GI & Renal pathology Flashcards
hiatal hernia Etiology and Definition
When the stomach passed through the diaphragm into the thoracic cavity.
90% of cases = sliding hiatal hernia; the stomach and gastroesophageal junction displace superiorly though the diaphragm’s esophageal hiatus. Less common is the rolling hernia; gastroesophageal junction remains below the esophagealhiatus.
- Type I: Sliding hiatal hernia - laxity of phrenoesophageal ligament/membrane that causes displacement of the gastroesophageal junction (GEJ) >2cm
- Type II: Rolling hiatal hernia - gastric fundus of the stomach and not the GEJ, herniates above the diaphragm. Can progressively enlarge leading to surgery.
- Type III: Both the GEJ and the gastric fundus herniate above the diaphragm.
- Type IV: Herniation of other abdominal organs (spleen, colon, pancreas).
Theories on why it happens:
- Increased intraabdominal pressure results in the gastroesophageal junction to protrude through the diaphragm
- Fibrosis or excessive vagal stimulation (the vagus nerve also travels through the esophageal hiatus) causes a shortening of the esophagus which superiorly displaces the gastroesophageal junction.
- A loosening of the diaphragmatic hiatus allows the hiatal hernia to occur.
Hiatal Hernia: Risk Factors, Gender and age
The two most common risk factors for hiatal hernias are obesity and aging. Activities that increase intra abdominal pressure; lifting, straining, pregnancy, obesity, low fiber diet, and constipation can be increase intraabdominal pressure are risks for ACQUIRED hernias. Abdominal weakness post sx, trauma, and aging as well.
Women> men (belief based on pregnancy)
Geriatric, any age really but children can get them and not show symps till middle age
Hiatal Hernia: Clinical Presentation: Signs/symptoms
regurgitation and motor impairments within the diaphragm.
Heart burn post meals for sliding, pain with swallowing for rolling.
Hiatal Hernia: Diagnostic tests
Endoscopy and barium swallow, esophageal manometry in which the lower esophageal sphincter pressure and relaxation can be assessed
Hiatal Hernia: Medical Management
proton pump inhibitors for symptomatic mgmt: Prilosec, Aciphex, Prevacid, and Nexium. Head elevation during sleep and Sx after all other options are exhausted.
Hiatal Hernia:Physical Therapy Tests and Measures and Implications for evaluation, and best PT practices
monitor the progression/regression of symptoms
- SF-36 Questionnaire: track quality of life
- Global Rating of Change Scale (GROCS) - QoL
- Tracking anthropometric measurements (BMI, weight, Hip to Waist ratio, bf%)
- Proper wound care management for those who have recently had a surgery to correct a hiatal hernia.
- Avoid recumbent positions and Valsalva
- Education on weight loss, head of bed elevation, tobacco and alcohol cessation, avoidance of late-night meals, and cessation of foods that can potentially aggravate reflux symptomsincluding caffeine, coffee, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and foods with high fat content.
Chron’s Disease Risk Factors, Gender and age
Specific to CD smoking, appendectomy, and tonsillectomy. Common to IBD: urban living, antibiotics, oral contraceptives, soft drinks, vitamin D deficiency, and non-Helicobacter pylori-likeenterohepatic Helicobacter species.
Both genders affects equally, 10-30 years most common though it can happen at any age.
Chron’s Disease Clinical Presentation: Signs/symptoms
Mild to severe abdominal pain, abdominal mass in the right lower quadrant, mild skin rashes, and mild to moderate joint pain.
Less common: moderate diarrhea, weight loss, and bloody stools (unless the colon is involved.)
Significant complications: severe bleeding; abscess formation; bowel obstruction; fistula formation; impaired growth in children; nutritional deficiencies; and inflammation of the joints.
Other non GI symptoms: arthritis, ankylosing spondylitis
Chron’s Disease Diagnostic tests
requires both an endoscopy and a biopsy
CD can affect all layers of the intestine, Ulcerative Colitis is an inflammatory disorder of the mucosa of the colon. Biopsies alone only include the mucosa and not full thickness of bowel, so no distinction can be made between CD and Ulcerative Colitis. Thus, including an endoscopy or colonoscopy can help to make the differentiation between the two diseases, as it allows direct visualization of the intestines.
Chron’s Disease Medical Management
Often treated with meds, surgery only if there are complications. NSAIDS shouldnt be used.
Meds for moderate cases: Glucocorticoids 5-ASA, Azathioprine and 6-mercaptopurine
Severe cases can use biologic agents: infliximab, adalimumab, certolizumab, and natalizumab. Over the counter can use fiber, loperamide. Bc CD is an infamatroy dx, NSAIDS shouldnt be used.
Chron’s Disease Etiology and Definition
lifelong, inflammatory disorder, classified as an Inflammatory Bowel Disease. Typically affects the colon or ilium. Inflammation can “skip” segments. Exacerbation and remission episodes occur.
Etiology: complex interactions between an individual’s gut microbiota, host immunity, and intestinal mucosal response. Gene, increased microorganism, an incr in inflammatory cytokines.
Chron’s Disease Physical Therapy Tests and Measures and Implications for evaluation, and best PT practices
- Terminal ileum involvement, can produce pain that is referred to the low back, lower right quadrant or periumbilical area
- Abscess formation - refer pain into the buttock, hip, thigh, or knee, and often with antalgic gait. Referred pain, fever and lower abdominal pain may be abscess. iliopsoas muscle test, obturator muscle test, and palpation of the iliopsoas are tests that can be performed to rule out, or rule in abscess.
- Possible relief of symptoms after passing stool or gas, can be used to further assess the presence of IBD.
- PT can improve cardiovascular fitness, increase exercise tolerance, and ultimately improve QoL. Prevent low BMD and osteoporosis which is a risk to develop in CD. improve phycological effects: self esteem, depression, immunity and adverse corticosteriod use
Diverticulitis: Etiology and Definition
- Inflammation or infection of out pouchings of the colon or small intestine (diverticula) lead to complications such as perforation, abscess formation, obstruction, fistula. May leads to bulging or herniation of the intestinal wall into the pelvic cavity formation, and bleeding.
- Come from weakend areas of the muscle layers of the intestinal wall
- Diverticulitis is then the result of the diverticula developing ulcerations and/or perforations causing bacterial overgrowth in the outpouchings
- leads to risk of infection and abscess
Diverticulitis: Risk Factors, gender, age
risk Fxs
- constipation
- physical inactivity
- high red meat consumption
- obesity
- smoking
- NSAID use
- Underlying connective tissue disorder such as: Ehlers-Danlos syndrome, Marfan’s syndrome, sclerodoma
- Genetics via inheritance of defects in the muscular wall of the intestines
- Chronic steroid/ immunosuppressant use
** In ages below 50: more common in men
In ages above 50: more common in women
Most common in ages >60 years old, however average age is decreasing over time
- adults above 60 years old are estimated to have diverticula
- 10-25% at risk for developing complications such as diverticulitis.
- 80% of those with diverticular disease are asymptomatic
Diverticulitis clinical presentation:
Non-inflamed diverticular symptoms could be mistaken for symptoms similar to IBS: -bloating cramping -irregular bowel movements -flatulence
- *Inflamed diverticular disease (diverticulitis) symptoms include:
- (episodic or constant) left sided or middle abdominal pain
- fever
- changes in bowel habits
- nausea and vomiting
- pain with eating/increased abdominal pressure
- anorexia/eating disorders due to fear of pain
- potential urinary symptoms
- rectal bleeding/bloody stool
- anemia due to chronic GI blood loss
- pelvic floor, back, hip, or thigh pain due to underlying infection or abscess
Diverticulitis: Diagnostic Tests/Screens
CT scan of the abdomen and pelvis; assess complications; perforation abscess formation, obstruction, fistula formation, and bleeding
- blood tests for incr WBC
- Acute setting; colonoscopy is not initially performed 2/2 increased risk of perforation of the diverticula. 4-6 weeks after initial confirmation then a colonoscopy is warranted to confirm the extent of the diagnosis and rule out colorectal cancer.
Diverticulitis: Medical Management
Uncomplicated diverticulitis, medical management involves:
- a bowel rest/clear liquids
- antibiotics to treat or prevent infection
- pain medication
- education on diet, exercise, and habits to decrease constipation
For complicated or recurrent diverticulitis:
- a surgical laparoscopy (indicated for some cases)
- hospitalization to combat fever and leukocytosis
- antibiotics to treat abscesses < 3 cm
- drainage may be required for abscesses >3 cm-surgery for fistulas
- endoscopic dilation and temporary stent placements for obstruction
- rare, but severe perforation requires immediate surgery
- laparoscopic lavage as a non invasive option (currently in clinical trials)
Diverticulitis: Physical Therapy Tests and Measures and Implications for evaluation and Best Px
-Pts may CC of shoulder back, pelvic, thigh or hip pain.
-Get Hx of: changes in bowel and bladder function, pain with eating, weight changes, activity levels, smoking, diet info, hx of connective tissue disorders, med use and surgical procedures.
- Look for signs of
- distention, discoloration, scars, or contour.
- Pain provocation with positions that increase
intraabdominal pressure with bending, coughing,
lifting, straining.
-TTP in abdominals, Illiopsias or obturator for abcess/
inflamation, Mcburneys point.
-Perform pinch test and endurance testing.
- look for RED FLAGS: blood in the stool, fever that does not go away, severe back pain, and discoloration in the abdominal area.
- Running (also a decreasing risk Fx)/ Activity helps GI tract
- Limit pain causign activities that incr Ab pressure
- For pts post surgical abdominal sx, wound healing and scar mgmt is called for
GERD Etiology and Definition
Consequences from the backward flow, or reflux, of gastric contents into the esophagus.
Two type of GERD:
- *Erosive GERD **
- injury occurs and causes complications such as strictures, esophagitis, Barrett esophagus, or gastric cancer
Nonerosive GERD
-Termed due to no visible damage to the esophagus.
Etiology: healthy esophagus= 1. Anatomic barriers between stomach/ esophagus
2.mechanisms to clear the esophagus of stomach acid
3. maintaining acidic volume in the stomach.
when the lower esophageal sphincter (LES) relaxes (apart from swallowing), acid goes from the stomach to the esophagus, there for the LES most important anatomic barrier . Low pressure fo LES is common in those with GERD
GERD Risk Factors, gender, age
.Obesity -Advanced age -Hiatal hernias -Right side-lying -Male -Chocolate, Coffee, Fatty, Citrus, Spicy foods, Alcohol, Smoking -Certain medications -White race Add age and gender
GERD clinical presentation:
- Heartburn 2x week that radiates pain into chest, back, and neck/ occurs 30min post meals, effortless regurgitation with dysphagia, belching, nausea and vomiting.
- Position that incr HB: supine, laying/sitting on the right side and bending over.
- The elderly present many commodities and make it hard to dx GERD with their weight loss anemia ect
GERD Diagnostic Tests/Screens
- 1st the patient is tested w. proton-pump inhibitor (PPI) and reaction is monitored.
- Esophageal pH impedance and endoscopy = highest sensitivity and specificity and see liquid movement from stomach to eso.
- In addition to having HB 2 or more/week:
- Hx,
- endoscopy,
- barium radiography,
- esophageal pH monitoring H. pylori
- Newer measures= baseline impedance, esophageal mucosal impedance, GERD questionnaire, PPI test, esophageal pH impedance monitoring and endoscopy..
GERD Medical Management
lifestyle modifications:
- dont eat citrus, fatty, fried or spicy foods along with
caffeine and chocolate.
-Remaining upright for at least 3 hours after meals
-Dont eat before bed.
- Promote salivation by chewing sugarless gum.
- NO ETOH, or smoking, food diary
- H2 blockers which block histamine to prevent it from stimulating cells to secrete acid.
- endocoscopic therapy,
-antireflux surgery
- Magnetic spinter surgery
- Meds:
Aciphex, Prevacid, Nexium and Prilosec are proton pump inhibitors (PPIs) which suppress acid secretion- V effective & rec’d for short term use
- endocoscopic therapy,
-antireflux surgery
- Magnetic spinter surgery
GERD Physical Therapy Tests and Measures and Implications for evaluation AND Best practice for Physical Therapy Treatment
- 2/2 the link of obesity and GERD; monitor BMI and weight
- Must know the symps bc heart burn is seen w. cardiovascular issues
- lowering LES pressure with inspiratory muscle training
- aerobic capacity, 6 Minute Walk Test
- test for activity tolerance and sarcopenia with 5-rep max
- running or different types of aerobics that is considered strenuous exercise, can induce GERD symptoms
- Swimming and biking less impact
- Edu on avoiding triggering foods pre exercise
- avoid the valsava manuever and other risky triggers (Ab pressure).
- Watch for hiatal hernia and post surgical complications
Gastritis Definition and etiology
Group - common stomach disorders limited to the mucosa and not extended beneath the muscularis mucosae
Can be acute or chronic
-Acute gastritis - hemorrhagic
-Acute erosive- which is the presence of bleeding from the gastric mucosa
Chronic forms:
- H. pylori gastritis- caused by the bacteria H. pylori
- Multifocal atrophic gastritis: associated with H. pylori
and is patchy
- Autoimmune metaplastic atrophic gastritis: autoimmune
destruction of the body of the stomach
-Infectious gastritis: bacteria, viruses, and sometime fungi
and parasites
-Granulomatous gastritis
- Reactive (Acute erosive) gastritis: caused by Aspirin and
NSAIDs.medications and toxins, alcohol, portal
hypertensive gastropathy, cocaine, stress, radiation, bile
reflux, and aging gastropathy
Etiology:
Suppression of endogenous prostaglandins= main theory. Receptor are stimulted to make gastrin, acetylcholine, and histamine. Gastirc acid is inhibited by prostaglandins, when prostaglandins are inhibited, gastric acid increases and causes ulcers.
Gastritis: Risk Factors , age and gender
Long-term NSAID use •Inappropriate diet •Smoking,Alcoholism,Drugs •Intake of corrosive substances •Stress, Trauma •Surgical procedures •Septicemia, Systemic infections,The presence or absence of H. pylori •Liver failure •Irradiation upon the stomach African American males Age Preference: Older adults are more likely to develop gastritis.
Gastritis Clinical Presentation: Signs/symptoms (most common)
- Most are asymptomatic
- epigastric pain with a feeling of abdominal distention
- loss of appetite
- nausea.
- heartburn, low-grade fever, vomiting, and GI bleeding that isn’t visible.
- pain is more associated with ulcers than gastritis
Gastritis Diagnostic Tests/Screens
Rule out Dx by Upper endoscopic examination (biopsy)
(peptic ulcer, gastroesophageal reflux, gastric cancer,
biliary tract disease, food poisoning, and viral
gastroenteritis.)
Non invasive tests: Antibody testing, enzyme-linked immunosorbent assay, stool antigen tests, and urea breath testing
