Small Bowel, Biliary and Pancreatic Disorders Flashcards
important causes of acute abdomen are ____ or _____, both of which are potentially life threatening!
perforation, obstruction
always consider ____ for any pain waist to chin
MI
what is and causes intussusception?
telescoping invagination of proximal intestinal segment into distal segment (mc occurs at iliocecal junction) idiopathic, post-viral infection, meckel diverticulum
intussusception happens to pt at what age?
children around 2 years old
intussusception causes what characteristic symptoms and PE findings?
severe intermittent abd pain (colicky bc causing a bowel obstruction), screaming, abd distension, vomiting, current jelly
**abd pain causing pt to draw knees up to chest
stools PE: sausage shaped mass in RLQ, dance’s sign (retraction in RLQ)
best initial and definitive test to dx intussusception
initial: US “donut or target” sign definitive (and therapeutic): air contrast enema
tx of intussusception
fluid and electrolyte replacement FIRST reduction by pneumatic air enema (surgery if enema doesn’t work)
what causes appendicitis and at what age ranges do people generally get this?
obstruction of appendix by feca lith or lymphoid hyperplasia MC 10-30 yo
how does appendicitis present and PE findings?
periumbilical/epigastric pain migrating to RLQ, anorexia, SIGNS OF PERITONEAL IRRITATION (rebound tenderness, mcburney’s point tenderness) Psoa’s sign, oburator’s sign (LLQ)
rebound tenderness and referred tenderness are signs of what?
peritoneal irritation
cough pain is a sensitive way to note _____ without putting the patient through testing
rebound tenderness
appendicitis is a ____ Dx but …
clinical Dx but most surgeons will want imaging (CT scan w contrast) before surgery **get surgical consult before imaging in children (more likely to get US in children)
nonoperative txt option increasingly for ______ appendices
non-perforated *perforated will ALWAYS need surgery
positive CT finding of appendicitis shows…
thickened appendix and cecum wall
peptic ulcer: if its perforated what will that cause? What txt will this need?
unrelenting pain that radiates to back, free air under diaphragm. txt: surgery and Abx for anaerobes
what are the 5 Fs for? what are they?
risk factors for Cholelithiasis (biliary tract disease)- gallstones fat, forty, female, fertile, flatulent
what is the definition of cholelithiasis? three complications of this? most common types?
gallstones anywhere in the biliary tract (usually gallbladder) WITHOUT inflammation -comps: acute cholecystitis, choledocholithiasis, acute choleangitis -Cholesterol (MC), black stones (cirrhosis), brown stones
CP for cholelithiasis? how to dx?
most are AS, but if sxs, then BILIARY COLIC (crampy/colicky RUQ pain) triggered with eating fatty foods or large meals *colicky pain due to ball valve effect of stone clogging duct, sxs usually start when stone clogs a duct dx: US is initial test of choice
how to tx cholelithasis?
if AS = observation if sxs = ursodeoxycholic acid (artigall) may be used to dissolve the gallstones (takes 6-9 mo), elective cholecystectomy
what is choledocholithiasis? common sxs? how to dx and tx?
gallstones in the common bile duct CP: PROLONGED biliary colic, jaundice Dx: US often initial test, ERCP test of choice tx: ERCP stone extraction preferred vs cholecystectomy (bc stone actually isn’t in gallbladder)
perforated viscus is most dangerous if…
air under the diaphragm! send to OR!
symptoms of perforated viscus
tachycardia, diffuse guarding, rebound–> board like rigid abdomen.
what is a volvulus? who does this usually happen to?
generally referring to a sigmoid volvulus (most common)- sigmoid gets twisted upon itself. usually happens in older people b/c the sigmoid elongates with age.
proximal volvulus vs distal volvulus: what are the symptoms?
proximal- vomiting distal- distention and pain
symptoms of volvulus
obstruction sxs: crmapy abdominal pain, N/V, distention
neonates: bilious vomiting, colicky pain within first week of birth
vascular ischemia: fever, tachycardia, peritonitis
“beaked” appearance of rectosigmoid junction on a barium enema indicates what?
sigmoid volvulus
best imaging for volvulus? what do you see?
CT- shows mural edema, necrosis as obstruction persists (bowel wall thickening- means ischemia) if theres a perf you see free air
xray of obstruction/volvulus may show what kind of pattern?
“bent inner tube” or “coffee bean” sign: u-shaped, air-filled dilated bowel loops with loss of haustral markings
what is celiac disease (PP)
autoimmune mediated inflammation of small bowel caused by reaction to alpha-gliadin in gluten *autoimmune damage leads to loss of villi which leads to malabsorption
two CP for celiac disease?
1). signs of malabsorption: diarrhea, abdominal pain, distention, fatigue, weight loss, bloating, steatorrhea 2). dermatitis herpetiformis: itchy papulovesicular rash most common over extensor surfaces, neck, trunk, scalp
how to diagnose, screen for and confirm dx of celiac? how to tx?
CLINICAL dx: improvement with GF diet screen by transglutaminase IgA antibodies or endomysial Ab definitive dx: small bowel bx (see atrophy of villa) tx: GF diet
explain these terms related to small bowel obstruction (SBO) closed vs open loop complete vs partial distal vs proximal
closed: lumen is occluded at two points, which can cause ischemia/strangulation open: just closed at one point in bowel complete: obstipation often found (no gas) partial: crampy abdominal pain distal: presents with more abd distention proximal: presents with more vomiting
Common causes of SBO
1 cause is post-surgical adhesions #2 cause if incarcerated hernia malignancy, intussusception
common CPs of SBO
diarrhea that progresses to constipation (obstipation more likely for complete), crampy abd pain that progresses to more constant and severe, vomiting more proximal vs distended more distal, bowel sounds more HYPERACTIVE in early dz which progresses to HYPOACTIVE
how to diagnose SBO
dx: KUB 1st line (air fluid levels in step wise pattern, dilated bowel loops) *UGI series with SB follow through if needed
how to tx SBO (strangulated vs non strangulated)
nonstrangulated: NPO (bowel rest), IVF, bowel decompression via NG tube strangulated or doesn’t resolve spontaneously = surgical intervention
what is acute vs chronic cholecystitis?
acute: inflammation and infection of the gallbladder due to obstruction of the cystic duct (usually by gallstones), E. coli most common bug chronic: fibrosis and thickening of gallbladder due to chronic inflammation (associated with gallstones 95%) of time
clinical sxs and PE of acute cholecystitis
continuous epigastric/RUQ pain, may start after eating fatty foods or large meal, may have NV or anorexia PE: fever, may be palpable gallbladder, + MURPHY’S sign, + BOAS sign (referred pain tp right shoulder)
how diagnose and tx acute cholecystitis?
dx: US initial test of choice, CT is alternative and can detect complications, HIDA scan most accurate tx: NPO, IV fluids, ABX Ceftriaxone + Flagyl, and cholecystectomy
what is acute choleangitis? common causes? most common bug?
ascending biliary tract infection secondary to obstruction of common bile duct, common causes gallstones, post-procedure, malignancy, E. coli is most common bug
common CP of acute cholangitis?
CHARCOT’s TRIAD: fever, RUQ pain, jaundice REYNOLD’s PENTAD: hypotension + AMS
dx and tx of acute cholangitis?
Dx: US initial test of choice, MRCP most accurate, GS = cholangiography Labs: inc alk phos, inc bilirubin Tx: IV abx (ceft + flagyl) followed by CBD decompression and stone extraction once stable (ERCP)
PP of acute pancreatitis? usually caused by what?
acinar cell injury that leads to activation of pancreatic enzymes and autodigestion of pancreas
caused by gallstones and alcohol
CP for acute pancreatitis? two PE signs for necrotizing pancreatitis?
acute epigastric pain that is constant and boring (can radiate to back), pain worsened by eating/supine, NV, fever, tachycardia Cullen’s sign: blue periumbilical discoloration Turner’s sign: grey flank appearance
acute pancreatitis pt vs ureteral colic pt
ureteral colic: writhing in pain acute pancreatitis: in pain, can’t move
labs for acute pancreatitis show what?
elevated lipase and amylase (lipase more indicative)
How to dx and tx acute pancreatitis?
dx: usually US done first to rule out gallstones, Abdominal CT test of choice elevated lipase (more specific than amylase) tx: 90% recover with supportive measures only (pancreatic enzyme, NPO, IV fluids, Pain meds, ABX only for necrotic **surgery only for severe cases
what happens in chronic pancreatitis? MC cause?
progressive inflammatory changes that lead to loss of endocrine and exocrine function MC cause: ETOH use
CP, Dx and Tx of chronic pancreatitis
CP: TRIAD (calcifications, steatorrhea, DM), can also have weight loss Dx: amylase and lipase are normal, CT scan shows calcified pancreas, Abd XR: calcified pancreas Tx: treat underlying cause, oral pancreatic enzyme replacement, surgical therapy only if refractory to medical therapy
most common type of pancreatic cancer? where is primary location of CA? common RF?
adenocarcinoma (ductal) >90% 70% are found in head of pancreas RF: smoking, >55 yo, chronic pancreatitis, ETOH, DM, males
common CP for pancreatic cancer
PAINLESS JAUNDICE (classic)- CBD obstruction, weight loss, abd pain radiating to back, new onset DM, pruritis (due to increased bile salts in skin), dark urine (due to CBD obstruction) *usually have mets to regional lymph nodes and liver upon presentation
what PE finding is specific to pancreatic CA?
courvoisier’s sign: non-palpable, nontender, distended gallbladder due to CBD obstruction
how to dx and tx pancreatic cancer? what is used to monitor after tx?
dx: CT with contrast is initial test of choice (ERCP is most sensitive) if CT neg = endoscopic US to biopsy lesion if CT pos = surgical removal + biopsy Tx: WHIPPLE if cancer is confined to the head + post-op chemo (5-FU) +/- radiation If advanced or inoperative = ERCP with stent placement for palliative care of itching **CA 19-9 usually used to monitor, sometimes CEA
what is ERCP?
endoscopic retrograde cholangiopancreatography, The test looks “upstream” where digestive fluid comes from – the liver, gallbladder, and pancreas – to where it enters the intestines
what is an ileus? what are 4 common causes?
decreased or stopped peristalsis without structural obstruction (usually postop state, meds like opiates, metabolic hypokalemia or hypercalcemia, hypothyroidism)
how do you differentiate between ileus and SBO?
both have similar sxs except ileus ALWAYS has hypoactive bowel sounds and usually no peritoneal signs
dx: abd xr shows “dilated loops of bowel with NO transition zone”
Tx is similar with NPO, fluid/electrolyte replacement, but only NG decompress if persistent mod nv
what is emphysematous cholecystitis? some predisposing factors. how is this dx and tx?
life-theatening form of acute cholecystitis due to infection with gas forming bacteria (i.e. clostridium)
predisposing factors: immunosuppression (age over 50, DM) and vascular disease
dx: imaging shows gas in gallbladder wall
tx: emergent cholecystectomy and IV ABX (zosyn)
what three sxs could you see in an adolescent with undiagnosed celiacs?
1) . failure to thrive
2) . poor linear growth
3) . delayed puberty
what is trousseau’s syndrome?
it is migratory superficial thrombophlebitis which is commonly associated with pancreatic cancer
a patient with acute pancreatitis is at most risk for developing what complication?
pseudocyst
what is gilbert syndrome?
a congenital do in which the liver has a difficult time processing bilirubin. usually people are AS, with occasional jaundice but no further work up necessary
