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NUR4630 > Week 13: Acute GI dysfunction > Flashcards

Week 13: Acute GI dysfunction Flashcards

1
Q

upper GI type of bleeding?

A

arterial, hematemesis and melena

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2
Q

lower GI type of bleeding?

A

venous bleeding, hematochezia

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3
Q

Hematemesis bright and dark

A

bright: upper, higher up
darker: old bleed from jejunum where bile is breaking it down

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4
Q

melena

A
  • black tarry stool
  • foul smelling, black (can happen only with 50 cc of bleeding)
  • from small or ascending colon
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5
Q

hematochezia

A

-bright blood in stool=lower GI blood (from colon)

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6
Q

clinical manifestation of GI bleed

A

hematemesis, melena, hematochezia, fatigue, dyspnea, syncope, angina

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7
Q

Most common cause of upper GI bleeding

A

peptic ulcer disease

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8
Q

peptic ulcer disease

A

Causes: NSAIDS,H. Pylori, cigarette smoking
Types: Duodenal and gastric
Dx: H. pylori testing, visualization with endoscopy, barium x-ray, combination antibiotic (amoxy, clarithromycin, tetracycline, and metronidazole)
Treatment: H2 blockers, PPI

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9
Q

Acute erosive or hemorrhagic gastritis

A
  • Severe inflammation of the gastric mucosa (NSAID gastritis, alcohol gastritis, stress gastritis)
  • treatment: endoscopic sclerotherapy (inject something to make varices coagulate), vasopressin IV or intraarterial
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10
Q

esophageal and gastric varices

A
  • associates with cirrhosis, portal htn, and portal or splenic vein thrombosis
  • massive bleeding
  • treatement: sclerotherapy or esophageal balloon (creates pressure to stop bleeding), can also band the verice or pollup
  • this is often how end stage hepatic pts die
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11
Q

mallory-weiss tears

A
  • a small tear in the mucosal lining at the gastro-esophageal junction (often preceded by vomit, most bleeds stop without intervention)
  • DX with endoscopy
  • If bleeding is excessive may treat with vasopressin, usually stops on its own
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12
Q

acute lower GI bleeds

A

Causes: diverticular bleeding, ischemic bowel disease, inflammatory bowel disease, neoplasms

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13
Q

Diverticular bleeding

A

-only occurs in about 3% of those with diverticulosis
-when occurs, may have massive loss of blood that is life threatening
-artery ruptures to fill diverticula
-dx with colonoscopy to determine reason for bleeding
25% require surgical intervention to stop bleed

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14
Q

ischemic bowel disease

A
  • interruption of colonic blood supply (bowel obstruction, occlusion of blood flow through vascular system)
  • risk factors: surgical procedure to vasculature and bowel resection, afib, atherosclerosis, hypotn, sickle cell, DM, lupus, pacreatitis, anticoagulant therapy
  • S/S:* intermittent bleeding*. A pt. who’s h&h is dropping and we don’t know why, mixed dark and bright red bleeding, fever, abd pain
  • DX: endoscopy shows purple color bowel, xray may show air sacks, barium contrast shows thumbprints
  • TX: fix blood flow to bowel (fluid resuscitation), Antibiotic tx for infection, bowel resection as needed to remove necrotic bowel
  • FINAL EXAM “THUMBPRINTS” PICTURE OF ISCHEMIC BOWEL DISEASE
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15
Q

inflammatory bowel disease

A
  • S/S: bloody diarrhea, light to moderate bleeding
  • TX: Stop bleeding, administration of corticosteroids to control inflammation, anti-TNF tx (immune biologic therapy), surgical resection as needed
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16
Q

what is anti-TNF used for

A

helps with inflammation in IBS, it is an immune biologic therapy

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17
Q

neoplasms

A
  • up to 20% benign and malignant tumors are associated with bleeding
  • slow, chronic, and self-limiting
  • DX: barium x-rays, ct scan, mri, pet scan, endoscopy
  • TX: dependent on type, stage, patient wishes
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18
Q

management of acute GI bleeding unstable pt.

A
  • is the patient stable? (hypotn, tachy, altered LOC, cap refill delayed= unstable)
  • urgent interventions: hemodynamic resuscitation and oxygen delivery
  • establish cause of the bleeding once stabilized
  • Is it upper or lower?
  • Upper: hematoemesis and melana
  • Lower: hematochezia (bright)
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19
Q

management of acute GI bleeding stable pt.

A
  • stable? (bloody diahrrea, bp normal, AO=stable)
  • Look at labs, get a really good history, meds (NSAIDS), alcohol consumption, cigarette smoking, sickle cell, clotting factor disorders
  • is it upper or lower
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20
Q

initial assessment of GI bleed

A

Laboratory changes

  • H&H
  • Platelets
  • Electrolytes
  • BUN/Creat (helps differentiate upper and lower. If greater than 35 think upper GI, less than 35 is probably lower GI)
  • PT/INR
  • liver functions test
  • cardiac enzymes (might be getting ischemic to heart muscle itself bc of blood loss)
  • every pt. who comes in with GI bleed should be typed and crossed

Fluid Volume Status

  • hypotension (SBP less than 90)
  • narrowed pulse pressure (MAP less than 60)
  • orthostatic hypotension (concerned with drop in BP 20mmhg or rise in HR of 20bp/min)
  • tachycardia
  • ST changes (only when the pt is becoming ischemic. Need tele monitor)
  • cap refill delayed
  • mucous membranes dry
  • UO dropping below 30cc/hr
  • mental status changes
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21
Q

interventions in GI bleed

A
  • Maximized 02 carryping capacity, keep 02 sat above 92%
  • restore normovolemia: 2 large bore lvs, administer 2 liters of crystalloids (LR, normal saline, should see improvement in 20min), followed by PRBCs as needed, FFP, Platelets, Factor VIII
  • Patient positioning to maintain SBP
  • NG tube placement
  • Erythromycin 3mg/kg over 20 minutes one hour prior to procedures
  • PPI’s
  • Reglan 10 mg IV
  • Bowel Prep
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22
Q

what guage in a pt. going to surgery or hemodynamically unstable

A

18 gauge

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23
Q

if hemoglobin is less than 7, then?

A

give blood no matter what, even if they have had a fluid challenge

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24
Q

If they are anticoagulated, and their PT is going to be greater than 13, and INR greater than 1.5, you are going to give them?

A

-FFP or platelets (provider preference)

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25
Q

Platelets less than 5,000 or after 10 units of PRBCs?

A

platelets

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26
Q

patient may need what if they’re anticoagulated or on coummadin?

A

Vitamin K

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27
Q

PT positioning for systolic BP (will be on test)

A

patient is hypotensive, put them in supine or supine with legs elevated (head flat)

28
Q

NG tube placement bright blood, coffee ground,no blood or bile, or bile no blood means for each?

A
  • if you get bright blood on your NG placement, think upper GI
  • coffee ground, upper GI but probably not active
  • No blood and no bile, GI bleed is below the pyloric sphyncter
  • bile but no blood, thinking no upper GI bleed at all
29
Q

What does erythromycin do?

A

helps gastric motility to clear out stuff in upper GI so they can actually see what’s happening

30
Q

bowel prep to clean out bowel, most used?

A

go lightly

31
Q

proceedures

A

endoscopy: colonoscopy, sigmoidoscopy,
- injection therapy
- thermal coagulation therapy (light that causes coagulation)
- clip them

32
Q

Obstruction

A

a mechanical blockage arising from a structural abnormality that presents a physical barrier to the progresssion of gut contents
-can be partial or complete, simple or strangulated

33
Q

Ileus

A

is a paralytic or functional variety of obstruction

34
Q

patho of obstruction

A

results in

  • initial overcoming of the obstruction by increased peristalsis
  • increased intraluminal pressure by fluid and gas
  • vomiting
  • sequestration of fluid into the lumen from the surrounding circulation
  • lymphatic and veous congestion resulting in oedematous tissue
  • factors 3,4,5 result in hypovolaemia and electrolyte imbalance
  • further: localized anoxia, mucosal depletion necrosis and perforation and peritonitis
  • bacterial overgrowth with translocation of bateria and toxins causeing bacteraemia and septicaemia

What do we do?

  • decomplress with NGT to low/intermittent suction
  • replace lost fluid
  • correction electrolyte abnormalities
  • recognize strangulation and perforation (strangulation no passage of flatulance, severe pain, fever, peritoneal tenderness and swelling rigidity, leukocytosis, increases in amylase levels as well)
  • systemic antibiotics
35
Q

partial obstruction

A

classic sign, loose watery stool (passing around the blocking fecal matter)

36
Q

a simple

A

obstruction that causes it to become ischemic

37
Q

Small bowel adhesions

A
  • accounts for 60-70% of all SBO
  • results from peritoneal injury, platelet activation and givrin formation
  • associated with starch covered gloves, intraperitoneal sepsis, haemorrhage and wash with irritant solutions iodine and other foreign bodies.
  • As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years
  • 70% of patients had a single band
  • patient with complex bands are more likely to be readmitted
  • readmission in surgically treated patients is 35%
  • common surgeries you see them in: (25% colorectal surgery, 20% gynaecological, 14% in appendectomies)
38
Q

hernia

A
  • accounts for 20% SBO
  • common: femoral, ID inguinal, umbilical, incisional and internal
  • the site of obstruction is the neck of the hernia
  • compromised viscus is with in the sac
  • ischemia occurs initially by venous occlusion followed by edema and arterial compromise
  • strangulation noted by: persistent pain, discoloration, tenderness, constitutional symptoms
39
Q

Large Bowel obstruction

A
  • distinguishing ileus from mechanical obstruction is challenging
  • according to leplacs law: maximum pressure is at it’s maximum diameter. CECUM is at the greatest risk of PERFORATION
  • perforation resultes in release of feces with heavy bacterial contamination
40
Q

Role of CT

A
  • used with IV contrast, oral and rectal contrast (tripple contrast: IV, oral, and rectal contrast)
  • able to demonstrate abnormallity in the bowel wall, mesentery, mesenteric vessels and peritoneum
  • can show: level of obstruction, degree, causes, degree of ischemia, free fluid and gas
41
Q

Barium bastrografin studies

A
  • should not be used in pts with peritonitis
  • used in acute abdomen but is diluted
  • useful in recurrent and chronic obstruction
42
Q

Initial dagnostics for LBO

A

Lab

  • CBC
  • clotting
  • arterial blood gasses
  • U& CRT, na, K Amylase, LFT and glucose, LDH
  • group and save (x-match if needed)
  • optional (ESR< CRP< Hepatitis profile)

Radiological

  • x-rays
  • USS

ECG (cardiac ischemia)

43
Q

Clinical finding BO high

A
  • pain is rapid
  • vomiting copiuous and contains bile jejunal content
  • abdominal distention is limited or localized
  • rapid dehydration from vomiting
44
Q

Distal SBO

A
  • pain: central and colicky
  • vomitous is feculunt
  • distension is severe
  • visible peristalsis
  • may continue to pass flatus and feacus before absolute constipation
45
Q

Colonic BO

A
  • ? pre-existing change in bowel habit
  • colicky in lower abdomen
  • vomiting is late (has to back all the way up)
  • distension prominent
  • cecum ? distended
46
Q

persistent pain may be a sign of

A

strangulation

47
Q

Clinical examination general, abdominal, and others

A

general

  • vital signs, P, BP, Sat, RR, T
  • dehydration
  • anemia, jaundice, LN
  • assessment of vomitus if possible
  • full lung and heart exam

Abdominal

  • abdominal distension and it’s pattern
  • hernial orifieces
  • visible peristalsis
  • cecal distention
  • tenderness, guarding and rebound
  • organomegaly
  • bowel sounds (high pitched, absent)
  • rectal examination

Others

  • systemic examination
  • if deemed necessary (CNS, vascular, gynecological, musculoskeletal)
48
Q

Initial management of LBO

A
  • resuscitate (60-100%), insert 2 lines, IVF (120ml and hour crystalloids), add K+ at 1mmmol/kg bc of vomiting (dropping K)
  • draw blood
  • inform senior member in team
  • NPO, NG placement, urinary cath
  • IV antibiotics
  • If concern exist about fluid overloading a central line should be inserted
  • follow-up lab results and correction of electrolyte imbalance
  • pt should be nursed in intermediate care
  • rectal tubes should only be used in Sigmoid volvulus
49
Q

Indications for surgery

A
  • Evidence of strangulation
  • signs of peritonitis (bowel has ruptured)
  • if the obstruction won’t clear in 24-48 hours
  • not sure why there is an obstruction or what is going on
  • try to stabilize pt. before surgery
50
Q

Ileus

A

Associated with the following conditions:

  • postop and bowel resection
  • ischemia
  • infection inside and outside the stomach
  • endocrine
  • spinal and pelvic fractures
  • retro-peritoneal hematoma
  • metabolic abnormalities
  • bed ridden
  • drug induced (morphine, tryciclic meds)
51
Q

Ileus or obstruction?

A

Clinical features:

  • is there an underlying cause?
  • is the abdomen distended but tenderness is not marked
  • is the bowel sounds diffusely hypoactive

Radiological features

  • is the bowel diffusely distended
  • is there gas in the rectum
  • are further investigations helpful in showing an obstruction

Does the pt. improve on conservative measures?

52
Q

Types of IAH/ACS primary, secondary, recurrent

A
  • Primary: injury/disease of abdomino-pelvic region, “surgical”
  • Secondary: sepsis, cap leak, burns, “medical”
  • Recurrent: ACS develops despite surgical intervention
53
Q

IAP interpretation

A

Pressure Interpretation
0-5 Normal
5-10 Common in most ICU pts
>12 (grade 1) Intra-abdominal HTN
16-20 (grade 2) Dangerous IAH- begin non- invasive intervention
>21-25 (grade 3) Impending, decompressive lappi

54
Q

patho

A

ischemia leads to inflammatory responses, cap leakage, coupled with our fluid resuscitation, tissue edema, increases abd pressure, leads back to more ischemia creating this cycle

55
Q

causes of IAP elevation and findings

A
  • major abdominal/retroperitoneal problem
  • ischemic insult/SIRS requiring fluid resuscitation with a positive fluid balance of 5 OR MORE LITERS within 24 HOURS (10lb weight gain)

-temp, HR, and resp increases, WBC .12,000 (elevates)

56
Q

physiologic sequelae cardiac

A
  • increased ABD pressure cause compression of vena cava with reduced venous return
  • elevated intra-thoracic pressure with multiple negative cardiac effects

Result:

  • decreased cardiac output, increased SVR
  • increased cardiac work loads
  • decreased tissue perfusion
  • misleading elevations of CVP and PAWP
  • cardiac insufficiency, cardiac arrest
57
Q

physiologic sequalae pulmonary

A

incrased intra-abd pressure casuses
-elevated diaphragm, reduced lung bolumes and alveolar inflation, stiff thoracic cage, increased intersitial fluid

Results:

  • elevated intrathoracic pressure
  • incread peak pressure, reduced tidal volumes
  • Barotrauma-atelectasis, hypoxia, hypercarbia
  • ARDS
58
Q

physiologic sequalae gastrointestinal

A

increased intra abd pressure causes

  • compression and congestion of mesenteric veins and capillaries
  • reduced cardiac output to the gut

result

  • decreaes gut perfusion incresaed gut edema and leak
  • ischemia, necrosis
  • bacterial translocation
  • development and perpetuation of SIRS
  • further increase in IAP
59
Q

physiologic renal

A

elevated IAP causes

  • compression of renal veins, parenchyma
  • resuced cardiac output to kidneys

result

  • reduced BF to kidney
  • renal congestion and edema
  • dereaed glomerular filtration
  • renal failure, oliguria/anuria
60
Q

physiologic neuro

A

elevated IAP causes

  • increased intrathoracic pressure
  • increases in superior vena cava pressure with reduction in drainage of SVC into the thorax

result:
increaed central venous pressure and IJ pressure
-increased ICP
-decreaed CPF
-cerebral edema, brain anoxia, brain injury

61
Q

APP

A

abdominal perfusion pressure = MAP-IAP

  • reflects actual gut perfusion bettter than IAP alone
  • optimizing APP.60 mm HG should probably be primary endpoint
62
Q

Decompressive laparotmy

A

-delay in abd compression may lead to intestinal ischemia, decompress early

63
Q

bladder pressure monitoring how to?

A

insert catheter to bladder, hook to transducer, read pressures off of the bladder
-make sure transducer is level with the bladder

64
Q

patient meets one of the following criteria and has at least two risk factor for IAH:

A
  • new intensive care until admission
  • evidence of clinical deterioration or new organ failure

risk factors:

  • Diminished abd wall compliance
  • increased intraluminal contents
  • increased abdominal contents
  • capillary leak/fluid resuscitation
65
Q

how you messure

A
  • messure in expiration, pt. laying supine
  • put in 25 ml fluid to measure it against
  • wait 30 seconds and measure it

NUR4630 (34 decks)

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