Family Medicine: Abdominal Pain

Front 1

Cite the percentage of abdominal pain complaints in primary care which subside without a definitive diagnosis being reached.

Back 1

40-50%

Front 2

If you have an acute abdomen, what would you see for:
1) History
2) Physical exam
3) Appearance
4) Abdominal exam
5) Labs
6) Diagnostic test sensitivies/specificities

Back 2

Acute onset, trauma, no prior abdominal complaints. Pain severity may or may not
help differentiate "surgical" from “non-surgical” abdomen.

Vital signs: especially fever, low B.P., high pulse

Lying in one position (hurts to move or cough due to peritoneal irritation).

Distention or obstructive signs; tenderness to percussion or rebound, esp. if
localized (perforation or peritoneal irritation); blood on gastric aspirate or rectal
exam; include pelvic exam in women

Normal urinalysis; acute anemia or left shift on CBC; include HCG in Women

Discuss with the students the relative sensitivity of various radiographic imaging
studies for the diagnosis of acute appendicitis.
 Abdominal plain films (low sensitivity and specificity)
 Ultrasound (sensitivity 75-90%, specificity 86-100%)
 Spiral CT (sensitivity 90-100%, specificity 91-99%)

Front 3

Construct a plan to manage the potentially surgical abdomen by timely observation and
appropriate consultation.

Back 3

Consult surgeon early if any positive findings, above; co-manage with repeat exams,
judicious pain meds, repeat CBC's (increasing WBC’s?, decreasing hct?); start IV, type
and cross-match blood p.r.n.; keep patient n.p.o.

Front 4

Construct a stepped approach to the management of patients with gastroesophageal
reflux disease, based upon evidence based medicine as well as cost effectiveness

Back 4

A. Lifestyle modification - (elevated head of bed 6 inches, decrease fat intake, stop
smoking, decrease weight, avoid large meals or aggravating foods avoid, avoid
recumbency for three hours post-prandially.)
B. Antacid or H2-blocker - as needed.
C. Scheduled dose of H2-blocker, proton pump inhibitor, and/or a prokinetic agent,
e.g., metoclopramide (Reglan) for 8-12 weeks. Consider endoscopy if severe or
no response.
D. Maintain therapy with H2-blocker or proton pump inhibitor.
E. Surgical intervention for refractory cases.

Front 5

List and evaluate four tests for H. pylori.

Back 5

 Serology (whole blood or serum serology is cost effective initial approach in
symptomatic and at risk symptomatic patients; should confirm the test with a
different method if pre-test probability is low.
 C13 or C14 Urea Breath Test (UBT). The sensitivity and specificity of UBT is
approximately 88 to 95 and 95 to 100 percent, respectively. False positive results
are uncommon. To prevent false negative results, the patient should be off
antibiotics for at least four weeks and off proton pump inhibitors for at least two
weeks.
 Stool Antigen (if patient not on PPI or taking bismuth).
 Endoscopic Gastric Biopsy (reserved for patients undergoing EGD).

Front 6

List two causes of peptic ulcer disease and discuss treatment options.

Back 6

NSAID use - avoid NSAIDS. Treat with H2-blockers or proton pump inhibitor. Treat
H.pylori if present (see below).
 H.pylori - combined treatment with omeprazole, bismuth, metronidazole,
clarithromycin and/or amoxicillin. Several regimens available using 2-3 of the above
drugs for 1-2 weeks duration (e.g., lansoprazole 30mg + amoxicillin 1gm +
clarithromycin 500mg all bid X 14 day

Front 7

Differentiate chronic from acute diarrhea

Back 7

 2 weeks = chronic. (compare with cough  4 weeks = chronic)

Front 8

List symptoms that help differentiate viral from bacterial acute diarrhea.

Back 8

Viral is more likely associated with vomiting, watery diarrhea; and no fever, no blood
or pus in the stool

Front 9

Discuss rehydration in the treatment of dehydration due to acute diarrhea.

Back 9

Oral rehydration therapy (ORT); in children, also continue calorie intake (especially starches) with no major change in diet; ORT can be initiated and evaluated in the primary care office (to prevent hospitalization)

Front 10

Inflammatory Diarrhea
- Clinical presentation
- Site of involvement
- Causes (typical)
- Fecal leukocytes
- Further diagnostic evaluation

Back 10

- Bloody, small-volume diarrhea; lower left quadrant abdominal cramps; may be febrile and toxic

- Colon

- Shigella, some Salmonella
species, Helicobacter jejuni,
Yersinia, invasive or hemorrhagic E. coli, Campylobacter,
Clostridium dificil, Ameba
histolytica

- + LE

- further investigation indicated

Front 11

Non-Inflammatory Diarrhea
- Clinical presentation
- Site of involvement
- Causes (typical)
- Fecal leukocytes
- Further diagnostic evaluation

Back 11

- Large-volume watery diarrhea;
may have nausea, vomiting,
cramps

- Small intestine

- Viruses, Vibrio, Enterotoxigenic
Escherichia coli (ETEC) and
other enterotoxin-producing
bacteria, Giardia,
Cryptosporidium, Cyclospora,
Norwalk, Rotavirus, drugs.

- negative LE

- If severely volume depleted or
toxic, or if lasts > 2 weeks

Front 12

Name the most common organism causing traveler's diarrhea

Back 12

E. coli (various pathogenic mechanisms – mostly ETEC)

Front 13

Understand the evidence behind the use of probiotics and the treatment/prevention
of antibiotic-induced diarrhea.

Back 13

Probiotics that contain species of Lactobacillus or Saccharomyces decrease the
likelihood of diarrhea from antibiotics in children or adults (absolute risk reduction:
3 to 23 percent; NNT: 10). Tell patients to look for these products in the "diarrhea
section" of the pharmacy. A typical dosage is 5 to 10 billion viable organisms administered three to four times a day. The probiotics should be separated from
the antibiotics by a couple of hours. (Level of Evidence: 1a)

Front 14

Name a vaccine now available to reduce the disease burden of infectious diarrhea.

Back 14

Rotavirus is the leading recognized cause of diarrhea-related illness and death
among infants and young children. Every year, rotavirus is associated with 25
million clinic visits, 2 million hospitalizations, and more than 600,000 deaths
worldwide among children younger than five years of age. Earlier vaccines were
withdrawn because of association with intussusceptions. Two oral doses of the new live attenuated G1P[8] HRV vaccine were highly efficacious in protecting
infants against severe rotavirus gastroenteritis, significantly reduced the rate of severe gastroenteritis from any cause, and were not associated with an increased
risk of intussusception.