GI Symptom differentials Flashcards
List some differential diagnosis’ for epigastric pain
• Peptic Ulcer (gastric or duodenal) – • Gastritis – • GORD – • Acute Pancreatitis Chronic pancreatitis • Gallbladder (more right sided) • Liver: hepatitis (viral/alcoholic) • AAA – • Pneumonia – • Pulmonary Embolism – • AMI –
What would you expect to see in Peptic Ulcer (history)
(gastric or duodenal) – NSAIDs, look for pneumoperitoneum on erect CXR
What would you expect to see in Gastritis
alcohol history
What would you expect to see in • GORD
hx of reflux
What would you expect to see in pancreatitis
o Severe, radiates straight through to the back, a/w nausea & vomiting
What are the causes of acute pancreatitis?
Causes: Gallstones (biliary colic hx), alcoholic
G - Gallstones
E - Ethanol (alcohol!)
T - Trauma
S - Steroids M - Mumps A - Autoimmune - e.g. SLE / Crohn's S - Scorpion bites (rare!) H - Hypercalcaemia, hypothermia, hyperlipiaemia E - ERCP D - Drugs - e.g. azathiaprin -
What are the complications of acute pancreatitis?
o Complications → PANCREAS M Pulmonary failure (ARDS), peritonitis Acute Renal Failure Necrosis & nearby problems - infection, pancreatic abscess & pseudocyst Coagulopathy (DIC) Recurrent & chronic pancreatitis Erosion of gastric mucosa → haematemesis & maelena Acute psychosis Sepsis, sugars (diabetes – uncommon) Malabsorption, mortality (5%)
How do you diagnose acute pancreatitis?
- Serum lipase + may have low calcium
* Imaging : USS + CT
Treatment of acute pancreatitis
ERCP + may need cholecystectomy when pain settles
What would you expect to see in Chronic Pancreatitis
o Repeated attacks of moderately severe epigastric abdominal pain, persistent abdominal pain & back pain
• May be aggravated by alcohol, overating, opiates
What are the causes of chronic pancreatitis
o Causes: alcohol abuse is the main cause
• Also: cystic fibrosis
what are the complications of chronic pancreatitis
later diabetes mellitus, malabsorption & pancreatic pseudocysts in 10% of patients
What would you see in a AAA
older males, pain radiating to the back or down to the groin (mimics renal colic), weak pulses in lower limbs, pulsatile abdominal mass
What organs are involved in right upper quadrant pain?
Biliary Pathology
Liver
Peptic Ulcer
Right Lower Lobe Pneumonia
Who get’s biliary pathologies?
o Gallstones occur in: fat (high lipids, oestrogen), female, fertile (OCP, HRT, pregnant - oestrogen), fair, older
Cholelithiasis- what is it?
what are the clinical symptoms/signs?
Gall stone in the gall bladder
Colicky pain, radiates around to the back & to the tip of the scapula
• Worse after a fatty meal +/- vomiting
What is cholecystitis
what are the clinical symptoms/signs?
Inflammation of GB usually secondary to gallstones hence may start as biliary colic
Positive murphy’s sign, fever, sudden onset of pain (constant) (usually no jaundice)
- murphy’s sign- hand on gall bladder- get patient to breath out, when they breath IN it will be excruciating
May radiate to the shoulder blade, pain exacerbated by breathing & movement
May have systemic signs of inflammation – febrile tachycardia
USS will show THICKENED GALL BLADDER WALL
clinical symptoms/signs of choledocholithiasis/ WHAT IS IT?
Obstruction of the CBD,
sudden onset of pain, radiation to the right shoulder blade
Possible jaundice of skin and sclera, fever, nausea and vomiting
What is CHOLANGITIS?
Stone obstructing CBD causes stasis & infection above it
CHARCOT’S TRIAD: FEVER/RIGORS, RUQ PAIN & JAUNDICE
• Progressing to septic shock & confusion
• Stone obstructing CBD causes stasis & infection above it –
USS shows dilated CBD
• Treatment ERCP
What would an USS show in CHOLANGITIS?
What is the treatment of cholangitis?
USS shows dilated CBD
• Treatment ERCP
Liver pathologies for right upper quadrant pain would include
o Viral hepatitis – past diagnosis of Hep C or B, recent travel, unprotected sex, tattoos, IVDU
o Alcoholic hepatitis – full alcohol history
o Cyst or abscess
What would you be trying to RULE OUT in RUQ pain?
- Appendicitis – McBurney’s point, WCC
- AMI
- PE
- Ectopic pregnancy (beta-hCG)
- Pyelonephritis (phx UTI)
What are some causes of RLQ pain ?
- Mesenteric Adenitis
- Appendicitis –
- Ileitis (small bowel)
- Colitis (large bowel)
- Crohn’s disease -
- Ulcerative colitis
- Gynecological
- Renal
- Meckel’s diverticulum
- Testicular - Torsion or hernia
- Carcinoma of caecem of ascending bowel (family hx, APCC)
Who gets mesenteric adenitis?
o Kids – inflammation of the terminal ileum, history of URTI, febrile & tender
what are the clinical features you would see in appendicitis?
starts as central pain then localizes to RIF
what are the clinical features you would see in ileitis
o Viral, bacterial (shigella, salmonella, campylobacter, Yersinia), fungal, parasitic (amoeba)
What are the clinical features you would see in Colitis (large bowel)
o Infective – viral, bacterial, fungal, parasitic
o Inflammatory
• Crohn’s disease -
• Ulcerative colitis – lower abdominal pain relieved by defecation, haematochezia
o Iradiation
o Idiopathic
if you were thinking it was a gynecological cause of LIF pain, what would you be thinking?
- split up into 3*
Ovary: cyst, mittleschmertz (mid cycle pain), torsion (sudden, severe)
Tubes: ectopic pregnancy (date of LMP?), pelvic inflammatory disease (discharge, sex partners)
Uterus: retrograde, IUD
what pathologies would you suspect if you thought it was a large bowel obstruction causing the pain?
o Sigmoid volvulus (vomiting, constipation),Cancer
if you were thinking renal pathologies for left iliac fossa pain, what would you think?
stones, pyelonephritis
If a person experiences UMBILICAL PAIN, what are your differentials?
• AAA or ruptured
• Small Bowel
o Infarction: as opposed to the LI it has poor collaterals
o Obstruction: adhesions or hernia
- Paralytic ileus (post surgical), intussusception (children), faecal impaction, crohn’s disease
- Pancreatitis
- Appendicitis
- Peptic ulcer
- Gastroenteritis
If an individual presented with dysphagia, what would your course of action be in regard to clinical tests?
Barium swallow,
CXR,
endoscopy
if you think the dysphagia is more of an oropharyngeal link (clinically regurg, other symptoms dysphonia, coughing etc)
what are some pathologies you would be thinking?
Oropharyngeal
• Clinically: coughing due to aspiration, regurgitation, other neurological symptoms (dysphonia, diplopia, weakness), other associated symptoms
NEUROMUSCULAR o MND/ALS o Stroke o CNS tumour o Myasthenia gravis o Multiple Sclerosis o Parkinsons, dementia o Sjogrens STRUCTURAL o Cervical osteophytes o Cricoid web o Pharyngoesophageal diverticulum
if you think the dysphagia is more of an oesophopharyngeal link (pain on swallowing)
what are some pathologies you would be thinking?
STRUCTURAL
o Oesophageal strictures (benign peptic strictures) – secondary to GORD
o Oesophageal rings or webs
o Eosinophilic oesophagitis
o Neoplasia: SCC (upper 2/3 – smoking, hot drinks), adenocarcinoma (lower, GORD)
MOTILITY DISORDER
o Achalasia
o Diffuse oesophageal spasm
o Scleroderma
What are some differential diagnosis’ of haematemesis?
• Peptic ulcer – haemorrhage
• Oesophageal varices – a/w liver disease (cirrhosis), alcohol history
• Oesophageal cancer – a/w dysphagia, weight loss, night sweats
o SCC: smoking, hot drinks
o Adenocarcinoma: history of GORD
• Mallory Weiss tear – past history of vomiting LOTS
• Gastric carcinoma
PR Bleeding, Haematochezia. What are some differentials?
Passage of fresh blood, origin of bleeding in the lower GIT
• Haemorrhoids – secondary to straining, cirrhosis & increased px, pregnancy
• Diverticulitis
• Ulcerative Colitis
• Colorectal cancer
• Anal fissure
What is the causes, management, symptoms of Haemorrhoids
SYMPTOMS
• May have a change in bowel habits ie constipation preceding this
• Uncomplicated haemorrhoids: Painless bleeding after defecation
• May streak faeces or on the toilet paper
• If copious it may splash into toilet bowel or cause iron deficiency anemia
• Palpable lump
• Sensation of prolapse after defecation
• May cause perianal discomfort & discharge which can lead to pruritis
CAUSES
• Straining
• Cirrhosis leading to portal caval anastomoses
• Pregnancy
MANAGEMENT
• PR exam
• Involves inserting a gloved finger with lubricant into the anus to look for any abnormalities such as ulceration, lumps, fissures, prostate
• Gastro referral for colonoscopy (due to change in bowel habits, ? family history)
Differential diagnosis’ for malaena
- Peptic Ulcer
- Oesophageal cancer
- Gastric cancer
- Oesophageal varices
What are some differentials for altered bowel habit?
- Bowel Cancer –
- Haemorrhoids –
- Gastroenteritis –
- IBD – Crohn’s disease , UC
- Diverticular Disease
- Polyps
- Coeliac disease
- Irritable Bowel –
- Thyroid disease –
- Other
What other symptoms would you expect to see in BOWEL CANCER
weight loss, anorexia, night sweats + dull aching abdominal pain
What other symptoms would you expect to see in Crohn’s VERSUS UC
Crohn’s disease (diarrhoea, RLQ abdo pain), UC (mucous, blood)
What are some prehepatic causes of jaundice?
Unconjugated hyperbilirubinemia – light urine, pale stools
Can develop kernicterus (brain damage) if unconjugated bilirubin crosses the BBB (toxic)
• Haemolysis (decreased haptoglobin)
- –>Intrinsic: RBC defects – spherocytosis, thalassemia, sickle cell anemia
- –>Extrinsic: Mechanical (prosthetic valves, marching), immune
What are some hepatic causes of jaundice
May be conjugated or unconjugated hyperbilirubinemia depending on cause
• Congenital – impaired conjugation
o Lack of mature hepatic enzymes at birth
o Genetic deficiency (Crigler Najjar Syndrome)
o Gilbert’s Syndrome (AD, decreased UGT1A1 activity)
• Traumatic – massive trauma
• Infective – viral (EBV, CMV, hep A, B, C), bacterial (any), protozoa (malaria), fungi (candida)
• Inflammatory – NASH, Primary Biliary Cirrhosis
• Neoplastic – obstructive
• Metabolic – glycogen storage disease
• Endocrine – diabetes mellitus
• Toxic – ETOH, CaCl-
• Idiopathic
What are some post hepatic causes of jaundice
Conjugated hyperbilirubinemia, dark urine + pale stools + pruritis
• Biliary Tree
o Lymph node enlargement – mets/lymphoma
o Post surgical strictures
o Gallstones or parasite blockage – worms!
• Pancreas: Head of pancreas tumour (painless jaundice + enlarged non-tender gallbladder)
In someone with abdominal distension, what clinical signs would you look for to determine if SBO or LBO?
o SBO = vomiting, distension, pain → Adhesions, hernia
o LBO = constipation +- pain → Volvulus, cancer
INVESTIGATING GI SYMPTOMS
- what would you do in EXAMINATION?
Vital signs: Temperature, RR, pulse & BP
Abdominal palpation & examination ->Guarding, rigidity (ruptured PUD)
Resp – listen to lungs
Cardio – chest sounds, ?ECG
INVESTIGATING GI SYMPTOMS
- what would you do in IMAGING?
Erect CXR – pneumoperitoneum, heart & lung pathology
Abdominal USS ->Gallstones: in GB, dilated CBD in cholangitis, thickened gallbladder walls in cholecystitis
- >AAA, pancreas (oedema), appendix, kidneys (inflammation), ovaries
CT scan – gold standard for PANCREATITIS, contrast CT can help identify diverticulitis
Abdominal Xray – signs of Crohn’s or UC, volvulus or bowel obstruction
-> Bowel obstruction → Erect abdominal X-ray – air/fluid levels (>3), distended bowel loops (>3, 6, 9 cm)
Colonoscopy – looking for polyps (can biopsy), bleeding in diverticular disease
INVESTIGATING GI SYMPTOMS
- what would you do in LAB INVESTIGATIONS?
FBC – WCC for inflammation/infection, Hb for blood loss
LFTs – liver enzymes & bilirubin, albumin
UECs – surgical & medication purposes + if vomiting/dehydrated, kidney function
Lipase – pancreatitis
Urine MSU & MCS
Beta-hCG if considering ectopic pregnancy
What are the TWO MANAGEMENT options for biliary pathology
- ERCP
2. Laparoscopic Cholecystectomy
Explain an ERCP to a patiient
- Used in choledocolithiasis, cholangitis & gallstone pancreatitis
- Remove stone using ERCP (endoscopic retrograde cholioangiopancreatography) – pass tube through stomach & through the sphincter of oddi into CBD & remove stone (may need a sphincterotomy or to dilate the sphincter with a balloon). If the stone cannot be removed may just put in a stent
Explain a lap choley to a patient
- Most cholecystectomy’s are done laparoscopically & are often done as inpatients without the need for an overnight stay in hospital. They usually take about 2 hours in uncomplicated cases.
- The surgeon inflates stomach with air or CO2 to see clearly, then inserts a lighted scope attached to a video camera (laparoscope) into an incision near the belly button & uses this as a guide while inserting surgical instruments into other incisions to remove your GB.
- Usually you will have 4 incisions; one at the navel, one epigastric, mid clavicular (under rib), and anterior axillary.
- Lap cholecystectomy’s do not require the abdominal muscles to be cut, resulting in less pain, quicker healing & improved cosmetic results & fewer complications such as infection & adhesions.
- Indicated for patients with symptoms deemed to be due to gallstones & asymptomatic patients with gallbladder stones who are at risk of complications - diabetics, porcelain gallbladder (15-20% a/w carcinoma), history of pancreatitis, long-term immunosuppression.
- Risks: conversion to open operation (5-10%, usually secondary to unexpected inflammation, scar tissue, injury or bleedig), bile duct injury (<1%), bleeding (2%), bile leak (1%), risks of general anaesthesia.
- Because they have removed the GB, you can no longer store bile between meals – in most people this has little or no effect on digestion
