GI/nutritional part 1 Flashcards by Deborah Karp

PMH for abdomen

Prior medical problems related to abdomen: hepatitis, cirrhosis, gallbladder problems, pancreatitis

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Social hx for abdomen

Tobacco
EtOH (cirrhosis)
Illegal drugs (IVDA- hepatitis)
Medication hx (NSAIDs)
Recent travel

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ROS for abdomen

Fever
Vomiting
-Frequency, dry heaves vs vomiting, type
Bowel movements
-Diarrhea, frequency, last BM
-Consistency, color: bloody (hematochezia)/black, tarry (melena/ dark stools/ BRB/ white or grey (can indicate liver or gallbladder etiology))
-Painful BM
GU sx
-Dysuria, hematuria, frequency, dark urine
-Vaginal d/c, pelvic pain, testicular pain/swelling, penile d/c
-Flank pain
CP, SOB

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What does melena indicate?

Upper GI source

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PE of abdominal complaints

Vitals: febrile, hypotension, tachycardia (that triad is sepsis until proven otherwise)
General appearance: toxic or ill-appearing, pallor, or jaundice
Abdomen:
-Inspect: scars, distention, pulsations, hernia, striae
-Auscultate
–normal BS vs hyperactive vs hypoactive vs absent
—Early obstruction: high-pitched, tinkling bowel sounds
-Percussion
–Tympany (hollow sounds) vs dull
–Estimating size of liver and spleen
-Palpation
–Tenderness, guarding, rebound, rigidity, masses, organomegaly

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Carnett sign

Indicator of abdominal wall cavity abnormalities
Pt lies supine and points to where they absolutely hurt the worst
Palpate the area
Have them sit up
Pain getting worse with sitting up is a positive sign

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Labs for abdominal pain: CBC

Leukocytosis: infection (nl WBC does not r/o infectious process)
Anemia: GI bleed

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Labs for abdominal pain: CMP

Dehydration
Endocrine or metabolic d/o: DKA, pancreatitis
Abnl LFTs: cholecystitis, cholelithiasis, hepatitis
Abnl renal function: ARF, dehydration

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Labs for abdominal pain: UA, urine hCG, +/- urine C&S

Nitrites, leukocytes: UTI, pyelonephritis
Send a culture when treating d/t abx resistance
Culture if unsure about amount of bacteria in urine, etc.
RBCs: uterolithiasis
hCG +: ectopic
Every menstruating woman needs urine hCG

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Labs for abdominal pain: lipase

Elevated in pancreatitis

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Labs for abdominal pain: serum lactate

Possible mesenteric ischemia

Take a serum lactate when toxic, septic, high white count

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What should be done while you wait for lab results for abdominal pain

Treat nausea/vomiting
-Zofran (ondansetron)
-Phenergan (promethazine)
Control pain
-Morphine
-Dilaudid
-Toradol
Fluid resuscitation
-Caution in large bolus of fluids in elderly or hx of CHF
NPO if warranted

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RLQ pain differential

Aortic aneurysm
Appendicitis
Crohn's disease
Diverticulitis (cecal)
Ectopic pregnancy
Endometriosis
Hernia
Ischemic colitis
Meckel diverticulum
Ovarian cyst or torsion
PID
Testicular torsion
Ureteral calculi

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Etiology of appendicitis

Occurs when obstruction of appendix leads to inflammation and infection
MCC- fecalith

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Presentation of appendicits

Non-specific sx that progress with time
Early: vague periumbilical pain, anorexia, N/V
Later: classic presentation- pain migrates to RLQ: McBurney’s point, fever is late finding
Siogns: McBurney, Rovsing, Psoas, obturator, bump sign
Location of abdominal pain depends on location of appendix
If sudden decrease in pain, consider perforation

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Workup of appendicitis: labs

CBC
UA
Urine hCG
Nl WBC does not r/o appendicitis

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Workup of appendicitis: imaging

CT is study of choice
CT with IV AND oral contrast
Indicators on results: pericecal inflammation, abscess, periappendiceal phlegmon or fluid collections

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Workup of appendicitis: u/s

High sensitivity but limited by operator and if abnormally located appendix or ruptured appendix
Preferred modality in kids and pregnant pt

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Tx of appendicitis

Surgery: appendectomy
Abx: cover for anaerobes, enterococci and gram neg
-Zosyn (piperacillin/tazobactam)
-Unasyn (ampicillin/sulbactam)

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RUQ pain differential

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Cholecystitis
Cholangitis
Biliary colic
Hepatitis
Hepatic abscess
Myocardial infarction/ischemia
Perforated duodenal ulcer
Retrocecal appendicitis
Fitz-Hugh Curtis syndrome

Etiology of acute cholecystitis

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Caused by obstruction of the bile duct, usually by a gallstone, leading to inflammation

Presentation of acute cholecystitis

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RUQ or epigastric pain that is colicky and becomes steady and increases in intensity
Lasts longer than the typical 5 hours
Pain may radiate to R shoulder or subscapular area
Typically worse after eating, esp a high-fat meal
Usually with associated n/v, low-grade fever, anorexia
Signs: Murphy

Workup of acute cholecystitis: labs

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CBC, CMP, UA
Nl to elevated WBC
Nl to elevated LFTs
Nl to elevated serum bilirubin
-After 24 hrs, bilirubin levels increase in blood and urine

Workup of acute cholecystitis: imaging

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U/s is study of choice
-Indicators on u/s: thickened GB wall, gallstones, GB distention, pericholecystic fluid
-Positive sonographic Murphy’s sign is very sensitive for dx
CT is good too

Tx of acute cholecystitis

Surgery: cholecystectomy Abx: 3rd gen cephalosporin and metronidazole

Ascending cholangitis: etiology

``` Complete biliary obstruction (CBD stone or tumor) + bacterial superinfection Ascending infection (E. coli, enterococcus, Klebsiella, enterobacter) ```

Presentation of ascending cholangitis

Charcot's triad: fever + jaundice + RUQ pain Reynold's pentad: Charcot's triad + hypotension + AMS -Indicates sepsis; rapidly fatal

Workup for ascending cholangitis: labs

CBC, CMP, UA Leukocytosis Elevated bilirubin and alkaline phosphatase

Workup for ascending cholangitis: imaging

U/s | ERCP is optimal for dx and tx but should not be done until pt stable

Tx of ascending cholangitis

Abx: triple coverage -Ampicillin + gentamicin + clindamycin -Or metronidazole + 3rd gen cephalosporin or Zosyn + fluoroquinolone Immediate surgical consult -ERCP for drainage, sphincterotomy, stone removal, stent placement

Epigastric pain differential

``` Pancreatitis Swallowed foreign body GERD Esophageal perforation Aortic dissection MI Peptic ulcer Gastritis Esophagitis ```

Etiologies of acute pancreatitis

>50% secondary to EtOH abuse, others include: Cholelithiasis Meds (APAP, erythromycin, steroids, HCTZ, anti-retrovirals, etc) Severe hyperlipidemia (esp hypertriglyceridemia)

Presentation of acute pancreatitis

Epigastric pain that bores to the back with associated n/v that is constant and worse in supine and improves with leaning forward Epigastric or upper abdominal tenderness with palpation May have low-grade fever, tachycardia, hypotension If severe, could present with signs of shock, renal failure, AMS

Workup of acute pancreatitis: labs

CBC, CMP, amylase, lipase Lipase (at least 2-3x nl) is preferred diagnostic test, more sensitive/specific -Nl amylase does not exclude dx- no benefit to order both tests Elevated liver enzymes, esp alkaline phosphatase, suggests biliary dz and gallstone pancreatitis Leukocytosis generally present

Workup for acute pancreatitis: imaging

Abdominal CT preferred over u/s

Ranson criteria

``` Indicates poor prognosis for pancreatitis- the higher the score, the worse the prognosis Leukocyte count >16K Glucose >200 Lactate dehydrogenase >350 AST >250 Arterial pO2 <60 Base deficit >4 Calcium falling BUN rising ```

Cullen sign

Ecchymosis around umbilicus

Grey-turner sign

Ecchymosis around flank

Tx of acute pancreatitis

NPO Fluid resuscitation, anti-emetics, pain management Consider abx, esp for abscess, infected pseudocyst Admission (usually) with GI consult -Pts with mild dz, no systematic complications, or biliary tract dz + can tolerate clear liquid and PO pain meds can be managed with close f/u; advance PO intake ast tolerated --Advise pts to return if fever, pain, can't tolerate meds

LLQ pain differential

``` Diverticulitis Ectopic pregnancy Endometriosis Ischemic colitis PID Ovarian cyst or torsion Testicular torsion Ureteral calculi ```

Diverticulosis

Small herniations through wall of colon

Diverticulitis

Inflamed/infected diverticula

Complicated diverticulitis

Acute diverticulitis + bowel obstruction, abscess, fistula, or perforation

RFs of diverticular dz

Age Low fiber/high fat diet Obesity Tobacco use

Presentation of diverticulitis

``` Steady deep discomfort- typically in LLQ Tenesmus, change in bowel habits N/V Low-grade fever Signs of peritonitis with abscess, perforation ```

Workup of diverticulitis: labs

CBC, CMP, UA to help exclude other diagnoses, hemoccult may be positive

Workup of diverticulitis: imaging

CT abd/pelvis with IV and oral contrast is diagnostic

Tx of diverticulitis

IV fluids, anti-emetics, pain control Abx: cipro + metonidazole Clear liquid diet advance as tolerated to high fiber diet with avoidance of obstructing or constipating foods Close f/u Admission and surgical consult for complicated diverticulitis

DDx of diffuse abdominal pain

``` Aortic dissection AAA Early appendicitis Bowel obstruction Gastroenteritis Mesenteric ischemia Bowel perforation Peritonitis Volvulus IBS/UC/Crohns Spontaneous bacterial peritonitis ```

GI/nutritional part 1 Flashcards

(49 cards)