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GI / abd pain Flashcards

1
Q

Can’t miss diagnosis of abd pain?

A

AAA, mestenteric ischemia, SBO, ectopic pregnancy, ovarian torsion, appendicitis, MI, cholangitis

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2
Q

What is the classic triad seen in 50% of AAA patients?

A

hypotension/syncope, pulsatile mass, dull abd pain

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3
Q

What is the imaging to assess AAA?

A

abd bedside US or abd CT with contrast

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4
Q

When to use abd US for appendicitis eval?

A

young non-obese, pregnant

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5
Q

When to use abd CT for appendicitis?

A

everyone else! use oral contrast if broad ddx, and IV if thin

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6
Q

What are the cutoffs for making C diff severe disease?

A

age > 65, Cr > 1.5x baseline, wbc > 15

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7
Q

What is a surgical emergency associated with c Diff?

A

colonic ileus / toxic megacolon

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8
Q

What are RF for c diff coliits?

A

recent abx, recurrence, PPI, chemo, IBD

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9
Q

What is the branch point for diverticulitis in terms of mgmt?

A

uncomplicated (microperforation) vs complicated (macroperforation) - abscess, peritonitis, fistula formation, obstruction (from inflammation)

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10
Q

What is the outpt mgmt for divertculitis if pt meets criteria?

A

cipro and flagyl for 10-14 days

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11
Q

What are the criteria needed for diagnosis of pancreatitis?

A

Epigastric characteristic pain; lipase > 3x normal; abd imaging

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12
Q

What are things to check for pancreatitis?

A

TG, RUQUS, alcohol levels (if unclear story)

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13
Q

What is the imaging needed for ovarian torsion?

A

TVUS

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14
Q

What are the RF for mesenteric ischemia?

A

PVD, Afib, CAD, valvular disease, AAA

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15
Q

What is definitive imaging for Mestenteric ischemia?

A

CT angiography

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16
Q

What are the four main systems for abd pain?

A

think GI; think GU/gyne; think cardiac. Also think vascular.

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17
Q

What are the indications for an ERCP when suspecting CBD stone?

A

high risk of CBD

If imaging shows CBD stone OR
cholangitis OR
bilirubin > 4mg/dl AND
Dilated CBD (>6mm/8mm)

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18
Q

What about approach to intermediate risk of CBD stone?

A

EUS or MRCP or lap chole with intraop cholangiogram

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19
Q

Charcot’s triad vs Reynold’s pentad

A

RUQ pain, fever, jaundice

+/0 AMS and hypotension

not seen in more than half of cholangitis patients

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20
Q

What are other guidelines that can be used for Acute cholangitis?

A

Tokyo guidelines!

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21
Q

Immediate treatment of acute cholangitis?

A

IV fluids and IV abx

cipro +/- flagyl (GNR + enteroccocus)

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22
Q

2 out of 3 criteria for acute pancreatitis diagnosis?

A

1) lab - lipase 3x greater than normal
2) epigastric pain
3) CT imaging

single best imaging is abd ultrasound!

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23
Q

When is abd CT helpful in pancreatitis?

A

diagnosis unclear, not improving after 48-72 hr

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24
Q

What are labs and imaging you can get in pancreatitis?

A

labs - lipase, liver labs, TG (looking for dx)

imaging: CT esp if over 40 to look for mass if not sure about diagnosis

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25
What are predictors of mortality in acute panreatitis?
BUN if greater than 20 or rising more than 2 in 24 hours
26
what is harmless acute pancreatitis score
normal hct; normal Cr; no abd guarding and/or rebound - 99% PPV of it'll go ok!
27
What are fluid treatment requirements in pancreatitis?
Bolus 10cc/kg then 1.5 cc/kg/hr 1.5 cc / kg/hr WATERFALL 2022 NEJM study
28
Nutrition for pancreatitis ?
start within 24-48 hours do not NEED to start with clear liquids (low fat, normal fat, soft or normal diets are fine) NGT or NJT > TPN
29
when should CCY timing happen in mild gallstone pancreatitis?
BEFORE DISCHARGE
30
etiology of pancreatitis? three most frequent
smoking! remember that. also gallstone, alcohol
31
when to do early ERCP in gallstone pancreaitis?
if cholangitis OR retained CBD stone
32
what score can help with determinine discharge for pancreatitis?
PASS score can help prevent early re-admission
33
When does survival drop off re: MELD score?
Up until about 18-19
34
SAAG > = 1.1
diagnostic for portal hypertension!
35
Treatment for patients with cirrhosis
- Na resrricted diet 2gm per day - dual diuretics - spiro/furosemide 100/40 to balance potassium levels Fluid restriction not necessiary unless soidum < 125 mmol/L
36
What ismgmt option with refractory ascites?
1) serial large volume para + albumin 6-8g/L removed VS 2) TIPS (ideal for patients with MELD < 18) bridge to transplant
37
What are the key criteria for HRS?
1) AKI definition - rise by .3 in 48 hours or > 50% in prior 7 days 2) no Cr improvement after 2 days diuretic withdrawal 3) no Cr improvement after 2 days of albumin No signs of structural kidney injury, has bland urine sediment; absence of shock, nephrotoxins
38
What are the medicines that are useful for HRS>?
terlipressin + albumin (vasoconstrictor) OR cocktail - albumin/octretide/midodrine STOP NSBB, TRY albumin on day 1 and day 3
39
Tx for SBP?
1) CTX for 5 days 2) Albumin if BUN > 30, Cr > 1, serum bili > 4 3) stop NSBB
40
What are main tx for HE?
high protein diet lactulose +/- rifaximin treat underlying trigger (SBP, etc)
41
Acute bleeding management in cirrhosis
1) if non variceal - vit K, transfuse plt > 50K, fibrinogen > 100-120, consider anti-fibrinolytic 2) if variceal - management upper endoscopy within 12 hours, maintain Hgb 7-9 (higher can incvrease risk of bleeding) Also IV CTX antibiotic prophylaxis
42
With variceal bleeding, consider what meds class
NSBB (after octreotide acutely)
43
timing for referal for LT?
clinical decompensation (HE, ascites, varicael hemorrhage, HCC, HRS)+ biochemical decompsensation (MELD > 15)
44
what is the MELD?
MELD-Na since 2016, used since 2002 for liver allocation MELD > 15 is threshold survival benefit MELD inititally to predict survival post-TIPS
45
What scores to look at for peri-op clearnece for cirrhohtics?
CP score b/c > 30/80% risk of mortality MELD 12-15 - 25% risk of 30/90 day mortality
46
what is high risk for CBD stone?
high risk > 50% imaging shows it bilirubin > 4 AND dilated CBD > 6mm OR cholagntiitis intermediate abnormal LFT age > 55 year dilated CBD
47
what happens when patient is intermediate risk for CBD stone - what is test of choice?
MRCP is test of choice (want to avoid complications or ERCP) could be EUS as well OR lap ccy with intraop cholangiogram
48
What levels of bilirubin will you see with CBD stones?
AST / ALTS can be 1000s Bilirubin 4-6, < 12 typically
49
what should you do after an ERCP?
get a CCY
50
What are the guidelines to dx Cholangitis?
Tokyo guideliens - fever OR elevated WBC. +abnormal LFTs + abnormal imaging Charcot's triad - RUQ pain, fever, jaundice Reynolds pentad - + AMS, hypotension
51
What is the treatment for cholangitis?
IV antibiotics ERCP (urgent to emergent depending on grade of cholangitis)
52
When is abdominal CT is helpful with pancreatitis?
if diagnosis unclear, not improving after 48 hours, signs of severe pancreatitis or local complications
53
etiologies of acute pancretitis
gallstones, alcohol, SMOKING, metabolic (TG and hyperCa), structural/mass, ERCP, certain drugs or viral hep/HIV
54
signs of worsening pancreatitis -- what lab indicates rising mortality risk?
rising BUN (see Ranson, Glasgow, APACHE) also check HCT
55
who is a nonsevere acute pancreatitis - what two lbs?
normal HCt, normal Cr
56
what are the two general categories of pancreatitis complications?
interstitial edematous vs necrotizing
57
what is the fluid management strategy for acute pancreatitis?
don't be too aggressive (WATERFALL trial in NEJM) 1.5cc/kg and goal is to decrease BUN
58
When do you start patients with pancreatitis on nutrition?
within firt 24-48 hours, can start on clear liquids OR low fat, normal fat, soft or normal diet and if can't eat... NGT better than TPN, start on tube feeds
59
when should you get CCY timing in mild gallstone pancreatitis?
before discharge (!)
60
what are cuases of decompensated cirrhosis?
ascites jaundice encephalopathy variceal bleeding
61
What does MELD score predict?
3 month survival
62
What does Child Turcotte Pugh Score
1 year survival
63
what is the dosage for spiro/lasix in cirrhosis with ascites?
100/40 up to 400/160
64
What are the potential steps w/ refractory ascites
TIPS vs large volume paras if large volume paras --- albumin infusions 6-8g/L imporves survival
65
what MELD score is favorable for those with ascites rerfactory considering for TIPS
MELD score < 18
66
What is treatment for SBP?
CTX for 5 days albumin BUN > 30, Cr 1.0, serum bili > 4
67
when to start SBP primary or secondary prophylaxis
prior hx of SBP Childs B or C patients with GI bleeding hx ascites total protein < 1.5g/dl AND renal failure OR liver failure Bactrium is choice or cipro
68
what are some precipitants of HE encepalopathy?
infection, electrolyte abnormal, gi bleeding, constipation, dehydration, sedataives
69
what is treatment or HE?
lactualoise 2-4 bowel movements daily >>> rifaximin
70
what is blood level goal for Hgb in variceal bleeder?
7-9 Hgb level best IV CTX for max. days octretoide for 2-5 days --> NSBB consider TIPS in Childs C or Childs B with active bleeding
71
what is BB used in gastroesophageal varices?
carvedilol 6.5mg qDaily to 12.5mg qdaily (or nadalol)
72
when is best time to refer for Liver transplant?
clinical decompensation (HE, ascites, EV, HC, HRS, hepatopulm) AND biochecmical decompensation (MELD>15)
73
how to risk stratify for decomp cirrhosis and SURGeRY?
use VOCAL-PENN score or MELD or Child Pughs score to stratify

Adult medicine (14 decks)

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