Gastrointestinal/ GU

Urinary Tract Infection

• The most common bacteria associated with UTIs is E. coli.
• Symptoms include urinary frequency, lower abdominal or back discomfort, burning and pain with urination (dysuria), cloudy or foul-smelling urine, and hematuria.
• Fever is rare in adults but common in children with upper UTIs.
• Red flags include fever, chills, vomiting, lower abdominal/back pain, and CVA tenderness, which may indicate pyelonephritis.
• Diagnosis of a UTI involves a urinalysis showing WBCs, positive leukocytes esterase, nitrites, and protein.
• First-line treatments are Nitrofurantoin (Macrobid), TMP-SMX (Bactrim), and Fosfomycin (Monurol).
• Health promotion: Instruct patients to wipe from front to back to prevent UTIs.

Cholecystitis

• Most cases are associated with the presence of gallstones.
• Patients may experience RUQ pain or epigastric pain that radiates to the right shoulder or subscapular area, mild fever, anorexia, nausea, and vomiting.
• Symptoms often occur after a large or fatty meal.
• A red flag is a positive Murphy's sign, where pain occurs when pressing the RUQ of the abdomen while the patient holds their breath.
• Diagnostics: Ultrasound is the first line; a HIDA scan is used if the ultrasound is negative.
• Elevated WBC count suggests infection/inflammation as well as elevated liver enzymes (AST, ALT) and bilirubin in some cases
• Treatment of severe attacks includes NPO, while mild cases require avoiding fatty foods.
• Can treat with Laparoscopic or open cholecystectomy within 72 hours of diagnosis.

Pancreatitis

• Characterized by the abrupt onset of deep epigastric pain, often radiating to the back, described as burning or shooting pain, accompanied by nausea, vomiting, sweating, and weakness, abdominal tenderness and distention, guarding, fever and tachycardia.
• Diagnostics involve leukocytosis and elevated serum amylase and lipase, with levels more than 3x the upper limit of normal within 24 hours.
• CT scans confirm the diagnosis and assess severity.
• Ultrasound evaluates gallstones or biliary obstruction.
• MRCP (Magnetic Resonance Cholangiopancreatography) is used for detailed biliary imaging.
• Treatment relies on resting the pancreas via NPO for 3 days, bed rest, NG suction in severe cases, meperidine (Demerol) for pain relief, and IV fluids and electrolyte management.
• Health promotion: Educate on how alcohol abuse and gallstones account for most cases in the US.

Nephrolithiasis/Urolithiasis

• Recognition: Severe colicky pain (renal colic) in the abdomen, flank, or groin along with blood in the urine.
• Most serious type of stone is staghorn due to large branching.
• Spiral CT is the gold standard for diagnostics, but remains expensive
• KUB x-ray will not identify uric stones, small stones, or stones over bony prominences
• Ultrasound is a cost-saving measure for pregnancy
• Treatment includes supportive care and surgery
• Education includes hydration

Gastric Ulcer

• Usually asymptomatic, but dyspepsia is the most common complaint; may be associated with reflux and N/V.
• Other symptoms are pain w/ eating, which may be dull, burning, or gnawing, iron deficiency anemia, and perforation, leading to a board-like abdomen with rebound tenderness.
• Diagnostics include upper endoscopy, double-contrast barium radiography of the upper GI system, and a urea breath test for H. pylori, which requires a 6-hour fast and no PPI use.
• Treatment: PPI for 8 weeks based on etiology.
• Sucralfate may be prescribed.

Gastroesophageal Reflux Disease (GERD)

• Can cause chronic sore throat, hoarseness, dysphagia, teeth erosion, heartburn (cardinal sign, pyrosis), regurgitation, lump in throat sensation, chest pain.
• Bilious vomiting and hematemesis are red flags in children.
• A complication from GERD is Barret esophagus
• Diagnostic approach is based on symptoms.
• An 8-week course of PPIs is a common treatment.
• Lifestyle modifications include avoiding caffeine, chocolate, tomatoes, and spicy foods, as well as weight control.

Acute Kidney Injury

• Characterized by abrupt onset within 48 hours, oliguria may be present, a rise in serum creatinine of >0.3mg/dL or an increase of >1.5 times baseline serum creatinine with reduction of urinary volume of <0.5mL/kg/hr for at least 6 hours.

Hemorrhoids

• Are most common in pregnant women
• Symptoms: constipation, increased venous pressure, bleeding, itching, and pain with defecation.
• Anemia and colon cancer could be red flags
• Treatment includes: Preparation H, fiber, stool softeners, avoiding prolonged sitting, avoiding straining, sitz baths and surgery (rubber band ligation)

Pyelonephritis

• Involves fever with high chills, CVA tenderness, unilateral flank pain, N/V, headache, delirium, and dysuria, frequency, and urgency when urinating.
• Delirium, AKI, sepsis, and renal scarring are red flags.
• Diagnostics: Urinalysis with culture and sensitivity (C&S) and CBC (leukocytosis).

Constipation

• Results in bloating/distention, guarding pain, foreign body feeling in rectum, decreased bowel movements, rectal inflammation
• Hemorrhoids, obstruction, cancer, and anticholinergic medications are red flags.
• Diagnostics include physical exam, DRE, occult blood test, and TSH
• Treatment involves MiraLAX/fiber, stool softeners, hydration, Senakot (stimulates bowel muscles), and Linzess (draws water to bowels).

Prostatitis

• Recognition: E. coli is more common in those >35 years old, while gonorrhea/chlamydia is more common for those <35 years old.
• Symptoms include low back pain, perineal pain including the scrotum, testes, and penis, and a decreased urinary stream secondary to urinary retention.
• DRE: Gentle prostate exam should be performed only if it's done.
• The prostate will be extremely tender, boggy, and possibly warm.
• UA (large WBCs, hematuria) and urine C&S, repeat 4-6 weeks after treatment initiated.

• 35yrs olds should take Ciprofloxacin or Levaquin (educate about risk of tendon rupture) for 4-6 weeks

• <35yrs olds should treat for gonorrhea and chlamydia
• Administer antipyretics, stool softener, sitz bath.
• Refer to ED if septic or toxic

Hernia

• Recognize inguinal hernia via physical exam and CT of the abdomen, pelvis
• Push it back in, surgery is an option, education on referrals and follow up
• Red Flags: blockage or a strangulated hernia- a medical emergency

Epididymitis

• <35 years: gonorrhea & chlamydia

• 35 years: Enterobacteriaceae (E. coli)

• If testicular torsion is suspected, do not delay treatment to obtain imaging