Term
| What is the next step in management of a patient in whom you suspect small bowel obstruction? |
|
Definition
| place an NG tube, begin fluid resuscitation, place a foley to monitor urine output |
|
|
Term
| What are some complications associated with SBO? |
|
Definition
| strangulation, bowel necrosis, and sepsis; aspiration pneumonitis, intravascular fluid loss leading to prerenal azotemia and acute renal insufficiency |
|
|
Term
| A patient with suspected SBO has episodic pain that becomes constant. What caused this change in pain pattern? |
|
Definition
| severe bowel distention (venous congestion, decreased boewl perfusion and necrosis) or bowel ischemia secondary to strangulation |
|
|
Term
| What are signs associated with a complicated SBO? |
|
Definition
| fever, tachycardia, leukocytosis, elevated serum amylase, and radiographic signs of a high grade SBO |
|
|
Term
| In a patient with complicated SBO who needs laparotomy, how should they be managed prior to surgery? |
|
Definition
| NG tube placement to prevent further vomiting and potential aspiration, fluid resuscitation, administration of broad-spectrum antibiotics |
|
|
Term
| Why is a closed loop obstruction more serious? |
|
Definition
| more rapid progression to strangulation and is unlikely to resolve without operative therapy |
|
|
Term
|
Definition
| distension of the small bowel and/or colon from nonobstructive causes like metabolic derangements, recent abdominal surgery and adverse effects of medications |
|
|
Term
| What is an internal hernia? |
|
Definition
| congenital or acquired defect within the peritoneal cavity that can lead to small bowel obstruction |
|
|
Term
| What is the typical clinical presentation of gallstone ileus? |
|
Definition
| intermittent SBO forseveral days until the stone lodges in the distal small bowel and causese complete obstruction |
|
|
Term
| SBO in a child is most likely the result of... |
|
Definition
| hernia, malrotation, meconium ileus, Meckel diverticulum, intussusception, or intestinal atresia |
|
|
Term
| What arecommon causes of SBO in an adult? |
|
Definition
| adhesions, hernia, Crohn's disease, gallstone ileus, or tumor |
|
|
Term
| T/F Patients with SBO will state that they have not had a bowel movement since the pain started. |
|
Definition
| F; acute obstruction can stimulate peristalsis leading to a bowel movment early in the disease process |
|
|
Term
| Fever with symptoms of SBO can be due to... |
|
Definition
| bowel ischemi/inflammation; pulmonary complications from aspiration |
|
|
Term
| What is the typical finding on abdominal exam of SBO? |
|
Definition
| tenderness (diffuse or local) and distention; localized tendernessmay or may not indicate ischemia of a specific segment of bowel |
|
|
Term
| What does DRE reveal with SBO? |
|
Definition
| little or no stool in the rectal vault; the finding of a large amount of stool in the rectum is unusual and may suggest ileus ratherthan mechanical obstruction as thecause of distension |
|
|
Term
| What causes fluid to accumulate in small bowel when there is an obstruction? |
|
Definition
| decreased absorptivefunction causes fluid accumulation from osmosis; localinflammation and venous congestion causes fluid shift via pressure; vomiting also causes fluid loss |
|
|
Term
| What should you do if you suspect large bowel obstruction and want to confirm? |
|
Definition
|
|
Term
| What should you do if you suspect small bowel obstruction? |
|
Definition
| check for an incarcerated hernia, ask about history of abdominal operation, if no history of abdominal operation get a CT scan |
|
|
Term
| What labs should be ordered on a patient with suspected small bowel obstruction? |
|
Definition
| CBC with diff, serum electrolytes, amylase, urinalysis and ABGs (for selected patients) |
|
|
Term
| T/F Uncomplicated small bowel obstruction can present with WBC counts of 10-14. |
|
Definition
| true; but after hydration the leukocytosis should resolve or there may be complications |
|
|
Term
| In a patient with SBO a CT scan can help by determining etiologies such as... |
|
Definition
| ileus, inflammatory bowel disease, tumors, gallstone ileus; can also determine where the bowel obstruction is |
|
|
Term
| What is the use of getting constrast radiography like upper gastrointestinal and small bowel follow-through? |
|
Definition
| can determine whether it isa mechanical obstruction or ileus and can determine location and severity of bowel obstruction |
|
|
Term
|
Definition
| contrast study of the upper GI tract with small bowel follow through |
|
|
Term
| What items in the patient history point to strangulated SBO? |
|
Definition
| constant pain, constipation |
|
|
Term
| What items on physical exam point to strangulated SBO? |
|
Definition
| localized tenderness, fever, tachycardia, peritonitis, tender mass |
|
|
Term
| What laboratory findings point to strangulated SBO? |
|
Definition
| leukocytosis, elevated amylase, elevated lactate |
|
|
Term
| What radiographic findings point to strangulated SBO? |
|
Definition
| complete obstruction, fluid filled bowel, thickened bowel wall, mesentery edema (CT), free fluid (CT) |
|
|
Term
| How do you treat patients with uncomplicated partial small bowel obstruction from adhesions? |
|
Definition
| trial of nonoperative therapy consisting of NPO, placement of NG tube, close monitoring of fluid status, serial clinical examinations, and lab/radiographic followup |
|
|
Term
| What is the change in a patients clinical status of SBO if they are treated sucessfully by medical management? |
|
Definition
| decrease in abdominal discomfort and distention, decrease in volume of NG aspirate, and radiographic resolution of bowel distention |
|
|
Term
| Early post op SBO is characterized by symptoms developing within ____ following an abdominal operation. |
|
Definition
|
|
Term
| What are the exceptions to getting a CT in a clinical scenario of SBO? |
|
Definition
| simple adhesive obstruction and absence of indicators of complicated SBO |
|
|
Term
| What is the initial treatment of carpal tunnel syndrome? |
|
Definition
| nighttime splint and NSAIDS; avoidance of excess activity with the hand |
|
|
Term
| The median courses underneath what ligament at the wrist? |
|
Definition
| transverse carpal ligament |
|
|
Term
|
Definition
| in a patient with carpal tunnel syndrome, reproductions of the patient's symptoms by percussion of the median nerve at the wrist |
|
|
Term
| The smallest cross-sectional area of the carpal canal is created by... |
|
Definition
| extremes of flexion and extension of the wrist |
|
|
Term
| Why is carpal tunnel worse at night? |
|
Definition
| edema; tenosynovitis may also be present |
|
|
Term
|
Definition
|
|
Term
| What endocrine conditions is carpal tunnel associated with? |
|
Definition
| diabetes, myxedema, hyperthyroidism, acromegaly, and pregmancy |
|
|
Term
| Besides endocrine conditions, what other conditions are associated with carpal tunnel? |
|
Definition
| autoimmune disorders, lipomas of the canal, bone abnormalities, hematomas |
|
|
Term
| What are the demographics of patients with carpal tunnel syndrome? |
|
Definition
|
|
Term
| What physical exam finding is characteristic of carpal tunnel syndrome? |
|
Definition
| exertion of direct digital pressure by the examiner of the median nerve at thecarpal tunnel frequently reproduces the symptoms in approximately 30 seconds |
|
|
Term
| What is the phalen maneuver? |
|
Definition
| gravity induced wrist flexion reproduces symptoms of pt's carpal tunnel syndrome |
|
|
Term
| What type of sensory loss is most common with carpal tunnel? |
|
Definition
|
|
Term
| What percent of carpal tunnel syndrome patients have it bilaterally? |
|
Definition
|
|
Term
| What studies can be used to diagnosis carpal tunnel syndrome? |
|
Definition
| electrophysiologic studies comparing median and ulnar or radial sensory stimulation values at the wrist; radiographs can also help to detect arthritis or fractures; CT and MRI are rarely needed |
|
|
Term
| What test has the greatest sensitivity and specificity in the evaluation of CTS? |
|
Definition
| MRI but it is reserved for patients with symptoms and equivocal EMG findings |
|
|
Term
| What should splints for CTS do? |
|
Definition
| be light and hold the wrist in a neutral or slightly extended position |
|
|
Term
| Are steroid injections effective treatments for CTS? |
|
Definition
| work in 80-90% of patients but symptoms recur in months or years |
|
|
Term
| T/F Diuretics can treat CTS. |
|
Definition
|
|
Term
| When is surgery indicatedfor CTS? |
|
Definition
| intractable symptoms that are refractory to medical management |
|
|
Term
| If a patient does not do well after carpal tunnel syndrome what might you suspect? |
|
Definition
| either misdiagnosis or incomplete transection of the ligament |
|
|
Term
| T/F Carpal tunnel surgery can be preformed endoscopically. |
|
Definition
|
|
Term
| What is the posoperative care after carpal tunnel surgery? |
|
Definition
| wrist should be splinted for two weeks |
|
|
Term
| What are the advantages of endoscopic carpal tunnel surgery? |
|
Definition
| lessdiscomfort, minimal scarring, shorter period of immobilization, and a more rapid recovery |
|
|
Term
| Namesome complications of cholecystitis? |
|
Definition
| pancreatitis, choledocholithiasis, cholangitis, and gallstone ileus |
|
|
Term
| What differentiates true cholecystitis from biliary colic? |
|
Definition
| elevated leukocyte count, U/S findings of gallbladderwall thickening, TTP in RUQ, persistent pain, fever, mild and nonspecific elevations in liver enzymes |
|
|
Term
| How is cholecystitis treated? |
|
Definition
| hospital admission, IV antibiotics, lap chole prior to d/c from hospital |
|
|
Term
| What organisms most commonly cause acute cholecystitis? |
|
Definition
| Ecoli, klebsiella, proteas, streptococcus faecalis |
|
|
Term
| What type of gallbladder problems occur almost always in patients hospitalized with a critical illness? |
|
Definition
|
|
Term
| What is theMOA of acalculous cholecystitis? |
|
Definition
| biliary stasis --> gallbladder distension --> venous congestion --> decreased perfusion |
|
|
Term
| What are the symptoms of chronic cholecystitis? |
|
Definition
| presistent or recurrent localized RUQ pain without fever or leukocytosi |
|
|
Term
| What does chronic cholecystitis look like on ultrasound? |
|
Definition
| thickened gallbladder wall; contracted gallbladder |
|
|
Term
| What percent of patients with cholangitis have Charcot's triad? |
|
Definition
|
|
Term
| What is the treatment for cholangitis? |
|
Definition
| antibiotic therapy and suportive care in most cases; with severe cholangitis, treatment is endoscopic decompression of the bile duct by ERCP or surgery |
|
|
Term
|
Definition
| endoscopic retrograde cholangiopancreatography |
|
|
Term
| How sensitive is U/S in identifying gallstones? |
|
Definition
|
|
Term
| What percent of stones in the common bile duct can be visualized by ultrasound? |
|
Definition
| 50%; but the diameter of the common bile duct can be measured which can suggest choledocholithiasis |
|
|
Term
| What are the complication rates of ERCP? |
|
Definition
|
|
Term
| How many new cases of gallstones are there each year? |
|
Definition
|
|
Term
| What percent of people with gallstones develop symptoms? |
|
Definition
|
|
Term
| What's the difference between biliary colic and acute cholecystitis symptoms? |
|
Definition
| biliary colic is postprandial pain usually less than 6 hrs in duration; acute cholecystitis is RUQ pain lasting more than 8 hrs |
|
|
Term
| What's the difference in laboratory values of biliary colic and acute cholecystitis? |
|
Definition
biliary colic- normal WBC count, normal LFT normal amylase
cholecystitis= normal WBC count; normal or mildly elevated LFT values |
|
|
Term
| Whatare teh symptoms of choledocholithiasis? |
|
Definition
| postprandial abdominal pain that improves with fasting |
|
|
Term
| What are the lab values in patients with biliary pancreatitis? |
|
Definition
| leukocytosis, serum amylase level frequently >1,000 U/L, LFT values may be transiently elevated but persistence may indicate CBD stones |
|
|
Term
| Choledocholithiasis should besuspected if... |
|
Definition
| US shows common bile duct diameter greater than 5 mm in the presence of elevated liver enzyme levels |
|
|
Term
| WHen should you perform cholangiography with a lap chole? |
|
Definition
| some surgeons always perform it; others think that cholangiogram should be performed if the common bileduct is dilated and liver enzyme levels are elevated |
|
|
Term
| How are patients with gallstone pancreatitis treated? |
|
Definition
| bowel rest and IV hydration and then lap chole when the pancreatitis resolves clinically |
|
|
Term
| After a resolved episode of biliary pancreatitis, what percent of patients will develop a second bout of pancreatitis in the next 6 weeks if they do not have a cholecystectomy? |
|
Definition
|
|
Term
| Normal gallbladders have a ejection fraction of more than ___ after CCK injection. |
|
Definition
|
|
Term
| What is the best initial treatment for a patient with upper GI hemorrhage? |
|
Definition
| ABCs, NG tube on suction to determine whether bleeding is active, irrigation and aspiration until aspirate is clear, endoscopy, possible endoscopic therapy to control hemorrhage |
|
|
Term
| Class III hemorrhagic shock is characterized by loss of __% of the blood volume. |
|
Definition
|
|
Term
| When should a pt with upper GI bleed be intubated before endoscopy? |
|
Definition
| if they have massive upper GI bleeding, agitation, or impaired respiratory status |
|
|
Term
| What labs should you order in a patient who is having upper GI bleeding? |
|
Definition
| CBC, LFTs, PT, PTT; order a type and cross match |
|
|
Term
| What is the treatment for a Mallory Weiss tear? |
|
Definition
| supportive care and endoscopic management |
|
|
Term
| What is a Dieulafoy erosion? |
|
Definition
| bleeding from an aberrant submucosal artery located in the stomach; frequently significant and requires prompt diagnosis by endoscopy, followed by endoscopic or operative therapy |
|
|
Term
| What is it called when there is massive bleeding from an abberrant submucosal artery in the stomach? |
|
Definition
|
|
Term
| What is the course of an upper GI bleed caused by an AV malformation? |
|
Definition
| bleeding is abrupt but the rate of bleeding is slow and self limiting |
|
|
Term
| Describe the presentation of a patients with upper GI bleeding due to esophagitis? |
|
Definition
| usually occult bleeding and history of GERD |
|
|
Term
|
Definition
| less than 750 mL of blood loss; well compensated |
|
|
Term
|
Definition
| 750-1500 mL of blood loss; slight tachycardia, normal blood pressure |
|
|
Term
|
Definition
| 1500-2000 mL of blood loss, moderate tachycardia; hypotension |
|
|
Term
|
Definition
| more than 2000 mL of blood loss;marked tachycardia and prominent hypotension |
|
|
Term
| What percent of GI bleeds are proximal to the ligament of Trietz? |
|
Definition
|
|
Term
| What percent of upper GI bleeds are variceal? |
|
Definition
|
|
Term
| Name some common nonvariceal causes of upper GI bleeds? |
|
Definition
| 25% duodenal ulcers; 20% gastric erosions; 20% gastric ulcers; 15%Mallory-Weiss tears |
|
|
Term
| What percent of patients with upper GI bleeds have multple etiologies of bleeding identified during endoscopy? |
|
Definition
|
|
Term
| What percent of patients with upper GI bleeding have self limited bleeds? |
|
Definition
|
|
Term
| What is the mortality rate associtaed with upper GI tract bleeding? |
|
Definition
|
|
Term
| Patient mortality with acute upper GI tract bleeding increases with what factors? |
|
Definition
| rebleeding, increased age, patients who develop bleeding in the hospital |
|
|
Term
| What is the risk of esophageal varices rebleeding? |
|
Definition
|
|
Term
| What is the risk of gastric cancer rebleeding? |
|
Definition
|
|
Term
| What is the risk of gastric ulcers rebleeding? |
|
Definition
|
|
Term
| What is the risk of duodenal ulcers rebleeding? |
|
Definition
|
|
Term
| What is the risk of gastric erosions rebleeding? |
|
Definition
|
|
Term
| What is the risk of Mallory Weiss tears rebleeding? |
|
Definition
|
|
Term
| What is the risk of UGI rebleeding when no source of bleeding can be found? |
|
Definition
|
|
Term
| What are the clinical factors associated with increased rebleeding and mortality in patients with upper GI bleeds? |
|
Definition
| shock on admission, prior history of bleeding requiring transfusion, admission hg < 8, transfusion requirement of morethan 5 units of PRBCs, continued bleeding in NG aspirate, age >60 (increased mortality but no increase in rebleeding) |
|
|
Term
| What endoscopic factors are associated with increased rebleeding and moratlity? |
|
Definition
| visible vessel in ulcer base (50% rebleeding risk), oozing of bright blood from ulcer base, adherent clot at ulcer base, location of ulcer (worse prognosis when located near large arteries) |
|
|
Term
| What percent of NSAID usershave GI tract complications each year? |
|
Definition
|
|
Term
| What percent of patients taking daily NSAIDS develop an acute ulcer? |
|
Definition
|
|
Term
| How often is endoscopy able to establish a diagnosis in UGIBs? |
|
Definition
|
|
Term
| How can hemostasis be achieved endoscopically? |
|
Definition
| thermotherapy with a heater probe, multipolar or bipolar electrocoagulation and ethanol or epinephrineinjections |
|
|
Term
| For nonvariceal bleeding, endoscopic hemostasis is usually achieved with the use of... and the success rate is... |
|
Definition
| epinephrine injections followed by thermal therapy; sucess rate is 80-90% |
|
|
Term
| If a patient presents with upper GI bleeding that is nonvariceal and controlled with endoscopic therapy, what is the next step in management? |
|
Definition
| long term medical therapy with antisecretory agents such as H2 blockers or proton pump inhibitors; testing for H pylori, any NSAID use should be discontinued or prostaglandin analog (misoprostal) given or selective COX2 used |
|
|
Term
| When is surgery indicated for UGIBs? |
|
Definition
| if after endoscopy, bleeding continues or recurs; complicated peptic ulcer diseaes with massive, persistent, or recurrent upper GI tract hemorrhage or in association with nonhealing or giant ulcers (>3cm) |
|
|
Term
| What ishe treatment for a bleeding gastric ulcer where there is a concern for possible malignancy? |
|
Definition
| either gastrectomy or excision of the ulcer |
|
|
Term
| What is the treatment for a bleeding gastric ulcer where there is NO concern for malignancy? |
|
Definition
| ligate the vessel and perform vagotomy and pyloroplasty |
|
|
Term
| How do you treat pts with UGIB when you can't find the source of the bleeding but they are clearly having active bleeding? |
|
Definition
| selective angiography todiagnose and treat bleeding with arterial embolization with gel foam, metal coil springs, or a clot |
|
|
Term
| What is the success rate of selective angiogram in patients with UGIB? |
|
Definition
|
|
Term
| What substance can be injected into the arterial system to stop bleeding in patients with PUD? |
|
Definition
|
|
Term
| Whatis teh most common cause of significant upper GI tract hemorrhage in the pediatric population? |
|
Definition
| variceal bleeding from extrahepatic portal venous obstruction |
|
|
Term
| What is the significance of having maroon colored stool? |
|
Definition
| mixture of fecal material and blood indicating that the bleeding source is located proximal to the lowerrectal segment and anus |
|
|
Term
| What percen tof patients with bleeding from the duodenum have nothing in their NG tubes? |
|
Definition
|
|
Term
| What are the most likely causes of acute lower GI tract bleeding in patients older than 40? |
|
Definition
| diverticulosis, angiodysplasia, and neoplasm |
|
|
Term
| differential diagnosis for lower GI tract bleeding + abdomenal pain = |
|
Definition
| ischemic bowel, inflammatory bowel disease, intussusception, rupture abdominal aneurysm |
|
|
Term
| Occult GItract bleeding is most commonly associated with... |
|
Definition
| neoplasm, gastritis, and esophagitis |
|
|
Term
| What are the most common causes in children and adolescents of overt lower GI tract bleeding? |
|
Definition
| Meckel diverticulum, inflammatory bowel disease, polyps |
|
|
Term
| What are the most common causes of overt lower GI bleed in adults from 20-60? |
|
Definition
| diverticulosis, neoplasm and inflammatory bowel disease |
|
|
Term
| What is the most common cause of lower GI tract bleeding in adults over 60? |
|
Definition
| diverticulosis, neoplasm and angiodysplasia |
|
|
Term
| Tagged RBC scan can identify a bleed at what rate? |
|
Definition
|
|
Term
| When should you perform tagged RBC scan for lower GI bleed? |
|
Definition
| as an initial screening study before performing mesenteric angiography because of poor ability to localize bleeding site |
|
|
Term
| During mesenteric angiography, injection of ____ can be given during angiography to treat active bleedingin patients who are not surgical candidates. |
|
Definition
|
|
Term
| How much bleeding has to be present to be identified by angiography? |
|
Definition
|
|
Term
| What is rigid proctosigmoidoscopy? |
|
Definition
| bedside procedure in which a nonflexible endoscope is used to visualize the most distal 25 cm segment of the lower GI tract |
|
|
Term
| Angiodysplasia occurs where and in what populations? |
|
Definition
| in the cecum and ascending colon of paitents older than 50 years |
|
|
Term
| What percent of patients with angiodysplasia have an associated cardiac disease? aortic stenosis? |
|
Definition
| 50% have cardiac disease; 25% have aortic stenosis |
|
|
Term
| Patients who present with lower GI bleed should be asked if they have ever had what type of surgery? |
|
Definition
| abdominal vascular reconstruction |
|
|
Term
| What causes blood to become melena? |
|
Definition
| degradation of hgby bacteria that forms after blood has remained in the GI tract for more than 14 hours |
|
|
Term
| Why are tagged RBC scan resulst difficult to interpret when evaluating a pt with GIB? |
|
Definition
| they localize bleeding to a region of the abdomen but not necessarily a specific segment of the GI tract |
|
|
