Jaynstein - Abdominal Pain Flashcards
(171 cards)
1
Q
mc GI complaint in primary care
A
constipation
2
Q
6 mc GI complaints in primary care
A
- constipation
- diarrhea
- abd pain
- gastric pain
- nausea
- regurgitation
3
Q
__% of abdominal concerns do not need GI referral
A
75%
4
Q
__% of GI complaints can be managed in primary care
A
80
5
Q
almost 50% of GI referrals eventually get diagnosed as __
A
IBS
6
Q
mc dx related to acute abdominal pain in primary care
A
no clinical dx/unknown/functional
7
Q
causes of acute abdominal pain
A
appendicitis -> mc
cholecystitis
SBO
gynecological
pancreatitis
renal colic
diverticulitis
perforation
ischemia
peptic ulcer
AAA
ectopic
PID
nephrolithiasis
cancer
8
Q
goal of abdominal pain management in primary care
A
determine who needs work up and how extensive that work up should be
9
Q
3 options for management of abdominal pain in primary care
A
symptomatic care -> watch and wait
labs/diagnostics
referral
10
Q
4 GI complaints that can usually be managed in primary care w. minimal work up
A
diarrhea
constipation
gastroenteritis
food related (celiac, lactose)
11
Q
chronic abdominal pain lasts > __
A
6 months
12
Q
causes of chronic abdominal pain
A
PUD
esophagitis
IBD
chronic pancreatitis
gastroparesis
IBS
abdominal wall (muscle strain, hernia)
functional
13
Q
what do you think when you see abdominal pain out of proportion
A
acute ischemia
14
Q
mc age for abdominal ischemia
A
60-70
15
Q
huge do not miss red flag w. abdominal pain that providers commonly get sued over
A
AAA
16
Q
4 indications for emergent care w. abdominal pain complaint
A
unstable
toxic
extreme pain
potential surgical complaint
17
Q
ddx w. RUQ pain
A
cholecystitis and biliary colic
hepatitis
pancreatitis
appendicitis
perforated duodenal ulcer
right lower lobe PNA
MI
hepatic abscess
18
Q
ddx for diffuse abd pain
A
pancreatitis
AAA
SBO
early appendicitis
gastroenteritis
mesenteric ischemia
perforated viscous
peritonitiis
sickle cell crisis
19
Q
ddx for LUQ pain
A
pancreatitis
gastric ulcer
gastritis
left lower lobe PNA
MI
splenic enlargement/rupture
20
Q
LLQ pain is mc
A
diverticulitis
21
Q
RLQ pain is mc
A
appendicitis
22
Q
RUQ pain work up should focus on differentiating what 3 general causes
A
pulmonary
urinary
hepatobiliary
23
Q
first step in work up of RUQ pain if UTI is suspected
A
UA
24
Q
4 indications for US w. RUQ pain
A
colic
fever
steatorrhea
(+) murphy’s
25
gs diagnostic test for eval of RUQ pain
US
26
RUQ pain + pulmonary sx makes you think (2)
PE
PNA
27
work up of RUQ pain w. pulmonary sx
1. CXR
2. Ddimer vs CT
28
RUQ pain + urinary sx makes you think of (2)
UTI
nephrolithiasis
29
gs imaging for nephrolithiasis
CT w.o contrast
30
RUQ w. colic makes you think (2)
hepatobiliary cause
nephrolithiasis
31
work up of RUQ pain w. colic
1. US
2. if negative -> consider nephrolithiasis
32
t/f: most people w. cholecystitis need lap chole
f!
only 300,000 out of 20 million diagnosed
33
most sensitive PE test for cholecystitis
Murphy's sign
34
diagnosis of cholecystitis focuses on differentiating cholecystitis from __
cholelithiasis
35
labs to order for acute cholecystitis work up
CBC
CMP
36
when would you order lipase for suspected cholecystitis (2)
if GERD/indigestion issues
if they are toxic appearing
37
indication for US w. cholecystitis
suspect gallstones
PLUS
abnormal labs
can usually watch and wait if labs are nl
38
t/f: most patients w. cholelithiasis need cholecystectomy
f!
50% don't
39
indications for cholecystectomy w. cholelithiasis
(+) US
PLUS
abnormal labs
40
ideal window for cholecystectomy in pt. w. cholelithiasis and abnormal labs
w.in 72 hr
41
gallbladder US evaluates
structure -> wall, stones, etc
42
HIDA scan of gallbladder evaluates
fxn -> contraction etc
43
__ is never first line imaging choice for gallbladder work up
HIDA
US is first line
44
ddx for epigastric pain (9)
PUD
GERD
esophagitis
gastric/esophageal ca
biliary dz
gastritis
pancreatitis
med s.e
cardiopulmonary
45
2 do not miss vascular causes of epigastric pain
ACS
AAA
46
generalized term for epigastric discomfort
dyspepsia
47
common complaints related to dyspepsia (5)
pain
discomfort
burning
nausea
vomiting
48
acid-related causes of dyspepsia (2)
GERD
PUD
49
inflammatory causes of dyspepsia (2)
h.pylori
NSAID erosions
50
3 cancers associated w. dyspepsia
gastric
esophageal
pancreatic
51
__ and __ are responsible for 40% of dyspepsia
GERD
PUD
52
2 symptoms that strongly suggest dyspepsia related to GERD
heartburn
regurgitation (almost always GERD)
53
3 rf for PUD
stress
caffeine
smoking
54
6 indications of dyspepsia related to GERD
burning
belching
chronic cough
worse w. food/regurgitation
worse when lying down
relief w. OTC meds
55
__ can aid in the diagnosis of GERD
relief w. TUMS
56
6 causes of dyspepsia
PUD
GERD
biliary dz
pancreatitis
ca
meds
57
3 indications of dyspepsia elated to biliary dz
jaundice
dark urine
worse after eating
58
4 indications of dyspepsia related to pancreatitis
stabbing pain radiating to the back
etoh
prev hx pancreatitis
severe, abrupt pain
59
indications of dyspepsia related to ca
wt loss
f/c/night sweats
dysphagia
age > 50
prolonged vomiting
smoker
60
indications for DRE
you have a finger, they have melena
61
PE clue for PUD
melena
62
PE clue for GERD
dental erosions
63
PE clue for pancreatitis
uncontrolled pain
64
PE clues for biliary dz
jaundice
(+) murphy
65
5 PE clues for ca
wt loss
(+) FOBT
palpable mass
virchow nodes
acanthosis ingrains
66
gs imaging for pt w. dyspepsia and alarming sx
endoscopy
67
5 indications for endoscopy w. dyspepsia
age > 50
dysphagia
wt loss/f/c/night sweats
GI bleed
prolonged vomiting
68
if a pt has no alarming sx related to dyspepsia, what are your work up/tx options
1. endoscopy
2. empiric acid suppression
3. test for h.pylori and tx if positive
4. empiric eradication of h.pylori
5. test for h.pylori and perform endoscopy if (+)
69
endoscopy is gs test to exclude (3)
gastroduodenal ulcers
reflux esophagitis
upper GI cancers
70
gs test for dyspepsia in general
endoscopy
71
t/f: once a pt tests positive for h.pylori using a blood test, they will remain positive fo' life
t!
can only use it for initial dx or if pt tested negative on prior test
72
advantage of empiric eradication of h.pylori
avoids cost of h.pylori testing and endoscopy
73
3 disadvantage of empiric eradication of h.pylori
increases abx resistance
increases complications
complicated drug regimen
74
advantages of h.pylori work up and endoscopy if test if (+)
endoscopy identifies multiple conditions
prior testing minimizes abx resistance
75
what conditions is endoscopy useful for detecting (4)
gastric ulcers
duodenal ulcers
reflux esophagitis
upper GI cancers
76
disadvantages of h.pylori testing and endoscopy if (+)
invasive procedure w. risks
unnecessary if h.pylori test is (+)
77
3 medication options for dyspepsia
empiric abx
ppi
h2 blockers
78
MOA for both ppi's and h2 blockers
reduce acid secretion
79
how long should antisecretory drug trial be
daily for 2-4 weeks
80
first line antisecretory med for dyspepsia
h2 blockers:
cimetidine (tagamet)
famotidine (pepcid)
81
2 indications to use ppi for dyspepsia
h2 blocker not working
h.pylori confirmed
82
major disadvantage of ppi
lots of ddi
83
PUD occurs in 5-20% of ppl who use long-term ___
NSAIDs
84
mc cause of gastric and duodenal ulcers
h.pylori
85
4 red flags with PUD
age > 55
wt loss/anorexia
persistent vomiting
jaundice/anemia
86
2 complications of PUD
GIB
perforation
87
which antisecretory drug is most effective for PUD
ppi
88
triple antibiotic therapy for h.pylori
ppi
clarithromycin
amoxicillin
89
quadruple antibiotic therapy for h.pylori
tetracycline
omeprazole
metronidazole
bismuth
90
duodenal ulcers usually heal w.in __ weeks
4
91
gastric ulcers usually heal w.in __ weeks
8
92
5 causes of pancreatitis
cholelithiasis
etoh
hypertriglyceridemia
congenital
med s.e
93
mc cause of pancreatitis
cholelithiasis
94
most sensitive and specific lab for pancreatitis
lipase
95
lipase is __ x nl in pancreatitis
3 x
> 540
96
t/f: lipase trends down as pancreatitis resolves
t!
97
t/f: leukocytosis is commonly seen w. pancreatitis
t
98
imaging of choice for pancreatitis
when is it indicated (3)
CT abd/pelvis w. contrast
for first episode
suspect gallstones (US)
99
2 complications of pancreatitis
necrosis
pseudocysts
100
when would you order US for pancreatitis
if you suspect gallstones
101
3 indications for emergent care for pancreatitis pt
unstable
severe pain
intractable vomiting
102
when can a pancreatitis pt be d.c'ed (3)
vss
tolerating PO
pain controlled
103
op tx for pancreatitis (2)
CLD
pain control
104
when can pt expect to see improvement in pancreatitis
3-7 days
105
what do you think of when you see RLQ pain
appendicitis
106
3 urinary causes of RLQ pain
UTI
pyelo
nephrolithiasis
107
4 female GU causes of RLQ pain
ovarian cyst
torsion
TOA
ectopic
108
2 colon-related causes of RLQ pain
colonitis
IBD
109
imaging of choice to evaluate RLQ pain
CT w. contrast
110
imaging of choice if you suspect scary ovary stuff
transvaginal US
CT won't show the scaries and most ovarian differentials are emergent
111
describe appendicitis pain
usually starts somewhere else (mc epigastric) and then migrates to RLQ
112
what pt pop gets a CT 95% of the time if they present w. new onset abdominal pain
> 65 yo
113
what symptom has 100% sensitivity for appendicitis
pain before vomiting
114
mc age for appendicitis
10-30 yo
but can occur at any age
115
management of appendicitis in op setting (2)
NPO
ER
116
what condition do you think of when you see LLQ
diverticulitis
117
other causes of LLQ besides diverticulitis
same as RLQ
118
imaging of choice for eval of LLQ
CT
transvaginal US for females
119
sx of diverticulitis (4)
LLQ
abd distension
abd tenderness
rectal bleeding
120
2 complications of diverticulitis
perforation
abscess
121
indications for imaging w. diverticulitis
first episode
dx unclear
atypical presentation
other dx of similar likelihood
mod-severe sx
can't tolerate po fluids
peritoneal signs
no improvement 2-3 days after starting abx
122
management of diverticulitis (3)
start w. CLD diet -> move to high fiber
abx
pain control
123
abx regimen for diverticulitis
flagyl 500 tid x 7-10 days
PLUS
cipro
alt flagyl plus levaquin or bactrim
124
when can you expect to see improvement in diverticulitis pt
48-72 hr
125
mc condition seen by GI
IBD
126
peak dx age of IBD
20-39
127
3 diagnostic keys for IBD
bowel alterations
mucous stools
sensation of incomplete emptying
128
2 diagnostic criteria for IBD
ROME III
Manning
if they meet criteria -> just treat - don't usually need full work up
129
red flags w. IBD (6)
stool incontinence (not including urgency)
nighttime awakenings (pain or BMs)
wt loss/fever/night sweats
heme (+)
fam hx colon ca
leukocytosis, anemia, (+) ESR
130
management of IBD (4)
diet
stress reduction
sx directed
GI referral -> scope
131
risk of recurrence w. nephrolithiasis
50%
132
diagnostic keys for nephrolithiasis
unilateral flank pain
hematuria
133
indications for imaging w. nephrolithiasis (2)
first time
uncertain dx
134
3 imaging options for nephrolithiasis
CT abd/pelvis w.o contrast
renal US
KUB
135
gs imaging for nephrolithiasis
CT abd/pelvis w.o contrast
136
when would you order US for nephrolithiasis
suspected hydronephrosis
137
KUB can detect __% of kidney stones
60%
138
when can nephrolithiasis be managed op
vss
tolerating po
pain controlled
no h.o CKD
139
management of nephrolithiasis (4)
fluids
NSAIDs vs toradol vs narcotics
flomax x 14 days
urology consult
140
indications for emergent care w. nephrolithiasis (5)
uti
aki
sig hydro
vs unstable
intractable pain
141
3 indications for urology consult w. nephrolithiasis
stone not passed in a few days
stone > 7 mm w. hydro
all pt w. stones > 10 mm
142
calculi < __ mm pass 90% of the time
5 -> no consult
143
calculi __ mm pass in 50% of cases
5-7
144
calculi __ mm pass in 10% of cases
7
145
what size stone won't pass
10 mm or larger
146
mc place for kidney stone
UVJ
147
flomax works best for __ stones
distal
148
true pyelonephritis is characterized by __ flank pain
bilateral
149
true kidney stones are characterized by __ flank pain
unilateral
150
4 complications of nephrolithiasis
concurrent UTI/infxn
obstruction
AKI
151
greatest rf for SBO
adhesions
152
diagnostic keys for SBO
adhesions/h.o GI surgery
constipation
colicky abd pain w. dissension and tympany to percussion
153
mc sx of SBO
constipation
154
garbage PE exam that really shouldn't be used in work up of SBO
bowel sounds
155
if you do get a question about bs related to SBO, how do you describe early vs late
early: high pitched, hyperactive
late: hypoactive, absent
156
KUB can show __% of obstructions
90
157
gs imaging for SBO
CT abd/pel w. contrast
158
management of SBO (4)
ER
NPO
NGT
+/- surgery
159
sx of ectopic usually start around __ weeks gestation
6-7
160
describe abd pain w. ectopic
non specific
poorly localized
161
what should you do if you have any suspicion for ectopic whatsoever
transvaginal US
even if bHCG is negative
162
transvaginal US has 95% sensitivity for detecting ectopic if bHCG is > __
25
163
abd pain is ectopic until proven otherwise in what pt pop
any patient with baby making parts of child bearing age
164
5 considerations for management of abd pain in the elderly
diminished pain sensation
comorbid dz
polypharmacy
vague, nonspecific presentations
> 65 yo 2x more likely to need surgery
165
6 abd pain related dx's commonly missed in elderly
diverticulitis
sepsis from UTI
occult UTI
perforated viscus
AAA
ischemic bowel
166
what GI sx occurs in 40% of pt's w. ACS
vomiting
167
always think about appendicitis if you have what 3 conditions on your differential
gastroenteritis
PID
UTI
168
always order what test in elderly patients with abd pain and cardiac rf
EKG
169
3 indications for ER with any abd pain
uncontrolled pain
vs unstable
can't tolerate PO
170
2 basic indications for CT w. contrast
infxn
vascular concerns
171
3 basic indications for CT w.o contrast
stones
bones
blood in the brain
