4. GI Luminal Disease Flashcards
(132 cards)
1
Q
RUQ pain - dDx?
A
Biliary colic, cholecystitis, cholangitis, Hep,Liver abscess, pancreatitis
2
Q
Epigastrium pain - dDx?
A
Gastritis, GORD, PUD, Gastric peforation, pancreatitis, oesophagitis
3
Q
LUQ pain - dDx?
A
Splenic rupture/infarct/abscess, pancreatitis
4
Q
Right or left flank pain -dDx?
A
Renal colic, pyelonephritis, colitis
5
Q
Periumbilical pain - dDx
A
SBO, Ruptured AAA, Gastroenteritis, Mesenteric ischaemia
6
Q
RIF pain - dDx?
A
Appendicitis, ovarian torsion, tubo-ovarian abscess, ectopic pregancy, colitis, ovarian cyst
7
Q
Suprapubic pain - dDx?
A
Cystitis, pelvic inflammatory disease, STI, pregnancy
8
Q
LIF pain - dDx?
A
Colitis, diverticulitis eg. sigmoid colon, ovarian torsion, TOA, ovarian cyst, ectopic pregnancy
9
Q
Visceral abdominal pain suggestive of?
A
Poorly localised, autonomic pain
10
Q
Which structures are colicky pain more likely to be experienced in?
A
Luminal structures- pain gets more sever if bowel contracts against obstruction
11
Q
How is the pain of peritonitis described
A
Sharp, well localiseed ( dermatomal innervation), but if perforated may be generalised, pain may get very severe
12
Q
How does pain from cholecystitis radiate
A
RUQ to right shoulder
13
Q
How does pain from pancreatitis radiate and what other Sx and FHx might there be
A
To back, vomitting and possible hc of gallstones or alcohol access
14
Q
What disease can commonly cause peritonism
A
Appendictis
15
Q
What does guarding indicate, and what other sign may be observed
A
Peritonitis, guarding
16
Q
Common obs and blood in cholecystitis?
A
Pain and unwell, high CRP
17
Q
Common obs and blood in cholangitis
A
Very unwell, deranges LFT- billi and ALP raised
18
Q
Is pancreatitis more likely to be epigastric or RUQ pain
A
epigastric pain
19
Q
Can appendicitis cause RUQ pain
A
yes if retrocaecal
20
Q
Value of CRP in RUQ pain
A
Check for infxn (w/ WBC)
21
Q
What is lactate a marker of
A
Bowel ischaemia- or just not very well
22
Q
What are glucose and amylase markers of
A
Hepatitis
23
Q
What is the role of urinalysis in abd pain
A
Signs of infxn or kidney stones (haematuria)
24
Q
What can CXR show in abd pain
A
Air under diaphragm- perforation
25
Differnce in sensitivity of USS and MRCP for gallstones and bile duct stones
USS better for gallstones, MRCP for BDS
26
Appendicitis signs and Ix
Sudden, severe RIF pain, or pain from central (vague pain) to IF (Localised) , worse on coughing
Rebound tenderness
May have guarding and rigidity
Generally malaise and unwell
May have N+V+D
Mild fever,High CRP, WBC, normal Hb
If systemically unwell, may have high fever, severe abd pain and more generalised abdominal pain
27
ERCP findings for biliary colic and cholecystitis
Gallstones and thickened gallbladder wall resp.
28
Tx for acute cholecystitis
IV abx and cholecystectomy for acute cholecystitis
29
Biliary colic treatment
Cholecystitis, but in OPD
30
Likely cause of small amount of free air under diaphragm
Duodenal Ulcer
31
What to rule out in 22 yo lady with lower abd pain, what Ix for this
ectopic pregnancy, ovarian diseases, appendicitis, pelvic USS
32
Possible GI causes of lower abd pain
Appendicitis, diverticulitis
33
70 year old male with generalised abd pain, abd distention and vomitting
Grad onset, vomitting dark green liquid
Waves for the last 48 hrs
2 similar ep over past 12 mo (colicky pain), resolved spontaneously
Possible cause? Ox and Ix?
Other sx
SBO. Tympanic to percussion,
Tinkling bowel sounds on ascul, mildy tender, RIF scar, tachycardia. Do CXR, may do CTAP - eg. can show SBO with transtition point in RIF, Dilatation of bowel -
Adhesion may be caused by scar tissue
34
Possible causes of BO include
SBO
Hernias, adhesion (previous operations- should check for scars), CD ( LBO rare, suacute with colickly pain more common)
LBO
Colon cancer and volvulus ( eg. that of sigmoid colon or caecum)
35
Na and K levels in vomitting
Low
36
Early Mx for SBO
Analgesia, IV fluids + bowel rest, nil by mouth large bore NGT to decompress bowel
Conservative Mx in adhesions or partial obstruction in CD
Exploratory laoratomy to address pri cause eg. resect stricture or CRC
37
Operation vs observation for SBO
If ischaemic due to close loop obstruction, may need to cut scar tissue and resect bowel
If relatively well then NGT and fluids for 2? Days, pt may get better w/o op.
38
When should CXR be done most commonly for abd pain
obstruction (dilated loops) or perforation (free air)
39
When should amylase be tested
suspected pancreatitis
40
What is passing flatus a common sx of
BO
41
Likely disease if particular foods trigger it
Gallstone disease
42
What disease is more likely to improve with passing of motion or flatus
IBS
43
Unwell, gen. abd pain, peritonism, tachycardia, hypotension, fever, guarding, generalised perionism - what may this be
May be perforated viscus?
44
Signs of BO
Abd distension, not moving bowels or passing flatus , vomitting
45
Where is pain likely to be in rupture AAA and other Sx
shoulder tip referred pain, palpable AA, pain that goes to the back, hyperT
46
Sx in abdominal ischaemia, and is pain acut or chronic
Generalised peritonism and SUDDEN ACUTE SEVERE abd pain
High lactate, passage of red or darker blood in stool
May eventually have peritonitis
SHARP STABBING pain
47
Age of pts who get mesenteric ischaemia
Age > 50 years
48
More severe Sx of acute mesenteric ischaemia
bowel necrosis and perforation, and, in advanced cases, fever, tachycardia, and hypotension will be present
49
Ix of acute mesenteric ischaemia
-FBC, U+E, LFT, lactate and ABG
- CT of abdomen:
- vessel thrombosis; thickened bowel wall; abnormal bowel wall enhancement; pneumatosis; portal or mesenteric venous gas
- Plain abdominal x-rays:
- may see dilated loops of bowel; air-fluid level; bowel wall thickening; formless loops of large or small bowel; pneumatosis; vascular gas‘
- CXR:
- Free air under diaphragm
50
Sx of IBS
Bloating , const. or diarrheoa, esp if gets better on BO
51
How might Crohn's disease cause recurrent abdominal pain?
Prev resections- adhesions, or stricturing which may cause obstruction- more subacute/chronic than obstructing bowel cancer
52
Difference in patient positioning in peritonism vs colic
Staying still ( as movement aggravates pain) vs writhing around
53
What is pallor a sign of in acute abdomen
Shock - Sepsis, GI bleeding, perforation
54
What is jaundice in acute abdomen sign of
Gallbladder or liver problems
55
What are the causes of localised peritonism vs generalised peritonism
Appendicitis vs advance perforation
56
Describe bowel sounds in peritonism
absent
57
Describe bowel sounds in BO
Tinkling/high pitch
58
What are deranged cholestatic liver FTs a sign of
Cholangitis, gallstones, cholecystitis
59
What can urinalysis tell you in acute abdomen
Ketones + glucose suggest DKA, WCC may suggest pyelonephritis
60
What does fluid level on AXR show
Obstruction
61
What can be seen on AXR apart from dilated loops of bowel and fluid level
Toxic megacolon
62
what can ultrasound abdomen show you
Gallstones, cholecystitis
63
When would CTAP be done
Infective peforation or abdominal complications susp.
64
What does sudden onset pain suggest
Perforation ( duodenal ulcer, IBD), rupture of aneurysm or ovarian cyst, torsion of ovarian cyst, acute pancreatitis
65
what does back pain suggest
Acute pancreatits, rupture of aortic aneurysm ( back to front, sever pain), renal tract disease eg. kidney stones or pyelonephritis
66
What does more gradual onset of abd pain suggest
Inflammatory conditions like appendicitis, IBD, diverticulitus
67
abd pain with rectal bleeding/ melena
PMHx of AF and COPD, sats 91, BP 90/60, Pulse 160 AF, Temp 36, abdomen rigid and silent to auscultation. Elevated CRP, lactate and WCC
Intestinal ischaemia
68
Causes of intestinal ischaemia
Acute - vascular occlusion due to embolism or rupture of pre-existing arterial thrombosis, in low output states like shock in pts with pre-existing vasc disease
Chronic- insidious development of ischaemic Sx like abdominal pain that is worse after eating
69
Risk factors for Intestinal ischaemia
Elderly pts with vasc disease, co-existing cardiac arrhythmias and co-morbitites like diabetes
Secondary to conditions resulting in low output like shock of any cause
70
Diff in presentation of colonic and SB ischaemia
Colonic- acute abdomen, significant LGIB ( fresh rectal), large areas of ulceration, Splenic flexure and left proximal colon often affected , usually resolves spontaneously
SB - may have sig. weight loss if chronic due to nutritional failure, may have acute abdomen, perotinsim, diarrheoa/ melena, fresh rectal bleeding, very unwell
71
Mx of acute bowel ischaemia
Aspirin and statins for intestinal ischaemia
Agressive resucscitation, broad spectrum abx
CT angiogram or MRA considered to see if there is a critical vasc lesion that can be treated by stenting
Exploratory laparotomy with potential resection of affected bowel can be considered in severe intestinal iachaemia with acute abd
Catheter directed thrombolysis or angioplasty with stenting as alternative revasc strategies
72
dDx for appendicitis
Ileo-caecal CD with abscess formation - often have RIF pain
Acute salpingitis in women - vaginal discharge and adnexal tenderness of vaginal examination
Non-specific mesenteric lymphadenitis in younger indiv
Acute Terminal ileitis sec to infxn
73
How to confirm Dx of appendicitis and what other Ix can be done
CTAP or ultrasound (esp in pregnant women or children)
urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
FBC - increased inflammatory markers, neutrophil predom leukocytosis
74
Mx of appendicitis
Laparoscopic or open removal
Treatment with abx and drainage if appendix mass or abscess is present due to rupture
75
possible MHx in BO
CD- prone to stricturing or narrowinng of bowel
Gut or abd op - adhesions ( most common cause)
Opiates- slow transit constipation leading to obstruction
76
Risk factors for LBO include
Colorectal adenomas, IBD, diverticular disease are all risk factors , so is radiotherapy
77
Px of BO, Ox and Bloods
Central colicky abdominal pain, abdominal distention and vomiting, reduced/no bowel movement
May have constipation
Possible pyrexia or nausea
Increased bowel sounds, Tinkling bowel sounds in complete obstruction
Elevated WCC and CRP
78
Initial Ix for SBO
AXR
also do DRE - may reveal lower colonic path like rectal cancer in LBO
CT or MRIAP may provide more accurate data on level of obst,
CT should be first line? ABG and FBC should also be done
79
How is pain of abdominal colic described
Diffuse, vague visceral pain according to divisions of foregut, midgut and hindgut
80
SBO vs LBO vs complete BO
Profuse vomiting vs less vomiting, no bowel movement or flatus? ( and may have tenesmus) vs no passage of wind and sig. distention- and peritonitism will develop over time
81
What does peritonism suggest in BO
Strangulation or perforation of intestine
82
Mx of BO, including complete SBO
Bowel rest, nil by mouth
Large bore NGT to decompress
Complete- supportive care first line, fluid resusc, decompress and analgesia
Abx if signs of perforation, ischaemia or if surgery is planned
83
What is parlytic ileus
Cond where intestinal motility stops, can occur postoperatively or in electrolyte imbalances, features can mimic mechanical obst.
84
How to diff parlaytic ileus from BO
Absent bowel sounds vs high pitched tinkling sounds
PI more likely to occur post surgery
85
What causes peritonitis
- gastroduodenal ulcers (UGI)
- CD, appendicitis (SB)
- Divericular disease ( Colon)
- Following instrumentaiton eg. colonscopy
- Breakdown of intestinal surgical anastomosis post-operatively
- Pancreatic fluid in severe pancreatitis
- Bile from free bile from gallbladder or bileducts
- SBP, common in advance ALD pts
86
Features of peritonitis
pain more localised, assoc with guarding
Pain worse with coughing and deep breathing, rebound and percussion tenderness, rigity
87
Effect of peritonitis on gut motility, what is seen on XR
Toxix, may have silent abdomen with no bowel sounds, dilatation of intestines on X-ray
88
Complication of peritonitis
If uncontrolled can lead to SIRS and septic shock
89
Mx of peritonitis
If sec to intestinal perforation, need surgical intervention to resect tissue or repair perforation and wash out peritoneal cavity
IV abx
90
What do Ix for adhesions show
- dilated loops of proximal bowel with collapsed loops posterior to site of obstruction
- May have high-pitched bowel sounds or absent bowl sounds, tenderness, involuntary guarding, distended abdomen?
- Elevated CRP may be observed
- Chest x ray may show free air under diaphragm
- CXR shows dilated bowel (maybe)
91
Sx of diverticulitis
- LLQ pain
- Fever, anorexia, nausea, vomitting
- Abdominal distension with ileus
- Fever, LLQ tenderness, peritoneal signs ( guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess
- Elevated WBC,CTAP - diverticulitis may be observed, bowel wall thickening , free abdominal air
92
When should surgery be done for BO
- Surgery is indicated in patients with adhesional obstruction if there are signs of peritonitis, hernia strangulation, or bowel ischaemia.
- Computed tomographic evidence of a non-adhesional cause (tumour, hernia, volvulus, or gallstone) a is an indication for surgery
93
Is IBS more common in men or women and which age group in particular
Women, <40yo
94
What is the Rome IV criteria
Recurrent abdominal pain on average at least 1 day/week in last 3 mo, assoc with two of more of:
Related to defecation
Assoc with change in freq of stool
Assoc with change in form of stool
95
What tests should be done in IBS pts to rule out organic cause
Faecal calprotectin- high -ve predictive value to rule out organic cause esp in diarrhoea predom sx
Other test includes routine bloods for IDA< alterations in LFT or UnEs, and coeliac screen
96
When should pts have further Ix for suspected IBS and what should it be
Colonoscopy if change in bowel habits has lasted for more than 6 wks esp if >50 yo
Unexpla9ned weight loss
Abdominal or rectal mass
Rectal bleeding or bloody diarrhoea
Noctural sx
97
What are drugs for IBS-D
antimotility durgs like loperamide, ondansetron or bile acid sequestrants if evidence of bile salt malabsorption
Dietary exclusions ( triggers- wheat, dairy and lactose)
FODMAP diet
98
What are drugs for IBS-M
Bulkforming laxative like fibrogel, methylcellulose, bowel regulators, dietary exclusion and FODMAP
99
How to treat patients with abdominal sx in IBS
Buscopan- antispasmodic
100
IBD features
Long history of diarrhoea ( weeks at least), may have weight loss, abd pain, tiredness
Tenderness in lower abdomen, may have fever esp in severe flares
Anaemia and high platelets
101
Rectal bleeding seen in IBD?
Only in UC and not CD usually
102
Extraintestinal manifestations of IBD
Mouth ulcers, ocular inflammation, arthitis, eryhtema nodosum, pyoderma
103
Abdominal mass palpable in CD or UC? And in which area?
CD, RIF
104
Key Ix for IBD and what else should be done
Sigmoidoscopy or colonoscopy with biopsy
MRI of small bowel to investigate small bowel involvement, MRI pelvis if perianal disease suspected, CTAP if suspicion of abscess or perfortion or other complcations,
105
What does CD histology show
Transmural, deep, patch inflammation with granuloma. May have cobblestone mucosa
106
What does UC histology show
Superficial and CONTINUOUS colonic inflammation with crypt abscesses
107
Mx of UC
Not severe
Basically Topical AS --> Oral ASS--> Topical CTS -> Oral CTS
Treatment for severe colitis - IV steroids first line, ciclosporin if steroids contra
108
Is PSC more commonly associated with CD or UC
UC
109
In which disease is there an increase in goblet cells
CD
110
IS CD or UC closely assoc with smoking
CD
111
How to induce remission in CD
Glucocorticoids
Mesalazine second line, aza may also be added on
112
Maintaining remission of CD
Stope smoking and aza
113
Where does CD most common affect
Ileo-caeacal region
114
What kind of ulcers are seen in CD
Apthous ulcers
115
Common sx in CD
Weight loss esp if SB affected, anaemia, diarrhoea
May have abd pain if BO present
May have perianal abscess- severe perianal pain
116
Where does UC typically start in
Rectum
117
Sx of UC
Rectal bleeding, tenesmus, small volume diarrhoea for rectum or sigmoid
Extensive - significant bloody diarrhoea with high stool frequency
118
Sx of fulminant colitis
Fever, tachycardia, peritonism toxic megacolon
119
Sx of severe UC flatre
Evidence of systemic disturbance, e.g.
fever
tachycardia
abdominal tenderness, distension or reduced bowel sounds
anaemia
hypoalbuminaemia
120
Rnship of UC to smoking
Presents on cessation of smoking
121
ix for fulminant UC
Significant weaking and dilatation of colon, usually will have empty and gas filled colon with loss of haustra. Pts will be very sick and at high risk of colonic perforation
122
What are factors that are linked to flares
Stress, meds (Abx, NSAIDs), smokinng cessation
123
How to treat perforation
surgical intervention along with broad-spectrum antibiotics to treat any resultant infection
124
Do adhesions cause chronic or recurrent abd pain
Both?
125
What medications can cause constipation
Opiates, antidepressants, oral iron
126
Possible perineal examination findings of constipation
Prolapse or fissure or fistula ( CD)
127
When should colonoscopy be done for pts with constipation
If CRC suspected
128
When should flex sig be done fo constipation
To exclude left sided obstructing lesions- diverticular segment, cancer, stricture etc
129
When should AXR be done for constipation
If there is retained stool, eg. faecal loading, colonic dilatation, pseudooobsrtuction and megacolon
130
Mx of constipation
Diet and fibre intake?
Bulk forming laxatives if pts ave pellet type stools, hyperosmolar like macrogol to keep bowels easy to pass, lactulose in hepatic encephalopathy
131
What can be used for patients with constipation from chronic opiate use
Naloxegol
132
