GI Test 2
Name all 7 of the Alvarado Score Criteria.
- Tenderness to the right lower quadrant (2 points) - Leukocytosis of WBC > 10 or 100 (2 points) - migratory RLQ pain - Anorexia - Nausea and vomiting - Fever >37.5/99.5 - Rebound tenderness to RLQ
What are the 3 steps to conducting a strong evaluation for a patient with chronic diarrhea?
1. Good H& P, med list review, and warning signs 2. LABS: CBC, CMP, TSH, B-12, Folate, Iron, ESR/CRP, Celiac Serologies. Stool samples: C. Diff toxin, Ova & parasites, Giardia Ag, Fecal Leukocytes, FOBT/FIT. 3. Schedule Colonoscopy +/- EGD
You are performing the visual component of a rectal exam of a pt. You ask the pt to valsalva and see a purple, swollen nodule protrude from the anus once the patient bears down. When they end the valsalva, the nodule reduces back inside the anus. No bleeding is noted, but some mucous discharge is seen. What treatment would you recommend for this patient?
1. Increase fiber (25-35g/ day) and water intake. 2. Stool softeners to avoid ANY strain. 3. Sitz baths- 10-20 minutes 4. For Mucous discharge- cotton ball next to anal orifice after defecation
Name the two Alvarado score criterion that, with only these two criterion being met, reach a score that suggests the patient should be evaluated for appendicitis.
1. Tenderness to the right lower quadrant (2 points) 2. Leukocytosis of WBC > 100 (2 points) The other 5 criteria are all worth 1 point each. A score of 4 should indicate a patient needs a workup for appendicitis. - migratory RLQ pain - Anorexia - Nausea and vomiting - Fever >37.5/99.5 - Rebound tenderness to RLQ
A patient presents with the chief complaint of "Diarrhea for a month". What are 5 history questions that you want to ask this patient?
1. onset/duration 2. # stools/day 3. Color 4. Consistency 5. Volume of stool 6. Blood, mucous 7. Normal pattern 8. Fever 9 Relationship to meals 10. Diet changes 11. Nausea, vomit, abd. pain? 12. weight loss? 13. Nocturnal wakening. 14. Travel or camping? 15. Meds? 16 Surgical history
After what amount of time would we consider diarrhea to be chronic? A. >4 weeks B.< 2 weeks C. > 1 week D. Never. No such thing as chronic diarrhea
> 4 weeks.
What treatment method would be most useful for pain relief for an anal fissure? A. Sitz Baths B. Diltiazem Ointment C. Topical Prednisone D. Enema
A.
What is NOT a requirement for stool continence? A. Appropriate dietary intake of fiber B. Distensable rectum that can serve as a reservoir C. In tact sensation of rectal fullness D. In tact pelvic musculature & innervation E. Ability to get to a toilet on time
A. The other requirement is solid-semisolid stool
Normal stool osmolality should be equivalent to serum osmolality, which is what? A. 290mOsm/Kg B. 200mOsm/Kg C. 190mOsm/Kg D. 100mOsm/Kg
A. 290mOsm/Kg
When do we see CRP increase with Appendicitis? A. 6-12 hrs B. 0-6 hrs C. 18-24 hrs D. 12-18 hrs
A. 6-12 hrs.
Select 3 vitamins/mineral levels that we should check with chronic diarrhea. A. Folate B. Iron C. B-12 D. Ascorbic acid
A. B. C. D. is Vitamin C, not too concerned unless they have bleeding gums and scurvy!
A patient describes a tearing and painful sensation during defecation with bright red blood on the toilet paper after they wiped. What would be the appropriate treatment plan for this problem? (may be multiple correct choices) A. Nitroglycerin Ointment B. Sitz Baths & Fiber C. Internal Sphincter Botulinum toxin injection D. Flex Sig/ electrocautery
A. B. C. Not D...
A patient presents to your clinic with colicky RLQ pain that has been going on for ~ 36 hrs. WBC count is 85 and CRP is normal. How likely is it that they have appendicitis? A. 0% B. 20% C. 80% D. 100%
A. C Reactive Protein increases within 6-12 hrs of onset appendicitis. If CRP is normal after having symptoms of appendicitis for > 24 hrs, there is almost a 100% negative predictive value! AKA you can say with almost 100% certainty that this person does not have appendicitis. ***Still have to keep all other lab tests and factors in mind.
What would the alvarado score be for a patient who would undergo diagnostic laparoscopy then appendectomy if indicated? A. Female Patient scoring 7-9 B. Male patient scoring 7-9 C. 4-6 D. 0-3
A. Female patient scoring 7-9
How would you treat your ICU patient whom you suspect has a stool impaction? A. Enemas or manual disimpaction B. Loperamide C. Miralax D. Wait and See approach
A. Get it done.
Which of these medications for Anal Fissures has headaches as a fairly common side effect? A. Nitroglycerin Ointment B. Diltiazem Ointment C. Botulinum Toxin in the anal sphincter D. Topical Lidocaine
A. Nitroglycerin Diltiazem is a calcium channel blocker
A 25 year old female patient presents to your clinic with recent onset of depressive behavior, and tremor. Upon physical exam, you note Kayser Fleischer rings. Low serum ceruloplasm is found during lab testing. What would be the appropriate treatment for this patient? A. Penicillamine B. Corticosteroids & Azathioprine C. Phlebotomy & PPI D. Diet and Exercise
A. Penicillamine 0.75 g/day - This is a copper chelating agent, which is used to treat Wilson's Disease. Patients may also use Zinc which decreases GI absorption of copper. They will also likely need to avoid Chocolate, nuts, organ meats, shellfish, and mushrooms, all of which contain high copper levels.
What patient population has the highest appendicitis perforation rate? A. Pregnant women B. Children Under 6 C. People aged 65+ D. Immunocomprimised
A. Pregnant women have a perforation rate of 43% vs 4-19% in non-pregnant patients.
Which appendicitis test demonstrates pain in RLQ with palpation of LLQ? A. Rovsing's B. Dunphy's C. Markle's D. Aaron's
A. Rovsing's
Your chronic diarrhea patient has output 1700g of stool over 24hrs during a QUANTITATIVE stool collection. What type of underlying process are they likely experiencing? A. Secretory B. Malabsorptive C. Osmotic D. Parasitic
A. Secretory. That's a lot of feces. Secretory must be considered with > 1,000-1500g stool / 24 hrs.
What would be the best diagnostic tool to rule out proctitis, rectal cancer, fissures, hemorrhoids, or fistulas in a patient presenting with fecal incontinence? A. Sigmoidoscopy B. Anal ultrasound or pelvic MRI C. Anal Manometry D. EMG, Proctography
A. Sigmoidoscopy
A patient presents after suffering complete, uncontrolled stool evacuation. What would you suspect would be the cause of their incontinence? A. Recent history of stroke B. An IBS-C diagnosis C. Ulcerative Proctitis D. External Hemorrhoids
A. This falls under the "Central Process' error for major fecal incontinence.
You are performing the visual component of a rectal exam of a pt. You ask the pt to valsalva and see a purple, swollen nodule protrude from the anus once the patient bears down. When they end the valsalva, the nodule reduces back inside the anus. How would you classify this finding?
An INTERNAL hemorrhoid, Stage II.
What structure typically becomes obstructed in the development of a perianal/perirectal abscess?
Anal crypt glands.
What is the best treatment for Appendicitis?
Appendectomy.
Anatomy flashback: What is the blood supply to the appendix?
Appendiceal artery & Ileocecal artery
Which of the following are an indication for ERCP? May be more than 1 correct answer. A. Palliative stint placement for esophageal cancer B. Palliative stent placement for pancreatic/ biliary cancers C. LES Myotomy D. Sphincterotomy
B and D
Pt presents with macrocytic anemia and a history of Crohn's Disease and hemorrhoids. What would you first suspect to be the underlying cause of the anemia?
B-12 or folate malabsorption, which would be caused by the Crohn's, NOT the Hemorrhoids. Hemorrhoids usually do not bleed bad enough to cause anemia
What age group does appendicitis most often occur in? A. 1-9 B. 10-30 C. 30-60 D. 61-90
B.
Which of the following are an indication for ERCP? May be more than 1 correct answer A. Concern of pancreatic cancer when EUS w/ fine needle aspiration and CT have had positive findings. B. Concern of pancreatic Cancer, but EUS and CT are normal C. Concern pt may have Ulcerative Colitis D. Painless hematochezia
B. Not A, because you already have biopsied and have a positive diagnosis. An ERCP would be an uneccessary procedure unless performing a therapeutic treatment of the cancer.
Which of these medications should a person suffering from hemorrhoids use NO LONGER than 7 days? A. Pramoxine B. Hydrocortisone C. Phenylephrine D. Witch Hazel
B. (It's a corticosteroid and can thin the skin)
What would be the best diagnostic tool to assess defects in sphincter anatomy? A. Sigmoidoscopy B. Anal ultrasound or pelvic MRI C. Anal Manometry D. EMG, Proctography
B. Anal Ultrasound or Pelvic MRI
what diagnostic tool should we use for a chronic diarrhea evaluation when we want to rule out malignancy, IBD, and microscopic colitis? A. CT abdomen B. Colonoscopy w/ Biopsy C. ERCP D. EGD with biopsy
B. Colonoscopy w/ biopsy
Which Appendicitis sign demonstrates increased pain with coughing? A. Rovsing's B. Dunphy's C. Markle's D. Aaron's
B. Dunphy's
A pt presents with a complaint of anal bleeding and anal pain with hemorrhoids. Their history includes being receptive partner during anal intercourse, and past HPV infection. On PE, a very firm granular mass is noted at the anal orifice. What are your next steps in evaluation of this patient? A. Incision and Drainage B. Biopsy and CT/MRI C. Conservative therapy (Increase fiber, water, Sitz baths) D. Rubber band ligation
B. Hemorrhoids RARELY present with pain. This is suspected anal cancer, given the presenting symptoms, history, and appearance of the lesion.
What would the alvarado score be for a patient who would proceed directly do appendectomy? A. Female Patient scoring 7-9 B. Male patient scoring 7-9 C. 4-6 D. 0-3
B. Male patient scoring 7-9
Pt presents to the ER with periumbilical pain, with a normal WBC count. Should you rule out appendicitis at this point? A. Yes B. No C. No idea
B. NO - WBC only catches 80% of appendicitis cases, especially in the elderly, young, or early in the disease process.
What is the best imaging modality to use on kids with suspected appendicitis? A. CT with contrast B. Ultrasound C. ERCP D. Plain films
B. Ultrasound. DON'T DO CTs on KIDS.
What appendicitis diagnostic test should you choose when assessing a child vs an adult?
Because children don't always have McBurney's point, do the Heel tap! (MARKLE)
Why do we try to avoid surgery as a treatment for anal cancer?
Because often the cancer invades the anal sphincter, which would require removal and patients end up with a colostomy bag. Outcomes are no better with surgery than with chemo & radiation alone.
What are 4 treatment options for someone who suffers from solid fecal incontinence?
Biofeedback & Kegels Submucosal anal injections w/ dextronamer/ sodium hyaluronate gel Sacral nerve stimulation Tap water enemas or glycerine suppositories followed by scheduled toileting.
Which of the following are an indication for ERCP? May be more than 1 correct answer. A. Suspected gastroparesis B. Assessment & Biopsy for Celiac Disease C. Diagnose & treat biliary obstruction D. Biopsy Pancreatic duct
C and D
When should a patient with anal fissure expect full healing? A. 2 weeks B. 1 month C. 2 months D. 6 months
C.
Where are anal fissures usually located? A. Anterior Lateral B. Posterior Lateral C. Posterior Midline D. Anterior Midline
C.
Your patient is a professional dancer who also suffers from recurrent anal fissures. She wants a treatment plan that will provide her with healing, but also enable her to continue to publicly perform. Which of the following treatment options would NOT be a good choice for this patient? A. Nitroglycerin Ointment B. Diltiazem Ointment C. Internal Sphincter Injection of Botulinum toxin D. Lateral Internal Sphincterotomy
C. & D. Both of these treatments run a high risk of fecal incontinence, which would be inconvenient for a ballerina during a sold-out performance of the Nutrcracker at Christmastime.
What treatment methods actually promote healing of anal fissures? A. Fiber supplements B. Topical Lidocaine C. Diltiazem ointment D. Nitroglycerin Ointment
C. & D. fiber just helps with soft stools Topical Lidocaine is for pain relief only.
What would the alvarado score be for a patient who would be admitted for observation and re-examination. Then, if their score remained the same after 12 hrs would be recommended for surgical intervention? A. Female Patient scoring 7-9 B. Male patient scoring 7-9 C. 4-6 D. 0-3
C. 4-6
What are 6 fecal tests we should consider with chronic diarrhea?
C. Diff/ GDH ag Ova and parasites (2-3 types) Giardia Ag Fecal leukocytes/lactoferrin FOBT/FIT Fecal electrolytes
Which appendicitis test demonstrates pain when the patient stands on their toes and then lets their heels fall to the floor, jarring the peritoneum? A. Rovsing's B. Dunphy's C. Markle's D. Aaron's
C. Markle's
Your patient has external hemorrhoids. Which of the following items would you NOT use to treat them? A. Topical Hemorrhoid Foam B. Increase water & Fiber intake C. Suppositories D. Preparation H
C. Suppositories (these are only for Internal symptomatic Hemorrhoids)
What is typical of appendicitis pain? A. Inguinal pain that migrates to the periumbilical region after 12-24 hrs. B. LLQ pain that persists for more than 24 hrs. C. Periumbilical pain that migrates to the RLQ after 12-24 hrs. D. Nausea and vomiting followed by acute onset pain in the RLQ.
C. Typical appendicitis pain starts as colicky and dull but becomes sharp and constant, migrating from the periumbilical region to the RLQ after 12-24 hrs. The pain is worsened by coughing, jumping, or moving. Pain typically starts BEFORE nausea and vomiting. Nausea and vomiting are later signs, and increase our suspicion if they happen after the pain starts.
Using WBC count as the standard, at what point does Appendicitis fall lower on the DDX specifically with children? A. WBC > 15 and pain for > 24 hrs B. WBC < 10 and pain for < 24 hrs C. WBC < 10 and pain for > 24 hrs. D. WBC > 15 and pain for < 24 hrs.
C. WBC< 10 and pain for > 24 hrs. Any WBC > 15 warrants investigation. If pain has been present for more than 24 hrs and WBC is not that high, it could be some other process.
A women presents to your clinic 3 months postpartum with complaints of fecal incontinence. She had a traumatic childbirth and suffered a 4th degree perineal tear. Based on this history alone, what would be the most likely type of incontinence she is experiencing? A. Major incontinence due to Central Neurological disease process B. Major incontinence due to pudendal nerve damage. C. Major incontinence due to Sphincter damage D. Minor incontenence due to prolapsed hemorrhoids
C. a 4th degree perineal tear will reach the anal canal and tear through the internal and external anal sphincters. B is also possible because she could have pudendal nerve damage, but really looking at the key "Childbirth, Episiotomies, trauma" history elements here.
What diagnostic imaging should we order if a patient with chronic diarrhea presents with severe abdominal pain or tenderness, or when we suspect diarrhea is from an inflammatory source?
CT Abdomen/Pelvis MR Enterography- no radiation but $$$ Barium small bowel followthrough - Cheapest, less sensititve.
A patient presents with constant throbbing pain in the perianal area, and recently developed a fever and chills. PE does not reveal any significant findings. What should the next steps be to identify the cause?
CT or MRI to identify suspected perianal/perirectal abscess.
How do we primarily treat anal cancer?
Chemo + radiation
When would we see a "Sentinel Pile"?
Chronic anal fissures - fibrosis of tear with a skin tag on outer anal verge.
Pt present with exquisite pain in the anal region. He states he achieving a PR 450lb squat in the gym today after it reopened post COVID. On exam, you see a blue/purple nodule protruding from the anus. It is very tense upon palpation, and he cries in pain when you touch it. How would you approach treatment of this patient?
Clot evacuation procedure since he has presented within the first 48 hrs. - Follow up with conservative management (Sitz baths, increase in fiber & Water, Stool softeners until the hemorrhoid heals.
What color do you suspect the average ascites fluid to be?
Colors of albumin Straw-colored, clear- Normal Cloudy- infection MIlky- High triglycerides or lymphatic source Bloody- traumatic tap or malignant.
You find an anal fissure in an anterolateral position on a patient. What other diagnoses should you be considering at this point?
Crohn Infection (HIV/AIDS, TB, Syphilis) Malignancy
What diseases should we consider if a perianal fistula has a rectal communication?
Crohn LGV (STI) Cancer
Which are more likely to have occult bleeding, UC or Crohn's?
Crohn's. UC typically has hematochezia, while Crohn's manifests as occult bleed from the small bowel.
A patient presents with a small amount of stool leakage after toileting or during sneezing. What would you suspect would be the cause of their incontinence? A. Rectal Prolapse B. CVA C. Spinal Cord injury D. Prolapsed internal hemorrhoids
D. This would be considered mild incontinence typically caused by a local anal issue
What would the Alvarado score be for a patient who has a low risk of appendicitis and would be discharged with advice to return if there was no improvement in symptoms? A. Female Patient scoring 7-9 B. Male patient scoring 7-9 C. 4-6 D. 0-3
D. 0-3
Which appendicitis test demonstrates pain in heart or stomach with palpation of McBurney's Point? A. Rovsing's B. Dunphy's C. Markle's D. Aaron's
D. Aaron's
A 36 year old female presents to the emergency department with pain that started in the periumbilical region ~ 18 hrs prior. It has since shifted to the LLQ. What is the likely diagnosis? A. Appendicitis B. GERD C. Internal Hemorrhoids D. Diverticulitis
D. Diverticulitis is much more common than appendicitis with LLQ point tenderness.
What diagnostic tool should we use for a chronic diarrhea evaluation when we want to rule out celiac disease, whipple disease, or when the patient presents with malabsorption? A. CT abdomen B. Colonoscopy w/ Biopsy C. ERCP D. EGD with biopsy
D. EGD w/ biopsy
Which fecal test indicates an inflammatory nature to the chronic diarrhea your patient is presenting with? A. GDH antigen B. Giardia Antigen C. FIT D. Fecal Leukocytes
D. Fecal Leukocytes
If a patient presents with fecal incontinence and their primary issue is liquid stools, what is the best course of treatment? A. Biofeedback and Kegel exercises B. Nitroglycerin Ointment C. Sacral Nerve Stimulation D. Scheduled Loperamide
D. Scheduled Loperamide
A 25 year old female patient presents to your clinic with recent onset of depressive behavior, and tremor. Upon physical exam, you not Kayser Fleischer rings. What labs would you order to confirm your suspected diagnosis? A. Ultrasound of the liver B. CBC W/ Diff C. Antinuclear Antibody D. Serum Ceruloplasm and 24 hr Urinalysis
D. Serum ceruloplasm and 24 hr urine analysis. This person likely has Wilson's Disease, a disorder of inappropriate copper absorption and retention. The typical patient presents under 40 with liver or neuropsychiatric symptoms. Kayser Fleischer Rings are specific to this disease.
What Procedure can help us stage cancer and determine depth of tumor tissue in the stomach, duodenum, pancreas, or rectum, and help in identification of suspicious looking lymph nodes?
Endoscopic Ultrasound (EUS)
You are suspicious of pancreatic cancer in a patient after a CT scan finds a suspicious tumor. What diagnostic procedure would you utilize to obtain a sample of the suspected lesion?
Endoscopic Ultrasound (EUS) with Fine Needle Aspiration.
What are 6 PE components that we should be conducting with a patient who presents for chronic diarrhea workup?
General inspection Vitals Skin HEENT (Lymph and mouth moisture) Abdominal Exam Anorectal exam (Guaiac) Mental status for elderly.
The same patient who you previously performed rubber band ligation for hemorrhoids has come back to the office. They continue to experience chronic bleeding with their Stage III Hemorrhoids. What would you recommend as the next step in their treatment?
Hemorrhoidectomy (Surgical Management)
When someone presents with Fecal incontinence, what PE components do we need to be sure to assess?
Inspection- hygiene DRE- Sphincter tone at rest & w/ squeeze - Fecal impaction - Masses
If a hemorrhoid originates above the dentate line but prolapses externally, is this an internal or external hemorrhoid?
Internal (origin above dentate line)
You are performing the visual component of a rectal exam of a pt. and immediately see a purple, swollen nodule protruding from the anus. The hemorrhoid cannot be manually reduced. What key history findings would help you differentiate this as a Stage IV Internal Hemorrhoid vs an External Hemorrhoid?
Internal Hemorrhoid symptoms include a sensation of fullness and mucus discharge. PAINLESS External Hemorrhoids symptoms will include per-ianal irritation and a throbbing sensation. PAINLESS BOTH will present with bright red blood in small amounts usually with defecation. NEITHER have significant bleeding or pain.
Do internal or external hemorrhoids assist in anal closure to aid in fecal continence?
Internal Hemorrhoids. - These are located above the dentate line and everyone has these. External Hemorrhoids are below the dentate line.
A QUALITATIVE fecal fat stain of your chronic diarrhea patient resulted in 510 g/ 24 hrs. What type of underlying issue is this patient experiencing?
Malabsorption
Name 3 Special tests that can help to diagnose appendicitis.
Mcburney's Point Psoas Sign Obturator Sign Rebound Tenderness Robsing's sign Dunphy's Markle's Aaron's
What symptoms would you find with a patient presenting with stage 1 hemorrhoids.
NONE. Stage 1 hemorrhoids are present in all people and are not palpable and non-painful. they do not protrude outside the anal canal with valsalva.
How do we approach management of appendicitis?
No eating, IV opioids, IV fluids, ABX (Zosyn, Cipro or Levaquin)
Your just received your patient's initial paracentesis lab results. They report a low SAAG level. What is most likely the cause of your patient's ascites?
Non-portal hypertensive causes: Pancreatitis TB Nephrotic Syndrome Peritoneal Carcinomatosis
Normal stool osmolality is 290mOsm/Kg. You receive electrolyte levels for your patient, which are
Normal osmotic gap is <50. >75 is osmotic or malabsorptive.
When would we use CT w/ contrast to diagnose appendicitis?
Only when all other items have been considered and the diagnosis is still uncertain.
You are performing the visual component of a rectal exam of a pt. You ask the pt to valsalva and see a purple, swollen nodule protrude from the anus once the patient bears down. When they end the valsalva, the nodule reduces back inside the anus. What key PE findings would help you differentiate this as an internal Hemorrhoid vs an External Hemorrhoid?
PE: Internal Hemorrhoids- if you don't see it, it is probably internal... If you see it only after bearing down, it is internal. DRE: Nonpalpable and nontender. PE: External Hemorrhoids- you will immediately see it. It will be soft and nontender. Should be no findings on DRE, because it will be external only.
You have a patient who is about to undergo ERCP. What are some of the major risk factors you should counsel them on?
Pancreatitis (up to 5% of pts) Cholangitis Bleeding Infection perforation Adverse Drug/Dye reaction
A patient presents to the ER with a painful, taught, protuberant abdomen, fever, and documented history of decompensated cirrhosis. What procedure would be indicated in this situation? What do you hope to accomplish from doing this procedure?
Paracentesis - Removal of ascites is shown to reduce mortality in hospitalized patients. - Lab Specimens: RBC count > 50,000= hemorrhagic ascites WBC count? 350 = Infection. PMN count > 250 = Spontaneous Bacterial Peritonitis. Protein count Gram stain Glucose (low= Cancer) LDH (spontaneous bacterial peritonitis, bowel perfs
Your just received your patient's initial paracentesis Lab results. They report a 1.5 Serum Albumin-Ascites Albumin (SAAG) level. What is most likely the cause of your patient's ascites?
Portal hypertension most commonly caused by Cirrhosis. (SAAG Level >1.1)
Your patient presents to the office after failed conservative therapy for their symptomatic Stage III Hemorrhoids. What would you recommend as a next step in treatment?
Rubber Band Ligation (preferred) Sclerotherapy Electrocoagulation.
What test do we order for suspected Carcinoid?
Serum Chromogranin A.
What test do we order for a VIPoma?
Serum VIP
Name 4 diagnostic tools we would use when a patient presents with fecal incontinence.
Sigmoidoscopy Anal Ultrasound/Pelvic MRI Anal manometry EMG, Proctography.
You have a patient who you feel could benefit with therapy using ERCP, however, they have significant cardiopulmonary disease. What is your major concern for this patient undergoing an ERCP procedure?
Significant pulmonary disease means that they are at high risk for sedation complications Other relative contraindications include pregnancy and Zenker's Diverticulum.
You are working an ICU floor and you have a patient who has been on prolonged bed rest and is on continuous dosing of opiates for pain relief. The patient begins to complain of abdominal discomfort and nausea with anorexia, and you note some abdominal distention and tenderness to palpation with normal bowel sounds . What are you concerned about at this point?
Stool impaction
A 22 year old male presents to the emergency department with pain that started in the periumbilical region ~ 18 hrs prior. It has since shifted to the suprapubic region. He now has an elevated WBC count and nausea/vomiting. Why should we still consider this to be appendicitis even though it didn't spread to the typically RLQ area?
The appendix has a lot of anatomical variability and can end up retrocecal, retroperitoneal, suprapubic, or even intrapelvic.
Name 5 other disease processes that Appendicitis could be confused for in a woman.
UTI Kidney stones Diverticulitis Ectopic pregnancy PID Constipation Perfortated duodenal ulcer Small bowel obstruction Obarian cyst or abscess Enteritis IBD
In follow-up surveillance for Anal cancer, how often are chest/ abd/pelvis CTs required after the patient is in remission?
Yearly x 3 years.
Why would we need to order a serum fasting gastrin level? What symptoms would this patient be presenting with?
Zollinger-Ellison, often present with chronic diarrhea and Steatorrhea.
Patient has noticed a purulent discharge coming from the area of the anus, associated with bowel movements and prolonged sitting. The patient has a documented diagnosis of Crohn's disease. Upon PE, an opening just lateral to the anus is noted and is very tender. What does this patient have and what is the recommended course of treatment?
perianal fistula - surgical intervention is the mainstay UNLESS due to Crohn's- make sure pt is on a biologic therapy, which can heal the fistula in Crohn's
