RUQ and Epigastric Abd pain DSA

Question 1

What are the two types of gallstones?

Answer 1

1. Cholesterol - more common, 50%+ cholesterol monohydrate
2. Pigment stones - <20% cholesterol, mainly calcium bilirubinate

Question 2

What are the sx of gallstones?

Answer 2

often asx

biliary colic: severe stead ache in RUQ or epigastrium; often after meals; can radiate to right scapula or back

N/V

Question 3

What are lab and imagins like with gallstones?

Answer 3

labs - normal typically

imaging -

US can show stones

HIDA can be used to assess the patency of the cystic duct and gallbladder emptying function

Question 4

When are men more likely to get gallstones over women?

Answer 4

cirrhosis or hep C

Question 5

What are the two types of pigment stones?

Answer 5

a. black
b. brown - form in bile ducts due to bacterial infection

Question 6

What is a unique sx of acute cholecystitis?

Answer 6

tea colored urine and/or acholic stools

Question 7

What US findings suggest acute cholecystitis?

Answer 7

GB thickening, pericholecystic fluid, sonographic murphy sign

Question 8

What are complications of acute cholecystitis?

Answer 8

gangrene of GB

emphysematous cholecystitis

empyema

hydrops

fistulization

gallstone ileus

porcelain GB

Question 9

What is essential to dx of choledocholithiasis?

Answer 9

stones in common bile duct

Question 10

What is the charcot triad? reynold pentad?

Answer 10

1. RUQ pain + fever (and chills) + jaundice
2. Charcot Triad + altered mental status (confusion) and hypotension –> signifies acute suppurative cholangitis and is an endoscopic emergency

*both considerations in ascending cholangitis

Question 11

What organisms are often present with ascending cholangitis?

Answer 11

• E. coli*
• Klebsiella*
• Enterococcus*

Question 12

What is seen on US for biliary dyskinesia?

Answer 12

normal US

also have normal liver enzymes, conjugated bilirubin, amylase/lipase

*use Rome III diagnostic criteria for functional GB

Question 13

What are lab tests like with chronic cholecystitis typically?

Answer 13

normal

US - usually shows gallstones within contracted GB

Question 14

What is porcelain GB? courvoisier’s GB?

Answer 14

Question 15

If you suspect a pt of acute pancreatitis, what diagnositc tool should be avoided when serum Cr > 1.5 mg/dL?

Answer 15

rapid bolus intravenous contrast enhanced CT

Question 16

What APACHE II score is associated with higher mortality of acute pancreatitis pts?

Answer 16

>8

Question 17

What is the first step in tx of acute pancreatitis?

Answer 17

fluid resuscitation - LOTS

Question 18

What is seen here? associated condition?

Answer 18

Sentinel loop or localized ileus

acute pancreatitis

Question 19

What conditions can elevated amylase be present in?

Answer 19

Pancreatitis

High intestinal obstruction

Gastroenteritis

Mumps (salivary amylase)

Ectopic pregnancy

Administration of opioids

After abdominal surgery

Question 20

What is the cardinal sx in chronic pancreatitis?

Answer 20

pain

Question 21

What are diagnostic tests for chronic pancreatitis?

Answer 21

Question 22

Tumefactive chronic pancreatitis is a concern for?

Answer 22

pancreatic cancer

Question 23

what is the main cause of death in chronic pancreatitis pts?

Answer 23

pancreatis CA

Question 24

What are the four pancreatitc function tests?

Answer 24

Question 25

What is a unique aspect about the pain associated with pancreatic cancer?

Answer 25

worse at night due to lying flat on back

Question 26

What are the risk factors for pancreatic CA?

Answer 26

Smoking

Obesity

Male

African American

>65 yo

Diabetes Mellitus

Chronic pancreatitis

Liver cirrhosis (alcohol)

Family history

Question 27

When might you do a urine antigen chest in the setting of epigastric pain?

Answer 27

to check for causes of pneumonia

specifically Strep pneumo and Legionella

Question 28

What is the drawback in checking IgA abs when looking for H. Pylori?

Answer 28

the Abs can stick around for about 2 yrs after irradication - have to know pt’s hx

Question 29

What is an immune-related bowel dz with ASCA Abs?

Answer 29

Crohn’s dz

Question 30

When would you do a HIDA scan w/ CCK?

Answer 30

to look for decreased biliary ejection fraction = biliary dyskinesia

Question 31

When do you use ROME IV criteria?

Answer 31

IBS eval

Question 32

When do you use Rumack-Matthew Nomogram?

Answer 32

in setting of acute acetaminophen toxicity to eval risk of liver toxicity

Question 33

What GI drug can have a side effect of tardive dyskinesia?

Answer 33

metaclopramide (D2 antagonist)

Question 34

According to Ranson criteria, what predicts a severe course of pancreatitis w/ necrosis w/ sensitivity of 60-80%

Answer 34

3 or more of the following:

age > 55

WBC > 16x10^3/mcL

Blood glucose > 200

serum LDH > 350

AST > 250

Question 35

What are the Ranson Criteria?

Answer 35

Question 36

When do you do a georgia Law assessment?

What is it?

Answer 36

At admission for assessing acute pancreatitis severity

Question 37

When do you do a Calvin and Hobbes assessment and what is it?

Answer 37

48 hrs after admission to assess severity of acute pancreatitis

Question 38

What is the BISAP score and when do you use it?

Answer 38

To assess severity of acute pancreatitis at admission or within 24 h

BUN > 25

Impaired mental status

SIRS >/= 2 of 4 present

Age > 60

Pleural Effusion

Question 39

When might you see low fecal chymotrypsin?

Answer 39

in chronic pancreatic insufficiency

Question 40

What are SIRS criteria and when are they used?

Answer 40

the “S” in BISAP score for eval of acute pancreatitis

(need 2-4 to meet criteria in BISAP)

Core temp <36 C or > 38

HR > 90

RR > 20 or PCO2 <32

WBC > 12000, <4000, or 10% bands

Question 41

What do you call the initial episode of acute pancreatitis that starts chronic pancreatitis?

Answer 41

SAPE

sentinel acute pancreatitis event

Question 42

When do you see CA 19-9?

Answer 42

pancreatic cancer