Week 7 GI Flashcards
GI red flags
Orthostatic hypotension
Weight loss
Iron deficiency anemia
New onset pain
> 50 years old
Early satiety
Palpable mass
Fever
Change in bowel habits
Fecal incontinence
melena/coffee ground emesis
Guaiac positive stools
Dysphagia
Odynophagia
Long term NSAID use
Persistent hoarseness
Chest pain
Smoker / hx of smoking
Hx heavy ETOH use
Failure to improve w treatment
Pain out of proportion to exam
Abdominal distension
Increase LFT/jaundice
Abnormal PE
pediatric red flags
bilious vomit
fever
bloody diarrhea
weight loss/poor weight gain
nocturnal pain or diarrhea
lethargic
toxic appearing
gold standard imaging for appendicitis
CT scan
Ultrasound imaging for what GI issues
cholecystitis, pyloric stenosis, intussusception, pancreatitis
2-3 weeks of age, projectile nonbilious vomiting immediately after feeding, Caucasian 1st born males
pyloric stenosis
insatiable appetite, weight loss, dehydration, constipation
get ultrasound
manage with fluid/electrolytes, surgery
burning, aching, gnawing pain 2-5 hours after last meal
relieved by food or antacids
epigastric pain
- peptic ulcer disease: mucosal defect in gastric area
- H pylori
- tx: antibiotics and PPI first line
- complications: bleeding ulcer/perforation
gold standard test for h pylori?
gold standard imaging?
- urea breath test (stop PPI 1 week prior)
- or stool antigen testing (stop PPI 4 wks prior
- both shows active infxn
- (antibodies useless bc it lasts for years so doesn’t tell us active infection)
imaging: EGD (esophagogastroduodenoscopy)
Eradication therapy for Helicobacter pylori in children
amoxicillin
clarithromycin
PPI - omeprazole/ranitidine
BID
common causes of acute pancreatitis
I GET SMASHED
- Idiopathic
- Gallstones *2nd common
- Ethanol *1st common
- Trauma
- Steroids
- Mumps/malignancy
- Autoimmune
- Scorpion sting
- Hypertriglycerides/lipidemia or Hypercalcemia
- ERCP
- Drugs
first line imaging for acute pancreatitis
abdominal ultrasound
Diagnosis of pancreatitis
2 or more:
- epigastric pain consistent with pancreatitis
- Serum lipase and amylase > 3 times upper limit of normal
- Abd Ultrasound
clinical presentation of acute pancreatitis
- severe sudden onset of constant, sharp, poorly localized abdominal pain radiating to back (pancreas retroperitoneal)
- Epigastric or LUQ pain, worse when lying down
- Cullen sign (bruising around umbilicus)
- Grey turner (bruising of flank)
- rebound tenderness = late sign
cholelithiasis clinical manifestations
- [gallstones]
- RUQ pain/tenderness
- biliary colic with intermittent or steady pain radiates to R posterior shoulder after 1 hour eating a large meal esp high fat
- mild to severe; lasts 1-6 hrs
- n/v
acute cholecystitis clinical manifestations
- biliary colic lasts longer 4-6 hrs
- sharper RUQ pain, radiates to R shoulder/scapula esp after eating fatty foods
- Charcot triad: RUQ pain, fever, jaundice
- muscle guarding/rigidity
- distended tender gallbladder (confirms)
- hypoactive bowel sounds
- Murphy’s sign (inability to take deep breath from discomfort during palpation under right costal margin)
- sometimes jaundice if biliary obstruction
risk factors for cholelithiasis
- increasing age (> 45 yrs)
- obese, rapid weight loss
- pregnancy
- fibrates, OC, estrogen, progesteron, ceftriaxone
- females
- TPN, fasting
- metabolic dz (crohns, cirrhosis, DM etc)
when to send to ER for cholelithiasis
severe pain or bilirubin elevated
Labs for cholelithiasis/cystitis
CBC
UA
LFT
electrolytes, BUN, Cr
intussusception clinical manifestations
- 3 months - 3 years old
- sudden RLQ pain, palpable mass sausage shaped
- classic triad:
- intermittent colickly (crampy) abdominal pain
- non bilious vomiting
- currant jelly mucous stools / + guaiac stools
intussusception diagnostics and management
- Dx: abd US
- Dx & tx: air contract enema
- management:
- emergency management and consult with pediatric radiologist and surgeon
- rehydration
- surgery if perforation, peritonitis, hypovolemic shock
- observe 12-18 hrs
- LLQ, colicky abdominal pain with no inflammatory process (spasms of sigmoid colon)
- <102F
- leukocytosis
- constipation
- hyperactive bowel sounds
- peritonitis if have abdomen tenderness
diverticulosis
diverticulosis labs
CBC, ESR, UA, stool for occult, Sed Rate, BMP
what imaging for diverticulosis? when is it warranted?
NO imaging needed if pt has classic sx’s (LLQ, intermittent pain, low grade temp) and not septic
want imaging if signs of peritonitis (rigid abdomen, bloody stool, 102+F) = abdomen CT
diverticulosis management
- Mild leukocytosis, low fever, minimum and tenderness: outpatient
- Clear liquid diet x 2-3 days
- Metronidazole + Cipro if >101F or elevated leukocytosis
- f/u few days
- Moderate to severe complications
- High fever, septic, abscess, rectal bleeding = HOSPITALIZE! Can get complications like sepsis
- Educate: 30-35g fiber/day, nuts and seeds okay
- f/u GI 4-6 wks later for underlying cancer
diverticulosis vs diverticulitis
diverticulosis is out pouching saclike hernias of mucosa wall from increased pressure gradient/wall weakness
Diverticulitis is from stagnant fecal in single diverticulum = pressure necrosis = inflammation = can cause perforation
hemorrhoids
masses of vascular tissue that cushion in submucosal layer of anal canal
maintain anal closure and continence
normal anatomic structures until they cause symptoms
hemorrhoids sx’s (internal vs external)
- bleeding, pruritic, protrusion, pain
- internal: painless, bright red rectal bleeding; blood on toilet paper/water/ on stool
- external: less likely to bleed; asymptomatic unless thrombosis develops; anal irritation, pruritic, palpable nodule
hemorrhoid management
conservatively or little/no tx
high fiber, increase fluid intake
bulk forming agents/stool stiffeners
sitz baths
oral analgesics for inflammation
hemorrhoid management
conservatively or little/no tx
high fiber, increase fluid intake
bulk forming agents/stool stiffeners
sitz baths
oral analgesics for inflammation
pediatric dehydration volume repletion (mild, moderate, severe)
- Oral pedialyte preferred than sports drink /apple juice
- Mild: 50mL/kg over 4 hours
- Moderate: 100mL/kg over 4 hours
- Severe: NS or LR IV 20mL/kg boluses
gastroenteritis
- norovirus
- severe diarrhea young children
- fecal-oral
- watery diarrhea x 3-8 days, cramps, chills, dehydration
gastroenteritis management
- NO antibiotic; tx is oral rehydration therapy
- should resolve in 1 week
- serious infxn sx’s:
- food borne illness
- bloody diarrhea, weight loss, severe abdominal pain, high fever
- neuro involvement
- if diarrhea > 2 weeks + sx’s above: get labs
- stool culture and examination for parasites
- CBC
- electrolytes
severe rectal pain with bowel movement
burning, tearing, bright red bleeding on toilet/tissue
anal fissure
can be from trauma from large hard stool
anal fissure management
- if chronic → nitrates/nitroglycerin = inc blood flow to this area to heal better
- Refer for surgery conservative therapy don’t work
- educate: 6 weeks to heal
- keep stools soft w/ high fiber diet, increase fluid, possible laxatives, sitz bath, lidocaine cream, stool softeners
epigastric/periumbilical pain migrating to RLQ, abdominal rigidity
after pain occurs, these sx’s occurs: n/v, anorexia, constipation, low fever
appendicitis
Refer ASAP! Hospitalization and surgery may be needed
appendicitis signs
- elevated WBC
- rebound tenderness, guarding
- rovsing sign - pressing LLQ causes pain in RLQ
- obturator sign - passive rotate R leg with R hip and knee flexed while supine
- psoas sign - supine, raise straightened R leg against resistance by me
- mc Burney’s sign - pain when pressing down midpoint of RLQ
appendicitis imaging for adult vs children
adult: CT abdomen/pelvis with contrast
children: Ultrasound
appendicitis management
treatment: appendectomy w/in 24 hrs of sx onset to prevent perforation/peritonitis
(NPO, IV fluids, e- repletion)
if appendix perforated = antibiotic therapy to cover
