GI (3%) Flashcards
Warning signs of a surgical abdomen
Intractable pain followed by vomiting (vomiting before or with pain onset is typically not surgical) Acute, steady, or progressive severe pain Pain that causes syncope Pain that disturbs sleep Persistent pain for > 6 hours Well-localized pain Pain unrelieved by analgesics Old surgical scars on the abdomen
Common abdominal signs with examples
Murphy’s sign – pain with palpation of the RUQ (ex: cholecystitis)
Cullen’s sign – superficial edema and bruising around umbilicus (ex: intraperitoneal bleeding)
Psoas sign – abdominal pain with passive extension of the thigh (ex: acute appendicitis)
Obturator sign – abdominal pain with flexion and internal rotation of hip (ex: acute appendicitis)
Rosving’s sign – pain in RLQ with palpation of LLQ (ex: acute appendicitis)
Grey-Turner’s sign – bluish discoloration of the flanks (ex: retroperitoneal bleeding)
Bowel obstruction causes
- Causes – HANG IV mnemonic – Hernia, Adhesions, Neoplasm, Gallstone ileus, Intussusception/inflammation, Volvulus/vascular
- Can also be caused as a consequence of decreased GI mobility (narcotics, gastroparesis, etc.) or dehydration in elderly
- Can be small or a large bowel obstruction
Small bowel obstruction
- Symptoms – epigastric abdominal pain, nausea, vomiting, abdominal distention, vomiting stool, high-pitched/tinkling bowel sounds
- Diagnostics – abdominal film shows dilated loops of small bowel in horizontal pattern
- Treatment – fluid resuscitation, GI decompression, gastric tube with contrast and repeat imaging in 8 hours to determine surgical course, surgery for peritonitis or ischemic bowel
Large bowel obstruction
- Symptoms – abdominal pain, nausea, vomiting, abdominal distention, hypoactive/absent bowel sounds (for complete obstruction)
- Diagnostics – abdominal film shows picture frame pattern of large bowel
- Treatment – fluid resuscitation, GI decompression, gastric tube, medical treatment for partial obstruction (correct underlying cause), surgery for peritonitis, ischemic bowel, or total obstruction
Cholecystitis
- Acute inflammation of the gallbladder r/t stone impaction in the cystic duct
- Symptoms – RUQ pain typically after fatty meal with radiation, Murphy’s sign (press on RUQ causes sharp intake of breath and pain), nausea/vomiting, fever
- Diagnostics – RUQ US (diagnostic of choice) will show gallbladder wall thickening and sonographer will report + Murphy
- Treatment – NPO, IV fluids, analgesia, antibiotics if needed (Zosyn 3.375 g IV q6h), cholecystectomy (rare)
Appendicitis
- Luminal obstruction and inflammation/infection of the appendix
- Symptoms – periumbilical pain → RLQ pain, nausea, vomiting, sense of constipation, RLQ rebound tenderness, Psoas/obturator signs present (lie on left side and right hip is flexed backward causing pain; lie on back, hips and knees at 90, internal rotation of hips causes pain)
- Diagnostics – CT abdomen is diagnostic study of choice, ↑ WBC
- Treatment – analgesia, antibiotics (choice depends on if perforated or not), appendectomy
- Non-perforated antibiotics – cefoxitin 2g IV or cefazolin + Flagyl 0.5 g IV
- Perforated antibiotics – combination of Flagyl 0.5 g IV + ceftriaxone, ciprofloxacin, or levofloxacin
Diverticulitis
- Inflammation, rupture, and/or infection of diverticula in the colon
- Classifications – simple (localized) vs. complicated (abscess, peritonitis, obstruction, strictures)
- Symptoms – LLQ pain, fever, nausea, vomiting, constipation, stool is heme positive in 25% of cases (on exam, if heme positive, think of something else)
- Diagnostics – typically can be done without use of diagnostics, plain abdominal film to r/o free air or obstruction; however abdominal CT (study of choice) will assess complicated disease; do not scope during a flare
- General management – liquid diet until symptoms improve, low fiber, IV fluids (if not tolerating PO), gastric tube (if ileus/obstruction), pain control (typically narcotics), smoking cessation
- Antibiotics – FIRST LINE – mild disease = Bactrim 1 tab PO BID or Ciprofloxacin 750 mg PO BID; moderate disease = Zosyn 3.375 g IV q6h or 4.5 g IV q8h
C. Diff.
- Profuse, watery, foul-smelling diarrhea
- Diagnostics – positive C. diff stool culture
- Risk factors – antibiotic use (clindamycin is well known to cause this), direct exposure to another person with C. diff
- Mild disease – WBC < 15, no incease in creatinine
- Moderate disease – WBC > 15 OR > 50% increase in creatinine
- Severe disease – WBC > 15 OR > 50% increase in creatinine OR Zar score ≥ 2
- Mild treatment – vanco 125 mg PO BID x 10 days
- Moderate treatment – vanco 120 mg PO QID x 10 days
- Severe treatment – vanco 500 mg PO q6h + Flagyl 500 mg IV q8h
Upper GI bleed
- Risk factors – NSAID use, H. pylori, retching, liver disease
- Etiology – PUD, esophageal varices, Mallory-Weiss tear, AVM, tumor, etc.
- Symptoms – melena, nausea, vomiting, hematemesis, abdominal pain, hematochezia (if fast bleed)
- Diagnostics – EGD
- Consult GI
Lower GI bleed
- Etiology – diverticular, ischemia, colitis, malignancy, hemorrhoids, anal fissure, AVM
- Diagnostics – colonoscopy with/without biopsy
- Consult GI
Constipation
- Unsatisfactory defecation characterized by infrequent stools and/or difficult stool passage
- Primary (not attributed to structural abnormality or systemic disease) vs. secondary (r/t disease or medication)
- Medical tx tailored to underlying etiology
- Dietary or lifestyle changes (ex: increase fiber, exercise, dedicate time)
- Primary unresponsive to diet/lifestyle changes – laxatives are mainstay (bulk laxatives with/without stool softener)
- Chronic (> 3 months) – education, lifestyle modification, increase fiber, increase fluids, bulk laxatives
- No response to bulk laxatives after 6 weeks – osmotic laxatives (lactulose, polyethylene glycol, mag citrate)
- Do not give Mg-containing laxatives to those with renal disease
Diarrhea
- Increased stool frequency (more than 3 loose/liquid BMs/day)
- Acute management – most cases are self-limiting, clear liquid diet and advance as tolerated, rehydration, anti-diarrheals (do not use if bloody or diarrhea in hospital until C. diff ruled out), fluoroquinolones are oral drug of choice for empiric therapy
- Chronic management – thorough H&P, order routine stool specimens, anti-diarrheal if appropriate
Ileus
- Non-mechanical insult that disrupts the normal coordinated propulsive motor activity of the GI tract
- Symptoms – nausea and/or vomiting, distention, hypoactive bowel sounds, constipation, diarrhea
- Diagnostics – abdominal film, CT of abdomen
- Treatment – most resolve with conservative treatment, bowel rest, IVF, limit narcotics, ambulation, NG tube, electrolyte replacement
Hepatorenal Syndrome
The development of renal failure in patients with advanced chronic liver disease
Symptoms – fatigue, malaise, decreased urine output, signs of renal failure (ex: asterixis, spider nevi, ascites, hepatosplenomegaly, etc.)
Hepatitis B serology
- HBsAg (Hep B surface antigen): positive result = exposure + acute or chronic infection
- Anti-HBs (Hep B surface antibody): positive result = exposure [vaccine or natural] + recovery or immunity
- Anti-HBc (Total Hep B Core antibody): positive result = exposure + previous or ongoing infection
- IgM Anti-HBc (IgM antibody to Hep B core antigen): positive result = recent infection
Inpatient treatment for acute hepatitis infection
- Risk factors for acute illness – hep A infection with previous chronic Hep B or C; typically patients are hospitalized secondary to complications or progression from chronic infection
- Management – supportive – hydrate (3-4 L/day; be careful because of third-spacing), lactulose PO PRN for increased ammonia levels, loop diuretics for edema/ascites, paracentesis to relieve intraabdominal pressure if respiratory distress, replace albumin losses
Cirrhosis and end-stage liver disease
Risk factors – hx of hepatitis, etoh consumption, DM, use of ilicit drugs, family hx, presence of autoimmune disease
Symptoms – asymptomatic until later stages, spider angiomas, hepatomegaly, splenomegaly, ascites, jaundice
Diagnostics – liver biopsy (confirmatory), US/MRI/CT will often uncover findings suspicious of cirrhosis (nodular liver, enlarged liver)
Treatment – stop insult (if known), symptomatic tx (diuretics for ascites and edema; lactulose for encephalopathy), liver transplant
Pancreatitis
Acute inflammation of the pancreas secondary to direct injury or insult to pancreas causing release of pancreatic enzymes
Symptoms – epigastric abdominal pain with radiation to back, nausea/vomiting, abdominal tenderness, jaundice (with biliary obstruction), Cullen’s/Gray-Turner’s sign with retroperitoneal bleeding and shock
Diagnostics – ↑ amylase (> 3x upper limit of normal), ↑ lipase (most specific), ↑ ALT (> 3x upper limit of normal)
Management – typically supportive – fluid restriction with LR, NPO initial then increase diet (use enteral feeding by 48 hours if expecting to be NPO > 7 days), and analgesia
Antibiotics only for suspicion of infected pancreatic necrosis (gas in area of necrosis on CT, increased CRP, and/or persistent fever) – Imipenem 0.5-1 g IV or meropenem 1g IV q8h
GERD
- Symptoms – pyrosis must be present +/- chronic cough, dysphonia, sore throat, eructation (burping), pharyngeal burning/irritation, bitter taste; typically worse with lying flat and/or after eating
- Diagnostics – generally diagnosed clinically (by hx or PPI trial); can do an endoscopy if no response to PPI trial or any of the BOWED symptoms
- Management – lifestyle modifications (ex: weight loss, smoking cessation, avoid large/late meals, elevate HOB), once-daily PPI 30 minutes before breakfast, add pre-dinner PPI if no response to the one before breakfast; if unresponsive to BID PPI, refer to GI
BOWED acronym for EGD indications
- Bleeding
- Odynophagia
- Weight loss – unplanned
- Early satiety
- Dysphagia
Peptic Ulcer Disease (PUD)
- Cause – most commonly H. pylori and NSAID use; risk increases with long-term systemic corticosteroid use
- Symptoms – mild/no symptoms (early), gnawing epigastric pain with rhythmic property, pain resolved with eating (duodenal ulcer), pain worse with eating (gastric ulcer)
- Physical exam is typically unremarkable, may have mild/localized epigastric pain with deep palpation
- Management – conventional therapy – PPI is mainstay (ex: omeprazole, pantoprazole); other agents include sucralfate, misoprostol, antacids
- Risk factors for bleeding or perforation – NSAIDs, aspirin, alcohol, stress from acute illness
H. pylori testing and management
- Histology – used for initial dx, typically done with EGD
- Fecal antigen testing – use for follow-up
- First line treatment (10 days) – PPI + amoxicillin 1g BID + clarithromycin 500 mg BID
Ulcerative colitis
- A chronic, idiopathic inflammation of large bowel mucosa
- Symptoms – grossly bloody diarrhea (> 6 blood BMs per day), lower abdominal cramping, bowel urgency, cramping rectal pain
- Diagnostics – colonoscopy (diagnostic of choice) shows granular and friable mucosa with diffuse ulceration; crypt abscesses
- Acute flare management – continue their home treatment, corticosteroids (PO prednisone for less severe, IV for systemic toxicity), cyclosporine 2mg/kg IV infusion x7 days then oral (severe flare), surgery
- Complications – toxic megacolon, stricture
Crohn’s Disease
- A chronic idiopathic inflammation of the GI mucosa
- Symptoms – abdominal pain, non-grossly bloody diarrhea, fever, malaise, weight loss
- Diagnostics – EGD and colonoscopy with small bowel imaging shows non-friable mucosa, cobble-stoning, deep and long fissures, mouth to anus, “skip” lesions
- Acute flare treatment – continue home treatment, PO prednisone (PO for moderate cases, IV systemic toxicity, antibiotics (Cipro + Flagyl or amoxicillin clavulanate [Augmentin]), surgery
- Complications – perianal/perirectal abscess, stricture, fistula, abscess, malabsorption
Mesenteric Ischemia
- Vascular disorder with high mortality secondary to decreased/inadequate perfusion to intestines
- Risk factors – advanced age, smoking, hypercoagulable states (ex: clotting disorders, recent surgery), atrial fibrillation, abdominal surgery
- Symptoms – sudden/profound abdominal pain out of proportion to physical findings
- Diagnostics – abdominal CT
- Non-pharmacologic management – surgical consultation (laparotomy is gold standard), NG for decompression, TPN
- Pharmacologic management – anticoagulation for venous thrombus (first line), broad spectrum antibiotics (Levaquin + Flagyl), inotropes, IVF
