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ECOS 3 Midterm > Left Abdomen > Flashcards

Left Abdomen Flashcards

1
Q

3 Primary causes of enlarged spleen

A

Passive engorgement with blood due to vascular pressure
•Examples: CHF, Cirrhosis, Portal hypertension, Thrombosis of Portal, Hepatic or Splenic Veins

–Increase in size due to hemolysis/sequestration
•Examples: Hemolytic anemias, spherocytosis

–Enlargement due to infiltration by cells or other material
•Examples: –Infection –hepatitis, Cytomegalovirus, Mononucleosis–Inflammation –Sarcoid, lupus

Splenomegaly is physical finding, not a disease

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2
Q

Splenomegaly symptoms

A

–Symptoms secondary to an enlarged spleen
•LUQ pain,early satiety, abdominal fullness or distention, pain referred to the chest or left shoulder

–may be asymptomatic

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3
Q

Splenomegaly ROS

A

–fever, sore throat –infectious cause
•Pharyngitis -especially in a young adult, suggests infectious mononucleosis.

–Weight loss –possible malignancy

–lymphadenopathy

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4
Q

Splenomegaly Past Medical Hx

A

–CHF, Cirrhosis/Ascites/liver failure
–Sickle cell, hemolytic anemias
–lupus, sarcoid

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5
Q

Splenomegaly Social Hx

A

–alcoholism, hepatitis, drug use

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6
Q

Splenomegaly Family Hx

A

–blood diseases
•Examples: Hemolytic anemia, sickle cell

–malignancy

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7
Q

Diagnostic Testing for splenomegaly

Lab?
Imaging?
Other?

A

•Depends on the patient’s clinical status and the possible reasons for the splenomegaly -driven by working DDX (suspected DX and life threats)

•Lab
–CBC with differential and peripheral blood smear
–Comprehensive metabolic panel (LFT’s + electrolytes)
–Serologies, mono test, blood cultures, PT/PTT/INR

•Imaging
–CXR, CT Abd& Pelvis with IV and oral contrast, Splenic US, MRI abdand pelvis

•Other
–biopsy (spleen, liver, lymph nodes)

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8
Q

Splenomegaly treatment

A

–Ranges from no treatment to splenectomy

  • Stabilize patient if necessary
  • Treat underlying cause
  • Always advise patients to refrain from sports and other activities with a high risk of splenic injury
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9
Q

What is intestinal ischemia?

A

(Mesenteric/small bowel and Colonic/large bowel)

caused by any process that reduces intestinal blood flow
–arterial occlusion, venous occlusion, or arterial vasospasm

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10
Q

Intestinal Ischemia - severity?

A

Wide range of symptom severity and presentation depending on degree and location of ischemia/infarction
–Similar to CAD, and Cerebrovascular disease, etc.

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11
Q

How do we name Intestinal Ischemia?

Small bowel?
Large bowel?

A

Named differently based on location of bowel ischemia

small bowel = Mesenteric Ischemia
large bowel =Colonic Ischemia

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12
Q

Risk factors for intestinal ischemia? (9)

A

•any condition that reduces perfusion to the intestine
•hypertension, diabetes, hyperlipidemia, smoking (CAD risk factors )
–Atheroscerosis, CAD, PAD
•Aorto-iliac surgery or instrumentation
•Hemodialysis
•Acquired and hereditary thrombotic conditions
–protein C, Protein S, Antiphospholipid antibody, etc.
•Shock
•Vasoconstrictivemedications
•MI/Cardiomyopathy, hypovolemia, inflammation/infection
•Old age
•Female gender

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13
Q

Acute Mesenterich ischemia symptoms

A

–Difficult to diagnose because sx’s are nonspecific; vague and variable
–Poorly localized abdominal pain, periumbilical
–+/-nausea, vomiting, diarrhea

–Acute(complete occlusion)
•Sudden onset of pain
•Patient appears severely ill
•Key historical finding: The abdpain is “out of proportion to the exam”. The patient may be screaming in pain, but the abdis soft without rebound or guarding.
•GI bleeding uncommon until late

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14
Q

Chronic Mesenteric ischemia symptoms

A

–Difficult to diagnose because sx’s are nonspecific; vague and variable
–Poorly localized abdominal pain, periumbilical
–+/-nausea, vomiting, diarrhea

–Chronic (non-occlusive)
•Intermittent postprandial abdominal pain, an aversion to eating, and unintentional weight loss

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15
Q

Acute Colonic ischemia symptoms

A

–Acute(complete occlusion)
•rapid onset of mild cramping abdominal pain and tenderness over the affected bowel, most often involving the left abdomen
•Patient does not appear severely ill
•Rectal bleeding or bloody diarrhea often present

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16
Q

Chronic Colonic ischemia symptoms

A

–Chronic (non-occlusive)
•recurrent abdominal pain, bloody diarrhea, weight loss from protein-losing enteropathy, recurrent bacteremia, persistent sepsis, or symptomatic colonic strictures

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17
Q

Colonic ischemia ROS

A

–Fever/chills, blood in the stool, nausea/vomiting, diarrhea

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18
Q

Intestinal Ischemia (sm & lg) past medical hx

A

–Atrial fibrillation, atherosclerosis, CAD, CHF, hypercoagulability,hxof prior embolic event (DVT, PE, CVA), Sickle Cell, Vasculitis, lupus

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19
Q

Intestinal Ischemia (sm & lg) social history

A

Smoking, cocaine, methamphetamine

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20
Q

Intestinal Ischemia (sm & lg) family hx

A

Hypercoagulability, DVT, PE

21
Q

medications that present risk factor for Intestinal Ischemia (sm & lg)

A

blood thinners, Birth control pills, migraine meds, digoxin, vasopressors

22
Q

Diagnostic Testing for Intestinal Ischemia (LAB)

A

Laboratory studies are nonspecific
–abnormal laboratory values may be helpful to increase suspicion but normal laboratory values do not exclude intestinal ischemia

•Order
–CBC, Comprehensive metabolic panel (electrolytes + LFT’s), PT/PTT/INR, lactic acid, D-Dimer, pregtest if pregnancy still possible, type and screen/cross if GI bleed

  • Leukocytosis, and metabolic acidosis (low bicarb), concerning for intestinal ischemia
  • Lactic acid elevation a late finding, concerning for bowel infarction
23
Q

Diagnostic Testing for Mesenteric Ischemia (Imaging)

A

Test of choice = CT angiogram of abdomen/pelvis (IV contrast only)

•Order only if high degree of suspicion for Mesenteric Ischemia
–Ct abd/pelvis with IV and oral contrast

•Order If less certain of diagnosis (most of the time)
–Arteriography may be needed if Ct angiogram is inconclusive
–Other less desirous imaging options

•MRI angiogram of abd/pelvis, Ultrasound of GI vasculature

24
Q

Diagnostic Testing for Colonic Ischemia (Imaging)

A

–Tests of choice = Colonoscopy/sigmoidoscopy

•Usually required to make diagnosis
–Ct abd/pelvis with IV and oral contrast

•Usually shows nonspecific colitis

25
Q

Intestinal ischemia treatment - general

A

–Initial supportive management: fluid resuscitation, hemodynamic monitoring and support, correction of electrolyte abnormalities, pain and nausea control
–Systemic anticoagulation under most circumstances ( may hold if GI bleed present)
–initiation of broad-spectrum antibiotics

26
Q

Intestinal ischemia treatment - acute or chronic

A

depends on the specific etiology (arterial occlusion or thrombosis, mesenteric venous thrombosis, and nonocclusivemesenteric ischemia)

–Options:arterialembolectomy, bypass, or stenting, arterial or venous thrombolysis, and intra-arterial vasodilator infusion

•Surgery required if intestinal infarction or perforationis suspected

27
Q

Risk Factors for IBD

A

Smoking—Smoking is a risk factor for Crohn disease but not for ulcerative colitis

Physical activity—Physical activity has been associated with a decrease in risk of Crohn disease, but not ulcerative colitis

Dietary factors—
–High intake of dietary fiber, particularly from fruit and cruciferous vegetables, has been associated with a decrease in risk of Crohn’s disease but not ulcerative colitis
–Fats –Increased dietary intake of total fat, animal fat, and polyunsaturated fatty acids has been correlated with an increased incidence of ulcerative colitis and Crohn’s disease

28
Q

Crohns Disease HPI

A

–Cardinal symptoms
•Crampyabdominal pain (RLQ if terminal ileum involved)
•chronic intermittent diarrhea (with or without gross bleeding), fatigue, and weight loss

  • –May present with signs and sx’s of intestinal obstruction (abdpain, intractable vomiting) if crohn’shas caused intestinal strictures*
  • –Perianal disease (fistulas, abcessesand fissures) in 1/3 of crohn’spatients*
29
Q

Crohns Disease ROS

A

–Extraintestinalmanifestations, such as iritis, arthritis, skin disorders, may occur in patients with IBD
–Intermittent low grade fever, intermittent diarrhea

30
Q

Diagnostic Testing for Crohn’s Disease (Lab)

A

Laboratory testing does not establish the diagnosis.
•Labs: CBC, CMP, UA, pregnancy test, Serum iron, vitamin D, and vitamin B12 levels, C-reactive protein, albumin–anemia, hypoalbuminemia, vitamin B12 deficiency, vitamin D deficiency often occur in patients with Crohn’s disease
CRP is elevated in the acute phase of IBD

•If diarrhea present then send stool for stool studies; –Enteric pathogens, culture and sensitivity, ova, and parasite fecal leukocytes, or fecal lactoferrin, and Clostridium difficile test

31
Q

Diagnostic Testing for Crohn’s Disease (Imaging)

A

•Colonoscopy including the terminal ileum with biopsies–Diagnostic test of choice –Definitive
–Endoscopic features include focal ulcerations adjacent to areas of normal appearing mucosa along with nodular mucosal changes that result in a cobblestone appearance
–Skip areas of involvement are typical with segments of normal-appearing bowel interrupted by large areas of disease.

  • Ct of Abd/pelvis with IV and oral contrast or MRI of the Abdomen and pelvis with contrast are comparable in sensitivity and specificity
  • Capsule Imaging
32
Q

Crohns Disease treatment

A

Acutely ill patients requiring inpatient hospitalization
–intravenous fluid and electrolyte replacement, intravenous broad spectrum antibiotics, nutritional assessment, and consultation with a gastrointestinal surgeon.

•Medications–5-aminosalicylates (Sulfasalazine)
–Corticosteroids (Prednisone, or methylprednisolone)
–Immunomodulators(azathioprine, 6-mercaptopurine,methotrexate)

–Biologic therapies
•Anti TNF Therapies, Anti-Integrins, Anti-IL-12/IL-23 antibodies

33
Q

Ulcerative Colitis Physical Exam –Things to Look For…

General
HEENT
Chest
Cardiac
Abd
Rectal
Extremities
Skin

A
  • General: signs of distress, abnormal vitals
  • HEENT: uveititis, iritis, aphthousulcers
  • Chest: Tacyhpnea
  • Cardiac: tachycardia
  • Abd: location and severity of abdpain, signs of peritonitis
  • Rectal: hematochezia, bloody diarrhea
  • Extremities: joint pain
  • Skin: pyoderma gangrenosum, erythema nodosum, pallor
34
Q

Diagnostic testing for UC

A

Laboratory –CBC, CMP, UA, pregnancy test
–Fecal occult blood

Imaging–Colonoscopy with biopsies is the gold standard for diagnosis of UC.
–Ct of Abd/pelvis with IV and oral contrast

35
Q

Treatment for UC

Mild?
Moderate?
Acute?

Curative?

A
  • Mild UC –Topical mesalamine(Asacol), an NSAID, given as a suppository
  • Moderate to severe UC –Immunomodulators(azathioprine, 6-mercaptopurine,methotrexate) –Biologics (Anti-TNF, Anti-Integrins,Anti-IL-12/IL-23 antibodies)
  • Acute severe UC–Hospitalization–Corticosteroids IV, Anti-TNF or cyclosporine

Total Colectomy is curative

36
Q

Diverticulitis symptoms

A

–Abdominal pain is the most common symptom
•LLQ (85% of the time)
•Abdpain is usually constant and is often present for several days prior to presentation
•Approximately 50 percent of patients have had one or more prior episodes of similar pain

–Nausea and vomiting
•reported in 20 to 62 percent of patients

–Low grade fever is often present
–constipation reported in approximately 50 percent of patients
–diarrhea in 25 to 35 percent of patients.
–Hematochezia is rare
–Approximately 10 to 15 percent of patients have urinary urgency, frequency, or dysuria

37
Q

Diverticulitis hx
social?
Family?
Meds?

A

Shx–Advanced age, Smoking, High dietary intake of red meat, low dietary fiber, lack of vigorous physical activity, BMI (≥25 kg/m2)

  • Fhx–Uncertain if genetic predisposition at this time
  • Medications–Several medications are associated with an increased risk of diverticulitis and diverticular bleeding including nonsteroidal antiinflamatorydrugs, steroids, and opiates
38
Q

Diagnostic Testing for Diverticulitis

A
  • Laboratory –Lab tests are not sensitive or specific for diverticulitis –CBC, CMP, UA, pregnancy test
  • Leukocytosis would support the diagnosis
  • Imaging–Ct of Abd/pelvis with IV and oral contrast has a high sensitivity and specificity for acute diverticulitis and can exclude other causes of abdominal pain.
39
Q

Diverticulitis outpation treatment

A

Outpatient management
–Oral antibiotics and close follow up
Augmentin or (Flouroquinoloneor Bactrim + metronidazole)

40
Q

Diverticulitis Inpatient treatment

A

Inpatient management

–Supportive care (if indicated)
•fluid resuscitation, hemodynamic monitoring and support, correction of electrolyte abnormalities, pain and nausea control

–IV antibiotics
•Ciprofloxacin (a fluoroquinolone) + flagyl(metronidazole)

–Surgery
•may be required for severe disease, perforation or abscess

41
Q

Colon Cancer HPI

A

–hematochezia or melena
–abdominal pain
–otherwise unexplained iron deficiency anemia
–a change in bowel habits
•constipation

–Less common presenting symptoms include
•abdominal distention, and/or nausea and vomiting, which may be indicators of obstruction

42
Q

Risk Factors for Colon Cancer

A
  • Advanced age
  • male gender
  • smoking
  • a family history of colorectal cancer
  • inflammatory bowel disease (especiallyUlcerative Colitis)
43
Q

Colon Cancer past medical hx

A

Colorectal cancer, inflammatory bowel disease, diabetes, history of abdominal irradiation, acromegaly, renal transplant

44
Q

colon cancer social hx

A

obesity, tobacco use, excess consumption of alcohol, excess consumption of processed meat, and lack of physical activity

45
Q

colon cancer medications hx (risk factors)

A

protective effect of aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) on the development of colonic adenomas and cancer

46
Q

Colon cancer physical exam - what to look for

A

•Asymptomatic
•Abdominal pain or mass
•Abdominal distention
•Rectal exam
–Positive fecal occult blood
–Mass
•Anemia

47
Q

Diagnostic testing for colon cancer

A

•Screening–Fecal Occult Blood
–fecal immunochemical testing (FIT)
–Colonoscopy

•Laboratory –CBC, CMP, UA, pregnancy test
–Fecal occult blood

•Imaging–Ct of Abd/pelvis with IV and oral contrast
–Colonoscopy : The gold standard
-allows for detection of polyps and malignant lesions as well as biopsy of suspicious lesions.

48
Q

Colon cancer treatment

A

Treatment and management depends on the stage of the cancer

•Surgical resection
–the only curative modality for localized colon cancer
–Most patients who present with metastatic disease are not surgical candidates

  • Chemotherapy
  • Radiation
  • Combination of the above

ECOS 3 Midterm (14 decks)

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