Week 3 Abdominal Pain DSA Flashcards
Where is the most common location of ischemic colitis?
splenic flexure
(watershed area of SMA and IMA)
What arteries create the watershed area of the sigmoid colon?
IMA and hypogastric A
What are the top 5 considerations for RUQ abd pain?
- Gallbladder
- Duodenal ulcer
- Hepatitis
- Pancreatitis
- Budd-Chiari syndrome
What is Budd-Chiari Syndrome?
occlusion of hepatic vein or IVC that drain the liver
triad of sx: Abd pain, ascites, liver enlargement
How can ascending cholangitis classicly present?
Charcot triad: RUQ pain + fever (and chills) + jaundice
Reynold pentad: Charcot triad + altered mental status + hypotension (signifies acute suppurative cholangitis and is an endoscopic emergency)
What are the most common positive blood cultures seen in ascending cholangitis?
E. coli
Klebsiella
Enterococcus
How do serum aminotransferase levels change in ascending cholangitis?
transient/striking increase
often greater than 1000 units/L
What might you see on X-ray in acute pancreatitis?
sentinal loop - segment of air-filled small intestine (most commonly in LUQ)
Colon cutoff sign
might see calcified gallstones
When should you avoid rapid-bolus IV contrast CT when evaluating pancreatitis?
if serum Cr > 1.5 mg/dL
What are the 4 clinical criteria systems for assessing acute pancreatitis?
Ranson criteria
APACHE II (ICU scoring system for anything to predict hospital mortality)
Bedside Index for Severity in Acute Pancreatitis (BISAP)
HAPS (predicts benign/ non-severe course w/ 98% accuracy)
What lobe of the liver might be prominent in Budd-Chiari Syndrome?
caudate lobe
What is the preferred screening test for Budd-Chiari and what are the other options?
preferred = contrast-enhanced US
color or pulsed-doppler US (unclear if this is the same as contrasted-enhanced US?)
MRI an option
Direct venography - delineate caval webs and occluded hepatic veins (spider-web pattern) most precisely
What are the 2 buzzwords for Budd-Chiari and what do they mean?
spider-web pattern = occluded hepatic veins seen on direct venography
nutmeg liver = the centrilobuluar congestion you would see on biopsy
Where in the world is Budd-Chiari associated w/ a poor standard of living?
india
china
south africa
How long must you stop PPI during tx of H. Pylori to re-do a fecal and breath tests?
14 days
What are the top 4 considerations for LUQ abdominal pain?
- Gastric Ulcer
- Gastritis
- Pancreatitis
- Perforated subdiaphragmatic viscus
(also spleen issues, but not discussed here)
What are the top 6 considerations for RLQ abdominal Pain?
- appendicitis
- ectopic pregnancy
- Ovarian torsion
- IBD (CD>UC)
- Ogilvie syndrome
- Meckel’s diverticulum
Which type of IBD is more likely to present with RLQ abd pain?
What about LLQ?
RLQ = Crohn’s Dz
LLQ = UC
How might a retrocecal appendix present with inflammation?
might have RUQ pain
(instead of the classic RLQ pain)
What typically initiates appendicitis?
a fecalith obstructs the appendix –> increased intraluminal pressure, venous congestion, infection
(obstruction might also be caused by inflammation, foreign body, or neoplasm)
What is the association w/ the appendix and Ulcerative Colitis?
appendectomy before age 21 –> protective against UC
Where do ectopic pregnancies most often occur?
tubal
How do you dx ectopic pregnancy?
severe lower quadrant abd pain
+ pregnancy test, but failure of HCG to double every 48 hrs
no intrauterine pregnancy on transvaginal US
On which side do ovarian torsions most commonly occur and why?
70% on right side
due to increased length of utero-ovarian L on the R and the sigmoid colon on left limiting space
What IBD sx may mimic appendicitis?
acute ileitis in Crohn Disease
What is Ogilvie syndrome?
acute colonic psuedo obstruction
spontaneous massive dilation of cecum or R colon without mechanical obstruction
what imaging do you do to dx and manage ogilvie syndrome?
X-ray or CT to dx
do repead imaging every 12 hours to acess cecal size
What cecal diameter in ogilvie syndrome is alarming?
greater than 10-12 cm is associated w/ increased risk of colonic perforation
How do you manage Ogilvie syndrome?
conservative = first step if cecum is smaller than 12 cm
tx underlying illness
nasogastric and rectal tube should be placed
stop all drugs that might reduce intestinal motility (opiods, anticholinergics and CCBs)
*oral laxitives not helpful
intervention if needed
When do you do intervention (vs conservative tx) in ogilvie syn?
considered in pts with any of the following:
no improvement or get worse after 24-48 hrs of conservative tx
cecal dilation > 10 cm for more than 3-4 days
cecal dilation > 12 cm
What are the 3 intervention methods for Ogilvie Syn?
neostigmine injection –> rapid decompression; monitor heart (risk of bradycardia)
colonoscopic decompression w/ aspiration of air or decompression tube
surgery if other stuff doesnt work = tube cecostomy
What cardiac drug must be stopped if a person develops ogilvie syn?
CCBs
On what side is colon cancer more common?
LLQ
What are the 5 top considerations in periumbilical abd pain?
- early appendicitis
- mesenteric A ischemia
- ruptured aortic aneurysm
- bowel obstruction
- IBD
What is the test of choice to see vasculature in mesenteric ischemia?
CT angiography of abd and pelvis w/ IV contrast
How does chronic mesenteric ischemia present?
abdominal angina - dull, crampy periumbilical pain 15-30 min after a meal and lasting for several hours; food fear, weight loss, diarrhea occasionally
evaluate w/ mesenteric arteriography for possible bypass graft surg
Who gets primary bacterial peritonitis most commonly?
pts w/ cirrhosis
How do you diagnosis primary bacterial peritonitis?
Tx?
peritoneal fluid is sampled and has > 250 PMNs/uL
Tx: 3rd gen cephalosporin and piperacillin/tazobactam
What bacteria cause secondary peritonitis?
mixed flora
gram negative bacilli and anaerobes predominate
What is the significance of the HFE gene?
gene that encodes a protein that regulates iron uptake –> mutation leads to autosomal recessive hemochromatosis –> leads to increased susceptibility to yersinia infection
