Lower GI Flashcards
microbiome
vitamin K absorption
absorption and reabsorption - how many liters are produced in 24 hours?
Saliva, gastric, bile, pancreas, small bowel, all produce GI fluids
7 liters of fluids in 24/hours
All but 100 mL is reabsorbed terminal ileum
crohn’s disease - what side? (lee leans to the right)
right
diverticulitis - what side?
left
important labs (4, 3, 2)
K (at 4), Phos (at 3), mag (at 2)
lactic acid tells us if
someone is septic
pre-albumin is
recent nutrition
albumin is
nutrition over several months
pancreas enzymes
amalyse and lypase
ABG tests for
lactate
occult blood
blood you can’t see, the test is a guiac
barium enema (are clear liquids ok?)
pt needs to be able to swallow, but can be given via tube. clear liquids. may give laxatives, enema. if they can’t drink, give liquids IV. make sure barium comes out the other end.
gastroscopy - NPO for how long? And sedation?
NPO 6-8 hrs, bowel prep, conscious sedation, aspiration is a risk. ex. endoscopy, EGD. should be totally awake afterwards.
stool
FIT, FOBT, iFOBT, C and S, and O & P
constipation
Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass
constipation causes
meds, chronic laxative use, immobility, fatigue, can’t increase abdomen pressure, diet, ignoring urge, lack of exercise
perceived constipation
subjective, when person’s elimination is not consistent w/ what is believed to be normal
constipation symptoms
less than 3 a week, distention and bloating, sensation of not evacuating, straining, small dry stools
cause of chronic constipation
usually idiopathic
diagnostics for constipation (constipation is defcon 1)
MRI, Defecography and colonic transit studies
constipation complications (constipation/mega)
decreased C/O, fecal impaction, hemorrhage, fissures, prolapse, megacolon (abnormal dilation)
types of diarrhea (diarrhea pac)
acute, persistent, or chronic
diarrhea causes
infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes
manifestations of diarrhea
Increased frequency and fluid content of stools
Abdominal cramps
Distention
Borborygmus (grumbling)
Anorexia and thirst
Painful spasmodic contractions of the anus
Tenesmus (feeling like you need to have a bowel movement)
C.diff
About1 in 6 patientswho getC. diffwill get it again in the subsequent 2-8 weeks. One in 11 people over age 65diagnosed with a healthcare-associatedC. diffinfection die within one month.
fecal incontinence - causes
anal sphincter weakness, trauma, neuropathies, pelvic floor disorders, CNS disorders, diarrhea, behavioral disorders
gastroparesis (is it painful?)
Motor and nerve functions of digestive organs are impaired
Accompanied by pain
gastroparesis - Weakness of stomach
muscles cannot fully aid in the digestive process. Delayed stomach emptying.
gastroparesis - causes (paralyzed by diabetes and opioids)
DM, electrolyte imbalances (K+, Mg, Ca+), opioids, hypothyroid vagus nerve damage, pancreatitis, scleroderma
gastroparesis - S & Sx (think full)
bloating, abdominal distention, early satiety, abdominal pain, vomiting (large pieces undigested food), GERD, malnutrition
treatment for gastroparesis - how long to sit upright? and what type of diet? (slow needs low fiber and low fat)
Control N, V, abdominal pain
Nutrition/Diet –low fiber, low fat, soft or liquid with good hydration, MVI to prevent malnutrition, position upright after meals 4-5 hours, eat early in the day
gastroparesis - diagnostics
gastric emptying study, antro-duodenal motility study (measures strength of contractions); electrogastrogram (measures electrical voltage of contractions, endoscopy, CT
meds for gastroparesis
Promotility medications in liquid form –metoclopramide, domperidone, erythromycin, SQ octreotide
lowe GI bleed - causes - but esp which one?
Diverticula
IBD
Crohn’s (some with crohns). UC (especially UC), gastroenteritis
Perianal disorders
Hemorrhoids
Carcinoma
AV malformation
Hemorrhoids - does bleeding hurt?
can be internal or external, bleeding is usually painless.
external hemmoroids usually
itchy. bleeding is like a streak. some can prolapse during defacation and then back to normal.
hemmoroids treatment
cold baths, topicals to shrink, stool softeners, topical nitroglycerin.
hemmoroids treatment
cold baths, topicals to shrink, stool softeners, topical nitroglycerin.
Diverticula - type of bleeding (D for dieverticula, D for dark)
Diverticula - Sustained dark bleeding
IBD - type of bleeding (I for IBD, I for intermittent)
IBD -Intermittent bleeding & frequent BM’s
Perianal disorders - type of bleeding (perianal is bright)
BRB per rectum
Cancer - type of bleeding(cancer is the occult)
CA - Occult bleeding with intermittent melena
AV malformations - type of bleeding (AVs go either way)
AV malformations - Intermittent BRB (bright red blood), dark with clots from cecum
perforation - symptoms
Symptoms include: severe abdominal pain, cramping, N/V, bleeding, tenderness to palpation, distention, rigidity, fever/chills, change in stool
Stomach perforation pain is
sudden
Colon perforation may come on (colon is slow)
more gradually
perforation etiologies
PUD, forceful vomiting, UC, Crohn’s, diverticulitis, toxic megacolon, strangulated hernia, bowel ischemia, bowel obstruction, abdominal surgery (anastamotic leaks), trauma, foreign body, corrosive substance ingestion, appendicitis
2nd most common cause of sepsis
peritonitis (#1 cause organ perforation)
peritonitis (peri inflames sara)
inflammation of the serosal membrane that lines the abdominal cavity
peritonitis - causes
perforation - bile from perforated gall bladder, liver laceration, gastric acid from perforated ulcer, surgical leak, foreign bodies, ectopic pregnancy, ruptured ovarian cyst or appendix, infected PD catheter or G-J Tube
peritonitis - s & sx - early and then later (and what relieves it?) (peri hurts my shoulder)
Early vague, diffuse pain, may become sharp and radiate to shoulder; progresses with intensity & is worse with movement, might be slightly relieved with fetal position
peritonitis - gold standard for diagnosis
CT scan
one way to define peritonitis is (peri has a high WBC - what number)
WBCs >500 with peritoneal lavage
peritonitis - interventions
Minimize complications-hypoxia, shock, AKI/ARF, sepsis, acidosis
Supplemental oxygen
Bowel rest
NPO, NGT suction (low to continous suction)
Maintain FEN/Acid-base balance
IV hydration
Electrolyte additives/replacements
Caloric supplementation (PPN, TPN)
peritonitis surgeries
Exploratory lap, open lavage, I & D abscess, lysis of adhesions, resections of tumors or c=necrosis, temporary or permanent fecal diversions, drains
peritonitis - post op
ABC
Prevent pulmonary complications, dehydration and malnutrition
Positioning, oxygen, pulmonary toilet, mobility
Identify infection early, antibiotics
Hydration
Acid-base/FEN
Wound drainage/management (tubes, drains, positioning)
Pain/anxiety management (motility compromise)
Maintain mobility
sepsis - what is the mortality rate? (not quite 50)
distributive shock, 30% mortality. 50% of survivors have post-sepsis syndrom.
sepsis shock
Inadequate vessel tone
Blood pressure is a function of cardiac output and systemic vascular resistance (SVR).
If SVR decreases from vasodilation, blood pressure decreases.
Massive vasodilation can occur from loss of sympathetic nervous system function or chemicals released within the body.
Bacteria and toxins in the blood lead to vasodilation and increased capillary permeability.
Treatment includes vasoconstriction and volume restoration.
post sepsis syndrome - causes
Causes of PSS
DIC, decreased CO, amputations, ARDS, pulmonary edema, ATN/ARI, liver
post sepsis syndrome - symptoms (like ptsd)
Both physical and psychological long-term effects
Sleep pattern disturbances, nightmares, hallucinations, panic attacks, PTSD
Disabling muscle or joint pain
Difficulty concentration, decreased cognitive ability
Loss of self esteem, depression
Hair loss
Chronic fatigue
High risk for viral respiratory infections
IBS - more common in men or women?
2x more in women
IBS triggers (not so much foods)
chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods
IBS manifestions (IB bloated)
Alteration in bowel patterns
Pain
Bloating
Abdominal distention
IBS diagnostics
Stool studies
Contrast radiography studies
Proctoscopy
Barium enema
Colonoscopy
Manometry
Electromyography
malabsorption - conditions
Mucosal (transport) disorders
Infectious disease
Luminal disorders
Postoperative malabsorption
Disorders that cause malabsorption of specific nutrients
malabsorption manifestations
Symptoms similar to irritable bowel syndrome
Manifested by weight loss and vitamin and mineral deficiency
gluten is found in
Gluten is most commonly found in wheat, barley, rye, and other grains malt, dextrin, and brewer’s yeast.
celiac can lead to (Celia and hashi are friends)
hashimotos
celiac disease - manifestations
Diarrhea
Steatorrhea
Abdominal pain
Abdominal distention
Flatulence
Weight loss
inflammatory bowel disease - 2 types
UC and Crohns
UC - where is it located? (U see it’s just large)
Ulcerative IBD that is just in the large intestines
crohns - inflammation where? and where is it found? (Crohn’s hangs out w/ illeana)
Also called regional enteritis
Inflammation and erosion of the ileum
Can be found throughout the GI tract and anywhere
S/Sx of IBD (IB rebound cheese w/ anemia)
N, V D
Weight loss
Cramping
Rectal bleeding
Dehydration
Hematochezia
Anemia
Fever
Rebound tenderness
can UC be cured?
yes, removal of part of colon
can Crohn’s be cured?
no
more bleeding with UC or crohns?
UC
IBD treatment (nothing really)
Hydration
Pain control
Diet
Correct anemia
Education
Support
IBD meds
Antidiarrheals (Only given with mildly symptomatic UC)
Antibiotics
Sulfonamides (for Peritonitis)
Steroids (To decrease inflammation)
Immune system suppressors
Potentiate the effects of corticosteroids
6 mercaptopurine & azathioprine
IBD - Immune system suppressors
Potentiate the effects of corticosteroids
6 mercaptopurine & azathioprine
IBD meds (IB ending in mab)
Bind to TNF
Remicade (infliximab) & Humira (adalimab), Stelara (ustekinumab)
Diverticular Disorders - what part of colon? (sigfried descends on his dive)
Major cause of lower GI bleed
Diverticula are small herniations in the bowel wall caused by weakness in sigmoid or descending colon
dDiverticular Disorders - risk factors (just 2 things) (ol and constipated is the big d)
> 60 years, constipation
Diverticular Disorders - complications
Diverticulitis
inflammation/infection
Obstruction, rupture
Bleeding, perforation
Intra-abdominal abscess
Adhesions, fistulas
divertula - treatment (divers need fiber)
keep things moving, give fiber, exercise
diverticulitis - what to eat? (dive softly w/ food)
soft diet, avoid inflammation
diverticular disorders - pathos
herniation of colonic mucosa.. outpouchings form..fecal material trapped…microperforation…contamination of surrounding tissues…inflammatory response…abscess formation… may erode vessels… bleeding…perforation
diverticular disorders - S/Sx - where is the pain? (Dive to the left, it’s worse after you eat)
flares/remissions; constipation, diarrhea, flatulence; pain is acute, LLQ, and worst after meals; relieved with BM; rectal bleeding; fever/chills
diverticular disorders - diagnostics (dive cutie)
history/physical, CT, abdominal ultrasound, CBC with diff
diverticular disorders - prevention - fiber good or bad?
Prevention
High fiber diet, increase bulk of stools with colloid laxative During “flare”: AVOID high fiber. Pain management (anticholenergics; minimize opiates
ABX
Bowel rest from clears for 48 hours to NPO and IV hydration
diverticular disorders - surgeries (drain the pool before diving)
abscess drainage, resections, temporary fecal diversion, repair/manage fistulas, relieve obstructions
Acute paralytic ileus (adynamic ileus)
results from loss of intestinal peristalsis
Acute paralytic ileus (don’t touch a cute illeana)
Causes: handling of the bowel during surgery, trauma, electrolyte disturbances, intestinal ischemia, infections, peritonitis, sepsis, toxic metabolic conditions, pain, spinal cord trauma/lesions and medications that decrease gastric motility
Ogilvie’s syndrome (olga is dilated)
Massive dilation
NO peristalsis
illeus - s/sx
Pain, dehydration, vomiting (not prominent), abdominal distention & tenderness, hiccoughs, decreased/absent bowel sounds, no flatus/stool
illeus - complications
Obstruction, delay/inability to ingest food/fluids, pain, delayed healing, peritonitis
illeus - does it resolve on its own? (Illeana helps herself)
Usually self limiting (2-3 days)
Correct underlying cause
Bowel rest (NPO, NGT LC/I WS (wall suction) fluids
Increase mobility (ambulate)
Increase GI motility (warm, medications, guided imagery and other integrative approaches
Wean from opioids or oral naloxone
intestinal bowel obstruction - what about the kidneys?
Partial or complete
Mechanical
Non-Mechanical
Vascular
If unresolved can lead to AKI d/t 3rd spacing, hypovolemia; bowel perforations, bowel ischemia/infarction, `peritonitis, sepsis, death
most bowel obstructions occur in
the small intestines
bowel obstruction
Distention of gas and fluid occurs proximal to the distention.Trapped fluid and electrolytes leak out into the peritoneal cavity. inflammation causes na to get stuck. strangulation, perforation or cardiovascular collapse are are worst case scenarios.
bowel obstruction - fluid replacement
keep them euvolemic (equal fluids)
bowel obstruction - risks
Motility problems
Elderly
Postoperative
Bedridden
Multisystem dysfunction
Multiple abdominal or bowel surgeries
adhesions
bowel obstruction - treatments
FLUIDS
Isotonic
NPO
NGT
I & O
Antibiotics for strangulation
Surgical consultation
KUB
Abdominal CT
gastroparesis - who is at risk?
Patient with diabetes, surgical anastamoses and certain viral conditionsp are at greatest risk for developing gastroparesis
peritonitis - hypo or hypervolemia? any distention? (you’ve lost the fluid, so…)
Abdominal distention, A/N/V decreased bowel sounds
Dehydration/hypovolemia (HR up, BP down) with hemoconcentration (elevated HCT, Na+, BUN)
Acidosis, elevated WBC
Fever, chills
Free air on KUB, CT with perforation
gastroparesis symptoms (full and paralyzed)
Patients report feeling full and tired, nauseated and often vomit
