GI/nutritional part 2 Flashcards
Etiology of intestinal obstruction
Result of mechanical blockage or loss of nl peristalsis
Paralytic ileus more common and usually self-limiting
Mechanical etiologies of SBO: adhesions from prior surgeries, incarcerated hernias, inflammatory diseases
-Always ask about prior surgeries
LBO most commonly caused by neoplasm, diverticulitis with stricuture, sigmoid volulus
Presentation of intestinal obstruction
Crampy, intermittent progressive abdominal pain with inability to have a bowel movement or pass flatus
Vomiting
-Bilious in proximal obstructions, feculent in distal obstructions
Abdominal distention
May have surgical scars, hernia or masses on exam that can provide clues to sight of obstruction
Localized to generalized tenderness
Active, high-pitched (tinkling or rushes) BS that later become absent
Tympany with percussion
Workup of intestinal obstruction
Rectal exam and hemoccult
-Stool in rectum does not exclude obstruction
Labs: CBC, CMP
Imaging:
-Abdominal series (plain films) may show air-fluid levels and multiple dilated loops of bowel
-CT scan abd/pelvis (with IV contrast if possible) is diagnostic procedure of choice
Tx of intestinal obstruction
IV fluid resuscitation, IV anti-emetics
NPO
NG tube to decompress bowel
+/- broad-spectrum abx (give if going to surgery or suspect infection)
-Zosyn or Unasyn OR Rocephin + clindamycin or Flagyl
Surgery consult and admission
In pts with pseudo-obstruction, colonoscopy is both diagnostic and therapeutic
Upper GI bleed
More common than lower Bleed originating proximal to ligament of Treitz Causes: -PUD -Erosive gastritis or esophagitis -Esophageal or gastric varices -Mallory-Weiss syndrome
Lower GI bleed
Bleed originating distal to ligament of Treitz Causes: -Diverticular dz -Colitis -Adenomatous polyps -Malignancies -IBD -Trauma
Presentation of GI bleed
Upper: hematemesis, melena Lower: hematochezia May present with signs of shock, hypovolemia, or hemodynamic instability -Tachycardia -Syncope -Weakness -Hypotension -AMS -Confusion -Angina
Workup of GI bleed
Labs: CBC, CMP, hemoccult and/or gastroccult, coag studies, type and cross
-Initial hematocrit level may not reflect actual amount of blood loss
Tx of GI bleed
Stabilize ABCs IV fluid resuscitation (consider 2 large-bore IVs) NPO O2 Cosnider transfusion NG tube Upper: PPI (pantoprazole) Surgery consult and admission
What is toxic megacolon?
Extreme dilation and immobility of colon, non-obstructive
>6 cm of transverse colon
Cause of toxic megacolon in adults
Occurs as a complication of:
- Inflammation (IBD) or
- Infection (C. diff, CMV, shigella, campylobacter)
Presentation of toxic megacolon
Severe abdominal pain
Signs of systemic toxicity: fever, tachycardia, AMS, hypotension
Abdominal distention
May have diarrhea that is often bloody
Rigid abdomen with diffuse or localized pain and rebound tenderness
Dehydration
Workup of toxic megacolon: labs
CBC, CMP, lipase, hemoccult
Leukocytosis, anemia, electrolyte abnormality
+/- positive hemoccult
Workup of toxic megacolon: imaging
Abdominal plain films (show colonic dilation)
CT abd/pelvis may be helpful
Tx of toxic megacolon
Stabilize, fluid resuscitation, NPO Correct fluid and electrolyte imbalance NG tube IV broad-spectrum abx IV steroids Surgical consult -Decompression of colon -Colostomy or complete colonic resection may be required
Etiology of mesenteric ischemia
Caused by arterial embolus or thrombosis or venous thrombosis of a major mesenteric vessel
Leads to hypoperfusion, which leads to necrosis of bowel wall, which leads to sepsis, peritonitis, gangrene, death
RFs of mesenteric ischemia
AFib Recent MI CHF ATherosclerosis Digoxin therapy Past DVT Liver dz Hypercoagulability
Presentation of mesenteric ischemia
Severe abdominal pain that may be sudden or gradual
-Classic clinical description: abdominal pain out of proportion to physical exam findings
-Often refractory to pain medication
Nausea, vomiting, anorexia common, +/- diarrhea
Abdominal exam relatively nl
As ischemia progresses, abdomen becomes grossly distended, absent BS, peritonitis develop
Workup of mesenteric ischemia
Hemoccult pos (late finding)
Labs: CBC, CMP, serum lactate (elevated)
Imaging: CT abd/pelvis with IV CONTRAST ONLY
Tx of mesenteric ischemia
Aggressive hemodynamic monitoring and support, fluid resuscitation
Restore blood flow ASAP
GI decompression- NG tube
Correct metabolic acidosis
Anticoagulation (usually): heparin or LMWH
Broad-spectrum abx
Surgical consult for revascularization ASAP
-Do not delay consult if obvious infarct, perforation or peritonitis
Incarcerated hernia
Contents of hernia are not reducible
Can lead to bowel obstruction and strangulation
Strangulated hernia
Vascular compromise of incarcerated contents
Acute surgical emergency
Can lead to gangrene, perforation, peritonitis, septic shock
Presentation of hernia
Abdominal pain localized to mass, severe if strangulated
Nausea, vomiting
Induration and erythema may be present if strangulated
Protruding mass on exam
-May be more obvious if ask pt to lift head off table while in supine position
Workup of hernia
CT abd/pelvis
Labs have limited value
Tx of incarcerated/strangulated hernias
Emergent surgical referral
NPO
IV fluids, IV pain control, IV broad-spectrum abx
Diarrhea
3 or more watery stools/day
Workup for diarrhea
Pts with abdominal pain, fever, and bloody diarrhea should undergo stool studies
CBC, CMP
Consider hemoccult
Tx of diarrhea
Correct fluid and electrolyte problems BRAT diet as tolerated Anti-motility agents -Loperamide, bismuth subsalicylate -No if bloody or suspected inflammatory diarrhea Abx for infectious diarrhea -Cipro, Flagyl, Vanc, etc (depends on bug) -Acute infectious and TD: Cipro, Flagyl -C. Diff- Flagyl, Vanc Education -Hand washing, work excuses Admission if toxic or complications
Pathophysiology of constipation
There could either be issues of stool consistency or issues of defecatory behavior
Etiology of constipation
Primary constipation: Normal-transit constipation- MCC of primary constipation Slow-transit constipation Pelvic floor dysfunction Secondary constipation: Dietary issues Structural causes Systemic diseases Meds Toxicologic Psychological issues
Hx of constipation
General: Abdominal bloating Pain on defecation Rectal bleeding Spurious diarrhea LBP Suggest that pt may have difficult rectal evacuation: Feeling of incomplete evacuation Digital extraction Tenesmus Enema retention
S/sx of constipation that are grounds for particular concern
Rectal bleeding Abdominal pain Inability to pass flatus Vomiting Unexplained wt loss
Questions regarding constipation hx to ask
Detailed inquiry into the pt’s nl pattern of defecation
Frequency with which the current problem differs from the nl pattern
Perceived hardness of the stools
Whether the pt strains in order to defecate
Amount of time spent on the toilet while waiting to defecate and what maneuvers used to treat
PE of constipation
Abdominal distention or masses may indicate the presence of colonic stools or tumors Pelvic exam in women may reveal internal prolapse or rectocele Assess in rectum: -Perianal excoriation -Skin tags/hemorrhoids -Anal fissure -Anocutaneous reflex -Prolapse during straining -Stool amount and consistency
Workup of constipation
CBC CMP TSH Radiography in acute abdominal pain, fever, leukocytosis, and other sx suggesting systemic or intra-abdominal processes CT Barium study Defecography Colonic transit study Lower GI endoscopy Anorectal manometry
Tx of constipation
Increased fiber intake Increased fluid intake Failure of diet changes: look into compliance and search for other physical causes Bulk agents Emollient stool softeners Rapidly acting lubricants Prokinetics Laxatives Osmotic agents Prosecretory drugs Surgery for the tougher problems
Pathophys of hepatitis
Hep A: Virus excreted in stool during first few weeks of infection, before onset of sx (15-45 day incubation period)
HepB: Incubation period, 40-150 days
Transmitted through parenteral or sexual transmission
Hep C: Incubation period of 8 wks
4 phases of hepatitis: phases 1 and 2
Phase 1 (viral replication phase)- pts are asymtomatic; lab studies demonstrate serologic and enzyme markers of hepatitis Phase 2 (prodromal phase)- Pts experience anorexia, nausea, vomiting, alterations in taste, arthralgias, malaise, fatigue, urticaria and puritis, and some develop an aversion to cigarette smoke. When seen by a healthcare provider during the phase, pts are often diagnosed as having gastroenteritis or a viral syndrome
4 phases of hepatitis: phases 3 and 4
Phase 3 (icteric phase)- Pts may note dark urine, followed by pale-colored stools; in addition to the predominant GI sx and malaise, pts become icteric and may develop RUQ pain with hepatomegaly Phase 4 (convalescent phase)- sx and icterus resolve, liver enzymes return to nl
Hx of Hep A
Incubation period 2-7 wks Presentation similar to that of gastroenteritis or a viral respiratory infection MC s/sx: Fatigue Nausea Vomiting Fever Hepatomegaly Jaundice Dark urine Anorexia Rash
Hx of Hep B
Incubation: 30-180 days
Prodromal phase, characterized by gradual onset of anorexia, malaise, and fatigue. Pt may experience RUQ pain during this time
Icteric phase: jaundice develops
Urine darkens and stools lighten in color
May have nausea, vomiting, and pruritis
Hx of Hep C
Incubation: 15-150 days
Sx may appear similar to those of HBV infection
In up to 80% of cases, pts are asymptomatic
PE of hepatitis
PE findings vary with the type of hepatitis and time of presentation
Often present with low-grade fever
Those experiencing sig vomiting and anorexia may show signs of dehydration
Icteric phase: may have icterus of the sclerae or mucous membranes or discoloration of the TMs
Skin may be jaundiced and may reveal macular, papular, or urticarial rashes
Liver may be tender and diffusely enlarged with a firm, sharp, smooth edge
Workup for hepatitis: hep A
Acute infection: IgM antibody to hep A virus anti-HAV
Workup for hepatitis: hep B
HBsAg is the first serum marker seen in persons with acute infection
HBeAg is also present until viral replication slows, then replaced with anti-HBe
First antibody to appear is HBcAg anti-HBc, of the IgM class
Workup for hepatitis: hep C
Elevated AST and ALT
Hep C serology
HCV RNA testing
Tx of acute hepatitis
Hep A: Supportive tx, hospitalization whose nausea and vomiting places them at risk for dehydration
Hep B: Mostly supportive
Hep C: Early interferon therapy should be considered
