Gastrointestinal Exam Flashcards

Question

Drug therapy for GI bleed con...

Answer 1

H.pylori- triple therapy- PPI and 2 antibiotics for 7-14 days PPIs- Prilosec, prevacid, aciphex, protonix, nexium H2 receptor antagonists- Zantac, Pepcid, Axid Prostaglandin analogues- cytotec (most commonly used to prevent NSAID induced ulcers) side effect is uterine contractions- makes menstrual cramps worse Antacids- Mylanta, Maalox (aluminum hydroxide and magnesium hydroxide), can interact with certain drugs- Dilantin, tetracycline-interfering with effectiveness Mucosal barrier fortifiers- Sucralfate (Carafate), does not inhibit acid secretion, but binds bile acids and pepsins, reducing injury from these substances. Used in conjunction with H2 receptor antagonists and antacids, but should not be administered within 1 hour of the antacid. Main side effect is constipation.

Answer 2

Endoscopic therapy can assist in achieving hemostasis- EGD to cauterize vessels Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents and prevent rebleeding Upper GI bleeding may require the health care provider to insert nasogastric tube. Saline lavage requires the insertion of a large-bore nasogastric tube.

Answer 3

Excessive relaxation of lower esophageal sphincer

Answer 4

Most common symptom is pain in the left lower quadrant Nausea with meals and defecation Crampy abdominal patterns are accompanied by constipation and diarrhea

Answer 5

Interventions include health teaching, drug therapy, and stress management Keep a symptom diary- record potential triggers and bowel habits for a period of time can assist in identifying new triggers. 5-HT4 antagonists- last resort in women with diarrhea predominant symptoms M3-receptor antagonists- inhibit intestinal motility Tricyclic antidepressants- used in patients with pain as the predominant symptom

Answer 6

Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes Types of hernia include: Indirect inguinal-sac formed from the peritoneum that contains a portion of the intestine or omentum, pushes down into the inguinal canal Direct inguinal- pass through a weak point in the abdominal wall Femoral- protrude through the femoral ring, plug of fat enlarges and pulls the peritoneum and often the bladder into the sac Umbilical- congenital (infancy) or acquired (direct result from increased intra-abdominal pressure Incisional or ventral- at the site of a previous surgical incision, result of inadequate healing (post-op infection, inadequate nutrition, obesity)

Answer 7

Reducible- when contents of the hernial sac can be placed back into the abdominal cavity by gentle pressure Irreducible (incarcerated)- cannot be reduced and requires immediate surgical evaluation Strangulated- blood supply to herniated segment of the bowel is cut off by pressure from the hernial ring, there is ischemia and obstruction of bowel loop

Answer 8

Signs of strangulation- abdominal distension, nausea, vomiting, pain fever and tachycardia

Answer 9

Ecchymosis- may indicate internal bleeding Turner’s- may be a sign of retroperitoneal bleeding into abdominal wall Ballance’s- indicated ruptured spleen Kehr’s- splenic injury

Answer 10

Sessile: broad based (villous adenomas- greater cancer risk) Pedunculated: stalk-like (tubular adenomas)

Answer 11

Acute inflammation of the vermiform appendix—the blind pouch attached to the cecum of the colon

Answer 12

Abdominal pain in the epigastric or periumbilical area is the initial symptom of classic appendicitis McBurney’s point- localized tenderness during later stages of appendicitis Perforation- abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis

Answer 13

Life-threatening acute inflammation of visceral/parietal peritoneum and endothelial lining of abdominal cavity, or peritoneum Caused by contamination by bacteria or chemicals Less common- perforating tumors, leakage or contamination during surgery, peritoneal dialysis patients

Answer 14

Rigid, boardlike abdomen, abdominal pain, distended abdomen, high fever, tachycardia, dehydration, low urine output, hiccups, compromised respiratory status, nausea and vomiting, anorexia, diminishing bowel sounds, inability to pass flatus or feces, rebound tenderness

Answer 15

Increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract (small bowel) Bacterial form—Campylobacter, Shigella, Escherichia coli Viral form—Norwalk virus

Answer 16

Vomiting , loss of appetite, nausea , bloating

Answer 17

Inflammatory disease of the small intestine and the colon, or both. It can affect the GI tract from mouth to anus but mostly the terminal ileum. Transmural inflammation causing thickening of the bowel wall with strictures and deep ulcerations with bowel fistulas commonly developing. Rarely, cancer of the small bowel and colon develop. Malabsorption of vitamins and nutrients characteristic of Crohn’s. Fistula formation is very common.

Answer 18

Diverticulosis is the presence of many abnormal pouch- like herniations in the wall of the intestine. Diverticulitis is inflammation of one or more of the diverticula Typically in the sigmoid colon. Muscle of the colon hypertrophies, thickens, and becomes rigid and herniation of the mucosa and submucosa through the colon wall is seen. Occur at points of weakness, often at areas where blood vessels interrupt the muscle layer (result of aging or lack of fiber in diet) Undigested food or bacteria get stuck in the diverticula- blood supply is decreased, bacteria invade diverticulum, resulting in infection- can lead to perforate and develop abscess

Answer 19

Straining to pass stool, Crohn's, tuberculosis, leukemia, neoplasm, trauma (foreign body, anal sex, perirectal surgery)

Answer 20

Wormlike animals that are often parasitic and capable of causing infectious disease (roundworms, flukes, tapeworms) Enterobiasis (pinworm) Most common helminth infection in US Oral intake of contaminated food or drink Trichinosis Transmitted through eating under-cooked pork Hookworms Enter through the skin Tapeworms 5 types can infect humans- tapeworms found in cattle, fish, dogs, pigs, rodents Transmitted through consumption of under-cooked beef, raw fish, or other contaminated food or water or accidentally swallows infected lice or fleas from dogs

Answer 21

Acute cholecystitis is the inflammation of the gallbladder.

Answer 22

Calculous cholecystitis Most common Cholelithiasis (gallstones) cause irritation and inflammation that can obstruct the cystic duct, gallbladder neck, or common bile duct Trapped bile is reabsorbed and becomes chemical irritant Decreased circulation, edema, and distension leads to ischemia and infection and gallbladder can become necrotic

Answer 23

Acalculous cholecystitis inflammation can occur in the absence of gallstones Typically associated with biliary stasis Conditions that can cause acalculous cholecystitis Sepsis, severe trauma or burns, long-term TPN, multisystem organ failure, major surgery, hypovolemia.

Answer 24

Repeated episodes of cystic duct obstruction result in chronic inflammation Pancreatitis, cholangitis occur as complications of cholecystitis Jaundice/icterus- most common in chronic vs. acute Obstructive jaundice- occurs when flow of bile is impeded by stones or compression of duct Pruritus- accumulation of excess bile salts in the skin Stool may be clay colored as bilirubin does not make it to the large intestine Urine becomes dark and foamy as kidneys try to clear excess bilirubin

Answer 25

``` Gas, indigestion, belching, anorexia, nausea and vomiting, abdominal pain, fever, jaundice Biliary colic Severe pain caused by obstructed cystic duct and tissue spasm Murphy’s sign Pain with deep inspiration Blumberg’s sign Rebound tenderness Steatorrhea Fatty stools ```

Answer 26

Nutrition therapy low-fat diet, fat-soluble vitamins, bile salts Drug therapy opioid analgesic such as morphine or hydromorphone, anticholinergic drugs (relax smooth muscle and decrease ductal tone/spasm), antiemetic Extracorporeal shock wave lithotripsy Used for patients who are not surgical candidates Only for patients who are normal weight, good gallbladder function Percutaneous transhepatic biliary catheter Opens blocked ducts Can be internal, external, internal/external Internal diverts bile from liver, past stricture to duodenum External connected to drainage bag on the outside of body Internal/External- part of bile empties into a drainage bag, other part empties into the duodenum

Answer 27

Serious and possibly life-threatening inflammatory process of the pancreas Premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells Necrotizing hemorrhagic pancreatitis Diffusely bleeding pancreatic tissue with fibrosis and tissue death Acute- 4 main processes: Lipolysis- fatty acids combine with ionized calcium, hypocalcemia Proteolysis- splitting proteins, thrombosis, gangrene Necrosis of blood vessels- elastase activated by trypsin, dissolves elastic fibers of blood vessels Inflammation Secondary bacterial infection can lead to pus collection, fibrosis can occur and develop into a pseudocyst

Answer 28

Primary exocrine function is secreting an inactive form of enzymes that breaks down starches, proteins, and fats (activated in small intestine) Early activation causes inflammation **Hemorrhagic pancreatitis is life-threatening- can cause shock from extensive pancreatic damage**

Answer 29

Hypovolemia Hemorrhage Acute renal failure Paralytic ileus Hypovolemic or septic shock Pleural effusion, respiratory distress syndrome, pneumonia Amylase passes through transdiaphragmatic lymph channels Multisystem organ failure (NHP) Disseminated intravascular coagulation (DIC) Release of necrotic tissue and enzymes into the blood stream Hypercoagulation of blood, with consumption of clotting factors and development of microthrombi Diabetes mellitus Pancreatic infection

Answer 30

``` Generalized jaundice Cullen’s sign Turner’s sign Bowel sounds Abdominal tenderness, rigidity, guarding Pancreatic ascites Significant changes in vital signs ```

Answer 31

Progressive destructive disease of the pancreas, characterized by remissions and exacerbations Typically develops after several episodes of alcohol induced acute pancreatitis Chronic obstruction of CBD Pancreatic insufficiency causes loss of exocrine and endocrine function Manifestations may differ from acute pancreatitis (chart 62-2) Nonsurgical management includes: Drug therapy Analgesic administration H2 Blockers, PPIs Insulin therapy Nutrition therapy Enzyme replacement (chart 62-3) TPN Low- fat, high protein, carbohydrates

Answer 32

Pancreatic Abscess Most serious complication of pancreatitis; always fatal if untreated Results from extensive inflammatory necrosis of the pancreas that is invaded by bacteria High fever Blood cultures Determine infectious organism Drainage via the percutaneous method or laparoscopy to prevent sepsis May need to be repeated Antibiotic treatment alone does not resolve abscess

Answer 33

* Hiatal hernias, also called diaphragmatic hernias, involve the protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm into the chest. * Most patients with hiatal hernias are asymptomatic, but some may have daily symptoms similar to those with GERD. * Patients with hiatal hernias may be managed either medically or surgically based on the severity of symptoms and the risk of serious complications. * The primary focus of care after conventional surgery is the prevention of respiratory complications.

Answer 34

* Although esophageal tumors can be benign, they are most often malignant * Esophageal tumors grow rapidly because there is no serosal layer to limit their extension and spread to the lymph nodes occurs early. * The diagnosis of esophageal cancer causes high patient anxiety, as it is accompanied by distressing symptoms and is often terminal. * Medical and surgical treatment is based on the extent and location of the tumor. * Respiratory care is the highest postoperative priority for patients having an esophagectomy. * Before beginning oral feedings postoperatively, a cine-esophagram study is performed to detect the presence of anastomotic leaks, strictures, or signs of aspiration. * When discharged, teach patients about the signs of anastomosis leakage and the importance of reporting them to the health care provider immediately. * Teach the patient and family members to report the presence of fever and a swollen, painful neck incision, which could indicate an anastomotic leak.

Answer 35

* Diverticula are sacs that may develop anywhere along the length of the esophagus, resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue. * Zenker’s diverticula is the most common form and occurs most often in older adults. * Patients complain of dysphagia, regurgitation, nocturnal cough, and halitosis, and may be at risk for perforation because the mucosa is without the protection of the normal esophageal muscle layer. * Esophageal diverticula are diagnosed by barium swallow and esophagogastroduodenoscopy. * Surgical management is aimed at removing the diverticula.

Answer 36

• Colorectal cancer is cancer of the colon or rectum and is one of the most prevalent malignancies, utilizing a significant proportion of health care dollars. • Most are adenocarcinomas, arising from the glandular epithelial tissue of the colon. • Colorectal cancer can metastasize by direct extension or through the blood or lymph. • Most colorectal cancers have no known predisposing cause, although age, previous colorectal cancer, and family history are considered risk factors. o The major risk factors for the development of colorectal cancer (CRC) include being older than 50 years, genetic predisposition, personal or family history of cancer, and/or diseases that predispose the patient to cancer such as familial adenomatous polyposis (FAP), Crohn’s disease, and ulcerative colitis. o There is also strong evidence that long-term smoking, increased body fat, physical inactivity, and heavy alcohol consumption are risk factors for colorectal cancer • People of average risk who are over 50 years of age, without a family history, should undergo regular screening, including fecal occult blood testing and colonoscopy every 10 years or double-contrast barium enema every 5 years. • People who have a personal or family history of the disease should begin screening earlier and more frequently. • A positive test result for occult blood in the stool indicates bleeding in the GI tract. • CT or MRI of the chest, abdomen, pelvis, lungs, or liver helps confirm the existence of a mass, the extent of disease, and location of distant metastases. • Colonoscopy is the definitive test for the diagnosis of colorectal cancer. • CT-guided virtual colonoscopy is growing in popularity and may be more thorough than traditional colonoscopy. However, treatments or surgeries cannot be performed when a virtual colonoscopy is used. • The type of therapy used is based on the pathologic staging of the disease. • Preoperative radiation therapy may provide local or regional control of the disease. • Postoperative radiation has not demonstrated any consistent improvement in survival or recurrence but is used palliatively to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease. • Adjuvant chemotherapy after primary surgery is recommended in stage II or stage III. • Surgical removal of the tumor with margins free of disease is the best method of ensuring removal of the cancer. • If a colostomy is required, assess the characteristics of the stoma, which should be reddish pink and moist and immediately report abnormalities such as ischemia and necrosis or unusual bleeding to the surgeon.

Answer 37

* Polyps are small growths covered with mucosa and attached to the surface of the intestine, which are usually benign, but may become malignant. * Polyps are usually asymptomatic and are discovered during routine diagnostic testing, but may cause rectal bleeding, intestinal obstruction, or intussusceptions. * Diagnostic studies involve a barium enema examination and sigmoidoscopy or colonoscopy. * Biopsy specimens of polyps can be obtained and the entire polyp can be removed with the use of a snare that fits through the sigmoidoscope or colonoscope.

Answer 38

* Hemorrhoids are unnaturally swollen or distended veins in the anorectal region. * Internal hemorrhoids, which cannot be seen on inspection of the perineal area, lie above the anal sphincter. * External hemorrhoids lie below the anal sphincter and can be seen on inspection of the anal region. * Prolapsed hemorrhoids can become thrombosed or inflamed, or they can bleed. * Prevention of constipation by increasing fiber in the diet and drinking plenty of water is the most important preventive measure. * Local treatment and nutrition therapy are used when symptoms begin. * The surgeon can perform several procedures for symptomatic internal hemorrhoids on an ambulatory care basis, including ultrasound coagulation, rubber band ligation, circular stapling, laser assisted or simple resection of the hemorrhoids.

Answer 39

* Appendicitis is an acute inflammation which occurs when the lumen of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix. * It affects individuals of all ages, but is usually more serious in older adults. * The initial obstruction is usually a result of fecaliths, which are very hard pieces of feces, but less common causes are malignant tumors, worms, or other infections. * An abscess may develop in slow onset, but a rapid process may result in peritonitis. * All complications of peritonitis, such as gangrene and perforation, are serious. * Laboratory findings do not establish the diagnosis, but often there is a moderate elevation of the white blood cell count with a “shift to the left.” * A WBC elevation greater than 20,000/mm3 may indicate a perforated appendix. * Keep the patient with suspected or known appendicitis NPO to prepare for the possibility of emergency surgery and to avoid making the inflammation worse. * Surgery is required as soon as possible.

Answer 40

* Peritonitis is a life threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. * The cardinal signs of peritonitis are abdominal pain and tenderness. * Flat, upright and decubitus abdominal x-rays or abdominal sonogram can assess for free air or fluid in the abdominal cavity, indicating perforation. * The physician may also perform a diagnostic peritoneal lavage. * IV fluids and broad-spectrum antibiotics are started immediately after diagnosis. * Exploratory laparotomy is the usual surgical approach, followed by irrigation with antibiotic solutions and drain insertion before closing the abdominal cavity. * For patients taking oral opioid analgesics such as oxycodone with acetaminophen (Tylox, Percocet, Endocet) for any length of time, a stool softener such as docusate sodium (Colace, Regulex) may be prescribed

Answer 41

* Gastroenteritis is an increase in frequency and water content of stools or vomiting related to infection and inflammation of the mucous membranes of the stomach and intestinal tract, usually self-limiting unless complications occur. * Some clinicians classify infectious disease of the intestine as bacterial, viral, or parasitic, without using the term gastroenteritis. * Treatment with antibiotics may be needed if bacterial gastroenteritis. * Weakness and cardiac dysrhythmias may be the result of loss of potassium (hypokalemia) from diarrhea.

Answer 42

* Ulcerative colitis creates widespread inflammation of mainly the rectum and rectosigmoid colon, associated with periodic remissions and exacerbations. * The patient’s stool typically contains blood and mucus and patients report tenesmus, an unpleasant and urgent sensation to defecate, and lower abdominal colicky pain. * A colonoscopy is the most definitive test for diagnosing ulcerative colitis. * At the onset of treatment, activity is generally restricted because rest can reduce intestinal activity, provide comfort, and promote healing. * In addition to dietary changes, complementary and alternative therapies may be used to supplement traditional management of ulcerative colitis. * Some patients with ulcerative colitis require a surgical colon removal and ileostomy, including those with bowel perforation, toxic megacolon, hemorrhage, dysplastic biopsy results, failure of conventional treatment, and colon cancer. * An ileostomy is a procedure in which a loop of the ileum is placed through the abdominal wall for drainage of fecal material into a pouching system. * Having an ileostomy impacts the patient’s body image and self-esteem, therefore, assess for coping strategies and identify support systems.

Answer 43

* Crohn’s disease is an inflammatory disease of the small intestine, the colon, or both. * It is a slowly progressive, unpredictable, and recurrent disease with involvement of multiple regions of the intestine with normal sections in-between. * Crohn’s disease results in severe diarrhea and malabsorption of vital nutrients. * Anemia is common, usually from iron deficiency or malabsorption issues. * Cause is not known, but may include genetic, immune, and environmental factors. * X-rays show the common narrowing, ulcerations, strictures, and fistulas. * Specific interventions vary with the severity of disease and the complications present. * Fistulas are common with acute periods of Crohn’s disease. * The patient with one or more fistulas often has complications such as systemic infections, skin problems, malnutrition, and fluid and electrolyte imbalances. * Treatment of the patient with a fistula is complicated and includes nutrition and electrolyte therapy, skin care, and prevention of infection. * Surgical resection of the diseased area is usually performed for those patients who have not improved with medical management, or with complications, perforation, massive hemorrhage, intestinal obstruction or strictures, abscesses, or cancer

Answer 44

* Diverticula are pouch-like herniations of the mucosa through the muscular wall of any portion of the gut, but most commonly in the colon. * Diverticulosis is the presence of many abnormal pouch-like herniations. * Diverticulitis is the inflammation of one or more diverticula. * The patient with diverticulosis usually has no symptoms unless pain or bleeding develops, so it is often found incidentally on routine colonoscopy. * The patient with diverticulitis usually does not undergo invasive procedures in the acute phase of the illness because of the risk for rupture. * A computed tomography scan may be performed to diagnose an abscess or thickening of the bowel related to diverticulitis

Answer 45

* Anorectal abscess is a localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus from obstruction of the ducts of glands. * Anorectal abscesses are managed by surgical incision and drainage. * An anal fissure is a superficial tear in the anal lining causing discomfort and disability which resolves on its own or heals quickly with conservative treatment. * Chronic fissures recur and surgical treatment may be needed. * An anal fistula is an abnormal tract leading from the anal canal to the perianal skin, usually resulting from anorectal abscesses. * A proctoscope is used to identify the source of symptoms and to locate the fistula. * Because fistulas do not heal spontaneously, surgery is necessary. * Instruct patients with anorectal disorders to use sitz baths, bulk-forming agents, and stool softeners to decrease pain.

Answer 46

* Cholecystitis is an inflammation of the gallbladder that affects many people in affluent countries. * It may be either acute or chronic, although most patients have the acute type. * Two types of acute cholecystitis are calculous and acalculous cholecystitis. * The most common type is calculous cholecystitis, in which chemical irritation and inflammation results from gallstones that obstruct the cystic duct most commonly, gallbladder neck, or common bile duct. * Acalculous cholecystitis, inflammation occurring without gallstones, is associated with biliary stasis caused by changes in the regular filling or emptying of the gallbladder. * Chronic cholecystitis results when repeated episodes of cystic duct obstruction result in chronic inflammation, most often with calculi. * Jaundice, seen as yellow discoloration of the skin and mucous membranes, and icterus, which is yellow discoloration of the sclera, can occur in patients with acute cholecystitis, but is most commonly observed with the chronic form of the disease. * Women from 20 to 60 years of age are twice as likely to develop gallstones as men. * Obesity, pregnancy, estrogen, birth control pills, and combinations of those factors are major risk factor for gallstone formation, especially in women. * Teach patients to avoid losing weight too quickly and keep weight under control to help prevent gallbladder disease. * Patients with acute cholecystitis present with abdominal pain, although clinical manifestations vary in intensity and frequency. * There are no laboratory tests specific for gallbladder disease, so differential diagnosis rules out diseases causing similar symptoms, such pancreatitis. * When the cause of cholecystitis or cholelithiasis is not known or the patient has manifestations of biliary obstruction, such as jaundice, an endoscopic retrograde cholangiopancreatography may be performed

Answer 47

* Acute pancreatitis is a serious and, at times, life-threatening inflammatory process. * Pancreatitis can range from mild involvement evidenced by edema and inflammation to necrotizing hemorrhagic pancreatitis, which is characterized by diffusely bleeding pancreatic tissue with fibrosis and tissue death. * The majority of deaths in patients with acute pancreatitis are from irreversible shock. * Acute pancreatitis may result in severe, life-threatening complications such as jaundice from swelling of the head of the pancreas, calculi or pancreatic pseudocyst, transient hyperglycemia from release of glucagon, left lung pleural effusions, and total destruction of the pancreas, leading to type 1 diabetes. * Multisystem organ failure may be caused by necrotizing hemorrhagic pancreatitis and the patient is at risk for acute respiratory distress syndrome (ARDS). * The diagnosis of pancreatitis is made on the basis of the clinical presentation combined with the results of diagnostic studies. * Clinical manifestations vary widely and depend on the severity of the inflammation, but usually involves severe pain in the mid-epigastric area or left upper quadrant

Answer 48

* Chronic pancreatitis is a progressive, destructive disease which has remissions and exacerbations, usually developing after repeated episodes of alcohol-induced acute pancreatitis or associated with chronic obstruction of the common bile duct. * Idiopathic and hereditary chronic pancreatitis may be associated with SPINK1 and CFTR gene mutations. * The focus of caring for the patient with chronic pancreatitis is to manage pain, assist in maintaining a sufficient nutritional intake, and prevent recurrence. * Surgery is not a primary intervention for treatment but may be used for intractable abdominal pain, incapacitating pain, or abscesses and pseudocysts.

Answer 49

* Pancreatic abscesses are the most serious complication of acute necrotizing pancreatitis because if untreated, they are always fatal. * Pancreatic abscesses occur after severe acute pancreatitis, exacerbations of chronic pancreatitis, or biliary tract surgery. should be performed as soon as possible to prevent sepsis since antibiotic treatment alone does not resolve it. * Drainage via the percutaneous method or laparoscopy

Answer 50

* Pancreatic pseudocysts, or false cysts, are so named because unlike true cysts they do not have an epithelial lining. * Risk factors for pseudocysts are acute pancreatitis, abdominal trauma, and chronic pancreatitis. * To provide external drainage, the surgeon inserts a sump drainage tube to remove pancreatic secretions and exudate. * Pancreatic fistulas are common after surgery, and skin breakdown may occur from corrosive pancreatic enzymes in patients who have external drainage.