GI System: differential Dx Flashcards
gall bladder referred pain to
R shoulder and R scapula
stomach referred pain to
between the R and L scapulae
pancreatitis referred pain to
L2 area
appendicitis may refer pain to
coccygeal area
asymptomatic gallstones → biliary colic →
cholecystitis
a colicky pain (pain that starts and stops abruptly) of fewer than 6 hours in duration
biliary colic
where is the gall bladder located?
right upper quadrant; underneath the liver
where does the bile come from?
produced in the liver, stored in the gall bladder
what is the purpose of bile?
to break down (emulsifies) fat and proteins
When food containing fat enters the digestive tract, it stimulates the secretion of
cholecystokinin CKC
Cholecystokinin, previously called pancreozymin, is synthesized and secreted by enteroendocrine cells in the duodenum, the first segment of the small intestine. Its presence causes the release of digestive enzymes and bile from the pancreas and gallbladder, respectively, and also acts as a hunger suppressant
In response to CCK, the adult gallbladder, which stores about 50 ml (1.7 oz) of bile, will…
contract and release its contents into the duodenum
CCK cholecystokinin causes
- contraction of the gall bladder: secretion of bile
- secretion of digestive enzymes from the pancreas
- stops hunger
These calculi (gallstones) are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as
the cystic duct, common bile duct, or pancreatic duct.
A _______ is a crystalline concretion formed within the gallbladder by accretion of bile components.
gallstone
Gallstones may temporarily obstruct the cystic duct or pass through into the common bile duct, leading to symptomatic
biliary colic.
Gallstones can be divided into 2 categories:
Cholesterol stones (80%) and pigment stones (20%).
Stones that remain for greater than 6 hours in the cystic duct lead to
ischemia and then infarct and gangrene of the gallbladder.
cholecystitis.
cholecystitis occurs when
obstruction at the cystic duct is prolonged (6 hours) resulting in inflammation/ ischemia/infarction/infection of the gallbladder wall → Cholecystitis
Acute cholecystitis develops in approximately ___% of patients with biliary colic if they are left untreated.
20%
Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately _______ operations annually.
500,000
Gallstone Risk Factors
- Female
- Fertile
- Fair (light skin)
- Forty
- Fat (or rapid weight loss)
- Flatulent
Clinical Presentation of Biliary Colic
- generally includes 1-5 hours of colicky pain
- Pain typically begins after eating a fatty meal, frequently at night, awakening the pt from sleep.
- most commonly in the epigastrium or right upper quadrant with radiation to right scapula/upper back
- may include nausea, vomiting, pleuritic pain, and fever.
Cholecystitis is differentiated from biliary colic by
the persistence of constant severe pain for more than 6 hours.
Abdominal examination in gallbladder colic and cholecystitis is remarkable for
epigastric or right upper quadrant tenderness and abdominal guarding.
name of test
an inspiratory pause on palpation of the right upper quadrant can be found on abdominal examination of a patient with cholecystitis.
Name of sign?
The Murphy sign
Murphy sign is extremely sensitive (97%) and predictive (93%) for cholecystitis
________ studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis.
Ultrasonography and nuclear medicine
if ultrasound can’t be used for diagnosis of gallstones because the patient can’t tolerate the pain →
CT scan
treatment of biliary colic
patient education, avoid fats
In mild cholecystitis, in which inflammation is the primary process, the treatment is
antibiotics are prophylactic but are usually used.
treatment of acute cholecystitis
broad-spectrum antibiotic coverage is used.
Historically, cholecystitis was operated on emergency, resulting in increased mortality. The current practice is
to cool off the gallbladder and perform a cholecystectomy after several days or to readmit the patient at a later date.
Indications for urgent surgical intervention include patients with complications such as
empyema, emphysematous cholecystitis, or perforation.
Emergent cholecystectomy is usually performed in 20% of such cases.
The pancreas is a gland located in the
upper posterior abdomen
One of the hallmarks of recognizing pancreatitis is
The position of the patient: they can’t lay on their back
Most patients will sit up or curl up/lean forward for pain relief.
The Cullen sign is a
bluish discoloration around the umbilicus resulting from hemoperitoneum. (“Worse case scenario”)
Pancreatitis, end stage
Pancreatitis; a minority of patients exhibit _______ (approximately 28%)
jaundice
The Grey-Turner sign is a
reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes; more commonly, patients may have a ruddy erythema in the flanks secondary to extravasated pancreatic exudate.
Grey-Turner sign
pacreatitis
The Cullen sign
pancreatitis
ulceration/erosion/break of the mucous membrane of the stomach, or duodenum (most common,) or rarely the esophagus, or at the Meckel’s Diverticulum due to action of the gastric acid.
Peptic Ulcer Disease
most common peptic ulcer disease location
duodenal
Duodenal ulcers occur ____ times more often than gastric ulcers. Duodenal ulcers occur most commonly b/w ages of 30-55
5 x
________ is a Gram-negative, microaerophilic bacterium that inhabits various areas of the stomach and duodenum. It causes a chronic low-level inflammation of the stomach lining and is strongly linked to the development of duodenal and gastric ulcers and stomach cancer.
Helicobacter pylori
To colonize the stomach H. pylori survives the acidic pH of the lumen and burrows into the mucus to reach its niche, close to the stomach’s epithelial cell layer. The bacterium has flagella and moves through the stomach lumen and drills into the mucoid lining of the stomach. This leads to
chronic inflammation and ulcer development.
Tumors (gastrinomas) of the duodenum or pancreas producing the hormone gastrin. Gastrin then causes an excessive production of acid which can lead to peptic ulcers (in almost 95% of patients.) These tumors are most commonly malignant.
Zollinger Ellison Disease
Peptic Ulcer Disease gold standard diagnosis
Endoscopy is the diagnostic gold standard of PUD.
Visualization of the ulcer confirms the clinical diagnosis.
defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay.
Appendicitis
McBurney point location
2/3 of the way from the umbilicus to the iliac crest
RLQ pain with internal and external rotation of the flexed right hip:
suggests that the inflamed appendix is located deep in the right hemipelvis.
Name of sign?
The obturator sign
RLQ pain with extension of the right hip or with flexion of the right hip against resistance
suggests that an inflamed appendix is located along the course of the right psoas muscle.
name of sign?
The psoas sign
the most specific sign
