1. Pain

2. Pyrosis

3. Nausea and/or emesis

4. Derangement of swallowing

5. Increaseing Abdominal Girth

6. Jaundice

7. Change in Bowel Habits

8. GI Bleeding

ROS Complaints Referable to the Abdomen...PAIN

1. How does the bowel cause visceral pain?

2. How might the bowel cause somatic pain?

3. What should you always relate the pain to (FOUR THINGS)?

4. What two qualities of the pain should always be asked about?

5. What disease does gnawing epigastric pain made better with milk or bland food suggest?

6. What is severe spasmodic pain coming in paroxysms  that often make the patient writhe referred to as?

7. What is COLIC caused by?

8. What type of Colic DOES NOT HAVE a spasmodic quality

9. What disease should you be aware of if pt with risk factors for vascular obstruction (Afib, Peripheral Vascular disease) presents with very severe central abdominal pain that far exceeds the abdominal tenderness early on?

1. Bowel causes visceral pain by distention, contraction, and ischemia, NOT BY CUTTING OR INFLAMMATION

2. Somatic pain is experience if peritoneal inflammation ensues due to physical contact of an inflamed organ or rupture with peritonitis (ABDOMINAL WALL PAIN...focal pain with associated tenderness)

3. Should always relate pain to food intake (better/worse), bowel movements, DEMOGRAPHICS, PREDISPOSITIONS TO DISEASE (for these last two, help you with you INDEX OF SUSPICION...Ex: acute appendicitis is usually in a young person, and western diet good for appendicitis, whereas in other places without western diet, some parasitic ascaris worms might more cause those sx...so need to know where you are...)

4. Always ask about the character and radiation of the pain (Pain that STARTED OUT VISCERAL can TURN INTO SOMATIC PAIN

5. Duodenal Ulcer

6. Colic

7. COLIC is caused by peristaltic contractions of a muscular tube (Bowel, biliary tree, pancratic duct, ureters, uterus, and fallopian tubes)

8. Biliary Colic

9. MESNENTERIC ISCHEMIA (deadly if not discovered and treated early)

ROS Complaints Referable to the Abdomen...PYROSIS

1. Commonly termed? (what does it feel like)

2. Is infrequent pyrosis unusual?

3. What does severe and/or frequent pyrosis indicate?

4. What is the most common cause of severe pyrosis? (what is it due to?)

5. How does this most common cause of sever pyrosis present?

6. What does dysphagia complicating GERD suggest?

1. Heartburn.  Feels like a retrosternal sensation of warmth of burning, usually radiating to neck and occasionaly to the arms

2. No

3. Severe/frequent pyrosis indicates esophogeal pathology

4. GERD, usually caused by lower esophogeal sphincter incompetence. (refluxate contacting inflamed mucosa...esophagitis)

5. GERD PRESENTS WITH...

 a. May Present  as chronic cough, asthma, hoarseness, Pulmonary Aspiration, or Angina-like Ches pain

 b. Spontaneous apperance of fluid in mouth and foul morning breath

 c. Symptoms typically appearing after a large meal or when supine, with Bleeding/Stooping

6) Peptic Stricture

ROS Complaints Referable to the Abdomen...NAUSEA and/or EMESIS

1. What may emesis be medaited by? (3 things under one generall umbrella)

2. Why might the significance of acute anorexia in one patient be equivalent to emesis in another?

3. What TWO THINGS should you always note with emesis?

1. Emesis may be mediated by neural stimulation as in...

 a. Acute Peritonitis

 b. Bowel Obstruction

 c. Toxins/Drugs actiing at the medullary trigger zone

2. Because the sensation necessary to produce vomiting is the same in every patient

3. Always note...

 a. precipitating events to emesis, including eating, pain, etc

 b. Quality of vomitus (stomach contents, bilious material, feculent material, blood...all this may help decide the location of a bowel obstruction IF one is present)

4.

DERANGEMENT OF SWALLOWING

1. What is the term for difficulty swallowing?

2. What is the term for painful swallowing?

3. What is painful swallowing fairly specific for?

4. What is the term for the sensation of having a lump in your throat, but there is no difficulty when actual swallowing is performed?

5. With difficulty swallowing, why should you always ask the patient the location of the obstruction?

6. What two things associated with eating should you ask the patient?

7. Name three things amonst many that can cause difficulty swallowing

1. Dysphagia

2. Odynophagia

3. Painful swallowing is fairly specific for Esophogeal Erosion/Inflammation (if upper airway source is excluded)

4. GLOBUS HYSTERICUS

5. With Dysphagia, you should always ask the patient the location of the obstruction because...

 a. Localization SUPERIOR to the sternal notch is INNACURATE

 b. Localization to the chest usually denotes OBSTRUCTION BELOW THE NECK

6. Ask the patient some things about eating...

 a. Do Solids or foods cause difficulty?

 b. Must food be regurgitated after eaten for failure to pass?

7. Dysphagia can be caused by many things, four of which are...

 a. problems with the oropharyngeal phase of swallowing (Stroke, ALS)

 b. Motility Disorders

 c. Intrinsic or Extrinsic Obstruction

ROS Complaints Referable to the Abdomen...INCREASING ABDOMINAL GIRTH

1. What is the most obvious cause?

2. New onset ascities may be the presentation of what four things amonst many?

3. What are two things seen in women that can cause an enlarging abdomen? (what exam will show these)

4. What GI issue can present as an enlarging abdomen? (What will this sound like)

5.

1. Obeisity

2. NEW ONSET ASCITES...

 a. Hepatic Cirrhosis

 b. Right Sided Heart Failure

 c. Peritoneal Tuberculosis

 d. Ovarian Cancer with Metastisis

3. Pregnancy and very large benign ovarian tumors (recorded >200 lbs) (confirmed on pelvic exam)

4. GI OBSTRUCTION with consequent dilation (Distended Bowel will be TYMPANIC)

5.

ROS Complaints Referable to the Abdomen...JAUNDICE

1. What is it due to?

2. Name three places it is initially noticed

3. Name Five Causes (what are the most common?)

4. What must True Jaundice be differentiated from?

5. What six things must one always ask the patient about when see Jaundice?

6. What do Clay colored (acholic) stools suggest?

7. What do silver colored stools suggest?

8. In addition to many other diseases, what may GENERALIZED PRURITIS be a prominent symptom in?

1. Hyperbilirubinemia

2. Sclera, Skin, Tea Colored Urine

3. FIVE CAUSES (usually result of Liver/Biliary Disease)

 a. Liver Disease

 b. Biliary Tract Disease

 c. Brisk Hemolysis

 d. Ineffective Erythropoesis (as in B12 deficiency)

 e. Prolonged Fasting

4. True Jaundice must be differentiated from CAROTENEMIA (excess intake of carotene containing foods) where the skin may be yellowed but sclera remains white

5. Always ask...

 a. Liver disease

 b. Hematologic Disease

 c. Family History

 d. Drug History

 e. Dieatary History

 f. Color of Stools

6. Clay colored (ACHOLIC) stools suggest Biliary Obstruction

7. Silver colored stolls suggest Carcinoma of Ampulla of Vater (small amount of blood and acholic stool)

8. GENERALIZED PRURITIS May be prominent symptom in CHRONIC BILIARY OBSTRUCTION, Particularly PRIMARY BILIARY CIRRHOSIS

ROS Complaints Referable to the Abdomen...CHANGE IN BOWEL HABIT

1. What should diarrhea be divided into?

2. What is Acute diarrhea usually due to?

3. Name three symptoms of food poisining (If suspect food posining, need to relate sx to food, and get evidence of others eating food being sick)

4. What is DYSENTARY? (what three sx accompany it?)

5. What is Chronic Diarrhea defined by? (six things it may be due to)

6. The presence of ?? should be ascertained in any patient with diarrhea or loose stools (What is a common sx of this thing?)

7. What can Steatorrhea occur secondary to?

8.  Name seven (amont many) causes of CONSTIPATION

9. If pt has Constipation, what is it impt to ask pt about?

1. Acute vs Chronic

2. Acute Dirrhea usually due to INFECTION or ENTERIC TOXIN (produced by infecteous agent)

3. FOOD POISINING...sx hrs after ingestions

 a. Diarrhea

 b. Nausea

 c. Emesis

4. DYSTENTARY is term given to acute diarrhea or small volume due to INVASIVE INFECTION Of large bowel....  

 a. The stool is mized with mucous and blood

 b. a/w cramping

 c. a/w urge to defecate with little result (TENESMUS)

5. Chronic Diarrhea is defined by its persistence for weeks or months.  May be due to...

 a. inflammatory disease

 b. pancreatic insufficiency

 c. intestinal atrophy

 d. secratory tumors

 e. partial obstruction by tumor

 f. functional syndromes (irritable bowel syndrome)

6. Presence of MALABSORBTION (Steathorrhea is common sx: greasy foul smeelling stolls that float in bowel and are difficult to flush)

7. Steatorrhea can occur secondary to Pancreatic Insufficiency or Diffuse Small Bowel Disease (eg Celiac Sprue)

8. Constipation

 a. inadequate dietary roughage

 b. lack of exercise

 c. supression of urge

 d. FUNCTIONAL ABNORMALITIES

    i. Drug use (anti-cholinergics, narcotics)

    ii. Electrolyte abnormalities

    iii. Hypothyroidism

 e. MECHANICAL PROBLEMS

    i. Colorecatal Carcinoma

    ii. Others

9. Ask CONSTIPATION PT about...

 a. prescription and illicit drug use

 b. evidence of systemic disease

 d. bleeding, pain

 e. Change in Stool Caliber (thin stools may be due to rectal or sigmoid cancer)

ROS Complaints Referable to the Abdomen...GI BLEEDING

1. How is it "divided?"

2. Bleeding proximal to ?? has potential to produce Hematemesis?

3. What does blood that has undergone partial digestion look like?

4. What four places may bleeding arise from?

5. Is bleeding from Biliary Tree and Pancreatid Ducts common or rare?  Upper or Lower Tract?

6. What does blood that has undergone digestion look like?

7. In addition to digested blood, what can brisk upper tract bleeding cause? (what is the TERM?)

8. Bleeding from Below the Ligament of Trietz is much more likely to have WHAT ORIGIN and WHAT WILL IT PRESENT WITH?

1. Divided into UPPER and LOWER tracts by ILIOCECAL VALVE

2. Bleeding proximal to LIGAMENT OF TRIETZ has the potential to be vomited up...Hematemesis

3. Dark, often described as "coffee-ground."

4. Bleeding may arise from ESOPHAGUS, STOMACH, DOUDENUM

5. Rare, Upper

6. Blood that has undergone digestion is black and tarry...MELENA or MELANIC STOOL. 

7. Brisk Upper Tract Bleeding can cause passage of blood per Rectum..HEMATOCHEZIA

8. Bleeding from Below the Ligament of Trietz is much more likely to have COLONIC or RECTAL ORIGIN (*Ask regaring HEMMARHOIDS) and Presnent with FRANK HEMATOCHEZIA or FLECKS OF BLOOD in toilet bowel or on toilet paper

1. Iron

2. Bismuth

NINE things to ask a patient with a history of GI BLEEDING

**Also seek to include evidence of HEPATIC CIRRHOSIS and CAREFUL SKIN EXAMINIATION**

*Many syndromes may manifest GI BLEEDING with charactersitic Derm findings*

1. Ethanol History (a/w Peptic Ulcer, Cirrhosis)

2. Sx suggestive of PUD

3. NSAID use (Peptic Ulcer)

4. Hx of Hepatic Cirrhosis (variceal Bleeding in particular, but coagulopathy in general predisposes to bleeding)

5. Bleeding Diathesis

6. Change in Bowel Habits (Constipation and lower bleeding-consider colon cancer, many other associations)

7. Vomiting or Retching (consider esophogeal tear-Mallory Weiss syndrome)

8. Presence of hemorrhoids

9. Hx of abdominal surgery or Aortic Aneurysm

1. What is the approach to the ABDOMINAL EXAM?

2. "Absent" Bowel sounds requires listening for how long?

1. Inspection, Auscultation, Palpation

2. Requires listening for 1-2 minutes

ABDOMINAL EXAM TECHNIQUE: Checking for Rebound Tenderness

1. Where is rebound tenderness felt?

2. What is it a sign of?

3. Do experts think its a great test?

1. Pain felt on letting up after deep palpation of the abdomen, classically in an area distint from the examining hand

2. Sign of generalized peritoneal inflammation

3. No.   They think causes more discomfort than help.

ABDOMINAL EXAM TECHNIQUE: Palpating the Aorta

1. What is the most common cause of enlargement of the abdominal aorta?

2. How do you palpate it?

3. What should you consider if you feel a large pulsatile mass, esp if tender?

1. Atherosclerosis with weakening of the vessel wall

2. Gently palpate the epigastric area until pulsations are felt.  Determine width using both hands with the fingertips

3. Rapidly enlarging Aneurysm at risk for rupture

ABDOMINAL EXAM TECHNIQUE: Checking for Ascites

1. Can you tell if pt has it on gross inspection?

2. What is the best test for Ascites?

3. How is this test performed?

1. Usually (bulging flanks in a cirrhotic pt).  However, a small amount of fluid is easily missed even by the best examiner

2. SHIFTING DULLNESS.

3. Alternately placing pt in supine and lateral decubitus positions and marking the change in dullness.  Testing for a fluid wave may also be done, but this is generally less helpful

ABDOMINAL EXAM TECHNIQUE: Assessing Liver Size

1. Name a few techniques available to determine liver size (superior vs inferior edge)

2. Why is it impt to perform both?

3. When palpating inferior edge, in addition to size, what else are you feeling for?

4. In pts with Alcoholic Cirrhosis, which lobe of the liver may be disproporiotnaly changed?

1. Liver Percussion or Scratch Test for Superior, Simple palpation of RUQ with deep inspiration (for inferior edge)

2. Because Liver can be displaced inferiorly by condition such as emphysema, and this may make a normal organ appear larger

3. Also feeling for consistency and nodularity

4. In pts with Alcoholic Cirrhosis, the LEFT LOBE of the liver may be disproportionally enlarged

ABDOMINAL EXAM TECHNIQUE: Assessing Splenomegaly

1. As spleen enlarges, where does it move?

2. When looking for an enlarged spleen, where should you feel, and why?

3. What is the technique?

1. It moves inferiorly below the costal margin

2. Always start at the pelvic brim on the left and palpate upwards (allows you NOT TO MISS palpating a massively enlarge organ such as occurs during CML and certain parasitic diseases)

3. As move upwards, palpate with the right hand while gently placing pressure in the left flank, trying to "lift" the spleen into the examining hand.  ASK PT TO TAKE A SLOW DEEP BREATH.  If Splenomegaly is suspected but not confirmed, place the patient in the right lateral decubitus position and repeat the maneuver.  BE GENTLE (enlarged spleens may be tender, and pt may involuntarily limit respiratory excursion to prevent palpation by a "rough" hand)

ABDOMINAL EXAM TECHNIQUE: KIdney Palpation

1. Are normal kidneys palpeable?

2. When kidneys are found to be enlarged, name things on differential

1. Not really, only in really thin people

2. Differential for enlarged kidneys include...

 a. Renal Cell Carcinoma

 b. Polycystic Kidney Disease

 c. Hydronephrosis

 d. Xanthogranulomatous Pyleonephritis (rare complication of reccurrent infection)

ABDOMINAL EXAM: Murphey's Sign

1. What is it?

1. Splinting and increased tenderness on inspiration upon palpation of the RUQ in acute cholecystitis

ABDOMINAL EXAM: Courvoisier's Sign

1. What is it?

2. What does it suggest?

1. A palpable (occasionaly visibly enlarged) GALLBLADDER

2. It suggests extra-hepatic Biliary Obstruction (Often due to PANCREATIC CANCER)

ABDOMINAL EXAM: Obturator Sign

1. What is it?

2. What are two common conditins that produce it?

1. Internal rotation of the flexed hip causes hypogastric pain when inflammation overlies the fascia of the obturator internus muscle

2. Perforated Appendix, Abscess localized to this region

3. Obturator sign can be in acute appendicitis.  It can be in anything involving that inflammation, but in the appropraite setting, due to acute appendicitis.  But not very specific.  Vermiform appendix (which gets blocked and inflamed) could be pointing in any direction, and could be touching various things.  So these signs are trying to figure out where it could be inflamed.

ABDOMINAL EXAM: Rovsing's  Sign

1. What is it?

2. What does it suggest?

1. Pain the RLQ upon pressure to the LLQ

2. Suggests acute appendicits

ABDOMINAL EXAM: Psoas Sign

1. What is it?

2. When positive, what does it denote?

3) Name three possible causes

4) Are most cases of Acute Appendicitis Positive?

1. Pt lies on side opposite that of suspected pathology.  Examiner extends thigh to full extent.  Alternatively the patient can be asked to actively flex the thigh against pressure.  When the patient feels PAIN UPON EXTENSION, this is a POSITIVE PSOAS SIGN

2. Positive Psoas sign denotes INFLAMMATION of the overlying psoas muscle, Usually due to Inflamed Appendix, but like with the obturator sign, ANY cause of inflammation could potentially produce this response)

3) CAUSES...

 a. Appendicits

 b. abscess

 c. diverticulitis

4) NO (not the most common position for the inflamed appendix) (SENSITIVE BUT NOT SPECIFIC)

ABDOMINAL EXAM: Splenic Percussion Sign

1. What is it?

2. What does it suggest?

1. Change in percussion note from tympany to dullness with inspiration

2. Suggests Splenomegaly

ABDOMINAL EXAM: Hepatic Bruit

1. What is it?

2. What does it suggest?

1. A pulsatile "whooshing" sound with arterial pulsation heard over the liver

2. Suggests hepatocellular carcinoma (alcoholic hepatitis is also reported as a cause)

ABDOMINAL EXAM: Hepatic Venous Hum

1. What is it?

2. What does it suggest?

1. A soft humming sound heard in BOTH systole and diastole. 

2. Suggests increased collateral circulation between portal and systemic venous circulations as in hepatic cirrhosis

ABDOMINAL EXAM: Friction Rubs

1. What is it?

2. What does it indicate?

3. Name four conditions in which it may be present

1. It is a grating sound overlying an area heard with respiratory variation

2. It indicates focal inflammation of the peritoneal surface of an organ

3. May be present in...

 a. Hepatocellular Carcinoma

 b. Splenic Infarction

 c. Perihepatitis

 d. Recent Liver Biopsy

ABDOMINAL SYNDROMES: Acute Appendicitis

1. Predominately a disease in what population?

2. How does the disease come about?

3. Give the chronology of the signs and sx (there are five of them)

4. Where is the pain intially?

5. What two signs may detect posterior/pelvic appendiceal inflammation?

6. If a pt has a truly rigid abdomen, what two things can be assumed?

7. What addition sign may also be present?

1. Young Westerners (HIGHEST in 2nd and 3rd decade)

2. Impacted fecalith produces obstruction of the mouth of the appendix with consequent inflammation, bacterial superinfection and abscess formation, and rupture with perotinitis

3.  Chronology of signs and Sx...

 a. Pain (epigastric, periumbilical)

 b. Anorexia, Naseua, vomiting (can occur a few hours after onset of pain)

 c. Deep Tenderness

 d. Fever

 e. Leukocytosis

4. INITIALLY, the pain is NOT over the RLQ, but over time, the pain and tenderness becomes evident in this area, depending on the anatomic location of the structure. 

5. Psoas and Obturator signs may detect the inflam

6. Rupture and Peritonitis

7. Rovsing's Sign

ABDOMINAL SYNDROMES: Acute Cholecystits

1. Initial pain is that of ??

2. With time, what differentiates the pain here from that of Biliary Cholic

3. With this progression, what is the pain now due to?

4. What else is present here that should be absent in uncomplicated biliary Cholic?

5. What may be felt on the abdominal exam?

6. What sign may be present here that is absent in Biliary Colic?

1. Biliary Colic

2. However, with acute cholecystitis, the pain returns after a pain free interval of several hours and is then different in quality

3. Pain is now due to irritation of the peritoneum by an inflamed gallbladder and is described as a constant ache made worse by motion, cough, or sneezing

4. Low grade fever

5. A hard, distended gallbladder

6. Murphy's Sign

ABDOMINAL SYNDROMES: Acute Hepatitis

1. Name six potential causes

2. With the classic case of viral Hep, how do the sx begin?

3. What may this pt complain of?

4. Name 3 things that may develop in such a patient 1-2 weeks after prodromal sx

5. Name 2 differences to the liver that may be noted on abdominal exam

1. Six potential causes of Acute hepatitis (among others)...

 a. Viral

 b. Other infecteous agents

 c. Ethanol Abuse

 d. Numerous drugs and toxins

 e. Autoimmune

 f. Metabolic Diseases

2. With the classic case of viral hep, the sx begin with general constitutional complaints such as malaise, fatigue, headache, arthralgia, and Upper Respiratory sx

3. Pt may complain of unpleasant taste to food and coffee

4. Clay Colored Stools, Darkened Urine, and ultimately Jaundice may develop 1-2 wks after prodromal sx

5. The liver may be TENDER to palpation and is often enlarged

ABDOMINAL SYNDROMES: Acute Pancreatitis

1. Most bouts of Acute Pancreatitis occur secondary to ??

2. Name five other less common causes

3. What is the most important sx, and what is it often accompanied by?

4. What is the quality of the pain?

5. Where is the pain felt?

6. Where does the pain radiate?

7. What happens if significant bleeding occurs? (What two signs may be present?)

8. What is a potential finding (in addition to maybe seeing these signs) on abdominal exam?

1. secondary to Alcohol or Gallstones

2. Less common causes include...

 a. Hypertriglyceridemia

 b. Hyperparathyroidism

 c. Drugs

 d. Autoimmune

 e. Idiopathic

3. Pain is most impt sx, often a/w vomiting/retching

4. Pain is generally SEVERE (but pain CAN be less pronounced with lesser degrees of organ injury)

5. Pain is felt in EPIGASTRUM and in the back/loin area

6. Occasionaly the pain will radiate to the left scapular area

7. If significant bleeding occurs, extravasated blood may track through the fascial planes of the peritoneum and may be seen over the flanks as Greenish/Yellowish discoloration (sing of GREY TURNER) or Perimumbillically (CULLEN'S SIGN)

8. Abdomen is generally Tender over the epigastrum

ABDOMINAL SYNDROMES: Biliary Colic

1) Although described as Colic, why is it different?

2) When does this symptom occur?

3) What kind of PAIN? (a/w with what?)

4) Where may the pain be localized to? (what else may feel in one of these areas?)

5) What is this pain's charactersitic radition?

6) When do the sx and exam findings resolve?

1) Although described as Colic, Biliary Colic is not paroxysmal as in other Colics

2) This symptom occurs when a GALLSTONE because lodged in the CYSTIC, HEPATIC, or COMMON BILE DUCT

3) This event causes acute onset of severe, constant pain, often associated with vomiting

4) May be localized to the RUQ and/or MIDLINE EPIGASTRUM (also may feel TENDERNESS in RUQ)

5) Characterstic radition of pain to an area BELOW right scapula

6) WHen stone passes, the sx and exam findings resolve

ABDOMINAL SYNDROMES: Diverticulitis

1) Younger or older pts?

2) How does it occur? (what side is more common?)

3) Because this process occurs outside the peritoneum, signs and sx are similar to, but usually not as striking as that found in ??

4) On exam, tenderness can usually be found over ??

5) What may be palpated, where, and what does it represent?

1) Typically in OLDER pts (Is present in 20-50% of pts >50)

2) Occurs due to FECALITH obstructing the mouth of a diverticulum in the left colon...becomes inflamed...may develop into an abscess and rupture (LEFT:RIGHT 3:1)

3) Because this process occurs outside the peritoneum, signs and sx are similar to, but usually not as striking as that found in ACUTE APPENDICITIS

4) On exam, tenderness can usually be found over LLQ

5) Occasioanly a mass may be palpated in the LLQ, reflecting a localized diverticular abscess

ABDOMINAL SYNDROMES: Appendicitis VS. Diverticulitis

1) EARLY, VISCERAL PAIN

2) NAUSEA, EMESIS

3) CHANGE IN BOWEL HABIT

4) FEVER and LEUKOCYTOSIS

5) LATER PAIN and TENDERNESS

1) EARLY, VISCERAL PAIN

 a. Appendicitis: Epigastric or Periumbilical

 b. Diverticulosis: Hypogastric

2) NAUSEA, EMESIS

 a. Appendicitis: Prominent

 b. Diverticulosis: LESS Prominent

3) CHANGE IN BOWEL HABIT

 a. Appendicitis: Initial Urge to Defecate is common

 b. Diverticulosis: More prominant Diarrhea

4) FEVER and LEUKOCYTOSIS

 a. Appendicitis: Absent Early

 b. Diverticulosis: More pronounced

5) LATER PAIN and TENDERNESS

 a. Appendicitis: Shifts to RLQ

 b. Diverticulosis: Shifts to LLQ/Suprapubic Area

ABDOMINAL SYNDROMES: Hepatic Cirrhosis

1) Four potential causes

2) Always symptomatic?

3) How may Cirrhotic pts initially present? (due to what)

4) What are four sx it may present with?

5) Need to take a very careful history with the pt, especially noting what FIVE things?

6) Name four exam findings related to high blood levels of Estrogen

7) What accounts for the Hyperventilation often seen?

8) Name FOUR Sequale of portal hypertension

9) Name three other common exam findings relating to the head (one is in eyes, two are in brain)

10)  Ways the liver can look?  What about if Alcoholic?

11) In addition to many of the above findings, name two exam findings that Alcoholics with Cirrhosis may have

1) Potential Causes

 a. Ethanol Abuse

 b. Prior Viral Infection

 c. Metabolic Disease

 d. Autoimmune Conditions

2) May be asymptomatic and discovered in the evaluation of other complaints

3) May initially present with massive GI bleeding due to portal hypertension

4) Symptoms...

 a. Anorexia

 b. Fatigue

 c. Abdominal Distension due to ascites

 d. Jaundice

5) A careful history, noting...

 a. Drug use (prescription and illicit)

 b. Alcohol Use

 c. Prior Hepatitis

 d. Family History

 e. Occupational Exposure

6) Four exam findings related to high blood levels of Estrogen...

 a. Spider Angiomas

 b. Palmar Erythema

 c. Gynecomastia

 d. Testicular Atrophy

7) INCREASED PROGESTINS account for the Hyperventilation often seen

8) FOUR Sequale of portal hypertension...

 a. ASCITES

 b. Splenomegaly

 c. Dilated Abdominal Wall Veins

 d. Enlarged INTERNAL hemmorrhoids (on rectal exam)

9) SCLERAL ICTERUS, ENCEPHALOPATHY, and ASTERIXIS (change in AA profile) are also often present

10) The liver can be enlarged, normal in size, or small.  In end-stage alcoholic cirrhosis, the liver is small, firm, and finely nodular

11) Also in Alcoholics...

 a. DUPUYTREN'S CONTRACTURES

 b. TOM WOLFE'S SIGN (full head of hair in an old man)...but not necissarilty indicative of cirrhosis per se

ABDOMINAL SYNDROMES: Peptic Ulcer

1) Two places it may occur

2) Are most pts symptomic?

3) If have sx, what is main one (quality and location)

4) How do antacids and food differ in terms of relief of sx of ulcer based on its location?

5) Doudenal Ulcer: when does it occur, where may it be felt in 10% of cases?

6) If peptic Ulcer disease is UNCOMPLICATED, what may physical exam reveal?

7) What are some COMPLICATIONS of peptic Ulcer disease? (FOUR)

8) Gastric Ulcer VS Duodenal Ulcer in terms of...

 a. AGE

 b. EFFECT OF FOOD

 c. CANCER POTENTIAL

1) May occur in STOMACH or DOUDENUM

2) Many pts are Asymptomatic

3) The COMMONEST complaint is PAIN described as gnawing, burning, or sharp.  (Typically located in the EPIGASTRUM)

4) Antacids and food improve pain of a doudenal ulcer in minutes, but NOT DO NOT AS RELIABLY RELIEVE THE PAIN OF A GASTRIC ULCER

5) Doudenal Ulcer occurs 90-180 minutes after eating, may be felt RIGHT OF MIDLINE in 10% of cases?

6) If peptic Ulcer disease is UNCOMPLICATED, physical exam may reveal tenderness in the epigastric area but LITTLE ELSE.

7) If peptic Ulcer disease is COMPLICATED, may get...

 a. Perforation with Peritonitis

 b. Pancreatitis (usually caused by a doudenal ulcer

 c. Hemmorhage

 d. Gastric Outlet Obstruction

8) Gastric Ulcer VS Duodenal Ulcer in terms of...

 a. AGE: Gastric: 6th Decade.  Doudenal: Younger

 b. EFFECT OF FOOD: Gastric: Less reliable Relief.  Doudenal: Relieves better

c. CANCER POTENTIAL: Gastric: YES  Doudenal: NO

ABDOMINAL IMAGING

THREE Settings in which CT has advantages over MR

For what TWO ORGANS is MRI better than CT for?

1) In settings where TIME is of essence (trauma, ruptured AAA, emergencies)

2) CT is better at Visualization of GI TRACT and CALCIFIED LESIONS

3) CT and MRI are roughly equivalent for the SOLID ABDOMINAL ORGANS, except...

4) MRI is better for the UTERUS and PROSTATE

ABDOMINAL IMAGING: Staging for Malingant Disease

*This is complex and depends on type of cancer, but in general...

1) CT used to stage what tumors?

2) PET-CT is used to stage what cancers?

3) MRI is useful in staging what cancers?

4) For what two cancers is a bone scan helpful?

1) CT used for SOLID TUMORS and usually done for GI TRACT, Lung, Liver, Pancreas, Renal, Adrenal, Lymphoma, Uterine, Breast, Cervical, Ovarian, and Prostate Cancers

2) PET-CT is used to stage cancers that are hypermetabolic on PET

3) MRI is useful for staging Uterine, Prostate, and Cercix Cancers

4) Bone Scan is Helpful in Breast and Prostate Cancers

1) Peptic Ulcer

2) Gall Bladder Disease

3) Pancreatitis

4) Myocardial Ischemia (esp in pt with known CAD...heightens suspicion for MI)

5) POSSIBELY GERD (less pain, more of a retrosternal BURNING...and less serious and should be considered AFTER these other causes)

ABDOMINAL PAIN

1) Where does visceral pain often start?

2) What is a good example of visceral pain turning into somatic pain?

1) often begins in teh center of the abdomen and later moves (impt in exams)

2) Biliary Colic (visceral) progresseing to focal tenderness and pain of acute Cholecystitis (somatic..caused by inflam of peritoneal surface)

 a. A good example is Biliary Colic.  Have stone in cystic duct.  Have distension of Gallbladder, and contraciton of cystic duct on stone...causes visceral type sensation.  If stone does not get dislodged, and go onto get inflammation and acute cholcystitis, you have inflamed viscus next to liver and skin, and now it is tender.  So pain is now more focal (along with fever and leuckocytosis).  VERY IMPT CONCEPT.

1) Colic

2) Acute Pancreatitis

3) Peptic Ulcer (usually with perforation...if not perforated does not cause pain)

4) Mesenteric Ischemia

5) Ruptured Ectopic Pregnancy (For Ruptured Ectopic Pregnancy, always think about this in acute lower ab pain in woman of childbearing age.  Always ask, and check preggers test.)

6) Aortic Rupture

7) Pyelonephritis (usually slower onset) (Pyelonephritis: Not ab condition, but has to be thought of, along with kidney stones in any pt with acute ab pain..easily differentiated.  Pain is mostly in back, but can cause pain referred to abdomen)

NON-ABDOMINAL PATHOLOGY

8) Pneumonia (lower lobe pneumo irritating pleura where diaphragm is can present like ab pain)

9) Porphyria (Acute intermittent porphyria, is rare, but can present like this.)

10) MI***ESP

1) Where did is start and when?

2) Has it moved? (ex acute appendicitis)

3) Has the character changed?

4) Are there other areas that hurt? (referred pain can be helpful)

5) Prior Abdominal Surgery? (Likely adhesions, and scars.  Bowel is likely to hang up on scars, can get volvulus, etc)

6) Alcohol use/abuse? (Ulcers, Pancreatitis, Liver Disease)

7) Risk factors for candidate disorders (Peptic Ulcer, Pancreatitis, Biliary Disease, Mesenteric Ischemia, etc)

-Peptic Ulcer: besides Smoking/H Pylori, most impt risk factor is presence of previous peptic ulcer
-Pancreatitis: Etoh abuse, Biliary Stones, hyperlipedemia, certain drugs (mostly Etoh abuse and biliary stones),

8) Urinary Symptoms (Dysuria (pain), Urgency, Frequency, Flank Pain/Tenderness, Hematuria/Passed Stone

9) ALWAYS ask about PREGNANCY when possible

-Pregnancy test better than hx, but if can't, ask about "could you be pregnant, is it at all possible?", last menstral period, was it a normal menstrual period...not just little spotting"

PAIN REFERRED TO BACK

1) Where is perforated doudenal ulcer or ruptured spleen reffered to?

2) Where is biliary colic reffered to?

3) Where is acute pancreatitis and Renal Colic referred to?

4) Where is uterine and rectal pain reffered to?

1) Perforated doudenal ulcer or ruptured spleen reffered to TRAPEZIUS (irritates diaphragm...innervation referred pain...over trapezuis area)

2) Biliary colic is reffered to RIGHT BELOW THE SCAPULA

3) Acute pancreatitis and Renal Colic refer to BACK (because they are RETROPERITONEAL)

4) Uterine and rectal pain reffer to SACRUM

ABDOMINAL PAIN: THE COLICS

1) What is Colic?

2) What do pts do?

3) Name 6 types

1) Paroxysmal spasmodic pain caused by distension and peristaltic contraction (Small tubes typically DO NOT produce the paroxysm...typically more dulle and constant)

2) Pts may writhe or "double up" with paroxysm

3) TYPES

 a. Intestinal Colic

 b. Biliary Colic (steady, not paroxysmal)

 c. Pancreatic Colic (Steady, not paroxysmal)

 d. Renal Colic

 e. Uterine Colic (dysmennorhea)

 f. Kidney Stones

EXAM: ABDOMINAL PAIN

1) What is the correct order

1.5) What three things do you LOOK for?

2) What do you listen for?

3) What is the presence of normal bowel sounds AGAINST the dx of?

4)What defense mechanism of the pt should you try to overcome?

5) What diffuse mechanism should you look for signs of?

6) In addition to abdominal structures, what retroperitoneal structure should you assess signs of?

7) How do you palpate?

1) Violate the usual pattern of the exam.
-Look
-Listen
-Feel

1.5) Look for distension, visible peristalsis, attitude in bed (writhing...If someone has colic, will move and writhe and get better) (If have intestinal ischemia for ex, will not be writhing, but will be in general constant pain)

2) Listen for bowel sounds (Sometimes, if hear tinkling high pitched bowel sounds, it  can be obstruction.  Pretty specific, but not sensitive.)

3) normal bowe sounds AGAINST dx of small bowel obstruction

4) Try to overcome GAURDING

*Look for Voluntary Gaurding vs Involunary Gaurding
-As you try to push, takes time, seeing if pt, after a while, will let you push deep
-If they can't relax, they have involuntary gaurding, and usually suggests diffuse peritoneal inflammation of diffuse peritonitis. 

*If pt gaurding all time, can get them to bend their knees and flex up on the bed, can help to relieve gaurding.

5) Look for signs of Peritonitis

6) Asses for signs of RENAL pathology (CVA tenderness and flank tenderness)

7) Palpation: Start AWAY from tender areaStart touching very lightly.  When push, do so with two hands on top of each other, and push with hand not feeling with

Consistent with...

1) Cyst

2) Biliary Colic

3) Cancer (could be courvasiers sign a/w cancer)

Not Consistent with..

1) Acute Cholecystitis (would be a/w tenderness)

1) What is tympanic percussion of RUQ imply?

2) What does Pain in RLQ with compression of LLQ imply?

1) implies intra-peritoneal air, which in this setting would suggest ruptured bowel (Perforated Ulcer)

2) Rovsing's Sign: Acute Appendicitis

**Biliary Colic, on its own, is not an inflammatory condition and should NOT have a change in fever

Do get fever if progresses to acute cholecystitis

Pain upon gently pickin gup abdominal wall skin

Could be acute appendicitis as well

DIFFUSE PERITONITIS

1) What is it usually due to?

2) Intestinal contents spill, causing overwhelming infection and inflammation of peritoneum, leading to...

3) What is the radiological hallmark?

1) Usually due to perforated bowel (appendix, peptic ulcer, small bowel, etc)

2) Intestinal contents spill, causing overwhelming infection and inflammation of peritoneum, leading to...

 a. Intense Pain
 b. Hemodynamic collapse (Tachycardic, Hypotensive...getting diffuse inflam infection)
 c. Silent Abdomen (absent bowel sounds...not terribly reliable)
 d. INVOLUNTARY Gaurding
 e. Abdomen will get bigger (distended)
 f. Tender (REBOUND: Push deep, and let up quickly.)    g. Then ask pt: does it hurt everywhere when you let up, not just in that place.  Doesn't add too much on top of Involuntary Gaurding
 h. Pts are REALLY SICK.  If do not fix them, they will die eventually.

3) Radiologic Hallmark is free intra-peritoneal air

1) Mucosal Injury

2) Neoplasm

3) Vascular Abnormality (Vascular abnormality: like Talengectasia)

4) Bleeding Disorder (because bleed freely, any little thing can cause them to bleed abnormally.)

GI BLEEDING TERMS

1) Hematemesis

2) Melana (or Melanic Stool)

3) Hematochezia

1) Hematemesis: Vomiting Blood: Bright Red or Coffee Ground.

2) Melana (or Melanic Stool): Black AND TARRY stool, reflects digested blood (60 cc required) (Has to be digested partially, because reflects a somewhat high origin)

3) Hematochezia: bloody stool:Frank Blood or Darker Blood

1) UPPER GI bleeding source proximal to ligament of Trietz may produce what THREE THINGS?

2) Lower GI bleeding can cause what TWO THINGS?

1) UPPER GI bleeding source proximal to ligament of Trietz may produce...

 a. Hematemesis

 b. Melena (Iron and Bismuth like PB may darken stools, but won't be Tarry as well like in Melena)

 c. Hematochezia (very brisk bleeding)

2) Lower GI bleeding can cause...

 a. Hematochezia

 b. Blood Flecked Stool (Guaiac Positive Stool may be UPPER or LOWER in origin...need to get OTHER historical facts)

 *NOT Melana, Not Hematemesis with LOWER Bleed

CAUSES OF UPPER GI BLEEDING

0) Name the structures PROXIMAL to the ligament of Trietz

1) ESOPHAGUS (3, two are very common**)

2) STOMACH/DOUDENUM (3, two are very common**)

3) BILIARY TREE/PANCREAS (just a fact)

4) SMALL BOWEL (two, none are very common)

0) Structures PROXIMAL to the ligament of Trietz

 a. Esophagus

 b. Stomach

 c. C loop of Doudenum (the ligament holds up this C loop to the retroperitoneum)

1) ESOPHAGUS

 a. **Tear (Mallory-Weiss Syndrome) (Mallery Weiss tear: hx of retching, usually where meets stomach, usually "benign" unless involve large artery)

 b. **Variceal Bleeding

 c. Esophagitis (Esophagitis can occasioanly bleed, but not that bad.)

2) STOMACH/DOUDENUM

 a. **Peptic Ulcer

 b. **Erosive Gastritis

 c. Others

3) BILIARY TREE/PANCREAS

 a. Rare

4) SMALL BOWEL

 a. Tumor

 b. Meckel's Diverticulum

 c. RARE, wont hold us responsible for that

 d. But is hard place for GI docs to get to.  But seeing these many feet of small bowel sometimes difficult with "oscopy,"  Not have them take capsules with cameras in them

Name FIVE common causes of LOWER GI BLEEDING

1) Colitis (infectious, Inflammatory, Ischemic)

2) Diverticulosis

3) Neoplasm

4) Hemorrhoids

5) Vascular Malformations

GI BLEEDING.  For the following potential causes of GI Bleeding, name a few historical facts that would suggest the following causes of GI bleeding...

1) PUD and Erosive Gastritis

2) Variceal Bleeding

3) Mallory-Weiss Syndrome

4) Pain with Bleeding

5) Neoplasia

6) Anticoagulant use

1) PUD and Erosive Gastritis

 a. Known or Prior PUD, tobacco, Etoh, Nsaid

 b. Strongest is Known or Prior PUD

 c. Stressful lifestyle may add on/play a part

2) Variceal Bleeding

 a. High pressure in their portal vein backing up into anastamotic channels in Esoph
 b. Cirrhotics from Etoh, Chronic Hep B or Hep C
 c. Rarely from Splenic Vein thrombosis w/out getting Hepatitis: proximal obstruction, so have focal increased pressure

3) Mallory-Weiss Syndrome

 a. Emesis/wretching

4) Pain with Bleeding

 a. *Mucosal Bleeding is Painless*  Unless have ulcer that is eroding, or something else, will not have pain.  If have pain, think about these things (aortic aneurysm bulging into doudenum, Ischemia, Perforation)

5) Neoplasia

 a. Change in bowel habit

 b. Weight loss

6) Anticoagulant use

 a. very common, esp after CV procedure

EXAM CAVEATS: GI BLEEDING

1) 1st, what do you look for evidence of?

2) If someone has chronic bleeding, or flecks of blood, what is an Exam you NEED to perform?

3) Beware the tendor abdomen!

4) Name two rare disorders that cause GI bleeding that should NOT be missed

1) 1st, look for evidence of Liver Disease

 a. Hepatitis, EtoH abuse etc

 b. Because hx of liver disease ups the anty of esophogeal varicy bleeding..which will kill you (about 40% mortality)

2) Anal Exam

 a. If someone having chronic bleeding (part bloody diarrhea over a long period of time), an ANAL exam is especially important. 

 b. Looking for Fissures, Anal Fissures in Crohns Disease (key finding) or Lesion with examining finger, esp if have flecks of blood or bright red blood per rectum

3) Beware the tendor abdomen!

4) Rare disorders not to be missed...

 a. AORTO ENTERIC FISTULA..look for
    -Hx of Aortic Aneurysm
    -ESPECIALLY history of prior surgery of abdominal    aneurysm (Surgical Scar)

 b. OSLER-WEBER-RENDU
     -HERIDITARY Telangiectasia syndrome
      -see mucosal talengectasias

SICKLE CELL

1) Pain and tenderness in the legs is consistent with sickle cell crisis.  Why?

2) Does the hemolysis that occurs with sickle crisis produce a jaundice?

3) Is SS associated with Splenomegaly

4) Can Sickle Cell Disease produce RUQ pain and tenderness?

1) **Common symptoms of Sickle Cell is PAIN.  Because RBCs sticking together and clogging up BV---Ischemia, and feel that as pain.  Can be ANYWHERE in the body. 

2) It produces a mild jaundice (max total bilirubin 3-5%)

3) SS disease is NOT a/w Splenomegaly (This is because the Spleen has AUTO-INFARCTED a long time ago...Another Type, SC, much less common, can have splenomegaly...but if he says Sickle Cell, Splenomegaly will NOT be the right answer)

4) Yes, this could be ascending cholangitis caused by a pigmentary stone from chronic hemolyis lodging in the Common Bile Duct (most pts with SCD have had their gallbladder taken out by the time they are 20 y/o)

CAUSES OF JAUNDICE (Scleral Icterus detecteable at a Bilirubin of 2-2.5 mg/dl)

1) OVERPRODUCTION

 a. More or less common

 b. What is Max Bilirubin level usually

 c. Are livers and kidneys messed up?

 d. Name two potential causes

 e. What is a great CLUE?

2)IMPAIRED HEPATIC UPTAKE/CONJUGATION/EXCRETION

 a. Parenchymal Liver disease (name 2)

 b. Cholestatic Disease (name 3)

 c. More or less common?

1) OVERPRODUCTION

 a. much less common

 b. Usually 3-5 mg/dl MAX

 c. Have NORMAL Liver and Renal Function (but if these are damaged, could be even higher because not getting rid)

 d. Could be caused by HEMOLYSIS from Sickle Cell Anemia

 e. Could be caused by INEFFECTIVE ERYTHROPOIESIS (Hemolysis occuring within BM itself) from B12 deficiency, Thalassemia

 f. CLUE: Pts will Be ANEMIC

2)IMPAIRED HEPATIC UPTAKE/CONJUGATION/EXCRETION

 a. Parenchymal Liver Disease (Hepatitis, Cirrhosis)

 b. Cholestatic Disease: Disease in Bile Ducts (Choledocholithiasis: CBD obstruction by gallstone w/ or w/out ascending cholangitis, Tumor of Pancreas or Bile Ducts, or PBC: disease of small microscopic bile ducts within the liver)

 c. Much MORE common

DIFFERENTIATING JAUNDICE

1) Can deep Jaundice be due to overproduction alone?

2) What is overproduction due to? (what will be present?)

3) What TYPE of hyperbilirubinemia does overproduction cause?

4) Splenomegaly may be seen in what two types of disorders, and NOT seen in what disease?

1) NO

2) Overproduction due to a hematologic problem (ANEMIA should be present)

3) Overproduction produces unconjurgated Hyperbilirubinemia---little to no change in Urine Color (in contrast, liver/biliary disease have increased CONJUGATED FORM, which DOES change your urine color)

4) Splenomegaly may be seen in both hepatobiliary and hematologic disorders (but NOT in SS sickel cell disease)

If see Jaundice, name some ways  to differentiate it from being a HEPATITIS cause or a CIRRHOSIS cause

1) HEPATITIS (3 things)

2) CIRRHOSIS (2 things)

1) HEPATITIS

 a. Should have symptoms and signs of inlammation (Fever, malaise, fatigue, etc)

 b. Often have TENDER liver

 c. Infrequent evidence of portal hypertension and functional impairement (not present in acute hep)

2) CIRRHOSIS (2 things)

 a. Liver NON-Tender (except in Cirrhosis due to right heart failure: Back pressure down into IVC and in to Hepatic Vein and into Liver, over time can cause Cirrhosis--nutmeg liver---swollen and tendor beacuse of increased pressure. OR also may be tender in cirrhosis with chronic hepatitis)

 b. Will have traditional findings of portal hypertension and functional impairement

HEPATITIS A: Clinical Findings

1) What percentage are ANICETRIC

2) Of those who are ANICETRIC, what did 77% report?

3) THherfore, what is a great thing to ask about?

4) List a few more things to ask about in descending order of presence

1) 1/3 to 1/5 are anicteric

2) Of those, 77% reported DARK URINE because of Bilirubin in Urine

3) Dark Urine is a GOOD QUESTION. then can go on to ask these other questions...

4) More things the Hep A pts report...

 -Lassitude (91%)

 -Loss of Appetite (90%)

 -Fever (76%)

 -Headache (70%)

 -Ab pain/discomfort (65%)

 -Whitish Stools (52%)

 -Arthralgia (21%)

A matrix for thinking about SPLENOMEGALY

1) GI (1)

2) RETICULOENDOTHELIAL (3)

3) HEMATOPOEITIC (3)

1) GI

 a. Portal Hypertension

2) RETICULOENDOTHELIAL

 a. Infections, typically chronic (Malaria is a BIG one, kid in picture had visceral leschmeniasis)

 b. Granulomatous inflammatory States (ex: Sarcoid)

 c. Lymphoma and Related Disorders (ex: Hodgins)

3) HEMATOPOEITIC

 a. Leukemia

 b. Extramedullary Hematopoiesis (when BM not working, like in Myelofibrosis)

 c. Chronic Hemolytic States (Not SS, but other kinds of hemolysis)

ASCENDING CHOLANGITIS

1) What is it?

2) Why does it produce light colored stools?

3) What is the triad?

1) Infection of the common bile duct often produced by an impacted gallstone. 

2) Common Bile duct obstruction decreases Bile Flow (source of pigment giving stool the brown color eg Stercobilibogen/Stercobilin), thus producing light colored stools

3) CHARCOT'S TRIAD:Fever, Jaundice, and RUQ Pain

1) What is the key to dx when someone presents with acute diarrheal syndrome with fever and evidence of significant hypovolemia?

2) When acute diarrheal syndrome is caused by food, what is the time course between ingestion of food and diarrhea?

1) Would consider Enteric Infections and toxins.  s such, the KEY to dx is history, including Travel, Sexual practices, and diet

2) 24 hours

C DIff related diarrhea

1) What is the key history?

2) What is the diarrhea like?

1) recent Antibiotic use (within 4 weeks)

2) DOES NOT present with Profound volume depletion

DEFINITIONS

1) Diarrhea

2) Constipation

1) Diarrhea: Frequent passage of poorly formed watery stool

2) Constipation: less than customary frequency of bowel movements (WIDELY variable...some texts say 1/2 weeks is norm...)

TYPES OF DIARRHEA

1) Small bowel

2) Malabsorbtion

3) Colon (esp distal colon)

1) Small bowel

 a. Stools light colored

 b. Larger volume

 c. Frothy

 d. Blood and pus LESS LIKELY

2) Malabsorbtion (Hallmark is STEATORRHEA).  Caused by...

 a. Biliary Obstruction

 b. Exocrine Pancrease Insufficiency (For these top two, because not getting enzymes into bowel, but not as bad as 3rd because still have some intrinsic enzymes in gut)

 c. Small bowel disorders (like Celiac Sprue)

3) Colon (esp distal colon) (Dysentary)

 a. Smaller Volume

 b. Tenesmus

 c. Rectal urgency

 d. Pus and Blood MORE LIKELY

PATHOGENESIS OF DIARRHEA
1) Secratory

2) Exudative/Invasive

3) Malabsorbtion

1) Secratory

 a. Watery Stool, NO blood/pus

 b. Increase ELECTROLYTE SECRETION

 c.  Does NOT STOP WITH FASTING.

 d. Toxin mediated: Cholera, Viral

 e. Islet Cell Tumors: Carcinoid, or "VIPOMA" (Vasoactive Intestinal Peptide is secreted, and secrete fluid into the bowel))

2) Exudative/Invasive

 a. Impaired absorbtion due to mucusoal injury

 b. Blood and Pus in the stool, often with systemic illness (FEVER, etc)

 b. Shigela, Salmonella, Certain E. Coli, amoebic

 c. Diverticulitis

 d. Inflammatory Bowel Disease (UC, Crohns)

 e. THIS DIARRHEA WAKES YOU UP

3) Malabsorbtion

 a. Osmotoically active agent ((similar to medicine to tx constipation....drawing water into bowel))

 b. Decreased Surface area ((Celiac Sprue))

 c. Increased transit time ((like in hyperthyroidism...can decrease absorption because everything is sped up))

HISTORY IS THE KEY TO THE ETIOLOGY OF DIARRHEA

1) Secratory

2) Exudative Invasie

3) Malabsorbtion

1) Secratory

 a. Watery diarrhea (NO BLOOD OR PUS)

 b. Does NOT stop with fasting

2) Exudative Invasie

 a. Travel and Exposure history is key

 b. sexual history is impt, esp homosexual/anal sex

 c. Does NOT STOP with FASTING

 d. Use of antibiotics...

  i. Changes bowel flora ((and get loose stools not big
deal. goes away with stop))

  ii.  Risk for C Diff ((very big deal, can cause
bowel necrosis))

 e. This diarrhea WAKES YOU UP (bloody, pus in stool, often a/w systemic illness)

3) Malabsorbtion

 a. Ask about steatorrhea and tons of laxitive use

 b. NPO=cessation of diarrhea ((If stop everything (incl. taking laxatives), and diarrhea stops))

 c. If chronic, consider vitamin and mineral deficiency

DIARRHEA: EXAM FOCUS

1) What do you look for GENEARLLY?

2) What do you look for OUTSIDE of intestines?

3) What does the Abdomen look like?

4) What might be found in the anus and rectum?

1) General signs of Acute illness (vitals: evidence of volume depletion and fever)

2) Extra-intestinal findings (eyes, skin, joints)

 a. ((Esp if have IBD like Crohns, UC, there are shared Ag's in the bowel mucosa with the eyes, skin, and joints.  Can get an inflam Arthritis (Reiters), Uveitis, etc.  Can be with other kinds of inflam diarrhea (Morehead got Uveitis from Salmonella), like infecteous too, does not have to be IBD.  Esp when think about Chronic Diarrheas, ask about Eye, Joint, Skin Q's))

3) Abdromen is tender...focal or general

4) Anus and Rectum: Fissures, obstructing mass, focal tenderness

 a. ((Esp in Crohns look for Anal Fissures and Fistula))

 b. ((In Older people esp. can have mass and diarrhea around mass, so do digital rectal exam.))

CONSTIPATION CONSIDERATIONS

1) Just know there is extreme variability among normal

2) Frequent complaint among what population?

3) Differentiate it from ??

4) Name 4 causes of pathological obstruction

2) Frequent complaint among ELDERLY

3) Differentiate it from ACUTE BOWEL OBSTRUCTION...

...FOUR causes of pathological obstruction...

1) Mechanical Obstruction

 a. Neoplasia

 b. Impacted Stool ((esp someone with poor bowel habits))

2) Medications

 a. Narcotics

 b. Anticholinergics

3) Systemic Disease

 a. Myxedema (or hypothyroidism)

4) Neural Plexus abnormality

 a. Hirschsprung's Disease ((congenital in kids))

 b. Chagas Diseas ((from americanTrypanosomiasis))

1) What is weight loss with Dysphagia worrisome for?

2) do non-malig conditions of Esophagus like GERD and Achalasia cause weight loss?

3) What are two other risk factors for esophogeal carcinoma, but less so than weight loss?

4) What does chronic intermittent dysphagia to both solids and liquids suggest?

5) What is the cardinal sx of Gerd, and what can this lead to (2 things) if uncontrolled?

1) Esophogeal Cancer

2) NOT USUALLY

3) Tobacoo and Alcohol

4) Suggests either a motor disorder or a benign web ((This is the classic history you get for a benign cause))

5) Heartburn...uncontrolled can lead to stricture and adenocarcinoma of esophagus

SWALLOWING TERMINOLOGY

1) What is Pyrosis?

2) Is nausea a/w regurgitation?

1) Pyrosis is heartburn, a retrosternal burning sensation a/w GE REFLUX

2)Nausea is NOT a/w regurgitation ((Bringing up of food contents, no associated N (if have blockage for ex))

TYPES OF DYSPHAGIA
1) MECHANICAL
2) MOTOR

1) MECHANICAL

 a. Intrinsic: Benign Stricture, Tumor, Web

 b. Extrinsic: anything COMPRESSING esophagus ((Ex: Big Osteophyte in cervical Spine...Ex: Big Tumor in Thyroid can push backwards))

2) MOTOR

 a. Lesion affecting INITIATION of swallowing ((Ex: Like stroke involving swallowing mechanism.  THe esophagus is okay, but the oropharyngeal mechanism involved in swallowing is out.))

 b. Bulbar Paralysis

 c. Myopathy

 d. Achalasia

ETIOLOGY OF DYSPHAGIA: OTHER HISTORY

1) Associated Odynophagia

2) Nasal Regurgitation

3) Hoarseness

4) Prolonged Pyrosis

1) Associated Odynophagia

 a. Infecteous ((like Herpes, or Candidiasis))

 b. Pill ((can lodge and cause problems))

2) Nasal Regurgitation

 a. ALS

3) Hoarseness

 a. Laryngeal Lesion

 b. Spread of cancer

4) Prolonged Pyrosis

 a. Peptic Stricture

EXAM CLUES IN PATIENTS WITH DYSPHAGIA

1) Examine for Weight loss (JUST KNOW)

2) Evaluate for compressive mass (where?)

3) Look for neurologic disease/weakness (see what?)

4) Look for evidence of mets cancer (see what?)

5) What do you look for on the skin?

1) Examine for WEIGHT LOSS (JUST KNOW)

2) Evaluate for COMPRESSIVE MASS

 a. Upper airway-tumor, swelling

 b. Neck-thyromegaly, mass, tracheal deviation

3) Look for NEUROLOGIC disease/weakness

 a. Ptosis, nasal voice, *FASCICULATIONS (esp with ALS

4) Look for evidence of mets cancer

 a. Lymphadenopathy

 b. Hepatomegaly

5) Loof for SCLERODERMA (can be a/w esophogeal disease)

GERD Epidemiology

1) Affects what % of population

2) What are some risks?

EPIDEMIOLOGY: Affects up to 20% of the population; r

Risks include...

 a. hiatus hernia

 b. obesity

 d. older age,

 e. alcohol and tobacco use

 f. scleroderma

ACHALASIA

1) Mechanistically, what is it the opposite of?

2) What are some symptoms?

3) What may occur due to retained food?

4) How to diagnose?

5) What parasitic disease may cause achalasia?

1) Mechanistically, the opposite of GERD.  It is a SMOOTH MUSCLE DISORDER affecting the LES, resulting in a TOO TIGHT LES

2) SYMPTOMS

 a. Dysphagia (to solids AND liquids)

 b. Chest Pain

 c. Regurgitaion

 d. NO PYROSIS

 e. SOME weight loss can occur, but NOT profound

 f. ((Can complain of foul breath))

3) ASPIRATION may occur due to retained food.

4) Dx RADIOGRAPHICALLY (Endoscopy to exclude other causes)

5) As for Colon disease, american Trypanosomiasis or CHAGAS can cause Achalasia

ESOPHOGEAL CARCINOMA

1) Usually what age?

2) What are some predispositions?

3) What is the common clinical scenario?

4) What may accompany dysphagi?

5) What may occur due to regurgitation OR trachea-esophogeal fistula?

6) How do you diagnose?

7) Is Hematochezia a likely presentation?

8) Where does cancer usually arise?

1) Usually >50

2) MANY predispositions

 a. Smoking

 b. Alcohol

 c. lower SES

 d. Radiation

 e. Lye

 f. Chronic GERD

 g. Barret's Epithelium

3) PROGRESSIVE Dysphagia with WEIGHT LOSS is the clinical scenario (solids--semi-solids--liquids)

4) Odynophagia MAY accompany dysphagia ((MAY have pain with swallowing, may NOT))

5) Pneumonia may occur due to regurgitation OR trachea-esophogeal fistula

6) Dx by HISTORY* and imaging/endoscopy ((Have to have STRONG Index of Suspicion and use Imaging))

7) NO

8) While longstanding GERD may produce Barret's Epithelium, cancer usually arises in DISTAL  ESOPHAGUS???

((**MOST ARE SQUAMUS CELL, NOT ADENO))

ACUTE PYLEONEPHRITIS

1) CAUSES (3)

2) PREDISPSING FACTORS (4)

2) SYMPTOMS

3) EXAM FINDINGS

1) CAUSES

 a. Ascending infection (urethra-bladder-kidney)

 b. Impacted Stone

 c. Congenital Anatomical Abnormality

2) PREDISPOSING FACTORS

 a. Diabetes

 b. Multiple Sexual partners

 c. Prior UTI

 d. Renal Stones

2) SYMPTOMS (relate to Urinary Tract involvement...Dysuria=Urethra, Suprapubic=Bladder, CVA pain=Kidney)

 a. Pain is NOT colicky, but dull and seatdy (if renal...due to stretching of renal capsule)

 b. Pain may radiate to Umbilicus

 c. Other Urinary Symptoms (dysuria, frequency, urgency, cloudy or dirty urine with foul odor)

3) EXAM FINDINGS (relate to inflamed structures)

 a. CVA/flank tenderness (KIDNEY)

 b. Suprapubic tenderness (BLADDER)

AORTIC ANEURYSM

1) ARe most symptomatic or asymptomatic?

2) When have sx, name three

3) What is done on exam? (MAIN THING, 2 things you might expect but are not actually present, and 1 thing may see retroperitoneally)

1) Most asymptomatic; PAIN PORTENDS RUPTURE

2) SYMPTOMS

 a. Aching or throbbing prior to rupture

 b. Epigastrum (over aorta) and/or back

 c. Pain often presents days before rupture

3) EXAM: ASSES AORTIC SIZE

 a. Peripheral pulses may be IN TACT

 b. Bruit may NOT be heard

 c. Retroperionteal rupture  may produce Grey-Turner's Sign (if not immediately fatal)

ETIOLOGY OF BLEEDING IN CIRRHOTICS (contrasts with "all comers," where peptic ulcer accounts for about half of all significant bleeding)

1) ??

2) ??

3) ??

4) ??

1) Esophogeal and Gastric Varicies (53%)

2) Gastritis (22%)

3) Peptic Ulcer (doudenal or gastric) (20%)

4) Unknown site (9%)

ACUTE HEPATITIS: HISTORY

1) HEPATITIS A
2) HEPATITIS B

3) TOXIN INDUCED HEPATITIS

1) HEPATITIS A

 a. F-O

 b. Diet and travel

 c. Deviant sex practices

2) HEPATITIS B

 a. Blood/serum/Sexual transmission

 b. IV drug use, tattoos, acupuncture, razors

 c. Sexual history

 d. institutionalized MR

3) TOXIN INDUCED HEPATITIS

 a. Ethanol, acetominophin, other drugs

 b. Tylonol in "therapeutic" doses can be toxic in alcoholics

 c. Narcotics often combined with tylonol

GILBERT'S DISEASE

1) What is it?

2) How does it manifest?

3) What exacerbates it? (6 things)

4) What do labs show? (3 things)

1) Congenital Benign problem with Bilirubin conjugation (usuay 1.2-5 mg/dl)

2) Manifests as MILD SCLERAL ICTERUS

3) Exacerbating Factors...

 a. Fasting

 b. Surgery

 c. Fever

 d. Infection

 e. Alcohol Ingestion

 f. Exertion

4) LABS...

 a. Increased conjugated Bilirubin

 b. Otherwise normal liver function tests

 c. NO Hemolysis

Malabsorbtive Diarrhea comes in TWO TYPES

1) Decreased Surface Area Induced

2) Osmotic Agent induced

Name the differences

DECREASED SURFACE AREA--MALABSORBITVE DIARRHEA

1) Characterstic: Steatorrhea

2) When chronic, think about vit and min deficiency: ADEK, B12, Fe

3) Classicaly, should STOP WITH FASTING

4) Examples

 a. Sprue (celiac and tropical)

 b. Pancreatic Insufficiency (Many causes)

 c. Giardia (complex pathogenesis)

OSMOTIC AGENT--MALABSORBITVE DIARRHEA

1) Characteristic: Watery, LARGE Volume

2) HISTORY is key (taking this agent)

3) Removal of offending agent cures the diarrhea

4) Examples

 a. Lactase Deficiency

 b. Laxative Abuse (usually have concurrent eating disorder)