GI / Nutritional Part 1 (Abdominal pain - Cholelithiasis/choledocholithiasis) Flashcards
1
Q
What are some causes of RUQ pain?
Think organ location
A
- Gallbladder issues
- Liver issues
- biliary colic, cholecystitis/angiitis
- hepatitis, thrombosis
2
Q
What are some of the causes of LUQ pain?
Think organ location
A
Spleen issues
Splenomegaly
Splenic infarct
Splenic Abscess
Rupture
3
Q
What are some of the causes of epigastric pain? (6)
A
- MI
- Pancreatitis (acute/chronic)
- PUD
- GERD
- Gastritis/opathy/paresis
- Dyspepsia
4
Q
Classic cause of RLQ pain vs LLQ pain
A
RLQ = Appendicitis
LLQ = diverticulitis
5
Q
What are some GI causes of anorexia?
A
- Gastric/duodenal ulcers
- Gastric/GI cancers
- Hematochezia
6
Q
What is Cholelithiasis specifically?
A
Merely Gallstones in the biliary tract (usually in the gallbladder) w/o inflammation
7
Q
MC type of gallstone?
A
cholesterol
others are black stones (hemolysis), brown stones in infections and Asian pop
8
Q
RF for Cholelithiasis
remember, just gallstones
A
5 Fs and Native Americans
fat, fair, female, forty, fertile
also OCPs
9
Q
What does Cholelithiasis feel like?
A
Nothing typically
sometimes biliary colic ( episodic, abrupt RUQ or epigastric pain, resolves slowly, lasting 30min-hrs; may be associated w/ nausea & precipitated by fatty foods or large meals)
10
Q
What is the diagnostic test of choice for:
1. Cholelithiasis
2. Acute Cholecystitis
3. Choledocholithiasis
4. Acute Ascending Cholangitis
5. Primary Sclerosing Cholangitis
A
- Cholelithiasis = US
- Acute Cholecystitis = HIDA scan if US not dx
- Choledocholithiasis = ERCP diagnostic and theraputic
- Acute Ascending Cholangitis = cholangiography
- Primary Sclerosing Cholangitis = MRCP/ERCP
Typically start with US for all of these though?
11
Q
MCC of Acute Cholecystitis
A
E coli
also klebsiella, other gram-neg enteric organisms
12
Q
If you have Chronic Cholecystitis, you can bet you have ____
A
gallstones
13
Q
Describe the pain of Acute Cholecystitis
1. Location
2. Precipitating factors
A
Continuous RUQ or epigastric pain – may be precipitated by fatty foods or large meals
may be associated w/ nausea, guarding, anorexia
14
Q
PE of Acute Cholecystitis and classic finding
A
fever (often low-grade); enlarged, palpable gallbladder
MURPHY’S SIGN: RUQ pain or inspiratory arrest w/ palpation of the gallbladder
15
Q
Apart from Murphy’s sign, what is another PE sign that is sometimes seen in Acute Cholecystitis and what causes it?
A
Boas sign: referred pain to the right shoulder or subscapular area (phrenic nerve irritation)
16
Q
Upon first-line imaging of Acute Cholecystitis, you will see ____ of the gallbladder and sometimes a ____ sign
A
1) Thickening of the gallbladder wall
2) Sonographic Murphy’s sign
remember, HIDA scan is most accurate scan though and it is used when the GB cannot be visualized
17
Q
Overall management of Acute Cholecystitis
A
NPO (prep for surg)
IV fluids
ABX followed by:
Cholecystectomy
18
Q
What are the ABX used pre-Cholecystectomy?
A
rocephin + metronidazole
MR
19
Q
If a pt cannot have a Cholecystectomy, what is another treatment option for Acute Cholecystitis?
A
Cholecystostomy (percutaneous drainage) if nonoperative
20
Q
Cholesterolosis presentation and treatment
A
fat deposits on GB
“strawberry GB”
tx is cholecystectomy (only if symptoms)
21
Q
How does Choledocholithiasis differ anatomically from Cholelithiasis and why is it a concern?
A
Gallstones in the common bile duct (can lead to cholestasis due to blockage)
CBD is formed from the merging of the cystic and hepatic ducts, meaning that drainaige from the liver is blocked as well
22
Q
Presentation of Choledocholithiasis
A
Prolonged biliary colic: RUQ or epigastric pain, N/V – pain usually more prolonged due to the presence of the stone blocking the bile duct
PE: RUQ or epigastric tenderness, jaundice
23
Q
Lab findings of Choledocholithiasis
A
↑ AST/ALT, alk phos, & GGT
cholestasis
24
Q
Management of Choledocholithiasis
A
Typically US first, but:
ERCP stone extraction preferred over laparoscopic choledocholithotomy
ERCP: dx TOC – diagnostic + therapeutic
25
What differs Acute Ascending Cholangitis from
1) Cholecystitis
2) Choledocholithiasis
**Sorta a combo of the two**:
1) different from *Cholecystitis* in that the infection is a result from **blockage of the CBD** rather than just the cystic duct
2) Different from *Choledocholithiasis* in that there is a **presence of infection** in addition to blocking the CBD
26
MCC of Acute Ascending Cholangitis
E coli
## Footnote
same as Cholecystitis, EZ!
27
What is the classic triad of Acute Ascending Cholangitis?
Charcot’s Triad: fever + RUQ pain + jaundice
## Footnote
Reynold’s Pentad: charcots + shock or AMS
28
What are the lab findings of Acute Ascending Cholangitis and why does this make sense?
1. Leukocytosis
2. ↑ alk phos & GGT
↑ bilirubin > increased ALT/AST
## Footnote
Again, labs suggest a hybrid of Cholecystitis and Cholangitis
29
You start with an US and are sus of Acute Ascending Cholangitis, so you use ____
Cholangiography via ERCP: gold standard
30
Treatment of Acute Ascending Cholangitis
| remember, infectious process and stones are present
Zosyn OR
Metro + ceph OR
Metro + cipro
ERCP removal
Eventually elective cholecystectomy
## Footnote
**ZAC MC** (**z**osyn **a**cute **c**holangitis or **m**etro + **c**eph/cipro)
31
Apart from Acute Ascending Cholangitis, what condition can present with Charcot’s Triad?
## Footnote
however, it does not classically present with all three
Primary Sclerosing Cholangitis
## Footnote
it CAN but not characteristic of the condition
32
What is Primary Sclerosing Cholangitis?
**Autoimmune**, progressive **cholestasis** leading to diffuse fibrosis of intra/extrahepatic biliary ducts
33
Your patient has Primary Sclerosing Cholangitis, what else do they likely have?
IBD (specifically ulcerative colitis)
| 90% association
## Footnote
also likely a 20-40 yo male
34
What symptom can help you differ Primary Sclerosing Cholangitis and from Acute Ascending Cholangitis?
Pruritis
| also see fatigue and hepatosplenomegaly
35
What conditions have ↑ alk phos & GGT, ↑ AST/ALT (3)
## Footnote
uniting feature?
1. Choledocholithiasis
2. Acute Ascending Cholangitis
3. Primary Sclerosing Cholangitis
## Footnote
all involve the CBD or hepatic duct (for PSC)
36
What key lab findings are seen in Primary Sclerosing Cholangitis?
IgM
**P-ANCA**
37
With this most accurate test, you will see ____ for Primary Sclerosing Cholangitis
**MRCP**, **ERCP** – most accurate test: **beaded appearance of biliary ducts** (narrowing, strictures)
| beaded appearance due to chronic sclerosis and tissue healing?
## Footnote
liver bx rarely used for dx - but remember that the hepatic ducts are affected
38
Management of Primary Sclerosing Cholangitis
1) symptomatic relief
2) pruritits
3) definitive
1) symptomatic relief = stricture dilation (allowing emptying)
2) pruritits = cholestyramine (bile sequestrant reducing bile acids)
3) definitive = liver transplant (affects hepatic/bile ducts, remember?)
39
MCC of acute vs chronic pancreatitis
acute = gallstones
chronic= alcohol
## Footnote
2nd MCC of acute = alcohol
40
what specific cells are injured in pancreatitis and what is the normal function of these cells?
**acinar cells**, which secrete exocrine enzymes
| exocrine enzymes (amylase, lipase, and protease)
41
Meds that can lead to acute pancreatitis (4)
Thiazides
Protease inhibitors
exanitide
valproic acid
## Footnote
**PRO vet**
Protease inhibitors
Valproic acid
Exantide
Thiazides
42
Classic presentation of acute pancreatitis
**Epigastric pain radiates to back**
| exacerbated if supine, relieved leaning forward
## Footnote
N/V and fever
43
Classic PE findings of severe acute pancreatitis
**Cullen’s sign** (periumbilical)
**Grey Turner sign** (flank)
## Footnote
suggests necrotizing hemorrhage
44
Most useful lab for acute pancreatitis
## Footnote
also, what electrolyte abnormality is sometimes seen?
Lipase
| 3x UNL
## Footnote
can also see HYPOcalcemia
45
Imaging for acute pancreatitis
**NOT NEEDED**
only use if patient does not have classic symptoms OR lipase is < 3x ULN
## Footnote
**CT w/ contrast** is imaging of choice
46
What might an abd xray show for acute pancreatitis? (2)
1) **sentinel loop** = localized ileus of small bowel segment in LUQ
2) **colon cutoff sign**: abrupt collapse of colon near pancreas
47
Dx of acute pancreatitis
Ranson's criteria
Admission:
(1) glucose >200mg/dL
(2) age >55yrs
(3) LDH >350IU/L
(4) AST >250IU/dL
(5) WBC >16,000/µL
Within 48hrs:
(6) calcium <8mg/dL
(7) hematocrit fall >10%
(8) PO2 <60mmHg
(9) BUN >5mg/dL
(10) base deficit >4mEq/L
(11) sequestration of fluid >6L
## Footnote
Interpretation:
≥3 🡪 severe pancreatitis likely
<3 🡪 severe pancreatitis unlikely
48
Tx of acute pancreatitis
**Rest the pancreas**
NPO
*high-volume IVF (LR preferred)
*analgesia (Meperidine)
Antibiotics:
*indicated only if >30% necrosis seen
49
Triad of Chronic Pancreatitis
calcification + steatorrhea (fatty stool) + DM
| seen only in 1/3 of pts: think inhibited abs d/t problem with pancreas
## Footnote
also see weight loss from poor abs
50
How do labs differ from acute vs chronic pancreatitis
Chronic has normal amylase/lipase
51
What might a CT scan show for chronic pancreatitis?
calcifications
52
Most sensitive and specific test for chronic pancreatitis
**fecal elastase** most sensitive & specific; **pancreatic stimulation w/ secretin & CCK**
## Footnote
not usually done
53
Management of chronic pancreatitis
**Lifestyle**
ETOH abstinence, pain control, low fat diet, vitamin supplementation
Oral pancreatic enzyme replacement
Pancreatectomy only if retractable pain despite medical therapy
54
Describe the pathophys of achalasia?
## Footnote
what plexus is involved?
Loss of peristalsis & failure of relaxation of the LES
PATHO: idiopathic proximal degeneration of myenteric/Auerbach’s plexus leads to increased LES pressure & impaired LES relaxation
## Footnote
MC presents <50yrs of age
55
What will a patient with achalasia complain of?
dysphagia to both solids & liquids
## Footnote
can't keep food down and will often cough it up - even can have chest pain
56
Diagnosis of choice and classic finding for achalasia
Barium esophagram:
”bird’s beak” appearance of the LES
57
Treatment of choice for achalasia and definitive
Pneumatic dilation of LES
## Footnote
Esophagomyomectomy is definitive
58
MC site of anal fissure
Linear, longitudinal tear in the posterior midline
| skin tags are seen in chronic
## Footnote
bright red blood is seen in toilet
pain, straining
59
Initial treatment of anal fissure
Supportive
## Footnote
sitz baths
high fiber and increased H2O to minimize straining
consider surg if refractory, but can lead to fecal incontinence
60
MC location of Perianal Abscess and Fistulas
posterior rectal wall
61
What does a fistula allow if a patient has a Perianal Abscess?
connects an abscess w/ skin or adjacent organs
62
Symptoms of Perianal Abscess and Fistula and how this differs from just an abscess
1. **SEVERE** **pain** paired with **fever** and **malaise**
2. If there is a fistula, it is a more chronic, non-healing abscess - leading to purulent drainaige that is **itchy** and **malodorous**
63
How to diagnose Perianal Abscess and Fistulas
Abscess = clinical
Fistula = MRI & endosonography
## Footnote
You can not feel a fistula on PE alone?
64
Treatment of Abscess and Fistulas
I&D, Antibiotics; sitz baths, high fiber
*Augmentin, cipro + metronidazole
| Fistula requires surgical treatment
## Footnote
Cure My Abscess
(cipro + metro) augmentin
65
Stage 1-4 hemorrhoids
**I**: **Does not prolapse** (confined to anal canal); may bleed w/ defecation
**II**: **Prolapses w/ defecation** or straining but spontaneously reduce
**III**: Prolapses w/ defecation or straining, **requires manual reduction**
**IV**: **Irreducible** & may **strangulate**
66
What are the veins involved with internal vs external hemorrhoids?
Internal = superior hemorrhoid vein; above dentate line
External = inferior hemorrhoid vein; below dentate line
67
How do symptoms differ between internal vs external hemorrhoids?
Internal = painless bleed
External = painful non-bleeding
## Footnote
opposites
68
Dx of hemorrhoids
DRE with fecal occult blood testing
## Footnote
sometimes anoscopy or proctosigmoidoscopy or colonoscopy if worried of other etiologies
69
Intial Tx of hemorrhoids
**Same as anal fissures pretty much**
high fiber diet, increased fluids; warm sitz baths; topical rectal corticosteroids
70
Procedures for failed conservative treatment of hemorrhoids
rubber band ligation
71
What is Zollinger-Ellison Syndrome?
gastric-secreting neuroendocrine tumor leading to severe PUD & diarrhea
| gastrinoma
## Footnote
ZES reminds me of zombies - which are associated with your brain (neuroendocrine)
72
MC site of gastrinomas for ZES
| Zollinger-Ellison Syndrome
**duodenal wall**, pancreas, lymph nodes, other sites
## Footnote
ZED (d = duodenum)
73
Presentation of ZES
| Zollinger-Ellison Syndrome
severe, recurrent, multiple, or refractory ulcers + diarrhea
Severe PUD:
*multiple peptic ulcers
*refractory ulcers
*abdominal pain
Diarrhea
**increased acidity** inactivated the pancreatic enzymes, leading to malabsorption
## Footnote
increased acidicty d/t PUD?
74
What imaging is used for ZES and why?
| Zollinger-Ellison Syndrome
endoscopy – confirm presence of ulcer
## Footnote
remember, ZES is associated with PUD and the diagnosis of choice for PUD is endoscopy + biopsy to confirm ulcer
75
Lab findings seen in ZES
| Zollinger-Ellison Syndrome
elevated basal or stimulated gastrin levels
## Footnote
secreted by the gastrinoma!
76
You want to screen a patient for ZES, what do you do?
| Zollinger-Ellison Syndrome
Check fasting gastrin levels and gastric pH
| gastrin should not be elevated while fasting as it is secreted w/ meals?
## Footnote
elevated fasting gastrin levels
*>1000pg/mL + gastric pH <2 = likely diagnosis
77
How to confirm ZES
| Zollinger-Ellison Syndrome
**Secretin test** w/ persistant gastrin elevation
| persistent gastrin elevations upon trial of secretin confirms diagnosis
## Footnote
Secretin SHOULD inhibit gastrin release in a healthy GI tract, but gastrin release in gastrinomas are not impacted by secretin
78
MC location of METS for ZES
## Footnote
Zollinger-Ellison Syndrome
Liver and lung lymph nodes
## Footnote
pLants vs ZES
79
Treatment of ZES and treatment if it METS
| Zollinger-Ellison Syndrome
Tumor resection
## Footnote
lifelong high dose PPIs if METS (to raise pH and manage symptoms?)
80
MCC of appendicitis
fecalith
81
preop ABX for appendicitis
cephalosporins + metronidazole
or zosyn
82
What is Paralytic Ileus?
temporary functional impairment of peristalsis
| NOT a physical barrier
83
Meds that can cause Paralytic Ileus
Opioids and anticholinergics
## Footnote
Can't see, **can't poop**
84
Electrolyte abnormality that can cause Paralytic Ileus
HYPOkalemia
85
MCC of SBO vs LBO
## Footnote
small bowel vs large bowel
SBO = post abd surgical adhesions
LBO = adenocarcinoma > scarring secondary to diverticulitis > volvulus
86
What is volvulus?
torsion of bowel on its axis ⇢ closed loop obstruction
## Footnote
torsion of mesenteric vascular pedicle ⇢ occlusion/thrombosis of mesenteric vessels ⇢ bowel strangulation, ischemia, & gangrene
87
MC location of volvulus
Sigmoid colon
## Footnote
sigmoid makes the letter "S", which is more susceptible to be twisted?
88
Explain the evolution of abd sounds in a SBO/LBO
Peristalsis intially increases greatly early on followed by abscence of bowel sounds in later course
| hyperactive followed by hypoactive bowel sounds
89
Which bowel obstruction type is emesis more common in?
| SBO or LBO?
SBO
## Footnote
more proximal, so it makes sense
90
3/6/9 rule of bowel obstruction
small bowel >3cm
large bowel >6cm
cecum >9cm
91
Classic sign seen in sigmoid volvulus
coffee bean sign
92
Classic finding of volvulus on CT
whirl sign = pathognomonic
## Footnote
remember, it winds on itself leading to blood flow compromise
93
Initial Tx of SBO
1. NG Tube for gastric decompression (1)
2. Fluids prior to surg if strangulation sus
## Footnote
(1) NG tube helps prevent aspiration and relieves gastric distension by removing gastric fluids + gas
94
Tx of SBO if 24 hours w/out improvement
## Footnote
I'm assuming without improvement w/ NG tube and whatnot?
1. laparotomy
2. Lysis of adhesions
3. resect nonviable intestine followed by primary anastomsis of resected segments
95
Overall Tx of LBO
Surgery (in nearly all cases)
## Footnote
goals ⇢ resection of necrotic bowel &
decompression of obstructed segment
96
Surgery options for LBO (3)
1) *resection + primary anastomosis
2) *resection + diversion, diversion alone
3) *endoscopic stent placement
97
Treatment of cecal volvulus
ileocecal resection or R colectomy w/ ileocolic anastomosis
## Footnote
quick refresher; order of small intestine/ large intestine flow:
duodenum, jejunum, ileum, cecum, ascending colon, hepatic flexure (right colic flexure), transverse colon, splenic flexure (left colic flexure), descending colon, sigmoid colon, rectum, anus
98
Treatment of sigmoid volvulus w/OUT signs of peritonitis
sigmoidoscopy w/ rectal tube insertion for decompression, detorsion, & reduction
## Footnote
surgery if all else fails
99
Treatment of sigmoid volvulus WITH signs of peritonitis
sigmoid colectomy & primary anastomosis
100
Apart from BMI, in order to be a candidate for bariatric surgery, what do you need to do?
Fail a dietary program
## Footnote
Proof of failure typically required
101
BMI guidelines for bariatric surg
35+ if comorbidities (HTN, DM)
40+ otherwise
102
Goals of restrictive bariatric surgeries
Limit coloric intake by limiting the stomach's resivoir capacity
103
2 restrictive bariatric surgeries
1. Sleeve gastrectomy
2. Laproscopic adjustable band
104
Sleeve gastrectomy involves _____
resection of greater curvature of stomach
| restrictive + hormonal change = less hunger and better insulin control
## Footnote
reduces the size of the stomach and leads to a 60% weight loss @ 2 years
105
Which bariatric surgery is strictly restrictive
LAGB
| Laparoscopic Adjustable Gastric Banding
## Footnote
not used much anymore
106
Roux-en-Y Gastric Bypass (RYGB)
▪︎small stomach pouch created & connected directly to small intestine ▪︎70% weight loss @2y
107
Dumping syndrome
| what is this often seen in?
nausea, weakness, sweating, faintness, & possibly diarrhea soon after
eating within first few years after surgery ⇢ symptoms intensify w/ high-sugar foods
## Footnote
seen in Roux-en-Y Gastric Bypass (RYGB)
108
Which bariatric surgery involves removing the LESSER curvature of the stomach
One-Anastomosis Gastric Bypass (OAGB): “mini-gastric bypass”
109
Gastroparesis vs Ileus
## Footnote
for constipation
**Gastroparesis**: condition that affects the stomach muscles & **prevents proper stomach emptying**
**Ileus** = **hypomobility of the GI tract** in the absence of mechanical bowel obstruction
## Footnote
Gastro = specifically stomach
Ileus = GI tract
110
MCC of Gastroparesis
DM
## Footnote
chronic damage to nerves of GI tract (autonomic neuropathy)
111
s/s of gastroparesis vs ileus
1. **Gastroparesis** = nausea, **full feeling after little food is eaten**, constipation
2. **Ileus** = diminished bowel sounds and constipation
## Footnote
both constipation
112
treatment of gastroparesis and ileus
Underlying cause + treat constipation
113
Overall meds for constipation
1. Fiber
2. Bulk forming laxatives
3. Osmotic laxactives
4. Stimulant laxatives
114
MOA of fiber
retains water & improves GI transit
increases bulk of stool
115
What are the bulk forming laxatives?
1. Psyllium
2. Methylcellulose
3. Polycarbophil
4. Wheat dextran
## Footnote
notice how the names of these are related to carbs:
cellulose
carbophil
wheat
(then psyllium)
116
MOA of bulk forming laxatives
absorbs water & increases fecal mass; increases the frequency & softens the consistency of stool w/ minimal effects
## Footnote
*dietary fiber + bulk forming laxatives most physiologic & effective approach
117
What are the osmotic laxatives? (3) Specifically saline laxatives? (2)
1. Sorbitol
2. Polyethylene glycol (PEG)
3. Lactulose
Saline = milk of magnesia, mag citrate (basically mg)
118
MOA of osmotic/saline laxatives
causes water retention in stool (osmotic effect pulls water into gut)
119
What are the SE of saline laxatives?
hypomagnesemia
## Footnote
idk why? fact check?
120
What are the stimulant laxatives? (2)
Bisacodyl
Senna
121
MOA of stimulant laxatives
increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa
122
All of the treatments for constipation (fiber + laxatives) have a SE of bloating except
stimulant laxatives
## Footnote
diarrhea, abdominal pain
