Intestine 1 Flashcards
Infrequent stools (<3/week), hard or lumpy stools, excessive straining, sense of abdominal fullness, sense of incomplete evacuation
Decreased appetite, N/V (feculent), diarrhea, palpable stool in colon
constipation
what are alarm symptoms for constipation?
hematochezia, weight loss, anemia, FOBT or FIT, history of family colon cancer
what are risk factors for constipation?
Comorbidities, medications, poor eating, decreased motility, inability to sit on a toilet
> 50 should be evaluated for colon cancer
What causes constipation
MCC:
– inadequate fiber or fluid intake
– poor bowel habits
– irritable bowel syndrome
OR: systemic disease, medications, structural abnormalities, slow colonic transit, pelvic floor dyssynergia
Primary* (not related to disease) or secondary (disease, medications, lesions)
Exclude lesions in colonoscopy if
> 50 years
Alarm symptoms → hematochezia, weight loss, anemia, + feces occult
Family history of colon cancer
normal stool function
Normal function = 3 stools/day → 3 stools/week
DRE – assess anatomic abnormalities + pelvic floor motion
Ask patient to “bear down” + assess muscle tone
Ask them to “strain” to assess pelvic floor and ability to defecate
Labs: CBC, electrolytes, calcium, glucose, TSH
Anorectal manometry w/ balloon expulsion test (defecatory disorders)
Imaging not required unless meeting criteria
constipation
further diagnostics for constipation in
Patients 45-50 or older w/ no prior screening
“Alarm” symptoms
Family history
What’s treatment for constipation?
Dietary + lifestyle measures – optimize toileting habits, adequate dietary fluid + fiber intake, regular exercise, discontinue meds, maybe probiotics
Bulk forming laxatives – psyllium, methylcellulose, calcium polycarbophil, guar gum
osmotic laxatives - polyethylene glycol/Miralax or magnesium citrate,
stimulant laxatives (rescue - bisacodyl),
secretagogues (less optimal - lubiprostone),
serotonin 5-HT4-receptor agonist (prucalopride),
opioid-receptor antagonist (for those with opioid-induced constipation that have not responded to other medications)
Also: stool surfactants, enemas
use laxatives for constipation if
not responding to lifestyle changes
what are osmotic constipation treatments
polyethylene glycol/Miralax or lactulose. Purgative laxatives: magnesium citrate or milk of magnesia
Decreased appetite, abdominal pain/distention, N/V (may be feculent), possible diarrhea, bowel obstruction
fecal impaction
fecal impaction is common in
institutionalized elderly patients
how do you treat a fecal impaction
Digital disruption of impaction
Enema to allow digital disruption
– saline, mineral oil, soap suds
Decreased appetite, pain in RLQ, fever
Starts with vague, periumbilical or epigastric pain → shifts to RLQ
Vomiting occurs after pain
appendecitis
what are atypical appendcitis symptoms
Pelvic appendicitis with lower abdomen, and urge to urinate/defecate and no pain
Older patient diagnosis is often delayed
In pregnancy may have pain in RLQ, periumbilical area, or right subcostal area
MC emergency surgery, initiated by obstruction of the appendix (Fecalith, inflammation, foreign body, neoplasm)
appendicitis
PE: sickly/toxic, RLQ rebound tenderness and guarding, light percussion may elicit pain
Rovsing
Psoas
Obturator
McBurney’s point
Labs: moderate leukocytosis (10k-20k) w/ neutrophilia + microscopic hematuria/pyuria
Abdominal US + CT (more accurate)
appendictis
perforation should be suspected with appendicits in
Pain persisting > 36 hours
High fever
Diffuse abdominal tenderness or peritoneal findings
Palpable abdominal mass
Marked leukocytosis
what is indicated by high fever, chills, bacteremia, jaundice w/ appendictis
septic thrombophlebitis
What’s treatment for appendicitis
Early, uncomplicated = surgical appendectomy with broad spectrum antibiotics
IV cefoxitin or cefotetan
IV amp/sulb
IV ertapenem
Conservative management w/ antibiotics alone may be considered with non-perforation + surgical CIS or strong preference
Perforation = emergency appendectomy
Contained abscess – Percutaneous CT-guided drainage of abscess w/ IV fluids + abx for inflammation to subside + interval appendectomy after 6 weeks
Fever, abdominal pain, peritoneal signs, presence of a causative diagnosis or comorbidity (acute abdominal infection)
Rebound tenderness
peritonitis
Inflammation of the peritoneum –
Primary (spontaneous) w/o another intra abdominal process
Secondary (from other inflammation)
Tertiary (persistent inflammation)
peritonitis
What’s treatment for peritonitis
Surgical emergency → general or acute care surgery
Fever, abdominal pain (mild), AMS, common in cirrhotic patients
spontaneous bacterial peritonitis
Infection of ascitic fluid w/o intraabdominal source of infection
Almost always monomicrobial:
E.coli, klebsiella, strep pneumo, viridans strep, enterococcus
bacterial peritonitis
Abdominal tenderness, signs of chronic liver disease, ascites
Labs: possible hepatorenal syndrome
→ bedside paracentesis: albumin, protein, RBCs. WBCs, ALP, amylase, cytology, glucose, CDH
Cell count: ascitic fluid PMN>250
Secondary = high LDH, low glucose, high protein
Culture fluid
Spontaneous bacterial peritonitis
How do you treat bacterial peritonitis
3rd gen cephalosporin IV 5-10 days
IV albumin for patients at high risk for hepatorenal failure
- Cr >1
- BUN > 30
- Bilirubin > 4
Discontinue beta blockers permanently due to adverse effects in cirrhosis pts (MC pts to get SBP)
for bacterial peritonitis, consider antbiotic prophylaxis if
prior episode or at-risk patients with 1+:
→ low protein ascites, SCr>1.2, decomp. cirrhosis
Chronic (3m+) abdominal pain (intermittent, crampy, lower abdomen) w/ altered bowel habits, continuous or intermittent (with symptoms at least 6 months prior to dx)
Does not occur at night/interfere w/ sleep
Supportive symptoms:
Abnormal stool frequency, form, passage, abdominal bloating or feeling of abdominal distention
Also may have: dyspepsia, heartburn, chest pain, fatigue, myalgias, urologic dysfunction, gynecological symptoms, anxiety, depression
common in late teens-twenties
irritable bowel syndrome
Functional GI disorder – idiopathic
Constipation + diarrhea predominant w/ visceral hypersensitivity, intestinal inflammation, psychosocial abnormalities
> 50% of patients have underlying depression, anxiety, or somatization
IBS
What are the 3 categories of IBS
IBS w/ diarrhea
- Loose or watery
- >3/day
- Urgency or incontinence
IBS w/ constipation
- Infrequent <3/week
-Hard or lumpy
= straining
IBS w/ mixed
- Features of both
- Non-subtype
Screen for eating disorders
PE: usually normal with mild abdominal tenderness
Perform DRE in those with constipation to screen pelvic floor
Pelvic exam in postmenopausal women w/ recent onset constipation and lower abdominal pain to screen for gynecologic malignancy
Clinical dx!
If chronic diarrhea:
CBC, CRP, fecal calprotectin level (>50 → endoscopy)
Celiac disease
PCR
IBS
routine colonoscopy is not recommended <45 years w/ IBS w/o alarm symptoms but can be considered with –
failure of conservative management
all patients >45 = colonoscopy to exclude malignancy
Alarm symptoms
further investigation in IBS is needed in
→ acute onset of symptoms (>45y)
→ nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, fever
→ family history of cancer, IBD, or celiac disease
psychological therapies can be used in IBS like
CBT, relaxation, yoga, hypnotherapy
How do you treat IBS?
Reassurance, education, support
Discuss importance of mind-gut interaction
Pain, bloating, altered bowel habits → anxiety/distress → further exacerbation
Exercise
Dietary therapy – fatty foods, alcohol, caffeine, spicy, grains are poorly tolerated
w/ diarrhea, bloating, or flatulence → lactose intolerance excluded, FODMAPs may exacerbate these symptoms (eliminate fructose, lactose, fructans, wheat, sorbitol, raffinose)
“Beano” can help high galactoside content
Poorly fermentable soluble fiber
Fermentable or insoluble fiber can increase gas/bloating
Utilize drug therapy for IBS with no response –> targeting specific symptoms with what agents?
Antispasmodic = enteric-coated peppermint oil formulations, anticholinergics to treat pain/bloating (hyoscamine, dicyclomine)
Antidiarrheal = loperamide, bile-binding agents (“chole-“)
Anticonstipation agents
Psychotrophic = SSRIs (fluoxetine, paroxetine, citalopram; help constipation), low TCAs (nortriptyline, desipramine, imipramine; help diarrhea)
Nonabsorbable antibiotics = rifaximin (refractory, 2 wks)
Probiotics maybe help
Chronic constipation, abdominal pain, fluctuating bowel habits, painless rectal bleeding
diverticulosis
RF for diverticulosis
Low fiber
Abnormal motility
Hereditary factors
Connective tissue diseases
commonly, diverticulosis is in the
sigmoid colon
PE normal – may have mild LLQ tenderness w/ thickened, palpable sigmoid + descending colon
diverticulosis
tx of diverticulosis
Increase dietary fiber in diet or with supplements
Mild-moderate aching abdominal pain in LLQ, constipation or loose stools, N/V, low grade fever
diverticulitis
Sigmoid colon is MC location
Inflammation of diverticulum
diverticulitis
diverticulitis severity –
REFER IF:
Failure to improve w/n 72 hours
Presence of significant abscesses (>4)
Generalized peritonitis/sepsis
Recurrent
Chronic complications
ADMIT IF:
Severe pain or inability to tolerate oral intake
Signs of sepsis/peritonitis
CT signs
Failure to improve
Immunocompromised
PE: low grade fever, LLQ tenderness, palpable mass
Labs = stool occult blood, leukocytosis
Perforation → general abdominal pain + peritoneal signs
Abdominal CT if:
– first time with mild symptoms
– exclusion needed for complicated disease with fever, leukocytosis, sepsis, peritonitis, immunocompromised
Colonoscopy or CT colonography if:
– 6-8 weeks after resolution of symptoms
– exclusion of colorectal cancer
DO NOT if in acute stage
diverticulitis
How do you treat diverticulitis?
Mild + no peritoneal signs = clear liquid diet 2-3 days
Antibiotics ONLY in:
- Immunocompromised
- Significant comorbid disease
- Small pericolonic abscess
For 7-10 days or until afebrile for 3-5 days
– augmentin or metronidazole AND ciprofloxacin or bactrim
Then high fiber diet
If increasing fever, pain, inability to tolerate fluids, immunocompromised or significant comorbid illness, abscess, severe = hospitalization
diverticulitis
IV fluids, NPO, NG tube if ileus, IV antibiotics
Cefoxitin, pip/taz, ticarcillin/clav
Metronidazole or clindamycin PLUS AG or 3rd gen ceph
Severe diverticulitis tx
Surgical consult + repeat abdominal CT in all with severe disease + no improvement in severe disease
If abdominal abscess, percutaneous catheter drain
Emergent surgical management if general peritonitis, large abscesses, deterioration
Severe if high fevers, leukocytosis, or peritoneal signs
Asymptomatic or
GI bleeding - dark red or maroon stools, adults with black or tarry stools
Painless
Males
Children most commonly have complications
meckel’s diverticulum
Remnant of fetal omphalomesenteric duct, outpouching of distal ileum
MC congestive anomaly
– can lead to intestinal obstruction
meckel’s diverticulum
PE is benign
CT scan, Meckel’s scan
meckel’s diverticulum
how do you treat meckel’s diverticulum
Monitor
Other complications = surgery
