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CCFP 3 > Abdo pain ** > Flashcards

Abdo pain ** Flashcards

1
Q

AXR findings for bowel obstruction

A

air fluid levels
distended loops of bowel
free air
pneumonitis
bowel wall thickening
lumen narrowing
portal vein air
pleural effusions
gallstones
masses

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2
Q

CXR findings for bowel obstruction

A

free air under diaphragm
masses in chest
pleural effusions
widening mediastinum

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3
Q

Top 3 causes of SBO

A

Malignancy
Adhesions
Hernias

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4
Q

Top 3 causes of LBO

A

Cancer
Diverticulitis
Volvulus

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5
Q

Causes of paralytic ileus

A

Post Operative
Infection/Sepsis
Medications (opiates, anesthetics)
Electrolyte Disturbances (sodium, potassium, calcium)
Clostridium Difficile
Inactivity

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6
Q

causes of epigastric pain

A

Cardiac: aortic dissection, AAA, MI, pericarditis
GI: gastritis, PUID, mallory-weiss tear

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7
Q

causes of RUQ pain

A

Hepatobiliary: biliary colic, cholecystitis, cholangitis, hepatitis, appendicitis
Genitourinary: nephrolithiasis, pyelonephritis, mass, ischemia
Cardiopulmonary: RLL PNA, CHF (causing hepatic congestion), MI, pericarditis, pleuritis
Other: shingles, costochondritis

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8
Q

causes of LUQ pain

A

Pancreatic: pancreatitis, tumor
GI: gastritis, PUD, mallory-weiss tear
Splenic: rupture, infarct, abscess, aneurysm
GU: nephrolithiasis, pyelonephritis, mass, ischemia
Cardiopulmonary: aortic dissection, AAA, MI, pericarditis, LLL PNA

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9
Q

causes of RLQ pain

A

GI: appendicitis, Crohns, TB, intusseception, mesenteric lymphadenitis, diverticulitis, volvulus, hernia
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones

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10
Q

causes of LLQ pain

A

GI: diverticulitis, cancer, fecal impaction, proctitis, volvulus
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones

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11
Q

causes of pelvic pain

A

GI: appendicitis, Crohns, TB, intusseception, mesenteric lymphadenitis, diverticulitis, volvulus, hernia, cancer, fecal impaction, proctitis
Gynae: Mittelschmerz, PID, ectopic, ovarian torsion, fibroid, endometriosis, ovarian abscess, salpingitis
GU: cystitis, hydroureter, epididymitis, testicular torsion, retention, kidney stones

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12
Q

causes of diffuse abdo pain

A

Peritonitis
Pancreatitis
Mesenteric ischemia
Pan-colitis
Ruptured AAA
Porphyria
DKA
Addison’s
Uremia
Hypercalcemia

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13
Q

Where do the following radiate to?
Ureteric obstruction
Biliary colic
Pancreas
AAA
Perf ulcer

A

ureteric obstruction -> ipsilateral testes or labia
biliary colic -> ipsilateral shoulder/ scapula
pancreas -> back
AAA -> back
perf ulcer -> RLQ

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14
Q

What ix to order for abdo pain, including ?mesenteric ischemia, Zollinger Ellison syndrome, endometriosis and ?obstruction

A

CBC, U+Es, ex lytes, LFTs, lipase, CRP, glucose, urinalysis, bHCG
3 view abdo ?obstruction = >3 air fluid levels in upright AXR
CT angio for mesenteric ischemia
Gastroscopy/ colonoscopy
Urea breath test for H pylori
Fasting serum gastrin levels for Zollinger Ellison syndrome
Stool samples for ova + parasites
Diagnostic laparoscopy for endometriosis

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15
Q

GERD Ix

A

Lifestyle Modifications Trial
Pharmacotherapy Trial
Barium Swallow
24 hour pH Monitoring
Gastroscopy
Acid Perfusion Test

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16
Q

GERD Red flags

A

Dysphagia
Weight Loss
Anemia
Early Satiety

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17
Q

Complications of GERD

A

Barrett’s - histologically - Metaplasia (Squamous to Columnar Epithelium
Esophaheal adenocarcinoma

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18
Q

RF for GERD

A

Obesity
Alcohol Use
Smoking
Diet (high fat foods, chocolate, mint, citrus, spicy foods, caffeine…)
Hiatal Hernia
Delayed Gastric Emptying/Clearance
Pregnancy
Medications (anticholinergics, nitrates, calcium channel blockers, NSAIDS, bisphosphonates)
Scleroderma

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19
Q

GERD Management

A

Wt loss, reduce alcohol + caffeine, elevating head of bed, stop smoking
Antacids
H2 Blockers
Proton Pump Inhibitors - try PPI holiday annually. Unlikely to respond to surgery if not responding to PPI
Bariatric surgery if obesity is a factor

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20
Q

Sx PUD

A

Epigastric pain
Early satiety
Post prandial fullness
Bloating, N/V

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21
Q

Precipitating factors of PUD

A

Caffeiene, high fat, alcohol, smoking, NSAID/ ASA use, CCB

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22
Q

Ix for PUD

A

H pylori urea breath test, fecal antigen test or biopsy. Hold PPI for 2 weeks to prevent false positive

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23
Q

Management of PUD

A

Stop smoking
Lifestyle: eat smaller, more frequent meals, reduce alcohol, avoid spicy food, maintain ideal weight
Negative H pylori: PPI x4 weeks for duodenal ulcers, 8 weeks for gastric
Positive H pylori: PPI BID + amox 1000mg BID + clarithromycin 500mg BID + metronidazole 500mg BID x 2 weeks
NSAID induced - lower/ stop NSAID and ASA use, consider using alternatives like Tylenol. 4-6 weeks PPI for duodenal ulcers or 6-8 wks for gastric ulcers
Physiological stress induced (often in ICU) - prophylaxis with PPI or H2 blockers during ventilation

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24
Q

Extraintestinal sx of UC

A

Flares: peripheral arthritis of large joints, episcleritis, apthous ulcers, erythema nodosum
Continuous: ankylosing spondylitis (pain in SI joint), uveitis (serious, needs optho consult), primary sclerosing cholangitis (check LFTs)
Gallstones, ureteric obstruction as a complication

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25
Q

Ix for UC

A

colonoscopy + biopsy, barium study, CT abdo

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26
Q

Lifestyle management of UC

A

Stop smoking
Electrolyte, vitamin supplementation (Vit D, calcium, Mg, Zinc)

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27
Q

Crohns RF

A

smoking, Ashkenazi Jews

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28
Q

Crohns exacerbating factors

A

infection, smoking, NSAIDs

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29
Q

Ix for Crohns

A

endoscopy + biopsy, air contrast barium enema, US, MRI/ CT, CBC, CRP, B12, albumin

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30
Q

Complications of Crohns

A

Urinary calculi
Liver problems
Cholelithiasis
Epithelial problems
Retardation of growth
Arthralgias
Thrombophlebitis
Vit deficiency
Eyes
Colorectal carcinoma
Obstruction
Leakage (perforation)
Iron deficiency
Toxic megacolon
Stricture/ fistulae

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31
Q

Crohns management

A

Stop smoking
Electrolyte, vitamin supplementation (Vit D, calcium, Mg, Zinc)
Assess for depression, anxiety and stress and treat accordingly
Check med adherence
Iliocolonoscopy 8 years after sx onset for cancer screening
Keep vaccines UTD and screen for hepatitis and TB before starting immunosuppressants
Influenza
Refer to GI for immunosuppressants
Functional sx: loperamide, anti-spasmodics, neuropathic agents, Tylenol, 5-ASA (sulfasalazine)

Colon only: prednisone
Terminal ileum/ right colon: budesonide

Then
1) thiopurine +/-
2) biologics eg infliximab
3) methotrexate

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32
Q

Primary vs secondary dysmenorrhea

A

Primary = pain during menses in absence of pelvic pathology
Secondary = associated w/ pelvic pathology eg endometriosis

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33
Q

RF for dysmenorrhea

A

Smoking
Poor social support
Mood disorders

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34
Q

Causes of secondary dysmenorrhea

A

Endometriosis
Adenomyosis
Uterine myomas
Cervical stenosis

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35
Q

Management of dysmenorrhea

A

Lifestyle:
Exercise
Heated pads
Ginger
Non hormonal:
Tylenol
NSAIDs
COCP continuous
Progestin IUD, depo or POP
Surgical:
Uterine nerve ablation (fertility preserving)
Endometrial ablation
Hysterectomy

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36
Q

Endometriosis RF

A

family hx, nulliparity, short menstrual cycle, diet high in red meat

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37
Q

Sx endometriosis

A

dysmenorrhea, deep dyspareunia, dyschezia, dysuria, chronic pelvic pain, infertility

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38
Q

Management of endometriosis

A

NSAIDs
COCP continuously
Progestin only (depo, pill, IUD)
GnRH agonist (Dnaazol)
Surgical: refractory pelvic pain, severe invasion, infertility

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39
Q

DDx for dysmenorrhea

A

Endometriosis
Adenomyosis
Pelvic Inflammatory Disease
Fibroids
Endometrial Polyps
Intrauterine Device
Cervicitis
Cervical Stenosis
Chronic Pelvic Pain Syndrome
Ovarian Cysts
Cystitis
Interstitial Cystitis
Pelvic Malignancy

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40
Q

What are uterine fibroids?

A

Benign, hormone sensitive smooth muscle tumor

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41
Q

RF for fibroids

A

nulliparity, obesity, FH, HTN

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42
Q

Sx of fibroids

A

asymptomatic, abnormal uterine bleeding, pelvic pressure, bowel dysfunction, bladder sx

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43
Q

Complications of fibroids

A

IDA, infertility, miscarriage, fetal malpresentation

44
Q

Management of fibroids

A

IUD
GnRH agonist (leuprolide acetate)
Selectie progesterone receptor modulators (ulipristal acetate)
COCP
POP
Androgens (danazol)
Uterine artery embolization
Myomectomy
Hysterectomy

45
Q

What does a rigid abdo mean?

A

Perforated viscus

46
Q

Pain out of proportion to exam?

A

ischemic bowel

47
Q

Generalised pain that later localises

A

appendicitis

48
Q

Waves of pain with other sx like hiccups/ N/V

A

bowel obstruction

49
Q

Sx of appendicitis

A

fever, migratory pain periumbilical moving to RLQ, fever, anorexia, nausea

50
Q

Complications of appendicitis

A

perforation, abscess, phlegmon

51
Q

Management of appendicitis

A

laparoscopic surgery + ampicillin, gentamicin + metronidazole x24hrs

52
Q

RF cholecystitis

A

obesity, multiparity, female gender, OCP, forties

53
Q

Charcot’s triad

A

fever, RUQ pain, jaundice

54
Q

Reynold’s pentad

A

fever, RUQ pain, jaundice, shock, confusion

55
Q

Murphy’s sign

A

RUQ pain, severe, constant

56
Q

Complications of cholecystitis

A

biliary obstruction, duodenal perforation, pancreatitis, ascending cholangitis, sepsis

57
Q

Ix for cholecystitis + results

A

↑WBC, ↑conjugated bili, ↑ALT, ↑AST, ↑↑ALP, US (distended gallbladder, pericholecystic fluid, stone in cystic duct, thickened gallbladder wall)

58
Q

Rx for cholecystitis

A

NPO, IVF, NG if persistent vomiting, ampicillin + gentamicin + metronidazole, lap chole

59
Q

How to diagnose Primary biliary sclerosis

A

anti mitochondrial antibodies

60
Q

Sx of diverticulitis

A

fever, LLQ pain, change in BMs, urinary sx, N/V

61
Q

RF for diverticulitis

A

Increased Age
Constipation
Low Fibre Diet
Obesity
Sedentary Lifestyle

62
Q

Complications of diverticulitis

A

abscess, fistula, obstruction, perforation

63
Q

Ix for diverticulitis

A

CT or US if not available

64
Q

Rx for diverticulitis

A

Bowel rest, clear fluids then high fibre diet, abx if comorbid conditions (cipro 500mg BID + flagyl 500mg BID x7/7). If severe, NPO, NG, suction. Surgery if unstable w/ peritonitis, abscess

65
Q

RF for diverticulitis recurrence

A

young age, obesity, abscess

66
Q

Prevention of diverticulitis

A

stop smoking, reduce meat, exercise, lose weight, reduce NSAID use

67
Q

What Ix to avoid in diverticulitis?

A

Barium Enema (risk chemical peritonitis in acute diverticulitis)
Colonoscopy/Sigmoidoscopy (risk of perforation in acute diverticulitis)

68
Q

Causes of pancreatitis

A

gallstones, alcohol, tumors, scorpion stings, TB, mumps, SLE, surgery, hyperlipidemia, emboli, furosemide

69
Q

Sx of pancreatitis

A

persistent epigastric pain, N/V, fever, jaundice

70
Q

Complications of pancreatitis

A

abscess, pleural effusion, ARDS, ATN, pericardial effusion

71
Q

Ix for pancreatitis

A

↑WBC, ↑lipase + amylase, ↑ALT, US, ERCP to r/o stone

72
Q

Rx for pancreatitis

A

IVF, NPO, NG suction, analgesia, drain abscess, surgery if necrotic or acute biliary pancreatitis

73
Q

Prognosis tool for pancreatitis

A

use Ranson’s criteria

74
Q

Which Fat soluble vitamins absorption are affected by pancreatitis?

A

Vit A, D, E, K

75
Q

Ix for renal stones

A

US + KUB XR

76
Q

What abdo concerns do you get in neonates?

A

necrotising enterocolitis, malrotation, volvulus, incarcerated hernia, non-accidental trauma

77
Q

What abdo concerns do you get in toddlers?

A

Meckles diverticulum, testicular torsion, intussusception, trauma

78
Q

What abdo concerns do you get in 3-15y/o?

A

appendicitis, DKA, testicular torsion, constipation, functional pain

79
Q

What abdo concerns do you get in the elderly?

A

cholecystitis, spontaneous bacterial overgrowth, appendicitis, large bowel obstruction, strangulated hernia, necrotising pancreatitis, infarcted bowel

80
Q

What can make AAA worse?

A

Fluids

81
Q

Sx of IBS

A

altered bowels, abdo pain, distension, mucus, dyspepsis

82
Q

How do you diagnose IBS?

A

Rome criteria for dx: recurrent abdo pain weekly w/ associated sx: related to defecation, change in frequency or form of stool

83
Q

Exacerbating factors - IBS

A

alcohol
caffeine
fat
fibre
stress
menstruation

84
Q

Rx for IBS

A

FODMAP, increase fibre
Constella
Ibsrela
Constipation: linaclotide, SSRIs, lactulose, PEG, GI referral
Diarrhea: amitryptiline
Pain + bloating: anti-spasmodics like hyosciamine or peppermint oil

85
Q

Colorectal cancer RF

A

age >50, IBD, personal hx of colorectal or polyps, 1st degree relative with colorectal cancer, known genetic predispositions like familial adenomatous polyposis, Lynch syndrome, low physical activity, diet low in fibre/ fruits/ vegs, alcohol + tobacco use, obesity

86
Q

Colorectal cancer sx

A

abdo pain, anemia, rectal bleeding, change in BMs, narrowing of stool diameter (ribboning), tenesmus (rectal cancer)

87
Q

What to assess in annual review of UC

A

Assess for depression, anxiety and stress and treat accordingly
Check med adherence
Iliocolonoscopy 8 years after sx onset for cancer screening
Keep vaccines UTD and screen for hepatitis and TB before starting immunosuppressants

88
Q

Medical therapy for UC, inc functional sx rx

A

Functional sx: loperamide, anti-spasmodics, neuropathic agents, Tylenol, 5-ASA (sulfasalazine) for Crohns only in colon
Corticosteroids for flares (oral budesonide 1st, prednisone 2nd line)
Thiopurine + Anti-TNF TOGETHER for induction + remission
Immunomodulators for severe disease (TNF antagonists (infliximab)), fistulas/ abscesses = surgery

89
Q

Signs associated w/ appenditicis

A

pain on McBurneys point (tenderness ⅓ from ASIS)
Rovsing’s sign (palpation of left abdo causes pain in McBurneys point)
psoas sign (pain on flexion of hip against resistance)
obturator sign (flexion then rotation of right hip causes pain)

90
Q

Recommended diet for IBS

A

low FODMAP

91
Q

FODMAP foods

A

oligosaccharides (wheat, legumes), disaccharides (milk, yogurt), monosaccharides (mangoes, honey), polyols (blackberries, lychee)

92
Q

alarm features of abdo pain

A

wt loss, melena, age >55, palpable mass, GI blood loss

93
Q

H pylori management

A

4 drugs, 14 days, PPI, bismuth, metronidazole, tetracycline

94
Q

Prevention of Barrett’s

A

lifestyle, high dose PPI, ASA

95
Q

Long term PPI risks

A

B12 deficiency, C diff, dementia, fractures

96
Q

Management of ureteral stones <5mm + >5mm

A

<5mm = conservative management, tamsulosin if distal
>5mm/ obstructive ureteral stones = timely decompression, refer to uro

97
Q

ureteral stones imaging

A

XR + US KUB

98
Q

pancreatitis RF

A

septra, flagyl, HCTZ, ACEi, progesterone, atorvastatin, estrogen, gallstones, alcohol

99
Q

gallstone RF

A

female, forty, fertile, obese, OCP

100
Q

Biologics for UC

A

Humira, Stelara, Entyvio

101
Q

How to diagnose hiatus hernia?

A

Barium swallow or scope

102
Q

How to diagnose GERD?

A

Barium swallow, med trial, scope

103
Q

How to diagnose esophageal spasm?

A

Scope, barium swallow or nuclear medicine

104
Q

ROME criteria for dyspepsia

A

postprandial fullness
early satiety
epigastric pain
epigastric burning

severe enough to interfere with the usual activities and occur at least 3 days per week over the last 3 months with an onset of at least 6 months in advance

105
Q

Classification of GI ulcers

A

forrester

CCFP 3 (67 decks)

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