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59 Cards in this Set
- Front
- Back
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what causes biliary colic?
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transient cystic duct blockage from impacted stones
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what are risk factors for cholelithiasis and biliary colic?
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Female
Fat Fertile Forty but the d/o is common and can occur in any pt |
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what is cholelithiasis?
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gallstones in the gall bladder or cystic ducts
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what are less famous risk factors for gallstones?
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OCP use
rapid wt. loss (+)FH chronic hemnolysis (pigment stones) small bowel resection TPN |
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how does one get pigmented gallstones?
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hemolysis
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what % of gallstones are radiopaque?
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only 10-15%
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typical hx and PE of pt with cholelithiasis and biliary colic?
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- postprandial abdominal pain (usually in RUQ) radiating to R subscapular area or epigastrium
- pain is abrupt, followed by gradual relief - n/v, poor tolerance of fatty foods, dyspepsia and flatulence |
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can gallstones be asymptomatic?
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yes, in up to 80% of pts; exam may show some RUQ tenderness and a palpable gallbladder
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how do you dx cholelithiasis?
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- plain x-rays are poor (why?)
- RUQ u/s is 85-90% sensitive - consider and upper GI series to r/o hiatal hernia or ulcer |
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what do you need to rule out in cholelithiasis?
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hiatal hernia or ulcer
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what are 3 items to think about in tx?
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1. cholecystectomy is curative and elective
2. pts may need pre-op ERCP for common bile duct stones 3. treat nonsurg candidates with dietary modifications (no fatty foods!) |
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what are possible complications from cholelithiasis?
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- recurrent biliary colic
- acute cholecystitis - choledocholithiasis - acute cholangitis - gallstone ileus - gallstone pancreatitis |
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what is acute cholecystitis?
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prolonged blockage of cystic duct (usually impacted stone) -> obstructive distention, inflammation, superinfection, possible gangrene of gallbladder
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when do you get acalculous cholecystitis?
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occurs in absence of cholelithiasis in chronically debilitated pts (pts on TPN, trauma, or burn victims)
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what is hx and PE of pt with acute cholecystitis?
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RUQ pain, n/v, low-grade fever (sx are more severe and longer duration than in biliary colic)
RUQ tenderness, Murphy's sign, low-grade fever, leukocytosis, mild icterus, guarding or rebound tenderness |
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what are the steps in dx of acute cholecystitis?
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- CBC, amylase, lipase, LFT panel
- u/s to see stones, bile sludge, pericholecystic fluid, a thickened gallbladder wall, gas in gallbladder, u/s Murphy's sign |
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when do you get a HIDA scan?
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when u/s is equivocal in the dx of acute cholecystitis
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what does it mean if the gallbladder can't be visualized on HIDA scan?
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likely acute cholecystitis
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what do you do if pt with DM and acute cholecystitis needs surgery?
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delay surgery until acute inflammation resolves; then perform cholecystectomy
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how do you tx acute cholecystitis?
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1. admit pt, IV abx, IV fluids, replete electrolytes
2. early cholecystectomy (w/in 72hrs of symptom onset); do preop ERCP or intraoperative cholangiogram to r/o common bile duct stones |
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what % of acute cholecystitis resolve spontaneously?
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50%; therefore, delay surgery for poor surg candidates (eg. DM pts)
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complications of acute cholecystitis?
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gangrene
empyema perforation gallstone ileus fistulization sepsis abscess formation |
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what is choledocholithiasis?
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gallstones in the common bile duct
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what is the hx and PE of choledocholithiasis?
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- sometimes asymptomatic
- often present with biliary pain, jaundice, episodic colic, fever, and pancreatitis |
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how dx choledocholithiasis?
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(+)alk phos and (+)total bili, which may be the only abnormal lab values
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how do you tx choledocholithiasis?
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ERCP with sphincterotomy, followed by semielective cholecystectomy
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what is acute cholangitis?
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acute bacterial infx of biliary tree that can occur 2* to obstruction (gallstones) or 1* sclerosing cholangitis
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what is primary (1*) sclerosing cholangitis?
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progressive inflammation of biliary tree assoc. with ulcerative colitis
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what are most common pathogens in acute cholangitis?
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gram (-) enterics (eg. E. coli, Enterobacter, Pseudomonas)
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what are risk factors for acute cholangitis?
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bile duct stricture, ampullary carcinoma, pancreatic pseudocyst
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what is hx and PE of acute cholangitis?
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Charcot's triad (RUQ pain, jaundice, f/c)
or Reynolds' pentad (Charcot's triad plus shock and altered MS) in acute suppurative cholangitis and suggests sepsis |
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what does Reynold's pentad suggest?
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acute suppurative cholangitis and possible sepsis
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how dx acute cholangitis?
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- look for leukocytosis, (+)bilirubin, (+)alk phos
- get blood cx to r/o sepsis - u/s or CT could help, but dx is mostly clinical - ERCP is both diagnostic and therapeutic (biliary drainage) |
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how does ERCP help in acute cholangitis?
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both diagnostic and therapeutic
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how tx acute cholangitis?
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- admit to ICU for monitoring, hydration, BP support, and broad spectrum abx
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what do you do c pts who have acute suppurative cholangitis?
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emergent bile duct decompression via ERCP sphincterotomy, percutaneous transhepatic drainage, or open decompression
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risk factors for diarrhea?
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- viral/bacterial GI infection
- systemic infection - sick contacts - immunosuppression - recent antibiotic use - recent travel |
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when do you make a lab diagnosis of diarrhea?
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- high fever, bloody diarrhea, diarrhea lasts >4days
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what labs do you send for diarrhea?
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- fecal leukocytes
- bacterial cx - C. difficile toxin - O & P |
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when do you consider sigmoidoscopy in diarrhea pts?
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bloody diarrhea
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what type of diarrhea is generally infectious and self-limited?
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acute diarrhea
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in what diarrhea pts do you avoid antimotility agents?
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- those with bloody diarrhea, high fever, or systemic toxicity
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how do you treat acute diarrhea?
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- if bacteria not suspected, then use antidiarrheals (loperamide, bismuth salicylate) and oral fluids with electrolyte replacement
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how do you treat chronic diarrhea?
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ID underlying cause and tx symptoms with loperamide, opioids, octreotide, or cholestyramine
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what do you do for kids with diarrhea who can't take meds or PO fluids?
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hospitalize, give IV fluids, and treat underlying cause
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DOC for Campylobacter?
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erythromycin
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most common etiology of infectious diarrhea?
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Campylobacter
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bug?
- diarrhea after ingesting contaminated food or water - affects young kids and young adults - lasts 7-10 days - fecal RBCs and WBCs |
Campylobacter
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what do you look out for in pts with C. difficile?
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toxic megacolon
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how do you treat C. difficile?
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PO metronidazole or PO vancomycin
IV metronidazole if pt can't tolerate PO meds |
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is C. difficile more common in large or small bowel?
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large bowel, but it can affect the small bowel
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bug?
- recent antibiotic tx (cephalosporins, clindamycin) - hospitalized adult pt - fever, abdominal pain, possible systemic toxicity - fecal WBCs and RBCs |
Clostridium difficile
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what 2 antibiotics are commonly associated with C. difficile infx?
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cephalosporins
clindamycin |
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bug?
- contaminated food or water - travel in developing countries - incubation of up to 3mos - severe abdominal pain, fever, fecal RBCs and WBCs |
Entamoeba histolytica
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chronic amebic colitis mimics what disease?
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IBD
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how do you treat Entamoeba histolytica? what should be avoided?
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tx with metronidazole
avoid steroids (possible fatal perforation) |
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hemolytic uremic syndrome is a possible complication of what infectious diarrhea?
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E. coli O157:H7
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bug?
- contaminated food (esp. raw meat) - affects both children and elderly - lasts 5 to 10 days - severe abdominal pain, low grade fever, vomiting - fecal RBCs and WBCs |
E. coli O157:H7
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what do you need to r/o if you suspect E. coli O157:H7?
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- ischemic colitis
- GI bleed |
