Gastrointestinal problems Flashcards
Abdominal pain
visceral=in organs, dull and pain poorly localized
Parietal pain-sharp and well localized
RUQ
chest cavity liver gallbladder stomach bowel right kidney
LUQ
pancreas
left kidney
spleen
heart and chest cavity
RLQ
Appendix bowel right ureter perlvis ovary
LLQ
bowel-diverticulitis
ureter
pelvis
Appendicitis
Good oral history/OLDCARTS
Get consult when:BWAD
blood in stool
weight loss
anemia
dysphagia
Appeddicitis
obstruction of appendix with feces, inflammation, or stricture
occurs in all age groups-more common in males 10-30
higher mortality in complications of children and those over 55
leading cause of surgery in abdomen
Appedicitis-S/S
Acute onset of periumbilcal or epi-gastric pain
Anorexia, n/v
Shifting of pain to right lower quadrant
McBurneys point after several hours
aggravated by coughing/walking
pain may be in testicles, spasm, contipation more so than diarrhea
appendicitis-after 24 hours
if perforates may have sudden cessation of pain, abdominal rigidity, high fever, vominting, dehydration, decreased bowel sounds, shock
appendicitis- physicla findings before perforation
fever
abdominal rigidity, point and rebound tenderness in RLQ, decreased bowel sounds, +psoas and obturator signs
rectal exam-tenderness in right perirectal area
Psoas-
pain when lifting right leg against pressure
Obturator sign
positive when hip and knee is flexed and rotate right leg into the inside
Appendicitis labs
CBC with diff-leukocytosis with increased band cells (shift to the left)
C-reactive protein (normal after 24 hours would mean NO appendicitis)
Urinalysis
HCG-ectopic
abdominal ultrasound- if uncertain
Appedicitis
Mayy reveal mass when doing rectal exam and it will be tender, refer to surgeon
Nausea and Vomiting
Caused by: GI, PUD, CNS (motion sickness)
systemic-pregnancy, food poisoning
Iatrogenic-meds, bulemia
NO lab if no systemic S/S and duration is <24 hrs
N/V
No solids for 4 hours, clear liquids gradually increase
N/V-medications
Phergen-generalized n/v bismuth subsalicylate-pepto bismal-n/v Transdermal scope-motion sickness Benzamides-due to reflux, diabetes phenothiazines-sever nausea & vomiting Chemo-5-HT (serotonin rec antagonists dopamine, cannabinoids,benzodiazepines, and antihistaines and anticholinergic agents for motion sickness and migraines
N/V during pregnancy
Reglan- Class B
zofran-Class B
Complimentary-ginger, B6
Consult if persists over 24 hours
Constipation
Medications that cause constipation are anticholinergics, calcium channel blockers, diuretics, antacids
Constipation
2 of the following for 3 months and 6 months previous to that
fewer than 3 movements per week, hard lumpy stools, sensation of straining, feeling of incomplete evacuation, obstruction,
Constipation
caused by hypothyroidism, DM, slow transit, pelvic floor dysfuntion
Constipation lab studies
urnialysis stool occult for blood TSH CBC and differential Chemistry profile stool culture
Constipation
lifestyle changes bulk forming laxatives stool softners osmotic laxatives stimulant laxatives chloride channel activators
IBS
Functional disturbance of intestinal motility
diarrhea or constipation
influenced by emotional factors
IBS- relieved abdominal discomfort by pasage of stool or associated with diarrhe, constipation, or mucus in stool
young adulthood, no blood in stool
IBS
3x per month for 3 months begining 6 mos prior to dx
dx of exclusion
abdomen - mild abdominal tenderness
ROME III Diagnositc criteria
must have two or more of the following: improvement with defecation, onset associated with change in frequency (less than 3 BMs per week or more than 3 per day) onset associated with change in appearance (lumpy hard or loose and watery) One or more on 25% of the time Abnormal stool abnormal passage stool form bloating or distention mucous in stool loose stools Must be present for 6 mos prior to dx at least e days per mo for 3 mos.
Constipation or Diarrhea will affect the education
Abdominal pain must be present
IBS
Usually unremarkable exam . mild abdominal tenderness, normal or mild hyperactive bowel sounds
IBS labs
CBC, sed rate, blood chemistry, TSG Stool occult Fecal leukocytes Pts > 50 colonoscopy Pts <50 sigmoidoscopy Rule out lactose intolerance
How to rule out lactose intolerance
Intolerance with a two week lactose free dite OR drink a quart ofmilk and check for symptoms/hydrogen breath testing
IBS-constipation Tx
High fiber diet
bulking agents
drug therapy for sever symptoms-1/3rd
IBS-diarrhea
Antispasmodics-Bentyl or Hyoscomine
Immodium
Anti-depressants SSRIs
Behavioral therapy, etc
IBS constipation
Miralax, therapy, SSRIs, etc.
IBS education
Sit on toilet after breakfast every morning for 20 minutes
Meds and lifestyle
Watch for blood, fever, unintentional weight loss and then refer
Regular Diarrhea
No labs if under 48 hours and no s/s
Stop all soldis for 12-24 hours, rehydrate
kaopectate of pepto bismol for symtomatic relief, Donnatol for cracmping
Infectious diarrhea
Most is viral
Antibiotics if fecal leukocytes, occult blood, fever with watery diarrhea or symptoms > a week (salmonella, campy, shigella)
Give Cipro 500 mg every 12 hours orally 1-3 days in adults.
No antimotility drugs if fecal leukocytes or blood in stools
none
C-difficile
Metronidazole 500 mg 3x/day for 10-14 days or vancomycin
Travelers Diarrhea
Antibiotics if fecal leukocytes, occult blood, fever with watery diarrhea or symptoms great than 1 week (usually salmonella, shigella, campylobactor
Cipro
No antimotility drugs if fecal leukocytes or blood in stools
Slows the bug from excreting form the body.
Diarrhea over 2 weeks consider giardia
Tx with flagyl
Dyspepsia and heartburn
disturbed digestion GERD
GERD
Daily presence of heartburn, 10% in normal adults, is a defect in esophageal motility
GERD
retrosternal aching or burning occurring 30-60 minutes after eating and associated with large meals and aggravated by lying down-can mimic angina with heavy chest and pressure daiating down to the neck or jaw or shoulders-regurgitation of food particles, nonturnal aspiration can cause pneumonia or bronchospasm
GERD-physical findings
epigastric tenderness, stool for occult blood have them do at home. Dysphagia with weight loss, loss of dental enamal from acid
GERD labs
Usually dx by history
Endoscopy indicated if
>50 with sudden onset
does not respond to therapy
alarm symptoms (bleeding, anemia, dysphagia, odynophagia
long standing symptoms at risk for barretts esophagus
GERD Management
lifestyle modification
PPI x 8 weeks and if no response then endoscopy
Follow up 2-4 weeks
Treat with antacids first then PPI’s
GERD differentials
Angina
PUD
gastritis
heart attack
GERD
Decrease meal size smoking cessation reduce alcohol consumption reduce carbonated drinks redeuce fat weight loss
GERD labs
if indicated CBC and stool occult. Usually only after meds dont work
Barretts esophagus can lead to caner
If PPI’s don’t work refer
Causes of negative blood in melena
iron, pepto, licorice
Jaundice
elevated aspartate aminotransferase (AST) and alamine aminotransferase (ALT) are indicate hepatocyte damage
jaundice
ALT is usually higher in viral hepatitis
In alcoholic hepatitis the AST may be higher
AST ratio with ALT over 2
indicates cirrohsis and alcohol problem
Alkaline phosphatase is found in the liver (alp-1 and the bone alp-2)
Elevated in a teen means bone growth. Could be fetal bone growth
elevated alkaline phosphatase
cirrohsis or cholecstasis, obstructive liver disease
gamma glutamyl transferase (GTT)
May determine the cause of elevated ALP
ALP and GTT are elevated in disease of the bile ducts
and in some liver diseases
Only ALP will be elevated in bone disease
If GTT is normal and a high ALP it is most likely bone disease
ALP is up in bone disease
Got that !!
Peptic Ulcer Disease
ulceration of the GI mucosa
bathesd by acid pepsi, stomach, and esophagus
PUD
H. pylori
NSAID usage
PUD aggravating factors
severe trauma, burns. shock
alcohol and nicotine use
presence of cirrohsis, chronic pancratitis
famiy hx
PUD
80% are duodenal
PUD s/s
intermittent epigastric pain
begins 1-3 hours after eating, awakens a person at night
pain relieved by food
They eat then feel better
If its a gastric ulcer
people get skinny and don’t like to eat.
PUD dx
pain-food-relief pattern
PUD Dx
limited to epi tenderness
include rectal exam and testing for occult blood
CBC with diff-could be anemia
H. pylori testing
H. Pylori testing
serum culture
breath test
fecal antigen test
serum culture will not tell if previous or now
Next two test can only be done if not PPI’s for a week previous
PUD
Endoscopy in pt over 50. Do if two week PPI shows no improvement
to locate bleeding site in those with dx or suspected blood loss
Management of PUD
relieve symptoms stop smoking avoid nsaids reduce stress reduce alcohol and caffeine
PUD medication
1st line PPIs most potent, but expensive
H2RA’s 4-6 weeks then nightly pm x 1yr
H. Pylori
PPI twice daily 10-14 days
Clarithromycin 500 mg/twice a day
Amoxicillin 1000mg/twice/day
PUD education
no evidence for bland diet
encourage avoidance of known gastric acid stimulants, coffe, soda
stress reduction
report lack of response, rectal bleeding, weight loss, increased weakness or dizziness
PUD f/u
1-2 weeks to check on response to meds, GI bleeding, toxic side effects of meds
Diverticulitis
Inflammation of the diverticuli occurs in 25% of population Increases after 45 MOre in women and low fiber diets mostly in sigmoid colon 15% will develop complications
Diverticulitis
acute lower left quadrant pain-steady and severe or crampy and lasts for days constipation more usual than diarrhea pain increased with defecation flatulence N/v low grade fever
Diverticulitis findings
mild fever, tachycardia guarding rebound tenderness rigidity over LLQ tender palable mass if abcess has formed
Diverticulitis Dx labs
CBC with slight leukocytes urinalysis-wbc Stool for occult blood plain abdominal films if no response to tx CT scan colonoscopy after acute phase
Diverticulitis Tx
clear liquids for 2-3 days
Metronidazole 500 bid AND
Cipro 500 mg BID 7-14 days of Bactrim or Augmentin
If moderate or severe will require hospitilization
Diverticulitis
Should be better in 1-2 days or refer
Diverticulitis
After acute phase, gradually increase fiber, avoid laxatives, use bulk forming agents
F/U in 24-48 hrs and again after antx therapy
Acute pancreatitis
Severe abdominal pain, poorly localized, frequently radiates to the back
rebound tenderness
Pancreatitis
Cullens and Grey turners can be seen in sever cases. rare but loooks like bluing in the flank area
Pancreatitis- labs
Serum amylase is the most common test Rises 6-12 hours after onset and then normal in 3-5 days. A three fold serum lipase elevation is more diagnostic and is elevated in both alcoholic and non alcoholic pancreatitis Chem 7, bun creatinine tryipsynogin C-reactive protein TSH
pancreatitis
abnormal CT scan is useful
Refer to gastroenterologist
