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OSCES- SURG > GI Symptom differentials > Flashcards

GI Symptom differentials Flashcards

1
Q

List some differential diagnosis’ for epigastric pain

A 
•	Peptic Ulcer (gastric or duodenal) – 
•	Gastritis – 
•	GORD – 
•	Acute Pancreatitis
	Chronic pancreatitis
•	Gallbladder (more right sided)
•	Liver: hepatitis (viral/alcoholic)
•	AAA – 
•	Pneumonia – 
•	Pulmonary Embolism – 
•	AMI –
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2
Q

What would you expect to see in Peptic Ulcer (history)

A

(gastric or duodenal) – NSAIDs, look for pneumoperitoneum on erect CXR

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3
Q

What would you expect to see in Gastritis

A

alcohol history

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4
Q

What would you expect to see in • GORD

A

hx of reflux

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5
Q

What would you expect to see in pancreatitis

A

o Severe, radiates straight through to the back, a/w nausea & vomiting

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6
Q

What are the causes of acute pancreatitis?

A

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 -
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7
Q

What are the complications of acute pancreatitis?

A 
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%)
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8
Q

How do you diagnose acute pancreatitis?

A
  • Serum lipase + may have low calcium

* Imaging : USS + CT

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9
Q

Treatment of acute pancreatitis

A

ERCP + may need cholecystectomy when pain settles

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10
Q

What would you expect to see in Chronic Pancreatitis

A

o Repeated attacks of moderately severe epigastric abdominal pain, persistent abdominal pain & back pain
• May be aggravated by alcohol, overating, opiates

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11
Q

What are the causes of chronic pancreatitis

A

o Causes: alcohol abuse is the main cause

• Also: cystic fibrosis

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12
Q

what are the complications of chronic pancreatitis

A

later diabetes mellitus, malabsorption & pancreatic pseudocysts in 10% of patients

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13
Q

What would you see in a AAA

A

older males, pain radiating to the back or down to the groin (mimics renal colic), weak pulses in lower limbs, pulsatile abdominal mass

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14
Q

What organs are involved in right upper quadrant pain?

A

Biliary Pathology
Liver
Peptic Ulcer
Right Lower Lobe Pneumonia

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15
Q

Who get’s biliary pathologies?

A

o Gallstones occur in: fat (high lipids, oestrogen), female, fertile (OCP, HRT, pregnant - oestrogen), fair, older

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16
Q

Cholelithiasis- what is it?

what are the clinical symptoms/signs?

A

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

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17
Q

What is cholecystitis

what are the clinical symptoms/signs?

A

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

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18
Q

clinical symptoms/signs of choledocholithiasis/ WHAT IS IT?

A

Obstruction of the CBD,
sudden onset of pain, radiation to the right shoulder blade
Possible jaundice of skin and sclera, fever, nausea and vomiting

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19
Q

What is CHOLANGITIS?

A

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

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20
Q

What would an USS show in CHOLANGITIS?

What is the treatment of cholangitis?

A

USS shows dilated CBD

• Treatment ERCP

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21
Q

Liver pathologies for right upper quadrant pain would include

A

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

22
Q

What would you be trying to RULE OUT in RUQ pain?

A
  • Appendicitis – McBurney’s point, WCC
  • AMI
  • PE
  • Ectopic pregnancy (beta-hCG)
  • Pyelonephritis (phx UTI)
23
Q

What are some causes of RLQ pain ?

A
  • 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)
24
Q

Who gets mesenteric adenitis?

A

o Kids – inflammation of the terminal ileum, history of URTI, febrile & tender

25
Q

what are the clinical features you would see in appendicitis?

A

starts as central pain then localizes to RIF

26
Q

what are the clinical features you would see in ileitis

A

o Viral, bacterial (shigella, salmonella, campylobacter, Yersinia), fungal, parasitic (amoeba)

27
Q

What are the clinical features you would see in Colitis (large bowel)

A

o Infective – viral, bacterial, fungal, parasitic
o Inflammatory
• Crohn’s disease -
• Ulcerative colitis – lower abdominal pain relieved by defecation, haematochezia
o Iradiation
o Idiopathic

28
Q

if you were thinking it was a gynecological cause of LIF pain, what would you be thinking?
- split up into 3*

A

Ovary: cyst, mittleschmertz (mid cycle pain), torsion (sudden, severe)

Tubes: ectopic pregnancy (date of LMP?), pelvic inflammatory disease (discharge, sex partners)

Uterus: retrograde, IUD

29
Q

what pathologies would you suspect if you thought it was a large bowel obstruction causing the pain?

A

o Sigmoid volvulus (vomiting, constipation),Cancer

30
Q

if you were thinking renal pathologies for left iliac fossa pain, what would you think?

A

stones, pyelonephritis

31
Q

If a person experiences UMBILICAL PAIN, what are your differentials?

A

• 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
32
Q

If an individual presented with dysphagia, what would your course of action be in regard to clinical tests?

A

Barium swallow,
CXR,
endoscopy

33
Q

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?

A

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
34
Q

if you think the dysphagia is more of an oesophopharyngeal link (pain on swallowing)
what are some pathologies you would be thinking?

A

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

35
Q

What are some differential diagnosis’ of haematemesis?

A

• 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

36
Q

PR Bleeding, Haematochezia. What are some differentials?

A

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

37
Q

What is the causes, management, symptoms of Haemorrhoids

A

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)

38
Q

Differential diagnosis’ for malaena

A
  • Peptic Ulcer
  • Oesophageal cancer
  • Gastric cancer
  • Oesophageal varices
39
Q

What are some differentials for altered bowel habit?

A
  • Bowel Cancer –
  • Haemorrhoids –
  • Gastroenteritis –
  • IBD – Crohn’s disease , UC
  • Diverticular Disease
  • Polyps
  • Coeliac disease
  • Irritable Bowel –
  • Thyroid disease –
  • Other
40
Q

What other symptoms would you expect to see in BOWEL CANCER

A

weight loss, anorexia, night sweats + dull aching abdominal pain

41
Q

What other symptoms would you expect to see in Crohn’s VERSUS UC

A

Crohn’s disease (diarrhoea, RLQ abdo pain), UC (mucous, blood)

42
Q

What are some prehepatic causes of jaundice?

A

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
43
Q

What are some hepatic causes of jaundice

A

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

44
Q

What are some post hepatic causes of jaundice

A

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)

45
Q

In someone with abdominal distension, what clinical signs would you look for to determine if SBO or LBO?

A

o SBO = vomiting, distension, pain → Adhesions, hernia

o LBO = constipation +- pain → Volvulus, cancer

46
Q

INVESTIGATING GI SYMPTOMS

- what would you do in EXAMINATION?

A

Vital signs: Temperature, RR, pulse & BP
Abdominal palpation & examination ->Guarding, rigidity (ruptured PUD)
Resp – listen to lungs
Cardio – chest sounds, ?ECG

47
Q

INVESTIGATING GI SYMPTOMS

- what would you do in IMAGING?

A

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

48
Q

INVESTIGATING GI SYMPTOMS

- what would you do in LAB INVESTIGATIONS?

A

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

49
Q

What are the TWO MANAGEMENT options for biliary pathology

A
  1. ERCP

2. Laparoscopic Cholecystectomy

50
Q

Explain an ERCP to a patiient

A
  • 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
51
Q

Explain a lap choley to a patient

A
  • 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

OSCES- SURG (6 decks)

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