Think Appendicitis - Classic chronological order: 1. Periumbilical pain (intermittent and crampy) 2. Nausea/vomiting 3. Anorexia 4. Pain migrates to RLQ (constant and intense pain), usually in 24 hours
Gastric ulcers: Epigastric pain Vomiting, anorexia, and nausea
Duodenal ulcers: Epigastric pain—burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain) Bleeding Back pain Nausea, vomiting, and ↓ appetite
Lower GI bleed: Hematochezia (bright red blood per rectum [BRBPR]), with or without abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock
Carcinoma of the gallbladder: Biliary colic, weight loss, anorexia; many patients are asymptomatic until late; may present as acute cholecystitis
Pancreatic carcinoma: Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in the skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes
What are the 4 cardinal signs of strangulated bowel?
The 4 cardinal signs of strangulated bowel: fever, tachycardia, leukocytosis, and localized abdominal tenderness.
Small bowel obstruction - Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery
Large bowel obstruction - Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly
Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds.
KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon
Dilated loops of bowel and air-fluid levels in the abdomen
Treatment: Bowel rest, NG tube placement, surgery as directed by underlying cause
More likely to be malignant: sessile, > 1 cm, villous
Less likely to be malignant: Pedunculated, < 1 cm, tubular
Tx: resection and adjuvant chemotherapy
Colon cancer screening for average-risk patients should begin at 45 years and end at 75 years of age
Stool tests:
Guaiac based fecal occult blood (gFOBT) – once per year
Fecal immunochemical test (FIT) – once per year
FIT-DNA test (combines FIT with a test that detects altered DNA in stool) – once every one or three years
Flexible sigmoidoscopy – once every 5 years or every 10 years with a FIT every year (serious complications occur in approximately 3.4 per 10,000 procedures)
Colonoscopy: once every 10 years
Perforation of the colon occurs in an estimated 3.8 per 10,000 procedures
Serious complications—including perforation, major bleeding, diverticulitis, severe abdominal pain, and cardiovascular events occur in an estimated 25 per 10,000 procedures
CT colonography: once every 5 years (1 additional individual per 1000 would develop cancer in his or her lifetime due to radiation exposure)
**When adequate screening colonoscopy is accomplished, intercurrent stool tests (i.e., between colonoscopy examinations) are not necessary. In addition, for patients who have had a negative colonoscopy and have been recommended to have routine screening in 10 years, screening with FIT or other screening tests is not indicated prior to the end of the 10-year period.
**There is adequate evidence that the benefits of detection and early intervention decline after age 75 years
Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly
Illeus
Hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
Ileus that persists for more than 3 d following surgery is termed postoperative adynamic ileus or paralytic ileus
Signs: Absent bowel sounds
CT scan with gastrografin—must exclude mechanical obstruction
Gastroparesis
A condition that affects the stomach muscles and prevents proper stomach emptying
MCC: Diabetes
Diarrhea
Pseudomembranous colitis
Inflammation of the colon caused by the bacteria Clostridium difficile
Occurs secondary to treatment with antibiotics with broad-spectrum antibiotics - penicillins, cephalosporins, and FQ
Mild watery foul-smelling diarrhea (> 3 but <20 stools/day)
IV metronidazole OR PO vancomycin (this is the only use for oral vancomycin)
LLQ pain, tenderness, abdominal distention, fever and leukocytosis in older patients
Inflammation of an abnormal pouch (diverticulum) in the intestinal wall, usually found in the large intestine. The presence of the pouches themselves is called diverticulosis. When they become inflamed, the condition is known as diverticulitis.
The most common cause of massive lower gastrointestinal bleeding
DX: Diagnose using abdominal and pelvic CT with oral, rectal, and IV contrast; do colonoscopy 1 to 3 months after the episode to look for cancer.
CT revealing fat stranding and bowel wall thickening
TX: Management depends on severity but typically includes conservative management (pain control + liquid diet x 2-3 days), sometimes antibiotics, and sometimes percutaneous or endoscopic ultrasound-guided drainage or surgical resection
Recurrent attacks or the presence of perforation, fistula, or abscess require surgical removal of the involved portion of the colon
Increase bulk the diet with high-fiber foods and bulk additives such as Metamucil
Solid food dysphagia in a patient with a history of GERD
GERD and Scleroderma
Ingestion of corrosive substances
Viral or bacterial infections
Symptoms
Difficulty and painful swallowing, weight loss, Regurgitation of food
Esophageal achalasia: primary esophageal motility disorder characterized by the absence of lower esophageal peristalsis.
Difficulty swallowing caused by a failure of the LES to relax and poor peristaltic waves, producing a motor disorder signified by initial complaints of dysphagia for solids and liquids.
DX: Barium swallow shows there is acute tapering at the lower esophageal sphincter and narrowing at the gastroesophageal junction, producing a "Bird’s beak" or "rat's tail" appearance - distal 2/3 most common
Esophageal manometry is the best test to diagnosis shows the absence of esophageal peristalsis
TX: EGD dilation of the esophagus or myotomy is the preferred treatment
Esophageal web: thin membranes in the mid-upper esophagus. May be congenital or acquired
Plummer-Vinson: esophageal webs + dysphagia + iron deficiency anemia
A Schatzki ring is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur
Esophageal cancer: progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis
Gastrointestinal System Neoplasms: Abdominal pain and unexplained weight loss are most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool
Indirect(Most Common):Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
Direct: Passage of intestine through the external inguinal ring at Hesselbach's triangle, rarely enters the scrotum.
Ventral: Often from previous abdominal surgery, obesity. Abdominal mass noted at the site of previous incision.
Umbilical hernia: Very common, generally is congenital and appears at birth. Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life.
Strangulated: Hernia becomes strangulated when the blood supply of its contents is seriously impaired.
Obstructed: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel.
Incarcerated: Hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.
Gastric cancer, duodenal ulcers, right-sided colon cancer, portal hypertension with esophageal varices, severe erosive esophagitis, Mallory-Weiss syndrome.
Hematochezia: bright red blood per rectum (BRBPR) - lower GI bleed
Hemorrhoids, anal fissures, polyps, proctitis, rectal ulcers, and colorectal cancer. Diverticulosis is generally an incidental finding, since diverticular bleeding is usually of greater volume.
Postoperative nausea and vomiting (PONV) is an unpleasant complication affecting 30 percent of children and adults after anesthesia
Vomiting or retching can result in wound dehiscence, esophageal rupture, aspiration, dehydration, increased intracranial pressure, and pneumothorax.
Nausea can have causes that aren't due to underlying disease. Examples include motion such as from a car and plane, taking pills on an empty stomach, eating too much or too little, or drinking too much alcohol
Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer
DX:
ERCP
abdominal CT scan: 75% show tumor at the head of the pancreas, 25% at the tail
pancreatic Bx
abdominal MRI
elevated serum bilirubin
abnormal liver function tests
CA 19-9 is present in about 80% of patients who have pancreatic cancer
TX:
At the time of diagnosis, only about 20% of pancreatic tumors can be removed by the standard procedure is called a pancreaticoduodenectomy (Whipple procedure).
When the tumor is confined to the pancreas but cannot be removed, a combination of radiation therapy and chemotherapy may be recommended
PUD is an ulcer of the upper GI tract mucosa involving the proximal duodenum (90%) and distal stomach (10%). There are 2 main types of ulcers duodenal and gastric
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
Gastric ulcer (foodclassically 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 postprandial
Bleeding — Acute upper gastrointestinal hemorrhage is the most common complication of peptic ulcer disease
DX: 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
Ulcer biopsy of benign-appearing duodenal ulcers is not recommended
All ulcers with malignant features should be biopsied
TX: All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (eg, omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks
Patients with evidence of H. pylori on biopsy should receive eradication therapy
Treatment for H.Pylori ⇒ think Baseball "CAP" = clarithromycin + amoxicillin + PPI
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
A 24-year-old man with ulcerative colitis receives Lomotil for excessive diarrhea and develops fever, abdominal pain and tenderness, and a massively dilated colon on abdominal x-ray.
Toxic patient: sepsis, febrile, abdominal pain
Megacolon: acutely and massively distended colon
Can occur with IBD (UC > Crohn's)
Decompression of the colon is required
In some cases, colostomy or even complete colonic resection may be required
