2. Anorexia, nausea, vomiting

Question 1

2 general mechanisms for nausea and vomting

Answer 1

neurological

peripheral

Question 2

neurological cause for nausea and vomiting

Answer 2

Stimulation of the area postrema, which ‘senses’ noxious chemical agents (e.g., poisons, chemotherapy agents, digoxin) and subsequently stimulates the vagal nuclei, which evokes nausea and co-ordinates the emesis reflex.
Diseases of the central nervous system (CNS) such as infections or brain tumours stimulate CNS structures and elicit nausea and vomiting, ultimately through vagal pathways.

Question 3

peripheral causes for nausea and vomtiing

Answer 3

Diseases and disorders that originate in peripheral organ systems, such as the gastrointestinal tract, stimulate vagal or spinal afferent nerves that connect with the vagal sensory (tractus solitarius) and vagal efferent motor nuclei. Ultimately, cortical centres where nausea is perceived and the efferent pathways that mediate vomiting are stimulated.
Tumours, infections, and drugs in the periphery may cause local dysfunction in a variety of organ systems that is sensed as nausea that, when severe, evokes vomiting.

Question 4

gastritis Hx

Answer 4

use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food; may be aggravated by recent stress or anxiety

Question 5

gastritis O/E

Answer 5

tenderness to palpation in the epigastrium or normal examination

Question 6

gastritis Ix

Answer 6

upper gastrointestinal endoscopy:
gastritis; antral mucosal biopsies may reveal H pylori infection, which requires antibiotic therapy; may confirm aetiology such as eosinophilic gastritis
Helicobacter pylori antibody:
positive

Question 7

GORD Hx

Answer 7

typical: heartburn and regurgitation; atypical: minimal epigastric burning or regurgitation; nausea predominates; morning nausea common

Question 8

GORD O/E

Answer 8

tenderness in the epigastrium on palpation or normal examination

Question 9

GORD Ix

Answer 9

upper gastrointestinal endoscopy:
may be normal or reveal oesophageal inflammation ranging from erythema to frank ulceration (not required for diagnosis)
24-hour oesophageal pH study:
confirms acid reflux if endoscopy normal

Question 10

diagnosis of GORD made based on

Answer 10

history, endoscopy, or 24 hour pH study

Question 11

peptic ulcer disease Hx

Answer 11

use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food

Question 12

peptic ulcer disease O/E

Answer 12

tenderness to palpation in the epigastrium or normal examination

Question 13

peptic ulcer disease Ix

Answer 13

Helicobacter pylori antibody:
positive
upper gastrointestinal endoscopy:
reveals gastritis, gastric ulcer, duodenal ulcer, or duodenitis; antral mucosal biopsies reveal H pylori infection, which requires antibiotic therapy

Question 14

acute gastroenteritis Hx

Answer 14

diarrhoea; abdominal pain; low-grade fever in viral disease; high-grade fever with toxicity in bacterial aetiology

Question 15

acute gastroenteritis O/E

Answer 15

diffuse abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)

Question 16

acute gastroenteritis labs

Answer 16

serum electrolytes:
low sodium and potassium
stool culture:
may identify microbial agent; usually unrevealing (most cases are viral in origin)

Question 17

food poisoning Hx

Answer 17

diarrhoea, abdominal pain; symptoms develop within 24 hours of a meal; symptoms may improve or persist for weeks leading to chronic disease

Question 18

food poisoning O/E

Answer 18

epigastric tenderness; lower abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)

Question 19

food poisoning labs

Answer 19

serum electrolytes:
low sodium and potassium
stool culture:
may reveal Campylobacter, Salmonella, Shigella

Question 20

migraine Hx

Answer 20

recurrent nausea and/or vomiting in the presence of headache and disturbed vision

Question 21

migraine O/E

Answer 21

no neurological findings but abdomen may be tender due to vomiting/retching

Question 22

migraine Ix

Answer 22

no initial test:
clinical diagnosis
CT head:
may exclude alternate diagnosis
MRI head:
may exclude alternate diagnosis

Question 23

benign paroxysmal positional vertigo Hx

Answer 23

brief, sudden, episodic vertigo

normal neurological exam

Question 24

benign paroxysmal positional vertigo Ix

Answer 24

Dix-Hallpike manoeuvre:
positive

Question 25

stroke Hx

Answer 25

transient nausea, loss of vision, instability, dizziness focal neurological deficits

Question 26

Stroke Ix

Answer 26

CT head: oedema or infarct in brainq

Question 27

hypercalcaemia Hx

Answer 27

alterations of mental status, abdominal pain, constipation, muscle pains, polyuria, headache

Question 28

hypercalaemia Ix

Answer 28

calcium: elevated; >2.63 mmol/L (>10.5 mg/dL) parathyroid hormone: suppressed (non-hyperparathyroid diagnoses such as malignancy) or elevated (hyperparathyroidism)

Question 29

hypothyroidism Hx

Answer 29

fatigue; cold intolerance; dyspepsia hair loss; dry skin; delayed reflexes; goitre

Question 30

hypothyroidism Ix

Answer 30

thyroid-stimulating hormone: elevated in primary hypothyroidismMore T4 (serum free thyroxine): low or normalMore

Question 31

T4 in hypothyroidism

Answer 31

Low free T4 with an elevated thyroid-stimulating hormone is diagnostic of primary hypothyroidism. However, free T4 may be normal in subclinical hypothyroidism, despite a mildly elevated thyroid-stimulating hormone.

Question 32

gastric outlet obstruction Hx

Answer 32

history of peptic ulcer disease; vomitus is yellow gastric juice or may contain blood; upper abdominal pain is prominent

Question 33

gastric outlet obstruction O/E

Answer 33

epigastric tenderness and/or distension; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

Question 34

gastric outlet obstruction Ix

Answer 34

upper gastrointestinal series: gastric distension upper gastrointestinal endoscopy: reveals the site and cause of obstruction (strictures and cancers can be biopsied) CT abdomen: reveals the site of obstruction or free air under the diaphragm indicating perforation

Question 35

small bowel obstruction Ix

Answer 35

bilious vomiting; peri-umbilical location of pain

Question 36

small bowel obstruction O/E

Answer 36

peri-umbilical tenderness; abdominal distension; bowel sounds high pitched or absent; rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

Question 37

small bowel obstruction Ix

Answer 37

acute abdominal x rays: air fluid levels in small bowelMore CT abdomen: reveals site of obstruction or free air under the diaphragm indicating perforation

Question 38

colonic obstruction Hx

Answer 38

lower abdominal pain with or without distension; faeculent vomitus

Question 39

colonic obstruction O/E

Answer 39

tenderness and/or distension in lower abdomen; bowel sounds may be absent; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis

Question 40

colonic obstruction Ix

Answer 40

acute abdominal series: distended colon proximal to site of obstruction; air fluid levels in small bowel CT abdomen: reveals site of colonic obstruction; free air under the diaphragm indicating perforation colonoscopy: may reveal mucosal lesion that may narrow the bowel lumen

Question 41

choledocholithiasis Hx

Answer 41

right upper quadrant (RUQ) or epigastric pain, postprandial symptoms RUQ tenderness; may have jaundice

Question 42

choledocolithiasis Ix

Answer 42

abdominal ultrasound: stones in gallbladder or bile duct`

Question 43

cholecystitis Hx

Answer 43

history of prior biliary colic; right upper quadrant (RUQ) pain; may have fever or referred right shoulder pain

Question 44

cholecystitis O/E

Answer 44

may have positive Murphy sign (right subcostal tenderness, worse after deep inspiration); may have tender RUQ mass; possible jaundice

Question 45

cholecystitis Ix

Answer 45

CBC: elevated WBC count LFTs: cholestatic pattern ultrasound RUQ: may show thickened gallbladder wall with calculi or pericholecystic fluid collection

Question 46

post-GI surgery Hx

Answer 46

previous surgery (fundoplication, oesophagectomy, gastrojejunostomy [Bilroth I or II], or bariatric operation); epigastric discomfort; bloating; regurgitation after oesophagectomy with early satiety

Question 47

post Gi surgery O/E

Answer 47

epigastric tenderness; tender scars, positive Carnett's sign (occurs when a combination of pressure on the scar and flexion of the head clearly exacerbates the patient's typical pain)

Question 48

post Gi surgery Ix

Answer 48

upper endoscopy: mechanical obstruction at site of surgery, mucosal abnormalities, or normal gastric emptying study: gastroparesis or normal electrogastrogram: gastric dysrhythmia or normal

Question 49

severe constipation Hx

Answer 49

constipation; altered bowel habits; abdominal pain; pain on defecation tender abdomen; palpable abdominal mass

Question 50

severe constipation Ix

Answer 50

acute abdominal series: dilated loops of bowel; faecal loading in right colon

Question 51

IBS Hx

Answer 51

altered bowel habits (alternating constipation and diarrhoea), bloating, abdominal pain and distension, stress-related symptoms

Question 52

IBS O/E

Answer 52

normal in most patients; abdominal tenderness in some cases

Question 53

IBS Ix

Answer 53

no initial test: diagnosis of exclusion acute abdominal series: dilated loops of bowel colonoscopy: may demonstrate alternate diagnosis such as inflammatory bowel disease or neoplasm

Question 54

cyclic vomiting syndrome Hx

Answer 54

onset in childhood; migraine common; symptom-free weeks normal

Question 55

cyclic vomiting syndrome Ix

Answer 55

solid-phase gastric emptying study: >50% retained at 2 hours; >10% retained at 4 hours electrogastrogram: tachygastria, bradygastria, or mixed dysrhythmia endoscopy: normal

Question 56

gastric dysrhythmias Hx

Answer 56

nausea, early satiety, fullness worse after meals normal

Question 57

gastric dysrhythmias Ix

Answer 57

electrogastrogram: tachygastria, bradygastria, or mixed dysrhythmias endoscopy: normal (excludes mucosal disease) gastric emptying study: normal (excludes gastroparesis)

Question 58

gastroparesis Hx

Answer 58

nausea, early satiety, fullness, and vomiting of undigested food; all symptoms are worse after ingestion of meals; history of diabetes or Parkinson's disease

Question 59

gastroparesis O/E

Answer 59

succussion "splash" rarely detected; weight loss, orthostatic hypotension

Question 60

gastroperesis Ix

Answer 60

solid-phase gastric emptying study: >50% retained at 2 hours; >10% retained at 4 hours non-digestible capsule test: diagnosis is confirmed if capsule not emptied within 5 hours after it is ingested electrogastrogram: tachygastria, bradygastria, or mixed dysrhythmia endoscopy: no evidence of mucosal inflammation

Question 61

bacterial peritonitis Hx

Answer 61

abdominal pain; nausea or vomiting ranges from mild to severe; fever low grade to severe; recent abdominal surgery rigid abdomen with rebound tenderness

Question 62

bacterial peritonitis Ix

Answer 62

acute abdominal series: air under diaphragm indicates perforation CT abdomen: air under diaphragm, ascites; thickened bowel wall, intra-abdominal fluid or masses

Question 63

anorexia nervosa Hx

Answer 63

abnormalities in body image, depression, amenorrhoea, or psychosocial dysfunction

Question 64

anorexia nervosa O/E

Answer 64

cachexia; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension), signs of malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema)

Question 65

anorexia nervosa Ix

Answer 65

solid-phase gastric emptying study: gastroparesis electrogastrogram: tachygastria, bradygastria, mixed dysrhythmia

Question 66

bulimia nervosa Hx

Answer 66

abnormalities in body image, depression, other psychosocial dysfunction

Question 67

bulimia nervosa O/E

Answer 67

normal examination; possible signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension) and malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema); may have teeth enamel erosion from repeated vomiting

Question 68

bulimia nervosa Ix

Answer 68

solid-phase gastric emptying study: normal electrogastrogram: normal

Question 69

drug induced Hx

Answer 69

symptoms not related to eating or bowel movements; onset days to weeks after starting the medicine; symptoms recur 3 to 4 days after re-initiation of medicine (e.g., chemotherapy agents); causative medications include non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, anti-arrhythmics, opioids, chemotherapy, oestrogen/progesterone, theophylline, digoxin, lubiprostone, metformin, exenatide epigastric tenderness may be present with NSAIDs

Question 70

nephrolithiasis Hx

Answer 70

flank pain, may radiate to groin; dysuria costovertebral angle tenderness

Question 71

nephrolithiasis Ix

Answer 71

urinalysis: microscopic or gross haematuria noncontrast CT abdomen: size and location of stones

Question 72

uraemia Hx

Answer 72

existing renal disease or diabetes; fatigue, anorexia, weight loss; severe cases may have muscle cramps, pruritus, mental and visual disturbances; increased thirst

Question 73

uraemia O/E

Answer 73

oedema; sallow skin; pallor; occult gastrointestinal bleed; hypertension

Question 74

uraemia Ix

Answer 74

24-hour urine creatinine clearance: <10 to 20 mL/minute renal profile: hyperkalaemia; acidosis; hypocalcaemia; hyperphosphataemia ultrasound kidneys: large kidneys in hydronephrosis, obstructions; small kidneys in chronic irreversible damage CT abdomen: size and morphology of the kidneys, lymph nodes

Question 75

idiopathic functional dyspepsia/post prandial distress syndrome

Answer 75

vague epigastric discomfort, early satiety, and prolonged fullness no initial test: diagnosis of exclusion upper gastrointestinal endoscopy: excludes structural lesions or inflammation