4.3 - PPT GI System & Electrolytes Flashcards
Week 4, Wednesday
Which of the following exercises in MOST likely to cause a worsening of symptoms of a umbilical hernia?
Abdominal crunches
BIL shoulder flexion
Deep diaphragmatic breathing
Seated knee extension
Abdominal crunches
AVOID strong abdominal contractions & Valsalva maneuver w/ any hernia
“umbilical” = belly button
A patient is receiving chemotherapy to treat metastatic bone cancer. What type of room would the patient be placed in? Why?
Positive-pressure room
Negative-pressure room
Positive-pressure room
Increased air pressure in room than outside
When door opens –> air is pushed out of the room
Reduces chances of air from outside (that contains pathogens, etc.) from entering the room
Because patient is likely immunocompromised, would want to decrease risk of infection
Describe the common GI symptoms
Nausea
Vomiting
Diarrhea
Constipation
Heartburn
Abdominal pain
Anorexia - decreased appetite
Cachexia - muscle wasting
Describe each of the following types of GI bleeds and their potential sources
Coffee-ground emesis
Hematemesis
Melena
Hematochezia
Coffee-ground emesis - blood that has been in contact w/ stomach acid
- Ex: Peptic ulcer
Hematemesis (“bloody vomit”) - vomiting of bright red blood
- Ingested blood (ex: nose bleed)
Melena - black, tarry stools
- Upper GI bleed
Hematochezia - maroon-colored stools; bleeding from rectum
- Lower GI bleed
Define emesis
Vomiting
What are some of the major causes of upper GI tract bleeding?
Trauma
NSAID’s
Peptic ulcers
Chronic alcohol abuse
What are some indicators of GI bleeding?
Low Hb
Low Hct
Positive fecal blood test
Describe how food can affect symptoms of the following:
Gastric ulcers
Duodenal ulcers
Gastric ulcers
- Pain begins w/in 30-90 min after eating
Duodenal uclers
- Pain begins 2-4 hours after eating
- Food could relieve pain (it is unclear why)
Describe what viscera commonly refer to the following areas:
Epigastric
Periumbilical
Hypogastrium
Epigastric:
- Esophagus
- Heart
- Stomach
- Duodenum
- Liver
- Pancreas
Periumbilical
- Pancreas
- Small intestine
- Appendix
- Proximal colon
Hypogastrium
- Large intestine
- Colon
- Bladder
- Uterus
Describe the common referral pattern for each of the following
Esophagus
Stomach/duodenum
Liver / gallbladder
Small intestine
Appendix
Pancreas
Large intestine / colon
Esophagus - epigastric
Stomach/duodenum - epigastric, R shoulder
Liver / gallbladder - RUQ, R shoulder
Small intestine - periumbilical
Appendix - RLQ
Pancreas - LUQ; L shoulder
Large intestine / colon - hypogastric
Describe GERD
Clinical Presentation
Clinical considerations
GERD - reflux of stomach acid beyond the lower esophageal sphincter back into the esophagus
Clinical Presentation:
- heartburn (epigastric pain)
AGG: eating certain foods, lying supine, bending forward, belching
ALLEV: antacids, sitting upright, L sidelying
Clinical Considerations:
- Avoid exercise that involve lying supine or bending over
- Avoid Valsalva maneuver
- L sidelying can be helpful due to curve of lower esophagus
- Schedule PT before meals or at least 90 minutes after eating
Describe hiatal hernia
Clinical Presentation
Risk Factors
Clinical Considerations
Hiatal hernia - herniation of the upper portion of the stomach beyond the opening in the diaphragm
Clinical Presentation:
- Similar presentation as GERD (heartburn 30-60 min after meal)
Risk Factors:
- Anything that weakens the diaphragm
- Increased in intra-abdominal pressure
Clinical Considerations:
- Avoid supine, Valsalva maneuver, or exercises that increase intra-abdominal pressure
- May require surgery
Describe gastritis
Common causes
Gastritis - inflammation of the gastric (stomach) lining
Common Causes:
- NSAIDs
- Stress induced
- Infection
Describe Peptic Ulcer
Cause
Clinical Presentation
Treatment
Peptic ulcer - ulcer in the gastric (stomach) lining
- Breakdown in mucosal lining of stomach, exposing submucosal areas to gastric secretions
Cause:
- Heliobacter pylori (H. pylori) (90% of ulcers)
- Chronic NSAID use
- Increasing age
Clinical Presentation:
- Referred pain: midthoracic back, epigastric region, R shoulder
- Burning pain
- Symptoms WORSE on an EMPTY STOMACH
- Flare-ups at night are common
- Sx may come and go for few days to weeks
- Coffee-ground emesis
Treatment:
- ABX for H. pylori
- Reduce level of acid (histamine blockers, PPIs, antacids)
Describe Crohn’s disease
Pathophysiology
Clinical Presentation
Potential Complications
Crohn’s disease - inflammatory bowel disease
Clinical Presentation:
- Remissions & exacerbations of s/sx
- Abdominal pain
- Diarrhea
- Weight loss
- Arthralgias
Potential Complications:
- Bowel obstruction
- Ulcers
- Malnutrition
- Increased risk of colon CA
What are the 2 subtypes of IBD? Describe each
Crohn’s disease
- Inflammation occurs DISCONTINUOUSLY; often in lower part of small intestine or colon; involves ALL bowel layers
Ulcerative colitis
- Inflammation occurs UNIFORMLY beginning in rectum, extends proximally and abruptly stops; involves MUCOSA & SUBMUCOSA layers
Describe the treatment for IBD
Treatment directed toward reducing inflammation
- Anti-inflammatories, immune system suppressors
CD: INCURABLE, chronic, debilitating; periodic remission & exacerbations; may require surgery to address complications
UC: CURABLE - colon resection
Describe IBS
Clinical Presentation
Treatment
IBS - collection of s/sx that are NOT attributed to an identifiable bowel abnormality; a functional GI disorder
Clinical Presentation:
- Abdominal pain / cramping
- Diarrhea
- Constipation
- Bloated feeling
- Flatulence
Treatment: focus is on symptom relief
- Drugs - antidiarrheal, antispasmodics
- Lifestyle changes - diet (fiber, probiotics); stress reduction
Describe peritonitis
Inflammation of the walls of the abdominal cavity (peritoneum)
Define a hernia
What are the most common types of hernias?
Describe reducible vs irreducible vs strangulated
Clinical Presentation
Hernia - bowel pushes through weakened abdominal wall
Common types:
- Inguinal (most common)
- Femoral
- Umbilical
- Incisional
- (Hiatal)
Reducible - contents can be replaced back into the abdominal cavity w/ manual manipulation
Irreducible - cannot be replaced by manipulation
Strangulated - protruding organ is constricted to the extent that circulation is impaired (EMERGENT referral!)
Clinical Presentation:
- Intermittent or persistent bulge
- Bulge increases w/ increases in intra-abdominal pressure
Describe the s/sx of a strangulated hernia
Persistent pain
Systemic signs - vomiting, fever, tachycardia
Describe the following types of hernias
Inguinal
Femoral
Umbilical
Indirect Inguinal - herniation through inguinal ring
- May protrude into scrotum
Direct inguinal - herniation above inguinal ligament
Femoral - herniation through enlarged femoral ring / canal
- More common in multiparous women
- High risk of becoming irreducible and strangulated
Umbilical
Describe diverticulitis
Clinical presentation
Clinical considerations
Diverticula - small pouches in wall of colon
Diverticulitis - inflammation of diverticula
Diverticuli fill w/ stagnant fecal material leading to infection & inflammation
Clinical Presentation:
- Severe pain
- Abrupt onset
- LLQ pain
- Pain steadily worsening over time
- Fever, n/v, constipation
Clinical Considerations:
- Daily exs moves bowels!
- Avoid exercises that increase intraabdominal pressure
Describe appendicitis
Clinical Presentation
Special Tests
Clinical considerations
Treatment
Appendicitis - inflammation of the appendix (tube that connects to the end of the cecum)
Clinical Presentation:
- Peak incidence 15-20 yrs
- RLQ PAIN
- Migration of pain from periumbilical area to RLQ
- Nausea, vomiting
- Symptoms progress in <48 hrs typically
Special Tests
- McBurney’s point
- Rebound tenderness
- Iliopsoas test
If appendicitis is suspected –> emergent referral
- Instruct patient not to eat / drink in case of surgery
Treatment:
- Appendectomy (removal of appendix)
- Preop ABX
Colorectal Cancer
How common is it?
Clinical Presentation
3rd most common CA in USA
Clinical Presentation:
- May be asymptomatic
- CHANGE in bowel habits (diarrhea, constipation, narrow stools)
- Blood in stool - melena or frank blood
- Bloating, fullness, cramps
- Unintended weight loss
- Fatigue
Pancreatitis
Risk Factors
Pathogenesis
Clinical Presentation
Clinical considerations - position of comfort?
Risk factors:
- Heavy alcohol use
Gallstones
Alcohol –> increased permeability of ducts –> causes digestive enzymes to be released sooner into pancreatic tissue
Gallstones –> lodge & obstruct pancreatic duct –> back up of enzymes into pancreatic tissue
Clinical Presentation:
- , Mid-epigastric & LUQ pain, L SHOULDER pain
- CONSTANT & SEVERE pain (hours to days)
- AGG: eating, alcohol intake, walking, lying supine (EVERYTHING LOL)
- Bluish discoloration of abdomen
- Tachycardia
- Fever, n/v
Position of Comfort: bending forward in sitting; L sidelying fetal position
Define steatorrhea
Excessive amounts of fat in feces
Describe how the liver affects each of the following body systems
GI
Integumentary
Hepatic
MSK
Neurologic
GI
- sense of fullness
- Anorexia
- n/v
Integumentary
- Jaundice
- Spider angioma
- Pallor, bruising
Hepatic:
- Dark urine
- Light / gray-colored stool (not producing bile)
- Ascites
MSK
- R shoulder pain
- Rhabdomyolysis
Neurologic
- Confusion, sleep disturbances
- BIL tarsal tunnel syndrome & carpal tunnel syndrome
Define ascites
Abnormal accumulation of fluid in the peritoneal cavity
Describe potential viscera sources of pain in each of the abdominal quadrants
RUQ: Liver, gallbladder
LUQ: spleen, pancreas, stomach
RLQ: appendix, psoas, ascending colon
LLQ: descending colon, sigmoid colon
Describe how to identify a psoas abscess
RLQ pain
Pain w/ active hip flexion; passive hip extension of involved side
“Psoas Sign” - L sidelying, move hip passively into extension
- typically used for appendicitis
A patient reports RLQ pain taht is exacerbated with stair climbing. Which special test is likely to reproduce the symptoms?
Psoas sign
Scour test
SLR test
Thompson test
Psoas sign
