GI and gallbladder Flashcards
69yo M w confusion, abd pain, chills, rectal temp of 94F, jaundice. XRay - air in biliary tree. Dx?
Acute cholangitis
Charcot triad? What disease?
RUQ pain, jaundice, fever. Cholangitis
Elevated leuk, gallbladder wall thickening, RUQ abd pain. Cholecystitis or biliary colic?
Cholecystitis (elev leuk and GBW thickening)
Treatment of acute cholecystitis?
Admit, IVF, NPO, Abx, Cholecystectomy
GI bleed, what to do next? (How is it different for massive GI bleed?)
Fluid resuscitate, diagnosis, treat. Early endoscopy. For massive GI bleed, endotracheal tube before endoscopy. CBC, LFT, PT, PTT, type and cross, FFP (coagulopathy) or platelets (thrombocytopenia).
Mallory-Weiss tear, where is it?
Proximal gastric mucosa tear from cough/vomit. Self-limited, mild.
Dieulafoy erosion, what is it?
Bleed from aberrant submucosal artery in stomach. Prompt endoscopy diagnosis and operation
Inject what for nonvariceal upper GI bleed via endoscopy?
Epinephrine followed by thermal therapy, or clips
Size cutoff for peptic ulcer to be operated on for recurrent upper GI bleed
> 3cm
Which causes anemia but not acute GI hemorrhage?
Gastric ulcer, duodenal ulcer, gastric erosions, esophageal varices, or gastric cancer?
Gastric cancer
M is vomiting lots of bright red blood, what do you do first?
Fluid resuscitation
Acute hematemesis from bleeding esophageal varices in M with cirrhosis - endoscopic sclerotherapy or balloon tamponade of esophagus?
Endoscopic sclerotherapy effective in 90% of cases. Other therapies include vasopressin or octreotide to dec portal pressure
3 most likely causes of acute lower GI bleed in >40yo (painless)
diverticulosis, angiodysplasia, neoplasm
4 causes of lower GI bleed with abdominal pain
ischemic bowel, IBD, ruptured abdominal aneurysm, intussusception
3 most common causes of overt lower GI bleeds (hematochezia or melena) in children and adolescents
Meckel’s, IBD, polyps
79yo F w 1 wk abd distention and pain, 1 day vomiting. Phys exam: no hernias, consistent with distal sm bowel obstruction. Afebrile, WBC 4000. First next step? Nonoperative tx for 48hr? Upper GI endoscopy? Immediate ex lap? CT scan?
CT scan
72yo M with n/v, past appendectomy at age 25. Ab tender and distended. Afebrile, wbc 18000, Na 140, K 4.2, Cl 105, HCO3 14. Best therapy?
NG tube and observe Colonoscopy for intussusception Barium enema to relieve volvulus Abx and supportive care Surgery
Surgery. Anion gap acidosis, probably from lactic acid reflecting ischemic bowel or fluid depletion. Old people are often afebrile. (If CT was an option, do that first, but most likely these oldies have obstruction or intra-abd sepsis)
32yo M with n/v POD20 s/p appendectomy. Ab tender and distended. Afebrile, wbc 18000, Na 140, K 4.2, Cl 105, HCO3 14. Best therapy?
NG tube and observe Colonoscopy for intussusception Barium enema to relieve volvulus Abx and supportive care Surgery
NG tube. within 30 d s/p ab surgery, SBO often and resolves with NG decompression and supportive care. CT scan can identify cause.
(compare this case to the 72yo)
19yo F with 2d RLQ pain, no fever. Tender right adnexal mass, normal WBC, neg HCG, normal UA. What’s next?
CT ab + pelvis Discharge patient Diagnostic laparoscopy Observation with serial labs Ab+pelvis U/S
Ab+pelvis U/S because patient has findings of pelvic path. CT is less sensitive and specific for pelvic path.
24yo M with colicky intermittent umbilical and RLQ pain for 24hr. Anorexia and nausea. T 98F. Most likely diagnosis?
Acute appendicitis Chronic appendicitis Gastroenteritis Acute pancreatitis Intussusception
Gastroenteritis. Only gastroenteritis and intussusception present with intermittent pain, but intussusception less likely in 24yo M
18yo F w 1d worsening lower ab pain, nausea, vomiting, T 99F. Possible right adnexal tenderness. Which test would definitively differentiate PID from acute appy?
CT MRI U/S Laparoscopy Clinical response to Abx
Laparaoscopy
43yo F w 1d right flank and RLQ pain. Has hx of nephrolithiasis but pain is different. T 101.3, ab and right flank tender to deep palpation. UA shows 10-20wbc, 10-20rbc. What next?
Pelvic U/S to r/o ovarian torsion Hospitalize, IVF, analgesics, Abx for UTI CT ab Diagnostic laparoscopy Cystoscopy and ureteral stent placement
CT ab. Will identify kidney stones, and r/o pyelo, or appy.
14yo boy with 2d RLQ ab pain. Had been ill past 10d with cough, runny nose, fever. Ab pain over last 12 hr improving. T 100.4F. Ab tender in RLQ, no masses or peritonitis signs. WBC 11, UA normal. CT shows no inflammatory changes in area of cecum but several prominent lymph nodes in the mesentery of small bowel. Bowel wall not thickened. Diagnosis and treatment?
Mesenteric adenitis. Discharge with follow-up. Common in kids, no Abx needed. NOT lymphoma (which would have diffuse intraabdominal and retroperitoneal adenopathy)
