Acute GI

Question 1

Appendicitis Types

Answer 1

Acute appendicitis is described as simple, gangrenous, or perforated on the basis of operative findings. In simple appendicitis, the appendix is viable and intact. Gangrenous appendicitis is characterized by necrosis of the appendiceal wall. Perforated appendicitis refers to disruption of the appendix.

Question 2

Appendicitis Symptoms

Answer 2

Initial epigastric / umbilical pain that migrates to RLQ (McBurney’s point)
Abd rigidity comes later, rebound tenderness may occur
Anorexia, fever, elevated WBC may occur
CT scan or Ultrasound needed to confirm

Treatment is surgical, perioperative antibiotics (cephalosporin or flagyl)

Question 3

Most common cause of N/V

Answer 3

Uncomplicated viral gastroenteritis (without metabolic imbalance or dehydration) can be managed with nonpharmacologic interventions including increased fluid intake and diet restrictions. A clear liquid diet should be followed for 24 hours, followed by 24 hours of the BRAT (banana, rice, applesauce, and toast) diet. This regimen will provide the bowel with sufficient rest. A bland diet may be necessary the following week if the patient is still symptomatic.

Question 4

Small Bowel Obstruction

Answer 4

Common cause of acute abdominal pain - Partial or complete or paralytic ileus
Fluids, gas, accumulate and cause N/V, pain, eventual vascular compromise

Abd pain often intermittent and crampy, N/V, abdomen distension, fever, hypoactive bowel

Exclude other causes. Xray may show SBO but CT scan better

Question 5

Markle Test

Answer 5

Stand on tip toes and drop heels down hard. Pain = appendicitis or perotonitis

Question 6

Obturator Test

Answer 6

Supine, knes at 90 degrees with foot on bed. Rotate hip = pain then appendicitis or abscess

Question 7

Psoas Test

Answer 7

Place patient on left side, flex right thigh. Pain = positive for perotonitis

Question 8

Rovsing Test

Answer 8

Palpating left lower abdomen causes pain in right lower abdomen

Suggestive of appendicitis or peritonitis

Question 9

Murphy Sign

Answer 9

Place hand on right costal margin and have patient take deep breath. Apply slight pressure. Pain or halting breaths is positive and suggests cholecystitis

Question 10

Vomit Types

Answer 10

Fecal = small bowel obstruction
Gastric liquid = peptic ulcer
Coffee grounds = duodenal ulcer

Question 11

Parietal Pain

Answer 11

Steady, sharp, knife-like
Increases with cough, movement
AAA, Appendix, Diverticulitis, Perotonitis, Gallbladder, Pancreas

Question 12

Visceral Pain

Answer 12

Dull, poorly localized, crampy, burning

Mesenteric ischemia, spleen, pancreas, kidney, gastroenteritis, small bowel obstruction

Question 13

Constipation Red Flags

Answer 13

Refer if sudden change in bowel habits, patient is older than 50, weight loss, bloody stool, family history of colon cancer or IBS

Question 14

Hemorrhoids

Answer 14

External = below dentate line, Internal = above dentate
1-4th degree classifications
3rd degree are prolapsed during defecation, 4th degree permeant prolapse and require referral
Treat 1-3 with high fiber, stool softeners (refer if no improvement)

Question 15

Anal Fissures

Answer 15

Most occur due to hard/large stool
Atypical or suspicious - suspect STI
Severe sharp rectal pain during and after bowel movements, minute bleeding

Treat with fiber, stool softeners

Question 16

Pruritus Ani

Answer 16

Anal itching, most often idiopathic, usually worse at night
Cellophane tape to check for pinworms
Treat with 1% hydrocortisone cream and antihistamines

Question 17

Anorectal Abscess / Fistula

Answer 17

Infection from obstruction of anal gland, fistula can result from chronic
Perineal pain, swelling increasing with movement/sitting, purulent drainage

Requires I&D, antibiotics

Question 18

Causes of Pancreatitis

Answer 18

Alcohol
Autoimmune
Blunt trauma, biliary obstruction
CongenitalDrugs
Formations / Tumors
Cholesterol
Infectious
Idiopathic

Question 19

Pancreatitis Types

Answer 19

Mild = no organ dysfunction
Moderate severe = transient dysfunction / systemic complications
Severe = persistent organ failure

Interstitial edematous (enhanced on CT) or Necrotizing (non-enhanced on CT)

Question 20

Pancreatitis Symptoms

Answer 20

sudden sharp poorly localized abd pain radiates to back
N/V
Pain so severe that deep breaths are difficult
Elevated serum amylase / lipase (lipase 3x more than normal is highly suggestive)
CT scan (x-ray to rule out other abdominal)

-Always rule out cardiac first!

Question 21

Chronic Pancreatitis

Answer 21

amylase and lipase may be normal
morphologic and histologic changes resulting in endocrine and exocrine dysfunction
Pain occurs within 15 min of eating, greasy stool

Secretion test for diagnosis, patients are often chronic alcohol users

Question 22

Cholecystitis

Answer 22

Biliary colic
RUQ pain radiating to right shoulder within an hour of eating
Cholecystitis = pain doesn’t taper and fever, chills, anorexia while cholelithiasis pain tapers off
Treat with fluids, antiemetics, antibiotics, antispasmodics (Ketorolac is analgesia of choice)
Surgical removal may be indicated

Question 23

Cholelithiasis

Answer 23

3 types of stones

• Cholesterol
• Pigmented (bilirubin)
• Mixed

RUQ pain radiating to back that tapers off

Question 24

Diarrhea Types

Answer 24

Osmotic - Water and salt is drawn into colon

Secretory - absorptive function of gut is compromised, fatty stools more common, can occur with long term use of levadopa

Question 25

Diarrhea Assessment

Answer 25

Stool habits, frequency, abdominal pain? Abdominal assessment,
Many cases medication related
Rule out infectious cause

If stools ^+ in 24 hours and fever = suspect C. Diff

Question 26

ROME IV Criteria for Constipation

Answer 26

2+ of the following for 3 months

• < 3 bowel movements per week
• hard/lump stools
• Straining in 25% or more of bowel movements
• Need to use manual maneuvers in 25% or more of bowel movements

Question 27

perforated peptic ulcer

Answer 27

abrupt onset of severe abdominal pain followed rapidly by peritoneal signs. Pain begins in the epigastrium and spreads rapidly throughout the abdomen with frequent early radiation of pain to the scapular areas. Vomiting of coffee-ground emesis, hematemesis, or melena or hematochezia occurs in some patients. The abruptness, severity, and rapid progression of symptoms lead the patient to seek prompt medical attention. Clinically, patients often demonstrate signs of improvement, such as decreased pain and vomiting, 6 to 12 hours after perforation. However, peritoneal signs remain, the clinical improvement does not last long. nclude boardlike abdominal rigidity

Question 28

Pancreatitis Signs

Answer 28

Fever
N/V
Rapid onset of pain - RUQ radiates to back or upper
Pain lessened when leaning forward