Week 7 GI Flashcards
A patient presents with fever, nausea, vomiting, anorexia, and right upper quadrant abdominal pain. An ultrasound is negative for gallstones. Which action is necessary to treat this patient’s symptoms?
A.
A. Empirical treatment with antibiotics
B. Hospitalization for emergent treatment
C. Prescribing ursodeoxycholic acid
D. Supportive care with close follow-up
B hospitalization
This patient has symptoms of acute acalculous cholecystitis and is critically ill. Hospitalization is required. Empirical treatment with antibiotics and supportive care with follow-up do not address critical care needs. Ursodeoxycholic acid is a medication that helps with gallstone dissolution; this patient does not have gallstones.
A patient reports a sudden onset of constant, sharp abdominal pain radiating to the back. The examiner notes both direct and rebound tenderness with palpation of the abdomen. What is the significance of this finding?
A
Compression of the common bile duct
B
Presence of a pancreatic pseudocyst
C
Retroperitoneal hemorrhage
D
Severe acute pancreatitis with peritonitis
D severe acute pancreatitis with peritoniits
Direct and rebound tenderness is an ominous sign suggesting severe peritonitis. Jaundice is present with compression of the common bile duct. Palpation of a mass suggests the presence of a pancreatic pseudocyst. Bruising of the periumbilicus or flank suggests retroperitoneal hemorrhage.
A patient has both occasional “coffee ground” emesis and melena stools. What is the most probable source of bleeding in this patient?
A. Hepatic
B. Lower gastrointestinal (GI) tract
C. Rectal
D. Upper gastrointestinal (GI) tract
Upper GI tract
Coffee ground emesis is usually old blood from an upper GI source and melena is black, shiny, foul-smelling as a result of blood degradation and is usually upper GI in origin. Lower GI and rectal bleeding will cause bright red blood in stools. Hepatic bleeding usually does not affect the GI tract.
A patient has persistent, epigastric pain occurring 2–3 hours after a meal. Which test should be considered for this patient?
A. Barium swallow with radiography
B. Breath test or stool antigen testing for H. pylori
C. Endoscopy with biopsy of gastric mucosa
D. Physical exam with percussion of the upper abdomen
Endocscopy
Endoscopy provides the most accurate diagnosis of PUD and allows biopsy of multiple areas to exclude malignancy. Barium swallow may still be performed in patients unwilling to undergo endoscopy. Breath tests and stool antigen testing for H. pylori can confirm a bacterial cause. Physical exam generally yields negative findings.
An 18-month-old child has a 1-day history of intermittent, cramping abdominal pain with nonbilious vomiting. The child is observed to scream and draw up his legs during pain episodes and becomes lethargic in between. The primary care pediatric nurse practitioner notes a small amount of bloody, mucous stool in the diaper. What is the most likely diagnosis?
A. Appendicitis
B. Gastroenteritis
C. Intussusception
D. Testicular torsion
Intussusception is characterized by intermittent pain associated with drawing up the legs, “currant jelly” stools, and lethargy in between episodes. Appendicitis is characterized by pain localizing to the RLQ and is not intermittent. Gastroenteritis is likely when vomiting precedes symptoms of pain or discomfort. Testicular torsion involves the testicles and thus has different physical findings and would not be accompanied with bloody stools.
When would you need a specialist referral for abdominal pain?
- suspected GI bleeding
- bowel obstruction
- orthos
- abnormal findings
- jaundice
- Pregnancy
- severe localized/unilateral lower abdominal pain
- trauma,
- peritoneal irritation
what are the three s/s most predictive of acute appendicitis?
pain that starts in epigastrum/periumbilical area
migration of pain to RLQ
Abdominal rigidity
How do you assess a patient with appendecitis?
elicit abd tenderness with pt coughing
Usually can specify pain spot with one finger “McBurney point”
+psoas, obturator, Rovsing
how to diagnose appendicitis?
Treatment
Diagnosis
- H&P
- CBC: Elevated WBC w/left shift
- Pregnancy: r/o atopic pregnancy
- Serum amylase & lipase
- CRP
- UA
- Ultrasound
Treatment
- EMERGENCY ROOM
- lower threshold for elderly
What would you suspect in a patient with appendicitis who has shaking and chills?
pylephlebitis (septic thrombophlebitis of the portal venous system)
Perforated peptic ulcer
Presentation
Diagnosis
Presentation
- Abrupt onset sever abdominal pain followed by peritoneal signs
- epigastric pain spreads to abdomen
- Radiates to scapula
- improvement within 12 hours onset then become severely ill
- rigid abdomen = chemical peritonitis
- Tachycardia
- Orthostatic = hypovolemic
Diagnosis
- Xray = pneumoperitoneum, air over liver,
- Ct w/oral contrast = extravasation of oral contrast
Treatment
- EMERGENCY
what is the most common cause of primary spontaneous bacterial peritonitis?
cirrhosis complicated by variceal hemorrhage and ascites
what is secondary peritonitis?
spillage of GI or GU organisms into the peritoneal space
usually d/t peritoneal dialysis or pancreatitis, appendicitis, diverticulitis, cholecystitis, etc
how to diagnose peritonitis
Physical exam findings: fever, abdominal pain, tendernes, leukocytosis
CXR
CBC
CMP
What signs of peritonitis would warrant a laparotomy for diagnosis?
- decreased BS
- Increasing tenderness
- rebound tenderness
