RUQ and Epigastric Abdominal Pain Flashcards
+ Murphy’s sign =
Pain or inspiratory arrest is induced with deep inspiration or cough during palpation of the RUQ
Major SX of cholelithiasis
Biliary colic - severe steady ache in the RUQ or epigastrium that begins suddenly (30-90 min. post meals)
-pain radiates to the right scapula
Nausea and vomiting
What lab changes may occur in cholelithiaisis?
What is the best imaging tool?
Mild/transient elevations in BR
US (only 10% show up on XR)
What are 3 complications of cholelithiasis?
Cholecystitis
Pancreatitis
Cholangitis
In what setting are men more likely to have cholelithiasis than women?
In patients with cirrhosis and/or hep C
What ethnicities are most likely to have gallstones?
NAs > Mexicans > whites > blacks
Acute calculous gallstones occur as a result of:
> 90% cases
Occur as a result of blockage of cystic duct, inflammation develops behind obstruction
Acute acalculous gallstones is NOt due to…
Not due to stones - “true cholecystitis”
What is the appearance of urine/stools in acute cholecystitis?
Tea-colored urine and/or acholic stools
What are some lab findings in acute cholecystitis? (5)
Leukocytosis Bilirubinemia Increased AST Increased ALP Increased GGT Increased serum amylase
What findings on US suggest acute cholecystitis? (3)
Gb wall thickening, pericholecystic fluid and sonographic Murphy’s sign
2 major complications of the Gb in acute cholecystitis
Gangrene of the Gb - from ischemia, necrosis, Gb perforation
Emphysematous cholecystitis - secondary to infection; warrants urgent cholecystectomy
Where are stones found in choledocholithiasis?
Common bile duct
Essentials of Dx in choledocholithiasis (3)
H/O biliary pain +/- jaundice
N/V
Stones in CBD
What tests can detect choledocholithiasis?
ERCP or EUS
SX of choledocholithiasis (3)
Frequent attacks of sever RUQ pain for hours
Chills and fevers associated with pain
H/O of jaundice associated with episodes of abdominal pain
What is the procedure of choice for choledocholithiasis?
ERCP w/ sphincterotomy and stone extraction
When should ascending cholangitis be suspected?
Fever followed by hypothermia and G- shock, jaundice and leukocytosis
What is Charcot triad?
RUQ pain + fever/chills + jaundice
May be present in ascending cholangitis
What is Reynold pentad?
What might it suggest?
Charcot triad (RUQ pain + fever/chills + jaundice) + altered mental status + hypotension May be present in ascending cholangitis
Signifies acute suppurative cholangitis and is an endoscopic emergency
What cultures may be positive in ascending cholangitis? (3)
E. coli
Klebsiella
Enterococcus
What is the etiology of biliary dyskinesia?
What are the symptoms?
Unknown etiology
Very similar to biliary colic: episodic RUQ pain, pain that limits dailynliving, nausea
A normal US is seen in what Gb disease?
What labs are normal? (3)
Biliary dyskinesia
NL liver enzymes, conjugated BR, amylase/lipase
What should be considered in patients with biliary dyskinesia?
Rome III diagnostic criteria for functional Gb
What is used to diagnose biliary dyskinesia?
What is a normal vs. abnormal result?
HIDA scan
Normal: Gb visualized within 1 hr
Abn: Gb not seen -> stone in cystic duct or cholecystitis
What EF should indicate cholecystectomy in biliary dyskinesia?
EF of 35-38%
3 major etiologies of acute hepatitis
Viral infection
Drugs
Ischemia (shock)
What is evident on PE in a patient with acute hepatitis?
RUQ pain (tenderness over liver) Jaundice Hepatomegaly Skin changes Abdominal pain
What 3 diagnostics should be done in acute hepatitis?
CMP
PT/INR
Acetaminophen level
What can cause acute pancreatitis? (2 major causes)
Gallstones <5mm in the biliary tract
Heavy EtOH use
Symptoms of acute pancreatitis
Epigastric abdominal pain (constant pain that penetrates to the back)
May present similar to Gb pathology
What is required for a Dx of acute pancreatitis?
2 of the following 3:
Epigastric pain
Lipase 3x normal limit
CT changes consitent with pancreatitis
What signs are positive in acute pancreatitis?
Gray Turners sign (ecchymosis of flank)
Cullen sign (ecchymosis of umbilicus)
What might be seen on XR in acute pancreatitis?
“Sentinel loop” - segment of air-filled SI (LUQ). Signals the presence of an adjacent irritative or inflammatory process
“Colon cutoff sign” - gas-filled segment of transverse colon abruptly ending at the site of pancreatic inflammation and focal atelectasis of the LL of the lungs
What level of the APACHE II criteria suggests a higher mortality?
> 8
What is HAPS?
“Harmless acute pancreatitis score”
Predicts non-severe course w/ 98% accuracy
- no tenderness or guarding
- NL Hct
- NL serum creatinine
What are some complications of acute pancreatitis? (5)
Intravascular volume depletion - 3rd spacing and pre-renal azotemia
Pleural effusions (fluid collections)
Necrosis and infection
Pseudocysts
ARDS
Pancreatic ascites
What is emphysematous pancreatitis?
What 3 bugs can cause it?
Infected pancreatic necrosis with secondary gas formation
C. perfringens
Enterobacter aerogenes
E. faecilis
Decreased fecal elastase (<100 mcg/g) suggests:
Chronic pancreatitis
CT findings in chronic pancreatitis (3)
Ductal dilation
Heterogeneity/atrophy of the pancreas
“Tumefactive chronic pancreatitis” = concern for pancreatic cancer
Etiologies of chronic pancreatitis (6)
TIGAR-O
T - toxic-mediated: EtOH I - idiopathic (smoking is risk factor) G - genetic (CFTR, PRSS1, SPINK1, etc.) A - autoimmune (IgG4 - hypergammaglobinemia) R - recurrent acute pancreatitis O - obstruction
2 major complications of chronic pancreatitis
Brittle DM: >80% of adults develop DM within 25 years after the onset
Pancreatic cancer
Avoid opioids in…
Chronic pancreatitis
4 pancreatic function tests
Trypsinogen: low levels cause steatorrhea (<20)
Fecal elastase: low in pancreatic insufficiency
Pancreatic malabsorption: when enzyme secretion is <5-10%; takes > 5 years to develop
Stimulation tests: CCK/secretin
What ethnicity of patients are at highest risk for pancreatic cancer?
> 65 y/o, black ethnicity
