MDT Upper GI 2 Flashcards
1
Q
What is diverticula/diverticulum?
A
Sac-like protrusion of the colonic wall
2
Q
What is Diverticulosis?
A
- Defined by the presence of diverticula
- May be asymptomatic or symptomatic
3
Q
What is diverticular bleeding?
A
Characterized by painless hematochezia due to segmental weakness of the vasa recta associated with a diverticulum
4
Q
How is diverticulitis defined?
A
Inflammation of a diverticulum
5
Q
Symptoms of diverticulosis/diverticulitis?
A
- Localized inflammation or infection report mild to moderate aching in LLQ
- Constipation or loose stools
- Nausea/vomiting
- Low grade fever
- LLQ tenderness
- Possible palpable mass
- Stool occult common, hematochezia uncommon
- Mild to moderate leukocytosis
6
Q
Labs for diverticulosis/diverticulitis?
A
CBC w/ Dif
Occult blood
7
Q
Rad for diverticulosis/diverticulitis?
A
- Colonoscopy after resolution of clinical symptoms
8
Q
Treatment for mild symptoms of diverticulosis/diverticulitis?
A
- Clear liquid diet and broad spectrum oral antibiotics
- Amoxicillin and Clavulanate (Augmentin) or Metronidazole
AND - Ciprofloxacin or Trimethoprim-sulfamethoxazole (Bactrim)
9
Q
When do patients require hospitalization for diverticulosis/diverticulitis?
A
- Fever
- Increased pain
- Inability to tolerate oral fluids
10
Q
Treatment of severe diverticulitis (high fever, leukocytosis, peritoneal signs), immunosuppressed, or elderly?
A
- Acute hospitalization
- NPO
- IV fluids
- If ileus present, NG tube
- IV antibiotics
11
Q
Diverticulitis recurs in how many patients and warrant want?
A
- 10-30%
- Warrants elective surgical resection
12
Q
Disposition diverticulosis/diverticulitis?
A
MEDEVAC
13
Q
General considerations for appendicitis?
A
- Most common abdominal surgical emergency
- most common between 20-35
- Common between 10-35
14
Q
Why does appendicitis typically manifest?
A
Some sort of blockage of the lumen of the appendix
15
Q
The majority of lumen blockages in appendicitis are due to?
A
- Fecalith
- Immune response/expansion of lymph tissue (viral infections or vaccinations)
- Neoplasms
16
Q
Presentation of appendicitis?
A
- Gradual onset RLQ pain
- Post exams
- RLQ pain during bearing down/coughing
17
Q
Atypical symptoms of appendicitis?
A
- Pain in flank
- Lower back pain
- Groin pain
- Tenesmus
- Non-specific lower abdominal pain
18
Q
Gold standard for diagnosis of appendicitis?
A
CT scan of the abdomen
19
Q
Labs for appendicitis?
A
CBC
Fecal Occult
UA
20
Q
Antibiotic treatment of appendicitis?
A
- Ampicillin-sulfabactam
- Ertapenem
21
Q
What are the two types of gallstones?
A
- Cholesterol gallstones (most common)
- Pigmented gallstones
22
Q
Flow of bile
A
- Created in liver
- Stored in gallbladder
- Ejected into cystic duct
- Travels to common bile duct
- Flows into duodenum
- Works in duodenum to emulsify fats
23
Q
What does the gallbladder do for bile?
A
- Acts as a reservoir for bile
- Stores excess bile
24
Q
Two main components of bile?
A
- Bile salts
- Cholesterol and bilirubin
25
Common situations that cause an increase in cholesterol in circulation resulting in gallstones?
- Increased estrogen in pregnancy
- Increased total circulating cholesterol due to:
* poor diet
* rapid weight loss
* fatty acids
26
How are pigmented gallstones formed?
Formed by the precipitation of bilirubin( a metabolite of hemoglobin)
27
How do precipitates (stones) form?
If the amount of cholesterol or bilirubin exceeds the among of bile salts
28
What are the common disease processes when precipitates occlude ducts within the biliary tract
- Asymptomatic Cholelithiasis
- Biliary colic
- Cholecystitis
- Choledocholithiasis
- Cholangitis
29
What does Asymptomatic Cholelithiasis refer to?
A condition in which a Pt has gallstones present but has not had any Sx's
30
What does Biliary colic refer to?
Situation in which gallstones have formed in the Pt's gallbladder and intermittently obstruct the lumen of the cystic duct
31
Signs/symptoms of biliary colic?
- Sx's last less than 6 hours
| - No S/Sx of inflammatory process
32
What is Cholecystitis?
Inflammation of the gallbladder
33
Signs/symptoms of cholecystitis?
- Sx's must be present for over 6 hours
| - Have S/Sx's of inflammatory process (possible fever)
34
What is Choledocholithiasis?
Inflammation of the gallbladder caused by obstruction of the common bile duct
35
Signs/symptoms of Choledocholithiasis?
- Have S/Sx's of inflammatory process (possible fever)
- Increased conjugated bilirubin
- May have jaundice
- Impossible to differentiate between cholecystitis and choledocholithiasis
36
What is Cholangitis?
Bacterial infection of the biliary tract
- Believed to be caused due to an ascending infection into the biliary tract from the duodenum
- Pt tends to be very sick
37
Signs/Symptoms of Cholangitis?
- Same as Choledocholithiasis
- Also Charcot's Triad:
* RUQ pain
* Fever
* Jaundice
38
Presentation of biliary colic?
- Acute onset of intermittent, sharp, RUQ pain
| - Precipitated by meals
39
Treatment/disposition of biliary colic?
- Change in diet
- Close monitoring and strict return precautions
- Sx usually self limiting
40
What is Acalculous cholecystitis?
No radiological evidence of gallstones in gallbladder or biliary tract
- Have had major surgery within past 2-4 weeks
- Are NPO
41
Cholecystitis secondary to viral infection may be caused by what?
AIDS
42
6 F's of cholecystitis?
```
Fat
Fertile
40
Female
Flatulence
Fever
```
43
Presentation of cholecystitis?
- S/Sx consistent with obstruction
- Sudden onset RUQ pain following high fat meal
- + murphy's sign
44
Diagnosis cholecystitis?
```
CBC
LFT
Lipase
Bilirubin
RUQ Ultrasound (gold standard)
```
45
Treatment and disposition of cholecystitis/choledocholithiasis?
- Cholecystectomy is mainstay
- Antibiotics
- NPO
- MEDEVAC
46
Mild to moderate cholecystitis/choledocholithiasis antibiotics?
Ertapenem
| Ceftriaxone
47
Severe cholecystitis/choledocholithiasis antibiotics?
Piperacillin-tazobactam and metronidazole
48
Presentation of choledocholithiasis?
- Same as cholecystitis
- 6 F's
- May have jaundice
49
Radiology/imaging for choledocholithiasis?
- RUQ Ultrasound (gold standard)
| - ERCP
50
Disposition of Cholangitis?
- Diagnostic work up and management same as cholecystitis
- Pt's tend to be much more ill and require fluid resuscitation and close monitoring
- MEDEVAC
51
What is pancreatitis
Inflammation in the pancreas
| - Sensitive structure that is crucial to the regulation of blood sugars and digestion of nutrients
52
Most common causes of pancreatitis?
- Alcohol
- Gallstones
- Other
* ERCP, Trauma, hyperlipidemia, infections, certain drugs
53
Presentation of Pt pancreatitis?
- May have Hx of cholelithiasis and/or cholecystitis treated without surgery
- Hx of alcoholism
- May have described having similar episodes
54
Symptoms of pancreatitis?
- Abrupt onset epigastric abdominal pain
- Steady, boring, severe abdominal pain worse with walking/lying
- Pt's describe feeling of relief with sitting upright and leaning forward
- Pain typically radiates to the back
- Mild jaundice common
- Nausea/vomiting
- Weakness, fever, anxiety
- Possible upper abdominal mass
55
Gold standard of diagnosis of pancreatitis?
Serum lipase for lab
| CT Scan for rads
56
Management/Treatment of pancreatitis?
- Pt's tend to be very sick and require constant monitoring
- NPO
- Aggressive fluid resuscitation (gold standard)
- Ileus (moderate to severe pain)
- Abdominal distension
- Vomiting (consider NG Tube)
57
Hallmark of therapy for Pancreatitis?
- Fluid resuscitation
- Early resuscitation shown to reduce frequency of Systemic Inflammatory Response Syndrome (SIRS)
- LR preferred over NS
- 5-10ml/kg/hr initially
ICU monitoring required in severe patients where aggressive hydration needed
58
Pain Control for pancreatitis?
Ketorolac
Hydrocodone
Morphine
59
Disposition of pancreatitis?
Hx of pancreatitis DQ for submarine duty
| MEDEVAC
60
Hasselbach's triangle for inguinal hernia?
- Inferior epigastric vessels (superior border)
- Lateral aspect of rectus abdominas (medial border)
- Inguinal ligament (inferior border)
61
What is a hernia?
Defined as a protrusion of any body part through a cavity.
- Can be internal or external
- Types:
* inguinal, femoral, hiatal, umbilical (most common)
* Obturator, lumbar (less common)
62
What accounts for approx 75-80% of all hernias?
Inguinal
63
What are direct hernias?
Abdominal contents herniate directly through Hasselbach's triangle
64
What are indirect hernias?
Abdominal contents herniate through inguinal canal
65
Indirect hernia facts?
- Most common R>L
| - Frequently incarcerate and strangulate
66
Direct hernia facts?
- Due to muscular weakness in Hasselbach's triangle
- Acquired defects
- Occur predominately in adults
67
Typical congenital hernias (umbilical hernia)?
- Outy belly button
- Increased prevalence in African-Americans
- In children, majority resolve by 5
68
Presentation of hernias?
- All hernias have ability to present as small bowel obstruction
- Bulging mass at site of hernia
- Direct: Lower anterior mass
- Indirect: Scrotal mass
- Umbilical: Outy belly button
- Mass may or may not reduce spontaneously
- Variable amounts of pain at site of mass
69
Presence of incarcerated hernias?
- May have bruising or overlying redness at location of hernia
- Present with tachycardia and +/- fever with extreme pain with palpation
70
Pt may be toxic if what happens to a hernia?
Strangulation?
71
Unrelieved strangulation of a hernia may lead to?
- Perforation
- Abscess formation
- Peritonitis
- Septic shock
72
Management of incarcerated hernias?
- Require immediate attention
- If there is a reliable Hx of incarceration recently ( within 24 hours), an attempt may be made to reduce hernia
- Do not attempt reduction if there is any question of duration
- Surgical fixation for incarcerated hernia that cannot be manually manipulated
73
What to do if strangulation is suspected or shock is present?
- Broad-spectrum antibiotics (ertapenum)
| - Fluid resuscitation
74
Closed passive reduction technique?
- Morphine for pain
- Diazapam for muscle relaxation
- Pt in supine trendelenburg position
75
Closed active reduction technique?
- Only if passive ineffective
- Place one hand to guide neck of hernia sack into peritoneal cavity
- Use other hand to provide gentle and steady compression over hernia
76
Disposition of Hernia?
- Acutely irreducible incarcerated hernia: MEDEVAC for immediate surgical repair
- Adult Pt's with reducible hernias: Refer to Gen surg, avoid situations that increase intra-abdominal pressure
77
What may Pt's who do need operative care be fitted with?
Trusses
