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Dyspepsia - Constipation Flashcards

1
Q

Define Dyspepsia and what it may be associated with?

A

Predominant epigastric pain

Associated w/ epigastric fullness, N/V, heartburn

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2
Q

When/who is an endoscopy warranted for?

A

ALL PTs 60 or older

Younger PTs with alarms

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3
Q

If PT complains of dyspepsia but doesn’t have any alarms, what is the next step?

A

H Pylori testing

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4
Q

What is the next step if PT are H Pylori neg/not improving with eradication should be given?

What if the PT has refractory Sx?

A

Empiric PPI therapy

Refractory= TCA, Pro-kinetic agent or psychological therapy

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5
Q

Pathophysiology of Gastritis?

A

Autoimmune/hypersensitivity
Infection
Inflammation

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6
Q

What can cause Autoimmune/hypersensitivity gastritis?

A

Pernicious anemia- +Schilling test, decreased intrinsic factor and parietal cell Abs

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7
Q

What are the infection causes of gastritis?

A

H Pylori- most common
Tests: Urea breath test, Fecal Ag test
Tx: PPI, Clarithromycin, Amoxicillin

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8
Q

What are the inflammation causes of gastritis?

A

NSAIDs- reduce prostaglandin production in stomach and duodenum
ETOH

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9
Q

How does gastritis present in clinic?

A

Dyspepsia

Abdominal pain

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10
Q

What is the diagnostic study for gastritis?

A

Gold Standard diagnosis= endoscopy w/ 4 biopsies along stomach lining

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11
Q

What are the causes of Acute and Chronic Gastritis?

A

Acute- H Pylori, NSAIDs, ETOH, Portal HTN

Chronic- H Pylori, autoimmune

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12
Q

How does acute/chronic gastritis present in clinic?

A

Epigastric discomfort
N/V
GI Bleeding

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13
Q

How is acute/chronic gastritis diagnosed?

A

H Pylori testing

Endoscopy

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14
Q

What is prescribed for acute/chronic gastritis?

A

Avoid causative agent
H Pylori eradication
PPI
Parenteral B12

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15
Q

What is the sequence of care for PT younger than 60 complaining of dyspepsia?

A

H Pylori test/treat

No response to eradication / negative Pylori test= PPI to TCA/Prokinetic to Psychotherapy

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16
Q

“Upset Stomach” part of dyspepsia is not clinically relevant unless Sx have been preset for how long?

A

One month or more

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17
Q

What are the Alarm Signs of dyspepsia?

A 
Concomitant weight loss
Persistent vomiting
Constant/severe pain
Progressive dysphagia
Hematemesis
Melena
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18
Q

What should the PT Hx for dyspepsia include?

A 
CLR DQ FEW Changes
Chronicity, location, quality, duration and relationship to meals
Changes to diet/exercise/stress
ETOH/Caffeine/Spicy meals
Medication Hx
F/c, N/V/D, Weight loss
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19
Q

What are the “alarm” alarm signs of dyspepsia?

A 
Constant/severe pain
WE RAD
Weight loss
Evidence of GI bleed
Recurrent vomiting
Anemia
Dysphagia
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20
Q

Dysphagia PE will usually be unremarkable so what other issues are ruled out during exams?

A

Organomegaly
Masses
Focal/Severe TTP

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21
Q

What are the lab tests for dyspepsia work up?

A

CBC
Chem 17- CMP
Thyroid panel
H Pylori

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22
Q

What are the “other” tests that can be done during a dyspepsia work up?

A

Celiac Dz
Stool for ova/parasite
Fecal fat

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23
Q

How would a PT with celiac Dz but complaining of dyspepsia present?

A

Diarrhea, steatorrhea, flatulence, weight loss, weak and ab distension

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24
Q

How is Celiac Dz diagnosed?

A

IgA anti-endomysial;
Anti-tissue transglutaminase;
Small bowel biopsy

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25
Celiac Dz is also associated with what other issue?
Dermatitis Herpetiformis
26
When is an EGD recommended for dyspepsia complaints?
S/Sx suggest etiology other than uncomplicated dyspepsia such as: Ulcer Esophagitis Malignancy Failure to respond to therapy within 6wks All PTs +60 w/ new onset PTs younger with alarm signs
27
Upper endoscopy is the study of choice for diagnosing what issues?
Gastroduodenal ulcers Erosive esophagitis Upper GI malignancy
28
How are gastroduodenal ulcers and erosive esophagitis treated empirically?
H Pylori eradication or, PPI Or both
29
Upper endoscopy is mainly indicated to look for ?
Upper gastric/esophageal malignancy in PTs over 60 w/ new onset dyspepsia Younger PTs with alarms
30
Initial empiric treatment for dyspepsia is warranted for what PTs?
Younger than 60 with no alarms
31
What does empiric treatment for dyspepsia include?
1st- H Pylori testing | 2nd- PPI trial x 4wks
32
What are the etiologies of dyspepsia?
``` F Di HLF BPM Food/Drug intolerance H Pylori infection Luminal GI dysfunction (organic) Functional dyspepsia Biliary tract Dz Pancreatic Dz Miscellaneous comorbidity ```
33
Describe Food/Drug Intolerance etiology of dyspepsia?
``` HOMIEES Indigestion Over eating Eating too quickly Stress eating High fat food ETOH/Caffeine Medications ```
34
What medications can cause dyspepsia?
``` ADAM AND CEFO Aspirin Diabetes drugs ABX- metronidazole, macrolides MOA Inhibitors- Parkinson's ACEI/ARB NSAIDs Digoxin Corticosteroids Estrogens Fe Opioods ```
35
What is the most common cause of chronic dyspepsia?
Functional dyspepsia- 75% of PTs don't have an organic cause
36
How can dysfunctional dyspepsia develop?
DEP'D Delayed gastric emptying or impaired to psychological stressors May develop De Novo following enteric infection
37
What type of PT population usually has functional dyspepsia?
Younger w/ variety of GI complaints but show signs of anxiety/depression
38
How is Functional Dyspepsia treated?
Once all organic causes are rule out Life style change- d/c ETOH/caffeine, eat smaller, food diary Pharm- anti-secretory, TCAs, metoclopromide to decrease gastric emptying time Psychotherapy
39
What are the organic disorders that can cause dyspepsia?
``` PUD: 5-15% GERD: 20% Neoplasm: less than 1% Lactose intolerant Malabsorption Gastroparesis ```
40
Gastroparesis is an organic disorder than can lead to dyspepsia especially in what PT population?
DM | Parasitic Infection
41
What are the most common causes of PUD?
H Pylori | NSAIDs
42
How does PUD present in clinic?
Gnawing epigastric pain Duodenal ulcer= pain alleviated w/ food (DUDe give me food) Gastric ulcer= exacerbated w/ food intake
43
What are the diagnostic studies for PUD?
H Pylori- fecal Ag test or | Urea breath test
44
What is the management plan for PUD?
H Pylori eradication w/ Triple Therapy: Omeprazole, Clarithromycin, Amoxicillin
45
What is the most common cause of upper GI bleeds?
PUD
46
S/Sx of a duodenal ulcer?
PT wakes at night Pain relived w/ food Postprandial pain, 1-2hrs More common than gastric
47
S/Sx of a gastric ulcer?
Early satiety | Pain immediately after meals
48
What are five complications that can arise from PUD?
``` Bleeding Gastric outlet obstruction Penetration Fistulation Perforation ```
49
What most commonly causes GERD?
LES dysfucntion
50
How does a GERD PT present?
Hx of nocturnal cough or asthma | Retrosternal burning radiating up, usually after eating
51
What are the diagnostic studies for GERD?
PPI trial or, | H2 blockers
52
How are GERD cases managed?
Weight Loss Elevate head when sleeping Avoid certain foods/drinks
53
What are the 3 dominant pathophysiological mechanisms causing GERD?
Transient LES relaxation HOTN LES Anatomic disruption of GE junction
54
What are the Sx of Lactose Intolerance?
``` Bloating/cramps Flatulence Diarrhea N/V Borborygmi ```
55
What is the definitive diagnostic test for lactose intolerance?
Lactose hydrogen breath test
56
How is lactose intolerance treated?
Avoidance Lactose free products Lactase supplements
57
What diseases is H Pylori associated with?
Gastritis Gastric/Duodenal ulcers Gastric carcinoma MALTomas
58
What are the H Pylori tests and Spec/Sens?
Fecal Ag- 98%Spec, 94% Sens C13- 96%Spec, 98% Sens Serology- 79%Spec, 85% Sens
59
What is Triple Therapy for H Pylori consist of?
``` CAMP Omeprazole PO BID Clarithromycin 500mg PO BID Amoxicillin 1g PO BID Metronidazole 500mg PO BID if PCN allergic` x 14 days ```
60
What is Quadruple Therapy for H Pylori consist of and when is it used?
``` Please Be My Treatment Clarithromycin resistant Bismuth two tabs PO QID Metronidazole 500mg PO TID Tetracycline 500mg PO QID Omeprazole/other PPI PO BID x 14 days ```
61
What are the characteristics of H Pylori in the absence of PUD?
Spiral Gram-Neg rod residing adjacent to epithelial cells at mucosal surface and gastric pits
62
H Pylori testing is indicated for what 3 types of PTs?
Dyspepsia Chronic GERD Suspected/confirmed PUD PTs
63
When is fecal Ag test more likely be used?
Detect post-treatment eradication
64
If a young PT needs to be tested for H Pylori what non-invasive tests are used?
First: Urea breath test, Fecal Ag
65
What type of results in a young PT can virtually exclude PUD when testing for H Pylori?
Breath or fecal test is neg AND PT is not taking NSAIDs
66
How does dyspepsia presnt in a PT w/ pancreatic Dz?
More severe pain
67
How does dyspepsia present in PTs with biliary tract diseases?
Abrupt onset of epigastric/RUQ pain due to cholelithiasis/choledocholithiasis
68
What are the miscellaneous comorbidities of dyspepsia?
Diabetes Thyroid disease CDK MI
69
Define Nausea | Define Anorexia
Vague, intense disagreement sensation of sickness Decreased appetite
70
What are visceral afferent stimulants that can cause N/V?
``` HIPPO MT D Hepatobiliary/pancreatic disorder Infection Post-Op Peritoneal irritation Other- HF, HDz, urologic dz Mechanical obstruction Topical GI irritants Dysmotility ```
71
What are the types of mechanical obstructions that can cause N/V?
Gastric outlet obstruction- PUD, malignancy, volvulus Small Intestine obstruction- adhesion, hernia, Crohns, carcinomatosis
72
What are the causes of dysmotility that can cause N/V?
Hastroparesis- diabetic, post viral/vagotomy Small intestine scleroderma, amyloidosis, chronic pseudo-obstruction, myoneuropathy
73
What are the peritoneal irritants that can cause N/V?
Peritonitis VGE- Norwalk, Rotavirus Food poisoning Acute systemic infections
74
What are the hepatobiliary/pancreatic disorders that can cause N/V?
Hep A/B Pancreatitis Cholecystitis/Choledocholithiasis
75
What are the topical GI irritants that can cause N/V?
ETOH NSAIDs ABX
76
What are the other reasons that can lead to N/V development?
Cardiac disease- MI/HF | Urologic Dz: stones, pyelonephritis
77
What vestibular disorders can cause the development of N/V?
Labyrinthitis Meniere Syndrome Motion sickness
78
What CNS disorders can cause N/V?
Inc ICP Migraine Infections Psychogenic
79
What chemoreceptor trigger zone irritants can cause N/V?
Anti-tumor meds Medicaitons/drugs Radiation therapy Systemic disorders
80
What causes vomiting?
Afferent vagal fibers from GI viscera Stimulation of vestibular fibers CNS- amygdala Chemoreceptor trigger zone
81
What types of stimulus affects the visceral fibers possibly leading to vomitting?
Numerous serotoning 5-HT3 receptors may be stimulated by biliary/GI distension, irritants or infections
82
What N/V Hx questions are asked?
``` N or N w/ V Hematemesis Onset/relation to meals Pain Location Meds/Diet Sick contacts ```
83
What types of stimulants can trigger the higher CNS and cause vomiting?
Sight/smell, emotional experiences
84
What triggers the chemoreceptor trigger zone to cause vomiting?
``` Drugs Chemo/radiation Toxins Hypoxia Uremia Acidosis ```
85
What are the S/Sx of N/V?
Acute onset w/ pain= peritoneal irritation, acute obstruction, gastroparesis Acute onset w/out pain= food poisoning, acute gastroenteritis, systemic illness
86
What is checked for during a N/V PE?
Ab exam- TTP, Distention, Organomegaly
87
What are the S/Sx of dehydration in a PT with N/V?
Dry mucous membranes Skin turgor Orthostatic VS- tilts
88
Explain the Tilts test
``` Lie in bed 3-5min BP and pulse while supine Sit x 1min BP/P Stand and take BP/P Repeat in 3min ```
89
How are the Tilts Test results interpreted?
Dec >20mm SBP or Dec >10mm DBP After 3min of standing HR inc of 30bpm after 3min of standing= hypovolemia independent OHOTN criteria
90
What are the further work up images for N/V PTs?
Not indicated unless Hx/PE suggests focal cause Plain film- abdominal flat and upright Ab CT
91
What labs can be drawn for N/V PTs?
CBC | BMP/CMP- E+, Serum pH, Liver Enzymes, Amylase/lipase
92
What complications can emerge from vomiting?
``` Dehydration Hypokalemia Metabolic alkalosis Aspiration Boerhaave Synd- rupture Mallory-Weiss tear ```
93
What is the pathophysiology of Mallry-Weiss Syndrome?
Incomplete longitudinal tear in esophageal mucosa AND proximal stomach in PTs with Hx of forceful vomiting
94
How will PTs with Mallory-Weiss Syndrome present? What is the diagnostic study for them? How are they managed?
Hematemesis Upper endoscopy Supportive Endoscopic therapy- active bleed Acid suppression- nonactive bleed
95
What are the risk factors of Mallory Weiss Syndrome?
Alcohol use | Hiatal hernia
96
What are the treatments for N/V?
Supportive Consider IV Consider if PO meds can be tolerated
97
What type of supportive care is recommended for PTs with N/V?
Frequent small sips of clear fluids BRAT diets Adv to ginger if tolerated Profile/work note
98
What medication is a serotonin 5-Ht3 receptor antagonist
Ondansetron- Zofran
99
5-HT3 receptor antagonists are effective as single agents for preventing ? How can these meds be enhanced?
Chemo induced N/V Combo therapy w/ corticosteroid (Dexameth) and NK1 receptor antagonist
100
How do corticosteroids enhance the efficacy of serotonin receptor antagonists?
Enhance efficacy of serotonin receptor antagonists for preventing acute and delayed N/V in PTs receiving moderate/high emetogenic chemo regimes
101
What two dopamine antagonists may be used for N/V?
Promethazine | Procloperazine
102
What triple med combo is highly effective to prevent acute/delayed N/V from high chemo regimes?
Neurokinin receptor antagonists Corticosteroids Serotonin antagonists
103
What drug class is valuable in preventing vomiting from labryinth stimulation (motion sickness, vertigo, migraines)?
Antihistamines and Anticholinergics
104
What is the first-line therapy for N/V during pregnancy?
B6 and doxylamine combo
105
What are the antihistamines that may be used for N/V PTs?
Meclizine Dimenhydrinate Scopolamine Diphenhydramine
106
Define Singultus
Hiccups, involuntary contraction of diaphragm | Usually L > R
107
What can cause constipation in adults?
``` Most common- inadequte fiber and poor bowel habits Systemic Dz Meds Structural abnormalities Slow colonic transit Pelvic floow dyssynergia IBS ```
108
What are the Tx for Singultus?
``` Tsp dry sugar Nasopharynx stimulation Valsalva Rebreath Scare Relieve gastric distension ```
109
What medication is given for intractable hiccups?
Chlorpromazine
110
What is the cause of benign, self limiting hiccups?
Gastric distention Sudden temp changes Alcohol ingestion Heightened emotion
111
What is the cause of persistent hiccups?
``` CNS- neoplasm, infection, trauma Metabolic- uremia, hypocapnia Chronic irritation of vagus/phrenic Post-Op Psychogenic ```
112
Chronic/persistent hiccups need what further investigatory steps performed?
Full Hx and PE
113
Define Eructation and Flatus
Gastric distention resulting in transient LES relaxation
114
Eructation/flatus is typically due to ? and is only problomatic if ?
Aerophagia | Sx
115
Define Eructation
Belching | In/voluntary release of gas from stomach or esophagus most frequently after meals
116
Define Flatus
Farting
117
GI gas is derived from what two sources?
Swallowed air, primarily N | Bacterial fermentation of undigested Carbs
118
What is the first step in Tx of Flatus/Eructation
Investigate potential malabsorption syndromes
119
When investigating causes of flatus/eructation, a food diary may elicit specific causes and prompt avoidance of ?
FODMAPs foods Short chain carbs- fermentable, oligo/di/monosaccharides and polypols Lactose- dairy Fructose- fruit, corn syrup, sweetner Polypols- stone fruit, mushroom, sweetners Fructans- legumes, cruciferous vegs, pasta, whole grains/wheat
120
What are the recommended pharmacotherapies for treating flatus/eructation?
Beano | Simethicone
121
What gases are found in farts?
O N H CO2, H2S, NH4, methane
122
What gases account for the foul smell of farts?
H2S Ammonia Methane
123
Define Constipation
Fewer than 3 Bm/wk Hard Excessive straining Sense of incomplete evacuation
124
What are common causes of constipation?
``` Most common in older women Inadequate fiber Poor hydration/habits Systemic Dz Obstruction lesion Meds- opiods, diuretics, Ca/Fe supplements, CCBs IBS-C ```
125
What two systemic diseases can cause constipation?
Hypothyroidism | Diabetes
126
What type of PT is most likely to present with constipation?
Women w/ alternating constipation/diarrhea
127
How will female PT with IBS present?
Abdominal discomfort relieved by BMs
128
What is the diagnostic study for IBS?
Rome criteria
129
What is the management plan for IBS PTs?
Sx care | FODMAPs
130
What is the Rome IV Criteria for IBS?
Recurrent ab pain averaging >1 day per wk for 3mon and associated with two or more of: Related to defecation Onset with change in stool freq Onset with change of stool appearance
131
Define IBS
GI syndrome of chronic ab pain and altered bowel habits in absence of an organic cause
132
What are the clinical associations of IBS?
Chronic ab pain that varies in intensity | Altered bowel habit (diarrhea , constipation, both)
133
What are the subtypes of IBS?
IBS-C IBS-D Mixed Unclassified
134
What is the initial therapy dietary modifications for IBS?
``` Exclusion of gas producing foods Avoid lactose/gluten Low FODMAP Fiber Food allergy testing ```
135
What are the initial therapies for IBS management?
Education/reassurance Dietary mod Physical activity
136
What are the adjunctive pharmacologic therapies for IBS?
Constipation- osmotic laxative, lubiprostone, linaclotide Diarrhea- antidiarrheal, bile acid sequestrates, serotonin 3 receptor agonists Pain-bloating- antispasmodic, antidepressant, ABX
137
What are the common characteristics of IBS-C Primary?
More common Not attributed to any structural abnormality or systematic dz. CCO- infrequency, bloating, straining w/ Hx of psychosocial disorder
138
What are the common characteristics of IBS-C Secondary?
Systemic Dz Meds Obstructions More sudden onset w/out prior Hx of constipation
139
What is extremely important when determining cause/type of IBS-C?
Hx- differentiates between primary and secondary | Ask about systemic sx, meds and prior Hx
140
What will be found upon exam of a PT with IBS-C?
Dullness to percussion on L quads | DRE to r/o structural abnormalities; hard stool in rectal vault may be noticed
141
Why is a DRE performed on a PT with suspected IBS-C?
R/o obstruction abnormalities
142
What does a workup for IBS-C consist of?
Colonoscopy for PTs that are: +50y/o Severe constipation Signs of organic disorder
143
What are the alarm Sx of IBS-C?
``` Hematochezia Weight loss Pos FOBT FamHx of colon cancer IBDz ```
144
What labs are ordered for IBS-C PTs?
CBC CMP- Ca, glucose Thyroid panel
145
What will a radiograph of a IBS-C PT show?
Abnormal film shows non-specific bowel gas pattern
146
What is the next imaging modality for IBS-C after x-ray?
Endoscopy- colonoscopy or flexible sigmoidoscopy
147
How is IBS-C treated?
``` Diet/life changes Optimize toilet habits- timing, position Inc dietary fiber/fluids Fiber supplement trial Exercise ```
148
If IBS response to fiber therapy is not immediate, how should changes be made?
Gradual increase over 7-10 days
149
Fiber therapy is most likely to benefit what type of IBS PT but not benefit ? type?
Benefit- Normal colonic transit | Not- Colonic inertia, defecatory disorders, opioid induced, IBS; could EXACERBATE these PTs
150
What osmotic laxatives are recommended for IBS?
Magnesium hydroxide Polyethelyne glycol 3550 Polyethelyne glycol Magnesium citrate
151
Magnesium containing saline laxatives should not be given to PTs with ?
Chronic renal insufficiency
152
What is the time for osmotic laxatives on set in? | What is used if a more rapid result is needed?
24hrs | Purgative laxative- magnesium citrate (may cause hypermagnesium)
153
If osmotic laxatives do not work, what is the next option?
Stimulant laxative | Oral agents taken PO at bed
154
What are the common preparations of stimulant laxatives?
Bisacodyl Senna Cascara
155
What is the stool surfactant name? | What are the two parts of an enema?
Docusate sodium Tap water Saline- fleet
156
What are the pharmacotherpies for constipation treatment?
Osmotic Stimulant Stool surfactant Enema
157
What type of PT is likely to have fecal impactions?
Elderly bed bound
158
How does a fecal impaction present?
Belly cramp and bloat Small stool leakage Rectal discomfort
159
What are the etiological factors of fecal impactions?
``` Low fiber Opiods IBS Diabetes Hypothyroidism ```
160
What are two complications that can arise from a fecal impaction?
Rectal necrosis | Ulcers
161
How are fecal impactions managed?
Manual disimpaction Stool softening Osmotic laxative Surgery
162
Fecal impactions may have paradoxical ? and may require ?
Diarrhea | Manual disimpaction- manual fragmentation followed by oil-retention enema (mineral oil)
163
What are two common complications of constipation?
Fecal impaction | Hemorrhoids
164
Define external hemorrhoids
Lower 1/3 of anus, below dentate line | Presents with pain and pruitus requiring excision
165
Define Internal hemorrhoid
Upper 1/3, above dentate line | No pain, bright red blood, pruritus and rectal discomfort treated with fiber, sitz baths and possible reduction
166
How are hemorrhoids classified?
1- no protrusion 2- prolapse but reduce spontaneously 3- prolapse but require manual reduction 4- cannot be reduce and may strangulate
167
Wis a PT with constipation referred?
``` Refractory Sx to treatment Abnormal structure Evidence of obstruction Over 50y/o Alarm Sx ```
168
Stopped at
End of Constipation

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