Gastrointestinal Disorders Flashcards

Question

Appendicitis: What is it?

Answer 1

Inflammation of the vermiform appendix, a projection from the apex of the cecum. Appendicitis is a medical emergency; the organ must be removed before it ruptures.

Answer 2

Obstruction of the appendix secondary to stool, inflammation, stricture, foreign body, or neoplasm. The obstructed lumen prevents drainage. The resultant increased pressure decreases mucosal blood flow, and the appendix becomes hypoxic.

Answer 3

1. Family history 2. Abdominal neoplasm

Answer 4

1. Abd pain, usually severe; initially presents throughout abdomen or periumbilical area and later becomes localized to the RLQ 2. Most common symptoms: anorexia, abd pain, N/V (typically present in this order) 3. Constipation and diarrhea occur after the pain 4. Maximum abd tenderness and rigidity occurs over the right rectus muscle (McBurney's point) 5. Psoas sign: pain with right thigh extension 6. Obturator sign: pain with internal rotation of flexed right thigh 7. Fever 8. Decreased bowel sounds 9. Older adults may present with weakness, anorexia, tachycardia, and abd distention

Answer 5

- A rectal exam is no longer best practice - A pelvic exam should be performed on all women with lower abd pain to rule out pelvic inflammatory disease, adnexal mass, ectopic pregnancy, or uterine pathology.

Answer 6

1. UA: may be positive for RBCs and leukocytes 2. CBC: higher leukocytosis associated with bowel perforation 3. Urine pregnancy test: negative 4. KUB xray: may show gas-filled appendix 5. Abd and pelvic CT with and without contrast 6. Ultrasound: imaging study of choice in children and pregnancy 7. Pediatric appendicitis score for children 8. Alvarado score for acute appendicitis

Answer 7

1. Keep NPO 2. Instruct to refrain from laxatives, enemas, or heat application to the abdomen 3. Prompt surgery is treatment of choice

Answer 8

- Preoperative antibiotics may be prescribed by surgeon

Answer 9

1. Routine postoperative assessment at 2 weeks and 6 weeks 2. May require postoperative antibiotics if perforation has occurred.

Answer 10

- Quick recovery usually follows surgical removal of intact appendix - Activity should be restricted for 2-6 weeks

Answer 11

Inflammation of the gallbladder usually associated with gallstone disease; can be acute or chronic.

Answer 12

1. Gallstone obstructs the gallbladder-cystic duct junction, resulting in inflammation (90-95% of cases) and acute pain 2. In small number of cases, gallbladder inflammation occurs without stone formation 3. Obstruction of common bile duct can cause jaundice, light-colored stools, and biliary colic 4. Obstruction of pancreatic duct can produce pancreatitis; pain over upper abdomen; nausea and vomiting 5. Gallbladder sludge

Answer 13

1. Pregnancy 2. Rapid weight loss (ex: bariatric surgery) 3. Obesity 4. Gallstones or bile duct blockage 5. Infection 6. Tumor 7. Surgery or trauma 8. Sickle cell anemia 9. Age greater than 40 10. Female sex 11. Sedentary lifestyle 12. Use of OCP 13. Family history of gallstones 14. Crohn's disease 15. Medications such as clofibrate, ceftriaxone, and octreotide

Answer 14

1. Patients are usually ill-appearing, febrile, and tachycardic 2. Murphy's sign 3. RUQ pain: may be unremitting with or without rebound pain; may radiate to right shoulder or right subscapular area 4. Nausea and vomiting/anorexia 5. Attack follows meal (especially high in fat) by 1-6 hours 6. Low grade fever 7. Palpable RUQ mass ** A patient with acute cholecystitis usually avoids movement because peritoneal inflammation is present and discomfort worsens with movement

Answer 15

- Occurs with cholecystitis - Inspiratory arrest with deep palpation of the RUQ

Answer 16

CBC - mild leukocytosis Bilirubin - normal or mild elevation Amylase - normal ALT/AST - slightly elevated ALP - Normal GGT - Normal

Answer 17

CBC - Leukocytosis Bilirubin - Elevated Amylase - Usually elevated ALT/AST - Normal ALP - Elevated GGT - Elevated

Answer 18

CBC - Leukocytosis Bilirubin - Elevated Amylase - Elevated ALT/AST - Elevated ALP - Normal GGT - Normal

Answer 19

1. Severe attacks: NPO 2. Mild attacks: avoid fatty meals 3. NG tube for persistent nausea or abd distention 4. Lap chole or open chole within 72 hours of diagnosis 5. Reduce fatty meals in diet

Answer 20

1. Ursodeoxycholic acid - treatment of gallstones 2. Antiemetics - promethazine; ondansetron

Answer 21

GI syndrome presenting as unsatisfactory defecation with infrequent stools, difficult stool passage, or both. - Patients describe hard stools, and feeling of incomplete evacuation, abd discomfort, bloating, and distention

Answer 22

1. Primary - most patients have constipation that cannot be attributed to any structural abnormalities or systemic disease. These patients may be further categorized as having normal colonic transit time, slow transit, or defectatory disorders (with or without colonic transit) 2. Secondary - may be caused by secondary disorders, medications, or obstructing colonic lesions

Answer 23

1. Advanced age 2. Inadequate intake of dietary fiber 3. Inadequate fluid intake 4. Sedentary lifestyle 5. Ignoring the urge to defecate 6. Change in daily routine 7. Medications 8. IBS 9. Laxative abuse 10. Neurologic, endocrine, and metabolic disorders 11. Diverticulosis 12. Hirschsprung's disease 13. Intestinal obstruction

Answer 24

1. Antacids containing aluminum 2. Antidepressants 3. Anticholinergics 4. Anticonvulsants 5. Antihypertensives 6. Antihistamines 7. Calcium supplements 8. Cough suppressants containing codeine 9. Diuretics 10. Iron supplements 11. Narcotics

Answer 25

1. Decrease in number of BMs compared to patient's "usual" frequency 2. Hard, dry stools 3. Pain and difficulty with defecation 4. Abd distention 5. Associated symptoms including abd pain/cramps, fever, rectal bleeding, mucus in stool, anorexia, HA, depression, anxiety 6. Rectal fissures 7. Inflammation of rectal area

Answer 26

1. Fiber supplements once or twice per day 2. Establish regular toileting routine; respond to urge to have BMs 3. High fiber diet (20-35g/day); beans, whole grains, bran, fruit, veggies 4. Adequate intake of water and juice (1.5 - 2 liters/day) and elimination of caffeine (dehydrating effects) 5. Adequate exercise 6. Avoidance of medications that contribute to constipation 7. Limit use of laxatives, enemas, and stool softeners

Answer 27

1. Bulk Producing Agents 2. Stool Softeners 3. Hyperosmotic Agents 4. Stimulants/Irritants 5. Lubricant/Emollient 6. Saline Laxatives 7. IBS Medications

Answer 28

- Psyllium - Methylcellulose - Polycarbophil

Answer 29

- Lactulose - Polyethylene glycol

Answer 30

- Bisacodyl - Senna

Answer 31

- Mineral Oil

Answer 32

Magnesium sulfate

Answer 33

- Linaclotide (Linzess) - Lubiprostone (Amitiza)

Answer 34

The repeated passage of stool in inappropriate places, such as on clothing or the floor. May be involuntary or voluntary. Considered abnormal after toilet training has been achieved, generally around age 4 years. - Also known as fecal incontinence

Answer 35

1. Functional constipation 2. Functional fecal incontinence - Retentive - Nonretentive

Answer 36

Defined by criteria that include: - Stool frequency - Hardness - Size - Fecal incontinence - Painful defecation - Volitional stool retention - With or without abdominal pain

Answer 37

It's retentive if: - If associated with functional constipation - Most constipation in children has a functional cause, meaning that the symptoms are real, but there is no sign of injury or infection, blood, or anatomic abnormality - About 80% of children with fecal incontinence have underlying constipation - Only a small percentage of cases in children is caused by disease

Answer 38

It's nonretentive if: - Absence of symptoms and signs of functional constipation - One-month history in a child greater than 4 years old - Defecation into places inappropriate to the social context - No evidence of fecal retention - Fecal incontinence cannot be explained by another medical condition after medical evaluation - Physical exam normal - No excessive stool on exam

Answer 39

- Chronic constipation in infancy - Dehydration - Inappropriate use of laxatives - Major life or family stress - Positive family history - Inappropriate toilet training or irregular toileting patterns - Painful bowel movements - Changes in diet - Physical or sexual abuse

Answer 40

-Hx of constipation: often large volumes of stool with painful defecation - Hx of soiling (rarely during sleep) - Large amounts of stool noted on abd and rectal exams, with intermittent passage of extremely large BMs - May note stool smeared around anus, anal fissures, or lax sphincter - Fecal/foul odor surrounds child - Rectum enlarged and filled with soft stool - Negative occult stool - Normal neuro findings - Normal anal wink, normal sensation, normal reflexes - Reports of hiding during play, fear of toilet, low self-esteem, social difficulties, risk for bullying - Decreased quality of life

Answer 41

- High fiber diet - Age-appropriate fluid intake - Physical activity - Prebiotics - Probiotics - Limit milk intake in child older than 1 year - Encourage child to take responsibility for toileting; development of bowel routine - Initially, scheduled toilet sitting recommended (ex. 10 minutes 2-3 times per day) - Reinforce cooperation with treatment plan with age-appropriate awards

Answer 42

- Assist with development of appropriate bowel routine: child should be instructed to use the bathroom at specific times - Give responsibility to child - Put footstool near toilet - Reinforce appropriate bowel habits with rewards - Diet adequate in fluid and fiber

Answer 43

- If impacted, disimpaction can be achieved with oral cathartics, enemas, or combination - After initial bowel evacuation (or if not impacted), initiate therapy with laxatives/stool softeners to achieve one or two soft stools a day - Wean from medications when goal of regular, soft stools achieved

Answer 44

No recommendations for pharmacologic management

Answer 45

Is the movement of GI contents into the esophagus or beyond, facilitated by decreased lower esophageal sphincter (LES) tone. Some reflux is physiologic. GERD is present when gastric contents flow upward into the esophagus or oropharynx, producing symptoms

Answer 46

- Affects 1/3rd of Americans - Affects 81% of patients 60 years and older - Affects 50-60% of women during pregnancy - Little is known about prevalence in children and adolescents - Small number of infants develop GERD, but recurrent vomiting common: but resolves spontaneously in nearly all infants

Answer 47

1. Factors that reduce LES tone 2. Aging 3. DM, diabetic gastroparesis 4. Delay in gastric emptying 5. Increased gastric acid secretion 6. Medications that irritate esophageal mucosa 7. Zenker's diverticulum 8. Zollinger-Ellison syndrome 9. Childhood GERD

Answer 48

1. Alcohol ingestion 2. Anticholinergic medications, beta blockers, diazepam, theophylline 3. Calcium channel blockers 4. Caffeine 5. Chocolate, peppermint 6. Fatty, spicy, citrus foods 7. Hormones: estrogen, progesterone, glucagon, secretin 8. Meperidine 9. Nicotine 10. Overweight 11. Pregnancy

Answer 49

1. NSAIDs 2. Tetracycline 3. Quinidine 4. Caffeine 5. Alendronate 6. Bupropion 7. Citalopram 8. Paroxetine 9. Hydrocodone 10. Dulaglutide 11. Exenatide 12. Liraglutide

Answer 50

- Chest pain (requires cardiac workup) - Chronic sore throat, hoarseness - Dysphagia - Erosion of teeth by acid - Esophageal pain referred by neck, midback, upper abdomen - Extraesophageal presentation: asthma, chronic cough, laryngitis - Postnasal drip, throat clearing - Pyrosis (heartburn) is cardinal symptom: burning beneath sternum, typically postprandial and nocturnal - Regurgitation - Sensation of lump in throat - Ulceration: hematemesis, fatigue, anemia

Answer 51

1. Lifestyle modifications 2. Maintain a healthy weight 3. Eat smaller meals 4. Avoid trigger foods 5. Do not lie down for 2-3 hours after eating meals 6. Elevate head of bed 6-8 inches 7. Quit smoking 8. Limit alcohol consumption

Answer 52

1. 8 week course of PPI therapy is treatment of choice 2. PPI therapy should be dosed once a day and before first meal of the day 3. If partial response to daily PPI, increased BID dosing 4. If symptoms persist after 8 weeks of PPI therapy, refer to GI specialist

Answer 53

Calcium carbonate

Answer 54

1. Cimetidine 2. Antacid and alginic acid 3. Famotidine 4. Nizatidine

Answer 55

1. Dexlansoprazole 2. Esomeprazole 3. Lansoprazole 4. Omeprazole 5. Pantoprazole 6. Rabeprazole

Answer 56

The protrusion of viscera or adipose tissue through the inguinal or femoral canal

Answer 57

1. Indirect 2. Direct 3. Femoral

Answer 58

Abdominal tissue passes through an abdominal wall defect into the internal inguinal ring and inguinal canal

Answer 59

Abdominal tissue protrudes through the posterior wall of the inguinal canal

Answer 60

Hernia located inferior to the inguinal ligament and protruding through the femoral ring. - 40% are incarcerated or strangulated (EMERGENCY)

Answer 61

Contents cannot be replaced into the abdomen

Answer 62

Blood supply to the entrapped bowel is diminished; a surgical emergency. Pain is out of proportion to exam. Erythema, hyperesthesia, or wound drainage may be present

Answer 63

Hernia easily replaced into the abdomen using gentle pressure or may occur spontaneously

Answer 64

1. Congenital or acquired defect 2. Familial or hereditary predisposition 3. Connective tissue disorder 4. Decreased collagen levels

Answer 65

1. 8-10 times more common in men 2. Age of 60 years 3. Cigarette smoking: can damage connective tissue 4. Inheritance: first degree relatives, especially in women 5. Connective tissue disorder 6. Prostatectomy history 7. Previous contralateral hernia 8. Low BMI

Answer 66

1. A heavy or dragging sensation in the groin or hernia 2. Painful or painless swelling or lump in groin or into scrotum; may increase with standing or sitting 3. Bulge may be intermittent and palpable during episodes of increased abd pressure (defecation, micturation, coughing, exercise, sexual activity). Symptoms worse at the end of day and relieved by laying down or manually reducing hernia 4. In women, bulge may be seen in the labia majora 5. Strangulated hernia: colicky abd pain, N/V, abc distention

Answer 67

- Educate about s/sx of strangulation and advise to seet immediate medical help if these occur - Do not attempt to reduce a strangulated hernia - Surgical correction (herniorrhaphy) is required if hernia does not resolve spontaneously

Answer 68

May occur together or separately. Nausea often precedes or accompanies vomiting. N/V may be a component of arganic and functional disorders, a defense mechanism to expel ingested toxins, or related to neurological trauma. Other causes are damage to or abnormality of the chemoreceptor trigger zone, intestinal obstruction, or chronic GI mucosal disease

Answer 69

- Numerous (depending on etiology) - May be acute or chronic

Answer 70

- Causes unrelated to GI tract should be ruled out, with attention to the CNS - Abdominal examination to assess for presence of distention, characteristics of bowel sounds, and presence of tenderness, guarding or rebound - Rectal examination to assess for fecal impaction - Examine vomitus if possible, to determine feculent vs. undigested food vs. bilious in nature - Oral cavity examination to assess for dental involvement or chronic situation (bulimia)

Answer 71

1. Prochlorperazine 2. Promethazine

Answer 72

** For N/V 1. Metoclopramide (Reglan)

Answer 73

** For N/V 1. Chlorpromazine

Answer 74

** For N/V 1. Scopolamine

Answer 75

** For N/V 1. Ondansetron 2. Dolasetron mesylate

Answer 76

1. Dehydration 2. Orthostatic hypotension 3. Arrhythmias 4. Electrolyte abnormalities 5. Acute renal failure

Answer 77

An intestinal worm infection caused by Enterobius vermicularis, a helminth parasite. - Transmission is through the fecal-oral route - Adult female pinworm 8-13 mm - Adult male pinworm 2-5 mm

Answer 78

- Eggs are deposited around the anus by the worm and may be transferred to vectors such as hands, fingernails, toilet seats, clothing, bedding, and toys - Eggs are commonly ingested and less commonly inhaled: possible due to the very small size of the eggs - Eggs hatch in the duodenum and the larvae grow rapidly and migrate through the small intestine toward the colon as they become adults - The male and female pinworms mate in the ileum. Males die after mating and are passed in stool. Gravid females slowly transmit through the digestive tract, emerging from the anus approximately 5 weeks after initial ingestion to lay eggs - Each female produces 11,000 to 16,000 eggs - Eggs can survive 2-3 weeks in an indoor environment

Answer 79

- Family contacts of infected children - Primary caregivers of infected children - Day care center attendance, institutional residence - Children 4-11 years at highest risk - Common in parents aged 30-39 due to transmission from their children - Finger sucking and nail biting - Poor hygiene and improper handwashing - Crowded living conditions - Sexual contact with infected person

Answer 80

- 30-40% of people are asymptomatic - Perianal and/or vaginal itching; worse at night - Vulvovaginitis in girls and women - UTIs in young girls - Childhood enuresis - Perianal trauma, anal dermatitis, and/or perianal folliculitis - Abd pain - Irritability, restlessness, insomnia - Anorexia - Weight loss - N/V

Answer 81

1. Directly visualize female worm at night 2-3 hours after asleep (or early morning) by shining a flashlight on the perianal area 2. Glass slide microscopic analysis: egg and larva 3. Transparent adhesive tape test: identification of ova on low-power microscope after touching tape to perianal area in the mornings before voiding or bathing 4. Paddle test: clear, plastic paddle with adhesive surface is pressed against perianal area; paddle inspected under a microscope for worms 5. All microscopy methods should be performed on three separate occasions, which increases sensitivity from 50% to 90% 6. Stool and serology are not diagnostic

Answer 82

- Successful eradication requires at least 2 doses of medication separated by 2 weeks - Total elimination of the parasite in a household may require repeated doses for up to a year or more - All family members or classmates who are infected must be treated simultaneously

Answer 83

** For pinworm infections 1. Pyrantel 2. Mebendazole 3. Albendazole

Answer 84

Recurrent abd pain no associated with meals, change in bowel habits, or menstruation, persisting for 6 months or more. Is a chronic debilitating condition associated with loss of daily function. ** Also known as functional abdominal pain syndrome (FAPS) - Coexisting anxiety, depression, or somatization often occurs - Many patients have poor coping mechanisms and social support

Answer 85

- Unknown - Sometimes confused with common GI disorders such as IBS or dyspepsia - Chronic pain has sensory, emotional, and cognitive components

Answer 86

1. Prior abd surgeries 2. Chronic pain syndrome 3. IBS, IBD 4. Fibromyalgia 5. Depression, anxiety 6. Recent alcohol consumption/binge 7. Prior ileus/bowel obstructions 8. High stress levels

Answer 87

1. CBC with diff: normal 2. Liver panel: exclude elevation 3. Amylase/lipase: exclude 4. UA: normal 5. Urine pregnancy test: negative 6. Flat and erect Xray of abd: negative * No further workup needed if physical exam is negative and no alarming symptoms are present (unexplained weight loss, anorexia, or bloody bowel movements)

Answer 88

- Introduce the possibility that the pain is functional (inorganic) - Discuss relationship between stress and pain - Increase dietary fiber and ensure adequate hydration if constipation is present - Dietary/lifestyle modification for healthy diet and exercise pattern - Stress management

Answer 89

- Pain medications generally not helpful - Identify etiology to determine which pharmacologic agent would work best (SSRIs, SNRIs, TCAs, and/or anticonvulsants)