increase in volume, fluidity, or frequency of bowel movements relative to their usual

breakdown product of haem unconjugated is carried in plasma to the liver where it is conjugated to form 'conjugated bilirubin' then excreted in bile gives colour

unpleasant sensation vaguely referred in epigastrium and upper abdomen unpleasant feeling of impending vomit

forcible ejection of some digestive system contents (usually stomach) through the oesophagus and mouth voluntary or involuntary often associated with nausea

Disturbance in digestion Flashcards by Danielle Mercier

eructation

burp

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diarrhoea

increase in volume, fluidity, or frequency of bowel movements
relative to their usual

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What factors are necessary for the formation or normal stools and normal defecation?

food quantity, quality, fluid
ability to swallow
integrity of all digestive system (liver, gall bladder and pancreas)
peristaltis, enzyme, hormone, surface area
blood supply, innervation (& spinal cord)
willingness to defecate

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What are the common causes of diarrhoea?

laxative abuse
gastroenteritis (rotavirus, Campylobacter jejuni, Salmonella sp, Vibrio cholera, giardia, helminths)
food poisoning
coeliac, lactose
spurious (faecal impaction or obstruction)
IBS
drugs (magnesium containing antacids, antibiotics), diet, stress

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What are some other less common causes of diarrhoea?

colonic causes (carcinoma of colon, diverticular disease, inflammatory bowel disease, dysentery, pseudomembranous colitis)
malabsorption states
endocrine (hyperthyroidism, diabetes mellitus, Addison’s disease, carcinoid syndrome, Zollinger-Ellison syndrome)
Non-Hodgkin’s lymphoma
AIDS

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List the classifications of diarrhoea?

1) osmotic - lower water reabsorption
2) secretory - electrolytes
3) motor
4) exudative -movement of fluid and cells from wall

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What is motor diarrhoea?

• increased motility of bowel

> faecal mater less time contact with bowel wall
> decreased water reabsorption

• drugs, infective, hyperthyroidism, IBS

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What is osmotic diarrhoea?

• decreased water reabsorption into bowel wall

> more water in faecal material
> loose stools
less viable surface
excessive non-absorptive molecules in bowel lumen

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What is secretory diarrhoea?

Increase secretion of electrolytes from bowel wall into lumen

> water follows electrolytes
> increased fluid in stools

• cholera

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What is exudative diarrhoea?

Excessive movement of cells and fluid from the intestinal wall into the lumen
-> pus and excess fluid in faecal mater +/- blood

ulcerative colitis
shingellosis

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Which electrolytes are usually measured in a standard biochemistry screen?

Sodium
Potassium
Chloride
Bicarbonate
Calcium (sometimes)
Urea (a waste product, not an electrolyte)
Creatinine (a waste product, not an electrolyte)

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What is measured in “liver function tests”?

Bilirubin-total, con-/uncon-jugated
ALT
Alkaline phosphatase
Gamma-glutamyl transferase
Total protein and Albumin
prothrombin line

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What are common causes of constipation?

Low fibre, fluid, exercise
Laxative abuse
Aged and invalids
Poor defecation habits

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What are the other less common causes of constipation?

IBS, IBD
anxiety
drugs
acute diverticulitis
intestinal obstruction
neuromuscular disorders
painful defecation (haemorrhoids, anal fissures)
connective tissue disorders
electrolyte disturbances (hypokalaemia, hypocalcaemia, hypercalcaemia)
chronic lead poisoning
typhoid fever

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What are the mechanisms by which constipation occurs?

diminished motility of colon (drug, hypothyroidism, low exercise)
pain with defecation-avoiding poop (anal fissure, haemorrhoids)
small faecal mass -> low stimulus by faeces on wall -> low defecation (low fibre)
hard dry stools -difficult elimination (low fluid)
repetitively delaying response to urge -> lower sensitivity of rectum receptors (kids)
mechanical blockage

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What is a colonoscopy?

• Uses a fibre-optic endoscope
• Can visualise as far as caecum
• Requires thorough preparatory bowel cleansing
• Can visualise, aspirate fluids, biopsy, perform endoscopic surgery etc
• Indications for use include the diagnosis of:
- Tumours of colon
- Inflammatory disorders of colon
- Source of GIT bleeding
- Diverticular disease

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What is bilirubin?

breakdown product of haem
unconjugated is carried in plasma to the liver where it is conjugated to form ‘conjugated bilirubin’
then excreted in bile
gives colour

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Nausea

unpleasant sensation vaguely referred in epigastrium and upper abdomen
unpleasant feeling of impending vomit

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Vomit

forcible ejection of some digestive system contents (usually stomach) through the oesophagus and mouth
voluntary or involuntary
often associated with nausea

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Explain the pathophysiology of jaundice by relating these to the possible disturbances in the bilirubin pathway?

Old RBCs + precursors in bone marrow + heme in liver

> biliverdin -> unconjugated bilirubin
> conjugated in canaliculi
> some excreted by kidney OR most excreted by liver via hepatic ducts
> common bile duct
> cystic duct OR small intestine
> cystic duct -> gall bladder -> bit excreted in urine
> small intestine -> deconjugated by flora -> excreted in faeces

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What is the pathophysiology of nausea?

Subjective sensation due to:
• (-) stomach muscle tone and activity
• (+) duodenum muscle tone
• Reflex of chyme/juices from duodenum to stomach
• ANS activity (sweating, salivation, pallor, (-) HR, (-) BP)

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What are the triggers of vomiting?

Triggered by any event or situation which stimulates the medullary vomiting centre, and may be from:

1) Digestive tract.
2) Cerebral cortex
3) Labyrinthine structures
4) Medullary chemoreceptor trigger zone (gets stimuli from whole body and drugs)

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One there is a trigger for vomiting, then what happens?

• stimulus integrated within medullary vomiting centre
• transmission of nerve impulses via:
1) Phrenic nerve -> diaphragm contraction
2) Spinal nerves -> abdominal wall muscles contraction
3) Visceral efferent nerves -> pylorus contraction, and fundus & gastroesophageal sphincter relaxation
4) Inhibition of respiration
5) Elevation of the soft palate
6) Closure of the glottis

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What are the possible causes of vomiting?

Disorders from the intra- abdominal structures
Intracranial disorders
Metabolic disorders and endocrine disorders
Motion sickness
Labyrinthine disorders
Pregnancy
Toxins: drugs, withdrawal, alcohol, poisons
Cardiovascular disorders
Psychogenic
Acute systemic infections
Intense pain

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What section of the GIT does a colonoscopy see?

only up until ascending colon | -doesn't see terminal ilium

How does the duration of a diarrhoea help find the diagnosis?

* some diseases are self-limiting * cholera short duration * Crohn's long duration * long duration gives chance to modify diet or find alleviating factors

What is the aetiology of diarrhoea within 6hrs of a "suspect" meal of dairy products, creamed fillings or mayonnaise?

staph aureus

What is the aetiology of diarrhoea at least 14hrs after eating eggs or poultry?

salmonella

What is the aetiology of diarrhoea at least 14hrs after eating seafood?

vibrila

What is the aetiology of diarrhoea 8-14hrs after eating meat kept warm for a long period of time?

clostridium

What is the possible cause of diarrhoea with mucus?

* disentry type * salmonella * Crohn's * ulcerative colitis

What is the possible cause of bloody diarrhoea?

* crohn's * ulcerative colitis * bleeding in GIT

What is the possible cause of diarrhoea appearing black?

melon from upper GIT

What is the possible cause of diarrhoea appearing green?

infective organism

What is a nervous colon?

spastic colon | IBS

What are the 2 types of colonoscopy?

Endoscope up anus: examen and take specimen Swallow camera: virtual colonoscopy

What is the meaning of stools that are frothy and watery?

osmotic diarrhoea -> lactose intolerance

What is the significance of a healthy appetite BUT weight loss?

malabsorption, maldigestion, malmetabolism

What are the possible causes of alternating diarrhoea and constipation?

* IBS * Crohn's * colon or rectum carcinoma * diverticular disease * faecal impaction * laxative abuse

What is the significance of angular stomatitis and diarrhoea?

vitamin deficiency

What is the significance of smooth red tongue and diarrhoea?

vitamin deficiency

What is the significance of oedema with diarrhoea?

Decreased absorption albumin - > low serum albumin - > low osmotic pressure - > oedema

What are the possible causes of protuberant abdomen?

* fat * flatus * faeces * fulminating neoplasm * foetus * fluid

Which diseases have diarrhoea and anal lesions?

Crohn's | ulcerative colitis

What does a prolonged prothrombin time mean?

bleeding tendency

What are the big 2 causes of constipation in elderly adults ?

* colorectal cancer | * diverticular disease

What are the pros and cons of a colonoscopy in the elderly?

Pros: • prove diverticular disease • find early carcinoma Cons: • very invasive • elders most likely have many comorbidities Depends on mental state and health of patient

What is hydrochlorothiazide?

diuretic medication to treat hypertension

What are the types of jaundice?

Pre-hepatic • hypersplenism Hepatic • obstruction of canaliculi • from swelling of liver Post-hepatic • obstruction of common bile duct

Why do we ask a patient with jaundice about arthritis, pruritus, urticaria?

looking for systemic causes of the jaundice

Explain the pathophysiology of dark urine and pale stools in jaundice?

Bilirubin gets conjugated by canaliculi, but it is blocked by swelling of hepatocytes - >can't be excreted by hepatic duct into common bile duct into small intestine - >most excreted into urine

asterixis

flapping wrist extension

Babinski sign

sign of UMN lesion

How do you get Hepatitis A?

faecal oral

What are the clinical features of chronic liver failure?

* glucose intolerance * steatorrhea * hepatic encephalopathy * bleeding tendency * ascites, oedema * jaundice (dark urine, pale stools) * vitamin deficiencies (swollen tongue, angular stomatitis) * mineral deficiencies * excess hormones (spider nave, palmar erythema, testicular atrophy, gynaecomastia, menstrual irregularities) * excess glucocorticoids (cushings like symptoms) * excess mineralocorticoids (salt and water retention) * increase drug side effects * infections * portal hypertension (hematemesis) * clubbing

What is hepatic encephalopathy?

* sign of chronic liver failure | * buildup of ammonia -> changes blood pH -> damages brain

What are the possible causes of hepatomegaly?

* vascular congestion (H failure) * biliary duct obstruction * infiltration: leukaemia, lymphoma, fat, amyloid, iron, granuloma (TB) * cysts * inflammatory or infective: hepatitis, mono, typhoid fever, abscess, crohn's * cirrhosis * tumours: hepatoma, metastatic from bowel

What is the consequence of laxative abuse on bowel habits?

diarrhoea but can also be constipation if stopping after long term abuse

What is the consequence of painful anal lesions on bowel habits?

constipation -because unwilling to defecate to avoid pain

What is the consequence of drugs on bowel habits?

constipation or diarrhoea

What is the consequence of IBS on bowel habits?

alternating constipation and diarrhoea

What is the consequence of AIDS on bowel habits?

diarrhoea

What is the presentation of acute appendicitis?

* acute onset of umbilical colicky pain * vomiting, anorexia, fever * migrates to R iliac fossa, worse over McBurney's point * rebound tenderness * pain becomes constant * if retrosecal -> psoas and obturator tests * high HR, fever

What are the causes of paralytic ileum?

* spinal cord trauma * drugs * peritonitis

What is important to think of about the 75 year old demographics?

* malignancies * degenerative (cardiovascular, joints, brain) * lifestyle diseases (diabetes, smoking, obesity, alcohol) * organs not working as well anymore * more than one problem at once * ADLs, independence

What is the DDx of a 42yr old male with a 10 year Hx of constipation with intermittent diarrhoea?

* IBS * Coeliac disease * Lactose intolerance * Crohn's * Ulcerative colitis

What is the DDx of a 39yr old thin female with a 20yr Hx of intermittent diarrhoea with occasional blood?

* Crohn's * Ulcerative colitis * (NOT IBS because of the blood)

How can you tell the difference between Crohn's and ulcerative colitis?

colonoscopy

What is the possible cause of watery diarrhea following use of antibiotics, plus abdominal pain?

* overgrowth of pathogenic bacteria | * pseudomembranous colitis

What is the possible cause of diarrhoea with fever?

* infective cause | * neoplastic or ischaemic origin

What is the possible cause of chronic diarrhoea with peri-anal lesions?

Crohn's

What is the possible cause of diarrhoea with blood and mucus?

* ulcerative colitis | * chronic gastroenteritis

What is the possible cause of diarrhoea with abdominal pain and flatus, relieved by defecation?

* IBS | * distal colon disorder

What is a complication of chronic diverticular disease?

colorectal cancer

What is under the R hypochondrium?

liver | gallbladder

What is the presentation of Hep A?

* spreads by fecal oral route * starts as a GIT illness * fever

Compare the presentation of Hep A and mono

Mono: • looks like Hep A • BUT starts as URT issue and not GIT

What investigations can we do to confirm a suspected hep A infection?

* urine test for bilirubin * full blood count (high lymphocytes) * liver function test (high AST and ALT) * serology for antibodies against hep A

How can you differentiate which hepatitis it is?

serology for antibodies against that type of hep in the blood

What are the effects of alcohol abuse on the GIT?

* acute gastritis * increased chance of GIT carcinoma * fatty liver, cirrhosis, liver failure * acute or chronic pancreatitis

Which hepatitis may become chronic?

all except for hep A

How do you get Hep B?

* piercing * unprotected sex * needle sharing

What are the potential causes of episodic vague upper abdominal pain?

Stomach: diet, GORD, reflux, idigestion Gallbladder Pancreatic cancer Ovarian cancer

What are the potential causes of fainting?

* psychogenic * pain * low BP, glucose, O2 * drugs * alcohol * seizure * transient ischaemic attack * arrhythmia

What can cause upper GI bleed?

* peptic ulceration * oesophageal varices * malignancy * poison

What is the possible significance of dark red blood mixed with the stools?

upper colon bleed

What is the possible significance of bright red blood found on the surface of the stools?

rectum-sigmoid colon bleed

What is the possible significance of bright red blood, predominantly found on toilet paper, rather than stools?

anal lesions fissure of haemorrhoids

What is orthostatic hypotension and what causes it?

* when blood pressure drops from prone to siting or standing | * dehydration is common cause