GI and nutrional surgery #1

Hiatal Hernia Diagnosis

Barium upper GI series and upper endoscopy

Murphy's sign

pain with palpation of the RUQ during inspiration, indicative of cholecystitis

GERD complications

-Barrett Esophagus (increased risk for adenocarcinoma) -Peptic stricture (causes reduced heartburn but more dysphagia) "Once Barrett's esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."

Nephrolithiasis symptoms

-flank pain -N/V -cramping -hematuria -renal colic -dysuria -Anuria Colicky flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting

acute pancreatitis symptoms

1. Abrupt onset of steady, severe epigastric pain worsened by walking and lying supine 2. Pain improved by sitting and leaning forward 3. Pain usually radiates to the back but radiate elsewhere 4. Nausea/Vomiting usually present 5. Weakness, sweating, anxiety in severe attacks -Epigastric "boring/drilling" pain radiating to back -Better with sitting and leaning forward -Worse with lying supine -N/V -Fever -Tachycardia

Cholelithiasis risk factors

90% cholesterol stones - (Fat, female, forty, and fertile) OCP's, chronic hemolysis, cirrhosis, infection, rapid weight loss, IBD, TPN, fibrates, increased triglycerides

Cholecystitis risk factors

40, fat and female age, family history, obesity, rapid weight loss, females using oral contraceptives, long labor, traumatic injury, septic, diabetic

Acid reflux (GERD)

A digestive disease in which stomach acid or bile irritates the esophagus Acid reflux and heartburn more than twice a week may indicate GERD Symptoms include burning pain in the chest that usually occurs after eating and worsens when lying down

hiatal hernia

A condition in which part of the stomach pushes up through the diaphragm muscle Hiatal hernias can have no symptoms. In some cases, they may be associated with heartburn and abdominal discomfort

Appendicitis diagnosis

Acute appendicitis is a clinical diagnosis. Laboratory findings (mild leukocytosis) are only supportive. Imaging studies may be helpful if diagnosis uncertain or in atypical presentations. CT scan (sensitivity 98% to 100%)—lowers the false-positive rate significantly. Ultrasound (sensitivity of 90%).

Patient will present as → a 37-year-old male complaining of rapid onset of severe mid-epigastric pain with radiation to the back after eating a large meal. The pain lessens when the patient leans forward or lies in the fetal position. Physical exam shows a low-grade fever, epigastric tenderness, diminished bowel sounds, and bruising of the flanks. An abdominal CT scan (seen here) shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity.

Acute and chronic pancreatitis

acute pancreatitis

Acute Pancreatitis - epigastric abdominal pain with radiation to the back and elevated lipase - pain lessens when the patient leans forward Etiology: Most common causes are ETOH and gallstones Acute-onset, persistent upper abdominal pain radiating to the back

Patient will present as → a 49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level.

Acute and chronic cholecystitis Prolonged (>4 to 6 hours) RUQ or epigastric pain, fever. Patients will have abdominal guarding and Murphy's sign

Appendicitis

Abdominal pain which classically starts in the epigastrium moves toward umbilicus, and then to the RLQ. With distention of the appendix, the parietal peritoneum may become irritated, leading to sharp pain. Classic chronological order: Periumbilical pain (intermittent and crampy) Nausea/vomiting Anorexia Pain migrates to RLQ (constant and intense pain), usually in 24 hours Key points: Anorexia is always present. Appendicitis is unlikely if the patient is hungry. Nausea and vomiting (typically follow pain). Periumbilical pain initially that radiates to the right lower quadrant. Associated with anorexia, nausea, and vomiting

Peptic Ulcer Disease Treatment

All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (e.g., omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks Patients with evidence of H. pylori on biopsy should receive eradication therapy Triple therapy: PPI + Amoxicillin 1g PO BID or Metronidazole 250 mg QID + Clarithromycin 500 mg PO BID (think baseball "CAP" = Clarithromycin + Amoxicillin + PPI)Quadruple therapy: PPI + Bismuth subsalicylate 524 mg 4 times a day + Metronidazole 250 mg 4 times a day + Tetracycline 500 mg 4 times a day Best initial therapy in areas where the clarithromycin resistance rate is > 15%In patients with active bleeding, a negative biopsy result does not exclude H. pylori, and a breath test or a stool antigen test for H. pylori should be performed to confirm a negative result In patients who receive treatment for H. pylori, eradication should be confirmed four or more weeks after the completion of therapy Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs) Patients with NSAID-associated ulcers should be treated with a PPI for a minimum of eight weeks PPI therapy for four to eight weeks in patients with H. pylori-negative ulcers that are not associated with NSAID use Zollinger-Ellison syndrome: PPI and resect the tumor Patients with duodenal ulcers who have been treated do not need further endoscopy unless symptoms persist at four weeks or recur In the event of rupture - immediate surgical intervention is required for treatment.

An endoscopy for presumed esophagitis shows multiple shallow ulcers. What is the most likely diagnosis?

Herpes simplex virus

Patient will present as → a 42-year-old man with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining.

Hiatal hernia

Chronic gastroesophageal reflux disease can put patients at risk for which disease?

Barrett esophagus

Patient will present as → a 34-year-old woman with a 3-day history of hematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain. On examination, she does not look ill. Her temperature is 37.5 ° C. Her abdomen is nontender. There is no CVA tenderness.

Cystitis

types of kidney stones

Calcium oxalate (80%) Struvite Uric Acid Cysteine Oxalate Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque - avoid grapefruit juice (makes calcium oxalate stones worse) Struvite (10%): Associated with chronic UTI with Klebsiella and Proteus species, radiopaque Uric Acid (7%): Form in individuals with persistently acidic urine - Excess meat/alcohol, gout, radiolucent Cystine (1%): Rare genetic, radiolucent (young boy with kidney stones)

Cholangitis symptoms

Charcot Triad: -RUQ pain (re-occurring) -Fever and chills -Jaundice Reynolds Pentad = suppurative cholangitis (emergency): -Charcot triad -Altered mental status -Hypotension The presenting symptoms associated with ascending cholangitis include fever, chills, right upper quadrant pain, and jaundice (Charcot's triad) With spread of the infection, the patient may also develop hypotension and mental status changes; these additional symptoms in conjunction with Charcot's triad are known as Reynolds' pentad Additional symptoms of common bile duct obstruction include light-colored stools and dark, tea-colored urine

Patient will present as → a 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced

Cholangitis

Cholangitis

Cholangitis is a complication of gallstones with symptoms secondary to an infected obstruction of the common bile duct (E.coli is the #1 cause)

Peptic Ulcer Disease (PUD)

Chronic irritation, burning pain, and erosion of the mucosa to form an ulcer Burning abdominal pain, nausea, vomiting, bloating. History of using a PPI or H2 blocker. Pain presents post-prandially and usually resolves on its own. Not likely to have significant weight loss. History of H. pylori and/or chronic NSAID use Epigastric pain or discomfort is the most prominent symptom PUD is an ulcer of the upper GI tract mucosa involving the proximal duodenum (duodenal ulcer~90%) and distal stomach (gastric ulcer~10%)

What is a risk factor for an increased incidence of duodenal and gastric ulcers, as well as a decrease in rate of healing?

Cigarette smoking

chronic pancreatitis

Clinical features are the same as those of acute pancreatitis, with the addition of fat malabsorption and steatorrhea late in the disease. Fecal fat will be elevated if malabsorption is present. The classic triad (look for this on your exam) of pancreatic calcification, steatorrhea, and diabetes mellitus occurs in only 20% of patients Permanent and progressive damage to the pancreas Epigastric abdominal pain, weight loss, diarrhea, and pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue) ERCP is the most sensitive for chronic pancreatitis Epigastric pain radiating to the back

Cystitis

Cystitis is an infection of the bladder Characterized by dysuria (painful urination) WITHOUT urethral discharge frequent urination/urgency, +/- hematuria Abdominal or suprapubic pain New-onset incontinence (in toilet-trained children) Absence of fever, chills, or flank pain Associated with dysuria, frequency, urgency, and hematuria

Gastritis diagnosis

Diagnosed by ENDOSCOPY IS GOLD STANDARD with 4 biopsies along stomach lining will reveal the location and extent of the gastritis as well as the presence of H.pylori Urea breath test, fecal antigen testing or serology can be used to detect H.pylori

esophagitis diagnosis

Diagnosis is by endoscopy, biopsy, double-contrast esophagram, and culture Eosinophilic esophagitis - barium swallow will show a ribbed esophagus and multiple corrugated rings

duodenal ulcer

Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food) Duodenal ulcers are more than twice as common as gastric ulcers Duodenal ulcers are most commonly caused by H. pylori (95%) Pts typically present with epigastric pain that is better postprandial Rarely, it can be caused by Zollinger-Ellison syndrome (this is a gastrinoma; tumor of the pancreas that causes the stomach to produce too much gastrin with subsequent acid secretion leading to ulcer formation. Diagnosed with gastrin levels >200 pg/mL)

Liver abscess

Entamoeba histolytica Fever and abdominal pain are the most common symptoms

Gastritis symptoms

Epigastric pain Indigestion Nausea Belching Loss of appetite Bleeding can occur Dyspepsia and abdominal pain are common indicators of gastritis Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis

Patient will present as → a 54-year-old female with odynophagia (painful swallowing), dysphagia, and retrosternal chest pain

Esophagitis

Esophagitis

Esophagitis often causes painfull, difficulty swallowing, and chest pain with eating. Emergency symptoms include food stuck in the esophagus and chest pain that lasts more than a few minutes Causes include GERD, infection, some medications, and allergies

GERD risk factors

Factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and drugs.

What is the most specific test for acute cholecystitis?

HIDA

gastric ulcer

Gastric ulcer (food classically causes pain) Gastric ulcers are most commonly caused by H. pylori. Can also be caused by NSAIDs, acid reflux, smoking Pain is described as gnawing or burning and usually radiates to the back Pts typically present with epigastric pain that is worse with food (postprandial) It is most commonly found at the lesser curvature of the antrum PUD is the MC cause of non-hemorrhagic GI bleed, typically presenting as melena

Peptic ulcer disease

Gastric ulcer: Patient will present with → abdominal discomfort that is worse with meals and gets better an hour or so later after eating. Duodenal ulcer: Patient will present as → a 62-year-old female with complaints of epigastric pain and belching which improves when she eats food but gets worse a few hours after her meal. She said he has noticed a change in the color of her stool.

Patient will present as → a 37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day.

Gastritis

Patient will present as → a 55-year-old male with complaints of heartburn, belching, and epigastric pain which is aggravated by drinking coffee, eating fatty foods, and lying down. He says it gets better when he takes antacids.

Gastroesophageal reflux disease

Nephrolithiasis treatment

General measures (for all types of stones) Analgesia: IV morphine, parenteral NSAIDs (ketorolac) Vigorous fluid hydration—beneficial in all forms of nephrolithiasis Antibiotics—if UTI is present Alpha-blocker therapy (Flomax) for patients with symptomatic ureteral stones >5 mm and ≤10 mm to facilitate ureteral stone passage (usually given to most patients independent of size) Outpatient management is appropriate for most patients. Indications for hospital admission include:Pain not controlled with oral medicationsAnuria (usually in patients with one kidney)Renal colic plus UTI and/or fever Stones < 5 mm will have an 80% chance of spontaneous passage Stones > 5 - 10 mm have a 20% chance of passage and may require elective lithotripsy - patients should be considered for early elective intervention Stones > 10 mm are not likely to pass spontaneously. Ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized. Urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones of less than 2 cm or for ureteral stones of less than 10 mm Mild to moderate pain: high fluid intake, oral analgesia while waiting for the stone to pass spontaneously (give the patient a urine strainer) Severe pain (especially with vomiting) Prescribe IV fluids and pain control Obtain a KUB and an IVP to find the site of obstruction If a stone does not pass spontaneously after 3 days, consider urology consult Ongoing obstruction and persistent pain not controlled by narcotics—surgery is necessary Extracorporeal shock wave lithotripsy - Most common method, it breaks the stone apart; once the calculus is fragmented, the stone can pass spontaneously. Best for stones that are >5 mm but <2 cm in diameter Percutaneous nephrolithotomy - If lithotripsy fails, best for stones >2 cm in diameter

Reynolds' pentad

Hypotension Confusion Right upper quadrant pain Jaundice Fever

cholelithiasis treatment

If asymptomatic may observe or use oral bile dissolution treatment Cholecystectomy (usually laparoscopic) in symptomatic patient

Gastroesophageal reflux disease

Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia or cancer. Associated with heartburn, regurgitation, and dysphagia

Primary sclerosing cholangitis

Inflammation and fibrosis of intrahepatic and extrahepatic bile ducts that presents with obstructive jaundice Primary sclerosing cholangitis (PSC) is a chronic liver disease characterized by a progressive course of cholestasis with inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts Occurs commonly in patients with ulcerative colitis The underlying cause of the inflammation is believed to be autoimmune More common in males than females

Acute and chronic cholecystitis treatment

Laparoscopic cholecystectomy is the procedure of choice for uncomplicated acute and chronic cholecystitis. Stones can be composed of cholesterol (most common), pigment, and mixed stones Early cholecystectomy is generally preferred, best done during the first 24 to 48 h in the following situations Prophylactic cholecystectomy for asymptomatic cholelithiasis is generally not recommended

Zenker's diverticulum

MC pulsion diverticulum of esophagus; halitosis (stinky breath, food gets stuck); near UES Patients with foul odor of the breath and increasing symptoms think Zenker's Diverticulum which is an outpouching of hypopharynx resulting in regurgitation of solid foods - needs surgical repair.

Gastritis treatment

Management is focused on identifying and treating the underlying cause Remove causative factors (NSAIDs, alcohol) and initiate lifestyle and dietary modification Low dose H2RA (famotidine, cimetidine) prn (mild) ⇒ increase H2RA to bid if persistent symptoms low (10 mg omeprazole daily)/standard (20 mg omeprazole daily) dose PPI daily (frequent or more severe) x 4-8 weeks Taper and discontinue PPI when asymptomatic for 8 weeks If recurrent symptoms occur within 3-months of discontinuing acid suppression perform upper endoscopy Triple or quadruple therapy if H.Pylori positive

Gastroesophageal reflux disease (GERD) TREATMENT

Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, anticholinergics), specific foods (eg, fats, chocolate), and smoking. Weight loss is recommended for overweight patients and those who have gained weight recently Drug therapy is stepwise:Start with a low-dose histamine 2 receptor antagonists QD then increasing to BID if neededSwitch to a proton pump inhibitor if symptoms persist. Start low dose and increase to standard dose if neededOnce symptoms are controlled, treatment should be continued for at least eight weeks

Esophagitis treatment

Management: treat the underlying condition Candida: treat with fluconazole 100 mg PO daily HSV: treat with acyclovir CMV: treat with ganciclovir Corrosive: treat with steroid Eosinophilic: treat by removing foods that incite allergic response, topical steroids via inhaler Medication-induced: to prevent bisphosphonate-related esophagitis treat by drinking pills with at least 4 ounces of water, avoid laying down for at least 30-60 minutes after ingestion

nephrolithiasis treatment

NSAIDs or opiates + wait for stone to pass for stones Lithotripsy: Stones > 1 cm unlikely to pass. Lithotripsy is indicated in patients with stones > 6 mm in size or intractable pain. Hydration: Stones < 5 mm likely to pass

Patient will present as → a 45-year-old woman who presents to the ED with sharp, severe, colicky right flank pain radiating to the groin that she reports started suddenly several hours ago. She also reports discolored urine when she last voided, along with nausea and vomiting. Vital signs are within normal limits. On exam, the patient is visibly in pain and shifts positions every few minutes. Costovertebral tenderness is elicited on percussion. Her abdominal radiograph is shown here. Past medical history is significant for type II diabetes mellitus, fibromyalgia, gout, and depression.

Nephrolithiasis

Nephrolithiasis diagnosis

Non-contrast CT CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis Urinalysis will often show microscopic hematuria Cannot determine the type of stone from CT so give the patient a strainer and have them strain the urine so you can catch the stone as it passes for identification

Patient will present as → a male patient with a history significant for ulcerative colitis who has been stable and free of problems for over 7 years. He describes worsening symptoms of fatigue, pruritus, anorexia, and indigestion over the past 6 months. His wife reports that his skin and eyes appear yellow although she adamantly denies alcohol consumption. Labs reveal an elevated alkaline phosphatase, mild elevations in AST and ALT. ERCP fails to show common bile duct obstruction

PRIMARY SCLEROSING CHOLANGITIS = pruritus + jaundice

Cholangitis treatment

Patients suspected of having acute cholangitis should be admitted to the hospital for evaluation and treatment Empiric antibiotic coverage for colonic bacteria, followed by tailored therapy based on blood culture results ERCP to remove stones, insert a stent, repair the sphincter Cholecystectomy (performed post-acute)

Gastroesophageal reflux disease (GERD) DIAGNOSIS

Patients with typical symptoms of GERD may be given a trial of PPI therapy Patients who do not improve, or have long-standing symptoms or symptoms of complications, should be studied Endoscopy with cytologic washings and biopsy of abnormal areas is the test of choice Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett's esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-h pH testing. The PH Probe study is the gold standard for diagnosis Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy

Fitz-Hugh-Curtis syndrome

Perihepatic infection which results in liver capsule inflammation from pelvic infections such as gonorrhea & chlamydia RUQ pain with a pleuritic component, pain is sometimes referred to the right shoulder

Onion skin fibrosis

Primary sclerosing cholangitis

PPI side effects

Proton pump inhibitors may promote hypochlorhydria and interfere with absorption of calcium, leading to increased frequency of hip fracture. PPI use has also been associated with lowered serum B12 and magnesium. Decreased gastric acid production may also allow for bacterial overgrowth and is associated with an increased risk of respiratory infections such as pneumonia. PPIs have also been associated with C.diff associated diarrhea."

Patient will present as → a 32-year-old female presents with fever, chills, nausea, and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts.

Pyelonephritis

Ranson criteria for pancreatitis

Ranson's criteria: The Ranson criteria form a clinical prediction rule for predicting the severity of acute pancreatitis. Three or more means more severe course: At admit: Age > 55 Leukocyte: >16,000 Glucose: >200 LDH: >350 AST: >250 At 48 hrs: Arterial PO2: <60 HCO3: <20 Calcium: <8.0 BUN: Increase by 1.8+ Hematocrit: decrease by >10% Fluid sequestration >6L

NON-INFECTIOUS ESOPHAGITIS

Reflux esophagitis: mechanical or functional abnormality of the LES Medication-induced: think NSAIDS or bisphosphonates Eosinophilic: Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal epithelium. Diagnosed with a biopsy A barium swallow will show a ribbed esophagus and multiple corrugated rings Radiation: radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin Dysphagia lasting weeks-months after therapy Radiation exposure of 5000 cGy associated with increased risk for stricture Corrosive: Ingestion of alkali or acid from attempted suicide

Charcot's triad

Right upper quadrant pain Jaundice Fever

Cholangitis diagnosis

Right upper quadrant ultrasonography will generally show biliary dilation or stones and is a good initial test ERCP is the optimal procedure both for diagnosis and for treatment In patients with Charcot's triad and abnormal liver tests, proceed directly to ERCP to confirm the diagnosis and provide biliary drainage

cholecystitis symptoms

Symptoms include rapid onset of intermittent cramping abdominal pain in the upper-right quadrant, which gradually becomes worse and lasts several hours; fever, nausea, and vomiting may be present in some cases. Physical findings include right-upper-quadrant pain, guarding, and a positive Murphy's sign (significant tenderness with palpation in the right upper quadrant with inspiration). Chronic cholelithiasis follows a more indolent course with less severe symptoms that are shorter in duration and are recurrent. The condition is seen more commonly in women than in men The incidence increases with age + Murphy's sign = acute RUQ pain/inspiratory arrest with GB palpation Precipitated by fatty foods or large meals Classic Patient is: Fertile + Fat + Forty + Boas sign = referred pain to right subscapular area due to phrenic nerve irritation Chronic cholecystitis may lead to porcelain GB (premalignant condition)

appendicitis signs

Tenderness in RLQ (maximal tenderness at McBurney point: two-thirds of the distance from the umbilicus to the right anterior superior iliac spine) Rebound tenderness, guarding, diminished bowel sounds. Low-grade fever (may spike if perforation occurs) McBurney's sign (watch video): Pain with palpation of RLQ Rovsing's sign (watch video): Palpation or rebound pressure of the LLQ results in pain in the RLQ. Obturator Sign (watch video): Pain in RLQ when flexed right thigh is internally rotated when the patient is supine. Iliopsoas sign (watch video): The patient is supine and attempts to raise the right leg against resistance.

GERD diagnosis tests

The PH Probe study is the gold standard for diagnosis The upper GI study is a study of anatomy not for reflux A chronic cough can be an easily overlooked symptom of GERD Chronic GERD may predispose to Barrett's esophagus and cancer

Cholelithiasis diagnosis

The diagnostic procedure of choice in this patient is abdominal ultrasonography Ultrasound examination should be done after 8 hours of fasting because gallstones are visualized better in a distended, bile-filled gallbladder Alkaline phosphatase (ALK-P): Not specific to liver—also found in bone, gut, and placenta ALK-P is elevated when there is obstruction to bile flow (e.g., cholestasis) in any part of the biliary tree. Normal levels make cholestasis unlikely. Bilirubin GGT is often used to confirm that the ALK-P elevation is of hepatic origin Albumin—decreased in chronic liver disease, nephrotic syndrome, malnutrition, and inflammatory states (e.g., burns, sepsis, trauma)

acute pancreatitis treatment

The mainstay of treatment for acute pancreatitis is supportive therapy: NPO, IV fluids (best), analgesics, bowel rest Antibiotics ERCP if biliary sepsis is suspected Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue) Patients with mild pancreatitis can progress to severe pancreatitis over the initial 48 hours, often due to inadequate fluid replacement The only definitive treatment for chronic pancreatitis is to address the underlying cause, which is most commonly alcohol, low-fat diet

Infectious esophagitis

This occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia and chest pain Fungal: Infectious Candida: linear yellow-white plaques with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily Viral: HSV: shallow punched out lesions on EGD, treat with acyclovir CMV: large solitary ulcers or erosions on EGD, treat with ganciclovir EBV, Mycobacterium tuberculosis, and Mycobacterium avium intracellular are additional infectious causes

white blood cell cast

This white blood cell cast suggests an acute pyelonephritis.

Acute and chronic cholecystitis diagnosis

Ultrasound is the 1st-line imaging procedure - in patients with a typical history for gallstones, an US is likely to show stones GOLD STANDARD: Perform a radionuclide scanning (HIDA) when clinical suspicion is high with an equivocal ultrasound or when acalculous cholecystitis is suspected. A HIDA scan may be useful if performed during an attack since the scan assesses the patency of the cystic duct Serum bilirubin and AST levels are usually normal except at the time of an attack Patients with chronic cholecystitis rarely have abnormal laboratory studies

Acute gastritis

Transient inflammation of the gastric mucosa Most commonly associated with local irritants such as bacterial endotoxins, alcohol, and aspirin Causes include: NSAID overuse EtOH abuse pathophysiologic stress (i.e. burns, CNS injury) H. pylori infection Herpes, CMV Gastritis is defined as inflammation of the stomach lining Protective factors include mucus, bicarbonate, prostaglandins, alkaline state, hydrophobic layer, and epithelial renewal. Any imbalance in protective factors can lead to inflammation The clinical features reflect the underlying syndrome rather than the gastric injury itself Dyspepsia and abdominal pain are common indicators of gastritis

Appendicitis treatment

Treatment is an appendectomy (usually laparoscopic)

Pyelonephritis diagnosis

White blood cell casts in urine is pathognomonic pyelonephritis If complicated pyelonephritis order a renal ultrasound may show hydronephrosis secondary to obstruction

Hiatal hernia TREATMENT

Type 1 hernias are treated medically (with antacids, small meals, and elevation of the head after meals); 15% of cases may require surgery (Nissen fundoplication) if there is no response to medical therapy or if there is evidence of esophagitis. Type 2 hernias treated with elective surgery due to risk of above complications.

The initial diagnosis of cholelithiasis is best made with what imaging technique?

Ultrasound

Cystitis treatment

Uncomplicated UTI (adolescents and adults who are nonpregnant, nondiabetic, afebrile, immunocompetent, and without genitourinary anatomic abnormalities) Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim): 160/800 mg PO BID × 3 days, best where the resistance of E. coli strains <20% A 5-day course of nitrofurantoin or 3-day fluoroquinolone course should be used in patients with allergy to TMP-SMZ and in areas where E. coli resistance to TMP-SMZ >20%. Fosfomycin (Monurol): 3 g PO single dose (expensive) The urinary tract topical analgesic phenazopyridine 100-200 mg TID produces rapid relief of symptoms and should be offered to patients with more than minor discomfort; it is available over the counter. This medication is not a substitute for definitive treatment. This medication also may alter urinalysis but not the urine culture. Treatment of uncomplicated UTIs reduces morbidity, but the risk of recurrence stays the same All pregnant women with bacteriuria should be treated Lower UTI in pregnancy Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days Cephalexin (Keflex): 500 mg PO BID × 7 days

Peptic ulcer disease DIAGNOSIS

Upper endoscopy is the most accurate diagnostic test for peptic ulcer disease Biopsy for H. pylori should be obtained in all patients undergoing upper endoscopy for PUD unless contraindicated

Cystitis diagnosis

Urine dipstick ⇒ nitrite, leukocyte esterase (enzyme created by white blood cells) Urinalysis: pyuria (white blood cells in urine), bacteriuria, +/− hematuria, +/− nitrites Urine culture (gold standard)> 100,000 CFU/mL (women)> 1000 CFU/mL men or cath patients→ takes 24 h to obtain results Imaging studies are not required for most women with UTIs and are warranted only if pyelonephritis, recurrent infections, or concern for anatomic abnormalities

Budd-Chiari syndrome

What is the term for the syndrome consisting of hepatomegaly, ascites, and abdominal pain due to hepatic vein thrombosis? Symptoms include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy

Sliding hiatal hernias (type 1)

account for >90% of cases. Both the gastroesophageal junction and a portion of the stomach herniate into the thorax through the esophageal hiatus (so that the gastroesophageal junction is above the diaphragm). This is a common and benign finding that is associated with GERD.

Paraesophageal hiatal hernia

accounts for <5% of cases. The stomach herniates into the thorax through the esophageal hiatus, but the gastroesophageal junction does not; it remains below the diaphragm. This uncommon hernia can become strangulated and should be repaired surgically.

Patient will present as → a 43-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.

acute cholecystitis

Patient will present as → a 38-year-old female who has just returned from a 2-week trip to Mexico. She complains of nausea, vomiting, loss of appetite, and right upper quadrant abdominal pain. She has been sick for the past 3 days. She complains of passing dark-colored urine for the past 2 days. She has had no exposure to blood products, has no history of intravenous drug use, and has no significant risk factors for sexually transmitted disease. On examination, she looks acutely ill. Her pulse is 100 beats/minute, blood pressure 110/70 mm Hg, respirations 18, and temperature 101°F. Her sclerae are icteric, and her liver edge is tender.

acute hepatitis RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia. Patients may also have jaundice, dark urine, and light-colored stools

Patient will present as → a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient's mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.

appendicitis

Complications of cholelithiasis

choledocholithiasis acute cholangitis acute cholecystitis Cholecystitis: cystic duct obstruction by gallstones Choledocholithiasis: gallstones in the biliary tree - associated with ductal dilation and biliary colic or jaundice. Treat with stone extraction via ERCP Cholangitis: biliary tract infection secondary to obstruction by gallstones. Diagnose with ERCP

Grey Turner's sign

ecchymosis in the flank Flank ecchymosis often related to pancreatitis Grey Turner's sign (flank bruising) refers to bruising of the flanks, the part of the body between the last rib and the top of the hip

Cullen's sign

ecchymosis in umbilical area, seen with pancreatitis Cullen's sign (bruising near umbilicus) is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus

acute pancreatitis diagnosis

elevated amylase and lipase Will have prandial epigastric pain, labs will show increased serum lipase (more sensitive and specific than amylase, but only with elevations of threefold or greater) Abdominal CT is the diagnostic test of choice Sentinel loops on X-Raylook for diminished bowel sounds as part of the exam question ERCP is the most sensitive for chronic pancreatitis

Pyelonephritis presentation

fever chills flank pain costovertebral angle tenderness hematuria WBC casts in urine Presents with fever, chills, nausea, and flank pain (+) CVA Tenderness If severe symptoms or unable to take PO will need to be hospitalized Associated with dysuria, frequency, urgency, hematuria, fever, chills, flank pain, and costovertebral angle tenderness

Cholelithiasis

gallstones in the gallbladder Cholelithiasis refers to stones in the gallbladder (i.e., gallstones) without inflammation Most cases are asymptomatic. Majority of patients found to have incidental gallstones will remain asymptomatic

cystitis causes

he most common cause is E. coli (80%) - gram-negative - Klebsiella; Proteus; Enterobacter; CitrobacterGram-positive bacteria: Enterococcus; S. saprophyticus, second most common, esp. in young individuals who are biologically female, sexually active Common in women, in whom cases of uncomplicated cystitis are often preceded by sexual intercourse (honeymoon cystitis) In men, a bacterial infection of the bladder is usually complicated and usually results from ascending infection from the urethra or prostate or is secondary to urethral instrumentation The most common cause of recurrent cystitis in men is chronic bacterial prostatitis

cholecystitis

inflammation of the gallbladder; usually associated with gallstones Cholecystitis (inflammation of the gallbladder) usually results as a complication of cholelithiasis (gallstones) and obstruction of the biliary duct by gallstones

gastritis

inflammation of the lining of the stomach Any of a group of conditions in which the stomach lining is inflamed Causes include infection (H.pylori), injury, regular use of pain pills called NSAIDs, and too much alcohol Protective factors include mucus, bicarbonate, prostaglandins, alkaline state, hydrophobic layer, and epithelial renewal. Any imbalance in protective factors can lead to inflammation Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis

Pyelonephritis treatment

outpatient: ciprofloxacin inpatient: ampicillin/gentamicin 7 days of outpatient treatment is equivalent to longer treatment regimens IV antibiotics are indicated for inpatients who are toxic or unable to tolerate oral antibiotics Oral regimen is considered best initial outpatient treatment Ciprofloxacin: 500 mg BID for 7 days Ciprofloxacin XR: 1,000 mg/day for 7 days Levofloxacin: 750 mg/day for 5 days Trimethoprim/sulfamethoxazole (TMP-SMX) (160/800 mg): 1 tab PO BID for 14 days provided uropathogen known to be susceptible and ceftriaxone 1 g initial IV dose given Management of acute pyelonephritis in pregnant women includes hospital admission for parenteral antibiotics Empiric therapy includes IV/IM ceftriaxone

biliary colic

pain in the gallbladder caused by gallstones obstructing bile flow Intense, dull discomfort located in the RUQ or epigastrium. Associated with nausea, vomiting, and diaphoresis. Generally lasts at least 30 minutes, plateauing within one hour. Benign abdominal examination Biliary colic is the cardinal symptom of gallstones and is due to temporary obstruction of cystic duct by a gallstone. Pain occurs as the gallbladder contracts against this obstruction Classically presents as right upper quadrant pain that begins abruptly, continues in duration, resolves slowly lasting 20 min to several hours, is associated with nausea and precipitated by fatty foods and large meals Boas sign—referred right subscapular pain of biliary colic

Primary sclerosing cholangitis symptoms

pruritis steatorrhea fat soluable vitamin deficiency Pruritus with progressive jaundice is key to the diagnosis Cholangiography will show fibrosis of the bile ducts with dilatation between strictures

hiatal hernia types

sliding and paraesophageal There are two types of hiatal hernias: sliding (type 1) and paraesophageal (type 2)

Primary sclerosing cholangitis is associated with

ulcerative colitis