GI system Flashcards
Cholecystitis is…
Inflammation of the gall bladder
What is the cause of cholecystitis in 95% of cases
Gall stones
Risk factors for cholecystitis
Female Fat Fourty Fertile Rapid weight loss Medications: Thiazides, birth control pills, lipid lowering agents
Cause of Black stones
Bilirubin and calcium
Cause of Brown stones
Cholesterol and bacteria
Signs and symptoms of cholecystitis
Pain after a fatty mean
N/V- very common 70% of cases and causes temporary relief of pain
Right scapula referred pain
Low grade temp
Physical findings of Cholecystitis
RUQ tenderness, guarding Rebound tenderness Epigastric pain \+ Murphy's sign Charcots triad Courvoisers sign Jaundice
Murphys sign
Deep pain on inspiration, fingers under rib cage when they breathe they have severe pain
Charcots triad
RUQ pain
Jaundice
Fever
Courvoisers sign
Palpable enlarged gall bladder that is contender- unlikely to be gall stones
Lab findings of cholecystitis
Leukocytosis
Elevated bilirubin, ALT, AST, Alk phos, and serum amylase
Diagnostic findings of cholecystitis
Ultrasound is best for looking for stones
Radiograph- may see radiopaque stones
Cholangiogram- will see bile duct obstruction
HIDA scan- Also for visualization of obstruction
Treatment for Cholecystitis
NPO or a low fat, low volume diet Think about NGT to LIS IV fluids- they need volume Pain control ABX Surgery- treatment of choice for most cases
ABX for cholecystitis
Third generation cephalosporins (Cefazolin, cefuroxime, ceftriaxone) and metronidazole
For severe cases:
Fluoroquinolones (ciprofloxacin) plus metronidazole
Appendicitis is…
Inflammation of the appendix
Most common surgical emergency
Causes of appendicitis
Low fiber diets, fecaliths, strictures, neoplasms
More common in males
Signs and symptoms of appendicitis
Nausea Anorexia Fever Periumbilical pain that moves to the RLQ Severe constipation Rupture- you will have a sudden decrease in pain severity
Lab findings for appendicitis
Leukocystosis
Urine- hematuria, pyuria
Ultrasound- 98% accurate to detect, CT to detect perforation or abscess
Treatment for appendicitis
Surgery
IV fluids
Pain control
ABX
Physical findings of appendicitis
Fever Tachycardia Rebound tenderness in RLQ Pain at mcBurneys point Psoas sign Rovsigs sign Obturator sign Muscle rigidity and guarding
Psoas sign
Pain with right thigh extendion
Rovsigs sign
Right LQ pain on palpation of LLQ
Obturator sign
Pain with internal rotation of the flexed right thing
ABX for appendicitis
Prior to surgery- cefoxitin, cefotan
Gangrenous or perforation- single or combination therapy with flagyl
Immunocompromised or elderly- carbapenem plus flagyl
Diverticulitis is…
Inflammation of a diverticulum in the intestinal tract, causing stagnation of feces in little distended sacs of colon and pain
Usually in the descending or transverse colon except in asian populations more common in ascending colon
Causes of Diverticulitis
low fiber diets
Defects of colon wall
Adults over 50
signs and symptoms of diverticulitis
diffuse LLQ pain Fever Constipation/diarrhea Distention hyperactive BT with obstruction Hypoactive BT more common Frequency and dysuria
Physical findings of diverticulitis
Tachycardia
Guarding
Fever
LLQ tenderness
Lab findings of diverticulitis
Elevated ESR, Procalcitonin and CRP
+ Guiac
Diagnostic findings in diverticulitis
Plain radiograph to look for free air, ileum, distention, obstruction
CT scan- diagnostic test of choice for acute illness, may also reveal abscessed cavity or fistula
Barium enema- but do not use in acute setting, may cause perforation
C-reactive peptide elevated
Over 50
LLQ pain
No vomitting think
Diverticulitis
Treatment for mild diverticulitis
Mild w/o perforation can be managed outpatient
Oral ABX
clear liquids advanced to low fiber diet
ABX for severe diverticulitis
Inpatient: (7-10 days of IV ABX but can switch to oral if improved after 5 days).
- Fluoroquinolones, cipro or levofloxacin plus metrondiazole
- 3 or 4 generation cephalosporin (cefotaxime, ceftriaxone or cefepime) plus metronidazole
- Zosyn
- Timentin
- Imipenem: for immunocompromised patients
ABX for mild diverticulitis
Acute uncomplicated: oral ABX for 7-10 days. Cipro, Bactrim or Levo plus flagyl or Amoxicillin and clavulanate
Treatment for severe diverticulitis
IV ABX Bowel rest may need TPN NGT for ileum IVFs Surgery
Diverticulitis symptoms in females think…
Ectopic pregnancy
STDs
PID
Pancreatitis is…
Acute inflammatory, auto digestive process of the pancreas
Causes of pancreatitis
Alcohol Gall stones post ERCP Hypoperfusion Abdominal trauma
signs and symptoms of pancreatitis
Epigastric pain abrupt onset severe N/V Weakness, sweating Absent or hypoactive BT Fever Tachycardia Hypotension Tachypnea Jaundice Ascites RUQ mass
If hemorrhagic pancreas…
Grey turner sign
Cullens sign
Grey turner sign
Flank discoloration
Cullens sign
Umbilical discoloration
Lab findings for pancreatitis
Amylase and lipase (lipase is more specific and stay elevated longer)
Leukocytosis
Trypsin will be positive in absence of renal disease
HCT may be elevated except with hemorrhage
Hyperglycemia in severe disease
Elevated BUN
AST and LDH may be elevated (tissue necrosis)
Bilirubin and alk pos may increase as a result of common bile duct obstruction
Hypocalcemia in severe cases
Low albumin
Diagnostics for pancreatitis
MRI/MRCP has great advantages to evaluate the biliary and pancreatic ducts
Treatment for pancreatitis
Pain control IV hydration (hypovolemia and shock are a major cause of death) NPO until clinically improved then frequent small meals (low cholesterol, high protein, low fat, bland) NGT for ileum and vomiting Monitor CA and replace as needed Monitor pulmonary function ABX if necessary TPN Surgery
Need for surgery in pancreatitis
Perforation
Gall stones
Cyst
Abscess
ABX will be necessary for pancreatitis in
Septicemia
Abscess
Pseudocyst
ABX for pancreatitis
Imipenem
Cefuroxime
Ransons criteria
Calculates the risk for complications and death in pancreatitis
Ranson risk scores
< 3 risk factors: 1% mortality
3-4 risk factors: 15% mortality
5-6 risk factors: 40% mortality
>7 risk factors: close to 100% mortality
Risk factors on admission for ransons criteria
- > 55 years old
- WBC: 16000
- Glucose: > 200
- LDH: > 350
- AST: > 250
Risk factors at 48 hours for ransons criteria
- Hct drops > 10%
- BUN increases > 5
- Calcium < 8
- Arterial O2 < 60
- Base deficit > 4
Estimated fluid sequestration > 6000 ml
Peritonitis is…
An acute inflammation of the peritoneum
Clinical manifestations in peritonitis
Acute diffuse abdominal pain, exacerbated by motion
Fever
N/V
Constipation
Treatment of Peritonitis
IVF
ABX- 10 day therapy
ABX for peritonitis
3rd generation cephalosporin
Ampicillin for enterococcus
Small bowel obstruction definition
Blockage of the lumen of the intestine- not allowing normal functioning results in distention and fluid loss from the gut
Necrosis, toxicity and perforation may occur
Fluid and electrolyte imbalances
Causes of SBO
Adhesion- most common Hernias internal and external Volvulus- twisting of bowel on itself Strictures- r/t crohns disease, radiation, ischemia Hematomas r/t trauma; anticoagulation Intussusception Feces Tumors Foreign bodies
Clinical manifestations of SBO
Periumbilical Cramping that is sporadic As distention develops pain becomes continuous and diffuse Ostipation- complete obstruction Watery diarrhea in partial obstruction Tenderness High pitched "tinkling" bowel sounds visible peristalsis dehydration
High SBO
Upper abdominal pain
Profuse vomiting
Middle or distal SBO
Cramping colicky, diffuse pain
distention and episodic vomiting
Feculent vomiting and increase in NGT output in SBO means
more distal SBO
Lab findings in SBO
leukocytosis
Hemoconcentration and electrolyte imbalances (decreased K, metabolic alkalosis)
Supine and upright CXR- dilated bowel, little or no air in colon, thickening of intestinal wall, pneumatosis (sign of ischemia),
Barium radiography confirms diagnosis
US- Accurate in the diagnosis of SBO
Management of SBO
Bowel rest, NPO IV fluids and electrolyte replacement NGT to LIS Possible broad spectrum ABX Surgical consultation for complete obstruction that does not improve
Colonic obstruction is..
Emergency requires early identification and swift surgical intervention
Due to infectious, inflammatory, neoplastic or mechanical pathology
Colonic obstruction causes
tumors
diverticulitis- hypertrophy of colonic wall, lumen narrowing
Intussusception
Ogilvie syndrome- those who have diabetes or pain meds. Loss of peristalsis. Obstruction not evident but colon becomes significantly and dangerously dilated
Colonic obstruction Meds
Broad spectrum ABX early; Clindamycin, flagyl
Lab studies for colonic obstruction
CBC, electrolytes, PT, Type and crossmatch
Diagnostic tests in colonic obstruction
upright chest xray- look for free air and volvulus
CT scan with IV and rectal contrast
Management of colonic obstruction
NPO
NGT
IVF
Early consult to general surgery
Paralytic ileus is..
an ileus that is a nontechnical obstruction
Causes of paralytic ileus
Medications- narcotis Infections Mesenteric ischemia Injury to blood supply Post intra-abdominal surgery Metabolic disturbances
Management of paralytic ileus
Continuous decompression
Neostigmine
Increased portal pressures causes…
esophageal varices
Esophageal varies cause…
- Cirrhosis
- Portal venous hypertension of at least 12 mm Hg (normal 2-6)
- Occurs in the distal 5 cm of the esophagus and upper portion of the stomach
Clinical manifestations of Esophageal varices
Hematemesis Melena Abdominal Pain Hypovolemic shock Hematochezia (a lot of blood in the stool, maroon color)
Lab findings in esophageal varices
H/H decreases WBC elevated Platelets decreased Potassium decreases then increases Sodium decreases then increases Calcium decreases Hyperglycemia BUN/Cr elevates Elevated lactate Liver enzymes abnormal low albumin
Diagnostic findings in esophageal varices
Endoscopy- after stabilization
Barium studies define the presence of Peptic ulcers, bleeding sites, tumors, and inflammation
Management of esophageal varices
insert 2 large bore IVs Type and Cross pt/ptt, CBC, Electrolyte panel, LFT, RFT Crysatlloids pending products Maintain SBP > 110, CVP < 10 and pcwp < 8 FFP for coagulapathies Foley NPO Consult surgeon or GI Admit to ICU 60-80% stop spontaneously Octreotide Balloon tamponade
Complications of balloon tamponade
Gastric balloon rupture
Esophageal rupture
Ulcerations of the esophageal and gastric mucosa
Prevention of rebreeding in esophageal varices
Long-term follow up with endoscopy Beta blockers TIPS (stent) Portosystemic shunt liver transplantation
Definition of upper GI bleed
loss of blood anywhere from the upper esophagus to the duodenum (above the ligament of trees)
Causes of UGI bleed
Mallory weiss tear
Esophageal varices
Peptic ulcer disease
Neoplasm
Manifestations of UGI bleed
Abdominal pain
hematemesis (bright red or coffee ground)
Melena (dark tarry stool)
signs and symptoms of UGI bleed
Hypovolemic shock (>40% blood volume) Skin pallor Orthostatic changes (20% loss) signs of liver disease (spider angiomata, palmar erythema, icterus) NGT- BRB or Coffee ground
Labs of UGI bleed
T/C for 4 units PRBC H/H pt, ptt, plt, electrolyte, BUN/Cr, Liver enzymes EKG (ischemia related to blood loss) Endoscopy
Managments of UGI bleed
Intubate if needed Consult surgery and GI Emergency resuscitation- blood transfusions NGT Endoscopy PPI Octreotide Balloon tamponade (rare) Surgery
Definition of Lower GI bleed
Bleeding that comes from Below the ligament of trees, small intestine, or colon
Causes of Lower GIB
Diverticulitis (40 %) Neoplasm IBS Anal-rectal disease ischemic colitis
Clinical manifestations of Lower GIB
Hematochezia or melena
Pallor, Tachycardia, postural hypotension- in chronic blood loss
Labs for Lower GIB
R/O UGIB with NGT
CBC
Iron, TIBC, Ferritin
Fecal Occult blood
Management of Lower GIB
Resuscitate
DC ASA and NSAIDS
Colonoscopy- within 6-24 hours from admissionArteriography
Surgery if indicated
Hepatitis is
Inflammation of the liver
Causes of hepatitis
Virus (Most common) Drugs (alcohol) Chemicals Autoimmune hepatitis Genetic diseases Metabolic abnormalities
The main cause of inflammation of liver cells and liver damage in hepatitis is because of…
Cell apoptosis
Classic symptoms of progression of hepatitis
Fever Malaise Nausea Hepatomegaly Pain ALT, AST increase in blood Increase in atypical lymphocytes Jaundice Dark urine Increase urobilinogen
Which liver test will be higher and stay elevated longer in viral hepatitis?
ALT
Hepatitis infection for < 6 months
Acute hepatitis
Hepatitis infection > 6 months
Chronic hepatitis
Hepatitis A is acquired
Fecal-oral, contaminated food
Acute- no chronic
Hepatitis E is acquired
Fecal-oral, undercooked sea food or contaminated water
Acute- no chronic
Hepatitis C is acquired
Via the blood Childbirth Sex IV drug use Acute and chronic
Hepatitis B is acquired
Via the blood Childbirth Sex IV drug use Acute- only becomes chronic in 20% of cases Linked to liver cancer
Hepatitis D is a virus that…
Can only infect a host if a host is infected with HBV
Types of hepatitis
A, B, C, D, E
Hepatitis A is a…
RNA virus
Hepatitis B is a…
DNA virus
Hepatitis C is a…
RNA virus
Hepatitis D is a…
Defective RNA virus (delta virus)
Hepatitis E is a…
RNA virus
acute phase of hepatitis
phase of maximal infectivity
lasts 1-4 months
Pruritis in hepatitis
accumulation of bile salts under the skin
Complications of hepatitis
acute liver failure
Chronic hepatitis
Cirrhosis
Hepatocellular carcinoma
True or false the resolution of jaundice in hepatitis means resolution of infection
false
Lab testing for hepatitis
testing for the specific antigen and or antibody for each type of hepatitis
