1.6 Acute Mgmt GI Complaint

Question 1

Your patient presents with nausea and vomiting without significant abd pain/tenderness. What are some of your top DDx/suspicions?

Answer 1

• Adverse drug rxn
• IBS
• Gastritis
• Cyclic vomiting syndrome
  
  • Medications, cannabinoid, EtOH
• Acute MI
• Gastroparesis
• DKA
• Food-borne toxin
• Viral enteritis
• Head injury/increased ICP
• Migraine
• Vertigo
• Pregnancy
• Acute renal failure
• Hepatic failure
• Drug intox/withdrawal
• Psychogenic

Question 2

How do you work up your patient with N/V (and no significant abd pain) to generate a dx?

Answer 2

• If clinical suspicion high for viral gastroenteritis, ADR, substance-related AND no red flags
  
  • No dx workup necessary
  • Anti-emetic and hydration
• Labs:
  
  • CBC
  • BMP
  • LFTs
  • Lipase
  • Troponin
  • UA
    
    • Ketones (dehydration)
    • Blood (nephritis)
  • HCG
  • Lactic acid if ill-appearing or hypertensive
• Dxics:
  
  • EKG if concerning for cardiac cause
  • Imaging per suspicion
    
    • Bowel obstruction, get it

Question 3

What are the mainstays of N/V treatment?

What else can be done?

Answer 3

• Mainstays
  
  • Fluids
  • Anti-emetics
    
    • Zofran (prolong QT)
    • Reglan (agitation rxn, treat w benadryl)
    • Phenergen (sedating)
    • Compazine (sedating)
    • Ativan (cyclic vomiting/psychogenic)
• Acupressure
  
  • Pressure point
  • Well documented efficacy in chemotherapy
• Aromatherapy
  
  • EtOH swab under nose
• Cannabonoid Hyperemesis
  
  • Capsaicin cream
  • Hot shower
• Electrolyte replacement as needed
• H2 blockers
  
  • Faster acting than PPIs with fewer SEs
  • Gastritis
• Treat underlying cause
• Hospitalize if inability to tolerate oral fluids, severe lyte disturbance, or severe comorbidities

Question 4

Break down different causes of Acute vs. Chronic Diarrheal Illness

Answer 4

Acute

• Virus
  
  • Rotavirus, norovirus, adenovirus
• Bacteria
  
  • Campylobacter, E coli, Salmonella, Shigella, C diff
• Drug induced
  
  • Abx, metformin
• Parasite
  
  • Giardia, cryptosporidium
• Stool impaction

Chronic

• Celiac
• Chron’s
• IBS
• Ulcerative colitis
• Chronic pancreatitis
• Liver dz
• Food intolerance: lactose/fructose, sugar alcohols
• Post-operative
  
  • Cholecystectomy
  • Bowel resection
  • Bariatric surgery

Question 5

Describe your dx workup for your patient with diarrhea?

Answer 5

• None needed if pt well-appearing and history suggests viral enteritis
• Labs
  
  • CBC, BMP, UA minimum
  • LFTs, lipase, HCG, CRP, stool studies, occult blood
• Imaging
  
  • If pt ill appearing or suspicion for acute abd

Question 6

Describe mgmt for your patient with diarrhea

Answer 6

• Fluid resuscitation
• Electrolyte replacement
  
  • Calcium, potassium
• Antidiarrheal for severe sx
  
  • Loperamide
  • Diphenoxylate-atropine
  • Bismuth subsalicylate
• Probiotics
• Treat underlying cause
  
  • Abx if indicated
  • Oral pred for inflammatory bowel dz
• Outpt GI referral for chronic sx

Question 7

Describe ‘functional’ constipation

Answer 7

• Rome III criteria: at least 25% of defecations involve
  
  • Straining
  • Lumpy/hard stools
  • Sensation of incomplete evacuation
  • Sensation of anorectal obstruction
  • Use of manual maneuvers
  • Under 3 defecations per week
• Normal transit
  
  • Stool softeners, laxatives, increased fiber
• Slow transit
  
  • Dx req motility studies
  • Tx: increase fiber, water, biofeedback
• Outlet obstruction
  
  • Spasms of anal sphincter

Question 8

What are secondary causes of constipation?

Answer 8

• Medications
  
  • Opioids
  • Antacids w calcium
  • Calcium supplements
  • Iron supplement
  • Antihistamines
  • CCBs
• Medical condition
  
  • Depression
  • Hypothyroid
  • IBS
  • DM –> gastroparesis
  • Immobility
  • Spinal cord injury
  • Bowel obstruction
  • Colon cancer –> mass
  • Parkinsons
  • MS

Question 9

Describe dx workup for constipation

Answer 9

• None needed for functional constipation
• Start w digital rectal exam for stool impaction
• Labs as indicated by hx
  
  • BMP - lyte abnormalities
  • TSH - hypothyroid?
  • HCG - r/o preg
• Imaging as indicated by hx
  
  • SBO
  • Stool impaction –> stercoral colitis
  • Colon mass
  • Ileus

Question 10

Describe mgmt for your patient with constipation

Answer 10

• Manual disimpaction
• Enema
• Surg consult if severe impaction
• Functional constipation
  
  • Encourage fluids, high fiber, exercise
  • Osmotic laxatives
    
    • Polyethylene glycol
    • Lactulose
  • Stool softener: Colace
  • Stimulant: Avoid if possible - pt becomes dependent
    
    • Senna
    • Bisacodyl
    • Saline
    • Mg citrate
    • Milk of magnesia
    • Linzess - chronic idiopathic constipation, increases intestinal fluid secretion and motility
    • Amitiza - same as above, but also for opioid induced constipation
• Secondary constipation
  
  • Tx underlying causes
    
    • Discontinue offending agent
    • Opioid induced: Relistor (methylnaltrexone)
• Hospitalize if sx severe
• Outpatient GI referral for further testing (i.e. colo) and long-term mgmt

Question 11

Describe pain mgmt for abdominal pain

Answer 11

• Pain mgmt
  
  • Bowel rest
  • Liquid/bland diet
  • H2 blocker, viscous lidocaine, sucralfate
    
    • Gastritis or esophagitis
  • Antispasmodics (diclyclomine)
    
    • Diarrhea a/w spasm
  • Acetaminophen
  • Simethicone
    
    • Breaking up gas, passable
  • NSAIDs
    
    • Hold for gastritis, GIB, peptic/duodenal ulcer
  • Opioids for acute abdomen
    
    • Not indicated for chronic pain
    • Can worsen vomiting, cramping, constipation
• Hospitalize for intractable sx
• Referral to GI for further w/u and mgmt as outpt