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Internal Medicine > Symptom to Diagnosis - Abdominal Pain > Flashcards

Symptom to Diagnosis - Abdominal Pain Flashcards

1
Q

What is the 1st pivotal step in diagnosing abdominal pain?

A

To identify the LOCATION of the pain.

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2
Q

What can cause pain in the RUQ?

A
  1. Biliary disease
  2. Hepatitis
  3. Renal colic
  4. Diverticulitis
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3
Q

What can cause pain in the epigastrium?

A
  1. MI
  2. PUD
  3. Pancreatitis
  4. Biliary disease
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4
Q

What can cause pain in the LUQ?

A
  1. Splenic injury
  2. Renal colic
  3. Diverticulitis
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5
Q

What can cause pain in the periumbilical area?

A
  1. IBD
  2. Bowel obstruction/ischemia
  3. Appendicitis
  4. AAA
  5. IBS
  6. DKA
  7. Gastroenteritis
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6
Q

What can cause pain in the RLQ?

A
  1. Appendicitis
  2. Ovarian disease
  3. PID
  4. Ruptured ectopic pregnancy
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7
Q

What can cause pain in the LLQ?

A
  1. Ovarian disease
  2. PID
  3. Ruptured ectopic pregnancy
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8
Q

Mention some features that help differentiate the abdominal pain, besides location.

A
  1. Character and acuity.
  2. Factors that make the pain better/worse (eating).
  3. Radiation of the pain and associated symptoms (nausea, vomiting, anorexia, inability to pass stool and flatus, melena, hematochezia, fever)
  4. Pulmonary/Cardiac symptoms can be clues to pneumonia, or MI, presenting as abdominal symptoms.
  5. In women, sexual and menstrual histories are important.
  6. Patient should be asked about alcohol.
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9
Q

What is important to keep in mind about the clinical examination of a patient with abdominal pain?

A 
Includes more than just abdominal exam.
Vital signs:
1. Hypotension
2. Fever
3. Tachypnea 
4. Tachycardia
5. HEENT exam for pallor or icterus
6. Careful lung/heart exams suggest pneumonia or other extra-abdominal causes.
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10
Q

What is useful to keep in mind about abdominal palpation?

A

Should be done last.
It is useful to distract the patient by continuing to talk with him or her during abdominal palpation.
The painful area should be palpated last.

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11
Q

What is the textbook presentation of appendicitis?

A
  1. Abdominal pain that is initially diffuse and then intensifies and migrates toward the RLQ to McBurney point.
  2. Patients often complain of bloating and anorexia.
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12
Q

What is the lifetime occurrence rate of appendicitis?

A

7%.

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13
Q

What makes the initial diffuse pain, localized?

A

The involvement of parietal peritoneum.

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14
Q

What is the risk for perforation in appendicitis for the different age groups?

A

10% for 10-40 age.
30% for 60 age.
50% for >75 age.

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15
Q

What is important to keep in mind about appendicitis?

A
  1. In one study, guarding was completely absent in 22% of patients.
  2. Rebound was completely absent in 16%.
  3. Fever was present in ONLY 40% of patients with perforated appendices.
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16
Q

What other causes of RLQ pain may occur in women, besides appendicitis?

A
  1. PID
  2. Ruptured ectopic pregnancy
  3. Ovarian torsion
  4. Ruptured ovarian cyst
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17
Q

What are the most useful clinical clues that suggest PID?

A
  1. History of PID
  2. Vaginal discharge
  3. Cervical motion tenderness on pelvic exam
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18
Q

How can we rule out ectopic pregnancy in women of childbearing age who complain of abdominal pain?

A

By testing urine beta-hCG.

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19
Q

What are the differences in the symptoms of appendicitis in octogenerians than in patients aged 60-79?

A
  1. Duration of symptoms is longer prior to evaluation (48vs24h).
  2. Less likely to report pain that migrated to the RLQ (29% vs 49%).
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20
Q

What is the role of the WBC count in the diagnosis of appendicitis?

A 
Very low (17.000) substantially increase or decrease the likelihood of appendicitis respectively.
Moderate elevations are less predictive.
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21
Q

Does a low WBC exclude appendicitis in patients who have severe rebound or guarding?

A

80% of such patients have appendicitis even when WBC <8000.

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22
Q

What may urinalysis reveal in acute appendicitis?

A

Pyuria and hematuria due to bladder inflammation from an adjacent appendicitis.

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23
Q

Is CT scanning helpful in appendicitis?

A

Yes –> It is an accurate imaging method when the diagnosis is uncertain.
Studies show that is more sensitive than US in adults.

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24
Q

Will a patient who had a CT scan undergo an unnecessary appendicectomy?

A

No –> Only 3% of patients.
Versus 6-13% of patients who did not have a CT scan performed.
–> CT scanning resulted in lower overall costs.

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25
Q

What is the treatment for appendicitis?

A
  1. Observation is critical.
  2. Monitor urinary output, vital signs.
  3. IV fluid resuscitation.
  4. Broad-spectrum antibiotics, including gram(-) and anaerobic coverage.
  5. Urgent appendicectomy
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26
Q

What is important to remember when evaluating a patient with possible appendicitis?

A

Frequent clinical observations are exceptionally useful.

27
Q

What is the textbook presentation of biliary colic?

A

Gallstone disease may present as incidentally discovered asymptomatic cholelithiasis, biliary colic, cholecystitis, cholangitis, or pancreatitis.

  • -> Pattern depends on the location of the stone and its chronicity.
  • -> Typically presents with episodes of intense abdominal paei that begin 1hr or more after eating - Usually lasts for more than 30 minutes and may last for hours.
28
Q

What are the predisposing factors of asymptomatic cholelithiasis?

A
  1. Incr. Age –> Predominant: 8% in patients older than 40 and 20% in those older than 60.
  2. Obesity
  3. Gender - Women>Men.
  4. Gallbladder stasis
  5. Family history
  6. Crohn disease
  7. Hemolytic anemias can lead to incr. Bilirubin excretion and bilirubin stones (eg. Thalassemia, sickle cell disease).
29
Q

Is cholecystectomy advised in patients with asymptomatic cholelithiasis?

A

No - Make sure the gallstones are causing the pain before advising cholecystectomy.

30
Q

What is the annual risk of biliary colic developing in patients with asymptomatic gallstones?

A

1-4%.

31
Q

What must happens for biliary colic to occur?

A

Gallstones becomes lodged in cystic duct and the gallbladder contracts against the obstruction.

32
Q

What is the duration of biliary colic?

A

Lasts usually <2-4h.

An episode longer than 4-6h, fever, or marked tenderness, suggest cholecystitis.

33
Q

What is characteristic of biliary colic?

A

Episodes of pain with pain free intervals of weeks to years.

34
Q

When does the pain of biliary colic begin?

A

1-4h after eating or may awaken the patient during the night - May be precipitated by fatty meals.

35
Q

With what is the pain of biliary colic usually associated?

A

With nausea and vomiting.

36
Q

In what percentage of symptomatic patients does biliary colic recur?

A

In 50%.

37
Q

What are the complications of biliary colic?

A
  1. Pancreatitis
  2. Acute cholecystitis
  3. Ascending cholangitis
    Occur in 1-2% of patients with biliary colic per year.
38
Q

Can biliary colic develop in patients without stones?

A

Yes - Secondary to sphincter of Oddi dysfunction or scarring leading to obstruction.

39
Q

What is the location of the biliary colic pain?

A 
54% in the RUQ.
34% in the epigastrium.
It may occur as a band in the entire upper abdomen, or rarely in the midabdomen.
Pain may radiate to the:
1. Back
2. Right scapula
3. Right flank 
4. Chest
40
Q

What should be the LFTs, lipase, and urinanalysis in uncomplicated biliary colic?

A

Normal. Abnormalities suggest other diagnoses.

41
Q

What is the test of choice in biliary colic?

A

Ultrasonography

42
Q

What is the treatment of biliary colic?

A
  1. Cholecystectomy is recommended.
  2. Lithotripsy is not advised.
  3. Dissolution therapies (eg, ursodiol) are reserved for non surgical candidates.
43
Q

What is the textbook presentation of IBS?

A
  1. Intermittent abdominal pain accompanied by diarrhea or constipation or both of YEARS of duration.
  2. Diarrhea is often associated with cramps that are relieved by defecation.
  3. Pain cannot be explained by structural or biochemical abnormalities.
  4. Weight loss or anemia should alert the clinician to other possibilities.
44
Q

What percentage of the population is affected by IBS?

A

10-15% of adults - women 2 times more common than men.

45
Q

What is the etiology of IBS?

A

A combination of altered motility, visceral hypersensitivity, autonomic function, and psychological factors.

46
Q

What may often exacerbate IBS?

A

Psychological or physical stressors.

47
Q

Are there any biochemical or structural markers for IBS?

A

No.

48
Q

How is the diagnosis of IBS usually made?

A

Combination of:

  1. Fulfilling the Rome criteria.
  2. Absence of alarm features.
  3. Limited work-up to exclude other diseases.
49
Q

What are the Rome criteria?

A

Recurrent abdominal pain or discomfort (of >6months duration) at least 3 days per month for the past 3 months + two or more of the following symptoms:

  1. Improvement with defecation.
  2. Onset associated with a change in frequency of stool.
  3. Onset associated with a change in form (appearance) of stool.
50
Q

What are the alarm symptoms of IBS that suggest alternative diagnosis and necessitate evaluation?

A
  1. Positive fecal occult blood test or rectal bleeding.
  2. Anemia
  3. Weight loss >10lbs
  4. Fever
  5. Persistent diarrhea causing dehydration
  6. Severe constipation or fecal impaction
  7. Family history of colorectal cancer
  8. Onset of symptoms at age 50 years or older
  9. Major change in symptoms
  10. Nocturnal symptoms
  11. Recent antibiotic use
51
Q

What are the common recommendations for patients fulfilling Rome criteria WITHOUT alarm symptoms?

A
  1. Obtain a CBC
  2. Test stool for occult blood
  3. Perform serologic tests for celiac sprue in patients with diarrhea as the predominant symptom.
  4. Routine chemistries are recommended by some experts.
52
Q

In what IBS patients is colonoscopy with biopsy (to rule out microscopic colitis) recommended?

A

In patients with alarm symptoms, in those aged >50 years, and in patients with a marked change in symptoms.

53
Q

Is there evidence that routine flexible sigmoidoscopy or colonoscopy is necessary in young patients without alarm symptoms?

A

No evidence.

54
Q

What else should be evaluated in IBS patients with alarm symptoms?

A
  1. TSH levels
  2. Basic chemistries
  3. Stool for Clostridium difficile toxin + presence of ova and parasites.
55
Q

What foods may worsen symptoms of IBS?

A

Common offenders include:

  1. Milk products
  2. Caffeine
  3. Alcohol
  4. Fatty foods
  5. Gas producing vegetables
  6. Sorbitol products (sugarless gum and diet candy)
56
Q

What is the specific therapy of IBS when abdominal pain is the predominant symptom?

A
  1. Modify diet when applicable.
  2. Medications include anticholinergics (dicyclomide, hyoscyamine), nitrates, low dose TCAs (Amitriptyline, nortriptyline) or smooth muscle relaxants (not in the USA).
  3. Cognitive behavioral therapy appears to be as effective as pharmacologic therapy.
57
Q

What is the specific therapy for IBS when diarrhea is the predominant symptom?

A
  1. Change diet when applicable.
  2. Medications: loperamide, diphenoxylate, cholestyramine.
  3. Alosetron is a 5-HT3 blocker useful in women with diarrhea-predominant IBS.
58
Q

Is there a problem with alosetron in the treatment of diarrhea-predominant IBS?

A
  1. Rare, but serious complications –> Bowel obstructions and ischemic colitis.
  2. Recommended only in women with severe diarrhea-predominant IBS, who have not responded to other antidiarrheal therapies.
59
Q

What is the specific therapy when constipation is the predominant symptom in IBS?

A
  1. Change in diet (fiber, psyllium).

2. Osmotic laxative: lactulose, polyethylene glycol, or other.

60
Q

What are the 3 distinct clinical subtypes of ischemic bowel?

A
  1. Chronic mesenteric ischemia (chronic small bowel ischemia).
  2. Acute mesenteric ischemia (acute ischemia of small bowel).
  3. Ischemic colitis (ischemia of the large bowel).
61
Q

What is the textbook presentation of chronic mesenteric ischemia?

A

Patients with chronic mesenteric ischemia typically complain of recurrent postprandial abdominal pain (often in the first hour, diminishing 1-2h later) + food fear + weight loss.
–> Often history of tobacco use, peripheral vascular disease, or CAD.

62
Q

What is usually the cause of chronic mesenteric ischemia?

A

Secondary to near obstructive atherosclerotic disease of the SMA or celiac artery or both (both are involved in 91% of affected patients).

63
Q

In what percentage of patients with chronic mesenteric ischemia does weight loss occur?

A

In 80% and is due to food aversion.

64
Q

What is the MCC for hospital admission in the US?

A

Abdominal pain.

Internal Medicine (107 decks)

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