MA - Abdo (essentials of para)

Question 0

S+S of appendicitis

Answer 0

Diffuse colicky (cramping/spasm) pn
Nausea, vomiting, low grade fever
Often periumbilical, will later localize LRQ 4-5cm above ant. Iliac crest (McBurneys point)
No appetite
Rupture = diffuse via peritonitis
Tenderness/guarding around the umbilicus or LRQ
Do not continually press for rebound tenderness, could cause damage

Question 1

Define Somatic pn

Answer 1

Sharp, localized pn that originates in walls of the body such as skeletal muscles

Question 2

Define visceral pn

Answer 2

Dull, poorly localized pn that originates in the walls of hollow organs.
Inflammation, distension, ischemia. Nerves that transmit this pn attach to different levels of the spine, leading to the vague pn.
NOTE: body often responds sympathomimetic (nausea,vomiting, diaphoresis, tachycardia)

Question 3

Define referred pn

Answer 3

Pain that originates in a region other than where it is felt

Question 4

Define peritonitis

Answer 4

Inflammation of the peritoneum, which lines the abdo cavity. Somatic pn

Question 5

GI causes of chest pn

Answer 5

Gastroesophageal reflux, gastric ulcers, duodenal ulcers, gallbladder disease

Question 6

Cullen’s sign

Answer 6

Ecchymosis in the peri umbilical area

Question 7

Grey-turners sign

Answer 7

Ecchymosis in the flank

Question 8

Auscultation or palpitation first?

Answer 8

Auscultation first. At least 2 min, quadrant furthest from injury first.

Question 9

Volume of abdomen?

Answer 9

Can hold 4-6L of fluid before noticeable change in girth

Question 10

Upper GI tract

Answer 10

Mouth
Esophagus
Stomach
Duodenum
- all before the ligament of treitz (supports duodenojejunal junction)

Question 11

6 major causes of upper GI hemorrhage (common to less…)

Answer 11

Peptic ulcer disease (50%)
Gastritis (25%)
Variceal rupture
Mallory-Weiss tear
Esophagitis
Duodenitis

Question 12

Define hematemesis

Answer 12

Bloody vomitus

Question 13

Define melena

Answer 13

Dark, tarry, foul smelling stool indicating the presence of partially digested blood.
For it to be visible, >150ml passed + 5-8 hrs

Question 14

What upper GI bleeds can lead to dangerous shock?

Answer 14

Ulcer through the gastric mucosa

Esophageal varied or tear

Question 15

What is the tilt test?

Answer 15

Orthostatic hypotension - 10mmHg change in BP or 20 bpm change in HR when pt rises from supine to standing. Circulating volume drops ~15% before positive signs are seen = aggressive fluid resus.

Question 16

Esophageal varix - associated with…

Answer 16

Alcoholism (can also be caused by ingestion of caustic substances)
Portal vein normally has little pressure. Liver damage leads to back up which backs up to left gastric vein which then backs up to esophageal veins. Varices caused when these “evaginate”, dilating and expanding until they rupture.

Question 17

S+S of esophageal varices

Answer 17

Painless bleeding and hemodynamics instability
Bright red hematemesis (can be forceful if hemorrhage large)
Dysphasia (difficulty swallowing)
Painful, tearing as further irritation of esophagus.
Difficulty clotting (no tamponade, backup of pressure into spleen destroys platelets)

Question 19

What is acute gastroenteritis?

Answer 19

Inflammation of the mucosal linings of the stomach and intestines w/ sudden onset of vomiting and diarrhea due to destruction of villi in GI that absorb water

Question 19

What makes you think acute gastroenteritis?

Answer 19

> alcohol/tobacco consumption
NSAIDS (aspirin) (all break down stomach lining)
Systemic (salmonella) and ingested (staphylococcus) can cause gastroenteritis

Question 20

S+S of Acute Gastroenteritis

Answer 20

Sudden onset of Vomiting and diarrhea (melena or hematochezia)
Diffuse abdo pn, tenderness through abdo
Dehydration (no uptake), general malaise
C/P or arrhythmia a possible due to electrolyte imbalances due to dehydration

Question 21

What is the primary cause of chronic gastroenteritis?

Answer 21

Microbial Infection - Usually H. Pylori
Others: E. Coli, K. Pneumoniae, Enterobacter, C. Jejuni, V. Cholerae, Shigella, Salmonella
Can also be Viral: Norwalk, Rotovirus
or parasitic
Microbes transmitted via fecal-oral route/ infected food/water

Question 22

Define Hematochezia

Answer 22

Bright red blood in the stool

Question 23

S+S of Chronic Gastroenteritis

Answer 23

Nausea + Vomiting, Fever, Diarrhea, abdo pn, cramping, anorexia (loss of appetite), lethargy, possibly shock (dehydration)
Intensity of S+S very with level of contamination

Question 24

What are the two types of upper GI (Peptic) ulcers

Answer 24

Peptic and Duodenal

Question 25

Gastric Ulcers - More common Male or Female?

Answer 25

Male (4x)

Question 26

Duodenal Ulcers - More common Male or Female?

Answer 26

Female (2-3x)

Question 27

What makes you think Gastric Ulcer?

Answer 27

Male, over 50 and work in jobs with Physical Activity. Pn incr w/ food/full stomach, no pn at night

Question 28

What makes you think Duodenal Ulcer?

Answer 28

Female, 25-50, family hx, execs/leaders with high stress. Pn at night, or empty stomach (last oral intake?).

Question 29

Common causes of peptic ulcers

Answer 29

NSAIDS, Acid Stimulators (Alcohol, Nicotine) or H. Pylori all lead to increase acid in the GI.

Question 30

What are some common NSAIDS

Answer 30

Aspirin, Ibuprofen (Motrin, Advil),Naproxen (Aleve, Naprosyn)

Question 31

What is Zollinger-Ellison Syndrome?

Answer 31

Tumor making the stomach to produce excessive amounts of hydrochloric acid and pepsin

Question 32

What is another cause of duodenal ulcers (only deuodenal)?

Answer 32

Blocked Pancreatic Duct - As chyme passes through the pyloric sphincter into the intestine, the pancreas should be secreting bicarbonate ionss with it's solution. No solution, much higher acidity.

Question 33

S+S Ulcers

Answer 33

- Chronic bleeding could result in anemia - Ecchymosis/distension could be found, but severe situation - Palp, pn diffuse or localized - May have relief of pn after eating or coating GI tract with liquid (milk) - Acute pn? Beware rupture to peritoneal cavity. - Ulcers location may vary colour of stool/hematemesis - Bouts of nausea/vomiting

Question 34

Common Ulcer meds pt may have taken?

Answer 34

Histamine blockers - Zantac, Pepcid | Antacids - Rolaids, Tums

Question 35

Lower GI Tract consists of

Answer 35

``` Jejunum Ileum Large Intestine Rectum Anus ```

Question 36

Major Causes of lower GI bleeding

Answer 36

``` Diverticulitis Colon Lesions Rectal Lesions Inflammatory Bowel Disorder Normally chronic, rarely exsanguinating hemorrhage ```

Question 37

Hematochezic stool means 2 things -

Answer 37

Distal Lower GI bleed or a large enough amount that it's passing through before melenic changes can occur. Possibly rectal fissures or hemorrhoids

Question 38

Melenic stool means

Answer 38

indicates a slow GI bleed

Question 39

Lower GI Diseases

Answer 39

``` Ulcerative Colitis Crohns Disease Diverticulitis Hemorrhoids Bowel Obstruction ```

Question 40

What is Ulcerative Colitis

Answer 40

Ideopathic Inflammatory Bowel Disorder | Continuous ulcers that usually originate in the rectum (distal) and may progress into the colon

Question 41

What is Pancolitis

Answer 41

Ulcerative colitis spread through the entire colon

Question 42

What is proctitis

Answer 42

Ulcerative colitis limited to the rectum

Question 43

Ulcerative colitis normally occurs with what age group?

Answer 43

25-40 y/o

Question 44

S+S of Ulcerative Colitis?

Answer 44

Bloody diarhea or mucous in stool Colicky abdo pn (cramping/spasms), usually lower quadrants Nausea/vomiting occasionally fever Will appear restless, but no hemodynamic instability Sever cases could present with signs of a hemorrhagic GI bleed... not a lot to pick up on here...

Question 45

What is Crohns Disease

Answer 45

Ideopathic IBD of the small intestine (but can occur anywhere from mouth to rectum). Mucosa is damaged leading to inner wall becoming rubbery and indistendable, limiting the internal diameter, and resulting in fissures/tears. Bleeds can result.

Question 46

What makes you think Crohns?

Answer 46

Family hx, white female, jewish background

Question 47

S+S of Crohns

Answer 47

Very Drastically (near impossible to pre-hospital diagnose) GI Bleeding Recent weight loss intermittent abdo pn/cramping (non specific, diffuse tenderness) nausea and vomiting diarrhea, fever Absence of bowel sounds possible surgical emergency

Question 48

What is diverticulitis?

Answer 48

Diverticulitis (inflammation secondary to infection) is a common complication of diverticulosis (presence of, with or without bleeding), the presence of diverticula (small outpouchings in the mucosal lining of the intestinal tract)

Question 49

How does diverticulitis occur?

Answer 49

Fecal matter moves slow, intestine increases muscular pressure. Small openings in the lumen of the outer layer of the intestine wall that allow for nerves/blood flow into reach the mucosal layers herniate, small pockets of mucosal tissue slip "outside" of the intestine (more likely to occur at an older age). These pockets then catch small amounts of fecal matter and bacteria other than normal fauna can flourish causing infection. (pg 640 vol 2)

Question 50

S+S of Diverticulitis?

Answer 50

``` Common in elderly Colicky abdo pn LLQ Low fever nausea and vomiting pn on palp. possible hematochezia "Left sided appendicitis"- 95% cases in sigmoid colon C/o not being able to fully evacuate rectum, even after defecation ```

Question 51

Complications of Diverticulitis?

Answer 51

Possible hemorrhage or perforation of the intestine into the peritoneal cavity, causing peritonitis

Question 52

What are hemorrhoids?

Answer 52

small masses of swollen veins that occur in the anus or rectum.

Question 53

S+S of Hemorrhoids?

Answer 53

Usually occur in 30's. Very common particularly 50+ Mostly ideopathic (Can result from pregnancy or portal hypertension, low fibre diet or straining at defecation. External often from heavy lifting) Significant bleeding or bleeding hemorrhoids in a alcohilic pt require closer monitoring+follow up

Question 54

What are some of the common causes of Bowel Obstruction?

Answer 54

Hernia, Intussusception, adhesion, volvulus and foreign body.

Question 55

Most common location for foreign body bowel obstruction?

Answer 55

small intestine due to length and small diameter

Question 56

Define hernia

Answer 56

Protrusion of an organ through it's protective sheath

Question 57

Define intussusception

Answer 57

Condition that occures when part of an intestine slips into the part just distal to itself (think telescoping, but not extended)

Question 58

Define adhesion

Answer 58

union of normally separate surfaces by a fibrous band of new tissue

Question 59

Define volvulus

Answer 59

twisting of the intesitine on itself

Question 60

S+S of bowel obstruction

Answer 60

(Vary with Chronic vs. acute) decreased appetite fever malaise nausea and vomiting (large amounts of bile, possibly feces-like vomit) weight loss if rupture occurs, peritonitis diffuse visceral pn, usually poorly localized to one location. incr on palp. (lightly!) May be hemodynamicall unstable due to necrosis within organ Visual may reveal distension, peritonitis, free air or ecchymosis Bowel sounds may be high pitched in early cases, reduced or absent in later.

Question 61

What are four accessory organ diseases?

Answer 61

Appendicytis Cholecystitis (Chloecystisis) Pancreatitis Hepatitis

Question 62

What is appendicitis?

Answer 62

inflammation of the vermiform appendix at the juncture of the larg and small appendix (LRQ) Most often older children, young adults, most common surgical emergency

Question 63

Cause of Appendicitis?

Answer 63

Often due to fecal matter blocking its duct. Leads to it swelling, cutting off its own blood supply. Leads to necrosis at which point the walls weaken and rupture

Question 64

What is Cholecystitis?

Answer 64

Inflammation of Gallbladder | Cholelithiasis (gallstones) causes 90% of cases

Question 65

Cholecystitis 4F's

Answer 65

Fat, Forty, Female, Flatulent (often with more than biological child too)

Question 66

When does chronic Cholecystitis or acalculus Cholecystitis occur?

Answer 66

Chronic via bacterial infection (inflammatory similar to gallstones blocking pancreas duct) Acalculus (no gallstones) - sepsis, burns, diabetes, multiple organ failure

Question 67

Murphy's sign

Answer 67

Pn on palp point tenderness under the right costal margin

Question 68

S+S Cholecystitis

Answer 68

Acute attack of diffuse right sided tenderness, URQ or Murphy's sign. Can be extreme pn as epithelium of pancreas erodes (prostaglandins) Referred Pn to the right shoulder due to irritation of the diaphragm Rarely ecchymosis or distension Often Pn is after a fatty meal (gallblader wants to release more bile but can't do to blockage). Sympathomimetic due to pn - cold cool, clammy skin. May be warm if peritonitis has occured. Nause + vomiting are common

Question 69

Causes of acute pancreatitis

Answer 69

Alcohol Abuse Gallstones Elevated serum lipids (cholesterol and triglycerides) Drug-induced

Question 70

Overall mortality of pancreatitis

Answer 70

30-40%

Question 71

S+S of Mild Pancreatitis

Answer 71

Epigastric pn Abdo distension Nausea/vomiting Elevated amylase/lipase Intense pn (reflecting amount of damage) localized to LUQ or may radiate to the back of the epigastric region Nausea followed by uncontrolled vomiting and retching (can further aggravate)

Question 72

S+S of Severe Pancreatitis

Answer 72

-Refractory Hypotensive Shock -Blood loss -Resp failure -Diaphoresis, tachycardia, possible hypotension if massive hemorrhaging -Ecchymosis and swelling in the LUQ may be present to do hemorrhage or organ edema -Epigastric pn -Abdo distension -Nausea/vomiting -Elevated amylase/lipase -Intense pn (reflecting amount of damage) localized to LUQ or may radiate to the back of the epigastric region -Nausea followed by uncontrolled vomiting and retching (can further aggravate)

Question 73

What organ does Cholecystitis effect

Answer 73

Gallblader

Question 74

What is acute pancreastitis

Answer 74

Blockage of the duct (mechanical, metabolic, vascular, infectious), leads to digestive enzymes backing up and starting to cause edema, and the swelling prevents blood flow and therefore ischemia

Question 75

What is chronic pancreatitis

Answer 75

Often due to chronic alcoholism, drug toxicity, ischemia or infectious disease. Often with alcoholism, plately plug is formed, digestive enzymes back up, begin to digest the organ itself. This can lead to hemorrhaging. INTENSE Abdo pn.

Question 76

What is hepatitis?

Answer 76

Any injury to hepatocytes (liver cells) associated with infection or inflammation

Question 77

How many types of hepatitis?

Answer 77

5 viruses - A B C D E (accounts for 60-70% of all cases) plus alcoholic hepatitis (20-30%) Trauma + other diseases account for remaining 10%

Question 78

Factors leading to hepatitis?

Answer 78

Crowded unsanitary living conditions | poor personal hygiene that invites oral-fecal transmission, exposure to bloodborne pathogens, chronic alcohol intake

Question 79

Which Hepatitis are the BAD ones?

Answer 79

B and C. A lasts for a few days, D is dormant until activated by B, E is waterborne infection

Question 80

What do you need to aware of with tx of hep pts? (besides BSI)

Answer 80

Careful with drug administration/hx as the liver metabolizes a lot, how does that effect what's in play?

Question 81

S+S Hepatitis

Answer 81

Relate to severity of the disease URQ pn on palp no relief from antacids, food or positioning Possibly anorexic (no appetite), weight loss Stool becomes clay colour possible fever jaundice (yellow skin) + scleral icterus (yellowing of the white of the eyes) May also have severe nausea/vomiting, general malaise, photophobia, pharyngitis and coughing Due to possible irrititation of diaphragm may also have referred pn to R shoulder. Palp may show enlarged organ Skin ranges from infected to hypotensive (both options possible)