management of abdominal pain yasar kucukardalı md yeditepe university department of internal...
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Management of Management of ABDOMINAL ABDOMINAL
PAINPAIN
Yasar Kucukardalı MD Yasar Kucukardalı MD
Yeditepe UniversityYeditepe University
Department of Internal Medicine Department of Internal Medicine
Presentation Presentation
Definition Definition
LocationLocation
Work-upWork-up
Acute pain syndromesAcute pain syndromes
Chronic pain syndromesChronic pain syndromes
TYPES OF ABDOMINAL TYPES OF ABDOMINAL PAINPAIN
VisceralVisceral– originates in abdominal organs covered by originates in abdominal organs covered by
visceral visceral peritoneumperitoneum
ColicColic– crampy pain crampy pain
ParietalParietal– from irritation of parietal peritoneumfrom irritation of parietal peritoneum
ReferredReferred– produced by pathology in one location felt at produced by pathology in one location felt at
another locationanother location
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Peritonun, karın duvarlarına yapışık olan kısımlarına “Parietal periton” adı verilir. Karın içersindeki iç organları kapatmakta olan periton yaprağına ise “Viseral plevra” adı verilir. Parietal periton ve viseral periton arasında meydana gelen boşluğa ise “Periton boşluğu” adı verilir.
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
ORGANIC VERSUS FUNCTIONAL PAINHISTORY ORGANIC FUNCTIONAL
Pain character Acute, persistent pain Less likely to changeincreasing in intensity
Pain localization Sharply localized Various locations
Pain in relation to sleep Awakens at night No affect
Pain in relation to Further away At umbilicus umbilicus
Associated symptoms Fever, anorexia, Headache, dizziness,vomiting, wt loss, multiple system
com-anemia, elevated ESR plaints
Psychological stress None reported Present
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Epigastric PainEpigastric Pain
PUDPUD GERDGERD MIMI AAA- abdominal aortic AAA- abdominal aortic
aneurysmaneurysm Pancreatic painPancreatic pain Gallbladder and common Gallbladder and common
bile duct obstructionbile duct obstruction
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Right Upper Quadrant PainRight Upper Quadrant Pain
Acute Cholecystitis and Biliary Colic Acute Cholecystitis and Biliary Colic Acute Hepatitis or AbscessAcute Hepatitis or Abscess Hepatomegaly due to CHFHepatomegaly due to CHF Perforated Duodenal UlcerPerforated Duodenal Ulcer Herpes ZosterHerpes Zoster Myocardial IschemiaMyocardial Ischemia Right Lower Lobe Pneumonia Right Lower Lobe Pneumonia
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Left Upper Quadrant PainLeft Upper Quadrant Pain
Acute PancreatitisAcute Pancreatitis Gastric ulcerGastric ulcer GastritisGastritis Splenic enlargement, rupture or infarctionSplenic enlargement, rupture or infarction Myocardial ischemiaMyocardial ischemia Left lower lobe pneumoniaLeft lower lobe pneumonia
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Right lower Quadrant PainRight lower Quadrant Pain Appendicitis Appendicitis Regional EnteritisRegional Enteritis Small bowel obstructionSmall bowel obstruction Leaking AneurysmLeaking Aneurysm Ruptured Ectopic PregnancyRuptured Ectopic Pregnancy PIDPID Twisted Ovarian CystTwisted Ovarian Cyst Ureteral CalculiUreteral Calculi HerniaHernia
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Left Lower Quadrant PainLeft Lower Quadrant Pain
DiverticulitisDiverticulitis Leaking AneurysmLeaking Aneurysm Ruptured Ectopic pregnancy Ruptured Ectopic pregnancy PIDPID Twisted Ovarian CystTwisted Ovarian Cyst Ureteral CalculiUreteral Calculi HerniaHernia Regional EnteritisRegional Enteritis
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Periumbilical PainPeriumbilical Pain
Disease of transverse colonDisease of transverse colon GastroenteritisGastroenteritis Small bowel painSmall bowel pain AppendicitisAppendicitis Early bowel obstructionEarly bowel obstruction
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Diffuse PainDiffuse Pain
Generalized peritonitisGeneralized peritonitis Acute PancreatitisAcute Pancreatitis Sickle Cell CrisisSickle Cell Crisis Mesenteric ThrombosisMesenteric Thrombosis GastroenteritisGastroenteritis Metabolic disturbancesMetabolic disturbances Dissecting or Rupturing AneurysmDissecting or Rupturing Aneurysm Intestinal ObstructionIntestinal Obstruction Psychogenic illnessPsychogenic illness
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Referred PainReferred Pain
Pneumonia (lower lobes)Pneumonia (lower lobes)
Inferior myocardial infarctionInferior myocardial infarction
Pulmonary infarctionPulmonary infarction
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Karın ağrısı, bulantı , hafif ateş
History Taking in Abdominal History Taking in Abdominal Pain PresentationsPain Presentations
““OLD CARS”OLD CARS”– O- onsetO- onset– L- locationL- location– D- durationD- duration– C- characterC- character– A-alleviating/aggravating factorsA-alleviating/aggravating factors– R- radiationR- radiation– S- severityS- severity
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Physical Exam in Abdominal Physical Exam in Abdominal Pain PresentationsPain Presentations
InspectionInspection– Distention, scars, bruisesDistention, scars, bruises
AuscultationAuscultation– Present, hyper, or absentPresent, hyper, or absent– Actually not that helpful!Actually not that helpful!
PalpationPalpation– Often the most helpful part of examOften the most helpful part of exam– Tenderness versus painTenderness versus pain– Start away from painful area firstStart away from painful area first– Guarding, rebound, massesGuarding, rebound, masses
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Physical Exam in Abdominal Physical Exam in Abdominal Pain PresentationsPain Presentations
SignsSigns– IliopsoasIliopsoas– Murphy’sMurphy’s
Extra-abdominal examExtra-abdominal exam– Pelvic or scrotal examsPelvic or scrotal exams– Lungs, heartLungs, heart
RectalRectal– Adds very little (despite the angst) beyond Adds very little (despite the angst) beyond
gross blood or melenagross blood or melena
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
WORK-UPWORK-UP
LABORATORY TESTSLABORATORY TESTS
U/AU/A
CBCCBC
Additional depending on rule outsAdditional depending on rule outs– amylase, lipase, LFT’samylase, lipase, LFT’s
Definition Definition
LocationLocation
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Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
WORK-UPWORK-UP
DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES
Plain X-rays (flat plate)Plain X-rays (flat plate)
Contrast studies - barium (upper and lower Contrast studies - barium (upper and lower GI series)GI series)
UltrasoundUltrasound
CT scanningCT scanning
EndoscopyEndoscopy
Sigmoidoscopy, colonoscopySigmoidoscopy, colonoscopy
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Abdominal Pain Across Abdominal Pain Across the Agesthe Ages
Ages 0-2Ages 0-2– Colic, GE, viral illness, constipationColic, GE, viral illness, constipation
Ages 2-12Ages 2-12– Functional, appendicitis, GE, toxinsFunctional, appendicitis, GE, toxins
Teens to adultsTeens to adults– Addition of genitourinary problemsAddition of genitourinary problems
ElderlyElderly– Beware of what seems like everything!Beware of what seems like everything!
Common Acute Pain Common Acute Pain SyndromesSyndromes
Appendicitis Appendicitis
Acute diverticulitisAcute diverticulitis
CholecystitisCholecystitis
PancreatitisPancreatitis
Perforation of an ulcerPerforation of an ulcer
Intestinal obstructionIntestinal obstruction
Ruptured AAARuptured AAA
Pelvic disordersPelvic disorders
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
10320 patient10320 patient
AppendicitisAppendicitis 28%28%
CholecystitisCholecystitis 10%10%
Small bowel obstructionSmall bowel obstruction 4%4%
GynaecologicalGynaecological 4%4%
PancreatitisPancreatitis 3%3%
Renal colic Renal colic 3%3%
Peptic ulcerPeptic ulcer 2%2%
CancerCancer 2%2%
No clinical diagnosisNo clinical diagnosis 34%34%
De Dombal, Scand J De Dombal, Scand J Gastroenterol Gastroenterol 11988988
APPENDICITISAPPENDICITIS
Inflammatory disease of wall of Inflammatory disease of wall of appendixappendix
Diagnosis based on history and Diagnosis based on history and physicalphysical
Classic sequence of symptomsClassic sequence of symptoms– abdominal pain (begins epigastrium abdominal pain (begins epigastrium
or periumbilical area, anorexia, or periumbilical area, anorexia, nausea or vomitingnausea or vomiting
– followed by pain over appendix and followed by pain over appendix and low grade feverlow grade fever
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS of of APPENDICITISAPPENDICITIS
Physical examinationPhysical examination– low grade feverlow grade fever– McBurney’s pointMcBurney’s point– rebound, guarding, +psoas signrebound, guarding, +psoas sign
CBC, HCGCBC, HCG– WBC range from 10,000-16,000WBC range from 10,000-16,000
SURGERYSURGERY
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIVERTICULITISDIVERTICULITIS
Results from stagnation of fecal Results from stagnation of fecal material in single diverticulum material in single diverticulum leading to pressure necrosis of leading to pressure necrosis of mucosa and inflammationmucosa and inflammation
Clinical presentationClinical presentation– most pts have h/o diverticulamost pts have h/o diverticula– mild to moderate, colicky to mild to moderate, colicky to
steady, aching abdominal pain - steady, aching abdominal pain - usually LLQusually LLQ
– may have fever and leukocytosismay have fever and leukocytosis
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
PHYSICAL EXAMINATION• With obstruction bowel sounds hyperactive• Tenderness over affected section of bowelDIAGNOSIS• Often made on clinical grounds• CBC - will not always see leukocytosis
MANAGEMENT of DIVERTICULITIS• Spontaneous resolution common with low-grade fever, mild leukocytosis, and minimal abdominal pain• Treat at home with limited physical activity, reducing fluid intake, and oral antibiotics (bactrim DS bid or cipro 500mg bid & flagyl 500 mg tid for 7-14 days)• Treatment is usually stopped when asymptomatic• Patients who present acutely ill with possible signs of systemic peritonititis,, sepsis, and hypovolemia need admission
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
CHOLECYSTITISCHOLECYSTITIS
Results from obstruction of cystic or Results from obstruction of cystic or common bile duct by large common bile duct by large gallstonesgallstones
Colicky pain with progression to Colicky pain with progression to constant pain in RUQ that may constant pain in RUQ that may radiate to R scapularadiate to R scapula
Physical findingsPhysical findings– tender to palpation or percussion RUQtender to palpation or percussion RUQ– may have palpable gallbladdermay have palpable gallbladder
Definition Definition
LocationLocation
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Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSIS of CHOLECYSTITIS
• CBC, LFTs (bilirubin, alkaline phosphatase), serum pancreatic enzymes• Plain abdominal films demonstrate biliary air hepatomegaly, and maybe gallstones•Ultrasound - considered accurate about 95%MANAGEMENT• Admission
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
PANCREATITISPANCREATITIS
History of cholelithiasis or History of cholelithiasis or alcohol alcohol abuseabuse
Pain steady and boring, Pain steady and boring, unrelieved by position change - unrelieved by position change - LUQ with radiation to back - LUQ with radiation to back - nausea and vomiting, diaphoreticnausea and vomiting, diaphoretic
Physical findings;Physical findings;– acutely ill with abdominal distention, acutely ill with abdominal distention,
BS BS– diffuse rebounddiffuse rebound– upper abd may show muscle rigidityupper abd may show muscle rigidity
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• Diagnostic studies- CBC- Ultrasound- Serum amylase and lipase-Amylase rises 2-12 hours after onset and
returns to normal in 2-3 days- lipase is elevated several days after attack
Management- Admission
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
PEPTIC ULCER PEPTIC ULCER PERFORATIONPERFORATION
Life-threatening complication of Life-threatening complication of peptic ulcer disease - more peptic ulcer disease - more common with duodenal than common with duodenal than gastricgastric
Predisposing factorsPredisposing factors– Helicobacter pylori Helicobacter pylori infectionsinfections– NSAIDsNSAIDs– hypersecretory stateshypersecretory states
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
•Sudden onset of severe intense, steady epigasric pain with radiation to sides, back, or right shoulder• Past h/o burning, pain worse with empty stomach• Physical findings
- epigastric tenderness- rebound tenderness- abdominal muscle rigidity
• Diagnostic studies- upright or lateral decubitis X-ray shows air under the diaphragm or peritoneal cavity
REFER - SURGICAL EMERGENCY
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
PEPTIC ULCER PEPTIC ULCER PERFORATIONPERFORATION
SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION
Distention results in decreased Distention results in decreased absorption and increased absorption and increased secretions leading to further secretions leading to further distention and fluid and electrolyte distention and fluid and electrolyte imbalanceimbalance
Number of causesNumber of causes
Sudden onset of crampy pain Sudden onset of crampy pain usually in umbilical area of usually in umbilical area of epigastrium - vomiting occurs early epigastrium - vomiting occurs early with small bowel and late with large with small bowel and late with large bowelbowel
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• Physical findings- hyperactive, high-pitched BS- fecal mass may be palpable- abdominal distention- empty rectum on digital exam
• Diagnosis- CBC- serum amylase- stool for occult blood- type and crossmatch- abdominal X-ray
• Management- Hospitalization
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION
RUPTURED AORTIC RUPTURED AORTIC ANEURYSMANEURYSM
AAA is abnormal dilation of AAA is abnormal dilation of abdominal aorta forming abdominal aorta forming aneurysm that may rupture aneurysm that may rupture and cause and cause masif bleeding masif bleeding into peritoneuminto peritoneum
More frequent in elderlyMore frequent in elderly
Sudden onset of pain may be Sudden onset of pain may be felt in chest or abdomen and felt in chest or abdomen and may radiate to legs and backmay radiate to legs and back
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• Physical findings - appears shocky-deficit or difference in femoral pulses• Diagnosis
- CT or MRI- ECG, cardiac enzymes
SURGICAL EMERGENCY
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
RUPTURED AORTIC RUPTURED AORTIC ANEURYSMANEURYSM
PELVIC PAINPELVIC PAIN
Ectopic pregnancyEctopic pregnancy
PIDPID
UTIUTI
Ovarian cystsOvarian cysts
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
CHRONIC PAIN CHRONIC PAIN SYNDROMESSYNDROMES
Irritable bowel syndromeIrritable bowel syndrome
Chronic pancreatitisChronic pancreatitis
DiverticulosisDiverticulosis
Gastroesophageal reflux disease (GERD)Gastroesophageal reflux disease (GERD)
Inflammatory bowel diseaseInflammatory bowel disease
Duodenal ulcerDuodenal ulcer
Gastric ulcerGastric ulcer
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROME
GI condition classified as GI condition classified as functional as no identifiable functional as no identifiable structural or biochemical structural or biochemical abnormalitiesabnormalities
Affects 14%-24% of females Affects 14%-24% of females and 5%-19% of malesand 5%-19% of males
Onset in late adolescence to Onset in late adolescence to early adulthoodearly adulthood
Rare to see onset > 50 yrs Rare to see onset > 50 yrs oldold
Definition Definition
LocationLocation
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Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROMESYMPTOMSSYMPTOMS
Pain described as Pain described as nonradiating, intermittent, nonradiating, intermittent, crampy located lower crampy located lower abdomenabdomen
Usually worse 1-2 hrs after Usually worse 1-2 hrs after mealsmeals
Exacerbated by stressExacerbated by stress
Relieved by BMRelieved by BM
Does not interrupt sleepDoes not interrupt sleep– critical to diagnosis of IBScritical to diagnosis of IBS
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS Of IBS Of IBSROME DIAGNOSTIC CRITERIAROME DIAGNOSTIC CRITERIA
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSTIC TESTSDIAGNOSTIC TESTS Of IBS Of IBS
Limited - R/O organic diseaseLimited - R/O organic disease
CBC with diffCBC with diff
ESRESR
ElectrolytesElectrolytes
BUN, creatinineBUN, creatinine
TSHTSH
Stool for occult blood and O & PStool for occult blood and O & P
Flexible sigmoidoscopyFlexible sigmoidoscopy
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
MANAGEMENTMANAGEMENT OF IBS OF IBS
Goals of managementGoals of management
exclude presence of underlying exclude presence of underlying organicorganic disease disease
provide support, & reassuranceprovide support, & reassurance
Dietary modificationDietary modification
PharmacotherapyPharmacotherapy
Alternative therapiesAlternative therapies
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
CHRONIC CHRONIC PANCREATITISPANCREATITIS
Alcohol major causeAlcohol major cause
Malnutrition - outside USMalnutrition - outside US
Patients >40 yrs with pancreatic Patients >40 yrs with pancreatic dysfunction must be evaluated for dysfunction must be evaluated for pancreatic cancerpancreatic cancer
Dysfunction between 20 to 40 yrs Dysfunction between 20 to 40 yrs old R/O cystic fibrosisold R/O cystic fibrosis
50% of pts with chronic 50% of pts with chronic pancreatitis die within 25 yrs of pancreatitis die within 25 yrs of diagnosisdiagnosis
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMSSYMPTOMS of of CHRONIC CHRONIC PANCREATITISPANCREATITIS
Pain - may be absent or severe, Pain - may be absent or severe, recurrent or constantrecurrent or constant
Usually abdominal, sometimes Usually abdominal, sometimes referred upper back, anterior referred upper back, anterior chest, flankchest, flank
Wt loss, diarrhea, oily stoolsWt loss, diarrhea, oily stools
NNauseaausea, V, Vomitingomiting, or abdominal , or abdominal distention less reporteddistention less reported
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS of of CHRONIC CHRONIC PANCREATITISPANCREATITIS
CBCCBC
Serum amylase (present during acuteSerum amylase (present during acute attacks)attacks)
Serum lipaseSerum lipase
Serum bilirubinSerum bilirubin
Serum glucoseSerum glucose
Serum alkaline phosphataseSerum alkaline phosphatase
Stool for fecal fatStool for fecal fat
CT scanCT scan
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
MANAGEMENTMANAGEMENT of of CHRONIC CHRONIC PANCREATITISPANCREATITIS
Should be coShould be co--managed managed with a specialistwith a specialist
Pancreatic dysfunction Pancreatic dysfunction
- diabetes- diabetes
- steatorrhea & diarrhea- steatorrhea & diarrhea
- enzyme replacement- enzyme replacement
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIVERTICULOSISDIVERTICULOSIS
Uncomplicated disease, Uncomplicated disease, either asymptomatic or either asymptomatic or symptomatic symptomatic
Considered a deficiency Considered a deficiency disease of 20th century disease of 20th century Western civilizationWestern civilization
Rare in first 4 decades - Rare in first 4 decades - occurs in later yearsoccurs in later years
Incidence - 50% to 65% by Incidence - 50% to 65% by 80 years80 years
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMSSYMPTOMS of of DIVERTICULOSISDIVERTICULOSIS
80% - 85% remain symptomless 80% - 85% remain symptomless - found by diagnostic study for - found by diagnostic study for other reasonother reasonIrregular defecation, intermittent Irregular defecation, intermittent abdominal pain, bloating, or abdominal pain, bloating, or excessive flatulenceexcessive flatulenceChange in stool - flattened or Change in stool - flattened or ribbonlikeribbonlikeRecurrent bouts of steady or Recurrent bouts of steady or crampy paincrampy painMay mimic IBS except older ageMay mimic IBS except older ageTherapy/ Therapy/ Increased fiber intake - Increased fiber intake - 35 g/day35 g/day
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS of of DIVERTICULOSISDIVERTICULOSIS
CBCCBC
Stool for occult Stool for occult bloodblood
Barium enemaBarium enema
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
GASTROESOPHAGEAL REFLUX GASTROESOPHAGEAL REFLUX DISEASEDISEASE
Movement of gastric Movement of gastric contents from stomach to contents from stomach to esophagusesophagusMay produce May produce burning,pain burning,pain within esophagus, within esophagus, pharynx, larynx, pharynx, larynx, respiratory tractrespiratory tractMost prevalent condition Most prevalent condition affecting GI tractaffecting GI tract
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMSSYMPTOMS of GORD of GORD Heartburn - most common (severity of Heartburn - most common (severity of does not correlate with extent of tissue does not correlate with extent of tissue damage)damage)
Burning, gnawing in mid-epigastrium Burning, gnawing in mid-epigastrium worsens with recumbencyworsens with recumbency
Water brash (appearance of salty-Water brash (appearance of salty-tasting fluid in mouth because tasting fluid in mouth because stimulate saliva secretion)stimulate saliva secretion)
Occurs after eating may be relieved Occurs after eating may be relieved with antacids (occurs within 1 hr of with antacids (occurs within 1 hr of eating - usually large meal of day)eating - usually large meal of day)
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• Dysphagia & odynophagia predictive of severe disease• Chest pain - may mimic angina• Foods that may precipitate heartburn
- high fat or sugar- chocolate, coffee, & onions- citrus, tomato-based, spicy
• Cigarette smoking and alcohol • Aspirin, NSAIDS, potassium, pills
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS of GORD of GORD
History of heartburn without other History of heartburn without other symptoms of serious diseasesymptoms of serious disease
Empiric trial of medication without Empiric trial of medication without testingtesting
Testing for those who do have Testing for those who do have persistent or unresponsive heartburn or persistent or unresponsive heartburn or signs of tissue injurysigns of tissue injury
CBC, CBC, H. pyloriH. pylori antibody antibody
Barium swallowBarium swallow
Endoscopy for severe or atypical Endoscopy for severe or atypical symptomssymptoms
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
MANAGEMENTMANAGEMENT of GORD of GORD
Lifestyle changesLifestyle changes– smoking cessationsmoking cessation– reduce reduce alcohol alcohol consumptionconsumption– reduce dietary fatreduce dietary fat– decreased meal sizedecreased meal size– weight reductionweight reduction– elevate head of bed elevate head of bed
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• elimination of medications that are mucosal irritants or that lower esophageal pressure• avoidance of supine position for 2 hours after meal avoidance of tight fitting clothes
MEDICATIONSMEDICATIONS for GORD for GORD
Antacids with lifestyle changes may be Antacids with lifestyle changes may be sufficientsufficient
Histamine receptor antagonists in divided Histamine receptor antagonists in divided dosesdoses– approximately 48% of pts with esophagitis will approximately 48% of pts with esophagitis will
heal on this regimenheal on this regimen– tid dosing more effective for symptom relief tid dosing more effective for symptom relief
and healingand healing– long-term use is appropriatelong-term use is appropriate
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
INFLAMMATORY BOWEL INFLAMMATORY BOWEL DISEASEDISEASE
Chronic inflammatory Chronic inflammatory condition involving intestinal condition involving intestinal tract with periods of remission tract with periods of remission and exacerbationand exacerbation
Two typesTwo types– Ulcerative colitis (UC)Ulcerative colitis (UC)– Crohn’s diseaseCrohn’s disease
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
ULCERATIVE COLITISULCERATIVE COLITIS
Chronic inflammation of Chronic inflammation of colonic mucosacolonic mucosa
Inflammation diffuse & Inflammation diffuse & continuous beginning in continuous beginning in rectumrectum
May involve entire colon or May involve entire colon or only rectum (proctitis)only rectum (proctitis)
Inflammation is continuousInflammation is continuous
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
CROHN’S DISEASECROHN’S DISEASE
Chronic inflammation of all Chronic inflammation of all layers on intestinal tractlayers on intestinal tract
Can involve any portion from Can involve any portion from mouth to anusmouth to anus
30%-40% small intestine (ileitis)30%-40% small intestine (ileitis)
40%-45% small & large 40%-45% small & large intestine (ileocolitis)intestine (ileocolitis)
15%-25% colon (Crohn’s 15%-25% colon (Crohn’s colitis)colitis)
Inflammation can be patchyInflammation can be patchy
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
• Annual incidence of UC & Crohn’s similar in both age of onset & worldwide distribution•About 20% more men have UC• About 20% more women have Crohn’s• Peak age of onset - between 15 & 25 yrs
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMSSYMPTOMS / /CROHN’S DISEASECROHN’S DISEASEDefinition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
PHYSICAL EXAMINATION PHYSICAL EXAMINATION CROHN’S DISEASECROHN’S DISEASE
May be in no distress to acutely illMay be in no distress to acutely ill
Oral apthous ulcersOral apthous ulcers
Tender lower abdomenTender lower abdomen
Hyperactive bowel soundsHyperactive bowel sounds
Stool for occult blood may be +Stool for occult blood may be +
Perianal lesionsPerianal lesions
Need to look for fistulas & abscessesNeed to look for fistulas & abscesses
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSIS DIAGNOSIS of of CROHN’S CROHN’S DISEASEDISEASE
CBCCBC
Stool for culture, ova & parasites, Stool for culture, ova & parasites, C. C. difficiledifficile
Stool for occult bloodStool for occult blood
Flexible sigmoidoscopy - useful to Flexible sigmoidoscopy - useful to determine source of bright red blooddetermine source of bright red blood
Colonoscopy with biopsyColonoscopy with biopsy
Endoscopy may show “skip” areasEndoscopy may show “skip” areas
May be difficult to distinguish one from May be difficult to distinguish one from other other
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DUODENAL ULCERSDUODENAL ULCERS
Incidence increasing secondary to Incidence increasing secondary to
increasing use of NSAIDs, increasing use of NSAIDs,
H. pyloriH. pylori infections infections
Imbalance both in amount of Imbalance both in amount of
acid-pepsin production delivered acid-pepsin production delivered
form stomach to duodenum andform stomach to duodenum and
ability of lining to protect selfability of lining to protect self
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
RISK FACTORSRISK FACTORS / / DUODENAL ULCERSDUODENAL ULCERS
StressStressCigarette smokingCigarette smokingCOPDCOPDAlcoholAlcoholChronic ASA & NSAID useChronic ASA & NSAID use
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
INCIDENCEINCIDENCE / / DUODENAL ULCERSDUODENAL ULCERS
About 16 million individuals will have during About 16 million individuals will have during lifetimelifetime
More common than gastric ulcersMore common than gastric ulcers
Peak incidence; 5th decade for men, 6th Peak incidence; 5th decade for men, 6th decade for womendecade for women
75%-80% recurrence rate within 1yr of 75%-80% recurrence rate within 1yr of diagnosis without maintenance therapydiagnosis without maintenance therapy
>90% of duodenal ulcers caused by >90% of duodenal ulcers caused by H.pyloriH.pylori
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMSSYMPTOMS / / DUODENAL ULCERSDUODENAL ULCERS
Epigastric painEpigastric pain
Sharp, burning, aching, gnawing pain Sharp, burning, aching, gnawing pain occurring 1 - 3 hrs after meals or in occurring 1 - 3 hrs after meals or in middle of nightmiddle of night
Pain relieved with antacids or foodPain relieved with antacids or food
Symptoms recurrent lasting few days Symptoms recurrent lasting few days to monthsto months
Weight gain not uncommonWeight gain not uncommon
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
GASTRIC ULCERSGASTRIC ULCERS
H. pyloriH. pylori identified in 65% identified in 65% to 75% of patients with non-to 75% of patients with non-NSAID useNSAID use
5% - 25% of patients taking 5% - 25% of patients taking ASA/NSAID develop gastric ASA/NSAID develop gastric ulcers (inhibits synthesis of ulcers (inhibits synthesis of prostaglandin which is prostaglandin which is critical for mucosal critical for mucosal defense)defense)
Malignancy cause of Malignancy cause of
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
OTHER RISK FACTORSOTHER RISK FACTORS //GASTRIC ULCERSGASTRIC ULCERS
Caffeine/coffeeCaffeine/coffee
AlcoholAlcohol
SmokingSmoking
First-degree relative with gastric ulcerFirst-degree relative with gastric ulcer
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
SYMPTOMS SYMPTOMS / / GASTRIC GASTRIC ULCERSULCERS
Pain similar to duodenal but may Pain similar to duodenal but may be increased by foodbe increased by food
Location - LUQ radiating to backLocation - LUQ radiating to back
Bloating, belching, nausea, Bloating, belching, nausea, vomiting, weight lossvomiting, weight loss
NSAID-induced ulcers usually NSAID-induced ulcers usually painless - discovered secondary painless - discovered secondary to melena or iron deficiency to melena or iron deficiency anemiaanemia
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
DIAGNOSISDIAGNOSIS / / GASTRIC GASTRIC ULCERSULCERS
CBCCBC
Serum for Serum for H. pyloriH. pylori
Carbon-labeled breath testCarbon-labeled breath test
Stool for occult bloodStool for occult blood
EndoscopyEndoscopy
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes
MANAGEMENT MANAGEMENT / / GASTRIC GASTRIC ULCERSULCERS
Treat Treat H.pyloriH.pylori if present if present
Proton pump inhibitors shown to be superior to HProton pump inhibitors shown to be superior to H22--RARA
Need to use proton pump inhibitor for up to 8 wksNeed to use proton pump inhibitor for up to 8 wks
Do not need maintenance if infection eradicated Do not need maintenance if infection eradicated and NSAIDs and NSAIDs discontinueddiscontinued
Consider misoprostol if cannot d/c NSAIDConsider misoprostol if cannot d/c NSAID
Definition Definition
LocationLocation
Work-upWork-up
Acute pain Acute pain syndromessyndromes
Chronic pain Chronic pain syndromessyndromes