Part 21 Flashcards
Most common type of distributive shock
-Sepsis (sepsis is the next step of SIRS -systemic inflammatory response phenomenon)
Nonhemorrhagic hypovolemic shock is most often due to ___ losses
Gastrointestinal
Third space losses
A type of nonhemorrhagic hypovolemic shock where fluid in a potential space sees filling due to capillary leakage (think peritoneum or pleura) and this depletes intravascular volume overall
Massive transfusion protocol
1:1:1 of packed RBC (first choice O neg, Op pos and type specific are alternatives), plasma, and platelets
Neurogenic shock pathophysiology
Dilation of the arterial and some degree of the venous side of the systemic circulation
Examples of obstructive shock (5)
(this is the least common type)
- PE
- tension pneumothorax
- pericardial tamponade
- constrictive pericarditis
- abdominal compartment syndrome
Swan ganz catheterization of the right heart to obtain pulmonary capillary wedge pressure gives a measure of ___
left atrium
Cardiogenic shock diagnosis (2)
- pumonary artery catheterization
- echocardiogram of left ventricle
SIRS criteria (4)
- temp >38 or <36C
- HR >90bpm
- RR >20 or PaCO2 <32 (respiratory alkalosis)
- WBC count >12000 or <4000 or >10% immature bands
qSOFA criteria for sepsis (3)
- RR >22
- SBP <100
- altered mental status (due to suspected infection)
Sepsis treatment options (3)
- administer broad spectrum antibiotics piperacillin, ampicillin
- steroids that mute the immune response (leukotriene storm)
- initiate pressors as needed (norepi)
Goal directed therapy for sepsis (4)
Meet the following criteria:
- Central venous o2 sat of > or =70
- central venous pressure > or =8-12
- mean arterial pressure > or = 65
- urine output > or = .5cc/kg/hr
Neurogenic shock etiologies (4)
- spinal anesthesia
- vagal stimulation
- cord transection
- NOT head trauma
Why don’t you use antihistamines for anaphylaxis?
Because most mast cells have already degranulated at the point of anaphylaxis presence
Conduction requires ___ while convection is dependent on ___
physical contact, wind velocity air and water vapor molecules moving around the body
Thermoregulation mechanism of action
- increased body temp
- thermostat in hypothalamus activated by temp receptors
- skin blood vessels dilate so warm blood allows heat to radiate from the skin surface
- sweat glands activated increasing evaporative cooling
- when body temp decreases
- thermostat in hypothalamus activated by temp receptors
- skeletal muscle activated to begin shivering to generate heat
- skin blood vessels constrict diverting blood from skin to deeper tissues reducing heat loss from skin surface
- body temp increases
Heat rash (prickly heat) definition and treatment
Skin irritation due to blocked sweat ducts trapping sweat beneath the skin, typically found on the neck, chest, groin, in skin folds, might be papular, pustular, or vesicular, may sting or be pruritic but typically self limiting and not a problem, can be prevented by wearing loose fitting clothing, avoiding extreme heat, etc
Heat edema definition and treatment
Dependent edema from vasodilatory pooling, too much sodium can aggravate fluid retention, greater risk in rapid transiton from cold to warm climate, treatment is NOT diuretics but rather just elevate extremities and put in a cool environment
Heat exhaustion signs and symptoms (4)
- early identification critical to prevent progression to heat stroke
- fatigue/malaise/weakness
- N/V/D
- in tact mental status
Heat exhaustion treatment options (3)
- move to cool area, ice packs, remove excess clothing, spray with lukewarm water, trendelenberg, etc
- gradual rehydration oral and or IV
- monitor for progression to heat stroke (patients should respond if all they have is indeed heat exhaustion)
Heat stroke signs and symptoms (4)
- Elevated core temp >40.5C
- Hot dry skin
- CNS symptoms and lack of intact mental status
- NVD
Heat stroke complications (2)
- high core body temp leads to multisystem damage (DIC, hepatocellular necrosis, acute kidney injury)
- cerebral hypoperfusion leads to mental status changes and can cause cereberal ischemia
Heat stroke diagnostic studies (5)
- CT of head to rule out edema
- CXR
- CBC, CMP, PT/PTT
- EKG
- urinalysis (rhabdo concerns)
Heat stroke treatment options (5)
- Rapid cooling measures within 30 min
- ice water immersion most effective
- antipyretics ineffective and may be harmful
- IV hydration
- admit to hospital
2 types of cold injuries
- Freezing (frostbite)
- nonfreezing (chilbain or trench foot)
Frostnip definition and treatment
Mildest form of peripheral cold injury, superficial nonfreezing cold injury secondary to vasoconstriction, sees pale skin with associated numbness and paresthesias but skin is still pliable***, occurs in the apical structures (ears, nose, hands, feet), treated by simple warming techniques
Chilblains (pernio) definition and treatment
More severe than frostnip caused by exposure to nonfreezing temps and damp air, onset 1-5 hours of cold exposures but can be longer, develops over hours and subsides slowly over weeks, develop red to violet raised lesions (papules and nodules) most often on unprotected extremities such as fingers and toes, seen most often in middle aged women or those with chronic conditions such as raynauds, treated with local heat, gentle massage, nifedipine, corticosteroids, minimize cold exposure to prevent recurrent lesions or secondary infection
Immersion (trench) foot definition and treatment
Occurs when feet are wet but not freezing for prolonged periods of time, most common in homeless and military starting with numbness and tingling pain with pruritis progressing to leg cramps and complete numbness, managed with gentle rewarming, careful washing and air drying, slight limb elevation, possible bed rest, prevented by keeping feet dry at least 8 hours a day
Frostbite definition and its 4 degrees of severity
Skin and deeper structure freeze resulting in tissue injuries, water crystals disrupt cell membranes and tissue structures resulting in ischemia and death of cells, has 4 degrees of severity (hyperemia and edema, accompanied by blisters, has hemorrhagic fluid in the blisters, and comprete necrosis with gangrene)
Frostbite management (4)
- do NOT start if still risk of re-freezing as this has worse outcomes
- restore core body temp first
- RAPID rewarming in a water bath until extremity has flushed appearance, once rewarming started, avoid weight bearing, very painful process
- tetanus prophylaxis
Frostbite complications (4)
- compartment syndrome
- limb/digits amputaitons
- digital shortening if growth plate injured in children
- susceptible to reinjury
Hypothermia definition
Body’s mech for temp regulation is overwhelmed in face of cold stressor, core temp <95 F or 35C, classified as accidental (unanticipated exposure in unprepared person), intentional (therapeutic post cardiac arrest), primary (environmental exposure) or secodnary (underlying medical issue)
Hunter’s response
Paradoxical and cyclical vasodilation following initial vasoconstriction that occurs in response to cold often the fingers, toes, and face
Hypothermia signs and symptoms (7)
- altered mental status, mood changes
- shivering
- flushing
- tachycardia then bradycardia
- facial edema
- hypotension
- paradoxical undressing
“They’re not dead till they’re warm and dead” meaning
Refers to how it is required to warm body before declaring death as hypothermia can often present with v-fib, dilated pupils, lack of responsiveness, etc
Hypothermia management (4)
- passive external rewarming
- minimally invasive active rewarming (IV fluids warmed)
- invasive active rewarming (bladder lavage, thoracic lavage)
- ECMO
If a patient is stable and can stand, what type of CXR do they get? What if they cannot get out of bed?
- PA and lateral chest
- AP x ray portable
FAST exam
Focused assessment with sonography for trauma, looking for air or fluid in the body usually due to trauma to chest or abdomen, no specific contraindications but should not interfere with resuscitation, looks at pericardium for cardiac tamponade, peritoneal spaces including perihepatic (morrisons pouch), perisplenic, and pelvic, also form called eFAST which includes the looking for pneumothoraces or hemothoraces
Most common pathogens involved in human bites from the oral flora (2) and the patient’s skin (2)
- Eikenlla
- Group A strep
- staph
- strep
Clenched fist bites
Injuries that most often occur as lacerations in the 3rd or 4th MCPs or PIPs of dominant hand and highly prone to infection because often ignored, occur most often when clenched fist of person strikes teeth of another
Occlusal bites
Semicircular or oval, skin may or may not be intact, more common on fingers, hands, or arms
Infections are more common with what type of animal bite?
Cat bites
Treatment for bite wound (4)
- cleansing, irrigation, dressing, daily eval for infection, foreign body removal
- most bites should be left to heal by secondary intention (left open) due to high risk of infection
- augmentin prophylaxis (almost everyone)
- IV if signs of systemic illness
Rabies post exposure prophylaxis
If high risk wild animal then need it, if stray dog will need it, if low risk animal or vaccination status of animal is known then do not, can monitor animal status to see if they die within 10-14 days, if patient never had exposure before need immunoglobin and vaccine (0, 3, 7, 14, and 28 if immunocompromised), if patient has then need vaccine only on day 0 and 3
Toxidromes
Signs and symptoms associated with a specific class of poisoning in a patient (anticholinergic, cholinergic, sympathomimeetic, sedative, serotonergic)
Coma coctail (3 parts)
Used for patient with altered consciousness and includes
- dextrose (hypoglycemia)
- thiamine
- naloxone
Toxidrome approach (7)
- pupil size
- temp
- bowel sounds
- heart rate
- blood pressure
- respiratory rate
- skin findings
Common anticholinergic toxidromes (5)
- antihistamines (diphenyhdramine, hydroxyzine)
- antispasmotics (dicyclomine, oxybutynin)
- atropine
- TCAs (amitriptyline)
- Jimson weed
Anticholinergic toxidrome findings
- hyperthermic, tachycardia, hypertensive
- CNS agitation and delirium
- mydriasis**
- skin dry, warm flushed**
- diminished bowel sounds, urinary retention
Common cholinergic toxidromes (3)
- organophosphates and insectisides
- cholinesterase inhibitors
- nerve agents
Cholinergic toxidrome findings
- bradycardia, high or low BP, high or low breathing
- CNS agitation and confusion
- pinpoint pupils, lacrimation
- diaphoresis***
- salivation, vomiting, diarrhea, incontinence***
Common sympathomimetic toxidromes (5)
- cocaine
- PCP
- amphetamines
- LSD
- bath salts
Sympathomimetic toxidrome findings
- Hyperthermia, tachycardia, hypertension
- CNS enhanced alertness, delirium, seizure, coma
- Mydriatic pupils
- diaphoretic, hot skin
- normal or active bowel sounds
Common opioid toxidromes (6)
- opium
- morphine
- heroin
- hydrocodone (vicodin)
- oxycodone
- fentanyl
Opioid toxidrome findings
- hypothermia, bradycardia, normal or low BP, bradypnea
- CNS lethargy and coma
- pupil miosis
- skin cool, pale, moist, evidence of needle injections
- hypoactive bowel sounds, constipation***
- hyporeflexia on neurologic exam
Common sedative hypnotic toxidromes (4)
- alcohol
- benzos
- barbituates
- sleeping aids
Sedative hypnotic toxidromes findings
- hypothermia, normal or bradycardia
- CNS drowsy, lethargy, coma
- pupils miotic
- decreased or no bowel sounds
- dry
Sympatholytic toxidrome findings
- bradycardia, hypotension, bradypnea
- CNS normal to lethargic
- pupils mid size
Common serotonin syndrome toxidromes (3)
- MAOIs
- SSRIs
- NSRIs
Serotonin syndrome toxidrome findings
- hyperthermia, tachycardia, hypertension
- CNS confusion, agitation, lethargy
- pupils mydriatic
- diaphoretic flushed skin
- hyperreflexia, tremors, clonus
Common sympatholytic toxidromes (3)
- B blockers
- a blockers
- a2 adrenergic agonists
Acetaminophen toxicity antidote
N acetylcysteine
Anticholinergic agents toxicity antidote
Physostigmine
Benzodiazepine toxicity antidote
Flumazenil
Carbon monoxide toxicity antidote
Oxygen
B or Ca2+ channel blockers toxicity antidote
IV fluids, calcium, glucagon, insulin
Cocaine or other sympathomimetics toxicity antidotes
Benzodiazepines
Acetone in ethanol, alcohol, chloroform, and salicyates have a characteristic ___ odor.
Cyanide has a characteristics ___ odor.
Arsenic, organophosphates, phosophorus have a ___ odor.
Organophoshates have a ___ odor.
Hydrogen sulfide has a ___ odor.
Methyl salicylate has a ___ odor.
Phosgene has a ___ odor
Fruity Bitter almonds Garlic kerosene Rotten eggs Wintergreen Freshly mown hay
Opioid toxicity antidote
Naloxone
Salicylates toxicity antidote
Alkalinization, hemodialysis
Warfarin toxiticy antidote
Fresh plasma, vit K
Max dose of acetaminophen in adults and children, when do peak serum levels occur?
- 4g/day or 3g/day if daily alcohol
- 80mg/kg/day
-4 hours after overdose (get a 4 hour acetaminophen level!)
Carbon monoxide poisoning symptoms (4)
- nonspecific
- vague, flu like symptoms without fever or lymphadenopathy, cherry red coloration
- multiple patients from the same household
- source presence such as smoke, car exhaust, malfunctioning in heating symptoms
Oral vs IV contrast
Oral such as barium is used for bowel opacification and not nephrotoxic, IV is iodine based for vascular structures or solid abdominal and pelvic regions
Endoscopic retrograde ccholangiopancreatography (ERCP) technique, uses, risks
Invasive procedure that uses endoscopy to directly visualize bile duct, most effective for choledocholithiasis and used as diagnoistic and treatment of stones, tumors, bile duct strictures, stent placement, risks include pancreatitis, bleeding, perforation
Hepatobiliary iminodiacetic acid scan (HIDA)
Nuclear medicine scan where a radiotracer is injected IV for imaging of gallbladder and biliary tree, most useful for acute cholecystitis
“Stack of coins” sign
X ray visual where small bowel folds are smoothly and uniformly thickened caused by intramural bleeding
“Free air under the diaphragm”
A finding on a chest x ray where there is separation of the diaphragm above the bowel contents indicative of bowel perforation causing peritonitis allowing for bacteria to potentially cause sepsis
Bird beak sign
A finding on a barium swallow where the lower esophageal spincer fails to open due to a variety of obstructive reasons
Zollinger ellison
A tumor secreting gastrin from pancreas into the stomach that can cause hyper acidity in patients that causes erosion of the walls and rugae thickening
Pyloric stenosis and “olive sign”
Common pediatric disease in newborns 3 weeks where they consistently throw up due to occlusion of the pylorus visible on a barium contrast study as “olive sign”
Magnetic resonance cholangiopancreatography (MRCP)
Test of choice to examine diseases of liver, gallbladder, bile ducts, pancreas, and pancreatic duct to evaluate tumors, stones, inflammation or infection, is non invasive and has high sensitivity with highly detailed images but should not be used in patients with decreased renal function
Sentinal loop
Short segment of adynamic ileus close to intra-abdominal inflammatory process in cases such as pancreatitis or appendacitis visualized on x ray in a patient with abdominal pain
Intussusception places a person at significant risk for…
….bowel ischemia and necrosis
Sausage sign or target sign
Visualizations on a ultrasound or CT respectively that are indicative of intussusception of the bowel
Fecolith seen on imaging study, when associated with abdominal pain, has a 90% probability of being…
…acute appendicitis
Apple core lesion
A visualization on a CT study in the large bowel indicative of a colon cancer presence
Cobblestoning and skip lesions and string sign
Visualizations on a contrast imaging study that are indicative of crohns caused by inflammation and swelling of the bowel wall
Thumbprint sign (GI)
A radiographic sign of the large bowel wall thickening usually caused by mucosal edema from an infective or inflammatory process
No liver # on an LFT is a true reflection of…
….liver function
ALT/AST measures
Slight elevations indicate low grade inflammation, high elevations indicate acute liver injury/necrosis, but normal does not mean no inflammation
Alkaline phosphatase measures
Indicator of bile duct inflammation (obstruction, autoimmune, infection, etc.), can be elevated secondarily in pregnancy
Bilirubin/alk phos measures
Prehpatic jaundice is due to elevated unconjugated bilirubin, hepatic is both conjugaed and unconjugated elevated, post hepatic is elevated conjugated bilirubin in serum
Albumin measures
Non specific, somewhat related to liver function but also related to nutritional status, can lead astray (usually suggests chronic disease such as cancer or cirrhosis)
ALT/AST elevated out of proportion to alk phos think ___, vise versa think ___
liver inflammation, obstruction (cholestatic pattern)
Isolated hyperbilirubinemia should indicate the first test to order to be…
….fractionate it to determine amount of conjugated vs unconjugated
Isolated hyperbilirubinemia primarily conjugated think ____ or ____. Unconjugated think ____ or ____
Dubin Johnson, Rotor syndrome
Gilbert’s syndrome, Crigler Najjar syndrome
Most important test to evaluate liver function
INR (coumadin will mess it up) (INR that does not correct with parenteral vit K is suspicious for severe hepatocellular injury)
____ may be the first sign of liver disease even years before liver disease is diagnosed
Low platelet count
Extraneous labs to order in initial lab eval (acute) of liver patient (3)
- tox screen
- tylenol level
- acute viral hep panel
Acute liver failure definition
Acute hepatocellular injury, hepatic encephalopathy (confusion), and prolonged PT (elevated INR), LFT’s typically >10x upper limits of normal, may need transplant if INR continues to rise
Initial first line imaging study for suspected liver disease
Right upper quadrant ultrasound (can do with doppler)
General liver disease advice (5)
- no alcohol
- vaccinate hepA/B
- limit acetaminophen no more than 2 grams a day
- avoid raw seafood
- control weight, cholesterol, diabetes
Hepatitis A
Single stranded RNA virus, almost exclusively spread fecal oral route most often person to person, incubation 2-6 weeks, increasing age increases symptoms as newborns are usually asymptomatic and anicteric, boiling water/iodine/chlorine are effective for destroying virus, risk highest in developing countries, usually self limiting, prognosis generally excellent without lasting sequelae
2 phases of Hep A infection
Prodrome - mild flu like symptoms
Icteric - develop dark urine then pale stools, jaundice
If you order a patient a total Hep A antibody panel (IgM + IgG) and they have only IgG, then…
….patient either previously had disease or was vaccinated
Hep A treatment
- supportive
- sugarcane in developing countries
- locate primary source to prevent further outbreaks
- post exposure prophylaxis with gammaguard within 2 weeks of exposure for non immunized close contacts
Hepatitis B
DNA virus, estimated 1/3 of global population has been infeected, incubation period 1-6 months, transmitted via body fluids (blood/semen/vaginal secretions) including sexual/parenteral/perinatal, anicteric hepatitis has greater tendency to develop chronic hep
2 phases of hep B infection
- Acute phase - majority asymptomatic
- Viral prodrome with icteric hepatitis (arthralgias, skin rash, low grade fever, jaundice for 1-3 months)
Hepatitis Ig labs
- core IgM indicates acute infection
- core IgG indicates past infection (not from vaccination)
- surface antigen indicates acute or chronic infection
- surface antibody indicates had virus (if core antibody positive) or vaccine (if only positive value then vaccinated)
- E antigen indicates active viral replication and highly contagious
- E antibody indicates a carrier
Any patient with chronic hep B requires….
….screening regimen for hepatocellular carcinoma (HCC), which is an ultrasound every 6-12 months
Hep B 3 treatments
- pegylated interferon alpha
- entecavir
- tenofovir disoproxil fumarate
Hepatits C
Single stranded RNA virus, most frequent cause for liver transplant in US, most frequently occurring nonA nonB hepatitis worldwide, 80% will remain viremic and 20% of that will develop cirrhosis, transmitted primarily via iv drug use, transfusion prior to 1990, needle stick, increased risk of transmission if co infection with HIV, incidence rising due to opioid epidemic, good prognosis if treated acutely
Who should be screened for hep C (4)
- evidence of liver diz
- HIV infected individuals
- incarcerated
- needle stick injury
Hep C treatment (acute (1)and chronic (2))
- acute, monitor for spontaneous clearing for 6 months
- chronic sofosbuvir (sovaldi) or simeprevir (olysio)
Hepatitis D
RNA virus transmitted same modes of hep B, only seen in patients with hep B, uncommon in west, chronic hep B with D progresses more rapidly to cirrhosis, 90% asymptomatic, treated same way as hep B (and vaccine against B is effective against D as well)
Fatty liver disease
Accumulation of triglycerides and other fats in liver cells, may have associated hepatic inflammation and liver cell death, need to distinguish nonalcoholic vs alcoholic etiology (alcoholic is reversible, metabolic syndrome is commonly associated with nonalcoholic fatty liver)
Ligament of treitz divides these 2 conditions
Upper GI vs lower GI bleed
HemOCCULT testing
Taking a sample of stool, placing it on a card that then undergoes reagant droplet testing, with blue color meaning that it contains blood
Mallory weiss tear
Uncommon cause of upper GI bleed, longitudinal mucosal laceration at the gastroesophageal junction or the gastric cardia caused by forceful retching or vomiting, often associated with alcohol use, overt bleeding is minor and bleeding ceases spontaneously unless severe then need intervention
Bleeding varices
An uncommon cause of upper GI bleed due to friable weak tissue that usually resultes in sudden overt major bleeding, can be fatal
AIMS65 score
Predictor of in hospital mortality due to upper GI bleed based on risk factors
Albumin <3g/dL (produced by liver and keeps fluid in circulation)
INR greater than 1.5 (can’t spontaneously clot)
-Mental status <14 of glascow coma score
Systolic BP <90
Age greater than 65
Diverticular bleed #1 site
Ascending colon
Diverticular bleed does not necessarily mean a patient has…
…diverticulitis (this one is more common on the sigmoid colon on the left and is infectious while diverticular bleed is ascending colon most of time, and typically painless and stop spontaneously)
Lower GI sources of blood loss (5)
- diverticular bleed
- polyp/cancer
- angiodysplasia
- IBD
- hemorrhoid or fissure
Postural hypotension
Supine to upright fall in systolic BP of >10mmHg or increase in heart rate of >20 bpm indicating a moderate blood loss (up to 20% of circulatory volume)
If a patient is in a deep GI bleed, we want to do what?
Give O neg blood cells until blood type identified, lacted ringer’s solution, no vasopressors (it will just cause them to squirt)
Intrahepatic portosystemic shunt
Used in upper GI bleed secondary to esophageal varicies to treat portal hypertension by percutaneously creating a connection within the liver between portal and systemic circulations (diverting portal blood flow)
Sphincter of oddi
The hepatopancreatic spincter that joins together the common bile duct and the pancreatic duct
Acute pancreatitis presentation and repeating of episodes
Inflammatory process of the pancreas associated with abdominal pain (a boring pain drilling thru the gut) sometimes radiating to back only slightly relieved bending forward, shortness of breath, febrile, elevated pancreatic enzymes, and variable involvement of other regional tissue, repeated bouts may eventuate into chronic pancreatitis due to permanent alterations in function and morphology
Common causes of acute pancreatitis (6)
- biliary tract stones**
- endoscopic retrograde cholangiopancreatography
- alcohol abuse***
- scorpion sting
- coxsackievirus/mumps
- trauma
Common causes of chronic pancreatitis (3)
- alcohol abuse***
- autoimmune
- hereditary
The 3 F’s of cholellithiasis development
- fat (obese)
- fertile (child bearing age)
- forty
Common duct theory
The idea that because a gallstone lodges in the duct that is common between the pancreas and the gallbladder, the pancreas becomes inflamed as a result and can cause acute pancreatitis
Drugs that are known to cause acute pancreatitis (3)
- estrogens
- nitrofurantoin
- sulfonamides
Pancreatitis lab studies (6) and the expected results of them
- Serum amylase (can be elevated, not specific)
- ***serum lipase (specific for pancreatic disease) –> hospitalization
- serum electrolytes (many get hypocalcemic)
- Lipids (elevated)
- blood sugar (hyperglycemia)
- LFT’s (prognostic indicators)
Acute pancreatitis imaging studies (3)
- abdominal ultrasound (1st line)
- Confirmatory CT
- ERCP can be 3rd line in urgent intervention
Treatment for acute pancreatits (6)
- maintain NPO
- IV fluids
- pain control (meperidine or dilaudid)
- IV antiemetic
- determine cause and treat
- surgical management in severe necrotic situations
Ranson’s prognostic signs/APACHE
An assessment of factors to determine point values that when added up assess risk of mortality of patient with acute pancreatitis clinical course, <2 mortality is 0% and >7 is up to 95%
Chronic pancreatitis treatment (6)
- supplemental pancreatic enzymes
- fat restriction on diet
- stop alcohol
- pain control
- surgery
- whipple procedure (intense surgery cutting out damaged area of pancreas and readjoin vasculature)
Pancreatic cancer has a very poor 5 year survival rate because of…
What is the most common type?
…lack of detection until late stage metastasis
…adenocarcinoma (ductal epithelium)
Suspected pancreatic cancer signs*** and best way to diagnose
Weight loss (>5lbs per month), hypercoaguable state, biliary duct blockage (painless jaundice) and constantly present burning pain, diagnosis by helical CT is best***
Painless jaundice is..
…pancreatic cancer until proven otherwise
Courvoisier’s sign
Palpable non tender gallbladder often associated with jaundice in cachectic patients highly suspect of pancreatic cancer
Acute pancreatitis requires***… (also what 6 things are monitored in this case)
…hospitalization, and monitoring during that everyday of serum lipase, ca2+ levels, blood glucose, CBC, LFT’s, and lipid panel
Regions of the stomach
Cardia (first part contains cardiac sphincter)
Fundus rounded dome left of cardia and below diaphragm
body - largest main part
antrum - lower part of stomach that holds food ready for small bowel
Pylorus (part of stomach that connects to the duodenum including pyloric sphincter)
Peptic ulcer disease definition
Break in lining of esophagus, stomach, or duodenum caused by corrosion due to acid* and pepsin**, most common in stomach and proximal duodenum, less common sites associated with zolinger ellison syndrome, hiatal hernieas, or ectopic gastric mucosa
Zollinger ellison syndrome
rare disorder with increased production of gastrin causing unopposed acid secretion typically due to pancreatic/duodenal gastrin secreting tumor, may be associated with multiple endocrine neoplasia type 1, presents with abdominal pain, diarrhea, heartburn
Peptic ulcer vs erosion
Ulcer is deeper, incites local inflammatory reaction and extends thru the muscularis mucosa while erosion is just partial
Excluding patients who use NSAIDS, __% of gastric and duodenal ulcers are associated with…
90%….H pylori infection
Peptic ulcer risk factors (5)
- NSAIDS
- H pylori infection
- severe physiologic stress
- hypersecretory states
- local radiation
H Pylori infection mech of action
Gram - spirochete that produces urease to alkanize microenvironment to survive the acidity oft he stomach and colonizes the gastri mucosa, this impairs duodenal bicarb secretion and increases levels of gastrin and pepsinogen which promotes gastric metaplasia in the duodenum increasing susceptibility to acid injury
NSAID gastric ulceration mech of action
Inhibition of cyclooxygenase decreasing prostaglandins resulting in decreased mucus and bicarb secretion, decreased epithelial cell proliferation, and decreased blood flow
Peptic ulcer disease clinical presentation (6) between gastric and duodenal ulcers
- burning epigastric pain typically after eating (gastric) with little relief with antacids
- nocturnal pain waking them up more characteristic of duodenal ulcer, which eating diminishes pain and is relieved with antacids
- dyspepsia
- heartburn
- anemia
- hematemesis or melena or hematochezia
Sudden onset of sharp pain often exacerbated by movement in peptic ulcer disease should raise concern for…
….perforation
Diagnostic study for peptic ulcer disease (2)
- EGD (can tell benign smooth regular ulcers and malignant irregular shaped ones)
- upper GI x ray series (back up if high risk for sedation)
H pylori infection testing
- Serum ELISA (useful only for first infection)
- urea breath test (highly accurate but expensive)
- stool antigen test
- endoscopic biopsy
How to screen for zollinger ellison syndrome (or a patient with multiple ulcers or strong family history)
-fasting serum gastrin level
A nonhealing gastric ulcer is…
…cancer until proven otherwise
Gastric cancer
3rd most common cause of cancer related death in the world, 5th most common globally, most often adenocarcinoma, early stages lacks symptoms while late stage sees sister mary joseph node and virchows node as well as N/V
