GI/nutritional part 1 Flashcards
PMH for abdomen
Prior medical problems related to abdomen: hepatitis, cirrhosis, gallbladder problems, pancreatitis
Social hx for abdomen
Tobacco EtOH (cirrhosis) Illegal drugs (IVDA- hepatitis) Medication hx (NSAIDs) Recent travel
ROS for abdomen
Fever Vomiting -Frequency, dry heaves vs vomiting, type Bowel movements -Diarrhea, frequency, last BM -Consistency, color: bloody (hematochezia)/black, tarry (melena/ dark stools/ BRB/ white or grey (can indicate liver or gallbladder etiology)) -Painful BM GU sx -Dysuria, hematuria, frequency, dark urine -Vaginal d/c, pelvic pain, testicular pain/swelling, penile d/c -Flank pain CP, SOB
What does melena indicate?
Upper GI source
PE of abdominal complaints
Vitals: febrile, hypotension, tachycardia (that triad is sepsis until proven otherwise)
General appearance: toxic or ill-appearing, pallor, or jaundice
Abdomen:
-Inspect: scars, distention, pulsations, hernia, striae
-Auscultate
–normal BS vs hyperactive vs hypoactive vs absent
—Early obstruction: high-pitched, tinkling bowel sounds
-Percussion
–Tympany (hollow sounds) vs dull
–Estimating size of liver and spleen
-Palpation
–Tenderness, guarding, rebound, rigidity, masses, organomegaly
Carnett sign
Indicator of abdominal wall cavity abnormalities
Pt lies supine and points to where they absolutely hurt the worst
Palpate the area
Have them sit up
Pain getting worse with sitting up is a positive sign
Labs for abdominal pain: CBC
Leukocytosis: infection (nl WBC does not r/o infectious process)
Anemia: GI bleed
Labs for abdominal pain: CMP
Dehydration
Endocrine or metabolic d/o: DKA, pancreatitis
Abnl LFTs: cholecystitis, cholelithiasis, hepatitis
Abnl renal function: ARF, dehydration
Labs for abdominal pain: UA, urine hCG, +/- urine C&S
Nitrites, leukocytes: UTI, pyelonephritis
Send a culture when treating d/t abx resistance
Culture if unsure about amount of bacteria in urine, etc.
RBCs: uterolithiasis
hCG +: ectopic
Every menstruating woman needs urine hCG
Labs for abdominal pain: lipase
Elevated in pancreatitis
Labs for abdominal pain: serum lactate
Possible mesenteric ischemia
Take a serum lactate when toxic, septic, high white count
What should be done while you wait for lab results for abdominal pain
Treat nausea/vomiting -Zofran (ondansetron) -Phenergan (promethazine) Control pain -Morphine -Dilaudid -Toradol Fluid resuscitation -Caution in large bolus of fluids in elderly or hx of CHF NPO if warranted
RLQ pain differential
Aortic aneurysm Appendicitis Crohn's disease Diverticulitis (cecal) Ectopic pregnancy Endometriosis Hernia Ischemic colitis Meckel diverticulum Ovarian cyst or torsion PID Testicular torsion Ureteral calculi
Etiology of appendicitis
Occurs when obstruction of appendix leads to inflammation and infection
MCC- fecalith
Presentation of appendicits
Non-specific sx that progress with time
Early: vague periumbilical pain, anorexia, N/V
Later: classic presentation- pain migrates to RLQ: McBurney’s point, fever is late finding
Siogns: McBurney, Rovsing, Psoas, obturator, bump sign
Location of abdominal pain depends on location of appendix
If sudden decrease in pain, consider perforation
Workup of appendicitis: labs
CBC
UA
Urine hCG
Nl WBC does not r/o appendicitis
Workup of appendicitis: imaging
CT is study of choice
CT with IV AND oral contrast
Indicators on results: pericecal inflammation, abscess, periappendiceal phlegmon or fluid collections
Workup of appendicitis: u/s
High sensitivity but limited by operator and if abnormally located appendix or ruptured appendix
Preferred modality in kids and pregnant pt
Tx of appendicitis
Surgery: appendectomy
Abx: cover for anaerobes, enterococci and gram neg
-Zosyn (piperacillin/tazobactam)
-Unasyn (ampicillin/sulbactam)
RUQ pain differential
Cholecystitis Cholangitis Biliary colic Hepatitis Hepatic abscess Myocardial infarction/ischemia Perforated duodenal ulcer Retrocecal appendicitis Fitz-Hugh Curtis syndrome
Etiology of acute cholecystitis
Caused by obstruction of the bile duct, usually by a gallstone, leading to inflammation
Presentation of acute cholecystitis
RUQ or epigastric pain that is colicky and becomes steady and increases in intensity
Lasts longer than the typical 5 hours
Pain may radiate to R shoulder or subscapular area
Typically worse after eating, esp a high-fat meal
Usually with associated n/v, low-grade fever, anorexia
Signs: Murphy
Workup of acute cholecystitis: labs
CBC, CMP, UA Nl to elevated WBC Nl to elevated LFTs Nl to elevated serum bilirubin -After 24 hrs, bilirubin levels increase in blood and urine
Workup of acute cholecystitis: imaging
U/s is study of choice
-Indicators on u/s: thickened GB wall, gallstones, GB distention, pericholecystic fluid
-Positive sonographic Murphy’s sign is very sensitive for dx
CT is good too
Tx of acute cholecystitis
Surgery: cholecystectomy
Abx: 3rd gen cephalosporin and metronidazole
Ascending cholangitis: etiology
Complete biliary obstruction (CBD stone or tumor) + bacterial superinfection Ascending infection (E. coli, enterococcus, Klebsiella, enterobacter)
Presentation of ascending cholangitis
Charcot’s triad: fever + jaundice + RUQ pain
Reynold’s pentad: Charcot’s triad + hypotension + AMS
-Indicates sepsis; rapidly fatal
Workup for ascending cholangitis: labs
CBC, CMP, UA
Leukocytosis
Elevated bilirubin and alkaline phosphatase
Workup for ascending cholangitis: imaging
U/s
ERCP is optimal for dx and tx but should not be done until pt stable
Tx of ascending cholangitis
Abx: triple coverage
-Ampicillin + gentamicin + clindamycin
-Or metronidazole + 3rd gen cephalosporin or Zosyn + fluoroquinolone
Immediate surgical consult
-ERCP for drainage, sphincterotomy, stone removal, stent placement
Epigastric pain differential
Pancreatitis Swallowed foreign body GERD Esophageal perforation Aortic dissection MI Peptic ulcer Gastritis Esophagitis
Etiologies of acute pancreatitis
> 50% secondary to EtOH abuse, others include:
Cholelithiasis
Meds (APAP, erythromycin, steroids, HCTZ, anti-retrovirals, etc)
Severe hyperlipidemia (esp hypertriglyceridemia)
Presentation of acute pancreatitis
Epigastric pain that bores to the back with associated n/v that is constant and worse in supine and improves with leaning forward
Epigastric or upper abdominal tenderness with palpation
May have low-grade fever, tachycardia, hypotension
If severe, could present with signs of shock, renal failure, AMS
Workup of acute pancreatitis: labs
CBC, CMP, amylase, lipase
Lipase (at least 2-3x nl) is preferred diagnostic test, more sensitive/specific
-Nl amylase does not exclude dx- no benefit to order both tests
Elevated liver enzymes, esp alkaline phosphatase, suggests biliary dz and gallstone pancreatitis
Leukocytosis generally present
Workup for acute pancreatitis: imaging
Abdominal CT preferred over u/s
Ranson criteria
Indicates poor prognosis for pancreatitis- the higher the score, the worse the prognosis Leukocyte count >16K Glucose >200 Lactate dehydrogenase >350 AST >250 Arterial pO2 <60 Base deficit >4 Calcium falling BUN rising
Cullen sign
Ecchymosis around umbilicus
Grey-turner sign
Ecchymosis around flank
Tx of acute pancreatitis
NPO
Fluid resuscitation, anti-emetics, pain management
Consider abx, esp for abscess, infected pseudocyst
Admission (usually) with GI consult
-Pts with mild dz, no systematic complications, or biliary tract dz + can tolerate clear liquid and PO pain meds can be managed with close f/u; advance PO intake ast tolerated
–Advise pts to return if fever, pain, can’t tolerate meds
LLQ pain differential
Diverticulitis Ectopic pregnancy Endometriosis Ischemic colitis PID Ovarian cyst or torsion Testicular torsion Ureteral calculi
Diverticulosis
Small herniations through wall of colon
Diverticulitis
Inflamed/infected diverticula
Complicated diverticulitis
Acute diverticulitis + bowel obstruction, abscess, fistula, or perforation
RFs of diverticular dz
Age
Low fiber/high fat diet
Obesity
Tobacco use
Presentation of diverticulitis
Steady deep discomfort- typically in LLQ Tenesmus, change in bowel habits N/V Low-grade fever Signs of peritonitis with abscess, perforation
Workup of diverticulitis: labs
CBC, CMP, UA to help exclude other diagnoses, hemoccult may be positive
Workup of diverticulitis: imaging
CT abd/pelvis with IV and oral contrast is diagnostic
Tx of diverticulitis
IV fluids, anti-emetics, pain control
Abx: cipro + metonidazole
Clear liquid diet advance as tolerated to high fiber diet with avoidance of obstructing or constipating foods
Close f/u
Admission and surgical consult for complicated diverticulitis
DDx of diffuse abdominal pain
Aortic dissection AAA Early appendicitis Bowel obstruction Gastroenteritis Mesenteric ischemia Bowel perforation Peritonitis Volvulus IBS/UC/Crohns Spontaneous bacterial peritonitis
