Abdominal Pain: Etiology, Symptoms, and Referral

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Questions and Answers

Which condition, associated with RLQ pain, anorexia, nausea, vomiting, and potentially constipation or diarrhea, is a common cause of abdominal pain?

  • Ruptured Aortic Aneurysm
  • Small Bowel Obstruction
  • Peritonitis
  • Appendicitis (correct)

A patient presents with intermittent, crampy abdominal pain, vomiting, obstipation, and abdominal distention. Hyperactive bowel sounds and fever are noted. What condition is most likely?

  • Small Bowel Obstruction (correct)
  • Ruptured Aortic Aneurysm
  • Appendicitis
  • Perforated Peptic Ulcer

A patient experiences a sudden onset of severe abdominal pain followed rapidly by peritoneal signs. This presentation is most indicative of which condition?

  • Small Bowel Obstruction
  • Ruptured Aortic Aneurysm
  • Perforated Peptic Ulcer (correct)
  • Peritonitis

A patient presents with a high fever and acute abdominal pain that may be diffuse, localized, or referred, accompanied by vomiting and diarrhea/constipation. Which condition is most likely?

<p>Peritonitis (A)</p> Signup and view all the answers

A patient reports a sudden onset of severe abdominal pain that may be confined to the flank, low back, or groin, potentially preceded by abdominal, flank, or back pain. Which condition is most indicative?

<p>Ruptured Aortic Aneurysm (C)</p> Signup and view all the answers

When evaluating a patient with abdominal pain, which of the following diagnostic tests would be LEAST helpful in determining the underlying cause?

<p>UA (B)</p> Signup and view all the answers

A patient presents reporting right lower quadrant (RLQ) pain, nausea, and a low-grade fever. Which physical exam finding would MOST strongly suggest appendicitis?

<p>RLQ guarding and rebound tenderness (B)</p> Signup and view all the answers

Which of the following physical findings is MOST associated with small bowel obstruction rather than other causes of abdominal pain?

<p>Hyperactive bowel sounds (D)</p> Signup and view all the answers

A patient presents with suspected appendicitis. Which of the following diagnostic findings would be MOST indicative of potential perforation?

<p>High fever (B)</p> Signup and view all the answers

Upon assessing a patient, you elicit pain with right thigh extension. Which sign does this MOST likely indicate?

<p>Psoas sign (D)</p> Signup and view all the answers

A patient with suspected appendicitis experiences right lower quadrant (RLQ) pain upon palpation of the left lower quadrant (LLQ). Which of the following signs is being demonstrated?

<p>Rovsing's sign (B)</p> Signup and view all the answers

For a patient suspected of having appendicitis, current guidelines recommend performing an appendectomy within what timeframe from symptom onset to minimize the risk of perforation?

<p>Within 24 hours (D)</p> Signup and view all the answers

When assessing a patient with a small bowel obstruction, which finding would suggest the obstruction is progressing to strangulation, requiring more urgent surgical intervention?

<p>Pain that progresses in severity and becomes constant (B)</p> Signup and view all the answers

A patient undergoing evaluation for a possible small bowel obstruction would have which finding on diagnostic imaging to confirm the diagnosis?

<p>Dilated loops of bowel with air-fluid levels on X-ray (C)</p> Signup and view all the answers

Which feature is MOST characteristic of internal hemorrhoids?

<p>Usually painless (B)</p> Signup and view all the answers

You are evaluating a patient complaining of rectal bleeding and discomfort. How is the prolapse of internal hemorrhoids classified?

<p>By degree of prolapse (B)</p> Signup and view all the answers

When examining a patient to diagnose hemorrhoids, what procedure plays a critical role because because it allows direct visualization of the entire anus and distal rectum?

<p>Anoscopy (D)</p> Signup and view all the answers

For which anorectal condition would a healthcare provider MOST likely perform a colonoscopy?

<p>Bleeding source not identified by other means in a patient over 50 (D)</p> Signup and view all the answers

What is the MOST appropriate first-line treatment for symptomatic hemorrhoids?

<p>Increase fiber and fluid intake (B)</p> Signup and view all the answers

When is surgical excision MOST appropriate for a thrombosed external hemorrhoid?

<p>If it has been present for less than 3 days (A)</p> Signup and view all the answers

Which of the following is a common cause of anal fissures?

<p>Inflammatory bowel disease (prolonged diarrhea) (A)</p> Signup and view all the answers

What physical exam finding would MOST strongly suggest the presence of a CHRONIC anal fissure rather than an acute one?

<p>Indurated, fibrotic appearance with associated anal skin tag (B)</p> Signup and view all the answers

A patient is diagnosed with an acute anal fissure but is unable to tolerate topical treatments due to severe irritation. What is the MOST appropriate next step?

<p>Administer topical anesthetic before bowel movements (C)</p> Signup and view all the answers

What intervention is considered the gold standard for treating chronic anal fissures that have not healed with conservative treatments?

<p>Lateral internal sphincterotomy (LIS) (C)</p> Signup and view all the answers

What is the MOST common cause of cholecystitis?

<p>Gallstones blocking the bile duct (A)</p> Signup and view all the answers

Which of the following is a known risk factor for cholelithiasis?

<p>Increasing age (B)</p> Signup and view all the answers

When assessing a patient with suspected acute cholecystitis, which of the following examination findings is MOST specific to this condition?

<p>Murphy's sign (A)</p> Signup and view all the answers

What diagnostic test is considered the MOST accurate for confirming a diagnosis of cholecystitis?

<p>Ultrasound (A)</p> Signup and view all the answers

A patient presents to the clinic with right upper quadrant pain and is ultimately diagnosed with cholelithiasis. Of the following medications, which may cause cholelithiasis?

<p>Fibrates (B)</p> Signup and view all the answers

What is the MOST appropriate initial management for symptomatic gallbladder disease caused by cholelithiasis?

<p>Isotonic fluids and electrolyte correction (B)</p> Signup and view all the answers

What is the MOST common cause of cirrhosis?

<p>Alcoholic liver disease (D)</p> Signup and view all the answers

What is the MOST accurate way to diagnose the CAUSE of cirrhosis?

<p>Liver biopsy (D)</p> Signup and view all the answers

A patient with cirrhosis develops ascites. What dietary modification is MOST important?

<p>Low-sodium diet (C)</p> Signup and view all the answers

What is MOST important to include in the management plan for a patient with cirrhosis and hepatic encephalopathy?

<p>Lactulose (B)</p> Signup and view all the answers

According to the Rome III criteria, how many bowel movements per week is generally considered consistent with chronic constipation?

<p>Fewer than 3 (C)</p> Signup and view all the answers

Long term constipation can be caused by a number of lifestyle factors. Constipation could result from all of the following EXCEPT:

<p>Increased fiber intake (D)</p> Signup and view all the answers

A patient reports symptoms of chronic constipation and alarm symptoms are ruled out. What is the BEST initial step in managing this patient's constipation?

<p>Trial of laxatives (A)</p> Signup and view all the answers

If increased fiber and osmotic laxatives don't relieve constipation, what should be prescribed next?

<p>Stimulant laxatives (D)</p> Signup and view all the answers

Which of the following characteristics is MOST consistent with non-infectious diarrhea?

<p>More than 3 stools daily (D)</p> Signup and view all the answers

A patient mentions that their stools are greasy, bulky, and have a rancid smell. Which problem is MOST likely?

<p>Small bowel or pancreatic dysfunction (C)</p> Signup and view all the answers

What is primarily associated with diverticulitis?

<p>Decreased dietary fiber (C)</p> Signup and view all the answers

A patient is diagnosed with diverticulitis but without any complications. What instructions should they receive regarding physical activity?

<p>Limit physical activity (A)</p> Signup and view all the answers

A patient is diagnosed with dysphagia. What should occur first?

<p>Refer to a gastroenterologist or speech language pathologist. (A)</p> Signup and view all the answers

A middle-aged patient presents with signs of acute abdomen. Upon examination, the patient exhibits orthostatic vital sign changes and severe, localized lower abdominal pain. Considering the information provided, what is the MOST appropriate next step?

<p>Immediately consult a specialist for suspected GI bleeding or bowel obstruction. (D)</p> Signup and view all the answers

A patient presents to the clinic with right upper quadrant abdominal pain. To BEST differentiate between cholelithiasis and cholecystitis, which of the following questions is MOST relevant?

<p>Is the pain constant or intermittent? (A)</p> Signup and view all the answers

A patient with known cirrhosis presents with recent onset ascites. After initiating dietary sodium restriction, which medication is MOST appropriate?

<p>Spironolactone. (C)</p> Signup and view all the answers

An elderly patient reports chronic constipation. Initial management includes increased fiber and osmotic laxatives, which have provided minimal relief. What is the MOST appropriate NEXT step in managing this patient's constipation?

<p>Evaluate for underlying metabolic diseases. (B)</p> Signup and view all the answers

A patient presents with new-onset dysphagia. After initial assessment, the provider suspects a motility disorder. Which of the following would be MOST appropriate to confirm this suspicion, determine the location, and assess for aspiration?

<p>Barium swallow (modified barium swallow). (A)</p> Signup and view all the answers

In assessing a patient presenting with acute abdominal pain, which finding would necessitate specialist referral?

<p>Orthostatic vital sign changes (C)</p> Signup and view all the answers

When evaluating a patient for a suspected ruptured aortic aneurysm, what aspect of their history would be MOST concerning?

<p>Sudden onset of severe abdominal pain radiating to the back (B)</p> Signup and view all the answers

Which diagnostic test would be MOST useful in differentiating between various causes of acute abdominal pain?

<p>CT scan (A)</p> Signup and view all the answers

When managing a patient with acute abdominal pain secondary to suspected diverticulitis, if the patient has a fever of 101.5°F (38.6°C) and signs of localized peritonitis, what is the MOST appropriate course of action?

<p>Admit the patient to the hospital for IV antibiotics and further evaluation (D)</p> Signup and view all the answers

A patient's history includes acute salpingitis, gastroenteritis and ruptured ectopic pregnancy. This information is MOST relevant when considering which aspect of their current abdominal pain complaint?

<p>A differential diagnosis (D)</p> Signup and view all the answers

When evaluating a patient's anorectal complaints, what is the PRIMARY purpose of performing anoscopy?

<p>To visualize the anus and distal rectum directly (A)</p> Signup and view all the answers

Which of the following situations warrants specialist referral for abdominal pain?

<p>Patient with unilateral abdominal pain and positive pregnancy test (B)</p> Signup and view all the answers

What is the PRIMARY goal of conservative management for symptomatic hemorrhoids?

<p>Managing the patient's symptoms. (C)</p> Signup and view all the answers

A middle-aged patient reports painful bowel movements and blood on the toilet paper. Clinical exam reveals a small tear in the distal anal canal. What should be the INITIAL recommendation?

<p>Recommend increased fiber intake, stool softeners, and sitz baths (B)</p> Signup and view all the answers

What is the rationale behind avoiding opioid prescriptions for patients with anal fissures?

<p>Opioids can worsen constipation. (A)</p> Signup and view all the answers

In a patient presenting with severe anorectal pain, what is the rationale for considering the timing of surgical intervention for a thrombosed external hemorrhoid?

<p>To provide the most effective pain relief and reduce complications. (A)</p> Signup and view all the answers

What is the MOST appropriate initial step in managing a patient with suspected acute cholecystitis?

<p>Perform an ultrasound to confirm diagnosis. (B)</p> Signup and view all the answers

What symptom separates cholelithiasis from cholecystitis?

<p>Fever and chills (C)</p> Signup and view all the answers

When planning care for a patient with symptomatic cholelithiasis, what dietary recommendation is MOST appropriate?

<p>Discourage alcohol consumption. (A)</p> Signup and view all the answers

A patient is diagnosed with cirrhosis. What aspect of their history is MOST important for management decisions?

<p>History of alcohol and Hepatitis B/C (D)</p> Signup and view all the answers

A patient with cirrhosis and hepatic encephalopathy is being discharged. Which laboratory parameter is MOST crucial to monitor regularly?

<p>Ammonia (A)</p> Signup and view all the answers

How should a provider counsel a patient with cirrhosis regarding sodium intake when managing new-onset ascites?

<p>Restrict dietary sodium intake to 1 to 2 grams per day (A)</p> Signup and view all the answers

Which of the following symptoms would cause a provider to suspect SBO as the cause of acute abdominal pain?

<p>Persistent vomiting and abdominal distention (D)</p> Signup and view all the answers

To help diagnose between different causes of referred abdominal pain, all of the following should be documented EXCEPT:

<p>CVA tenderness (B)</p> Signup and view all the answers

What is the MOST appropriate initial instruction for a patient with infrequent bowel movements who reports straining?

<p>Suggest increased fiber intake and increased fluid intake. (D)</p> Signup and view all the answers

What is the PRIMARY goal when managing constipation with increased intestinal transit time?

<p>To increase the water content of stool (C)</p> Signup and view all the answers

When evaluating a patient with anorexia and chronic diarrhea, which historical factor would MOST suggest malabsorption?

<p>Frequent consumption of sugar-free candies (C)</p> Signup and view all the answers

During an evaluation for diarrhea, a patient reports a history of malabsorption and weight loss. Which area should be prioritized during the history and physical exam?

<p>Gastrointestinal (A)</p> Signup and view all the answers

A patient with symptoms of fever, LLQ pain, and constipation wants to be managed with diet instead of antibiotics. How should this be addressed?

<p>Emphasize the need for medication due to the risk of abscess or fistula (D)</p> Signup and view all the answers

An elderly patient with a history of dysphagia is diagnosed with malnutrition and dehydration. How can they achieve adequate nutrition?

<p>Provide education regarding swallowing strategies and refer to GI (A)</p> Signup and view all the answers

How can a provider evaluate the need for further testing when diagnosing dysphagia?

<p>Scheduling a modified barium swallow study (MBS) (A)</p> Signup and view all the answers

Which of the following patients would MOST likely require cough-based dysphagia treatment?

<p>Patients aspirating while swallowing (D)</p> Signup and view all the answers

What diagnosis can be suspected from bloody or mucus-filled stools and generalized spasms during a diarrhea evaluation?

<p>An inflammatory process (D)</p> Signup and view all the answers

A provider is evaluating a patient for abdominal pain and wants to use diagnostic testing. If a patient is experiencing nausea and vomiting, what is the best choice?

<p>Use an abdominal X-Ray. (B)</p> Signup and view all the answers

What is the goal in managing cirrhosis with medications like Tylenol, amiodarone and varied antibiotics?

<p>To prevent further liver damage (B)</p> Signup and view all the answers

What is the most important aspect of providing the best quality of care with cirrhosis treatment?

<p>Referring to a multidisciplinary health team (D)</p> Signup and view all the answers

Which of the following interventions is MOST appropriate for managing acute diarrhea?

<p>Recommend hypertonic fluid and electrolyte replacement (B)</p> Signup and view all the answers

The most appropriate choice when addressing both bacterial balance and malabsorption is which plan?

<p>Treating SIBO and treating secretory disorders (D)</p> Signup and view all the answers

Which initial treatment for constipation will address stool softening?

<p>Stool softeners 2nd (Docusate 100 mg BID) (A)</p> Signup and view all the answers

A patient has been educated regarding increasing their fluid and fiber intake in order to address constipation. They've been referred for physical activity to help. What is the purpose?

<p>To accelerate transit time and stimulate peristalsis (D)</p> Signup and view all the answers

After diagnosing diverticulitis, what lifestyle changes should be discussed with a patient?

<p>Exercise more frequently, increasing gut motility (C)</p> Signup and view all the answers

A patient presents with abdominal pain and jaundice. Based on the information provided, which of the following conditions warrants specialist referral?

<p>Suspected bowel obstruction (B)</p> Signup and view all the answers

A patient with anorectal complaints is undergoing an evaluation. What is the PRIMARY diagnostic utility of performing anoscopy?

<p>To directly visualize the anus and distal rectum (B)</p> Signup and view all the answers

You're counseling a patient with symptomatic cholelithiasis who is managing their condition non-surgically. Which dietary recommendation is MOST appropriate for this patient?

<p>Consuming a diet with evenly distributed fat throughout the day (B)</p> Signup and view all the answers

What is the MOST important aspect of providing high-quality care for a patient with cirrhosis?

<p>Treating the underlying cause of the cirrhosis and managing complications (D)</p> Signup and view all the answers

A patient reports new-onset dysphagia. After the initial assessment, the provider suspects a structural disorder. What finding would MOST strongly support the need for referral to GI?

<p>Progressive dysphagia, unintentional weight loss and advanced age (D)</p> Signup and view all the answers

Flashcards

When is specialist referral indicated?

Indicated for suspected GI bleeding or bowel obstruction.

What are the signs of appendicitis?

A condition with RLQ pain, anorexia, nausea/vomiting, and low-grade fever.

What indicates a small bowel obstruction?

A condition marked by intermittent abdominal pain, vomiting, and abdominal distention.

Signs of a perforated peptic ulcer?

A condition characterized by abrupt onset of severe abdominal pain followed by peritoneal signs.

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What are the sign of peritonitis?

A condition with high fever and acute abdominal pain.

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What are the signs of a ruptured aortic aneurysm?

A condition with sudden onset of severe abdominal pain that may be confined to the flank, low back, or groin.

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Initial steps in examining abdominal pain?

Assess vital signs, thorough PMHx, & Family Hx

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What could mimic appendicitis?

Conditions that may resemble appendicitis.

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What is the initial step in managing abdominal pain?

In abdominal pain, prompt referral to ED

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What is the typical appendicitis pain progression?

Vague, colicky umbilical pain that shifts to RLQ.

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What does a positive Psoas sign indicate?

Pain with right thigh extension.

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What does a positive Obturator's sign indicate?

Pain with internal rotation of flexed right thigh.

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What do X-rays show in SBO?

Dilated bowel loops and air-fluid levels

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What are hemorrhoids?

Vascular masses that cushion anal layers.

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Internal versus external hemorrhoids?

Occur above dentate line; usually painless.

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External hemorrhoids?

Arise below dentate line; sensitive to touch.

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What are signs of hemorrhoids?

Anal irritation, pruritus or a palpable nodule.

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How do you diagnose hemorrhoids?

Visualizing the anus and rectum using use of an anoscope

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Why can pregnancy trigger hemorrhoids?

Increases pressure on the pelvic floor.

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What defines an anal fissure?

Painful linear tear in anal canal lining.

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What are common symptoms of Anal fissure?

Severe rectal pain with bowel movements.

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What do Perineal and rectal exams show in anal fissures?

Heat, swelling and purulence.

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What conservative treatments for fissures?

Increase fiber, stool softeners & sitz baths

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Define cholecystitis.

Inflammation of the gallbladder, often caused by gallstones blocking the bile duct

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What is cholelithiasis?

Formation of gallstones in the gallbladder.

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What are the types of gallstones?

Cholesterol, Pigmented, and Mixed

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When the gallbladder inflamed, what happens?

Inflammation causes the release of prostaglandins

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What sensations accompany chronic cholecystitis?

Recurrent, mild to moderate RUQ pain.

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How is Acute version different?

Sharp and severe RUQ pain.

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Distended gallbladder?

Can help confirm diagnosis via distended gallbladder

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How do you diagnose?

Gold standard is ultrasound

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Cholelithiasis risk?

Increasing age, Obesity, rapid weight loss.

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What do you do?

If symptomatic consider cholecystectomy

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Cirrhosis?

end-stage consequence of progressive hepatic fibrosis

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Why does cirrhosis occur?

Common causes are alcohol

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Cirrhosis caused by?

Result of exposure to persistent toxins

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What early symptoms cirrhosis?

Earliest form is nonspecific (Pruritus)

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What do you feel in cirrhosis

Tremors and Glossitis

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How would you assess it?

Assess with Alkaline phosphatase

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How do you deal?

Goal is: Bulk and Soften

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Warning signs?

Diarrhea that has Blood or mucous is stool

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More stool?

Increase stool

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How to deal!

Caused by meds, inflammation

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Diverticolosis

Uncompilcated, asymptomatic

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Signs of

Mild Colicky pain

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Why is abdominal pain a common primary care complaint?

Etiology of pain is diverse- acute abdomen indicated emergency referral

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Clinical sign of Perforated Peptic Ulcer

Sudden onset of severe abdominal pain followed rapidly by peritoneal signs

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Clinical sign of Peritonitis

High fever and acute abdominal pain that can be diffuse, localized, or referred, vomiting, diarrhea/constipation

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Signs of Small Bowel Obstruction

Intermittent and crampy abdominal pain, vomiting, obstipation, abdominal distention, hyperactive bowel sounds, and fever

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What diagnostics are used for abdominal complaints?

Serum amylase and lipase, CBC, CRP, Lactate dehydrogenase test, Liver panel, UA, CT scan, US

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How do you manage abdominal pain/infection?

ED referral, surgery (appendectomy), hydration (IVF), proton pump inhibitors and empirical antibiotic therapy

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Further Management for Abdominal pain and infection

Surgical consult may be needed along with collaborative, interdisciplinary management and analgesia.

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Lab findings in appendicitis

WBCs 10,000-20,000, hCG in childbearing age, CRP, amylase/lipase & CT or Ultrasound

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Lab findings in Small Bowel Obstruction

Elevated WBC, plain films or CT often used

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Appendicitis Management

Refer to ED is surgical or pain management, appendectomy within 24 hours to prevent peritonitis/perforation

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Small Bowel Obstruction Management

Refer for NG suction and rehydration, broad-spectrum antibiotics if strangulated bowel, antiemetics, GI surgical consult is needed

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What are anorectal complaints?

Benign anorectal disorders of structure and/or function

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Where are internal Hemorrhoids located?

Located above dentate line and covered by columnar epithelium

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Where are external Hemorrhoids located?

Lie below the dentate line and are covered by squamous epithelium

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Clinical Presentation for External Hemorrhoids.

Sensitive to touch, temperature, stretch and less likely to bleed

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Diagnoses for Anorectal Complaints

Inflammatory bowel disease, Condyloma and Other sexually transmitted disease.

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Conservative Hemorrhoid Treatment

Bulk-forming agents and stool softeners in addition to fiber therapy

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Differentials for anal fissures

Inflammatory bowel disease (prolonged diarrhea), Cancer, Crohn's disease and TB

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How does Cholelithiasis and Cholecystitis form?

Inflammatory, infectious, neoplastic, metabolic, or congenital conditions causing gallstone formation and bile duct obstruction

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Pathophysiology of Cholecystitis.

The gallbladder becomes inflamed as a result of various processes, including continued blockage of the cystic or common bile duct

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Physical Exam findings in Cholelithiasis

P.E. may be unremarkable in symptomatic and chronic cholelithiasis

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Cirrhosis Common Causes

Alcoholic liver disease, nonalcoholic liver disease, nonalcoholic steatohepatitis (NASH) and Chronic Hepatitis B and C

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How is perineal descent measured in constipated patients.

Perineal descent (bear down while lying in left lateral position. Normal perineal descent while straining is 1-4 cm)

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Why does secondary constipation occur?

Medications and diet (low fiber/fluid intake)

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Define Diarrhea

An increase in stool frequency of more than 3 stools per day, typically appearing loose or liquid, consistent with a stool weight greater than 250 g daily.

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Assessing cause of Diarrhea

Assess pt's normal stool pattern compared with the new-onset diarrhea

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Management for Diarrhea

Anti-nausea agents, IBD with Relaxation therapy and psychological support

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Medical mgmt. to treat ascites

Nonselective beta- blocker therapy (prevention of bleeding/esophageal varix rupture) is often used for variceal bleed

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What is diverticulosis

An uncomplicated, asymptomatic or symptomatic disease without inflammation or bleeding

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Study Notes

Abdominal Pain and Infections

  • Abdominal pain is a common complaint in primary care

Etiology and Referral

  • Acute abdominal pain can indicate an emergency referral
  • Symptoms are subjective, specialist referral is needed if:
  • Suspected GI bleeding
  • Bowel obstruction
  • Orthostatic vital sign changes
  • Abnormal findings
  • Jaundice
  • Positive pregnancy test
  • Severe localized or unilateral pain
  • History of trauma
  • Any sign of peritoneal irritation

Conditions Associated with Abdominal Pain

  • Appendicitis is indicated by RLQ pain, anorexia, nausea/vomiting, low-grade fever, constipation, or rarely diarrhea
  • Small bowel obstruction is indicated by abdominal pain, vomiting, obstipation, abdominal distention, hyperactive bowel sounds, and fever
  • Perforated peptic ulcer presents with sudden abdominal pain, followed by peritoneal signs
  • Peritonitis can cause high fever and acute widespread, localized, or referred pain, vomiting, diarrhea, or constipation
  • Ruptured aortic aneurysm may previously cause abdominal, flank, or back pain, acute rupture causes sudden severe abdominal pain from flank, low back, or groin

Physical Examination and Diagnostics

  • Key components of Physical Exam:
  • Assess vital signs
  • Thorough PMHx
  • Family Hx
  • Medications review
  • Complete physical exam
  • Abdominal provocative screening tests
  • CVA tenderness
  • Diagnostic tests:
  • Serum amylase and lipase
  • CBC
  • CRP
  • Lactate dehydrogenase test
  • Liver panel
  • UA
  • CT scan
  • US

Differential Diagnoses

  • Include gastroenteritis, mesenteric lymphadenitis, acute salpingitis, Mittelschmerz, ectopic or corpus luteum pregnancy, ureteral or Meckel's diverticulitis, perforated peptic ulcer, cholecystitis
  • Other possible diagnosis include intestinal obstruction, cecal diverticulitis, intestinal ischemia, perforated colonic carcinoma, basilar pneumonia

Management Strategies

  • Referral to the ED
  • Surgery, in cases like appendectomy
  • Hydration using intravenous fluids
  • Proton pump inhibitors
  • Empirical antibiotic therapy if indicated
  • Surgical consult
  • Collaborative interdisciplinary management
  • Analgesia and treatment of the underlying cause

Appendicitis

  • Symptoms include vague, colicky umbilical pain that shifts to point tenderness on RLQ, nausea/vomiting, and worsening pain with coughing
  • Physical exam findings: RLQ guarding with rebound tenderness that is localized, Psoas sign with R thigh extension, Obturator's sign with internal rotation of flexed R thigh, Rosving's sign with RLQ pain with pressure to LLQ
  • Lab and diagnostics include WBCs of 10,000-20,000, pregnancy test if childbearing age, CRP, amylase/lipase, CT scan/ultrasound
  • Low-grade fever indicates high perforation risk
  • Management includes ED referral for surgery or pain management and appendectomy within 24 hours of onset

Small Bowel Obstruction

  • Signs and symptoms include cramping, intermittent umbilical pain, abdominal distension, hyperactive bowel sounds, fever, vomiting with pain, pain relief from vomiting with decompression
  • Common causes are adhesions, hernias, or tumors
  • Obstruction of the bowel lumen or paralysis (ileus) of the intestinal musculature result in SBO
  • Physical findings may show minimal or pronounced abdominal distension and guarding, mild midabdominal rebound tenderness, and high-pitched bowel sounds
  • Inability to pass stool or gas indicates SBO
  • Diagnosis involves elevated WBC, plain films, xray or ultrasound, or CT scan showing dilated loops
  • Management involes; NG suction for rehydration, broad spectrum antibiotics, GI surgical consult for pain, surgery if needed.

Anorectal Complaints: Hemorrhoids

  • Very common, vascular cushions serve to connect muscular tissue within the anus
  • Function: helps maintain anal closure and continence

Types of Hemorrhoids

  • Internal hemorrhoids are above the dentate line and covered by columnar epithelium
  • External hemorrhoids lie below the dentate line and are covered by squamous epithelium

Causes and Triggers

  • Hemorrhoids are often due to diet, toileting habits, genetics, pregnancy, enlargement/prolapse of submucosal vascular tissue, and increased pelvic floor pressure

Clinical Presentations of Hemorrhoids

  • Clinical findings for internal hemorrhoids:
  • Bleeding
  • Pruritus
  • Protrusion
  • Pain Internal hemorrhoids: almost always painless
  • Intermittent, reducible protrusion after defecation, classified by degree of prolapse
  • External Hemorrhoids: sensitive to touch/temperature, less likely to bleed, asymptomatic unless thrombosis occurs with tender lump
  • Other findings could be palpable nodule/anal irritation

Diagnosing Hemorrhoids

  • Inspection of the perineum and perianal area is key while patient is at rest or straining
  • External hemorrhoids can be visualized
  • Internal hemorrhoids are best visualized with an anoscope
  • Palpate for abnormal lesions with rectal examination
  • Internal hemorrhoid must be thrombosed to be felt
  • CBC screening for anemia and fecal occult blood testing
  • Anoscopy should be used for hemorrhoid diagnosis and visualization of the entire anus/distal rectum
  • Colonoscopy should be performed if no bleeding is found age 50+ or with colon cancer family history

Differential Diagnoses

  • Proctitis
  • Inflammatory bowel disease
  • Condyloma
  • Other STDs
  • Rectal prolapse
  • Anal skin tags
  • Hypertrophied anal papillae
  • Rectal polyps
  • Cancer
  • Anal fissure
  • Anal papillitis

Management

  • Based on symptom severity:
  • High-fiber diet with increased fluid intake (20–30 g of fiber per day)
  • Bulk-forming agents and stool softeners
  • Topical or oral analgesics
  • Rectogesic (glyceryl trinitrate 0.2%)
  • Topical nitro (0.4%) or nifedipine
  • Hydrocortisone acetate creams
  • Frequent warm water sitz baths
  • Surgical excision if hemorrhoid is thrombosed within 3 days

Anal Fissures

  • Painful linear cracks or tears in the lining of the anal canal distal to the anatomical dentate line
  • Causes: Inflammatory bowel disease (IBD), cancer, Crohn’s disease, Tuberculosis, HIV, Syphilis, Leukemia, Trauma, frequent diarrhea, anal stenosis, etc...

Acute and Chronic Anal Fissures

  • Acute: Less than 6 weeks and superficial with longitudinal tear distal anoderm
  • Chronic: More than 6 weeks, is associated by edema and fibrosis, tender skin tags, and anal papilla

Clinical Presentation

  • Sharp pain during and after bowel movement
  • Small amounts of bright red rectal bleeding
  • Tearing sensation when passing stool
  • Avoidance from bowel movements dues to pain and hard stools

Diagnosis and Differentials

  • Physical exam: Perineal erythema, heat, swelling, tenderness, and purulence.
  • Acute/chronic anal fissure
  • Diagnostic: Visual inspection, Complete blood count, Digital Rectal Exam and Anoscopy, Ultrasound, CT Scan/MRI
  • Differential diagnosis: Crohn’s disease, pilonidal sinus, hidradenitis suppurativa, anorectal malignant neoplasm, sexually transmitted diseases, and lymphoma

Management Strategies

  • Increasing fiber and softening stool will help minimize constipation and relax anal muscles
  • Fiber supplements and sitz baths are first-line treatments
  • Avoid opioids as they can worsen constipation
  • Anesthetic should be used topically before BM
  • For chronic anal fissures, use topical nitrates or calcium channel blockers

Cholelithiasis and Cholecystitis

  • Inflammatory, infectious, neoplastic, metabolic, or congenital conditions that cause gallbladder issues
  • Cholelithiasis: Formation of gallstones in the gallbladder
  • Cholecystitis: Inflammation of the gallbladder
  • Gallbladder inflammation is caused by gallstones blocking the bile duct
  • Primary types of gallstones: cholesterol, pigmented, mixed, patterns
  • Stone size determines the severity of distress

Pathophysiology of Gallstones

  • Three primary types of stones: cholesterol, pigmented, mixed
  • The gallbladder becomes inflamed as a result of various processes, including continued blockage of the cystic or common bile duct
  • Small gallstones pass through the duct, avoiding further distress
  • Larger stones obstruct the bile duct, causing increased pressure resulting in pain, nausea, and vomiting

Clinical Presentation and Physical Evaluation

  • P.E: Patient may be unremarkable initially
  • Gallstones are generally asymptomatic
  • Symptomatic cholelithiasis may be caused by Intermittent or steady RUQ pain
  • Chronic cases may be recurrent, caused by epigastric pain radiating
  • Murphy's Sign: Deep pain on inhalation
  • Acute cholecystitis develops similarly, though develops into anorexia, N/V and possible sepsis
  • Hypoactive bowel sounds
  • Jaundice may be present

Diagnostics and Differentials

  • CBC with differential/CMP, UA, LFTS, Serum pancreatic enzymes, Serum electrolyte values, BUN and creatinine, Blood cultures if sepsis is suspected, hCGs if of childbearing age, Electrocardiography if cardiac risk factors or suspect cardiac involvement, .
  • Ultrasound- gold standard to confirm diagnosis shows gallbladder thickening and murphy sign.
  • CT scan is used if there is reason for doubt.
  • Differential diagnoses include: bowel obstruction, pancreatitis, peptic ulcer disease, pneumonia
  • Other diagnostics include: chronic cholecystitis, diverticulitis, gastritis, gastroenteritis, hepatitis or hepatic abscess, irritable bowel syndrome, myocardial ischemia or infarction, neoplasm, pelvic inflammatory disease, pyelonephritis, renal colic, or appendicitis

Management of Cholelithiasis and Cholecystitis

  • Mnemonic for who is at risk for cholelithiasis:
  • Age: Increasing age
  • Body Habitus: Obesity, rapid weight loss
  • Childbearing: Pregnancy
  • Drugs: Estradiol, estrogen
  • Ethnicity
  • Female
  • Family Hx
  • If symptomatic or acute cholecystitis, consider cholecystectomy
  • Initial treatment for symptomatic gallbladder disease: isotonic fluids and electrolyte correction (no oral hydration
  • Pharmacologic therapy for acute cholecystitis: Prophylactic antibiotics (secondary infection can develop

Cirrhosis

  • Cirrhosis is a complex irreversible disease caused by exposure to persistent toxins, resulting in liver failure
  • End-stage liver consequence of persistent hepatic fibrosis affecting normal liver function
  • Replacement of normal tissue with injuries leads to impaired nodule development
  • High risk: Older men, T2D, alcohol abuse

Causes of Cirrhosis

  • Alcohol
  • Nonalcoholic liver disease
  • Chronic Hepatitis B/C
  • Tylenol, amiodarone, methotrexate, isoniazid, carbon tetrachloride
  • Inherited idiopathic causes

Clinical Presentation of Cirrhosis

  • Can't be insidious.
  • Early S/Sx are nonspecific
  • Prutitus -W/loss -Anorexia -Muscle Cramps
  • Late stage-Jaundice

Physical Exam of Cirrhosis

  • Jaundice
  • Spider angiomas of face, check abd
  • Gynecomastia
  • Ascites
  • Fatigue
  • Tremors
  • Muehrcke nails

Diagnostics and Differential Diagnosis

  • Idiopathic
  • Primary
  • Hep C & Primary hepatic
  • Cardiac failure
  • Dx- Liver BX

Management

  • Lactulose (encephalopathy)
  • Wernicke Encephalopathy
  • ascites - Spironolactone

Constipation

  • A chronic disorder marked by a lack of vitality, low fluid intake, high fat/protein, decreased activity or medicines
  • Less than 3 bowel movements per week
  • 2 or more of the following sx for 3+ months with onset 6 months
  • Soft, easily passed stools are not present without the use of medication
  • Large amount of feces via digital exam = constipation

Factors Contributing to Constipation

  • Storage of fecal contents to the point that water is resorbed.
  • reduced colonic motility.
  • prolonged gut transit time.

Constipation: Etiology

  • Colonic transit problems
  • Sedentary disorders
  • Medical and psychogenic conditions
  • Structural abnormalities/tumors
  • Low water consumption
  • Ignoring urge to defecate!

Symptoms of Constipation

  • Highly subjective
  • 24- hour dietary and fluid review

Constipation: Additional Findings

  • Palpable mass Oral- poor detention and dehydration
  • Rectal - screening for prolapse, impaction of hemroids

Constipation Diagnostics

  • Dependant on symptomology.

Contipation: Differential Diagnosis

  • R/ O Ileus
  • Intra abdominal infections
  • Megacolon
  • Rule out systemic disease

Constipation: Management

  • Increase fluids to 1.5 -2L a day and fiber 20-30g daily, but slowly
  • Keep a stool diary
  • initiate physical activity
  • massage abdomen to stimulate persistalsis
  • establish regular bowels

Pharmacologic Intervention

  • Probiotics
  • Stool softeners
  • Osmotics like milk of magnesia
  • Stimulants if needed

Diarrhea (Non-Infectious)

  • Def= frequency of 3+ stools on daily basis and consistenty liquid content (stool weigh 250+g)
  • Acute Diarrhea (less than 2 weeks/ usually by infection/ self resolving)
  • Chronic Dia = more than month (autoimmune, endocrine & surgical issues)

Diarrhea Key Notes

  • Look for fever & abd pain dehydration
  • Pt normal stool
  • Chart = when it started + frequency/ consistency
  • Abrupt urgency, abd spams
  • Bloody mucus in stool

Assessment (Diarrhea)

  • recent illness/ trauma
  • W loss. PMDX

Diarrhea Lab Work

stool for blood cbs (electrolyte etc)

DD (Dia)

CDIFF

  • Stress

Dia Treatment

  • antispdsmotic

Diverticular Disease

  • Inflamed/uninflamed and bleeding
  • Colonoscopy often is 1st indicator

Diverticulitis: Clinical Patterns.

  • Most common if asymptomatic with multiple colonic diverticula
  • D: may result in abscess/ fistula formation
  • Hem -associated w/ R sided diverticulum or diverticula.

Diverticulosis

  • Risk fact- red products/ obseity /smoking
  • reduce risks = dietrary fiber, vegetarian

DDX of this Condition

  • colitis, rectal pressure.

Diverticular Disease: Treatments

  • Increase fiber & Exercise as able.
  • If symptoms of colitis - clear liquids & antibiotics

Etiology of Dysphagia

  • The swallowing disorder which can involve 1 or multiples in the normal process.
  • Mild - severe; which can lead malnutrition/dehydration
  • Oropharyngeal area is primary site.

Diagnosis and symptoms

  • Neuromuscular / metabolic disorder / inf /tumor that leads to diff swallowing.

Clinical Presentation

  • Loss of weight.
  • Neuro damage: gait & muscle / stroke is important

Dysphagia: Treatment

  • Diet changes & swallowing therapies like chin tuck rotation
  • The goal is to assist swallow & reduce risk of infection,
  • Head positioning (head tilt, chin tuck, head rotation to affected side, lie on side/elevation), and swallow maneuvers (supraglottic wallow, super supraglottic swallow, effortful swallow, Mendelsohn maneuver) are examples of swallowing strategies and therapies
  • Diet changes can help patients manage with thickened or thin liquids.
  • Gastrostomy tube placement may be necessary

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