Lecture 5 - GI Flashcards
Most gallbladder pathology start with…
gallstones
Who is at highest risk of getting gallstones?
female middle aged overweight caucasian estrogen exposure/multiple pregnancies
5 Fs female fat fair fertile forty
Cholagnitis
ascending
bascially a person who look like they have cholecystitis but they look way worse than expected
septic
they are going to the ICU +/- OR to remove the gallbladder
- ABX
- pressers (they’re BP is typically very low)
Anatomy of the gallbladder and biliary tree
Gallbladder is attached to cystic duct
This cystic duct merges with the common hepatic duct to form common bile duct
What medications put you at risk of getting gallstones?
Ceftriaxone (rocephin)
octreotide
clofibrate
Besides the fat, forty, fertile, fair, female, what are other risk factors for gall bladder disease?
estrogen/progesterone replacement tx
rapid weight loss (bariatric surgery)
dyslipidemia (hypertriglyceridemia)
DM2/insulin resistance
Medications (ceftriaxone)
Lysolecithin
a byproduct of lecithin
lecithin is normally present in bile
if there is gallbladder trauma, lysolecithin is release and results in inflammation and wall thickening —> cholecystitis
What are the sxs of acute cholecystitis?
RUQ pain, +/- radiation to R shoulder pain is constant and severe pain is worse after consumption of fatty food N/V anorexia fever
What are the PE findings in cholecystitis?
RUQ pain with voluntary and involuntary guarding \+ Murphys sign pt is lying still, movement worsens sxs fever tachycardia
What labs do you order for a pt with acute cholecystitis?
CBC
CMP
Lipase (if you are considering pancreatitis)
US –pt should not have eaten before this US because we want the bile to be in the gallbladder
What do we expect the radiologic (US) report to say for a pt with acute cholecystitis?
stones
thickness of gallbladder wall
+ Sonographic Murphys sign (the radiologist will take the probe and directly place it over the gallbladder and have the pt inhale)
If we suspect a pt has cholecystitis but the US does not come back with a clear answer, where do we go from there?
HIDA scan - bile ejection test
What is the treatment for acute cholecystitis?
GI tract rest - NPO IV pain meds IV NS - hydration \+/- surgery ABX if elevated WBC or fever
Perforated viscus
perforation of any abdominal organ
dangerous because bacteria are introduced into peritoneal space with no mechanism for drainage
may be caused by trauma, infection, instrumentation, obstruction
will lead to sepsis if untreated
What are the signs and sxs of perforated viscus?
may feel abrupt onset of pain or abrupt relief of pre-existing pain at the time of perforation
may have fever/hypotension if perforation occured a while ago
may have rigid abdomen (this is a sign of peritonitis –BAD sign, these pts are DYING)
How do we dx perforated viscus?
plain films both supine and upright –look for free air
possible CT
heme 8 to look for leukocytosis
Free air under diaphragm
think perforated viscus
What is the treatment for perforated viscus?
surgery ASAP
supportive care until surgery
-O2, fluids, ABX
What causes acute appendicitis?
1) appendix becomes blocked by stool plug
2) bacterial or viral infection can cause ulceration of the mucosa –> inflammation or abscess
Who is more likely to get appendicitis?
teens and young adults
body/men until age 30 –> then M = W
perforation (and mortality) is more common in people <18 and >50 d/t delay in dx
What are the sxs of acute appendicitis?
diffuse or peri-umbilical pain that eventually localized to the RLQ
anorexia
N/V/D
low grade fever
How do ask a pt about anorexia?
“If i could get you your favorite food, would you be interested in eating it?”
What PE findings do you expect in a pt with acute appendicitis?
diffuse pain
McBurneys point tenderness
Rovsing sign
Psoas sign
McBurneys point
seen in appendicitis
1/3 the distance between the right anterior superior iliac spine and the umbilicus
this one is ideal to do last because all the other ones will give you a sense of how tender this area will be –risk of rupturing the appendix if you palpate too hard
Rovsing’s sign
seen in appendicitis
pain in RLQ with deep plalpation in the LLQ
d/t peritoneal irritation at the site of the appendix
good to perform this before you exam RLQ
Psoas sign
seen with appendicitis
pain on passive extension of the right thigh
pt lies on left side
examiner extends pts right thigh while applying counter resistance to the right hip
Obturator sign
seen with appendicitis
pain on passive internal rotation of the flexed thigh.
examiner moves lower leg laterally while applying resistance to the lateral side of the knee resulting in internal rotation of the femur
What labs do you order for a pt with acute appendicitis?
CBC CMP wet prep in women to r/o pelvic infection UA to rule out UTI urine HCG in women
What is the gold standard to dx acute appendicitis?
CT scan with oral and IV contrast
RLQ US is helpful for pts who can not get CT (like pregnant pts or pts with renal failure or allergy to contrast)
US is only useful if the appendix is definitively visualized and measured (often times the US is unable to see the appendix – not useful)
What is the logical next step for a pregnant pt you suspect of appendicitis but the US was unable to locate the appendix?
surgery
What do you expect to see on CT for a pt with appendicitis?
fluid around the appendix or thickened appendix walls
Mesenteric ischemia
like a stroke or MI of the intestines
this is often missed. Has 70-90% mortality! Always keep this in the back of your mind.
“pain out of proportion to exam”
primarily pts >50yo
arterial emboli (MC)
subacute presentation with post-prandial abdominal pain
Which age group is more common to get mesenteric ischemia?
> 50 yo
What is the MC cause of mesenteric ischemia?
arterial emboli
What are risk factors for mesenteric arterial embolism?
post-myocardial infarction mural thrombi CHF PVD (peripheral vascular disease) chronic atrial fibrillation aortic aneurysms or dissections coronary angiography
What are risk factors for mesenteric venous thrombus?
hypercoagulable state hypercholesterolemia PVD pancreatitis, diverticulitis, appendicitis trauma DM
How is mesenteric ischemia dx?
“pain out of proportion to exam”
heme-positive stool
elevate serum lactate
CT is suggestive
angiography is gold standard
What is the gold standard for dx mesenteric ischemia?
angiography
