GI Concerns Flashcards
Difference between upper GI bleeds and lower sx/signs
Upper GI: Hemoptysis, melena (as long as not massive bleed), coffee grounds hematemesis
Lower GI: hematochezia, bright red blood rectal bleed
Indications for investigation of GI and bleeds
Age + risk factors for CA, showing signs of iron deficiency, if they are not stable, other medical conditions (IBD, GERD, ulcers, renal or liver disease), chronic medications (NSAIDS, anti-platelet/ anti-coagulation)
Types of investigations for lower GI bleeds
Rectal exam/ and abdominal
Full set of vitals, look at skin for other signs of disease
Lab works - inflammatory markers, hemoglobin, iron
Colonoscopy
Investigations for upper GI bleed
Lab work + (Ab test for H.pylori), gastroscope, breath urea test for H.Pylori
Abdominal exam, consider HEENT
Risk factors for colorectal CA
Age over 50, family hx (Lynch syndrome), smoking, high red meat/ processed meat diet, alcohol, DM, colonic polyps and IBD
What causes portal hypertension and esophageal varices
Damage to the liver, most commonly cirrhosis, causes decreased flow of blood from the GI through the liver, leads to back up and increased pressure. Blood is then shunted inappropriately through collateral blood supply - leading to varicosities
Gastroesophageal collateral = esophageal varices
Superior rectal vein = hemorrhoids
Round ligament remnant = caput medusae
What causes peptic ulcers
Can be related to several factors: is caused when acid and pepsin break through the mucosa of the stomach
- H.Pylori
- Alcohol use
- NSAIDS
- secondary to malignancy
- Zollinger-Ellison syndrome - too much gastric acid
Why do NSAIDS cause GI bleeds
Inhibits COX 1 which makes prostaglandins, which help produce bicarbonate and mucus and reduce gastric acid and pepsin and maintain adequate blood flow to stomach
What increases the likelihood of a person having another GI bleed?
Continued NSAID use/ added anti-coagulants or anti-platelets
Failure to modify precipitating lifestyle factors (straining with hemorrhoids, diet, alcohol use).
Age greater than 65, poor overall health, comorbidities, low hemoglobin, continued melena/ fresh blood, evaluated urea, creatinine, ALT
On endoscopy - active bleeding, visible vessels, large ulcer (>2cm), posterior ulcer
Can use Blatchford score or Rockall score
Tx for hemodynamically unstable patient
Fluids +++, cross and type to prepare for transfusion
Hbg less than 70 transfuse, locate source of bleeding and try to stop it (POCUS, rectal exam, bladder scan) - for esophageal varices endoscopic ligation, esophageal catheter/ intubation
Consider transexmic acid
IV octreotide - to reduce pressure for esophageal varices
Current guidelines for colon CA screening
Age greater than 50 to 74 - FIT every 2 years or colonoscopy every 10
If family hx - start at 10 years earlier than family member DX, with colonoscopy every 5 yrs
Recommendations for PPI use
PPI are only indicated for less than 8 weeks, try to de-prescribe after 4 - only indicated for dual anti-platelet therapy, prior GI bleed, ongoing NSAID, Barrett’s esophagus or ongoing hyper secretions of gastric acid
Long term use - try to take off or reduce for part of the year, consider Mg supplementations and Vit C with iron if needed, Ca++ supplementation if needed.
Risks of long-term PPI use
- Enteric infections (C. difficile, Campylobacter, Salmonella)
- Fractures
- Pneumonia (hospital or community acquired)
- Spontaneous Bacterial Peritonitis in cirrhosis patients
- Hypomagnesemia
- Acute Interstitial Nephritis
- Vitamin B12 deficiency
Organisms causing bloody diarrhea
Shigella
Salmonella
Campylobacter jejuni
E.coli ( O157:H7)
Meckel’s Diverticulum - rule of 2s?
2% of people, under 2, 2 ft from the illeocecal valve
N/V/ painless rectal bleed
Osmotic vs secretory diarrhea?
Osmotic - due to increased pull of fluids out of the bowel into the lumen - think lactose intolerance - improves with fasting
Secretory - is active secretion of water and electrolytes into the lumen - persists despite fasting
Inflammatory - damage to the mucusa = leaky and poor absorption
Motor = too much movement to let H2O get absorbed
Acute vs Chronic diarrhea?
Timing less than 2 weeks - acute - usually infectious and self-limiting
More than 4 weeks - chronic - needs more work up
Management for a child with diarrhea
Oral rehydration as much as possible, then consider IV or NG
Pathophysiology of celiacs
Gluten triggers immune response in the small intestine causes damage to the intestine wall, leading to malabsorption
Work up for a patient with diarrhea?
Stool cultures, CBC, lytes, BUN/Cr/ eFGR, ESR/CRP consider a scope/ imaging
When should you refer a constipated kid?
Many kids are constipated - this is a functional constipation
Refer when it is refractory to treatment, when they have red flags/ systemic sx
Causes of infant diarrhea
Diet (how much fruit juice?)
Intestinal damage (intussusception)
Infection (rota)
Causes child with diarrhea
Malabsorption (lactase deficiency, celiac disease, CF)
Infection (rota)
IBD, drugs, laxative abuse
Causes child with constipation?
Obstruction - stenosis, atresia, Hirschsprungs
Poverty, lack of access to water, withholding (behavioural)
Endocrine - hypothyroid, diabetes
Treatment of functional constipation
Education, laxatives - PEG 3350, maintain hydration and try to keep stool soft as possible.
Can use up to 1 enema or suppository a day - to get rid of impaction
IV fluids for rehydrating a child?
Calculate fluids lost via pre and post illness weights, this gives % dehydration
4, 2, 1 rule for maintenance fluids, + estimated fluid lost - go slowly and try to switch back to oral soon.
Morbidity risks for diarrhea?
Severe dehydration (hypovolemic shock) Electrolyte imbalance
Distinguishing functional from behavioural constipation?
Can use the Rome criteria for grading functional constipation
When does this happen? - At school, at home etc. Withholding behaviours, pain, soiling
Any associated symptoms - weight loss, failure to pass meconium, vomiting, mucus or blood in stool
In under 6 months with no red flags - it is either due to breastfeeding or functional. Evaluate for inaction
Inflammatory vs Non-inflammatory diarrhea
Non-inflammatory - usually viral (noro/rota) increases intestinal secretion without any damage to mucosa, milder disease, watery diarrhea
Inflammatory - bacteria - cytotoxic or cell invasion damages the mucosa, leads to bloody diarrhea - more severe
Determining volume status?
Cap refill, BP, Anterior fontanelle, skin turgor, eyes sunken, HR, oral mucosa, output of urine
Signs and sx of celiacs?
FTT starting at 6 months (introduction of solid foods), diarrhea, and steatorrhea, herpeiformis dermatitis
Work up for celiacs
IgA and IgA TTG (are there IgA antibodies and are they against gluten)
Child must be eating gluten at this time.
Endoscopy and biopsy confirm.
Pathophysiology of Hirschsprungs
Failure of the nervous plexi, intestine not innervated does not move
Classically - failure to pass meconium, bilious vomiting, abdominal distension
4 sources of the vomiting reflex
Chemoreceptor trigger zone, vestibular system, vagal from GI system, central nervous system
Ondansatron acts
Selective serotonin antagonist and acts mainly peripherally on the vagal pathway
Metoclopromide acts
On the area postrema in the CRTZ is a dopamine antagonist, also stimulate GI motility
Dimenhydrinate action
Acts on the vestibular system as antihistamines - makes you sleepy
Approach to melena
Likely indicates upper GI bleed (above the 4th part of the duodenum)
- alcohol, NSAID, hx of ulcers, smoking, risk factors
- is the bleeding ongoing - could have bright red blood too (fast), unstable vitals
Get IV large bore - group and screen - for 4 units of blood, octreotide, abx, PPI,
