Ch 4 MDT Flashcards by Chris Weber

Diarrhea

How many Bowel movements a day for dx?

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Diarrhea can be diagnosed as:

Acute or Chronic

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Diarrhea acute in onset and persisting for less than 2 weeks is most commonly caused by:

Infectious agents

Bacterial toxins (either produced in the gut)

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Infectious sources can be transmitted by fecal-oral contact, food and water and usually have incubation periods between:

12 and 72 hours

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Percentage of all water absorbed in the GI tract takes place in the small intestine

> 90%

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What is the major site of water resorption?

Jejunum

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Colon absorbs additional fluid, transforming a relatively liquid fecal stream in the cecum to a well-formed solid stool in the:

Rectosigmoid

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Disorders of the small intestine result in increased amounts of diarrheal fluid with a greater loss of:

Water

Electrolytes

Nutrients

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Infectious agents are the most common causes of:

Acute gastroenteritis

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Diarrheal disease (three of more times per day or at least 200g of stool per day) of rapid onset that lasts less than 2 weeks

May be accompanied by nausea, vomiting, fever, or abdominal pain

Acute Gastroenteritis

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Common findings on physical examination of patients with acute viral gastroenteritis include:

Mild diffuse abdominal tenderness on palpation

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Gastroenteritis that is usually self-limited and is treated with supportive measures (fluid repletion and unrestricted nutrition)

Acute viral gastroenteritis

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Increase fluid secretion and/or decreased absorption, produces an increased luminal fluid content that cannot be adequately reabsorbed leading to dehydration.

Mechanisms that cause diarrhea:

Adherence

Mucosal invasion

Enterotoxin production

Cytotoxin production

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Gastritis involves ONLY the:

Stomach

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Endoscopic or radiologic characteristics of abnormal-appearing gastric mucosa

Gastritis

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Diagnosis of gastritis is defined as and requires:

histopathologic evidence of inflammation

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Two most common causes of gastritis

Chronic NSAID use

Chronic Alcohol use

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Gastritis is typically self limited but patients may benefit from:

PPI

Removal of the offending agent

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If gastritis does not resolve with conservative management, consider referral for:

Endoscopy and H. Pylori testing

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Chronic diarrheal illnesses may be classified as follows:

Osmotic

Inflammatory

Secretory

Chronic infections

Malabsorption syndromes

Motility disorders

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Due to an increase in the osmotic load presented to the intestinal lumen either through excessive intake or diminished absorption

Osmotic (Medications/Zollinger - Ellison Syndrome)

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Diarrhea

Chronic Parasitic Infection

Giardia Lamblia

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Malabsorption syndromes:

Celiac disease

Whipple

Crohn disease

Lactose Intolerance

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Motility disorder:

Irritable bowel syndrome

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From a diagnostic and therapeutic standpoint, it is helpful to classify infectious diarrhea into syndromes that produce:

Inflammatory or blood diarrhea AND Non-inflammatory, non-bloody, or watery

The term "Inflammatory diarrhea" suggests colonic involvement by:

Invasive bacteria Parasites Toxin production

Frequent bloody, small-volume stools Fever, abdominal cramps, tenesmus, and fecal urgency

Inflammatory diarrhea

Common causes of inflammatory diarrhea

Shigella Salmonella E. Coli Protozoal: Entamoeba histolytica

Community outbreaks of acute infectious diarrhea suggest:

Viral etiology Common food source

Acute infectious diarrhea in family members suggest:

Infectious origin

Acute Infectious Diarrhea Ingestion of improperly stored or prepared food implicates:

Food Poisoning

Acute non-inflammatory diarrhea is generally milder and is caused by:

Viruses or toxins that affect the small intestine

The viruses or toxins in acute non-inflammatory diarrhea interfere with ________ balance, resulting in large-volume water diarrhea, nausea, vomiting, and cramps.

Salt and water

Food Poisoning with a short incubation Symptoms 1-6 hours after consumption is from a:

Toxin

Short incubation food poisoning symptoms

Vomiting is the major complaint Fever is absent

Longer incubation period of food poisoning (8-16) symptoms:

Vomiting is less prominent Abdominal cramping is frequent Fever is absent

Treatment for 90% of acute non-inflammatory diarrhea respond with in ___ days to simple rehydration therapy or antidiarrheal agents

Diarrhea When should stool be sent for fecal leukocyte, ovum and parasite evaluation, and bacterial culture?

More than 7 days

Diarrhea Prompt medical evaluation:

Fever, bloody diarrhea, or abdominal pain Six or more unformed stools in 24 hours Profuse watery diarrhea with dehydration

Diarrhea Pay specific attention to the patient's level of:

Hydration Mental Status Abdominal tenderness or peritonitis

Peritoneal findings may be present in infection with

C difficile Enterohemorrhagic E coli

Diarrhea Hospitalization is required in patients with

Severe dehydration Toxicity Marked Obesity

Symptoms: - Sudden onset - Diffuse abdominal tenderness - Distention - Increased bowel sounds - Usually afebrile - Positive tilts on fluid loss

Diarrhea

Labs for diarrhea

CBC/DIFF Fecal Leukocyte Fecal Occult Stool Culture C Difficile assay if recent hospitalization or antibiotics

Diarrhea labs: Waterborne and foodborne disease, daycare center outbreaks, and international travelers

Stool exam for Giardia Lamblia (Giardiasis suspected)

Initial care of diarrhea

Assess vital signs for stability Treat symptomatically - Loperamide - Bismuth subsalicylate

Diarrhea Antibiotic treatment is recommended for:

Shigellosis, cholera, salmonellosis, listeriosis, and C. Diff

Diarrhea Parasitic infection treatment is required for:

Amebiasis Giardiasis Cryptosporidiosis

Most digestive complaint

Constipation

Constipation may primarily originate within the _____ or may originate externally

Colon and rectum

Most common cause of constipation

Diminishing intake of fiber with decreased fluid intake

Systemic diseases that causes constipation

Hypothyroidism Hyperparathyroidism Diabetes Chronic neurologic disorders

Medications that cause constipation

CCBs Iron Narcotic analgesics Antipsychotics

Structural abnormalities that cause constipation

Colonic mass with obstruction Neoplasm (Adenocarcinoma) Anal Fissure

Constipation Slow colonic transit is present in patient with a history of:

Chronic laxative abuse

Slow colonic transit may be:

Psychogenic or idiopathic

Symptoms: - Infrequent stool - Excessive straining - Sense of incomplete evacuation - Need for digital manipulation

Constipation

Labs for constipation

CBC for anemia TFTs for suspected hypothyroidism Electrolyte abnormalities

RADs for constipation

Upright Chest film and Abdominal Flat and erect for intestinal obstruction

First line treatment in constipation

Strict dietary changes and an exercise regimen Increase water & fiber

Second line treatment of treatment for constipation

Stool softening or laxative use

Third line treatment for constipation

Suppositories or enemies

Hemorrhoids located above the dentate line Subepithelial Cushions of the anorectum No nervous innervation

Internal Hemorrhoids

Hemorrhoids from inferior hemorrhoidal veins Below the dentate line Covered with squamous epithelium Nervous innervation

External Hemorrhoids

Occur in all adults and contribute to normal anal pressures and ensure a water-tight closure of the anal canal

Hemorrhoidal Venous Cushions

Rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, common causes of anal pathology

Hemorroidal Venous Cushions

Subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers, and arteriovenous communications between terminal branches of the superior rectal artery and rectal veins

Internal Hemorrhoids

Three primary locations of internal hemorrhoids

Right anterior Right posterior Left lateral

Hemorrhoids may become symptomatic as a result of activities that:

Increase venous pressure (result in distention and engorgement)

Can contribute to hemorrhoids

Straining, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets

Thrombosis of the external hemorrhoidal plexus results in:

Perianal hematoma

From coughing, heavy lifting, or straining Exquisitely painful, tense and bluish perianal nodule Pain is most severe within within the first few hours, gradually eases over 2-3 days

Perianal hematoma (thrombosis of external hemorrhoids)

Stage of Internal Hemorrhoids Confined to the anal canal

Stage I

Stage of Internal Hemorrhoids Gradually enlarge and protrude from the anal opening

Stage II

Stage of Internal Hemorrhoids Manual reduction after bowel movements

Stage III

Stage of Internal Hemorrhoids Chronically protruding and unresponsive to manual reduction

Stage IV

Protuberant purple nodules covered by mucosa

Prolapsed Hemorrhoids (internal)

Readily visible on perianal inspection Tense bluish perianal nodule Extremely tender to palpation

External hemorrhoids

RADs Colonoscopy should be performed in all patients with:

Hematochezia

Treatment for thrombosed external hemorrhoids

Warm sitz baths Analgesics and ointments

What time frame can you remove a hemorrhoid clot?

First 24-48 hours

Surgical excision (hemorrhoidectomy) is reserve for __% of patients with chronic severe bleeding from stage III or stage IV hemorrhoids or patients with acute thrombosed stage IV hemorrhoids

5-10%

Linear or rocket shaped ulcers that are usually <5mm in length

Anal Fissures

Anal Fissures occur most commonly in the:

Posterior Midline

Fissures that occur off midline raise suspicion of:

Serious diseases or Sexual assault

Fissures occur most from

Trauma to the anal canal during defecation

Symptoms: - Severe, tearing pain - Bright red blood - Visual Inspection: Cracks in the epithelium

Anal Fissures

Treatment for Anal Fissures

Promote effortless painless bowel movements - Fiber, sitz baths - Topical anesthetics - Oral Analgesics (Tylenol/NSAIDS)

Anal Fissures Healing occurs within 2 months in up to __% of patients with conservative management

45%

Chronic fissures should be referred and treated with:

Topical Nitroglycerin Diltiazem Botulinum toxin injection

Obstruction of an anal gland that opens in the base of an anal crypt which normally drains into the anal canal

Anorectal abscess

Abscesses are frequently encountered in:

Perianal and Perirectal region

Almost all abscesses begin with involvement of an:

Anal crypt and its Gland

Infections from abscesses usually involve ____ tissue, where there is little resistance to the progression of infection.

Fatty

Spaces which can become infected alone or in combination with each other are:

Perianal Intersphincteric Ischiorectal Deep postanal Supralevator or pelvirectal

Most common and least common locations for anorectal abscesses

Most Common: Perianal Abscess Least Common: Supralevator Abscess

What can occur from persistent anorectal abscesses?

Fistula formation

Anorectal abscesses are more common in:

Young middle-aged males

Symptoms: Dull, aching, or throbbing pain that becomes worse immediately before defecation, lessened after defecation, but persists between bowel movements

Anorectal Abscess

RADs for Anorectal Abscess

Ultrasound for deep abscesses

Treatment for Anorectal Abscesses

Surgical and should be performed as soon as the diagnosis is made Drainage - early and extensive

All perirectal abscesses should be drained in the:

Operating room

Isolated, simple, fluctuant perianal abscesses can be drained in:

Emergency Department

Simple, linear drainage incision is made, the abscess is more likely to occur because of:

Premature closure of skin edges

Anorectal abscesses with a linear drainage incision must be packed with gauze stops for at least:

24 hours

Abscesses with a cruciate/elliptical incision can be made over the fluctuate part. Trimming the flaps prevents closures and allows drainage. No packing is required but if done should be removed in:

24 hours

Abscesses with fever, leukocytosis, valvular heart disease, or cellulitis should be given:

Broad-Spectrum antibiotics

Initial Care of: Anorectal Abscesses

Incision and Drainage Complicated Cases: Refer to General Surgery

The chronic manifestation of the acute perirectal process that forms an anal abscess. When the abscess ruptures or drains, an epithelialized track can form that connects the abscess in the anus or rectum with the rectal skin.

Anorectal Fistula

"Non Healing" anorectal abscess following draining Chronic purulent discharge Intermittent rectal pain

Anorectal Fistula

Treatment plan for Anorectal Fistula

Require higher level of care. MEDEVAC if unstable. Consider MEDEVAC if in pain for appropriate treatment/medications.

A malformation in the sacrococcygeal region; ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses.

Pilonidal Disease

Pilonidal sinuses or cysts occur in the midline in the:

Upper part of the natal cleft, over the sacrum and coccyx

Pilonidal sinus is formed by the:

Pentation of the skin by an ingrown hair

Pilonidal disease usually occurs before what age?

Symptoms: - Swelling, pain, persistent discharge over the lower sacrum and coccyx - Pt complains of a Tender mass - Exam reveals inflammation midline with one or more sinus openings

Pilonidal disease

The most common finding of pilonidal disease

Single opening from which hair is protruding

Spontaneous and ongoing drainage is the common indicator and if an abscess is present it is usually:

Small

Considered diagnostic for pilonidal disease

Patient gives a history of recurrent infection at the base of spine

Labs for pilonidal disease

CBC if patient has systemic symptoms (fever, chills, etc)

Treatment for pilonidal disease

Surgical treatment

Definitive treatment for pilonidal disease

Surgical excision

Surgical excisions are typically performed __ weeks after initial infection

6 weeks

Pilonidal disease Simple I&D's recure because of:

Hair follicles within the sinus tracts were not debrided

Initial care of pilonidal disease

I&D with suction. In more complicated cases refer to general surgery.

Inflammatory bowel disease includes what conditions?

Ulcerative Colitis Crohn's diease

What influences inflammatory bowel disease?

Genetic factors

Inflammatory bowel disease What disrupts the intestinal mucosa and leads to a chronic inflammatory process?

Immune response

Inflammation that is limited to colonic mucosa Can have pseudo-polyps

Ulcerative Colitis

Can affect any segment of the GI tract "Skip lesions" Transmural inflammation

Crohn's Disease

Crohn's disease and ulcerative colitis may be associated in __% of patients with a number of extra-intestinal manifestations

50%

Most common portion affected by the GI tract from Crohn's

Terminal ilium

When Crohn's affects the ilium, what is affected?

Malabsorption of digested foods Vitamin B12 deficiency Malabsorption of bile salts and calcium

Crohn's The clinician should take particular note of:

Fevers General sense of well-being Weight loss Abdominal pain Number of liquid bowel movements per day Surgical/hospitalization history

Crohn's ___ of patients with large or small bowel involvement develop perianal disease

1/3

Symptoms: Intermittent bouts of low-grade fever, diarrhea, RLQ pain Diffuse abd pain/discomfort, RLQ mass/tenderness Perianal diease

Crohn's

Crohn's __ of cases involve the small bowel only

1/3

Crohn's ___ of all cases involve the small bowel and colon, usually ileocolitis

Half

Strongly associated with the development of Crohn's disease, resistance to medical therapy, and early disease relapse

Cigarette Smoking

Lab for Crohn's disease that should be obtained in all patients to assess immune response and nutritional status

CBC and serum albumin

RADs for Crohn's

Endoscopy Colonoscopy ACUTE Exacerbations: CT

Available therapies for Crohn's

5-aminosalicylic acid derivatives (5-ASA) Corticosteroids Immuno-modulating and biologic agents

Crohn's: Tender abdominal mass with fever and leukocytosis Diagnosis: Emergent CT Treatment: Broad-spectrum antibiotics

Intra-abdominal abscess formation

Crohn's: Develop secondary to active inflammation Precipitated by dietary indiscretion or untreated flare Diagnosis: Up-right abdominal X-ray Treatment: NG tube to decompress GI tract

Small bowel obstruction

Symptom that is unusual in patients with Crohn's

Bleed/severe hemorrhage

Screening colonoscopy for patients with Crohn's to detect cancer should be done every:

8 or more years after initial flare/diagnosis

Patients with Crohn's are __x likely to develop colon cancer than the general population

20x

Ulcerative Colitis is limited to:

Colonic mucosa

Ulcerative Colitis is caused by:

Abnormal activation of the immune system

Ulcerative Colitis causes:

Ulceration Edema Bleeding (Common) Fluid and electrolyte loss

UC that extends to the splenic flexure

Left-sided colitis

UC that extends more proximally

Extensive colitis

UC is more common in what type of patients?

Non-smokers and former smokers

Ulcerative Colitis is less severe in:

Active Smokers

Associated with reduced risk of developing ulcerative colitis

Appendectomy before the age of 20

What can mimic the symptoms of Ulcerative Colitis?

Infectious colitis (Diverticulitis)

Pertinent patient history for Ulcerative Colitis

Stool frequency and character Presence and amount of rectal bleeding Diffuse crampy abdominal pain Fecal urgency Tenesmus

Hallmark of Ulcerative Colitis

Bloody diarrhea

Symptoms: Bloody diarrhea Lower abdominal cramps and fecal urgency Anemia and low serum albumin Negative Stool cultures

Ulcerative Colitis

Ulcerative Colitis: - Gradual onset of infrequent diarrhea (<5 a day) - Stool is formed or loose - Fecal urgency and tenesmus - Cramps relieved by defecation - No abdominal tenderness

Mild UC

Ulcerative Colitis: -Severe diarrhea with frequent bleeding Abdominal pain and tenderness (not severe) Mild fever, anemia, hypoalbuminemia

Moderate UC

Ulcerative Colitis: - More than 6 blood bowel movements per day resulting in severe anemia, hypovolemia, and impaired nutrition with hypoalbuminemia - Abdominal pain and tenderness

Severe UC

Initial assessment of UC patient with a flair should focus on:

Volume status (BP, HR, Urine output, mental status) Nutritional status

Labs for Ulcerative Colitis

CBC ESR & CRP (Inflammatory studies) Stool Bacterial culture C Diff Ova and Parasites Serum Albumin Electrolytes

What lab values reflect Ulcerative Colitis disease severity?

Hct Sedimentation rate Serum Albumin

RADs for Ulcerative Colitis

CT Colonoscopy to screen for cancer (8 years post initial diagnosis)

Two main treatment objectives when treating patients with ulcerative colitis

Terminate the attack Prevent recurrence of attacks

Medication options for UC

Mesalamine Corticosteroid 5-ASA, Immunomodulating & biologic agents Antidiarrheal agents (NEGATIVE for C Diff)

Curative treatment for Ulcerative Colitis

Total proctocolectomy

Treatment for mild/moderate colitis:

Treatment recommended by GI Limit intake of caffeine and gas-producing vegetables

Treatment for severe UC

Hospitalization Discontinue all oral intake for 24-48 hours Restore volume with fluids Serial abdominal exams

The physiology of sensation in the gut is:

Multifaceted

What is involved in the perception autonomic response to visceral stimulation?

5-HT (Serotonin) Substance P Norepinephrine Nitric Oxide

Characterized by abdominal pain of discomfort that occurs in association with altered bowel habits

Irritable bowel syndrome (IBS)

__ months of symptoms are required to diagnose IBS

3 months

IBS is thought to occur from a combination of:

Psychosocial abnormalities Intestinal permeability Immune system Nervous system

What plays a big role in the pathophysiology of IBS?

Mental Health

Symptoms: - Being in late teens/twenties - Abnormal stool frequency, stool form, passage - HALLMARK: Abdominal discomfort that is relieved immediately after defecation with a otherwise normal physical exam

Irritable Bowel Syndrome

Diagnosis of IBS is abdominal discomfort or pain that has at least TWO of the THREE:

Relief with defecation Change in stool frequency Change in stool form

IBS-C

IBS with constipation

IBS-D

IBS with diarrhea

IBS-U

Infrequent bowel movements

IBS-M

IBS with constipation & diarrhea

Alarm symptoms of IBS

Starts at the age of >40 Nocturnal diarrhea Severe constipation Hematochezia Weight loss Fever Family history of cancer, IBS, or Celiac disease

IBS is a diagnosis of:

Exclusion

RADs for IBS: All patients over >50 should get:

Colonoscopy to exclude cancer

Does IBS increase risk of cancer?

IBS: What is closely associating with bettering and worsening of symptoms?

Diet

IBS: Avoid foods with:

Fat or caffeine | fiber has little value

IBS patients may benefit from a diet low in:

Fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) Lactose Gluten

Drugs that can benefit IBS

Antidiarrheal/Anticonstipation Antispasmodic (anticholinergics) Psychotropic agents (antidepressants)

IBS Patients with underlying psychological abnormalities should be evaluated by:

Mental Health

Patients with severe disability should be referred to:

Pain treatment center

What type of reflux episodes typically occur postprandially, short-lived, asymptomatic, and rarely occur during sleep?

Physiologic

What type of reflux is associated with symptoms or mucosal injury and often occurs nocturnally

Pathologic

GERD: Endoscopy demonstrates abnormalities in ___ of patients

1/3

Plays a vital role in the frequency and severity of GERD

Lower Esophageal Sphincter

GERD: Secondary to the stimulation and activation of mucosal chemoreceptors by acid

Pain

Exacerbate the symptoms of GERD

Spicy, Acidic, Salty foods Alcohol

Heartburn occurs ___ minutes after meals and upon laying down

30-60 minutes

Atypical or extraesophageal manifestations of GERD:

Asthma Chronic cough Chronic Laryngitis Sore throat Non-Cardiac Chest pain

Condition in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells

Barrett Esophagus

The most serious complication of Barrett esophagus is:

Esophageal Adenocarcinoma

Manifested by the gradual development of solid food dysphagia progressive over months to years

Peptic Stricture

Most peptic strictures are located at the ______ junction

Gastroesophageal

RADs for complicated GERD patients

Endoscopy

Treatment for mild/intermittent symptoms

Lifestyle modifications - Eat smaller meals - Eliminate acidic foods - Eliminate foods that precipitate reflux Weight loss

Foods that precipitate reflux

Fatty foods Chocolate Peppermint Alcohol Cigarettes

Patients with nocturnal GERD should avoid lying down within __ hours after meals

3 hours

GERD Medications: Role is limited, only used as relief of mild GERD symptoms

Antacids (-tidines)

Medications of troublesome GERD

PPI (-prazoles)

PPIs have an onset of delay of 30 minutes but relief heartburn for up to __ hours.

8 hours

When would you refer a GERD patient?

Does not resolve with maximum management of twice-daily PPI's for 3 months

Initial Care of GERD

Eliminate the causative factor Lifestyle modifications

Esophagitis could range from:

Pill induced Reflux Eosinophilic infections

Medications that cause direct esophageal mucosal injury

Antibiotics - Tetracycline, Doxycycline, Clindamycin Anti-inflammatory medications - Aspirin Bisphosphonates

Patients with GERD who have endoscopic evidence of esophageal inflammation

Reflux esophagitis

Infectious Esophagitis (thrush) occurs in ______ patients

Immunocompromised

Symptoms: - Retrosternal pain/Heartburn - Odynophagia - Dysphagia - Often have a history of swallowing a pill without water

Esophagitis

Pill induced esophagitis onset of symptoms occur:

Few hours to one month

Hallmark of Candida esophagitis is:

Odynophagia (pain when swallowing) Discrete retrosternal pain

Labs for Esophagitis

CBC Specimen culture Swab for Candida

RADs for Esophagitis

Consider Endoscopy

Treatment for Candida esophagitis

Evaluate for: HIV, Cancer, Diabetes

Treatment for Esophagitis with fever and elevated WBC

Broad spectrum antibiotic

Most infectious esophagitis requires what to diagnose?

Endoscopy and biopsy

Promotes motility, via peristalsis, of introduced food to the stomach

Esophagus

Esophageal strictures are likely caused as a result of:

GERD

Why does stricture formation happen in patients with GERD?

To lower the volume of reflux Reduce Symptoms

What percentage of patients with esophageal stricture is unrelated to GERD? Examples include: Radiation, Sclerotherapy, or Caustic ingestions

25%

More commonly recognized cause of esophageal strictures, particularly in young men

Eosinophilic Esophagitis

Symptoms: - Localized substernal chest pain - Heartburn - DYSPHAGIA (Hallmark)

Esophageal stricture

RADs for esophageal stricture

Endoscopy Barium study

Treatment for mild esophageal stricture

Treat for GERD

Treatment for severe esophageal stricture

MEDEVAC for potential surgery

Esophageal stricture Refer all patients to Gastroenterology for:

Dilation and Evaluation

Severe symptoms of Esophageal stricture

- Dysphagia - Food impactions - Asphyxiation

Complications of esophageal stricture

Mallory-Weiss Tear Asphyxiation Esophageal Paresis

Idiopathic motility disorder which causes loss of peristalsis in the distal two thirds of the esophagus and impaired relaxation of LES Impaired inhibitory innervation, leading to premature and rapidly propagated contractions in the distal esophagus

Esophageal Spasm

Symptoms: - Gradual onset of dysphagia - Can be present for months - Substernal discomfort/fullness - Lifting neck or throwing shoulders back to enhance gastric emptying

Esophageal Spasm

RADs for Esophageal Spasm

CXR Barium Esophagography Endoscopy

Treatment for Esophageal Spasm

PPI if GERD is present Eat smaller bites of food Invasive procedures (Botox injection)

Complications of Esophageal Spasm

Asphyxiation Dysphagia Esophageal Dysmotility Mallory-Weiss Tear Peptic Stricture

Occurs when the balance between the aggressive factors and the defensive mechanisms is disrupted

Peptic ulcer

What can lead to peptic ulcers?

NSAIDs H. pylori infection Bile salts, acid, & pepsin

Diagnostic procedure of choice for H. pylori infection

Upper endoscopy with gastric biopsy

Break in the gastric or duodenal mucosa that arises when the normal mucosal defensive factors are impaired

Peptic Ulcer

Peptic ulcers that extend through the muscularis mucosae are over ___ in diameter

5mm

Lifetime prevalence of ulcer in the adult population is:

10%

Ulcers occur most commonly in the:

Duodenum (Five times more common)

Duodenal ulcers occur at the ages of:

30-55

Gastric ulcers occur at the age of:

55-70

Ulcers are more common in patients who:

Smoke Chronic NSAID use

Gastric ulcers are increasing as a result of:

NSAIDs Low-dose aspirin

Three major causes of peptic ulcer disease:

NSAIDs Chronic H pylori infection Acid Hypersecretory states

What should be sought in all patients with peptic ulcers?

H pylori infection NSAID ingestion

Cofactor for the majority of duodenal and gastric ulcers not associated with NSAIDs

H pylori

Approximately __%/year of long-term NSAID users will have an ulcer that causes clinically significant dyspepsia or a serious complication

2-5%

Peptic Ulcer: The risk of NSAID complications is greater in:

First 3 months of therapy Prior History of ulcers Combination with aspirin, corticosteroids, or anticoagulants

Hall mark of peptic ulcer disease

``` Epigastric pain (dyspepsia) -Gnawing, dull, aching, or "Hunger-like" ``` NOT BURNING

Peptic Ulcer: A change from a patient's typical rhythmic discomfort to constant or radiating pain may reflect:

Ulcer penetration or perforation

Nausea and anorexia may occur in:

Gastric Ulcers

Peptic Ulcer: Physical exam is often:

Normal

Labs for peptic ulcer with severe pain that suggests penetration into the pancreas

Elevated serum amylase

Labs for a patient with a history of peptic ulcer or when an ulcer is diagnosed by upper GI series

H pylori with fecal antigen assay Urea breath testing

RADs for peptic ulcers

Upper Endoscopy

Retards the rate of ulcer healing

Smoking

Treatment for Peptic Ulcers

Eat balanced meals at regular intervals Stop taking NSAIDs -4 to 6 week PPI Therapy

Treatment for H pylori infection Peptic Ulcers

Anti-H pylori regimen for 10-14 days | -PPI with a combination of Antibiotics

Confirm successful eradication of H pylori ulcers with urea breath test, fecal antigen test, or endoscopy with biopsy __ weeks after completion of antibiotic treatment and __ weeks after PPI treatment

4 weeks 1-2 weeks

Disposition of Peptic Ulcers

Stay on ship unless not responsive to PPI therapy

Initial care of Peptic Ulcer Disease

D/c the causative agent Eradicate H pylori

Anatomical landmark that defines the border between the upper and lower GI track

Ligament of Treitz

Proximal to the Ligament of Treitz

Upper GI tract

Distal to the Ligament of Treitz

Lower GI tract

Most common source of lower GI Bleeding, often occult

Colon Carcinoma

Visible Blood loss

Overt

Coffee-ground hematemesis is from hemoglobin interacting with:

Gastric acid

Bright red hematemesis means the bleed is proximal to the:

Lower esophageal sphincter

Melana "tar like" stool indicates

Upper GI bleed

Hematochezia, bright red blood in stool indicates

Lower GI bleed

Two most common presentations of upper GI bleed

Hematemesis Melana

Melena develops after as little as __mL of blood

50mL

Upper GI bleeds can present with hematochezia if:

The bleed is massive (>1000mL)

RADs, gold standard for Upper GI bleed

Upper endoscopy

Hematocrit takes ___ hours to equilibrate

24-72 hours

Labs for Upper/Lower GI Bleed

CBC PT/PTT INR

Upper GI Bleed: - Diagnostic and therapeutic - Should be done on all patients with active upper GI bleed

NG tube

Confirms upper GI source of bleeding

Aspiration of red blood or "coffee grounds"

GI Bleed: <100 SBP

Severe blood loss (30-40%)

GI bleed: HR >100 SBP >100

Moderate blood loss (15-29%)

The gold standard medication of choice for severe bleeds

PPIs

Upper GI bleeding is self-limited in __% of patients

80%

Common causes of lower GI Bleeding

Diverticulitis Inflammatory bowel disease (UC > Crohn's) Anorectal Disease Hemorrhoids Fissures

Large volumes of bright red blood sugggest:

Colonic source

Marron stools imply a lesion in the:

Right colon or small intestine

Black tarry stools predict a source ______ to the ligament of Treitz

Proximal

Management of lower GI Bleed

Initial stabilization, blood replacement, and triage Colonoscopy

Two conditions that may result in an upper GI Bleed

Mallory-Weiss Boerhaave Syndrome

Characterized by a non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction

Mallory-Weiss

Severe laceration of the anterior esophagus associated with a full perforation of the esophagus into the mediastinum

Boerhaave's syndrome

Mallory-Weiss and Boerhaave's Syndrome: Patient will typically be a:

Heavy alcohol user

Boerhaave's syndrome Crunching sound heard on auscultation of the mediastinum

Hartman's sign

Boerhaave's chest X-ray findings

Mediastinal air

Treatment for Mallory-Weiss

NPO IV PPI IV/IM Antiemetic

Treatment for Boerhaave's Syndrome:

NPO IV PPI IV/IM Antiemetic ANTIBIOTICS (IV)

Disposition for Mallory-Wiess and Boerhaave Syndrome

MEDEVAC Surgical evaluation

Sac-like protrusion of the colonic wall

Diverticula (-lum)

Diverticulosis is defined by the presence of:

Diverticula (sacs)

Diverticular bleeding is characterized by painless hematochezia due to:

Weakness of the vasa recta

Inflammation of a diverticulum is caused by:

Small pockets fill with stagnant fecal material and become inflammed

Diverticulitis can lead to disease which can then lead to:

Perforation (micro is the most common)

Symptoms: - Low grade fever - LLQ tenderness and a possible palpable mass - Leukocytosis is mild to moderate

Diverticulitis

Labs for Diverticulitis

CBC w/ Diff Occult blood

Diverticulitis: Treatment for patients with mild symptoms and no peritoneal signs

Clear liquid diet Dual Therapy Antibiotics

Diverticulitis: Symptomatic improvement occurs __ days from starting antibiotics

Diverticulitis recurs in __% if patients treated with medical management

10-30%

Disposition: Diverticulitis

MEDEVAC

Most common abdominal surgical emergency

Appendicitis

Appendicitis is most common between what ages?

20-35

Appendix is found at the:

Base of the cecum

Located one third of the distance from the right anterior superior iliac spine to the umbilicus

McBurney's Point

Believed to be involved with the development of intestinal bacterial flora

Appendix

Appendicitis typically manifest from:

Blockage of the lumen

Most common appendix luminal blockage

Fecalith

Obturator sign is a positive test for:

Inflamed appendix deep in the pelvis

Psoas sign is positive for

Retro-cecal appendix

Atypical symptoms of appendicitis

Pain in the flank Lower back pain Groin pain (very thin females) Tenesmus Non-specific lower abdominal pain

Gold standard for diagnosis of appendicitis is:

CT scan of the abdomen

Labs for appendicitis

CBC Fecal occult blood UA

Bile is made in the:

Liver

Bile is stored in the:

Gallbladder

In response to fat entering the proximal small intestine, bile is ejected from the gallbladder into the:

Cystic duct

Bile flows from the cystic duct into the:

Common bile duct

Bile flows from the common bile duct into the:

Duodenum

Bile works in the duodenum to:

Emulsify fats

Bile is reabsorbed into circulation in the:

Terminal ilium (distal small intestine)

Without bile, fats would aggregate to form large:

Hydrophobic micelles

Bile is composed of:

Bile salts Cholesterol & Bilirubin

Most common form of Gallstones

Cholesterol gallstones

Situations that raise cholesterol (gallstones)

Increased estrogen (pregnancy) Increased circulating cholesterol - Diet - Rapid weight loss

Pigmented gallstones are formed by:

Precipitation of bilirubin

What will happen if the amount of cholesterol or bilirubin present in the gallbladder exceeds the amount of bile salts needed to dissolve it?

Precipitates (stones) form

Disease processes that can occur from stones occluding ducts within the biliary tract

Asymptomatic Cholelithiasis Biliary Colic Cholecystitis Choledocholithiasis Cholangitis

Gallstones are present but patient does not have any symptoms

Asymptomatic cholelithiasis

__% of individuals with gallstones will be asymptomatic their entire life

80%

Gallstones are present and intermittently obstruct the lumen of the cystic duct Symptoms last less than 6 hours

Biliary Colic

Inflammation of the gallbladder Usually from a gallstone permanently lodged in the cystic duct Symptoms last longer than 6 hours

Cholecystitis

Inflammation of the gallbladder caused by obstruction of the common bile duct Patients may show jaundice

Choledocholithiasis

Bacterial infection of the biliary tract RUQ pain Fever Jaundice

Cholangitis

Charcot's Triad

RUQ Pain Fever Jaundice

Management of biliary colic

Recommend a change in diet

Cholecystitis Associated with gallstones in over __% of the cases

90%

Cholecystitis 10% is caused by:

Acalculous cholecystitis and infectious agent

No radiologic evidence of gallstones Had a major surgery within the past 2-4 weeks NPO due to critical condition

Acalculous Cholecystitis

6 F's of cholecystitis/choledocholithiasis

Fat, fertile, 40, Female Flatulence, Fever

Sudden onset of RUQ pain after eating a meal high in fat Murphy's sign Palpable gallbladder (15% of cases)

Cholecystitis

Labs for cholecystitis

CBC LFTs Lipase (rule out pancreatitis) Bilirubin (elevated, dx with choledocholithiasis)

Gold standard imaging for cholecystitis

RUQ Ultrasound

Why is a CT not indicated for cholecystitis?

Cholesterol gallstones are radiolucent and tend to not be visible

Cholecystitis Continuous symptoms for >24 hours suggests possible:

Necrosis of the gallbladder

Necrosis of the gallbladder may develop without definite signs in:

Obese, Diabetic, Elderly, Immunosuppressed

Mainstay treatment for cholecystitis

Cholecystectomy IV Antibiotics

Patients treated with conservative management will require cholecystectomy __ days after initial presentation

2-4

Gallstone obstructing the common bile duct (CBD) causing inflammation of the gallbladder Backed of bilirubin caused jaundice

Choledocholithiasis

Bacterial infection of the common bile duct

Cholangitis

Typical infectious organism that causes cholangitis

E. Coli

Cholangitis patients will present with:

Charcot's Triad - Fever - RUQ Px - Jaundice

Disposition for Cholangitis

IV antibiotics MEDEVAC

Produces enzymes that are released into the duodenum via the common bile duct Produces hormones that are secreted into the vascular system

Pancreas

Most common causes of pancreatitis

Alcohol Gallstones Other

Causes auto-activation of pancreatic enzymes while still in the pancreas resulting in enzymatic destruction of pancreas

Alcohol

Can obstruct the ampulla of Vater, causing impaired extrusion of enzymes into the duodenum. Leads to auto-digestion of pancreas tissue

Gallstones

Patient presentation: History of cholelithiasis and/or cholecystitis treated without surgery History of alcoholism Similar episodes of pain

Pancreatitis

Symptoms: - Abrupt onset - Steady, boring, severe abdominal pain - worse when walking and laying down - Relief when sitting upright and leaning forward - Mild jaundice - Nausea and vomiting - Weakness, fever, anxiety - Grey-Turner and Cullen's sign in severe disease - Possible upper abdominal mass

Pancreatitis

Labs for pancreatitis:

CBC (Leukocytosis) Gold standard: Elevated serum Lipase is diagnostic - UA - Glucometer: Hyperglycemia - Elevated Serum lactate - Elevated aspartate

Gold standard imaging for pancreatitis

Gold standard treatment for uncomplicated pancreatitis

NPO & Aggressive fluid resuscitation

Disposition of pancreatitis

Fluids Pain control MEDEVAC

What makes up the inguinal canal

Inguinal ligament External inguinal ring Internal inguinal ring

Hasselbach's triangle (Inguinal triangle)

Inferior epigastric vessels Lateral aspect of the Rectus Abdominis Inguinal Ligament

Protrusion of any body part through a cavity

Hernia

Most common type of hernias (75-80%)

Inguinal Hernias

Two main types of Inguinal hernias

Direct (Directly through Hasselbach's triangle) Indirect (inguinal canal)

What side is more common in indirect inguinal hernias?

Right

All hernias have the ability to present with signs and symptoms of:

Small Bowel Obstruction

Lower anterior abdominal mass

Direct hernia

Scrotal mass

Indirect hernia

Out-y belly button

Umbilical hernia

"Turn your head and cough" checks for:

Inguinal canal hernias

Labs for Hernia

CBC (incarceration/strangulation) CMP (hydration and toxicity levels) UA

Hernia Imaging

CT and US may benefit before surgery

What kind of hernias require immediate attention?

Incarcerated

Hernia treatment if strangulation is suspected or shock is present

Broad-spectrum IV antibiotics and fluid resuscitation

Hernia: Place patient in supine Trendelenburg Administer Narcotic for analgesia Administer Diazepam for muscle relaxation Allow for passive reduction

Closed Passive Reduction technique

Disposition for irreducible incarcerated hernia - all ages

MEDEVAC for immediate surgical eval/repair

Disposition for reducible hernias

Refer to general surgery Avoid heavy lifting

Two main subcategories of intestinal obstruction

Mechanical Paralytic ileus

A physical blockage of the intestinal tract

Mechanical obstruction

Dysfunction of the intestinal tracts ability to move bowel contents through its lumen

Paralytic ileus

Two most common causes of small bowel obstruciton

Adhesions (most common) Hernias

Symptoms: - Crampy, intermittent abdominal pain - Urge to move - Distention - Vomiting - Constipation, bloating - Tympany on percussion - High-pitched bowel sounds (rushes)

Mechanical Bowel obstruction

Bowel Obstruction Symptoms: - Less intense pain that is more constant - Constipated - Diminished bowel sounds

Paralytic ileus or Large Bowel (colon)

Labs for Bowel obstruction

CBC CMP

Gold standard imaging for bowel obstruction

Upright abdominal X-Ray

Management and treatment for bowel obstruction

NPO NG Tube Two IV sites with aggressive fluid resuscitation MECHANICAL: IV Antibiotics

__% of completely obstructed SBO patients will fail conservative therapy

60%

Almost all Large bowel obstructions are caused intrinsically from:

Adenocarcinoma

Inflammation of the localized or generalized peritoneum

Peritonitis

Inflammation of the peritoneal surface without another intra-abdominal process Also known as Spontaneous Bacterial Peritonitis (SBP)

Primary Peritonitis

Lines the outer portions of all intra-abdominal organs

Visceral peritoneam

Lines the interior portion of the abdominal wall

Parietal Peritoneum

Posterior to the posterior parietal peritoneal membrane

Retroperitoneal Space

"Acute abdomen" or "Surgical abdomen" Indicates severe intra-abdominal infection

Peritonitis of the entire peritoneum

Most common causes of acute peritonitis

Perforated Appendicitis Perforated Diverticulitis Pancreatitis

Patient Presents: - Fetal positions or supine with legs bent (or on pillow) - DO NOT want to move (unlike obstructive bowel) - Board like abdomen - Absent bowel sounds in all 4 quadrants

Peritonitis

Labs for peritonitis

CBC w/ Diff UA Blood Culture Female: HCG

RADs for peritonitis

Upright Abdominal X-ray Abdominal CT

All patients with suspected peritonitis need:

Antibiotics

Disposition for Peritonitis

IV Antibiotics IV fluids and NPO Pain control (Morphine) MEDEVAC

Three regions of the abdomen

Intrathoracic True abdomen Retropertioneal

What organs are in the intrathoracic abdomen?

Liver, Gallbladder, Spleen, Stomach, Transverse Colon

Any penetrating injury at or below the __th intercostal space is suspected to be in the abdomen

4th

Organs in the True Abdomen

Large and small intestine Portion of the liver and the bladder (females: uterus, fallopian tubes, ovaries)

Organs in the retroperitoneal

SADPUCKER ``` Suprarenal (adrenal) gland Aorta Duodenum Pancreas Ureters Colon Kidneys Esophagus Rectum ```

Common injuries with a direct blow (blunt)

Splenic rupture and liver fractures

Common injuries in deceleration injury from MVA's or falls (Blunt)

Duodenal and aortic rupture

The sum of the number of bullet wounds and actual bullets seen on diagnostic imaging should always be an even number

"Bullet Rule"

Momentum transmitted to neighboring organ due to changing bullet velocities caused by tissue density variation

Blast effect

Abdominal trauma: All patients should get:

DRE for blood and rectal tone

Labs for abdominal trauma

CBC/Diff UA Fecal Occult Blood Type and screen Females: HCG