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Emergency Med rotation > GI/nutritional part 2 > Flashcards

GI/nutritional part 2 Flashcards

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1
Q

Etiology of intestinal obstruction

A

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

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2
Q

Presentation of intestinal obstruction

A

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

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3
Q

Workup of intestinal obstruction

A

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

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4
Q

Tx of intestinal obstruction

A

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

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5
Q

Upper GI bleed

A 
More common than lower
Bleed originating proximal to ligament of Treitz
Causes:
-PUD
-Erosive gastritis or esophagitis
-Esophageal or gastric varices
-Mallory-Weiss syndrome
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6
Q

Lower GI bleed

A 
Bleed originating distal to ligament of Treitz
Causes:
-Diverticular dz
-Colitis
-Adenomatous polyps
-Malignancies
-IBD
-Trauma
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7
Q

Presentation of GI bleed

A 
Upper: hematemesis, melena
Lower: hematochezia
May present with signs of shock, hypovolemia, or hemodynamic instability
-Tachycardia
-Syncope
-Weakness
-Hypotension
-AMS
-Confusion
-Angina
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8
Q

Workup of GI bleed

A

Labs: CBC, CMP, hemoccult and/or gastroccult, coag studies, type and cross
-Initial hematocrit level may not reflect actual amount of blood loss

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9
Q

Tx of GI bleed

A 
Stabilize ABCs
IV fluid resuscitation (consider 2 large-bore IVs)
NPO
O2
Cosnider transfusion
NG tube
Upper: PPI (pantoprazole)
Surgery consult and admission
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10
Q

What is toxic megacolon?

A

Extreme dilation and immobility of colon, non-obstructive

>6 cm of transverse colon

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11
Q

Cause of toxic megacolon in adults

A

Occurs as a complication of:

  • Inflammation (IBD) or
  • Infection (C. diff, CMV, shigella, campylobacter)
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12
Q

Presentation of toxic megacolon

A

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

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13
Q

Workup of toxic megacolon: labs

A

CBC, CMP, lipase, hemoccult
Leukocytosis, anemia, electrolyte abnormality
+/- positive hemoccult

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14
Q

Workup of toxic megacolon: imaging

A

Abdominal plain films (show colonic dilation)

CT abd/pelvis may be helpful

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15
Q

Tx of toxic megacolon

A 
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
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16
Q

Etiology of mesenteric ischemia

A

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

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17
Q

RFs of mesenteric ischemia

A 
AFib
Recent MI
CHF
ATherosclerosis
Digoxin therapy
Past DVT
Liver dz
Hypercoagulability
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18
Q

Presentation of mesenteric ischemia

A

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

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19
Q

Workup of mesenteric ischemia

A

Hemoccult pos (late finding)
Labs: CBC, CMP, serum lactate (elevated)
Imaging: CT abd/pelvis with IV CONTRAST ONLY

20
Q

Tx of mesenteric ischemia

A

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

21
Q

Incarcerated hernia

A

Contents of hernia are not reducible

Can lead to bowel obstruction and strangulation

22
Q

Strangulated hernia

A

Vascular compromise of incarcerated contents
Acute surgical emergency
Can lead to gangrene, perforation, peritonitis, septic shock

23
Q

Presentation of hernia

A

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

24
Q

Workup of hernia

A

CT abd/pelvis

Labs have limited value

25
Q

Tx of incarcerated/strangulated hernias

A

Emergent surgical referral
NPO
IV fluids, IV pain control, IV broad-spectrum abx

26
Q

Diarrhea

A

3 or more watery stools/day

27
Q

Workup for diarrhea

A

Pts with abdominal pain, fever, and bloody diarrhea should undergo stool studies
CBC, CMP
Consider hemoccult

28
Q

Tx of diarrhea

A 
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
29
Q

Pathophysiology of constipation

A

There could either be issues of stool consistency or issues of defecatory behavior

30
Q

Etiology of constipation

A 
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
31
Q

Hx of constipation

A 
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
32
Q

S/sx of constipation that are grounds for particular concern

A 
Rectal bleeding
Abdominal pain
Inability to pass flatus
Vomiting
Unexplained wt loss
33
Q

Questions regarding constipation hx to ask

A

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

34
Q

PE of constipation

A 
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
35
Q

Workup of constipation

A 
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
36
Q

Tx of constipation

A 
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
37
Q

Pathophys of hepatitis

A

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

38
Q

4 phases of hepatitis: phases 1 and 2

A 
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
39
Q

4 phases of hepatitis: phases 3 and 4

A 
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
40
Q

Hx of Hep A

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
41
Q

Hx of Hep B

A

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

42
Q

Hx of Hep C

A

Incubation: 15-150 days
Sx may appear similar to those of HBV infection
In up to 80% of cases, pts are asymptomatic

43
Q

PE of hepatitis

A

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

44
Q

Workup for hepatitis: hep A

A

Acute infection: IgM antibody to hep A virus anti-HAV

45
Q

Workup for hepatitis: hep B

A

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

46
Q

Workup for hepatitis: hep C

A

Elevated AST and ALT
Hep C serology
HCV RNA testing

47
Q

Tx of acute hepatitis

A

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

Emergency Med rotation (12 decks)

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