1
Q
What are some causes of acute, abrupt onset, abdominal pain?
A
- Perforation
- Ruptured abscess
- Obstruction
- Intestinal infarction
- Acute cardiac or pulmonary event
- Ruptured ectopic pregnancy
- Ruptured aortic aneurysm
2
Q
What are some causes of acute, gradual onset, abdominal pain?
A
- Acute inflammation
- Strangulated hernia
- Intestinal obstruction
- Pelvic pathology
3
Q
What are some causes of acute, intermittent, abdominal pain?
A
- Partial obstruction
- Gastroenteritis
4
Q
What are some causes of RUQ abdominal pain?
A
- Pleurisy
- Subdiaphragmatic abscess
- Cholecystitis
- Perforated duodenal ulcer
- Appendicitis
- Perforated colon
- Ectopic pregnancy, TA
5
Q
What are some causes of LUQ abdominal pain?
A
- Pleurisy
- Splenic rupture/infarct
- Perforated gastric ulcer
- Pancreatitis
Diverticulitis (splenic flexure) - Perforated colon
- Ectopic pregnancy, TA
6
Q
What are some causes of RLQ abdominal pain?
A
- Appendicitis
- Acute cholecystitis
- Acute Crohn’s
- Incarcerated hernia
- Ectopic, TA, torsion
- PID
- Cecal diverticulitis
- Colon cancer
- Leaking aortic aneurysm
7
Q
What are some causes of LLQ abdominal pain?
A
- Sigmoid diverticulitis
- PID
- Ectopic, TA
- Perforated sigmoid carcinoma
- Perforated gastric ulcer
- Incarcerated inguinal hernia
- Leaking aortic aneurysm
8
Q
What are some characteristics of abdominal pain?
A
- Crampy
- Burning or gnawing
- Sharp of constant
- Change of the pain
9
Q
What are some different types of abdominal pain?
A
- Visceral
- Parietal
- Extra-abdominal
- Referred pain
10
Q
What are some commonly associate symptoms with abdominal pain?
A
- Fever or chills
- Nausea, vomiting
- Constipation, diarrhea
- Urinary symptoms
- Vaginal bleeding, irregular, missed period
11
Q
What are some common aggravating or relieving factors associated with abdominal pain?
A
- Foods
- Bowel activity
- Urination
- Sexual activity
- Exertion
- Position
12
Q
What are some factors in the PMH do we want to ask about when evaluating abdominal pain?
A
- Medications
- Recent history immobilization, travel
- Abdominal/gynecological surgery
- Cardiovascular diseases
- GI disorders
- DM, anemia, bone/joint problems
- Gynecological hx
- FH
- Diet or food intolerances, ETOH use
13
Q
What are some worrisome features in abdominal complaints?
A
- host
- abrupt onset
- awakens patient from sleep
- unrelenting or worsening pain
- weight loss
- symptoms present < 24 hours
- blood
14
Q
What are some red flags about the physical exam in assessing abdominal pain?
A
- shocky
- peritoneal signs
- abdominal distention
- atypical presentation
- change in bowel sounds
15
Q
What are the features of PERITONITIS?
A
- P lace: front, back, sides, shoulders
- E lectrolytes fall, shock ensures
- R igidity or rebound
- I mmobile abdomen, patient
- T enderness w/ voluntary guarding
- O bstruction
- N ausea and vomiting
- I ncrease in pulse, decrease in BP
- T emperature elevation, tachypnea
- I ncrease in abdominal girth
- S ilent abdomen
16
Q
What is primary vs. secondary peritonitis?
A
- primary spontaneous bacterial peritonitis = peritoneal infection in absence of precipitating factor
- secondary peritonitis = spillage of GI or GU organisms into peritoneal space
17
Q
what are some causes of abdominal distention?
A
- fat
- fluid
- feces
- fetus
- flatus
- fibroid
- full bladder
- fatal tumor
18
Q
general diagnostic studies for abdominal pain
A
- CBC with diff
- UA
- urine or serum HCG
- CMP
- KUB
- abdominal/pelvic US
- CT scan with contrast unless contraindicated
- CXR
- EKG
19
Q
52 y/o woman with a vague epigastric pain since yesterday, low grade fever and today has nausea. Unable to eat breakfast. Pain has now radiated to RLQ. Slight loose stools.
- vital signs T:100°, P 99, r 20, BP 140/90
- abdomen: soft
- McBurney sign
- obturator sign
- rosvig sign
- tenderness right perirectal area
What are your differential diagnoses?
A
- appendicitis
- ruptured ectopic pregnancy
- strangulated hernia
- ovarian cyst
- renal calculi
- regional ileitis
- acute salpingitis
20
Q
atypical presentation of appendicitis in the elderly
A
- unexplained weakness, anorexia
- abdominal distention w/ little pain
- sx may be mild, tachycardia
- classic sequence may be absent
- take serious even if rebound tenderness and guarding are absent
- increase in bands without leukocytosis
21
Q
72 y/o male LLQ w/ low grade fever 99°F developed over the last couple of days. Nausea and increase in flatulence. Hx. of constipation and diverticulosis. Pain has progressively gotten worse over the last 24 hours. VS: T 100°F, P 100, R 26 tenderness to palpation palpable mass LLQ bowel sounds decreased \+rebound tenderness \+ stool guaiac
What are your differential diagnoses?
A
- diverticulitis
- appedicitis
- IBD, IBS (lactose intolerance)
- colon cancer
- urologic (pyelonephritis)
- in females consider gynecologic
22
Q
what is diverticulitis?
A
- most common complication of diverticulosis
- inflammation condition that involves 1 or more colonic diverticula
- always symptomatic
23
Q
diagnostic studies for diverticulitis
A
- CBC, CMP
- UA
- stool guaiac
- abdominal plain films
- US abdomen
- *CT with contrast
- delay colonoscopy until after acute episode
24
Q
treatment for diverticulitis
A
- clear fluids for 1-2 days, bland diet
- amoxicillin clavulanate 875 mg/125 mg BID or
- ciprofloxacin 500 mg BID +
- metronidazole 500 mg TID
- 7-10 days or afebrile 2-3 days
- dietary restrictions
- indication for hospitalization
- surgery
25
- 55 y/o, woman w/ acute onset
- epigastric, deep, steady pain for and improves after 15-20 minutes. Pain radiates to subscapular area. Nausea, vomiting and anorexia, not precipitated with any meal.
- Pmhx dyspepsia
- fever is low grade
- localized tenderness in RUQ
- +rebound
- + murphy’s sign
- cholecystitis
- appendicitis
- hepatitis
- pneumonia
- MI
- liver abscess
26
pathogenesis of cholecystitis
- gallstone impacts in Hartmann's pouch
- edema of gallbladder wall
- increased intraluminal pressure
- gallbladder distention
- increased fluid secretion
- increased prostaglandin I2 and E2 secretion
27
diagnostic tests for cholescystitis
- CBC with diff
- CMP
- EKG and CXR
- US, CT abdomen
- HIDA or PIPIDA scan
- elevated AST, ALT, ALP, amylase
28
treatment for cholecystitis
- based on patient risk
- hospitalization
- surgery or medical management
- non-invasive procedure
29
what is a common chronic complication associated with cholecystectomy and how do we manage that?
- 1 in 3 develop chronic diarrhea
- cause unclear
- could be increase in bile, especially bile acids entering large intestines act as laxative
- treatment: imodium or meds that impair bile acids, i.e. Cholestryamine or Aluminum hydroxide
30
what is GERD?
chronic symptoms or mucosal damage produced by abnormal reflux of gastric contents into esophagus or beyond, into oral cavity (including larynx) or lung
31
what are some causes of increased exposure of esophagus to gastric refluxate
- defective esophageal clearance
- LES dysfunction
- hiatal hernia
- increased intra-abdominal pressure
- delayed gastric emptying
32
which medications impair LES function?
- beta-adrenergic agonists
- theophylline
- anticholinergics
- TCAs
- progesterone
- alpha-adrenergic antagonists
- diazepam
- calcium channel blockers
33
which medications damage mucosa?
- ASA and NSAIDs
- tetracycline
- quinidine
- bisphophonates
34
how do you diagnose GERD?
- presumptive dx of GERD in setting of typical sx of heartburn and regurgitation
* **empiric medical tx with PPI is recommended in this setting***
- pts with non-cardiac chest pain suspected of GERD should have diagnostic eval before institution of therapy
* **cardiac cause needs to be excluded***
35
what diagnostic studies are not recommended first line for GERD?
- barium radiographs
- upper endoscopy (recommended in presence of alarm s/s and screening for high risk for complications)
- screening for H. pylori not recommended
36
what are some indications for additional investigation of GERD?
- atypical history
- sudden s/s in a pt 50 years or older
- sx frequent, long-standing, or don't respond to therapy
- alarm s/s present
37
what are some alarm s/s when assessing for GERD?
- severe dysphagia
- weight loss
- bleeding
- hematemesis
- mass in upper abdomen
- anemia
38
complications of GERD
prolonged exposure of the esophagus to gastric refluxate can cause
- metaplasia
- malignancy
- ulceration
- strictures
- hemorrhage
39
what is Barrett's esophagus and how is it managed?
- premalignant condition associated with chronic esophageal injury (>5 years) due to reflux
- risk for esophageal adenocarcinoma is 30-40x higher
- periodic EGDs with biopsies recommended
- surveillance EGD every 3 years
40
what is metaplasia of the esophagus?
change in the esophageal epithelium from squamous epithelium to columnar epithelium
41
what is the only reliable technique for detecting Barrett's esophagus?
endoscopy
42
GERD management goals
- provide complete relief from heartburn and other sx
- heal underlying esophagitis
- maintain symptomatic and endoscopic remission
- tx or prevent complications
43
what are some lifestyle interventions for managing GERD?
- weight loss
- decrease meal size
- HOB elevation
- avoidance of meals 2-3 hours before bedtime
- routine global elimination of food triggers such as chocoalte, caffeine, alcohol, acidic or spicy foods IS NOT RECOMMENDED
- smoking cessation
- reduced carbonated drink
44
how do you manage GERD?
- PPI therapy initiated
- 8 weeks duration
- once a day 30-60 minutes before 1st meal
- maintenance PPI for those who continue w/ s/s after PPI is discharged and those w/ erosive esophagitis or Barrett's
- pts w/ partial response may be given BID
- H2RA can be used for maintenance therapy w/ erosive disease, or bed time for nighttime reflux
- non-responders referred for evaluation
45
what are some potential risks associated with PPIs?
- effects on vitamin and mineral absorption (iron, calcium, b12, magnesium)
- can cause c.diff and should be used w/ caution in pts at risk
- short term use PPI may increase risk for CAP
- PPI does not need to be altered in concomitant use w/ clopidogrel users
46
what are some extraesophageal presentations of GERD?
- asthma, chronic cough, and laryngitis
- can be considered a co-factor in GERD
- dx of reflux laryngitis should not be based solely on laryngoscopy findings
- PPI is recommended to tx extraesophageal sx if pt has typical sx of GERD
- pH reflux monitoring should be considered before PPI in pts with extraesophageal sx
- non-responders to PPI should have upper EGD
47
what causes the cough associated with GERD?
acid refluxate entering the lung and/or stimulating the vagus nerve
48
what is the main cause of peptic ulcer disease?
- 90% duodenal caused by H. pylori
| - 85-90% gastric caused by H. pylori
49
what are some other causes of PUD?
- NSAIDS
- other meds: steroids, bisphosphonates, KCL, chemo
- rare causes: Zollinger-Ellison syndrome, gastric cancer, lymphoma, lung cancers, stress
50
what are the characteristics of Helicobacter pylori?
- gram negative, motile spiral rod found in 48% of patients with PUD
- H. pylori bacteria adhere to gastric mucosa
51
what are the risk factors for PUD?
- 50 years or older
- drink alcohol excessively
- smoke cigarettes or use tobacco
- FH ulcer disease
52
what are the risk factors for NSAID induced PUD?
- 60 years or older
- past experiences with ulcers and internal bleeding
- steroid use or anticoagulation
- consume alcohol or use tobacco on a regular basis
- chronic NSAIDs or taking higher than recommended
53
s/s of PUD
- burning, gnawing pain in epigastric area
- pain when stomach is empty, but may occur at any time
- pain will last anywhere from a few minutes to several hours
- pain may occur in the middle of the night
- duodenal ulcer: food alleviates s/s
- gastric ulcer: food worsens s/s
- other: N?V, hemoptysis, melena, loss of appetite, anemia
54
atypical s/s in the elderly
- discomfort may be vague
- poorly localized
- radiating inconsistently
- dysphagia, fatigue, anorexia, and weight loss may be the first symptoms
55
ROS for PUD
- NSAID use, PO coricosteroids
- 1st degree relatives
- COPD, cirrhosis, chronic renal disease
56
tx for PUD with alarm s/s
- EGD or barium studies
- If ulcer present, abx for H. pylori, PPI, tx bleeding/other complications, biopsy gastric ulcer
- If no ulcer, PPI or H2RA
57
tx for PUD w/o alarm s/s
- Detect and tx H. pylori, d/c NSAIDs/smoking/ETOH/drugs, PPI or H2RA
- If good clinical response, observe and consider maintenance with H2RA or PPI if sx recur
- If persistent s/s, continue H2RA or PPI for 4-8 weeks
- If good response observe or maintenance with H2RA or PPI
- If no response consider EGD, recheck and retreat for H. pylori, check for noncompliance, consider hypersecretory states
58
what are some non-endoscopic methods for diagnosing H. pylori?
- serology via ELISA IgG
- urea breath test
- fecal antigen test via ELIZA monoclonal
59
what are some endoscopic methods for diagnosing H. pylori?
- rapid usease test (1 antrum and 1 corpus)
- histology (1 antrum and 1 corpus)
- culture
60
indications for early endoscopy
- new onset s/s >50yo
- anorexia
- dysphagia
- GIB
- mass
- unexplained anemia
- unexplained weight loss
- severe vomiting
61
1st line H/ pylori tx for pts w/o PCN allergy and have not previously received a macrolide
- PPI BID
- clarithromycin 500 mg BID
- amoxicillin 1000 mg BID for 10-14 days
62
1st line H/ pylori tx for pts w/ PCN allergy and have not previously received a macrolide/metronidazole or unable to tolerate bismuth quadruple therapy
- PPI BID
- clarithromycin 500 mg BID
- metronidazole 500 mg BID for 10-14 days
63
1st line H/ pylori tx for pts w/ PCN allergy and failed one course of H. pylori tx
- bismuth subsalicylate 525 mg QID
- metronidazole 250 mg QID
- tetracycline 500 mg QID
- PPI BID 10-14 days
OR
- bismuth subcitrate 420 mg QID
- metronidazole 375 mg QID
- tetracycline 375 mg QID
- PPI BID 10-14 days
64
how do you select appropriate abx tx for H. pylori?
- abx resistance
- prior abx exposure
- pt compliance
65
tx for NSAID associate ulcers
- d/c offending agent
- pts over 60yo have a greater than 5% year developing an ulcer
- COX2 selective agent preferred in high risk pts for limited time
- PPI for 8 wks
- misoprostol (Cytotec) 100-200 mcg QID
66
H. pylori complications
- GI bleeding
- gastric outlet obstruction
- perforation
- pancreatitis
67
when to refer someone with H. pylori infection
- failure to response to therapy
- relapse
- weight loss
- hematemesis
- melena
- dysphagia
- odynophagia
68
criteria for irritable bowel syndrome (IBS)
recurrent abdominal pain at least 1 day/week, on average, in the past 3mo associated w/ 2 or more of the following:
- defecation
- change in frequency of stool
- change in form of stool
s/s onset should occur at least 6mo prior to dx and s/s should be present during last 3mo
69
pathophysiology of IBS
- involves enteric nervous system, visceral smooth muscle, and neurohormonal control of gut fx
- caused by malfunction of chemical messengers such as serotonin
- measured alterations in bowel motility occur in response to such stimuli as eating, stress (physical and psychological)
70
more likely to develop IBS: women or men?
women 2-3x more likely
71
typical onset IBS
adolescence, but people don't often seek care until 30-50yo
72
what races less commonly affected by IBS?
asians and hispanics
73
triggers for development of IBS
- infection
- trauma
- cholecystectomy
74
physical characteristics of IBS
- crampy, flatulence, bloating, borborygmi
- constipation and diarrhea
- pain relieved by BM
- urgency, straining, mucus in stool
- dyspepsia
- absence of constitutional sx
- absence of nocturnal diarrhea
75
d/dx for IBS
- lactose intolerance
- celiac disease
- giardia (parasite)
- IBD
- hyperthyroidism
- PUD
- diverticulosis
- laxative abuse
- infectious colitis
- neoplasm
76
red flags when dx IBS
- weight loss
- age >50yo
- fever
- nocturnal sx
- heme positive stools
- anemia
- dehydration
- FH celiac disease, IBD, or colon cancer
- failure to respond to therapy
77
bristol stool chart
- type 1: separate hard lumps, like nuts
- type 2: sausage shaped but lumpy
- type 3: like a sausage but with cracks on the surface
- type 4: like a sausage or snake, smooth and soft
- type 5: soft blobs w/ clear-cut edges (passed easily)
- type 6: fluffy pieces with ragged edges, a mushy stool
- type 7: watery, no solid pieces
78
steps in diagnosing IBS
- exclude red flags
- CBC, CMP, TSH
if warranted:
- stool hemocult, culture, ova and parasites
- IgA, IgG transglutaminase and endomysial antibody tests for celiac disease
- r/o lactose intolerance
- sigmoidoscopy, colonoscopy not necessary in absence of red flags
79
tx IBS-C, constipation predominates
- soluble fiber
| - linaclotide, lubiprostone, PEG laxatives
80
tx IBS-D, diarrhea predominates
- dietary modification
| - rifaximin, alosetron, loperamide
81
common foods containing FODMAPs
- excess fructose: fruits, sweeteners, large total fructose dose, honey
- lactose: milk, cheeses
- fructans: vegetables, cereals, fruits
- galactans: legumes
- polyols: fruits, vegetables, sweeteners
82
what is inflammatory bowel disease (IBD)?
a chronic inflammatory condition
83
2 types of IBD
- ulcerative colitis (UC)
| - crohn's disease (CD)
84
what is ulcerative colitis?
chronic inflammation of lining of colonic muscosa, beginning in rectum and may involve entire colon
85
what is crohn's disease?
chronic inflammation of all layers of intestinal tract and can involve any portion from mouth to anus
86
s/s differences btwn IBS and IBD
- IBS: constipation, gas,
- UC+CD: vomiting, severe diarrhea, bloody stool, weight loss
- CD: mucus in stool, higher likelihood of fistulae
87
diagnostic finding differences btwn IBS and IBD
- IBS: by elimination, colonoscopy/biopsy neg
- UC: ulcer on interior wall large intestine, biopsy will show signs of disease
- CD: inflammation of intestines, ulceration less likely, biopsy will show signs of disease
88
different causes of IBS vs IBD
- IBS: trauma to gut, i.e. food poisoning, stomach flu; micro-inflammation causing overproduction of histamines; bacterial overgrowth; nervous system disorders; psychosomatic causes
- IBD: autoimmune
89
differences in tx of IBS vs IBD
- IBS: diet, probiotics, fiber, laxatives, antidepressants
| - IBD: diet, abx, anti-inflammatories, corticosteroids, immunosuppressive drugs, surgery
90
diagnostics of IBD
- CBC with diff, CBC, CRP, ESR, B12, folate
- celiac antibody panel
- genetic testing
- stool tests: C and S, O and P, fecal leukocytes
- imaging/endoscopy: MRI, CT, small bowel capsule endoscopy, upper EGD, sigmoidoscopy, colonoscopy, barium enema
* GI MDs are completing work up and tx of IBD pts*
91
PCP considerations for IBD pts
- managed by GI MD
- ensure pts are f/u w/ GI MD and up to date w/ colonoscopies (more frequent)
- nutritional needs (b12/folic acid supplementation and monitoring)
- meds prescribed by GI MD may need lab monitoring and caution when prescribing other meds
92
diagnostic criteria for functional constipation
must include 2 or more:
- straining during > 25% of defecations
- lumpy/hard stools (Bristol types 1-2) > 25% defecations
- sensation of incomplete evacuation > 25% defecations
- sensation anorectal obstruction/blockage > 25% defecations
- manual maneuvers to facilitate > 25% of defecations (i.e. digital evacuation, support of pelvic floor)
loose stools rarely seen w/o use of laxatives
insufficient criteria for IBS
*criteria fulfilled for last 3 mo w/ sx onset at least 6 mo prior to dx
93
primary cause of constipation
colonic transit and pelvic floor dysfunction
94
secondary causes of constipation
medical and psychogenic conditions, meds, structural abnormalities, lifestyle
95
common triggers of constipation in adults
- low-fiber diet
- inadequate fluid intake
- sedentary lifestyle
- ignoring gastrocolic reflex (urge to defecate)
- travel- and scheduling-related factors (varying mealtimes, limited toilet availability)
- poor toilet access (2/2 physical/functional limitations)
- lack of privacy/comfort
- med SE
- anal pain/discomfort
96
meds associated w/ constipation
- opioids
- NSAIDs
- iron
- calcium
- antacids
- TCAs
- antipsychotics
- gen anesthesia
- diuretics (non-K sparing)
- polystrene sodium sulfate
- muscle relaxants
- antiepileptics
- anticholinergics
- antiemetics
- CCBs
- ganglionic blockers
- clonidine
- barium
- drugs for detrusor hyperactivity
- polypharmacy (> 5 meds)
97
ROS for constipation
- acute vs chronic
- diet
- laxative use
- straining, fecal soiling
- incontinence feces or urine
- hemorrhoids/other anorectal disease
98
eval for pt with constipation
- acute: r/o obstruction, ileus (flat and upright films, i.e. KUB)
- constitutional sx present
- FH colon CA, IBD
- CBC, CMP, TSH, stool for occult blood
- colonoscopy, sigmoidoscopy, barium enema
99
tx options for constipation
- phase 1 - lifestyle changes
- phase 2 - bulk-forming laxatives
- phase 3 - stool softeners
- phase 4 - osmotic laxatives
- phase 5 - stimulant laxatives
- phase 6 - chloride channel activators
- phase 7 - severe cases may require both oral laxatives and enemas
100
colorectal cancer risks
- colon cancer 2nd most lethal cancer
- lifetime incidence of average risk approx 6%
- 2-3x higher for persons w/ affected 1st degree relative
- persons w/ IBD 5-6x higher
- persons w/ familial polyposis risk 20-30x higher
101
ppl w/ avg risk for colon cancer
- age 50+ (45+ for AA or American Indian/Alaska native)
- no personal hx polyps and/or colorectal cancer
- no personal hx IBD
- no FH colorectal cancer
- no FH adenomatous polyps
102
ppl w/ increased risk for colon cancer
- FH colorectal cancer or polyps
- 1st degree relative w/ colorectal cancer or advanced adenoma < age 60
- 2nd degree relative w/ colorectal cancer or advanced adenoma (colonoscopy q 5yrs beginning age 40 or 10 years younger than age at dx of youngest affected relative)
- personal hx colorectal cancer
- personal hx IBD
103
clinical manifestations of colon cancer
- rectal bleeding
- anemia
- vague, poorly localized abdominal pain
- change in bowel habits
palpable mass
- large bowel obstruction
- asymptomatic
- weight loss
104
d/dx colorectal cancer
- IBS
- diverticular disease
- ischemic colitis
- IBD
105
screening guidelines
- ACA = age 45
| - AAFP, USPSTF = ages 50-75
106
yearly recommendations for colorectal cancer screening
- gFOBT
| - FIT
107
3 year recommendations for colorectal cancer screening
- fecal DNA
108
5 year recommendations for colorectal cancer screening
- CTC (CT colonography)
- flexible sigmoidoscopy
- barium enema
109
10 year recommendations for colorectal cancer screening
- colonoscopy
110
what is celiac disease?
disorder of small bowel malabsoprtion
111
pathophysiology of celiac disease
- mucosal inflammation, villous atrophy, and crypt hyperplasia w/ exposure to gluten (wheat, barley, rye)
- clinical and histological improvement w/ withdrawal of gluten from the diet
112
associations w/ untreated celiac disease
- nutritional derangements
- anemia
- reduced bone density
- intestinal lymphoma
113
risks for celiac disease
- FH celiac disease
- T1DM
- iron deficiency anemia
- low bone mass density
114
what screening is done to detect celiac disease?
- endomysial antibodies (EMA)
| - tissue transglutaminase (tTG) antibodies (95% sensitivity, 100% specificity)
115
definition of diarrhea
increase in stool frequency of > 3 stools/day, typically appearing loose or liquid
116
acute vs chronic diarrhea
- acute: lasting < 2 weeks, 10% is noninfectious
| - chronic: continues for a month w/o improvement
117
questions about history of diarrhea
- character of stool
- timing of stool
- duration of sx
- fever
- weight loss
- relationship to food
118
ROS diarrhea
- travel
- occupational or residency
- meds
- FH
- sexual history
- PMH and PSH
119
what diagnosis should we consider if someone has acute onset diarrhea for less than one week after recent travel?
traveler's diarrhea
120
what diagnosis should we consider if someone has acute onset diarrhea for less than one week after abx exposure?
C. difficile
121
what diagnosis should we consider if someone has acute onset diarrhea for less than one week that is bloody with a fever, chills, and cramps?
bacterial or amebic dysentery
122
what diagnoses should we consider if someone has acute onset diarrhea for less than one week that is watery?
- viral gastroenteritis
| - food poisoning
123
what diagnosis should we consider if someone has acute onset diarrhea for less than one week after recent anorectal sex?
sexually transmitted GI infection
124
what are some characteristics of non-inflammatory diarrhea?
- watery, non-bloody
- periumbilical cramps, bloating
- nausea or vomiting (suggests small bowel enteritis)
- typically mild, but may be voluminous
- no tissue invasion, fecal leukocytes usually not present
125
what are some inflammatory pathogens that cause diarrhea?
- shigella
- salmonella
- campylobacter
- E. coli
- entamoeba histolytica
126
when would you use loperamide to tx diarrhea?
- mild watery diarrhea
| - mod-severe non-travel-associated diarrhea
127
when would you use abx tx for diarrhea?
- mod-severe travel-associated diarrhea
- mod-severe non-travel-associated diarrhea for more than 72hr with a fever of 101
- dysenteric diarrhea (passage of grossly bloody stools)
128
common tx for bacterial diarrhea
- azithromycin
- metronidazole
- ciprofloxacin
- doxycycline
129
common tx for protozoal diarrhea
- TMP/SMX (bactrim)
- metronidazole
- albendazole
130
diagnostics in a patient with diarrhea
- CBC with diff
- CMP
- stool for occult blood
fecal leukocytes
- stool for ova and parasites
- culture for C. diff
Imaging (if indicated):
- KUB
- CT abdomen
- colonoscopy
- upper endoscopy w/ small bowel follow through
131
who is at risk for ova and parasite infection?
- community waterborne outbreak
- exposure to daycare center
- HIV/AIDS
- MSM
- recent travel to developing countries, Russia, Nepal, or Rocky Mountain
132
some characteristics of diarrhea from ova and parasites?
- persistent diarrhea > 2 weeks
| - stools blood but few leukocytes
133
how is C. diff diagnosed?
- fecal test on diarrheal (unformed) stool, unless ileus due to C. diff suspected
- dx based on clinical and lab findings
- hx abx or antineoplastic agents w/in past 8 weeks
134
tx for acute mild to moderate diarrhea
- stop soilds for 1st 48 hours
- rehydrate
- adsorbents
- anti-motility
- anti-secretory
- abx
- probiotics (if indicated)
135
chronic causes of diarrhea
- colon cancer
- endocrine
- HIV
- IBD
- IBS
- malabsorption
Primary Care Exam 4
flashcards
Decks in class (3)
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