vomiting, diarrhea, constipation Flashcards
chronic nausea/vomiting, think what conditions??
gastroparesis: DM neuropathy, unable to digest
dx with a radio labeled egg that is undigested
tx: Reglan, metoclopromide (prokinetic)
erythromycin (but tachyphylaxis? effect: tolerance, stops working after several doses)
FYI can put in gastric pacemakers
with excessive vomiting, watch out for ??
rupture of esophageal varicose: can rupture
if drink drano, don’t induce vomiting because ??
will corrode esophagus 2x!!
induced vomiting can b ??
medication/iatrogenic in the hospital
on purpose
N/V mediated by
Brainstem mediated in medulla
stimulated by: 4 next cards
Afferent vagal fibers from GI viscera 5-HT3 receptors due to ??
biliary or GI distention, mucosal or peritoneal irritation, or infections. (pre-formed toxins)
Vestibular system, ??
H1 and muscarinic cholinergic receptors
Amygdala, ??
sights/smells/emotion
Chemoreceptor trigger zone (outside blood brain barrier)
Rich in opioid, serotonin 5-HT3, dopamine D2 receptors
effected by meds
mechanical obstructions
gastric outlet obstruction, PUD, Ca, gastric volvulus
small int. obstruction, adhesions, hernias, volulus Crohn’s, Ca
dysmotility
gastroparesis, DM, postviral, post vagotomy
sm. int: scleroderma, amyloidosis, chronic intestinal pseudo obstruction
peritoneal irritation
peritonitis: perforated viscus, appendicitis,(rebound tenderness) spontaneous bacterial peritonitis (bac from gut into peritoneal cavity: if cirrhotic, dec. immune system)
viral gastroenteritis: Norwalk, rotavirus
“food poisoning”: Bacillus cereus, S. aureus, C. perfringes
Hepatitis A, B
acute systemic infections
hepatobiliary or pancreatic disorders
acute pancreatitis
cholecystitis (inflamed GB) or choledocholithiasis (stone in common bile duct)
topical GI irritants
etOH, NSAIDs, oral abx (tetras)
postop
due to anesthesia
other causes of N/V
cardiac disease: acute MI, HF
urologic disease: stones, pyelonephritis
vestibular disorders
labyrinthitis, Menieres, motion sickness
CNS disorders
inc. ICP: CNS tumors (morning), subdural, SAH
migraine
infections: meningitis, encephalitis
psychogenic
irritation of CRTZ
antitumor chemo meds/drugs?? (nicotine gum misuse) radiation tx systemic disorders DKA pregnancy
morning vomiting
Pregnancy, alcohol, increased ICP
after meals
biliary, GB issue
undigested foods?
Gastroparesis or gastric outlet obstruction
Green Emesis
Bowel obstruction, biliary emesis
examination
Rebound?
RUQ Pain? Murphy’s?
Pelvic Pain in Woman? (think gyne, ovarian pathology) PID, ovarian torsion
vomiting CMP
Hypochloremic, hypokalemic, metabolic alkalosis (prolonged emesis
other testing
KUB, Obstructive Series NM Gastric Emptying Study Barium Upper GI Study EGD CT w or w/o, RARELY w and w/on (note that is 2 scans) (pick ONE typically) Head CT? (check for tumor)
slide 12 on left
stool seen on right on pt
slide 12 on right
see air bubbles: small bowel obstruction
most common dx
Viral Gastroenteritis Bacterial Gastroenteritis Ileus Small Bowel Obstruction Opiate Induced Gastroparesis Pregnancy Chemotherapy Anesthesia Gallstone Pancreatitis *Ascites (from inc. pressure)
complications of vomiting
Dehydration, electrolytes
aspiration (into lungs: chemical inflammation, if have fever start on anaerobic abx coverage)
Boerhaave’s Syndrome (rupture esophagus, emergency, rare, v. painful)
Mallory Weiss Tears (more common, less serious, smaller tears from force of vomiting)
vomiting tx
Symptomatic management
-Clear liquids to full liquids to soft diet
Admit patient?
NG tube? (swallow when going down to ensure not in lungs, XR to figure out in lungs, listen for gurgling sound with sterile saline)
Antiemetic Medications
serotonin 5-HT3 antagonists
ondansetron (zofran) IV, oral
granisetron (chemo?)
dolasetron
Palonosetron (chemo)
ondansetron
oral or IV
postop N/V
granisetron
IV for chemo
dopamine receptor antagonists
metoclopramide IV, oral
*prochlorperazine IV, IM, oral, rectum
*promethazine IV, oral, rectum
trimethobenzamide oral, IV
SEs: dyskinesias
marijuana: used as tx and causes vomiting
THC active ingredient, available by Rx as dronabinol
Helps with nausea of chemo, has CNS side effects
NOTE: some have paradoxical reaction, Cyclic Vomiting Syndrome, Canabis Hyperemesis Syndrome:
Classic History: Improvement of symptoms of N/V with taking a hot shower
2nd Case: traveller’s diarrhea
pepto bismol
Postinchain doesn’t like cipro: risk of C. diff
Diarrhea
Range from acute self limiting to fatal (cholera)
10L approximately entering duodenum, all but 1.5 L absorbed, colon absorbs rest less than 200ml in stool lost
Definition: 200-300g in 24 hour period
Alternate Definition: more than 3 bowel movements per day (may be norm) or liquidity
acute diarrhea
less than 2 weeks -Non inflammatory: Watery, non bloody Self limited Virus or noninvasive bacteria -Inflammatory: Blood, pus or fever Invasive organism or toxin producing Clostridium difficile, E coli O157:H7
risk for acute diarrhea
Pregnancy? Higher risk of listeriosis (avoid soft cheese)
Day care? Hiking? Higher risk Giardia or Cryptosporidium
Traveler’s diarrhea
Antibiotics? C diff colitis (metronidazole, vanco SLD) (can have without C. diff)
HIV? ie: CMV
med risk for acute diarrhea ??
Do NOT give immodium (loperimide) or diphenoxylate with atropine, risk of increased contact time with gut
virus causing diarrhea on cruiseship
norovirus
slide 24
slide 25
causes
slide 26
algorithm send for fecal leaks routine stoll cx C. diff assay o/p more
med Good for traveler’s
Bismuth subsalicylate
opioid receptor agaonist
Loperamide
IBD??
UC or Crohn’s: affects terminal ileum
chronic diarrhea time
> 4 wks
slide 29, 30
types/causes
laxatives
malabsorption: lactase deficiency, malfuncitoning pancreas
case 3: constipation
can add metamucil
prune juice
10-15% of adults
More common in women, elderly
If bed bound, may be due to inability to get to toilet
dx constipation
History is key
Physical examination: rectal exam, FOBT
Labs: BMP, Mag, TSH
? Colonoscopy (only if thinking tumor)
slide 34 more causes
inadequate fluid hypothyroidism *hyperthyroidism: can lead to hyperCa2+ and cause constipation* neuro disorders CCBs
primary constipation
Normal transit time is 35 hours, more than 72 hours is abnormal
Impaired relaxation of anal sphincter and/or pelvic floor muscles
Irritable Bowel Syndrome (IBS) (pain relieved with bowel movement, can fluctuate C/D)
secondary constipation
Systemic disorders, medications, obstructing colonic lesions:
Hypercalcemia, hypokalemia, hypothyroidism, calcium channel blockers (amlodipine/nifedipine)
secondary constipation: cancer: Warning signs:
Age >50 with: hematochezia, weight loss, anemia, FOBT +, family history of colon CA, IBD patients
constipation tx
Lifestyle measures
Dietary changes
Mineral oil
Laxatives, Osmotic laxatives, Stimulant laxatives
Magnesium citrate – AKA “liquid TNT” – Magnesium Mg “makes you go”
Prune juice
Opioid Induced Constipation: Methylnaltrexone (Relistor), subcutaneous injection
Enema or Suppository
Fecal Impaction
Manual disimpaction
OMT: colonic milking
most common
polyethylene glycol (miralax, golytely)
stimulant lax: senna: ExLax, may cause cramps add with docusate (1st line)
Lactulose: prevents buildup of ammonium, good for liver pts
Ogilvie syndrome
AKA Acute Colonic Pseudo-obstruction (ACPO)
massive dilation of large intestine
put tube in colon, suck air out, stop opiates, get pt to walk around
FA facts
Projective vomiting in 2-6 week old = palpable “olive” mass: Congenital pyloric stenosis
Achalasia – bird’s beak on barium swallow, ? (pic) If from Chagas disease
Boerhaave syndrome – esophageal rupture
FA facts 2
Diverticulosis vs. Diverticulitis (when it becomes INFECTED) (LLQ Pain, fever, leukocytosis)
Intussusception – “currant jelly” stools
