GI disorders Flashcards
1
Q
Epigastric pain usually indicates…
A
liver, pancreas, biliary tree, stomach, duodenum
2
Q
Periumbilical pain usually indicates…
A
distal end of the small intestine, cecum, appendix, ascending colon
3
Q
Visceral pain is usually described as…
And where?
A
Described as dull, diffuse, cramping, burning or nauseating
From dissension and muscular contraction
Pain in lower abdomen: from hindgut structures (distal colon and GU tract)
Periumbilical pain: from midgut structures (small bowel, proximal colon and appendix)
Pain in upper abdomen: from foregut structures (stomach, duodenum, liver and pancreas)
4
Q
Suprapubic pain usually indicates…
A
distal intestine, urinary tract infection, pelvic organ dysfunction
5
Q
What history should be taken with GI distress?
A
- feeding habits (any food intolerance?)
- change in appetite
- bowel habits
- constipation/diarrhea
- presence of pain
- N/V
- Thirst level
- Heart burn, belching, flatulence
6
Q
Define: globus
A
complaint of something stuck in their throat
7
Q
Define: dysphagia
A
Difficulty swallowing
8
Q
What are 4 main causes of dysphagia?
A
- structural defect: narrowing of esophagus or extrinsic obstruction. Usually solids harder to swallow than liquids
- neurological disorder: from cerebral palsy, or muscular dystrophy
- motor disorder: uncommon in children
- mucosal injury: usually from GERD or gastritis
9
Q
What history is common for dysphagia?
A
- progressive dysfunction
- persistant drooling or cough
- discomfort with swallowing (esp. solids)
- picky eating or food refusal
- heartburn, halitosis, chest pain
10
Q
What physical exam areas to focus on in dysphasia?
A
In children:
- feeding, oral motor skills, safety in swallowing
- PE: mouth, neck, throat
11
Q
What differential diagnosis should be considered with dysphagia?
A
- trouble swallowing solids only: obstructive/compression lesion
- trouble with liquids and solids: physiological dysfunction
- trouble feeding: child/feeder dysfunctional feeding relationship
12
Q
Vomiting vs. Regurgitation
A
Vomit: forceful expulsion
Regurg: passive reflux
13
Q
How can vomit be described?
A
- bilious or non-bilious
- bloody or non-bloddy
14
Q
What are potential diagnosis of a newborn or new infant with vomiting?
A
- infectious process
- congenital GI anomaly
- CNS abnormality
- inborn errors of metabolism
15
Q
What are the potential diagnosis of an infant or young child with vomiting?
A
- gastroenteritis
- GERD
- Mild/soy allergy
- pyloric stenosis or obstructive lesion
- inborn errors of metabolism
- intussusception
- child abuse
- intracranial mass lesion
16
Q
What are the potential diagnosis of an older child or adolescent with vomiting?
A
- gastroenteritis
- systemic illness
- CNS (cyclic vomiting syndrome, abdominal migraine, meningitis, brain tumor)
- pregnancy
- intussusception
- rumination
- superior mesenteric artery syndrome
17
Q
What is non bilious vomit usually causes by?
A
- infection
- inflammation
- metabolic/neurologic,psychological problems
18
Q
What is bloody vomit usually caused by?
A
active bleeding in the upper GI tract (gastritis or peptic ulcer disease)
19
Q
What is intussusception?
A
- when part of the intestine telescopes itself
- very rare
- S&S: loud cry ever 15-20 minutes, vomiting and stool has blood and mucus in it, lethargic, loss of appetite
- Treatment: enema or surgery
20
Q
What is gastritis?
A
- when your stomach is inflamed
- S&S: pain, nausea, vomiting, loss of appetite, bloating, belching, indigestion, hiccups
- Treatment: antibiotics (Amoxicillin, Clarithromycin, Metronidazole) and antacids (Pantoprazole (Protonix), Rabeprazole (AcipHex), Dexlansoprazole (Dexilant))
21
Q
What is esophagitis?
A
- when your esophagus is inflamed
- S&S: chest pain with eating, epigastric pain, dysphagia, heartburn, regurgitation, vomiting
- Treatment: Antifungal (diflucan) or Antacid (Pantoprazole)
22
Q
What is annular pancreas?
A
When the ring of the pancreas squeezes and narrows the small intestine so food cannot pass.
- S&S: infants take in less milk, cry often, and vomit
- Treatment: surgery
23
Q
What is pyloric stenosis?
A
- When the opening between the stomach and small intestine thickens
- S&S: projectile vomiting, baby colic, failure to thrive, insufficient urination, lump in abdomen, weight loss, dehydration, lethargy
- Treatment: surgery
24
Q
What is a tracheoesophageal fistula?
A
- When the trachea and esophagus have a connection that lead to severe and fatal pulmonary complications
- S&S: cyanotic infant, trouble feeding, rattling respiration and coughing episodes
- Treatment: surgery
25
What is hirschsprung's disease?
- Large blockage in the large intestine which leads to trouble passing stool. No ganglia in the distal colon, so movement in slowed or doesn't occur.
- S&S: newborn unable to pass stool, constipation, vomiting, flatulence and failure to thrive
- Treatment: bowel resection
26
What is Necrotizing Enterocolitis?
- Occurs in formula-fed premature infants in 2-3 week of life.
- S&S: vomiting, diarrhea, delayed gastric emptying, abdominal distension, decreased bowel sounds
- Treatment: hospitalization with antibiotics, maybe surgery
27
What could visceral epigastric pain be?
indigestion, cholecystitis
28
What could visceral periumbilical pain be?
intestinal obstruction, early appendicitis
29
What could visceral suprapubic pain be?
small or large intestine, UTI, IBS
30
What is referred pain?
Pain received distant from its source. Due to the lack of dedicated sensory pathways in the brain for information concerning internal organs.
31
What is parietal or somatic pain? What does it feel like?
Parietal pain comes from the parietal peritoneum.
Feels sharp and well localized.
Due to acute ischemia, infection or inflammation
i.e. acute appendicitis or acute cholecystitis
32
What is psychogenic pain?
- Chronic, non-progressive pain, may wax and wane
- Usually multiple body complaints
- Could be Somatic symptoms of depression
- Perform light and deep palpation with stethoscope to assess for tenderness/rebound to validate their account
33
How does serotonin play a role in pain?
The neurotransmitter and a hormone that plays a role in: mood, sleep, temp, appetite, pain perception, sexual behavior and other hormones.
- When in the gut, it increases the gut motility, allows the stomach to expand and transmits info to the CNS.
- Use SSRIs in IBS
34
What should be included in the ROS for a GI complaint?
trouble swallowing, heartburn, appetite changes, nausea, vomiting, hematemesis, indigestion, BM frequency, last BM, rectal bleeding, melena, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or flatus, hemorrhoids, jaundice, cholecystitis, hepatitis, weight loss, nocturnal symptoms
35
What should the physical exam included for a GI complaint?
General, temp, color and VS (low BP: worried about low blood volume)
Assess respiratory, signs of pneumonia
Assess for CVAT, hernia, and pulses
With acute pain, do abdominal, pelvic, and rectal exam
36
When is it an acute (surgical) abdomen?
- pain is acute (lasting > 6hrs with no relief)
- Symptoms are progressive
- pain is well localized (often rebound tenderness, guarding and rigidity)
- N/V and anorexia associated
- Absent bowel sounds
37
If you suspect an acute abdomen, what should you include in your physical exam?
- check for orthostatic blood pressure and pulse
- cold, clammy extremities
- tachycardia
- impaired mentation
- oliguria (less than 500mL output per day)
- fever
38
What are some signs of peritonitis?
- worse when they move or cough. They lie very still and want to keep their knees to chest
- infants will lie very still with flexed hips and are quiet
39
What are the potential causes of peritonitis?
- appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, PID, mesenteric ischemia
- intraperitoneal blood from ruptured aneurysm, trauma, sugary, ectopic pregnancy
- Barium
- Ascites, peritoneo-systemic shunts, drains, dialysis catheters
40
What should you look for in elderly to suspect peritoneal irritation?
- usual signs of peritoneal irritation are absent in the elderly
- instead, they may have a mild fever, tachycardia, reduced bowel sounds, vague abdominal discomfort without refund or guarding
- May also be: cardiac, respiratory, or GU problem
41
What are some non GI sources of Upper quadrant pain?
- herpes zoster
- lower lobe pneumonia
- MI
- radiculitis (never pain from the spine)
42
What is GERD? What contributes to it?
Reflux of gastric contents into the esophagus from:
- LES relaxation
- Irritants
- Decreased secondary peristalsis
- Decreased resistance to caustic liquids
- possibly from a large hiatus hernia
Contributors:
- tabacco
- alcohol
- exercise
43
What are some triggers of GERD? How can you tell?
Triggers:
- Spicy or fatty or fried or food
- Citrus
- Caffeine
Try: cutting out all possible triggers and re-introducing one at a time to find the triggers
44
What are the clinical features of GERD?
- heartburn 30-60 minutes after eating
- worse symptoms when laying down or wear tight clothes
- pain radiates upward in the heart area
- May also have regurg, nocturnal aspiration, ulcers, hemorrhage, dental erosions, laryngitis, asthma symptoms or Barrett's esophagus
45
What should you ask about with possible GERD patient?
- Onset, duration, progression of heartburn
- what helps/ aggravates its?
- smoker?
- NSAID/ ASA use?
46
What is needed to make a GERD diagnosis?
Dx can be made on history alone if:
- > 45 years old
- history of heartburn
- no dysphagia
- no weight loss
- no blood loss
47
What physical exam is needed in possible GERD patient?
- height/weight
- abdominal exam for masses and tenderness
- occult blood test of stool
- only need endoscopy if atypical presentation of GERD
48
What is the first phase of GERD therapy?
Nonpharmacologic therapy for 2 weeks:
- IF obsess, lose 10 lbs.
- smoking cessation
- elevate the head of the bed
- eat smaller meals and don't eat 2-3 hours before bed
- reduce triggering foods
- use antacids PRN
49
What is the second phase of GERD therapy?
If failure of first phase or moderate sx:
- H2 receptor antagonist, BID like Zantac or Pepcid.
- PPI, 30 minutes before meals like omeprazole or Prilosec
Use PPI if H2 doesn't work or erosive esophagitis
50
What are the long-term side effects of PPIs?
- PPI associated pneumonia
- possible connection with C.diff infection
- hypomagnesemia
- decrease Ca absorption
- interferes with Vit B 12 absorption
51
How long do therapies for GERD need to be put into place for?
Re-evaluate after 1-2 weeks
If controlled, keep on for 12 weeks.
Then discontinue or lower the medication as much as possible.
If unresolved: refer to gastroenterologist
52
What is Barrett's Esophagus?
- Complication of GERD
- a pre-malignant condition, usually white men over 50 years old
- Presents with heartburn or dysphagia
- tissue injury due to chronic exposure to gastric acid, pepsin and bile
53
What is gastroparesis?
impaired gastric emptying, usually from uncontrolled hyperglycemia/ DM
- impacts both sympathetic and parasympathetic nerve fibers
- affects food absorption, which affects glycemic control
- Causes nausea and vomiting
- Symptoms improve with control of hyperglycemia
54
How is gastroparesis diagnosed?
endoscopy or gastric emptying study
55
How is gastroparesis treated?
- Dietary modifications
| - Med: reglan (metoclopramide)- increases motility but CI in elderly
56
What is dysphagia?
A swallowing disorder that involved one or more of the stages of swallowing (either oropharyngeal or esophageal)
- Oropharyngeal: usually a functional cause
- Esophageal: usually a structural cause
57
What are the risks of dysphagia?
- malnutrition
- dehydration
- choking
- aspiration
- pneumonia
58
What is transfer dysphagia?
type of oropharyngeal
| usually neurological with difficult initiating swallowing
59
What is achalasia?
the most common motor dysphagia
slow progressive loss of peristalsis
60
What type of dysphagia is rapid and usually affects solids?
A mechanical obstruction
| if less than 1 year, it could be malignant
61
Describe the onset of a motor disorder dysphagia.
gradual onset, slow progression and chronic
62
Describe the onset of an obstructive disorder dysphagia
Rapid onset and progression
63
Why ask about respiratory symptoms with a dysphagic patient?
recurrent unexplained pneumonia may occur from tracheal aspiration of esophageal contents
- think esophageal disease
64
What does heartburn and dysphagia suggest?
inflammatory stricture or disease
65
What does intermittent dysphagia suggest?
lower esophageal problems
66
What does dysphagia associated with swallowing suggest?
mucosal inflammation
67
What does dysphagia of solids and heartburn suggest?
stricture
68
What does dysphagia and diplopia suggest?
myasthenia gravis
69
What does dysphagia with reflux, skin changes and cold extremities suggest?
scleroderma, Raynaud's phenomena
70
What does dysphagia associated with a tremor suggest?
parkinson's disease
71
How would dysphasia that comes from the oral stage manifest?
poor bolus control, spillage from lips, dry oral membranes, oral residue and difficult chewing
72
How does pharyngeal dysphagia manifest?
delayed swallowing, nasal/oral regurgitation, coughing, choking or gurgling
73
What do you prescribe a patient with dysphagia, if bolus is present or reflux symptoms?
1. H2 block or PPI
If it doesn't help, then refer to GI
74
What do you prescribe a patient with dysphasia with post nasal drip?
1. Try nasal spray, like Flonase
If it doesn't help, then refer to ENT
75
What referrals should be made for a patient with dysphagia, suspected with an obstruction, malignancy, lesion, reflux, infection or Schatzki's ring?
Refer to endoscopy and biopsy
76
What is Schatzki's ring?
narrowing of the lower esophagus that can cause dysphagia. The narrowing is caused by a ring of mucosal tissue or muscular tissue.
77
What should be tested if you suspect dysphasia is caused by muscle weakness?
manometry- measures intraluminal pressure during swallow
78
How can calorie intake be achieved with dysphasia? In motor and mechanical obstruction.
Motor- eat small meals slowly
Mechanical obstruction- liquid or soft diets
79
How is structural dysphagia treated?
surgery of dilation
80
Which type of peptic ulcers tend not to be malignant?
duodenal ulcers- tend not to be malignant
gastric ulcers- malignant 2-4% of the time
81
Which type of peptic ulcers tend to be more common?
duodenal ulcers are more common than gastric ulcers
82
Which type of peptic ulcer tends to caused by H.pylori?
duodenal ulcers
83
Which type of peptic ulcer tends to be caused by NSAIDS?
gastric ulcers
84
Which type of peptic ulcer is helped with food?
duodenal ulcers
85
Which type of peptic ulcer is worse with food?
gastric ulcers- pt. tend to loose weight
86
What are alarm symptoms in peptic ulcer disease?
Signs of bleeding: Anemia, hematemeis, melena and heme positive stool
signs of obstruction: vomiting
Signs of cancer: weight loss or anorexia
Signs of penetration to deeper mucosa: persistent upper abdominal pain radiating to the back
Signs of perforation: severe, spreading upper abdominal pain (Emergency!)
87
What diagnostic tests should be performed for all patients with suspected peptic ulcer disease?
occult blood
Hcb/Hct
88
What diagnostic tests should be performed for a patient with PUD and has an alarm symptom or is not responding to the treatment?
Endoscopy
89
What test can be given if you suspect PUD with H.pylori?
ELISA
UBT (urea breath test)
stool antigen test
endoscopy biopsy
90
How is H.pylori treated?
Regimin for 10-14 days:
1. PPI, twice a day
2. Amoxicillin 1g or flagyl 500mg, twice a day
3. Clarithromycin 500mg twice a day or Bismuth subsalicylate 525mg, four times a day
4. Tetracycline 500mg, four times a day,
5. Histamine H2 blocker BID
aka PREVpac
-should be taken OFF NSAIDs
91
How can PUD be prevented? (lifestyle changes)
STOP: NSAIDs and smoking
Reduce stress
92
When is PUD follow up?
Repeat endoscopy in 2-3 months to monitor ulcer healing
93
Name the 3 different acid neutralization surgeries?
Biliroth
Vagotomy
Subtotal gastrectomy
94
What is the clinical presentation of gastric cancer?
- insidious (gradual) onset of abdominal pain that ranges
- Weight loss, abdominal pain, anorexia, vomiting
- change in bowel habit, dysphagia, melena, anemia, hemorrhage
95
What diagnostic tests need to be ordered for suspected gastric cancer?
CBC with diff, electrolytes, LFTs
Stool occult sample
CT radiograph/scan of abdomen
Endoscopy and biopsy
96
What treatments of offered for gastric cancer?
Surgery or resection
- chemo does NOT work
97
What is celiac disease?
- chronic, autoimmune inflammatory disease of the small intestine
triggered by wheat, barley and rye gluten proteins
98
What are the clinical features of celiac disease?
Anemia
Short stature or no weight gain
Delayed onset of puberty/menarche
osteopenia (loss of bone density)
transaminitis (elevated AST/ALT)
Recurrent abdominal pain
99
What are the diagnostic tests for celiac disease?
- Genetic testing for HLA gene
- IgA-Ttg
- IgA-EMA
- Blood tests: CBC, LFTs, cholesterol, albumin, vitamin levels, TSH
100
What are the blood test abnormalities in celiac disease?
- abnormal LFTs
- low ferritin
- hypocholestrolemia
- hyperamylasemia
- hypoalbuminemia
- elevated ESR
- prolonged PT
- vitamin deficiency
- hypocalcemia
101
How does non-celiac gluten sensitivity differ from celiac disease?
Non-celiac gluten sensitivity experience similar symptoms as celiac disease, but lack the same antibodies
It's like having a gluten allergy
Tx: avoid gluten
102
What is the treatment for celiac disease?
Gluten- free diet, and may need separate cook wear.
- not avoiding gluten can lead to other autoimmune disease
103
What is cholecystitis?
acute/chronic inflammation of the gallbladder
usually caused by gallstones that make a mechanical obstruction, local inflammation or both
Common in FFF: female, fat, fifty
104
What increases your risk of developing gallstones?
- rapid weight loss or cyclic weight loss
- childbearing, due to increased estrogen
- Drugs: TPN, estrogen, ceftriaxone- prophylactic antibiotic
- Native american or scandinavian
- women
- first degree relative
- ileal disease
- increasing age
105
What is the clinical presentation of cholecystitis?
- colicky, RUQ pain radiating to flanks and right should
- occurs 1 hour after eating a large meal and lasts for hours
- associated with anorexia, nausea, fever
106
What would you find on the physical exam for a patient with cholecystitis?
- RUQ tenderness
- involuntary guarding
- Murphy's sign
- gallbladder may be palpable
107
How is chronic cholecystitis diagnosed?
- CBC with differential, LFTs and GGT
- gallbladder ultrasound- pt. must fast for the test
- HIDA (shows how well the gallbladder contracts) Done if the ultrasound is negative
108
How can cholecystitis be treated?
- cholecystectomy- removed the gallbladder
- oral dissolution therapy using bile acid- dissolved the gallstones, 25% of medically managed patients will redevelop gallstones within 5 years
109
What can a delayed diagnosis of cholecystitis lead to?
Acute cholecystitis is when cystic duct is blocked
Delayed treatment can lead to gangrenous cholecystitis, gallbladder perforation and biliary peritonitis
110
What is choledocholithiasis?
when gallstones migrate from gallbladder to common bile duct.
Usually they pass spontaneously into duodenum
111
What is pancreatitis? What 3 types are treated in primary care?
Pancreatitis- inflammation of the pancreas
Treated in Primary Care:
1- recovery from acute pancreatitis
2- chronic relapsing, will have chronic abd pain
3- pancreatic insufficiency- will have steatorrhea
112
What is steatorrhea?
fatty stool with bad smell
From too much ETOH or biliary tract disease
113
What is the clinical presentation of pancreatitis?
- mild/severe epigastric pain with radiation to the flank or back
- pain is: dull, boring, and worse when supine
- Alleviated when sitting in fetal position
- Triggers- heavy meal or alcoholic binge
- Nausea and non-feculent (clear) vomiting
114
What would you find on physical exam for a patient with pancreatitis?
Temp elevated
Tachycardia
Abdomen: distended, muscle spasms, LUQ pain on palpation
Skin is jaundice
115
What labs are needed with suspected pancreatitis?
Amylase- rises within 2-72 hours
Lipases- rises within 4-24 hours
Trypsin- most accurate, but not always available
116
What radiology can help identify pancreatitis?
Ultrasound- can show stones
CT scan- the best
ERCP- endoscopy that can also remove the stone from the common bile duct
117
How to manage acute pancreatitis?
- rehydrate aggressively
- Pain meds: NO Morphine, use demerol and an antiemetic
- withhold food to reduce pain
118
How to manage pancreatitis recovery?
- high card, low fat, low protein diet
- check/treat for alcoholism
- eliminate meds that trigger pain
119
How to manage chronic pancreatitis?
- treat underlying cause
- begin with mild analgesic and may go up to methadone
- limit fat during flare ups
- rule out carcinoma
- monitor blood glucose
120
What should be check for in N/V exam?
- Abdomen is soft
- Mental status, gait and CNS if functional
- Is there fecal impaction of bleeding?
121
When/What labs should be ordered for N/V patient?
When: If persistent fo 24 hours or more
- do urine dip if worried about hydrations status
What: UA, serum electrolytes, glucose, BUN, keytones, TSH, drug levels, LFTs, Hcg, CBC w/ diff
If chronic: barium swallow, CT scan, endoscopy, head CT and ECG.
122
How to manage patient (non-pharm) for N/V?
- no solid food or clear liquid for 24 hours
- sip fluids 1tbsp. every 10 minutes
- pt. should void every 2-3 hours
- bland diet for 1 week
123
How to manage a patient with severe N/V- not responding to mgmt?
IV hydration
Med: dramamine, regland, Tigan, compazine, zofran if not pregnant, promethazine
Never give anti emetics to children
124
When should a child with N/V be sent to the ER?
Emisis and colicky or fever for 24+ hours
125
What are the potential causes of hematemesis?
esophageal (varicies, ulceration, esophagitis)
Gastritis, cancer, PUD, neoplasm
126
What are the potential causes of Melena?
Meckel's diverticulum
Crohn's disease
Ulcer disease
varicies
127
What are the potential causes of hematochezia?
hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD
128
What diagnostic tests should be run for a potential GI bleed?
CBC, coagulation studies, renal function and liver function
If hematochezia and 50+ y.o. do a colonoscopy
If hematemesis- do endoscopy, and biopsy for H.pylori
129
What medication is prescribed to prevent a bleed in a known varicose secondary to cirrhosis?
Nadolol or Propanolol
130
What is prescribed for a suspected ulcer/gastritis?
H2 blockers, omeprazole
131
What are some physical exam signs of appendicitis?
psoas sign
obturator sign
132
What labs/tests confirm acute appendicitis?
elevated WBC (above 10,000)
CT scan
133
How is appendicitis treated?
- surgical removal of the appendix
134
What are the two diseases of IBD?
Inflammatory bowel disease:
| ulcerative colitis and crohns disease
135
What are the peak onset age of IBD?
15-25 years old
Second pear: 60's and 70's
136
What is the biggest risk factor is IBD?
family history
137
What is the difference between ulcerative colitis and Crohn's disease?
Ulcerative colitis is a confluent inflammatory disease of the bowel mucosa
Crohn's disease is a chronic relapsing inflammatory-autoimmune disease that is segmented anywhere from mouth to anus. Extends through all layers of the GI tract.
138
How will ulcerative colitis present?
- blood diarrhea, urgency, fecal incontinence, abdominal pain
- maybe: fever, anorexia, weight loss
- arthritis, uveitis, jaundice, skin lesions
139
How is ulcerative colitis managed?
During flare up: reduce dietary fiber
In remission: increase fiber, iron and folic acid
Initial treatment/prophylaxis: mesalamine (anti-inflammatory) or sulfasalazine (anti-inflammatory)
Other meds: steroids, opiates, immunosuppressants
140
How will Crohn's disease present?
diarrhea, RLQ pain or distension,
weight loss, food avoidance,
n/v, fever, recurrent UTI,
pneumaturia,
psoas abscess
arthritis
aphthous oral ulcers
141
How is crohn's disease diagnosed?
Colonoscopy
EGD
Capsule EGD
Barium enema
Tissue biopsy
142
How is Crohn's disease managed?
Food: increased fiber for diarrhea, no milk, decrease fat
May need TPN for bowel rest
Meds: 5-ASA: Asacol, Pentsa, Apriso
Others: antibiotics, steroids, immunosuppresents, opiates, methotrexate and adalimumab (chemo drugs)
Surgery reserved for intractable disease
143
What is IBS?
Irritable bowel syndrome is a catch all term for people with no structural or biochemical etiologies but have symptoms of: abdominal pain, bloating, and disturbed defecation
Women are more effected than men.
144
What is the clinical presentation of IBS?
bloating, cramping and diarrhea and/or constipation
usually being late teens/ early 20's
LLQ abdominal pain is intermittent, crampy
Worse 1-2 hours after meals
Exacerbated by stress, better after BM, doesn't disturb sleep
145
What is the Rome III criteria for IBS?
recurrent abd pain/discomfort for 3 days/month in the last 3 months.
2 of 3 must be true:
- improves with BM
- change in stool frequency
- change in form of BM
146
What is the IBS work up?
- abdominal exam: LLQ tenderness, guarding, masses
- rectal exam: tendeness, masses, blood
- Labs
- If severe symptoms or unsure, give colonoscopy
147
What test should be run for IBS?
CBC, ESR (erythrocyte sedimentation rate- non specific inflammation test), TSH, glucose, electrolytes, BUN (kidney function), fecal occult, stool culture, UBT (urea breath test for H.pylori),
abdominal ultrasound
x-ray: KUB (kidney, ureter and bladder x-ray), Barium enema.
148
What does IBS management entail?
- treat the symptoms
- dietary/medication modifications to relive gas
- fiber to bulk stool in predominate diarrhea
- Miralax for constipation (osmotic laxative)
- Bentyl (Muscarinic antagonist) for abdominal cramping TID or Levsin (anti spams) for abdominal cramping PRN
- reduce stress and increase exercise
149
How is constipation defined?
A decrease in the frequency of BMs
150
What are the common causes of constipation?
Functional: ignoring the urge, not enough fiber/fluids, sedentary life, disorders of the endocrine, neuro or colorectal
In elderly: decreased activity, chronic illness, poor diet, not enough fluids, medications
151
What are the Rome III criteria of functional constipation?
Must have 2:
1. straining 25% of the time
2. lumpy/hard stool
3. incomplete evacuation feeling
4. sensing anorectal blockage
5. need to help stool out
6. fewer than 3 stools per week
152
What diagnostic tests could be used with constipation?
CBC with diff, Chem profile, TSH, UA, stool culture
KUB (kidney, ureter, bladder x-ray), abdominal x-ray
Abdominal ultrasound
Barium enema
Colonoscopy
Anorectal manometry (measures pressure)
Colonic transport studies (motility)
Electromyelogram (assesses nerve/muscle cell health)
153
How is constipation managed?
- increase water, exercise, fiber and fiber supplements
- Use Senna, Miralax if straining still present- only sporadic use
- Refer if 50+ yo and: unresponstive to tx, positive hem occult or weight loss
154
How is diarrhea defined?
Increase in liquidity and frequency of stools
usually abrupt, self limiting (less than 1 week), and due to infection like viral gastroenteritis
155
How is chronic diarrhea defined?
diarrhea lasting lover than 2-3 weeks
Can be intermittent or continuous
Classified as inflammatory, osmotic, secretory, factitious or altered intestinal motility
156
What is tenesmus?
when you feel like you have to dedicate, when you don't.
Related to inflammation
157
What are some potential associated symptoms with diarrhea?
N/V
abdominal pain or cramping
fever
malaise
158
What diagnostic tests could be run for diarrhea over 48 hours?
stool culture w/ fetal leukocytes and occult blood
CBC with diff, electrolytes, glucose, BUN, SCr
159
What should be looked for on physical exam for a patient with diarrhea?
- Temperature, weight changes
- CV status- do they have postural hypotension from dehydration
- Skin- turgor, rash, joint inflammation
- HEENT: conjunctivitis (or joint inflammation = Reiter's)
- Abdominal: tenderness, distension, rigidity, tympany
- Rectal: tenderness, mass, fecal impaction, occult blood (could abuse laxatives which would lead to impacted stool with liquid stool leaking around it)
160
How is diarrhea managed?
oral fluid replacement, IV if severe or very young/old
Educate: handwashing
If bacterial- appropriate antibiotics
If not resolved with above- start Florastor probiotic
No anti-motility (loperimide/simethicone) with bloody diarrhea
F/U in 48 hours, if unresolved, need to find underlying cause
161
What is C.diff?
Pseudomembranous colitis from enterotoxin or cytotoxin
Can occur up to 3 months after antibiotics are taken
162
How is C.diff diagnosed?
stool sample
163
How is C.diff treated?
metronidazole (flagyl) (250-500mg QID in adults)
if no response: vancomycin (125-500mg in adults)
164
What is diverticular disease?
abnormal herniations of colonic mucosa
increases risk with age
165
What is the difference between diverticulosis and diverticulitis?
Losis- asymptomatic, but have the abnormal mucosa
Litis- plugged and inflamed mucosa leading to LLQ pain, mild fever and increased leukocytes
Risk- can perforate, create fistulas, obstructions and hemorrhage
166
How is diverticulitis diagnosed?
CT scan with oral/IV contrast
167
How is diverticulitis treated?
Bedrest and a clear liquid diet
non-opiate analgesic
mild fever: Broad spectrum antibiotic
Fever >101 and worse symptoms: hospitalization
168
How is diverticulosis treated?
increase dietary fiber
avoid small seeds/popcorn
Avoid laxatives, enemas and laxatives
Anticholenergics may help, but may constipate
Educate: report fever, tenderness and bleeding
169
What are hemorrhoids?
masses of vascular tissue that form a cushion in the submucosa of the anal canal
170
What is the clinical presentation of hemorrhoids?
painless or some pain
rectal bleeding
anal discomfort
puritis
protrusion
171
What can increase the risk of developing hemorrhoids?
recent pregnancy
constipation
liver disease
anorectal disease
cyclists
sedentary life
172
What diagnostic tests for hemorrhoids?
CBC with diff
Serial fecal occult test
Flex sig or colonoscopy
173
What are differentials for hemorrhoids?
anal fissure (painful defecation because re-tears)
crown's disease
anal skin tags
condyloma
rectal prolapse
anorectal abscess
perianal tumors/rectal polyps
174
How are mild hemorrhoids managed?
high fiber diet
witch hazel pas
sitz baths 1-2x per day to make mucosa soft
anusol (prepH) QID for 7 days
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How are moderate hemorrhoids managed?
proctoCream-HC 2.5% or Anusol-HC 2.5% ceam (has hydrocortozone and lidocaine)
Analpram-HC/ pramoxine 1%/1% (stool softener)
176
How are severe hemorrhoids managed?
surgery
177
What are risk factors of colorectal cancer?
prior CRC
IBD
Hereditary/genetic factors
Hx: breast or female general cancer
High fat, low bulk diet
70-90% CRC arise from adenomatous polyps
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When does colorectal cancer screening begin?
50 yo for general population
40 yo for family Hx
After the pt. has had hx of colon cancer/adenomatous polyps
Annually for IBD disease
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What does colorectal cancer screening entail?
annual digital rectal exam
fecal occult blood testing annually
OR
Flexible sigmoidoscopy every 5 years
OR
Colonoscopy every 10 years
180
What are the red flags for constipation in pediatrics?
| Hirschsprung's disease?
Failure to thrive
Small stools
Fever
Bloody stool
Bilious vomiting
Tight anal sphinter
empty rectum with palpable fecal mass
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What are the red flags for constipation in pediatrics? (Pseudo-obstruction)
abdominal distension
bilious vomiting
ileus (inability to move fecal matter out)
182
What are the red flags for constipation in pediatrics?
| spinal cord abnormalities
decrease in lower extremity reflexes or muscle tone
absence of anal wink
presence of pilonidal dimple or hair tuft
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What are the red flags for constipation in pediatrics? (hypothyroidism)
fatigue
cold intolerance
bradycardia
poor growth
184
What are the red flags for constipation in pediatrics? (diabetes insipidus)
polyuria
polydipsia
185
What are the red flags for constipation in pediatrics? (cystic fibrosis)
diarrhea
rash
failure to thrive
fever
recurrent pneumonia
186
What are the red flags for constipation in pediatrics? (Gluten enteropathy)
diarrhea after wheat was introduced into the diet
187
What are the red flags for constipation in pediatrics? (congenital anorectal malformations)
abnormal position or appearance of the anus
188
What should be included on the physical exam of a child with diarrhea?
digital rectal exam- use pinky!
| radiography can be used if digital rectal exam not possible
189
How can constipation be treated in children?
infant: disimpaction with glycerin supplement or enema
>1yr old: osmotic laxative like lactulos, senns, polyethylene glycol powder, or sorbitol
190
How should management change if constipation has not improved in 6 months?
peds gastroenterologist
Relapse rate of constipation is high
191
What are the differential diagnoses for children in acute abdominal pain?
Meckel's diverticulum (congenital abnormality)
Incarcerated hernia or intestinal obstruction
testicular torsion
Hirschsprung's disease
Constipation
Appendicitis
Intussusception
192
What is the clinical presentation for intussusception?
severe colicky pain with sudden onset
current jelly stools
193
What is intussusception?
one portion of the bowel slides into the next
causes bowel obstruction, swelling, inflammation and decreased blood flow to the intestines
Common: RUQ mass
194
How is intussusception diagnosed?
Ultrasound
195
What is Meckel's diverticulitis?
Congenital pouch about 2 inches from end of small intestine that can contain 2 types of ectopic tissue: stomach or pancreas
2x more likely in males
196
How is failure to thrive defined?
Weight for age falls below 5th% on multiple occasions
OR
Weight declines 2 major percentile lines on growth chart
197
What are the causes of failure to thrive?
inadequate caloric intake due to behavioral/psychosocial issues, so routine labs don't help identify cause
Inadequate caloric intake in relation to caloric expenditure
198
How is failure to thrive best treated?
Multi-disciplinarian team: visiting nurse and nutritional counseling
199
What is NIH criteria for bariatric surgery?
BMI >40 OR BMI >45 with other co-morbid diseases
AND
H/o failed sustained weight loss
AND
No substance abuse, psychoses or uncontrolled depression
200
What are the types of bariatric surgeries?
Restrictive- decreases food intake by decreasing appetite
Malabsorptive- limits digestion and absorption
201
What is vertical band gastroplasty?
purely restrictive
Stomach stapled, or ring is put on outlet
Failure rate is high => being abandoned
202
What is the LAP-BAND surgery?
purely restrictive
silicone band put on upper part of stomach
leads to early satiety/appetite suppression
Can adjust restriction through mediport, so it is reversible if necessary
Not used due to complications and not making desired outcome
203
What is the gastric-sleeve?
Reduces the size of the stomach by 25% and removes the Ghrelin hormone (hunger stimulating hormone), non reversible
Limits the food eaten and reduces hunger sensation
Quicker weight loss
More common today
