Lecture 11: Abdominal Pain Part 2 Flashcards
Classic presentation of Viral Gastroenteritis
- Rapid onset of diarrhea (watery)
- Non-bilious N/V
- +/- abd pain
- Fever (More common in kids)
- Dehydration
- Abd PE is generally normal
What qualifies as diarrhea for gastroenteritis?
3-13 days of watery stool or 200g of stool/d
Diagnostics for viral gastroenteritis
- BG if lethargic/unresponsive
- BMP + Mg to assess lytes
Primary management of mild-mod viral gastroenteritis?
- Rehydration via oral fluid challenge (30mL PO then rest 15 mins, repeat)
- Pedialyte/gatorade only!
Rehydration for severe viral gastroenteritis
- Adults 500-1000 mL bolus
- Children: 20 mL/kg bolus
When is zofran indicated for viral gastroenteritis?
Met all discharge criteria EXCEPT PO challenge.
May cause worsening diarrhea
When is an antidiarrheal indicated in viral gastroenteritis?
Diarrhea leading to dehydration
What are the antidiarrheal options for gastroenteritis?
- Antimotility (loperamide, lomotil): CId in peds/IBD
- Antisecretory (peptobismol): CId in peds/pregnancy
What food? might help reduce the duration of viral gastroenteritis symptoms?
Probiotics
Dietary recommendations for viral gastroenteritis?
- BRAT diet
- Avoid lactose/raw fruit/caffeine/sorbitol
- Avoid dairy for 1 week post symptom resolution
Lactose, raw fruit and sorbitol contain types of sugar that are irritating to the GI tract. Raw fruit contains high contents of fiber, also irritating to the GI tract. Caffeine is a stimulant and irritates the GI tract.
What is the discharge criteria for viral gastroenteritis? (3)
- Normal VS
- Normal Abd exam
- Successful PO challenge
When does viral gastroenteritis need to be admitted?
- Toxic
- Severe dehydration (with lyte abnormalities)
- Persistent vomiting/diarrhea
- Comorbidities (Preggo, DM, immune)
- Young/elderly
- Symptoms longer than 1 week
What are the two versions of bacterial gastroenteritis?
- Toxin mediated (secretory)
- Invasive (inflammatory)
How does bacterial gastroenteritis typically present?
- Lots of watery diarrhea or bloody mucopurulent diarrhea (dysentery)
- Cramping/tenderness
- +/- fever
What is the main complication we are worried about in bacterial gastroenteritis?
Hemolytic Uremic Syndrome (HUS)
Who is HUS MC in and what causes it specifically?
- Elderly and children < 10 y/o
- Enterohemorrhagic E. coli (EHEC)
Hx of exposure to undercooked beef, water, unpasteurized dairy or fecal contamination.
What are the main 3 S/S of HUS?
- Hemolytic anemia
- Renal Failure
- Thrombocytopenia
Dx of bacterial gastroenteritis
- FOBT
- BMP
- CBC (if HUS suspected)
- Stool studies (if indicated)
- Plain film/CT Abd
When are stool studies indicated for gastroenteritis and what are the stool studies?
- Severely dehydrated/toxic
- Dysentery
- Immunocompromised
- Diarrhea > 3days
- Includes fecal leukocytes, lactoferrin, and cultures (salmonella, shigella, campylobacter)
Management of Bacterial Gastroenteritis
- Fluids
- Replacement of lytes if needed
- Empiric cipro or azithromycin for adults
- Can use peptobismol in adults
Only give abx to child if culture +
What must you AVOID in bacterial gastroenteritis?
Antimotility agents
May lead to HUS
What separates a UGI from a LGI bleed anatomically?
Ligament of Treitz
Suspensory ligament of duodenum
The ligament of Treitz, also known as the suspensory ligament of the duodenum, is a double fold of peritoneum suspending the duodenojejunal flexure from the retroperitoneum.
How does bloody vomit/stool description tell you if its UGI or LGI?
- Frank blood/coffee-ground suggests UGI bleed.
- Black, tarry stool suggests UGI bleed.
- Bright red stool usually suggests LGI bleed. (or massive UGI bleed)
Why is hx of similar symptoms important in GI bleeds?
For UGI bleeds, 60% will bleed from the same lesion.
What can mimic melena? What can mimic hematochezia?
- Melena: Iron or bismuth
- Beets: Hematochezia
When performing an abdominal exam for someone with a suspected GI bleed, what do these suggest?:
- Hyperactive bowel sounds
- Tenderness
- Non-tender
- Ascites or hepatosplenomegaly
- Hyperactive Bowel sounds suggest an UGI Bleed
- Tenderness suggests inflammatory/infectious cause
- Non-tender suggests vascular etiology
- Ascites or hepatosplenomegaly suggests Liver dz
What does MCV on a CBC suggest for bleed timing?
- Normocytic = acute
- Microcytic = chronic
Your CMP returns with a BUN:Cr over 30, what does this suggest?
Acute UGI bleed
What lab must you check prior to performing endoscopy to search for GI bleed?
INR < 2.5
If your NG tube has blood, what do you do?
You can perform a gentle gastric lavage.
What is the ratio of PRBCs to FFP in GI bleed transfusion?
4 units of PRBCs: 1 unit of FFP
When do you tranfuse for GI bleed?
- Hemodynamic instability + no response to 2L NS
- Hgb < 7
- Older pts who cannot tolerate anemia, transfuse at hgb < 9
Gotta be pretty low to tranfuse
What happens if your GI bleed pt now has an INR > 2?
Hold their AC and reverse any AC with its reversal agent + Kcentra for warfarin.
Adexxa, Praxbind, Vit K
High INR = high time to clot
What conditions do these drugs primarily treat in terms of UGI bleed: PPIs, Somatostatin analog (octreotide)?
- PPIs: PUD with bleeding ulcer
- Octreotide: Esophageal varices
For LGI bleeds, what imaging is up for consideration?
- EGD to r/o massive UGI bleed.
- Colonoscopy
- Angiography
What is the d/c criteria for GI bleeds?
- Hx of mild bleed (hemorrhoids or anal fissure)
- No BRBPR on DRE
- No melanotic stool
- Good vitals
- No comorbidities
Everyone else admit
Buzzword for mallory weiss tear
Hx of Forceful vomiting
What are some of the biggest red flags for a LGI bleed 2/2 malignancy?
- Change in stool shape
- Change in stool habits
- Wt Loss
Classic presentation of PUD
- Burning, epigastric pain relived by ingestion of food/milk/antacids
- Worse supine, waking up at night
Consider atypical in elderly
Main 3 complications of PUD
- Perf (rigid + general tenderness)
- Outlet obstruction (Distension + succussion splash)
- Bleed (Occult or gross rectal blood)
MC Demographic for nephrolithiasis
20-50 year old white MALE
Top S/S for nephrolithiasis
- Renal colic
- HEMATURIA
- Tachycardia
- N/V
- Pain
Remember to check fever and CVA tenderness
What lab findings suggest pyelo?
- UA showing pyuria and bacteriuria
- CBC showing WBC >= 15k
Do a C&S for UA if you see pyuria and bacteriuria
Best imaging for first time renal colic pt
Non CT of abd & pelvis
When is Renal US indicated for renal colic eval?
- CT is CI
- Recurrent nephro
- Pt is preggo, pediatric, or had a recent CT already
What is the main condition renal US catches?
Hydronephrosis
What will renal US show for a kidney stone?
- Uretal dilation
- Hydronephrosis
- Density if stone > 5 mm
What is a good study to pair with Renal US for kidney stone eval?
KUB XR
90% of stones are radiopaque
What med can help with getting rid of a kidney stone?
Alpha-blockers (tamsulosin)
When would you admit for kidney stones?
- Intractable pain/emesis
- Coexisting pyelo
- Stone is huge/anatomic abnormality (You aint getting rid of it quick)
- Renal dysfunction
F/u and education for kidney stones
- Go see a urologist in 24-48h
- Drink 2-3 liters of water
- Give them a strainer for their urine
How does pyelo present?
- Cystitis (dysuria, urgency, frequency)
- Flank/abd/suprapubic pain
- N/V
- +/- fever
- CVA TENDERNESS
What two things are positive on UA dip that suggests pyelo?
- Leukocyte esterase
- Nitrite
Leukocyte casts on microscopy too
Outpatient empiric ABX for pyelo
- Cipro BID x 7d or Levaquin QD x 5d
- One initial dose of rocephin
- Bactrim DS x 14d (Only if can’t take FQ + not resistant)
Inpatient empiric ABX for pyelo
- Cipro
- Rocephin/cefotax/cefepime
- Gentamicin +/- ampicillin
- Zosyn
- Carbapenems
Choice depends on local resistance data.
Admission indications for pyelo (7)
- PO intolerable
- Concerned about compliance
- Diagnostic uncertainty
- Severe illness
- Comorbid illness
- Failed OP therapy
- Pregnant or ureteral stone
OP recommendations for discharged pyelo pts
- F/u with PCP in 24-48h
- Drink more water
What drug is known for inducing drug-related hepatitis?
Acetaminophen
Classic S/S for hepatitis
- +/- Jaundice & icterus
- RUQ pain + tender
- Fever
- Dark urine
- Hepatomegaly
- Liver failure
What AST:ALT ratios suggest alcoholic hepatitis? Other causes? Tylenol toxicity/acute viral/acute liver failure?
- AST:ALT < 1 = other causes
- AST: ALT > 2.5 = alcoholic
- AST + ALT > 1000 = tylenol/acute viral/etc
How long will it take PT/INR to prolong in hepatitis?
Usually at least a day as liver worsens
What is the admission criteria for acute hepatitis?
- Elderly/preggo
- Not responding well to supportive
- Bilirubin >= 20
- PT > 50% above normal
- Hypoglycemic or GI bleed
- Ascites => resp compromise
What is the mainstay of therapy for acute hepatitis?
Treat underlying cause
Tylenol toxicity vs viral vs liver failure vs etc
ER return precautions for acute hepatitis
- Poor PO intake
- Worsening Vomiting/jaundice/abd pain
MC location for AAA
Infrarenal aorta
Just above where it bifurcates
For an unstable AAA pt, what do you wanna do immediately? (diagnostic)
Bedside abd US
What triad of S/S in AAA suggests immediate vascular surg consult?
- Abd/back pain
- Pulsatile abd mass
- Hypotension
CALL ASAP!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Goal SBP while awaiting surgery for AAA rupture/dissection
80-90 SBP
Define dissecting AAA vs rupturing AAA
- Dissecting means it just entered the media layer.
- Rupture means the adventitia got ruptured
