GI / Nutritional Part 1 (Abdominal pain - Cholelithiasis/choledocholithiasis) Flashcards
What are some causes of RUQ pain?
Think organ location
- Gallbladder issues
- Liver issues
- biliary colic, cholecystitis/angiitis
- hepatitis, thrombosis
What are some of the causes of LUQ pain?
Think organ location
Spleen issues
Splenomegaly
Splenic infarct
Splenic Abscess
Rupture
What are some of the causes of epigastric pain? (6)
- MI
- Pancreatitis (acute/chronic)
- PUD
- GERD
- Gastritis/opathy/paresis
- Dyspepsia
Classic cause of RLQ pain vs LLQ pain
RLQ = Appendicitis
LLQ = diverticulitis
What are some GI causes of anorexia?
- Gastric/duodenal ulcers
- Gastric/GI cancers
- Hematochezia
What is Cholelithiasis specifically?
Merely Gallstones in the biliary tract (usually in the gallbladder) w/o inflammation
MC type of gallstone?
cholesterol
others are black stones (hemolysis), brown stones in infections and Asian pop
RF for Cholelithiasis
remember, just gallstones
5 Fs and Native Americans
fat, fair, female, forty, fertile
also OCPs
What does Cholelithiasis feel like?
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)
What is the diagnostic test of choice for:
1. Cholelithiasis
2. Acute Cholecystitis
3. Choledocholithiasis
4. Acute Ascending Cholangitis
5. Primary Sclerosing Cholangitis
- 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?
MCC of Acute Cholecystitis
E coli
also klebsiella, other gram-neg enteric organisms
If you have Chronic Cholecystitis, you can bet you have ____
gallstones
Describe the pain of Acute Cholecystitis
1. Location
2. Precipitating factors
Continuous RUQ or epigastric pain – may be precipitated by fatty foods or large meals
may be associated w/ nausea, guarding, anorexia
PE of Acute Cholecystitis and classic finding
fever (often low-grade); enlarged, palpable gallbladder
MURPHY’S SIGN: RUQ pain or inspiratory arrest w/ palpation of the gallbladder
Apart from Murphy’s sign, what is another PE sign that is sometimes seen in Acute Cholecystitis and what causes it?
Boas sign: referred pain to the right shoulder or subscapular area (phrenic nerve irritation)
Upon first-line imaging of Acute Cholecystitis, you will see ____ of the gallbladder and sometimes a ____ sign
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
Overall management of Acute Cholecystitis
NPO (prep for surg)
IV fluids
ABX followed by:
Cholecystectomy
What are the ABX used pre-Cholecystectomy?
rocephin + metronidazole
MR
If a pt cannot have a Cholecystectomy, what is another treatment option for Acute Cholecystitis?
Cholecystostomy (percutaneous drainage) if nonoperative
Cholesterolosis presentation and treatment
fat deposits on GB
“strawberry GB”
tx is cholecystectomy (only if symptoms)
How does Choledocholithiasis differ anatomically from Cholelithiasis and why is it a concern?
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
Presentation of Choledocholithiasis
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
Lab findings of Choledocholithiasis
↑ AST/ALT, alk phos, & GGT
cholestasis
Management of Choledocholithiasis
Typically US first, but:
ERCP stone extraction preferred over laparoscopic choledocholithotomy
ERCP: dx TOC – diagnostic + therapeutic