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Clin Specialties - EMed > Lecture 5 - GI > Flashcards

Lecture 5 - GI Flashcards

1
Q

Most gallbladder pathology start with…

A

gallstones

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2
Q

Who is at highest risk of getting gallstones?

A 
female
middle aged
overweight
caucasian 
estrogen exposure/multiple pregnancies 
5 Fs
female
fat
fair
fertile
forty
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3
Q

Cholagnitis

A

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)
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4
Q

Anatomy of the gallbladder and biliary tree

A

Gallbladder is attached to cystic duct

This cystic duct merges with the common hepatic duct to form common bile duct

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5
Q

What medications put you at risk of getting gallstones?

A

Ceftriaxone (rocephin)
octreotide
clofibrate

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6
Q

Besides the fat, forty, fertile, fair, female, what are other risk factors for gall bladder disease?

A

estrogen/progesterone replacement tx

rapid weight loss (bariatric surgery)

dyslipidemia (hypertriglyceridemia)

DM2/insulin resistance

Medications (ceftriaxone)

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7
Q

Lysolecithin

A

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

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8
Q

What are the sxs of acute cholecystitis?

A 
RUQ pain, +/- radiation to R shoulder 
pain is constant and severe 
pain is worse after consumption of fatty food 
N/V 
anorexia 
fever
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9
Q

What are the PE findings in cholecystitis?

A 
RUQ pain with voluntary and involuntary guarding 
\+ Murphys sign 
pt is lying still, movement worsens sxs 
fever
tachycardia
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10
Q

What labs do you order for a pt with acute cholecystitis?

A

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

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11
Q

What do we expect the radiologic (US) report to say for a pt with acute cholecystitis?

A

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)

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12
Q

If we suspect a pt has cholecystitis but the US does not come back with a clear answer, where do we go from there?

A

HIDA scan - bile ejection test

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13
Q

What is the treatment for acute cholecystitis?

A 
GI tract rest - NPO 
IV pain meds 
IV NS - hydration 
\+/- surgery 
ABX if elevated WBC or fever
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14
Q

Perforated viscus

A

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

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15
Q

What are the signs and sxs of perforated viscus?

A

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)

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16
Q

How do we dx perforated viscus?

A

plain films both supine and upright –look for free air
possible CT
heme 8 to look for leukocytosis

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17
Q

Free air under diaphragm

A

think perforated viscus

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18
Q

What is the treatment for perforated viscus?

A

surgery ASAP
supportive care until surgery
-O2, fluids, ABX

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19
Q

What causes acute appendicitis?

A

1) appendix becomes blocked by stool plug

2) bacterial or viral infection can cause ulceration of the mucosa –> inflammation or abscess

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20
Q

Who is more likely to get appendicitis?

A

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

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21
Q

What are the sxs of acute appendicitis?

A

diffuse or peri-umbilical pain that eventually localized to the RLQ
anorexia
N/V/D
low grade fever

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22
Q

How do ask a pt about anorexia?

A

“If i could get you your favorite food, would you be interested in eating it?”

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23
Q

What PE findings do you expect in a pt with acute appendicitis?

A

diffuse pain
McBurneys point tenderness
Rovsing sign
Psoas sign

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24
Q

McBurneys point

A

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

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25
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
26
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
27
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
28
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 ```
29
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)
30
What is the logical next step for a pregnant pt you suspect of appendicitis but the US was unable to locate the appendix?
surgery
31
What do you expect to see on CT for a pt with appendicitis?
fluid around the appendix or thickened appendix walls
32
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
33
Which age group is more common to get mesenteric ischemia?
>50 yo
34
What is the MC cause of mesenteric ischemia?
arterial emboli
35
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 ```
36
What are risk factors for mesenteric venous thrombus?
``` hypercoagulable state hypercholesterolemia PVD pancreatitis, diverticulitis, appendicitis trauma DM ```
37
How is mesenteric ischemia dx?
"pain out of proportion to exam" heme-positive stool elevate serum lactate CT is suggestive angiography is gold standard
38
What is the gold standard for dx mesenteric ischemia?
angiography
39
What is the treatment for mesenteric ischemia?
IV fluids immediately to try and improve flow of blood to mesentery immediate surgical consult --if the bowel had died it needs to be removed IV ABX to protect if there was perforation aggressive pain control if there is a known thrombus, start heparin
40
What are the most common causes of SBO?
small bowel obstruction ``` Adhesions from prior surgery (MC!) hernias tumors (think with that older pt who has never had surgery) strictures Crohn's disease ```
41
What are the signs and sxs of SBO?
small bowel obstruction ``` crampy abdominal pain inability to pass flatus or stool vomiting (esp. if vomiting stool) abdominal distention (late sign) if pain changes from crampy to constant --may be a sign of intestinal strangulation ```
42
What questions do you NEED to ask your pt that you suspect has a SBO?
prior abdominal surgery hx of malignancy or sxs suggestive of malignancy hx of crohns disease
43
What PE findings will there be for a pt with a SBO?
``` +/- surgical scar on abdomen abdominal distention (later sign) HIGH PITCHED BOWEL SOUNDS rigid abdomen (peritonitis) diffuse abdominal tenderness to light palpation ```
44
What is the workup for someone with a suspected SBO?
Xray - supine and upright - look for air/fluid levels - fluid under the diaphragm -- worried about perforation CR if xray is non-specific or if you suspect malignancy as underlying cause Heme 8 , coags, chemistries gastroccult any vomitus (looking for blood)
45
What is the treatment for SBO?
NG tube (esp if they are vomiting stool so you suction) NPO IV hydration +/- surgery some will resolve on their own after bowel rest and rehydration if no improvement in 12-24 hours --> surgery
46
Why is there a rise in acute pancreatitis in US?
d/t obesity strongly associated with alcoholism or gallbladder disease
47
Who is more likely to get acute pancreatitis?
M >W AA > all other races obese pts alcoholics pts with hx of gallbladder dz
48
What are the most common causes of acute pancreatitis?
biliary tract disease (~40%) | ETOH use and abuse (35%)
49
How do pts with acute pancreatitis present?
abrupt onset of epigastric pain described as "boring" and "going through my stomach to my back" pain starts intermittent but becomes constant and severe N/V improved pain with supine position
50
"Boring" and "going through my stomach to my back"
think acute pancreatitis
51
What do you expect to see on PE for a pt with acute pancreatitis?
``` abdominal tenderness epigastric guarding fever tachycardia hypotension pt appears in significant pain and/or toxic ```
52
What labs should be ordered for a pt with acute pancreatitis?
``` CBC, CMP, PT/PTT lipase (amylase) consider CRP if pt appears seriously ill, consider: -ABG -LDH ```
53
How is acute pancreatitis dx?
RUQ US if concerned for biliary cause CT for moderate to severe pancreatitis with a pancreatitis protocol (not just plain CT)
54
What is the treatment for acute pancreatitis?
IV access pain control NPO aggressive IVF close observation for hemodynamic collapse generally do NOT give ABX, even if pt is febrile admit
55
What is the prognosis for acute pancreatitis?
``` overal mortality 10-15% prognosis is determined with clinical scoring system: ranson glasgow apache 2 ```
56
Ranson Criteria
used to determine prognosis of acute pancreatitis criteria at time of admission to hospital and criteria over the first 2 days in the hospital score 0-2 = 1% mortality score 7-11 = 99% mortality
57
What is the leading cause of viral gastroenteritis in children and adults?
children: rotavirus adults: norovirus
58
How does a pt with viral gastroenteritis typically present?
first: vomiting second: diarrhea low grade fever decreased urine output inability to hold food down someone close sick in the last 24-72h
59
What PE findings are there for a pt with viral gastroenteritis?
``` look unwell, miserable (don't say sick) low grade fever mild tachycardia look for signs of dehydration mental status changes in elderly mild TTP in epigastrum ```
60
What is the treatment for viral gastroenteritis?
rehydration --ideally oral but IV can be used BRATY diet probiotics at home hospitalize if pt can't hold PO
61
What bacterial pathogens most commonly cause bacterial gastroenteritis?
salmonella shigella campylobacter
62
Who is at greater risk for bacterial gastroenteritis?
PPI users | undercook food and international travel are highly implicated
63
How do pts with bacterial gastroenteritis typically present?
first: vomiting second: diarrhea bacterial - level fever crampy abd pain others who ate the same thing are also sick exposure to undercooked food or recent international travel
64
What PE findings will you see for a pt with bacterial gastroenteritis?
``` look very unwell, miserable higher fever mild-moderate tachycardia look for signs of dehydration mental status change in elderly mild - moderate lower abdominal pain borborygmi (really loud stomach sounds) ```
65
What is the work up for bacterial gastroenteritis?
stool cultures and fecal leukocytes CBC CMP
66
What is the treatment for bacterial gastroenteritis?
``` rehydration (ideally orally) ABX (presumptive) diaper cream for their bottom probiotics at home BRATY diet hospitalize if pt is seriously dehydrated or cannot stop volume loss ```
67
GI bleed
high mortality
68
Anatomically what determines if something is upper or lower GI bleed?
upper: proximal to the ligament of Treitz lower: distal to the ligament of Treitz
69
What is a major cause of GI bleeds in elderly?
NOACs
70
Etiology of upper GI bleed
``` NSAID/ ASA use PUD/ H.pylori infection alcoholism causing gastritis, varices, cirrhosis gastric/duodenal cancer mallory weiss tear post procedural bleeding ```
71
What are the sings and sxs of upper GI bleed?
bright red blood on vomiting "coffee grounds emesis" Melena (black, tarry stool) lighteheadedness (late) signs of UGI bleed are only present once the bleed becomes super significant - tachycardia - pallor - orthostatic hypotension
72
When you suspect upper GI bleed, what questions must you be sure to ask?
``` medication use (anticoags and NSAIDs) ETOH use/abuse IVDU hepatitis hx hx of ulcers or bleed quantities of blood vomited ```
73
What PE findings are seen with pt who have upper GI bleed?
bruising/petechiae epigastric tenderness EVERYONE gets a rectal exam
74
What labs are done for a pt with upper GI bleed?
``` serial CBCs Hct/Hgb (do this multiple times because they could still be bleeding) INR/PT/PTT type and screen hemoccult/gastroccult testing gastric lavage via NG or OG tube metabolic panel ```
75
Who might get a false positive hemoccult/gastroccult?
``` recently ingested: PPIs vitamin C pills red meat cherry jello ```
76
What is the treatment for upper GI bleed?
FIRST THING: AT LEAST 2 LARGE BORE IVS (18g or larger) ``` immediate, aggressive fluid resuscitation IV PPI consider early transfusion FFP O2 via NC ```
77
Blackmore tube
used for bleeding varices --upper GI bleed compresses esophageal varices
78
Etiology of lower GI bleed
``` diverticulae that bleed angiodysplasia hemorrhoids NSAIDs IBD ```
79
What are the sxs of lower GI bleed?
BRBPR - bright red blood per rectum maroon stools +/- abd pain
80
What is the treatment for lower GI bleed?
AT LEAST TWO LARGE BORE IVS (18g or larger) immediate, aggressive fluid resuscitation O2 via NC consider early transfusion FFP eventually will need endoscopy
81
In adults, food gets stuck in 1 of three areas of physiologic narrowing in the esophagus, what are they?
upper esophageal sphincter level of the aortic arch diaphragmatic hiatus
82
What are the sxs of esophageal foreign body?
abrupt onset of dysphagia with inability to swallow saliva, often after eating meat neck tenderness sense of fullness or "something is stuck" often pt had attempted to induce vomiting to fix the problem
83
How do you dx esophageal foreign bodies?
plain films of neck, chest, abd: may show: radiopaque foreign body signs of esophageal perforation nothing (most foods are not radiopaque)
84
What is the treatment for esophageal impaction with food?
glucagon 1mg IV --may relax esophagus, facilitating passage of food bolus endoscope can be used to push food into the stomach gently
85
If disc batteries are ingested they have to be removed ASAP, why?
acid in GI tract can erode the battery and release toxic metals into pt and cause inflammation of esophagus can lead to peritonitis
86
Why is ODing on acetaminophen not an ideal way to commit suicide?
you wont die today | you will die in 18 months from liver failure
87
What are the different phases of acetaminophen OD?
``` phase 1 (0-24h): no sxs phase 2 (18-72h): RUQ pain, N/V, decreased urine output phase 3 (72-96h): N/V, abd pain, tender liver margin, jaundice, coagulopathy, hepatic encephalopathy phase 4 (96h-3w): if they survive, liver begins to regenerate ```
88
What is the treatment for acetaminophen OD?
N-acetylcysteine (NAC) IV
89
What is the antidote to opiates?
naloxone (narcan)
90
What is the antidote to benzos?
flumazenil
91
What is the antidote to tricyclines?
bicarbonate
92
What is the antidote to CCB?
calcium
93
What is the antidote to BB?
glucagon
94
What is the antidote to methanol?
ethanol
95
What is the antidote to digoxin?
digibind
96
What is the antidote to iron?
deferoxamine

Clin Specialties - EMed (11 decks)

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