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IPAP > Dyspepsia - Constipation > Flashcards

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
Q

Celiac Dz is also associated with what other issue?

A

Dermatitis Herpetiformis

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26
Q

When is an EGD recommended for dyspepsia complaints?

A

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

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27
Q

Upper endoscopy is the study of choice for diagnosing what issues?

A

Gastroduodenal ulcers
Erosive esophagitis
Upper GI malignancy

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28
Q

How are gastroduodenal ulcers and erosive esophagitis treated empirically?

A

H Pylori eradication or,
PPI
Or both

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29
Q

Upper endoscopy is mainly indicated to look for ?

A

Upper gastric/esophageal malignancy in PTs over 60 w/ new onset dyspepsia
Younger PTs with alarms

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30
Q

Initial empiric treatment for dyspepsia is warranted for what PTs?

A

Younger than 60 with no alarms

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31
Q

What does empiric treatment for dyspepsia include?

A

1st- H Pylori testing

2nd- PPI trial x 4wks

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32
Q

What are the etiologies of dyspepsia?

A 
F Di HLF BPM
Food/Drug intolerance
H Pylori infection
Luminal GI dysfunction (organic)
Functional dyspepsia
Biliary tract Dz
Pancreatic Dz
Miscellaneous comorbidity
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33
Q

Describe Food/Drug Intolerance etiology of dyspepsia?

A 
HOMIEES
Indigestion
Over eating
Eating too quickly 
Stress eating
High fat food
ETOH/Caffeine
Medications
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34
Q

What medications can cause dyspepsia?

A 
ADAM AND CEFO
Aspirin
Diabetes drugs
ABX- metronidazole, macrolides
MOA Inhibitors- Parkinson's
ACEI/ARB
NSAIDs
Digoxin
Corticosteroids
Estrogens
Fe 
Opioods
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35
Q

What is the most common cause of chronic dyspepsia?

A

Functional dyspepsia- 75% of PTs don’t have an organic cause

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36
Q

How can dysfunctional dyspepsia develop?

A

DEP’D
Delayed gastric emptying or impaired to psychological stressors
May develop De Novo following enteric infection

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37
Q

What type of PT population usually has functional dyspepsia?

A

Younger w/ variety of GI complaints but show signs of anxiety/depression

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38
Q

How is Functional Dyspepsia treated?

A

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

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39
Q

What are the organic disorders that can cause dyspepsia?

A 
PUD: 5-15%
GERD: 20%
Neoplasm: less than 1%
Lactose intolerant
Malabsorption
Gastroparesis
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40
Q

Gastroparesis is an organic disorder than can lead to dyspepsia especially in what PT population?

A

DM

Parasitic Infection

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41
Q

What are the most common causes of PUD?

A

H Pylori

NSAIDs

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42
Q

How does PUD present in clinic?

A

Gnawing epigastric pain
Duodenal ulcer= pain alleviated w/ food (DUDe give me food)
Gastric ulcer= exacerbated w/ food intake

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43
Q

What are the diagnostic studies for PUD?

A

H Pylori- fecal Ag test or

Urea breath test

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44
Q

What is the management plan for PUD?

A

H Pylori eradication w/ Triple Therapy: Omeprazole, Clarithromycin, Amoxicillin

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45
Q

What is the most common cause of upper GI bleeds?

A

PUD

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46
Q

S/Sx of a duodenal ulcer?

A

PT wakes at night
Pain relived w/ food
Postprandial pain, 1-2hrs
More common than gastric

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47
Q

S/Sx of a gastric ulcer?

A

Early satiety

Pain immediately after meals

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48
Q

What are five complications that can arise from PUD?

A 
Bleeding
Gastric outlet obstruction
Penetration
Fistulation
Perforation
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49
Q

What most commonly causes GERD?

A

LES dysfucntion

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50
Q

How does a GERD PT present?

A

Hx of nocturnal cough or asthma

Retrosternal burning radiating up, usually after eating

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51
Q

What are the diagnostic studies for GERD?

A

PPI trial or,

H2 blockers

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52
Q

How are GERD cases managed?

A

Weight Loss
Elevate head when sleeping
Avoid certain foods/drinks

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53
Q

What are the 3 dominant pathophysiological mechanisms causing GERD?

A

Transient LES relaxation
HOTN LES
Anatomic disruption of GE junction

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54
Q

What are the Sx of Lactose Intolerance?

A 
Bloating/cramps
Flatulence
Diarrhea
N/V
Borborygmi
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55
Q

What is the definitive diagnostic test for lactose intolerance?

A

Lactose hydrogen breath test

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56
Q

How is lactose intolerance treated?

A

Avoidance
Lactose free products
Lactase supplements

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57
Q

What diseases is H Pylori associated with?

A

Gastritis
Gastric/Duodenal ulcers
Gastric carcinoma
MALTomas

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58
Q

What are the H Pylori tests and Spec/Sens?

A

Fecal Ag- 98%Spec, 94% Sens
C13- 96%Spec, 98% Sens
Serology- 79%Spec, 85% Sens

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59
Q

What is Triple Therapy for H Pylori consist of?

A 
CAMP
Omeprazole PO BID
Clarithromycin 500mg PO BID
Amoxicillin 1g PO BID 
Metronidazole 500mg PO BID if PCN allergic`
x 14 days
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60
Q

What is Quadruple Therapy for H Pylori consist of and when is it used?

A 
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
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61
Q

What are the characteristics of H Pylori in the absence of PUD?

A

Spiral Gram-Neg rod residing adjacent to epithelial cells at mucosal surface and gastric pits

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62
Q

H Pylori testing is indicated for what 3 types of PTs?

A

Dyspepsia
Chronic GERD
Suspected/confirmed PUD PTs

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63
Q

When is fecal Ag test more likely be used?

A

Detect post-treatment eradication

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64
Q

If a young PT needs to be tested for H Pylori what non-invasive tests are used?

A

First: Urea breath test, Fecal Ag

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65
Q

What type of results in a young PT can virtually exclude PUD when testing for H Pylori?

A

Breath or fecal test is neg AND PT is not taking NSAIDs

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66
Q

How does dyspepsia presnt in a PT w/ pancreatic Dz?

A

More severe pain

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67
Q

How does dyspepsia present in PTs with biliary tract diseases?

A

Abrupt onset of epigastric/RUQ pain due to cholelithiasis/choledocholithiasis

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68
Q

What are the miscellaneous comorbidities of dyspepsia?

A

Diabetes
Thyroid disease
CDK
MI

69
Q

Define Nausea

Define Anorexia

A

Vague, intense disagreement sensation of sickness

Decreased appetite

70
Q

What are visceral afferent stimulants that can cause N/V?

A 
HIPPO MT D
Hepatobiliary/pancreatic disorder
Infection
Post-Op
Peritoneal irritation
Other- HF, HDz, urologic dz
Mechanical obstruction
Topical GI irritants
Dysmotility
71
Q

What are the types of mechanical obstructions that can cause N/V?

A

Gastric outlet obstruction- PUD, malignancy, volvulus

Small Intestine obstruction- adhesion, hernia, Crohns, carcinomatosis

72
Q

What are the causes of dysmotility that can cause N/V?

A

Hastroparesis- diabetic, post viral/vagotomy

Small intestine scleroderma, amyloidosis, chronic pseudo-obstruction, myoneuropathy

73
Q

What are the peritoneal irritants that can cause N/V?

A

Peritonitis
VGE- Norwalk, Rotavirus
Food poisoning
Acute systemic infections

74
Q

What are the hepatobiliary/pancreatic disorders that can cause N/V?

A

Hep A/B
Pancreatitis
Cholecystitis/Choledocholithiasis

75
Q

What are the topical GI irritants that can cause N/V?

A

ETOH
NSAIDs
ABX

76
Q

What are the other reasons that can lead to N/V development?

A

Cardiac disease- MI/HF

Urologic Dz: stones, pyelonephritis

77
Q

What vestibular disorders can cause the development of N/V?

A

Labyrinthitis
Meniere Syndrome
Motion sickness

78
Q

What CNS disorders can cause N/V?

A

Inc ICP
Migraine
Infections
Psychogenic

79
Q

What chemoreceptor trigger zone irritants can cause N/V?

A

Anti-tumor meds
Medicaitons/drugs
Radiation therapy
Systemic disorders

80
Q

What causes vomiting?

A

Afferent vagal fibers from GI viscera
Stimulation of vestibular fibers
CNS- amygdala
Chemoreceptor trigger zone

81
Q

What types of stimulus affects the visceral fibers possibly leading to vomitting?

A

Numerous serotoning 5-HT3 receptors may be stimulated by biliary/GI distension, irritants or infections

82
Q

What N/V Hx questions are asked?

A 
N or N w/ V
Hematemesis
Onset/relation to meals
Pain
Location
Meds/Diet
Sick contacts
83
Q

What types of stimulants can trigger the higher CNS and cause vomiting?

A

Sight/smell, emotional experiences

84
Q

What triggers the chemoreceptor trigger zone to cause vomiting?

A 
Drugs 
Chemo/radiation
Toxins
Hypoxia
Uremia
Acidosis
85
Q

What are the S/Sx of N/V?

A

Acute onset w/ pain= peritoneal irritation, acute obstruction, gastroparesis

Acute onset w/out pain= food poisoning, acute gastroenteritis, systemic illness

86
Q

What is checked for during a N/V PE?

A

Ab exam- TTP, Distention, Organomegaly

87
Q

What are the S/Sx of dehydration in a PT with N/V?

A

Dry mucous membranes
Skin turgor
Orthostatic VS- tilts

88
Q

Explain the Tilts test

A 
Lie in bed 3-5min
BP and pulse while supine
Sit x 1min
BP/P
Stand and take BP/P
Repeat in 3min
89
Q

How are the Tilts Test results interpreted?

A

Dec >20mm SBP or
Dec >10mm DBP
After 3min of standing

HR inc of 30bpm after 3min of standing= hypovolemia independent OHOTN criteria

90
Q

What are the further work up images for N/V PTs?

A

Not indicated unless Hx/PE suggests focal cause
Plain film- abdominal flat and upright
Ab CT

91
Q

What labs can be drawn for N/V PTs?

A

CBC

BMP/CMP- E+, Serum pH, Liver Enzymes, Amylase/lipase

92
Q

What complications can emerge from vomiting?

A 
Dehydration
Hypokalemia
Metabolic alkalosis
Aspiration
Boerhaave Synd- rupture
Mallory-Weiss tear
93
Q

What is the pathophysiology of Mallry-Weiss Syndrome?

A

Incomplete longitudinal tear in esophageal mucosa AND proximal stomach in PTs with Hx of forceful vomiting

94
Q

How will PTs with Mallory-Weiss Syndrome present?

What is the diagnostic study for them?

How are they managed?

A

Hematemesis

Upper endoscopy

Supportive
Endoscopic therapy- active bleed
Acid suppression- nonactive bleed

95
Q

What are the risk factors of Mallory Weiss Syndrome?

A

Alcohol use

Hiatal hernia

96
Q

What are the treatments for N/V?

A

Supportive
Consider IV
Consider if PO meds can be tolerated

97
Q

What type of supportive care is recommended for PTs with N/V?

A

Frequent small sips of clear fluids
BRAT diets
Adv to ginger if tolerated
Profile/work note

98
Q

What medication is a serotonin 5-Ht3 receptor antagonist

A

Ondansetron- Zofran

99
Q

5-HT3 receptor antagonists are effective as single agents for preventing ?
How can these meds be enhanced?

A

Chemo induced N/V

Combo therapy w/ corticosteroid (Dexameth) and NK1 receptor antagonist

100
Q

How do corticosteroids enhance the efficacy of serotonin receptor antagonists?

A

Enhance efficacy of serotonin receptor antagonists for preventing acute and delayed N/V in PTs receiving moderate/high emetogenic chemo regimes

101
Q

What two dopamine antagonists may be used for N/V?

A

Promethazine

Procloperazine

102
Q

What triple med combo is highly effective to prevent acute/delayed N/V from high chemo regimes?

A

Neurokinin receptor antagonists
Corticosteroids
Serotonin antagonists

103
Q

What drug class is valuable in preventing vomiting from labryinth stimulation (motion sickness, vertigo, migraines)?

A

Antihistamines and Anticholinergics

104
Q

What is the first-line therapy for N/V during pregnancy?

A

B6 and doxylamine combo

105
Q

What are the antihistamines that may be used for N/V PTs?

A

Meclizine
Dimenhydrinate
Scopolamine
Diphenhydramine

106
Q

Define Singultus

A

Hiccups, involuntary contraction of diaphragm

Usually L > R

107
Q

What can cause constipation in adults?

A 
Most common- inadequte fiber and poor bowel habits
Systemic Dz
Meds
Structural abnormalities
Slow colonic transit
Pelvic floow dyssynergia
IBS
108
Q

What are the Tx for Singultus?

A 
Tsp dry sugar
Nasopharynx stimulation
Valsalva
Rebreath
Scare
Relieve gastric distension
109
Q

What medication is given for intractable hiccups?

A

Chlorpromazine

110
Q

What is the cause of benign, self limiting hiccups?

A

Gastric distention
Sudden temp changes
Alcohol ingestion
Heightened emotion

111
Q

What is the cause of persistent hiccups?

A 
CNS- neoplasm, infection, trauma
Metabolic- uremia, hypocapnia
Chronic irritation of vagus/phrenic
Post-Op
Psychogenic
112
Q

Chronic/persistent hiccups need what further investigatory steps performed?

A

Full Hx and PE

113
Q

Define Eructation and Flatus

A

Gastric distention resulting in transient LES relaxation

114
Q

Eructation/flatus is typically due to ? and is only problomatic if ?

A

Aerophagia

Sx

115
Q

Define Eructation

A

Belching

In/voluntary release of gas from stomach or esophagus most frequently after meals

116
Q

Define Flatus

117
Q

GI gas is derived from what two sources?

A

Swallowed air, primarily N

Bacterial fermentation of undigested Carbs

118
Q

What is the first step in Tx of Flatus/Eructation

A

Investigate potential malabsorption syndromes

119
Q

When investigating causes of flatus/eructation, a food diary may elicit specific causes and prompt avoidance of ?

A

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
Q

What are the recommended pharmacotherapies for treating flatus/eructation?

A

Beano

Simethicone

121
Q

What gases are found in farts?

A

O N H CO2, H2S, NH4, methane

122
Q

What gases account for the foul smell of farts?

A

H2S
Ammonia
Methane

123
Q

Define Constipation

A

Fewer than 3 Bm/wk
Hard
Excessive straining
Sense of incomplete evacuation

124
Q

What are common causes of constipation?

A 
Most common in older women
Inadequate fiber
Poor hydration/habits
Systemic Dz
Obstruction lesion
Meds- opiods, diuretics, Ca/Fe supplements, CCBs
IBS-C
125
Q

What two systemic diseases can cause constipation?

A

Hypothyroidism

Diabetes

126
Q

What type of PT is most likely to present with constipation?

A

Women w/ alternating constipation/diarrhea

127
Q

How will female PT with IBS present?

A

Abdominal discomfort relieved by BMs

128
Q

What is the diagnostic study for IBS?

A

Rome criteria

129
Q

What is the management plan for IBS PTs?

A

Sx care

FODMAPs

130
Q

What is the Rome IV Criteria for IBS?

A

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
Q

Define IBS

A

GI syndrome of chronic ab pain and altered bowel habits in absence of an organic cause

132
Q

What are the clinical associations of IBS?

A

Chronic ab pain that varies in intensity

Altered bowel habit (diarrhea , constipation, both)

133
Q

What are the subtypes of IBS?

A

IBS-C
IBS-D
Mixed
Unclassified

134
Q

What is the initial therapy dietary modifications for IBS?

A 
Exclusion of gas producing foods
Avoid lactose/gluten
Low FODMAP
Fiber
Food allergy testing
135
Q

What are the initial therapies for IBS management?

A

Education/reassurance
Dietary mod
Physical activity

136
Q

What are the adjunctive pharmacologic therapies for IBS?

A

Constipation- osmotic laxative, lubiprostone, linaclotide

Diarrhea- antidiarrheal, bile acid sequestrates, serotonin 3 receptor agonists

Pain-bloating- antispasmodic, antidepressant, ABX

137
Q

What are the common characteristics of IBS-C Primary?

A

More common
Not attributed to any structural abnormality or systematic dz.
CCO- infrequency, bloating, straining w/ Hx of psychosocial disorder

138
Q

What are the common characteristics of IBS-C Secondary?

A

Systemic Dz
Meds
Obstructions

More sudden onset w/out prior Hx of constipation

139
Q

What is extremely important when determining cause/type of IBS-C?

A

Hx- differentiates between primary and secondary

Ask about systemic sx, meds and prior Hx

140
Q

What will be found upon exam of a PT with IBS-C?

A

Dullness to percussion on L quads

DRE to r/o structural abnormalities; hard stool in rectal vault may be noticed

141
Q

Why is a DRE performed on a PT with suspected IBS-C?

A

R/o obstruction abnormalities

142
Q

What does a workup for IBS-C consist of?

A

Colonoscopy for PTs that are:
+50y/o
Severe constipation
Signs of organic disorder

143
Q

What are the alarm Sx of IBS-C?

A 
Hematochezia
Weight loss
Pos FOBT
FamHx of colon cancer
IBDz
144
Q

What labs are ordered for IBS-C PTs?

A

CBC
CMP- Ca, glucose
Thyroid panel

145
Q

What will a radiograph of a IBS-C PT show?

A

Abnormal film shows non-specific bowel gas pattern

146
Q

What is the next imaging modality for IBS-C after x-ray?

A

Endoscopy- colonoscopy or flexible sigmoidoscopy

147
Q

How is IBS-C treated?

A 
Diet/life changes
Optimize toilet habits- timing, position
Inc dietary fiber/fluids
Fiber supplement trial
Exercise
148
Q

If IBS response to fiber therapy is not immediate, how should changes be made?

A

Gradual increase over 7-10 days

149
Q

Fiber therapy is most likely to benefit what type of IBS PT but not benefit ? type?

A

Benefit- Normal colonic transit

Not- Colonic inertia, defecatory disorders, opioid induced, IBS; could EXACERBATE these PTs

150
Q

What osmotic laxatives are recommended for IBS?

A

Magnesium hydroxide
Polyethelyne glycol 3550
Polyethelyne glycol
Magnesium citrate

151
Q

Magnesium containing saline laxatives should not be given to PTs with ?

A

Chronic renal insufficiency

152
Q

What is the time for osmotic laxatives on set in?

What is used if a more rapid result is needed?

A

24hrs

Purgative laxative- magnesium citrate (may cause hypermagnesium)

153
Q

If osmotic laxatives do not work, what is the next option?

A

Stimulant laxative

Oral agents taken PO at bed

154
Q

What are the common preparations of stimulant laxatives?

A

Bisacodyl
Senna
Cascara

155
Q

What is the stool surfactant name?

What are the two parts of an enema?

A

Docusate sodium

Tap water
Saline- fleet

156
Q

What are the pharmacotherpies for constipation treatment?

A

Osmotic
Stimulant
Stool surfactant
Enema

157
Q

What type of PT is likely to have fecal impactions?

A

Elderly bed bound

158
Q

How does a fecal impaction present?

A

Belly cramp and bloat
Small stool leakage
Rectal discomfort

159
Q

What are the etiological factors of fecal impactions?

A 
Low fiber
Opiods
IBS
Diabetes
Hypothyroidism
160
Q

What are two complications that can arise from a fecal impaction?

A

Rectal necrosis

Ulcers

161
Q

How are fecal impactions managed?

A

Manual disimpaction
Stool softening
Osmotic laxative
Surgery

162
Q

Fecal impactions may have paradoxical ? and may require ?

A

Diarrhea

Manual disimpaction- manual fragmentation followed by oil-retention enema (mineral oil)

163
Q

What are two common complications of constipation?

A

Fecal impaction

Hemorrhoids

164
Q

Define external hemorrhoids

A

Lower 1/3 of anus, below dentate line

Presents with pain and pruitus requiring excision

165
Q

Define Internal hemorrhoid

A

Upper 1/3, above dentate line

No pain, bright red blood, pruritus and rectal discomfort treated with fiber, sitz baths and possible reduction

166
Q

How are hemorrhoids classified?

A

1- no protrusion
2- prolapse but reduce spontaneously
3- prolapse but require manual reduction
4- cannot be reduce and may strangulate

167
Q

Wis a PT with constipation referred?

A 
Refractory Sx to treatment 
Abnormal structure
Evidence of obstruction
Over 50y/o
Alarm Sx
168
Q

Stopped at

A

End of Constipation

IPAP (212 decks)

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