GI EM Flashcards
cholelithiasis & biliary colic- defined
*cholelithiasis: stones in the gallbladder
*biliary colic: results from transient cystic duct blockage from impacted stones
cholelithiasis - risk factors
*four Fs: Female, Fat, Fertile, and Forty
*oral contraceptive pill (OCP) use
*rapid weight loss
*chronic hemolysis (pigment stones in sickle cell disease)
*small bowel resection (loss of enterohepatically circulated bile
*TPN (total parenteral nutrition)
cholelithiasis - presentation
*may be asymptomatic, or may cause biliary colic
*postprandial abdominal pain (usually in RUQ; commonly seen after eating fatty meals) that radiates to the right suprascapular area or the epigastrium, often associated with nausea and vomiting, dyspepsia, and flatulence
*caused by temporary occlusion of the cystic duct by a stone
cholelithiasis - lab results
*normal total bilirubin
*normal alkaline phosphatase
*normal serum amylase
cholelithiasis - diagnostic imaging
*RUQ ultrasound
cholelithiasis - treatment
*cholecystectomy is curative & recommended for patients with symptomatic gallstones
*asymptomatic gallstones do not require treatment
*lifestyle modifications (reduced refined carbs, adequate fiber intake, glycemic control in diabetics, weight loss at modest pace) may aid in elimination of asymptomatic gallstones
porcelain gallbladder - overview
*characterized by gallbladder calcification
*often asymptomatic and discovered incidentally
*increased risk of gallbladder adenocarcinoma
*cholecystectomy is indicated if symptomatic or asymptomatic with high risk features
postcholescystectomy syndrome
*potential complication of gallbladder removal
*can stem from retained stones, strictures, or extrabiliary causes
*sx: early satiety, bloating, dyspepsia after cholecystectomy
*dx made with additional abdominal imaging (ultrasound, ERCP, MRCP)
cholecystitis - defined
*inflammation of the gallbladder, typically caused by a stone occluding the CYSTIC DUCT
*prolonged blockage of the cystic duct by a gallstone leads to progressive distention, inflammation, and infection
*acalculous cholecystitis occurs in the absence of cholelithiasis in pts who are chronically debilitated or critically ill
cholecystitis - presentation
*history: RUQ pain, nausea, vomiting, fever
*PE: RUQ tenderness, cessation of inspiration with deep palpation of RUQ (Murphy sign), low-grade fever
cholecystitis - lab results
*elevated WBC
*normal total bilirubin
*normal alkaline phosphatase
*normal serum amylase
cholecystitis - diagnostic imaging
*best initial test = ultrasound (may reveal stones, bile sludge, pericholecystic fluid, thickened gallbladder wall, gas in wall of gallbladder, and/or an ultrasonic Murphy sign)
*if US is equivocal, next best step = HIDA scan (hepato-iminodiacetic acid scan)
cholecystitis - treatment
*broad-spectrum IV antibiotics
*IV fluids
*laparoscopic cholecystectomy indicated
choledocholithiasis - defined
*gallstone(s) in the common bile duct (CBD)
choledocholithiasis - presentation
*symptoms vary according to the degree of obstruction, the duration of the obstruction, and the presence/severity of infection
*history: biliary colic/RUQ pain, JAUNDICE, afebrile (unless current infection), and/or pancreatitis
choledocholithiasis - lab results
*elevated alkaline phosphatase
*elevated total and direct bilirubin
*normal/elevated WBC
*elevated amylase/lipase (if pancreatitis is present)
choledocholithiasis - diagnostic imaging
*ultrasound often does NOT show the stone, but may show dilated common bile duct
*MRCP and ERCP are definitive
MRCP: magnetic resonance cholangopancreatography
ERCP: endoscopic retrograde cholangiopancreatography
choledocholithiasis - treatment
*ERCP with sphincterotomy to remove stone, followed by cholecystectomy
cholangitis - defined
*an acute bacterial infection of the biliary tree
*infection of the common bile duct, usually caused by a stone in the CBD
*most commonly due to obstruction (choledocholithiasis), but other etiologies include: bile duct stricture, primary sclerosing cholangitis (PSC), and malignancy
*most common pathogens = gram negative enterics
cholangitis - presentation
*Charcot triad: RUQ pain, jaundice, and fever/chills
*Reynolds pentad: Charcot triad + septic shock and altered mental status (may be present in acute suppurative cholangitis)
cholangitis - lab results
*elevated WBC
*elevated bilirubin
*elevated alkaline phosphatase
*positive blood cultures
cholangitis - diagnostic imaging
*best initial test: ultrasound diagnostic for CBD dilation
*most accurate test: ERCP (diagnostic & therapeutic)
cholangitis - treatment
*pts often require ICU admission for monitoring, hydration, BP support, and broad-spectrum IV antibiotics
*pts with acute suppurative cholangitis require emergent bile duct decompression via ERCP/sphincretotomy, percutaneous transhepatic drainage, or open decompression
diverticula - defined
*outpouching of mucosa and submucosa (false diverticula) that herniate through the colonic muscle layers in areas of high intraluminal pressure; most commonly found in the sigmoid colon
diverticulosis - defined
*presence of many diverticula
*most common cause of acute lower GI bleeding in patients > 40 years of age
*predominantly left-sided in Western countries
*bleeding usually results from weakened intestinal vasa recta vessels
diverticulitis - defined
*inflammation following microperforations secondary to fecalith impaction and high luminal pressure
*inflammation/infection of diverticula
risk factors for diverticular disease
things that increase colonic intraluminal pressure, such as:
*diets that worsen constipation (low fiber, red meat, and high-fat content)
*advanced age (>80yo)
*connective tissue disorders
diverticulosis - clinical presentation
*often asymptomatic until patients present with sudden, intermittent, painless bleeding (can cause sx of anemia when bleeding is severe)
*associated with chronic constipation, which increases intraluminal pressure of the color and worsens outpouchings
diverticulitis - clinical presentation
*LLQ abdominal pain
*fever
*nausea/vomiting
*changes in bowel habits: (constipation, diarrhea, blood in stool)
complications of diverticulitis
- perforation - presents with peritonitis and shock
- abscess
- obstruction
- fistula formation
diagnosis of diverticular diseases
*colonoscopy - most definitive dx for diverticular disease
*AVOID colonoscopy in acute diverticulitis due to risk of perforation; instead, CT abd/pelvis
treatment of diverticular disease
- uncomplicated diverticulosis: routine follow-up
- diverticular bleeding: bleeding usually stops spontaneously; if it doesn’t, hemostasis by colonoscopy, etc
- diverticulitis: bowel rest (NPO), NG tube placement, broad spectrum abx
most common cause of lower GI bleeding in adults
*diverticulosis
antibiotic treatment of diverticulitis
-
piperacillin-tazobactam
OR - metronidazole PLUS one of: cefazolin, cefuroxime, ceftriaxone, ciprofloxacin, or levofloxacin
peptic ulcer disease (PUD) - pathophysiology
*results from damage to the gastric or duodenal mucosa caused by impaired mucosal defense and/or increased acidic gastric contents
*risk factors: H pylori, NSAIDs, alcohol & tobacco use, concomitant use of corticosteroids & NSAIDs, male sex
peptic ulcer disease (PUD) - clinical presentation
*history: chronic or periodic dull, burning epigastric pain that is often related to meals and can radiate to the back; usually worse at night; nausea, hematemesis, melena
*PE: usually normal, but may reveal epigastric tenderness & stool guaiac
*risks: acute perforation (rigid abdomen, rebound tenderness, and/or guarding)
peptic ulcer disease (PUD) - diagnosis
*most accurate test - upper endoscopy with biopsy
*H pylori testing (urea breath test, etc)
*if perforation is suspected, perform upright CXR to evaluate air under the diaphragm or CT abd
peptic ulcer disease (PUD) - management
*goals: protect the mucosa, decrease acid production, eradicate H pylori infection
*mild disease: tx with antacids, PPIs, or H2 blockers
*H pylori infection: triple therapy - omeprazole, clarithromycin, & amoxicillin
*discontinuation of exacerbating agents
abdominal aorta - anatomy
*retroperitoneal structure
*begins at the diaphragm and extends to its bifurcation into R and L common iliac arteries in the lower abdomen
abdominal aortic aneurysm (AAA) - defined
*in adults, > 3.0 cm diameter at any location along the abdominal aorta = an aneurysm
-small aneurysms < 4 cm
-medium aneurysms 4.0-5.5 cm
-large aneurysms > 5.5 cm
abdominal aortic aneurysm (AAA) - risk factors
*most important factor for aneurysm expansion: ongoing smoking
*other risk factors: older age, Caucasian, HTN, FHx of AAA, presence of other aneurysms in body, atherosclerosis
*most important risk factor for *AAA rupture = aneurysmal SIZE
abdominal aortic aneurysm (AAA) - screening
*any male 65-75 yo who has ever smoked
*any male or female 65-75 yo with a first-degree relative with a AAA
*screening done by ultrasound
abdominal aortic aneurysm (AAA) - clinical presentation
*classic presentation when you should consider AAA: any patient age 65+ presents to ED with abd/back/flank pain
*majority are asymptomatic
*classically, a palpable, pulsatile abdominal mass
*if symptomatic, sx include: abd pain, flank pain, back pain, pelvic/groin pain, pre-syncope or syncope
ruptured abdominal aortic aneurysm (AAA) - clinical presentation
*classic triad: severe pain (tearing abd pain that radiates to back, iliac fossae, or groin), hypotension, and a pulsatile abdominal mass
*most commonly ruptures into the retroperitoneum but can bleed into the peritoneum
ruptured abdominal aortic aneurysm (AAA) - management
*ultimately: emergent surgery for hemorrhage control and repair
*ED “next steps” in management: PROMPT & AGGRESSIVE resuscitation
1. aggressive management with large-bore IVs
2. emergent release blood in whom rupture is suspected (skip the crystalloids)
3. if free fluid in abd, immediately call surgery
incidental abdominal aortic aneurysm (AAA) - management
*close outpatient follow up, including:
-repeat US screening of the aneurysm
-potential vascular surgery consult in the office setting
upper vs. lower GI bleeding - defined
*upper: from mouth to ligament of Treitz (more common than lower)
*lower: from ligament of Treitz to anus
recall - ligament of Treitz is a suspensory muscle of duodenum; located at terminal duodenum & beginning jejunum
UGIB - clinical presentation
*melena & hematemesis (either frank blood or other coffee-ground material)
LGIB - clinical presentation
*hematochezia (bright red blood if distal from L colon; dark maroon/bloody stool if R colon)
*rarely hematemesis
UGIB - common ddx
*PUD
*gastritis
*varices
*Mallory-Weiss tear
*cancers
unstable UGIB - management
*ABCs (intubate those at high risk for aspiration, including AMS, worsening respiratory drive, massive UGIB e.g. varices)
*large bore IV access
*immediate resuscitation (to Hb < 9)
*EGD within 12 hours (if variceal bleeding) or < 24 hours if not
esophageal varices - clinical presentation
*painless esophageal bleeding with hematemesis due to portal HTN
*relentless, sudden hematemesis with no precipitant vomiting
esophageal varices - acute treatment
*airway protection
*resuscitation with large IVs
*IV octreotide, IV PPI, IV ceftriaxone
*EGD with banding or sclerotherapy
LGIB - common ddx
*diverticulosis
*anorectal causes (hemorrhoids, anal fissures, rectal ulcers)
*colorectal cancer
*mesenteric ischemia
*inflammatory bowel disease
*angiodysplasia
*infectious colitis
acute pancreatitis - pathophysiology
*transient obstruction of pancreatic ducts, either by toxic metabolites, stones, or faulty membrane channels, leads to stasis and accumulation of deadly pancreatic enzymes released from acinar cells, which eventually activate and cause harm to nearby tissues
acute pancreatitis - common causes
*gallstones
*alcohol
*trauma (handlebar trauma or any direct blunt trauma to epigastrium - classically in children)
*steroids
*malignancy/mumps
*autoimmune
*scorpions
*hypertriglyceridemia
*ERCP complication
*drugs (tetracyclines, azathioprine, thiazides, valproate, didanosine)
acute pancreatitis - clinical presentation
*acute, sudden onset of central abdominal pain, mainly epigastric
*RUQ pain may occur, associated with gallstone disease
*possible additional sx include: pain radiating to back, pain worse when sitting up, nausea/vomiting
acute pancreatitis - diagnosis
*elevated lipase > 3x upper limit
*other workup: CBC, CMP, urine studies, urine pregnancy test
acute pancreatitis - imaging
- RUQ US (does not show pancreatitis but gallstones, the most common cause of pancreatitis)
- CT abd/pelvis with contrast
- MRI +/- contrast
acute interstitial pancreatitis - management
*symptomatic management with aggressive fluid hydration
*NPO at first with aggressive IV lactated Ringers & nausea meds
*prophylactic antibiotics are NOT recommended
