CEN study set 4, GI, GU, OB-GYN Flashcards
At the completion of this section, the learner will be able to:
Prioritize treatments for patients with esophageal emergencies
Recognize signs of gastritis
Verbalize discharge instructions for patients with hepatitis
Differentiate between symptoms of small bowel obstructions and large bowel obstructions
Identify the abdominal organ most frequently injured in traumatic situations
The CEN exam contains ten questions on gastrointestinal emergencies which involve the following topics:
Acute Abdomen, e.g. peritonitis, appendicitis, Bleeding, Cholecystitis, Cirrhosis, Diverticulitis, Esophageal varices, Esophagitis, Foreign bodies, Gastritis, Gastroenteritis, Hepatitis, Hernia, Inflammatory Bowel Disease, Intussusception,
Obstructions, Pancreatitis, Trauma, Ulcers
what is a Mallory-Weiss tear?
small tears in the junction of the esophagus and stomach caused by violent retching and vomiting.
describe the treatment and bleeding of a Mallory-Weiss tear
Bleeding is usually self limiting
In rare cases, may need fluid resuscitation and injection of epinephrine to control bleeding.
what is Boerhaave’s syndrome
Rupture of the esophageal wall secondary to violent retching and vomiting.
what is involved in the treatment of Boerhaave’s syndrome
IV fluids
Antibiotics
Surgical repair
explain Esophageal varices
bleeding from distended blood vessels in the esophagus and stomach, usually secondary to liver disease
explain the treatment of Esophageal varices
Treat hypovolemic shock with intravenous fluids and blood products Vasopressin (Pitressin) or sandostatin (Octreotide) - may be given with nitroglycerin to prevent cardiac ischemia Vitamin K (aquaMEPHYTON) to reverse underlying coagulopathies of liver disease Endoscopic procedures to control bleeding Sengstaken-Blakemore tube or Minnesota tube
what are the causes of Esophagitis
Gastroesophageal Reflux Disorder (GERD), Achalasia impaired motility of the lower 2/3 of the esophagus, Esophageal infections, drugs that inflame the esophagus.
what are some causes of Gastritis
Helicobacter Pylori infection, ingestion of noxious substances, stress, tobacco
what are the symptoms of Esophagitis
Pain
Burning in the chest
Worse with activities that increase intra-abdominal pressure
Worse 30 - 60 minutes after eating.
what are the symptoms of Gastritis
Epigastric pain relieved by eating food Nausea and vomiting (hematemesis) Diarrhea Anorexia Intestinal gas
what are some of the treatments of gastritis and esophagitis
cholinergics, dopamine antagonists, antacids, histamine H2 receptor antagonists, proton pump inhibitors, and acid protective agents such as carafate
how do cholinergics treat esophagitis and gastritis?
such as bethanechol (Urecholine), increase lower esophageal sphincter pressure and promote gastric emptying.
how are dopamine antagonists used to treat esophagitis and gastritis?
such as metoclopramide (Reglan), move food through the gastrointestinal system faster.
what is the mechanism of action of antacids that make it useful in the treatment of esophagitis and gastritis
such as aluminum and magnesium (Maalox), neutralize stomach acid.
what do proton pump inhibitors do that make them useful in the treatment of gastritis and esophagitis?
Proton pump inhibitors, such as lansoprazole (Prevacid), shut down the acid pump in the stomach.
what do Histamine (H2)-receptor antagonists do that make them useful in the treatment of gastritis and esophagitis?
Histamine (H2)-receptor antagonists, such as ranitidine (Zantac), block acid production.
Acid-protective agents, such as sucralfate or Carafate do what
provide a thick protective coat over the lower esophagus and stomach.
discharge instructions for the treatment of gastritis and esophagitis might include:
Avoid irritating substances (NSAIDs, alcohol)
Avoid foods which decrease pressure on lower esophagus (chocolate, fatty foods, onion, garlic, peppermint, spearmint, tea and coffee).
Avoid medications which relax the lower esophagus (anticholinergics, beta-blockers, calcium channel blockers, diazepam, morphine sulfate, nicotine, nitrates, progesterone, estrogen and theophylline)
Eat small meals
Elevate HOB on 6 - 8” blocks
Encourage weight loss and smoking cessation
Regardless of site of ulcer, typical pain is described as
“squeezing”, “indigestion”, “gnawing”, “colicky”, “aching” or “feeling of fullness” that is often epigastric and may radiate through to the mid back
what is the common demographic or age group affected by Duodenal ulcers and what causes and relieves pain?
Common between the ages of 30 and 55
•Pain starts prior to meals and is relieved by food or antacids
what is the common age group affected by gastric ulcers and when does the pain usually start?
Common between the ages of 55 and 70.
•Pain usually occurs after eating
describe the pain usually associated with cholecystitis
RUQ tenderness, guarding and rigidity, aggravated by taking a deep breath
Typically follows ingestion of fried ro fatty foods or ingestion of a large meal.
Murphy’s sign (inability to inhale deeply during palpation under the right costal margin near the liver).
define Murphy’s sign
inability of the patient to inhale deeply during palpation under the right costal margin
what is cholecystitis
acute or chronic inflammation of the gallbladder, usually caused by a gallstone that cannot pass
what are some of the signs and symptoms of cholecystitis?
pain, fever with infection, jaundice and dark urine
what is used to diagnose cholecystitis?
Elevated white blood cell count, serum and urine bilirubin and ALT.
Thickened gallbladder wall, gallstones and pericholecystic fluid on ultrasound.
what is the method used in the treatment of cholecystitis?
IV fluids Antiemetics and analgesics NPO/Gastric tube Antibiotics Cholecystectomy after infection has subsided
what are the clinical manifestations of pancreatitis?
Pain - Rapid onset epigastric through to the back aggravated by eating, alcohol intake,
walking or lying supine but relieved by leaning forward or assuming fetal position
Abdomen tender to palpation
Abnormal labs include elevated WBC, serum amylase, serum glucose and serum triglycerides.
what are some Complications associated with pancreatitis
Pleural effusion and acute respiratory distress syndrome (ARDS), Pancreatic abscess and sepsis, Retroperitoneal bleeding and hypovolemia, hypocalcemia
how does pancreatitis lead to PE and ARDS?
Pancreatic inflammation can lead to activation of the inflammatory response with capillary permeability can lead to fluid accumulation in the lungs (ARDS) and pleural effusions.
Pancreatic abscess and sepsis will manifest as
The infection can lead to pancreatic abscesses and sepsis. Symptoms may include a worsening fever, increasing abdominal pain and indications of sepsis.
why does pancreatitis cause retroperitoneal bleeding and hypovolemia
Autolysis caused by release of pancreatic enzymes can cause bleeding from the pancreas and other abdominal structures. Signs and symptoms include hypotension, tachycardia, a diminishing hematocrit, abdominal distension, bruising of the flanks and umbilicus
pancreatitis can cause hypo_______. What are the symptoms of this condition?
Symptoms include tetany and serum calcium levels below 8 mg/100 dL.
how are Nitroglycerin or papaverine used to treat pancreatitis
relaxation of the smooth muscles
how are Antispasmodics such as dicyclomine (Bentyl or propantheline bromide (Pro-Banthine) used to treat pancreatitis
Decrease vagal stimulation and release of pancreatic enzymes
how are Carbonic anhydrase inhibitors such as acetazolamide or Diamox used to treat pancreatitis?
reduction on volume and concentration of pancreatic juices
how are antacids effective in the treatment of pancreatitis?
neutralize gastric secretions
how do Carbonic anhydrase inhibitor such as acetazolamide (Diamox) treat pancreatitis?
Reduction in volume and concentration of pancreatic juices)
how do Histamine H2-receptor antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) help with the treatment of pancreatitis?
decreases hydrochloric acid which can diminish pancreatic secretions
how does calcium gluconate help with the treatment of pancreatitis?
it helps to alleviate hypocalcemia
how do corticosteroids help with the treatment of pancreatitis?
treatment of sepsis
how does glucagon help with the treatment of pancreatitis?
reduces the pancreatic inflammation and decreases serum amylase as well as suppressing pancreatic secretions
how is hepatitis A transmitted and what are two notable details
transmission is through the fecal/ oral route. It causes epidemic and there is a vaccine available
how is hepatitis B transmitted and what are two notable details
Parenteral/Sexual/ occupational exposure/ perinatal/human bites
Can be acute (< 6 months) or chronic (> 6 months)
• Vaccine available
how is hepatitis C transmitted and what are two notable details
Parenteral/occupational exposure/deviant sexual practices, perinatal
50% become chronic
• May be asymptomatic at first
how is hepatitis E transmitted and what are two notable details
Similar to Hepatitis A
• Rare in the USA, more common in Asia, Mexico and Africa
what are the indications of liver dysfunction (10)
Elevated ammonia levels/decreased urea levels treated with lactulose
Decreased albumin and calcium levels with generalized edema and ascites, treated with albumin administration and
removal of fluid from the peritoneum
Lack of clotting factors leading to petechiae, easy bruising and bleeding, treatedwith vitamin K
Elevated serum and urine bilirubin, decreased fecal bilinogens.
Clay colored stools and dark colored urine which foams when shaken.
Jaundice
Steattorhea
Liver enzymes (ALP, SGOT, SGPT and GGT) elevate.
Albumin decreases
PT and PTT climb
what liver enzymes are elevated with liver dysfunction?
Liver enzymes ALP, SGOT, SGPT and GGT elevate.
what are the clinical manifestations of mild hepatitis
malaise, fatigue, anorexia, nausea and vomiting, right upper quadrant pain, joint pain
what are the clinical manifestations of severe cases of liver dysfunction
jaundice, clay colored stools, dark colored urine
treatment of liver dysfunction include what
Acute cases must run their course Severity of chronic cases may be diminished with: Interferon-alpha Pegylated interferon Adefovir dipivoxil Lamivudine Riboflavin
what is Steatorrhea
Chunky yellow foul
smelling fatty stools which float in toilet water
what are the symptoms of appendicitis
Pain starts umbilical, then localizes to McBurney’s point in
the RLQ.
Pressure on the LLQ results in pain in the RLQ Rovsing’s
sign.
Flexion of the knees decreases pain
Pain may be in the RUQ in pregnant women
Elevated WBC
Fever
Vomit ing
Enlarged appendix on ultrasound or CT scan.
what is involved in the treatment for appendicitis?
surgery
what are the symptoms of peritonitis?
Pain Diffuse abdominal pain which worsens with movement or coughing. Relieved with flexion of the knees Tenderness to palpation Rigid (washboard) abdomen. Fever/sepsis Decreased bowel sounds Dehydration/electrolyte imbalances Respiratory difficulties
what is involved in the treatment of peritonitis?
NPO/Surgery
IV fluids and antibiotics
Analgesics/Antiemetics/Antipyretics
what is diverticulitis and what are the clinical manifestations
Inflammation of the diverticula of the colon, usually the sigmoid colon.
Clinical manifestations
Generalized abrupt onset aching cramping pain which localizes to the LLQ.
Fever and WBC
Abdominal tenderness
what is involved in the treatment of diverticulitis
NPO/gastric tube to rest bowel
IV fluid replacement
Antibiotics
Surgery for ruptured diverticuli
what is pyloric stenosis and where is it found in the body
Marked hypertrophy and hyperplasia of the pylorus muscle and narrowing of the gastric antrum. The pylorus is found between the stomach and the small intestine.
what is intussusception? Where does it usually present?
telescoping of the bowel within itself. Most common near the ileocecal valve or a Merkel’s diverticulum in adults, may occur near a colon tumor or polyp
what demographic is most effected by pyloric stenosis?
95% occur during the first 3 - 12 weeks of life.
what are the symptoms of pyloric stenosis
Projectile vomiting
- Poor weight gain
- Continual hunger and constipation
- Jaundice
- Gastric peristalsis prior to emesis
- Mobile, hard, “olive” shaped mass over pylorus
- Elevated bilirubin, hypochloremia, and hypokalemia
what are the symptoms of intussusception?
Colicky pain associated with peristalsis. Child may sleep for 15 - 30 minutes, then scream with pain and pull legs to abdomen for 15-30 minutes, then fall back asleep
- Lethargy and fever which worsen due to increased ischemia of the bowel.
- Mucusy bloody stool that may look like grape jelly
- Vomiting food, mucus or fecal matter
- Increased bowel sounds during painful episodes
- Tender, palpable “sausage-shaped” mass over the site of the intussusceptions in the right lower and middle abdomen
Treatment for bowel obstruction
IV fluids for fluid and electrolyte imbalance. Antiemetics and analgesics Rest the bowel (NPO and gastric tube) Barium enema - Intussusception Surgery - Volvulus Pyloric stenosis Indications of perforation
what are some clinical manifestations of regional ileitis?
Abdominal distension - Anemia - Weight loss - Low-grade fever - Nausea and Vomiting - Dehydration and fluid/electrolyte imbalances - Abdominal cramping and tenderness - Flatulence - 3 - 4 semi-soft stools daily with no blood, some fat is present and stools are foul smelling
what is Ulcerative colitis?
Chronic inflammatory disease affecting only the
large intestine commonly in the sigmoid and
rectal areas.
• Affects only the mucosal and sub-mucosal layers
what are the clinical manifestations of Ulcerative colitis?
Abdominal distension
• Anemia
• Weight Loss
• Fever
• Nausea and Vomiting
• Dehydration and fluid/electrolyte imbalances
• Abdominal cramping typically in the left lower
quadrant
• Diarrhea (5 - 25 stools/day) with blood, mucus
and pus but no fat
• Rectal Bleeding
regional ileitis and Ulcerative colitis are categorized as what?
functional bowel syndromes
what are the potential complications of functional bowel syndromes such as ulcerative colitis and regional ileitis?
Fistulas (with regional ileitus) Intestinal obstructions Malnutrition Bowel perforation Toxic megacolon
Most frequently injured abdominal organ
Associated with fractures of ribs 10 - 12 on the left.
spleen
what are the signs and symptoms of an injured spleen?
LUQ pain (referred to left shoulder)
LUQ bruising
Hypovolemia
Signs of peritoneal irritability
what are the signs and symptoms of an injured liver and what rib fx are associated with it locally?
RUQ pain (referred to right shoulder)
RUQ bruising
Hypovolemia
Rigid abdomen/rebound tenderness
Which of the following lab values is likely to be decreased in a patient with cirrhosis of the liver?
a) Serum bilirubin
b) Serum ammonia
c) Blood urea nitrogen
d) Partial thromboplastin time
c) Blood urea nitrogen
Which of the following presentations is most consistent with a patient who has pancreatitis?
a. Epigastric pain that radiates to the umbilical region
b. Epigastric pain that radiates midline through to the back
c. Left upper quadrant pain that radiates to the left shoulder
d. Right upper quadrant pain that radiates to the right shoulder
b. Epigastric pain that radiates midline through to the back
Which of the following conditions will likely go directly to the operating room from the emergency department?
a. Pancreatitis
b. Cholecystitis
c. Ulcerative colitis
d. Boerhaave’s syndrome
d. Boerhaave’s syndrome
The emergency nurse knows a patient with end stage cirrhosis of the liver has understood their discharge instructions if they state that they will minimize their intake of:
a) Starch
b) Protein
c) Carbohydrates
d) Fresh fruits and vegetables
b protein
what is renal colic?
accumulation of materials within the renal pelvis into a stone which typically exits out the genitourinary system causing significant discomfort.
