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CSI- Winter > Vomiting, Diarrhea, Constipation > Flashcards

Vomiting, Diarrhea, Constipation Flashcards

1
Q

Nausea and vomiting pathway

A

Brainstem mediated in medulla, stimulated by:

  • Afferent vagal fibers from GI viscera 5-HT3 receptors due to biliary or GI distention, mucosal or peritoneal irritation, or infections.
  • 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)
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2
Q

Visceral afferent stimulation caused by Mechanical obstruction

A

malignancy, gastric volvulus, peptic ulcer disease, adhesions, hernias, Crohns,
carcinomatosis

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3
Q

With abdominal/epigastric pain, always think

A

cardiac (MI)

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4
Q

Pancreatitis causes epigastric pain that radiates to

A

back (will see increased lipase on blood tests)

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5
Q

Cholelithiasis

A

gallstones

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6
Q

Cholecystitis

A

inflamed gallbladder

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7
Q

Choledocholithiais

A

stone on common bile duct

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8
Q

Visceral afferent stimulation caused by dysmotility

A

gastroparesis (from diabetes, post viral, post vagotomy), scleroderma, amyloidosis, familial myoneuropathies

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9
Q

Visceral afferent stimulation caused by peritoneal irritation

A

peritonitis, perforated viscus, appendicitis, spontaneous bacterial peritonitis, viral gastroenteritis, Norwalk agent, rotavirus, food poisoning toxins from Bacillus cereus, Staph aureus or clostridium perfringens, Hep A or B, acute systemic infection

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10
Q

Visceral afferent stimulation caused by Hepatobiliary or pancreatic disorders

A

acute pancreatitis, cholecystitis/lithiasis

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11
Q

Visceral afferent stimulation caused by topical GI irritants

A

alcohol, NSAIDs, antibiotics (Tetracyclines- take with milk or crackers)

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12
Q

Visceral afferent stimulation caused by Post op/other

A

cardiac disease, acute MI, heart failure, urologic disease, stones, pyelonephritis

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13
Q

Vestibular disorders that can cause N/V

A

Labyrinthitis, Meniere syndrome, motion sickness

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14
Q

CNS disorders that can cause N/V

A 
Increased intracranial pressure (CNS tumors, subdural/subarachnoid hemorrhage) 
Migraine infections (meningitis, encephalitis) 
Psychogenic- anticipatory vomiting, anorexia/bulimia, psych disorders
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15
Q

Irritation of CRTZ

A
  • Antitumor & Chemo/ Radiation meds
  • Meds/Drugs (opioids, anticonvulsants, antiparkinsons, Bblockers, antiarrhythmics, digoxin, nicotine, BC pills, cholinesterase inhibitors, diabetes meds)
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16
Q

Systemic disorders that can irritate CRTZ

A

Diabetic ketoacidosis, uremia, adrenocortical crisis, parathyroid disease, hypothyroidism, pregnancy, paraneoplastic syndrome

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17
Q

History clues- morning vomiting?

A

Pregnancy, alcohol, increased ICP

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18
Q

History clues- after meals?

A

Biliary (think gallstone or gallbladder issue possibly)

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19
Q

History clues- undigested food?

A

Gastroparesis or gastric outlet obstruction

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20
Q

History clues- green emesis?

A

Bowel obstruction, biliary (classic presentation)

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21
Q

Rebound pain?

A

Peritonitis

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22
Q

RUQ pain? Murphy’s sign?

A

appendicitis

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23
Q

Pelvic pain in woman?

A

gyn/ovarian pathology

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24
Q

CMP will show

A

CLASSIC: Hypochloremic, hypokalemic, metabolic alkalosis (prolonged emesis)
-Could be from vomiting, diuretics

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25
Q

Other Tests to order

A
  • KUB (kidney, urinary, bladder), Obstructive Series (xrays standing, sitting, laying, to check air fluid levels)
  • NM Gastric Emptying Study
  • Barium Upper GI Study (up to small intestine)
  • EGD (put camera in mouth/down throat to look into stomach)
  • CT w or w/o, RARELY w and w/on (note that is 2 scans)  usually only WITH or WITHOUT
  • Head CT? to rule out tumor
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26
Q

Small bowel obstruction on Xray

A

MUST KNOW FOR TEST!!

-air fluid levels (and stool on X-ray)

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27
Q

Complications

A

Dehydration, electrolytes, aspiration, Boerhaave’s Syndrome, Mallory Weiss Tears

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28
Q

Aspiration- if someone throws up look for complications; if they throw up and take deep breath, vomit goes into lungs, causes chemical inflammation- may show up hours or days later- if they spike a fever- start on ________

A

antibiotic for anaerobic coverage (bacteria from gut is in lungs)

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29
Q

Mallory Weiss Tears

A

small tear in esophagus and you throw up blood- from force of throwing up (bulimics and alcoholics)

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30
Q

Boerhaave’s Syndrome

A

esophageal rupture (in FA)

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31
Q

Treatment

A 
-Symptomatic management
(clear liquids to full liquids to soft diet)
-Admit patient?
-NG tube? Tube from nose to stomach
-Antiemetic Medications
32
Q

Antiemetics- Serotonin 5-HT3 antagonists

A

Ondansetron (most common), Granlsetron (chemo patients), Dolasetron, Palonosetron

33
Q

Antiemetics- Dopamine receptor antagonists

A

Metoclopramide, Prochlorperazine, Promethazine, Trimethobenzamide

34
Q

Marijuana as antiemetic

A

-THC active ingredient, available by Rx as dronabinol
-Helps with nausea of chemotherapy, 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

35
Q

Diarrhea

A

200-300g in 24 hour period or more than 3 bowel movements per day or liquidity

36
Q

Non-inflammatory Acute Diarrhea

A
37
Q

Inflammatory Acute Diarrhea

A
  • Blood, pus or fever (BAD- invasive pathogen)
  • Invasive organism or toxin producing
  • Clostridium difficile, E coli O157:H7 (Isolation, spore forming, hard to kill, not hand sanitizer, only soap and water, test for this in stool)
38
Q

What food to avoid during pregnancy and why

A

Avoid soft cheese- higher risk of Listeriosis

39
Q

Day care and hiking cause higher risk of

A

Giardia or cryptosporidium

40
Q

Using antibiotics (like Cipro from travelers diarrhea)

A

May cause C diff colitis

41
Q

Antibiotics for C diff

A

metronidazol (first line)- Vanco if that doesn’t work

42
Q

For pt with C diff or E coli DO NOT GIVE

A

Do NOT give immodium (loperimide) or diphenoxylate with atropine, risk of increased contact time with gut (increased risk for systemic infection, body can’t get rid of it)

43
Q

Stomach virus from cruise ship

A

Norovirus

44
Q

Noninflammatory diarrhea is from

A
  • norovirus, rotavirus
  • giardia, cryptosporidium, cyclospora
  • preformed enterotoxins (s. aureus, bacillus cereus, clostridium perfringens)
  • enterotoxin production (enterotoxogenic E coli, vibrio cholerae)
45
Q

Inflammatory diarrhea is from

A
  • CMV
  • entamoeba histolytica
  • Cytotoxin production (vibrio parahaemolyticus, EHEC O157:H5, C. diff)
  • Mucosal invasion (shigella, campy, salmonella, EIEC, aeromonas, pleisomonas, yersinia, chlamydia, n. gonorrhea, listeria)
46
Q

Treatment

A
  • Bismuth subsalicylate (Pepto- can turn stool black), good for traveler’s
  • Loperamide: opioid receptor agaonist

-Inflammatory Bowel Disease?
UC (ulcerative colitis) vs. Crohn’s (terminal ilea)

47
Q

Osmotic diarrhea

A
  • stool volume decreases w/ fasting, increased stoop osmotic gap
  • from meds (antacids, lactulose, sorbitol)
  • from dissacharidase deficiency (lactose intolerance)
  • factitious diarrhea (magnesium in antacids/laxatives)
48
Q

Secretory diarrhea

A
  • large volume (> 1L/day), little change with fasting, normal stool osmotic gap
  • hormonally mediated (carcinoid, zollinger ellison syndrome-gastrin)
  • factitious diarrhea (laxative abuse)
  • villous adenoma
  • bile salt malabsorption (idiopathic, crohns ileitis, post- cholecystectomy)
  • meds
49
Q

Inflammatory conditions

A
  • fever, hematochezia, abdominal pain
  • UC, crohns, microscopic colitis
  • malignancy (lymphoma, adenocarcinoma with obstruction and pseudodiarrhea(
  • radiation enteritis
50
Q

Meds causing diarrhea

A

-SSRIs, cholinesterase inhibitors, NSAIDs, PPIs, ARBs, metformin, allopruinol

51
Q

Malabsorption syndromes

A
  • weight loss, abnormal lab values, fecal fat > 10g/24 hrs
  • small bowel mucosal disorders (celiac sprue, tropical sprue, whipple dx, eosinophilic GItis, small bowel resection, crohns)
  • Lymphatic obstruction (lymphoma, carcinoid, infectious (tuberculosis), Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis)
  • Pancreatic dx (chronic pancreatitis, cancer)
  • Bacterial overgrowth (motility disorder like diabetes or vagotomy, scleroderma, fistulas, small int diverticula)
52
Q

Motility disorders

A
  • systemic disease, prior abdominal surgery
  • postsurgical (vagotomy, partial gastrectomy, blind loop with bacterial overgrowth)
  • systemic disorders (scelroderma, DM, hyperthyroidism)
  • IBS
53
Q

Chronic infections

A
  • parasites (giardia, e. histolytica, strongyloidiasis, capillaria)
  • AIDS related (CMV, HIV, C diff., mycobacterium avium complex, microsporidia, cryptosoiridium, Isospora belli)
54
Q

A 90 year old male with PMH of HTN, DM presents to your office with complaint of constipation. He reports normally would have a BM every day, but now often goes 2 days without one.
What do you tell the patient?

A

Prune juice- start with this- natural laxative

55
Q

Constipation overview

A
  • 10-15% of adults
  • More common in women, elderly
  • If bed bound, may be due to inability to get to toilet
  • History is key
  • Physical examination: rectal exam, FOBT (fecal occult blood testing)
  • Labs: BMP, Mag, TSH
  • Colonoscopy? not usually, unless you think tumor
56
Q

Most common causes of constipation are from

A
  1. inadequate fiber/fluid intake

2. poor bowel habits

57
Q

System diseases that can cause constipation are

A
  • endocrine (hypothyroidism, hyperparathyroidism, DM)
  • metabolic (hypokalemia, hypercalcemia, uremia, porphyria)
  • neuro (parkinsons, MS, sacral nerve damage from prior pelvic surgery or tumor, parapalegia, autonomic neuropathy)
58
Q

Meds that can cause constipation

A

-opioids, diuretics, calcium channel blockers, anticholinergics, psychotropics, calcium/iron supplements, NSAIDs, clonidine, cholestyramine)

59
Q

Structural abnormalities causing constipation

A
  • Anorectal (rectal prolapse, rectocele, rectal intussusception, anorectal stricture, anal fissure, rectal ulcer syndrome)
  • Perineal descent
  • Clonic mass with obstruction/adenocarcinoma
  • Hirschsprung disease
  • Colonic stricture (radiation, ischemia, diverticulosis)
  • Idiopathic megarectum
60
Q

Slow colonic transit can cause constipation from

A
  • idiopathic
  • psychogenic
  • eating disorders
  • chronic int pseudo-obstruction
61
Q

Other things causing constipation

A

Pelvic floor dyssynergia or IBS

62
Q

Zollinger Ellison syndrome

A

gastin secreting tumor

63
Q

Primary Constipation description

A
  • 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)- chronic abdominal pain, gets BETTER with bowel movement- sign of IBS, alternate diarrhea and constipation
64
Q

Secondary Constipation

A

-Systemic disorders, medications, obstructing colonic lesions
(Hypercalcemia, hypokalemia, hypothyroidism, calcium channel blockers like amlodipine/nifedipine)
-Cancer (Warning signs: Age >50 with hematochezia, weight loss, anemia, FOBT +, family history of colon CA, IBD patients–>refer to gastroenterologist)

65
Q

Treatment options

A

-Lifestyle measures
-Dietary changes
-Mineral oil
-Laxatives, Osmotic laxatives, Stimulant laxatives
(Magnesium citrate – AKA “liquid TNT” – Magnesium Mg “makes you go”)
-Prune juice
-Enema or Suppository
-For fecal Impaction use manual disimpaction
-OMT: colonic milking

66
Q

For Opioid Induced Constipation use

A

Methylnaltrexone (Relistor):

subcutaneous injection, expensive, blocks opioid receptors in gut only

67
Q

Examples for stool surfactants

A

-Docusate sodium, mineral oil

68
Q

Examples of Osmotic laxatives

A

-Magnesium oxide, lactulose or sorbitol, polyethylene glycol

69
Q

Examples of stimulant laxatives

A

bisacodyl, cascara, senna

70
Q

First line therapy (note from class)

A

Senna and docusate may come in combined pill- may cause cramping –> first line therapy

71
Q

Drug good for constipated pts with liver problems

A

Lactulose- good for liver patients, prevents ammonia build up in blood

72
Q

Ogilvie Syndrome

A

-AKA Acute Colonic Pseudo-obstruction (ACPO)
-Massive dilation of large intestine- electrolyte imbalances- older patients
-Tube in rectum to suck air out
-Stop opioid use
XRAY pic in slides

73
Q

Projective vomiting in 2-6 week old = palpable “olive” mass, think of

A

Congenital pyloric stenosis

74
Q

Bird’s beak on barium swallow, ? if from Chagas disease

A

Achalasia

75
Q

Boerhaave syndrome

A

esophageal rupture

76
Q

Diverticulosis vs. Diverticulitis - pain location and s/s

A

LLQ Pain, fever, leukocytosis

77
Q

Intussusception (intestine collapses on itself) will present with

A

“currant jelly” stools

CSI- Winter (44 decks)

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