Clinical Care of the Gastrointestinal System Flashcards
Diarrhea in an acute onset typically lasts less than ____ weeks and is most commonly caused by what?
2 weeks.
Infectious agents, bacterial toxins
How can infectious sources be transmitted, and what is their typical incubation period?
Fecal-oral contact, food and water
12-72 hours
Where does liquid feces move from to turn into well-formed solid stool?
> 90% of water is absorbed in the small intestine. The remaining water reaches the colon, transforms into liquid feces in the CECUM, and then turns into solid stool in the RECTOSIGMOID.
Disorders of what part of the intestines result in increased amounts of diarrheal fluid, and greater loss of water, electrolytes and nutrients?
Small intestine
This is a form of gastroenteritis caused by infectious agents and commonly seen in an operational setting. How is it defined?
Acute gastroenteritis
-Defined as three or more episodes a day or at least 200g per day.
-Rapid onset that lasts <2 weeks.
-May be accompanied by N/V, fever, and/or abdominal pain.
What is a common physical finding of a patient with acute viral gastroenteritis?
Mild diffuse abdominal tenderness
Soft abdomen with voluntary guarding
What are common infectious agents seen in acute infectious gastroenteritis?
Adherence, mucosal invasion, enterotoxin production, cytotoxic production
What are two common causes of gastritis?
Chronic NSAID use and chronic/large amounts of alcohol consumption
What is required to diagnose gastritis?
Histopathologic evidence of inflammation
What are the classifications of chronic diarrhea?
Osmotic
-Increased osmotic load, seen in medication use and Zollinger-Ellison syndrome
Inflammatory
-Inflammation of the mucosal lining of the intestine, like with IBD or malignancy
Secretory
-When secretions be secreting
Chronic infections
-Giardia Lamblia
Malabsorption syndromes
-Celiac, Whipple, Crohn’s, Lactose Intolerance
Motility disorders
-IBS
Inflammatory diarrhea suggests involvement of what organ by invasive bacteria, parasites, or toxins?
Colonic involvement
What do patients complain of in acute infectious diarrhea?
Bloody stool! Frequent, small volume bloody stool associated with fever, abdomen cramps, tenesmus, and fecal urgency.
What are common causes of acute infectious diarrhea?
Shigella, Salmonella, E. coli, E. coli O157:H7, Entamoeba histolytica
Community outbreaks suggest viral etiology or common food source
Recent illness in family suggests infectious origin
Ingestion of improperly stored/prepared food suggests food poisoning.
This type of diarrhea is generally milder and is caused by viruses or toxins that affect the small intestine.
Acute non-inflammatory diarrhea
Non-bloody in nature.
They interfere with salt and water balance, resulting in large volume watery diarrhea, often with N/V and cramps.
What are common causes of acute non-inflammatory diarrhea?
Viruses, enterotoxin-producing E. coli, Giardia Lamblia, crytosporidium, cyclospora
In food poisoning caused by a preformed toxin, the incubation period will be how long, and what will the major complaints be?
Short (1-6 hours after consumption)
Vomiting, fever is usually absent
In food poisoning where the organism is already present but the toxin hasn’t been produced in the food at time of consumption, what will your typical incubation period be? What will your complaints be?
Longer (8-16 hours)
Vomiting is less prominent. Abdominal cramping is frequent. Fever is absent.
Over 90% of patients with acute non-inflammatory diarrhea responds within __ days to what type of treatment?
5 days
Rehydration therapy or antidiarrheal agents (it is a self-limiting condition)
If diarrhea worsens or persists for __ days or more, what should be done?
7
Send stool sample for fecal leukocyte, ovum and parasite evaluation, and bacterial culture.
Prompt medical evaluation is indicated in what situations (diarrhea)?
Signs of inflammatory diarrhea
-Fever >38.5 C)
-Bloody diarrhea
-Abdominal pain
Six or more unformed stools in 24 hours
Profuse watery diarrhea or s/s of dehydration
For patients with diarrhea, hospitalization is required in what situations?
Severe dehydration, toxicity, marked abdominal pain
Send fecal sample for bacterial culture
Symptoms of diarrhea with a sudden onset
N/V and decreased appetite
Crampy abdominal pain
Loose stool
Malaise
Fatigue
Stool examination for Giardia Lamblia is important for what situations?
Waterborne and food borne disease outbreaks, daycare center outbreaks, illness in international travelers
Oral rehydration of a patient with diarrhea can be accomplished with what liquids?
Fluids containing glucose, Na+, K+, Cl-, and bicarbonate or citrate
A convenient mixture of 1/2 tsp salt, 1 tsp baking soda, 8 tsp sugar, and 8 tsp OJ diluted to 1L with water can be used.
Avoid high fiber foods, fats, dairy, caffeine and alcohol.
Oral electrolytes can be used alternatively, given at a rate of 50-200 mL/kg/24h.
What antidiarrheal medications can be used to treat a patient?
Loperamide
-4mg, 2mg after every loose stool, max dose of 16mg/day.
-Do not use in patient with infectious diarrhea or prolonged QT interval
Bismuth
-2 tablets/30mL PO q 30-60 min PRN, max 16 tablets/240mL/24 hours
-Produces black stool, educate your patient.
What infectious bacteria and parasites indicate the use of empiric antibiotic therapy?
Shigellosis, cholera, salmonellosis, listeriosis, C. difficile.
Amebiasis, giardiasis, cryptosporidiosis
This is a condition with histologic evidence of inflammation of the epithelial or endothelial lining of the stomach.
Gastritis
Categorized into 3 types:
-Erosive and hemorrhagic
-Non-erosive and non-specific
-Specific
How is erosive and hemorrhagic gastritis typically diagnosed?
Endoscopically, typically because a patient complains of dyspepsia or upper GI bleeding
What types of patients typically present with gastritis?
Alcoholics, critically ill patients, patients taking NSAIDs
Common causes are drugs, alcohol, stress, and portal hypertension
Common symptoms of gastritis
Epigastric pain, N/V, hematemesis (nonspecific bleeding)
Upper GI bleeding with “coffee grounds” emesis or bloody aspirate on NG tube
What are the typical lab findings on a patient with gastritis?
Low HCT due to significant bleeding (if it occurred)
Iron deficiency
H. pylori testing
Fecal occult blood
What is the most sensitive method (“Gold Standard”) to diagnose gastritis?
Upper endoscopy
Usually performed within 24 hours for patients with upper GI bleeding
How do you treat a patient with NSAID gastritis?
Discontinue NSAIDs, reduce to lowest dose or administer NSAIDs with meals.
Give PPI for 2-4 weeks.
How do you treat a patient with alcoholic gastritis?
Discontinue alcohol use.
Give H2 receptor antagonist, PPI, or sucralfate for 2-4 weeks.
What are the common causes of non-erosive, non-specific gastritis?
H. pylori infection
Pernicious anemia
Eosinophilic gastritis
How can you test for non-erosive, non-specific gastritis due to H. pylori?
Histology via endoscopy, or serology
Serology is not helpful in patients with previous H. pylori infectious due to presence of antibodies.
What three coordinated things occur during defecation?
Coordinated colonic peristalsis, rectal contraction, and early anal relaxation.
What are the multifactorial causes of constipation?
Diminished intake of fiber and fluids (most common)
Systemic diseases
Medications
Structural abnormalities
Slow colonic transit
IBS-C
Hirschsprung disease
What do patients experiencing constipation complain of?
Infrequent stool
Excessive straining
Sense of incomplete evacuation
Need for digital manipulation
What are the first line treatments of constipation?
Dietary changes and exercise regimen.
Increased water intake.
Fiber supplementation.
-Usually no immediate response, increase doses over 7-10 days.
What are the second line treatments of constipation?
Stool softeners or laxatives.
Emollients such as Docusate sodium
-100mg daily to twice daily
Stimulants such as Bisacodyl
-5-15mg daily or 10mg TID
What are the third line (last resort) treatments of constipation?
Suppositories or enemas.
Examples include glycerin suppository or fleet enemas.
When may fecal disimpaction be necessary?
Obstipation or constipation refractory to treatment. Complicated/chronic cases should be referred to gastroenterology.
Where are internal and external hemorrhoids located? Describe each.
Internal: above the dentate line.
-Subepithelial cushions of the anorectum comprised of submucosa and muscularis.
-NO NERVOUS INNERVATION.
External: below the dentate line.
-Arise from inferior hemorrhoidal veins, covered with squamous epithelium.
-INNERVATED WITH NERVES - PAINFUL WHEN THROMBOSED
What structure of the anus provides a water tight closure of the anal canal?
Hemorrhoidal venous/vascular cushions.
What three primary locations do internal hemorrhoids occur in?
Right anterior
Right posterior
Left lateral
What is unique about the pain level of internal hemorrhoids?
They lack a nerve supply so they are not painful when present.
These hemorrhoids occur below the dentate line and are painful when thrombosed.
External hemorrhoids
What results when hemorrhoids become symptomatic due to pressure?
They become distended, engorged and they bleed.
This condition occurs due to thrombosis of the external hemorrhoidal plexus, and typically occurs in healthy adults due to coughing, heavy lifting and straining.
Perianal hematoma.
This condition is characterized by acute onset of an exquisitely painful, tense and bluish perianal nodule covered with skin that may be up to several centimeters in size.
Perianal hematoma
The pain is most severe in the first few hours but gradually eases over 2-3 days as edema subsides.
What are the physical findings seen in an internal hemorrhoid?
Painless bleeding, prolapse, mucoid discharge.
Bleeding can be streaks of blood or drips in the toilet.
Describe the 4 stages of internal hemorrhoids.
Stage I: Dilated, confined to the anal canal.
Stage II: Prolapsed during straining, reduces spontaneously.
Stage III: Prolapse, requires manual reduction.
Stage IV: Chronically prolapsed.
This condition may result in a sense of fullness or discomfort and mucoid perianal discharge resulting in irritation and soiling of underclothes.
Chronic prolapsed hemorrhoids.
For a thrombosed external hemorrhoid, if seen within the first __-__ hours, removal of what may help relieve your patient?
24-48 hours
Removal of the clot.
When removing the clot of a thrombosed external hemorrhoid, how will you anesthetize your patient?
Anesthetize the skin around and over the lump with 1% lidocaine using a tuberculin syringe with a 30 gauge needle.
Most patients with stage I and II hemorrhoids can be managed with what?
Conservative treatment.
For edematous and prolapsed hemorrhoids, gentle manual reduction can be supplemented with what?
Suppositories
Topical witch hazel
Warm sitz baths
*Surgical excision is reserved for 5-10% if patients with chronic severe bleeding due to stage III or IV hemorrhoids.
What is the definitive treatment for internal hemorrhoids? How is it done?
Rubber band ligation (surgical banding)
A specialist places a rubber band around the base of an internal hemorrhoid to restrict blood flow.
This is ONLY done on INTERNAL hemorrhoids due to the lack of nerve innervation.
These are linear, rocket shaped ulcers that are typically <5mm in length.
Anal fissures.
Where do anal fissures normally occur?
The posterior midline (6 o’clock), but 10% occur anteriorly (12 o’clock, toward the genitals).
Fissures away from the midline should be concerning for serious diseases or assault.
This condition has severe, tearing pain during defecation followed by throbbing discomfort.
Anal fissures.
The pain may lead to constipation due to the fear of pain.
How do acute and chronic fissures appear during inspection?
Acute: like cracks in the epithelium.
Chronic: fibrosis and skin tags at the outermost edge.
What are your treatment options for anal fissures?
Goal is to promote effortless, painless BMs.
-Fiber supplements and sits baths.
-Topical anesthetics.
-Oral analgesics
-Tylenol
-NSAIDs
In 45% of patients with anal fissures, healing occurs within 2 months with conservative management to include:
Sitz baths, fiber intake, stool softeners.
Chronic fissures should be referred and may be treated with topical nitroglycerin, diltiazem, or botulinum injections.
This condition is frequently encountered in the perianal and perirectal regions, and almost always begins with involvement of an anal crypt and its gland.
Anorectal abscess.
What spaces can anorectal abscesses occur? What are the most and least common areas?
1) Perianal space (most common)
2) Intersphincteric space
3) Ischiorectal space
4) Deep postanal space
5) Supralevator/pelvirectal space (least common)
What is a common sequela of anorectal abscesses?
Fistulas.
This condition presents with a dull, aching, or throbbing pain that becomes worse immediately before defecation, is lessened after defecation, but persists between BMs.
Anorectal abscesses.
The pain is significantly increased by the pressure in the rectum just before defecation.
What is the treatment of a perianal abscess?
Treatment is surgical and should be done immediately before the abscess becomes fluctuant.
All perirectal abscess drainage should be done in the OR.
Isolated, simple, fluctuant perianal abscesses can be done in the ED or outpatient.
Patients with an abscess and accompanying fever, leukocytosis, valvular heart disease, or cellulitis should be prescribed what?
Cephalexin 250mg PO QID or doxycycline 100mg BID for seven days
This chronic condition occurs when an anal abscess is ruptured or drained and an epithelialized track is formed that connects the abscess in the anus or rectum with the perirectal skin.
Anorectal Fistula (or “Fistula-in-Ano”)
What are the symptoms of an anorectal fistula?
Nonhealing anorectal abscess following drainage.
Chronic purulent drainage and a pustule like lesion in the perianal or buttock area.
Intermittent rectal pain.
Intermittent malodorous perianal drainage and pruritus.
Antibiotics should be given to a patient with an anorectal fistula based on what?
Clinical judgement (typically the proximity of the involved area, patient stability, etc.)
This condition ranges from asymptomatic hair-containing cysts and sinuses to large abscesses of the sacrococcygeal region.
Pilonidal disease
Pilonidal abscesses can occur due to S. aureus invading through the openings caused by ingrown hairs.
What anatomical area do pilonidal cysts and sinuses most often occur?
The sacral area superior to the gluteal fold.
(TG: midline in the upper part of the natal cleft overlying the lower sacrum and coccyx)
A patient presents with complaint of swelling, pain, persistent discharge, and a tender mass in the sacral area. What is the diagnosis?
Abscessed pilonidal sinus/cyst
What is the treatment of choice for pilonidal disease? What is the definitive treatment for recurrent infections?
Surgical treatment. For abscessed cysts in the superior gluteal crease, perform I&D. Recurrences are common.
Recurrent infections and drainage are better treated with a complete excision of the area that can be performed 6 weeks after an active infection.
Ulcerative colitis and Crohn’s disease are two diseases known as what term?
Inflammatory Bowel Disease
This disease causes inflammation to the colonic mucosa, and can have pseudo-polyps.
Ulcerative colitis
*UC can be cured whereas Crohn’s cannot
This is an island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue.
Pseudo-polyp seen in ulcerative colitis.
This disease can affect any segment of the GI tract. Skip lesions will appear all over the GI tract in segments. What is it and what kind of inflammation does it cause?
Crohn’s disease. It causes transmural inflammation which can form fistulas.
Which of the IBDs will be more likely to have extra-intestinal manifestations?
Crohn’s
What is the difference between the way Crohn’s and Ulcerative Colitis affect the layers of the GI tract?
Crohn’s: transmural inflammation, which is complete inflammation of all layers of the bowel wall.
UC: Involves only the mucosal layer of the bowel wall.
What is the most common portion of the GI tract that Crohn’s affects, and what does it cause?
The terminal ilium, which results in malabsorption of vitamin B12, bile salts and calcium.
*B12 deficiency causes a macrocytic anemia with neurological symptoms.
Crohn’s can affect ANY SEGMENT of the GI tract and will develop “skip lesions.”
What should a clinician take note of when assessing a patient for Crohn’s?
Fevers
Patient’s sense of well-being*
Weight loss*
Abdominal pain
Number of liquid BMs per day*
Surgical/Hospitalization history
What is the most common finding in a patient with Crohn’s, and when they have diarrhea how will it appear?
Ileitis or ileo-colitis is the most common finding.
Diarrhea will be NON-bloody in nature.
Intra-abdominal masses are also common (often due to the formation of an abscess).
Small bowel obstruction is a complication of what disease? What are its signs and symptoms?
Crohn’s disease.
Abdominal distention, N/V, intermittent liquid stools and/or constipation, postprandial bloating, cramping pain, loud borborygmi.
A patient reports “peeing out air.” What is the disease process, and what is the complication that is causing this symptom?
Crohn’s disease. Fistula to the bladder due to a sinus track formation is the complication.
1/3rd of patients with large or small bowel involvement secondary to Crohn’s disease will develop ____ disease. What are the signs and symptoms of this complication?
Perianal disease.
-Large painful skin tags
-Anal fissures
-Perianal abscesses
-Perianal fistulas
During acute exacerbations of Crohn’s disease, what modality should be used to assess for abscess or fistula formation?
CT scan of the abdomen
Crohn’s disease puts a patient at increased risk for developing what?
Colon carcinoma. Screening colonoscopy to detect dysplasia or cancer is recommended for patients with a history of 8 or more years after initial flare/diagnosis.
Patients with Crohn’s are 20 times more likely to develop colon cancer than the general population.
This is an inflammatory condition that only involves the mucous of the large intestine, but can involve the rectum, and the inflammation manifests in a continuous fashion.
Ulcerative colitis.
Inflammation of the colon seen in ulcerative colitis can cause what issues/complications?
Bleeding seen in the feces
Ulcerations, edema, fluid and electrolyte loss
What are the 3 areas of the colon that are most commonly affected in ulcerative colitis, and what percentage of patients does each affect?
33%: recto-sigmoid region
33%: splenic flexure (left sided colitis)
33%: proximal (extensive colitis)
*It is more common in non-smokers and former smokers.
*Appendectomy before the age of 20 for acute appendicitis is associated with a reduced risk of UC.
What pertinent history should be asked about a patient with ulcerative colitis?
Stool frequency and character
The presence and amount of rectal bleeding
Diffuse crampy abdominal pain
Fecal urgency
Tenesmus (consistent urge to defecate)
What are the symptoms of ulcerative colitis?
Hallmark symptom: bloody diarrhea
Lower abdominal cramps and fecal urgency (important note: these cramps will be reproducible)
Anemia and low serum albumin
Negative stool cultures
A patient experiencing severe symptoms of ulcerative colitis will exhibit what symptoms?
Six to ten bloody BMs per day, resulting in severe anemia, hypovolemia, and hypoalbuminemia secondary to impaired nutrition.
Abdominal pain and tenderness also present.
What are the average age ranges for patients who first experience ulcerative colitis and Crohn’s?
UC: 30s-40s
Crohns: 20s
What is the curative/definitive surgical treatment of ulcerative colitis?
Total proctocolectomy (removing the entire GI tract distal to the end of the small intestine) because UC only affects the colonic mucosa.
What are the substances within the body that are involved in the perception of autonomic response to visceral stimulation as seen in Irritable Bowel Syndrome?
5-HT (serotonin), Substance P, Norepinephrine, Nitric Oxide
Irritable Bowel Syndrome is characterized by abdominal pain/discomfort and altered bowel habits, which requires how many months of continued symptoms for diagnosis?
3 months
Irritable Bowel Syndrome typically begins at what age?
Late teens to 20s.
What are the primary signs and symptoms seen in Irritable Bowel Syndrome?
Abnormal stool passage and abdominal bloating, or a feeling of abdominal distention.
HALLMARK: abdominal discomfort that is immediately relieved after defecation, with an otherwise normal physical exam (no concern for other disease processes).
What is required to diagnose a patient with Irritable Bowel Syndrome?
3 months of symptoms, and abdominal pain or discomfort with at least two of the three following features:
1) Relieved with defecation
2) Change in frequency of stool
3) Change in form of stool
What are the three major categories of Irritable Bowel Syndrome?
IBS with constipation (IBS-C)
IBS with diarrhea (IBS-D)
IBS with mixed constipation and diarrhea (IBS-M)
What are the alarm symptoms that are not typically seen in patients with Irritable Bowel Syndrome, which should be assessed to rule out more serious conditions?
1) Acute onset of symptoms, especially in patients >40-50 years
2) Nocturnal diarrhea
3) Severe constipation
4) Hematochezia/unexplained IDA
5) Weight loss
6) Fever
7) Family history of cancer, inflammatory bowel disease, or celiac disease
In patients with IBS aged 50 and older, what diagnostic study should be obtained, and for what reason?
Colonoscopy should be obtained to rule out malignancy.
What medication can be used to treat IBS-D?
Loperamide (antidiarrheal agent)
What medication can be used to treat IBS-C?
Osmotic laxatives - caution because these can exacerbate symptoms due to bloating.
What medications are found to be the most effective for treating IBS?
Tricyclic Antidepressants
-Works by increasing the synaptic concentration of serotonin and/or norepinephrine.
-Amitriptyline or Imipramine
-Works best for treating IBS-D
This type of reflex occurs in episodes typically postprandially, are short lived, asymptomatic, and rarely occur during sleep.
Physiologic reflux
This type of reflux is associated with symptoms of mucosal injury and often occurs nocturnally.
Pathologic reflux.
What part of the esophagus plays a vital role in the frequency and severity of GERD?
Lower esophageal sphincter
Pain associated with GERD is secondary to what?
The stimulation and activation of mucosal chemoreceptors by acid.
Spicy, acidic, salty foods, and alcohol also contribute.
What are the symptoms of GERD?
Heartburn occurring 30-60 minutes after a meal and upon bending over and laying down.
-Patients report relief from taking antacids or baking soda.
Complaints of regurgitation of gastric contents.
What symptom occurs in 1/3rd of GERD patients, and what is it due to?
Dysphagia, due to erosive esophagitis, abnormal esophageal peristalsis, or an esophageal stricture.
What are the atypical/extraesophageal manifestations of GERD that are concerning?
1) Asthma
2) Chronic cough
3) Chronic laryngitis
4) Sore throat
5) Non-cardiac chest pain
Barrett Esophagus is a complication of GERD in which the squamous epithelium of the esophagus is replaced (changed into) what tissue?
How is this caused?
Changed into metaplastic columnar epithelium containing goblet and columnar cells
It arises from chronic reflux-induced injury to the esophageal squamous epithelium. These patients will have a long history of more severe GERD symptoms.
Your patient reports a history of GERD, and says that his symptoms have slowly been getting better, but now he is experiencing dysphasia when eating solid foods. What complication of GERD is he experiencing?
Peptic Stricture, most of which occur in the gastroesophageal junction.
How should you educate a patient experiencing night time symptoms of GERD?
Avoid laying down within 3 hours of eating a meal
Elevate the head of the bed with 6 inch blocks or foam wedge
This medication does not prevent GERD, but can provide relief for symptoms?
Antacids.
Why is Famotidine useful in treating GERD?
It is a Histamine H2 Antagonist, which means it reduces the secretion of gastric acid by inhibiting the actions of histamine at the H2 receptor cells in the stomach.
What is the treatment of choice for GERD, especially for patients experiencing troublesome symptoms?
PPIs
These agents have a delayed onset of 30 minutes but can provide relief for 8 hours.
When should a patient with GERD be referred for specialty evaluation?
No relief after maximum empiric management with three months of twice daily PPI use.
Significant dysphasia or other alarm symptoms.
Barrett Esophagus or esophageal stricture
What medications cause esophagitis due to direct esophageal mucosal injury?
Antibiotics
-Tetracycline
-Doxycycline*
-Clindamycin
Anti-inflammatories
-Aspirin and other anti-inflammatories
Bisphosphates
What symptom often occurs alongside esophagitis in immunocompromised patients and can be helpful in determining the cause of the esophagitis?
Thrush
What are the signs and symptoms of medication induced esophagitis?
Retrosternal pain or heartburn (60% of patients)
Odynophagia (50%)
Dysphagia (40%)
In some cases, pain is so severe that swallowing saliva is difficult. These patients often have a history of swallowing a pill without water at bedtime.
What are the signs and symptoms of pill induced esophagitis?
Hematemesis, abdominal pain, weight loss. Onset of symptoms can occur within a few hours to one month after ingesting the medication. Patients also have a history of swallowing pills without water at bedtime.
This condition is an AIDS-defining illness most commonly seen in HIV infected patients. What are its symptoms?
Candida esophagitis/esophageal candidiasis.
The hallmark symptom is odynophagia. Patients localize their pain to a discrete retrosternal area. White mucosal like plaque-like lesions will be seen on an endoscopy.
Approximately 25% of esophageal strictures are unrelated to GERD. What is a major concerning cause of these strictures?
External beam radiation
What are the signs and symptoms of esophageal stricture?
Hallmark sign: dysphagia
Localized substernal chest pain
Heartburn
How do you treat mild and severe esophagitis?
Mild: treat for GERD as the causative factor.
Severe: consider MEDEVAC and surgery.
Refer all patients to gastroenteritis.
What are the more severe symptoms of esophageal stricture?
Dysphagia (hallmark), food impaction, asphyxiation
What layer of the esophagus does an esophageal spasm affect?
The distal two-thirds of the muscularis.
Muscle spasms = muscularis.
This condition has a gradual onset of dysphagia with symptoms that come and go but can be present for months. The patient complains of frequent regurgitation. What is the condition, and what is a hallmark symptom?
Esophageal spasm
Lifting neck or throwing shoulders back to enhance gastric emptying.
What condition occurs when NSAIDs break down the walls of the stomach?
Peptic ulcers
What are the common causes of peptic ulcers?
NSAIDs, H. pylori, infection, bile salts, acid, pepsin.
What is the diagnostic choice for peptic ulcers?
Upper endoscopy with gastric biopsy
This condition is a break in the gastric or duodenal mucosa that arises when the normal mucosal defenses are overwhelmed by acid and pepsin.
Peptic ulcers
By definition, peptic ulcers extend through the muscularis and are over 5mm in diameter.
Peptic ulcers appear __ times more commonly in what portion of the intestines?
Five times more commonly in the duodenum. 95% are in the bulb or pyloric channel.
Who are peptic ulcers commonly seen in?
Smokers and long term NSAID users.
What are the three major causes of peptic ulcers?
1) NSAIDs
2) Chronic H. pylori
3) Acid hypersecretory states
The risk of peptic ulcer NSAID complication is greater in what situations?
1) Within the first 3 months of therapy.
2) In those with prior history of ulcers.
3) Those who take NSAIDs in combination with aspirin, corticosteroids, or anticoagulants.
A patient presents with epigastric pain that he describes as gnawing, dulll, aching and hunger like. He also says that the pain wakes him at night. What is his condition?
Peptic ulcers
2/3rds of duodenal ulcers and 1/3rd of gastric ulcers cause nocturnal pain that awakens patients.
Lab values are typically normal in uncomplicated peptic ulcers. What lab value will be abnormal in a patient with severe peptic ulcers? What will it indicate?
An elevated serum lipase in a patient with severe epigastric pain, which will indicate ulcer penetration into the pancreas.
What is the 10-14 day anti-H. pylori peptic ulcer treatment regimen?
PPI PO BID.
Clarithromycin 500mg PO BID
Amoxicillin 1g PO BID (or Metronidazole 500mg PO BID if allergic to Penicillin.)
What test is used to confirm successful eradication of H. pylori peptic ulcers?
Fecal antigen test
Urea breath test
Endoscopy with biopsy at least 4 weeks after completion of antibiotics and 1-2 weeks after completion of PPI.
Define the following:
-Diverticula/Diverticulum
-Diverticulosis
-Diverticular disease
-Diverticular bleeding
-Diverticulitis
-Diverticula/Diverticulum: a sac-like protrusion of the colonic wall.
-Diverticulosis: the presence of a diverticula. It can be symptomatic or asymptomatic.
-Diverticular disease: clinically significant and symptomatic diverticulosis.
-Diverticular bleeding: painless hematochezia due to segmental weakness of the vasa recta associated with a diverticulum.
-Diverticulitis: inflammation of a diverticulum.
In this condition, small pockets of the wall of the colon fill with stagnant fecal material and become inflamed. They can rarely cause obstruction, perforation and bleeding. What is the condition?
Diverticulitis
What portion of the large intestine is most commonly affected by diverticulitis?
Sigmoid colon. It is an intraperitoneal organ so it is moveable and can pop out of place.
Most patients with inflammation or infection secondary to diverticulitis will report pain in what quadrant? What are other symptoms?
Left lower quadrant.
Slow onset of LLQ pain, fever, palpable mass.
What are differentials for a female patient experiencing LLQ pain consistent with diverticulitis?
Ectopic pregnancy, ovarian cyst or torsion.
How do you conservatively treat a patient with diverticulitis?
Clear liquid diet plus broad spectrum PO antibiotics.
Augmentin OR Flagyl
PLUS
Bactrim OR Cipro
7-10 days or until afebrile for 3-5 days.
*Severe symptoms will require IV antibiotics.
This type of GI bleeding is visible via a test or microscope.
Occult blood.
What is the most common source of lower GI bleeding?
Colon carcinoma
What type of blood is hematemesis? What are the two types of hematemesis you will see?
Overt blood. Hematemesis = bloody vomit.
1) “Coffee ground” black
-This blood occurs at or distal to the stomach, because the iron in the blood interacted with gastric acid.
2) Bright red blood
-This blood occurs at or proximal to the lower esophageal sphincter, because the iron has NOT interacted with gastric acid.
This type of bloody stool is dark black and tar-like, indicating an upper GP bleed.
Melena
Conversely, hematochezia is bright red blood per rectum, indicating a lower GI bleed.
What are the two most common types of upper GI bleeds, and how do they present? What is the gold standard for diagnosing the source of bleed?
1) Hematemesis
-Bright red blood or coffee ground black
2) Melena
-Develops after as little as 50mL of upper GI blood loss
Upper endoscopy
What modality should be placed in all patients with a suspected active upper GI bleed?
NG tube.
The aspiration of red blood or “coffee grounds” confirms an upper GI source of bleeding.
What are the most common causes of upper GI bleeds?
Peptic ulcers (50%)
Mallory Weiss Tear (10%)
Erosive Gastritis
What is the medication treatment of an upper GI bleed?
IV PPIs are the gold standard for severe bleeds.
A stable patient can take PO PPIs.
List the stool colors seen in lower GI bleeds and their causes.
1) Large volumes of bright red blood suggesting colonic source.
2) Maroon stools implying a lesion in the right colon or small intestine.
3) Black tarry stools indicate a source proximal to the ligament of treitz.
What diagnostic study is used for patients with a lower GI bleed?
Colonoscopy.
Mallory Weiss Syndrome and Boerhaave Syndrome affect what portion of the esophagus?
The gastro-esophageal junction, also known as the squamo-columnar junction.
This condition is caused by a sudden increase in transabdominal pressure, and presents as non-penetrating vertical mucosal tears at the gastroesophageal junction.
Mallory Weiss Tears.
A history of heavy alcohol use leading to vomiting has been noted in 40-80% of patients.
This condition is caused by backup of blood into the esophagus due to a disease of the liver.
Esophageal varices.
What is Boerhaave’s Syndrome, and what are its signs?
A more severe laceration of the anterior esophagus associated with full penetration of the esophagus into the mediastinum.
-Hartman’s sign: crunching sound on auscultation
-Possible crepitus of the chest
What are the signs seen in both Mallory-Weiss and Boerhaave’s?
1) Heavy alcohol use
2) S/S of upper GI bleed
3) Hematemesis with or without melena
4) Hallmark: retching, vomiting, straining
5) Hypovolemia
How do you treat Mallory Weiss and Boerhaave’s?
Mallory-Weiss
-NPO
-IV PPI
-IV/IM antiemetic
Boerhaave’s
-All of the above, plus IV antibiotics: Ertapenem 1g IV qD
What age ranges will most often be affected by appendicitis?
10-35, most commonly 20-35.
Where is McBurney’s point located?
1/3rd of the distance from the right anterior superior iliac spine to the umbilicus.
This condition manifests as a blockage of the lumen of an organ protruding from the base of the cecum.
Appendicitis
When the lumen of the appendix is blocked off and begins to expand, what else occurs? What are the most common causes of this blockage?
The appendix expands and outgrows its blood supply, resulting in necrosis and perforation of the appendix.
Fecalith (most common)
Immune response and expansion of lymph tissue
Neoplasms
This condition presents with a gradual onset of periumbilical abdominal pain over 12-24 hours, which progresses to more localized pain in the right lower quadrant.
Appendicitis
A positive Obturator sign is described how, and indicates what?
Pain with right hip flexion and internal rotation of the femur with a flexed knee.
It indicates appendix deep in the pelvis.
What positive test can indicate retro-cecal appendicitis?
Psoas sign.
Patients with signs of an acute abdomen are concerning for what condition?
Perforated appendix.
A female reports with progressively worsening RLQ pain. In addition to testing for appendicitis, what tests should be performed on this patient?
Beta-HCG and pelvic exam regardless of her reported sexual history.
What is the gold standard for diagnosing appendicitis?
CT scan of the abdomen.
What is the first line of treatment, and the gold standard definitive treatment of appendicitis?
First line: antibiotics
Gold standard: appendectomy
*Use morphine for pain control. Patient should be NPO and given IV fluids.
What is bile composed of?
Bile salts, cholesterol, and bilirubin
What are the two major types of gallstones?
Cholesterol gallstones (most common)
Pigmented gallstones
What are the types of causes of cholesterol gallstones?
Increased estrogen from pregnancy
Increased total circulating cholesterol (poor diet, high trans and saturated fats, rapid weight loss)
This type of gallstone is formed by the precipitation of bilirubin.
Pigmented gallstones
Describe how gallstones are formed.
The amount of cholesterol or bilirubin in the gallbladder exceeds the amount of bile salts needed to dissolve it.
What situations can cause gallstones to form?
A decrease in the amount of bile salts (i.e. Crohn’s disease)
Excess cholesterol or bilirubin
What ducts combine to form the common bile duct?
Cystic duct and common hepatic duct
This is defined as a patient with gallstones present but has no symptoms associated with them.
Asymptomatic cholelithiasis
Usually found incidentally, 80% of patients will be asymptomatic their whole life.
This condition occurs when gallstones have formed in a patient’s gallbladder and will intermittently obstruct the lumen of the cystic duct.
Biliary colic
These stones cause temporary obstruction when the gallbladder contracts, but they eventually dislodge themselves. Symptoms last less than 6 hours.
No lab abnormalities. No fever.
This condition occurs when a gallstone is permanently lodged in the cystic duct. The patient presents with increased white blood count, fever, and symptoms that are present for over 6 hours.
Cholecystitis
This condition refers to inflammation of the gallbladder caused by obstruction of the common bile duct.
Choledocholithiasis
Fever and elevated WBC count will likely be present. Lab values will reflect increased conjugated bilirubin.
Choledocholithiasis causes an obstruction of the common bile duct, which causes an increase in conjugated bilirubin in the blood. How might your patients appear?
Jaundiced.
What is cholangitis?
A bacterial infection of the gallbladder, caused by bile stasis (often secondary to choledocholithiasis).
What is Charcot’s Triad?
RUQ pain
Fever
Jaundice
A patient presents with acute, sharp RUQ pain after eating a meal. What is the diagnosis?
Biliary Colic
-Intermittent obstruction of the cystic duct by a gallstone
How do you treat biliary colic?
No specific treatment. Change diet, closely monitor.
Symptoms are SELF LIMITING.
Define Acalculous Cholecystitis and who it is seen in
Signs and symptoms consistent with cholecystitis without radiologic evidence of gallstones.
These patients have had major surgery within the past 2-4 weeks or are NPO due to a critical condition (ICU patients)
What condition may occur in patients with AIDS?
Acute cholecystitis secondary to viral infection.
What are the Six F’s of cholecystitis?
Fat, Fertile, 40s, Female
Flatulence, Fever
What are the signs and symptoms of cholecystitis?
Six F’s
Sudden onset of RUQ pain after eating meal high in fats.
Murphy’s Sign
Palpable gallbladder
This sign is an abrupt cessation of inspiration with deep palpation of the RUQ secondary to pain.
Murphy’s Sign
What is the gold standard radiologic diagnostic tool of choice for cholecystitis?
RUQ Ultrasound
Continuous symptoms of cholecystitis for over 24 hours suggests what complication?
Necrosis of the gallbladder.
This can develop without definite signs in the obese, diabetic, elderly, or immunosuppressed.
What is the definitive treatment for cholecystitis?
Cholecystectomy, the mainstay of treatment.
All patients need antibiotics regardless.
How do you conservatively manage cholecystitis?
MEDEVAC
NPO
Antibiotics
-Ertrapenem or Ceftriaxone
What major lab value will you see in a patient with choledocholithiasis?
Conjugated bilirubin in the blood.
What are the signs and symptoms of choledocholithiasis?
Same as cholecystitis, with the addition of jaundice.
Six F’s
Signs and symptoms of obstruction
Sudden onset of RUQ after eating a meal high in fat.
What is the gold standard diagnostic tool for choledocholithiasis?
RUQ ultrasound.
ERCP can be diagnostic and therapeutic.
What is the typical infectious origin of cholangitis?
E. coli
A patient that has cholangitis presents RUQ pain, fever, and jaundice. What is this referred to?
Charcot’s Triad
How will cholangitis patients present, and what intervention do they need?
They tend to be very ill, and require fluid resuscitation - 2 large bore and IV antibiotics.
What are the most common causes of pancreatitis?
Alcoholic
-Causes auto-activation of pancreatic enzymes resulting in enzymatic destruction of the pancreas
Gallstones
-Can obstruct the ampulla of vater causing impaired extrusion of enzymes into the duodenum which leads to auto-digestion of pancreas tissue
Patients with pancreatitis typically have a history of what condition?
Cholelithiasis or cholecystitis.
Also have a history of alcoholism or heavy drinking.
Patients often report having felt similar symptoms before.
What are the signs and symptoms of pancreatitis?
Abrupt onset with severe epigastric pain
Steady, boring, severe abdominal pain made worse by walking and lying supine
Relieved by sitting upright and leaning forward
Pain radiates to the back
N/V
Gray-Turner and Cullen’s
What are the lab findings in a patient with pancreatitis? What is the gold standard radiologic test?
Leukocytosis - 10,000-30,000/mcL
Gold standard: elevated serum lipase
RAD gold standard: CT scan which shows enlarged pancreas and demonstrates severity of disease
What is the treatment of a patient with pancreatitis?
NPO + aggressive IV fluids is the gold standard for uncomplicated pancreatitis.
Fluid resuscitation is the hallmark of therapy.
A history of what condition is disqualifying for serving aboard submarines?
Pancreatitis.
What are the borders of Hasselbach’s Triangle?
Inferior Epigastric vessels (superior)
Lateral aspect of the Rectus Abdominis (medial)
Inguinal ligament (inferior)
What is the most common type of hernia, accounting for __-__% of hernias?
Inguinal
75-80%
What are the two types of inguinal hernias, and where do they occur?
Direct hernia
-Herniates directly through the Hasselbach’s triangle.
Indirect hernia
-Herniates through the inguinal canal
What is the major cause of an indirect hernia that is due to an open communication between the intraperitoneal and inguinal canal?
Patent Processus Vaginalis
More commonly occurs in men because of the fetal development of testicles.
What kind of hernias are more commonly seen in females and in the first year of life?
Incarcerated and strangulated hernias.
What kind of hernia passes through the abdominal wall musculature (Hasselbach’s Triangle)?
Direct Inguinal Hernia
They are acquired defects and do not pass through the inguinal canal. They occur in adults and rarely incarcerate or strangulate. Recurrence after repair is common.
What are the two types of umbilical hernias, and how do they present?
Congenital
-Outtie belly button
-Prevalent in black children
-Spontaneously resolve by 5 years old typically
-Rarely incarcerate
Acquired
-Present in adulthood (pregnancy, surgery etc)
-More likely to incarcerate
What are the signs of a direct, indirect, and umbilical hernia?
Direct: lower anterior abdominal mass
Indirect: scrotal mass
Umbilical: outtie belly button
What is an incarcerated hernia?
A hernia that does not reduce spontaneously.
How will a patient with a strangulated hernia appear?
Hernia will have bruising or overlying redness at the site of the hernia.
Tachycardia, fever may be present, extreme pain at the site of the hernia.
Patient may become toxic.
How will indirect and direct hernias feel upon examination in males?
Indirect: tapping sensation at the tip of the finger
Direct: hernia bulges anteriorly and pushes against the side of the finger
In what situation can you manually reduce an incarcerated hernia?
If there is a reliable history that the incarceration occured within 24 hours. If not, do not try to reduce it because it could release dead bowel into the abdominal cavity. The ultimate treatment for this type of hernia is surgical fixation.
If strangulation of a hernia is suspected or shock is present, what is a necessary antibiotic treatment?
Broad spectrum IV antibiotics with fluid resuscitation
Ertapenem 1g IV
How do you perform the Closed Passive Reduction Technique?
Place patient in Trendelenburg to let gravity assist with hernia reduction.
Administer morphine and diazepam and allow for reduction over 30-40 minutes.
If the Closed Passive Reduction Technique fails, what do you do?
Perform the Closed Active Reduction Technique.
Place one hand over the neck of the hernia sack to guide the contents into the peritoneal cavity.
Use the other hand to provide gentle and steady distal to proximal compression over the hernia.
This type of SBO is not caused by a physical blockage, but rather a dysfunction of the intestinal tract’s ability to move bowel contents through its lumen.
Adynamic Ileus / Paralytic Ileus
What are the two most common types of SBO?
1) Adhesions (most common)
-Scar tissue causing the small intestine to wrap around and become obstructed.
2) Hernias
What are the symptoms of a SBO?
Crampy, intermittent abdominal pain
Urge to move and feeling uncomfortable
Abdominal distention
Vomiting
-Bilious if obstruction is proximal
-Feculent if the distal ileum is obstructed
Possible diarrhea
Constipation and bloating
Tinkling
Mechanical bowel obstruction may produce what sound on auscultation?
Active, high-pitched bowel sounds with occasional rushes. Referred to as tinkling.
This type of SBO has less intense pain that is more constant, and patients tend to be constipated with diminished bowel sounds.
Paralytic Ileus
What is the gold standard imaging for a SBO, and what will you see?
Upright x-ray of the abdomen.
Air fluid levels in the stomach and portions of the small intestine.
Multiple dilated loops of the small bowel.
No air in large intestine or rectum.
What is the first line of treatment of a SBO?
NG tube
NPO
Discontinue medications
Two site IV access and aggressive fluid resuscitation
