Term
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Definition
| chest pain, vomiting, repeated vomting, shoulder pain |
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Term
Diffuse Esophageal Spasm
Presentation
A 47-year-old man presents to the emergency room saying that he is having a heart attack. He reports that the pain started after he ate some of his favorite soup. It is noted that he also had some difficulty swallowing when the symptoms began. |
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Definition
Symptoms ◦symptoms may occur following ingestion of cold liquids and include ◾difficulty swallowing
◾painful swallowing
◾sudden onset chest pain not related to exertion ◾spontaneous and radiated to back, ears, and neck
•Physical exam ◦symptomatic relief with nitroglycerin |
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Term
Nutcracker Esophagus
A 72-year-old woman is brought to the emergency room complaining of chest pain and difficulty swallowing. Barium swallow is shown. It is determine via manometry that there is 180mmHg of pressure created by the esophagus during peristalsis. |
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Definition
Symptoms ◦symptoms may occur with or without food ingestion and include
◾spontaneous chest pain ◾that radiates to back, ears, and neck
◾difficulty swallowing
•Physical exam ◦usually no obvious signs on physical exam |
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Term
Zenker's Diverticulum
A 73-year-old female is being seen at the emergency department after having recurrent coughing spells and regurgitation following meals. Her breath is nearly unbearable upon arrival to the ED. She is also noted to have a palpable, fluctuant neck mass on physical examination. |
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Definition
Symptoms ◦dysphagia
◦regurgitation
◦choking
◦chronic cough
◦bad breath (halitosis)
•Physical exam ◦palpable, fluctuant neck mass may be appreciable |
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Term
Hiatal Hernia
A 45-year-old man presents to the emergency room with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining. |
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Definition
Symptoms ◦may be asymptomatic, usually identified incidentally on radiography
◦chest pain
◦heart burn
◦GERD
•Physical exam ◦usually no significant findings |
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Term
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Definition
Caused by ingestion of strongly acidic or basic chemical ◦Lye, HCl
•Results in ◦esophageal perforation
◦esophageal stricture formation |
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Term
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Definition
•Commonly seen in AIDS patients
•May be viral or fungal ◦HSV, CMV, or Candidia
•Odynophagia is main symptom |
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Term
Plummer-Vinson Syndrome
A 63-year-old woman with chronic anemia presents to her primary care physician complaining of difficulty swallowing. An upper endoscopy is ordered. |
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Definition
Symptoms ◦difficulty swallowing
◦chronic cough
◦weakness/malaise
◦nail changes
•Physical exam ◦atrophic glossitis
◦esophageal webs
◦anemia
◦spoon nail deformities |
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Term
Boerhaave's Syndrome
Topic updated on 06/18/14 5:43pm |
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Definition
Symptoms ◦sudden-onset, severe, retrosternal chest pain
◦difficulty or painful swallowing
◦hematemesis ◾though more common in Mallory-Weiss tears
•Physical exam ◦pleuritic chest pain
◦hyperventilation
◦tachycardia |
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Term
Upper GI Bleed
A 65-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals, and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on exam |
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Definition
Symptoms ◦hematemesis (bloody vomiting) ◾coffee ground appearance
◦melena (dark stools) ◾secondary to metabolized RBCs passing into lower GI tract
◦rarely hematochezia (more common in lower GI bleeds)
◦some cases may not present with observable bleeding
◦patients may initially present with vital sign instability ◾tachycardia/hypotension
◦malaise/weakness
◦fever
◦dizziness
•Physical exam ◦positive stool guiaic
◦hypotension
◦tachycardia
◦fever |
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Term
Gastritis
A 35-year-old male presents to his primary care physician complaining of epigastric pain, nausea, vomiting, all worsened by eating. |
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Definition
Symptoms ◦may be asymptomatic
◦epigastric pain
◦nausea/vomiting
◦bloody vomiting
◦dark stools
•Physical exam ◦epigastrum may be tender to palpation
◦may have positive stool guiaic |
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Term
Gastroesophageal Reflux Disease (GERD)
Mr. Quin, a 65-year-old male presents with complaints of heartburn, belching, epigastic pain which is aggravated by drinking coffee and eating fatty foods. He says it gets better when he takes TUMS. |
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Definition
•Symptoms
◦heartburn 30-90 minutes after a meal ◾worse with reclining
◾improves with antacids
◦sour taste
◦regurgitation
◦dysphagia
◦wheezing |
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Term
Peptic Ulcer Disease
A 65-year-old male presents with complaints of epigastric pain and belching which improves when he eats food but gets worse a few hours after his meal. He said he has noticed a change in the color of his stool. |
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Definition
•Symptoms
◦nausea
◦hematemesis
◦melena or hematochezia
◦symptoms may very by ulcer location ◾gastric ulcers ◾midepigastic gnawing pain
◾worse with meals
◾duodenal ulcer ◾chronic dull, burning, aching epigastric pain
◾improves with meals
◾worsens 1-3 hours after eating
◾radiates to the back
◾awaken patient at night
•Ulcer Perforation ◦pain in right shoulder ( air under the diaphragm)
◦rebound tenderness
◦ileus occur as a result of chemical peritonitis
•Acute perforation ◦may lead to peritoneal signs |
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Term
Zollinger-Ellison Syndrome
A 42-year-old male executive complains of upper abdominal pain. He say he is under considerable stress at work and smokes a pack of cigarettes every day. He has no history of SOB, swelling of the feet, chest pain, or allergies. Further history reveals that the pain is worse at night and often wakens him from sleep. It occurs between meals and is appeased by drinking milk and eating a bland diet. On one occasion he vomited blood. Testing reveals a basal acid output (BA)) of 60 mEq (normal is <5 mEq and a serum gastrin level of 1000 pg/ml (normal is <300 pg/ml) |
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Definition
Symptoms ◦similar to PUD
◦diarrhea ◾because the acidity in the duodenum inactivates pancreatic enzymes |
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Term
Mallory-Weiss Tear
A 21-year-old male presents to the emergency department with hematemesis. He had been out drinking every night that week with his friends in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, his friends noticed that there was streaking of blood and brought him into the emergency department. |
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Definition
Symptoms
blood in vomit
◦blood in stool
◦dark stools
◦epigastric pain
◦back pain
Physical exam
◦upper GI bleed
◦hemodynamic instability
◾can occur with large bleeds
◾signs include hypotension/tachycardia |
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Term
Dumping Syndrome
A post surgical complication
•Caused by any procedure that impairs the integrity of the pylorus
•Leads to free delivery of hyperosmotics chyme to small intestine ◦causes fluid shift into the intestinal lumen and distention |
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Definition
•Symptoms ◦presents with the following symptoms 30 minutes after eating meal ◾diaphoresis
◾light-headedness
◾tachypnea
◾abdominal pain
◾flatus
◾hypotension |
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Term
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Definition
| A 35 year-old with duodenal ulcer diseae had a 10 unit blood transfusin for upper GI bleeding 3 months ago. He presents with flu-like symptoms, malaise, and tender hepatomegaly. Jaundice is present on physical exam. Labs show an atypical lymphocytosis. |
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Term
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Definition
Physical exam ◦jaundice
◦scleral icterus
◦tender hepatomegaly |
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Term
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Definition
Symptoms ◦range from minor to severe
◦can be acute or chronic
◦fatigue
◦abdominal pain
◦joint pain
◦pruritus
◦skin rashes
◦dark-colored urine
◦amenorrhea in women - often an initial complaint |
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Term
Cirrhosis
A 65-year-old male with a long history of alcohol abuse presents to an emergency room with a painful hemorrhoid. You note severe ascites on exam. rrhosis |
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Definition
•Physical exam ◦caused by two main disease processes ◾hepatic failure ◾palmar erythema
◾Dupuytren's contracture
◾encephalopathy ◾↓ excretion of ammonia
◾worse in alkalemic states ◾NH3 favored over NH4+
◾jaundice ◾↓ excretion of billirubin
◾pitting ankle edema ◾↓ synthesis synthesis of albumin
◾gynecomastia/spider angiomas/female hair distribution ◾↓ degradation of estrogens
◾bleeding (↑ PT) ◾↓ synthesis of coagulation factors
◾asterix ◾"flapping" tremor |
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Term
portal hypertension
A 58-year-old alcoholic presents with an episode of upper GI vomiting. On physical exam, severe abdominal ascites is noted. (Ruptured esophageal varicies secondary to portal hypertension) |
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Definition
hepatosplenomegaly ◾splenomegaly is secondary to portal hypertension
Symptoms ◦ascites
◦abdominal pain
◦altered mental status
•Physical exam ◦abdominal fluid wave
◦shifting dullness
◦splenomegaly
◾caput medusae
◾ascites ◾also due to hypoalbuminemia, secondary hyperaldosteronism |
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Term
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Definition
•Symptoms ◦abdominal distention
•Physical exam ◦shifting dullness
◦fluid wave
Evaluation
•Paracentesis ◦send ascitic fluid for WBC count, gram stain, culture, glucose, protein
•Serum Albumin Ascites Gradient (SAAG) ◦SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid).
◦if > 1.1 g/dL) indicates the ascites is due to portal hypertension with 97% accuracy.
◦if < 1.1 g/dL indicates causes of ascites not associated with increased portal pressure |
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Term
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Definition
Functional renal and hepatic failure seen in severe liver disease ◦decreased GFR in absence of shock or organic renal dysfunction
◦kidneys are morphologically normal but function poorly and do not respond to fluids
•Inciting events may include ◦hypovolemia ◾overly aggresive diuretic administration
◾hemorrhage
◾large volume ascitic taps
Presentation
•Physical exam ◦hypotension |
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Term
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Definition
Physical exam ◦palmar erythema ◾unique to alcoholic liver disease
◦hepatosplenomegaly ◾splenomegaly is secondary to portal hypertension
◦ascites
◦spider angiomas
◦gynecomastia ◾due to estrogen build up because it is not metabolized in the liver
◦testicular atrophy |
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Term
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Definition
Symptoms ◦vomiting
◦stupor
◦coma
◦death
•Physical exam ◦jaundice ◾not typically seen in Reye's
◦hepatomegaly |
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Term
Reye's Syndrome
A 10 year-old child has skin papules that began 5 days ago and was given aspirin for fever. She now presents with vomiting and lethargy. PE shows mild hepatomegaly. Total bilrubin, and serum ammonium are increased. |
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Definition
•Symptoms ◦biphasic course with prodromal fever, asymptomatic interval, followed by abrupt onset of ◾vomiting
◾delirium
◾stupor
◾hepatomegaly
◾symptoms of increasing ICP |
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Term
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Definition
•Symptoms ◦dementia
◦seizures
◦obtundation / coma
•Physical exam ◦hyperreflexia
◦asterixis (flapping of extended wrists) |
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Term
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Definition
•Symptoms ◦cirrhosis
◦malabsorption ◾secondary to destruction of exocrine pancrease
◦amenorrhea/↓ libido ◾secondary to hypogonadism
◦arthritis ◾chondrocalcinosis |
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Term
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Definition
Liver abcess caused by entameba histolytica
•Seen in travelers to endemic areas
•Typically a single cyst in the right side of the liver
Symptoms ◦most are asymptomatic
◦RUQ pain
◦dysentery |
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Term
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Definition
Liver cyst caused by echinococcus granulosus
•Seen in people with close contacts with dogs and sheep
Symptoms ◦mostly asymptomatic
◦nausea, vomiting, RUG pain, hepatomegaly |
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Term
| Spontaneous Bacterial Peritonitis (SBP) |
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Definition
•Infection of ascitic fluid
•Most common organism depends on ascitic cause ◦streptococcus pneumonae seen in nephrotic syndrome
◦e. coli seen in cirrhosis
Presentation
• Physical exam ◦abdominal pain with guarding
◦fever |
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Term
Cholelithiasis and Biliary Colic
A 49 year old obese Hispanic female presents with RUQ colicky pain that is made worse by eating fatty foods. |
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Definition
•Symptoms ◦choledocholithiasis is asymptotic by definition
◦biliary colic is symptomatic cholelithiasis when gallstone impacts cystic or common bile duct ◾sharp colicky pain made worse with fatty food
◦Symptoms similar to colic can also be caused by Spincter of Oddi dysfunction, which can be diagnosed with spincter manometry and treated with spincerterotomy via ERCP |
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Term
Acute Cholecystitis
A 45-year-old obese woman presents in the ER with steady, severe, aching pain in the upper right quadrant that radiates to the right scapula. The onset was acute and occurred 30 minutes after lunch. She had nausea with vomiting. On physical exam, she noted that she stops breathing on deep palpation of the right quadrant. Laboratory studies show an absolute neutrophillic leukocytosis with a left shift. |
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Definition
•Symptoms ◦RUQ pain ◾sudden onset
◾15-30 minutes after eating
◾steady and aching
◾radiates to the right scapula
◦nausea
◦vomiting
•Physical exam ◦RUQ tenderness
◦inspiratory arrest during deep palpation of the RUQ (Murphy's sign)
◦low grade fever
◦mild icterus may be present
◦Gallbladder palpable in 30-40% of patients |
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Term
Choledocholithiasis
A 49-year-old, obese, Hispanic female presents with RUQ pain, nausea, vomiting and jaundice. |
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Definition
•Symptoms ◦obstructive jaundice
◦acute pancreatitis ◾if stone lodges in Ampulla of Vater
Evaluation
•RUQ ultrasound
◦shows CBD > 9mm
•Labs ◦elevated conjugated bilirubin
◦hypercholesterolemia
◦elevated alk phos |
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Term
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Definition
•Symptoms ◦bowel obstruction ◾nausea
◾vomitting
◾failure to pass stool
◦this condition is often seen in severely ill patient who may not be aware enough to localize pain but may present with altered mental status
•Physical exam ◦nonspecific
Evaluation
•Xray shows free air in the gallbladder (40% of the cases) |
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Term
Ascending Cholangitis
A 50 year-old woman presents with fever, jaundice, and right upper quadrant pain. Labs reveal an elevated direct bilirubin and alkaline phosphatase. |
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Definition
•Symptoms ◦present with Charcot's Triad (85% senstive for cholangitis) ◾RUQ pain
◾jaundice
◾fever/chills
◦Reynold's pentad
◦Charcots triad plu ◾hypotension
◾altered mental status
◾may be present in acute suppurative cholangitis |
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Term
Primary Sclerosing Cholangitis
A 28-year-old male with a past medical history significant for ulcerative colitis presents with a gradual worsening fatigue associated with jaundice |
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Definition
•Symptoms/Physical exam ◦the onset is usually insidious with ◾gradual, progressive fatigue
◾pruritus
◾jaundice
◾some present with hepatosplenomegaly or features of cirrhosis
◦the terminal phase is characterized by ◾decompensated cirrhosis
◾portal hypertension
◾ascites
◾liver failure |
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Term
| Primary Biliary CIrrhosis |
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Definition
•Symptoms ◦chronic cholecystitis
◦pruritis (itching) ◾one of the first manifestations
◾caused by excess bile salts deposited in the skin
◦jaundice
Evaluation |
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Term
| Secondary Billiary Cirrhosis |
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Definition
Billiary cirrhosis that results from long standing biliary obstruction
•Causes include
◦cholangitis
◦cholelithiasis
◦tumors
•Symptoms
◦jaundice
◦acholic stool
◦dark/fatty stool
•Physical exam
◦xanthomas
Evaluation
•Increased serum cholesterol |
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Term
Acute Pancreatitis
A 35-year old man complains of rapid onset of midepigastric pain with radiation to the back after eating a large meal. Physical Exam shows low grade fever, epigastric tenderness, and decreased bowel sounds. AXR shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity. |
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Definition
•Symptoms ◦severe epigastric pain ◾described as steady and boring
◾radiates to the back
◾relieved by leaning forward
◦nausea
◦vomiting
◦weakness
◦low fever (70-85%)
◦shock (20-40%, due to loss of fluid in peripancreatic third space)
•Physical exam ◦abdominal tenderness without guarding or rebound
◦diminished bowel sounds from a localized ileus
•Hemorrhagic pancreatitis indicated by ◦Grey Turner's sign (purple discoloration of the flank)
◦Cullen's sign (periumbilical purple discoloration)
•Jaundice is rare |
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Term
Chronic Pancreatits
Mr. S, a 52 year-old male, with a twenty year history of alchoholism presents in the ER with persistant epigastric pain, constipation, and steatorrhea. His labs are are remarkable for an elevated amylase and lipase. AXR shows a mild ileus. |
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Definition
Symptoms ◦persistant epigastric pain
◦constipation
◦flatulance
◦steatorrhea
◾because of decreased lipase |
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Term
Pancreatic Pseudocyst
A 42 year-old man with a known history of chronic pancreatitis comes to your office because he says he can feel a mass in his stomach. His records show that he has a persistently elevated serum amylase and urine amylase. |
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Definition
•Symptoms ◦abdominal pain
•Physical exam
◦abdominal mass
Evaluation
•Ultrasound
•CT
•Persistent hyperamylasemia.
Treatment
•If pseudocyst persists for 4 to 6 weeks or continues to enlarge: ◦percutaneous drainage
◦surgical decompression (pancreaticogastrostomy)
◦cyst fluid is drained into the stomach or bowel.
Prognosis, Prevention, and Complications
•Can become infected and lead to peritonitis |
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