N/V/D + hernias Flashcards
What can cause acute N/V without abdominal pain?
food poisoning, infectious gastroenteritis, drugs, systemic illness
What can cause acute N/V WITH abdominal pain?
peritoneal irritation, acute gastric or intestinal obstruction, pancreaticobiliary disease
what can cause persistent vomiting?
pregnancy, gastric outlet obstruction, gastroparesis, intestinal dysmotility, psychogenic disorders, CNS disorders, systemic disorders
What can cause N/V before breakfast?
pregnancy, uremia, alcohol intake, increased ICP, cannabinoid hyperemesis syndrome
What can cause N/V after meals?
bulimia, psychogenic
What can cause N/V of undigested food 1+ hours later?
gastroparesis, gastric outlet obstruction
What can cause generally N/V?
Mechanical obstruction, dysmotility, peritoneal irritation, infections, hepatobiliary or pancreatic disorders, GI irritants, post-op, vestibular disorders, CNS disorders, irritation of chemoreceptor trigger zone
What should a workup include for N/V?
– serum electrolytes
Hypokalemia, azotemia, metabolic alkalosis
– flat + upright abdominal XR
Dilated loops
– CT of abdomen
Best for SBO
– upper endoscopy
Gastric outlet obstruction
– nuclear scintigraphy studies or C-octanoic acid breath tests
Gastroparesis, delayed gastric emptying
– liver enzymes, amylase, lipase
Pancreaticobiliary disease
– head CT or MRI
CNS
How do you treat N/V?
Clear liquids, ginger
IV saline w/ KCl
NG tube for gastric or mechanical SBO
Serotonin 5-HT3-receptor antagonists:
Ondansetron, granisetron, palonosetron (enhanced with NK1 + steroid), post-op, chemo
Steroids: dexamethasone
Neurokinin receptor antagonists: aprepitant, fosaprepitant, rolapitant (+ for chemotherapy)
Dopamine antagonists: prochlorperazine, promethazine (sedative)
Antihistamines and anticholinergics: meclizine, scopolamine, dimenhydrinate (motion sickness, vertigo, migraines)
B6 & doxylamine for pregnancy
Cannabinoids: dronabinol
Asymptomatic or epigastric discomfort, postprandial bloating/fullness, dysphagia, SOB, nausea/vomiting after eating, anemia, reflux symptoms
hiatal hernia
What predisposes someone to a hiatal hernia?
Age, obesity, power-lifting, scoliosis
What’s the MC type of hiatal hernia?
sliding (upward herniation of stomach/GE junction)
Type I “sliding” of upward herniation of stomach/GE junction – MCC
Type II “rolling” GE junction stays fixed with gastric fundus herniating adjacent to esophagus with risk of strangulation
Type III “mixed” both GE junction AND fundus herniate through hiatus, fundus above GE Junction
Type IV “large defect”, presence of structure other than stomach within hernia sac
hiatal hernia
Hiatal hernia dx
Barium swallow
endoscopy to determine if gastric or esophageal inflammation is present and ruling out cancer
Reflux symptoms = manometry and pH monitoring
How do you treat a hiatal hernia?
Type I = GERD → PPIs and weight loss
Type II = surgical repair
Type III = surgical repair
Type IV = surgical repair
asymptomatic = swelling or fullness in hernia site, enlarges with increased intraabdominal pressure/standing, may develop scrotal swelling
Incarcerated = painful, enlargement, N/V if bowel obstruction
Strangulated = systemic toxic
inguinal hernia
What predisposes someone to an inguinal hernia?
Prior surgery
Obesity
Increased abdominal pressure, aging, congenital
hesselbach’s triangle – indirect (MC) or direct protrusion
inguinal hernia
How do you treat other hernias?
Small incisional hernias treated early – direct fascia-fascia repair, nonabsorbable sutures, increased tension
OR
Elastic corset
Larger hernias: dissection, non-absorbable mesh
bulge near femoral nodes
femoral hernia
femoral hernias are common in
women
protrusion of abdominal cavity contents below inguinal ligament
Highest rate of incarceration and strangulation
femoral hernia
umbilical hernias are most common in
<2
surgery is required for umbilical hernias if unresolved by
age 5
incisional hernias can happen after
abdominal surgery
What are RFs for diarrhea?
Age
Immunodeficiency
Medications
Travel
Infected food/water
Food sensitivity
What are the many types of diarrhea?
Osmotic, secretory, inflammatory, medication induced, malabsorption, motility disorder, chronic infections
Acute = <2 weeks noninflammatory (toxin-producing bacterium) or inflammatory (disruption and destruction of intestinal epithelium), mostly infectious
Chronic = >2-4 weeks from conditions, medications
What may you see on a PE for diarrhea?
PE: poor skin turgor, HOTN, AMS, abdominal tenderness, rebound tenderness, hemoccult, weight loss
Worrisome findings: high fever >101.3, dehydration, frequent bloody stools w/ tenesmus, severe abdominal pain, immunosuppression, no improvement
Can do: stool tests, cultures, testing, endoscopy, mucosal biopsy, imaging
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline), cholinesterase inhibitors (rivastigmine, donepezil/memantine, galantamine), NSAIDs, ARBs, metformin, PPIs, allopurinol, orlistat
chronic medication-induced diarrhea
Stool volume decreases with fasting, increased stool osmotic gap
osmotic diarrhea
what can cause osmotic diarhrea?
Meds – antacids, lactulose, sorbitol
Disaccharidase deficiency – lactose intolerance
Factitious diarrhea – magnesium (antacids, laxatives)
Large volume >1L/day, little change with fasting, normal stool osmotic gap
secretory diarrhea
What can cause secretory diarrhea?
Hormonal - VIPoma, carcinoid, medullary carcinoma of thyroid, Zollinger-Ellison syndrome
Factitious diarrhea (laxative abuse)
Villous adenoma
Bile salt malabsorption
Antibiotics, metformin
cholerae
Fever, hematochezia, abdominal pain
UC, Chron’s disease
Microscopic colitis
Malignancy
Radiation enteris
inflammatory conditions inducing chronic diarrhea
Weight loss, abnormal lab values, fecal fat >10g/24 hour
Small bowel mucosal disorders, lymphatic obstruction, pancreatic disease, bacterial growth
malabsorption syndromes inducing chronic diarrhea
Prior abdominal surgery or systemic disease
Post-surgical, systemic disorders, IBS
motility disorders inducing chronic diarrhea
chronic infections are often
parasite or aids related
what’s first line in treating diarrhea
DIET:
bowel rest by avoiding high-fiber foods, fats, milk products, caffeine, and alcohol
Drink tea and “flat” beverages
Eat easily digested foods (soup, crackers, bananas, applesauce, rice, toast
Rehydrate
Lactated rings if severe dehydration
for NONINVASIVE diarrhea, what are meds you can try?
Antidiarrheal/antimotility (NOT for those with invasive diarrhea):
Bismuth subsalicylate (pepto-bismol)
Safe with dysentery (fever + bloody diarrhea)
SE: dark colored stools
NO in children with viral illness
Opioid agonists
diphenoxylate/atropine (lomotil)
SE: CNS/anticholinergic effects, N/V, abdominal pain, constipation
Loperamide
Indicated for noninvasive diarrhea
Avoid with dysentery
is empiric treatment always indicated for diarrhea?
no. risk of HUS with STEC.
what are safe abx meds for diarrhea generally?
fluoroquinolones and azithromycin
specific antimicrobial treatment is not recommended in those with
nontyphoid salmonella, campylobacter, or yersinia expect in SEVERE disease
STEC should/should not be treated with antibiotics
SHOULD NOT
