Lecture 6 (GI)-Exam 2 Flashcards
Obesity:
* Defined as what?
* Disease is multifactorial stemming from what?
- Defined as abnormal accumulation of adipose tissue that may impair health (via contribution to CAD/DM/HTN/HLD).
- Disease is multifactorial stemming from mismatch of calories intake versus expenditures and further influenced by genetic (obesity os very heritable), social and societal factors.
One-thirdof adults and about 17% of adolescents in the UnitedStates are obese
Obesity
* What is a genetic syndrome associated with extreme obesity?
* What is the gene implicated with obesity ?
- Prader-Willi is the most common genetic syndrome associated with extreme obesity
- FTO gene is implicated with obesity
- What is leptin?
- What is ghrelin?
- Leptin – adipocyte hormone that reduces food intake via appetite suppression and therefore reduces body weight
- Ghrelin is an appetite stimulant hormone and works as an antagonist to leptin
What does leptin resistance cause?
Leptin resistance on cellular level increases obesity and promotes free fatty acid secretion that increases inflammation and cause triglyceride levels to rise and increase insulin secretion (NIDDM basic-> T2D)
What happens with leptin and ghrelin levels before and after eating?
- What is Metabolic obese normal weight (MONW) ?
- What is Metabolically healthy obese (MHO) ?
Metabolic obese normal weight (MONW)
* Subjects with normal BMI suffer from metabolic complications normally found in obese individuals
Metabolically healthy obese (MHO)
* Individuals have BMI over 30 kg/m2 but do not have the characteristics of insulin resistance or dyslipidemia
He said low yield
What are the BMI ranges?
- Underweight: less than 18.5 kg/m2
- Normal range: 18.5kg/m2to 24.9 kg/m2
- Overweight: 25kg/m2to 29.9 kg/m2
- Obese, Class I: 30 kg/m2 to 34.9 kg/m2
- Obese, Class II: 35 kg/m2 to 39.9 kg/m2
- Obese, Class III: more than 40 kg/m2
What should be measured for obesity dx and what are the values for males and females?
Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:0.8 is considered significant.
Obesity Treatment: Multiprong individualized approach
* Manage what?
* Provide what supportive treatment? (4)
* Who are the medications for?
- Manage contributing conditions (hypothyroidism, dietary and behavioral modifications)
- Provide supportive treatment: physical activity, exercise, nutrition, and weight maintenance.
- Medications: reserved for patients with BMI >30 or >27 + comorbid condition
What are the examples of obesity medications?
Orlistat, phentermine, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine
Obesity
* What is surgery reserved for?
* What are the types of surgery?
* What are the SE of surgery?
Surgery: reserved for BMI >40 or 35 + severe comorbid conditions
* Adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy
* Rapid weight loss can lead to gallbladder problems
* Chronically may lead to malabsorption refeeding or dumping syndrome.
What are the 5 types of GI bleeding?
- Acute
- Chronic
- Overt – clinical signs/symptoms present
- Occult – not clinically evident (+ FOBT and/or iron deficiency anemia)
- Obscure – routine evaluation (upper and lower endoscopy has not revealed source)
Gastrointestinal Bleeding
* Upper GI vs. Lower GI location is determined by what?
the Ligament of Treitz
What are locations of UGI and LGI bleeds?Dx by?
UGI – proximal to Ligament of Treitz
* Esophagus
* Stomach
* Duodenum
* Dx by EGD
LGI – distal to Ligament of Treitz
* Jejunum and Ileum
* Colon
* Dx by colonoscopy
GI Bleed Presentation
* What can happen with vomit that is probably an UGI source?
Hematemesis (vomiting blood) – probably an UGI source
* Bright Red Blood with or without clots
* Coffee grounds – blood accumulates in stomach
Stool color, consistency, frequency:
* Wha tis melena and hematochezia? What do they indicate?
- Melena (black tarry stools) – Typically suggests upper GI source, but can be seen with LGI small bowel or proximal colon bleeds.
- Hematochezia (bright red blood per rectum) – Typically suggests a lower GI source on left side, however, but can be seen with brisk UGIB
Hemodynamic Changes: GI bleed
* What can happen with BP? what can be some sxs?
- Orthostatic drop in BP > 10 mm Hg or HR > 20 bpm - usually indicates > 20% reduction in blood volume(+/- syncope, lightheadedness, nausea, sweating, thirst)
- Shock, BP < 100 mm Hg systolic - usually indicates > 30 % reduction in blood volume(+/- pallor, cool skin)
Work-up of GI Bleeds
* What do you need to do?
- Vital Signs + orthostatic BP
- Physical Exam w/ Rectal Exam
- Labs: CBC, PT/INR/PTT/LFTs, Electrolytes/renal function
Work-up of GI Bleeds
* Why do we have to get CBC?
* Why PT/INR/LFTs?
* Why electrolytes/renal function?
CBC
* Check and monitor hemoglobin and hematocrit
* Crossmatch 2 – 6 units PRBC depending on level of active bleeding
* Platelet count (< 50,000/mcl with active bleeding requires transfusions of platelets and FFP to replete lost clotting factors)
PT/INR/PTT/LFTs to r/o advanced liver disease (coagulopathy)
* INR must be kept less than 1.5
Electrolytes/renal function
* Prerenal changes (i.e. azotemia)
Early Management of GI Bleeds
* What do you need to check, place and give?
- ABCs (airway, breathing, circulation)
- Bilateral 14/16-gauge upper extremity peripheral IV (need large bore IV)
- Resuscitation: IV Fluids, PRBCs after type and cross and Correct underlying coagulopathies
- Foley catheter to monitor renal perfusion
- NG Tube lavage (for UGIB)
NG tube/gastric lavage
* What is the aspirate if UGIB and LGIB?
* WHat is nondiagnostic?
- UGIB - Fresh blood or coffee-ground aspirate
- Probable LGIB – Non-bloody, bilious aspirate
- Clear, non-bilious aspirate is NONDIAGNOSTIC (May miss duodenal source of bleeding)
* Bile is aspirated in duodenum, not gastrum
A 28 year old patient has been passing tarry stools for two days. Blood pressure in the supine position is 110/70 mm Hg with pulse of 98 bpm. In the sitting position blood pressure is 96/72 mm Hg with pulse of 110 bpm. Nasogastric aspirate is negative for blood. The most likely location of this bleed is:
A. Esophageal
B. Duodenal
C. Rectal
D. Large Bowel
E. Posterior nasopharynx
Duodenal
Causes of Upper GI Bleeding
* What are the different types of esophagus bleeds? (4)
- Esophageal varices (#3 cause) – present with Portal HTN
- Esophagitis
- Esophageal Ulcer
- Mallory-Weiss tear (mucosal tear at GE junction due to retching-ETOH, Bulimia, sick) (#4 cause)
Causes of Upper GI Bleeding
* What are the examples of stomach bleeds? (3)
- Gastric ulcer (#2 cause)
- Gastritis
- Gastric antral vascular ectasia – Longitudinal erythematous stripes on gastric mucosa (known as Watermelon Stomach) (rare)
Causes of Upper GI Bleeding
* What is a dieulafoy’s lesion?
Dieulafoy’s Lesion - Artery at gastric fundus erodes to surface and may bleed heavily (rare)
Causes of Upper GI Bleeding
* What is an duodenum cause?
* What are two other cuases of UGIBs?
- Duodenum: Duodenal ulcer (#1 cause)
- Coagulopathy (liver, drugs, bleeding disorders)
- Arteriovenous malformations
Upper GI Bleed management
* _
* Keep what? Why?
* What do you need to give for meds?
* What do you need to do EARLY?
- Resuscitation
- Keep NPO – prevent aspiration
- High dose Proton Pump Inhibitors – prevent acidity to ulcer.-> Consider loading dose and drip of Protonix
- EARLY esophagogastroduodenoscopy (EGD) to identify the source of the bleeding & for therapeutic intervention
Lower GI Bleeds
* What are the small bowel causes? (4)
- Neoplasm
- IBD
- Aortoenteric Fistula
- Mesenteric ischemia
Lower GI Bleeds
* What are the colon causes? (6)
- Diverticuli – most common cause
- Angiodysplasia/AVM
- Inflammatory Bowel Disease
- Neoplasm
- Infectious
- Radiation Proctitis
Lower GI Bleeds
* What are the perianal examples? (3)
* What is another reason?
Perianal
* Hemorrhoid
* Fissure
* Fistula
Coagulopathy (drugs, liver disease, etc.)
Suspected LGIB
* What will happen 80% of the time?
* Exclude waht?
* What is the primary option?
- Bleeding stops spontaneously 80% of the time
- Exclude upper GI source 1st
- Colonoscopy is the primary option
If the patient has massive ongoing bleeding with hemodynamic instability, what is indicated?
If the patient has massive ongoing bleeding with hemodynamic instability, urgent angiography vs emergent endoscopy is indicated
* Colonoscopy Prep Emergently: Purge with 4 – 8L of polyethylene glycol solution given orally or per NG tube
Additional Studies if Needed
* New CT scan guidelines request what?
* If both CT or colonoscopy do not reveal a source, but bleeding continues, what should be ordered?
- New CT scan guidelines request oral and IV contrast when evaluating lower GI bleeding with CT abdomen and Pelvis, which can help identify site of extravasation
- If both CT or colonoscopy do not reveal a source, but bleeding continues – tagged RBC scan should be done to localize bleeding +/- angiography if positive
Nuclear bleeding scan
* How does it work?
“Red blood cells are labeled with 15 mCi of technetium-99m (in vitro) and reinfused into the patient. Images are then acquired sequentially at one minute intervals in the anterior projection. Early in the study, a focus of increased activity appears in the left lower quadrant of the abdomen. Activity then progresses in a curvilinear fashion approximating the course of the sigmoid colon. “
- If colonoscopy does not reveal a source, but bleeding stops do what?
- Consider what?
- If colonoscopy does not reveal a source, but bleeding stops, observe the patient
- Consider small bowel evaluation (Capsule endoscopy)
Surgery: GI bleeds
* Who is surgery reserved for? (2)
* Every effort should be made to do what?
Surgery is reserved for patients
* Who have failed medical, colonoscopic, & angiographic intervention
* Who have ongoing bleeding >4U PRBC per 24 hr
Every effort should be made to localize the source of bleeding prior to surgery (especially in diverticular disease)
Diarrhea
* What is the criteria?
- Increase in stool weight (>200 g/day)
- Decreased stool consistency
- Increased stool frequency, urgency, fecal incontinence
The Intestines
* How much ingested fluid and secretions enter the intestines each day
* How much is absorbed in small and large intestines?
* What is normal fluid in normal stool day?
- 10 liters of ingested fluid and secretions enter the intestines each day
- 90% is absorbed in the small intestines
- Of the fluid that remains, 90% is further absorbed in the large intestines
- 80-100ml of fluid is in normal stool day
Diarrhea
* How long is acute? What are the two types?
* How long is chronic?
Acute – lasting less than 4 weeks
* Infection (most common)
* Medications (Metformin)
Chronic – lasting more than 4 weeks
What are the different pathophysiologies of diarrhea?(5)
- Osmotic
- Secretory
- Malabsorption/Maldigestion
- Altered Motility
- Inflammatory
* Inflammatory Bowel Diseases
* Infectious Diarrhea
- What is the osmotic gap for serum?
- Feces is normally in osmotic equilibrium with what?
- 290 mOsm/kg - 2 ([Na]+ + [K]+) – for serum
- Feces is normally in osmotic equilibrium with blood serum, which the human body maintains between 290–300 mOsm/kg.
Fecal Osmotic Gap
* What is osmotic and secretory diarrhea level? Why does this happen?
- Osmotic diarrhea >125 – high fecal osmotic gap (can be due to lactulose)
- Secretory diarrhea <50- cholera – massive excretion (Na, K, HCO3, Cl) and low absorption of electrolytes. It doesn’t stop if patient fasts.
What is functional diarrhea? Typically in who?
Functional Diarrhea – Normal Gap >50 but <125 – Typically IBS or Altered Motility Type Disorder
Osmotic Diarrhea
* What is the definition?
Definition: Increased amounts of poorly absorbed, osmotically active solutes in gut lumen interferes with absorption of water
Osmotic Diarrhea
* What are Solutes are ingested that are osmotic? (4)
- Magnesium sulfate or citrate or magnesium containing antacids
- Sorbitol – sugar free gum
- Lactulose – Tx constipation
- PEG (polyethelane glycol) – Tx constipation
Osmotic Diarrhea
* besides the solutes, what is another cause?
Malabsorption of food
* Lactose intolerance
Lactose Intolerance
* What is this?
* Lactose remains where and what does that cause?
- Congenital or acquired deficiency in the brush border disaccharidase lactase that leads to malabsorption of lactose
- Lactose remains in the intestinal lumen and acts as a strong osmotic substance leading to osmotic diarrhea, flatulence, bloating
Lactose Intolerance
* what is the txt?
Treatment: Avoid lactose containing foods and/or supplement oral intake of dairy products with liquid or tablet form of the lactase enzyme
Osmotic Diarrhea
* what is the cause?
Nonabsorbable molecules accumulate in the gut lumen
Osmotic Diarrhea
* What are the clinical features?
Diarrhea stops with fasting
Electrolyte absorption is not affected, only water is affected
Fecal osmotic gap is high
* Test checks stool electrolytes
* Stool water is low in electrolytes
Secretory Diarrhea
* What is it?
Abnormal ion transport in intestinal epithelial cells -> increased secretion &/or decreased absorption of electrolytes
Secretory Diarrhea
* What are the clinical features?
Fasting does not stop diarrhea
Electrolyte absorption is affected
* Increased secretion and/or decreased absorption of Na+ and Cl-
Fecal osmotic gap is low
* Stool water is high in electrolytes
Secretory Diarrhea
* What are the bacterial or viral enterotoxins?
* What are the causes of Intestinal resection?
Bacterial or viral enterotoxins: Cholera, enterotoxigenic E. coli, B. cereus, S. aureus, Rotavirus, Norwalk virus (BRENCS)
Intestinal resection
* Decreased absorptive surface for not only nutrients but also electrolytes and fluid
* Combined malabsorption and secretory component
Secretory Diarrhea
* What type of laxatives?
* Circulating agents by what?
Non-osmotic laxatives (castor oil, senna)
Circulating agents by neuroendocrine tumors such as:
* Carcinoid Syndrome
* Zollinger-Ellison syndrome
Infectious Diarrhea
* Hx of what?
* _ contacts?
* Food?
* Can be what?
* is there what use?
- History of travel
- Sick contacts and their progression
- Food exposure history
- Could it be Hepatitis A or B or something non infectious
- Is there drug use or homelessness history
Infectious Diarrhea: essential of dx
* Acute:
* Chronic:
* Mild diarrhea:
* Moderate diarrhea:
* Severe diarrhea:
- Acute diarrhea: < 4 weeks
- Chronic diarrhea: > 4 weeks.
- Mild diarrhea: </= 3 stools per day
- Moderate diarrhea: >/= 4 stools per day w/ local symptoms (cramps, nausea, tenesmus)
- Severe diarrhea: >/= 4 stools per day w/ systemic symptoms (fever, chills, dehydration)
Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Bloody, THINK what?
* Recent hospitalization or antibiotic use (MC: Clindamycin)->
* Foreign travel->(5)
- Bloody, THINK Bacteria
- Recent hospitalization or antibiotic use (MC: Clindamycin)->C. diff
- Foreign travel-> Salmonella, Shigella, Campylobacter, E coli or V cholerae (VECSS)
Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Outbreak on cruise ship, school, LTCF->
* Recurrent C. diff =
* Undercooked hamburgers ->
- Outbreak on cruise ship, school, LTCF-> Norovirus
- Recurrent C. diff = Fecal microbiota transplantation
- Undercooked hamburgers -> EnterohemorrhagicEscherichia coli, including Shiga-toxin–producingE colistrains (STEC)
Infectious Diarrhea: Classification of inflammatory/bloody diarrhea
* What is involved?
* What are common sxs?
* What are common causes?
* What is often postive? What is required for definitive etiology?
- Colonic involvement (bacteria, parasites, toxins)
- Common symptoms: Frequent bloody, small-volume stools, often with fever, abdominal cramps, tenesmus and fecal urgency
- Common Causes: Shigella, Salmonella, Campylobacter, Yersinia, invasive strains of E.coli, Entamoeba histolytica and C. difficile (CCEESSY)
- Fecal leukocytes are often positive, stool culture required for definitive etiology
Infectious Diarrhea: Classification of noninflammatory, non-bloody or watery
* Milder, caused by what?
* interferes with what?
* Common sxs:
* Common causes:
- Milder, caused by viruses or toxins that affect small intestine
- Interferes w/ salt & water balance resulting in large-watery diarrhea
- Common Symptoms: Nausea, vomiting, cramps
- Common Causes: Rotavirus, norovirus, astrovirus, enteric viruses, vibriones, enterotoxin-producing E. coli, Giardia lamblia, crystosporidia & agents that cause food-borne gastroenteritis
Acute Gastroenteritis
* What is it?
* May include what?
* Temperature?
* Signs of what?
* What is a late sign?
* Consider waht?
- Flu-like illness with GI component
- May include Melena, or hematochezia depending on organism
- High fever
- Signs of dehydration
- Altered mental status -> late sign
- Consider hypovolemic shock (hemorrhagic and non-hemorrhagic)
AGE work up
* What type of tests? (3)
* What are the labs? (4)
* what is the imaging?
* R/O what?
- Blood cultures, stool culture, O and P specific tests
- CBC with differential
- CMP
- Fecal leukocytes
- Hemoccult vomit
- CT (with or without contrast depending on oral tolerance and Cr) if abdomen tender or you have guarding or rebound tn
- R/O Clostridium difficile via toxin test
Treatment AGE
* Most cases are what?
* What for fever?
* What is the diet?
* What do you give for pain?
- Most cases are self-limited
- Acetaminophen for fever
- Clear liquids until symptoms better, BRAT diet
- Pain: Ketorolac
Treatment AGE
* What do you give for anti-emetics?
* Fluids?
* Avoid what?
* If abnormal labs, then do what?
Treatment AGE: general measures
* Most cases of acute gastroenteritis are what?
* Txt usually consists of what?
- Most cases of acute gastroenteritis are self-limited and do not require therapy other than supportive measures
- Tx usually consists of replacement of fluids and electrolytes and, very rarely, management of hypovolemic shock and respiratory compromise
Treatment AGE: General measures
* mild diarrhea, increase what? May increase risk for what?
* What do you need to do severe dehydration?
Mild diarrhea, increase juices and clear soups
* May increase risk for osmotic diarrhea
Severe dehydration (postural light-headedness, decreased urination), oral glucose-based rehydration solutions (Ceralyte, Pedialyte
Treatment AGE: Specific Measures
* Immunocompetent adults->Empiric antimicrobial therapy for bloody diarrhea while waiting for results is recommended only with the following circumstances? (2)
- (1) documented fever, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella
- (2) returning travelers with a temperature of at least 38.5°C or signs of sepsis
Treatment AGE: Specific Measures
* What is the empiric antimicrobial therapy for bloody diarrhea?
* Empiric antibacterial treatment should be considered in who?
- Fluoroquinolone or azithromycin as empiric antimicrobial therapy for bloody diarrhea
- Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea
Treatment AGE: Specific Measures
* Loperamide may be given to who? When should it be avoided?
- Loperamide may be given to immunocompetent adults with acute watery diarrhea, but should be avoided with Shigella infection or in suspected or proven toxic megacolon
- Generally avoid loperamide unless you confirm lack of infection (viral or bacterial)
