Geri GI Flashcards
what is GERD?
Retrograde movement of stomach contents into esophagus secondary to transient relaxation of LES (incompetency)
causes of GERD?
- Sliding hiatal hernia (hernia of stomach thru diaphragm)
- Reduced LES pressure
- Reduced pinching action of Crus of Diaphragm
what are factors that aggravate GERD sx’s?
- Large meals
- Fatty foods
- Caffeine
- ETOH/smoking
- Obesity
- Supine after eating
what are the typical sx’s of GERD?
- Substernal burning with radiation to mouth/throat
- Sour tasting regurg
what are the atypical sx’s of GERD?
- Chronic cough
- Difficult-to-control asthma
- Laryngitis/hoarseness
- Recurrent chest pain
when is upper EGD done for dx of GERD?
in ALL pts w/new-onset GERD:
- > 50 y/o
- persistent/incomplete resolution of sx’s despite medical tx
- hx of acid reflux >5 years
how do you dx pts with atypical sx’s of GERD?
24hr pH probe after neg work-up
what other causes of atypical sx’s of GERD must be r/o?
Inferior MI, ACS, Aortic dissection, pulmonary disease
what are complications of GERD?
- Esophagitis
- Esophageal ulceration
- Bleeding
- Strictures
- Barrett esophagus
- Esophageal adenocarcinoma
pharmacologic tx of GERD?
PPIs and H2 receptor blocks (Famotidine, Ranitidine) - BEST AT NIGHT
Antacid liquids or tablets (temporary)
-Mylanta, Maalox, Tums, Rolaids
who is surgical tx for GERD reserved for? what is the surgery?
pts w/severe refractory GERD w/ complications
LAPAROSCOPIC FUNDOPLICATION - wrap upper part of stomach around LES to strength the sphincter, prevent acid reflux, and repair hiatal hernia
what is diverticulitis?
inflammation d/t micro perforation of a diverticulum
what is the MOST COMMON sx of diverticulitis?
LLQ Abdominal Pain (d/t involvement of sigmoid colon)
what is the pain like in diverticulitis?
CONSTANT (present for several days prior to presentation)
what is complicated diverticulitis?
Diverticulitis with:
- abscess
- obstruction
- fistula
- perforation (have peritoneal sx’s)
what may DRE and stool reveal for diverticulitis?
DRE may reveal mass in presence of a distal sigmoid abscess
Stool may be positive for occult blood
labs for diverticulitis
serum amylase and lipase normal or mildly elevated
UA reveals sterile pyuria d/t adjacent inflammation
what does presence of colonic flora on Ucx for diverticulitis suggest?
presence of a colovesical fistula
what is the imaging for diverticulitis?
CT scan w/PO contrast
what will you see on CT scan w/PO contrast for diverticulitis?
- Localized bowel wall thickening (>4mm)
- Increase in soft tissue density w/in pericolonic fat secondary to inflammation or fat stranding
- Presence of colonic diverticula
what are complications of diverticulitis?
abscesses
Bowel obstruction (dilated loops of bowel w/ air-fluid levels with pericolonic inflammation -> FAT STRANDING)
what is the tx of mild diverticulitis?
IV abx (for GN and anaerobic pathogens) until inflammation stabilized and pain/tenderness resolving (2-5 days)
Transition to PO abx (Cipro + Metro or Augmentin) for 10-14 days
Hospitalize if no improvmeent
tx for complicated diverticulitis?
surgery
what are the surgery indications for complicated diverticulitis?
- Failed med management
- Recurrent episodes of acute diverticulitis
- Peritonitis
- Failed percutaneous drainage of abscess
- Enterocutaneous fistula formation
- Bowel obstruction
what is the definition of constipation? seen in who?
Infrequent and/or unsatisfactory defecation < 3 times/week
> 65 y/o women
how long must sx’s of constipation be present for dx of CHRONIC constipation?
presence of sx’s for at least 12 weeks
is constipation a disease?
NO!!! IT’S A SYMPTOM
what are causes of constipation?
Changes in neuromuscular control of colon predispose to constipation (may occur with bed rest or constipating meds)
Passing hard stools or straining, incomplete or painful defecation
Hypothyroidism, Colon Cancer
disorders that are risk factors for constipation?
- Malignancy (colon ca)
- Endocrine/metabolic (DM, hypothyroidism, hypercalcemia, hypokalemia)
- Neuro d/o (Parkinson’s, diabetic autonomic neuropathy, spinal cord injury, dementia, stroke)
- Rheumatologic d/o (systemic sclerosis and other connective tissue d/o)
- Psych d/o (depression or eating d/o)
- Anatomic dysfxn (strictures, postsurgical abnormalities, anal fissures, megacolon, hemorrhoids
what are general risk factors for constipation?
- Female, >65 y/o
- Low caloric intake
- ***Polypharmacy
- Sedentary lifestyle
- Ignoring urge to defecate/chronic fecal retention
- Abnormal responses of the pelvic floor muscles during defecation
- Blunted rectal sensation
sx’s of constipation?
Bloating, fullness, and incomplete evacuation
Infrequent defecation, difficulty passing stool
what are ALARM SX’S of constipation?
- Hematochezia
- Fam hx of colon ca/IBD
- Anemia
- Pos. fecal occult blood test
- Unexplained weight loss >10lbs
- Constipation refractory to tx
- New-onset constipation w/out evidence of potential primary cause
what do you evaluate to dx constipation?
- Duration of sx’s
- Freq/consistency of stools
- Presence of excessive straining
- Feeling of incomplete evacuation
- Use of manual maneuvers during defecation
- Potential organic causes or drug rxn
Abdominal X-ray showing significant stool retention in colon suggests dx of what?
megacolon
if pt has alarm sx’s of constipation, what imaging should be done promptly?
abd CT
if pt with constipation is stable, how do you evaluate them?
with colonoscopy
what studies are used in pts w/infrequent defecation?
Marker studies/colonic transit studies
tx for pts with constipation and normal colonic transit time?
- Fluids, Dietary fibers (recommended 20-35g/day)
- Pts who don’t tolerate fiber require laxatives
- Stimulant laxatives: bisacodyl and senna
- Stool softener: Colace
Softeneruppers
what are the Softeneruppers?
Bulk agents: psyllium, methylcellulose, calcium polycarbophil, wheat dextrin
Nonabsorbed substances: PEG 3350, lactulose, MG salts
tx for pts with constipation and slow colonic transit time?
Osmotic laxatives, sorbitol, lactulose or polyethylene glycol
Probiotics may promote colonic mucosal health
Moveralongers
- stimulants: bisacodyl, Senna
- secretory drugs: lubiprostone, linaclotide
when is disimpaction done for tx of constipation?
before polyethylene glycol solution and/or enemas
maintenance for tx of constipation?
- Scheduled toileting after breakfast
- Add fiber supplements to regulate bowel havits and prevent constipation
- Regular use of a stimulant laxative such as senna or Dulcolax
what is the definition of diarrhea? based up presence of what?
Decr in fecal consistency lasting >4wks
Based upon presence of excessive stool freq
what is the cause of ACUTE diarrhea?
Infectious cause
-C. diff colitis
what are the causes of CHRONIC diarrhea?
- Fecal impaction
- IBS
- IBC (CD, UC)
- Malabsorption syndromes
- Chronic infections
- Colon CA
what are sx’s of diarrhea?
- recent weight loss
- bloating or gas (celiac disease/small bowel overgrowth)
- recent abx use/hospitalization (C. diff)
- mouth ulcers, skin rash, anal tissue or fistula (IBD)
- malabsorption (wasting, anemia, scars, from prior abd surgery)
- lymphadenopathy (infection)-a
- abnormal anal sphincter pressure/reflexes (fecal incontinence)
dx of acute diarrhea
stool cx to exclude infection (usually viral like rotavirus and Norwalk)
C. diff toxin assay (toxin A and toxin B) -> only if recent abx use
dx of chronic diarrhea
Colonoscopy in pts w/hx of weight loss, bloody diarrhea, and diarrhea lasting >4 weeks
Breath hydrogen/methane test in pts suspected to have small bowel bacterial overgrowth (confirms early fermentation of ingested sugars in small bowel)
Qualitative or quantitative stool fat for steatorrhea
TSH
how do you treat diarrhea if no acute infection/no blood in stool?
Loperamide or Bismuth subsalicylate
what meds should be avoided in C. diff colitis and why?
***Antidiarrheal agents should be avoided in C. diff colitis b/c of risk of precipitating ileus and megacolon
careful with what agents in elderly for diarrhea?
anti motility agents (ex: Lomotil) b/c has cholinergic effect
tx for diarrhea w/ mild small bowel overgrowth?
bismuth-containing meds
tx for diarrhea w/ severe small bowel overgrowth?
Cipro
Neomycin, Rifaxamin for 14-21 days
what is the definition of fecal incontinence?
Continuous/recurrent uncontrolled passage of fecal material for at least 1 month
what is the 2nd leading cause of nursing home placement?
fecal incontinence
50% in SNF pts
what are some contributing factors to fecal incontinence?
- dysfxn of internal or external anorectal sphincters
- pudendal nerve injury
- rectal prolpase
- immobility
what are the 4 types of fecal incontinence
(1) Passive incontinence
(2) Urgency incontinence
(3) Acute
(4) Intermittent incontinence
what is Passive fecal incontinence?
leakage of small quantities of liquid or solid stool w/out awareness
what is Urgency incontinence?
frequent urge to defecate, followed by passage of small quantities of liquid stool w/or w/out mucus or blood
what is Acute fecal incontinence?
diarrhea
what is Intermittent fecal incontinence?
in pts with dementia, delirium, pelvic floor denervation, or excessive laxative use
what are some sx’s of fecal incontinence?
abd tenderness, bloating, distention, presence of hard stool in rectal vault (all may indicate fecal impaction)
rectal prolapse or proposing hemorrhoids
Dementia/delirium based on MS exam (loss of self-toileting)
Absence of anal sphincter tone/wink (denervation of pudendal nerve from spinal cord lesion)
what does absence of anal sphincter tone/wink mean?
denervation of pudendal nerve from spinal cord lesion
dx of fecal incontinence
DRE (detects sphincter tone or presence of mass)
Abd plain film (fecal impaction)
Abd X-ray or CT (high impactions)
Spinal MRI (acute onset passive incontinence to r/o cord compression)
COLONOSCOPY (mechanical cause)
tx of fecal incontinence?
Disimpaction, bowel cleansing, hydrate, move more, no constipating meds, scheduled toiling after breakfast
where do hemorrhoids arise from?
Arise from plexus of dilated arteriovenous channels/cushion and connective tissue
why are external hemorrhoids painful?
contain somatic pain receptors and can thrombose
most hemorrhoids are what for sx’s?
asymptomatic
sx’s of symptomatic hemorrhoids?
- Hematochezia
- Pain
- Perianal pruritus
- Fecal soilage
MOST COMMON sx’s of hemorrhoids?
irritation/itching of perianal skin
PAINLESS BLEEDING associated w/BM (BRB)
how do you dx hemorrhoids?
Anoscopy or DRE ore just look
- BRBPR
- eval anal canal and distal rectum
when do you suspect thromboses hemorrhoid?
when hemorrhoids not detected on DRE
when do you do Flex sig or colonoscopy evaluation for hemorrhoids?
Flex sig or colonoscopy in pts >40 y/o, based on presence of associated sx’s and RF’s for colorectal cancer
what are the 4 grades of internal hemorrhoids?
Grade 1: see on anoscopy, bulges into lumen, but no prolapse
Grade 2: prolapses with defecation/straining but reduce spontaneously
Grade 3: prolapse out of anal canal with defecation/straining, but require manual reduction
Grade 4: irreducible and may strangulate
what is the tx of hemorrhoids?
fiber (psyllium or methylcellulose)
analgesics (topical ointments elective for relieving acute pain)
venoactive agents
antispasmodic agents (top .5% Nitro ointment to reduce internal anal sphincter spasm)
what is the surgery for bleeding internal hemorrhoids? what is not treated with this surgery? can also do what tx?
- **Rubber band ligation
- External tags and ext. hemorrhoids NOT treated with this
can also do Sclerotherapy
