairly normal.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Acute cholecystitis
    - begins as biliary colic but stone lodges in cystic duct and remains there until inflammatory process develops
  2. Dx:
    - -US usually diagnostic (gallstones, thickened gallbladder walls, & pericholecystic fluid)
    - - HIDA scan (radionucleotide scan) rarely needed (uptake in liver, common duct, & duodenum but NOT in occluded gallbladder)
  3. Tx:
    NG suction, NPO, IVF, Abx to “cool down”
    Followed by elective “urgent” cholecystecomy
    If no response to initial measure, may require emergency cholecystectomy
    –men & diabetics often require this
    –may temporize/stabilize with percutaneous transhepatic cholecystotomy (drainage catheter) if very sick with prohibitive surgical risk
77
Q

An elderly patient presents after an episode of biliary colic morphed into constant pain along with rigors and fevers up to 104.5 F. Her daughter thinks her skin appears yellowed. She is found to have a high WBC along with an extremely elevated alk phos and moderate hyperbilirubinemia.

  1. Likely diagnosis
  2. Diagnostic findings
  3. Tx
A
  1. Acute ascending cholangitis
    - DANGER!
    - gallstone reaches common duct, partially obstructing it and causing ascending infection
    * if complete obstruction, will not allow ascending infection
    - usually older & sicker patients
  2. Other findings:
    Some hyperbilirubinemia
    EXTREMELY HIGH ALK PHOS
    Very high WBC indicates possible sepsis
3. Tx:
IV Abx
Emergent decompression of common duct
-ERCP (best method)
-Alternatives: percutaneous transhepatic cholangiogram (PTC) or rarely surgical decompression
Eventual cholecystectomy
78
Q

Acute pancreatitis:

  1. Most common causes
  2. Categories
  3. Late complications
A
  1. Common causes: Alcoholism, Gallstones
  2. Types:
    - –Edematous
    - –Hemorrhagic
    - –Suppurative (pancreatic abscess)
  3. Late complications:
    - –pancreatic pseudocyst
    - –chronic pancreatitis
79
Q

A patient with a history of alcoholism presents after a binge with epigastric/mid-abdominal pain as well as nausea & vomiting. He continues to retch despite an now-empty stomach. The pain is constant and radiates straight through to the back. The physican finds tenderness and mild rebound in the upper abdomen. His CBC comes back and he is found to have an elevated hematocrit. Other labs are pending.

  1. Likely diagnosis
  2. Other abnormal labs
  3. Tx
A
  1. Acute edematous pancreatitis
    - may be 2/2 alcoholism (after binge) or gallstones (after heavy meal)
    - early lab clue: elevated hematocrit
  2. Elevated amylase or lipase
    - serum early on
    - urine after a couple of days
  3. Tx: pancreatic rest (NPO, NG sunction, IVF)
80
Q

A patient with a history of gallstones presents after Thanksgiving dinner with constant epigastric/mid-abdominal pain, nausea, and vomiting. The pain shoots straight through to her back. On exam, she has tenderness & rebound in the upper abdomen. Her labs show a low hematocrit and calcium along with a high WBC and glucose. The next morning, her hematocrit has fallen further, her serum calcium has not respond to supplement, and her BUN is elevated. She develops metabolic acidosis and low PaO2.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Acute hemorrhagic pancreatitis
    - similar initial presentation as the acute edematous form, but with low hematocrit, signs below, and much worse prognosis
  2. Dx:
    - elevated amylase/lipase
    - early lab clue: low hematocrit
    - Ranson’s criteria @ time of presentation include elevated WBC, elevated blood glucose, low serum calcium
    - If not caught early, the next morning things only worsen (lower hematocrit & Ca, high BUN, met acidosis, low PaO2)
  3. Tx
    - –Intensive supportive therapy in the ICU
    - –Daily CTs in order to anticipate and drain the multiple pancreatic abscesses that may develop (pathway to death)
    - –IV imipenum (or meropenum if sz d/o) if signs of infected pancreatitis
81
Q

Treatment of necrotic pancreas

A

Necrosectomy (best method)

  • often will wait as long as (at least 4wks) possible to allow dead tissue to dilineate well & mature for dissection
  • often must be openly drained or debrided (not percutaneously)
82
Q

A patient is treated for pancreatitis. About 10 days after its onset, he develops persistent fever and leukocytosis.

  1. Likely dx
  2. Dx
  3. Tx
A
  1. Pancreatic abscess (acute suppurative pancreatitis)
  2. Imaging (CT) showing pus collection(s)
  3. Percutaneous drainage
83
Q

A patient presents about 5 weeks after treatment for pancreatitis for symptoms of early satiety and a vague abdominal discomfort. A deep palpable upper abdominal mass is felt on exam.

  1. Likely diagnosis
  2. Dx
  3. Tx
A
  1. Pancreatic pseudocyst
    = collection of pancreatic juice outside pancreatic ducts (usually lesser sac)
    -late (~5wks) sequela of acute pancreatitis or pancreatic (upper abdominal) trauma
    -pressure symptoms (early satiety, vague discomfort, deep palpable mass)
  2. Dx: CT or US
  3. Tx: Depends on size/age of pseudocyst
    - –If =6cm or = 6 weeks old, unlikely to have complications –> observe for spontaneous resoluation
    - –Otherwise, more likely to rupture or bleed –> require drainage (percutanous, surgically into GI tract, or endoscopically into stomach)
84
Q

A alcoholic patient has had several episodes of pancreatitis and presents today with complaints of severe constant epigastric pain as well as foul-smelling greasy diarrhea, fatigue, polyuria, and polydypsia.

  1. Likely diagnosis
  2. Tx
A
  1. Chronic pancreatitis
    =calcified burned-out pancreas after several episodes of pancreatitis (usually alcoholic)
    -devastating disease
    –> steatorrhea, diabetes, constant epigastric pain
  2. Tx:
    - Diabetes: insulin
    - Steatorrhea: pancreatic enzymes
    - Pain:
    - –resistant to most tx
    - –wrecks sufferer’s life
    - –If specific points of obstruction/dilatation found on ERCP, may drain to help
85
Q

Treatment options for hernias

A

Elective repair –> prevent intestinal obstruction & strangulation

  • for all abdominal hernias EXCEPT:
  • –Umbilical hernias in pts prevent strangulation
  • if hernia becomes irreducible
  • *if has been irreducible for years, only need elective repair

SURGERY (12 decks)

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