Module 10 - Control and Disorders of Gastrointestinal Function Flashcards

1
Q

Functions of the GI System

A

Process food substances—dismantle & reassemble food

Produce enzymes and hormones for digestion

Absorb the products of digestion—nutrients, vitamins, minerals, electrolytes, and water

Store and synthesize vitamins

Provide an environment for microorganisms to synthesize nutrients, such as vitamin K

Collect and eliminate wastes

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2
Q

Digestion and absorption requires what two things

A

an intact and healthy GI epithelial lining that can resist the effects of its own digestive secretions

the presence of enzymes for the digestion and absorption of nutrients

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3
Q

Digestion and Absorption involves…

A

the movement of materials through the GI tract at a rate that facilitates absorption

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4
Q

Dumping

A

movement through the GI tract that is too fast to allow digestion and absorption

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5
Q

What are the sections of the digestive system

A

Upper part

middle portion

lower segment

fourth part - accessory organs

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6
Q

What does the upper part of the digestive system consist of and what does it do?

A

the mouth, esophagus and stomach

they act as an INTAKE source and receptacle through which food passes and in which INITIAL DIGESTIVE processes take place

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7
Q

What does the middle portion of the digestive system consist of and what does it do?

A

the small intestine: duodenum, jejunum, ileum

Most digestion and absorption processes occur here in the small intestine

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8
Q

What does the lower segment of the digestive system consist of and what does it do?

A

The cecum. colon, and rectum

Serves as a storage channel for the efficient elimination of waste and the large intestine allows for some fluid reabsorption

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9
Q

What is the fourth part of the digestive system and what does it do?

A

It is the accessory organs like the salivary gland, liver, and pancreas

They produce digestive enzymes that help dismantle food and regulate the use and storage of nutrients

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10
Q

What are the important anatomical portions of the mouth

A

Lips
Cheeks
Palate
Tongue
Teeth (Mastication)
Salivary Glands (Lubrication)
Muscles
Maxillary Bones

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11
Q

Saliva contains the enzyme ___ (___) that aids in digestion of ___

A

amylase (ptylain); starches

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12
Q

Esophagus

A

collapsible muscular tube (a transportation tube)

about 10 inches long

carries food from the pharynx to the stomach

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13
Q

What are the sections of the stomach?

A

the cardia, fundus, body, and pylorus

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14
Q

The Cardia

A

The portion of the stomach directly connected and closest to the esophagus

contains the cardiac opening

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15
Q

The Pyloris

A

The area at the bottom of the stomach closest to the duodenum of the small intestine

has the pyloric sphincter

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16
Q

Stomach Body and Fundus

A

the body is the largest mid portion while the fundus is the top portion above the level of the cardia or on the same level

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17
Q

Cardiac Opening

A

An opening into the stomach - not really a sphincter since stomach contents can get back out

opens and closes in the cardia

prevents reflux back into the esophagus

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18
Q

What is the pH of the esophagus compared to the stomach

A

esophagus pH of 8

stomach pH of 1-2

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19
Q

Pyloric Sphincter

A

sphincter near the end of the stomach leading to the duodenum

regulates the rate of stomach emptying into the small intestine

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20
Q

What does the stomach have that the esophagus does not which allows regeneration and protection from stomach acid

A

prostaglandins

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21
Q

Barret’s Esophagus

A

a condition of cellular change in the esophagus from stomach content reflux

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22
Q

What protects the stomach from enzymes and acids?

A

Gastric Mucosal Protection consisting of water soluble mucus and water insoluble mucus

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23
Q

Water Soluble Mucus

A

A gastric mucosal protection

It is washed from the mucosal surface and mixes with luminal contents

Its viscid nature makes it a lubricant to prevent MECHANICAL damage to the stomachs mucosal surface

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24
Q

Water Insoluble Mucus

A

A gastric mucosal protection

forms a thin and stable gel that adheres to the gastric mucosa surface

It gives protection from the proteolytic actions of pepsin

Forms an unstirred layer that traps bicarbonate thus forming an interface between the luminal contents of the stomach and its mucosal surface

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25
What gastric mucosal protection form is more stable?
Insoluble
26
Small intestine
Duodenum --> Jejunum --> Ileum --> Cecum --> Colon (not part) It is the major area of absorption of nutrients that is occurring
27
Duodenum
first part of the small intestine contains the openings of the bile and pancreatic ducts
28
Jejeunum
second part of the small intestine about 8 feet long
29
Ileum
the third part of the small intestine about 12 feet long terminates at the cecum
30
If there is a J tube or ileostomy bringing waste directly out of the small intestine, what would that look like and why?
It would be much more watery and loose since the large intestine is the one absorbing most of the water Because of this the feces is more full of nutrients that are unabsorbed, electrolytes, and water that we need to monitor for with imbalances
31
Cecum
area where the small and large intestine meet
32
What quadrant is the cecum/where the small and large intestine meet?
Right Lower Quadrant
33
What is the GI wall structure like?
Inner Mucosal Layer Submucosal Layer Muscularis Layer with Circular and Longitudinal Muscle Layers Outer serosal layer/Peritoneum
34
Inner Mucosal Layer
part of GI wall cells produce mucus here that lubricates and protects the INNER surface of the alimentary canal
35
Submucosal Layer
part of GI wall consists of connective tissues to keep GI sections where they belong contains blood vessels, nerves, and structures responsible for secreting digestive enzymes
36
Muscularis Layer
part of GI wall has a circular and longitudinal muscle layer facilitates movement of the contents of the GI tract (peristalsis)
37
Outer Serosal Layer/Peritoneum
loosely attached layer to the outer wall of the intestine (the peritoneal layer attaching to abdomen wall)
38
Mucus is a ___ and ___
lubricator and protector
39
What is the layers of the GI tract from outermost to innermost?
Peritoneum --> longitudinal muscle --> circular muscle --> submucosal layer --> inner mucosal layer/mucous membrane --> lumen of the gut
40
Peritoneum
serous membrane lining the abdomen and the abdominal organs
41
Parietal Peritoneum
The serous membrane that lines the abdominal cavity Lines the walls of the abdomen
42
Visceral Peritoneum
serous membrane that forms the mesentery (folds of the visceral peritoneum) which supports the intestines and blood supply covers the abdominal organs
43
Peritoneal Fluids
several mL of fluid that moisten the surface of the peritoneal layers The membranes are able to then glide smoothly over each other as the intestinal tract changes shape during digestion
44
Paracentesis
If someone has low plasma proteins, low oncotic pressure, or ascites/fluid build up from something like liver disease we can use a needle to remove some fluid
45
Where are the female reproductive parts located
in the peritoneal area
46
Where are the kidneys located
retroperitoneal (behind)
47
Disgestion
Process by which food is broken down mechanically and chemically in the GI to convert into an absorbable form chewing + enzymes
48
What are some processes of digestion
hydrolysis enzyme cleavage fat emulsification
49
Absorption
uptake of water, FAs, monosaccharides, amino acids, vitamins and minerals from the lumen of the gut into the capillary networks and lacteals (lymph capillaries) of the villi reusing the broken down parts
50
Absorption occurs primarily in the ...
small intestine
51
Where does carbohydrate digestion start?
Digestions of starch begins in the mouth with amylase
52
Brush Border Enzymes
enzymes in the small intestine that convert disaccharides to monosaccharides
53
What breaks down fats?
gastric and pancreatic lipase
54
Bile Salts act as ...
a carrier system
55
When does protein break down begin
in the stomach with the action of pepsin - it will then further break down via pancreatic enzymes
56
Pepsin is the reason what is important?
the mucosal protection of the layers of the stomach
57
What are some GI secretions that are important
Salivary (1200 mL) Gastric (2000 mL) Pancreatic (1200 mL) Biliary (700 mL) Intestinal (2000 mL) total =7100 mL
58
What functions does saliva provide?
protection and lubrication and a mucus coating of food antimicrobial action via lysozyme initiation of digestion of starches via ptyalin and amylase
59
Mucus Secreting Cells are located...
throughout the stomach
60
Oxyntic (Gastric) Glands
located in the body and fundus of the stomach These include parietal cells and chief cells
61
Parietal Cells
gastric cells that secrete HCl and intrinsic factor
62
Chief Cells
gastric cells that release pepsinogen for protein digestion
63
Pyloric Glands
glands found in the antrum that secrete mucus, some pepsinogen and gastrin in the stomach
64
Bile Salts
biliary product it can emulsify and help in the absorption of fats and fat soluble vitamins
65
Fat Soluble Vitamisn
ADEK
66
Brunner's Glands
intestinal glands located where the stomach empties and secretes large amounts of alkaline mucus protects the duodenum from acidic chyme and digestive enzymes
67
Crypts of Lieberkuhn
intestinal gland secrete serous alkaline fluids
68
Peptidases
surface enzymes that aid in absorption in the small intestine split amino acids
69
Disaccharidases
surface enzymes that aid in absorption in the small intestine split sugars
70
Enzymes used in the digestion of carbohydrates
lactase sucrase amylase maltase alpha dextranase
71
The end product of the enzymes that convert carbohydrates via digestion is...
glucose (and maybe some other stuff)
72
Pancreatic Enzymes that break down proteins in the Small Intestine
Trypsin Chymotrypsin Carboxypeptidase Elastase
73
The end product of the enzymes in the small intestine that convert proteins via digestion is...
always amino acids (maybe some other byproduct)
74
3 Levels of Control of Secretory Functions
Local Humoral Neural Influences
75
Local Control of Secretory functions
pH Osmolality Chyme *They act as stimuli for neural and humoral mechanisms*
76
Neural Influences of Secretory Functions
Mediated with the ANS Increased with parasympathetic stimulation Inhibited with sympathetic activity
77
___ nervous system causes more digestion
parasympathetic
78
___ nervous system causes less digestion
Sympathetic
79
Autonomic Neural Control: Sympathetic
Controlled via spinal nerves Inhibits smooth muscle contractions Vasoconstriction occurs *The last two are why SNS stops digestion*
80
Autonomic Neural control: Parasympathetic
Controlled via the vagus and pelvis nerves Promotes smooth muscle contraction Vasodilation occurs Leads to secretion of enzymes like pepsin
81
What receptors and neurotransmitter help with PNS and peristaltic activity
muscarinic receptors and acetylcholine (helps increase peristalsis and vasodilation in the GI system)
82
What does the enteric/intrinsic system do for neural control of the GI system
it controls motility of GI smooth muscles and secretion of blood flow via stretch of the wall
83
Auerback's (Mesenteric Plexus)
Enteric/Intrinsic Located in the muscular layer and primarily controls motility of GI smooth muscle
84
Meissner's (Submucosal Plexus)
enteric/intrinsic located in the submucosa and primarily controls secretion and blood flow to GI region
85
Gastrointestinal Movements
Tonic Movements Rhythmic Movements
86
Tonic Movements
continuous movements that last for minutes or even hours in the GI system contractions occur AT SPHINCTERS
87
Rhythmic Movements
intermittent contractions responsible for mixing and moving food along the digestive tract
88
What kind of GI movements are peristaltic movements?
RHYTHMIC (propulsive) movements
89
Important GI Hormones
Cholecystokinin Secretin Gastrin
90
Cholecystokinin
stimulates contraction of the gall bladder (helps move bile) Stimulates secretion of pancreatic enzymes slows gastric emptying
91
Secretin
stimulates secretion of bicarbonate containing solution by pancreas and liver
92
Gastrin
stimulates secretion of gastric acid and pepsinogen increases gastric blood flow stimulates gastric smooth muscle contraction stimulates growth of gastric, small intestine, and colon mucosa
93
Food must be ___ ___ and absorbed
broken down
94
What forms must carbohydrates be in for absorption
Monosaccharides (single sugars) ex: Fructose - facilitated diffusion (no energy need) ex: Glucose and galactose - Na dependent carrier system that requires ATP
95
What forms must fats be in for absorption
formation of MICELLES (action of bile salts) and transported to villi for absorption
96
Where does the absorption of fat primarily occur
in the upper jejunum
97
What are MCT and LCT and why is MCT better absorbed
they are middle and long chain triglycerides and it is easier to absorb the middle chain like coconut oil due to size
98
Water can follow ___ or ___
glucose or sodium
99
How big must proteins be for absorption?
1,2, or 3 amino acids long
100
How are proteins transported in absorption
by facilitated diffusion and ATP dependent sodium linked processes (no energy and energy)
101
Water in absorption is linked to absorption of osmotically active particles like...
glucose and sodium
102
Large Intestine
about 5 feet long absorbs water and eliminates wastes Manufactures vitamins including B vitamins and vitamin K
103
Pernicious Anemia
a megaloblastic macrocytic anemia occurs without intrinsic factor from parietal cells can be autoimmune there is a neurologic deficit without B12 that takes time to manifest
104
Large intestine only secretes ___
mucus
105
What are the areas of the large intestine
Ascending Colon (right lower quadrant) Transverse Descending Sigmoid Rectum
106
Rectum
part of the large intestine has valves and an internal and external sphincter
107
Ileocecal valve
valve in the rectum/large intestine that prevents contents of the large intestine from entering the ileum
108
Anal Sphincters
guard the anal canal internal and external we cannot see the internal but we can see the external
109
Internal Anal Sphincter
several CM long circular thickening of smooth muscle that lies inside the anus cannot be viewed by use outside
110
External Anal Sphincter
composed of striated voluntary muscle surrounding the internal sphincter Controlled by nerve fibers in the pudendal nerve (part of the somatic NS under voluntary control)
111
The largest gland in the body weight 3-4 pounds is the ___
liver
112
Kupffer's Cells
tissue macrophages in the liver remove bacteria in the portal venous blood
113
The liver is a ___
detoxifier
114
The liver will remove excess...
glucose and AA from portal blood
115
The liver synthesizes...
glucose, amino acids, and fats
116
The liver aids in the digestion of...
carbohydrates, proteins, and fat
117
The liver can do what 2 things to blood
store and filter it (200-400 mL of blood)
118
High First Pass
Metabolism If a drug passes through the liver it will go from an active form to inactive This may be why we do drugs IM IV or SQ
119
What, other than blood, can the liver store?
Vitamin A Vitamin D Vitamin B12 Iron
120
The liver secretes ___ the emulsify fats (500-1000 mL a day!)
Bile
121
What about the liver delays pernicious anemia
the fact it stores vitamin B12 there
122
The liver and gallbladder share ...
common ducts
123
Hepatic means
liver
124
Renal means
kidney
125
What duct comes directly off the liver
Hepatic Duct
126
what duct comes directly off the gallbladder
the cystic duct
127
The hepatic duct and cystic duct merge into the...
common bile duct
128
The common bile duct and pancreatic duct merge into the ...
ampulla of vater and sphincter of oddi
129
Where does the sphincter of oddi open up to
the duodenum
130
Location of a ___ determines what organ will be affected
block (ex: if the cystic duct is blocked only the gallbladder is effected)
131
The sphincter of oddi prevents..
reflux of intestinal contents into the common bile duct and pancreatic duct
132
What are not included in the secretions in the pancreatic duct?
insulin and glucagon these go directly into the blood
133
Gallbladdar
stores and concentrates biles can contract to force bile into the duodenum during fat digestion
134
How does the presence of fatty materials stimulate the release of bile
presence of fatty materials in duodenum stimulates cholecystokinin to release which leads to gall bladder contraction and relaxation of the sphincter of oddi
135
Exocrine
secreted into a duct
136
Endocrine
secreted into the blood
137
The pancreas as an exocrine gland does what
secretes sodium bicarbonate to neutralize the acidity of the stomach contents as they enter the duodenum
138
What is in pancreatic exocrine juices
pancreatic juices contain enzymes for digesting carbohydrates, fats, and proteins
139
The pancreas as an endocrine gland does what
Insulin secretion
140
Insulin secretion is produced by
the islets of langerhans cells in the pancreas
141
Insulin is secreted...
into the blood stream
142
Insulin is important for ___ metabolism
carbohydrate
143
Risk Factors for GI Disorders
Family Hx Chronic laxative, alcohol, tobacco use Chronic high stress levels Allergic reactions to food or meds Long term GI conditions like ulcerative colitis may predispose someone to colorectal cancer Previous abdominal surgery or trauma leading to adhesions Neuro disorders impairing movement, particularly with chewing or swallowing Cardiac, respiratory, and endocrine disorders can lead to constipation DM may predispose someone to oral candida infections
144
How does nicotine cause GI disorders
it stimulate muscarinic receptors and can lead to consipation
145
Adhesions
like scar tissue forming between the mucosa of the GI tract and wall of the abdomen leading to pleura or bowel pieces sticking together
146
What to look for on an abdominal assessment (in order)
Inspect - skin color, abnormalities, contour, tautness, distension Auscultate - bowel sounds Percuss - air or solids Palpate - tenderness
147
Borborygmi
a rumbling or gurgling noise made by the movement of fluid and gas in the intestines
148
What needs to be done before percussion and palpation?
auscultation (in all 4 quadrants)
149
Normal bowel sounds occur ___ to __ times a minute or __ to ___ seconds
5 to 34 times 5-15 seconds
150
If you are not hearing any bowel sounds how long must you listen in each quadrant
5 minutes
151
Upper GI Barium Swallow
An examination of the upper GI tract under fluoroscopy performed after the client drinks barium sulfate Requires fasting from foods and fluids overnight prior to the study
152
Post Barium Swallow what must the patient do?
drink 6-8 cups of water x2 days to pass the barium (since it can cause issues and constipation) May need a laxative to help
153
What will stool look like when passing barium
chalky
154
Lower GI Barium Enema
A fluoroscopic and radiographic exam of the large intestine after rectal instillation of barium sulfate May be done with or without air Requires laxative evening prior and morning of procedure and liquid diet the day before the procedure
155
After a barium enema, what must be done
increase fluids or use a laxative to monitor for passage of the barium
156
Gastroscopy
Insertion of an endoscopic instrument through the esophagus into the stomach and upper portion of the small intestine to visualize the mucosal lining look for lesions that need removal or wall ulceration
157
Important considerations for Gastroscopy
no fluids until gag reflex returns after procedure monitor resp, cardiac, and neuro status important to monitor VS before and after
158
What to monitor for after gastroscopy?
Monitor for signs of bleeding, as evidenced by hypotension, pallor, and tachycardia Monitor for perforation as evidenced by pain, tachypnea, and rales
159
Sigmoidoscopy
Endoscopic visualization of the sigmoid colon using a sigmoidoscope does not go far in but does need a clear GI tract to see
160
Sigmoidoscopy is invasive so...
it requires informed consent
161
What sort of diet should be done before a sigmoidoscopy
a full liquid diet and laxatives because they must have diarrhea and empty the GI tract for a clear sigmoid colon
162
What can be done following the sigmoidoscopy
Normal activities and diet may be resumed post procedure but notify provider if fever >101° F, difficulty breathing, stomach pain, or bright red rectal bleeding occurs there is risk for perforation and infection
163
Colonoscopy
A fiberoptic endoscopic study in which the lining of the large intestine is visually examined Requires informed consent - invasive looks at entire colon
164
Preparation for colonoscopy
clear liquid diet bowel preparation *all to clear colon
165
Post procedure colonoscopy
client returns to normal activities and diet monitor for signs of colon perforation, AEB abdominal pain or distention, malaise, fever, purulent rectal drainage, or lower GI bleeding
166
How must stool run before a colonoscopy
run clear or light yellow with no stool particles
167
Gallbladder Series
Oral cholecystography to study the dye-filled gallbladder by radiographic film
168
What is important to tell the client about regarding the dye for a gallbladder series?
Instruct client to go to the emergency department if a rash, itching or hives, or difficulty in breathing occurs after taking the tablets the dye can be painful to micturate
169
What must be done before a gallbladder series
a low fat supper before the test then fasting after midnight the night prior
170
After a gallbladder series what sort of diet should be done
a high fat meal to help with dye elimination from the gall bladder
171
___ is common since gallbladder series dye is excreted in urine
Dysuria (painful or difficult urination)
172
Liver Biopsy
A needle is inserted through the abdominal wall to the liver to obtain a tissue sample for biopsy and microscopic examination
173
What to do pre procedure for a liver biopsy
Obtain informed consent Assess hematological laboratory results Administer sedative as prescribed NPO after midnight on the day prior to the test Note that the client is placed in the supine or left lateral position during the procedure
174
What to do post procedure for a liver biopsy
Assess vital signs frequently (every 15 minutes for an hour after) Assess biopsy site for bleeding Monitor for peritonitis Maintain bedrest for 24 hours Place client on the right side for 1 to 2 hours to decrease the risk of hemorrhage
175
The liver is on the __ side of the body
right
176
How big is the needle for a liver biopsy
14-18 gauge (huge and thick)
177
Liver biopsy comes with a huge risk for waht
bleeding since the liver is so vascularized - could cause bleeding all over the peritoneum
178
Why does the patient lie on the left side for the liver biopsy and then the right side after
to allow access to the liver during and then put pressure on the site afterward
179
Paracentesis
Transabdominal removal of fluid from the peritoneal cavity for the analysis of electrolytes, red blood cells and white blood cells, bacterial and viral cultures, and cytology studies Obtain informed consent
180
What must be done prior to start of paracentesis
Void prior to the start of procedure to empty bladder and to move bladder out of the way of paracentesis needle Measure abdominal girth, weight, and baseline vital signs
181
What position is the patient in during paracentesis
the client is positioned sitting on the edge of the bed with the back supported and the feet resting on a stool, or lying prone during the procedure
182
What to do post paracentesis
Monitor for hematuria due to bladder trauma Instruct client to notify physician if the urine becomes bloody, pink, or red Possibility to nick the bladder is why we watch for hematuria
183
Stool Specimens
Examination of stool for the presence of occult bleeding
184
What to do pre stool specimen procedure
Instruct client to avoid aspirin, NSAIDs, red meat, poultry, and fish for 3 days prior to the collection These things can contribute to further occult bleeding or cause false positives
185
Occult Bleeding
bleeding that cannot be seen with the naked eye goes on a specimen card in with a reagent and will light up blue if positive for occult blood
186
Liver and Pancreas Lab Studies can look at levels of what things
Alkaline Phosphatase Prothrombin time (PT) Serum Ammonia Liver Enzymes (Transaminase Studies) Cholesterol Bilirubin Amylase and Lipase *these can alert us to liver damage
187
Alkaline Phosphatase
released during liver damage or biliary obstruction high amount above 13-120 or 0.5-2.0 can indicate liver damage
188
Prothrombin time
prolonged PT time with liver damage (coagulation time) above 12.5 seconds indicates damage The increase in PT means a greater risk of bleeding d/t decreased clotting factors
189
Serum Ammonia
Assesses the ability of the liver to deaminate protein by products if the liver cannot turn ammonia into urea, an increased ammonia amount means it is secondary to cirrhosis or hepatitis leading to confusion, sleepiness, hand tremors, or coma
190
What else could lead to a false high serum ammonia
high protein diet
191
Transaminase Studies (Liver Enzymes)
elevated levels with liver damage AST, ALT, and LDH (Aspartate Aminotransferase, Alanine Aminotransferase, Lactic Dehydrogenase) levels increase
192
Cholesterol Studies
increase can indicate pancreatitis or biliary obstruction (normal value under 200 mg/dL)
193
Bilirubin Studies
increases indicate liver damage or biliary obstruction can be direct, indirect, or total kind comes from recycled heme during the breakdown of RBC indirect is water soluble with direct fat soluble and we find indirect from the total and direct together
194
All liver and pancreas lab studies are done using __ blood
venous
195
Amylase and Lipase Studies
Elevations indicate pancreatitis / pancreas damage
196
S/S Common to GI Disorders
Anorexia Nausea vomiting or emesis GI bleeding
197
What 2 ways can nausea be stimulated
unpleasant subjective sensation from stimulation of the vomiting center in the medulla may be stimulated by duodenum distension
198
___ leads to nausea and vomiting
Hypoxia
199
Vomiting involves what areas of the brain to trigger
medulla vomiting center and the CTZ (chemoreceptor trigger zone)
200
What can act as neuromediators for vomiting
dopamine serotonin opioids
201
Vomiting serves a __ function
protective *it forcefully expels contents that may harm you
202
Vomitus
Emesis = Vomiting
203
Hematemesis
blood in the vomitus may be bright red or have a coffee ground appearance
204
Hematochezia
Passage of bright red blood in the stool Usually indicates bleeding is from the lower bowel Coating of stool with bright red blood is associated with hemorrhoids always concerning/frightening
205
Bright red bleeding in the stool usually means bleeding comes from ...
the lower bowel (or hemorrhoid)
206
Melena
Black tarry stool caused by digestion of blood in the GI tract Usually indicates bleeding above ileocecal valve May increase BUN due to absorption of nitrogenous end products from digestion of blood
207
The ileocecal valve is in what quadrant
the right lower quadrant
208
Melena indicates bleeding where
above the ileocecal valve- so small intestine and before
209
Occult Blood (Hidden) must be detected by and are usually caused by ?
Must be detected by chemical testing & usually caused by gastritis, peptic ulcer, or lesions of the small intestine
210
Swallowing mechanism
depends on the coordinated action of the tongue and pharynx
211
The tongue and pharynx (therefore swallowing) is innervated by what cranial nerves
V IX X XII
212
Strictures
narrowing of the esophagus
213
What causes swallowing disorders or alterations in swallowing
altered nerve function or strictures
214
What are some swallowing issues?
Dysphagia Odynophagia Achalasia Increased risk for aspiration!
215
Dysphagia
difficulty swallowing
216
Odynophagia
painful swallowing
217
Achalasia
lower esophageal sphincter fails to relax and food stays in the lower esophagus painful
218
Esophageal Diverticulum
outpouching of the esophageal wall leading to retention of food
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Common s/s of esophageal diverticulum
gurgling belching coughing foul smelling breath
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Mallory Weiss Syndrome
longitudinal tears in the esophagus Infection here can lead to inflammatory ulcer or mediastinitis
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What is Mallory Weiss Syndrome etiology associated with?
chronic alcoholism or severe retching or vomiting
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Gastroesophageal Reflux (GERD)
Backward movement of gastric contents into the esophagus resulting in heartburn Reflux of gastric contents results in irritation & erosion of the lower esophageal mucosa
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GERD is thought to be associated with ...
Thought to be associated with weak or incompetent lower esophageal sphincter that allows reflux to occur
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What is NOT a good indicator of extent of mucosal injury in GERD?
severity of heartburn
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GERD pain is ___ or ___ and may radiate to what areas?
epigastric or retrosternal radiates to throat, shoulder, back
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GERD can produce what S/S
respiratory symptoms like wheezing, chronic cough, hoarseness chronic persistent reflux can cause strictures from scarring, spasms, and edema Barret's esophagus
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Barrets esophagus can lead to ___ ___
esophageal cancer
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GERD can be mistook for...
something more serious like a heart attack
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Treatments for GERD
Avoiding large meals Avoiding alcohol use and smoking Eating meals sitting up Avoiding recumbent position several hours after a meal Avoiding bending for long periods Sleeping with the head elevated Losing weight if overweight Sit up for several hours as well after meals Avoid bending if overweight or have tight clothing
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Major Causes of gastric irritation and ulcer formation
Aspiring or non steroidal anti inflammatory drugs (NSAIDS) infection with H Pylori *also compounds with stress*
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How does NSAIDS cause gastric irritation and ulcer formation
irritates the gastric mucosa and inhibits prostaglandin synthesis (which allows the stomach to be attacked by its own secretions - prostaglandins release from damaged cells and cause fever and damage cell walls further usually but also help protect the stomach)
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Why do H Pylori cause ulcer formation
they thrive in acidic environments like the stomach disrupts the mucosal barrier that protects the stomach from harmful effects of its digestive enzymes
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To avoid NSAID GI harm always do what
take them with food
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Types of Gastritis
Acute Chronic Infective Erosive
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Acute Gastritis
A transient inflammation of the gastric mucosa Most commonly associated with local irritants such as bacterial endotoxins, alcohol, and aspirin
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Chronic Gastritis
Characterized by the absence of grossly visible erosions and the presence of chronic inflammatory changes Leads eventually to atrophy of the glandular epithelium of the stomach Caused by H pylori gastritis, autoimmune gastritis, multi focal atrophic gastritis, chemical gastropathy
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What may cause erosive gastritis
person who ingested ASA and had an acute lesion
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How to detect H Pylori infection
1. C Urea Breath test using a radioactive carbon isotope 2. stool antigen test 3. endoscopic biopsy for urease testing 4. blood tests to obtain serologic titers of H pylori antibodies
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What does H Pylori produce that we can detect to diagnose infection
Urea
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Peptic Ulcer Disease
An ulceration in the mucosal wall of stomach, pylorus, or duodenum in portions that are accessible to gastric secretions - holes in the stomach Erosion may extend through the muscle to the peritoneum
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The most common peptic ulcers are ___ and ___ ulcers
gastric and duodenal
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Gastric Ulcers
Involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach sharp stomach ulcer
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Predisposing Factors for Gastric Ulcers
stress smoking use of steroids NSAIDS alcohol hx of gastritis infection with H Pylori
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What exactly is gastritis
a group of GI issues involving stomach lining inflammation
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things seen on assessment of a gastric ulcer
gnawing sharp pain in or left of the mid epigastric region 1 to 2 hours after eating nausea and vomiting hematemesis
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Duodenal Ulcers
a break in the mucosa of the duodenum similar to gastric ulcer but a different pain pattern
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Risk factors for Duodenal Ulcers
alcohol intake smoking stress caffeine use of ASA corticosteroids NSAIDS H pylori infection
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What is seen on assessment of Duodenal Ulcers
burning pain in the mid epigastric region area 2 to 4 hours after eating and during the night pain that is often RELIEVED BY EATING melena
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Complications of Peptic Ulcers
1. Hemorrhage (from granulation tissue or from erosion of an ulcer into an artery or vein) 2. Obstruction (edema, spasm, contraction of scar tissue and interference with the free passage of gastric contents through the pylorus or areas nearby) 3. Perforation (when an ulcer erodes through all the layers of the stomach or duodenum wall)
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Risk factors for stress ulcers
Large surface-area burns Trauma Sepsis Acute respiratory distress syndrome Severe liver failure Major surgical procedures psychological stress *not just psych stress, but physical as well*
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Zollinger Ellison Syndrome
Highly malignant type of GI cancer caused by a gastrin secreting tumor (gastrinoma) More than 2/3 are malignant
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Where is the zollinger ellison syndrome tumor usually found?
in the pancreas but may be in the submucosa of the stomach or the duodenum
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What may assessment of Zollinger Ellison Syndrome show
diarrhea impaired fat digestion elevated serum gastrin decrease in intestinal pH
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Gastric Cancer
abnormal malignant growth in the stomach
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S/S of Gastric Cancer
Anorexia Nausea and vomiting Indigestion and epigastric discomfort A sensation of pressure Dysphagia Weight loss Palpable mass Fatigue Anemia Ascites Sensation of pressure is due to the growth
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Risk factors for Gastric cancer
Genetic predisposition Carcinogenic factors in the diet Diet high in starch and salt and low in fresh, green leafy vegetables and fresh fruits Smoking & alcohol History of gastric ulcers Presence of Helicobacter pylori Autoimmune gastritis Gastric adenomas or polyps
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Gastric Polyp
abnormal growth on the lining inside the stomach
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Vitamin B12 Deficiency Results from either..
1. inadequate VB12 intake 2. Lack of absorption of ingested VB12 from the intestinal tract 3. not making intrinsic factors 4. receptors for the complex cannot detect
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S/S of Vitamin B12 Deficiency
Severe pallor Fatigue Weight loss Smooth, beefy red tongue Slight jaundice Paresthesia of the hands and feet Disturbances with gait and balance
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One of the biggest concerns of VB12 deficiency is
neurological disorders
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Dumping Syndrome
rapid emptying of the gastric contents into the small intestine occurs following a gastric resection tonic and rhythmic movements are supposed to keep it moving at the right rate but this stops them somewhat
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S/S of Dumping Syndrome
Symptoms occurring 30 minutes after eating Nausea and vomiting Abdominal cramping Feelings of fullness Diarrhea Palpitations Tachycardia Perspiration Weakness and dizziness Borborygmi
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Altered Intestinal Function includes what things
Irritable bowel syndrome Inflammatory bowel disease Diverticulitis Appendicitis Alterations in bowel motility Malabsorption syndrome Cancer of the colon and rectum
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Irritable Bowel Syndrome (IBS)
persistent or recurrent symptoms of abdominal pain
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IBS S/S
altered bowel function varying complains of flatulence and bloatedness Nausea anorexia constipation diarrhea (may be a ton in 2 hours) anxiety or depression (can cause IBS or vice versa)
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What treats both diarrhea and constipation and why?
FIBER It can make diarrhea less watery and it adds bulk to move constipation
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Inflammatory Bowel Diseases (IBDs)
Crohn's Disease Ulcerative Colitis
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Chrohn's Disease (regional enteritis)
IBD a recurrent, granulomatous type of inflammatory response that can affect any area of the gastrointestinal tract from the mouth to the anus can look like canker sores if serious enough can cause need for colon resectioning/removal
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Ulcerative Colitis
A nonspecific inflammatory condition of the colon IBD
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Where does Crohn's Disease most likely occur
the terminal ileum
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What does Crohn's Disease often lead to
thickening and scarring a narrowed lumen fistulas ulcerations abscesses
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Crohn's Disease is characterized by __ and __
remissions and exacerbations
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S/S of Crohn's Disease
Fever Cramplike pain after meals Diarrhea semisolid and may contain mucus, pus, and blood Abdominal distention Anorexia, nausea, and vomiting Weight loss Anemia (poor iron and B1`2 absorption) Dehydration Electrolyte imbalances
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Fistulas
communications from one part of the bowel to another or to another organ
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Ulcerative Colitis
Ulcerative and inflammatory disease of the bowel results in poor absorption of nutrients loss of elasticity and ability to absorb nutrients occur
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What is the difference between ulcerative colitis and Crohns disease
UC is limited to the colon
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Ulcerative colitis commonly begins in and spreads to?
begins in the rectum and spreads upward toward the cecum
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What happens to the colon during ulcerative colitis
it becomes edematous and may develop bleeding lesions and ulcers these ulcers may lead to perforation
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what causes the loss of elasticity and ability to absorb nutrients in UC
scar tissue development
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UC is characterized by ..
various periods of remissions and exacerbations
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Acute UC results in...
vascular congestion hemorrhage edema ulceration of the bowel mucosa
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Chronic UC results in ...
muscular hypertrophy fat deposits fibrous tissue bowel thickening shortening narrowing
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S/S of Ulcerative Colitis
Anorexia Weight loss Malaise Abdominal tenderness and cramping Severe diarrhea that may contain blood and mucus Dehydration and electrolyte imbalances Anemia Vitamin K deficiency
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Why is there Vit K deficiency in UC
it is impacting an area (colon) with a lot of the bacteria that make Vitamin K
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What sort of areas are impacted with Crohn's disease v UC
Crohns - anywhere along the small and large intestine UC: more in the descending sigmoid colons and rectum
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Crohns Disease takes on a ___ appearance from edema and inflammation
cobblestone
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Ulcerative colitis is __ looking and in an ascending pattern
angry
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Crohn's Disease v Ulcerative Colitis: Location
CD - entire GI tract, sm. intestine and colon UC: Limited to the colon
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Crohn's Disease v Ulcerative Colitis: Level of Penetration
CD: primarily submucosal UC: primarily mucosal
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Crohn's Disease v Ulcerative Colitis: Rectal Involvement
CD: often spared UC: almost always involved
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Crohn's Disease v Ulcerative Colitis: Hx
CD: abdominal pain, weight loss UC: bloody diarrhea
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Crohn's Disease v Ulcerative Colitis: Colonoscopy
CD: skip lesions, cobblestone mucosa UC: continuous involvement, pseudopolyps
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Crohn's Disease v Ulcerative Colitis: Complications
CD: bowel obstruction, fistulas, and strictures UC: Colon cancer
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What does skip lesions mean in Crohn's Disease
areas of ulcer, healthy area, ulcer, health y area, etc (this isn't in UC, that has continuous)
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Why is Crohn's disease more likely to have fistulas?
it goes through the surface and muscle layers so it can tunnel to different areas and the strictures can close off the openings that open up
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Infections of the Intestine
Viral (rotavirus) Bacterial (c difficile colitis, E coli) Protozoal (E histolytica)
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Diverticulosis
Outpouching or herniations of the intestinal mucosa They can occur in any part of the intestine but are most common in the sigmoid colon
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Diverticulitis
Inflammation of one or more diverticuli Results when a diverticulum perforates, with local abscess formation A perforated diverticulum can progress to intra-abdominal perforation with generalized peritonitis
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S/S of Diverticulitis
Left lower quadrant abdominal pain that increases with coughing, straining, or lifting Elevated temperature Nausea and vomiting Flatulence Cramplike pain Abdominal distention and tenderness Palpable, tender rectal mass Blood in stools Slight fever Elevated WBC count
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The sigmoid colon is in what quadrant
Left lower quadrant
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Hemorrhoids
dilated varicose veins of the anal canal
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Hemorrhoids can be ___ ___ or ___
internal external or prolapsed
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Internal Hemorrhoids lie where?
above the anal sphincter and cannot be seen upon inspection of the perianal area
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External hemorrhoids lie where?
below the anal sphincter and can be seen on inspection of the perianal area
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Prolapsed hemorrhoids can become...
thrombosed or inflamed
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What can cause hemorrhoids?
portal HTN straining irritation increased venous or abdominal pressure labor and delivery pressures on the body in jobs like carpentry
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How does portal HTN cause hemorrhoids
you get a nodular liver and blood backs up since it cannot get through and it backs up into the intestines and causes esophageal varices and hemorrhoids
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S/S of Hemorrhoids
bright red rectal bleeding rectal mucus discharge pain associated with thrombosis rectal itching
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Appendicitis
inflammation of the appendix when the appendix becomes inflamed or infected rupture may occur within a matter of hours leading to peritonitis or sepsis
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S/S and Assessment of Appendicitis
Pain in periumbilical area that descends to the right lower quadrant Abdominal pain that is most intense at McBurney’s point Rebound tenderness and abdominal rigidity Low-grade fever Elevated WBC count Anorexia, nausea, and vomiting Client in side-lying position with abdominal guarding and legs flexed Constipation or diarrhea
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Pain from appendicitis occurs in what quadrant
Right lower quadrant
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Appendicitis is most intense at ___point
McBurney's
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Peritonitis
inflammation of the peritoneum infection of lining and can be life threatening
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S/S of Peritonitis
Increased fever and chills Progressive abdominal distention and abdominal pain Right guarding of abdomen Tachycardia and tachypnea Pallor Restlessness
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Types of Diarrhea
1. Large volume (osmotic and secretory - OS) 2. Small volume (inflammatory bowel disease, infectious disease, irritable colon - iii)
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We normally have how much stool a day?
150 g/day
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Diarrhea
an increase in volume of stool often it is an increase in stool fluid content and frequency
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What are the 4 basic pathophysiologic causes of Diarrhea
1. Increased secretion of electrolytes and water in bowel lumen (INCREASED SECRETION) 2. Increased osmotic load within the intestine --> water retention in the bowel lumen (INCREASED OSMOTIC LOAD) 3. Inflammation --> exudation of protein and fluid from intestinal mucosa (INFLAMMATION) 4. altered intestinal motility --> rapid transit times (ALTERED INTESTINAL MOTILITY)
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What things can cause increased secretion leading to diarrhea?
Cholera toxin Clostridium endotoxin Non-invasive microbial gastroenteritis Carcinoid syndrome Vasoactive intestinal peptide-secreting tumor Villous adenoma
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What things can cause increased osmotic load leading to diarrhea?
Sorbitol ingestion “sugar-free candy diarrhea” Bile salt malabsorption Lactase deficiency “lactose intolerance” Malabsorption – celiac sprue Post-antrectomy rapid gastric emptying “dumping syndrome” Magnesium containing laxatives
321
Sorbitol
an ingredient in sugar free candy that can cause increased osmotic load and cause diarrhea
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What can cause the inflammation leading to diarrhea?
Ulcerative colitis Crohn’s disease Radiation-induced enteritis Invasive microbial gastroenteritis
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What can cause the altered intestinal motility leading to diarrhea
Thyrotoxicosis Irritable bowel syndrome Neurologic disease (enteropathy in DM)
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things to gather during the Hx for Diarrhea
1. Is it acute or chronic 2. What is the nature of stool: watery (secretory), bulky and greasy (osmotic), blood w or w/o leukocytes (inflammatory) 3. Medications (antibiotics, laxatives, antihypertensive, anti inflammatory, diuretics) 4. Other things like fever, abdominal pain, flatulence, extraintestinal sx like arthritis rashes weight loss and edema, and association with meals or fasting
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What does secretory caused diarrhea look like
watery
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what does osmotic caused diarrhea look like
bulky and greasy
327
What does inflammatory caused diarrhea look like
bloody with or without leukocytes
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What to check on physical exam for diarrhea?
Degree of hydration Presence of abdominal tenderness Rectal mass or blood Character of bowel sounds Indicate --> etiology & severity of illness
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Common Causes of Constipation
Failure to respond to the urge to defecate Inadequate fiber in the diet (to add water to stool) Inadequate fluid intake Weakness of the abdominal muscles Inactivity and bed rest Pregnancy Hemorrhoids
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Mechanical Bowel Obstruction Issues
Adhesions Intussusception Volvulus Incarcerated Inguinal Hernia
331
Adhesions
parts of the bowel fuse together
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Intussusception
When the bowel slips on to itself
333
Volvulus
bowel twists
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Incarcerated Inguinal Hernia
when intestine descends through area tested go through and it gets pinched off and lacks of blood supply
335
Intestinal Obstruction can be caused by what:
mechanical obstruction paralytic ileus abdominal distention loss of fluids and electrolytes (hypokalemia)
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Paralytic Ileus
intestinal obstruction neurogenic or muscular impairment often occurs after abdominal surgery
337
What can cause abdominal distention leading to intestinal obstruction
Gases (swallowed air) and fluids Distention moves proximally
338
Intestinal Obstruction can lead to what
strangulation gangrenous changes perforation of the bowel
339
Intestinal Obstruction increases... leading to...
increases pressure leading to compromises of blood flow and leads to necrosis
340
Assessment of Intestinal Obstruction may show S/S like...
Pain Absolute constipation Abdominal distention Vomiting Borborygmi Visible peristalsis Extreme restlessness, weakness, perspiration, anxiety
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Risk factors for Paralytic Ileus
physical manipulation of the bowel Hypokalemia (potassium needed for good GI function) they have not eaten well neuro or muscular impairment common after abdominal surgery to check for bowel sounds
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If there is intestinal obstruction, then what may happen?
1. the need for surgery 2. need to have something come out someway, even vomiting
343
Causes for Peritonitis
Perforated peptic ulcer Ruptured appendix Perforated diverticulum Gangrenous bowel Pelvic inflammatory disease Gangrenous gallbladder Abdominal trauma and wounds
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Celiac Disease
Immune-mediated disorder triggered by ingestion of gluten-containing grains (wheat, barley, rye) Inappropriate T-cell response in genetically predisposed individuals May impair absorption of macro- & micro-nutrients may need blood test
345
The gall bladder is in what quadrant
upper right quadrant
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Classic Form of Celiac Diseas presents in ___ and manifests as...
infancy presents as: FTF, diarrhea, abdominal distention, occasionally severe malnutrition
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Symptoms of Intestinal malabsorption
Diarrhea or constipation Steatorrhea Flatulence Bloating Abdominal pain Belching Cramps Weakness, muscle wasting Weight loss and abdominal distention
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Intestinal Tumors
Malignant lesions that develop in the cells lining the bowel wall or develop as polyps in the colon or rectum Colonoscopies can detect these
349
Complications of intestinal tumors include...
Complications include bowel perforation with peritonitis, abscess and/or fistula formation, frank hemorrhage, and complete intestinal obstruction
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Metastasis of Intestinal tumors occurs via...
the circulatory or lymphatic system or by direct extension to other areas in the colon or other organs
351
The intestinal tract is very vascular and deeply involves with..
the lymph system (Peyers Patches) and nodes
352
S/S of Intestinal Tumor
Blood in stools Abnormal stools Anorexia, vomiting, weight loss Malaise Anemia Ascending colon tumor: diarrhea Descending colon tumor: constipation or some diarrhea, or flat ribbon-shaped stool due to a partial obstruction Rectal tumor: alternating constipation and diarrhea Guarding or abdominal distention Abdominal mass (a late sign) Cachexia (a late sign)
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Ribbon stools indicate ___
obstruction
354
Cachexia
wasting syndrome with decreased weight muscle atrophy fatigue weakness and very little appetite
355
Colorectal cancer is __ in cancer incidence and __ in cancer morality
3rd in incidence and 2nd in mortality
356
Etiology of Colorectal Cancer
Most arise from pre-existing benign adenomatous polyps that undergo sequential malignant transformation (only ~5% develop into cancer) Adenomas factors associated w malignant transformation (DNA damage, ras oncogene, inactivation of tumor suppressor gene, increasing size and histology) *the deeper it is the worse it is*
357
Adenomas
neoplastic lesions of glandular epithelium that display abnormal cellular differentiation & are of varying architecture, sizes & shapes (tubular, tubulovillous, villous)
358
If colorectal cancer is confined to the mucosa,,,
it is in situ (but it can progress to submucosa, muscularis propria and adjacent tissue - metastasis)
359
Colorectal cancer that is invasive ...
can spread to regional lymph nodes and distance sites
360
Recurrence of rectal cancer is more common...
after re-sectioning
361
Risk Factors for Colorectal cancer
Hx of adenomatous polyps familial disorders (familial polyposis) personal hx of another malignancy or cancer family hx of colon cancer in a first degree relative diet and lifestyle
362
Diet and Lifestyle risk factors for colo rectal cancer
High animal fat consumption (red meat) Low fiber consumption (lack of fruits & veggies) Obesity Ethanol Refined sugar Cigarette smoking
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What are the benefits and downfalls of ASA in the GI system
It can lower incidence of colorectal cancer (and heart attack) but increases risk for GI bleed (NOT A CURE FOR CANCER THO)
364
What things can be seen on H&P of colorectal cancer
Asymptomatic - but Sx in advanced disease occur There are few px specific findings mass may be found on external palpation of the abdomen or on DRE but that is uncommon
365
What are some advanced disease symptoms in colorectal cancer
GI bleeding (occult, anemia) Change in bowel habits (narrow caliber stool, chronic diarrhea, constipation) Abdominal pain Anorexia and weight loss (late)
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Colorectal cancer is often considered a...
silent killer
367
Screenings for Colorectal Cancer
Stool occult blood tests Digital rectal examination X ray studies using barium (ex: barium enema) Flexible sigmoidoscopy and colonoscopy May need a barium enema, and regular sigmoidoscopy and colonoscopies at a younger age