Module 6 - GI Flashcards
Appendicitis: Three most predictive sx
- Periumbilical or epigastric pain
- Migration of pain to RLQ
- Abdominal rigidity
Physical Exam for ____________:
1) Abdominal tenderness will be elicited with cough.
2) Painful spot can often be specified with one finger; Usually in RLQ between umbilicus and anterosuperior iliac spine
3) Signs of peritoneal irritation: guarding, rebound tenderness, positive obturator and psoas signs
4) Rectal exam may reveal tenderness or mass
5) Pelvic exam should be done in females
Suspected appendicitis
Describe obturator sign
Elicited by passive rotation of R leg with pt supine and R hip and knee flexed.
Describe psoas sign
Elicited by asking the supine patient to raise the straightened R leg against resistance by the practitioner.
Labs for suspected appendicitis:
CBC with diff for elevated WBC/neutrophils; serum beta Hcg to help rule out ectopic; C reactive protein- if normal after 24 hours of abdominal pain, suggests NOT appendicitis; Imaging if presentation is atypical - CT scan has high sensitivity & specificity
What do you do in the event appedicitis is suspected?
Immediately refer for surgical consult or send to ED.
Abdominal pain by region: Chest cavity Liver Gallbladder Stomach Bowel Right kidney
RUQ
Abdominal pain by region: Pancreas Left kidney Spleen Heart or chest cavity
LUQ
Abdominal pain by region: Appendix Bowel Right ureter pelvis
RLQ
Abdominal pain by region:
Bowel (diverticulitis)
Ureter
pelvis
LLQ
Obtain consult or refer GI disorders that present with BWAD. What is BWAD?
B - blood in stool
W- weight loss
A- Anemia
D- Dysphagia
Primary causes of constipation
Disordered colonic transport and pelvic floor or anorectal dysfunction
True/False
Secondary causes of constipation are related to medical and psychogenic conditions, medications, structural abnormalities, and lifestyle.
True
Hx for constipation should include :
- when the change in BM occurred
- # of stools per day & week
- last BM
- Need to strain?
- sensation of incomplete evacuation
- any episodes of fecal incontinence, diarrhea, abdominal pain, or blood, or pain with defacation
- systemic, neurologic or other related sx
- hx of assoc illnesses
- 24hr diet/fluid review
- complete medication review
What common meds can cause constipation?
anticholinergics, calcium channel blockers, diuretics, antacids
Diagnostic tests for constipation with abd. discomfort, nausea or vomiting? Why?
Abdominal x-ray or CT scan and CBC w/diff; to exclude obstruction, ileus, megacolon or volvulus
When is a colonoscopy or barium enema indicated with constipation?
With a recent change in bowels or the presence of abd. pain or rectal bleeding to evaluate for obstructive neoplasm.
What diagnostics for chronic constipation?
Stool sample for occult blood, TSH, CBC, CMP
True/False
Volvulus and obstruction require immediate surgical eval.
True
True/False
Ileus and pseudo-obstruction require immediate surgical eval.
False - can be medicallyy managed with NG suction and IV fluid
IBS presents with diarrhea, constipation or an alternating pattern of the two with ___________.
abdominal pain
How can IBS be differentiated from lactose intolerance?
2 week lactose free diet or hydrogen breath test to exclude lactose intolerance.
Rome criteria for IBS:
Abd. pain or discomfort with at least two of the following: (3)
Also must have one or more of the following on at seat 25% of occ.
- improvement with defacation
- onset assoc with change in freq of stool (< 3 bm/wk or > 3 bm/day)
- onset assoc with change in appearnace of stool (lumpy/hard, loose/watery)
- Abn frequency
- abn passage (straining)
- abn form (lumpy)
- bloating
- mucus in stool
- freq loose stools
At least 3 days/month for last 3 months with onset 6mos prior.
Tx for IBS
Education, reassurance, lifestyle and diet modifications. synthetic fiber
Triggers for IBS
dairy products, gas forming foods, artificial sweeteners, carbonated beverages, caffeine, and alcohol.
Pharmacotherapy for IBS:
Antispasmodics; antidiarrheal (immodium); anticonstipation (sythetic fiber); psychotropic (avoid tricyclics with constipation)
Tx for c diff diarrhea
flagyl tid for 10-14 days
Meaning of elevated AST and ALT ?
Hepatocellular necrosis or inflammation
A ratio of AST to ALT greater than 2 indicates _________ _______ ________
Alcoholic liver injury
Elevated alk phos indicates (3):
cholestasis, primary biliary cirrhosis, or infiltrative liver disease
What can an elevated alk phos mean in an adolescent?
growth spurt
What does elevated GGT indicate?
hepatobilliary disease
Diagnostics for GERD
Stool for occult blood x3; CBC with diff and EGD if indicated.
Tx for GERD
PPI x8wk followed by maintenance H2RA
Tx for travelers diarrhea?
Fluroquinolones cipro bid for 3-5days; e coli most likely
Tx for salmonella
usually deferred; if over 50 or infant; immunocompromised, sickle cell - then fluroquinolones and ceftriaxone
Tx for camplyobacter?
Macrolides
tx for shigella
cipro 500 q12 for 1-3 d
Risk factors for PUD?
H. pylori infection; NSAID use
Diagnostics for PUD
CBC; serum culture for H, pylori; urea breath test and fecal antigen test more accurate
Use of PPI can affect what test results?
urea breath test and fecal antigen test
Tx for PUD
2 wk trial of anti ulcer therapy. D/C Nsaid or cox2 inhibitors; if H. pylori - PPI with clarithromycin and amoxicillin or metronidazole for 10-14 days
What is Murphy’s sign? When is it seen?
Inability to take deep breath during palpation beneath the R costal margin; seen in cholecystitis
Gold standard test for pancreatitis?
helical contrast enhanced CT; serum amylase and lipase
Hep A: Route and Incubation
fecal/oral; 2-6wks
Hep A IgG
Past infection
Hep A IgM
Acute infection
Hep B route / incubation
blood/sex; 2-6months
