DDx 2 Ab pain

how does organ pain usually begin

centrally

what kind of pain is consistent with an irritated parietal peritoneum or organ capsule

localized pain

what kind of pain is consistent with renal/ureter dysfunction

radiation from back to groin

what kind of pain is consistent with a blockage of non-intestinal lumen, rupture, or major vascular event

sudden abrupt pain 

what conditions are pain in the lower right quadrant consistent with

appendicitis

PID

ectopic pregnancy

renal referral

what conditions are pain in the upper right quadrant consistent with

cholelithiasis 

hepatitis

fritz-hugh-curtis 

appendicitis 

will hepatitis feature acute pain

no

what is fitz-hugh-curtis

rare complicaiton of PID resulting in liver capsule inflammation

what population does fritz-hugh-curtis occur in 

almost exclusively in women 

what kind of pain is associated with appendicitis

acute pain

what population should we suspect appendicitis in

young

how does appendicitis typically begin 

anorexia and poorly localized mid-ab pain

followed by nausea and vomiting 

what is the etiology of appendicitis in children and teens

submucosal lymphoid hyperplasia

what is the etiology of appendicitis in adults

fruit seeds

worms

tumors

how does pain behave in appendicitis 

localizes to RLQ over 2-48 hours 

pain is constant and worsened with coughing/jarring 

what are the 2 most important findings associated with appendicitis

central pain migrating to RLQ

pain occurring before vomiting

is psoas sign sensitive or specific

specific

what are images we can take to help DX appendicitis 

high resolution real time ultrasonography 

what is the management for appendicitis

laparoscopic appendectomy

what is the classic presentation of PID

female of childbearing years

lower ab pain w/ fever, chills, dyspareunia and vaginal discharge

what are the most common causes of PID 

C. trachomatis

N. gonorrheae 

H. influenzae 

will lab testing be helpful in PID diagnosis 

no 

save WBC count 

how can we identify the underlying cause of PID

culdocentesis or gram stain discharge

how can we make a definitive diagnosis of PID

laproscopy

what is the treatment for PID 

antibiotics 

what can failure to treat PID lead to

fits-hugh-curtis

ectopic pregnancy

fertility problems

chronic pelvis pain

how common are ectopic pregnancy

1 in 100

where do 98% of ectopic pregnancies implant 

fallopian tube 

what are some s/s of ectopic pregnancy

signs of early pregnancy

tenderness of breasts

early morning nausea

how do we make a definitive diagnosis od ectopic pregnancy

diagnostic ultrasound

what is the treatment for ectopic pregnancy 

laparoscopy 

what hormone will be present in ectopic pregnancy

HCG

what population are kidney/ureter stones more common in 

men 

humid climates, during summer

what are the s/s of kidney/ureter stones

severe pain

nausea

vomiting

what images can be used to visaulize kindeyureter stones

radiographs

diagnostic ultrasound is best

what is the treatment for kidneystones 

allow stones to pass if small enough 

lithotripsy (rare) 

what are some underlying predispositions to kidneystones

genetic

structural

infections

GI disease

where is pain often felt with kidneystones

costovertebral area of lower ribs posteriorly

radiates anteriorly into groin

what are the 3 most common types of kidney stones 

calcium oxalate 

uric acid 

cysteine 

what labs are used to diagnose kidney/ureter stones

renal function (electrolytes, calcium, phosphorus, creatinine)

what can we use to diangose kidney/ureter stones

location of pain

urinalysis indicating hematuria

KUB indicating radiopacity are often diagnostic

what is the management of kidney/ureter stones 

80% pass spontaneously 

calcium channel blockeers 

lithotripsy 

what populations are chcolelithasis more common in

females

diabetics

native americans

oral contraceptive users

what kind of stones are most common in cholelithasis

cholesterol stones

what are s/s assocaited with cholelithasis 

severe RUQ pain with referral to inferior scapula, nausea, vomiting 

what can we use to diagnose cholelithasis

diagnostic ultrasound

what is the treatment associated with cholelithasis

laparoscopic removal

lithotripsy

dissolve stone chemically

what is the common presentation of cholelithasis/cholecystitis 

middle aged or older female with severe abdominal pain 

assocaited with nausea/vomiting after a fatty meal 

what is the etiology of cholecystitis

blockage of cystic duct by gallstones

secondary to pancreatitis or vascular problems in cystic duct

what is the etiology assocaited with cholecystitis

increased biliary cholesterol secretion

delayed emptying of gallbladder

other factors precipitating cholesterol

what are gallstones usually classified as 

cholesterol stones (75%) 

or calcium bilirubinate stones

how do calcium bilirubinate stones form

from breakdown products of hemolysis

what does evaluation look like for a pt with cholecystitis

jaundice on inspection

RUQ tenderness

positive murphy’s sign

referred pain to inferior border of scapula

gallbladder palpable 15% of time 

what will lab evaluation look like with cholecystitis/cholelithasis 

mild leukocytosis 

elevated AP in some cases 

what will treatment look like for cholecystitis

lap choli (persistent diarrhea due to decrease in colonic transit time)

dissolution therapy with bile salts

lithotripsy

what can help prevent cholecystitis/cholelithiasis

losing weight

activity

coffee intake

what are the main causes of hepatitis 

viral infection (medications or alcohol)

describe hepatitis A

mild symptoms

absorption through contaminated food/water

tends to resolve with onset of jaundice

describe hepatitis B

trasnmitted through blood, saliva, or seminal/vaginal fluids

pre-cancerous

describe hepatits C 

transmitted through blood, saliva, or seminal/vaginal fluids 

liver destruction often fatal 

describe reflux esophagitis

pain on full stomach

worse with recumbency

describe peptic ulcers

symptoms begin in 20’s

H. pylori superinfection

recurrent pain felt on empty stomach

relieved by antacids

unaffected by position

describe pancreatitis 

severe pain radiating to back with nausea and vomiting 

pt often bent forward or fetal position to relieve symptoms

describe pancreatitis causes (other than EtOH)

gall stones

medications (ACE, corticosteroids, statins) 

sudden stoppage of medications for diabetes and hyperlipidemia 

surgical procedures involving ERCP 

infection 

what will the evaluation look like with pancreatitis

mild fever

tender distended upper abdomen

possible signs of hypotension

what will exam look like with pancreatitis

absent bowel sounds

mild jaundice

flank discoloration

umbilicus discoloration

what labs will help diagnose pancreatitis 

serum amylase and lipase elevated to almost 3 times normal value 

what complications can be assocaited with pancreatitis

hypovolemia (secondary to fluid loss in bowels)

ARDS (adult respiratory distress syndrome)

what is the treatment associated with pancreatitis

pain medication

bed rest

what is the prognosis associated with pancreatitis 

spontaneous resolution 

how can we prevent pancreatitis

avoid causative agent/substance

weight loss to lessen severity of attacks

how can chronic recurrent abdominal pain mainfest

diarrhea/constipation

primary diarrhea with low back pain

sharp increase in pain during menses

what is diarrhea/constipation associated with 

IBS

spastic colon 

what is primary diarrhea with secondary low back pain associated with 

ulcerative colitis 

crohns 

what is a sharp increase in pain with menses associated with

endometriosis

pelvic tumor

describe crohns disease

patchy transmural involvement of small intestine

more likely to result in intestinal obstruction

describe ulcerative colitis 

superficial 

heavy bouts of diarrhea and main complaint 

blood in stool likely 

fluid levels may be concerning 

what do both crohns and ulcerative colitis have in common

associated HLA-B27

describe diverticulitis

herniation of mucosa/submucosa into colonic muscle wall

lower ab pain associated with low grade fever, blood ins tool and mild leukocytosis

how common is diverticulitis

found in 1/3 of people over 60 in wester societies

how will diverticulitis present 

elderly patient with pain/tenderness in LLQ 

associated low grade fever

herniation into submucosa due to colonic pressure of undistended bowel 

how can we evaluate diverticulitis

ab and chest x-rays to ID free air

how is the DX of diverticulitis made

upon hospitalization

with outpatient barium study

colonoscopy

how do we manage diverticulitis 

10-35g insoluble fiber 

if active antibiotics and IV may be necessary 

what is recommended for diverticulitis

bran- improves glucose tolerance and increases fat excretion, introduce gradually to avoid cramping 

what is the presentation of ulcerative colitis

younger patient with frequent bloody diarrhea

lower ab cramping

rectal urgency (10-20% have multiple joint pain)

what is the etiology behind ulcerative colitis

unknown

what are the locations of ulcerative colitis 

50% distal colon 

30% splenic flexure 

20% extended into proximal bowels 

what is the evaluation assocaited with ulcerative colitis

hypovolemia in severe cases

labs reveal decreased (HCT) and albumin

increased ESR and core temperature

how common is perinuclear antineutrophil cytoplasmic antibody (pANCA) in ulcerative colitis

50-85%

what is the management for ulcerative colitis 

NSAID or aspirin 

what is the treatment for ulcerative colitis

anti-inflammatory

anti-diarrheal

immunosuppressive meds

what are the dietary recommendations for ulcerative colitis

decrease meat and EtOH

increase omega 3

cod liver oil

wheatgrass

what is the presentation of crohns disease 

young person 

RLQ pain

diarrhea

low grade fever 

what is the etiology of crohns

unknown

possible genetic acquired sensitivity

environmentally triggered reaction to MMR, varicella, zoster

what happens in the intestines during crohns

chronic t-cell activation 

damaged by macrophage recruitment 

what is the evaluation for crohns

tender right lower quadrant upon palpation with weight loss

what labs are assocaited with crohns disease

relatively non-specific

increased ESR, MCV, leukocytosis

decreased albumin

what is the DX asscoaited with crohns disease 

colonscopy 

barium studies 

skip lesions

string sign 

what kind of lesions are assocaited with crohns

skip