GI+HG Flashcards
1
Q
What is the function of the GI tract
A
- Mastication (mouth)
- Ingestion (mouth)
- Propulsion (Waves of peristalsis from cardiac sphincter to pylorus about 3 times a minute)
- Mechanical and chemical digestion (begins in stomach completed in small intestine)
- Absorption (some in stomach rest in small intestine)
- Elimination of non-usable residues as faeces (large intestine)
2
Q
What are the different GI disorders?
A
- Nausea, vomiting, hyperemesis gravidarum
- Coeliac disease
- Constipation
- Irritable bowel syndrome
- Inflammatory bowel disease
o Crohn’s disease
o Ulcerative colitis
3
Q
Problems involving the small intestines
What is coeliac disease?
A
- Coeliac disease is not an allergy or an intolerance like some people believe, but a lifelong autoimmune disease where the body’s immune system damages the lining of the small bowel when gluten, a protein found in wheat, barley and rye, is eaten.
- More common in those with other autoimmune disorders
- Inflammatory condition of the small bowel (duodenum, jejunum, ileum) caused by an inability to digest GLUTEN (wheat protein)
- Gluten = mixture of 2 proteins (gliadin, glutenin)
- Lining of small intestine damaged on exposure to gluten; gut villi become inflamed and flattened, eventually undergoing atrophy
- Results in malabsorption, malnutrition, systemic illness
- Aetiology unknown but is related to a combination of genetic predisposition and environmental factors- the amount of gluten ingested, stress of a pregnancy or a GI infection.
4
Q
What are the signs and symptoms of coeliac disease?
A
- (Adults) General lassitude; diarrhoea; iron/folate deficiency; vitamin D/vitamin K deficiency; weight loss
- Adults may experience less acute symptoms than children
- (Children) Usually present at age 9 months to 3 years when cereals introduced into diet: Pale, bulky and foul-smelling stools; steatorrhoea- fat in the stools; malabsorption and failure to thrive; weight loss; abdominal distension; diarrhoea
5
Q
Investigations and management of coeliac disease
A
- Blood tests to detect auto-antibodies
- Stool sample, to exclude infection
- FBC (exclude anaemia; check WBC); CRP-inflammatory marker
- Small bowel biopsy (via endoscopy)
- Serological tests
- Women first presenting in pregnancy – need to consider the desirability, practicability and safety of the more invasive investigations
- Health education/advice; help with accessing information about Coeliac Disease; support breastfeeding; delay weaning in the infant
6
Q
What are the complications of coeliac disease?
A
- Anaemia
- Osteoporosis
- Short statures
- Reproductive problems
- Malignant disease
7
Q
What are the pregnancy issues related to coeliac disease?
A
- Can experience an aggravated response during pregnancy
- Haematological disorders: iron-deficiency anaemia
- Some studies have showed that if left untreated can increase risk of miscarriage, fetal growth restrictions and LBW.
- Further vitamins and mineral supplementations need to be given- folic acid.
8
Q
What is constipation?
A
- Definitions of constipation vary:
o fewer than 2 bowel motions per week
o feeling of incomplete defecation
o hard, lumpy stools
o straining to move bowels
o less frequent bowel motions than is customary
o nausea; bloated feeling - Related to fluid intake, dietary fibre content, activity levels, effectiveness of gastro-colic reflex, psychological factors, hormone levels
- Nausea & vomiting may cause reduced food/fluid intake
- Pregnancy: progesterone and prostaglandins slow GI tract motility; gravid uterus exerts pressure on the sigmoid colon and rectum –> constipation
- May have GI upset with iron supplementation
- May be exacerbated by presence of haemorrhoids or anal fissure, or increase the risk of developing them
- Impact: physical, emotional, behavioural effects; abdominal pain/discomfort; rectal bleeding; depression
9
Q
What are the interventions for constipation?
A
- Dietary advice: adequate fluid intake (at least 2 litres/day); increased fibre content - aim for gradual increase in fibre, to avoid bloating/discomfort
- Reduce caffeine – diuretic effects will increase water loss
- Consider temporarily stopping or changing iron tablets
- Increased physical activity/exercise will promote gut peristalsis
- Retraining the bowel – relaxation exercises; modify environment to facilitate comfort/privacy
- Laxatives, stool softeners, suppositories, enema, bulking agents; should be a last resort, short-term measure only
- Professional awareness of possibility of enforced immobility and changed environment (bed-rest, hospital in-patient stay) on normal bowel function
10
Q
What is IBS
A
- Functional disorder of the intestines
- Appears to be the results of motor disturbances in the intestine that respond to certain stimuli.
- Similar symptoms to other bowel functional disorders
- Recurrent abdominal pain, discomfort, distension, bloating (relieved on defecation); more frequent, looser stools; passage of mucus per rectum; feeling of incomplete evacuation of bowel; bouts of constipation
- May be linked with hormonal cycles (esp female); stress, genetic predisposition, food allergies and sensitivities, bacterial overgrowth in the intestines
- Symptoms exacerbated by certain antibiotics and non-steroidal anti-inflammatory drugs (noxious stimuli to gut)
- Symptoms may be exacerbated by pregnancy (especially if already experiencing constipation)
11
Q
Management of IBS
A
- Aetiology is unknown
- Thorough assessment of progress and impact of the condition; nature, timing and severity of symptoms
- Dietary review – reduce caffeine; avoid triggers; eliminate fructose and sorbitol sources; modify fibre content; avoid foods that ferment in the gut
- Assess and aim to reduce emotional stressors
- Provide environment that promotes relaxation, privacy, hygiene (may be difficult in hospital wards)
- Pharmacological treatments – symptom relief
- No evidence of malabsorption of nutrients
12
Q
Drug treatment in IBS
A
- Anticholinergic drugs (antispasmodics)
o Smooth muscle relaxants; clients with IBS have increased gut motility after eating, resulting in cramps, bloating and diarrhoea; e.g. hyoscine (Buscopan), dicyclomine (Merbentyl) - Peppermint oil
- Opioid derivatives (anti-diarrhoeal effect)
o Slow gut peristalsis; long-term use may worsen constipation - Antidepressants (including SSRIs)
o Have been used in clients unresponsive to conventional treatment; can reduce bowel’s response to distension/stimulation - Antibiotics and probiotics
o May help if there is overgrowth of gut bacteria
13
Q
Inflammatory Bowel Disease
Chron’s disease
A
- Chronic inflammatory disease affecting ANY part of GI tract
- Get granulomatous changes through whole thickness of bowel wall
- Unknown cause but thought to be some genetic predisposition. It is considered that the condition is in response to environmental triggers, such as infection and drugs.
- Less common than U.C: affects up to 5:10,000 people
- More common in smokers (compared with non-smokers); both sexes are equally affected
- Can lead to bowel perforation; stricture formation; fistulae; abscess formation
14
Q
Complications of chron’s disease
A
- Poor self esteem
- Fissures in the anal canal
- Abscesses in the pelvis
- Arthritis
15
Q
What is Ulcerative colitis?
A
- Inflammatory disorder affecting large bowel mucosa
- May involve rectum only, or part/whole of colon.
- Never involves the small intestine
- Unknown aetiology, but some evidence for genetic susceptibility
- Twice as common in non-smokers
- Affects women more frequently than men
- Can result in colonic dilatation; malignancy
16
Q
Signs and symptoms of IBD
A
- Watery diarrhoea (with blood & mucus)
- Lower abdominal pain/cramps
- Change in frequency of bowel motions; urgency
- Weight loss/malnutrition
- Abdominal tenderness
- Perianal abscesses, fistulae, skin tags (in C.D.)
- Anal/rectal strictures (in C.D.)
- R.I.F. mass (in C.D.)
- Fever
- Malaise
- Anorexia
- Tachycardia
- Ulcers in mouth
- Clubbing of fingers (proliferation of soft tissue)
- Arthritis symptoms
- Liver and kidney impairment
17
Q
Investigations of IBD
A
- Thorough history-taking, examination, record-keeping and referral to appropriate specialists
- Care should be offered by gastroenterologist who specialises in IBD.
- Bloods: FBC, ESR, CRP, U&Es, LFTs, blood cultures, serum iron, B12, red cell folate
- Stool sample for infection screening
- Abdominal X-ray (?during pregnancy)
- Colonoscopy; biopsy (rectum or colon)
- Barium enema (not during pregnancy or during an acute attack)
18
Q
Management of IBD in pregnancy
A
- Pregnancy does not usually affect the course of IBD; symptoms generally remain stable
- Most symptom changes occur in early pregnancy or postnatally
- Pregnancy outcome not affected by ‘quiescent’ IBD but may be adverse effects if active disease present
- Women may already have a stoma (ileostomy, colostomy), with or without a stoma bag (some may have a conduit for administration of medication only)
- Investigations: FBC, stool culture, serum albumin, sigmoidoscopy/proctoscopy
- LSCS only for obstetric indications, or if have severe perianal Crohn’s disease
- Anti-inflammatory drugs, such as sulfasalazine or mesalazine are safe to use during pregnancy and when breastfeeding
o Sulfasalazine interferes with folate metabolism, so these women should be advised to take folic acid supplements (high dose)
o Oral/rectal steroids safe to use in pregnancy
o Avoid immunosuppressive agents such as 6-mercaptopurine; azathioprine (use the latter with caution)
o Avoid NSAID’s as they may cause inflammations and bleeding in the small intestines.
19
Q
What is hyperemesis gravidarum?
A
- Very severe NVP
- May begin very early, even before a positive test
- Symptoms peak at 9-13 weeks, improve around 16-24 weeks but may continue throughout the pregnancy
- Weight loss is severe and rapid and dehydration is common
- If not managed appropriately complications can ensue
- Medical treatment is necessary
- Psychological support is beneficial
20
Q
Impacts of HG?
A
- Physical complications and risks for mum
o Hypokaleamia and hypocalcaemia
o Wernicke’s encephalopathy: brain condition
o Re-feeding syndrome
o Death
o Also: Oesophageal damage, ongoing gastrointestinal problems, burst blood vessels, torn stomach muscles, VTE, pressure sores. - Risks and complications for baby if poorly managed:
- Termination! IUGR, miscarriage, placental abruption, pre-term labour, intrauterine death. Malnutrition in early pregnancy linked with cardiometabolic disorders behavioural and development problems in childhood.
- Psychological complications
o Peri-natal depression, PTSD, flashbacks, PND
o Caused by hyperemesis not a cause of it!!
o Loss of hope of “normal pregnancy”
- Social impact o Unable to work and maintain household, loss of identity o Isolation o Financial hardship o Relationship difficulties o Concerns over care of other children
21
Q
HG is more likely in?
A
- Young primips
- Non-smokers
- Non-caucasian
- Multiple pregnancy
- Previous history of HG (risk of admission 29 times higher)
- Current or previous molar pregnancy
- Pre-existing diabetes
- Depression or psychiatric illness
- Hyperthyroid disorder
- Peptic ulceration or other gastrointestinal disorders
- Asthma
22
Q
Aetiology of HG
A
- Not entirely known, likely multifactorial
- Genetic factor – 86% recurrence in subsequent pregnancy vs 0.7% for non-sufferers. 30-35% risk if mother/sister suffered.
- Reduced risk of recurrence with a different partner – difficult to explain without genetics of foetus being involved!
- Various theories around thyroid function, H.Pylori- bug in the stomach, oestrogen and hCG, Prostaglandin E2: None stand up in robust studies
- New theories emerging around the hCG molecule, Growth and Differentiation Factor 15 (GDF15) and intracellular calcium release channel (RYR2) [1,2]
23
Q
Clinical indicators of HG
A
- Constant nausea and/or vomiting >5 x a day for >5 days
o or more severe but for less time? >10 times a day for 2-3 days is surely HG?
o Nausea so constant and severe that she can’t eat/drink for 3+ days? - Weight loss >5% pre-pregnancy weight
- Dehydration and malnutrition
- Metabolic disturbances
- Psychosocial morbidity, QoL affected – often the nausea is more impacting
- Ptyalism – excessive salivation
- Heightened/warped sense of smell
- Acid reflux (in addition to vomiting)
- Oesophagitis
- Lethargy and fatigue (symptom of hypocalcaemia)
- Headaches
- Sensitivity to sensory stimulation, lights/noise/movement etc
- Depression, effect not cause!
- Constipation
- Hair loss
- Loss of bladder control
24
Q
Diagnosing HG
A
- Differential diagnosis o Gastrointestinal o Neurological o UTI o ENT disease o Drugs o Metabolic and endocrine disorders o Psychological disorders ie. Eating disorders
Assessing symptoms
- History
- Severity of symptoms
- Impact of symptoms, physical/emotional/social/financial, be holistic
- Treatment to date
25
Treatments of HG
Principles of treatment
- Rehydrate
- Sort out the electrolytes/vitamins
- Maintain with anti-emetics
- Give realistic goals, it’s about managing rather than curing in the short term
- None of the treatments are miracle cures and some have unpleasant side effects – be honest
- Aim to work as a team with the patient to manage their condition
IV therapy
- Rehydration
o Rapid IV Fluid replacement
o Get 2 litres in them over 4 hours
o ie. 1 litre Hartman’s over 2 hours then 1 litre Normal Saline over 2 hours (with 20mmol potassium)
- Longer regimes never achieve full rehydration and they spiral down on discharge
- Avoid dextrose containing IV Fluids
- Vitamins Electrolytes
o Vitamin B1
Oral Thimine or IV Pabrinex
Risk of Wernike’s encephalophathy
Educate to need for tablet on discharge if vomiting is severe
o Potassium
10mmol KCL over 1 hour
Give in second bag of fluid
26
Types of HG
Spectrum within a spectrum
- “Mild HG” managed with cyclizine and perhaps second-line antiemetic, may need a round of rehydration. Symptoms improve significantly during second trimester
- “Moderate HG” managed with ondansetron or steroids. Rehydration required at least once. Symptoms likely to last for most of pregnancy but hopefully improvement in second trimester
- “Severe HG” is unresponsive to antiemetic therapy. Requires regular rehydration, possibly via a PICC line. Symptoms usually last until birth and complications can be ongoing for years. TOP may be necessary.
