DDX 1 – Week 8

1. DDX 1 – Week 8

2. Heartburn • Heartburn is due to irritation of the esophagus • The main cause is lower esophageal sphincter (LES) incompetence or loss of tone • Foods which decrease tone include: • fatty foods • coffee • chocolate • Drugs which are sympathomimetic decrease tone • Hiatal hernia is a secondary cause

3. Abdominal Pain • Organ pain usually begins centrally • If parietal peritoneum or capsule of organ is irritated, pain becomes localized because they are innervated by spinal nerves • If pain radiates from back to groin, renal/ureter problem is likely • Gynecologic causes may relate to menstrual cycle timing • Sudden (abrupt) pain indicates blockage of non-intestinal lumen, rupture, or major vascular event

5. Acute Abdominal Pain Lower Right Quadrant Appendicitis Pelvic Inflammatory Disease Ectopic Pregnancy Renal Referral Right Upper Quadrant Cholelithiasis (cystitis) Hepatitis Fitz-Hugh-Curtis Appendicitis

6. Appendicitis • Classically begins as central pain that over 6-12 hours • Localizes due to peritoneal irritation • Associated with nausea/vomiting and variable increases in WBC • Diagnosis with signs of rebound tenderness or Rovsings • Definitive diagnosis with diagnostic US • Tx involves laproscopic removal

7. Appendicitis? Paulson EK, Kalady MF, Pappas TN. NEJM, 348(3), 236-242, 2003 A review article which includes information on physical exam and special imaging sensitivity/specificity for Dx of appendicitis Hx findings most important were RLQ pain with anorexia with pain occuring before vomiting Exam most specific was the psoas sign

8. Sensitivity and Specificity of Clinical Findings for the Diagnosis of Acute Appendicitis Paulson E et al. N Engl J Med 2003;348:236-242

9. Clinical Algorithm for the Evaluation of Pain in the Right Lower Quadrant Paulson E et al. N Engl J Med 2003;348:236-242

10. McGee: Evidence based Physical Diagnosis (Saunders Elsevier)

11. % Bayesian reasoning Pre test 5% Post test 20% ? Appendicitis: McBurney tenderness LR+ = 3.4 Fagan nomogram %

12. Pelvic Inflammatory Disease (PID) • Due to Chlamydia or gonorrhea in most cases • Symptoms/signs vary in severity, usually includes fever, chills, and lower, unilateral abdominal pain; abdominal pain often worse at end or soon after period • Pelvic exam unusually sensitive; definitive Dx with culdocentesis • Tx with antibiotics; complication Fitz-Hugh-Curtis disease (involvement of liver capsule)

13. Ectopic Pregnancy 1% of all pregnancies; 99% in fallopian tubes Subtle signs of early pregnancy; breast tenderness, early morning nausea Missed period is helpful, however, spotting may occur Initial evaluation is with pelvic exam, pregnancy test (HCG), then diagnostic US

14. Kidney/Ureteral Stones • More common in males, in humid climates, and during the summer • Mainly due to dehydration • Pain is severe associated with nausea and vomiting; no position of relief • May be seen radiographically; diagnostic US best • Tx includes allowing stones to pass if small enough or use of lithotripsy; rare cases require surgery

15. Cholelithiasis • More common in women, in diabetics, in Native Americans, and those that take oral contraceptives • Cholesterol stones most common; bilirubin stones occur with hemolytic anemias • Severe pain, nausea, vomiting, sometimes referral to inf. border of scapula • Dx is with diagnostic US • Tx includes laproscopic removal, lithotripsy, and dissolving stone chemically

17. Acute Cholecystitis? Trowbridge RL, et al. JAMA, 289(1), 80-86, 2003 No single clinical or laboratory test is able to establish or exclude cholecysistitis without further evaluation with Dx US Highest on the list for specificity (rule-out) was the Murphy’s sign and with lab a combination of fever with leukocytosis ALT, AST, alkaline phosphatase and bilirubin were not very sensitive or specific Dx US has a specificity of 80% and sensitivity of 88%

18. Hepatitis • Mainly due to viral infection; may be due to medications or alcohol • Three main types A, B,and C • Symptoms are mild with A and tend to resolve with onset of jaundice • Acquisition of A is contaminated food or water; with B and C through blood, saliva, or vaginal fluids • B and C more commonly acquired through contaminated needles and sex • Testing for the presence of various antibodies is time sensitive

19. Epigastric Pain • Causes include: • reflux esophagitis • peptic ulcer • pancreatitis • Pain that is recurrent, felt on an empty stomach, relieved by antacids, and unaffected by position suggests ulcer • Pain on a full stomach, worse with recumbency suggests reflux • Severe pain radiating to back with a patient history of alcohol abuse suggests pancreatitis

20. Chronic Recurrent Abdominal Pain • Differentiate by location, associated signs such as diarrhea, constipation, or change in menstrual pain • Lower abdominal pain with alternating bouts of diarrhea/constipation suggest irritable bowel syndrome • If diarrhea is primary, consider inflammatory bowel diseases • Association with menstrual cycle as sharp increase in pain suggests endometriosis or other pelvic pathology

22. Irritable Bowel Syndrome Exclusion diagnosis for patients with chronic abdominal pain usually associated with constipation and diarrhea Probably due to decrease in peristaltic activity Stress and food are triggers for attacks and may be modified to improve Stool sample is clear of blood but often contains mucus No medical treatment; some herbals and diet modifications

23. Diagnostic Criteria for Irritable Bowel Syndrome Lynn R and Friedman L. N Engl J Med 1993;329:1940-1945

24. Suggested Components of the Evaluation of Patients with Symptoms of Irritable Bowel Syndrome Lynn R and Friedman L. N Engl J Med 1993;329:1940-1945

25. Inflammatory Bowel Disease • 2 types: Crohn’s (regional enteritis) and ulcerative colitis • Both have associated HLA-B27 as a factor with a small % of patients with peripheral joint pain • Crohn’s is patchy but transmural involvement of the small intestine mainly • Ulcerative colitis is superficial with heavy bouts of diarrhea as main complaint

26. Podolsky D. N Engl J Med 2002;347:417-429

27. Pathogenesis of Inflammatory Bowel Disease Podolsky D. N Engl J Med 2002;347:417-429

28. Dysmenorrhea 2 types: Primary and Secondary Primary is the baseline, normal discomfort felt with period Secondary is due to abnormal structure or function and creates a sharp increase in the degree of pain felt Most common cause is endometriosis Dx is primarily with diagnostic US, MRI, or surgical exploration

29. Diverticulitis • Herniation of mucosa/submucosa into colonic muscle wall • Primarily found in Western society in one-third of people over 60; due to lack of fiber in diet • Lower abdominal pain with associated low grade fever, blood in the stool, and mild to moderate leukocytosis • Need hospitalization for acute attacks primarily to perform rule-out Dx tests

30. Diarrhea Acute diarrhea is usually due to one of two major mechanisms: • Osmotic • usually a non-digested material such as lactose, sorbitol, manitol, or magnesium antacids • Secretory • usually due to bacteria • enteroinvasive - Campylobacter, salmonella, shigella • enterotoxic - staph, e. coli, clostridium

31. Diarrhea • Fecal leukocytes suggest enteroinvasive • Viral causes include: • adenovirus • rotavirus • Dysentery and Giardia • Chronic diarrhea differentiated by lab for blood, cysts, etc.. • Common bloody causes include inflammatory bowel disease • Non-bloody include antibiotics, other drugs, endocrine, malabsorption, IBS

32. Constipation • Constipation should be confirmed with specific questions about bowel habits • Constipation is usually due to two general mechanisms: • In-effective filling - examples include diabetes, drugs (CNS depressants), GI disease • In-effective emptying - from learned habit or local pathology causing painful defecation • Constipation is common with LBP patients; use mild laxative