GI Flashcards
Patients in whom abd pain is particular concern
Very old, very young, HIV+, immunosuppresed
What kind of abd pain is most common>
Visceral
What does visceral pain feel like>
Vague, dull, nauseating, poorly localized. Worse with distention and contraction.
What are foregut structures? Where do they cause pain?
Stomach, duodenum, liver, pancreas; cause upper abd pain
What are midgut structures? Where do they cause pain?
Small bowel, proximal colon, appendix; cause periumbilical pain
What are hindgut structures? Where do they cause pain?
Distal colon, GU tract; cause lower abd pain
Diseases that cause epigastric pain
Indigestion, cholecystitis
Diseases that cause periumbilical pain
intestinal obstruction, early appendicitis
Diseases that cause suprapubic pain
S/L intestine, UTI, IBD
Definition/Cause Referred Pain
Pain perceived distant from source; Due to lack of dedicated sensory pathways in brain for internal organs
Common examples of referred pain (Scapular, Groin, Shoulder)
Scapular - Biliary colic
Groin - Renal colic
Shoulder - Irritation of diaphragm from blood or infection
Definition and sxs of parietal/somatic pain
Comes from parietal peritoneum (lining of abd organs); sharp and well localized
Common causes of parietal pain
Acute inflammation, ischemia, infection; acute appendicitis, acute cholecystitis (vs. biliary colic causing visceral pain)
Psychogenic Pain - Description
Hx of multiple systems in pain, CHRONIC, non progressive, sxs of depression
Tips for assessing psychogenic pain
Do deep palpation with stethescope to assess true severity while pt distracted
What is seratonin
Neurotransmitter and hormone, important role in mood, sleep, appetite, temp regulation, pain perception, sex and secretion of other hormones
Where is most seratonin found (2 places)
GI tract, blood platelets
Seratonin role in GI system
Initiate gut motility, allow stomach to expand, transmit info to CNS
HPI for abd pain
localization, characterization, referral?, course/onset/resolution, aggrivating/aleviating, associated sxs
Examples of charictarization by disease (duodenal ulcer, intestinal obstruction, acute appendicitis)
Duodenal ulcer - burning/gnawing
Intestinal obstruction-crampy
Acute appendicitis - Aching
Most serious accociated sxs for abd pain
Weight loss, blood in stool, jaundice, N/V, fever
Social factors that affect GI
Caffine, ETOH, smoking, stress
What to include in abd PE (added for acute pain?)
Chest exam for pneumonia, CVAT, hernias, pulses; vitals (high RR and HR = pain, low BP can be low fluid volume); for acute include pelvic and rectal for occult blood
Sxs acute (surgical) Abd
- Pain acute, persistent >6hrs
- Symptoms progressed
- Pain localized with rebound -tenderness, gaurding, rigidity
- Pain worse with movement or cough
- Lying still with knees to chest
- Irritable infant lying still with flexed hips, quiet
- N/V/A associated
- Absent bowel sounds
Sigs of worse N/V
- Vomitus smelles like feces or is bilious
- Pain occurs before vomitting (pain during or after = gastroenteritus)
How long must you listen before absent bowel sounds?
3 min
PE for acute abdomen
orthostatic BP and pulse (orthostatic indicates hemorrhage or third spacing) Cold/clammy (blood shunting) Tachy Impaired mentation Oliguria Fever
What is peritonitis
Inflammation of peritoneal cavity caused by any condition that causes inflammation
What can cause peritonitis
- Appendicitis
- Diverticulitis
- Stranguilating intestinal obstruction
- pancreatitis
- PID
- Mesenteric ischemia
- Intraperitoneal blood
- Barium
- Peritoneo-systemic shunts
- Drains
- Dialysis catheters
- Ascities
Peritonitis presentation in elderly
- Mild fever
- Tachy
- Reduced bowel sounds
- Vague abd discomfort
- Also include cardiac/respiratory differentials
R/LUQ non GI sources of pain
- Herpes zoster
- Lower lobe pneumonia
- MI
- Radiculitis (nerve pain)
What is GERD
-Reflux of gastric contents (gastric acid and digestive enzymes) into esopphagus
Causes of GERD
- Relxation of LES
- Decreased secondary peristalsis
- Decreased resistance to caustic liquids
- Large hiatal hernia (stomach herniating through diaphragm)
- Tobacco, strenuous exercise, ETOH
- Calcium channel blockers -> decreased LES tone
Common GERD Food Triggers
Spicy, fried, fatty, citrus, caffine
Clinical features of GERD
- Heartburn within 30-60 minutes of eating
- Worse lying down, bending over, tight clothes
- May also have: regurgitation, nocturnal aspiration, ulcers, hemorrhage, dental erosion, laryngitis, asthma,Barrett’s esophagus
- Chest pain with heavyness or pressure radiating to neck, jaw, shoulder
GERD Hx
-Onset, agg/all, smoking?, NSAID/ASA, difficulty swallowing, weight loss, change in stool
When can you diagnose GERD just on history?
GERD PE
Ht/Wt, abd exam, occult blood in stool, usually no dx testing
Atypical GERD presentation/Referral
-Dysphagia, wt loss, melena; refer for endoscopy
Phase 1 GERD Therapy
Wt loss if obese, smoking cessation, elevate HOB, Smaller meals, no eating 2-3 hrs before bed, reduce high fat, chocolate, citrus, mints, coffee, alchohol, antacids PRN
Phase II GERD Therapy
- H2 blockers BID: Zantac, Pepcid
- PPI used when H2 fails or erosive esophagitis (Prevacid, Lansoprazole, Nexium, Protonix, Pantoprazole)
H2 Antagonists
-Zantac, Pepcid
-First line for GERD
MOA: suppress acid in stomach
Directions: Take before, after, with meal
-BID
-OTC doses lower then prescription
PPI
- Prevacid, Prilosec, Nexium
- If H2 fail or GERD returns
- MOA: Shut down acid producing proton pumps
- Directions: 30 min beforemeal
- Qday
Possible effets of long term PPI sue
- Pneumonia
- C.diff
- Hypomagnesemia
- Decreased Ca+ absorbtion
- Interfere with B12 absorbtion
What H2 blocker should you avoid/why?
Cimetidine; CYP450 interactions
Evaluation of GERD tx
1-2 weeks. If controlled, continue tx 8-12 wks. After 8, D/C or lower meds. Some need low-dose maintenace. If unresolved in 8 weeks refer to gastroenterologist
Barret’s Esophagus definition/cause
Complication of GERD Tissue injurty due to chronic exposure to pepsin, gastric acid, bile Premalignant condition of esophagus Typically White males >50 Presents as heartburn or dysphagia
Premalignant stages of Barrett’s
Low or high grade dysplasia
Metaplastic columnar epitheliazation of distal esophagus
Risk of adenocarsinoma with Barrett’s
-
Gastroparesis define/cause
Impaired gastric emptying r/t autonomic neuropathy; complication of uncontrolled DM
Effects of gastroparesis
Affects food absorbtion –> impaired glycemic control, N/V, sesation of always full
Gastroparesis Dx
Endoscopy, gastric emptying study
Gastroparesis Tx
Control hyperglycemia, dietary modifications, metroclopramide (reglan) short term (not in elderly)
Dysphagia definition
Swallowing disorder
Oropharyngeal or esophogeal
Oropharyngeal vs esophogeal dysphagia causes
Esophogeal usually has structural causes, oropharyngeal usually functional causes
Possible effects of dysphagia
Mild - Severe, malnutrition, dehydration, choking, aspiration, pneumonia, death
Transfer dysphagia (oropharyngeal)
- Usually neurological –> difficulty initiating swallow
- Common in elderly
- Caused by stroke, tumor, degenerative diseases, benzos, L-dopa
- Difficulty with liquids–> regurg, choking, aspiration
Achalasia
- Most common motor dysphagia
- Loss of peristalsis, LES fails to relax causing obstruction
- Substernal chest pain for most
- Difficulty with liquid and solid, cold makes it worse
Scleroderma (Dysphagia)
Causes loss of tone and propulsion in esophagus, more commonly leads to reflux
Dysphagia History
Onset: Gradual/chronic suggest motor, rapid and progressive suggest obstruction
- Swallowing difficulty liquid or solid, is cold worse?
- Effect of swallowing - Helps in motor, can cause regurg in obstruction
- Wt loss
- PMH neuro disease, chronic reflux, esophagitis
- Nocturnal respiratory trouble or pneumonia (r/t tracheal aspiration)
- Heart burn suggestions inflammatory stricture/disease
Dysphagia Differentials (Intermittent, w/ swallowing, solids, Diplopia, reflux and skin changes, tremor)
Intermittent - LES
With swallow - Mucosal inflammation
Difficulty with solids and heartburn - stricture
With diplopia think myasthenia
With reflux, skin changes, cold extremities - scleroderma or Raynaud’s
-With tremor - Parkinson’s
