Module 4 EB #1 Flashcards
Murphy sign
RUQ pain on deep inspiration or palpating the RUQ as they take a deep breath –> inflamed gallbladder
rovsing sign
palpation of the LLQ –> pain in the RLQ –> appendicitis
what imaging test is used to dx renal stones?
renal CT
appendicitis
-where is pain? where does it radiate to?
-periumbilical pain that later migrates to RLQ
what signs indicate appendicitis?
-pain at McBurney’s point (RLQ)
-rebound tenderness
-Obturator, Rovsing and Iliopsoas signs
-involuntary abd guarding (rigidity)
-low-grade fever
appendicitis
-symptoms
anorexia, periumbilical pain that later migrates to RLQ, N/V usually after onset of pain, prefers to remain still
appendicitis
-signs
pain at McBurney’s point (RLQ), rebound tenderness, + obturator, Rovsing, and Iliopsoas signs, involuntary abdominal guarding (rigidity), low-grade fever
appendicitis
-labs
WBC may be normal or slightly elevated
appendicitis
-diagnostic imaging
ultrasound very specific but not as sensitive as CT, useful in females to rule out gyn causes; CT more sensitive
appendicitis
-treatment
if high suspicion of appendicitis, some surgeons forego imaging prior to surgery
cholelithiasis/cholecystitis
-cause
can develop from mechanical obstruction, local inflammation, or combination of these factors
cholelithiasis/cholecystitis
-symptoms
pain is colicky, located in epigastrium or RUQ with radiation to the flanks and occasionally the R shoulder. Classic pain occurs within 1 hour after eating a large meal, lasts for several hours, and is followed by residual aching that can last for days
cholelithiasis/cholecystitis
-associated sx
anorexia, N/V, fever
cholelithiasis/cholecystitis
-signs
may have + murphy’s sign, guarding and rebound
cholelithiasis/cholecystitis
-labs
Inc WBC, total bili, ALT, Alk Phosphatase, and amylase
cholelithiasis/cholecystitis
-diagnostic imaging
RUQ ultrasound has a sensitivity >95% in detecting stones in the gallbladder. HIDA scan may show obstructed cystic duct
cholelithiasis/cholecystitis
-treatment
bowel rest (NPO), pain management, IV antibiotics
-Laparoscopic cholecystectomy, usually within 24 hours after infection is controlled
pancreatitis
-risks
history of gallstones, heavy alcohol use, HLD, some meds, abd trauma
-may be a hx of recent heavy drinking or large meal prior to attack
pancreatitis
-sx
abrupt onset of severe epigastric pain that may radiate to the back; pain is increased with movement or lying supine and patient prefers to sit up and lean forward
pancreatitis
-associated sx
N/V, sweating, and anxiety
pancreatitis
-signs
abd tenderness w/o guarding, rigidity, or rebound; distension
, absent bowel sounds; fever, tachycardia, pallor and hypotension may be present
pancreatitis
-labs
inc amylase and lipase. Inc WBC, inc ALT
pancreatitis
-diagnostic imagining
KUB, CT of abd
pancreatitis
-treatment
REFER for hospitalization
who has the highest risk for complications associated with gastroenteritis?
very young or elderly
Gastroenteritis
-cause: viruses, bacterial, parasites
-viruses (70-80%): rotavirus, adenovirus, or Norwalk virus - ingestion of contaminated food/water or by person-to-person spread
-bacterial infections (10-20%: S aureus, Salmonella, Shigella, C difficile, Vibrio, E coli - ingestion of contaminated foods or antibiotic exposure (C difficile)
-parasites: watery diarrhea which may be prolonged, cramps
Gastroenteritis
-sx: viral, bacterial, parasitic
-viral: large volume, watery stool, no blood, lasts 1-2 days, associated N/V, crampy abd pain, fever, malaise, dehydration in young children
-bacterial: variable from mild sx to severe, may have bloody diarrhea. C difficile may occur up to 8 weeks after exposure to antibiotics, esp. clindamycin or fluoroquinolones, with watery diarrhea and cramps
-parasitic: watery diarrhea which may be prolonged, cramps
Gastroenteritis
-labs
stool culture NOT NEEDED IF LESS THAN 3 DAYS DURATION UNLESS <3MO OLD OR >70YEARS, OR AT RISK TRANSMITTING TO OTHERS (FOOD SERVICE, DAY CARE WORKERS)
Gastroenteritis
-treatment
supportive; assess for dehydration (oral rehydration for all ages with mild to moderate diarrhea); infants and children may continue diet for age, adults should avoid dairy, caffeine and alcohol and eat rice, potatoes, wheat, bananas, yogurt, soup and crackers
Gastroenteritis
-medication
-antimotility agents Imodium (loperamide) or Kaopectate (bismuth subsalicylate) for ADULTS.
-DO NOT USE IN: SEVERE OR BLOODY DIARRHEA, HIGH FEVER OR SYSTEMIC TOXICITY
-administer antibiotics if bacterial cause is suspected
Gastroenteritis
-def
acute infectious diarrhea; usually self-limiting
Diverticulitis
-def
inflammation of a diverticulum that ranges from micro perforation with localized inflammation –> macro-perforation with abscess or peritonitis
Diverticulitis
-sx
mild to moderate aching abdominal pain (usually LLQ), constipation or loose stools, N& V may occur; usually sx are mild and pts don’t seek medical attention until several days after onset
-patients with perforation will have more severe sx
Diverticulitis
-signs
low grade fever, LLQ tenderness, palpable mass
Diverticulitis
-differential dx
perforated colonic carcinoma, Crohn’s disease, appendicitis, ischemic colitis, and gyn disorders
Diverticulitis
-labs
+ occult blood in stool, mild-moderate increased WBC
Diverticulitis
-diagnostic tests: mild, severe sx
-mild sx: empiric antibiotic tx WITHOUT imaging; perform colonic evaluation = colonoscopy, CT colonoscopy or barium enema (after sx resolve) to confirm dx (diverticulitis) and r/o colon CA
-severe sx: may need CT of abd in acute stage to evaluate severity
Diverticulitis
-tx: mild, severe sx
-mild: out-patient tx with clear liquid diet; advance diet if sx improve after 3 days; high fiber diet on resolution.
*Use of PO antibiotics in selective cases: 3 possible regimes
+Amoxicillin-clavulanate BID
+Trimethoprim-sulfamethoxazole BID PLUS metronidazole TID
+Ciprofloxacin BID PLUS Metronidazole TID
+Antibiotics for 7-10 days or until afebrile 3-5 days
-severe: refer for inpatient tx, IV antibiotics, possible surgery
GERD
-disorder caused by:
disruption of GI mucosal lining
GERD
-sx
heartburn is the typical sx; usually occurs 30-60min after meals and with reclininc; burning chest pain and regurgitation are common; pain may be relieved by antacids
-non-GI sx: asthma, chronic cough, laryngitis, sore throat or non-cardiac chest pain and sleep disturbance
-“alarm” sx: age >55, anemia, melena, or hematemesis, dysphagia, significant weight loss or difficult/painful swallowing
GERD
-patient disposition
-patients <55years WITHOUT alarm sx: treat empirically WITHOUT further testing
-patients with alarm sx or poor response to empiric therapy: REFER for upper GI endoscopy
GERD
-treatment: mild/intermittent sx, moderate/severe/chronic sx
-Mild, intermittent sx: requires lifestyle modifications –> smaller meals, eliminate spicy or acidic foods, eliminate foods that increase reflux (fatty, ETOH, peppermint, chocolate), elevate head of bed, DO NOT lay down for 3 hr after meals, weight loss if appropriate
*PRN antacids or H2 receptor antagonist: famotidine (pepcid), ranitidine (zantac), cimetidine (tagamet)
-Moderate-Severe, chronic sx: requires empiric therapy (PPI)
*proton pump inhibitor - once daily for 4-8 weeks (taken 30 min BEFORE breakfast); OTC formulations available (10-20% of patients will need BID daily PPI for relief); PPI are preferred over H2 receptor antagonists for acute and chronic GERD
+if no response to PPI –> REFER for upper GI endoscopy
+ positive response (good sx control on empiric therapy/PPI): continue taking PPI for 8-12 weeks
are there structural defects with GERD?
no
Peptic ulcer disease
-causes (2)
- NSAID use
- H Pylori infection
Peptic ulcer disease
-sx
dyspepsia
-gnawing, hunger-like burining pain in epigastric area; pain may awaken patient; sx wax and wane; may have relief with food intake or antacids and return of pain 2-4 hr later (up to 60% NASAID-induced PUD have no sx)
Peptic ulcer disease
-physical exam
may be normal or slight epigastric tenderness; may have new onset + guaiac stools
Peptic ulcer disease
-labs
usually normal; anemia (if bleeding has occurred)
Peptic ulcer disease
-diagnostic testing
upper endoscopy with biopsy (if gastric ulcers are present)
-H pylori testing: urea breath test or fecal antigen (if prior hx of PUD or if ulcer dx on barium upper GI)
-biopsy and rapid urea test & histology (if endoscopy is performed)
Peptic ulcer disease
-medications
-acid antisecretory agents: PPIs have replaced most H2 receptor antagonist
-antibiotics to eradicate H pylori
-combinations include PPI, antibiotics, +/- bismuth for 14 days
Peptic ulcer disease
-disorder caused by disruption of the ________?
GI mucosal lining
abdominal complaints in children >2yrs old
-colic
-intussusception
-incarcerated hernia
-intestinal malrotation
-pyloric stenosis
Colic
-def
healthy and well fed infant that cries for MORE THAN 3 HOURS/DAY, MORE THAN 3 DAYS A WEEK, and for MORE THAN 3 WEEKS
Colic
-characterized by:
severe & paroxysmal crying that occurs mainly in the late afternoon
Colic
-behavioral sign
infant’s knees are drawn up and its fists are clenched
-begins in the first few weeks and peaks at age 2-3 months (continues into 4-5th months in 30-40% of cases)
Colic
-management
parent education; medications have NOT been proven to ameliorate colic
what age does colic occur?
in children <2yrs old
Intussusception
-characterized by?
thriving infant aged 3-12 months with paroxysmal, colicky pain, draws up knees and screams
Intussusception
-symptoms
vomiting and diarrhea occur soon afterward in 90% of cases and bloody BMs with mucus appear within the next 12 hours (current jelly stools)
Intussusception
-signs
prostration and fever supervene
-tender, distended abdomen
-a sausage-shaped mass may be palpated in the upper mid abdomen
Intussusception
-diagnostic imaging
barium or air enema (diagnostic and therapeutic)
Intussusception
-prognosis
relates to the duration before reduction
Age of patients that tend to be diagnosed with Intussusception
children less than 2 years old
Incarcerated hernia
-what race is more affected by umbilical hernias?
full-term African American children
When do umbilical hernias tend to close in children?
-spontaneously
-surgically
-Most close spontaneously within 1st year of life and majority close by the 5th year
-large defects and those persisting after age 4 are repaired surgically
Umbilical hernia in an adult
-is repair important?
NEED REPAIR due to HIGH RISK OF INCARCERATION AND STRANGULATION
what percent of hernias are inguinal hernias?
75% of abdominal hernias
in children, what are the causes of inguinal hernias?
-congenital, but can be acquired from obesity, chronic cough, ascites, chronic constipation with straining, and lifting heavy objects
Hernia
-Management of hernias
DO NOT try to reduce strangulated hernias –> gangrenous bowel to enter the peritoneal cavity = REFER IMMEDIATELY
Hernia
-when do you refer immediately?
-strangulated hernias (can lead to gangrenous bowel which enters the peritoneal cavity) = REFER IMMEDIATELY
-Alarm Markers for Referral: acute onset of colicky abd pain, N&V, and edema and discoloration at the site
Hernia
-what does reducible hernia indicate?
Can refer for elective repair
-strapping an umbilical hernia (belly band or coin) DOES NOT speed the spontaneous closure
Intestinal Malrotation
-characterized by:
-healthy infant SUDDENLY REFUSING TO EAT
-vomits bile
-becomes INCONSOLABLE
=develops abd distension; usually occurs during first 3 weeks of life
Intestinal malrotation
-diagnosis (and CONFIRM with ??)
-upper GI endoscopy shows malrotation –> CONFIRM with a barium enema
Intestinal malrotation
-treatment
surgery
Pyloric Stenosis
-cause
unknown; males predominate
Pyloric Stenosis
-signs
-PROJECTILE VOMITING (NOT BILIOUS!! May be blood streaked): begins 2-4 wks of age and rapidly becomes projectile after every feeding
-onset at birth = 10% of infants; delayed onset in premature infants
Pyloric Stenosis
-behavioral signs
-appears hungry, eats frequently –> constipation, dehydration, weight loss, and is fretful
Pyloric Stenosis
-physical exam
-after feeding, upper abd may be distended
-prominent gastric peristaltic waves may be seen
-in some infants, an olive-sized mass can be felt on deep palpation in the RUQ
Pyloric Stenosis
-diagnosis
-upper GI series may be performed
-HOWEVER, ABD US will demonstrate the hypoechoic ring with a thickness >4mm
Pyloric Stenosis
-differentials for BILIOUS vomiting
malrotation, volvulus and other lesions causing small bowel obstruction
Pyloric Stenosis
-treatment
hydration and correct electrolyte of abnormalities PRIOR to surgical repair (pyloromyotomy) –> the post-op barium x-ray will remain abnormal for many months. Vomiting is common due to gastritis and GE reflux
Functional or Nonspecific Abdominal Pain
-Recurrent attacks of abd pain: how often does this need to occur for dx?
occur at least 2x week for >2mo
Functional or Nonspecific Abdominal Pain
-sx of recurrent attacks of abd pain
-pain is usually periumbilical, variable intensity and duration
-may be colicky or persistent and have associated N&V and pallor
-school attendance suffers
-NO ASSOCIATED weight loss, fever, or bleeding = normal growth and development
Functional or Nonspecific Abdominal Pain
-labs associated with recurrent attacks of abd pain
normal CBC, sed rate and stool (occult blood)
**diagnosis of exclusion
Functional or Nonspecific Abdominal Pain
-treatment associated with recurrent attacks of abd pain
reassurance, education, resumption of normal activities, esp. school
-Psychotherapy: assess stressors
-Antispasmodics: rarely helpful unless they have IBS
Functional or Nonspecific Abdominal Pain
-education regarding recurrent attacks of abd pain
educate parents on concept of visceral hyperalgesia = increased pain signaling from normal stimuli (gas, acid secretion or stool)
Functional or Nonspecific Abdominal Pain
-which age group is this most common in?
children older than 2 yrs
Gynecologic causes of abd pain: ectopic pregnancy
-characterized by?
acute onset of unilateral lower quadrant pain, usually continuous and crampy; some degree of vaginal bleeding and low-grade fever
Gynecologic causes of abd pain: ectopic pregnancy
-labs
positive pregnancy test
Gynecologic causes of abd pain: ectopic pregnancy
-diagnostic imaging
ultrasound fails to reveal intrauterine pregnancy
Gynecologic causes of abd pain: ectopic pregnancy
-treatment
emergent referral to OB
Lactose intolerance
-symptoms
-usually begin around 4-6 years of age
-intestinal dilation, bloating, increased flatulence, pain, and eventually diarrhea
Lactose intolerance
-onset of sx
2 hours after ingestion of milk or products (sometimes as long as 12 hrs after)
Lactose intolerance
-often confused with cow’s milk intolerance
occurs in infancy
-blood in stools
-often a manifestation of allergies (ezcema, hives, and asthma)
Lactose intolerance
-treatment
lactose supplement to dairy products (Lact-aid) or restriction of dairy products
Mittelschmerz
-cause
spillage of fluid from ruptured follicular cystic (during ovulation) –> irritates peritoneum –> MID-CYCLE PAIN
Mittelschmerz
-sx
sudden onset of localized unilateral lower quadrant pain –> persists for a few minutes to as long as 8 hours (rarely mimics the abdominal findings of appendicitis, torsion or rupture of ovarian cyst, or ectopic pregnancy)
Mittelschmerz
-anovulatory cycles
lead to a normal follicular cyst growing large over several cycles –> considerable pain on rupture reveal intrauterine pregnancy
Mittelschmerz
-treatment
emergent referral to OB
Mittelschmerz
-def
ovulation pain
-benign preovulatory lower abd pain that occurs midcycle (between days 7-24) in women
-may affect over 40% of women of reproductive age, and it occurs almost every month in these patients
Acute Cystitis
-def
infection of the bladder
Acute Cystitis
-cause
-coliform bacteria (E coli) and gram-positive (enterococci)
Acute Cystitis
-sx
irritative voiding symptoms, suprapubic discomfort, hematuria
Acute Cystitis
-Labs
UA (pyuria, bacteriuria, hematuria)
Acute Cystitis
-treatment of uncomplicated cystitis in women
-cephalexin, nitrofurantoin, trimethoprim-sulfamethoxazole
**FDA: restrict Fluoroquinolone use for uncomplicated urinary tract infections
Acute Cystitis
-REFER IF
radiographic abnormality evidence of urolithiasis or recurrent cystitis due to bacterial persistence
Acute Pyelonephritis
-def
infectious inflammatory disease of the kidney parenchyma and renal pelvis
Acute Pyelonephritis
-cause
gram negative bacteria most causative agents (E coli, Proteus, Klebsiella, Enterobacter, Pseudomonas)
Acute Pyelonephritis
-sx
fever, flank pain, shaking, chills, irritative voiding sx
Acute Pyelonephritis
-labs
-CBC: leukocytosis and a left shift
-UA: pyuria, bacteriuria, hematuria; white cell casts
Acute Pyelonephritis
-diagnostic imaging
renal ultrasound may show hydronephrosis
Acute Pyelonephritis
-differential diagnosis
acute cystitis or a lower urinary source
Acute Pyelonephritis
-outpatient treatment
-Empiric therapy: ampicillin Ciprofloxacin, levofloxacin, trimethoprim-sulfamethoxazole (Bactrim)
-CT or Ultrasound
-Catheter or nephrostomy drainage
Acute Pyelonephritis
-refer
complications, urolithiasis, obstruction
Acute Pyelonephritis
-admit to hospital
parenteral antibiotics, complicating factors, sepsis
Urinary Stone Disease
-prevalence
white men more frequently affected by urolithiasis
Urinary Stone Disease
-five major types of urinary stones
-calcium oxalate
-calcium phosphate
-struvite
-uric acid
-cystine
**most common types are composed of calcium
Urinary Stone Disease
-how geographic factors contribute to development of stones
areas of high humidity and elevated temperatures appear to be contributing factors
Urinary Stone Disease
-how sedentary lifestyles impact incidence
-sedentary lifestyles have higher incidence of urinary stone disease
Urinary Stone Disease
-what puts a patient at higher risk?
-higher rates or HTN, carotid calcification, and cardiovascular disease
-high protein, salt intake, inadequate hydration appears most important factors
Urinary Stone Disease
-sx
pain may occur episodically and radiate anteriorly over the abdomen
-nausea and vomiting
-obstructing urinary stones: acute and severe colic and severe flank pain
Urinary Stone Disease
-diagnosis
plain abd xray (kidney, ureter, and bladder - KUB) and renal US
-non-contrast CT
Urinary Stone Disease
-labs
urinary pH is a valuable clue to the cause
Urinary Stone Disease
-dietary counseling
sodium intake should be restricted to keep urinary sodium levels <150mEq/day
Urinary Incontinence
most common cause of persistent (INVOLUNTARY) incontinence in the elderly
Stress Incontinence
present when involuntary leakage occurs from effort or exertion or from sneezing or coughing
Transient Incontinence
incontinence less than 6 weeks spontaneously resolves with tx of underlying condition
Overflow Incontinence
prevalence of prostate disorders, incontinence in older men due to obstruction of urinary outflow
-sx = dribbling
Functional Incontinence
inability or unwillingness to toilet because of physical, cognitive, psychological, or environmental factors
-common in hospital and nursing home patients
eliciting CVA tenderness
-to elicit costovertebral angle (CVA) tenderness, have the patient sit upright facing away from you or have him lie in a prone position
-place the palm of your left hand over the left CVA, then strike the back of your left hand with the ulnar surface of your r
-repeat this percussion technique over the right CVA
-a patient with CVA tenderness will experience intense pain
Dyspepsia
-essentials of diagnosis: key findings
predominant epigastric pain for at least 1 month
-associated epigastric fullness, nausea, heartburn, or vomiting
**obtain endoscopy in all patients age >60 years or older and selected younger patients with alarm features
Dyspepsia
-what to test patients for?
test for H pylori
-if positive, administer antibacterial tx
-if negative or those that don’t improve after H pylori eradication: prescribe trial empiric PPI
Dyspepsia
-refractory sx
offer a trial of tricyclic antidepressant, a prokinetic agent, or psychological therapy
Dyspepsia
-labs (<60 yrs; >60 yrs)
-younger than age 60 years with uncomplicated dyspepsia: pursue initial noninvasive strategies (perform H Pylori test via urea breath or rectal antigen 1st)
-older than age 60 years: CBC, electrolytes, liver enzymes, calcium, & thyroid function tests
Dyspepsia
-when is peptic ulcer disease excluded?
if H pylori breath test or fecal antigen test results are negative in a patient not taking NSAIDs
Dyspepsia
-refractory sx (treatments - 3)
offer a atrial of tricyclic antidepressant, a prokinetic agent, or psychological therapy
Dyspepsia
-meds that cause
-aspirin
-NSAIDS
-abx (metronidazole, macrolides)
-dabigatran
-diabetes meds (metformin, alpha-glucosidase inhib., amylin analogs, GLP 1 recept)
-neuropsychiatric meds; (cholinesterase (venlafaxine, duloxetine))
-Parkinson’s (dopamine agonists, MAO-B inhib)
-corticosteroids
-estrogens, digoxin, iron & opioids
pancreatic disease
-pancreatic carcinoma & chronic pancreatitis
chronic epigastric pain (more severe, sometimes radiating to the back, associated w/ anorexia, rapid weight loss, steatorrhea, or jaundice)
Functional Dyspepsia
-no organic etiology determined by endoscopy or other tests
-MOST COMMON CAUSE
Functional Dyspepsia
-sx
-increased visceral afferent sensitivity, gastric delayed emptying or impaired accommodation to food or psychosocial stressors (may be chronic & difficult to treat)
-patients are often younger, report a variety of abdominal and extra-GI complaints, show signs of anxiety or depression, or have a hx of use of psychotropic meds
Etiology of dyspepsia
-food/drug intolerance
-pancreatic disease
-functional dyspepsia
-biliary tract dysfunction
-luminal GI tract dysfunction
-H pylori infection
-other complications
Dyspepsia
-biliary tract dysfunction
abrupt onset of epigastric or RUQ pain r/t cholelithiasis, elithiasis, or choledocholithiasis (should be readily distinguished from dyspepsia)
Dyspepsia
-Luminal GI Tract Dysfunction
*Peptic ulcer disease commonality?
*GERD commonality?
*gastric or esophageal cancer commonality?
-peptic ulcer disease: 5-15%
-GERD: 20% (despite significant heartburn)
-Gastric or esophageal cancer: <1%; extremely rare in <60 yrs old w/ uncomplicated dyspepsia
what must be ruled out during dx of luminal Gi tract dysfunction?
must rule out heart burn
-reflux almost always present in dyspepsia
Dyspepsia
-H Pylori Infection
chronic gastric infection w/ H Pylori cause of PID
Dyspepsia
-other complications associated
DM, thyroid disorder, CKD, MI, intraabdominal malignancy, gastric volvulus or paraoesophageal hernia, chronic gastric or intestinal ischemia, & pregnancy
Dyspepsia
-treatment
**initial empiric tx in all patients younger than 60 years w/o alarm features
**all others (especially sx not responsive to or relapse after empiric tx): upper endoscopy w/ subsequent tx directed at specific disorder identified (peptic ulcer, GERD, CA)
-obtain gastric biopsies during endoscopy to test for H pylori
-If infection is present, give abx
Dyspepsia
-empiric therapy: H Pylori Negative
antisecretory (PPI) x 4 weeks
-if relapse occurs after d/c of PPI, consider long-term PPI
Dyspepsia
-empiric therapy: H Pylori positive
administer abx therapy
-persistent dyspepsia after H pylori eradication = administer trial of PPI therapy
Empiric therapy: tx for functional dyspepsia
-general measures
no findings on endoscopy, <60 yrs, no response to H pylori tx or PPI
-reassurance & lifestyle changes
-reduce or d/c ETOH and caffeine use
-Consume small, low fat meals (if postprandial sx are present)
-Keep a food diary
Empiric therapy: tx for functional dyspepsia
-anti-H Pylori Tx
<10% benefit from H Pylori eradication therapy
-test and treat for H pylori
Empiric therapy: tx for functional dyspepsia
-other pharm agents - antisecretory therapy - PPI
-1/3 of pts obtain relief from placebo
-4-8 wks (omeprazole, esomeprazole, or rabeprazole (20mg), dexlansoprazole or lansoprazole 30mg, or PANTOPRAZOLE 40mg QD
Empiric therapy: tx for functional dyspepsia
-other pharm agents - low dose anti-depressants (moderate visceral afferent sensitivity)
desipramine or nortriptyline 20-50mg QD HS
Empiric therapy: tx for functional dyspepsia
-other pharm agents - amitriptyline
50mg/day for 10 weeks vs escitalopram
Empiric therapy: tx for functional dyspepsia
-other pharm agents - escitalopram
most improved w/ ulcer-like dyspepsia); increase doses slowly to minimize SE vs amitriptyline
Empiric therapy: tx for functional dyspepsia
-other pharm agents - metoclopramide
5-10mg TID
-BLACK BOX WARNING: no more than 3mo r/t tardive dyskinesia (older adults, women-HIGHEST RISK)
Empiric therapy: tx for functional dyspepsia
-other pharm agents - alternatives
-psychotherapy
-hypnotherapy
-herbals (peppermint, caraway)
Dyspepsia
-diagnostic studies: upper endoscopy (what does it help dx? when to use as dx study?)
-study of choice for GI ulcers, erosive esophagitis, increased GI malignancy
->60 years (evaluate for upper GI/esophageal malgnancy)
-new onset dyspepsia
-younger pts w/o “alarm features” (progressive weight loss, rapidly progressive dysphagia, severe vomiting, evidence of bleeding, anemia, or jaundice
Dyspepsia
-diagnostic studies: other reasons to perform endoscopy
-regions of higher incidence of GI cancer (central or south America, China, southeast asia or africa): perform at 45 years old
-sx fail to respond to initial empiric management
-frequent sx relapse occurs after d/c of empiric therapy
Dyspepsia
-diagnostic studies: other tests (tests done besides upper endoscopy)
-antibodies: celiac disease
-stool testing: ova and parasites
-giardia antigen, fat, or elastase: refractory sx of progressive weight loss
-Abd imaging (US or CT): pancreatic, biliary tract, vascular dx, or volvulus suspicion
Dyspepsia
-diagnostic studies: gastric emptying (when do you get this test? - with what sx)
-recurrent N/V and no response to empiric therapies
Dyspepsia
-clinical findings
nonspecific; clarify the chronicity, location, & quality of EG pain and relation to meals
Dyspepsia
-what are sx possibly accompanied by?
post prandial fullness, heartburn, N/V
Dyspepsia
-when should you obtain endoscopy or abd CT scan?
concomitant weight loss, persistent vomiting, constant or severe pain, progressive dysphagia, hematemesis, or melena
Dyspepsia
-what is the accuracy of reporting/development of dyspepsia affected by?
recent changes in employment, marital discord, physical and sexual abuse, anxiety, depression, & fear of serious disorder
Dyspepsia
-is a physical exam helpful in tx/dx?
No; rarely helpful
-often misdiagnose w/ peptic ulcers/GI reflux
Dyspepsia
-signs of serious organic disease
weight loss, organomegaly, abdominal mass, fecal occult blood
**REFER for further evaluation!
N/V
-definitions of N/V
-nausea: vague, intensely disagreeable sensation of sickness or “queasiness” and is distinguished from anorexia
-vomiting: often follows nausea, as does retching (spasmodic respiratory and abdominal movements); distinguish from regurgitation (effortless reflux of liquid, food, or stomach contents) and rumination (chewing and swallowing of food that’s regurgitated voluntarily after meals)
what is the sensation of emesis controlled by?
-brainstem vomiting center within medulla
-stimulated by 4 afferent inputs:
*afferent vagal fibers from the GI viscera: rich in serotonin 5-HT3 receptors stimulated by biliary or GI distention, mucosal or peritoneal irritation or infections
*fibers of the vestibular system: increase concentration of histamine H1
*increase CNS center (amygdala): certain sights, or emotional experiences may induce vomiting (pts w/chemo
where is the chemoreceptor trigger zone associated with N/V?
-what type of receptors are rich in this area?
-what is this area stimulated by?
-located outside the BBB (area postrema of the medulla)
-rich in opioid, serotonin 5HT3, neurokinin 1 (NK1), & Dopamine D2 receptors
-stimulated by drugs & chemotherapeutic agents, toxins, hypoxia, uremia, acidosis, & radiation therapy
N/V
-s/s (6)
- acute sx w/o abd pain: food poisoning, infectious gastroenteritis, drugs, or systemic illness (inquire about recent changes in medications, diet, other intestinal sx, or similar illnesses in family members
- acute onset of severe pain and vomiting: peritoneal irritation, acute gastric or intestinal obstruction, or pancreaticobiliary disease
- persistent vomiting: pregnancy, gastric outlet obstruction, gastroparesis, intestinal dysmotility, psychogenic disorders, and CNS or systemic disorders
- vomiting that occurs in the morning before breakfast: pregnancy (common), uremia, ETOH intake, and increased ICP
- vomiting immediately after meals: bulimia or psychogenic causes
- vomiting of undigested food one to several hours after meals: gastroparesis or a gastric outlet obstruction
N/V
-special exam:
severe or protracted vomiting
obtain serum electrolytes to assess for hypokalemia, azotemia, or metabolic alkalosis (due to loss of gastric contents)
N/V
-special exam:
flat and upright abdominal x-rays or abdominal CT
obtain for severe pain or suspicion of mechanical obstruction to look for free intraperitoneal air or dilated loops of small bowel
N/V
-special exam:
upper endoscopy
determines cause of gastric outlet obstruction
N/V
-special exam:
abdominal CT imaging
determines causing of small intestinal obstruction
N/V
-special exam:
nuclear scintigraph studies or C-octanoic acid breath tests
confirms diagnosis of gastroparesis
-shows delayed gastric emptying and no evidence of mechanical gastric outlet obstruction (upper endoscopy or barium upper GI series)
N/V
-special exam:
abdominal liver biochemical tests or elevated amylase or lipase
pancreaticobiliary disease –> OBTAIN ABDOMINAL SONOGRAM or CT SCAN for FURTHER EVALUATION
N/V
-special exam:
CT scan/MRI or head
determines CNS causes
N/V
-most causes of acute vomiting
self-limited, mild, and requires no treatment
N/V
-foods to help
clear liquids (broths, tea, soups, carbonated, bev), small dry food (crackers), & ginger
N/V
-what type of vomiting requires hospitalization?
-what are the sx of this type of vomiting?
-severe acute vomiting
-unable to eat, losing gastric fluids –> dehydration –> hypokalemia w/ metabolic acidosis). IVF: 0.45% NS w/ 20KCl
N/V
-when do you utilize NG suction?
gastric or mechanical small bowel obstruction (improves pt. comfort/permits monitoring I&O)
N/V
-antiemetic meds (6)
- serotonin 5-HT-receptor antagonists
- corticosteroids
- neurokinin receptor antagonists
- dopamine antagonists
- antihistamines and anticholinergics
- cannabinoids
N/V
-antiemetic meds: serotonin 5-HT-receptor antagonists
ondansetron, granisetron, dolasetron, and palonosetron are effective in preventing chemotherapy, and radiation-induced emesis when initiated prior to treatment
-due to its prolonged halflife and internalization of the 5-HT3-receptor, palonosetron is superior to other 5-HT2-receptor antagonists for the prevention of acute and delayed chemotherapy-induced emesis from moderately or highly emetogenic chemotherapeutic regimens
-although 5-HT3-receptor antagonists are effective as single agents for the prevention of chemotherapy-induced nausea and vomiting, their efficacy is enhanced by combination therapy w/ a corticosteroid (dexamethasone) and NK1-receptor antagonist
-serotonin antagonists increasingly are used for the prevention of postoperative N/V because of increased restrictions on the use of other antiemetic agents (such as droperidol)
N/V
-antiemetic meds: corticosteroids
-(dexamethasone) have antiemetic properties, but the basis for these effects is unknown
-these agents enhance the efficacy of serotonin receptor antagonists for preventing acute and delayed N/V in patients receiving moderately to highly emetogenic chemotherapy regimens
N/V
-antiemetic meds: neurokinin receptor antagonists
-aprepitant, fosaprepitant, and rolapitant are highly selective antagonists for NK1-receptors in the area postrema
-used in combination w/ corticosteroids and serotonin antagonists for the prevention of acute and delayed N/V w/ highly emetogenic chemotherapy regimens
-netupitant is another oral NK1-receptor antagonist that is administered in a fixed-dose combination w/ palonosetron
0combined therapy w/ a neurokinin-1 receptor antagonist prevents acute emesis in 80-90% and delayed emesis in more than 70% of patients treated w/ highly emetogenic regimens
N/V
-antiemetic meds: dopamine antagonists
-phenothiazines, butyrophenones, and substituted benzamides (prochlorperazine, promethzaine) have antiemetic properties that are d/t dopaminergic blockage as well as their sedative effects
-high doses of these agents are associated w/ antidopaminergic side effects, including extrapyramidal reactions and depression
-w/ the advent of more effective and safe antiemetics, these agents are infrequently used, mainly in outpatients w/ minor, self-limited sx
-the chemotherapy were already being given dexamethasone, an NK1-receptor antagonist, and a 5-HT3 antagonist, olanzapine was superior to placebo for the prevention of acute and delayed nausea
N/V
-antiemetics meds: antihistamines and anticholinergics (meclizine, dimenhydrinate, transdermal scopolamine)
-may be valuable in the prevention of vomiting arising from stimulation of the labyrinth (motion sickness, vertigo, and migraines)
-they may induce drowsiness
-a combination of oral vitamin B6 and doxylamine is recommended by the American College of Obstetricians and Gynecologists as first-line therapy for nausea and vomiting during pregnancy
N/V
-antiemetic meds: cannabinoids
-marijuana has been used widely as an appetite stimulant and antiemetic
-pure delta-9-tetrahydrocannabinol (THC) is the major active ingredient in marijuana and the most psychoactive and is available by prescription as dronabinol
-in doses of 5-15 mg/m2, oral dronabinol is effective in treating nausea associated w/ chemotherapy, but is associated with CNS SE in most patients
-some states allow the use of medical marijuana w/ a clinician’s certification
-strains of medical marijuana w/ different proportions of various naturally occurring cannabinoids (primarily THC and cannabidiol (CBD)) can be chosen to minimize its psychoactive effects
Hiccupping
-clinical findings (evaluation of the patient w/ persistent hiccups should include):
-what to do if cause remains unclear?
detailed neurologic exam, serum creatinine, liver chemistry tests, and a chest radiograph
-CT or MRI of the head, chest, and abd, echocardiography, and upper endoscopy
Hiccupping
-essentials of dx (what benign or not; what do persistent hiccups indicate; how hiccups can impact mechanical vent pts)
-usually benign and self-limiting annoyance
-persistent hiccups: sign of serious underlying illness
-pt w/ mechanical ventilation: hiccups can trigger a full respiratory cycle –> respiratory alkalosis
Hiccupping
-causes of benign, self-limiting hiccups
-gastric distension (carbonated beverage, air swallowing, overeating), sudden temp changes (hot then cold liquids, hot then cold shower), ETOH ingestion, & states of heightened emotion (excitement, stress, laughing)
Hiccupping
-causes of recurrent/persistent hiccups
over 100 causes including GI, CNS, CV, and thoracic disorders
Hiccupping
-simple remedies for acute benign hiccups
-irritation of nasopharynx: tongue traction, lifting the uvula w/ a spoon, catheter stimulation of the nasopharynx, or eating 1 teaspoon of dry granulated sugar
-interruption of the respiratory cycle: breath holding, Valsalva maneuver, sneezing, gasping (fright stimulus), or rebreathing into a bag
-Stimulation of the vagus: carotid massage
-Irritation of the diaphragm: holding knees to chest or by continuous positive airway pressure during mechanical ventilation
-relief of gastric distention: belching or insertion of NG tube
Hiccupping
-several drugs have been promoted as being useful in tx of hiccups
-chlorpromazine, 25-30mg orally or IM (most commonly used)
-anticonvulsants (phenytoin, carbamazepine), benzodiazepines (lorazepam, diazepam), metoclopramide, baclofen, gabapentin, and occasionally general anesthesia
Constipation
-prevalence
occurs in 15% of adults and up to one-third of elderly adults; common reasons for seeking medical attention
Constipation
-general considerations for elderly population
-predisposed d/t comorbid medical conditions, medications, poor eating habits, decreased mobility and, in some cases, inability to sit on a toilet (bed-bound patients)
Constipation
-1st step of evaluation
-determine what is meant by “constipation”
-may define constipation as infrequent stools (fewer than three in a week), hard stools, excessive straining, or a sense of incomplete evacuation
Constipation
-primary constipation: def
constipation unattributed to any structural abnormalities or systemic disease (MOST COMMON)
Primary Constipation
-normal colonic transit time
approx 35 hours (>72 hours = ABNORMAL)
Primary Constipation
-what causes slow colonic transit
-commonly idiopathic but may be part of generalized GI dysmotility syndrome
-may complain of infrequent BMs and abdominal bloating
-more common in women (hx of psychosocial problems - depression, anxiety, eating disorder, childhood trauma; sexual abuse)
Primary Constipation
-defecatory disorders (also known as dyssynergia defecation)
impaired relaxation or paradoxical contraction of the anal sphincter and/or pelvic floor muscles during attempted defecation that impedes the BM
-this problem may be acquired during childhood or adulthood
-excessive straining, sense of incomplete evacuation, or need for digital manipulation
Primary Constipation
-primary complaints of abd pain or bloating w/ alterations in bowel habits
constipation, or alternating constipation and diarrhea –> IBS
Secondary Constipation
-def
constipation caused by systemic disorders, medications, or obstructing colonic lesions
Secondary constipation
-causes
-Systemic disorders: neurologic gut dysfunction, myopathies, endocrine disorders, or electrolyte abnormalities (hypercalcemia or hypokalemia)
-medication side effects: anticholinergics or opioids)
what cause colonic lesions that obstruct fecal passage?
neoplasms and strictures (uncommon cause but important in new-onset constipation)
what are anorectal problems that impede or obstruct flow?
perineal descent, rectal prolapse, rectocele
-some of which may require surgery, and Hirschsprung disease (usually suggested by lifelong constipation)
