GI System: differential Dx Flashcards
1
Q
gall bladder referred pain to
A
R shoulder and R scapula
2
Q
stomach referred pain to
A
between the R and L scapulae
3
Q
pancreatitis referred pain to
A
L2 area
4
Q
appendicitis may refer pain to
A
coccygeal area
5
Q
asymptomatic gallstones → biliary colic →
A
cholecystitis
6
Q
a colicky pain (pain that starts and stops abruptly) of fewer than 6 hours in duration
A
biliary colic
7
Q
where is the gall bladder located?
A
right upper quadrant; underneath the liver
8
Q
where does the bile come from?
A
produced in the liver, stored in the gall bladder
9
Q
what is the purpose of bile?
A
to break down (emulsifies) fat and proteins
10
Q
When food containing fat enters the digestive tract, it stimulates the secretion of
A
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
11
Q
In response to CCK, the adult gallbladder, which stores about 50 ml (1.7 oz) of bile, will…
A
contract and release its contents into the duodenum
12
Q
CCK cholecystokinin causes
A
- contraction of the gall bladder: secretion of bile
- secretion of digestive enzymes from the pancreas
- stops hunger
13
Q
These calculi (gallstones) are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as
A
the cystic duct, common bile duct, or pancreatic duct.
14
Q
A _______ is a crystalline concretion formed within the gallbladder by accretion of bile components.
A
gallstone
15
Q
Gallstones may temporarily obstruct the cystic duct or pass through into the common bile duct, leading to symptomatic
A
biliary colic.
16
Q
Gallstones can be divided into 2 categories:
A
Cholesterol stones (80%) and pigment stones (20%).
17
Q
Stones that remain for greater than 6 hours in the cystic duct lead to
A
ischemia and then infarct and gangrene of the gallbladder.
cholecystitis.
18
Q
cholecystitis occurs when
A
obstruction at the cystic duct is prolonged (6 hours) resulting in inflammation/ ischemia/infarction/infection of the gallbladder wall → Cholecystitis
19
Q
Acute cholecystitis develops in approximately ___% of patients with biliary colic if they are left untreated.
A
20%
20
Q
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.
A
500,000
21
Q
Gallstone Risk Factors
A
- Female
- Fertile
- Fair (light skin)
- Forty
- Fat (or rapid weight loss)
- Flatulent
22
Q
Clinical Presentation of Biliary Colic
A
- 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.
23
Q
Cholecystitis is differentiated from biliary colic by
A
the persistence of constant severe pain for more than 6 hours.
24
Q
Abdominal examination in gallbladder colic and cholecystitis is remarkable for
A
epigastric or right upper quadrant tenderness and abdominal guarding.
25
# name of test
an inspiratory pause on palpation of the right upper quadrant can be found on abdominal examination of a patient with **cholecystitis.**
## Footnote
**Name of sign?**
**The Murphy sign**
Murphy sign is extremely sensitive (97%) and predictive (93%) for **cholecystitis**
26
\_\_\_\_\_\_\_\_ studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis.
**Ultrasonography** and nuclear medicine
27
if ultrasound can't be used for diagnosis of gallstones because the patient can't tolerate the pain →
CT scan
28
treatment of biliary colic
patient education, avoid fats
29
In mild cholecystitis, in which inflammation is the primary process, the treatment is
antibiotics are prophylactic but are usually used.
30
treatment of acute cholecystitis
broad-spectrum antibiotic coverage is used.
31
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.
32
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.
33
The pancreas is a gland located in the
upper posterior abdomen
34
The pancreas is responsible for
insulin production (endocrine pancreas) and the manufacture and secretion of digestive enzymes (exocrine pancreas) leading to carbohydrate, fat, and protein metabolism.
35
is an inflammatory process in which pancreatic enzymes autodigest the gland.
Pancreatitis
36
the exocrine cells of the pancreas produce
digestive enzymes: **amylase** and **lipase** are key digestive enzymes
37
cause most cases of acute **pancreatitis**.
Long-standing **alcohol consumption** and **biliary stone disease**
38
\_\_\_\_\_is a major cause of acute pancreatitis (accounting for at least 35% of cases.)
**Alcohol use**
"It can be one binge" Prof Verity
39
The cardinal symptom of acute pancreatitis is
**epigastric abdominal pain**, which is characteristically dull, boring, and steady.
40
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.
41
pancreatitis comes along with other systemic issues
**Fever** (76%) and **tachycardia** (65%) are common **abnormal vital signs;** **hypotension** may be noted.
42
**The Cullen sign** is a
bluish discoloration around the umbilicus resulting from hemoperitoneum. ("Worse case scenario")
**Pancreatitis,** end stage
43
Pancreatitis; a minority of patients exhibit _______ (approximately 28%)
**jaundice**
44
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.
45
**Grey-Turner sign**
**pacreatitis**
46
**The Cullen sign**
pancreatitis
47
Diagnosis of Pancreatitis
Serum **amylase** and **lipase** levels are typically elevated in persons with acute pancreatitis.
48
\_\_\_\_\_\_\_\_ are more specific to the pancreas than elevated amylase levels.
Elevated **lipase** levels
Lipase levels remain high for 12 days. ln patients with chronic pancreatitis (usually caused by alcohol abuse), lipase levels may be elevated in the presence of a normal serum amylase level.
49
Medical management of **mild acute pancreatitis** is relatively straightforward. The patient is kept
NPO (nil per os; that is, **nothing by mouth**), and intravenous (IV) fluid hydration is provided.
Analgesics are administered for pain relief.
50
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**
51
most common **peptic ulcer** disease location
**duodenal**
52
Duodenal ulcers occur ____ times more often than gastric ulcers. Duodenal ulcers occur most commonly b/w ages of 30-55
**5 x**
53
\_\_\_\_\_\_\_\_ 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**
54
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.
55
Person-to-person transmission (Heliobacter Pylori) by either ________ or ________ route is most likely. Consistent with these transmission routes, the bacteria have been isolated from feces, saliva and dental plaque of some infected people
the oral-oral or fecal- oral
56
**NSAIDS** such as ibuprofen (motrin and advil) alleve, aspirin, etc. **decrease the mucous production in the GI tract** thereby exposing the stomach and duodenum to increased damage from the acidic environment. This can lead to...
**Peptic Ulcer Disease**
"And the big problem is that 50% of people taking NSAID's will not manifest the pain"
57
Zollinger Ellison Disease
Zollinger-Ellison syndrome is a rare condition in which one or more **tumors** form in your pancreas or the upper part of your small intestine (duodenum). These tumors, called gastrinomas, secrete large amounts of the hormone **gastrin**, which causes your stomach to produce too much acid
58
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**
59
Pt has been treated for H Pylori and they still have ulcers that are not healing, they mau have
**Zollinger Ellison** **Disease**
malignant tumors
60
what causes peptic ulcers?
**H-Pylori** and **NSAID's**
also **Zollinger Ellison** **Disease**
61
what **exacerbate** peptic ulcers
**smoking**, **alcohol**, **spicy food**
these DO NOT cause peptic ulcer disease
62
Clinical Manifestations of PUD
* Gnawing Abdominal / Epigastrlc Pain
* **INTERSCAPULAR BACK PAIN**
* Pain is often induced or relieved by food
* Nausea
* 50% of patients with NSAID-induced ulcer are asymptomatic
* Vomiting blood or black stools (because you a digesting blood)
63
Diagnostic Laboratory findings of peptic ulcers
**H pylori Serologic testing - antibody testing**
* H Pylori fecal antigen
* H Pylori urea breath testing
* CBC
* Gastrin Levels (if **Zollinger-Ellison syndrome** is supected)
64
Peptic Ulcer Disease **gold standard** diagnosis
**Endoscopy** is the diagnostic gold standard of PUD.
Visualization of the ulcer confirms the clinical diagnosis.
65
Peptic Ulcer Disease treatment
* **H Pylori eradication** → **2 antibiotics for 2 weeks**
* (Biaxin 500mg bid Y - Amoxicillin 1gm BID)
* Proton Pump Inhibitor (stops acid production)
* **NO MORE NSAIDS**
66
to stop the stomach acid production (treatment of Peptic Ulcer Disease)
**Proton Pump Inhibitor** - Protonix or Nexium
67
Peptic Ulcer Disease Complications
* **Gastrointestinal Bleeding** - (Hematemesis - vomiting blood, Melena - Black tarry, foul smelling stool)
* Perforation of viscous
* Gastric cancer
68
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**
69
The average length of the appendix is
8-10 cm (ranging from 2-20 cm).
70
The most common causes of luminal obstruction include
* **lymphoid hyperplasia** secondary to inflammatory bowel disease (IBD)
* **infections** (more common during childhood and in young adults)
* **fecal stasis** and fecaliths (more common in elderly patients)
* **parasites** (especially in Eastern countries)
* or, more rarely, **foreign bodies** and neoplasms.
71
The incidence of appendicitis gradually rises from birth, peaks in _______ and gradually declines in the geriatric years.
the late **teen years**
72
The classic history of appendicitis is
* anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain to right low back, and vomiting.
* Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen.
* **This pain migration is the most discriminating feature of the patient's history.**
73
Tenderness on palpation in the RLQ over the ______ point is the most important sign in patients with **appendicitis**
**McBurney**
74
McBurney point location
2/3 of the way from the umbilicus to the iliac crest
75
**RLQ pain with palpation of the LLQ**
suggests peritoneal irritation in the RLQ precipitated by palpation at a remote location. **Name of sign?**
**The Rovsing sign**
76
**RLQ pain with internal and external rotation of the flexed right hip:**
suggests that the inflamed appendix is located deep in the right hemipelvis.
## Footnote
**Name of sign?**
**The obturator sign**
77
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**
78
Which is the most specific sign, sometimes called "the surgeon sign" for appendicitis
**the psoas sign**
79
\_\_\_\_\_\_\_ has become the most important imaging study in the evaluation of appendicitis patients.
**Computed tomography (CT) scanning** with oral contrast medium or rectal Gastrografin enema
80
Appendicitis Treatment
* **Appendectomy** remains the only curative treatment of appendicitis.
* According to several studies, antibiotic prophylaxis should be administered before every appendectomy.
* When the patient becomes afebrile and stable, antibiotic treatment may be stopped. (Cefotetan and cefoxitin seem to be the best choices of antibiotics.)
