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132 Cards in this Set
- Front
- Back
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What clues would let you know that abdominal pain is acute or surgical abdomen? |
Acute onset sever pain >6 hr rapidly worsening |
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What clues would let know that abdominal pain is acute or chronic onset? |
ACUTE: less than few days w. progressive worsening CHRONIC: interval of 12 weeks |
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What is emergent abdominal pain? |
<3 hours with fever and vomiting |
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What organs are anatomically located in the RUQ? |
liver, gallbladder, large intestine (hepatic flexure), small intestine, part of stomac, part of pancreas, kidney, ureter |
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What organs are anatomically located in the LUQ? |
part of stomach, pancreas, spleen, large intestine, small intestine, kidney ureter |
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What organs are anatomically located in the LLQ? |
large intestine, small intestine, sigmoid colon, ovary, fallopian tube, 1/2 uterus, 1/2 bladder, epididymis, ureter |
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What organs are anatomically located in the RLQ? |
appendix, large intestine, small intestine, ovary, fallopian tube, 1/2 uterus, 1/2 bladder, epididymis, ureter |
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If a patient describes abdominal pain as: "burning" or "gnawing" What is the likely cause/origin? |
ulcer |
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If a patient describes abdominal pain as: "colicky" "wavelike" "intermittent" What is the likely cause/origin? |
hollow tube obstruction: bowel (with hyperperistalsis) biliary tube ureter |
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If a patient describes abdominal pain as: "steady" "worse with cough" "palpation" "movement/increased pressure" What is the likely cause/origin? |
peritoneal irritation |
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If a patient describes abdominal pain as: "cramping" What is the likely cause/origin? |
altered bowel motility metabolic disturbances |
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If a patient describes abdominal pain as: "cyclic" "related to menses" What is the likely cause/origin? |
gynecologic cause |
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If a patient describes abdominal pain as: "related to meals" "abdominal angina" What is the likely cause/origin? |
vascular |
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If a patient describes abdominal pain as: "tearing" "radiating to back" What is the likely cause/origin? |
dissecting aneurysm |
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If a patient describes abdominal pain as: "constant aching" What is the likely cause/origin? |
distention of encapsulated structure: liver, kidney, spleen, ovary |
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If a patient describes abdominal pain as: "burning , along dermatome" What is the likely cause/origin? |
nerve irritation |
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What are the 3 types of abdominal pain? |
visceral parietal referred |
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What are the most common diagnoses of RUQ abdominal pain? |
* acute cholecystits-billiary colic (radiates to scapula)* *acute hepatitis* differential: hepatic abscess, hepatomegaly/CHF, perforated duodenal ulcer, acute pancreatitis, herpes zoster, MI, pleural or pulmonary (RLL pneumonia, pulmonary emboli, pleurisy) |
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What are the most common diagnoses of RLQ abdominal pain? |
*appendicitis (begins periumbilical)* differential: regional enteritis, leaking aneurysm, ruptured ectopic pregnancy, twisted ovarian cyst, PID, urteral calculi |
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What are the most common diagnoses of LUQ abdominal pain? |
*gastritis* differential: acute pancreatitis, splenic enlargement, rupture infarction, aneurysm, MI, LLL pneumonia |
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What are the most common diagnoses of LLQ abdominal pain?
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*sigmoid diverticulitis* differential: regional enteritis, leaking aneurysm, ruptured ectopic pregnancy, twisted ovarian cyst, ureteral calculi, incarcerated-strangulated inguinal hernia |
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What are key things to know about abdominal pain in older adult? |
often stuble always evaluate fever less likely may exhibit lethargy or mental status changes |
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When questioning abdominal pain in females, what must be done? |
Must obtain sexual history Must do pelvic exam in all females Consider PID Must exclude ectopic pregnancy if child bearing age |
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What is the risk of appendicitis? |
Inflammatory disease of wall of appendix that can cause gangrene & perforation in 24-36 hours |
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What are early reliable indicator symptoms that appendicitis is causing abdominal pain? |
Pain begins in epigastric or periumbilical area then localizes to the RLQ Colicky pain, becomes severe Worse with movement |
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What are late reliable indicator symptoms that appendicitis is causing abdominal pain? |
Nausea & vomiting Helps to differentiate gastroenteritis Vomiting begins before abdominal pain in gastroenteritis |
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What is the pathophysiology of appendicitis? |
Appendices lumen becomes inflammed, obstructed--> mucosa continues to secrete fluid--> pressure increases in appendix --> mucosa ulcerates--> bacteria invade--> increased swelling & ischemia--> appendix perforates |
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When doing an abdominal exam for appendicitis, what are expected findings? |
Localized tenderness McBurney's point (in between navel & iliac spine) Patient can point with one finger to pain |
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If peritoneal irritation is present in appendicitis, what will your exam findings be? |
Rebound tenderness Guarding +Psoas sign +Obturator sign |
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What is a positive psoas sign? |
Pain with passive right leg extension Indicates irritation of iliopsoas |
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What is a positive Obturator sign? |
Indicates irritation of Obturator muscle Patient lies supine with right hip knee flexed Passive rotation of right leg Pull right knee laterally (Hip external rotation) Pull right knee medially (hip internal rotation) |
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When doing a rectal exam what are expected findings? |
Tenderness Possible mass |
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What is McBurney's point? |
One third the distance from the anterior iliac spine to the navel *common location of the base of the appendix where it is attached to the cecum |
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What are diagnostic blood work that can be done for appendicitis? |
CBC w/ diff= Leukocytosis - elevated WBC Neutrophilia - elevated neutrophil Bandemia - elevated # bands (young neutrophils) Beta hCG UA CRP |
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What are diagnostic tests that may be done for appendicitis? |
Ultrasound **CT of abdomen - more accurate |
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What is a a small bowel obstruction? |
Partial or complete obstruction of bowel lumen -paralysis or ileus of intestinal musculature |
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What subjective questions to ask for small bowel obstruction, Q&A? |
Q: Acute diffuse abdominal pain? A: Intermittent, crampy pain Q: Vomiting? A: Relieves pain Q: Passing flatus, last BM, H/O abd/pelvis sx (adhesions) |
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What are physical findings that may be present in a small bowel obstruction exam? |
-distended tympanic abdomen -high pitched tinkling bowel sounds OR -NO bowel sounds -mid abdomen tenderness (guarding/ rebound) -check umbilicus for hernia -rectal exam (stool? Mass?) |
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What are diagnostics for a small bowel obstruction? |
Abdomen x-ray Upright/spine |
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What is the management for a small bowel obstruction? |
NPO - bowel rest NG tube for decompression May need laparotomy |
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What is a perforated peptic ulcer? |
16% of elderly c/o abdominal pain Most common is free perforation |
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What are subjective findings in a perforated peptic ulcer? |
Severe abdominal pain -begins in epigastrium -spreads throughout abdomen -radiates to scapula Vomiting H/O: PUD, h. Pylori, chronic NSAID use |
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What are physical findings present with a perforated peptic ulcer? |
-severe pain w. palpation in Upper abdomen -rigid abdomen -fever |
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What is the diagnostic & treatment plan for a perforated peptic ulcer? |
DX: Abd x-ray shows free air TX: surgical consult |
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Who is at risk for a ruptured aortic aneurysm? |
Age >65 H/O ASHD Hypertension Smoking |
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What are subjective findings of a ruptured aortic aneurysm? |
C/o abdominal pain radiating to flank, low back, groin |
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What are objective findings for a ruptured aortic aneurysm? |
Hypotension Pulsatile mass Aortic bruits Absent or unequal peripheral pulses |
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What is the management ruptured aortic aneurysm? |
Surgical consult |
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Anorectal complaints are similar to which other differential conditions? |
*hemorrhoids (enlarged/prolapse vascular tissue in the submucosal layer of anal canal) *anal fissure (linear cracks or tears in lining of anal canal) *pruritis ani (itching sensation of anus and perianal skin) |
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What are hemorrhoids? |
Enlarged or proposed vascular tissue in the submucosal layer of anal canal *Internal or external |
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How are hemorrhoids developed? |
A result of increased pressure applied to pelvic floor: - pregnancy - prolonged standing - straining - lifting - constipation - diarrhea |
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What distinguishes internal hemorrhoids? |
Above denate line columnar epithelium |
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What distinguishes external hemorrhoids? |
Below denate line squamous epithelium |
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In the clinical presentation of hemorrhoids, what are subjective complaints? |
Bleeding (Painless, bright, red blood - occurs after defecation - on toilet tissue, on stool or in toilet water) Pruritis Protrusion Pain |
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In the clinical presentation of hemorrhoids, what are objective findings? |
-internal: not palpable on rectal exam unless thrombosed -external: thrombosed vs. not-thrombosed Thrombosed, erythema,sensitive Not-thrombosed, tender dark blue nodule -severe rectal pain unusual, suggests gangrenous hemorrhoid
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What is the conservative management of hemorrhoids? |
High fiber diet / increased fluids Warm water sitz baths Topical anti-inflammatory preparations: *hydrocortisone (anusol-HC; ProctoCream) *hydrocortisone & pramoxine (analpram-HC; ProctoFoam-HC) |
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What is the management of thrombosed hemorrhoids? |
Surgical Evacuation If persistent: -rubber band ligation -laser coagulation -hemorrhoidectomy |
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What are anal fissures and what is their cause? |
Linear cracks or tears in lining of anal canal Caused by: Hard stool Frequent diarrhea Healing--> scar tissue formation & anal stenosis |
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What is the management of an anal fissure? |
Fiber / stool softner Sitz baths Topical anesthetics (i.e. lidocaine gel) prior to passing stool Topical glyceryl trinitrate (Rectiv nitroglycerin cream) causes increase blood flow and decrease sphincter pressure |
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What is pruritus ani and it's possible causes? |
Itch-Scratch cycle -idiopathic -infectious (pinworm) -improper hygiene -secondary to systemic causes: Diabetes, renal insufficiency, medications |
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What is the management of pruritus ani? |
-skin care to keep clean/dry -1% hydrocortisone topical -antihistamine PO (i.e. atarax) |
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How is diarrhea classified and determined? |
**Must know patient's normal stool pattern** Frequency: >3 times/day Volume: liquidity Morbidity (variable): mild & self-limiting / severe & life-threatening Acute: <2 weeks Chronic: >1 month |
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What are infectious causes of diarrhea? |
Age: most common <5 yr Non-inflammatory: viruses / bacteria / parasites Inflammatory: bacteria / parasites Spread by: *food & water contamination *person to person contact *Fecal-oral route *animals |
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What are causes of non-infectious (chronic diarrhea)? |
Medications Lactose intolerance Toxins, environmental Endocrine disorders: thyroid, diabetes Pernicious anemia Irritable bowel syndrome Inflammatory bowel syndrome Crohn's disease Malignancy HIV disease Celiac sprue Scleroderma Whipple's disease |
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When preforming an exam, what are subjective questions that should be asked? |
Onset # of diarrhea stools/day -normal stool pattern -occur with respect to meals/sleep -food related reactions Weight loss? Abdominal pain? Sense of incomplete evacuation? Blood or pus or mucous of fat in stool? Medications? PMH:all comorbidities? Tobacco, alcohol, illicit drug use? Laxative abuse? |
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On a physical exam for a patient with diarrhea, what should be done to check hydration status? |
Orthostatic VS Weight Mucous membranes Skin turgor |
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On a physical exam for a patient with diarrhea, what should be done to check abdomen? |
-distension? -ascultate: bowel sounds, bruits, succession splash, free fluid air, ga -palpate: pain, rigidity, rebound, guarding, masses, acites? -dre: fecal impactation, occult blood? -pelvic exam |
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Which symptoms should be present to order diagnostics for acute diarrhea? |
-fever -abdominal pain -dehydration -protracted nausea/vomiting -diarrhea >1wk -blood in stool -immunocompromised status |
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What does a stool analysis look for in acute diarrhea? |
-fecal leukocytes -occult blood -culture (bacterial) -ova parasites (>7-10 days) -c. difficile toxin A&B -giardia ELISA (antigen test for giardia) |
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What types of radiology diagnostics can be ordered for acute diarrhea? |
abdominal flat plate & upright |
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What are the diagnostic lab work for acute diarrhea? |
CBC, Serum electrolytes, BUN, Cr |
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What is the treatment to replace fluid and electrolytes in acute diarrhea? |
Oral Clear liquids or rehydration solutions Intravenous |
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What is the proper refeeding diet for a patient with acute diarrhea? |
Avoid: high fiber, diary, fats, caffeine, alcohol BRAT: bananas, rice, applesauce, and toast |
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What is the definition of chronic diarrhea? |
Decrease in fecal consistency for >4 weeks It's is classified by the etiology: Inflammatory, osmotic, secretory, altered intestinal motility, factitious |
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What are the causes of inflammatory diarrhea (lasts longer than 4 weeks)? |
Infectious, AIDS, eosinophilic gastroenteritis, radiation |
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What are the causes of osmotic diarrhea (lasting >4 wks)? |
Stops with fasting Malabsorption, lactase deficiency, chronic alcohol abuse, celiac disease, thyrotoxicosis, short gut post surgery |
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What are the causes of secretory diarrhea (>4 wks)? |
Large volume watery diarrhea continues with fasting Carcinoid syndrome, pancreatic adenomas |
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What are the causes of altered intestinal motility (>4 wks)? |
Most common in clinical practice Irritable bowel syndrome, neurologic disease, fecal impactation, diabetes |
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When evaluating for chronic diarrhea what causes may be excluded? |
Acute diarrhea Lactose intolerance Previous gastric surgery or ideal resection Parasitic infection Medication Systemic disease |
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For chronic diarrhea evaluation, what is done for a stool analysis? |
Electrolytes, pH Osmolarity Weight/24 hr Occult blood Leukocytes (WBC) Quanitive fecal fat |
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For chronic diarrhea, what is imaging can be done? |
Barium enema, CT abdomen to r/o pancreatic Colonscopy, sigmoidoscopy & biopsy, possible UGI or EGD |
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What are anti-motility agents for chronic diarrhea? |
Lomotil Immodium Codeine All are contraindicated in infectious diarrhea |
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What is the treatment for Lactose intolerance? |
Lactase (Lactaid) |
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What is the treatment for bile salt malabsorption? |
Questran |
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What is the treatment for colitis chronic diarrhea? |
Budesonide |
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What is the treatment for inflammatory bowel chronic diarrhea? |
Steroids Sulfasalazine |
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What is the treatment for carcinoid or peptide secreting tumors chronic diarrhea? |
Octreotide (Sandostatin) |
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What would be considered decreased frequency of bowel movements in constipation? |
-difficult defecation of hard stool -less than 3 BMs per week |
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Before diagnosis, onset within 6 months, which of the following are the ROME III Criteria |
-less than 3 bm/wks or hard or lumpy stool -sensation of straining -feeling of incomplete evacuation or anorectal obstruction -manual maneuvers to aid defecation in more than 25% of defecation AND -stool stool not passed easily w/o use of medication |
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What are primary causes of constipation? |
Prolonged total gut transit time -(Neuromuscular dysfunction) -decreased activity Pelvic floor or anorectal dysfunction -failure to empty rectum |
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What are secondary causes of constipation? |
-ignoring urge to defecate -inadequate fiber or fluid intake -medications -pregnancy -hypothyroidism -hypoparathyroidism -diabetes -hypokalemia -hypercalcemia -psychological/neurological disorders |
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What are common symptoms in the clinical presentation of constipation? |
Nausea Bloating Cramping Difficulty passing stool |
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What should be included in an assessment of constipation? |
Diet (24 hr food/fluid) Exercise Bowel pattern # of stools per day When changed occurred Straining Sense of incomplete evacuation Incontinence/ diarrhea Abdominal pain Blood in stool Complete Medication Review |
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What could be found on a physical exam of a patient with constipation? |
-Signs of dehydration -weight loss -abdominal scars -bowels sounds = increased/decreased -dullness over stool or mass -rebound |
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When preforming physical rectal exam in a person with complaints of constipation, what are you looking for? |
Sphincter tone Hemorrhoids Fissure Lesion Impaction |
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What central nervous system drugs cause constipation? |
Antidepressants Antipsychotics Anxiolytics Opiate analgesics |
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What cardiovascular / musculoskeletal drugs cause constipation? |
Antihypertensive Diuretics Cardiotonics Hematologic Muscle relaxants |
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What classes of drugs can cause constipation? |
Antacids Anticholinergic Antibiotics Antihistamines |
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What diagnostic blood work can be done for constipation? |
CBC, TSH, Chem profile: calcium, potassium, glucose, stool for OB, UA and culture |
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What are constipation diagnostic tests? |
Flat plate & upright of abdomen CT of abdomen Barium enema Colonscopy |
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What are emergent problems with constipation that would require a referral? |
Ileus Intrabdominal infection (Appendicitis, diverticulitis) Toxic mega colon Obstruction |
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What is phase 1 of constipation management? |
Lifestyle changes -Exercise regularly -Develop regular bowel habits Dietary changes -increase fiber -decrease fats (cheese) -increase fluids 1.5 to 2 liters/day |
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What is phase 2 of constipation treatment? |
Bulk forming laxatives Metamucil FiberCon |
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What is phase 3 of constipation treatment? |
Stool stoftners |
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What is phase 4 of constipation treatment? |
Osmotic laxatives: Lactulose Miralax MOM |
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What is phase 5 of constipation treatment? |
Stimulant laxatives: Ducolax, senokot |
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What is phase 6 of constipation treatment? |
Chloride channel activators: Lubiprostone (Amitiza) |
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What is phase 7 of constipation treatment? |
Combination oral laxatives Enema Suppository |
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What subcutaneous injections counteracts opioid induced hypomotility? |
Methyl naltexone (relistor) |
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What is diverticular disease? |
Diverticulum (single) Diverticula (pleural) --saclike protrusion of mucosa through the colon wall --defects in large colon, especially sigmoid --incidental finding on colonoscopy, BE or CT |
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What is diverticulosis? |
prescence of numerous non-inflammed diverticula, asymptomatic |
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What is diverticulitis? |
Inflammation of diverticula, may lead to perforation, abscess, fistula, or hemorrhage |
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What is the physiology behind diverticula formation? |
--herniation of muscular layer of colon (increased pressure in areas of relative weakness) --low fiber diets decrease bulk of stool requiring increased pressure to move fecal matter along --result of loss of non-absorbable fiber content in diet |
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What is the presentation of diverticulitis? |
--colicky or steady abdominal pain typically in LLQ --fever, N/V possible --irregular defecation: constipation/loose stools PAINLESS lower GI bleeding (brisk rectal bleeding of maroon or bright red blood) --may feel thickened palpable sigmoid & descending colon |
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What labwork may be done for diverticulitis diagnostics? |
CBC with differential Leukocytosis - left shift Anemia Stool for occult blood ESR UA |
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What radiology may be done for diverticulitis diagnostics? |
CT scan of abdomen w. contrast (preferred imaging for acute) X-ray: flat plate of abdomen to show ileus, free air (perforation) Ultrasound to show mass or abscess Procto-sigmoidoscopy to rule out mass Barium enema (never done for acute, can cause bowel perforation) |
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What is the conservative management for diverticulitis? |
NOT-ACUTE: clear liquids 2-3 days abx - treat for 7-14 days ciprofloxacin 500 bid plus metronidazole 500 tid OR trimethoprim-sulfamethoxazole 160/80 bid w. flagyl OR amoxicillin-clavulanate ER 1000/62.5 mg 2 tab bid bleeding stops spontaneously prevention: high fiber diet (no seeds) |
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What are the complications of diverticulitis? |
40-50 yrs abscess, fistula, obstruction abscess with rupture & suppurative peritonitis perforation with fecal peritonitis |
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What is challeneging about the presentation of diverticulitis in an older adult? |
minimal abdominal pain no fever abdomen exam with benign findings --> untreated may lead to sepsis |
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What characterizes peptic ulcer disease? |
ulceration of gastric and duodenal mucosa |
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What are the risk factors for peptic ulcer disease? |
NSAID use Helicobacter pylori infection Family history Smoking, caffeine, alcohol stress Cirrhosis COPD |
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What is the pathophysiology of a peptic ulcer? |
--high concentration of acid & pepsin secreted by parietal cells of stomach to digest food --GI mucosa secretes alkaline mucus to protect muscosa from self-digestion --H. pylori acquired by oral-fecal route attaches to gastric mucosa & injures local tissue (80% w/ duodenal ulcer & 60% w/gastric ulcer) |
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What is the presentation of a duodenal ulcer? |
more common pain: epigastric, sharp, gnawing, burning, aching 1-3 hours after eating as stomach empties after eating a meal AWAKENED DURING THE NIGHT relieved by eating food, antacids, or vomiting weight gain possible due to frequent meals |
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What is the presentation of a gastric ulcer? |
pain: epigastric, sharp, gnawing, burning, aching pain becomes worse with eating food because of increase in gastric acid nausea, vomiting, anorexia, weight loss more common |
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What diagnostic blood work should be done for a peptic ulcer? |
CBC (to check for anemia) Stool for occult blood H. pylori serum antibody |
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How is H. pylori testing done? |
Gastric biopsy *** Urea breath testing (PPIs can give false negative) Fecal antigen testing Serum antibody - use breath and fecal first |
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When do you refer for upper endoscopy for peptic ulcer? |
age > 50 yr alarm symptoms: weight loss anemia GI bleed |
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What is standard quadruple therapy (7 days) for H. Pylori eradication? |
PPI: choose from omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium) BID & Bismuth subsalicylate (Pepto Bismol) QID & Metronidazole QID & Tetracycline QID |
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What is sequential therapy (10 days) for H. Pylori eradication?
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PPI: choose from omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium) BID & Amoxicillin BID (days 1-5) & Clarithromycin BID (days 6-10) & Tinidazole (days 6-10) |
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What is triple therapy (14 days) for H. Pylori eradication? |
PPI: choose from omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium) BID & Clarithromycin BID & Amoxicillin BID OR Metronidazole BID |
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What is the pharmacological management of ulcers? |
PPI: 1st for 4-8 week omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium) H2 receptor antagonists: 2nd ranitidine (zantac), famotidine (pepcid), nizatidine (axid) |
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What preventative measures should be taken to stop ulcer formation? |
Stop NSAIDs (alternative COX2 inhibitor / misoprostol [cytotec]) Stop smoking Restrict alcohol Dietary modification |
