Lecture 15 - Right Abdomen Flashcards
What is the presentation for right abdominal pathology?
Nausea, vomiting, abdominal pain (colicky - crampy intermittent pain, constant, increasing)
A pt presenting with hepatitis A would present with a history including what?
Anorexia, nausea, vomiting, malaise, abdominal pain (mild and constant, mid-epigastric to RUQ), upper respiratory sx
Worse in adults than children
What would be the findings on the physical exam in a pt with hepatitis A?
Fever, enlarged liver (50% of cases), splenomegaly (15% of cases), jaundice (onset of jaundice and resolution of fever, elevated pulse coincidence)
Cervical adenopathy
A pt presenting with hepatitis B would present with a history including what?
Asymptomatic liver failure, anorexia, nausea, vomiting, malaise, abdominal pain (constant, mid-epigastric to RUQ)
What would the findings be on a physical exam for a pt with hepatitis B?
Low grade fever, enlarged liver, jaundice (onset of jaundice and resolution of fever, elevated pulse coincide)
Last 2-3 weeks
What would the history be for a pt with hepatitis C?
Mild usually asymptomatic
Anorexia, nausea, vomiting, malaise, abdominal pain (constant, mid-epigastric to RUQ)
What would the PE findings be for a pt with hepatitis C?
Mild usually asymptomatic
Fever, enlarged liver, jaundice
What is cholelithiasis?
Gall stones in the gallbladder
US to find
May be asymptomatic
May cause cholecystokinin due to wall irritation
Stones may be forced out of the gallbladder
What is acute cholecystitis?
90% associated with stones and may infectious
Inflammation proximal to the stone
Colicky abdominal pain (associated with fatty or spicy meal)
Nausea, vomiting (some relief), guarding, rebound tenderness
Murphy sign (pt unable to inhale due to pain while RUQ palpated)
May cause compression of right hepatic duct (associated with jaundice)
What is choledocholithiasis?
Stone in the common bile duct
Usually from gallbladder (may spontaneously come from liver)
2x risk with juxtapapillary duodenal diverticulum
What is charcot’s triad?
Frequent recurring attacks, severe, last for hours
Chills and fever associated with pain
Jaundice with abdominal pain
If Charcot’s triad worsens what will occur?
Reynolds Pentad which is Charcot triad + hypotension and mental status changes
What is IBS?
Functional bowel disorder with abd pain and alterations in bowel habits
A pt with IBS would present with a history including what?
Starts in late teens/early 20s
2016 ROME criteria (2/3) including abdominal pain 1. Related to defecation, 2. Associated with change in stool frequency, 3. Associated with change in form or appearance of stool
Abdominal pain >1wk
Negative evaluation of organic disease
Crampy/intermittent lower abdominal pain
Not at night or affecting sleep
What would the PE findings be for a pt with IBS?
Diffuse abdominal tenderness
No rebound, no guarding, no specific tests (McBurney, Murphy, Lloyd)
Hyper/hypoactive bowel sounds
What is the pathogenesis for IBS?
Abnormal motility
Intestinal inflammation
Visceral hypersensitivity
Psychosocial abnormalities
What is the abnormal motility associated with IBS?
Abnormal myoelectrical and motor abnormalities
Describe the intestinal inflammation in IBS
Diet, meds (esp Abx), infections change gut permeability
Changes motility
Changes hypersensitivity
Gastroenteritis —> 10% chance of developing IBS in the next year
Describe the visceral hypersensitivity associated with IBS
Lower visceral pain threshold
Report pain at lower volumes of gas insufflation
Describe the psychosocial abnormalities in pts with IBS
> 50% with IBS have underlying depression, anxiety or somatization
Changes how pts perceive/react to illness
Chronic stress alters motility and affects central and spinal perception of visceral afferent sensation
What would be in the history for appendicitis?
Periumbilical pain —> 12 hours later migrates to RLQ pain
Nausea and 1-2 episodes of vomiting — starts after pain
Sense of constipation
Low grade fever (high fever/chills - not appendicitis or perforated)
What findings would be present on the PE for appendicitis?
Rebound tenderness Guarding Rovsing sign Psoas sign Obturator sign
What are some atypical presentations for appendicitis?
Pregnancy —> uterine displacement of appendix moves pain superiorly (possible RUQ pain)
Elderly —> diagnosed layer due to vague or mild sx
Retrocecal appendicitis —> less pain and poorly localized, may be left sided, may be flank pain
Pelvic appendicitis —> pelvic pain, urge to urinate/defecate, tenderness on rectal/pelvic examination
What lab results are seen with hepatitis A?
WBC normal to low
Mild proteinuria
Bilirubinuria (proceeds to jaundice)
Very elevated ALT/AST leading to elevated bilirubin and alkaline phosphatase
What are the complications associated with hepatitis A?
Acute cholecystitis, acute kidney injury, arthritis, vasculitis, acute pancreatitis, aplastic anemia
What is the treatment for hepatitis A?
Bed rest, IV fluids (if dehydrated), avoid strenuous physical activity, avoid alcohol, avoid hepatotoxic agents, steroids no help
What are some differential diagnoses for hepatitis A?
Hepatitis B, hep C
Mono, CMV, HSV, middle easter respiratory syndrome
Influenza, Ebola, spirochetal infection, rickettsial infection
What would the lab results be for Hepatitis B?
WBC normal to low
Mild proteinuria
Bilirubinuria (proceeds jaundice)
Very elevated ALT/AST leading to elevated bilirubin and alkaline phosphatase (higher than hep A)
Elevated prothrombin time associated with increased mortality
What complications are associated with hepatitis B?
40% of chronic hep B develop cirrhosis
Hepatitis D co-infection worsens prognosis
What is the treatment for hep B?
Bed rest IV fluids if dehydrated) Avoid strenuous physical activity Avoid alcohol Avoid hepatotoxic agents Antivirals if liver failure or reactivating of chronic dz Recover in 3-6 months
What are some differential diagnoses for hep B?
Hep A or C
Mono, HSV, middle eastern respiratory syndrome
Influenza, Ebola, spirochetal infection, rickettsial infection
What labs should be performed for hep C?
Enzyme immunoassay
What are the complications associated with hep C?
Membranoproliferative glomerulonephritis Lichen planus Autoimmune thyroiditis Lymphocytic sialadenitis Idiopathic pulmonary fibrosis Sporadic porphyria cutaneous tarda Monoclonal gammopathies 20-30% increased risk of non HL Increased risk of end stage renal dz Hepatic steatosis
What is the treatment for hep C?
6 week course of ledipasvir and sofosbuvir
What is the prognosis for hep C?
Acute disease becomes chronic 85% of the time
30% of chronic hep C leads to cirrhosis
3-5% of hep C associated with cirrhosis leads to hepatocellular carcinoma
What is the treatment for asymptomatic cholelithiasis?
Dietary change —> low carb, Mediterranean, high fiber
Statin use (reduces cholecystectomy in women)
Increase exercise
NSAIDs
Ursodeoycholic acid (2 years)
What is the treatment for symptomatic cholelithiasis?
Laparoscopic cholecystectomy
What are the lab findings for acute cholecystitis?
Get US
Hepatic iminodiacetic acid scan (HIDA) - obstructed duct
WBC 12-15k
Serum bilirubin 1-4mg/dl (normal 0.2-1.2)
Elevated ALT up to 300 (normal 7-56)
Elevated alkaline phosphatase
Amylase moderately elevated (normal 23-85)
What is the treatment for acute cholecystitis?
NPO
IV alimentation
Analgesics
IV abx (2nd/3rd generation cephalosporin or metronidazole)
Cholecystectomy <24 hours (decreased cost, length of stay, greater pt satisfaction)
What are some DDx for acute cholecystitis?
Perforated peptic ulcer, acute pancreatitis, high lying appendicitis, liver abscess, hepatitis, right pneumonia, MI, cancer or diverticuli of hepatic flexure, hepatocellular jaundice, neoplasm
What labs should be obtained for choledocholithiasis?
Liver function tests >1000
Elevated bilirubin >1.8
Bilirubinuria (brown urine)
Secondary pancreatitis (increased amylase)
Elevated prothrombin time (PT)
Lipase 3x normal
Imagining —-> US (bile duct >6mm), CT, HIDA scan
What is the treatment for choledocholithiasis?
Endoscopic retrograde cholangio-pancreatography (ERCP)
-Endoscopic sphincterectomy and remove stones
72 hours layer perform laparoscopic cholecystectomy
What are the labs for IBS?
According to the American GI association guidelines
CBC for anemia
Fecal calprotectin (inflammatory bowel disease)
Serologic testing for celiac dz (TG IgA)
Stool specimen if likelihood fo parasites (daycare workers, foreign travelers, campers)
No routine sigmoid or colonoscopy (if no improvement with treatment or age >50)
What are the complications of IBS?
None known
What are some DDx for IBS?
Colonic neoplasia, IBD, bile acid diarrhea, hyper/hypothyroidism, parasites, malabsorption, carcinoid, gynecological issues, depression, panic disorder, anxiety
What is Tx for IBS?
Reassurance, education, support
Avoid FODMAPs
Medication
Psychological treatment
What is FODMAPs?
Fermentable oligo-di-mono-saccharides and polyols
Fructose, lactose, fructans (garlic, onion, asparagus, leeks)
Wheat, sorbitol (stone fruits), raffinose (beans)
Avoid for 2-4 weeks —> 50-60% less abdominal pain/bloating
What fraction of IBS pts respond to education, support and dietary modifications?
2/3
What’s the work up for appendicitis?
CBC (mild leukocytosis and neutrophilia)
Microscopic hematuria/pyuria - 25%
Imaging
-CT abd/pelvis with and without contrast
-US especially in peds pts (less radiation)
What are the complications of appendicitis?
Perforation (20%)
-suspect after 36 hours of sx, abscess, free fluid (leads to toxicity/sepsis)
Clinical signs of peroration: high fever, diffuse tenderness, possible palpable mass, elevated WBC
Thrombophlebitis of the portal system (add jaundice and bacteremia to above)
What are some DDx for appendicitis?
Gastroenteritis Gynecological (salpingitis, ovarian abscess, ovarian torsion, mittlesmertz, ectopic pregnancy) Ureteral colic Pyelonephritis Diverticulitis Carcinoid of appendicitis Perforated colon cancer Crohn’s ileitis Perforated peptic ulcer Cholecystitis Mesenteric Adventitis Meckel’s diverticulitis
What is the treatment for appendicitis?
Surgery (laparoscopic preferred, laparotomy)
80-90% uncomplicated appendicitis could be treated by 7 days of Abx
-recurrence 20-35% in 1 year
-non perforated
-surgical contraindications
-strong aversion to surgery
