GI Flashcards
Function of GI system
1) Ingestion and propulsion of food
2) Digestion
3) Absorption
4) Elimination
GI: Associated organs
- Salivary glands
- Liver: largest organ in body
- Gallbladder: Muscular pear-shaped sac (3-4”)
- Pancreas: flat organ about 6-9”; lies behind stomach
Obesity in pediatrics
- Genetics vs. lifestyle
- Breast feeding vs. bottle feeding
- Caloric intake - portion distortion
- Decreased activity/video games
- High fructose drinks and juices
Failure to thrive in children
- Weight for age that falls below 5th percentile or weight deceleration that crosses 2 major percentile lines
- Inadequate caloric intake
- inadequate caloric absorption
- Excessive caloric expenditure
GI Changes in elderly
- Oral cavity changes
- Decreased taste sensation
- Decreased thirst and saliva
- Decreased VitD and Ca+ intake
- Hypohydrochloria
- Decreased motility
Obesity in elderly
- Caloric intake > expenditures
- Reduced calories not nutrient - caloric decrease of 500cal = 1lb weekly
- Portion size controlled
- Limit ETOH
Failure to thrive in elderly
- Impaired physical functioning
- Malnutrition
- Depression
- Cognitive impairment
Aging and GI changes
- Decreased stomach acid production
- Decreased motility
- Liver size and function decreased
- Anorectal function decreased
- Anorexia
- Protein energy malnutrition
PUD (H. pylori): Treatment
- Eradicate H. Pylori: triple ABX plus acid reduction
* Biaxin, flagyl, prilosec - 14 days
PUD: Causes
- H. pylori: antral gastritis & duodenal ulcers
- NSAIDs and corticosteroids
- Pathologic hypersecretory disorders (i.e. Zollinger-Ellison syndrome; gastrinoma)
- Stress?
PUD: Facts (Duodenal)
- Most commonly men 20-50yo
- 80% duodenal
- Usually follow chronic course
- 5-10% need surgery
- H. pylori 90%
PUD: S/S (Duodenal)
- Epigastric pain that is gnawing, dull, aching, or “hunger-like”
- Pain relieved by food or antacids, but recurring 2-4hrs later
- Melena
PUD: Facts (Gastric)
- Usually men 55-70
- Risks: NSAIDs, ETOH, smoking
- May cause hemorrhage, shock, gastric outlet obstruction, and perforation
PUD: S/S (Gastric)
- Pan worsens with eating due to stretching
- Nausea and anorexia due to stretch
- Melena
PUD: Diagnosis
- Epigastric tenderness, hemoccult
- CBC, H. pylori, barium swallow, upper GI/small bowel series
PUD: Treatment (Duodenal H. pylori neg.)
- H2 blocker or PPI
- Antacids for breakthrough symptoms
PUD: Treatment (Gastric)
- PPI
- Benign ulcers usually heal in 2-3mo. Failure to heal may indicate malignancy
PPI Safety
- Variance per population - omeprazole metabolism
- Nexium vs. Plavix (Reduced effectiveness with PPI)
- Osteoporosis
- Magnesium - need to monitor
- C. diff (D/C PPI)
PPI meds (Others)
- Antacids: promotes healing of duodenal ulcers but less effective with gastric
- Sucralfate - protective coating over injured mucosa; frequent timed dosing (1g achs)
- Prokinetics: (reglan) 5-10mg qid achs
- Follow-up in 2-3wk
PUD: lifestyle modifications
- Avoid:
- ASA and NSAIDs
- ETOH
- Steroids
- Stress
- Offending foods
- Limit caffeine
GERD: Step therapy (Step I: Lifestyle)
- Weight loss
- Avoid high fat foods/large meals
- Smoking cessation
- Remain upright 2hr after eating
- smaller, more frequent meals
- Elevate HOB
GERD: Step therapy (Step II: Meds)
- Antacids
- Prokinetics
- H2 Blockers
- PPIs
GERD: Step therapy (Step III: Surgery)
- Fundoplication
- Endo-cinch
GERD: Follow-up
- reevaluate in 2wk: If improved, continue meds for 8wk; then reduce to lowest effective dose
- Usually chronic relapsing syndrome
GERD: Causes
- Acid
- Hypomotility
- Transient LES relaxation
- Bile salts
- Defective esophageal clearance mechanisms
- Increased pressure on LES
GERD: S/S
- Heartburn
- Regurgitation
- Water brash (extra saliva)
- Dysphagia
- Odynophagia
- Belching excessively
- Non-cardiac chest pain
GERD: Extra-esophageal reflux symptoms
- Asthma
- Hoarseness
- Laryngitis
- Enamel decay
- Chronic cough
- Globus
- PNA
- Bronchitis
- Halitosis
GERD Complications: Esophageal stricture
- Presents as dysphagia
- Occurs due to severe mucosal damage
- Composed of circumferential scar tissue
- Barium swallow
- Treated by dilation
GERD complications: Barrett’s Esophagus
- Metaplastic change of mucosa from squamous to specialized columnar
- Premalignant condition for adenocarcinoma of esophagus
- Occurs in approximately 10% of those with weekly GERD
- May be asymptomatic or less symptomatic than normal mucosa
- Does not spontaneously resolve
- 2x > in men; 4x > caucasians
- Frequent surveillance once detected (q2yr)
Cholecystitis/cholelithiasis
- RUQ pain, fever, leukocytosis
- Inflammatory or infections
- May need cholecystectomy or drainage of bile duct
- 3% mortality
GI Referral
- Do not respond to PPI/therapy
- Heartburn over 5yr
- Have weight loss
- anemic
- dysphagia
- Heme positive stools or hematemesis
- New occurrence in elderly
- Odynophagia
Hemorrhoids: Facts
- Enlargement of the venous plexuses at the lower end of the anal mucosa, internal and external
- Form a cushion to help maintain continence
- Increased pressure and straining pushes the hemorrhoids against the sphincter muscle and possible prolapse
Hemorrhoid: Treatment
- High fiber diet/increased fluids
- Avoidance of prolonged sitting on the commode
- Local anesthetic agents
- Hydrocortisone creams and suppositories
- Warm sitz baths
- Injection sclerotherapy or rubber band ligation
- Hemorrhoidectomy
Anal Fissure: Facts
- Painful linear cracks or tears in lining of the anal canal
- Severe rectal pain described as burning or tearing pain during BM
- 90% are posterior
Anal fissure: Treatment
- Local anesthetic
- Topical NTG 0.2%
- Stool softening
- sphincterotomy
Fatty Liver: Facts
- Accumulation of excess fat in liver
- 20-30% of adults have NAFLD
- can lead to cirrhosis
- Can be asymptomatic with normal exam to slightly enlarged liver or vague RUQ pain
- Can be found by incidental finding
Fatty liver: Causes
- Metabolic syndrome
- Insulin resistance
- Obesity
- Dyslipidemia
Fatty Liver: Management
- Diet and exercise
- Avoid high fructose drinks
- Monitor waist circumference
- Weight loss
- Bariatric surgery
Diverticulitis: S/S
- Mild-to-moderate aching ABD pain (usually LLQ)
- Intermittent or constant pain
- Change in bowel habits
- Anorexia
- N/V
- Leukocytosis
- Rare hematochezia
Severe diverticulitis
- ABD rigidity
- LLQ pain
- High fever and chills
- Hypotension/shock/sepsis
- Microscopic or massive hemorrhage
Diverticulitis: Treatment (Conservative)
- Clear liquid diet (ADAT)
- Broad spectrum ABX (Augmentin, septra, cipro)
- Improvement seen in 2-3d
- Call PCP for fever, anorexia, or increased pain
Diverticulitis: Treatment (Moderate-to-severe)
- IV fluids/ABX
- 15-30% of those hospitalized will need surgery
Diverticulitis: Lifestyle
- high fiber diet
IBD
- Work closely with GI MD for collaborative care
- After 8-10yr of IBD, need colonoscopy and increased monitoring for CA
- Chronic, relapsing, autoimmune disorder
Acute Pancreatitis: Causes
- Associated with ETOH, trauma, PUD, and biliary disease
- Drugs that may cause: TZDs, Lasix, sulfonamides, tetracycline, glucocorticoids, OC’s, NSAIDs, Pentamidine, 6-mercaptopurine, dideoxyinosine, and azathioprine
- Other causes: Hypercalcemia, hypertriglyceridemia, mumps, coxsackie, hyperthyroidism, CKD or transplantation, ERCP
Acute pancreatitis: Facts
- Inflammation caused by premature activation of enzymes causing damage
- 2 forms:
1) Edematous (interstitial) - causes fluid accumulation and swelling
2) Necrotizing - Causes cell death and tissue damage - If pancreatitis damages Islets of Langerhans, DM will result
Acute pancreatitis: S/S
- RUQ pain, may radiate to back, chest, flanks, and lower ABD
- Persistent N/V
- ABD distention
- Diminished bowel activity
- Crackles at lung bases
- Mottled skin (suggests hemorrhagic pancreatitis)
- Grey Turner’s sign: Bruising over flanks
- Cullen’s sign: Umbilical discoloration
- Tachycardia, fever, restlessness, malaise
Acute pancreatitis: Diagnosis
- Amylase and lipase
- CBC
- Bilirubin elevated in both chronic and acute
- Pleural effusions, pancreatic calculi
- Enlarged pancreas and pseudocysts
Pancreatitis: Treatment (mild)
- supportive care: pain control, fluid resuscitation, and nutritional support
Pancreatitis: Treatment (moderate-to-severe)
- Replacement of fluids, proteins, and electrolytes
- Fluid volume replacement
- Blood transfusion to replace loss from hemorrhage
- Withholding food and fluids to rest pancreas
- NGT - decrease stomach distention
- Pain mgmt. (demerol controversy)
- H2 blockers/antacids
- ABX (broad spectrum)
- Surgical/endoscopic laparotomy/sphincterotomy, ERCP
Acute upper GI bleed: Causes
- 2/3 of GI bleeds are upper
- PUD
- Varices
- Portal HTN
- Mallory-Weiss tears: mucosal tears at the gastroesphageal junction
Acute upper GI bleed: S/S
- Emesis/hematemesis
- Diarrhea
- Melena (black tarry stool)
- Hematochezia (red blood in stool)
- Postural hypotension, near-syncope, syncope (loss of >15% blood)
- Pain with peptic ulcer but NOT with Mallory-Weiss tears or Varices
- Serial CBC -> referral to ED -> Transfusion/surgery
Acute Lower GI bleed: Facts
- Bleeding that originates distal to the ligament of Treitz; includes sm. & lg. bowel sources
- M>W
- Blood in stool (various shades): color darker more proximal bleed
- Require less blood and less hemodynamically unstable
- Pattern of bleeding intermittent with spontaneous cessation in 80-85%
Acute Lower GI Bleed: S/S
- Blood in stool
- Hypotension/tacycardia
- Orthostatic hypotension
- Inflammatory colitis: blood mixed with mucous stool
- Large amounts of BRB = rapid, ongoing bleeding; clots suggest slow bleeding rates
Acute Lower GI Bleed: Treatment
- Referral
- Endoscopy/surgery
- Transfusion
GI Cancer
- S/S for further evaluation: Pain, Guaiac + stools; Jaundice; Rectal bleeding; IDA; Weight loss; odynophagia; change in bowel habits