GI Part 2 Flashcards

Question 1

Q

Nausea and Vomiting

Question 2

Q

N/V Clinical Presentation

Question 3

Q

N/V Associated Symptoms

Abdominal p____
H______, D____ness
Ti_____
Di______
F______
______ status changes
Pr______
An_______

Answer

A

Abdominal pain
Headache
Dizziness
Tinnitus
Diarrhea
Fever
Mental status changes
Pregnancy
Anxiety
If a patient has NO symptoms of abdominal pain this may be indicative of serious illness, especially if they have neuro symptoms*
Neuro symptoms: Headache, visual disturbances, ataxia, vertigo*

Question 4

Q

Acute Emergencies

(5)

Usually accompanied by f___ or p___

Answer

A

Acute pancreatitis

Appendicitis

Bowel obstruction (SBO or Ileus)

Peritonitis

Cholecystitis

*Usually accompanied by fever or pain

Question 5

Q

Chronic or Recurrent N/V

May be p______
Result of r____ or ch_____
G_____ disorders
M_____ headaches (aura)
Diabetic gastrop_____
M_____ or e_____ abnormality

Answer

A

May be psychogenic
Result of radiation or chemotherapy
Gastric disorders
Migraine headaches (aura)
Diabetic gastroparesis
Metabolic or endocrine abnormality

Question 6

Q

N/V Physical

W_____, t______; _____ BP, p___ rate
Skin exam to assess t____, co____, mo_____, ra___
C_ exam
Abdominal exam to assess for dis_______, per_____, _____ness, ri____, re_____, m______
M____ status, g____, C_ function
Additional exam in children to include: Presence of t____, Urination or # wet (1)

Answer

A

Weight, temperature; orthostatic VS; pulse rate
Skin exam to assess turgor, color, moisture, rash
CV exam
Abdominal exam to assess for distention, peristalsis, tenderness, rigidity, rebound, masses
Mental status, gait, CN function
Additional exam in children to include: Presence of tears, Urination or # wet diapers
Abdominal exam includes abnormal BS, peritoneal signs, focal or flank tenderness*
Neuro exam includes retinopathy and papilledema, nystagmus, stiff neck, ataxia of gait*

Question 7

Q

N/V Diagnostic

Diagnostics depend on differentials

If N/V is <24 hours =
Lab tests may include = (2)*
(1) if obstruction or peritonitis suspected

Answer

A

If N/V is <24 hours = no labs are generally needed; Presentation, history and diff dx will guide testing
Lab tests may include = UA or urine dipstick (SGravity), serum electrolytes, glucose, BUN, Scr, serum ketones, amylase (r/o pancreatitis), LFT’s (alk phos and AST r/o acute cholecystitis, choledocholithiasis) drug levels, Hcg, CBC with diff, TSH
Abd X-ray if obstruction suspected

Question 8

Q

N/V Non-Pharm Management

No _____ for at least 24 hours and ____ liquids for 24 hours; start with (1) (15mLs) every __ minutes
Hydration status should be assessed by pt’s ability to _____ every 2-3 hours
Followed by (1) diet for 24 hours
(1) diet approx 1 week

Answer

A

No solids for at least 24 hours and clear liquids for 24 hours; start with 1 tbsp. (15mLs) every 10 minutes
Hydration status should be assessed by pt’s ability to void every 2-3 hours
Followed by BRAT (bananas, rice, applesauce, toast) diet for 24 hours
Bland diet approx 1 week

Most n/v is self-limited and supportive therapy is all that is indicated; although must look at cause to dictate therapy
No solids for 8-12 hours in children
Advance diet as tolerated: if vomiting does not occur, double fluids every hour, if vomiting occurs, allow stomach to rest briefly and then start again
May use glucose-electrolyte solutions for infants and small children such as Pedialyte or Rehydralyte
Regular diet may resume as tolerated: usually 4 hours after vomiting stops
For children, advance to BRAT diet

Question 9

Q

N/V Pharm Management

Pharm management should be started if pt is too nauseated or does not respond to PO intake, IV hydration should be started

Antiemetics in children?

(1) for motion sickness
(1) for gastroparesis, GERD, chemo SE
(1) for cancer, RT, surgery (preg class B)
(1) for migraine induced vomiting (preg class C)

Answer

A

Antiemetics should not be given routinely in children

Dramamine for motion sickness
Reglan for gastroparesis, GERD, chemo SE
Zofran for cancer, RT, surgery (preg class B)
Promethazine (Phenergan) for migraine induced vomiting (preg class C)

Question 10

Q

N/V in Infants and Children

Usually mild, short-lived _____
Weight loss may indicate an _____ problem
Weight gain may indicate over-_____
Any child with emesis plus colicky abdominal pain or fever >24 hours must be?

Answer

A

Usually mild, short-lived virus
Weight loss may indicate organic problem
Weight gain may indicate over-feeding
Any child with emesis plus colicky abdominal pain or fever >24 hours must be evaluated immediately in the ED (acute abdomen?)

Infancy: consider pyloric stenosis: projectile vomiting, epigastric mass

Question 11

Q

Oral Rehydration and Diet in Peds

_____ to eat or drink for _-_ hours after vomiting; then start with 1 ___ (sip) of ____ liquid every __-__ min
If clear liquids tolerated for 2-3 hours may advance diet to _____ diet and ___ liquid as tolerated

Answer

A

Nothing to eat or drink for 2-3 hours after vomiting; then start with 1 tsp (sip) of clear liquid every 10-15 min
If clear liquids tolerated for 2-3 hours may advance diet to bland diet and full liquid as tolerated

Question 12

Q

Oral Rehydration and Diet in Peds

Type of liquids that should be avoided?

Type of food that should be avoided?

Recommended foods include a combination of complex _______ (r____, wh____, p____, br____), ____ meats, yo___, fr___, and v______

Answer

A

Apple, pear, and cherry juice, and other beverages with high sugar content, including sports drinks (Gatorade), should be avoided since they have too much sugar and have inappropriate electrolyte levels

High fat foods are difficult to digest and should be avoided

Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables

Question 13

Q

GI Bleeding

(1) esophageal (varices, ulceration, esophagitis), Gastritis, Cancer, PUD, neoplasm
(1) Meckel’s diverticulum, Crohn’s, Ulcer disease, Varices
(1) hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD

Answer

A

Hematemesis esophageal (varices, ulceration, esophagitis), Gastritis, Cancer, PUD, neoplasm
Melena Meckel’s diverticulum, Crohn’s, Ulcer disease, Varices
Hematochezia hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD

Question 14

Q

GI Bleeding Physical Exam

Vital signs: postural ______
C______ exam
Skin: p____, e____moses, pet____, tel______, stigmata of chronic ____ dx
Nose/Pharynx: source of _____
Lymph nodes: enlarged in ______
Abdomen: masses, He______
R___ exam

Answer

A

Vital signs: postural hypotension
Cardiovascular exam
Skin: pallor, ecchymoses, petechiae, telangiectases, stigmata of chronic liver dx
Nose/Pharynx: source of bleeding
Lymph nodes: enlarged in malignancy
Abdomen: masses, hepatosplenomegaly
Rectal exam

Question 15

Q

GI Bleeding Diagnostics

Labs: ____ (Hgb may not reflect acute loss), Co____ studies, R____ (elevated BUN) and L____ function
Hematochezia (fresh blood per anus) if >50yo, _____ is warranted
Hematemesis: En_____ + B______ to r/o (1) diagnosis
Melena: decide location first, probably ____
Occult bleeding: do a ________

Answer

A

Labs: CBC (Hgb may not reflect acute loss), Coag studies, Renal and Liver function
Hematochezia (fresh blood per anus) if >50yo, Colonoscopy is warranted
Hematemesis: Endoscopy + Biopsy to r/o H.Pylori diagnosis
Melena: decide location first, probably upper
Occult bleeding: do a colonoscopy

Question 16

Q

GI Bleeding Diagnosis

(1): cirrhosis, chronic liver disease, alcoholism, meds, epigastric pain
IBD sx: d_____, ur_____, cr_______
_____ rectal bleeding: diverticular, ulcerative colitis, rectosigmoid disease

Answer

A

Hematemesis: cirrhosis, chronic liver disease, alcoholism, meds, epigastric pain
IBD sx: diarrhea, urgency, cramping
Frank rectal bleeding: diverticular, ulcerative colitis, rectosigmoid disease

Question 17

Q

GI Bleeding Management

Ulcer/gastritis: (2) Rx
I____ replacement
Anal bleeding: cause- hemorrhoids (if secondary to constipation-tx: f____ supplements or stool softener)
(1) or (1) to prevent bleed in known varices (goal pulse < 70) secondary to ______
Refer for ____ bleed, those who need en_____, un____ etiology of bleed

Answer

A

Ulcer/gastritis: H2 blockers, omeprazole
Iron replacement
Anal bleeding: cause- hemorrhoids (if secondary to constipation-tx: fiber supplements or stool softener)
Nadolol or Propanolol to prevent bleed in known varices (goal pulse < 70) secondary to cirrhosis
Refer for acute bleed, those who need endoscopy, unclear etiology of bleed

Question 18

Q

Appendicitis

Appendicitis is defined as an inflammation of the _____ lining of the _____ appendix that _____ to its other parts

Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the ______ of the appendiceal ____
Left untreated, appendicitis has the potential for severe complications, including ______ or ____, and may even cause _____

Answer

A

Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts

Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the obstruction of the appendiceal lumen
Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death

Question 19

Q

Appendicitis

Most common in ages ___-___
No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation, and the classic history of an_____ and p______ pain followed by n_____, (1) quadrant pain, and v_____ occurs in only 50% of cases
PE: do a full (2) exam
Labs will show (1)

Answer

A

Most common in ages 10-15yo
No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation, and the classic history of anorexia and periumbilical pain followed by nausea, RLQ quadrant pain, and vomiting occurs in only 50% of cases
PE: do a full abdominal and rectal exam
Labs will show elevated WBC (may be mildly high)

Question 20

Q

Appendicitis Presentation in Children

=

Younger children have (2) more often
Exam: look for __Q tenderness, and m___ on rectal exam
Treatment: if pain is Periumbilical, you may _____ the pt in __ hours in the clinic or ER, depending on the patient and family

Answer

A

The younger child is irritable, lies still, quiet with flexed hips

Younger children have perforation and peritonitis more often
Exam: look for RLQ tenderness, and mass on rectal exam
Treatment: if pain is Periumbilical, you may re-evaluate the pt in 4 hours in the clinic or ER, depending on the patient and family

Question 21

Q

Appendicitis Provocative Tests

(2)

Answer

A

Psoas and Obturator Sign

Question 22

Q

Psoas Sign

=

What indicates a positive sign?

Answer

A

Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip.

Place your hand above the patient’s right knee. Ask the patient to flex the right hip against resistance.

Increased abdominal pain indicates a positive psoas sign

Question 23

Q

Obturator Sign

=

What indicates a positive sign?

Answer

A

Raise the patient’s right leg with the knee flexed. Rotate the leg internally at the hip.

Increased abdominal pain indicates a positive obturator sign.

Question 24

Q

Appendicitis Diagnostics

(2)*

Diagnosis of acute appendicitis is suggested by the (1)
CBC with diff (1) supports diagnosis
U__, Beta ____, QN
Imaging (1) or US if indicated

Answer

A

WBC and CT*

Diagnosis of acute appendicitis is suggested by the H&P
CBC with diff (WBC 10,000-16,000 supports diagnosis)
UA, Beta HCG, QN
CT scan or US if indicated

Question 25

Q

Appendicitis CT Results

Will show (2)

Answer

A

Dilated fluid-filled appendix

Fat stranding (Minimal inflammatory changes are also present in the adjacent mesenteric fat)

Question 26

Q

Appendicitis Management

All cases of appendicitis require?

(1) standard of care for acute uncomplicated appendicitis, give (1) pre-op
(1) has been studied as an alternative for uncomplicated appendicitis, however (1)

Answer

A

Surgical consultation

Laparoscopic appendectomy, give broad spectrum abx w gram - and anaerobic coverage

Non op management with antibiotics has been studied, however carries a recurrent appendicitis rate of 14-20% in 1st year

(Patients who present late (>4-5 days after symptom onset may be treated initially with antibiotics, bowel rest and drainage if any abscess. Later (4- 10wks) appendectomy can then be performed in this subgroup only)

Question 27

Q

Inflammatory Bowel Disease

Refers to (2) chronic diseases that cause inflammation of the intestines

Increases incidence of (1) CA

Peak onset __ to __ yo
Second ‘peak’ incidence: ___ to __ yo
Males vs. Females?
(1) is greaest risk factor
Ethnicity: (1) > (1) > (1)

Answer

A

Ulcerative Colitis, Crohn’s Disease

Risk for Colorectal CA

Peak onset 15 to 25 yo
Second ‘peak’ incidence: 50 to 65 yo
Approximately equal between males and females
Family history is greatest risk factor
Jewish > Non-Jewish and Caucasian > African American

Question 28

Q

Ulcerative Colitis

=

Answer

A

Diffuse inflammatory disease of bowel mucosa, superficial and only in colon

Question 29

Q

Crohn’s Disease

Answer

A

Chronic relapsing inflammation-autoimmune

Distribution of disease is segmented (skip lesions)

Extends through all layers of bowel wall, entire GI tract can be affected (mouth to anus) , most commonly effects ileocecal junction (between small and large intestine)

Question 30

Q

Crohn’s Disease Systemic Complications

E___ inflammation
Lower ____ density, g____ failure in children
Liver and B____duct inflammation, gall_____
S___ lesions
Kidney ____
Subf_____ (more so in females)
Ar_____, j____ pain

Answer

A

Eye inflammation
Lower bone density, growth failure in children
Liver and Bile duct inflammation, gallstones
Skin lesions
Kidney stones
Subfertility (more so in females)
Arthritis, Joint pain

Question 31

Q

Ulcerative Colitis Presentation

____ diarrhea, ur_____, fecal in_____ (from chronic diarrhea not the UC), abdominal p_____

May have f____, an_____, ____ loss

Extracolonic manifestations include: (2) itis, j_____, skin _____

Answer

A

Bloody diarrhea, urgency, fecal incontinence, abdominal pain

Fever, Anorexia, Weight loss

Arthritis, uveitis, jaundice, skin lesions

Question 32

Q

Ulcerative Colitis

Frequently involves what parts of the GI tract? (2)

Diagnosis may be done by (1)

90% go into _____ after 1st attack

Answer

A

Distal Colon and Rectum

Diagnosis may be done by Sigmoidoscopy

90% go into remission after 1st attack

Question 33

Q

Ulcerative Colitis Management

Mainstay =

Initial tx/prophylaxis =

During inactive disease =

During flareup

Screen for (1)

Answer

A

Biologics

Mesalamine (5-ASA)- NSAID that treats and prevents flare ups in UC (other 5-ASAs include Asacol, Pentasa, Lialda)

1-2 tsp of Metamucil per day

Reduce dietary fiber during flare-up

Screen for Colon CA

Others: steroids, immunosuppression (6-MP, AZA, CsA), opiates, psychological support, surgery

Question 34

Q

Biologics used in UC

(2)*

+ others

Answer

A

Vedolizumab (Amjevita), Golimumab (Simponi)

Adalimumab (Humira)
Infliximab (Remicade)
adalimumab-atto (Amjevita)
adalimumab-adbm (Cyltezo)
certolizumab pegol (Cimzia)
Infliximab-abda (Renflexis)
infliximab-dyyb (Inflectra)
tofacitinib (Xeljanz)

Question 35

Q

Crohn’s Disease Diagnosis

Involves mostly (2) parts of the GI tract

Diagnostics (3)

Answer

A

Mostly small intestine, terminal ileum

Colonoscopy/Tissue biopsy, EGD, Barium Enema

Question 36

Q

Crohn’s Disease S/S

D_____, abdominal p___ (__Q) or dis____, weight ___, food _____, n___, v_____, f____, p___anal pain /drainage, recurrent ____’s, pneumaturia, psoas ab____
Extraintestinal: ___itis, ankylosing spondylitis, ___itis, aphthous o____ ulcers, sclerosing cholangitis
May have discreet RLQ ____

Answer

A

Diarrhea, abdominal pain (RLQ) or distention, weight loss, food avoidance, nausea, vomiting, fever, perianal pain /drainage, recurrent UTI’s, pneumaturia, psoas abscess
Extraintestinal: arthritis, ankylosing spondylitis, uveitis, aphthous oral ulcers, sclerosing cholangitis
May have discreet RLQ mass

Question 37

Q

Crohn’s Disease Diet Modifications

Adequate p_____ and calories, (1) for those with diarrhea, decreased ___, no _____

Supplemental (1)

May need bowel ____ or T_ _

Answer

A

Adequate protein and calories; fiber for those with diarrhea, decreased fat; no milk

Vitamins

May need bowel rest or TPN

Question 38

Q

Crohn’s Disease Pharm Management

Rx (1)-(3) for control/prophylaxis

Others =

(1) reserved for intractable disease - most pts have to get it at some time

Answer

A

5-ASA agents (Asacol aka Mesalamine, Pentasa, Apriso)

Antibiotics, steroids, immunosuppression (6-MP, AZA), biologics, opiates, psychological support

Surgery

Question 39

Q

Biologics used in Crohn’s Disease

(6)

Answer

A

Adalimumab (Humira) + other variations

Certolizumab (Cimzia)

Infliximab (Remicade) + other variations

Natalizumab (Tysabri)

Ustekinumab (Stelara)

Vedolizumab (Entyvio)

Question 40

Q

Chronic benign GI disorder: abdominal pain, bloating, and disturbed defecation that is classified as functional bc there are no structural/biochemical abnormalities

Answer

A

Irritable Bowel Syndrome

Question 41

Q

Irritable Bowel Syndrome

Gender ___ > ___ (2:1)
Most common presentation: abdominal p___ and bl_____; d_____ &/or c_____
(1) criteria can help make diagnosis

Answer

A

Women affected more than men (2:1)
Most common presentation: abdominal pain and bloating; diarrhea &/or constipation
Rome criteria can help make diagnosis

Question 42

Q

Rome IV Criteria for IBS

New definition

Answer

A

Functional GI disorders have a new definition. Rome IV defines them as follows: “Functional GI disorders are disorders of gut-brain interaction.

It is a group of disorders classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.

Question 43

Q

Rome IV Criteria for IBS

A person may experience problems with:

(1): The movement of food and waste through the GI tract
(1): Heightened experience of pain in the internal organs
(1): Changes in the gut’s immune defenses
(1): Changes in the community of bacteria in the gut
(1): Changes in how the brain sends and receives from the gut

Answer

A

Motility disturbance
Visceral hypersensitivity
Altered mucosal and immune function
Altered guy microbiota
Altered central nervous system processing

Question 44

Q

Rome Criteria for IBS

_____ abdominal pain, on average, at least __ days/week in the last__ months associated with 2 or more of the following

Related to def_______
Change in _____ of stool
Change in _____ of stool

^*Criteria fulfilled for the last __ months with symptom onset at least** __ **months before diagnosis.

Answer

A

Recurrent abdominal pain, on average, at least 1 days/week in the last 3 months associated with 2 or more of the following

Related to defecation
Change in frequency of stool
Change in appearance/form of stool

^*Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.

Question 45

Q

IBS Work Up

Weight -usually _____
Abdominal exam: tenderness (usually __Q) guarding, bowel sounds, masses, H_ _
R____ exam: tenderness, masses, blood
Diagnostics: CBC, E___, TSH, glucose, lytes, BUN/Scr Fecal o____ ; stool for O&P x 3; stool culture, U___ breath test
May have imaging: Abd u/s and x-ray, KUB = , BE
If severe symptoms or unsure-proceed w/ (1)

Answer

A

Weight -usually stable
Abdominal exam: tenderness (usually LLQ) guarding, bowel sounds, masses, HSM
Rectal exam: tenderness, masses, blood
Diagnostics: CBC, ESR, TSH, glucose, lytes, BUN/Scr Fecal occult ; stool for O&P x 3; stool culture, Urea breath test
May have imaging: Abd u/s and x-ray, KUB (kidney, ureter, bladder), BE
If severe symptoms or unsure-proceed w/ colonoscopy

Question 46

Q

IBS Management

Rome IV emphasizes that the best management for functional GI disorders requires a ______ approach which takes into consideration

Early life influences: g_____, c_____, en____
Psychosocial factors: st____, per______, psychological state, cop___, social su___
Physiology: m____, sen____, i_____ function, microf____, food, diet

Answer

A

Biopsychosocial Approach

Early life influences: genetics, culture, environment
Psychosocial factors: stress, personality, psychological state, coping, social support
Physiology: motility, sensation, immune function, microflora, food, diet

Question 47

Q

IBS Management

Treatment is purely symptomatic and includes dietary modifications, medications, behavioral therapy, education and reassurance

Establish effective relationship with pt: ed_____ and re____ is key
Symptom d____ (timing, associated sx, feelings)
Predominate diarrhea: f____ to bulk stool; lo_____ 2-4 mg QID (45 min before meals) can be helpful
Constipation: dietary fiber; laxative- M_____ preferred

Answer

A

Establish effective relationship with pt: education and reassurance is key
Symptom diary (timing, associated sx, feelings)
Predominate diarrhea: fiber to bulk stool; loperamide 2-4 mg QID (45 min before meals) can be helpful
Constipation: dietary fiber; laxative- Miralax preferred

Question 48

Q

IBS Management Cont.

Gas/Bloating: diet
Abdominal ______: Bentyl 10-20mg TID, Levsin sl TID prn or Levbid
St_____ reduction, ___feedback, ex___
Moderate to severe IBS, consider Rx (1)
Follow-up in _-_ weeks then every _-_ mos

Answer

A

Gas/Bloating: diet
Abdominal cramping: Bentyl 10-20mg TID, Levsin sl TID prn or Levbid
Stress reduction, biofeedback, exercise
Moderate to severe IBS, consider SSRI
Follow-up in 3-6 weeks then every 3-6 mos

Question 49

Q

Role of Serotonin in IBS

Serotonin is a neurotransmitter and a hormone that plays an important role in numerous life processes, including mood, sleep, appetite, temperature regulation, pain perception, sexual behavior, and the secretion of other hormones.

Although most of the body’s serotonin is found in the ___________ system and in ______, its most well-known effects are in the _____.

Serotonin is an important signaling molecule in the gastrointestinal (GI) system, where it functions to initiate gut m_____, allow the stomach to ex____, and transmit information to the ____.

Answer

A

Although most of the body’s serotonin is found in the gastrointestinal system and in blood platelets, its most well-known effects are in the brain.

Serotonin is an important signaling molecule in the gastrointestinal (GI) system, where it functions to initiate gut motility, allow the stomach to expand, and transmit information to the CNS.

Question 50

Q

Defined as a decrease in the frequency of bowel movements

Most commonly occurring gastrointestinal complaint

This disorder does affect the pediatric population but is a common complaint among older adults and more prevalent in _____

Answer

A

Constipation

women

Question 51

Q

Common Causes of Constipation

Common causes (mostly functional)

______ urge to defecate (most common)
inadequate f____ and fl____ in diet; sed_____
met___, en____, n____, colorectal disorder

Elderly patients:

Diminished vit____, decreased act____, consequence of _____ illness and medications, poor d____ habits, and decreased fl___ intake

Answer

A

Common causes (mostly functional)

ignoring urge to defecate (most common)
inadequate fiber and fluids in diet; sedentary
metabolic, endocrine, neuro, colorectal disorder

Elderly patients:

Diminished vitality, decreased activity, consequence of chronic illness and medications, poor dietary habits, and decreased fluid intake

Question 52

Q

Rome Criteria for Constipation

Functional constipation categorized under new Rome criteria IV

IBS subtypes (constipation and diarrhea) are now based on abnormal _____ type occurring at least __% of days

Answer

A

IBS subtypes (constipation and diarrhea) are now based on abnormal stool type occurring at least 25% of days

New diagnoses added to this edition include reflux hypersensitivity syndrome, cannabinoid hyperemesis syndrome (CHS), opiod-induced constipation (OIC), and narcotic bowel syndrome (NBS). **

**“Many purists would say [these] are not really functional because [they have] a cause, but we have to rethink … this in the 21st century,” Drossman said. “What we’re really saying is that these are conditions that will mimic other so-called functional GI conditions, which … may have specific etiologies, and [they are] also consistent with our [new] definition [for functional GI disorders].”

Question 53

Q

Rome IV IBS Subtypes

Subtypes are based on how _____ you experience very ____ or very ____ stools.
The percentages are now based on stool ___ on days with at least one (1)
In Rome III, the percentages were based on ____ stools.

Answer

A

Subtypes are based on how frequently you experience very loose or very hard stools.
The percentages are now based on stool form on days with at least one abnormal bowel movement.
In Rome III, the percentages were based on total stools.

Question 54

Q

Constipation Eval: History

Pt def____ of constipation; stool p____ and recent changes, d___, act____, medication and lax_____ use, PMH, P_H

Rectal exam =
Check for im_____–esp in elderly or those with chronic constipation

Answer

A

History: pt definition of constipation; stool pattern and recent changes, diet, activity, medication and laxative use, PMH, PSH

Rectal exam: fissures, hemorrhoids, irritation, guiac disease
check for impaction–esp in elderly or those with chronic constipation

Question 55

Q

Meds Associated with Constipation

O_____ and related narcotics
Nonsteroidal anti-inflammatory drugs
At_____, dicyclomine, hyoscyamine, clidinium,
Tricyclic anti_____, Antip____ and neuroleptic , Anti-par_____ drugs,
Calcium channel antagonists, Central alpha adrenergic agonists, Hy_____
MAO inhibitors, Methyl-_____,
Aluminum (ant____, sucralfate), I____ supplements, Calcium supplements, Barium sulfate,
Heavy m____ intoxication (lead, mercury, arsenic), V____ alkaloid, Cholestyramine, Sodium polystyrene sulfate

Answer

A

Opioids and related narcotics
Nonsteroidal anti-inflammatory drugs
Atropine, dicyclomine, hyoscyamine, clidinium,
Tricyclic antidepressants, Antipyschotic and neuroleptic , Anti-parkinsonian drugs,
Calcium channel antagonists, Central alpha adrenergic agonists, Hydralazine
MAO inhibitors, Methyl-DOPA,
Aluminum (antacids, sucralfate), Iron supplements, Calcium supplements, Barium sulfate,
Heavy metal intoxication (lead, mercury, arsenic), Vinca alkaloid, Cholestyramine, Sodium polystyrene sulfate

Question 56

Q

Constipation PE

Not uncommon to have _____ findings
Orthostatic hypotension and/or tachycardia implies _______
Wt loss suggests an_____ or ca_____
O____ exam
G_, G___, R_____ exam
N_____ exam

Answer

A

Not uncommon to have normal findings
Orthostatic hypotension and/or tachycardia implies dehydration
Wt loss suggests anorexia or carcinoma
Oral exam
GI, GYN, Rectal exam
Neuro exam

Question 57

Q

Constipation Diagnostics

Labs (3)
(2) urine and stool
Imaging (4)
C______ or Flex Sig
Anorectal manometry (measures _____ of anal sphincter muscles)
Colonic tr______ studies
Electromyelogram (assess _____ of muscles and nerve cells that control them)

Answer

A

CBC with diff, Chemistry profile, TSH
UA, Stool for occult blood/Stool culture
AXR/ KUB, Abdominal u/s, BE
Colonoscopy or Flex Sig
Anorectal manometry (measures pressure of anal sphincter muscles)
Colonic transport studies
Electromyelogram (assess health of muscles and nerve cells that control them)

Question 58

Q

Constipation Management

Keep stool d____
Increase f____ intake
Increase dietary fiber and supplements: Meta____, Fiberall or Fibercon, stool s_____, or os_____ agents;
If straining still present a l_____ is indicated (3)
_____ if > 50 years old: unresponsive to tx, positive hemoccult, or weight loss

Answer

A

Keep stool diary
Increase fluid intake
Increase dietary fiber and supplements: Metamucil, Fiberall or Fibercon, stool softeners, or osmotic agents;
If straining still present a laxative is indicated
Senna, Bisacodyl, Miralax
Refer> 50 years old: unresponsive to tx, positive hemoccult, or weight loss

Question 59

Q

FDA Approved Meds for Constipation

(1) (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
(1) (linaclotide) is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
(1), a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
(1) (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
(1), taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
(1) (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
(1) (Ibsrela) ADULTS only

Answer

A

Amitiza (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
Linzess (linaclotide) is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
Lactulose, a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
Miralax (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
Trulance, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
Tegaserod (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
Tenapanor (Ibsrela) ADULTS only

Question 60

Q

Diarrhea

=

Acute diarrhea usually has ab_____ onset and lasts < ___ weeks, s____-limiting
- Most cases of acute diarrhea are _____ and occur within hours of exposure; most common etiology is (1)
Chronic diarrhea lasts longer than __ to __ weeks, can be intermittent or continuous, and is classified as inf____, os____, sec____, fac_____ or related to altered intestinal motility (1)

Medications, particularly ch___therapeutic agents, en____ feedings, laxatives, antib____, caf____, magnesium antacids, alcohol may cause diarrhea

Answer

A

Defined as an increase liquidity and frequency of stools

Acute diarrhea usually has abrupt onset and lasts < 1 week, self-limiting
1. Most cases of acute diarrhea are infectious and occur within hours of exposure; most common etiology is viral gastroenteritis
Chronic diarrhea lasts longer than 2 to 3 weeks, can be intermittent or continuous, and is classified as inflammatory, osmotic, secretory, factitious or related to altered intestinal motility (IBS)

Medications, particularly chemotherapeutic agents, enteral feedings, laxatives, antibiotics, caffeine, magnesium antacids, alcohol may cause diarrhea

Question 61

Q

Diarrhea Presentation

______ is the most helpful tool in determining etiology of illness
- D_____ of illness, fr_____ and l_____ of stool, presence of b___ or m____
- Social history including tr____, al___, emp____, residence, st_____, se____ practices
- Similar illness in f____
Assoc sx’s =

Answer

A

History is the most helpful tool in determining etiology of illness
- Duration of illness, frequency and liquidity of stool, presence of blood or mucus
- Social history including travel, alcohol, employment, residence, stress, sexual practices
- Similar illness in family
Assoc sx’s: N/V, abd pain or cramping, fever, malaise
- Increase thirst, oliguria, dizziness, tenesmus, wt loss, previous or current diagnosed condition (DM, thyroid, CA), current medications, dietary supplement

Question 62

Q

Diarrhea PE

VS (2)
CV (1)
HEENT (1)
Abdominal =
Rectal =

Answer

A

Temperature, Weight
Cardiovascular status- postural hypotension
Skin for color, turgor, rash, joint inflammation
HEENT: conjunctivitis (Reiter’s)
Abdominal exam: tenderness, distention, rigidity, tympany, bowel sounds, HSM
Rectal exam: tenderness, masses, ? fecal impaction, occult blood

Question 63

Q

Diarrhea Diagnostics

If duration 24-48 hours =
Labs =
(1): Think inflammatory factor such as toxin producing bacteria (Campylobacter, Shigella, Salmonella, C Diff, enterohemorrhagic E coli, Yersinia, E. histolytica)

Answer

A

If duration 24-48 hours, no tests indicated
Labs = Stool culture, including occult blood, fecal leukocytes, CBC with diff, electrolytes, glucose, BUN, Scr, for fever >24 hours
+ leukocytes: Think inflammatory factor such as toxin producing bacteria (Campylobacter, Shigella, Salmonella, C Diff, enterohemorrhagic E coli, Yersinia, E. histolytica)

Question 64

Q

Diarrhea Management

Usually ___-limiting, treatment measures should be directed toward ______ relief

_____ fluid replacement

__ hydration for severe hydration or for young, old or immunocompromised patients

Viral =
Bacterial =

Answer

A

Usually self-limiting, treatment measures should be directed toward symptomatic relief

Oral fluid replacement

IV hydration for severe hydration or for young, old or immunocompromised patients

Viral: no specific therapy; handwashing, keep children from day care until resolved
Bacterial: Treat according to organism

Answer 63

A

Pre-formulated solution such as Pedialyte is recommended in the pediatric population

½ teaspoon salt + 6 teaspoons sugar + 1 liter of safe drinking water

Too much sugar makes diarrhea worse, Too much salt is dangerous

Answer 64

A

Follow-up if diarrhea not resolved in Supportive therapy: maintain adequate hydration status (same as vomiting); pro____ (saccharomyces boulardii lyo-Florastor)
Antimotility agents should be avoided in pts with bloody diarrhea, but loperamide/simethicone may improve symptoms in pts with watery diarrhea
Chronic: treat underlying cause
Follow-up in office if diarrhea has not resolved in 48 hours

Answer 65

A

Clostridium Difficile

Can occur up to 3 months after the medication has been taken
Metronidazole (250-500mg QID in adults) or Vancomycin (125-500mg in adults) for intolerance or no response to Flagyl

Answer 66

A

Abnormal herniations of colonic mucosa

Prevalence <5% for age < 40 years
Peak incidence of occurrence in 6^th, 7^th and 8^th decades of life

May cause diverticulitis if plugged and inflamed: 10-30% with disease will present with diverticulitis
Diverticulosis usually asymptomatic
Diverticulitis: LLQ pain, fever, and leukocytosis (Asian patients usually have Rt sided disease)
Complications: perforation, fistulas, obstruction, hemorrhage

Answer 67

A

Diverticulosis: usually incidental finding
Diverticulitis: Mild (fever <101^oF, WBC 13,000-15,000)
1. bedrest and clear liquid diet
2. nonopiate analgesics for pain
3. May have abd pain, n/v/d
4. if febrile, broad spectrum antibiotic
5. CT is diagnostic tool of choice using oral, IV and rectal contrast (although oral and IV most commonly done)
6. Barium enema NEVER performed

Hospitalize - If temperature > 101^oF despite antibiotics, pain worsens, peritoneal signs develop or WBCs rise
Lower GI endoscopy- Once symptoms subside to rule out cancer

Answer 68

A

low fiber, high fat and red meat assoc with inc risk of symptomatic diverticular disease
avoid laxatives, enemas, and opiates
anticholinergics may help but constipate
Pt Ed: report fever, tenderness, bleeding ASA
Conflicting research on avoiding seeds, nuts, popcorn, cucumbers, tomatoes, figs, corns, strawberries, caraway seeds to prevent diverticular complications
JAMA 2008 large prospective study: no associations were seen between nut, corn, popcorn consumption

Answer 69

A

Diverticulitis: Mild fever (<101F), WBC 13,000-15,000

bedrest and clear liquid diet
Non opiate analgesics for pain
monitor temp, abd, WBCs
if febrile, broad spectrum antibiotic
If temperature > 101^oF despite antibiotics, symptoms worsens, intolerance to oral fluids, peritoneal signs develop or WBCs rise: hospitalize
If treating as outpatient re assess 2-3 days after initiation of abx and weekly thereafter until resolution of all symptoms

Answer 70

A

Cipro + Flagyl

Levofloxacin + Flagyl

Bactrim + Flagyl

Augmentin

Moxifloxacin

Answer 71

A

Perforation, Abscess, Fistula, Obstruction

Diverticulitis. CT scan obtained with oral and intravenous contrast material shows wall thickening in the sigmoid colon (arrows) with adjacent inflammatory changes in the pericolic fat.

Answer 72

A

Hemorrhoids

One of their functions is to maintain closure of the anus

They are part of normal human anatomy and therefore symptomatic hemorrhoids can potentially develop in all adults

Answer 73

A

painless bleeding
anal discomfort
pruritis
protrusion or pain

Answer 74

A

Anal fissure
Crohn’s disease
Anal skin tags
Condyloma
Rectal prolapse (more common elderly)
Anorectal abscess
Perianal tumors/rectal polyps

Answer 75

A

high fiber diet, bulk-forming agents, stool softener
witch hazel pads (Tucks) or baby wipes
sitz baths 1-2x/day
Anusol or PrepH QID x7days

Answer 76

A

ProctoCream-HC 2.5% cream or Anusol-HC 2.5% cream
Analpram-HC/ pramoxine 1%/1% or 2.5%/1% supp
Severe: refer for surgery

Answer 77

A

Colon cancer is the 3rd leading cause of cancer related deaths men and women (2^nd most common cause of death gender combined)
Blacks and Hispanics are less likely to present with early stages and have a 50% greater chance of dying from the disease

Answer 78

A

Prior CRC
IBD
Hereditary and Genetic factors, familial polyposis syn
Hx of breast or female genital cancer
High fat, low bulk diet

Lifetime risk of developing is 2.5% in the general population, and 5 to 10% in persons who have a first-degree relative with adenomatous colon polyp or colon cancer

Answer 79

A

Between 70 to 90% of colorectal cancers arise from adenomatous polyps (tubular adenoma, tubular villious, or villous adenoma).
Polyps greater than 1 cm make the possibility of malignancy greaterThose with familial adenomatous polyposis (FAP) syndrome have an almost 100% chance of developing cancer by age 40
The adenomatous polyposis gene (APC) increases susceptibility to the development of adenomatous polyps

The average time from onset of a polyp to onset of carcinoma is 10 to 15 years

Answer 80

A

Start at 50-75, 76-85 individual decision, dc at 85

Start at 40 or 10 years younger than diagnosis

Start at 10 years old

Offer screening starting at 45, continue from 50-75

Annual colonoscopy for IBD

Answer 81

A

Q 1-3 years depending on test

Q 10 years

Q 5-10 years (with FIT?)

Q 5 years

Answer 82

A

gFOBT (Guaiac FOBT)
FIT, also known as iFOBT (Fecal immunochemical or immunohistochemical test)
FIT-DNA (Multitargeted stool DNA testing)

Digital rectal exam has low sensitivity
Fecal occult testing: must do pt ed re: restricted diet x 3 days
colonoscopy is preferred test if fecal occult blood is positive
Can also do air contrast barium enema every 5-10 years, but not as sensitive as colonoscopy

Answer 83

A

Abdominal pain
Celiac disease
Colic
Diarrhea/Constipation
Failure to thrive
Feeding aversion/disorder
GERD
H. pylori
Lactose Intolerance
Vomiting

Answer 84

A

Defined as a delay or difficulty in defecation, present for > 2 or more weeks and responsible for ~ 3-5 % of visits

Constipation in children usually is functional and the result of stool retention
Constipation often causes more distress to parents and other caregivers than to the affected child

Answer 85

A

Hirschsprung’s disease (congenital aganglionic megacolon)
Pseudoobstruction
Spinal cord abnormality
Hypothyroidism
Diabetes insipidus
Cystic fibrosis
Gluten enteropathy
Congenital anorectal malformation

Answer 86

A

5-40, 2.9
5-28, 2
4-21, 1.4
3-14, 1.0

Answer 87

A

Continence is maintained by involuntary and voluntary muscle contractions.
- internal anal sphincter has an involuntary resting tone that decreases when stool enters the rectum
- External anal sphincter is under voluntary control.
If a child does not wish to defecate, he or she tightens the external anal sphincter and squeezes the gluteal muscles. These actions can push feces higher in the rectal vault and reduce the urge to defecate. If a child frequently avoids defecating, the rectum eventually stretches to accommodate the retained fecal mass, and the propulsive power of the rectum is diminished.
The longer that feces remains in the rectum, the harder it becomes

Answer 88

A

Hirschsprung’s disease
Pseudo-obstruction
Spinal cord abnormalities
Congenital anorectal malformations
Hypothyroidism
Diabetes insipidus
Cystic Fibrosis
Gluten enteropathy

Answer 89

A

Digital rectal exam
Rectal impaction, anal fissures (or papillae indicative of chronic anal fissures)

Answer 90

A

No imaging needed

Abdominal radiography may be considered

Answer 91

A

Glycerin Suppository or Enema
Saline, Mineral Oil, or 1:1 Milk Molasses enema
1. Oral laxative

Answer 92

A

Lactulose

Senna

Polethylene Gylcol

Answer 93

A

0.2-0.8 g/kg/day

Higher initial dose of 1 g/kg

Max 17 g/day

Once daily BM’s achieved, titrate dose

DO NOT stop med once stooling occurs

Answer 94

A

Meckel’s diverticulum (congenital abnormality, occurs in 2% of the population. Diverticulae of atresia, usually found 2 feet from ileocecal valve)
Incarcerated hernia or intestinal obstruction
Testicular torsion
Hirschsprung’s disease
Constipation
Appendicitis
Intussusception
Less common: pancreatitis, pneumonia, IBD, diabetic ketoacidosis, GYN, UTI, trauma

Answer 95

A

Intussusception

Can result in obstruction with the walls of the intestines pressing against one another
This in turn leads to swelling, inflammation, and decreased blood flow to the intestines involved

Answer 96

A

Common cause of pain & obstruction in infancy and childhood-up to age 6, 80% occur before a child is 24 months old
3 to 4 times more common in boys than girls

Answer 97

A

Currant Jelly Stools (blood and mucus)

Sudden onset of severe, colicky pain
- Periods of screaming alternating with quiet
May have vomiting

Answer 98

A

Refer for surgery immediately

Barium enema may reduce if done within 24 hours of onset

Untreated, can lead to loss of bowel dt ischemia

Answer 99

A

Refer for surgery immediately

Barium enema may reduce if done within 24 hours of onset

Untreated, can lead to loss of bowel dt ischemia

Answer 100

A

Meckel’s Diverticulum

First 2 years - first 2 decades of life
Infection, Bleeding, Obstruction

Answer 101

A

FTT in childhood is a state of malnutrition dt inadequate caloric intake or absorption or excessive caloric expenditure

Defined as a weight for age that falls below the 5th percentile on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart

In the US, it is seen in 5-10% of children in primary care settings
Most cases involve inadequate caloric intake caused by behavioral or psychosocial issues
The most important part of the outpatient eval is obtaining accurate amount of a child’s eating habits and caloric intake

Answer 102

A

Routine laboratory testing rarely identifies a cause and is not generally recommended.
Reasons to hospitalize a child for further evaluation include failure of outpatient management, suspicion of abuse or neglect, or severe psychosocial impairment of the caregiver.
A multidisciplinary approach to treatment, including home nursing visits and nutritional counseling, has been shown to improve weight gain, parent-child relationships, and cognitive development.
The long-term effects of failure to thrive on cognitive development and future academic performance are unclear.

Answer 103

A

Restrictive - restricts amt of food ingested
- Dec appetite, Early satiety, Slows digestion
- Sleeve gastrectomy, Adjustable gastric banding, Roux-en Y gastric bypass
Malabsorptive - limits digestion and absorption
- Decreases length of intestine exposed to digested food
- 25% of fat is absorbed
- Biliopancreatic Diversion/ duodenal Switch (least commonly performed)
- All operations can be performed open or laparoscopically

Answer 104

A

Gastric Sleeve

Limits amount of food eaten and reduces hunger sensation because portion of stomach that produces Ghrelin, hunger stimulating hormone, is removed
Fastest growing wt loss sugery in North America and Asia
May be converted to gastric bypass or duodenal switch for additional wt loss
Quicker wt loss than lap band
Not reversible

Answer 105

A

Lap Band System

Early feeling of satiety/ surgical appetite suppressant; requires more patient effort for initial wt loss than with gastric bypass or duodenal switch
Purely restrictve
Adjustable restriction through mediport
Reversible (if necessary)
Complications: slippage, erosion, tubing disconnect – outdated