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86 Cards in this Set
- Front
- Back
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what are the 3 diagnosis that accounts for the majority of acute abdominal pain?
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biliary disease- cholesthiasis, pancreatitis
Appendicitis Small bowel obstruction |
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how does a patient that needs an urgent surgical referral present?
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-rapid onset of symptoms
-severe pain -altered VS (fever, tachycardia) -dehydration -pallor -sweating |
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Red flags of abdominal pain
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-awakens from sleep
-continues more than 6 hrs -changes from original pattern -accompanied by syncope -precedes vomiting |
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how do elderly patients with Gastrointestinal diseases present?
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-present with lethargy and mental status changes
-Less likely: to become febrile, develop leukocytosis, may report/display typical pain |
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what are emergent differentials for abdominal pain?
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-Cardiopulmonary--atypical ischemia, dissecting aortic aneurysm, pulmonary embolism
-GI--appendicitis, cholecystitis, diverticulitis, small bowel obstruction, perforated peptic ulcer, peritonitis, bowel perforation, hemorrhagic or severe acute pancreatitis |
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Clinical Presentation of Peritonitis
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-Patients look sick
-Abdominal wall rigidity -Pain heightened w/mvmt and jarring -Iliopsoas, Markle sign -Diminished bowel sounds -Fever -Tachycardia -Hypotension |
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Markle sign
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a clinical sign in which pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing
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Peritonitis Diagnostics
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Labs:
-Ascitic fluid analysis, CBC, CMP, -HCG (childbearing age) -Amylase Imaging -Upright chest and abdominal x-ray for free air and air/fluid levels -CT scan- partial or incomplete obstruction -US guided aspiration |
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Management of Nausea/Vomiting
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-Correct / address the underlying cause
-Make sure to R/O intestinal obstruction or acute abdomen -Uncomplicated gastroenteritis-fluids and diet restriction - clear liquid followed by BRAT -Follow with bland diet -May need antiemetics and IV hydration |
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Name Antiemetics
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-Bismuth Subsalicylate – Pepto- Bismol
-Dimenhydrinate – Dramamine -Ondansetron- Zofran -Metoclopramide hydrochloride – Reglan -Prochlorperazine – Compazine -Promethazine hydrochloride – Phenergan -Trimethobenzamide hydrochloride - Tigan |
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Diagnostics for Nausea/Vomiting
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CMP, LFT's, Indicated drug levels,
Amylase, β HCG, UA with culture, CBC with differential, TSH, Ultra sound, Barium swallow, CT, EGD |
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4 types of Diarrhea
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1) Osmotic/Malabsorptive- lactose deficiency, magnesium
2) Secretory- Virus, Bacterial endotoxins 3) Exudative (Inflammatory)- inflammatory bowel disease 4) Secondary to Impaired Motility- IBS, hyperthyroid, bacterial overgrowth |
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what are the diagnostic labs for diarrhea?
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-stool assay if diarrhea > 2 weeks
-stool for O&P, WBC, C&S, occult blood -C diff (when indicated: exposed, hospitalized, on abx) -Giardia antigen (when indicated: foreign travel) -Sudan stain for fecal fat (when indicated) |
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Diarrhea management
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-Avoid antimotility drugs if infectious diarrhea
-can treat empirically without cultures with trimethoprim-sulfamethoxazole (TMP-SMZ) for traveler's diarrhea--Four or more unformed stools daily, fever, blood, pus, or mucus in the stool -Consider empiric |
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ABX treatment for diarrhea
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-Ciprofloxacin 500mg BID 3-5 days
-Norfloxacin 400mg BID 3-5 days -Azithromycin 500mg PO daily for 3 days -TMP-SMZ in children |
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Norovirus-- Viral Gastroenteritis
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-common cause of sporadic diarrhea and outbreaks of acute gastroenteritis (>90%)
-incubation period 1-2 days >50% vomiting, duration of illness 12-60 hrs -stool culture negative -diarrhea and vomiting in 70-90% -Low grade fever in 50% |
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how is norovirus transmitted?
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-Low infectious inoculum (18 viral particles)
-Multiple modes of transmission: Food & water, Person-to-person (prolonged shedding, 25% > 3 weeks), Air-borne (vomitus is loaded with virus) -Fomites live on computer keyboards/mouse -Resistant to disinfection |
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how do we prevent transmission of norovirus gastroenteritis?
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-Exclusion from work until asymptomatic > 72h
-On return to work restricted from handling kitchenware and ready-to-eat food for another 72hours -Hand washing |
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Management of Viral Gastroenteritis
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-Patient education regarding transmission
-Antiemetics -Hydration |
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Clinical Manifestations of Salmonella poisoning
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-Nausea, vomiting, fever, diarrhea, and cramping, usually occur within 24 to 72 hours of ingesting contaminated food or water
-Pea soup diarrhea -Self-limited, 4-10 days of diarrhea -Fever resolves in 48-72 hours >10 days warrants further investigatio |
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Management of Salmonellosis
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-Fluids and electrolytes
-Immunocompetent age 2-50 that are mild to moderately ill = NO ANTIBIOTICS -Immunocompetent age 2-50 that are severely ill= 3-7 day course of a fluoroquinolone OR third generation cephalosporin -Immunocompromised adults and |
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Management of Noninfectious diarrhea
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-Correction of fluid and electrolytes
-Treat underlying cause -If bacterial - use antibiotic or if evidence of fecal leukocytes -Antimotility meds (Imodium, Kaopectate, donatol) -Resume solid foods when symptoms subside |
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List the Rome III Criteria for Constipation
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1)Must include two or more of the following:
Straining Lumpy or hard stools Sensation of incomplete evacuation Sensation of anorectal obstruction and blockage Manual maneuvers to facilitate at defecations Fewer than 3 defecations per week 2) Loose stools are rarely present without the use of laxatives 3) There are insufficient criteria for IBS |
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what are drugs that cause constipation?
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Analgesics
Anticholinergics Antihistamines Antispasmodics Antidepressants Antipsychotics Iron supplements Aluminum (antacids, sucralfate) Neurally active agents Opiates Antihypertensives- Ca channel blockers |
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Management of Constipation
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-Address contributing factors
-Bowel retraining: have regular time set aside, 10-15mins after a meal, increase activity -Diet: high in fiber and fluids -Laxatives: Bulk-forming agents, Emolients (stool softeners), Osmolar agents (mag sulfate, lactu |
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Clinical Presentation of GERD
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-Persistent heartburn worse 1 hr after eating
-Persistent acid regurgitation - water brash (increased saliva secretion) -Chest pain -Dysphagia (difficult or painful swallowing) - Odynophagia - Globus sensation |
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Who is at risk for GERD?
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-Hiatal hernia
-Overweight -Cigarette smoking -Excessive alcohol consumption -Medications: Calcium channel blockers, progesterone, theophylline, NSAIDS, Acetylsalicylic acid, tetracycline, potassium chloride tablets |
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GERD Diagnostics
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-History
-Labs: CBC w diff, H. pylori IgG, stool for OB X 3 -Esophagogastroduodenoscopy Indicated for…Age- 50yrs +, Pos FOB, Persistent dysphagia, No success with empiric therapy, Long-standing symptoms requiring continued therapy -Biopsy indicate |
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Management of GERD
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-Smoking cessation
-Decreased alcohol consumption -Weight loss -Eliminate meds/foods that irritate mucosa/LES -Raise head of bed 6-8 inches -Avoid laying down for 2-3 hours after meals -Avoid tight fitting clothes -H2 antagonists/PPI |
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what are consquences of GERD?
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-Esophageal stricture
-Reflux induced asthma -Laryngitis -Chronic cough -Dental erosions -Laryngeal cancer -Barrett esophagus |
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when do you refer to Gastroenterology for pts with GERD?
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-Patient 50yrs of age +
-Dysphagia - difficult or painful swallowing -Odynphagia - pain with swallowing -Iron deficiency anemia -Weight loss -Positive occult blood -Obstructive symptoms- n/v or early satiety -Anorexia |
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Clinical Manifestations of Acute Gastritis
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-Epigastric pain
-Abdominal pain after meals/eating food -Relief with antacids -Anorexia -Melena -Hematochezia/Blood per Rectum -LUQ Pain/Tenderness -Painful vomiting -Persistent nausea -Precipitated by ingestion of caustic agent |
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Management of Acute Gastritis
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-Treatment of acute hemorrhagic gastritis depends upon the cause
-Eliminate offensive agent(s) -Diet modification -PPI therapy -Carafate- coats the stomach 1g 4 times/day, 1 hour before food and at bedtime for 4-8 weeks -Address anemia if present |
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Diagnostics for Acute and Chronic Gastritis
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-CBC, FOB
-Testing for H. pylori in chronic gastritis -EGD if evidence of bleeding -Biopsy is required to distinguish between acute, chronic active, and chronic gastritis |
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what bacteria is present in 90% of pts with chronic gastritis of the antrum?
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Helicobacter pylori
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how do you diagnose H pylori?
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Biopsy (most accurate)
-Urea breath testing* -Serology (IgG) low sensitivity -Stool antigen assay* -Polymerase chain reaction -Salivary assays -Urinary assays -Confirm eradication 4-6 weeks after treatment* |
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10-20% of pts with H pylori will develop______
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peptic ulcer
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Chronic infection with H Pylori increases risk for ______ 5-6x.
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Gastric carcinoma
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Management of Chronic Gastritis
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-Eradicate H. pylori with triple therapy
-PPI, amoxicillin and clarithromycin x14 days -Metronidazole if allergy to PCN -Continue PPI after abx therapy -Confirm eradication of H. pylori -Initial attempt fails 20% of the time, Change meds |
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what is peptic ulcer?
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-duodenal (98%) and gastric ulcers
-related to recurrent infection w/ h pylori, worsened with smoking -related to use of NSAIDS, Biphosphinates- fosamax, boniva -common in men |
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Clinical manifestations of peptic ulcer disease
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-Epigastric distress
-Gnawing hunger usually in the midline -Distress occurs 1-3 hours after meal -May awaken patient from sleep -Often relieved by food, antacids or vomiting -May c/o nausea, vomiting, bloating, belching |
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Red flags of peptic ulcer disease
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-Weight loss
-Anemia -Early satiety -Anorexia -Dysphagia -Palpable mass -History of PUD or gastric cancer |
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Peptic Ulcer Disease Diagnostics
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-CBC
-Upper GI or -EGD with biopsy -H. pylori testing -Fasting serum gastrin level-- r/o zollinger-ellison syndrome |
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Management of Peptic Ulcer Disease
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-If infected with H.Pylori - eradication
Reduce R.F. (smoking, NSAIDs). -If H.Pylori negative, repeat EGD -H2 blockers -PPI -Carafate -Can discontinue meds after 3 months in uncomplicated patients who are asymptomatic -Patients with refractory symptoms - refer |
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Complications of Perforated Peptic Ulcer
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-Bleeding
-Perforation -Penetration- pancreas -Obstruction *Urgent Surgical Referral |
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who's at risk for perforated ulcers?
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- NSAIDS
-Tobacco -H pylori infection mortality rate 10% |
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what is the progression of a perforated peptic ulcer? within 2 hrs, 2-12 hrs, and >12 hrs?
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-Within 2 hours: Abrupt onset of severe abdominal pain, vomiting,
Begins in epigastrium and spreads rapidly thoughout the abdomen; Abrupt severity may make pt seek medical attention, may cause syncope; Tachycardia, a weak pulse, cool extremities, a low |
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Perforated Ulcer Diagnostics
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-History and physical exam
-βHCG women -CBC – leukocytosis -Amylase- pancreatitis -Upper GI-presence of free air is highly indicative of perforated DU |
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Management of Perforated Peptic Ulcer
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Immediate hospitalization and surgical consult
IV fluid NG suction IV antibiotics May need transfusion |
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Clinical Manifestations of Celiac Disease
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-Diarrhea with bulky, foul-smelling, floating stools due to steatorrhea
-Flatulence -Meteorism (due to colonic bacterial digestion of malabsorbed nutrients) -Failure to thrive in children -Weight loss -Anemia -Neurologic disorders from deficiencies |
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How do you diagnose Celiac disease?
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-IgA anti tissue transglutaminase (anti-tTG)
-IgA endomysial antibody (IgA EMA) -Duodenal biopsy- Loss of villi -Dermatitis herpetiformis |
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Management of Celiac Disease
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-Dietary consult
-Lifelong adherence to a gluten-free diet--Wheat, rye, barley -May have a secondary lactose intolerance -Identification and treatment of nutritional deficiencies -Frequent follow-up: Bone loss secondary to hyperparathyroidism, Anemia |
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Clinical manifestations of Tropical Sprue
Treatment? |
-Consistent with malabsorption
-Large volume steatorrhea, flatulance, bloating, weight loss -Megaloblastic anemia due to folate deficiency -Cheilitis and glossitis -TX: broad spectrum abx |
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Clinical manifestations of Small Bowel Obstruction
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-Dehydration is hallmark
-Tachycardia, oliguria, and hypotension -Eventually colon becomes edematous -Abdominal distention -Feculent vomit -Crampy abdominal pain -Inability to pass flatus |
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Diagnostics for Small Bowel Obstruction
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-Leukocytosis in necrosis (only 10% of cases)
-Assess degree of dehydration -Upright chest and abdominal x-ray for free air and air/fluid levels -small bowel series -CT scan |
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Clinical Manifestations of Lactose Intolerance
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Crampy abdominal pain, bloating, flatulance, steatorrhea, borborygmi
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Diagnosis of Lactose Intolerance
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Lactose breath Hydrogen test
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Treatment of Lactose Intolerance
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-Reduced dietary lactose intake (milk and ice cream)
-Substitution of alternative nutrient sources to maintain energy and protein intake -Administration of a commercially available enzyme substitute -Maintenance of calcium and vitamin D intake |
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Acute and Chronic Presentation of Giardiasis
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Diarrhea /steatorrhea
Abdominal cramps and bloating Acute: Flatulence Nausea Weight loss Vomiting Chronic: Loose stools but usually not diarrhea Steatorrhea Significant weight loss Fatigue Abdominal cramping Borborygmi Flatulence Burping Functional lactose intolerance Fever |
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Diagnosis of Giardiasis
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Stool assay
-O&P -Giardia antigen -Duodenal biopsy |
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Treatment of Giardiasis
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-Metronidazole 250mg PO TID for 5 days
-Tinidazole 2g single dose |
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what is the Rome III diagnostic criteria for IBS?
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Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following
1) impvt with defecation 2) onset associated with a change in frequency of stool 3) onset 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 |
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diagnosis of IBS- irritable bowel syndrome
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-Labs essentially normal
-Diagnosis based on clinical history -No detectable organic pathology -Diagnosis of exclusion |
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Treatment of IBS- irritable bowel syndrome
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-Diet -25-30gms of fiber
-Antispasmodics such as bentyl (20-40mg qid) -antidepressants-SSRIs and TCAs -Antidiarrheal agents -Lubiprostone- Amitiza- for constipation |
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Clinical Manifestations of Chron's Disease
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-Diarrhea, often persists with fasting
-Exudative (inflammatory) -Malabsorptive if inflammation prevents absorption of bile salts -Weight loss, electrolyte disturbances -Fever -Abdominal pain, tenismus -Change in caliber of stool -Skin tags, anal f |
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Pancolitis for >10 years puts puts 20-30x risk for ____
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carcinoma
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Clinical manifestations of Ulcerative Colitis
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-May be similar to chron's disease
-First flare hopefully the last Majority will have relapse within 10 years -Approx 30% will require colectomy due to uncontrollable disease -Bloody, mucoid diarrhea -Anemia -Abdominal pain |
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Diagnosis of Inflammatory Bowel Disease
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-CBC
-CMP (BUN, creatinine, glucose) -Stool assay -Antibody tests: -anti-Saccharomyces cerevisiae antibodies (ASCA) for Chron's -antineutrophil cytoplasmic antibodies (pANCA) for ulcerative colitis -Endoscopy- biopsyof terminal ileum |
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Management of inflammatory bowel disease
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-Sulfasalazine
-Asacol -Pentasa -Colazal -Rowasa -Suspension and enema -Prednisone for flare ups |
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Clinical Manifestations of Diverticulitis
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-Acute or subacute LLQ pain (sigmoid colon)
-Fever, nausea, vomiting, and change in bowel habits |
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Diagnosis of Diverticulitis
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-CT with contrast preferred
-Stool for occult blood -CBC, CMP -colonosopy---look at old reports because an inflamed colon will perforate during scope |
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Treatment of Diverticular Disease
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for asymptomatic pts- high fiber diet
if recurrent diverticultis-- surgery sigmoid colon resection may be necessary |
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Management of Diverticulitis
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-Clear liquids only
-Treatment of infection -Ciprofloxacin, 500 mg PO twice daily plus Metronidazole, 500 mg PO three times daily -Amoxicillin-clavulanate (875/125 mg twice daily) is an alternative to cipro -Clindamycin if intolerant to metronidazole |
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Clinical Manifestations of Appendicitis
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-First symptom: epigastric discomfort attributed to indigestion, RLQ may be tender
-Or may start out as colicky periumbilical pain -Anorexia, nausea, vomiting common -Constipation common, if they have diarrhea, more likely gastroenteritis -within hrs |
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Management of Appendicitis
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-Diagnosis: Monitor patient, obtain stat white count
-Pelvic CT with contrast best choice -US can rule it in but can’t rule it out -Treatment: Refer for surgical consultation |
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who's at risk for cholelithiasis?
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-Over 40 years old
-women -Pregnancy -Oral contraceptives and estrogen replacement therapy -Family history and genetics -Obesity -Rapid weight loss -Diabetes mellitus Cirrhosis Gallbladder stasis Crohn's disease Hemolysis- Pigmented stones |
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Clinical presentation of cholelithiasis
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-Crampy abdominal pain, right upper quadrant or epigastrium
-Ingested fatty food 1 hour or more before -Radiates to the right shoulder or back -Pain with fever longer than 6 hours should arouse suspicion for acute cholecystitis -Murphy's sign |
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Diagnostics for Cholelithiasis and Cholecystitis
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-CBC
-Leukocytosis in cholecystitis -Liver panel -Bilirubin -Ultrasound: Thickened GB walls, Stones -Cholescintigraphy (HIDA Scan) |
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Clinical signs for acute pancreatitis
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-Acute upper abdominal pain
-1-3 days after binge drinking -Abrupt onset -Biliary colic may last for days -Relief when leaning forward -Bleeding and necrosis → Grey Turner / Cullen sign -Jaundice if obstructive stone in the CBD -Recent ERCP is |
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Diagnosis of Acute Pancreatitis
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Serum amylase elevated 3x normal
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60-70% of cirrhosis is caused by
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alcohol
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Clinical presentation of cirrhosis
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-Onset can be slow and asymptomatic
-Nonspecific -As condition progresses - anorexia, nausea and vomiting -Can have abdominal pain if ascites develops -Chest pain from right sided heart failure -Mental status changes -Menstrual abnormalities |
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Physical findings on exam of a patient with cirrhosis
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-Bruising
-Low grade fever -Anorexia -Jaundice -Right upper quadrant pain -Large- firm or nodular liver or a shrunken liver -Fluid wave -Increased abdominal girth -Rectal varices -Peripheral edema -Lethargy or coma |
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Diagnostics for Cirrhosis
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CBC with diff
Chemistry Serum protein Albumin LFT's GGT PT/PTT Imaging Ultrasound CT scan Liver biopsy Refer |
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management of cirrhosis
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collaboration with GI
prevent further liver dysfunction address underlying cause prevent decompensation avoid/manage portal hypertension SBP prophylaxis |
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Nonalcoholic steatohepatitis
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-Liver component of the metabolic syndrome
-Associated with obesity, dyslipidemia and type II diabetes -Can range from steatosis to steatohepatitis to fibrosis to end stage liver disease -Most common cause of elevated liver enzymes -Treatment: weight |
