GI / Nutritional Part 1 (Abdominal pain - Cholelithiasis/choledocholithiasis) Flashcards

1
Q

What are some causes of RUQ pain?

Think organ location

A
  1. Gallbladder issues
  2. Liver issues

  1. biliary colic, cholecystitis/angiitis
  2. hepatitis, thrombosis
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2
Q

What are some of the causes of LUQ pain?

Think organ location

A

Spleen issues

Splenomegaly
Splenic infarct
Splenic Abscess
Rupture

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3
Q

What are some of the causes of epigastric pain? (6)

A
  1. MI
  2. Pancreatitis (acute/chronic)
  3. PUD
  4. GERD
  5. Gastritis/opathy/paresis
  6. Dyspepsia
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4
Q

Classic cause of RLQ pain vs LLQ pain

A

RLQ = Appendicitis
LLQ = diverticulitis

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5
Q

What are some GI causes of anorexia?

A
  1. Gastric/duodenal ulcers
  2. Gastric/GI cancers
  3. Hematochezia
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6
Q

What is Cholelithiasis specifically?

A

Merely Gallstones in the biliary tract (usually in the gallbladder) w/o inflammation

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7
Q

MC type of gallstone?

A

cholesterol

others are black stones (hemolysis), brown stones in infections and Asian pop

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8
Q

RF for Cholelithiasis

remember, just gallstones

A

5 Fs and Native Americans

fat, fair, female, forty, fertile

also OCPs

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9
Q

What does Cholelithiasis feel like?

A

Nothing typically

sometimes biliary colic ( episodic, abrupt RUQ or epigastric pain, resolves slowly, lasting 30min-hrs; may be associated w/ nausea & precipitated by fatty foods or large meals)

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10
Q

What is the diagnostic test of choice for:
1. Cholelithiasis
2. Acute Cholecystitis
3. Choledocholithiasis
4. Acute Ascending Cholangitis
5. Primary Sclerosing Cholangitis

A
  1. Cholelithiasis = US
  2. Acute Cholecystitis = HIDA scan if US not dx
  3. Choledocholithiasis = ERCP diagnostic and theraputic
  4. Acute Ascending Cholangitis = cholangiography
  5. Primary Sclerosing Cholangitis = MRCP/ERCP

Typically start with US for all of these though?

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11
Q

MCC of Acute Cholecystitis

A

E coli

also klebsiella, other gram-neg enteric organisms

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12
Q

If you have Chronic Cholecystitis, you can bet you have ____

A

gallstones

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13
Q

Describe the pain of Acute Cholecystitis
1. Location
2. Precipitating factors

A

Continuous RUQ or epigastric pain – may be precipitated by fatty foods or large meals

may be associated w/ nausea, guarding, anorexia

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14
Q

PE of Acute Cholecystitis and classic finding

A

fever (often low-grade); enlarged, palpable gallbladder
MURPHY’S SIGN: RUQ pain or inspiratory arrest w/ palpation of the gallbladder

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15
Q

Apart from Murphy’s sign, what is another PE sign that is sometimes seen in Acute Cholecystitis and what causes it?

A

Boas sign: referred pain to the right shoulder or subscapular area (phrenic nerve irritation)

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16
Q

Upon first-line imaging of Acute Cholecystitis, you will see ____ of the gallbladder and sometimes a ____ sign

A

1) Thickening of the gallbladder wall
2) Sonographic Murphy’s sign

remember, HIDA scan is most accurate scan though and it is used when the GB cannot be visualized

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17
Q

Overall management of Acute Cholecystitis

A

NPO (prep for surg)
IV fluids
ABX followed by:
Cholecystectomy

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18
Q

What are the ABX used pre-Cholecystectomy?

A

rocephin + metronidazole

MR

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19
Q

If a pt cannot have a Cholecystectomy, what is another treatment option for Acute Cholecystitis?

A

Cholecystostomy (percutaneous drainage) if nonoperative

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20
Q

Cholesterolosis presentation and treatment

A

fat deposits on GB
strawberry GB
tx is cholecystectomy (only if symptoms)

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21
Q

How does Choledocholithiasis differ anatomically from Cholelithiasis and why is it a concern?

A

Gallstones in the common bile duct (can lead to cholestasis due to blockage)

CBD is formed from the merging of the cystic and hepatic ducts, meaning that drainaige from the liver is blocked as well

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22
Q

Presentation of Choledocholithiasis

A

Prolonged biliary colic: RUQ or epigastric pain, N/V – pain usually more prolonged due to the presence of the stone blocking the bile duct

PE: RUQ or epigastric tenderness, jaundice

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23
Q

Lab findings of Choledocholithiasis

A

↑ AST/ALT, alk phos, & GGT

cholestasis

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24
Q

Management of Choledocholithiasis

A

Typically US first, but:
ERCP stone extraction preferred over laparoscopic choledocholithotomy

ERCP: dx TOC – diagnostic + therapeutic

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25
Q

What differs Acute Ascending Cholangitis from
1) Cholecystitis
2) Choledocholithiasis

A

Sorta a combo of the two:

1) different from Cholecystitis in that the infection is a result from blockage of the CBD rather than just the cystic duct
2) Different from Choledocholithiasis in that there is a presence of infection in addition to blocking the CBD

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26
Q

MCC of Acute Ascending Cholangitis

A

E coli

same as Cholecystitis, EZ!

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27
Q

What is the classic triad of Acute Ascending Cholangitis?

A

Charcot’s Triad: fever + RUQ pain + jaundice

Reynold’s Pentad: charcots + shock or AMS

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28
Q

What are the lab findings of Acute Ascending Cholangitis and why does this make sense?

A
  1. Leukocytosis
  2. ↑ alk phos & GGT
    ↑ bilirubin > increased ALT/AST

Again, labs suggest a hybrid of Cholecystitis and Cholangitis

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29
Q

You start with an US and are sus of Acute Ascending Cholangitis, so you use ____

A

Cholangiography via ERCP: gold standard

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30
Q

Treatment of Acute Ascending Cholangitis

remember, infectious process and stones are present

A

Zosyn OR
Metro + ceph OR
Metro + cipro
ERCP removal

Eventually elective cholecystectomy

ZAC MC (zosyn acute cholangitis or metro + ceph/cipro)

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31
Q

Apart from Acute Ascending Cholangitis, what condition can present with Charcot’s Triad?

however, it does not classically present with all three

A

Primary Sclerosing Cholangitis

it CAN but not characteristic of the condition

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32
Q

What is Primary Sclerosing Cholangitis?

A

Autoimmune, progressive cholestasis leading to diffuse fibrosis of intra/extrahepatic biliary ducts

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33
Q

Your patient has Primary Sclerosing Cholangitis, what else do they likely have?

A

IBD (specifically ulcerative colitis)

90% association

also likely a 20-40 yo male

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34
Q

What symptom can help you differ Primary Sclerosing Cholangitis and from Acute Ascending Cholangitis?

A

Pruritis

also see fatigue and hepatosplenomegaly

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35
Q

What conditions have ↑ alk phos & GGT, ↑ AST/ALT (3)

uniting feature?

A
  1. Choledocholithiasis
  2. Acute Ascending Cholangitis
  3. Primary Sclerosing Cholangitis

all involve the CBD or hepatic duct (for PSC)

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36
Q

What key lab findings are seen in Primary Sclerosing Cholangitis?

A

IgM
P-ANCA

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37
Q

With this most accurate test, you will see ____ for Primary Sclerosing Cholangitis

A

MRCP, ERCP – most accurate test: beaded appearance of biliary ducts (narrowing, strictures)

beaded appearance due to chronic sclerosis and tissue healing?

liver bx rarely used for dx - but remember that the hepatic ducts are affected

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38
Q

Management of Primary Sclerosing Cholangitis
1) symptomatic relief
2) pruritits
3) definitive

A

1) symptomatic relief = stricture dilation (allowing emptying)
2) pruritits = cholestyramine (bile sequestrant reducing bile acids)
3) definitive = liver transplant (affects hepatic/bile ducts, remember?)

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39
Q

MCC of acute vs chronic pancreatitis

A

acute = gallstones
chronic= alcohol

2nd MCC of acute = alcohol

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40
Q

what specific cells are injured in pancreatitis and what is the normal function of these cells?

A

acinar cells, which secrete exocrine enzymes

exocrine enzymes (amylase, lipase, and protease)

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41
Q

Meds that can lead to acute pancreatitis (4)

A

Thiazides
Protease inhibitors
exanitide
valproic acid

PRO vet

Protease inhibitors
Valproic acid
Exantide
Thiazides

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42
Q

Classic presentation of acute pancreatitis

A

Epigastric pain radiates to back

exacerbated if supine, relieved leaning forward

N/V and fever

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43
Q

Classic PE findings of severe acute pancreatitis

A

Cullen’s sign (periumbilical)
Grey Turner sign (flank)

suggests necrotizing hemorrhage

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44
Q

Most useful lab for acute pancreatitis

also, what electrolyte abnormality is sometimes seen?

A

Lipase

3x UNL

can also see HYPOcalcemia

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45
Q

Imaging for acute pancreatitis

A

NOT NEEDED

only use if patient does not have classic symptoms OR lipase is < 3x ULN

CT w/ contrast is imaging of choice

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46
Q

What might an abd xray show for acute pancreatitis? (2)

A

1) sentinel loop = localized ileus of small bowel segment in LUQ
2) colon cutoff sign: abrupt collapse of colon near pancreas

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47
Q

Dx of acute pancreatitis

A

Ranson’s criteria

Admission:
(1) glucose >200mg/dL
(2) age >55yrs
(3) LDH >350IU/L
(4) AST >250IU/dL
(5) WBC >16,000/µL
Within 48hrs:
(6) calcium <8mg/dL
(7) hematocrit fall >10%
(8) PO2 <60mmHg
(9) BUN >5mg/dL
(10) base deficit >4mEq/L
(11) sequestration of fluid >6L

Interpretation:
≥3 🡪 severe pancreatitis likely
<3 🡪 severe pancreatitis unlikely

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48
Q

Tx of acute pancreatitis

A

Rest the pancreas

NPO
*high-volume IVF (LR preferred)
*analgesia (Meperidine)

Antibiotics:
*indicated only if >30% necrosis seen

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49
Q

Triad of Chronic Pancreatitis

A

calcification + steatorrhea (fatty stool) + DM

seen only in 1/3 of pts: think inhibited abs d/t problem with pancreas

also see weight loss from poor abs

50
Q

How do labs differ from acute vs chronic pancreatitis

A

Chronic has normal amylase/lipase

51
Q

What might a CT scan show for chronic pancreatitis?

A

calcifications

52
Q

Most sensitive and specific test for chronic pancreatitis

A

fecal elastase most sensitive & specific; pancreatic stimulation w/ secretin & CCK

not usually done

53
Q

Management of chronic pancreatitis

A

Lifestyle

ETOH abstinence, pain control, low fat diet, vitamin supplementation

Oral pancreatic enzyme replacement

Pancreatectomy only if retractable pain despite medical therapy

54
Q

Describe the pathophys of achalasia?

what plexus is involved?

A

Loss of peristalsis & failure of relaxation of the LES

PATHO: idiopathic proximal degeneration of myenteric/Auerbach’s plexus leads to increased LES pressure & impaired LES relaxation

MC presents <50yrs of age

55
Q

What will a patient with achalasia complain of?

A

dysphagia to both solids & liquids

can’t keep food down and will often cough it up - even can have chest pain

56
Q

Diagnosis of choice and classic finding for achalasia

A

Barium esophagram:
”bird’s beak” appearance of the LES

57
Q

Treatment of choice for achalasia and definitive

A

Pneumatic dilation of LES

Esophagomyomectomy is definitive

58
Q

MC site of anal fissure

A

Linear, longitudinal tear in the posterior midline

skin tags are seen in chronic

bright red blood is seen in toilet
pain, straining

59
Q

Initial treatment of anal fissure

A

Supportive

sitz baths
high fiber and increased H2O to minimize straining

consider surg if refractory, but can lead to fecal incontinence

60
Q

MC location of Perianal Abscess and Fistulas

A

posterior rectal wall

61
Q

What does a fistula allow if a patient has a Perianal Abscess?

A

connects an abscess w/ skin or adjacent organs

62
Q

Symptoms of Perianal Abscess and Fistula and how this differs from just an abscess

A
  1. SEVERE pain paired with fever and malaise
  2. If there is a fistula, it is a more chronic, non-healing abscess - leading to purulent drainaige that is itchy and malodorous
63
Q

How to diagnose Perianal Abscess and Fistulas

A

Abscess = clinical
Fistula = MRI & endosonography

You can not feel a fistula on PE alone?

64
Q

Treatment of Abscess and Fistulas

A

I&D, Antibiotics; sitz baths, high fiber
*Augmentin, cipro + metronidazole

Fistula requires surgical treatment

Cure My Abscess
(cipro + metro) augmentin

65
Q

Stage 1-4 hemorrhoids

A

I: Does not prolapse (confined to anal canal); may bleed w/ defecation
II: Prolapses w/ defecation or straining but spontaneously reduce
III: Prolapses w/ defecation or straining, requires manual reduction
IV: Irreducible & may strangulate

66
Q

What are the veins involved with internal vs external hemorrhoids?

A

Internal = superior hemorrhoid vein; above dentate line
External = inferior hemorrhoid vein; below dentate line

67
Q

How do symptoms differ between internal vs external hemorrhoids?

A

Internal = painless bleed
External = painful non-bleeding

opposites

68
Q

Dx of hemorrhoids

A

DRE with fecal occult blood testing

sometimes anoscopy or proctosigmoidoscopy or colonoscopy if worried of other etiologies

69
Q

Intial Tx of hemorrhoids

A

Same as anal fissures pretty much

high fiber diet, increased fluids; warm sitz baths; topical rectal corticosteroids

70
Q

Procedures for failed conservative treatment of hemorrhoids

A

rubber band ligation

71
Q

What is Zollinger-Ellison Syndrome?

A

gastric-secreting neuroendocrine tumor leading to severe PUD & diarrhea

gastrinoma

ZES reminds me of zombies - which are associated with your brain (neuroendocrine)

72
Q

MC site of gastrinomas for ZES

Zollinger-Ellison Syndrome

A

duodenal wall, pancreas, lymph nodes, other sites

ZED (d = duodenum)

73
Q

Presentation of ZES

Zollinger-Ellison Syndrome

A

severe, recurrent, multiple, or refractory ulcers + diarrhea

Severe PUD:
*multiple peptic ulcers
*refractory ulcers
*abdominal pain

Diarrhea
increased acidity inactivated the pancreatic enzymes, leading to malabsorption

increased acidicty d/t PUD?

74
Q

What imaging is used for ZES and why?

Zollinger-Ellison Syndrome

A

endoscopy – confirm presence of ulcer

remember, ZES is associated with PUD and the diagnosis of choice for PUD is endoscopy + biopsy to confirm ulcer

75
Q

Lab findings seen in ZES

Zollinger-Ellison Syndrome

A

elevated basal or stimulated gastrin levels

secreted by the gastrinoma!

76
Q

You want to screen a patient for ZES, what do you do?

Zollinger-Ellison Syndrome

A

Check fasting gastrin levels and gastric pH

gastrin should not be elevated while fasting as it is secreted w/ meals?

elevated fasting gastrin levels
*>1000pg/mL + gastric pH <2 = likely diagnosis

77
Q

How to confirm ZES

Zollinger-Ellison Syndrome

A

Secretin test w/ persistant gastrin elevation

persistent gastrin elevations upon trial of secretin confirms diagnosis

Secretin SHOULD inhibit gastrin release in a healthy GI tract, but gastrin release in gastrinomas are not impacted by secretin

78
Q

MC location of METS for ZES

Zollinger-Ellison Syndrome

A

Liver and lung lymph nodes

pLants vs ZES

79
Q

Treatment of ZES and treatment if it METS

Zollinger-Ellison Syndrome

A

Tumor resection

lifelong high dose PPIs if METS (to raise pH and manage symptoms?)

80
Q

MCC of appendicitis

81
Q

preop ABX for appendicitis

A

cephalosporins + metronidazole
or zosyn

82
Q

What is Paralytic Ileus?

A

temporary functional impairment of peristalsis

NOT a physical barrier

83
Q

Meds that can cause Paralytic Ileus

A

Opioids and anticholinergics

Can’t see, can’t poop

84
Q

Electrolyte abnormality that can cause Paralytic Ileus

A

HYPOkalemia

85
Q

MCC of SBO vs LBO

small bowel vs large bowel

A

SBO = post abd surgical adhesions
LBO = adenocarcinoma > scarring secondary to diverticulitis > volvulus

86
Q

What is volvulus?

A

torsion of bowel on its axis ⇢ closed loop obstruction

torsion of mesenteric vascular pedicle ⇢ occlusion/thrombosis of mesenteric vessels ⇢ bowel strangulation, ischemia, & gangrene

87
Q

MC location of volvulus

A

Sigmoid colon

sigmoid makes the letter “S”, which is more susceptible to be twisted?

88
Q

Explain the evolution of abd sounds in a SBO/LBO

A

Peristalsis intially increases greatly early on followed by abscence of bowel sounds in later course

hyperactive followed by hypoactive bowel sounds

89
Q

Which bowel obstruction type is emesis more common in?

SBO or LBO?

A

SBO

more proximal, so it makes sense

90
Q

3/6/9 rule of bowel obstruction

A

small bowel >3cm
large bowel >6cm
cecum >9cm

91
Q

Classic sign seen in sigmoid volvulus

A

coffee bean sign

92
Q

Classic finding of volvulus on CT

A

whirl sign = pathognomonic

remember, it winds on itself leading to blood flow compromise

93
Q

Initial Tx of SBO

A
  1. NG Tube for gastric decompression (1)
  2. Fluids prior to surg if strangulation sus

(1) NG tube helps prevent aspiration and relieves gastric distension by removing gastric fluids + gas

94
Q

Tx of SBO if 24 hours w/out improvement

I’m assuming without improvement w/ NG tube and whatnot?

A
  1. laparotomy
  2. Lysis of adhesions
  3. resect nonviable intestine followed by primary anastomsis of resected segments
95
Q

Overall Tx of LBO

A

Surgery (in nearly all cases)

goals ⇢ resection of necrotic bowel &
decompression of obstructed segment

96
Q

Surgery options for LBO (3)

A

1) *resection + primary anastomosis
2) *resection + diversion, diversion alone
3) *endoscopic stent placement

97
Q

Treatment of cecal volvulus

A

ileocecal resection or R colectomy w/ ileocolic anastomosis

quick refresher; order of small intestine/ large intestine flow:

duodenum, jejunum, ileum, cecum, ascending colon, hepatic flexure (right colic flexure), transverse colon, splenic flexure (left colic flexure), descending colon, sigmoid colon, rectum, anus

98
Q

Treatment of sigmoid volvulus w/OUT signs of peritonitis

A

sigmoidoscopy w/ rectal tube insertion for decompression, detorsion, & reduction

surgery if all else fails

99
Q

Treatment of sigmoid volvulus WITH signs of peritonitis

A

sigmoid colectomy & primary anastomosis

100
Q

Apart from BMI, in order to be a candidate for bariatric surgery, what do you need to do?

A

Fail a dietary program

Proof of failure typically required

101
Q

BMI guidelines for bariatric surg

A

35+ if comorbidities (HTN, DM)
40+ otherwise

102
Q

Goals of restrictive bariatric surgeries

A

Limit coloric intake by limiting the stomach’s resivoir capacity

103
Q

2 restrictive bariatric surgeries

A
  1. Sleeve gastrectomy
  2. Laproscopic adjustable band
104
Q

Sleeve gastrectomy involves _____

A

resection of greater curvature of stomach

restrictive + hormonal change = less hunger and better insulin control

reduces the size of the stomach and leads to a 60% weight loss @ 2 years

105
Q

Which bariatric surgery is strictly restrictive

A

LAGB

Laparoscopic Adjustable Gastric Banding

not used much anymore

106
Q

Roux-en-Y Gastric Bypass (RYGB)

A

▪︎small stomach pouch created & connected directly to small intestine ▪︎70% weight loss @2y

107
Q

Dumping syndrome

what is this often seen in?

A

nausea, weakness, sweating, faintness, & possibly diarrhea soon after
eating within first few years after surgery ⇢ symptoms intensify w/ high-sugar foods

seen in Roux-en-Y Gastric Bypass (RYGB)

108
Q

Which bariatric surgery involves removing the LESSER curvature of the stomach

A

One-Anastomosis Gastric Bypass (OAGB): “mini-gastric bypass”

109
Q

Gastroparesis vs Ileus

for constipation

A

Gastroparesis: condition that affects the stomach muscles & prevents proper stomach emptying

Ileus = hypomobility of the GI tract in the absence of mechanical bowel obstruction

Gastro = specifically stomach
Ileus = GI tract

110
Q

MCC of Gastroparesis

A

DM

chronic damage to nerves of GI tract (autonomic neuropathy)

111
Q

s/s of gastroparesis vs ileus

A
  1. Gastroparesis = nausea, full feeling after little food is eaten, constipation
  2. Ileus = diminished bowel sounds and constipation

both constipation

112
Q

treatment of gastroparesis and ileus

A

Underlying cause + treat constipation

113
Q

Overall meds for constipation

A
  1. Fiber
  2. Bulk forming laxatives
  3. Osmotic laxactives
  4. Stimulant laxatives
114
Q

MOA of fiber

A

retains water & improves GI transit

increases bulk of stool

115
Q

What are the bulk forming laxatives?

A
  1. Psyllium
  2. Methylcellulose
  3. Polycarbophil
  4. Wheat dextran

notice how the names of these are related to carbs:
cellulose
carbophil
wheat
(then psyllium)

116
Q

MOA of bulk forming laxatives

A

absorbs water & increases fecal mass; increases the frequency & softens the consistency of stool w/ minimal effects

*dietary fiber + bulk forming laxatives most physiologic & effective approach

117
Q

What are the osmotic laxatives? (3) Specifically saline laxatives? (2)

A
  1. Sorbitol
  2. Polyethylene glycol (PEG)
  3. Lactulose

Saline = milk of magnesia, mag citrate (basically mg)

118
Q

MOA of osmotic/saline laxatives

A

causes water retention in stool (osmotic effect pulls water into gut)

119
Q

What are the SE of saline laxatives?

A

hypomagnesemia

idk why? fact check?

120
Q

What are the stimulant laxatives? (2)

A

Bisacodyl
Senna

121
Q

MOA of stimulant laxatives

A

increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa

122
Q

All of the treatments for constipation (fiber + laxatives) have a SE of bloating except

A

stimulant laxatives

diarrhea, abdominal pain