week 10 Flashcards
what is typically right upper, right lower and left lower quadrants
right upper= liver and gallbladder
right lower= appendix
left lower= diverticulitis
must not miss conditions in the presence of abdominal pain
- Appendicitis
- Bowel obstruction
- Abdominal malignancy
- Cardiovascular origins of abdominal pain
- Gynecological: PID, ectopic pregnancy, ovarian torsion
4 highest LR+ for appendicitis
- right lower quadrant pain
- migrating pain from periumbilical area to right lower quadrant
- fever
- psoas sign
appendicitis imagining
abdominal CT scan or ultrasound if pregnant
what to do If have appendicitis
need antibiotics of surgery
may progress to ischemia, necrosis, perforation of bowel and sepsis
what is more common bowel obstruction of large or small bowel
small (76%)
ethology of large vs small bowel obstruction
large
* Cancer (53%)
* Sigmoid or cecal volvulus (17%)
* Diverticular disease (12%)
* Extrinsic compression from metastatic cancer (6%)
* Other (12%)
small
* Postsurgical adhesions, 70%
* Malignant (usually metastatic) tumor, 10–20%
* Hernia (ventral, inguinal, or internal), 10%
* IBD (with stricture), 5%
* Radiation
signs of bowel obstruction
absent bowel sounds and flatus
large bowel obstruction LR+
- constripation; LR+ = 8.8
- abdominal distention; LR+ = 5.7
- pain decreasing after vomiting LR+ - 4.5
small and large bowel obstruction LR+
- increased bowel sounds with history of prior surgery, LR+ =11
- distention associated with increased bowel sounds, vomiting, constipation or prior surgery, LR+= 10
- increased bowel sounds after vomiting, LR+ = 8
testing for large bowel obstruction
CT scan, barium enema for large bowel obstruction
testing for small bowel obstruction
radiograph (x-ray), ultrasound, CT scan
complete vs partial small bowel obstruction
complete could progress to bowel strangulation and infarction
-clinical signs DO NOT allow for identification of strangulation prior to infarction
-surgery
partial
-rarely progressed to strangulation of infarction
-can still pass stool or flatus
-resolves spontaneously
abdominal malignancy
- Colorectal cancer
- Gynecological cancers
- Pancreatic cancer
- Gall bladder/bile duct cancer
- Gastric cancer
- Liver cancer
systemic symptoms of cancer
- Unintentional weight loss (up to 36% of cancer diagnoses)
- Loss of appetite
- Significant night sweats
- Symptoms waking patient from sleep (diarrhea e.g.)
cardiovascular origins of abdominal pain
- Abdominal Aortic Aneurysm (AAA)
- Myocardial infarction (see Cardiovascular lecture)
- Pericarditis (see Cardiovascular lecture)
- Aortic dissection (see Cardiovascular lecture)
- Mesenteric ischemia
abdominal aortic aneurysm symptoms
- Pulsatile abdominal mass with ruptured AAA (LR+, 8.0; LR–, 0.6)
- Sensitivity severely limited in patients with rupture, large girth
- In patients without AAA rupture who are symptomatic:
- Abdominal pain: 83%
- Flank or back pain: 61–66%
- Syncope: 26%
- Abdominal mass on careful exam: 52% (only 18% had abdominal mass noted on routine abdominal exam)
- Hypotension or orthostasis: 48%
mesenteric ischemia acute vs chronic signs and symptoms
Acute:
* Abdominal pain intensity out of proportion to exam is a classic finding but is absent in 20–25%
* Vomiting (71%)
* Diarrhea (42%)
* Prior history of intestinal angina (50%)
Chronic:
* Recurrent postprandial abdominal pain (often in first hour and diminishing 1–2 hours later)
* food fear, weight loss
* history of tobacco use (75%),
* peripheral vascular disease (55%)
* coronary artery disease (43%)
* hypertension (37%)
* Abdominal pain: 94%
* Typically epigastric or periumbilical pain
* Postprandial pain: 88%
* Weight loss due to food aversion: 78%
* Diarrhea: 36%
IMAGING for mesenteric ischemia acute vs chronic
- CT angiography for acute
- Ultrasonography for chronic
gynecological conditions
Ectopic pregnancy
Ovarian torsion
Pelvic Inflammatory Disease (PID)
etopic pregnancy signs and symptoms
- Severe lower quadrant pain occurs in almost every case.
- Pain sudden onset , stabbing, intermittent, does not radiate
- At least 2/3 patients have a history of abnormal menstruation
- Slight vaginal bleeding (spotting)
- Pelvic adnexal mass may be palpable
investigations for topic pregnancy
serum beta- hCH (pregnancy test) and pelvic ultrasound
what is ovarian torsion
Ischemia or necrosis of the ovary usually due to the presence
of cyst or mass
who is at risk for ovarian torsion
pre-menarchal patients (before first period) and in pregnancy
ovarian torsion signs and symtposm
Almost 70% of torsions occur on the right side
* Sudden-onset, severe, unilateral, lower abdominal pain
* Pain may also have gradual onset and be mild or intermittent
* Nausea and vomiting present in 70% of cases
* Abdominal tenderness and guarding on palpation
* Presence of latero-uterine mass
* Close to 30% of patients have bilateral adnexal tenderness on bimanual examination
which side is ovarian torsion usually on
right side (70%)
investigation for ovarian torsion
transvaginal ultrasound with droppler
prognosis of ovarian torsion
Ovary and fallopian tube can be saved depending on duration and extent of ischemia/necrosis
signs and symptoms of pelvic inflammatory disease
- Lower abdominal pain
- Chills and fever
- Menstrual disturbances
- Purulent cervical discharge
- Cervical and adnexal tenderness
prognosis of pelvic inflammatory disease
- About 20% of women with PID become infertile, 40% develop chronic pain, and 1% of women who conceive have an ectopic pregnancy
- Can resolve spontaneously
investigations for pelvic inflammatory disease
- C-reactive Protein (CRP)
- Erythrocyte Sedimentation Rate (ESR)
- Endocervical culture
- Neisseria gonorrhoeae or Chlamydia trachomatis
other causes of abdominal pain
- Peptic Ulcer Disease
- Cholecystitis
- Cholelithiasis
- Nephrolithiasis
- Acute & Chronic Pancreatitis
- Diverticular disease
- Autoimmune conditions
- Infectious gastroenteritis
- Functional disorders
where do you get ulcer in peptic ulcer disease
gastric or duodenal lining
2 most common causes of peptic ulcer disease
- NSAID use
- H pylori infection
what increases risk or peptic ulcer disease
age
symptoms of peptic ulcer disease
could be asymptomatic
weight lossi
1st sign might be lift threatening complication like hemorrhage or perforation or bleeding
test for h pylori
- Urea breath test
- Stool antigen test
- Blood test (antibodies): cannot distinguish between past and current H. pylori infection
imaging for peptic ulcer disaese
- Esophagogastroduodenoscopy (EGD) (endoscopy) only recommended for >60 years old or if alarm features present
cholecystitis
Inflammation of the gall bladder and or bile ducts, secondary to cystic duct obstruction
high LR for cholecytitis
Murphys sign, right upper quadrant pain, fever, jaundice
investigations for cholecystitis
- Leukocytosis (elevated white blood cell count): (> 10,000/mcL) present in 52–63% of patients.
- Ultrasound
- Cholelithiasis is usually present (84–99%)
- Cholecystitis does not typically cause significant increases in lipase or liver biochemical tests
nephrolithiasis is aka
kidney stones
risk for nephrolithiasis
previous occurrence, men, family history
signs for nephrolithiasis
- Rapid onset of excruciating back and flank pain, may radiate to the abdomen or groin
- Pain may be associated with nausea, vomiting, dysuria, or urinary frequency
- Abdominal tenderness unusual
- Hematuria (gross or microscopic) (blood in urine) may be present, but absence does not rule out (LR+, 1.4; LR–, 0.49)
what investigations for nephrolithiasis
non contrast renal CT, urine culture, ph and stone analysis, serum calcium
what is the most common type of kidney stone
calcium oxalate stones
main causes of acute pancreatitis
80% is alcohol abuse and choledocholithiasis (obstruction of common bile duct(
20% of cases are idiopathic (undetermined cause), maybe due to microlithiasis or sphincter of oddi dysfunction
symptoms of acute pancreatitis
Signs & Symptoms
* Low-grade fevers (< 38.3°C) are common (60%).
* Pain may radiate to the back (50%) and may be exacerbated
in the supine position.
* Nausea and vomiting are usually present (75%).
* Rebound is rare on presentation; guarding is common (50%).
* Periumbilical bruising (Cullen sign) is rare.
* Pancreatitis (and other diseases) can lead to retroperitoneal bleeding and flank bruising (Grey Turner sign), which is a rare but valuable clue if present.
blood tests and imaging for acute pancreatitis
lipase, amylas, ALT or AST
transabdominal ultrasounds
chronic pancreatitis
recurrent acute pancreatitis from alcohol Abuse 70%
signs of chronic pancreatitis
Signs & Symptoms
* Chronic, disabling, mid-epigastric postprandial pain (80–100% of patients)
* Pain may radiate to the back and be relieved by sitting forward
* Abdominal bloating (30% of cases)
* Unintentional weight loss and diarrhea (68% of patients)
* Weight loss secondary to anorexia and malabsorption with steatorrhea
stetorrhea
- Manifestations include difficult to flush oily stools and weight loss
- Floating stools are not specific for steatorrhea. Bacterial gas may also cause stools to float.
diverticulitis vs diverticulosis
- Acute inflammation of outpouching of large intestine = diverticulitis
- Presence of outpouching = diverticulosis
itis= inflammation
where is pain in diverticular disease
left lower quadrant
signs of diverticular disease
- Left lower quadrant tenderness: (LR+, 3.4; LR–, 0.41)
- May present with fever (45% of cases)
scan for diverticular disease
ct scan
Potential complications of diverticulitis:
Potential complications of diverticulitis:
* Abscess
* Peritonitis
* Sepsis
* Colonic obstruction
* Fistula formation
2 types of infalmmatory bowel disease
ulcerative colitis and crohns disease
when to evaluate IBD and celiac disease
chronic diarrhea and ab pain
potential causes of diarrhea
Potential causes of diarrhea
* Infectious
* Bacterial, viral, parasitic
* Antibiotic Side Effect
* Autoimmune/inflammatory
* Ulcerative colitis
* Crohn’s disease
* Celiac disease
* Endocrine
* Hyperthyroid
* Bile acid malabsorption
* Dietary
* Food intolerances
* Food sensitivities
* Functional GI conditions
functional GI disorder
- Disorders of the Gut-Brain Interaction (DGBI)
- Limited abnormalities on diagnostic testing
- Symptom clusters
- Potential processes involved:
- Impaired GI motility
- Altered microbiome
- Visceral hypersensitivity
- Mucosal layer alterations
what is the difference between functional diarrhea and constripation and IBS
- IBS includes pain/visceral hypersensitivity, whereas FD and FC do not
- In both cases there is no clear cause that can be reliably tested
IBS ROME IV FCRITERIA
Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria:
1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (appearance) of stool
* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
britstol stool scale
1= constipated
4= normal
7= diarrhea
IBS-C, IBS-D, IBS-M, IBS-U
IBS-C (Constipation dominant)
* >25% of bowel movements with Bristol stool types 1 and 2 and <25% Bristol stool charts type 6 or 7.
IBS-D (Diarrhea dominant)
* >25% of bowel movements with Bristol stool types 6 and 7 and <25% Bristol stool charts type 1 or 2.
IBS-M (Mixed)
* >25% of bowel movements with Bristol stool types 1 and 2 and >25% Bristol stool charts type 6 or 7.
IBS-U (Unclassified)
* Patients who meet IBS criteria but whose bowel habits do not fall into the above categories.
testing for IBS-D or functional diarrhea
CBC, CRP, celiac disease
fecal calprotectin (to exclude IBD)
colonoscopy if >50 yrs +alarm features
SeHCAT for bile acid diarrhea
alarm features in IBS-D
Alarm features:
* Unintentional weight loss
* Nocturnal diarrhea
* Tenesmus
* Passing of bright red blood in stool (haematochezia)
* High‐volume diarrhea, or very high number of bowel movements
* Suspicion of malnutrition
* Family history of colorectal cancer
SIBO testing in IBS-D or functional diarrhea
recommend against SIBO testing unless predisposing conditions (e.g. gastrointestinalmotility diseases, gastrointestinal anatomical abnormalities, hypochlorhydria, various immune deficiency conditions, signs of malabsorption).
also recommend against microbiota (stool tests)
chronic constipation epidemiology
- More prevalent in females than males
- Prevalence increases with age
- Genetic predisposition
chronic/ functional constipation vs IBS- C
symptoms with absence of pain/visceral hypersensitivity
things to look for in digital rectal exam that can cause constipation
detect stool in the rectal vault, anorectal masses, hemorrhoids, anal fissures, rectal prolapse, and rectoceles that may cause constipation
rome IV criteria in functional constripation
- Straining with bowel movement
- Hard stools (Bristol 1‐2)
- Sensation of incomplete evacuation
- Sensation of anorectal obstruction
- Need for manual maneuvers to facilitate evacuation
- Less than 3 spontaneous bowel movements per week *present in 25% of bowel movements (ESNM 2022) *NB: absence of abdominal pain
red flag/ alarms in constipation
- Blood in stool
- Weight loss
- Anemia
- Family history of colon cancer, celiac disease or inflammatory bowel disease
- Acute onset at age older than 50
- Significant pain
- Vomiting, especially if recurrent
- Fever
prognosis of IBS
- Not at increased risk for colorectal cancer
- Small increased risk of developing celiac and IBD 5 years
post-diagnosis - Quality of life an important factor to consider
labs for IBS
IgG food sensitiivity
SIBO testing
SIBO risk factors
- Dysmotility (impaired motility of small intestine)
- Proton Pump Inhibitor (PPI) use
- Surgeries (gastric bypass)
- Conditions reducing acid secretion (H. pylori e.g.)
- Connective tissue disorders (Not significant based on Bohm 2020 study)
SIBO signs and symptoms
diarrhea, ab pain, bloating
maybe asymptomatic
- Diarrhea and/or constipation
- Esophageal reflux
- Dyspepsia
- Belching and/or flatulence
- Nausea
- Fatigue
does the lactulose breath test or glucose breath test for SIBO have a higher LR+
glucose; LR+ 3.24
testing for SIBO
-duodenal aspirate via endoscopy (accurate, but lack standardization and expensive)
-lactulose breath test Lr+ 1.43
-glucose breath test LR+ 3.24
allergy vs intolerance vs delayed sensitivity
- Allergy
- IgE mediated (Type I reaction)
- Short reaction time (minutes to hours) * Sxs: Anaphylaxis, urticaria, vomiting
- Intolerance
- Lacking enzyme for digestion (lactose e.g.)
- Sxs: abdominal bloating, gas, diarrhea, constipation…
- Delayed sensitivity
- IgG-mediated?
- Delayed reaction: up to 72 hours * Symptoms are varied
immunoglobulins in allergy vs delayed sensitivity
allergy- IgE
sensitivity- IgG
intolerance= lack __
enzyme
Do IgG antibody levels correspond to symptoms?
“In the light of current scientific knowledge, the IgG-specific antibody-mediated reactions are a body’s natural and normal defensive reactions to infiltrating food antigens, which are considered as pathogens. On the other hand, specific IgG antibodies against food allergens play a crucial role in the induction and maintaining of immunological tolerance to food antigens”
elimination diets based on IgG and IBS
see some benefits in IBS, quality of life, headaches,
food sensitivity testing
- Lack of published research to suggest a clear association between elevated serum IgG levels and clinical symptoms
- Mixed data suggests some improvement in IBS (and other) symptoms following an IgG-based elimination diet
- However:
- Studies are few and sample sizes are generally small
- Symptom improvements may be due to elimination of commonly aggravating foods in IBS, such as dairy and wheat (Hunter 2005)
pathogenesis of pain, gut brain axis and psychosocial factors
- Chronic Disorders of Gut-Brain Interaction pain is real
- Pain is perceived from sensory signals that are processed and
modulated in the brain - Peripheral factors can drive increased pain
- Pain is modifiable
patient dialogue around testing and treatment of IBS
“Phrase the diagnosis as “You have IBS”. This use of qualified language increases patient acceptance, reduces apprehension, and provides a framework to build upon for treatment recommendations, medication adherence, and a positive patient- provider relationship.
- Set shared goals and expectations for pain management
- “Phrase the diagnosis as “You have IBS” instead of “We think
you have IBS”. - This use of qualified language increases patient acceptance, reduces apprehension, and provides a framework to build upon for treatment recommendations, medication adherence, and a positive patient-provider relationship
