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Antepartum (UPenn) > GI concerns/Abdominal Pain > Flashcards

GI concerns/Abdominal Pain Flashcards

1
Q

Review normal anatomic and physiologic changes of the GI system

A

Gastric compression by gravid uterus

Increased serum progesterone → decreased lower esophageal sphincter tone, gastric acid secretion, bile and small bowel motility

Physiologic nausea and vomiting of pregnancy

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2
Q

List the physiologic causes of abdominal pain

A

Without other symptoms or signs can be due to an enlarging uterus, fetal pressure against adjacent organs, and Braxton-Hicks uterine contractions

Pain is generally in the quadrant where the affected organ is located

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3
Q

Differential diagnosis: common discomforts vs serious diagnosis

A

Pain intensity, nature, temporal pattern, radiation, exacerbating factors, and alleviating factors help narrow the differential dx

Common Discomforts

  • —Round ligament pain
  • —Nausea
  • —Fetal position or movement
  • —Acid reflux
  • —Braxton hicks
  • —Constipation

Serious Diagnosis

  • —Celiac disease
  • —Acute Fatty Liver of Pregnancy
  • —Appendicitis
  • —Pancreatitis
  • —Cholecystitis
  • —Peptic Ulcer disease
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4
Q

Red flag symptoms

A
  • —Moderate or severe pain associated with other symptoms (N/V, vaginal bleeding, HA)
  • —Fever greater than 100.5°
  • —N/V after 20 weeks
  • —Hematemesis
  • —Bloody diarrhea
  • —Jaundice
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5
Q

Discuss the management approach (work up) to pain

A
  • —Lab work - keep in mind normal pregnancy changes
    • —CBC with DIFF
      • WBCs of 10 - 14K normal → diff helpful
    • —LFTs
      • ALP normally elevated
      • AST/ALT usually stay the same
    • —BMP
      • Low Na+ (129 - 143) normal
    • —Amylase/Lipase
      • Lipase more sensitive, stays higher longer
      • Both usually dont change during pregnancy
    • —UA
  • —Imaging
    • —Ultrasound - preferred due to safety, not always best method
    • —MRI - safe, avoid contrast (but no evidence of teratogenicity)
    • —CT - only if life threatening
  • —Collaboration
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6
Q

Celiac disease

Definition, signs, and symtoms

A
  • Autoimmune disorder in that attacks gut
    • Ingestion wheat, rye, barley → chronic inflammation of small intestine → shrink villi → malabsorbtion
    • Genetic component—
    • 1% of population
    • Can walk around with it for years without knowing
  • Symptoms
    • Cramping
    • Gas
    • Wt loss
    • Nausea
    • Pale stools
    • Diarrhea
    • —Malabsorption
    • —Dermatitis Herpetiformis - very itchy, often on joints (elbows/knees)
      • 25% of people w/celiac
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7
Q

Celiac Disease

Diagnosis and treatment

A
  • —Best to do testing before starting gluten free diet
  • Diagnosis (does not need to be us, can’t hurt to refer to GI)
    • —IgA tTg - low cost, serum test of choice
    • —*Small bowel biopsy* - gold standard, looks for atrophic villi
    • —Skin biopsy for dermatitis herpetiformis
    • —Genetic testing
      • 99% of celiac have HLA DQ2, DQ8 or both
  • —Treatment
    • —Gluten free diet
    • —Dermatitis Herpetiformis: Dapsone (benefit outweighs risk. Use smallest amount for shortest amount of time possible)
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8
Q

Celiac Disease

Effects on pregnancy and effects of pregnancy on CD

A
  • Increased risk for:
    • Miscarriage
    • IUGR
    • LBW
    • Preterm delivery
  • —Referral
  • —Educate
    • Hidden sources of gluten, reading labels. “Modified food starch”
  • —Monitor
    • Risk for anemia due to malabsorption, weight gain, higher rates of depression
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9
Q

Acute Fatty Liver

Discuss incidence and signs and symptoms

A
  • Rare, serious, specific to pregnancy.
    • 1 in 10,000
    • More common in primipara, multiple gestation, 3rd tri
  • Accumulation of Microvesicular fat → takes over liver and prevents it from doing its job
  • Signs/symptoms
    • —Nausea/vomiting
    • —Malaise
    • —Anorexia
    • —Epigastric pain
    • —Progressive jaundice
    • —Signs suggestive of Preeclampsia
      • can be misdiagnosed or have both
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10
Q

Acute Fatty Liver

Diagnosis and treatment

A
  • —Diagnosis
    • —Lab values
      • —CBC
      • —LFTs
      • —Creatinine
      • —Coagulation studies
        • Fibrinogen < 200 concerning
      • —Hypoglycemia*
        • *helps distinguish from other issues*
    • —Imaging
    • —Liver biopsy—
  • —Treatment
    • —DELIVERY
    • —ICU
      • Many also have pancreatitis
      • Very sick patients
  • REFER
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11
Q

Appendicitis

Signs and symptoms

A
  • —Nausea/Vomiting/Anorexia
  • —RLQ pain (may start periumbilical first)
    • Most common presenting sx regardless of pregnancy
    • Gradual onset, may radiate to flanks/thighs
    • Appendix may migrate upward/laterally due to gravid uterus
  • —Fever/tachycardia
  • —Guarding/rebound tenderness
    • Dependent based on how hard you push
    • Abdominal wall laxity + interposition of the gravid uterus between the appendix and the anterior abdominal wall in late pregnancy may mask the classical signs of peritonitis
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12
Q

Appendicitis

Diagnosis and treatment

A
  • —Diagnosis
    • —Lab work
      • Elevated WBCs
    • —Imaging:
      • —Ultrasound
      • —MRI - better at dx
  • —Treatment
    • Appendectomy
      • Safer during 2nd tri, but can do 1st if needed.
      • Can be laprascopic during 1st & 2nd, possibly 3rd
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13
Q

Appendicitis

Morbidity/mortality related to delay in diagnosis

A
  • Need prompt recognition of emergency
  • Delay in diagnosis increases morbidity and mortality for both parent and fetus.
  • Perforation associated with higher mortality (esp for fetus)
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14
Q

Cholecystitis

Patho, signs, and symptoms

A
  • 2nd most common surgical case after appendicitis
  • Increased estrogen → increased cholesterol crystals and thicker sludgy bile → progesterone slows everything down
  • —Symptoms
    • RUQ or epigastric pain (focal)
    • —Referred pain to right scapula, shoulder, or back
    • —Nausea, vomiting
    • —Fever
    • —Murphys sign
    • Post prandial pain – often ate something fatty/greasy and pain starts after
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15
Q

Cholycystitis

Diagnosis and treatment

A
  • —Diagnosis
    • —Labs - WBC, AST/ALT, ALP elevations suspicious
      • —CBC
      • —LFTs
    • —Imaging
      • —RUQ ultrasound - very helpful
  • —Treatment
    • —Conservative - may lead to more ER visits, earlier induction/Cesarean
      • —Inpatient management
      • —Hydration
      • —Antibiotic therapy
    • —Surgical Intervention
      • —Laparoscopic cholecystectomy
      • —ERCP: endoscopic retrograde cholangiopancreatography
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16
Q

Cholycystitis

CNM/WHNP role

A
  • Known Hx of Cholelethiasis?
    • Education
      • Avoid fatty, greasy foods
    • Nutrition consult
  • Prompt recognition of an emergency – get to ER/triage for evaluation early
17
Q

Pancreatitis

Signs and symptoms

A
  • Similar regardless of pregnancy
  • —Epigastric pain radiating to back
    • may be more severe with leaning forward due to position of the pancreas
  • —Nausea /vomiting
  • —Fever (low grade)
  • —Abdominal distention
  • —Hypoactive bowel sounds
  • —Guarding
18
Q

Pancreatitis

Diagnosis and treatment

A
  • Diagnosis
    • —Lab work - degree of raise does not correlate with severity
      • —Amylase
      • —Lipase – most reliable marker
      • —WBCs
    • —Imaging
      • —Ultrasound - Hard to dx via US due to size of uterus
      • —MRCP: magnetic resonance cholangiopancreatography
  • Treatment
    • —IV fluids
      • May be inpatient longer, dehydration is generally harder to manage in pregnacy
    • —Analgesia
    • —Bowel rest/NPO
    • —Antibiotics with severe disease
19
Q

Pancreatitis

Disease effects of pregnancy on pancreatitis and pancreatitis on pregnancy

A
  • Occurs in about 1 per 3000 pregnancies
  • Most commonly during the 3rd tri
  • Gallstones cause about 70% of cases during pregnancy
  • Hyperlipidemia is 2nd most causative factor
  • Pregnancy does not necessarily predispose the patient to pancreatitis, BUT pregnancy does:
    • Increase serum cholesterol
    • Cause biliary stasis
    • Induces gall stone formation.
20
Q

Inflammatory Bowel Disease

Signs and symptoms

A
  • —Abdominal pain
  • —Diarrhea
    • Bloody diarrhea main symptom of UC x 4 weeks
  • —Fatigue
  • —Weight loss
  • —Fever
  • —Extraintestinal symptoms
  • —Arthritis - 20% have arthritis typically in large joints
  • —Skin disorders - 10% have derm issues
21
Q

Inflammatory Bowel Disease

Diagnosis and treatment

A
  • ——Diagnosis
    • Labs
      • Known diagnosis
        • —Iron
        • —B12
      • —Acute evaluation
        • —CBC
        • —CMP
    • —Ultrasound: r/o other dx
    • —Endoscopy with biopsy
      • gold standard → often delayed pp
  • Treatment
    • —IV fluids
    • —Correction of electrolyte disturbances
    • —Antibiotics
    • —Anti-inflammatory and immunosuppressive agents
      • —Anti-tumor necrosis factor agents
      • —Glucocorticoids
      • Methotrexate often used as treatement → SUPER contraindicated during pregnnacy
        • Need to be off at least 3 months, preferrably 6 months before conception.
22
Q

Inflammatory Bowel Disease

Discuss effects of IBD on pregnancy and effects of pregnancy on IBD

A
  • —Preconception Counseling – send to MFM
    • Timing conception is important – wait until in remission to become pregnant
    • Active disease doesn’t tend to get better during pregnancy
  • —Management
    • At risk for antepartum hemorrhage and LBW, premature delivery
    • Manage/eval B12
      • *need 2g of folic acid a day
      • High risk in 3rd tri with active disease
  • —Collaboration
  • —Nutrition consult
  • —Mode of delivery
23
Q

Peptic Ulcer

Discuss signs and symptoms

A
  • —Symptoms less common during pregnancy despite increased GERD
  • Most common causes: h. pylori, NSAIDS, ASA
  • Epigastric pain #1 symptom
  • —Nausea
  • —Anorexia, early satiety
  • —Heartburn

—

  • Duodenal Ulcer
    • —Pain may improve when eating
    • —Pain: 2-5 hours postprandial
  • —Gastric Ulcer
    • —Eating does not improve pain
    • —Pain: 30 min-2 hours postprandial
24
Q

Peptic Ulcer

Diagnosis and treatment

A
  • —Diagnosis
    • —CBC
      • Lab work not super helpful
      • May see anemia that you would see anyway
    • —Upper Endoscopy
    • —Endoscopic biopsy
  • —Treatment
    • —Antacids: 1st line
      • Avoid antacid with sodium bicarb to avoid fluid overload
      • Tums: dosage during pregnancy is different, read back of bottle
    • —H2 Receptors
    • —Proton-pump inhibitors
    • —H Pylori:
      • Timing is controversal. May delay tx until after 1st tri
      • —Amoxicillin 1000mg BID x 14 days WITH
      • —Clarithromycin 500mg BID
        • OR
      • Metronidazole 500mg BID
25
Q

Discuss the physiologic effects of pregnancy on abdominal disorders

A
  • Displaced organs (ie appendix moved superior and lateral)
  • Abdominal wall laxity
  • Position of the gravid uterus btw appendix and anterior abdominal wall in late pregnancy may mask the classical signs of peritonitis
  • Extraintestinal abdominal conditions/disorders promoted by pregnancy.
    • Diminished muscle tone in urinary tract from elevated progesterone levels and mechanical obstruction from uterine compression → mild hydronephrosis and hydroureter
      • Common during pregnancy, particularly early 3rd trimester .
      • Hydronephrosis in pregnancy is usually asymptomatic, may have positional abdominal discomfort
    • Mucosal immunity may be attenuated as part of the physiologic immunologic tolerance for the foreign fetal antigens.
      • Combined with urinary stasis → increased rate of cystitis and pyelonephritis.
    • Increased cholesterol synthesis + gallbladder hypomotility → cholelithiasis
26
Q

List causes, signs, symptoms of upper and lower GI bleeding

A

Most common causes of Upper GI hemorrhage:

  • GERD
  • Gastritis
  • Mallory-Weiss tear - tear of mucus membrane near where the lower part of the esophagus joins upper part of the stomach (often from coughing/vomiting)
  • Ulcers

Rare causes:

  • Esophageal varicies
  • Gastric cancer

Most common rectal bleed: hemorrhoids

27
Q

Ectopic pregnancy

Risk factors

A
  • Previous ectopic
  • Prior PID
  • Previous tubal surgery or blockage
  • Abdominal surgery
  • Advanced maternal age
  • Cigarette smoking
  • Intrauterine device
  • Prior abortions
  • History of subfertility
28
Q

Ectopic Pregnancy

Diagnostic modalities

A
  • Quantitative serum hCG
    • increase by less than 50% during a 48-hour period → almost always nonviable
  • Transvaginal US
    • should see gestational sac (GS) when hCG level is above discriminatory zone (1500 - 2000).
    • Sometimes can definitively dx by showing an extrauterine GS with a yolk sac or embryo
    • More frequently only suggestive of ectopic
      • Adnexal mass = most common sono finding in ectopic
        • solid or complex saclike ring
      • Pelvic free fluid.
  • MR imaging
    • Excellent to confirm or better define suspected ectopic esp when US doesnt show ectopic focus or distinguish from incomplete AB.
    • Can help dx the rare or complicated form of EP
    • Can better distinguish btw GS and corpus luteum cyst (look similar on US)
29
Q

Ectopic Pregnancy

Conservative management

A
  • Expectant management for clinically stable asymptomatic patients with:
    • US dx of EP and
    • Decreasing serum hCG initially < 1000 mIU/mL
  • Medical therapy (methotrexate) should be offered to:
    • serum hCG value < 3000 mIU/mL, and
    • minimal symptoms
  • Surgery is usually needed when:
    • Severe symptoms, bleeding, or high hCG levels are present.
    • Laparoscopic surgery is typically used.
    • Emergency laparotomy for ruptured ectopic

Antepartum (UPenn) (26 decks)

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