GI MDT S/S Hallmarks Flashcards
_More than 3 bowel movements every day
_Less than 2 weeks in duration
_Transmitted by fecal-oral contact, food, and water with incubation periods of 12-72 hours
_Caused by a BACTERIA, parasites, or toxins
_BLOODY, small volume stools
_Fever > 38.5 C
Acute Infectious Diarrhea
INFLAMMATORY
_More than 3 bowel every movements a days
_Less than 2 weeks in duration
_Transmitted by fecal-oral contact, food, and water with incubation periods of 12-72 hours
_Caused by a VIRUS or enterotoxins
_Large volume watery diarrhea
_NON BLOODY
Acute Infectious Diarrhea
NON-INFLAMMATORY
_Diarrhea present for greater than 4 weeks
Osmotic: Medication, Zollinger-Ellison Syndrome
Inflammatory: Inflammatory Bowel Disease, Malignancy
Secretory: Increase secretory activity Chronic infections: Parasites or giardia
Malabsorption syndromes: Celiac disease, Whipple, Crohn disease, lactose intolerance
Motility disorders: Irritable Bowel Syndrome
Chronic Diarrhea
_Typically diagnosed at endoscopy
_Endoscopy often performed because of dyspepsia, or upper GI bleeding
_Most commonly seen in ALCOHOLICS and LONG TERM NSAIDs USE, and critically ill patients
_Often asymptomatic
_Epigastric pain
_Nausea and vomiting
_Hematemesis
_Upper GI bleeding with “coffee grounds” emesis or bloody aspiration on NG Tube
Erosive and Hemorrhagic Gastritis
TYPES:
_H. Pylori
_Pernicious anemia
_Eosinophilic
_Typically asymptomatic
_May present as dyspepsia, bloating, and postprandial fullness/discomfort
Non-erosive and Non-specific Gastritis
_Most common digestive complaint in the United States
CAUSES:
_Diminishing intake of fiber and fluid
_Systemic disease
_Medication
_Structural abnormalities
_Slow colonic transit
_Irritable Bowel Syndrome
_Hirschsprung disease
_Infrequent stool
_Excessive straining
_Sense of incomplete evacuation
_Need for digital manipulation
Constipation
_Located above the dentate line
_No nerve innervation
Subepithelial Cushions:
_Submucosa (connective tissue, blood vessels)
_Muscularis
PRIMARY LOCATIONS:
_Right anterior and posterior
_Left lateral
_Painless, bleeding, prolapse, and mucoid discharge
_Not visible or palpable (may protrude through the anus with gentle straining)
_Prolapsed hemorrhoids are visible purple nodules covered by mucosa
_Bright red blood streaks visible on toilet paper/stool or bright red blood that drips into the toilet
Internal Hemorrhoids
_Arise from the inferior hemorrhoidal veins located below the dentate line
_Below the dentate line
_Possess nerve innervation
_PAINFUL
_Visible bluish perianal nodule
_Tender to palpation
External Hemorrhoids
_Occur most commonly in the posterior midline at 6 o’clock
_Acute anal fissures look like cracks in epithelium
_Chronic anal fissures can result in fibrosis and the development of skin tags
CAUSE:
_Trauma to the anal canal from straining, constipation, or high interval sphincter tone
_Linear or rocket shaped ulcer that is usually less than 5mm in length
_Severe, tearing pain during defecation followed by throbbing discomfort that may lead to constipation
_Bright red blood on stool or toilet paper
Anal Fissure
_Begins with the obstruction of an anal gland that opens in the base of an anal rectal crypt
_More common in young middle aged males
_As they persist, a fistula formation may develop
DIFFERENT ABSCESS SITES:
_Perianal most common
_Intersphincteric space
_Ischiorectal space
_Deep postanal space
_Supralevator less common
_Dull, aching, or throbbing pain that becomes worse immediately before defecation, is lessened after defecation, but persist between bowel movements
_Aggravated by straining, coughing, or sneezing
_Pain and tenderness interfere with walking or sitting
Anorectal Abscess
_A chronic manifestation of the acute perirectal process that forms an anal abscess
_Commonly referred as “fistula-in-ano”
_Nonhealing” anorectal abscess following drainage
_Chronic purulent drainage and a pustule-like lesion in the perianal or buttock area
_Intermittent rectal pain during defecation and sitting
_Intermittent and malodorous perianal drainage and pruritus
Anorectal fistula
_Asymptomatic hair containing cyst and sinuses to large symptomatic abscesses of the sacrococcygeal region
_Caused by ingrown hair
_Occur in the midline of the gluteal crease
_Swelling
_Pain
_Persistent discharge
_Tender mass
_Recurrent infection at the base of the spine
Pilonidal Disease
_A chronic recurrent disease characterized by diffuse mucosal inflammation involving ONLY the colon
_More common in non smoker and former smokers
_Pseudo-polyps
_Bloody diarrhea
_ Periods of symptomatic flare ups and remissions
_Lower abdominal cramps and fecal urgency
_Anemia
_Continuous inflammation of the mucosa layer distal to proximal of the colon
Ulcerative Colitis
_Is a chronic, recurrent disease characterized by patchy transmural inflammation involving ANY segment of the gastrointestinal tract from the mouth to the anus.
_Obtain surgical/hospitalization history
_Most common area ileitis or ileo-colitis
_Skip lesions
_NON bloody diarrhea
_Fever
_Weight loss and malaise
_General sense of well-being
_Cramping abdominal pain _Possible intra-abdominal abscess
Crohn’s Disease
_Chronic (more than 3 months) abdominal pain that occurs in association with altered bowel habits
_Late teens to early 20’s
NORMAL physical exam (no fevers, rashes, or bloody stool)
_Abdominal discomfort (lower abdominal region) is relieved immediately after defecation
_Bloating or feeling abdominal distention
Dx CRITERIA (PAIN + 2/3):
1. Relieved with defecation
2. Associated with change in frequency of stool
3. Associated with change in form (appearance) of stool
Irritable Bowel Syndrome (IBS)
_A condition that develops when the reflux of stomach contents causes troublesome symptoms or complications
_The LOWER ESOPHAGEAL SPHINCTER plays a vital role in frequency and severity
COMPLICATIONS
Barrett Esophagus:
Peptic Stricture:
_Heartburn occurs 30-60 minutes after meals and upon bending over or reclining
_Reports relief from taking antacids or baking soda
_Complain of regurgitation
_Dysphagia
_Dyspepsia
_Cough
_Chest pain
_Belching
_Hoarseness
Gastroesophageal Reflux Disease (GERD)
_History of taking pills without water or supine
_Bed bound patients are at greater risk
_Severe retrosternal chest pain
_Odynophagia and dysphagia often beginning several hours to one month after taking a pill
Pill Induced Esophagitis
_Is most common in HIV infected patients and in patients with hematologic malignancies
_May occur in patients with uncontrolled diabetes and those being treated with systemic corticosteroids
_Odynophagia or pain on swallowing
_LOCALIZED pain to a discrete retrosternal area swallowing
_White mucosal plaque like lesions are noted on the endoscopy
Candida Esophagitis
CAUSE:
_Esophageal irritation from chronic GERD
_Eosinophilic esophagitis
UNCOMMON CAUSES:
_Strictures secondary to external beam radiation, esophageal sclero therapy, caustic ingestions
_Localized substernal chest pain
_Heartburn
_Dysphagia
Esophageal Stricture
_Idiopathic motility disorder which causes loss of peristalsis in the lower distal 2/3 of the esophagus and impaired relaxation of the lower esophageal sphincter
_Gradual onset of dysphagia with solid foods and some liquid
_Can be present for months
_Substernal chest pain and discomfort/fullness
_Lifting neck or throwing shoulders back to enhance gastric emptying
_Regurgitation
Esophageal Spasm
_A break in the gastric or duodenal mucosa that arises when the normal mucosal defensive factors are impaired or overwhelmed
_Ulcers are 5X more common in duodenum
_Ulcers extend through the muscularis mucosa
TWO MAJOR CAUSES:
1. NSAIDs
2. H. Pylori
_Gnawing, dull, aching or “hunger like” epigastric pain
_Nausea and anorexia (gastric ulcers)
_Relief of pain with food or antacids and a recurrence of pain 2-4 hours later
Peptic Ulcer Disease
_Inflammation of the diverticulum (a sac like protrusion on the colonic wall)
_Acute abdominal pain and fever
_Left lower quadrant tenderness with palpable mass
_Constipation or loose stool
_Nausea and vomiting
Diverticulitis
_Bleeding that occurs proximal to the ligament of Treitz
COMMON PRESENTATION:
1. Hematemesis
2. Melena (develops after 50 ml of upper GI blood loss)
HEMATEMESIS:
_Bright red blood (indicates a bleed at or proximal to the LES
_“Coffee ground” emesis (indicates a bleed in the stomach or proximal duodenum)
MELENA:
_“Tar colored” black stool (iron in hemoglobin + gastric acid)
HEMATOCHEZIA:
_Massive upper GI bleed > 1000ml
UPPER GI Bleed
_Bleeding that occurs distal to the ligament of Treitz
COMMON CAUSE:
_Diverticulitis
_IBD (Ulcerative Colitis)
_Hemorrhoids
_Fissures
_Commonly presents as HEMATOCHEZIA (bright red blood per rectum)
_Large volumes of bright red blood suggest colonic source
_Maroon stool = right colon or small intestine
_Melena = source proximal to ligament of Treitz
LOWER GI Bleed
_Non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction
_More severe when tear is associated with portal hypertension and esophageal varicies
_Heavy ALCOHOL user
_S/S of upper GI bleed (hematemesis w/ or w/o melena)
_History of retching, vomiting, or straining
Mallory Wiess Tear
Boerhaave Syndrome
_A more severe laceration of the anterior esophagus associated with full perforation of the esophagus into the mediastinum
COMPLICATIONS:
_Sepsis
_Abscess
_Mediastinitis
_Hartman’s Sign (crunching sound heard on auscultation)
_Possible crepitus with palpation over the chest
_Most common abdominal surgical emergency
COMPLICATIONS:
_Perforation
_Peritonitis
_Abscess
_DEATH
_Periumbilical abdominal pain that progresses to more localized right lower quadrant pain
_Tender McBurney’s point
_Nausea and anorexia
_+/- Fever
_+/- Rosving sign
_+/- Rebound tenderness
_+/- Obturator sign
_+/- Psoas sign
Appendicitis
_Intermittent obstruction of cystic duct
_Symptoms last less than 6 hours
_Acute onset of intermittent sharp RUQ pain
_Pain precipitated by meals
_No fever
Biliary Colic
_Constant obstruction of the Cystic duct
_Symptoms greater than 6 hours
_Sudden onset of RUQ pain after eating a meal high in fat
_Murphy’s sign
_6 F’s: (Fat, Fertile, 40, Female, Fever, Flatulence)
Cholecystitis
_Gallstone obstructing the Common Bile Duct
_Symptoms greater than 6 hours
_Sudden onset of RUQ pain after eating a meal high in fat
_Murphy’s sign_6 F’s: (Fat, Fertile, 40, Female, Fever, Flatulence)
_Bilirubin: Increased (conjugated)
Choledocholithiasis
Ascending bacterial infection caused by obstruction of the common bile duct
Charcot’s Triad:
_RUQ pain
_Fever
_Jaundice
Cholangitis
_Inflammation of the pancreas
MOST COMMON CAUSE:
_Alcohol
_Gallstones
Abrupt onset epigastric abdominal pain
Steady, ‘boring’, severe abdominal pain that is made worse with walking and lying supine
Pain radiates to the back
Relief with sitting upright and leaning forward
_Grey Turner and Cullen’s sign
_Mild jaundice
_Nausea and vomiting
_Weakness, fever, and anxiety
_Elevated serum Lipase
Pancreatitis
_A protrusion of any body part through a cavity
_Abdominal contents herniate DIRECTLY through Hasselbach’s triangle
_Caused by muscular weakness
_Less likely to incarcerate and strangulate
_Lower anterior abdominal mass
Inguinal Hernia DIRECT
_Abdominal contents herniate through the inguinal canal
_Caused by a patent processus vaginalis
_Frequently incarcerate and strangulate
_Scrotal mass
Inguinal Hernia INDIRECT
_Typically congenital
_Usually resolve by 5 years old
_Rarely incarcerated
_“Out-y belly button”
Umbilical Hernia
_Mechanical: A physical blockage of the intestinal tract lumen
_Paralytic Ileus: A dysfunction of the intestinal tracts ability to move bowel contents through its lumen
MOST COMMON CAUSE:
_Adhesions
_Hernias
Mechanical:
_Crampy, intermittent abdominal pain
_Unable to find comfortable position
_Abdominal distention
_Vomiting
_Possible diarrhea
_Tympanic abdomen on percussion
_Constipation and bloating
_Active HIGH PITCHED bowel sounds with occasional “rushes”
Paralytic Ileus:
_Less intense abdominal pain that is more constant
_Constipation
_Diminished bowel sounds
Small Bowel Obstruction
MOST COMMON CAUSE:
_Adenocarcinoma
_Not as likely to incarcerate from hernias
_Constant aching diffuse lower abdominal pain
_Bloating and distention
_Constipation and inability to pass flatus
_Possible feculent vomitus
Large Bowel Obstruction
_Inflammation of the (localized or generalized) peritoneum
MOST COMMON CAUSES:
1. Perforated appendicitis
2. Perforated diverticulitis
3. Pancreatitis
_Very ill appearing
_Unstable vitals: (fever, tachycardia, hypotension)
_Typically DO NOT WANT to move
_Board-like abdomen
_May have absent bowel sounds
_Percussion: absence of dullness over the liver suggest free air/ perforation
Secondary Peritonitis
Direct blow: common injuries include splenic rupture and liver fractures
Crush: organ traction beyond a point of internal fixation
Deceleration injury: common injuries include duodenal and aortic rupture
_Patient may have no pain
_Little external evidence of injury
_Seat belt sign
Abdominal Trauma: Blunt
Direct penetration: gunshot or stab
Fragmentation: projectiles
Shock waves: blast effect
Patient may present in a variety of different ways depending on the mechanism of injury and location of injury
_Hypovolemic shock syndrome
_S/S of peritonitis
Abdominal Trauma: Penetrating
