Eval of abdomen pain in PC Flashcards
(171 cards)
1
Q
What is the 2nd mc pain in PC?
A
GI complaint
2
Q
What is the mc GI complaint?
A
Constipation then diarrhea
3
Q
What % of abd complaints are not referred to GI
A
75%
4
Q
What % eventually get dx with IBS?
A
50%
5
Q
What % of acute abdominal pain has no clinical dx?
A
34%
6
Q
Review slide 6
A
-
7
Q
Whats the goal with GI complaint?
A
Determine who needs a work-up for their abd pain (and how extensive that work up should be!)
8
Q
What are the treatment options for GI complaint?
A
- Symptomatic care / watch and wait
- Lab and diagnostic work up – outpatient or emergent?
- Referral
9
Q
What % will stay in PCP?
A
80%
10
Q
T/F We need to determine which pt are appropriate for “watch & wait” vs who you think has an underlying organic cause that needs to be treated
A
T
11
Q
Whats the most imp squeale from diarrhea?
A
Dehydration
12
Q
How is constipation dx?
A
Clinical, dont need KUB!
13
Q
Whats the common PC diagnoses?
A
Diarrhea
Constipation
Gastroenteritis
Food related (Celiac disease, Lactose intolerance)
14
Q
Do you always need a formal dx test?
A
No
15
Q
Whats the most common s/e of ulcer?
A
Perforation - suden onset of severe pain
16
Q
MC cause of obstruction?
A
adhesion from abdmen surgery
17
Q
if they have severe, pain out of proportion?
A
Acute ischemia, mc in elderly
18
Q
Whats the approach to pts with abd pain?
A
Determine whats unstable vs stable
19
Q
What do you do with unstable pt?
A
toxic, in extreme pain, or present with a potentially surgical complaint need to be sent to the emergency room
20
Q
What do you do with pts who are stable?
A
Non-toxic should be worked up in the office
A systematic approach by abdominal quadrant is the best step
21
Q
If pt comes with RUQ, what should you do?
A
focus on differentiating between pulmonary, urinary, and hepatobiliary pain
22
Q
If pt comes with RUQ and think its pulm causes what do you do?
A
- Imaging, labs
- Go down that roads
23
Q
If pt comes with RUQ and think its Urinary causes what do you do?
A
- think about UTI, Nephrolithiasis
- Urinalysis is starting point
24
Q
If pt comes with RUQ and think its hepatobiliary pain causes what do you do?
A
Patients with colic, fever, steatorrhea, or a positive Murphy’s sign should receive ultrasonography
25
If you are unsure of RUQ pain, what should you do?
Ultrasonography test of choice for evaluation of RUQ
26
What do we need to do with cholecystitis?
Need to differentiate between cholelithiasis vs acute cholecystitis
27
Murphy's sign is present in what % of population
65%
28
T/F just because we see a gallstone does not mean we need a surgery
True!!
29
What are PE thats helpful with cholecystitis
- abdomen tenderness
- Murphy sign
- Pain
30
is fever a strong factors with cholecystits?
No!
31
What labs/dx should you order with cholecystitis?
CBC
CMP + Lipase
US
32
Should all biliary complaints need lipase?
If with GERD, uncontrolled vomiting but other than not, not sure
33
if pt is 10/10 crappy, vomiting, sick what would you order?
Lipase for pancreatitis
34
If a pt is ok, US with nl labs, what should you do? (Cholelithiasis)
Watch and wait
35
What % of pt will gallstone does NOT require cholecystectomy?
50%
36
If they have abnormal labs, with cholecystits, what should you do?
Get US
37
What is US for?
Stone, structure and acute
38
What does HIDA scan for?
Contraction/function of gallbladder
39
T/F HIDA scan is the 1st line of gallballder
NO
40
What should you do if you have + US and abnormal labs?
ER bc gallbladder will prob be taken out
41
What should you do for pain control?
---
42
Whats your large ddx for epigastric pain?
PUD, GERD, esophagitis, gastric/esophageal cancer, biliary disease, gastritis, pancreatitis, medication SE, Cardiopulmonary – ACS, AAA
43
If you are unsure of about epigastric pain, where should you start?
Start by focusing on cause of dyspepsia
44
What is dyspepsia?
epigastric pain, discomfort, burning, nausea, and vomiting
45
Whats causes of dyspepsia? (5)
- Acid-related disorders (GERD)
- Peptic ulcer disease (PUD)
- helicobacter pylori gastritis
- (NSAID) related erosions
- Upper abdominal cancer
46
Whats the two most common cause of epigastric pain?
What %?
GERD
PUD
40%
47
If heartburn and regurgitation are the dominant symptoms, whats the likely dx?
GERD
48
if they have regurg with epigastric pain, whats the mc dx?
GERD
49
Whats important hx for PUD?
H/O ulcers? Stress? Caffeine intake? Melena? Worse/better with food? OTC meds alleviating? Smoker?
50
Whats important hx for GERD?
Burning? Belching? Chronic cough? Food related? Worse when lying down? OTC meds alleviating?
51
Whats important hx for biliary dz?
Jaundice? Dark urine? Worse after eating?
52
Whats important hx for pancreatitis
Stabbing pain radiates to back?
ETOH?
H/O similar?
Severe, abrupt pain?
53
Whats important hx for CA?
Weight loss?
F/C/night sweats?
Dysphagia?
Age > 50?
Prolonged vomiting?
Smoker?
54
if they had pancreatitis and they said yes, can you get it again?
yes, high chance for re-accurance
55
Which dx has severe abrupt pain?
Pancreatitis
56
is early saiety a red flag?
True, for CA
57
if they have melena, what do you need to do?
DRE for PUD
58
Whats GERD associated with PE?
Dental erosions
59
Whats hard to do with pancreatitis?
Difficult to control pain
60
PE clues for cancer?
- Weight loss
- a positive fecal occult blood test
- a palpable mass
- signal nodes (Virchow's nodes)
- acanthosis nigricans are signs of possible malignancy
61
What do you need to order for alarming symptoms?
GI referral for EGD
62
What are the alarming symptoms for GI referral for EGD?
age > 50, dysphagia, weight loss/f/c/night sweats, GI bleeding, prolonged vomiting
63
What is the advantage of EGD? (5)
- Gold standard test to exclude gastroduodenal ulcers, reflux esophagitis and upper gastrointestinal cancers.
- Beneficial because up to 40 percent of patients have an organic cause of dyspepsia.
- Provides adequate patient reassurance.
- Test of choice for targeting therapy.
- Endoscopic complications are rare.
64
What is the disadvantages of EGD?
- Expensive.
- Invasive.
- Not cost-effective or practical in young patients without alarming symptoms.
65
Whats the advantage of empiric tx with acid suppression?
- Least expensive strategy.
- Rapid relief of symptoms.
- High response rate.
- May reduce the number of endoscopies
66
Whats the disadvantage of empiric tx with acid suppression?
- High rate of symptom recurrence.
- May promote inappropriate long-term medication use.
- May delay diagnostic testing.
- May mask the symptoms of malignancy.
67
What another option work-up?
- test for h.pylori and treat if positive
68
Whats the advantage of h.pylori testing?
EBM recommends this approach
69
Whats the disadvantage of h.pylori testing?
- May increase levels of antibiotic resistance.
- Relies on accurate H. pylori testing.
- May result in overtreatment because of false-positive results or under-treatment because of false-negative results.
70
Whats the best testing for H. pylori?
- fecal testing
71
What is the gold standard for H.pylori?
Breath
72
Whats the antibody testing for h.pylori?
Blood
73
T/F once patients are positive serologically they will remain positive for the rest of their lives.
True
74
Whats the advantage of empiric tx for h. pylori?
Avoids cost of H. pylori testing and endoscopy
75
Whats the disadvantage for Empiric eradication of H. pylori?
- Most evidence does not favor this approach.
- May increase levels of antibiotic resistance and antibiotic related complications.
- Patient inconvenience because of complicated drug regimens.
76
What is the advantage for doing endoscopy after h.pylori is positive?
- Endoscopy will detect gastroduodenal ulcers, reflux esophagitis and upper gastrointestinal cancers.
- Minimizes antibiotic resistance.
77
What is the disadvantage of doing a endoscopy if H.pylori is positive?
- Not cost-effective
- Invasive & complication
Compared with testing for H. pylori followed by treatment if the test is positive. Invasive, complications.
78
Empiric antisecretory therapy must be in trial for how many weeks?
2-4
79
What are example of H2 blockers?
Ranitidine (Zantac)
Cimetidine (Tagamet)
Famotidine (Pepcid)
80
If H2 blocker isn't helping then try what?
PPI
81
T/F H.pylori can't be treated with H2 blocker
True
82
Whats the advantage of H2 blocker?
- helpful in 50-70% of pts
- cheaper
- less interactions than PPI
83
If pt have PUD, whats important to check?
H.pylori testing
84
What are the red flags for PUD?
- Age >55
- Weight loss/anorexia
- Persistent vomiting
- Jaundice/anemia
85
Whats PC considerations with PUD?
Check for GIB
Perforation
86
Whats the tx for PUD?
- Avoid NSAIDs
- Proton Pump Inhibitors have higher efficacy than H2 Antagonists
- H.pylori eradication
87
Whats in triple therapy?
PPI + Clarithromycin 500mg BID x 14 days + Amoxicillin 1gm BID x 14 days (Flagyl 500mg)
88
Whats in quad therapy?
Bismuth + tetracycline 500mg qid +Flagyl 500mg tid + Prilosec 20mg bid
89
Whats important in h.pylori testing?
Smoking cessation and avoid ETOH
90
How long will duodenal ulcers take to heal?
4 weeks
91
How long will gastric ulcers take to heal?
8 weeks
92
whats the causes of pancreatitis?
Medication SE, cholelithiasis (40%), ETOH (35%), hypertriglyceridemia, congenital
93
What is the MC of pancreatitis?
Cholelithiasis, not alcohol!
94
Whats diagnositc keys for pancreatitis?
- Lipase
95
What another test you can do for pancreatitis but clinically, its never ordered?
Amylase
96
Whats the lipase limits in pancreatitis?
>540, 3x more than NL
97
How long does it take for lipase to return back to normal?
7-14 days
98
Whats the amylase limits in pancreatitis?
Amylase >360, 3x NL
99
How long does it take for amylase to return to normal?
48-72 hrs
100
Whats are the complication of pancreatitis?
Necrosis
Pseudocysis
101
Whats the leukocytosis in pancreatitis?
15-20k
102
T/F Abx is needed for pancreatitis?
False
103
LFT are off, secondary to stone
104
When should you get advanced imaging for pancreatitis?
- Suspect or to dx first episode
- CT abd/pel with contrast – if concern for complications or first episode
- US if suspect stone disease
105
What pts should go to the ER for pancreatitis?
Unstable VS, severe pain, intractable vomiting
106
Who can be managed at home with pancreatitis?
VSS
Tolerating PO’s
Pain controlled
107
Whats the outpt treatment for pancreatitis?
Clear liquid diet
Pain control
108
For outpt pancreatitis, when should they improve?
improvement in 3-7 days in 90% of cases
109
what should be considered with RLQ?
Appendicitis
110
what should be considered with RLQ for a female?
Ovarian
111
Diff Dx of urinary for RLQ
UTI, pyelo, nephrolithiasis
Flank pain moved to side --> stone
112
Diff Dx for female RLQ
ovarian cyst, torsion, TOA, ectopic
113
Diff Dx for colon RLQ
itis, obs, inflammatory bowel disease
114
if you're unsure of RLQ, what should you do?
CT with intravenous contrast
115
Will a CT show ovarian cyst, torsion?
No! Only ultrasound
116
T/F Appendicits can occur at any age
True! Mc age is 10-30 but ANY AGE!!
117
T/F Appendicitis will have abd pain
Occurs in almost all cases but pain level is different
RLQ pain is mc hx finding
118
Which comes first? Pain or vomiting with appendicitis?
Pain
119
How does pain migrate for appendicitis?
Pain migration from Periumbilical Pain to Right Lower Quadrant Abdominal Pain
120
What should you tell pt who you send to the ER for appendicitis?
Keep NPO
121
LLQ is with what dx?
Diverticulitis
122
Unsure with LLQ, what should you do?
CT or US if female
123
What % will have lifetime incidence with diverticulitis?
25%
124
What % will have LLQ with diverticulitis?
92%
125
About 68% will have what with diverticulitis?
Leukocytosis
126
When should you get advanced imaging for diverticulitis?
Diagnosis unclear
Not classic LLQ pain with fever
Other diagnoses are of similar likelihood
Moderate to severe symptoms
Inability to tolerate oral fluids
Peritoneal signs
Failure to improve in 2-3 days after starting abx
127
What are the indication for outpt diverticulitis?
VSS
Tolerating PO’s
Pain controlled
128
Whats the tx for diverticulitis?
Clear liquid diet --> high fiber diet (for day/two)
Abx
Pain control
129
What abx should you put for diverticulitis?
Flagyl + FQ is MC combo
130
Which ABX combo does she like?
Flagyl + Cipro
131
When do pt usually get better with diverticulitis?
48-72 hours
132
What is MC condition seen by GI?
IBS
133
What is dx key for IBS?
- Bowel alterations
- Mucous stools in 40%
- Sensation of incomplete emptying in 70%
134
What is un-helpful with IBS?
"Piece-meal" work up, bc higher chance of repeat of work
135
Whats the diagnostic criteria?
ROME III, Manning)
If meet criteria just treat
136
What is red flag with IBS?
- Stool incontinence
- Nighttime awakenings (pain or BMs)
- Weight loss, fever, night sweats
- Heme +
- Family h/o colon cancer
- Laboratory abnormalities – leukocytosis, anemia, +ESR
137
T/F stool incontinence is neurosurgical emerg
True
137
T/F stool incontinence is neurosurgical emerg
True
138
Whats the tx for IBS?
Diet, stress reduction, symptom directed
139
What is the risk of reoccurrance for nephrolithiasis?
Risk of reoccurrence 50%, 10% have >3 episodes
140
Whats the mc age for nephrolithiasis?
20-50
141
Whats the dx key for nephrolithiasis?
Unilateral flank pain
Hematuria 90% of cases
142
When do you need to get advanced imaging for nephrolithiasis?
First time or uncertain dx
143
Whats the complication of nephrolithiasis?
- Obstruction
- AKI
- Infection
144
What is the dx choice for kidney stone?
CT abd without but if they get it every time then they dont need a CT every single tine.
145
Whats a good dx choice for hydronephrosis?
Renal US
146
if you see stone in KUB, do you need CT?
No
147
What does KUB not show with kidney stones?
Hydronephrosis
148
whats PC consideration with kidney stones?
Make sure no concurrent UTI
149
Whats indication for outpt kidney stone?
Does not have a h/o CKD
VSS
Tolerating PO’s
Pain controlled
Does not have a h/o CKD
150
Where is stone stuck most of the time?
UVJ
151
Whats the treatment for kidney stones?
- Fluids
- Pain control (NSAID's Toradol IM, narcs)
- Alpha blockers X 14 days (Flomax??)
152
Who gets sent to the ER for kidney stone?
UTI, AKI, sig hydro, VS unstable, intractable pain
153
When do you refer to urology?
- complicated stones
- Stone not passed in few days
- Stone >7mm with hydro
- All pts with stones > 10mm
154
What is cause of SBO?
Postop Adhesions but don't need to recent have surgery
155
Are BS good predicitive?
NO! TRASH
156
Whats the MC sx for SBO?
Constipation
Colicky abd pain with idstension and tympany on percussion
157
What is the initial BS for SBO?
Initial high pitched, hyperactive BS
158
Whats the later BS for SBO?
hypoactive or absent BS
159
Whats the workup for SBO?
Labs: CBC, CMP, lactate
- Mild/stable start with KUB
- Test Sensitivity: 60% (up to 80-90% in high grade obstruction). False negative early in process
High suspicion --> CT abd/pel with contrast
90% sensitive
160
Whats the tx for SBO?
Imaging + send to ER
NPO
NG tube for decompression
Surgery
161
Is SBO always a surgical?
No, not always, can be decompressed.
162
when will sx for ectopic start?
7 weeks of gestation
163
Whats the dx key for ectopic?
- Symptoms typically start around 7 wks of gestation
- Abd pain may be non-specific, poorly localized
- 30% will have no vaginal bleeding
164
if pregnancy is positive, and pt has abd pain what should you get?
US, can be ectopic
165
if pregancy is negative, can it be ectopic?
NO LOL but still get a pregnancy
166
Whats PC consideration for ectopic?
+ Bhcg + pelvic pain +/- vag bleed needs r/o ectopic -----> ER
167
Whats the tx for ectopic?
Tx directed by OBGYN or ER
168
Why/what should you be careful in abd pain in elderly?
Diminished sensation of pain in the elderly
Comorbid diseases
Polypharmacy
Combinations of above result in many more vague, nonspecific presentations
Age 65 Twice as likely to require surgery
169
T/F Diagnoses more common or often missed in older patients
True
170
Look at slide 35 pearls!
