GI/Abdomen Flashcards
Acute abdominal pain defined
sudden onset of acute pain, localized or diffuse, within or referred to the abdomen
categories of abdominal pain
medical (gastroenterittis
surgical (appy)
Characters of abdominal pain
Visceral
Parietal
Visceral pain
dull "ache" diffuse pain fibers in muscular wall of hollow viscera stimulated by tension and stretching poorly localized
Parietal Pain
sharp
localized
stimulated by inflammation in the parietal peritoneum
lateralization of pain
Locations of abdominal pain
Suprapubic
Epigastric
Periumbilical
Suprapubic pain indicates
distal intestine
urinary tract
pelvic organ
Epigastric pain indicates
liver pancreas biliary tree stomach upper part of small bowel
Periumbilical pain indicates
distal end of small intestine
cecum
appendix
ascending colon
Referred pain
sharp, localized pain felt in remote areas innervated by the same nerves as the affected organ
example: gallbladder pain felt in right shoulder
Gastrointestinal causes of abdominal pain in children
appendicitis mesenteric lympadenitis constipation trauma obstruction peritonitis food poisoning peptic ulcer Meckel's diverticulum Inflammatory bowel disease lactose intolerance
Liver, spleen and bilary tract disorders in children
hepatitis cholecystitis cholelithiasis splenic infarction spleen rupture
Genitourinary disorders in children with abdominal pain
UTI calculi dysmenorrhea mittelschmerz pelvic inflammatory disease ectopic endometriosis
What is a key factor in abdominal pain differential dx
age
Common causes of acute abd pain in toddler
gastroenteritis constipation appendicitis UTI pneumonia intussusception hernia pharyngitis trauma
Common causes of acute abd pain in school age
gastroenteritis mesenteric adenitis infection appendicitis trauma HUS HSP IBD
Acute abdominal pain mimickers in children
Strep pharyngitis lower lobe pneumonia sickle cell crisis DKA hepatitis
Physical abdominal exam in children
rectal exam
psoas and obturator signs
rebound tenderness
decreased bowel sounds
Lab for pediatric abd pain
CBC CMP Sed rate UA preg test Gc/chlamydial pap
Radiology for abdominal pain
KUB
chest x-ray
Abdominal and pelvic ultrasound
CT
AAP guidelines for pediatric pain
all children <5 refer to surgeon
infants/children with perf appendic have surgeon
anomalies and major issues should be in care of pediatric medical and surgical specialists
Patho of appendicitis
obstructed lumen
distention results in periumbilical pain
perforation result in RLQ pain
Appendicitis in children
difficult to dx
high index of suspicion required
rarely presents in textbook fashion
Classic finding in appendicitis
anorexia vomiting periumbilical pain elevated temp (< 103) RLQ pain
Physical exam findings with appendicitis
rebound tenderness guarding regidity pain with cough tenderness with percussion can't jump off the exam table pos heel drip jaring test
Rovsing’s sign
refereed pain in RLQ with palpation of LLQ
Psoas sign
pain with hip flexion against resistance
Obturator sign
passive internal rotation of the flexed right thigh
Lab results with appendicitis
left shift in CBC
WBCs present in UA
fecalith in radiology if there is a rupture
Diagnostic radiology in children
ultrasonography especially female
CT can be helpful if uncertian
Admission or surgical referral if
2 of the following present:
classic history
exam suspicious
abnormal lab
Mantrels system
scoring system for appendicitis and diagnosis
the cut off and diagnosis is made at 7
5 findings consistent with appendicitis in children
nausea RLQ pain difficulty walking rebound tenderness neutrophil count greater than 6,750
Hernia in children
male: scrotal, inguinal swelling including abdominal contents
female: swelling in abdomen and labia majora
Prevalence of hernia
more common in male
common in infancy, esp premature
common on right side
hydroceles can occur with
Signs and symptoms of inguinal hernia
palpable mass in inguinal area
mass in scrotum
may appear and disappear
Hydroceles lasting more than 1 year
should be approached like inguinal hernias
Diagnosing hernia with history
have parents record if it comes and goes find inguinal swelling silk sign scrotal bowel sounds transillumination when the bowl is filled with fluid may come and go with crying or straining
Incarcerated hernias
surgical emergency
Umbilical hernias in children
considered benign and usually resolves by 3-5 years
defects as large as 3-5cm can occur and resolve
Contraindicated in umbilical hernias
strapping and binding
Other conditions present with umbilical hernias
hypothyroidism
Downs
Preterm
Intussuseption
prolapse of a intestine into the distal bowel and becomes invaginated at ileo-cecal point
venous return is obstructed and eventually arterial return will become obstructed
common age for intussusception
3-33 months
most common 3-12 months
Symptoms of intussusception
sudden onset colicky abd pain
very painful with peristalsis
between episodes the abd is soft
Clinical triad of intussusception
vomiting without diarrhea
intermittent abdominal pain
guiac pos stools
Physical exam for intussusception
RUQ sausage shaped mass with absence of RLQ bowel (Dance’s sign)
hematest pos stools
passage of current jelly (late sign 24 hours after)
Dx of intussusception
ultrasound/doppler has >90% accuracy
Barium enema
Tx for intussusception
can use barium enema to tx as well
if can’t reduce with barium the surgical manipulation
you want hydrostatic pressure between 60-100
Post op intussusception
admit for observation bc reoccurance can happen within 24 hours
Pyloric stenosis
a narrowing of the outlet from the stomach to the small intestine (pyloris) and occurs in infants
Idiopathic hypertrophic pyloric stenosis
more common in first born males
familial pattern
most common surgical cause of vomiting
been reports with erythromycin in those
age range for pyloric stenosis
2-8 weeks
more common among whites
4 P’s of pyloric stenosis
Progressive vomiting for hours or days
Projectile vomiting
Palpable olive
Peristaltic wave that can be palpated
Additional s/s in pyloric stenosis
does not appear ill
hungry immediately after emesis
dehydration and mild jaundice
lab for pyloric stenosis
ultrasound can verify with a channel >16mm and thickness >4mm
Use Upper GI if ultrasound not avail
Sign of pyloric stenosis
string sign
must do prior to surgical repair
rehydration
Surgery for pyloric stenosis
Ramstedt pyloromyotomy
Post op pyloromyotomy
NPO 12 hours
36 hours resume normal diet
no bathing for 5 days
ridge where tape at is normal
Diarrhea defined
an increase in stool frequency
a decrease in stool consistency
Acute diarrhea
usually infectious; (viral) Rotavirus Iatrogenic; abx induced, lactose deficiency hyperosmotic; juices, foods anatomic; intussusception parenteral; UTI, AOM, pneumonia
Chronic diarrhea
could be infectious but suggests malabsorption
Rotavirus
leading cause of diarrhea (gastroenteritis) has 2 day incubation period diarrhea for 3-8 days common 4-24 months watery sweet smelling stools x10-20/day
Rotavirus season
November-May
Rota-Teq
rotavirus vaccination
give 3 liquid doses starting 6-12 weeks then 4-10 week intervals
do not give after 32 weeks
will make much more mild
may experience mild vomiting and diarrhea
Rotarix
rotavirus vaccination
2-4 months
Bacterial causes of diarrhea
salmonella shigella compylobacter yersinea e. coli
Salmonella
fever
blood/pea green diarrhea
usually self limited so abx only in high risk
Shigella
high fever seizures toxicity mucosy, water, bloody stools usually self limited
Compylobacter
mild temlp
watery stools with blood
get from well water and shopping carts
Yersinea
occasional blood, vomiting
more common north
E. Coli types
Shiga toxin-productin e. coli (0157:H7) Enteropathogenic E coli Enterotoxigenic E coli Enteroinvasive E coli Enteroaggregative E coli
Tx E. Coli
no antimotility agents with bloody diarrhea
TMP-Sulfa (Bactrum)
Azithromycin
Hemolytic Uremic Syndrome (HUS)
can occur with E coli 0157:H7
develops 2 weeks after onset of diarrhea
common ages 6months - 4 years
higher socioeconomic class
Triad of finding with HUS
acute renal failure- dialysis
thrombocytopenia
hemolytic anemia
Prevent HUS
cook beef
good hand washing
pasturize milk and cider
Clostridium difficle in children
restrict testing to those older than 1 year with two days of diarrhea with GI symptoms
don’t tx with vanco
Protozoa cause of diarrhea
Giardia
Cryptosporidium
Giardia
watery diarrhea no blood
flatulence
distention
suspect if > 7 days diarrhea
Cryptosporidium
diarrhea vomiting fatigue summer and fall recreational water/daycare
Recreational Water Illnesses
Cryptosporidium Giardia Sheigella E coli 0157:H7 Norovirus
Abx induced diarrhea
occurs with 20-40% of abx use
Co administer with probiotic lactobaccilus to decrease
Probiotics in children
recommend not to use
Tx Shigella
TMP-sulf/Azithrom
Tx Campylobacter
Erythromycin/Azithro
Tx Yersinea
TMP-sulfa/Tetracycline
Tx Giardia
Nitazoxanide/Metronidazole
Tx Cryptosporidium
Nitazoxanide
C. Diff
d/c abx
metronidazole
avoid vanco
Oral replacement therapy principles
use for rehydration over 3-4 hours
follow rehydration with normal diet
nurse the breastfed infant
2 phases of ORT
Rehydration- fluids given to replace those lost
Mainenance- ongoing replacement
what is most indicative of hydration
weight
mild dehydration by weight
<3%
moderate dehydration by weight
3-9%
severe dehydration by weight
> 9% need iv rehydration
ORT for mild dehydration
50ml/kg over 4 hours
Hospitalization for gastroenteritis
age less than 6 weeks
lethargy
when follow-up can’t be guaranteed
need close observation
Exclusion for ORT
less than 1 month
shock
unconscious
illeus
Recommended foods in children
complex carbs (rice,wheat, potatoes, bread) avoid fatty avoid juices and soft drinks
Oral zofran and rehydration
ODT 8-15kg = 2mg
if they vomit within 15 minutes give another dose
wait 15 minutes and then start oral rehydration
Differential dx RUQ pain adults
Biliary: cholecystitis, choleylithiasis Colonic: cholitis, diverticulitis Hepatic: hepatic absess Pulmonary: pneumo, embolus Renal: pyelo, nephrothyasis
Differential dx epigastric pain adults
Biliary
Cardiac: MI, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: mass, pancreatitis
Vascular: aortic disection, mesontaric ichemia
Differential dx LUQ pain adults
cardiac: angina gastric pancreatic renal vascular
Differential dx periumbilical abd pain
colonic: early appendicitis
gastric: peptic ulcer, esophagitis
vascular
Differential dx RLQ pain adults
Colonic: appy, IBS, diverticulitis
Gynecologic: ectopic, fibroids, PID, ovarian mass, torsion
Renal: pyelo
Differential dx Suprapubic pain adults
Colonic
gyn
renal
Differential dx LLQ pain adults
cholitis
gyn
renal: pyelo, nephro
Sudden and severe pain in adults
rupture
performation
ectopic
Rapid progression of abd pain in adults
appy
pancreatitis
Gradual progression of abd pain in adults
neoplasm
Burning pain
GERD
Pressure pain
cardiac
gnawing pain
peptic ulcer
Abdominal pain red flags
projectile vomiting no po intake GI blood loss syncope pregnancy recent surgery fever foreign body
Test of choice for adult abdominal pain
Supine and upright abdominal plain films
Imaging for RUQ
ultrasonography
Imaging for LUQ
CT
Imaging for RLQ
CT with iv contrast
imaging for LLQ
CT with iv and oral contrast
Imaging for suprapubic
Ultrasoonography
Functional non-ulcerative dyspepsia
postprandial fullness
early satiation
epigastric pain
burning in the absence of structural disease
Causes of dyspepsia
PUD
GERD
Indication for endoscopy for dyspepsia
unintended weight loss
persistent vomiting
GI bleed
family history of cancer
H2 blockers and PPIs in dyspepsia
can reduce symptoms
4 causes of peptic ulcers
H. pylori
NSAIDS
acid hypersecretory
idiopathic ulcers
Initial management of dyspepsia
a trial acid suppressants
test and treat for H. Pylori
early endoscopy
Tx H.Pylori
tx for 14 days
PPI + clarithromycin+ amox
or
PPI + Bismuth + metronidazole + tetracycline
Hepatopancreatobiliary complications
biliary colic
cholecystitis
acute pancreatitis
Biliary colic (choelithiasis
gallstones occlude cystic duct
epigastric RUQ visceral pain
pain builds over 15 to 60 mintues and slowly dissipates
Test of choice with cholecystitis
ultrasonography
usually see stone
get surgical consult
Causes of pancreatitis
gallstones
alcohol
S/S pancreatitis
focal epigastric tenderness
guarding
possible pos gray turner, cullen and fox sign but very rare
Gray Turner’s sign
flank ecchymosis with pancreatitis
Cullen’s sign
periumbilical ecchymosis with pancreatitis
Fox’s sign
unguinal ecchymosis with pancreatitis
Lab/Imaging for pancreatitis
amylase
lipase
3x normal indicate
CT scan to confirm
Tx for pancreatitis
IV volume resuscitation
Diverticulitis incidence
1/3 of those over 50
2/3 of those over 80
Diverticulitis described
diverticulum in the lining of the colon bulges through a weak spot and becomes inflammed
Test of choice for diverticulitis diagnosis
CT with oral contrast
thick with arrowhead sign
Tx diverticulitis
liquids and antibiotics
metronidazole + quinelone
Amoc-clur x7-10 days
Causes of bowel obstruction
peritoneal bands post surgical
hernias
S/S bowel obstruction
colicky diffuse pain that waxes and wanes over 5 min intervals
N/V
fecal emesis
Bowel obstruction Tx
NPO
NG tube
IV fluids
Surgical
What could be dx in older adult with abd pain
UTI
perforated viscus
ischemic bowel disease
