GI (3%)

Question 1

Warning signs of a surgical abdomen

Answer 1

	Intractable pain followed by vomiting (vomiting before or with pain onset is typically not surgical)
	Acute, steady, or progressive severe pain 
	Pain that causes syncope 
	Pain that disturbs sleep
	Persistent pain for > 6 hours 
	Well-localized pain
	Pain unrelieved by analgesics
	Old surgical scars on the abdomen

Question 2

Common abdominal signs with examples

Answer 2

 Murphy’s sign – pain with palpation of the RUQ (ex: cholecystitis)
 Cullen’s sign – superficial edema and bruising around umbilicus (ex: intraperitoneal bleeding)
 Psoas sign – abdominal pain with passive extension of the thigh (ex: acute appendicitis)
 Obturator sign – abdominal pain with flexion and internal rotation of hip (ex: acute appendicitis)
 Rosving’s sign – pain in RLQ with palpation of LLQ (ex: acute appendicitis)
 Grey-Turner’s sign – bluish discoloration of the flanks (ex: retroperitoneal bleeding)

Question 3

Bowel obstruction causes

Answer 3

• Causes – HANG IV mnemonic – Hernia, Adhesions, Neoplasm, Gallstone ileus, Intussusception/inflammation, Volvulus/vascular
• Can also be caused as a consequence of decreased GI mobility (narcotics, gastroparesis, etc.) or dehydration in elderly
• Can be small or a large bowel obstruction

Question 4

Small bowel obstruction

Answer 4

• Symptoms – epigastric abdominal pain, nausea, vomiting, abdominal distention, vomiting stool, high-pitched/tinkling bowel sounds
• Diagnostics – abdominal film shows dilated loops of small bowel in horizontal pattern
• Treatment – fluid resuscitation, GI decompression, gastric tube with contrast and repeat imaging in 8 hours to determine surgical course, surgery for peritonitis or ischemic bowel

Question 5

Large bowel obstruction

Answer 5

• Symptoms – abdominal pain, nausea, vomiting, abdominal distention, hypoactive/absent bowel sounds (for complete obstruction)
• Diagnostics – abdominal film shows picture frame pattern of large bowel
• Treatment – fluid resuscitation, GI decompression, gastric tube, medical treatment for partial obstruction (correct underlying cause), surgery for peritonitis, ischemic bowel, or total obstruction

Question 6

Cholecystitis

Answer 6

• Acute inflammation of the gallbladder r/t stone impaction in the cystic duct
• Symptoms – RUQ pain typically after fatty meal with radiation, Murphy’s sign (press on RUQ causes sharp intake of breath and pain), nausea/vomiting, fever
• Diagnostics – RUQ US (diagnostic of choice) will show gallbladder wall thickening and sonographer will report + Murphy
• Treatment – NPO, IV fluids, analgesia, antibiotics if needed (Zosyn 3.375 g IV q6h), cholecystectomy (rare)

Question 7

Appendicitis

Answer 7

• Luminal obstruction and inflammation/infection of the appendix
• Symptoms – periumbilical pain → RLQ pain, nausea, vomiting, sense of constipation, RLQ rebound tenderness, Psoas/obturator signs present (lie on left side and right hip is flexed backward causing pain; lie on back, hips and knees at 90, internal rotation of hips causes pain)
• Diagnostics – CT abdomen is diagnostic study of choice, ↑ WBC
• Treatment – analgesia, antibiotics (choice depends on if perforated or not), appendectomy
• Non-perforated antibiotics – cefoxitin 2g IV or cefazolin + Flagyl 0.5 g IV
• Perforated antibiotics – combination of Flagyl 0.5 g IV + ceftriaxone, ciprofloxacin, or levofloxacin

Question 8

Diverticulitis

Answer 8

• Inflammation, rupture, and/or infection of diverticula in the colon
• Classifications – simple (localized) vs. complicated (abscess, peritonitis, obstruction, strictures)
• Symptoms – LLQ pain, fever, nausea, vomiting, constipation, stool is heme positive in 25% of cases (on exam, if heme positive, think of something else)
• Diagnostics – typically can be done without use of diagnostics, plain abdominal film to r/o free air or obstruction; however abdominal CT (study of choice) will assess complicated disease; do not scope during a flare
• General management – liquid diet until symptoms improve, low fiber, IV fluids (if not tolerating PO), gastric tube (if ileus/obstruction), pain control (typically narcotics), smoking cessation
• Antibiotics – FIRST LINE – mild disease = Bactrim 1 tab PO BID or Ciprofloxacin 750 mg PO BID; moderate disease = Zosyn 3.375 g IV q6h or 4.5 g IV q8h

Question 9

C. Diff.

Answer 9

• Profuse, watery, foul-smelling diarrhea
• Diagnostics – positive C. diff stool culture
• Risk factors – antibiotic use (clindamycin is well known to cause this), direct exposure to another person with C. diff
• Mild disease – WBC < 15, no incease in creatinine
• Moderate disease – WBC > 15 OR > 50% increase in creatinine
• Severe disease – WBC > 15 OR > 50% increase in creatinine OR Zar score ≥ 2
• Mild treatment – vanco 125 mg PO BID x 10 days
• Moderate treatment – vanco 120 mg PO QID x 10 days
• Severe treatment – vanco 500 mg PO q6h + Flagyl 500 mg IV q8h

Question 10

Upper GI bleed

Answer 10

• Risk factors – NSAID use, H. pylori, retching, liver disease
• Etiology – PUD, esophageal varices, Mallory-Weiss tear, AVM, tumor, etc.
• Symptoms – melena, nausea, vomiting, hematemesis, abdominal pain, hematochezia (if fast bleed)
• Diagnostics – EGD
• Consult GI

Question 11

Lower GI bleed

Answer 11

• Etiology – diverticular, ischemia, colitis, malignancy, hemorrhoids, anal fissure, AVM
• Diagnostics – colonoscopy with/without biopsy
• Consult GI

Question 12

Constipation

Answer 12

• Unsatisfactory defecation characterized by infrequent stools and/or difficult stool passage
• Primary (not attributed to structural abnormality or systemic disease) vs. secondary (r/t disease or medication)
• Medical tx tailored to underlying etiology
• Dietary or lifestyle changes (ex: increase fiber, exercise, dedicate time)
• Primary unresponsive to diet/lifestyle changes – laxatives are mainstay (bulk laxatives with/without stool softener)
• Chronic (> 3 months) – education, lifestyle modification, increase fiber, increase fluids, bulk laxatives
• No response to bulk laxatives after 6 weeks – osmotic laxatives (lactulose, polyethylene glycol, mag citrate)
• Do not give Mg-containing laxatives to those with renal disease

Question 13

Diarrhea

Answer 13

• Increased stool frequency (more than 3 loose/liquid BMs/day)
• Acute management – most cases are self-limiting, clear liquid diet and advance as tolerated, rehydration, anti-diarrheals (do not use if bloody or diarrhea in hospital until C. diff ruled out), fluoroquinolones are oral drug of choice for empiric therapy
• Chronic management – thorough H&P, order routine stool specimens, anti-diarrheal if appropriate

Question 14

Ileus

Answer 14

• Non-mechanical insult that disrupts the normal coordinated propulsive motor activity of the GI tract
• Symptoms – nausea and/or vomiting, distention, hypoactive bowel sounds, constipation, diarrhea
• Diagnostics – abdominal film, CT of abdomen
• Treatment – most resolve with conservative treatment, bowel rest, IVF, limit narcotics, ambulation, NG tube, electrolyte replacement

Question 15

Hepatorenal Syndrome

Answer 15

 The development of renal failure in patients with advanced chronic liver disease
 Symptoms – fatigue, malaise, decreased urine output, signs of renal failure (ex: asterixis, spider nevi, ascites, hepatosplenomegaly, etc.)

Question 16

Hepatitis B serology

Answer 16

• HBsAg (Hep B surface antigen): positive result = exposure + acute or chronic infection
• Anti-HBs (Hep B surface antibody): positive result = exposure [vaccine or natural] + recovery or immunity
• Anti-HBc (Total Hep B Core antibody): positive result = exposure + previous or ongoing infection
• IgM Anti-HBc (IgM antibody to Hep B core antigen): positive result = recent infection

Question 17

Inpatient treatment for acute hepatitis infection

Answer 17

• Risk factors for acute illness – hep A infection with previous chronic Hep B or C; typically patients are hospitalized secondary to complications or progression from chronic infection
• Management – supportive – hydrate (3-4 L/day; be careful because of third-spacing), lactulose PO PRN for increased ammonia levels, loop diuretics for edema/ascites, paracentesis to relieve intraabdominal pressure if respiratory distress, replace albumin losses

Question 18

Cirrhosis and end-stage liver disease

Answer 18

 Risk factors – hx of hepatitis, etoh consumption, DM, use of ilicit drugs, family hx, presence of autoimmune disease
 Symptoms – asymptomatic until later stages, spider angiomas, hepatomegaly, splenomegaly, ascites, jaundice
 Diagnostics – liver biopsy (confirmatory), US/MRI/CT will often uncover findings suspicious of cirrhosis (nodular liver, enlarged liver)
 Treatment – stop insult (if known), symptomatic tx (diuretics for ascites and edema; lactulose for encephalopathy), liver transplant

Question 19

Pancreatitis

Answer 19

 Acute inflammation of the pancreas secondary to direct injury or insult to pancreas causing release of pancreatic enzymes
 Symptoms – epigastric abdominal pain with radiation to back, nausea/vomiting, abdominal tenderness, jaundice (with biliary obstruction), Cullen’s/Gray-Turner’s sign with retroperitoneal bleeding and shock
 Diagnostics – ↑ amylase (> 3x upper limit of normal), ↑ lipase (most specific), ↑ ALT (> 3x upper limit of normal)
 Management – typically supportive – fluid restriction with LR, NPO initial then increase diet (use enteral feeding by 48 hours if expecting to be NPO > 7 days), and analgesia
 Antibiotics only for suspicion of infected pancreatic necrosis (gas in area of necrosis on CT, increased CRP, and/or persistent fever) – Imipenem 0.5-1 g IV or meropenem 1g IV q8h

Question 20

GERD

Answer 20

• Symptoms – pyrosis must be present +/- chronic cough, dysphonia, sore throat, eructation (burping), pharyngeal burning/irritation, bitter taste; typically worse with lying flat and/or after eating
• Diagnostics – generally diagnosed clinically (by hx or PPI trial); can do an endoscopy if no response to PPI trial or any of the BOWED symptoms
• Management – lifestyle modifications (ex: weight loss, smoking cessation, avoid large/late meals, elevate HOB), once-daily PPI 30 minutes before breakfast, add pre-dinner PPI if no response to the one before breakfast; if unresponsive to BID PPI, refer to GI

Question 21

BOWED acronym for EGD indications

Answer 21

• Bleeding
• Odynophagia
• Weight loss – unplanned
• Early satiety
• Dysphagia

Question 22

Peptic Ulcer Disease (PUD)

Answer 22

• Cause – most commonly H. pylori and NSAID use; risk increases with long-term systemic corticosteroid use
• Symptoms – mild/no symptoms (early), gnawing epigastric pain with rhythmic property, pain resolved with eating (duodenal ulcer), pain worse with eating (gastric ulcer)
• Physical exam is typically unremarkable, may have mild/localized epigastric pain with deep palpation
• Management – conventional therapy – PPI is mainstay (ex: omeprazole, pantoprazole); other agents include sucralfate, misoprostol, antacids
• Risk factors for bleeding or perforation – NSAIDs, aspirin, alcohol, stress from acute illness

Question 23

H. pylori testing and management

Answer 23

• Histology – used for initial dx, typically done with EGD
• Fecal antigen testing – use for follow-up
• First line treatment (10 days) – PPI + amoxicillin 1g BID + clarithromycin 500 mg BID

Question 24

Ulcerative colitis

Answer 24

• A chronic, idiopathic inflammation of large bowel mucosa
• Symptoms – grossly bloody diarrhea (> 6 blood BMs per day), lower abdominal cramping, bowel urgency, cramping rectal pain
• Diagnostics – colonoscopy (diagnostic of choice) shows granular and friable mucosa with diffuse ulceration; crypt abscesses
• Acute flare management – continue their home treatment, corticosteroids (PO prednisone for less severe, IV for systemic toxicity), cyclosporine 2mg/kg IV infusion x7 days then oral (severe flare), surgery
• Complications – toxic megacolon, stricture

Question 25

Crohn's Disease

Answer 25

* A chronic idiopathic inflammation of the GI mucosa * Symptoms – abdominal pain, non-grossly bloody diarrhea, fever, malaise, weight loss * Diagnostics – EGD and colonoscopy with small bowel imaging shows non-friable mucosa, cobble-stoning, deep and long fissures, mouth to anus, “skip” lesions * Acute flare treatment – continue home treatment, PO prednisone (PO for moderate cases, IV systemic toxicity, antibiotics (Cipro + Flagyl or amoxicillin clavulanate [Augmentin]), surgery * Complications – perianal/perirectal abscess, stricture, fistula, abscess, malabsorption

Question 26

Mesenteric Ischemia

Answer 26

* Vascular disorder with high mortality secondary to decreased/inadequate perfusion to intestines * Risk factors – advanced age, smoking, hypercoagulable states (ex: clotting disorders, recent surgery), atrial fibrillation, abdominal surgery * Symptoms – sudden/profound abdominal pain out of proportion to physical findings * Diagnostics – abdominal CT * Non-pharmacologic management – surgical consultation (laparotomy is gold standard), NG for decompression, TPN * Pharmacologic management – anticoagulation for venous thrombus (first line), broad spectrum antibiotics (Levaquin + Flagyl), inotropes, IVF