GI 2021- Ross Study Guide Flashcards
What is the single MC reason for visits to the ED?
abdominal pain
The elderly population is at higher risk for serious pathology due to ____
to blunting of physiologic responses such as: -not spiking a fever, not becoming tachycardiac or hypotensive -weakened abdominal wall so don’t develop peritoneal signs -and for any given pathology they have much higher mortality rates
Bowel obstructions present with _____ _____ pain
diffuse colicky pain
Mesenteric ischemia presents with ____
pain out of proportion to exam
Pancreatitis epigastric pain radiates to:
back left shoulder blade.
Appendicitis pain: -in adults? -in children?
**periumbilical to RLQ -rectal pain in children
CT imaging can help answer a question such as: Is there a perforation, abscess or ______
obstruction or a mass
Avoid using a CT to shotgun an answer UNLESS the patient is ______
elderly **There is a low threshold to scan in patients older than 65.
Peptic ulcer disease and dyspepsia: -Gastritis is associated with _____ (list 3 things)
alcohol, NSAID, and stress (erosive gastritis)
Almost all non-NSAID and alcohol related ulcers are due to ________
Heliocobacter pylori
If a person with PUD has negative H. Pylori and is not drinking etoh or taking NSAID work up for a _____
**carcinoma should be considered!! especially in those loosing weight and not responsive to a trial of PPI..
H. Pylori can cause _____ carcinoma
gastric
Testing for H. pylori can include:
-serum antibody -stool antigen(good) or -**urea breath test= (best)
In patients with suspected PUD, and are NOT on NSAID’s, treat empirically for H. pylori with:
-triple medication for 14 days. -1st line tx includes PPI, Clarithromycin and amoxicillin.
Patients over 50 who present with dyspepsia or PUD symptoms should be scheduled to have an _______
endoscopy -**these Pts are at higher risk for gastric cancer
Patients with acute onset of intense pain, abnormal vitals and vomiting consider the diagnosis of _________
**perforated ulcer
Pts with a perforated ulcer will have ________, and therfore will be very still and generally have abnormal vitals
peritonitis -These Pts will need admission and consultation with surgery or GI
If there is no free air on KUB (kidney ureter bladder xray) consider consult with ___ instead of surgery first. ANY time there is free air you need a _____
GI -IF there is FREE air–> you need a surgeon.**This is a surgical emergency
Acute appendicitis: -typically which age group?
Typically teens and early 20’s but consider with any diagnosis of abdominal pain.
Acute appendicitis occurs when the appendiceal lumen becomes _______
obstructed by a fecalith, which leads to bacterial overgrowth and dilation of appendix.
Acute appendicitis: Classic presentation?
**umbilical pain that migrates to RLQ over a time period of hours. Pain that precedes vomiting typically surgical.
Acute appendicitis: Pain in pregnant women?
Pregnant women may have RUQ pain as the appendix is shifted upwards
Acute appendicitis: Pain variation for the general population?
includes a retrocecal appendix which may cause back pain
Acute appendicitis: -PE findings?
*Psoas, obturator and Rovsing signs are physical exam findings that are neither specific or sensitive enough to accurately diagnose (but fun when you find them) and are considered the best physical exam findings to indicated this pathology.
Acute Appendicitis: -best imaging study in adults? -best imaging study in pediatric population?
-**CT with contrast is imaging of choice in adults -pediatric population consider US of RLQ. **Needs pre-op antibiotics and pain management.
Mesenteric ischemia may also start with _________ pain commonly caused by ?
**generalized pain commonly caused by arterial emboli or thrombus; less commonly are hypoperfused (hypotension) states.
Mesenteric ischemia typically afflicts which population?
elderly and afib is a risk factor
Mesenteric ischemia: -imaging study? (findings?) -Tx?
-Abdominal CT with labs showing leukocytosis and a metabolic acidosis (need lactate). -Treat with aggressive resuscitation with fluids and Abx and early surgical evaluation.
Bowel obstructions: -non mechanical: Ileus= -etiology? -Abdominal exam findings?
Ileus means there is paralyzed intestine and the bowel does not have peristalsis. It is the MC cause for **SBO. -Ileus is caused by electrolyte imbalance, infections, spinal cord injury, and bowel surgery. -Abdominal exam has hypoactive sounds and mild tenderness
Bowel obstructions: -what are the MC causes of Mechanical small bowel obstructions? (list 3)
Adhesions, hernias and cancers
Mechanical Bowel obstructions: Sx?
-Pts have diffuse abdominal pain, distention and sometimes vomiting. -There is a decrease of peristaltic motion with no passing of gas or feces.
Mechanical Small Bowel obstructions: -Auscultation?
-reveals high-pitched hyperactive tinkling. Plain films can be helpful but miss early disease, CT more sensitive and can clarify the cause of the obstruction. Replace electrolytes, fluids and decompress stomach with gastric tube (debateable).
Mechanical Small Bowel Obstructions: -Plain films? Vs CT scan
Plain films can be helpful but miss early disease, CT more sensitive and can clarify the cause of the obstruction.
Mechanical Small Bowel obstructions: -Tx?
-Replace electrolytes, fluids and decompress stomach with gastric tube (debatable). -**All will need admission with a surgical consult.
Large bowel obstructions: -MC cause? -Exam findings? -Tx?
-commonly caused by a mass typically cancer and occasionally a volvulus -on exam–> there is no bowel in iliac fossa -Requires an admission and surgical consult.
Diverticulitis: -describe the onset of pain?
-slow onset of pain for 1-2 days -It is diffuse and non-specific but will eventually go to LLQ.
There are other areas of large bowel which form ________ but it is usually descending colon
diverticulitis
Diverticulitis: -Sx?
Patient may have fever, vomiting and decreased appetite
Diverticulitis: -MC location?
**descending and sigmoid colon
Diverticulitis: -Imaging of choice?
A CT scan with IV contrast is the diagnostic procedure of choice especially with a first presentation. Do NOT need repeat ct for every bout of diverticulitis. Obtain when you suspect a perforation or abscess.
Diverticulitis: -Tx for simple case? -tx for complicated case?
-simple case needs PO antibiotics and pain management (**metronidazole and cipro) -More complicated need IVF, Abx, and bowel rest. -Folks who have co-morbidities or no ability to follow up will need admission.
Classically the ligament of ____ defines upper and lower GI bleeds
**ligament of Treitz
Upper GI bleed: vomiting blood or coffee ground is called _______
hematemesis
Upper GI bleed: Pt can present with?
**bleeding per rectum it is usually dark, tarry (melana) colored (partially digested blood). So if melanotic stools consider bleeding from upper GI source.
Consider a Dx of ____ with perforation or esophageal varices
PUD
Patients who are vomiting blood need a _____
**high level of care
If you are unsure if they are actually bleeding or a Mallory Wiess tear (superficial), consider ____
cbc, and orthostatic vitals, as well as a stool guaiac and NG tube.
If patients are actively vomiting blood, have abnormal vitals, consider ____ -what needs to be a priority?
-2 IV’s and fluid resuscitation, may need blood transfusion as well. -Calling GI to perform esophagogastroduodensocpy needs to be a priority not only diagnostic but therapeutic.
If there are no orthostatic changes and vitals are normal and pt is guaiac negative and the NG tube shows no blood pt may have ____
PUD but NOT a bleeding ulcer. Consider watching for a few hours and discharge with GI follow up.
Lower GI bleeds often have?
**bright red or hematochezia KNOW
What is a common cause of lower GI bleeds?
Diverticulitis is a common cause also on the list are polyps , cancer, IBD, infectious diarrhea, and colitis.
GI bleeds: -On PE you should directly visualize the ____
On PE you should directly visualize the anus to look for hemorrhoids, **consider anoscopy
What is the MOST common cause of lower GI bleeds? -Consider using _____ score for evaluating lower GI bleeds
**Hemorrhoids= engorged vascular plexus of veins *Glascow-Blatchford score: –If there is no orthostasis: -HCT not low -Stool is neg for blood -BUN is normal =Ability to have 24 follow up
Internal hemorrhoids arise above the ____
dentate line, and are covered by mucosa and are not palpable.
BOTH internal and external hemorrhoids present with ___
as bright red blood per rectum
BOTH internal and external hemorrhoids require:
stool softeners, high fiber diet and localized topical anesthetics.
Soft hemorrhoids can be _____
reduced (like a hernia),
Thrombosed hemorrhoids need to be ____
removed. May need a surgical consult as outpatient to remove.
Pancreatitis: -describe the pain and Sx
Sharp, severe, persistent pain, with nausea and vomiting
Pancreatitis: Labs?
**Lipase is high (2-3x) as is amylase (although not as reliable). -*The pancreas autodigests
Pancreatitis: -MC cause in men? women?
In men typically due to alcohol in women due to gallstones.
Pancreatitis: 2 presentations
chronic and acute
Acute pancreatitis: -imaging? -tx?
pt need ct with IV contrast as well as aggressive fluid resuscitation (2-4 L if there is significant 3rd spacing). - Most get admitted overnight -monitor for complications such as: complications which include a pseudocyst, renal failure, pleural effusions, hypocalcemia, pancreatic abscess -Do this with repeat labs and repeat PE
Chronic pancreatitis: tx?
Chronic patient disposition depends on clinical situation and if can tolerate PO meds and have pain managed, if all are met –>they can go home
Pancreatitis: DONT FORGET that these Pts can have ____
an obstructing stone as the cause of the pancreatitis.
Cullen’s and Grey-Turner’s signs are manifestations of?
Gray-Turner’s sign= indicates hemorrhagic pancreatitis which is a severe form of the dz -And Cullen’s Sign (indicates severe Pancreatitis)**
_____ criteria can be used to assess severity of disease, be familiar with the ones used for initial evaluation (24hour)
Ranson’s criteria (pancreatitis) (is a predictor of mortality) it is used to distinguish alcohol vs biliary admission
Ranson’s Criteria: 24 hour
Esophageal Foreign body and Food bolus obstruction can occur anywhere there is ___
a narrowing (stricture, carcinoma, lower esophageal ring).
Foreign bodies are best removed by ________
endoscopy
For an impacted food bolus One can try: (list 2 things)
glucagon and nitrates (Side effects are nausea and vomiting. )
Elderly patients with food bolus that may have cleared still need a ____
scope as chance of reoccurrence is high. Consider an observation stay and consult with GI.
Otherwise patients with impaction who have drooling will need an ______ ASAP
endoscopy**
Why is Button battery ingestion especially worrisome?
it can leak and cause a perforation. Generally this occurs in kids and puppies.
Reducible hernia: -management?
needs little to no management except for pain -Consider outpatient referral to surgery if it impacts the person’s lifestyle -If you are unsure you can obtain a US.
Incarcerated Hernia: -management?
-MAY be reducible and patients may have sign of a bowel obstruction with nausea and vomiting - they may have peritoneal signs but this typically occurs in more severe disease
A strangulated hernia is ___ reducible
**NOT -it has no further blood supply and is necrotic, and must be taken out!!
Differentiating b/w strangulated and incarcerated Hernias:
-Sometimes it is difficult clinically to distinguish between the 2 disease process (incarcerated vs strangulated) -**Folks w/ peritoneal signs consider to be **strangulated. -Consider ordering labs; cbc, lactate (very high when there is necrotic tissue) and cmp to assist in that determination. -Either disease process will need a CT of the abdomen with IV contrast and a surgical consult
Femoral hernias: -how common? -More common in women or men? -location?
-are rare but more commonly found in women - there is a mass below the inguinal ligament
Intussusception=
=the inversion of one portion of the intestine within another
Intussusception: -predominantly occurs in which age group? -usually occurs post ____
-*Age up to 5 years dx predominantly of children, one intestinal segment telescopes onto another -usually post **viral infection and due to swollen lymph tissue (peyer’s patches).
Intussusception: -diagnosis? (what is the key Sx?) hint dr witwer likes it on crackers
-Difficult to dx, but intermittent crying with blood/mucus event (**currant jelly) in the diaper is the typical presentation. -Dx and tx are the same barium air enema. –***Sausage mass in mid abdomen, diarrhea with mucus and blood (currant jelly) KNOW these Sx!
Pyloric stenosis: -occurs in what age group? -Sx? -Diagnosis? -Requires?
-age birth to 5 months -Sx: Vomiting and possible weight loss -Olive shape mass in mid epigastrium, see peristalic waves, diagnosis via **US -Tx: requires surgical repair
60 yr old male complaining of 2 episodes of vomiting red blood 2 hours ago with no abdominal pain. -next step?
-2 large gauge IV
Gastroparesis=
= partial paralysis of the stomach, is a disease in which the stomach cannot empty itself of food in a normal way. If you have this condition, damaged nerves and muscles don’t function with their normal strength and coordination — slowing the movement of contents through your digestive system
Elderly Constipation: -normal bowel movement is __x or ___/week -tx?
3/day or 3 a week -if new onset older than 50 work up for cancer treat in ED: manual disimpaction -KUB full of stool: get perforation which kills -you are writing the wrong diagnosis -tx: bowel softeners, increase fluid intake, enema, physical activity -if more than 2 weeks may need scope -if on opioid may use: Methylnaltrexone (Relistor)
Gastroenteritis in Elderly
-Be concerned about mesenteric ischemia -empty bowel on both sides -get all the data and reevaluation
Esophagitis=
infectious with Candidiasis and or herpetic very painful
Motor disorders: -Esophageal stenosis=
- liquids are OK -Etiology: due to strictures Schatzki’s ring, Cancer -Neuromuscular disorders: difficulty with coughing and swallowing–> due to CVA, parkinsons, ALS
KNOW: -esophageal stenosis causes dysphagia for _____
**solid foods! slow progression of solid food dysphagia indicated a benign process such as a web or stricture while rapid implies a neoplasm
Achalasia is a esophageal motor disorder where ____ -Dx?
peristalsis is decreased degeneration of nerves in **Auerbach’s plexus –liquids and solids are problematic -Diagnosis of these disorders is made by barium swallow with video fluoroscopy esophageal manometry
Pediatric Foreign Body: -determine if ____
esophagus (drooling) or airway (stridor) -Peds: back blows or heimlick manuever
LLQ Pain=
Diverticulitis!! -Pathophysiology: Diverticulosis= small blood vessels called vasa recta penetrate the muscular wall of the colon it is there that herniations of the bowel can occur -Diverticulitis–> inflammation can ensue translocation of bacteria and small access formation micro perforations of the bowel **CT positive–> shows presence of colonic diverticula and wall thickening -pericolic fat infiltration -abscess formation -extraluminal air= (perforation) Tx: if mild–> observe and no Abx -otherwise Abx: cipro and metronidazole
RLQ pain=
acute appendicitis
