Section 3: Diverticular Disease to Acute Pancreatitis Flashcards
CF of diverticulosis
- Left lower quadrant abdominal pain
- Lower GI bleeding
Diverticulosis
- Most accurate test
- Best diagnostic test
- Rx
- Colonoscopy
- Abdominal CT scan
- High-fiber diet
CF of diverculitis
- Left lower quadrant (LLQ) abdominal pain
- Tenderness
- Fever
- Elevated white cell count in blood
Diagnosis:
LLQ pain + Tenderness + Fever + Leukocytocysis
Diverticulitis
True or False:
Colonoscopy and barium enema are contraindicated in diverticulitis.
Why?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6276-6277). . Kindle Edition.
True
Because of an increased risk of perforation.
Diverticulitis:
- Best diagnostic test
- Rx
- Abdominal CT scan
- Antibiotics are the main stay of Rx
- Ciprofloxacin + Metronidazole
- Cephalosporin + Metronidazole
A 74-year-old man with a history of aortic stenosis comes to the emergency department having had 5 red/ black bowel movements over the last day. His pulse is 112, blood pressure 96/ 64. What is the next best step in management?
a. Colonoscopy
b. Consult gastroenterology
c. CBC
d. Bolus of normal saline
e. Transfer to the intensive care unit
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6299-6311). . Kindle Edition.
D. The most urgent step in severe gastrointestinal (GI) bleeding is fluid resuscitation. When the systolic blood pressure is low or the pulse high, there has been at least a 30 percent volume loss. Step 3 does not allow you to order specific doses; hence, all you can order is a “bolus.” It is fortunate that you do not have to spend a lot of time calculating or memorizing specific doses of fluids or specific medications. Although endoscopy, such as colonoscopy, is important, it is not as important as fluid resuscitation.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6299-6311). . Kindle Edition.
GI bleeding:
- What is the important thing to do in acute GI bleeding?
- Define orthostasis
- How does orthostasis present as?
- Determine if there is hemodynamic instability
- Orthostasis is defined as a drop in systolic BP of > 20mmHg or a rise in pulse of > 10 beats per minute
- Systolic BP of < 100 mmHg or HR > 100. Means blood loss of > 30%
Emergency orders and diagnostic tests for large GI bleed in CCS
- Bolus of N/S or Ringer’s lactate
- CBC
- Prothrombin time/INR
- Type and cross-match
- Consultation with gastroenterology
- EKG
Large GI Bleeding:
- When do I transfuse packed red blood cells?
- When do I transfuse fresh frozen plasma?
- When do I transfuse platelets?
- What is the most common cause of death in GI bleeding?
- When is “nasogastric tube” the answer?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6342-6362). . Kindle Edition.
- • Hematocrit < 30 in an older person • Hematocrit < 20– 25 in younger patients with no heart disease
- When there is elevated prothrombin time/ INR and vitamin K is too slow
- If the patient is bleeding or to undergo surgery, transfuse platelets when they are < 50,000
- Myocardial ischemia. That is why you should get an EKG in older patients with severe GI bleeding. The myocytes of the left ventricle cannot distinguish between ischemia, anemia, carbon monoxide poisoning, and coronary artery stenosis. All of these lead to myocardial infarction.
- Place a nasogastric (NG) tube in the occasional patient when you are unsure whether bleeding is from an upper or lower gastrointestinal source. The nasogastric tube has no therapeutic benefit; it will not stop bleeding. Iced saline lavage is worthless and is always wrong.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6342-6362). . Kindle Edition.
Large GI bleeding:
- Best initial Rx
- Most imprtant measure of severity
- What to do if more fluid leads to hypoxia
- Which is more important: (1) Correcting anemia, thrombocytopenia, or coagulopathy OR (2) doing an endoscopy.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6371-6372). . Kindle Edition.
- Fluid resuscitation
- BP and pulse rate
- Continue to give fluid and increase oxygenation (intubate +/- packed cells)
- (1) Correcting anemia, thrombocytopenia, or coagulopathy is more important than endoscopy.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6371-6372). . Kindle Edition.
True or False:
Unnecessary stress ulcer prophylaxis with PPIs increases the risk of pneumonia and Clostridium difficile colitis.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6380-6381). . Kindle Edition.
True
Rx of variceal bleeding
- Fluid resuscitation
- Octreotide
- Endoscopy for banding
- TIPS (transjugular intra-hepatic portosystemic shunt)
- Blakemore gastric tamponade balloon (temporary measure to allow for TIPS)
- Propranolol prevents future variceal bleeds
Causes of upper GI bleeding
- Gastric/peptic ulcer disease
- Esophagitis
- Gastritis
- Duodenitis
- Varices
- Cancers
Causes of lower GI bleeding
- Diverticular disease
- Angiodysplasia
- Polyps
- Ischemic colitis
- Inflammatory bowel diseases
- Cancer
Diagnostic tests for upper and lower GI bleeding
Endoscopy
Technitium bleeding scan
Angiography
Capsule endoscopy
Acute mesenteric ischemia:
- Describe the pathogenesis
- CF
- Diagnostic tests
- Most accurate test
- Rx
- Embolus from the heart resulting infarction of the bowel
- Sudden onset of extremely severe abdominal pain out of proportion to PE; older patient; valvular heart disease
- Metabolic acidosis (elevated lactic acid) + elevated amylase level
- Angiography
- Surgical resection
Dumping Syndrome:
- Describe
- CF
- Pathogenesis
- Rx
- Dumping syndrome is a relatively rare disorder related to prior gastric surgery, usually done for ulcer disease. Treatment and eradication of Helicobacter pylori has made surgery for ulcer disease rare.
- CF
- Shaking
- Sweating
- Weakness
- Hypotension
- Hypotension: resulting from the rapid release of the gastric contents into the duodenum, which causes an osmotic draw into the bowel. The other reason is a rapid rise in blood glucose resulting in a reactive hypoglycemia.
- Frequent small meals.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6447-6453). . Kindle Edition.
Diabetic gastroparesis:
- CF
- Rx
- Bloating, constipation, diarrhea in a diabetic
- Erythromycin, Metoclopramide. (Erythromycin increases motilin in the gut, a hormone that increases gastric motility)
Constipation:
Causes of Constipation
Rx of constipation
Causes of Constipation
- Dehydration: BUN:Creatinin ratio >20:1
- Obstuction: IBD, Cancers
- Pain
- Endocrine: Hypothyroidism, DM
- Drugs:
- CCB
- Narcotic medication use (opiates)
- Anticholinergic medication including TCA
- Ferrous sulfate iron replacement
Use the mnemonic “DOPED”
Rx: Hydration and high-fiber diet
List the CF of acute pancreatitis
- Severe midepigastric pain + tenderness
- Vomiting without blood
- Anorexia
Severe cases involve:
- Hypotension
- Metabolic acidosis
- Leukocytosis
- Hemoconcentration
- Hyperglycemia
- Hypocalcemia caused by fat malabsorption
- Hypoxia
Causes of acute pancreatitis
- Gallstones
- Hypertriglyceridemia
- Trauma
- Alcohol
- Infection
- ERCP
- Medications:
- Thiazides
- Didanosine
- Stavudine
- Azathioprine
I GET SMASHED:
Idiopathitic/Infections
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (PAN)
Scorpion stings
Hyperlipidemia/ Hypercalcemia
ERCP
Drugs (including azathioprine and diuretics)
· Note: ‘Get Smashed’ is slang in some countries for drinking, and ethanol is an important pancreatitis cause.
· Note: Shortest answer is gallstones for women, and ethanol for men. And scorpian stings for people from Trinidad.
Diagnostic tests for acute pancreatitis:
- Best initial test
- Most accurate test
- Other tests
- Amylase and Lipase (higher specificity)
- abdominal CT scan
- MRCP (magnetic resonance cholangiopancreatography); ERCP (endoscopic retrograde cholangiopancreatography); trypsinogen activation peptide (a urinary test)
Rx of acute pancreatitis
- No feeding (bowel rest)
- Hydration
- Pain medications
Diagnosis of necrotic pancreatitis
Abdominal CT scan
Rx of necrotic pancreatitis
When the CT shows > 30 percent necrosis of the pancreas, the patient should receive antibiotics such as imipenem; and undergo CT-guided biopsy.
If the biopsy shows infected, necrotic pancreatitis, the patient should have surgical debridement of the pancreas.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6493-6497). . Kindle Edition.
Ranson’s Criteria for Acute Pancreatitis
- At diagnosis
- At 48 hours
- Prognosis based on Ranson’s criteria
- At diagnosis:
Age older than 55 years
WBC count above 16,000/mm3
Glucose level over 200 mg/dL
AST above 250 U/L
LDH above 350 U/L
- At 48 hoursHCT ↓ more than 10%
BUN ↑ more than 5 mg/dL
Base deficit above 4 mEq/L
Ca less than 8 mEq/L
PaO2 less than 60 mm Hg
Fluid sequestration greater than 6 L - PrognosisUp to 2 criteria: mortality rate less than 5%
3 to 4 criteria: mortality rate 15% to 20%
5 to 6 criteria: mortality rate 40%
7 or more criteria: mortality rate approaches 99% - Use the mnemonic “GA LAW” for admission criteria and “C & HOBBS (Calvin and Hobbes)”
Likely diagnosis:
- Painless jaundice
- Elevated conjugated bilirubin
- Elevated alkaline phosphatase
Test of choice for the diagnosis of the above condition
Pancreatic adenocarcinoma
CT abdomen
