Gastrointestinal MDT Flashcards
Diarrhea
How many Bowel movements a day for dx?
3
Diarrhea can be diagnosed as:
Acute or Chronic
Diarrhea acute in onset and persisting for less than 2 weeks is most commonly caused by:
Infectious agents
Bacterial toxins (either produced in the gut)
Infectious sources can be transmitted by fecal-oral contact, food and water and usually have incubation periods between:
12 and 72 hours
Percentage of all water absorbed in the GI tract takes place in the small intestine
> 90%
What is the major site of water resorption?
Jejunum
Colon absorbs additional fluid, transforming a relatively liquid fecal stream in the cecum to a well-formed solid stool in the:
Rectosigmoid
Disorders of the small intestine result in increased amounts of diarrheal fluid with a greater loss of:
Water
Electrolytes
Nutrients
Infectious agents are the most common causes of:
Acute gastroenteritis
Diarrheal disease (three of more times per day or at least 200g of stool per day) of rapid onset that lasts less than 2 weeks
May be accompanied by nausea, vomiting, fever, or abdominal pain
Acute Gastroenteritis
Common findings on physical examination of patients with acute viral gastroenteritis include:
Mild diffuse abdominal tenderness on palpation
Gastroenteritis that is usually self-limited and is treated with supportive measures (fluid repletion and unrestricted nutrition)
Acute viral gastroenteritis
Increase fluid secretion and/or decreased absorption, produces an increased luminal fluid content that cannot be adequately reabsorbed leading to dehydration.
Mechanisms that cause diarrhea:
Adherence
Mucosal invasion
Enterotoxin production
Cytotoxin production
Gastritis involves ONLY the:
Stomach
Endoscopic or radiologic characteristics of abnormal-appearing gastric mucosa
Gastritis
Diagnosis of gastritis is defined as and requires:
histopathologic evidence of inflammation
Two most common causes of gastritis
Chronic NSAID use
Chronic Alcohol use
Gastritis is typically self limited but patients may benefit from:
PPI
Removal of the offending agent
If gastritis does not resolve with conservative management, consider referral for:
Endoscopy and H. Pylori testing
Chronic diarrheal illnesses may be classified as follows:
Osmotic
Inflammatory
Secretory
Chronic infections
Malabsorption syndromes
Motility disorders
Due to an increase in the osmotic load presented to the intestinal lumen either through excessive intake or diminished absorption
Osmotic (Medications/Zollinger - Ellison Syndrome)
Diarrhea
Chronic Parasitic Infection
Giardia Lamblia
Malabsorption syndromes:
Celiac disease
Whipple
Crohn disease
Lactose Intolerance
Motility disorder:
Irritable bowel syndrome
From a diagnostic and therapeutic standpoint, it is helpful to classify infectious diarrhea into syndromes that produce:
Inflammatory or blood diarrhea
AND
Non-inflammatory, non-bloody, or watery
The term “Inflammatory diarrhea” suggests colonic involvement by:
Invasive bacteria
Parasites
Toxin production
Frequent bloody, small-volume stools
Fever, abdominal cramps, tenesmus, and fecal urgency
Inflammatory diarrhea
Common causes of inflammatory diarrhea
Shigella
Salmonella
E. Coli
Protozoal: Entamoeba histolytica
Community outbreaks of acute infectious diarrhea suggest:
Viral etiology
Common food source
Acute infectious diarrhea in family members suggest:
Infectious origin
Acute Infectious Diarrhea
Ingestion of improperly stored or prepared food implicates:
Food Poisoning
Acute non-inflammatory diarrhea is generally milder and is caused by:
Viruses or toxins that affect the small intestine
The viruses or toxins in acute non-inflammatory diarrhea interfere with ________ balance, resulting in large-volume water diarrhea, nausea, vomiting, and cramps.
Salt and water
Food Poisoning with a short incubation
Symptoms 1-6 hours after consumption is from a:
Toxin
Short incubation food poisoning symptoms
Vomiting is the major complaint
Fever is absent
Longer incubation period of food poisoning (8-16) symptoms:
Vomiting is less prominent
Abdominal cramping is frequent
Fever is absent
Treatment for 90% of acute non-inflammatory diarrhea respond with in ___ days to simple rehydration therapy or antidiarrheal agents
5
Diarrhea
When should stool be sent for fecal leukocyte, ovum and parasite evaluation, and bacterial culture?
More than 7 days
Diarrhea
Prompt medical evaluation:
Fever, bloody diarrhea, or abdominal pain
Six or more unformed stools in 24 hours
Profuse watery diarrhea with dehydration
Diarrhea
Pay specific attention to the patient’s level of:
Hydration
Mental Status
Abdominal tenderness or peritonitis
Peritoneal findings may be present in infection with
C difficile
Enterohemorrhagic E coli
Diarrhea
Hospitalization is required in patients with
Severe dehydration
Toxicity
Marked Obesity
Symptoms:
- Sudden onset
- Diffuse abdominal tenderness
- Distention
- Increased bowel sounds
- Usually afebrile
- Positive tilts on fluid loss
Diarrhea
Labs for diarrhea
CBC/DIFF
Fecal Leukocyte
Fecal Occult
Stool Culture
C Difficile assay if recent hospitalization or antibiotics
Diarrhea labs:
Waterborne and foodborne disease, daycare center outbreaks, and international travelers
Stool exam for Giardia Lamblia (Giardiasis suspected)
Initial care of diarrhea
Assess vital signs for stability
Treat symptomatically
- Loperamide
- Bismuth subsalicylate
Diarrhea
Antibiotic treatment is recommended for:
Shigellosis, cholera, salmonellosis, listeriosis, and C. Diff
Diarrhea
Parasitic infection treatment is required for:
Amebiasis
Giardiasis
Cryptosporidiosis
Most digestive complaint
Constipation
Constipation may primarily originate within the _____ or may originate externally
Colon and rectum
Most common cause of constipation
Diminishing intake of fiber with decreased fluid intake
Systemic diseases that causes constipation
Hypothyroidism
Hyperparathyroidism
Diabetes
Chronic neurologic disorders
Medications that cause constipation
CCBs
Iron
Narcotic analgesics
Antipsychotics
Structural abnormalities that cause constipation
Colonic mass with obstruction
Neoplasm (Adenocarcinoma)
Anal Fissure
Constipation
Slow colonic transit is present in patient with a history of:
Chronic laxative abuse
Slow colonic transit may be:
Psychogenic or idiopathic
Symptoms:
- Infrequent stool
- Excessive straining
- Sense of incomplete evacuation
- Need for digital manipulation
Constipation
Labs for constipation
CBC for anemia
TFTs for suspected hypothyroidism
Electrolyte abnormalities
RADs for constipation
Upright Chest film and Abdominal Flat and erect for intestinal obstruction
First line treatment in constipation
Strict dietary changes and an exercise regimen
Increase water & fiber
Second line treatment of treatment for constipation
Stool softening or laxative use
Third line treatment for constipation
Suppositories or enemies
Hemorrhoids located above the dentate line
Subepithelial Cushions of the anorectum
No nervous innervation
Internal Hemorrhoids
Hemorrhoids from inferior hemorrhoidal veins
Below the dentate line
Covered with squamous epithelium
Nervous innervation
External Hemorrhoids
Occur in all adults and contribute to normal anal pressures and ensure a water-tight closure of the anal canal
Hemorrhoidal Venous Cushions
Rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, common causes of anal pathology
Hemorroidal Venous Cushions
Subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers, and arteriovenous communications between terminal branches of the superior rectal artery and rectal veins
Internal Hemorrhoids
Three primary locations of internal hemorrhoids
Right anterior
Right posterior
Left lateral
Hemorrhoids may become symptomatic as a result of activities that:
Increase venous pressure (result in distention and engorgement)
Can contribute to hemorrhoids
Straining, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets
Thrombosis of the external hemorrhoidal plexus results in:
Perianal hematoma
From coughing, heavy lifting, or straining
Exquisitely painful, tense and bluish perianal nodule
Pain is most severe within within the first few hours, gradually eases over 2-3 days
Perianal hematoma (thrombosis of external hemorrhoids)
Stage of Internal Hemorrhoids
Confined to the anal canal
Stage I
Stage of Internal Hemorrhoids
Gradually enlarge and protrude from the anal opening
Stage II
Stage of Internal Hemorrhoids
Manual reduction after bowel movements
Stage III
Stage of Internal Hemorrhoids
Chronically protruding and unresponsive to manual reduction
Stage IV
Protuberant purple nodules covered by mucosa
Prolapsed Hemorrhoids (internal)
Readily visible on perianal inspection
Tense bluish perianal nodule
Extremely tender to palpation
External hemorrhoids
RADs
Colonoscopy should be performed in all patients with:
Hematochezia
Treatment for thrombosed external hemorrhoids
Warm sitz baths
Analgesics and ointments
What time frame can you remove a hemorrhoid clot?
First 24-48 hours
Surgical excision (hemorrhoidectomy) is reserve for __% of patients with chronic severe bleeding from stage III or stage IV hemorrhoids or patients with acute thrombosed stage IV hemorrhoids
5-10%
Linear or rocket shaped ulcers that are usually <5mm in length
Anal Fissures
Anal Fissures occur most commonly in the:
Posterior Midline
Fissures that occur off midline raise suspicion of:
Serious diseases or Sexual assault
Fissures occur most from
Trauma to the anal canal during defecation
Symptoms:
- Severe, tearing pain
- Bright red blood
- Visual Inspection: Cracks in the epithelium
Anal Fissures
Treatment for Anal Fissures
Promote effortless painless bowel movements
- Fiber, sitz baths
- Topical anesthetics
- Oral Analgesics (Tylenol/NSAIDS)
Anal Fissures
Healing occurs within 2 months in up to __% of patients with conservative management
45%
Chronic fissures should be referred and treated with:
Topical Nitroglycerin
Diltiazem
Botulinum toxin injection
Obstruction of an anal gland that opens in the base of an anal crypt which normally drains into the anal canal
Anorectal abscess
Abscesses are frequently encountered in:
Perianal and Perirectal region
Almost all abscesses begin with involvement of an:
Anal crypt and its Gland
Infections from abscesses usually involve ____ tissue, where there is little resistance to the progression of infection.
Fatty
Spaces which can become infected alone or in combination with each other are:
Perianal
Intersphincteric
Ischiorectal
Deep postanal
Supralevator or pelvirectal
Most common and least common locations for anorectal abscesses
Most Common: Perianal Abscess
Least Common: Supralevator Abscess
What can occur from persistent anorectal abscesses?
Fistula formation
Anorectal abscesses are more common in:
Young middle-aged males
Symptoms:
Dull, aching, or throbbing pain that becomes worse immediately before defecation, lessened after defecation, but persists between bowel movements
Anorectal Abscess
RADs for Anorectal Abscess
Ultrasound for deep abscesses
Treatment for Anorectal Abscesses
Surgical and should be performed as soon as the diagnosis is made
Drainage - early and extensive
All perirectal abscesses should be drained in the:
Operating room
Isolated, simple, fluctuant perianal abscesses can be drained in:
Emergency Department
Simple, linear drainage incision is made, the abscess is more likely to occur because of:
Premature closure of skin edges
Anorectal abscesses with a linear drainage incision must be packed with gauze stops for at least:
24 hours
Abscesses with a cruciate/elliptical incision can be made over the fluctuate part. Trimming the flaps prevents closures and allows drainage. No packing is required but if done should be removed in:
24 hours
Abscesses with fever, leukocytosis, valvular heart disease, or cellulitis should be given:
Broad-Spectrum antibiotics
Initial Care of:
Anorectal Abscesses
Incision and Drainage
Complicated Cases: Refer to General Surgery
The chronic manifestation of the acute perirectal process that forms an anal abscess. When the abscess ruptures or drains, an epithelialized track can form that connects the abscess in the anus or rectum with the rectal skin.
Anorectal Fistula
“Non Healing” anorectal abscess following draining
Chronic purulent discharge
Intermittent rectal pain
Anorectal Fistula
Treatment plan for Anorectal Fistula
Require higher level of care.
MEDEVAC if unstable.
Consider MEDEVAC if in pain for appropriate treatment/medications.
A malformation in the sacrococcygeal region; ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses.
Pilonidal Disease
Pilonidal sinuses or cysts occur in the midline in the:
Upper part of the natal cleft, over the sacrum and coccyx
Pilonidal sinus is formed by the:
Pentation of the skin by an ingrown hair
Pilonidal disease usually occurs before what age?
40
Symptoms:
- Swelling, pain, persistent discharge over the lower sacrum and coccyx
- Pt complains of a Tender mass
- Exam reveals inflammation midline with one or more sinus openings
Pilonidal disease
The most common finding of pilonidal disease
Single opening from which hair is protruding
Spontaneous and ongoing drainage is the common indicator and if an abscess is present it is usually:
Small
Considered diagnostic for pilonidal disease
Patient gives a history of recurrent infection at the base of spine
Labs for pilonidal disease
CBC if patient has systemic symptoms (fever, chills, etc)
Treatment for pilonidal disease
Surgical treatment
Definitive treatment for pilonidal disease
Surgical excision
Surgical excisions are typically performed __ weeks after initial infection
6 weeks
Pilonidal disease
Simple I&D’s recure because of:
Hair follicles within the sinus tracts were not debrided
Initial care of pilonidal disease
I&D with suction. In more complicated cases refer to general surgery.
Inflammatory bowel disease includes what conditions?
Ulcerative Colitis
Crohn’s diease
What influences inflammatory bowel disease?
Genetic factors
Inflammatory bowel disease
What disrupts the intestinal mucosa and leads to a chronic inflammatory process?
Immune response
Inflammation that is limited to colonic mucosa
Can have pseudo-polyps
Ulcerative Colitis
Can affect any segment of the GI tract
“Skip lesions”
Transmural inflammation
Crohn’s Disease
Crohn’s disease and ulcerative colitis may be associated in __% of patients with a number of extra-intestinal manifestations
50%
Most common portion affected by the GI tract from Crohn’s
Terminal ilium
When Crohn’s affects the ilium, what is affected?
Malabsorption of digested foods
Vitamin B12 deficiency
Malabsorption of bile salts and calcium
Crohn’s
The clinician should take particular note of:
Fevers
General sense of well-being
Weight loss
Abdominal pain
Number of liquid bowel movements per day
Surgical/hospitalization history
Crohn’s
___ of patients with large or small bowel involvement develop perianal disease
1/3
Symptoms:
Intermittent bouts of low-grade fever, diarrhea, RLQ pain
Diffuse abd pain/discomfort, RLQ mass/tenderness
Perianal diease
Crohn’s
Crohn’s
__ of cases involve the small bowel only
1/3
Crohn’s
___ of all cases involve the small bowel and colon, usually ileocolitis
Half
Strongly associated with the development of Crohn’s disease, resistance to medical therapy, and early disease relapse
Cigarette Smoking
Lab for Crohn’s disease that should be obtained in all patients to assess immune response and nutritional status
CBC and serum albumin
RADs for Crohn’s
Endoscopy
Colonoscopy
ACUTE Exacerbations: CT
Available therapies for Crohn’s
5-aminosalicylic acid derivatives (5-ASA)
Corticosteroids
Immuno-modulating and biologic agents
Crohn’s:
Tender abdominal mass with fever and leukocytosis
Diagnosis: Emergent CT
Treatment: Broad-spectrum antibiotics
Intra-abdominal abscess formation
Crohn’s:
Develop secondary to active inflammation
Precipitated by dietary indiscretion or untreated flare
Diagnosis: Up-right abdominal X-ray
Treatment: NG tube to decompress GI tract
Small bowel obstruction
Symptom that is unusual in patients with Crohn’s
Bleed/severe hemorrhage
Screening colonoscopy for patients with Crohn’s to detect cancer should be done every:
8 or more years after initial flare/diagnosis
Patients with Crohn’s are __x likely to develop colon cancer than the general population
20x
Ulcerative Colitis is limited to:
Colonic mucosa
Ulcerative Colitis is caused by:
Abnormal activation of the immune system
Ulcerative Colitis causes:
Ulceration
Edema
Bleeding (Common)
Fluid and electrolyte loss
UC that extends to the splenic flexure
Left-sided colitis
UC that extends more proximally
Extensive colitis
UC is more common in what type of patients?
Non-smokers and former smokers
Ulcerative Colitis is less severe in:
Active Smokers
Associated with reduced risk of developing ulcerative colitis
Appendectomy before the age of 20
What can mimic the symptoms of Ulcerative Colitis?
Infectious colitis (Diverticulitis)
Pertinent patient history for Ulcerative Colitis
Stool frequency and character
Presence and amount of rectal bleeding
Diffuse crampy abdominal pain
Fecal urgency
Tenesmus
Hallmark of Ulcerative Colitis
Bloody diarrhea
Symptoms:
Bloody diarrhea
Lower abdominal cramps and fecal urgency
Anemia and low serum albumin
Negative Stool cultures
Ulcerative Colitis
Ulcerative Colitis:
- Gradual onset of infrequent diarrhea (<5 a day)
- Stool is formed or loose
- Fecal urgency and tenesmus
- Cramps relieved by defecation
- No abdominal tenderness
Mild UC
Ulcerative Colitis:
-Severe diarrhea with frequent bleeding
Abdominal pain and tenderness (not severe)
Mild fever, anemia, hypoalbuminemia
Moderate UC
Ulcerative Colitis:
- More than 6 blood bowel movements per day resulting in severe anemia, hypovolemia, and impaired nutrition with hypoalbuminemia
- Abdominal pain and tenderness
Severe UC
Initial assessment of UC patient with a flair should focus on:
Volume status (BP, HR, Urine output, mental status)
Nutritional status
Labs for Ulcerative Colitis
CBC
ESR & CRP (Inflammatory studies)
Stool Bacterial culture
C Diff
Ova and Parasites
Serum Albumin
Electrolytes
What lab values reflect Ulcerative Colitis disease severity?
Hct
Sedimentation rate
Serum Albumin
RADs for Ulcerative Colitis
CT
Colonoscopy to screen for cancer (8 years post initial diagnosis)
Two main treatment objectives when treating patients with ulcerative colitis
Terminate the attack
Prevent recurrence of attacks
Medication options for UC
Mesalamine
Corticosteroid
5-ASA, Immunomodulating & biologic agents
Antidiarrheal agents (NEGATIVE for C Diff)
Curative treatment for Ulcerative Colitis
Total proctocolectomy
Treatment for mild/moderate colitis:
Treatment recommended by GI
Limit intake of caffeine and gas-producing vegetables
Treatment for severe UC
Hospitalization
Discontinue all oral intake for 24-48 hours
Restore volume with fluids
Serial abdominal exams
The physiology of sensation in the gut is:
Multifaceted
What is involved in the perception autonomic response to visceral stimulation?
5-HT (Serotonin)
Substance P
Norepinephrine
Nitric Oxide
Characterized by abdominal pain of discomfort that occurs in association with altered bowel habits
Irritable bowel syndrome (IBS)
__ months of symptoms are required to diagnose IBS
3 months
IBS is thought to occur from a combination of:
Psychosocial abnormalities
Intestinal permeability
Immune system
Nervous system
What plays a big role in the pathophysiology of IBS?
Mental Health
Symptoms:
- Being in late teens/twenties
- Abnormal stool frequency, stool form, passage
- HALLMARK: Abdominal discomfort that is relieved immediately after defecation with a otherwise normal physical exam
Irritable Bowel Syndrome
Diagnosis of IBS is abdominal discomfort or pain that has at least TWO of the THREE:
Relief with defecation
Change in stool frequency
Change in stool form
IBS-C
IBS with constipation
IBS-D
IBS with diarrhea
IBS-U
Infrequent bowel movements
IBS-M
IBS with constipation & diarrhea
Alarm symptoms of IBS
Starts at the age of >40
Nocturnal diarrhea
Severe constipation
Hematochezia
Weight loss
Fever
Family history of cancer, IBS, or Celiac disease
IBS is a diagnosis of:
Exclusion
RADs for IBS:
All patients over >50 should get:
Colonoscopy to exclude cancer
Does IBS increase risk of cancer?
No
IBS:
What is closely associating with bettering and worsening of symptoms?
Diet
IBS:
Avoid foods with:
Fat or caffeine
fiber has little value
IBS patients may benefit from a diet low in:
Fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs)
Lactose
Gluten
Drugs that can benefit IBS
Antidiarrheal/Anticonstipation
Antispasmodic (anticholinergics)
Psychotropic agents (antidepressants)
IBS
Patients with underlying psychological abnormalities should be evaluated by:
Mental Health
Patients with severe disability should be referred to:
Pain treatment center
What type of reflux episodes typically occur postprandially, short-lived, asymptomatic, and rarely occur during sleep?
Physiologic
What type of reflux is associated with symptoms or mucosal injury and often occurs nocturnally
Pathologic
GERD:
Endoscopy demonstrates abnormalities in ___ of patients
1/3
Plays a vital role in the frequency and severity of GERD
Lower Esophageal Sphincter
GERD:
Secondary to the stimulation and activation of mucosal chemoreceptors by acid
Pain
Exacerbate the symptoms of GERD
Spicy, Acidic, Salty foods
Alcohol
Heartburn occurs ___ minutes after meals and upon laying down
30-60 minutes
Atypical or extraesophageal manifestations of GERD:
Asthma
Chronic cough
Chronic Laryngitis
Sore throat
Non-Cardiac Chest pain
Condition in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells
Barrett Esophagus
The most serious complication of Barrett esophagus is:
Esophageal Adenocarcinoma
Manifested by the gradual development of solid food dysphagia progressive over months to years
Peptic Stricture
Most peptic strictures are located at the ______ junction
Gastroesophageal
RADs for complicated GERD patients
Endoscopy
Treatment for mild/intermittent symptoms
Lifestyle modifications
- Eat smaller meals
- Eliminate acidic foods
- Eliminate foods that precipitate reflux
Weight loss
Foods that precipitate reflux
Fatty foods
Chocolate
Peppermint
Alcohol
Cigarettes
Patients with nocturnal GERD should avoid lying down within __ hours after meals
3 hours
GERD Medications:
Role is limited, only used as relief of mild GERD symptoms
Antacids (-tidines)
Medications of troublesome GERD
PPI (-prazoles)
PPIs have an onset of delay of 30 minutes but relief heartburn for up to __ hours.
8 hours
When would you refer a GERD patient?
Does not resolve with maximum management of twice-daily PPI’s for 3 months
Initial Care of GERD
Eliminate the causative factor
Lifestyle modifications
Esophagitis could range from:
Pill induced
Reflux
Eosinophilic infections
Medications that cause direct esophageal mucosal injury
Antibiotics - Tetracycline, Doxycycline, Clindamycin
Anti-inflammatory medications - Aspirin
Bisphosphonates
Patients with GERD who have endoscopic evidence of esophageal inflammation
Reflux esophagitis
Infectious Esophagitis (thrush) occurs in ______ patients
Immunocompromised
Symptoms:
- Retrosternal pain/Heartburn
- Odynophagia
- Dysphagia
- Often have a history of swallowing a pill without water
Esophagitis
Pill induced esophagitis onset of symptoms occur:
Few hours to one month
Hallmark of Candida esophagitis is:
Odynophagia (pain when swallowing)
Discrete retrosternal pain
Labs for Esophagitis
CBC
Specimen culture
Swab for Candida
RADs for Esophagitis
Consider Endoscopy
Treatment for Candida esophagitis
Evaluate for: HIV, Cancer, Diabetes
Treatment for Esophagitis with fever and elevated WBC
Broad spectrum antibiotic
Most infectious esophagitis requires what to diagnose?
Endoscopy and biopsy
Promotes motility, via peristalsis, of introduced food to the stomach
Esophagus
Esophageal strictures are likely caused as a result of:
GERD
Why does stricture formation happen in patients with GERD?
To lower the volume of reflux
Reduce Symptoms
What percentage of patients with esophageal stricture is unrelated to GERD?
Examples include: Radiation, Sclerotherapy, or Caustic ingestions
25%
More commonly recognized cause of esophageal strictures, particularly in young men
Eosinophilic Esophagitis
Symptoms:
- Localized substernal chest pain
- Heartburn
- DYSPHAGIA (Hallmark)
Esophageal stricture
RADs for esophageal stricture
Endoscopy
Barium study
Treatment for mild esophageal stricture
Treat for GERD
Treatment for severe esophageal stricture
MEDEVAC for potential surgery
Esophageal stricture
Refer all patients to Gastroenterology for:
Dilation and Evaluation
Severe symptoms of Esophageal stricture
- Dysphagia
- Food impactions
- Asphyxiation
Complications of esophageal stricture
Mallory-Weiss Tear
Asphyxiation
Esophageal Paresis
Idiopathic motility disorder which causes loss of peristalsis in the distal two thirds of the esophagus and impaired relaxation of LES
Impaired inhibitory innervation, leading to premature and rapidly propagated contractions in the distal esophagus
Esophageal Spasm
Symptoms:
- Gradual onset of dysphagia
- Can be present for months
- Substernal discomfort/fullness
- Lifting neck or throwing shoulders back to enhance gastric emptying
Esophageal Spasm
RADs for Esophageal Spasm
CXR
Barium Esophagography
Endoscopy
Treatment for Esophageal Spasm
PPI if GERD is present
Eat smaller bites of food
Invasive procedures (Botox injection)
Complications of Esophageal Spasm
Asphyxiation
Dysphagia
Esophageal Dysmotility
Mallory-Weiss Tear
Peptic Stricture
Occurs when the balance between the aggressive factors and the defensive mechanisms is disrupted
Peptic ulcer
What can lead to peptic ulcers?
NSAIDs
H. pylori infection
Bile salts, acid, & pepsin
Diagnostic procedure of choice for H. pylori infection
Upper endoscopy with gastric biopsy
Break in the gastric or duodenal mucosa that arises when the normal mucosal defensive factors are impaired
Peptic Ulcer
Peptic ulcers that extend through the muscularis mucosae are over ___ in diameter
5mm
Lifetime prevalence of ulcer in the adult population is:
10%
Ulcers occur most commonly in the:
Duodenum (Five times more common)
Duodenal ulcers occur at the ages of:
30-55
Gastric ulcers occur at the age of:
55-70
Ulcers are more common in patients who:
Smoke
Chronic NSAID use
Gastric ulcers are increasing as a result of:
NSAIDs
Low-dose aspirin
Three major causes of peptic ulcer disease:
NSAIDs
Chronic H pylori infection
Acid Hypersecretory states
What should be sought in all patients with peptic ulcers?
H pylori infection
NSAID ingestion
Cofactor for the majority of duodenal and gastric ulcers not associated with NSAIDs
H pylori
Approximately __%/year of long-term NSAID users will have an ulcer that causes clinically significant dyspepsia or a serious complication
2-5%
Peptic Ulcer:
The risk of NSAID complications is greater in:
First 3 months of therapy
Prior History of ulcers
Combination with aspirin, corticosteroids, or anticoagulants
Hall mark of peptic ulcer disease
Epigastric pain (dyspepsia) -Gnawing, dull, aching, or "Hunger-like"
NOT BURNING
Peptic Ulcer:
A change from a patient’s typical rhythmic discomfort to constant or radiating pain may reflect:
Ulcer penetration or perforation
Nausea and anorexia may occur in:
Gastric Ulcers
Peptic Ulcer:
Physical exam is often:
Normal
Labs for peptic ulcer with severe pain that suggests penetration into the pancreas
Elevated serum amylase
Labs for a patient with a history of peptic ulcer or when an ulcer is diagnosed by upper GI series
H pylori with fecal antigen assay
Urea breath testing
RADs for peptic ulcers
Upper Endoscopy
Retards the rate of ulcer healing
Smoking
Treatment for Peptic Ulcers
Eat balanced meals at regular intervals
Stop taking NSAIDs
-4 to 6 week PPI Therapy
Treatment for H pylori infection Peptic Ulcers
Anti-H pylori regimen for 10-14 days
-PPI with a combination of Antibiotics
Confirm successful eradication of H pylori ulcers with urea breath test, fecal antigen test, or endoscopy with biopsy __ weeks after completion of antibiotic treatment and __ weeks after PPI treatment
4 weeks
1-2 weeks
Disposition of Peptic Ulcers
Stay on ship unless not responsive to PPI therapy
Initial care of Peptic Ulcer Disease
D/c the causative agent
Eradicate H pylori
Anatomical landmark that defines the border between the upper and lower GI track
Ligament of Treitz
Proximal to the Ligament of Treitz
Upper GI tract
Distal to the Ligament of Treitz
Lower GI tract
Most common source of lower GI Bleeding, often occult
Colon Carcinoma
Visible Blood loss
Overt
Coffee-ground hematemesis is from hemoglobin interacting with:
Gastric acid
Bright red hematemesis means the bleed is proximal to the:
Lower esophageal sphincter
Melana “tar like” stool indicates
Upper GI bleed
Hematochezia, bright red blood in stool indicates
Lower GI bleed
Two most common presentations of upper GI bleed
Hematemesis
Melana
Melena develops after as little as __mL of blood
50mL
Upper GI bleeds can present with hematochezia if:
The bleed is massive (>1000mL)
RADs, gold standard for Upper GI bleed
Upper endoscopy
Hematocrit takes ___ hours to equilibrate
24-72 hours
Labs for Upper/Lower GI Bleed
CBC
PT/PTT
INR
Upper GI Bleed:
- Diagnostic and therapeutic
- Should be done on all patients with active upper GI bleed
NG tube
Confirms upper GI source of bleeding
Aspiration of red blood or “coffee grounds”
GI Bleed:
<100 SBP
Severe blood loss (30-40%)
GI bleed:
HR >100
SBP >100
Moderate blood loss (15-29%)
The gold standard medication of choice for severe bleeds
PPIs
Upper GI bleeding is self-limited in __% of patients
80%
Common causes of lower GI Bleeding
Diverticulitis
Inflammatory bowel disease (UC > Crohn’s)
Anorectal Disease
Hemorrhoids
Fissures
Large volumes of bright red blood sugggest:
Colonic source
Marron stools imply a lesion in the:
Right colon or small intestine
Black tarry stools predict a source ______ to the ligament of Treitz
Proximal
Management of lower GI Bleed
Initial stabilization, blood replacement, and triage
Colonoscopy
Two conditions that may result in an upper GI Bleed
Mallory-Weiss
Boerhaave Syndrome
Characterized by a non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction
Mallory-Weiss
Severe laceration of the anterior esophagus associated with a full perforation of the esophagus into the mediastinum
Boerhaave’s syndrome
Mallory-Weiss and Boerhaave’s Syndrome:
Patient will typically be a:
Heavy alcohol user
Boerhaave’s syndrome
Crunching sound heard on auscultation of the mediastinum
Hartman’s sign
Boerhaave’s chest X-ray findings
Mediastinal air
Treatment for Mallory-Weiss
NPO
IV PPI
IV/IM Antiemetic
Treatment for Boerhaave’s Syndrome:
NPO
IV PPI
IV/IM Antiemetic
ANTIBIOTICS (IV)
Disposition for Mallory-Wiess and Boerhaave Syndrome
MEDEVAC
Surgical evaluation
Sac-like protrusion of the colonic wall
Diverticula (-lum)
Diverticulosis is defined by the presence of:
Diverticula (sacs)
Diverticular bleeding is characterized by painless hematochezia due to:
Weakness of the vasa recta
Inflammation of a diverticulum is caused by:
Small pockets fill with stagnant fecal material and become inflammed
Diverticulitis can lead to disease which can then lead to:
Perforation (micro is the most common)
Symptoms:
- Low grade fever
- LLQ tenderness and a possible palpable mass
- Leukocytosis is mild to moderate
Diverticulitis
Labs for Diverticulitis
CBC w/ Diff
Occult blood
Diverticulitis:
Treatment for patients with mild symptoms and no peritoneal signs
Clear liquid diet
Dual Therapy Antibiotics
Diverticulitis:
Symptomatic improvement occurs __ days from starting antibiotics
3
Diverticulitis recurs in __% if patients treated with medical management
10-30%
Disposition:
Diverticulitis
MEDEVAC
Most common abdominal surgical emergency
Appendicitis
Appendicitis is most common between what ages?
20-35
Appendix is found at the:
Base of the cecum
Located one third of the distance from the right anterior superior iliac spine to the umbilicus
McBurney’s Point
Believed to be involved with the development of intestinal bacterial flora
Appendix
Appendicitis typically manifest from:
Blockage of the lumen
Most common appendix luminal blockage
Fecalith
Obturator sign is a positive test for:
Inflamed appendix deep in the pelvis
Psoas sign is positive for
Retro-cecal appendix
Atypical symptoms of appendicitis
Pain in the flank
Lower back pain
Groin pain (very thin females)
Tenesmus
Non-specific lower abdominal pain
Gold standard for diagnosis of appendicitis is:
CT scan of the abdomen
Labs for appendicitis
CBC
Fecal occult blood
UA
Bile is made in the:
Liver
Bile is stored in the:
Gallbladder
In response to fat entering the proximal small intestine, bile is ejected from the gallbladder into the:
Cystic duct
Bile flows from the cystic duct into the:
Common bile duct
Bile flows from the common bile duct into the:
Duodenum
Bile works in the duodenum to:
Emulsify fats
Bile is reabsorbed into circulation in the:
Terminal ilium (distal small intestine)
Without bile, fats would aggregate to form large:
Hydrophobic micelles
Bile is composed of:
Bile salts
Cholesterol & Bilirubin
Most common form of Gallstones
Cholesterol gallstones
Situations that raise cholesterol (gallstones)
Increased estrogen (pregnancy)
Increased circulating cholesterol
- Diet
- Rapid weight loss
Pigmented gallstones are formed by:
Precipitation of bilirubin
What will happen if the amount of cholesterol or bilirubin present in the gallbladder exceeds the amount of bile salts needed to dissolve it?
Precipitates (stones) form
Disease processes that can occur from stones occluding ducts within the biliary tract
Asymptomatic Cholelithiasis
Biliary Colic
Cholecystitis
Choledocholithiasis
Cholangitis
Gallstones are present but patient does not have any symptoms
Asymptomatic cholelithiasis
__% of individuals with gallstones will be asymptomatic their entire life
80%
Gallstones are present and intermittently obstruct the lumen of the cystic duct
Symptoms last less than 6 hours
Biliary Colic
Inflammation of the gallbladder
Usually from a gallstone permanently lodged in the cystic duct
Symptoms last longer than 6 hours
Cholecystitis
Inflammation of the gallbladder caused by obstruction of the common bile duct
Patients may show jaundice
Choledocholithiasis
Bacterial infection of the biliary tract
RUQ pain
Fever
Jaundice
Cholangitis
Charcot’s Triad
RUQ Pain
Fever
Jaundice
Management of biliary colic
Recommend a change in diet
Cholecystitis
Associated with gallstones in over __% of the cases
90%
Cholecystitis
10% is caused by:
Acalculous cholecystitis and infectious agent
No radiologic evidence of gallstones
Had a major surgery within the past 2-4 weeks
NPO due to critical condition
Acalculous Cholecystitis
6 F’s of cholecystitis/choledocholithiasis
Fat, fertile, 40, Female
Flatulence, Fever
Sudden onset of RUQ pain after eating a meal high in fat
Murphy’s sign
Palpable gallbladder (15% of cases)
Cholecystitis
Labs for cholecystitis
CBC
LFTs
Lipase (rule out pancreatitis)
Bilirubin (elevated, dx with choledocholithiasis)
Gold standard imaging for cholecystitis
RUQ Ultrasound
Why is a CT not indicated for cholecystitis?
Cholesterol gallstones are radiolucent and tend to not be visible
Cholecystitis
Continuous symptoms for >24 hours suggests possible:
Necrosis of the gallbladder
Necrosis of the gallbladder may develop without definite signs in:
Obese, Diabetic, Elderly, Immunosuppressed
Mainstay treatment for cholecystitis
Cholecystectomy
IV Antibiotics
Patients treated with conservative management will require cholecystectomy __ days after initial presentation
2-4
Gallstone obstructing the common bile duct (CBD) causing inflammation of the gallbladder
Backed of bilirubin caused jaundice
Choledocholithiasis
Bacterial infection of the common bile duct
Cholangitis
Typical infectious organism that causes cholangitis
E. Coli
Cholangitis patients will present with:
Charcot’s Triad
- Fever
- RUQ Px
- Jaundice
Disposition for Cholangitis
IV antibiotics
MEDEVAC
Produces enzymes that are released into the duodenum via the common bile duct
Produces hormones that are secreted into the vascular system
Pancreas
Most common causes of pancreatitis
Alcohol
Gallstones
Other
Causes auto-activation of pancreatic enzymes while still in the pancreas resulting in enzymatic destruction of pancreas
Alcohol
Can obstruct the ampulla of Vater, causing impaired extrusion of enzymes into the duodenum. Leads to auto-digestion of pancreas tissue
Gallstones
Patient presentation:
History of cholelithiasis and/or cholecystitis treated without surgery
History of alcoholism
Similar episodes of pain
Pancreatitis
Symptoms:
- Abrupt onset
- Steady, boring, severe abdominal pain - worse when walking and laying down
- Relief when sitting upright and leaning forward
- Mild jaundice
- Nausea and vomiting
- Weakness, fever, anxiety
- Grey-Turner and Cullen’s sign in severe disease
- Possible upper abdominal mass
Pancreatitis
Labs for pancreatitis:
CBC (Leukocytosis)
Gold standard: Elevated serum Lipase is diagnostic
- UA
- Glucometer: Hyperglycemia
- Elevated Serum lactate
- Elevated aspartate
Gold standard imaging for pancreatitis
CT
Gold standard treatment for uncomplicated pancreatitis
NPO & Aggressive fluid resuscitation
Disposition of pancreatitis
Fluids
Pain control
MEDEVAC
What makes up the inguinal canal
Inguinal ligament
External inguinal ring
Internal inguinal ring
Hasselbach’s triangle (Inguinal triangle)
Inferior epigastric vessels
Lateral aspect of the Rectus Abdominis
Inguinal Ligament
Protrusion of any body part through a cavity
Hernia
Most common type of hernias (75-80%)
Inguinal Hernias
Two main types of Inguinal hernias
Direct (Directly through Hasselbach’s triangle)
Indirect (inguinal canal)
What side is more common in indirect inguinal hernias?
Right
All hernias have the ability to present with signs and symptoms of:
Small Bowel Obstruction
Lower anterior abdominal mass
Direct hernia
Scrotal mass
Indirect hernia
Out-y belly button
Umbilical hernia
“Turn your head and cough” checks for:
Inguinal canal hernias
Labs for Hernia
CBC (incarceration/strangulation)
CMP (hydration and toxicity levels)
UA
Hernia Imaging
CT and US may benefit before surgery
What kind of hernias require immediate attention?
Incarcerated
Hernia treatment if strangulation is suspected or shock is present
Broad-spectrum IV antibiotics and fluid resuscitation
Hernia:
Place patient in supine Trendelenburg
Administer Narcotic for analgesia
Administer Diazepam for muscle relaxation
Allow for passive reduction
Closed Passive Reduction technique
Disposition for irreducible incarcerated hernia - all ages
MEDEVAC for immediate surgical eval/repair
Disposition for reducible hernias
Refer to general surgery
Avoid heavy lifting
Two main subcategories of intestinal obstruction
Mechanical
Paralytic ileus
A physical blockage of the intestinal tract
Mechanical obstruction
Dysfunction of the intestinal tracts ability to move bowel contents through its lumen
Paralytic ileus
Two most common causes of small bowel obstruciton
Adhesions (most common)
Hernias
Symptoms:
- Crampy, intermittent abdominal pain
- Urge to move
- Distention
- Vomiting
- Constipation, bloating
- Tympany on percussion
- High-pitched bowel sounds (rushes)
Mechanical Bowel obstruction
Bowel Obstruction Symptoms:
- Less intense pain that is more constant
- Constipated
- Diminished bowel sounds
Paralytic ileus or Large Bowel (colon)
Labs for Bowel obstruction
CBC
CMP
Gold standard imaging for bowel obstruction
Upright abdominal X-Ray
Management and treatment for bowel obstruction
NPO
NG Tube
Two IV sites with aggressive fluid resuscitation
MECHANICAL: IV Antibiotics
__% of completely obstructed SBO patients will fail conservative therapy
60%
Almost all Large bowel obstructions are caused intrinsically from:
Adenocarcinoma
Inflammation of the localized or generalized peritoneum
Peritonitis
Inflammation of the peritoneal surface without another intra-abdominal process
Also known as Spontaneous Bacterial Peritonitis (SBP)
Primary Peritonitis
Lines the outer portions of all intra-abdominal organs
Visceral peritoneam
Lines the interior portion of the abdominal wall
Parietal Peritoneum
Posterior to the posterior parietal peritoneal membrane
Retroperitoneal Space
“Acute abdomen” or “Surgical abdomen”
Indicates severe intra-abdominal infection
Peritonitis of the entire peritoneum
Most common causes of acute peritonitis
Perforated Appendicitis
Perforated Diverticulitis
Pancreatitis
Patient Presents:
- Fetal positions or supine with legs bent (or on pillow)
- DO NOT want to move (unlike obstructive bowel)
- Board like abdomen
- Absent bowel sounds in all 4 quadrants
Peritonitis
Labs for peritonitis
CBC w/ Diff
UA
Blood Culture
Female: HCG
RADs for peritonitis
Upright Abdominal X-ray
Abdominal CT
All patients with suspected peritonitis need:
Antibiotics
Disposition for Peritonitis
IV Antibiotics
IV fluids and NPO
Pain control (Morphine)
MEDEVAC
Three regions of the abdomen
Intrathoracic
True abdomen
Retropertioneal
What organs are in the intrathoracic abdomen?
Liver, Gallbladder, Spleen, Stomach, Transverse Colon
Any penetrating injury at or below the __th intercostal space is suspected to be in the abdomen
4th
Organs in the True Abdomen
Large and small intestine
Portion of the liver and the bladder
(females: uterus, fallopian tubes, ovaries)
Organs in the retroperitoneal
SADPUCKER
Suprarenal (adrenal) gland Aorta Duodenum Pancreas Ureters Colon Kidneys Esophagus Rectum
Common injuries with a direct blow (blunt)
Splenic rupture and liver fractures
Common injuries in deceleration injury from MVA’s or falls (Blunt)
Duodenal and aortic rupture
The sum of the number of bullet wounds and actual bullets seen on diagnostic imaging should always be an even number
“Bullet Rule”
Momentum transmitted to neighboring organ due to changing bullet velocities caused by tissue density variation
Blast effect
Abdominal trauma:
All patients should get:
DRE for blood and rectal tone
Labs for abdominal trauma
CBC/Diff
UA
Fecal Occult Blood
Type and screen
Females: HCG
