1
Q
List 4 critical causes of abdominal pain
A
- Ruptured ectopic
- Ruptured AAA
- Acute mesenteric ischemia
- Perforated viscus
- Massive GIB
- Acute MI
2
Q
Box 23.1 List 5 patient populations who are high risk when presenting with abdominal pain
A
- Age >60
- Pregnant
- Prior abdominal surgery
**bariatric surgery - Recent instrumentation of GI tract
- Immunocompromised patient
- Hx of known vascular disease
- pts with known abdominal/ pelvic malignancy
3
Q
list 8 DDx for diffuse abdominal pain
A
peritonitis
pancreatitis
sickle cell crisis
appendicitis
mesenteric ischemia
gastroenteritis
ruptured AAA
aortic dissection
intestinal obstruction
DM
IBD
IBS
4
Q
List 8 DDx for RUQ pain
A
biliary colic
cholecystitis
gastritis
GERD
hepatic abscess
acute hepatitis
perforated ulcer
pancreatitis
retrocecal appendacitis
MI
AAA rupture
RLL pneumonia
pleural effusion
5
Q
list 8 DDx LUQ pain
A
gastritis
pancreatitis
GERD
splenic pathology
MI
pericarditis
myocraditis
LLL PNA
pleural effusion
pyelonephritis
6
Q
List 8 DDx RLQ pain
A
appendacitis
diverticulitis
AAA
ectopic
ovarian cyst
PID
endometritis
renal stones
psaos abscess
mesenteric adenitis
ovarian torsion
ovarian abscess
UTI
7
Q
List 8 DDx LLQ pain
A
AAA
sigmoid diverticulitis
incarcerated hernia
ectopic
ovarian torsion
ovarian cyst
ovarian abscess
PID
Endometriosis
Renal stones
psoas abscess
UTI
8
Q
When is XR abdo indicated in a patient presenting with abdominal pain
A
Suspicion for
1. obstruction
2. perforation = free air
3. foreign body
9
Q
When is ultrasound indicated for a patient presenting with abdominal pain?
A
- biliary pathology
- Liver pathology
- pregnant/suspected ectopic
- ovarian pathology
10
Q
What is the gold standard of imaging for a patient with undifferentiated abdominal pain?
A
CT abdomen infused
11
Q
When should CT KUB used for diagnostic imaging?
A
Suspected renal stone
12
Q
List 5 risk factors for developing PUD
A
- h pylori
- NSAIDS
- smoking
- EtOH
- COPD
13
Q
List 8 causes of gastritis
A
infectious
medications
inflammatory
toxins
ischemic
hpylori
NSAIDs
caustic
Bile
lipase
nicotine
etoh
shock
stress
14
Q
What are complications of PUD?
A
Hemorrhage
Perforation
Penetration
Obstruction
15
Q
List 6 risk factors for having a serious underlying causes of abdominal pain?
A
-age >60
-previous abdominal surgery, including bariatric surgery
-history of IBD
-recent instrumentation ex. Colonoscopy with biopsy
-known malignancy
-active chemotherapy
-immunocompromised, including low dose steroids
-fevers, chill, or systemic symptoms
-women of childbearing age
-recent immigrants
-language or cognitive barriers
16
Q
New onset painless jaundice is the classic presentation for which pathology
A
pancreatic head neoplasm/
17
Q
Elevated direct bilirubin + transaminases is indicative of what pathology
A
hepatocellular inflammation or injury.
18
Q
What are 3 broad categories for causes of abnormal bilirubin metabolism
A
- Increased production (hemolysis)
- Liver dysfunction (prevent conjugation)
- Obstruction (prevent secretion)
19
Q
List 4 risk factors for developing juandice
A
hemolysis
hypoalbuminemia
acidemia
drugs that competitively bind albumin
20
Q
List 8 causes of direct hyperbilirubinemia = conjugated bilirubin
A
Obstructive:
1. choledocholithiasis
2. CBD stricture
3. CBD neoplasm
4. Cholangitis
5. CBD compression
Hepatocellular
1. Viral hepatitis
2. Alcoholic hepatitis
3. AI hepatitis
4. Liver failure
5. Liver Ca
6. Liver ischemia
7. Toxins
8. Medications (Tylenol, Statins )
9. HELLP syndrome
21
Q
list causes of Indirect hyperbilirubinemia = unconjugated bilirubin
A
Hematologic causes
○ Hemolysis
○ Hematoma resorption
○ Ineffective erythropoiesis
○ Gilbert’s syndrome
22
Q
List 10 physical exam findings consistent with chronic liver disease
A
- petechiae/purpura
- caput medusae
- spider angiomata
- palmar erythema
- Dupuytren contractures
- gynecomastia
- testicular atrophy
- Jaundice
- scleral icterus
- Hepatomegaly
Findings of portal HTN
1. ascites, 2.splenomegaly
3.caput medusae
4. Right HF
5. Varicies
23
Q
List 5 critical and 5 emergent causes of jaundice from hepatic etiology
A
Critical: acute/ fulminant liver failure
- toxins
-viral
-alcoholic
-ischemic
-Reye syndrome
Emergent:
-AoC liver faliure
-wilson disease
- primary biliary cirrhosis
-AI hepatitis
liver transplant rejection
-Drug induced
-Toxins
24
Q
List 6 medications that cause jaundice by liver injury
A
Hepatocellular dysfunction:
1. izoniazide
2. tylenol
3. Statins
4. Anabolic steroids
5. NSAIDS
Intrahepatic cholestasis:
1. Amoxicillin
2. Anabolic steroids
3. Oral contraceptives
4. promethazine
25
List 6 medications that can cause indirect hyperbilirubinemia (ie drug-induced immune hemolytic anemia)
1. Cephalosporins** most common cause
2. Dapsone
3. Levodopa
4. Levofloxacin
5. Methyldopa
6. Nitrofurantoin
7. NSAIDs
8 Penicillin
9. Quinidine
***GDP6 deficiency (sulfa drugs and nitrofurantoin)
26
List 5 biliary causes of jaundice
Critical:
1. cholangitis
2. Choledocholithiasis
3. cholecystitis
4. CBD inflammation
5. CBD stricture
6. CBD Ca
27
List 2 critical causes and 2 emergent causes of systemic jaundice
Critical:
1. sepsis
2. heatstroke
Emergent:
1. sarcoidosis
2. amyloidosis
3. GVHD
28
List 5 cardiovascular causes of jaundice
Obstructing AAA
budd chiari syndrome
severe CHF
Right sided HF
veno-occlusive disease
29
List 5 gynecologic/ reproductive causes of jaundice
1. Pre-eclampsia
2. HELLP
3. Acute fatty liver of pregnancy
4. Cholestasis of pregnancy
5. hyperemesis gravidum
30
What is gilbert syndrome?
benign hereditary condition
characterized by: hyperbilirubinemia and jaundice d/t inadequate hepatic conjugation of bilirubin
(reduced activity of glucuronyl transferase)
31
Define wilsons disease
inherited, progressive d/o of copper metabolism
copper deposits in brain, liver, kidney, cornea
SxS:
- liver corrhosis
-degenerative brain changes
-pigmented ring on outer margins of cornea
32
list 6 clinical features of budd chiari syndrome
** hepatic vein obstruction
1. hepatopmegaly
2. abdo pain/ tenderness
3. intractable ascites
4. Mild juandice
5. Portal HTN
6. Liver failure
33
List 6 causes of budd-chiari syndrome
1. Polycythemia vera
2. Pregnancy
3. Post part state
4. Hepatocelluar carcinoma (hypercoagulable state)
5. use of OCP
6. Paroxysmal nocturnal hemoglobinuria
7. Lupus anticoagulants
8. Factor V (Leiden)
9. Antiphospholipid antibody syndrome
10. Antithrombin deficiency
11. Protein C deficiency
34
Define Reyes syndrome
-Rapidly progressive encephalopathy with hepatic dysfunction.
-children and teenagers
- often begins several days after recovery from a viral illness, especially varicella or influenza A or B
-clinical features
-vomiting
- confusion
- seizures
- coma
- Hepatomegaly
35
What is the most like diagnosis
- jaundice
-direct hyperbilirubinemia
-AST 2x ALT
EtOH hepatitis
36
List 6 etiologies that cause transaminases (AST/ALT) to be >1000
1. Viral hepatitis
2. Ischemic liver (hypotension, hypoxia, sepsis)
3. Drugs/Tox (acetaminophen)
4. AI hepatitis
5. acute CBD obstruction
6. Budd Chiari Syndrome (hepatic venous outflow obstruction)
7. Hepatic artery ligation/celiac artery ligation
37
What is Charcot’s triad and Reynold’s pentad?
These triads describe findings seen in ascending cholangitis.
Charcot’s Triad
1. Fever
2. RUQ pain
3. Jaundice
Reynold’s Pentad
1. Charcot’s Triad plus
2. Shock
3. Altered mental status
38
What are the stages of hepatic encephalopathy ?
Stage 1:
-impaired attention, irritability,
depression, or personality changes
-Tremor, incoordination
Stage 2
-confusion + asterixis
Stage 3
- stupor
-Hypoactive reflexes, nystagmus,
clonus, muscular rigidity
Stage 4
- coma + posturing
39
How is acute hepatic encephalopathy managed?
1. ABCs
2. Identify trigger
3. protein restriction
4. FLagyl/ lactulose/ rifaximin
40
List 5 triggers for hepatic encephalopthy
1. constipation
2. dehydration
3. infection
4. sedatives
5. AKI
6. GIB
7. electrolytes
41
Describe your approach to ancillary testing in patients with jaundice
1. Bilirubin:
- Conjugated - hepatic causes
-Unconjugated - hemolytic causes (send LDH, haptoglobin, reticulocyte
count, peripheral smear, coombs test)
2. Liver enzymes:
● AST (intracellular, liver, heart, muscle, kidneys, brain, pancreas, lungs,
RBC, LBC)
● ALT (specific to Liver)
● ALP (liver, bone, placenta, gut)
● GGT - specific to liver, can help confirm that ALP elevation caused by liver
3. Liver function tests:
Albumin
INR
4. Imaging:
○ US --> better for GB + CBD with non-malignant disease
○ CT --> for painless, progressive jaundice without hepatocellular injury
- ERCP/MRCP --> may be done to further characterize the obstruction
42
What are cholestatic enzymes
ALP/GGT/Bili
43
What are Hepatocellular enzymes
AST/ALT
44
What is the treatment for SBP
-CTX 2 g IV q 24h
-albumin 25% 1.5 g/kg IV infusion (prevents HRS)
45
Outline the neural pathway regulating nausea and vomiting.
Vomiting centre in the medulla
Afferent input from:
1. vestibular centre
2. GI tract receptors
3.Visceral receptors outside of the GI tract (i.e., biliary system, peritoneum, pharynx, genitalia,
and heart)
4. chemoreceptor trigger zone
Efferents:
- Vagus nerve
- Phrenic nerve
- Spinal Nerve
46
List 6 critical conditions on the DDx for acute vomiting
1. ICH
2. Stroke
3. ACS
4. Boerhaves
5. Testicular or ovarian torsion
6. Toxic ingestion
7. Sepsis
8. DKA
9. Pregnancy
47
List 8 DDx for acute vomiting
1. ischemic bowel
2. ruptures viscus
3. cholangitis
4. cholecystitis
5. bowel obstruction
6. appendacitis
7. Peritonitis
8. Acute pancreatitis
9. PUD
10. Gastro
11. Food poisoning
12. MI
13. Meningits
14. cerebellar infarct
15. drug WD
16. Renal colic
17. Pyelo
18. MI
19. Sepsis
20. CO poisoing
21. EtOH intoxication/ WD
48
List 8 DDx for chronic vomiting
1. chronic pancreatitis
2. gastroparesis
3. PUD
4. Gastritis
5. GOB
6. CNS tumor
7. Raised ICP
8. Migraine
9. Drug toxicity
10. Bulimia
11. Pregnancy
49
List 6 Ddx for episodic vomiting
1. Cholelithiasis
2. IBD
3. IBS
4. Gastritis
5. BPPV
6. motion sickness
7. chemotherpay
8. DKA
9. Uremia
10. Pregnancy
50
List causes of cyclical vomiting
1. cyclical vomiting syndrome
2. Cannaboid hyperemesis
3. Hyperemesis gravidum
51
List 6 complications of vomiting
1. hypovolemia
2. electrolyte abnormalities
3. MW tear
4. Boerhaves syndrome
5.Aspiration pneumonitis
6. Aspiration pneumonia
7. Metabolic alkalosis
52
Define Boerhaves syndrome
●Perforation of the esophagus due to increased intraesophageal
pressure during forceful retching and vomiting
●There is free passage of esophageal contents into the
mediastinum, causing chemical mediastinitis, ●causes sepsis, multi-organ failure, and death
●Surgical emergency
●Mortality rate 50% if no repair in 24 hours
53
Box 25.1 what are the ROME criteria for cannaboid hyperemesis syndrome
Must include all of the following:
1. Stereotypical, cyclic vomiting
2. prolonged, excessive cannabis use
3. Relief of cyclical vomiting with cannabis cessation
54
What ancillary tests are indicated in the patient with nausea and/or
vomiting?
- Chem 10
- CBC
- Renal Function
- Liver function (including coags)
- Liver enzymes
- LDH, haptoglobin, retics (if hemolysis suspected)
+/- Ammonia level
-Beta HCG
-Tylenol/ASA/EtOH
-VBG
-ECG
-CXR +/- abdo XR
-UA/UCLX
+/- blood cultures
+/- diagnostic paracentesis
US GB/LIVER/PELVIS
CT abdo/pelvis infused
+/- Head CT if aLOC
55
List 5 antiemetics that can be used in acute vomiting
1. Ondanstetron
2. Gravol
3. Metocloprimide
4. Haldol
5. Promethazine
56
List the following for ondansetron
a. Drug class
b. Site of action
c. dosage
d. Adverse effects
Class: serotonin agonist
Receptors: 5-HT/ receptors at CTZ and vagus nerve
Dose: 4-8 mg po/IV q 8 h
Adverse effects: HA, dizziniess, MSK pain, QT prolongation, pregnancy class B
57
List the following for metoclopramide:
a. Drug class
b. Site of action
c. dosage
d. Adverse effects
a. Drug class: dopamine and serotonin agonist
b. Site of action: D2 and 5HT + CTZ receptors
c. dosage: 10-20 mg po/IV q 6h PRN
d. Adverse effects:
-dystonic rxn
-tardive dyskinesia
-NMS
-restlessness/ agitation
-diarrhea
58
List the following for gravol :
a. Drug class
b. Site of action
c. dosage
d. Adverse effects
a. Drug class: antihistamine
b. Site of action: H1-R CTZ
c. dosage: 25-50 mg po/IV q 6h prn
d. Adverse effects: drowsiness, light headedness, ***caution elderly delerium
59
what is the black box waring for metoclopramide?
tardive dyskinesia
60
What are the three phases of vomiting?
1. Nausea
2. Retching
3. Vomiting
61
What is Hamman’s Sign and what pathology is it indicative of?
crunching sound that is synchronized with each heartbeat indicative
of air in the mediastinum.
should trigger concern for Boerhaave’s Syndrome in a patient with nauseated and vomiting.
62
What medication is indicated in the patient with intractable
chemotherapy-induced nausea and vomiting?
Dexamethasone 10 mg IV x 1, if refractory to multiple doses of antiemetics (typically
ondansetron if chemo-induced emesis)
63
DefineUGIB vs LGIB and differentiate between the two based on anatomic location
UGIB originates proximal to the ligament of Treitz (anchors small bowel at the duodenal-jejunal flexure)
LGIB Originates distal to ligament of Treitz
64
How do LGIB vs UGIB differ based on clinical presentation
UGIB:
-coffee ground emesis, frank hematemesis, melena
LGIB: blood per rectum, hematochezia
65
List 5 Ddx for LGIB in adults
PUD
erosive disease
varices
esophagitis
MW tear
malignancy
66
List 5 ddx for LGIB in adults
diverticulosis
hemorrhoids
inflammatory colitis
infectious colitis
ischemic colitis
malignancy
Iatrogenic
AVM
polyps
67
67
List 5 ddx for UGIB in children
MW tear
gastritis
esophagitis
foreign bodies
caustic ingestion
swallowed maternal blood (neonate)
coagulopathy
68
List 5 ddx for LGIB in children
anorectal fissure**
meckel diverticulum
allergic colitis
infectious colitis
polyps
angiodysplasia
NEC
69
what urea level is highly predictive of UGIB?
>35 is 90% specific
70
What is the gold standard diagnostic test for suspected UGIB
upper endoscopy
if unstable*** resuscitate then endoscopy
71
What is the preferred imaging for stable LGIB?
1. Lower Endoscopy
2. CTA (capable of detecting bleeding as slow as 0.3mL/min)
3. Angiography
4. Capsule study
72
What is the preferred imaging for the unstable LGIB?
1. Angiography □ Can localize and embolize bleeding sources)
2. Surgical
3. CTA
4. Lower endoscopy
73
What is 'Rosens' definition of massive GIB
active ongoing bleeding and shock index ~0.9 or greater
Shock index (HR/SBP)
74
Is TXA indicated in GIB
short answer~no
potentially more harmful
75
Box 27.2 List 6 characteristics of patients with high risk GIB
1. Medications use:
- ASA
-NSAIDs
-Steroids
-AC
-chemotherpay
2. Hx of PUD
3. Cirrhosis
4. Age >60
5. AUD
6. Current smoker
7. Chronic medical comorbidities
- CHF
-DM
-CKD
-malignancy
-CAD
8. Hx of AAA
76
What is the Glasgow-Blatchford Score
(GBS) stratifies upper GI bleeding patients who are 'low-risk' and candidates for outpatient management.
Use for adult patients being considered for hospital admission due to upper GI bleeding.
77
What are the components of the Glasgow-Blatchford Score
2x Labs:
1. BUN
2. Hgb
2xVS
1.HR
2.SBP
2x historical features
1. melena
2. Syncope
2x Comorbidities
1. Liver disease
2. heart failure
78
Outline the general management for acute GIB
1. ABCs
2. Airway- consider direct for better view, double suction set up, NG insertion to decompress stomach
3. Hypotension (~shock index >0.9 with active bleeding) IVF and emergency blood under pressure. Activate MHP if not responsive to 4U PRBC
(dont forget to replace calcium)
4. Reverse AC
- Vit K/ PCC/FFP
- Idarucizumab for dabigatran
5. Pharmacologic therapy
a. Octreotide 50 mcg bolus + 50 mcg/hr infusion for all UGIB patients
b. Pantoprazole 80 mg IV x1 then 40 mg BID
c. Erythromycin 250mg, 30 minutes prior to endoscopy for suspected UGIB
d. CTX 2g IV x 1 for all cirrhotics
5. Ballon tamponade with Blakemore or Minnesota
79
List 4 indications for surgery in GIB
1. Life threatening hemorrhage w/ no improvement following resusitation
2. Persistent bleeding despite endoscopic treatment
3. Co-existing indication (perforation)
4. Massive transfusion criteria
80
What is the transfusion threshold for stable GIB
70 g/L (7g/dL)
81
Define acute diarrhea
3+ liquid/watery stools in a 24 hour period, up to 14 days
82
Define Severe Acute Diarrhea
acute diarrhea that requires hospitalization --> accompanied by significant fluid losses and may be life threatening esp in children, elders, immunocompromised
83
Define osmotic diarrhea
Occurs when unabsorbed substances in the digestive tract draw extra water into the colon, leading to loose, watery stools
84
Define secretory diarrhea
toxins producing infectious agents stimulate intestinal cells to release fluids
large volume, non bloody
85
Define exudative diarrhea
d/t infectious / inflammatory conditions
○ Digestive tract epithelium is disrupted by pathogens
○ Can be bloody
86
Define dysmotility diarrhea
a. Usually a component of chronic diarrhea, but can contribute to acute cases
b. Increased motility decreases the time over which GI luminal contents can be absorbed. This results in limited water and electrolyte reabsorption
87
Define exudative diarrhea
Presence of blood or pus in the stool, suggesting an inflammatory process in the intestines.
Caused by infectious agents, lactose intolerance, celiac disease, pancreatic insufficiency
88
Box 27.1 List 10 infectious causes of diarrhea
Viral:
-cytomegalovirus
-adenovirus
-HIV
-Norovirus
-rotavirus
Invasive Bacterial (Dysentery)
- camplylobacter***
- C.Diff
-E.coli 0157: H7
-salmonella
-shigella
-yersinia
Protazoa:
- giardia
- entamoeba
-cryptospordium
-yclospora
89
list 6 causes invasive bacterial diarrhea (dysentary)
- yersinia enterocolitica
-shigella
-salmonella
-campylobacter jejuni
-Ecoli 0157:H7
-Vibro parahaemolyticus (seafood)
90
List 5 causes of non-invasive toxin forming bacterial diarrhea (watery)
1. Ecoli (ETEC)
2. C.Diff
3. Vibrio vulnificus (raw shell fish)
4. Vibrio cholera (raw shellfish)
5. Clostridium perfringens (meat)
91
List 5 causes of immediate food borne diarrhea (pre formed toxins)
1. Staph aureus (mayo)
2. Bacillus (rice)
3. Scombroid (soiled fish)
4. Ciguatera (coral fish)
92
List 10 non-infectious causes of diarrhea
Pharmaceuticals
1. antacids
2. antibiotics
3. antiretrovirals
4. chemotherapy agents
5. cholinergic agents
6. check point inhibitors
7. colchicine
8. lactulose
9. laxatives
Endocrinopathies:
1. adrenal insufficiency
2. pancreatic insufficiency
3. hyperthyroidism
4. DM
Systemic illness
1. EtOH/AUD
2. connective tissue disease/ scleroderma
3. cystic fibrosis
GI causes:
1. Celiac
2. IBS
3. lactose intolerance
4. malabsorption
5.radiation enteritis
6. short gut syndrome
Supplements:
- senna
-tumeric
-aloevera juice
-caffiene
-sorbitol
-xylitol
Runners diarrhea
organophosphate toxicity
opioid WD
93
List 5 important questions to ask on history for a patient presenting with diarrhea
- immunosuppression
- surgery
- recent travel
- EtOH/AUD
-antibiotic use in last 8-12 weeks
-food intake
-ill contacts
-meds/dietary supps
-comorbidities
94
LIST 6 special tests to consider in the work up of atypical diarrhea
○ Fecal leukocytes --> no specific/sensitive
○ Stool culture, generally not indicated in the ED
○ C. diff assay
○ Shiga toxin assay
○ Ova/Parasites
○ Giardia antigen assay/ serologic testing
95
List 5 patient populations who should be tested for CDIFF if presenting with acute diarrhea
-immunocompromised
-antibiotics within the last 3 months
-recent hospitalization
-nursing home residence
-employed in health care
-significant diarrhea (> 5/day for multiple days)
96
List 4 antibiotics associated with cdiff
1. cephalosporins
2. penicillin
3. fluoroquinolones
4. clindamycin
97
When is a shiga toxin assay indicated?
Fever + acute diarrhea + labs consistent with HUS
- anemia
- thrombocytopenia
- AKI/renal dysfunction
Or
-known outbreak
98
List 2 ova/parasites are a more common cause of diarrhea in pts with HIV
1. Histolytica
2. giardia
99
List 4 patient populations that should be tested for giarda when presenting with acute diarrhea
1. exposed to poor sanitation
2. immune comprimised
3. travel to developing cuontries
4. known ingestion or stream or spirng water
100
List 6 risk factors for having non-benign/pathologic diarrhea
- travel history
-recent hospitalization
-day care attendance
-nursing home residence
-wilderness or untreated water exposure
-abx
- raw shell fish
-farm animals
-known outbreak
-bloody stool
-diarrhea lasting >7-14 days
- chronic disease
-immunosuppression (organ transplant)
-immune deficiency (HIV)
-
101
When are empiric antibiotics indicated for the treatment of diarrheal illnesses?
1. Severe disease (fever, >6 stools per day, volume depletion warranting hospitalization)
2. Features suggestive of invasive bacterial diarrhea (e.g., bloody or mucoid stools) except
if features of non-severe disease and either afebrile or minimally febrile
3. Host factors that increase the risk for complications, including age >70, comorbidities
such as immunocompromised states and cardiac disease1. Severe disease (fever, >6
102
Outline the management of acute diarrhea in the ED
1. Rehydration
2. Correct electrolyte
imbalances
3. Antibiotics
a. ?immune compromised or signs of sepsis
PO ciproflox 500 mg po BID or lexoflox 500 mg po OD
IV CTX or cipro 400 mg IV BID
b. Cdiff vanco 125 mg po QID x10days
alternatives: metronidazole
c. Traveler's diarrhea single dose AZT 1g po
4. Anti motility agents for non toxic pts with acute watery diarrhea
5. Diet (BRAT)
-bananas, rice, apples, toast
6. Probitics
103
List 6 risk factors for constipation
1. Female
2. Age >70
3. High BMI
4. Sedentary lifestyle
5. Low SES
6. Low fiber diet
7. Multiple medications
8. Any co-morbidities that impair neurologic and motor function
104
List 6 medications that are associated with secondary constipation
a. Opiates
b. iron/Ca supplement
c. CCBs
d. Antidepressants
e. Diuretics
f. Antipsychotics
g. Anticholinergics
h. Antiepileptics
i. Antiparkinson drugs
105
List 6 red flags in a patient presenting with constipation
○ Fever
○ Anorexia
○ Nausea or vomiting
○ Hematochezia or melena
○ Symptomatic anemia
○ Weight loss of over 10lbs
○ Family History of colon cancer
○ Onset of constipation after age 50
○ Acute onset of constipation in elderly patient
106
List 4 causes of oropharyngeal dysphagia
Neuromuscular:
1. CVA ***most common
2. Degenerative aging
- alzheimers
-brain tumor
-diabetic neuropathy
-muscular dystrophy
-AMS
3. Autoimmune
-scleroderma
-myesthenia
-MS
-poly/dermatomyositis
4. Infectious
- botulism
-diptheria
-rabies
-tetanus
5. Metabolic
- Mg deficiency
- thyrotoxicosis
- lead toxicity
107
List the types of esophageal dysphagia
1. Mechanical lesion
a. extrinsic
b. intrinsic
2. Motor/ motility
a. Intrinsic
b. extrinsic
108
List 6 causes of mechanical eso dysphagia
Intrinsic:
- stricture
-rings
-tumors
-post op changes
-foreign body esophagitis
Extrinsic compression:
- tumor
-mediastinal mass
-aortic aneurysm
-thyroid goitre
-
109
List 6 causes of motility eso dysphagia
Intrinsic:
-achalasia
-diffuse eso spasm
-Hypertensive LES
-nutcracker esophagus
-scleroderma
Extrinsic:
- gastric volvulus
- DM
- EtoH/AUD
-GERD
110
List clinical features on history that would suggest an oropharyngeal cause for dysphasia
1. cant initiate swallow
2. gagging
3. choking
4. drooling
5. regurg through nose
6. ****multiple swallow attempts***
111
List clinical features on history that would suggest an esophageal etiology for dysphasia
1. difficulty seconds after initiating swallowing
2. delayed regurgitation
3. chest/ restrosternal pain with swallowing attempt
112
List clinical features on history that would suggest achalasia as an esophageal etiology for dysphagia
1. insidious onset
2. solids AND liquids
3. Improved swallowing with arms over head and standing up straight
4. Bird/cork screw appearance on barium swallow
5. worse with extremes of temperature in food
113
Which patient populations are higher risk for foreign body dysphagia
-peds
-psychiatric
-prisoners
-pre existing eso disease
-edentulous patient (no teeth)
114
List 4 areas of esophageal narrowing with potential for foreign body lodging
1. Cricopharyngeal muscle (UES) ***most common peds
2. aortic arch
3. L main stem bronchus
4. LES diaphragmatic hiatus ***most common adults
115
List clinical features of foreign body dysphagia
1. dysphagia
2. odynophagia
3. neck/chest pain
4. oral secretions
5. respiratory compromised if trachea impinged
- stridor
-cough
-choking
116
define cafe coronary syndrome
proximal esophageal obstruction by food -->sudden cyanosis and collapse
117
How is achalasia diagnosed and managed?
Dx: barium swallow shows cork screw or curling appearance
Tx:
- peroral endoscopic myotomy
- can use nitrates or CCB to bridge to definitive management
118
List 6 indications for urgent removal of esophageal foreign body
1. batteries (especially button)
2. high powered magnets
3. Foreign body that is >5cm
4. Sharp objects
5. Signs of perforation
6. Respiratory distress
7. Stuck > 24 h
8. large coins
119
What specific tests can be used to diagnose foreign body dysphagia
○ AP/L XR (neck, chest abdo)
○ Nasopharyngoscopy → laryngoscopy → endoscopy
○ Barium/Contrast swallow studies - are high risk for aspiration / perforation
○ CT - more sensitive for small fish bone/chicken bone or to look for signs
of inflammation/free air.
120
List 5 diagnostics tests that may be utilized for diagnosing dysphagia
● endoscopy
● Barium swallow
● Manometry
● Impedance monitoring
● CT - imaging with/without contrast for vascular / malignancy / external
compression
121
List 4 high risk complications of esophageal foreign body
1.perforation
2. aortoenteric fistula
3. tracheoesophageal fistula
4. abcess
122
List 8 causes of esophageal obstruction
1. Foreign body
- Adults - meat/bones; dentures; pen caps, etc.
- Kids - coins/batteries
2. Strictures (Schatzki’s ring) / webs
3. Eosinophilic esophagitis
4. Malignancy
5. Large Left atrium / ventricle
6. goiter
7. mediastinal mass
8. achalasia
9. Infectious (botulism, tetanus)
123
List 2 therapies for management of a food bolus obstruction
● Nitroglycerin-thought to work to relax LES tone
● Nifedipine (CCB) – thought to work to relax LES tone
NOT recomended:
- glucagon
-benzos
-effervescent
124
list 3 mechanisms by which button batteries cause damage:
1. alkali burn
2. pressure necrosis
3. Generation of electrical current - causing electrolysis of tissue fluids
125
List 2 acute and 2 long term complications of button battery ingestion
acute:
- esophageal perforation
-mediastinitis
-tracheal esophageal fistula
-esophageal aortic fistula
Chronic:
-esophageal dysfunction
-recurrent foreign bodies (food impaction)
-eso strictures
- eso carcinoma
126
What finding is diagnostic of button battery ingestion on plain radiographs?
double halo sign
127
What is the management of button battery ingestion
If seen in esophagus
- emergent endoscopic retrieval <2hr
Can use honey ingestion as a bridge to endoscopy
If seen in stomach will usually pass w/o intervention
128
List 5 indications for removal of a gastric foreign body?
○ Longer than 5 cm
○ Wider than 2.5 cm
○ Sharp and pointed objects (high risk of intestinal perforation)
○ Objects that remain in the stomach for more than 3-4 weeks
○ Objects that stay in the same intestinal location for 1 week
129
List 8 causes of esophageal perforation
1. vomiting
2. wretching/ valsava
3. endocsopy
4. NG placement
5. ETT placement
6. blunt chest trauma
7. penetrating chest trauma
8. foreign body ingestion
9. caustic ingestion
10. esophagitis
11. carcinoma
130
List 6 clinical features concerning for upper esophageal perforation.
What symptom triad is pathognomonic of upper eso perforation?
****mackler triad:
-subcut emphysema
-chest pain
-vomiting
-pain
-dysphagia
-respiratory distress
-fever
-odonophagia
-n/v
-hoarseness
-aphonia
131
what is the most common anatomical location for esophageal perforation?
90% of spontaneous perforations happen in the distal esophagus;
other sites:
pharyngoesophageal junction.
132
List 4 CXR findings of esophageal perforation
● Pneumothorax
● Subcutaneous air / emphysema
● Hydropneumothorax
● Pneumomediastinum
● Pleural effusions
● Pulmonary infiltrates
● Wide mediastinum
133
Outline is the ED management of a patient with esophageal perforation?
1. Broad spectrum abx~Pip-tazo + vanco +/- fluconazole (if significant risk for fungal colonization)
2. NPO
3. Surgical consultation
4. Admission
134
List 4 causes of esophagitis
-GERD
-eosinophilic infiltrates
-infection
-foreign body
-toxic ingestion
-radiation
135
List 10 agents or conditions associated with GERD
Decreased LES pressure
1. Anticholinergics
2. benzos
3. caffiene
4. CCB
5. chocolate
6. Estrogen
7. ethanol
8. fatty foods
9. nicoteine
10. nitrates
11. peppermint
12. progesterone
Decreased eso motility:
13. achlasia
14. DM
15. scleroderma
Increased gastric emptying:
16. GOO
17. diabetic gastroparesis
136
List 4 complications associated with GERD
1. Esophagitis
2 Stricture formation
3. Reflux induced asthma
4. Adenocarcinoma of the esophagus
5. Esophageal perforation → mediastinitis
6. Barrets metaplasia
137
List 6 lifestyle modifications for someone with GERD
● Avoidance of high risk foods (caffeine, chocolate, alcohol, fatty, spicy foods)
● Weight loss*
● Smoking cessation
● Elevation of the head of bed, and avoidance of lying down after meals*
● Exercise
● Alcohol cessation
138
List 4 pharmacologic therapies for GERD
PPI:
- esomeprazole 20-40 mg OD
-omeprazole 20 mg OD or 20 BID
-pantoprazole 40 mg OD or 20 BID
-rabeprazole 20 mg OD/BID
H2 inhibitor:
- famotidine 20 or 40 mg BID
-Nizatidine 150 mg bid
Acid neutralization
○ Milk of magnesia
○ TUMS
○ Pepto Bismol - bismuth salts
139
How is eosinophilic esophagitis diagnosed?
1. Clinical symptoms of esophageal dysfunction
2. Lack of response to high dose PPI
3. >15 eosiniphils on high power field eso biopsy
140
List 2 pharmacologic treatment options for eosinophilic esophagitis
1. High dose PPI ** first line
2. Swallowed glucocorticoids
3. Budesonide (corticosteroid)
4. Fluticasone propionate (MDI and swallowed)
5. Dupilumab (monoclonal antibody blocking IL4)
141
List 6 risk factors for infectious esophagitis
1. immunocompromised
2. inhaled steroids
3. immunosuppression
4. chemotherapy
5. braod spectrum abx
6. DM
7. AUD/ ETOH
8. Malignancy
9. corticosteroids
10. advanced age
142
List 3 of the most common pathogens causing infectious esophagitis
1. candida
2. HSV-1
3. CMV
143
How is CMV infectious esophagitis treated?
ganciclovir 5mg/kg IV BID
144
How is CMV infectious esophagitis treated?
usually self limiting 1-2 weeks
immunocompromised:
- acyclovir 400 mg po OD x14-21 days
145
list 6 of the most common medications to cause pill esophagitis
1. abx **tetracycline
2.antivirals
3. aspirin
4. NSAIDs
5. KCl
6. Quinidine
7. iron
8. bisphosphenates
146
Box 75.4 List 6 substances and/or conditions that damage the gastric mucosal barrier (ie causes of gastritis)
1. Bile
2. Tobacco smoke
3. Ethanol
4. Glucocorticoids
5. H-pylori***most common
6. NSAIDS
7. Pancreatic secreations
8. Shock state
9. Stress
147
How is gastritis diagnosed?
histologic diagnosis on endoscopic biopsy
148
List 6 NSAIDs that are high risk for causing GI complications
1. indomethacin
2. naproxen
3. diclofenac
4. piroxicam
5. tenoxicam
6. ibuprofen
149
What are clinical features of PUD in children?
Infants:
-poor feeding
-emesis
-FTT
Toddlers:
-abdo pain
-emesis
-hematemesis
-bloody BMs
150
List 4 complications of PUD
- hemorrhage
-perforation (most common duodenal ulcers)
-penetration
-GOO
151
What is the treatment for H pylori?
Quad therapy:
- pantoprazole 40 mg po OD
-metronidazole 250 mg po QID
-bismuth 525 mg po QID
- tetracycline 500 mg po QID x 10-14 days
Triple therapy:
-clarithromycin 500 mg bid
-metro 500 mg bid
-PPI x 10-14 days
152
What are the types of gastric volvulus?
1. Cause:
a. Primary: Subdiaphragmatic - stabilizing ligaments are too lax, allowing stomach to twist on itself
b. Secondary:
i. Supradiaphragmatic - due to diaphragmatic defects (hiatal hernia,
gastric ulcer/cancer, diaphragm paralysis ect)
2. Anatomy: axis of rotation
a. Twisting on its long axis (organoaxial)
b. Twisting on its short axis (mesenteroaxial)
3. Onset: acute vs. chronic
153
What is Borchardt Triad?
Clinical features of gastric volvulus
1. epigastric pain
2. abdo distention
3. violent vomiting + wretch
***cant pass NG tube
154
List risk factors for gastric volvulus
● Age 40-50 yrs
● Paraesophageal hernia
● **20% of cases occur in infants due to a congenital diaphragmatic defect (secondary)
155
List 5 complications of gastric volvulus
- gastric ischemia
- perforation
- ulceration
- hemorrhage
-pancreatic necrosis
- omental avulsion
156
List XR abdo findings of gastric volvulus
large gas filled loop of bowel in abdomen/ chest with air fluid level
157
what is the diagnosis?
Gastric volvulus
158
What is the mechanism of NSAID toxicity in PUD? List 3 at risk
populations and 2 methods of preventing PUD in these people.
● Prostaglandin inhibition due to COX inhibition!
● NSAID users, age > 60, hx of PUD, steroid/anticoag use
● Change to lower risk NSAID / stop use
● Concurrent PPI / acid suppressants.
159
Describe the mechanism of action of H2 blockers and PPIs
PPI:
- Most potent inhibitors of gastric acid secretion
-Parietal cell’s proton pump (H, K, ATP-ase) that produces HCl is irreversibly blocked by PPI’s
- Antisecretory effects last up to 72 hours
H2 Inhibitor:
-Histamine - is the primary stimulus for gastric acid secretion. H2 blockers attach onto the H2
receptor of the parietal cell and prevent the release of hydrochloric acid
160
What are the potential complications of antacid use?
1. Magnesium containing antacids:
○ Can cause diarrhea
2. Calcium containing antacids:
- milk-alkali syndrome
○ Acid rebound
○ Constipation
○ Hypercalcemia
○ Alkalosis
○ Renal insufficiency
3. Aluminum containing antacids:
○ Constipation
○ Electrolyte abnormalities
4. Decrease Absorption of: (Reduce this by taking them 1-3 hrs post meals)
○ Warfarin
○ Digoxin
○ Antibiotics,
○ Anticonvulsants
161
what type of contrast should be used for diagnostic imaging studies
when esophageal perforation is suspected.
water soluble contrast
162
what is the preferred therapeutic
intervention to remove proximal foreign bodies that can be reached by a scope
Flexible endoscopy with procedural sedation
163
List 8 differential diagnoses for hepatitis
1. Viral
2. Alcoholic
3. Autoimmune
4. Infectious (bacterial)
5. Infectious (parasite)
6. Infectious (fungal)
7. Tylenol
8. COngenital
9. Ischemic (shock)
10. pregnancy
11. Malignancy
164
List 8 viruses that can cause viral hepatitis
1. Hepatitis A = infectious
2. Hepatitis B = serum
3. Hepatitis C = post-transfusion / serum
4. Delta viruses
5. EBV
6. CMV
7. HSV
8. VZV
9. Adeno
10. cocksackie
11. Covid 19
12. Rubella
165
List 3 bacteria and 3 fungus that can cause infectious hepatitis
1. ecoli
2. Klebsiella
3. Yersinia
4. Enterococcus
5. Staph aureus
6. Syphilis
1. Candida
2. Cryptococcus
3. Histoplasma
4. Mucor
5. Aspergillis
6. Histoplasma
166
What are clinical findings suggestive of acute hepatitis?
- Fever
- Malaise
- Jaundice
-Scleral icterus
-N/V
-Wht loss
-Diarrhea
167
What is the definition of acute hepatitis?
Inflammation of hepatic parenchyma or hepatocellular necrosis resulting in increased liver enzymes lasting <6 months
168
What is the most common cause of acute viral hepatitis?
What is the route of transmission?
Hepatitis A (RNA enteroviral picornavirus)
Fecal-Oral
169
List 5 risk factors for hepatitis A
Developing country
Recent travel
Children
MSM
Food handling
health care
daycare
IVDU
170
How is hepatitis A diagnosed?
What is the treatment?
Dx:
- Elevated ALT > AST (1000)
+ve IgM AB (Acute)
+ve IgGAB (previous/cleared)
Tx: 100% clear virus
- supportive
171
What is the post exposure management for HAV?
ISG, 0.02 ml/Kg IM
HAV Immunoglobulin
reserved for:
● immunocompromised
● Liver disease
● allergic to Hep. A
vaccine.
● Close personal
contacts
● Day care centre
workers
● Within 2 weeks of
foodborne exposure
172
List 5 risk factors for Hep B
- immigrant from HBV endemic areas
-IVDU
-MSM
-male prisoners
-close contact with carrier
-Health care workers
173
What is the route of transmission for HBV/HCV
parenteral
IV
intercourse
174
How is hepatitis B diagnosed?
ALT>AST (1000s)
HBsAg
HBcAb IgM**
HBeAg = HIGH infectivity
Anti-HBs
- clearance and/or immunized
HBsAg persistent > 6mo = chronic infection
175
List clinical findings suggestive of HBV infection
- High risk individual
+/- Serum sickness in prodromal period
-B symptoms
- anorexia
-n/v
-jaundice
-RUQ pain
176
What are risk factors for hepatitis C?
- IVDU
-blood transfusion before 1992
-organ transplant before 1992
-pregnant mom with hep c
-multiple sexual partners
-MSM
-health care workers
-tattooing/ body piercing
177
How is HBV diagnosed and treated?
HCV RNA PCR
- repeat in 6 weeks to determine of acute or chronic
Tx:
- anti-virals (DAAs)
-8-12 weeks
-RNA undetectable @ 12 weeks
178
Which forms of viral hepatitis are transmitted fecal oral?
HAV
HEV
179
Which forms of hepatitis are transmitted parenteral/intimate contact?
HBV
HCV
HGV
180
Interpret the following serologic markers
Anti-HAV
Anti-HAV IgM
HBsAg
HBeAg
HBsAb
HBcAb
HBcAB-IgM
Anti-HDV
Anti-HCV
Anti-HAV- combo IgG +IgM ~ HAV infx acute or past
Anti-HAV IgM- acute HAV infx
HBsAg- acute HBV infx
HBeAg- active infx- high infectivity
HBsAb- acute or past infx
HBcAb- combo IgG+ IgM ~ acute or prev infx
HBcAB-IgM- acute infection
Anti-HDV
Anti-HCV - acute of past infx
181
Which diagnostic tests should be ordered in patients with suspected viral hepatitis
Chem 10
CBC
LFTs (increased bili)
LEs (ALT>AST) 1000s
Viral hepatitis serologies
182
How is suspected or confirmed viral hepatitis managed in the ED?
○ Most have self-limited disease with symptomatic and histologic resolution in 2-4 weeks
○ ED management:
- supportive
- Fluids, electrolytes, anti-emetics
- Avoid hepatotoxic medications
- Counsel against etoh
***No role for corticosteroids for treatment of acute viral hepatitis
-Should have isolation precautions, hand hygiene for Hep A
183
What is the post exposure management for HBV ?
Not immunized or unknown immunization:
- HBIG + HBV 2 weeks from time of exposure
-HBIG 0.06 mL/kg IM
Immunized- nothing
184
What is the post exposure management for HCV?
No vaccine available
No PREP available
occupational exposed individuals should be tested in 48 hr then again in 6 mo post exposure
185
For individuals working in health care occupation, what is the transmission rate of HIV/HBV/HCV infection after needle stick injury
HIV 1:300 (0.33%)
HCV 1:30 (3.3%)
HBV 1:3 (33%)
186
What forms of liver diseases are associated with AUD?
Progressive disease state:
1. steatosis (2 wk)
2. steatohepatitis
3. cirrhosis (5yr)
4. hepatocellular carcinoma
187
How is EtOH cirrhosis diagnosed
1. AST 2x > ALT (usually 10x ULN)
2. Liver US
3. R/O other causes
other tests:
- elevated WBC
-Hypoglycemia common
-Coagulopathy
188
List 5 non-hepatic complications/ manifestations of EtOH cirrhosis
1. GIB
2. Pancreatitis
3. Gastritis
4. HRS
5. volume overload
6. Sepsis
7. PSUD
8. Malnutrition
189
Describe the management of alcoholic hepatitis
- supportive
- manage hypoglycemia
-Thiamine 100 mg IV
-CIWA
-Nutrition (protein restriction if evidence of cirrhosis)
-PPI
-replace electrolytes
Aggressively manage any suspected variceal bleed:
o Octreotide / Somatostatin / Vasopressin
o Endoscopy +/- TIPS / stent placement
* Start corticosteroids on anyone with an mDF score > 32
* Watch for infections (SBP)
o Empiric ceftriaxone
190
Describe the Maddrey Discriminate Function score
Predicts prognosis and steroid benefit in alcoholic hepatitis.
4.6 × (Pt's PT-control PT) + TBili
>32 = poor prognosis + would benefit form steroids
191
What is the steroid regimen for pts with maddrey discrimination factor > 32
1. Prednisolone 40mg PO daily
2.Methylpred 32mg IV daily
192
What are the two main types of autoimmune hepatitis?
1. Primary biliary cirrhosis
2. Primary sclerosing cholangitis
193
List 6 stigmata of chronic liver disease
* Scleral / cutaneous icterus +/- pruritus
* Hepatomegaly
* Spider angiomata
* Caput medusa
* Patchy ecchymosis with thin skin
* Splenomegaly
* Gray / acholic stools
* Gynecomastia
* Muscle wasting
* Palmar erythema
* Dupuytren's contractures
* Testicular atrophy
194
List 4 types of cirrhosis and give an example for each
1. Laennec: Chronic etoh hepatitis
2. Post necrotic: chronic infectious, drug induced
3. Biliary cirrhosis: AIH or extrahepatic biliary obstruction
4. Cryptogenic: NAFLD
195
List 3 complications associated with cirrhosis
* Hepatocellular carcinoma
* GI bleeding (portal hypertension → variceal hemorrhage)
* Spontaneous bacterial peritonitis
* Encephalopathy
* Ascites
-HRS
196
Describe the MELD score
Score used to predict 3-month mortality of patient with end-stage liver disease
Calculated using serum creatinine, total bilirubin, INR, Na
Higher MELD scores (closer to 40) indicate more severe liver disease and a higher priority for transplantation.
197
How is GIB managed in the cirrhotic pt?
1. Cryoprecipitate 1u/10kg
* Plts > 50k
* Fibrinogen > 100 mg/dL
2. Vitamin K 10mg IV x 1
3. Ceftriaxone 1 g IV OD this is for SBP prophylaxis
4. Octreotide
5. PRBC for hgb <70
6. GI + Endoscopy
198
Define hepatic encephalopathy and describe the pathophysiology
Cerebellar and neuromuscular dysfunction 2/2 increased ammonia level and its effect on cerebral metabolism
Ammonia produced in GI tract by bacteria converted to urea by liver. When liver is damaged, ammonia accumulates and crosses BBB
combines with alpha-ketoglutarate and glutamate to form glutamine
disrupt the gamma-aminobutyric acid receptors (GABA)
199
Describe a grading scale for hepatic encephalopathy
Grade I - MCI + tremor
Grade II > Drowsiness / memory + behavioural changes + asterisks + tremor
Grade III > confusion + hypoactive reflexes, nystagmus
Grade IV > coma, unresponsiveness to painful stimuli, decerebrate, dilated pupils
200
Box 76.1 List 5 common underlying causes of HE in patients with known cirrhosis
1. GIB
2. Electrolyte abnormalities
- hypokalemia
-alkalosis
3. VTE
4. ileus
5. Constipation
6. Sedative medications
7. AoC CKD
8. Infection
201
Describe the management for HE
1. ABCs- intubate if unable to protect airway
2. Blood products for GIB
3. Antibiotics for sepsis/infection
4. Correct fluid / electrolyte imbalances:
- albumin
- hypoK
- hypoNa
- hypoglycemia.
- hypoMg
5. Discontinue all CNS sedatives / drugs / toxins
6. lactulose 30-60 mL for 2-3 BM’s daily
7. Rifaximin 400mg PO q8h
- Consider concurrent neomycin, vancomycin, metronidazole PO
8. High calorie diet, prevention of sarcopenia
202
How is HRS diagnosed?
List 3 common clinical features
AKI in patients with cirrhosis
diagnosis of exclusion
Clinical features:
- AKI with known liver dysfunction
-Absence of systemic HTN
-Normal urine sediment
-minimal or no protein in urine
-low urine Na
203
List 6 common precipitants of HRS in cirrhotic pts
1. Infection (SBP)
2. GIB
3. Aggressive diuresis
4. Excessive diarrhea from lactulose
5. Large volume paracentesis without adequate volume expansion
6. EtOH hepatitis
204
Describe the pathophysiology of ascites in cirrhosis
Occurs due to
- portal HTN
- impaired lymphatic flow
- hypoalbuminemia
- renal Na retention
205
Describe the management for symptomatic ascites in liver disease
1. Fluid removal via paracentesis
2. >5L removal = replace albumin with albumin 6-8 g/L (25% HSA)
3. Spironolactone +/- lasix
4. Na restriction (<2g/day)
5. Avoid ACEi, ARB, NSAIDs
6. EtOH cessation
206
List indications for ED paracentesis
1. Diagnostic
- Assessment for SBP
- Assessment of undifferentiated or new-onset ascites
2. Therapeutic
207
List 1 absolute and 3 relative contraindications for ED paracentesis
Absolute:
- acute abdomen
Relative:
- Thrombocytopenia
-coagulopathy
-DIC
-Large bowel ileus
-overlying abdominal wall cellulitis
-pregnancy
208
List 6 tests to order to assess ascitic fluid from paracentesis
- Cell count with differential
- Gram stain
- Aerobic + anaerobic clx
- Protein
- Glucose
- Albumin
- LDH
- Cytology if concern for malignant ascites
209
Describe the Serum Ascites Albumin Gradient (SAAG)
Defines presence of portal HTN (does not differentiate cause) in patients with ascites.
Ascitic albumin - serum albumin
>1.1 (transudative) is characteristic of portal HTN
<1.1 (exudative) can be seen in hypoalbuminemia, malignancy, infection
210
Describe the pathophysiology of SBP
List 3 common bacterial organisms
a. Transmural migration of enteric organisms
b. Iatrogenic
1. Ecoli
2. Klebsiella
3. enterococcus
4. anaerobes
211
How is SBP diagnosed
1. Ascites + abdominal pain
Dx: ascitic fluid analysis by paracentesis
1. PMN >250 (100 in peritoneal dialysis pt)
2. Organism identified on gram stain/ clx
3. pH <7.34
4. SAAG > 1.1 g/dL = early indicator
212
Describe the Runyon criteria. When should these criteria be used?
Helps to differentiate between SBP and secondary peritonitis
□ Total protein > 10g/L
□ Glucose < 2.8
□ LDH > 2/3 ULN serum
>2 = SBP
213
What are 2 treatment options for SBP?
Ceftriaxone 2g IV OD IV
Cefotaxime 2g IV q8h x5 days
214
List 3 types of drug-induced liver disease and give 2 examples for each
1. Cytotoxic ("ALT")
o Acetaminophen
o Lovastatin
o Tetracycline
2. Cholestatic ("ALP")
o Azathioprine
o haLdoL
o Phenobarbital
3. Veno-occlusive ("AAA")
o Anabolic steroids
o Azathioprine
o Anti-pregnancy (OCP’s)
215
What are 2 types of hepatic abscesses?
1. Pyogenic
2. Amoebic
216
Describe the etiology of pyogenic liver abscess?
List the 3 common pathogens
intra-abdo infections w/ extension to portal circulation, liver trauma
Pathogens:
1. ecoli
2. klebsiella
3. pseudomonas
4. enterococcus
5. Bacteroides
217
How are pyogenic liver abscesses diagnosed and treated?
CT with contrast is the test of choice.
U/S can be done to exclude biliary tract obstruction/ cholangitis
Broad spectrum abx x2-6 wk
Cefotaxime 2g IV q8h + metronidazole 500mg IV/PO q8h
Pip-taz and mero both good choices
Abscess > 3-5cm = image-guided percutaneous drainage (IR)
218
Which pathogen is known to cause amebic hepatic abscess?
protozoan entamoeba histolytica
- Fecal-oral route
- contaminated food/water
219
How are amebic hepatic abscesses diagnosed and managed?
Dx: Made through stool / ELISA testing
- marked transaminitis l
- US findings: peripherally located, ovoid, well-circumscribed border, homogenous, hypoechoic center
- CT/MRI
Tx:
Amoebicidal therapy:
□ Tissue Therapy: Flagyl 750mg q8h for 7-10 days
□ Luminal cysts: paromomycin 10mg/kg PO q8h x 7 days
May need percutaneous catheter abscess drainage if refractory or complicated cases
220
Define Budd-Chiari Syndrome?
Differentiate primary causes from secondary causes
Hepatic vein outflow obstruction
Primary: associated with disorders that promote excessive clotting
-FV Leiden
-Protein S or C deficiency
- Thrombophilia
-antithrombin III deficiency
-myeloproliferative disorder
- Bechet disease
- paroxysmal nocturnal hemoglobinuria
-OCP use
Secondary: extra hepatic compression of hepatic vein/IVC
221
How is Budd-Chiari Syndrome diagnosed?
○ Doppler US imaging of hepatic vein --> sensitivity 85-95% **Test of choice
○ Venography with access through internal jugular/cephalic/fem is most sensitive --> reserved for those where there is high suspicion, but non-diagnostic US
222
what is the treatment for Budd-Chiari Syndrome?
1. Acute decompensation
- Consider anticoagulation (LMWH → bridged to Warfarin) if no varices present
o TIPS procedure
o Percutaneous angioplasty
o Consider thrombolytic therapy
2. Chronic clot
o Diuretics / paracentesis
o May need liver transplantation
223
List 3 early and 3 delayed complications associated with liver transplant
Early:
- bleeding
-rejection
- necrosis
- biliary issues
-infection
Delayed:
-recurrence of disease
-malignancy
-infection
-chronic rejection
-medication toxicity
-renal failure
224
List 3 forms of hepatic disease that can occur in pregnancy
1. Benign cholestasis
2. Acute fatty liver
3. HELLP
225
What is the cause of benign cholestasis in pregnancy
How does it typically present?
How is it treated?
Cause : estrogen
Presentation:
-2/3 TM with progressive pruritus
Treatment:
ursodeoxycholic acid 300mg PO q8h until delivery
- resolves with delivery
226
Describe clinical features of acute fatty liver in pregnancy.
Include laboratory findings
*** obstetrical emergency
Clinical presentation:
- late 3rd TM
- more common in prime or twin gestation
-fatigue
-anorexia
-n/v
-jaundice
- RUQ tenderness
LABs:
- transaminitis 5-10x ULN
-elevated bili
-hypoglycemia
-DIC
227
Box 76.3 Describe the Swansea criteria for evaluation of in acute fatty liver of pregnancy?
Help with diagnosing acute fatty liver in pregnancy
6/15 required for diagnosis
1. abdominal pain
2. ascites
3. vomiting
4. polydipsia or polyuria
5. encephalopathy
6. Bilirubin >0.8 mg/dL
7. Hypoglycemia
8. elevated urea
9. elevated WBC
10. ALT > 42 U/L
11. Ammonia > 66
12. Cr > 1.7 mg/dL
13. Coagulopathy or PT >14s
14. Bright liver on US
15. Microvesicular steatosis on liver Bx
228
Describe the management for acute fatty liver in pregnancy
- Prompt delivery
- IVF, electrolyte support, glucose
- coagulopathy management
- If ARDS, may need ventilatory support
- NAC --> evidence is lacking
229
Define HELLP syndrome.
Hemolysis, Elevated Liver enzymes, and Low Platelets
Severe form of eclampsia
230
List 6 risk factors for cholelithiasis
* Age
* Female
* Obesity
* Rapid weight loss
* Cystic fibrosis
* Parity
* Drugs (clofibrate, OCPs)
* Famiy Hx
231
List 5 sonographic findings of cholelithiasis
1. Sonographic Murphy’s sign
2. Gallbladder wall thickening (>5 mm)*
3. Gallbladder wall edema (double wall sign)
4. Pericholecystic free fluid*
5. Gallstones*
*these three = 90% PPV for acute cholecystitis.
232
Which 3 sonographic findings have a 90% PPV for acute cholecystitis?
1. Gallbladder wall thickening (>5 mm)
2. Pericholecystic free fluid*
3. Gallstones*
233
List 3 XR findings suggestive of cholelithiasis
* Stones in the RUQ
-(usually the pigmented type if they contain >4% calcium and are
visible on plain film)
* Pneumobilia (air in the biliary tree)
* Air in/around the gallbladder wall (emphysematous cholecystitis)
* Upper Quadrant sentinel loop (indicating localized ileus due to inflamed GB)
234
List two types of 'stones' to cause cholelithiasis
1. Cholesterol
2. Pigmented
-Black- hemolysis + elderly
-Brown- infected
235
How is acute calculous cholecystitis managed?
- Cholecystectomy
- IVF
- antiemetics
- pain control
- Broad-spectrum abx: pip-tazo
236
What is 'acalculous' cholecystitis?
List 4 patient populations that are at higher risk for 'acalculous' cholecystitis
Inflammation of GB caused by stasis and ischemia (NOT obstruction from stone)
1. Elderly
2. Adm pt recovering from non-biliary tract surgery
3.AIDS patients with secondary CMV or cryptosporidium infection
4. Men, with uncontrolled diabetes (high risk for emphysematous cholecystitis as
well)
***Consider in those who are critically ill and presenting with either jaundice or sepsis from undifferentiated source
237
Define Emphysematous cholecystitis
Severe form of acute cholecystitis caused by gas-producing bacteria in the GB
characterized by presence of gas within the gallbladder's lumen, wall, or surrounding tissues on US or CT
238
What is the classic presentation of ascending cholangitis?
Charcot Triad:
- RUQ pain
- fever,
- aundice
Raynaud Pentad:
- RUQ pain
- fever
- jaundice
- hypotension
- AMS
239
Outline the management for ascending cholangitis
○ Broad spectrum Abx
○ IVF
○ Definitive management --> admit for biliary tract decompression
Can occur: surgically, traenshepatically, ERCP
240
What ultrasound finding differentiates cholangitis from cholecystitis?
Ultrasound in cholangitis shows dilated CBD /intrahepatic ducts
cholecystitis should have normal ducts.
241
What is AIDS CHOLANGIOPATHY?
List 2 common pathogens
Advanced HIV (CD4 <200) with:
- bile duct stricture
- papillary stenosis
- sclerosing cholangitis
Pathogens:
-CMV
-cryptosporidium
242
What is the significance of a calcified gallbladder?
Porcelain gallbladder, most often in elderly women.
May be palpable, but isn’t
usually tender.
Most should be referred for surgical removal due to the high incidence of associated cholangiocarcinoma.
243
BOX 76.2 List the Runyon Criteria for Spontaneous
Bacterial Peritonitis
Total protein > 1g/dL
Glucose < 50 mg/dL
LDH > the upper limit of normal for serum
244
What is the diagnosis? Describe the findings
1. Gallbladder with gallstones
2. Thickened gallbladder
wall
3. pericholecystic fluid
Together with a sonographic
Murphy sign, these findings constitute the sonographic findings in cholecystitis.
245
What is the diagnosis?Describe the findings
amebic abscess with
peripherally located abscess with a homogeneous, hypoechoic center
(arrow).
246
What is the diagnosis? Describe the findings
Emphysematous cholecystitis
CT scan demonstrating a
luminal air-liquid
level and air within the wall of the gallbladder.
247
List the two most common causes of acute pancreatitis
1. Gallstone obstruction
2. AUD
248
The pancreas has both endocrine and exocrine functions.
Which hormones are secreted by the pancreas?
Somatostatin
Glucagon
Insulin
249
Box 77.3 List 10 differential diagnosis for acute pancreatitis
1. PUD
2. Gastritis
3. Gastroenteritis
4. Cholelithiasis
5. Cholecystitis
6. Choledocholithiasis
7. Cholangitis
8. Nephrolithiasis
9. Bowel obstruction
10. Perforated viscus
11.Mesenteric ischemia
12. AAA
13. Ectopic pregnancy
14. MI
15. PNA
16. Pericarditis
17. Pleural effusion
18. Sickle cell crisis
19. Diabetic ketoacidosis
250
Box 77.1 List 10 causes of acute pancreatitis
Toxic/ Metabolic:
1. EtOH
2. Drugs
3. Hyperlipidemia
4. Hyper Ca
5. Uremia
6. scorpion venom
Obstructive (Mechanical)
7. Biliary stones
8. Congenital -pancreas divisum, annular pancreas
9. Tumors
-ampullary
-neuroendocrine
-carcinoma
10 Post ERCP
11. Ampullary stenosis
12. Duodenal diverticulum
13. Trauma
Infectious:
14. Viral
-mumps
-coxsackie
-HIV
-CMV
-EBV
-varicella
15. Bacterial
-TB
-Salmonella
-Campylobacter
-Legionella
-Mycoplasma
16.Parasitic
-Ascarsis
Vascular:
17. vasculitis
18. embolism
19. hypo-perfusion ischemia
Other:
20. Idiopathic
21. Hereditary
22. DM/DKA
23. Autoimmune
251
Box 77.2 List 2 local complications for
a. acute interstitial edematous pancreatitis and
b. acute necrotizing pancreatitis
a. acute interstitial edematous pancreatitis
1. Acute peri-pancreatic fluid collection (homogenous fluid collection adjacent to pancreas~<4 wk after sxs onset)
2. Pancreatic pseudocyst (homogenous fluid collection with well defined walls) >4 wk after sxs onset)
b. Acute necrotizing pancreatitis
1. Acute necrotic collection (heterogenous fluid collection ~intra or extra pancreatic)
2. Walled off necrosis heterogenous collection, well defined wall, >4wk sxs onset
252
List the criteria for diagnosing pancreatitis
1. Classic abdo pain
2. Serum lipase > 3x ULN
3. characteristic findings on imaging.
253
Which transaminase is specific for biliary pancreatitis?
ALT
254
What are most common causes of pancreatitis in children?
● Trauma (#1)
● Infection (viral: Mumps and other viruses (EBV, CMV)
● Congenital (aberrant ductal structure, stone forming diseases - sickle cell disease,
hereditary spherocytosis)
● Genetic lipid disorders
255
What is the imaging of choice for pancreatitis
CT with contrast
should only be done if diagnostic uncertainty
256
List 4 CT findings of pancreatitis
1. pancreatic parenchymal enlargement
2. lack pancreatic of
enhancement
3. loss of its typical texture and borders
4. surrounding retroperitoneal fat stranding
**Pancreatic necrosis is suggested by areas demonstrating no enhancement
257
Box 77.4 Describe the revised Atlanta classification of acute pancreatitis
Include a list of local complcations
Mild
- no organ failure
-no local or systemic complications
Moderate:
- Transient organ failure (<48h)
-local or systemic complications
Severe:
- persistent organ failure (<48h)
Local complications
- acute peripancreatic fluid collection
-pancreatic pseudocyst
-necrotic collection
-walled off necrosis
258
Describe the Ranson Criteria for grading severity of acute pancreatitis (w/o biliary cause)
A Ranson score ≥3 = severe pancreatitis
At admission
1. Age >55
2. WBC >16
3. Glc >200 (11.1)
4. AST >250
5. LDH >350
At 48h
1. Hematocrit drop >10%
2. BUN rise >5 mg/dl
3. Ca <8 mg/dl
4. PaO2 <60
5. Base deficit >4
6. Fluid needs >6L
259
Describe the Ranson Criteria for grading severity of acute pancreatitis (with biliary cause)
A Ranson score ≥3 = severe pancreatitis
At admission
1. Age >70
2. WBC >18
3. Glc >220 (11.1)
4. AST >250
5. LDH >400
At 48h
1. Hematocrit drop >10%
2. BUN rise >2 mg/dl
3. Ca <8 mg/dl
4. PaO2 <60
5. Base deficit >5
6. Fluid needs >4L
260
Describe the APACHE II system for predicting severity of pancreatitis
consists of 15 variables designed for ICU
to predict mortality
APACHE II score
≥8
Age
Temp
MAP
HR
RR
PaO2
pH or HCO3
Na
K
Cr
hematocrit
WBC
GCS
Chronic health issues
- Cirrhosis on biopsy
- NYHC >IV
- Severe COPD
- Hypercapnia, home O2,
- pHTN
- CKD on HD
- immunocompromised
261
Describe the modified CTSI for predicting severity of pancreatitis
Modified CT severity index (CTSI) based on CT imaging.
The CTSI allots points for:
1. pancreatic enlargement (2)
2. inflammation (2)
3. necrosis
<30% (2) >30% (4)
4. fluid collections (4)
5. extra-pancreatic complications (2)
MCTSI ≥4 are considered high risk for severe disease
262
Describe the BISAP index for predicting severity of pancreatitis
Evaluates five factors:
BUN >25 mg/dl
AMS
> SIRS
age >60
pleural effusions +ve
263
Describe 6 management priorities in acute pancreatitis
1. ABCs
2. Fluid resuscitation with RL
Goals:
- HR <120
-MAP 65-85
-U/O >0.5-1ml/kg/hr
3. Analgesia
4. Correct any absolute electrolyte deficits:
- low ionized Ca
-HypoMg
-HypoK
-Hyperglycaemia
5. Initiate oral or enteral feeding ASAP
6. Consider antibiotics if:
-septic
-Evidence of infected necrotizing pancreatitis
7. MRCP/ERCP for gallstone pancreatitis WITH obstruction
**indicated 24-48h for ongoing CBD obstruction or cholangitis
264
Box 77.5 List 10 causes of chronic pancreatitis
Toxic/Metabolic
1. EtOH
2. Tobacco
3. HyperCa
4. Hyper TGs
5. CKD
6. Medications
Idiopathic:
7. Tropical chronic pancreatitis
Genetic:
8. hereditary pancreatitis
9. PRSS1 mutations
10. CFTR mutations (R)
11. SPINK1 (R)
12. CTRC (R)
AI:
13. Type 1 (IgG4)
14. Type 2
Obstructive:
15. Pancreas divisum
16. Sphincter of Odi d/o
17. Malignant pancreatic duct obstruction
18. Post traumatic pancreas duct scars and strictures
265
List 4 early (<4 weeks) complications of acute pancreatitis
2x local
2x systemic
Local:
1. Bleeding
2. Ileus → bowel obstruction
3. Peripancreatic fluid collection (homogenous) - adjacent to pancreas - seen in I.E. pancreatitis
4. Acute necrotic collection (heterogeneous) - intra/extrapancreatic. - seen in necrotic pancreatitis.
Systemic:
1. SIRS - bacteremia - sepsis 2. pleural effusions
3. ARDS
4. Renal failure
5. Shock (3rd spacing)
6. DIC
266
List 4 late (<4 weeks) complications of acute pancreatitis
2x local
2x systemic
Local:
1. Pancreatic pseudocyst - homogeneous fluid collection with well defined wall ~ IEP
2. Walled-off necrosis (heterogenous) with fluid in a well-defined wall.
Intra/extrapancreatic.
3. Bowel necrosis
4. Splenic / portal vein thrombosis
Systemic:
○ Pleural effusions
○ Glucose intolerance
267
List 8 late complications of chronic pancreatitis
1. Pseudocysts
2. Pancreatic ascites
3. Ductal strictures
4. Duodenal stenosis
5. Pleural effusions
6. Pseudoaneurysms
7. Portal/splenic vein thrombosis
8. Malnutrition / malabsorption / steatorrhea
9 Diabetes
10. Renal failure
11. Cirrhosis
12. Pancreatic cancer
268
What is the 5 year survival rate for pancreatic cancer?
5 year survival of 7%
269
List 5 clinical features of pancreatic Ca
1. Epigastric pain
2. Unexplained weight loss
3. Anorexia, nausea
4. generalized weakness
5. Obstructing tumors:
- jaundice
- pancreatitis
- GOO
6. Newly diagnosed DM
7. Insulinomas:
- hypoglycemia
8. Glucagonomas:
- glucose intolerance
- weight loss
- dermatitis
9. Gastrinomas:
- PUD
- GERD
- diarrhea
270
How is pancreatic cancer diagnosed ?
○ CT with IV contrast
○ Endoscopic ultrasound (most sensitive test in the early disease)
271
List 4 treatment considerations if the patient with end stage pancreatic Ca
■ Pain control
■ Treatment of GI bleeding
■ Bowel obstruction correction
■ Treatment of acute cholangitis / venous thrombosis
272
list 10 drug causes of pancreatitis.
● Cannabis
● Codeine
● Dapsone
● Enalapril
● Furosemide
● Isoniazid
● Metronidazole
● Pravastatin
● Procainamide
● Simvastatin
● Sulfamethoxazole
● Tetracycline
● Valproic acid
273
List 5 causes of false-positive amylase elevation.
* Parotitis
* Malignancy
* Trauma
* Burns
* Liver disease
* Cholecystitis
* Renal failure
* HIV
* Pregnancy
274
List 5 causes of false-positive amylase elevation.
1. CKD
2. PUD
3. GI ischemia
4. Tubo-ovarian abscess
5. cirrhosis
6. non-hodgkin lymphoma
7. Tylenol OD
8. DKA
9. HIV
10. Sepsis
11. Cholecystitis
275
List the 3 most common causes of mechanical SBO
1. Post op adhesions (60%)
2. Turmors (20%)
3. Hernias (10%)
276
List 4 causes of mechanical SBO that are external to the the sm.intestine
1. Post op adhesions (60%)
2. Hernias
3. Volvulus
4. Compressing masses
277
List 6 causes of mechanical SBO that are intrinsic to the the sm.intestine
1. Primary neoplasm
2. IBD
3. Chrons
4. Radiation
5. Infectious
6. TB
7. Intussusception
8. Traumatic
9. Bezors
10. Intraluminal
11. Foreign body
12. Gallstones
13. Ascaris parasite infestation
278
Describe the difference between simple vs closed loop SBO
□ Simple: obstruction occurs at a single point
□ Closed loop: obstruction at two locations
- Twist develops in mesentery, or if hernia when loop of bowel becomes entrapped in the defect in the mesentery
**Closed loop can quickly lead to intestinal infarction /necrosis
279
Define 'adynamic ileus'
Neurogenic/Functional Obstruction = Disruption of coordinated peristaltic activity of GI tract in absence of physical blockage
280
List 5 causes of adynamic ileus
1. Metabolic disease
***hypokalemia
2. Medications
***narcotics
3. Infection
- retroperitoneal
-pelvic
-intrathroacic
4. Abdominal trauma
5. Laparotomy
281
List 4 causes of pseudo SBO
1. Degenerative myopthies
2. AI
3. paraneoplastic ds
4. hereditary conditions
282
What organs do the following major arteries supply?
a. Celiac trunk
b. superior mesenteric artery
c. Inferior mesenteric artery
a. Celiac trunk (foregut)
- liver
- stomach
- distal esophagus
- spleen
- superior portion of duodenum
- superior portion of pancreas
b. SMA (Mid gut)
-inferior duodenum
-small intestines
- cecum
- proximal 2/3 colon
c. IMA (Hind cut)
- distal 1/3 colon
-rectum
283
How are SBO diagnosed?
1. AXR
2. US
3. CT with contrast gold standard
284
List 5 AXR findings of SBO
1. >3 distended loops of bowel >3cm diameter
2. No gas in large bowel
3. Dilated loops of small bowel proximal to the obstruction
4. predominantly central dilated loops
5. multiple dilated loops of bowel
6. valvulae conniventes
7. gas-fluid levels if the radiographic is erect, especially suspicious if
a. >2.5 cm in width
b. in the same loop of the bowel but at different heights (>2 cm difference in height)
8. String of beads
285
List 4 findings of simple SBO on CT abdo
1. dilated small bowel loops >2.5 cm from outer wall to outer wall
2. normal caliber or collapsed loops distally
3. small bowel feces sign
4. fat notch sign (typically indicates adhesive SBO)
286
List 4 findings of closed loop SBO on CT abdo
1. asymmetric mesenteric edema
2. narrowing of the mesenteric vessels
3. radial distribution of several dilated, fluid-filled bowel loops
4. U-shaped or C-shaped configuration of the closed-loop
5. beak sign
6. whirl sign
7. intramural hemorrhage
287
Describe the acute management of SBO
1. Unstable: IVF/ resusitation
2. Ischemia/ strangulation > prompt surgical consult
3. NG decompression
4. Anti emetics
5. Antibiotics in the sick, hypotensive or rigid abdomen (CTX/cipro/flagyl)
6. NPO for complete bowel obstruction, fluids only for partial
7. analgesia
288
List 6 potential complications of SBO
❏ Hypovolemia / Shock
❏ Persistent N/V with inability to tolerate PO intake
❏ Metabolic alkalosis (contraction and loss)
❏ Perforation leading to peritonitis
❏ Intrabdominal abscess
❏ Sepsis
❏ Death
289
List 4 types of mesenteric ischemia
1. Mesenteric arterial embolus
2. Mesenteric arterial thrombosis
3. Nonocclusive mesenteric ischemia
4. Mesenteric venous thrombosis
290
What is the most common mesenteric artery to be affected by embolism
SMA > jejunum
291
What is the most common etiology for mesenteric artery embolism
L sided**
Cardiac embolism
292
List 5 risk factors for developing Mesenteric Arterial Embolism
1. MI/CAD
2. CM
3. ventricular aneurysm
4. AFIB
5. Post cCATH
6. Valvular heart Ds
7. endocarditis
8. AAA
9. Aortic dissection
10. Female
11. Age > 70
293
a. What is the etiology of mesenteric arterial thrombosis?
b. Where is the most common place of thrombosis?
c. List 3 risk factors
a. Rupture of atheromatous
plaque (think STEMI of gut)
b. Proximal SMA
c. advance age
- HTN
-DM
-Smoking
-Atherosclerosis
294
List 2 etiologies for Nonocclusive mesenteric
ischemia
Vasospams from
1. Hypo perfusion
2. Sympathetic storm
295
What is the least common cause of AMI?
Mesenteric Venous Thrombosis
296
Box 78.3 List 8 factors associated w/ mesenteric venous thrombosis
Hyper-coagulable states:
1. Factor V liden (most common)
2. Polycythemia vera
3. Antithrombin III deficiency
4. Protein S or C deficiency
5. Myeloproliferative d/o
6. Estrogen therapy
7. OCPs
8. Pregnancy
Inflammatory States:
9. Pancreatitis
10. Diverticulitis
11. Appendicitis
12. Cholangitis
Trauma
- Operative injury
-post splenectomy
-blunt abdo trauma
Other:
- CHF
-Decompression sickness (BENDS)
-pHTN
297
What percent of patients with mesenteric ischemia have a prior history of embolic events (DVTs/PEs)?
50%
298
How is mesenteric ischemia diagnosed? List 4 lab
abnormalities expected in acute mesenteric ischemia.
1. CTA or angiography
2. Lab:
❏ Leukocytosis,
❏ Elevated hematocrit secondary to hemoconcentration
❏ Metabolic acidosis.
❏ Biomarkers you can consider: lactate (sens 86% spec 42%), D-dimer (sens 96%
spec 40%), interleukin (IL)-6,
299
List 3 fidings of mesenteric ischemia on AXR
1. Thumbprinting
2. pneumatosis intestinalis
3. portal venous gas
300
Describe 4 management goals in treating mesenteric ischemia
1) Restore mesenteric blood flow
2) Treat underlying condition
3) Treat underlying persistent vasospasm (if present)
4) Reduce further clot propagation
301
Outline the management for mesenteric ischemia
1. ABCs
2. IVF
3. Antiemetics
4. analgesia
5. NG decompression
6. NPO
7. Anticoagulated with IV unfractionated heparin
○ 80u/kg bolus then 18 u/kg/hr infusion
8. If vasopressors are required: low-dose dopamine and milrinone are recommended (less vasoconstrictive effect on mesenteric vasculature)
9. ABX if evidence of infarction, perforation, peritonitis: pip-tax
10. Consult: gen surg, vascular surg, interventional radiology
○ If signs of intestinal infarction / perforation --> prompt laparotomy
302
Outline the management for mesenteric venous thrombosis
unique tretament
if no evidence of peritonitis
initial treatment with heparin infusion with bridge to long term AC on warfarin with INR goal 2-3
if peritonitis present > laparotomy
303
List 3 early and 3 late complications of mesenteric ischemia
Early:
1. Secondary reperfusion injury
2. Bowel necrosis
3. Resp failure
4. Hypovolemia
5. Metabolic acidosis
6. Perforation
7. Abcess
8. Sepsis
9. Shock
Late:
1. Wound infection
2. Short gut syndrome
3. DVT
4. PE
5. Malnutrition
6. SBO
304
Patient with acute onset severe epigastric pain, n/v.
Lipase: 5000
Physical exam:
T: 37.3, HR: 120, BP: 100/58, RR: 20, SPO2 98% RA
Cullen + grey turner sign +ve
++Tender upper quadrant
What is the most likely diagnosis?
hemorrhagic pancreatitis
305
List 10 ddx for appendicitis in adult patients (female and male)
1. Gastroenteritis
2. Epiploic appendagitis
3. Ureterolithiasis,
4. nephrolithiasis
5. IBD
6. Ileus
7. SBO
9. Intestinal perforation
10. Testicular torsion (males)
11. Incarcerated/ strangulated hernia
12. Diverticulitis
13. Ectopic pregnancy
14. Ovarian torsion
15. PID
16. Ovarian cyst
306
List 4 ddx for appendicitis in children
1. Henoch-Schönlein purpura
2. Mesenteric lymphadenitis
3. Meckel’s diverticulum
4. Ovarian torsion
5. Testicular torsion
6. Gastritis
307
List 4 populations at risk of appendix perforation
1. Young
2. Old
3. pregnant
4. women
308
Describe the
pathophysiology of appendicitis including pain location
1. Appendiceal lumen becomes obstructed preventing outflow of mucus and bacteria
2. obstruction causes luminal distention
3. Integrity of lumen wall compromised by invading bacteria
4. transmural inflammation causing localized somatic pain
5. Without intervention > necrosis + perforation
6. Luminal distention stimulates the T10 visceral sensory nerves of the appendix --> periumbilical pain classically lasts 4-6 hours
309
List 5 causes of acute appendiceal obstruction
1. Fecaliths (hard stools) (65%),
2. Appendicoliths (calcified deposits)
3. lymphoid hyperplasia (primary or secondary to an enteric infection).
4. foreign bodies
5. Tumors
6. intestinal parasites (ascaris)
310
Which 2 presenting symptoms with the highest likelihood ratio for predicting appendicitis in adults.
Which 2 presenting symptoms are most likely not appendicitis?
RLQ +LR 7.3-8.5
Abdominal rigidity +LR 3.8
RLQ pain -LR 0.28
migration/peri-umbilical pain -LR 0.5
311
List 5 specific physical exam maneuvers/ findings in appendicitis
1. Iliopsoas (psoas) sign
2. Rovsing’s sign
3. Obturator sign
4. McBurney’s point tenderness
5. +/- GU exam for testicular, pelvic or hernia etiologies
312
What is the gold standard diagnostic test for appendicitis
CT with contrast
313
List 4 US findings in appendicitis. what are the criteria for criteria for diagnosis?
**first 2 criteria must be met for diagnosis
● Diameter > 6mm
● Non compressible
● Hyperemia on Doppler flow
● Air shadowing, discontinuous mucosa.
● Fat stranding (hyperechoic signals associated with periappendiceal inflammation)
● Peritoneal fluid surrounding the appendix (secondary finding)
314
List 2 advantages and 2 limitations of using US in the diagnosis of appendicitis
Advantage:
1. less expensive
2. no radiation
3. decrease time to diagnosis
4. Can assess other organs (ovaries, uterus, prostate)
Limitations:
1. increased pain
2. less sensitive
3. appendix often not seen ~limited by body habitus, super imposed gas
4. Practitioner dependent
315
List 2 advantages and 2 limitations of CT in the diagnosis of appendicitis
***Gold standard
Adv:
1. sensitive
2. not operater depednent
3. Helps with surgical planning
4. Helps look for alternative diagnoses
5. Rapid
Limitations:
1. Risk for false-negative studies in thin patients (less intra-abd. fat) or special
circumstances (tip appendicitis)
2. Radiation
3. CT dye > kidney injury, anaphylaxis
4. Some centres do not have CT
316
List 4 findings of appendicitis on CT scan
1. Appendices diameter >6mm with surrounding inflammation
2. 8 > mm diameter w/o inflammation
3. Circumferential wall thickening >2mm (with mural enhancement)
4. Calcified appendix
5. Signs of peri appendiceal inflammation (eg fat stranding, clouding, of adjacent mesentary)
317
What is the most common general surgical problem encountered during
pregnancy?
Appendicitis
318
Outline the management for appendicitis
1. NPO
2. IVF
3. Analgesia/antiemetics
4. Antibiotics
- ciprofloxacin 400 mg IV + metronidazole 500 mg IV
- Pip-taz
- vanco only if hx of MRSA
5. Surgery consult
319
Describe the Alvarado Score for appendicitis
1. Migration of pain (1)
2. Anorexia (1)
3. N/V (1)
4. RLQ pain (2)**
5. WBC > 10 (2)**
6. Temp > 37.7 (1)
7. PMN >75%
“A low Alvarado score (<4) has more diagnostic utility to "rule out" appendicitis than
a high score (≥7) does to "rule in" the diagnosis.”
320
Describe the pediatric appendicitis score
1. Migration of pain (1)
2. Anorexia (1)
3. N/V (1)
4. RLQ pain (2)**
5. Rebound pain (2)**
6. RLQ pain with coughing/percussion (2)**
5. WBC > 10 (1)**
6. Temp > 38.0
7. PMN >75%
>8 = high risk for appendicitis (80%)
321
List 2 advantages and 2 disadvantages for surgical vs non-op management of uncomplicated, non-perforated appendicits
Non op (antibiotics)
1. Advantages:
- Avoid surgery and anesthesia
- Shorter duration of disability
- Not associated with an increased risk of appendix rupturing
2. Disadvantages:
-10 to 20% failure rate at 30 days*
- 30- 40% recurrence rate at 1 year*
- 40 to 50% recurrence rate at 5 years*
- Small risk of missed neoplasm (mostly in older patients)
Surgical:
Advantages:
- Permanent resolution without recurrence
- Lower incidence of subsequent hospitalization
Disadvantages:
- Requires surgery and anesthesia
- Longer duration of disability required to recover from surgery
322
Outline the management for uncomplicated appendicitis
1. Non perforated appendicitis confirmed on CT
2. Patients with the following > surgical management
-diffuse peritonitis
-hemodynamic instability
-severe sepsis
-pregnancy
-Immunosupressed
-Hx of IBD
3. Other wise healthy patients > discuss risks ad benefits of surgical vs non op (include rate of recurrence and liklihood of requiring appendectomy)
4. Admit to gensurge for 3 days of observation and IV abx
5. Clinical improvement with IV abx can be discharged home on po abx
6. No clinical improvement = appendectomy
323
List antibiotic treatment options for acute uncomplicated appendicitis (include IV and PO)
IV:
1. CTX 2g OD + flagyl 500 mg q 8 h
2. Levoflox 750mg OD + flagyl 500 mg q 8 h
3. Pip taz 4.5 g then 3.375 q6h
PO:
1. Amox-clav 875 BID
2. Cipro 500 mg BID + flagyl 500 mg q 8h
3. Levoflox 750 mg BID + flagyl 500 mg q 8 h
324
Define the diagnosis of diarrhea
> 3 liquid BM daily
Stool >200g daily
takes shape of container
325
Define ' Dysentry'
Inflammatory gastroenteritis that causes bloody/mucous liquid BMs
Key features:
- inflammatory
-bloody/ mucous
-fever/abdo pain
- tenesmus
326
Differentiate acute from chronic gastroenteritis
acute <2 weeks
Chronic >2 weeks
327
List 4 mechanisms/ etiologies of bacterial gastroenteritis
1. Invasive bacteria
2. Non-invasive bacteria
3. Toxin producing bacteria
4. Pre- formed toxins
328
List 3 features of invasive and non-invasive gastroenteritis
Invasive:
1. fever
2. bloody BM
3. Tenesmus
4. abdominal cramping
Non-invasive:
1.Watery diarrhea
2. absence of abdominal pain
3. Fever less common
329
What is the most common etiology for:
a. Travellers diarrhea (general)
b. Travel to southeast Asia
c. South America
d. Africa
a. Traveler’s diarrhea—enterotoxigenic E. coli
b. Southeast Asia—Vibrio species
c. South America, Asia, Africa--Rotavirus
330
List 3 of the most causes of diarrhea in patients who recently returned from a camping trip
1. Giardia
2. Aeromonas
3. Cryptosporidium
331
What is the most common etiology of diarrhea in someone who works at a day care/ attends daycare?
rotavirus
332
What is the most common cause of cruise ship (outbreak) diarrhea
novovirus
333
List 3 of the most common causes of diarrhea in patient with HIV
1. Mycobacterium avium-
2. Microsporidia
3. Cytomegalovirus
4. Giardia
334
What is the most common cause of diarrhea after ingestion of raw seafood?
Non Cholera Vibrio
335
List 6 indications/ patient populations that require stool sampling for dairrhea
1. Severe illness
2. Fever of 38.5° C (101°F) or higher,
3. Dysentery (mucous, bloody, tenesmotic),
4. Persistent diarrhea for 14 days or longer (send for O+P)
5. Patients who are immunocompromised
6. Recently hospitalized / recent antibiotics.
336
Outline the management for non-bloody diarrhea (possible non-invasive infection ie viral or toxin producing
bacteria)
1. Rehydration/ correct electrolyte imbalances
2. supportive care with anti emetics, Antimotility drugs (loperamide 4 mg PO prn)
3. consider stool for culture and O&P if:
- immunocompromised
-recent hospitalisation /
antibiotic use
4. Send for O&P if persisting beyond 14 days
5. No antibiotics
6. Early continuation of normal feeding
337
List 4 causes of viral gastroenteritis
1. Norovirus
2. Sapovirus
3. Rotavirus
4. Adenovirus
5. Astrovirus
338
list the top two causes of culture-proven bacterial
enteritis in developed countries
Campylobacter and Salmonella
339
What is the most common
cause of acute viral gastroenteritis in children and adults.
Norovirus
340
Why are antibiotics avoided in patients presenting with dysentry without +ve stool culture?
abx treatment in patients with gastroenteritis caused by:
a. E. coli O157:H7
b. Shiga toxin 2
can cause HUS or TTP
341
List 3 of the most common pathogens to cause classic food poisoning.
What is the duration of onset from ingestion?
Classic food poisoning usually manifests 1–6 h post ingestion of preformed
toxins from bacterial organisms such as
a. Staphylococcus
b. Bacillus cereus
c. Clostridium perfringens
342
What is the most common bacteria to cause infectious diarrhea?
List 4 risk factors?
List 2 clinical features
Campylobacter
Risk factors:
-backpacker's diarrhea /
backcountry water
sources
-raw / undercooked
poultry meat
Clinical features:
-acute watery diarrhea
-fevers
- dysenteric
characteristics
- durations 5-14 days
343
What is the treatment for stool +ve campylobacter?
Azithromycin 500mg daily x 3 days
344
List 4 complications associated with campylobacter gastroenteritis
1. GBS
2. Cholecystitis
3. Pancreatitis
4. GI hemorrhage
5. Meningitis
6. Endocarditis
345
List 3 subtypes of salmonella.
How they diagnosed?
1. Salmonella typhi - enteric fever (typhoid fever)
Dx: stool culutre
Non- Typhoid
2. Salmonella typhimurium - acute gastroenteritis
3. Salmonella enteriditis - acute gastroenteritis from eggs
Non-typhoid salmonella dx with stool PCR
346
List 4 clinical features and 2 physical exam findings of Salmonella typhi - enteric fever (typhoid fever)
Presentation:
- recent travel
-headache
-fever
-emesis/ abdo cramping
-bloody diarrhea
- myalgias
Physical exam:
- Rose spots- maculopapular rash upper abdomen/lower thorax
-hepatosplenomegaly
-bradycardia
347
List 4 risk factors for severe infection with salmonella typhi
RF for severe infection
1. Sickle cell disease
2. Extremes of age
3. Immunocompromised
4. Malignant neoplasms
5. Decreased gastric acidity (PPIs)
348
Describe the treatment for non-typhoid and typhoid salmonella gastroenteritis
1. Non-typhoidal
- no treatment unless general indications
- still symptomatic w/ positive culture (stool PCR)
- immunocompromised
- sickle cell
- public health indication
Typhoidal:
Out patient:
- Ciprofloxacin 500mg PO BID x 5-7 days
Inpatient
- IV CTX
Healthcare workers / food handlers - return to work
Once carrier state has abated
◊ Requires repeat cultures
◊ Contact public health
349
How is shigella diagnosed and treated?
Shiga toxin ***causes HUS
Diagnosed with +ve stool clx~S. dysenteriae
Tx:
-ciproflox 500 mg BIDx 3d
-AZT 500 mg po daily x3 d
requires stool culture to ensure resolution
350
How is Yersinia Enterohystolitica transmitted?
List 2 complications of yersinia enterohystolytica
1. Contaminated milk
2. Contaminated pork
3. Fecal-oral from animals
4. person-person fecal-oral
Complications:
1. erythema nodosum
2. poly arthritis
3. Mimics appendicits (local inflammation of terminal ileum and mesenteric lymphnodes)
351
What is the most common cause of gastroenteritis from raw fish?
How is it diagnosed?
How is it treated?
Vibrio parahaemolyticus
Dx: TCBS agar blood cultures
Tx: usually self limited (24-48h)
Abx if still symptomatic w/ +ve clx
- Septra DS 1 tab BID x3d
-cipro 500 mg po BID x3d
352
List the subtypes of ecoli. (5)
1. Uropathogenic
- non-invasive UTI
2. Enterotoxigenic
- non-invasive travelers
3. Enteropathogenic
- non-invasive diarrhea
4. Enteroinvasive
- invasive; no toxin
5. Enterohemorragic
- STEC; ecoli 0157:H7
-associated with HUS
353
List 4 risk factors for E. coli O157:H7 infection
- extremes of age
-contaminated H2O supply
-undercooked beef
-previous gastrectomy
354
What is the most common systemic complication associated with E. coli O157:H7 infection?
HUS
355
List 4 indications for antibiotics with culture +ve E. coli O157:H7 infection
What antibiotics should be given?
Abx usually not prescribed
- does not shorten course of illness or eradicate organism
-increase risk of HUS
Indicated when:
- still symptomatic w/ +ve clx
-immunocompromised
-sickle cell
-public health indication
ABX:
- cipro 500 mg po bid x 3-7 d
-AZT 500 mg daily 3-7 d
356
List 3 abx options for treating stoll +ve c-diff
1. Vancomycin 125 mg po qid x 10 days
2. fidaxomicin 200 mf po bid x 10 days
3. Flagyl 500 mg po tid x 10 days
357
list 5 features of illness that suggest invasive E.coli
o Watery diarrhea to bloody w/ incubation 3-4 days
o Severe abdominal cramps
o Low grade fever
o Thrombocytopenia
o MAHA
o Neurologic sequelae
358
List 6 infectious and 6 non infectious causes of bloody diarrhea in adults
Infectious :
-Campylobacter
- Salmonella
- EPEC
- Shigella
- Yersinia
- Vibrio
Non- infectious:
-Diverticulitis
- colitis
- UGIB
- LGIB
-angiodysplasia
- chrons
-IBD
-neoplasm
-anorectal source
359
What is the most common source of vibrio cholera?
Describe the MOA
○ Source: water / food contamination
**Most common: inadequately cooked shellfish
MOA: enterotoxin in vivo that stimulates enterocyte adenylate cyclase --> disrupts mucosal fluid absorption --> secretory diarrhea
○ "rice water diarrhea'
360
Outline the treatment for vibrio cholera (3)
○ Treatment:
-Rehydration + abx
Antibiotics:
□ Doxycycline 300mg PO x I
□ Cipro 500mg PO BID x 3d
□ AZT 500mg PO OD x 3d
361
List 4 risk factors for cdiff
1. Recent hospitalization
2. Recent antibiotics
3. Long term care facility
4. Antacid use
362
List 5 complications associated with cdiff infection
1. Septic shock
2. Hypovolemic shock
3. Pseudomembranous colitis
4. Toxic megacolon
5. Perforation
363
What is the mechanism of food poisoning gastroenteritis?
Preformed toxins
S. Aureus
B. cereus
Scromboid
Ciguatera
****all have symptom onset within 6 hours of ingestion
364
List 2 food born illnesses associated with marine species. List the corresponding toxin and marine species for each.
1. Scromboid
Toxin: Histamine
Marine species: spoiled tuna, mackerel, mahi mahi sardines
**flushing + palpitations
2. Ciguatera
Toxin: ciguatoxin
Marine species: reef fish ( barracuda, snapper, parrot fish, amberjack)
**Cold allodynia, paresthesias, perioral numbness
365
List infectious causes of HIV gastroenteritis.
VIral: CMV
Bacterial:
-MAC
-Salmonella
Parasitic:
- cryptosporidium (MCC)
- giardia
- Cyclospora
- entamoeba histolytica
366
Outlien the appropriate work up for HIV patients with severe diarrhea
A) stool examination & cultures
B) C Diff toxins and salmonella PCR
C) CMV and MAI if CD4+ count <200\
D) Acid fast smear for Cryptosporidium, Cystoisospora, Isospora, and Cyclospora
E) sigmoidoscopy
367
Which food-borne illnesses are associated with neurological symptoms?
● Campylobacter: GBS
● TTP from STEC
368
Describe the ROME IV criteria for IBS (3/8)
1. Abdo pain >1 day / week for 3 months.
2. Onset > 6 months before diagnosis
3. Abdo pain + 2/3 of:
○ Pain related to defection
○ Change in frequency of stool
○ Change in form (appearance of stool)
Patient has none of the following:
1. age >50, no hx colon cancer screening.
2. Recent chnage in bowel habits
3. GIB
4. Nocturnal pain or passage of stools
5. Unintentional wht loss
6. Family hx of Colon ca or IBD
7. Iron deficiency anemia
8. +ve fecal occult blood
369
List 10 ddx for IBS
IBS + Constipation:
1. Bowel obstruction
2. Malignancy
3. Adult onset hirschsprung ds
4. Rectocele
5. Paradoxical closure of anus during defecation
IBS + Diarrhea
6. Infectious
7. IBD
8. Lactose intolerance
9. Malabsorption
10. Radiation proctocolitis
11. celiac disease
IBS + mixed SxS
12. Ureteral colic
13. Diverticular disease
14. GERD/PUD
15. liver disease
16. Pancreatitis
17. lead toxicity
18. Porphyria
370
Outline the management for IBS:
Diet - Low FODMAP fermentable
oligosaccharides disaccharides monosaccharides
polyols)
Behavioural: BCT, hypnotherapy
Pharmacologic: ondansetron, loperamide, probiotics
371
List 10 factors that contribute to the development of diverticulitis
Weakness of the bowel:
1. non circumferential muscular layers
2. Insertion of vasa recta
3. localized ischemia
4. connective tissue d/o
5. ehlers-danlos syndrome
High intraluminal pressure:
6. Diverticular obstruciton
7. colonic stasis
8. chronic constipation
9. low fiber intake
Other:
10. smoking
11. age
12. obesity
13. EtOH
14. immunocompromised
15. Composition of intestinal flora
372
Describe the hinchey classification of diverticulitis
1a. Pericolonic phlegmon and inflammation w/o fluid collection
1b. Pericolonic abscess >4cm
2. Pelvic abscess >4cm
3. Purulent peritonitis
4. Feculent peritonitis
373
Outline the management for uncomplicated and complicated diverticulitis
1. Uncomplicated diverticulitis:
○ Abx: Cipro + metro
or Amox-Clav
***not all uncomplicated need abx
○ Outpatient f/u
2. Complicated
Abx: Cipro + metro
OR CTX + metro
Gen sx consult
374
List 6 causes of large bowel obstruction
- Stricture
- Hernia
- Adhesions
- Volvulus
- Inflammation
- Neoplasm
- Olgivie's
- Stercoral
375
List findings of large bowel obstruction on AXR
1. 3-6-9 rule
SM=3cm
LB=6cm
cecum = 9 cm
376
Outline the management for large bowel obstruction
Management:
- NPO
- Hydration
- Electrolytes
- Analgesia
- Consider: NG, Abx, OR, Stent
377
list 4 medications used to treat irritable bowel
syndrome
○ Dicyclomine (IBS-P)
○ Loperamide (IBS-D)
○ Rifaximin
○ Lactulose (IBS-C)
○ TCA’s
○ SSRIs
● Peppermint oil
● Probiotics
378
Define complicated diverticulitis
Any extension of inflammation beyond the pericolonic fat
○ Abscess formation
○ Peritonitis
○ Intestinal obstruction (inflammatory ileus)
○ Fistula formation (to the bladder)
379
What are the four types of GI volvulus?
1. Gastric
a. Organo-axial volvulus is more common in adults,
b. Mesentero-axial volvulus more common in children
2. Midgut
**approximately 75% of cases within a month of birth
3. cecum
4. Sigmoid **most common
380
List 4 risk factors for sigmoid volvulus
1. high fiber diet
2. Chronic constipation
3. Residents of long-term care facilities
4. neurologic
5. psychiatric disease
6. pregnancy
381
List 4 risk factors for cecal volvulus
1. coexisting trauma
2. adhesions
3. lymph nodes or malignancy
4. Pregnancy
5. Psych
6. LTC
382
How is sigmoid vs cecal volvulus differentiated on AXR and CT?
Sigmoid
AXR:
- haustra absent
-coffee bean sign points to RUQ
CT: whirl sign
Cecal:
AXR:
+ Haustra present
CBS points to LLQ
CT: whirl sign
383
Outline the management for sigmoid and cecal volvulus
Sigmoid:
- endoscopic +/- OR
Cecal:
-OR (too proximal for scope)
384
How does adult intussusception differ from peds? (age/etiology/SxS/Dx/Tx)
Adults:
● Vague, undifferentiated presentations - age 65 yrs
● Usually cause by a mass (60% benign neoplasms, 30% malignant)
● CT diagnosis
● Need surgery usually
Peds :
● Vague, undifferentiated presentations, but second most common cause of abdominal
pain in kids next to appendicitis (often age 4-10 months?)
● Idiopathic
● Diagnosed with U/S
● Usually ileocolic (at the cecal valve)
● Usually reduced with air/hydrostatic enemas (80% of cases)
385
List 6 extra-intestinal manifestations of IBD
● Inflammatory arthropathies/arthritis
● Iritis / uveitis / Episcleritis / Scleritis
● Erythema nodosum
● Pyoderma gangrenosum
● Aphthous stomatitis
● Ankylosing spondylitis
● Sacroiliitis
● Osteoporosis
● **Thromboembolic disease risk - 60% increased
- DVT
- PE
- Cerebral sinus thrombosis
- Ischemic heart disease
- Mesenteric ischemia
● Peripheral neuropathy
● Primary sclerosing cholangitis (UC)
386
Differentiate chrons disease from UC based on inflammation type and location
Chrons:
- transmural inflammation
- skip lesions
- anywhere in GI tract
UC:
-superficial inflammation
-continuous involvement of colon or rectum
387
How is chrons diseases diagnosed and treated?
Dx:
- endoscopy
-elevated fecal calprotectin
- stool lacterferrin
- Anti-Saccharomyces cerevisiae antibodies (ASCAs)
Tx:
1. Budesonide controlled ileal release (CIR) capsules
2. Systemic steroids
3. immunomodulators
4. biologics
5. +/- surgery
388
How is UC diagnosed and treated?
Dx:
- endoscopy
-elevated fecal calprotectin
- stool lacterferrin
-P-ANCA
Tx:
1. rectal or oral aminosalicylates
2. steroids
3. immunomodulators
4. biologics
5. colectomy
389
List 5 clinical features of UC
● Abdo pain
● Tenesmus
● Bloody diarrhea (4-6
or more stools per
day)
● Weight loss
● Rectal bleeding
● Pallor / fatigue
390
List 5 clinical features of chrons disease
● Abdo pain
● Tenesmus
● Bloody diarrhea (4-6
or more stools per
day)
● Nausea / vomiting
● Nocturnal diarrhea
● Fissures
● Anorectal abscesses
● Ulcerated
hemorrhoids
● Strictures
● Growth and pubertal
delay in children
● Weight loss
● Rectal bleeding
● Pallor / fatigue
● Peri-anal skin tags
● Dry mucous
membranes
391
List 4 categories of medical therapy for IBD and give one example for
each.
1. Oral aminosalicylates
- 5-ASA, mesalamine
2. Steroids
- methylprednisolone
- prednisone
3. Immunosuppressants
- cyclosporine
4. Antibiotics (Flagyl + Cipro)
392
List 4 radiologic features of toxic megacolon.
1. dilatation of the right colon > 6cm***
2. dilatation of the transverse colon
3. absence of normal colonic haustral markings
4. air-filled crevices between large pseudopolypoid projections extending into the colonic lumen.
393
Describe the pathophysiology of toxic megacolon
pathologic dilatation of colon due to inflammation and paralysis of the smooth muscle layers.
may occur as a complication of IBD, infectious colitis, ischemic colitis, volvulus, diverticulitis, and obstructive colon cancer.
394
List 4 triggers for toxic megacolon
1. anticholinergics
2. anti motility agents
3. narcotics
4. antidepressants
395
Outline the management for toxic megacolon
- aggressive IVF
- IV corticosteroids
- abx (cipro + flagyl)
396
What is Ogilvie’s Syndrome? List 3 RFs.
Colonic Pseudo-obstruction
acute dilatation of the intestine in the absence of an anatomic
lesion that obstructs the flow of intestinal contents
❏ Trauma, especially fractures
❏ Surgery especially involving spinal anesthesia
❏ Major orthopedic surgery / Obstetrical surgery / Pelvic / abdominal /
cardiothoracic surgery
❏ Severe medical illness (eg pneumonia/myocardial infarction/heart failure)
❏ Neurologic conditions
❏ Chemotherapy
❏ Retroperitoneal pathology (ie malignancy or hemorrhage)
397
List 3 Perianal complications of chrons disease
❏ Anal Fissures
❏ Skin tags
❏ Perianal Fistula
❏ Anorectal Abscess
❏ Anal Stenosis
❏ Ulcerated Hemorrhoids
❏ Elevated risk for adenocarcinoma in fistula tract and recurrent stenosis
398
What is stercoral colitis?
List 3 complications of stercoral colitis.
Rare complication of chronic constipation and fecal impaction
1. Colonic wall necrosis
2. Ischemic colitis
3. Stercoral ulcer formation
4. Bowel perforation
399
List 6 features of stercoral on CT abdomen
- fecal impaction
-colon dilation
-colon wall thickening
-mucosal discontinuity
-pericolonic fat stranding
-extra luminal air
400
List 3 treatment options for stercoral colitis
1. Bowel regimen
2. Enema
3. Manual disimpaction
401
List 6 extra intestinal manifestations of chrons disease
MSK:
- Arthritis
- ankylosing spondylitis
- polymyositis
- osteomalacia
Derm:
- Erythema nodosum
- pyoderma gangrenosum
- aphthous ulcers
- vesiculopustular eruption
- cutaneous vasculitis
- neutrophilic dermatosis
- Fissures and fistulas
- oral Crohn disease
- drug rashes
Nutritional deficiency
- Acrodermatitis enteropathica (zinc)
- purpura (vitamins C and
K)
- glossitis (vitamin B)
- hair loss and brittle nail (protein)
Hepatobiliary:
-Primary sclerosing cholangitis (PSC)
- bile duct carcinoma
- small duct PSC
- cholelithiasis
- fatty liver
-AI hepatitis
Occular:
- uveitis
- episcleritis
- scleromalacia
- corneal ulcers
- retinal vascular
disease
- retrobulbar neuritis
- Crohns keratopathy
Growth restriction
DVT
PE
Cerebral sinus thrombosis
Ischemic heart disease
Mesenteric ischemia
402
Box 81.7 Describe the disease severity criteria in IBD for UC
MIld:
- <4 stools day
- some blood in stool
- no signs of systemic toxicity
Mod:
->4 stools day
- minimal signs of toxicity
Severe:
> 6 bloody stools daily
-signs of systemic toxicity
Systemic toxicity
- fever
-tachycardia
-anemia
-elevated ESR/CRP
403
Box 81.7 Describe the disease severity criteria in IBD for chrons
Mild to moderate
-ambulatory, able to eat
-not dehydrated
-no toxicity
-absence of abdominal pain
-wht loss <10%
Moderate to severe:
- mild disease that has not responded to treatment
-mild toxicity
-significant wht loss
-anemia
-fever
-abdominal pain or mass
Severe:
- persistent symptoms on steroids and/or immunobiologics
-high fever
-persistent vomiting
-intestinal obstruction
-rebound tenderness
-cachexia
-abscess
404
What is the most likely diagnosis for the following clinical presentations
a. painless rectal bleeding
b. red blood on toilet paper
c. painful rectal bleeding
d. blood mixed with stool
e. bloody mucus
a. painless rectal bleeding
-internal hemorrhoid
- cancer
b. red blood on toilet paper
- anal fissure
-external hemorrhoid
c. painful rectal bleeding
- external thrombosed hemorrhoid
d. blood mixed with stool
- originates above the rectum
e. bloody mucus
-IBD
-proctitis
-cancer
405
List 5 key historical features for anorectal disorders:
●Bleeding,
● Swelling
● Pain
● Itching
● Discharge
● Incontinence
● Hx of radiation
● Hx of sexual practices involving the rectum/anus
● Hx of IBD
● cancer/polyps
● straining activities
●diabetes
406
List 5 risk factors for the develop of symptomatic haemorrhoids
● Family hx of hemorrhoids
● Straining and constipation
● Pregnancy & traumatic deliveries
● Prolonged sitting
● Heavy lifting
● Portal hypertension (technically these are rectal varices though!)
407
Describe 4 degrees of internal hemorrhoids and indicated management options
1st degree: no prolapse, just prominent vessels
Tx: medical
2nd degree: Prolapse with defecation but spontaneously reduce
Tx: Medical
3rd degree: Prolapse with or without defecation
Require manual reduction
Tx: Medical +/- surgical
4th degree: Prolapsed and cannot be reduced
Tx: surgery
408
Describe the WASH approach to medically treat hemorrhoids
Warm water sitz baths
- Water > 40 degrees C
work).
■ 5-10 mins BID-QID prn
Analgesics
- NSAIDS, tylenol (but can be constipating)
- Topical anesthetics (1-2% lidocaine gel)
- Topical corticosteroids (only apply for 1-2 days! - e.g. anusol HC)
- Topical nitroglycerin (helps decrease internal sphincter spasm)
- Witch hazel
- Mineral oils (ANUSOL over the counter)
- Cocoa butter
Stool softeners
■ PEG 3350
■ Sennokot
High fiber diet
■ Oats, broccoli, beans, whole grains, celery, peanuts, and others.
■ Fiber supplement
409
List 4 causes of fissures
● Constipation (especially in infants and kids)
● Straining
● Prolonged diarrhea
● Vaginal delivery
● Anal sex
● Secondary causes.
410
Describe the treatment of anal fissures – 5 options
- WASH regimen
- Nitro. Ointment 0.4% bid/tid
- Nifedipine gel 0.2% bid with lidocaine gel 1.5%
- Surgical options (botox, anal dilation, excision).
Most take 2-4 weeks to resolve.
411
What type of hemorrhoid requires emergent excision in the ED?
Thrombosed external hemorrhoids
412
List 6 conditions that are associated with the development of anal/peri anal abscesses and fistulas?
● IBD
● Trauma
● Cancer
● Radiation injury
● Infection
- TB
- Lymphogranuloma venereum
- Actinomycosis.
Usually staph. A.; E coli; streptococcus; proteus; bacteroides
Usually abscesses progress to fistulae.
413
List 5 types/sites of anorectal abscess.
1. Perianal
- painful perianal mass
2. Ischiorectal
- Buttock pain
3. Intersphincteric
- rectal fullness
-associated with fistual
4. Supralevator
- perianal and buttock pain
-systemic symptoms
5. Postanal
- rectal fullness, pain near coccyx
414
Which rectal abscesses cain be drained in ED?
Peri-anal
+/- ischiorectal
415
What is a pilonidal cyst?
Abscess containing hair and pus in the midline of the sacrococcygeal area
416
List 4 ddx for pilonidal abscess
- hidradenitis suppurativa
- sebaceous cyst
- TB granuloma
- furuncle
- IBD
417
List 8 causes of fecal incontinence.
1. Traumatic
- Spinal cord injury
- Post surgical
- obstetric injury
2. Neurologic
-DM
- Hirschsprung's disease
- Spinal cord lesions (cancer, ischemia, infection)
- Dementia
3. Mass effects
- Anorectal cancer
- Foreign body
-fecal impaction
- hemorrhoids
4. Medical
- Diarrhea
- laxative abuse
-IBD
5. Peds. patients
- Congenital
- meningocele
- spina bifida
6. Other causes
- Post-corrective surgery for an imperforate anus
- Sexual abuse
- Encopresis (young children experiencing emotional stress)
- chronic radiation proctitisw
418
List 8 causes of pruritus ani
1. Dermatitis
2. Fecal irritation
- poor hygiene
- fissure
-fistula
-skin tags
-perianal clafts
-caffeine
-spicy food
-citrus
-IV steroids
-cholchicine
-tetracycline
3. Contact dermatitis
4. Psoriasis
5. Lichen sclerosis
6. CKD
7. DM
8. polycythemia vera
9. myxedma
10. Uremia
11. Vit A def
12. Vit D def
13. Iron def
14. Malignancy
15. Infx
- scabies
-pin worm
16. STDs
419
How are rectal infections with pin works diagnosed and treated?
Scotch tape to perianal area 2-3 hrs after waking. Under microscopy there will be eggs
Tx: Mebendazole 100mg PO OD , repeat in 2 weeks
420
What is the treatment rectal /perianal scabies
1% lindane lotion or 5% permethrin cream
421
List 6 rectal STI’s and their management
1. Gonorrhea (neisseria)
- Ceftriaxone 250 mg IM
- Cefixime 400 mg PO x1
2. Chlamydia / LGV
- Doxycycline 100 mg BID x 7 days (21 days if for LGV)
- azithromycin 1 g po x1 for chlamydia
3. Syphilis
a. Primary (looks like anal fissure)
-Penicillin G. 2.4 Million units
IM x 1
b. Secondary (condyloma latum - smooth, raised, painless wart-like lesions that weep fluid and
smell foul):
- Penicillin G. 2.4 Million units IM x 1
4. HPV - (genital warts)
***All these patients should be tested for HIV
- Podofilox 0.5% topically or cryotherapy
5. HSV
a. 1st episode double the dose of acyclovir TID for 7-10 days
b. Recurrent:
i. Acyclovir 200 mg po five times per day for 7-10 days
ii. Valacyclovir 1 g PO daily for 7-10 days
6. Chancroid
**diagnosis of exclusion)
- Ceftriaxone 250 mg IM
- azithromycin 1 g x1
7. Ulcerative lesions in HIV patients
422
List 6 common and 6 atypical anorectal lesions in patients with HIV
Common:
1. anal fissure
2. abscess or fistula
3. Hemorrhiods
4. Pruritis ani
5. pilonidal disease
6. Gonorrhea
7. Chlamydia
8. Syphillis
9. condyloma acuminatum
Atypical:
- TB
-CMV
-actinomycosis
-cryptococcosis
-lymphoma
-kaposi sarcoma
-SCC
423
What is levator ani syndrome?
Type of functional rectal disease
○ Constant dull pressure in the sacrococcygeal region post defecation or long periods of sitting.
○ Anecdotal treatment: sitz baths, levator ani muscle massage, and muscle relaxants
424
What is proctalgia fugax
- Type of functional rectal disease
- intensely painful spasm in the rectal area that begins abruptly and lasts up to 30 minutes.
- D/t sudden spasm of levator muscle complex or sigmoid colon
425
What is hidradenitis suppurativa?
Infx of the apocrine glands in:
- young adults with poor hygiene
- hyperhidrosis
- obesity
- acne
- diabetes
- smoking
● apocrine ducts infx w/ Staph, Strep, E coli or proteus.
● Usually multiple small draining pustules in the intertriginous areas.
DC Flashcards
flashcards
Decks in class (46)
# Cards
-
Hot and Crazy6
-
Ch 87- Stroke58
-
Ch 88-Seizures68
-
Dizziness and Vertigo18
-
Ch 128- Hypothermia and Frost Bite24
-
HEENT6
-
Oral Medicine1
-
Endocrine8
-
Chapter 32-Multiple Trauma49
-
Chapter 33- Head Trauma65
-
Chapter 34-Facial Trauma25
-
Chapter 36- Neck Trauma44
-
Chapter 35- Spinal Trauma52
-
Chapter 37- Thoracic Trauma37
-
Chapter 38/39- Abdominal and GU Trauma40
-
Chapter 40- peripheral vascular trauma26
-
Chapter 50- wound management26
-
GI Chapters426
-
Chapter 42- Hand56
-
Chapter 54- Thermal injuries23
-
Chapter 43- wrist and forearm53
-
Chapter 44- Humerus and Elbow38
-
Chapter 45- shoulder63
-
Chapter 32/104 back pain31
-
Chapter 46- Pelvis39
-
Chapter 47- femur and hip52
-
Chapter 48- Knee65
-
Chapter 49- Ankle and Foot60
-
Chapter 103- Tendinopathy & Bursitis0
-
Chapter 102- Arthritis40
-
Care of the Pediatric Patient CH 155-159108
-
Chapter 160- Pediatric Trauma59
-
Chapter 161- Pediatric Fever98
-
Chapter 162-164 Pediatric Respiratory108
-
Chapter 165- Pediatric Cardiac Disease128
-
Chapter 166- Peds GI89
-
Chapter 167- Peds Infectious Diarrheal Disease and Dehydration39
-
Chapter 168- Peds GU/Renal64
-
Chapter 169- Peds Neuro60
-
Chapter 170- Peds MSK45
-
Chapter 171-Pediatric Drug therapies3
-
Chapter 172- Child abuse18
-
Environmental Injuries210
-
Respiratory162
-
CVS74
-
ID11
