MDT Lower GI Flashcards
1
Q
What is the definition of diahhrea?
A
- Increased stool frequency
- More than 3 BM’s daily
- Liquidity of feces
- Classified as either chronic or acute
2
Q
Acute onset of diahhrea and persisting for less than 2 weeks is commonly caused by what?
A
Bacterial toxins (either pre-formed or produced in gut)
3
Q
How can infectious sources of diahhrea be transmitted and what is the incubation period?
A
- Transmitted through fecal-oral contact
- Incubation periods between 12-72 hours
4
Q
What percentage of water is absorbed by the small intestine? Which portion has most absorption?
A
- > 90%
- Jejunum
5
Q
What illness is most common diarrheal illness in the operational setting?
A
Acute Infectious Gastroenteritis
6
Q
How is acute gastroenteritis defined?
A
Diarrheal disease (3+ times/day at least 200 g/day) of rapid onset that lasts less than 2 weeks
7
Q
How is acute viral gastroenteritis treated with?
A
- Self-limiting
- Treated with supportive measures (fluid repletion and unrestricted nutrition)
8
Q
What anatomy does gastritis include?
A
ONLY stomach
- do not confuse gastritis with gastroenteritis *
9
Q
What are two common causes of gastritis?
A
- Chronic NSAID use
- Chronic alcohol use and/or large amounts of alcohol consumption
- Can be caused by trauma and critically ill patients
10
Q
Treatment for gastritis?
A
- Self limiting
- Pt may benefit from PPI and removal of offending agent
- Refer for endoscopy and H. Pylori testing if conservative management fails
11
Q
How can chronic diarrheal illness be classified?
A
- Osmotic
- Inflammatory ( or mucosal)
- Secretory
- Chronic infections (parasites)
- Malabsorption syndromes
- Motility disorders
12
Q
What are osmotic chronic diarrheal illness causes?
A
- Medication
- Zollinger-Ellison syndrome
13
Q
What are common causes of acute infectious diarrhea?
A
- Shigella
- Salmonella
- Escherichia coli
- E coli O157:H7
14
Q
What is a common cause of acute non-inflammatory diarrhea?
A
- Viruses (Rotavirus, Norwalk virus, Vibriones)
- Entero-toxin E. coli
- Agents that cause food-borne gastroenteritis
15
Q
What are some common protozoal causes of acute non-inflammatory diarrhea?
A
- Giardia Lamblia
- Cryptosporidium
- Cyclospora
16
Q
What does the term “food-poisoning” denote?
A
Diseases caused by toxins present in consumed foods
17
Q
What is usually a major complaint of acute gasteroenteritis?
A
- Vomiting
- Fever is usually absent
18
Q
In over 90% of Pt’s, within how many days will acute non-inflammatory diarrhea respond to simple rehydration therapy or antidiarrheal agents?
A
5 days
19
Q
If diarrhea persists for more than 7 days, what must be done?
A
Send stool for:
- Fecal leukocyte
- Ovum and parasite evaluation
- Bacterial culture
20
Q
Prompt medical evaluation of diarrhea is indicated in what situations?
A
- Signs of inflammatory diarrhea with fever (>38.5 C), bloody diarrhea, or abdominal pain
- Passage of 6 or more unformed stools in 24 hours
- Profuse watery diarrhea and signs or symptoms of dehydration
21
Q
What do you want to pay special attention to on physical examination on gastroenteritis?
A
- Pay attention to Pt’s level of hydration
- Mental Status
- Presence of abdominal tenderness or peritonitis
22
Q
Symptoms for gastroenteritis (depends on causative agent)
A
- Sudden onset
- Nausea, vomiting, decreased appetite
- Crampy abdominal pain
- Loose stool
- Malaise
- Fatigue
- Diffuse abdominal tenderness
- Distension
- Increased bowel sounds
- Usually afebrile
- May see + tilts (depending on fluid loss)
23
Q
Differential diagnosis for gastroenteritis?
A
- Food poisoning
- IBS
- Malabsorption
- Medication effect
- Laxative abuse
24
Q
Labs for gastroenteritis?
A
- CBC with differential
- Fecal leukocyte
- Fecal O/P
- Stool culture
- C difficle assay
- Stool exam for Giardia Lamblia
25
Treatment of gastroenteritis?
- Assess vital signs for stability
- Treat symptomatically
- Rehydration
- BRAT (bananas, rice, applesauce, toast) diet, avoid irritating foods
- Antidiarrheal agents
26
What are rehydration methods for gastroenteritis?
- Oral rehydration with fluids containing glucose, NA+, K+, CL-, and bicarbonate or citrate
- Oral electrolyte solutions
- Lactated Ringers IV
- Tea, "flat" carbonated beverages
27
Antidiarrheal Agents for gastroenteritis?
- Loperamide
| - Bismuth Subsalicylate (Pepto-bismal)
28
When is empiric antibiotic therapy not indicated?
Acute, community acquired diarrhea
29
What infectious bacterial diarrheas for which antibiotic therapy is recommended?
- Shigellosis
- Cholera
- Salmonellosis
- Listeriosis
- C. difficile
30
What is the parasitic infection treatment (antibiotic therapy) for diarrhea?
- Amebiasis
- Giardiasis
- Cryptosporidiosis
31
What is the treatment for chronic non-infectious diarrheal illness?
Treat underlying cause
32
What is the pertinent anatomy associated with constipation?
- Large intestine (Cecum, rectosigmoid colon)
- Rectum
- Anus
33
What are some causes of constipation?
- Diminished intake of fiber
- Systemic diseases (hyperthyroidism, diabetes, neuro conditions)
- Medications (CCB, Iron, antipsychotics)
- Structural abnormalities (colonic mass, neoplasm, anal fissure)
- IBS
- Hirschsprung disease
34
What history do you want to ask when assessing constipation?
- Infrequent stool
- Excessive straining
- Sense of incomplete evaluation
- Need for digital manipulation
35
What are some differential diagnosis with constipation?
- Fecal impaction
- Intestinal-pseudo obstruction (Ogilvie Syndrome)
- Intestinal obstruction (refer to surgery)
36
Labs for constipation?
- CBC for anemia
- Thyroid function tests
- Electrolyte abnormalities
37
Rads for constipation?
- Upright chest film
- Abdominal flat and erect films
- Abdominal films
38
What is the first line treatment for constipation?
- Strict dietary changes
- Exercise regime
- Increased water intake
- Fiber supplementation
39
What is the second line treatment for constipation?
- Stool softening or laxative use
* Emollients (colace)
* Stimulants (Bisacodyl (dulcolax))
* Saline laxative (magnesium hydroxide aka milk of magnesium)
40
What is the third line treatment for constipation?
- Suppositories or enemas
* Suppositories: glycerin suppository
* Enemas: fleet enemas
41
MEDEVAC for constipation?
- Uncomplicated: retain on board
| - Complicated/chronic case: refer to gastroenterologist
42
Initial care of constipation?
- Treat empirically in acute phase
- Start less invasive
- Lifestyle change could prove pivotal
- Monitor for improvement or absence before progressing to next level of treatment
43
Where are internal hemorrhoids located?
- Located above dentate line
- Subepithelial cushions of anorectum
* submucosa and muscularis
- No nervous innervation
44
Where are external hemorrhoids located?
- Arise from inferior hemorrhoidal veins
- Below dentate line
- Covered with squamous epithelium
- Possess nervous innervation (painful when thrombosed)
45
What do internal hemorrhoids (subepithelial vascular cushions) consist of?
- Connective tissue
- Smooth muscle fibers
- Arteriovenous communications between terminal branches of superior rectal artery and rectal veins
46
What are the 3 primary locations of internal hemorrhoids?
- Right anterior
- Right posterior
- Left lateral
47
Hemorrhoids can become symptomatic as a result of what?
Activities that increase venous pressure, resulting in distension and engorgement
48
What can contribute to hemorrhoids?
- Straining at stool
- Constipation
- Prolonged sitting
- Pregnancy
- Obesity
- Low fiber diets
49
Thrombosis of an external hemorrhoid plexus results in?
Perianal hematoma
50
How can a perianal hematoma occur?
Commonly occurs in otherwise healthy adults and may be precipitated by:
- coughing
- heavy lifting
- straining at stool
51
What are the principle problems attributable to internal hemorrhoids?
- Painless bleeding (bright red blood)
- Prolapse
- Mucoid discharge
52
What are the stages of internal hemorrhoids?
Stage I - IV
53
What is internal hemorrhoids Stage I?
Internal hemorrhoids are confined to the anal canal
54
What is internal hemorrhoids Stage II?
Internal hemorrhoids gradually enlarge and protrude from the anal opening
- At first, mucosal prolapse occurs during straining and reduces spontaneously
55
What is internal hemorrhoids Stage III?
Prolapsed hemorrhoids may require manual reduction after bowel movements
56
What is internal hemorrhoids Stage IV?
May remain chronically protruding and unresponsive to manual reduction
57
What can chronically prolapsed hemorrhoids result in?
Sense of fullness or discomfort and mucoid perianal discharge resulting in irritation and soiling of undergarments
58
Are hemorrhoids palpable on physical examination?
- Internal: neither palpable or painful
| - External: Visible, extremely tender on palpation
59
Prolapsed hemorrhoids are visible as what?
Protuberant purple nodules covered by mucosa
60
What is a differential diagnosis for hemorrhoids?
- Anal Fissure/fistula
- Neoplasm of distal colon or rectum
- Ulcerative colitis or Chron colitis
- Rectal ulcers
61
Radiology studies with hemorrhoids?
Colonoscopy for Pt's with hematochezia
62
Treatment of thrombosed external hemorrhoids?
- Warm sitz baths
- Analgesics and ointment
- Removal of clot if seen within 24-48 hours
- High fiber diet
- Increase water intake
63
Gentle, manual reduction of edematous, prolapsed hemorrhoids may be supplemented by what?
- Suppositories
- Topical pads containing witch hazel
- Warm sitz bath
64
Surgical excision (hemorrhoidectomy) is reserved for what percentage and stage of patients?
- 5-10% of Pt's with chronic bleeding due to Stage III or IV
65
What is the initial care of hemorroids?
- Acute onset, stay with treatment protocol
| - Pt's presenting with problematic stage III or Stage IV require further assessment for surgical correction
