GI exam/procedures Flashcards
Visceral pain
(colic pain): source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Cramping- Not well localized.
parietal pain
Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.
right shoulder pain?
gallbladder
left shoulder pain?
spleen
back pain?
pancreas or aorta
RUQ pain?
cholecystitis, duodenal ulcer, hepatitis, appendicitis, pneumonia
epigastric pain?
inferior wall MI, peptic ulcer, acute cholecystitis, perforated esophagus
LUQ pain?
ruptured spleen, gastric ulcer, AA, perforated colon,
RLQ pain?
appendicitis, ectopic pregnancy, renal/uerter stone, Meckel’s, CD,
LLQ pain?
ectopic pregnancy, intestinal obstruction, acute pancreatitis, AA, diverticulitis, perforated colon, CD, UC
melena
Black tarry stools
50-60 ml of blood in the stomach can produce melena
Above the “Ligament of Treitz” (b/w duodenum and jejunum)
hematochezia
Blood unchanged by passage through the gut usually at the level of the colon or lower
Blood mixed with stool suggests colon, blood outside the stool suggests the anus
acholic feces?
often seen w/ dark urine
malodorous, gray to light colored stools
indicates biliary block
obstruction of bile?
see elevated conjucated hyperbilirubinemia
elevated Alk phos!!
most common cause of ascites?
cirrhosis!!
malignancy, CHF, TB
adequate exposure?
Xiphoid to the pubis
normal size of liver?
<10 cm at right MCL
normal aorta
2.5-3 cm
psoas sign?
turn patient on left side and extend the right leg to check for psoas muscle inflammation.
= appendicitis
obturator sign
place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
= appendicitis
acute cholecystitis?
RUQ postprandial pain. Biliary colic pain.
Pain radiating to the right shoulder.
Nausea and vomiting.
Anorexia
Obesity
Fever
The 5 “f’s” – female, fat, fertile, fair, flatulent.
Diagnostic Triad – RUQ pain, fever and leukocytosis.
murphy’s sign
RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
= acute cholecystitis
acute pancreatitis?
History: Acute onset Nausea/vomiting Pain radiating to the back Constant pain
Physical Examination:
- Low grade fever
- Hypotension
- Decreased or absent bowel sounds
- Epigastric tenderness
- Turner’s sign – discoloration around the flanks (indicates hemorrhagic pancreatitis)
- Cullen’s sign – discoloration around the umbilicus
see elevated amylase and lipase!!!
glucose threshold?
diabetes >180 in urine
indication of UTI?
leukocyte esterase in urine
nitrites in urine
pH change and WBCs in urine
RBC casts?
glomerulonephritis or severe tubular damage
WBC casts
acute pyelonephritis
most common bacteria in urine?
E. coli
CI’s of bladder catheterization?
Known urinary tract obstruction (stricture)
Reconstructive surgery of urethra or bladder neck
Combative or uncooperative patient
Pelvic trauma – suspect urethra injury
Acute infection of the prostrate and/or urethra (relative)
CI’s of suprapubic cath?
Uncooperative patient
Blood dyscrasia or anti coagulation treatment
Infection or cellulitis of the suprapubic area
how to do suprapubic cath?
1 cm lateral incision 5 cm above pubic symphysis
inserted inferiorly at 60 degrees
cytoscopy
a way to look in the bladder to evaluate pelvic pain/recurrent UTIs
IVP
Intravenous Pyelogram(IVP)
An x-ray of the kidneys, ureters, and bladder which uses contrast material (usually iodine based) injected into the vein
To detect problems in these areas including kidney stones, cancer, enlarged prostate
Extracorporeal Lithotripsy
procedure used to shatter simple stones in the kidney or upper urinary tract.
Ultrasonic waves are passed through the body focused to strike the stones
Intracorporeal Lithotripsy
Patient undergoes cystoscopy
Laser is introduced through the cystoscope into the ureter and stones are broken into small pieces that will pass
Procedure works well on stones in the ureter.
Levin vs. Salem Sump
NG intubation tubes
Levin tube is a one-lumen nasogastric tube. The Levin tube is usually made of PVC with several drainage holes near the gastric end of the tube
Salem-Sump tube is a two-lumen tube. It has a drainage lumen and a smaller secondary tube that is open to the atmosphere. The second lumen allows for continuous suction and prevents gastric mucosa from being aspirated into the tube.
EGD
Esophagogastroduodenoscopy
Other instruments can be passed through the endoscope to perform additional procedures. For example, a biopsy can be done in which a small tissue specimen is obtained for microscopic analysis. A polyp or tumor can be removed using a thin wire snare and electrocautery.
CIs:
Absolute contraindications
Known or suspected perforation
Medically unstable patients
Obstruction
Relative contraindications Anticoagulation Pharyngeal diverticulum Recent head or neck surgery Esophageal stricture
most common places for gastric cancer?
In western countries, the most common sites of gastric cancer are the proximal lesser curvature, cardia, and GE junction
In Asia, distal locations in the stomach are more common
sigmoidoscopy
rectum and the lower (sigmoid) colon is examined under direct visualization.
colorectal cancer screening
CI's: Absolute: contraindications Bowel perforation Acute diverticulitis Active peritonitis Fulminant colitis Cardiopulmonary instability
Relative contraindications:
Lack of informed consent (except in emergencies)
Lack of patient cooperation
Lack of good bowel preparation
Advantages:
- quick, few complications, minimal discomfort, may be able to remove polyps, less extensive cleansing needed than colonoscopy
Disadvantages:
- only view rectum/lower colon, very small risk of bleeding/perforation
colonoscopy
** The advantage of colonoscopy over flexible sigmoidoscopy is the ability to find and remove polyps in the parts of colon that are beyond the reach of the flexible sigmoidoscope
patient is mildly sedated
endoscope is inserted through the anus and advanced gently around the bends of the colon. If a polyp is encountered, a thin wire snare is used to remove it. Electrocautery (electrical heat) is applied to painlessly control any bleeding. Other tests can be performed during colonoscopy, including biopsy.
absolute CI’s:
Fulminant colitis
Known or suspected perforation
During early post-colectomy time period
Relative contraindications
History of radiation therapy for abdominal or pelvic cancer
History of abdominal or pelvic malignancy
Extensive adhesions from prior abdominal surgery
Bleeding dyscrasias
Anticoagulant therapy
Adv:
- allows doctors to view entire colon, can use to remove polyps/biopsy
Dis:
- may not detect all polyps, need thorough cleansing and sometimes sedation
- bleeding, tearing, perforation may occur
polyps
sessile = flat - more malignant
pedunculated = have a stalk - less malignant
UC
Patients generally have more pain, cramping and rectal bleeding
Diarrhea and fever are common
On colonoscopy, characterized by ulceration, bleeding, continuous involvement and pseudopolyps
Mucosa is more friable and bleeds more easily than Crohn’s
Risk of colon cancer rises each decade after diagnosis
CD
Symptoms can occur at any point along the gastrointestinal tract
Symptoms are similar to ulcerative colitis but usually:
***More cramping with diarrhea
Less bleeding
Symptoms wax and wane
On colonoscopy, characterized by inflammation, cobble-stone appearance and “skip” lesions
Virtual Colonoscopy/Colonography (VC)
Medical imaging procedure which uses imaging and computers to produce two- and three-dimensional images of the colon from the rectum, all the way to the distal ileum.
performed via x-rays, i.e. computed tomography (CT) or magnetic resonance imaging (MRI).
Adv:
- view entire rectum/colon
- non-invasive
Dis:
- may not detect small polyps, need thorough cleansing
Optical Colonoscopy
actual scope
occult blood
VERY sensitive, not specific (reacts w/ iron)
Should be repeated three to four times prior to drawing any conclusions
FOBT- colorectal screening test
advantages:
- No cleansing of the colon is necessary.
- Samples can be collected at home.
- The cost is low compared with other colorectal cancer screening tests.
- FOBT does not cause bleeding or tearing/perforation of the lining of the colon
Disadvantages
- This test fails to detect most polyps and some cancers.
- False-positive results are common.
- Dietary restrictions and changes, such as avoiding meat, certain vegetables, vitamin C, iron supplements, and aspirin are often recommended for several days before a guaiac FOBT.
- Additional procedures, such as colonoscopy, may be necessary if the test indicates an abnormality.
Double Contrast Barium Enema (DCBE)
Advantages
This test usually allows the doctor to view the rectum and the entire colon.
Complications are rare.
No sedation is necessary
Disadvantages
This test may not detect some small polyps and cancers.
Thorough cleansing of the colon is necessary before the test.
False-positive results are possible.
The doctor cannot perform a biopsy or remove polyps during the test.
Additional procedures are necessary if the test indicates an abnormality.
DRE
Advantages
Often part of a routine physical examination.
No cleansing of the colon is necessary.
The test is usually quick and painless.
Disadvantages
The test can detect abnormalities only in the lower part of the rectum.
Additional procedures are necessary if the test indicates an abnormality.
