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232 Cards in this Set
- Front
- Back
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Complications of Constipation
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fecal impaction
fecal incontinence sterocal ulcers Mega colon (half of elderly report constipation) |
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International Workshop on Constipation
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functional constipaiton
- straining 25% of times - pellet like hard stool - feeling of incomplete evacuation - less than 2 BM's per week rectal outlet delay - 25% of times being blocked, with prolonged defecation, or need to manually disimpact |
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Cilincal Definition of Constipation
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difficult defecation
straining prolonged passage pain and feeling of imcomplete evacuation |
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Dietary Causes of Constipation
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Fiber intake decreases in elderly
also accompanied by dehydration |
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Immobilization Causes of Constipation
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sedentary/ bed ridden state
harder to pass stools |
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Medication causes of Constipation
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antacids
anticholinergics antidepressants anti-parkinsons meds calcium supplements diuretics Iron salts NSAIDS opiates |
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Sysstemic causes of Constipation
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metabolic:
- hypothyroidism and hypercalcemia - hypokalemia, and hypomagnesia - Diabetes - Kidney fialure Neuro: - dementia and Parkinson's - Stroke - Depression - Multiple Sclerosis |
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Structural causes of Constipation
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Anal fissure
mucosal prolapse rectocele diverticulosis/diverticulitits colon cancer ischemic colitis strictures IBS |
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Functional Causes of Constipation
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defacatory dysfunction common in women
pudendal nerve damage - years of straining or pregnancies |
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Taking HPI with Constipation Patients
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appetite or weight fluctuations
diet and exercise sleep patterns BM: frequency character straining manual disimpaction fecal urgency stool caliber bleeding/mucoid laxative use |
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Taking PMH and FH with Constipated patient
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hypothyroidism
stroke diabetes MS demetia Parkinsons Depression Vaginal Births |
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ROS with Constipated Patient
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Endocrine - heat/cold intolerance, dry skin or nails, weight change, polyuria/polydipsia
Neuro - unilateral weakness, numbness, tingling Psych - sadness, loss of interest |
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Physical findings in Constipation patient
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look for systemic illness
abdominal - muscle tone, masses, stool filled bowel rectal - digital exam, sphincter tine at rest and with squeezing, anoscopy |
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Lab work and Xray for Constipation patient
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CBC, CCP, and TSH - look for anemia, leukocytosis, hypercalcemia, or elevated BUN
Xray for ileus obstruction, constipation or fecal impaction CT scan and Colonoscopy/Barium enema alt studies - transit studies, defecography, rectal manometry |
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Treatment for Chronic Constipation
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dietary fiber
education fluid intake fiber supplements hyperosmolar laxatives - sorbitol |
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treatment for Chronic-Intermittent constipation
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stimulant laxatives - senna, cascara, biscodyl (avoid castor/mineral oils)
saline laxatives suppositories/enemas stool softeners - used to prevent straining in hospital patients (not much of a laxative) |
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definition of Diarrhea
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abnormally frequent, watery discharge
increased urgency, frequency, and looseness over 200 grams |
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Classifications of Diarrhea
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acute vs chronic
infections vs nonifectious increased osmotic load increased secretions reduced contact time/surface area often more than one mechanism |
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Common causes of acute diarrhea
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viral - norwalk virus, rotavirus
bacterial infections - salmonella, shigella, campylobacter, E coli, C difficile parasites - giardia, entamoeba histolytic, cryptosporida food poisoning - staph, clostridium, perfringens drugs - laxatives caffeine, chemo drugs, colchicine, antibiotcis, quinine, lactose |
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Common causes of chronic diarrhea
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drugs - laxatives, caffeine, chemo, colchicine, quninie, AB's
functional - Irritable bowel sundrome diet - lactose intolerance inflammatory bowl disease - ulcerative colitis, Chron's disease surgery - intestinal/gastric bypass malabsorption - celiace, sprue, whipple's disease, pancreatic insufficiency tumors - colon cancer, lymphoma, villous adenoma of colon endocrine tumors - gastrinoma, thyroid carcinoma endocrine - hyperthyroidism |
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increased osmotic load
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unabsorbable water-soluble solutes stay in lumen and retain water
- from laxatives, lactose intolerance, sorbitol, manitol, high fructose corn syrup |
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Increased Secretions
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bowels secrete more than they absorb
- infections, fat malabsorption, drugs, endocrine tumors |
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Reduced contact time/surface area
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bowel resections
IBS colitis celiac sprue drugs |
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Complications of Diarrhea
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dehydration
electrolyte imbalances vascular colapse acidosis hypokalemia more serious in very young and very old |
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History in diarrhea patients
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determine onset and duration (chronic vs acute)
circumstances of onset: travel, food, antibiotics, diarrhea in close contacts associated symptoms - pain, nausea, vomiting, rectal pain, tenesmus, fever, chills, sweats, weight and appetite changes stool: frequency, timing, blood, mucus, fat, color previous surgeries |
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Physical in diarrhea patients
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bowel sounds, tenderness, masses
rectal exam - sphincter tone, masses, bleeding |
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Red flags in diarrhea patients
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blood, pus, fever, dehydration, chronic, weight loss
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Infectious diarrhea
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acute, watery diarrhea in otherwise healthy person
usually viral |
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Acutte bloody diarrhea
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bacterial infection
diverticular bleeding ischemic colitis |
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Evaluation of acute diarrhea
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does not typically require testing unless patient is:
dehydrated bloody stools fever severe pain in these cases - stabilize patient with fluids - take CBC, BUN, creatinine stool culture |
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Evaluation of chronic diarrhea
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routine labs
test for ova and parasites colonoscopy for tumor test gastin levels, calcitonin, histamine, and serotonin test for thyroid dysfunction |
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Treatment for diarrhea
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fluid and electrolytes
antidiarrheals for non bloody diarrhea |
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Ulcerative Colitis
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inflammatory disease is limited to the mucosa of the Large Intestine
can be mild and limited to distal colon adn rectum - or may involve entire colon pancolitis requires special care and long term management because of increased risk of CANCER |
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Crohn's Disease
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can be in any location within the gastrointestinal tract
typically involves the SI and colon (small bowel enteritis, colitis, or ileocolitis) involves all layers of the GI tract (transmural inflammation) can lead to development of a fistula, obstruction - may require surgical removal |
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Extraintestinal involvement of IBS
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joints
skin eyes liver confirms AI involvement |
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Etiology of IBS
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TNF-alpha involved in cytokine cascade
Infliximab - monoclonal antibody for treatment |
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Need to know Info on Diets/Supplements
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Increasing obesity rate in WV
25% of patients take vitamins increasing numbers of Bariatric surgeries herbal supplements is a multi billion dollar with 20% of population using them herbal users do not follow evidence based medicine |
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Definition of Obestiy
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BMI of 30 or higher
BMI is a ratio of height to weight |
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Dietary Trends
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vegetable fats are becoming more common but overall fat comsumption is up
60% of Americans eat snack foods regularly 20% of calories from snacks 1/2 of young adults skip breakfast 1/4 skip lunch |
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Artificial sweeteners
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increased 3 fold since 1965
also with a 14% increase in sugar use soft drink intake has surpassed milk intake in men and women |
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Quick Meals
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25% of calories are eaten away from home
"homecooked" meals are often processed, and precooked toaster ovens microwaves and other appliances have reduced prep time upswing in interest in eating healthy foods |
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Portion Size
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amount of calories consumed by women increased by 22% in last 30 years
men only increased calories by 7% during same time period serving sizes have become 2-5 times larger obesity rates have doubled 2/3 of americans are now overweight |
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Folic Acid
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Folic acid - water solube, B vitamin, safe, found in grains, legumes and vegetables
Use - pregnancy, high cholesterol, alcohol abuse, sensineural hearing loss, anemia |
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Magnesium
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essential mineral
linked to energy transport and muscle contractility nuts, eggs, vegetables and fruits Uses - cardiac arrythmias, constipation, alcohol abuse, diuretic depletion |
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Omega - 3
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antioxidant, membrane stabilizer
cold water fish, fish oil Uses - hypertriglycerdemia, joint issues, cardiac prevention, arrythmias |
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Herbal Supplements
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widely used and accepted
non-standardized frequently combined in preparations not alot of evidence for effectiveness questionable safety |
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GI Disease
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affects 70 million Americans
50 million physician visits, and 13% of hospitalizations |
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Pathophysiology of Oral Cavity
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dental caries, tooth loss, ill fitting dentures - all cause inadequate intake of nutrients
salivary amylase - degrades Carbs - can be used by bacteria - produce acid waste - demineralize teeth xerostomia |
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Nutritional Considerations
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milk and cheese buffer to prevent increased acidity
xylitol in chewing gum - not metabolized by bacteria black tea - possibly reducing dental caries |
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Inflammatory Conditions of Oral Cavity
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poor dental hygiene
lack of dental care Vitamin deficiency - riboflavin, niacin, pyridoxine chemo and radation |
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Nutrition Therapy
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soft, moist foods - blenderized
add milk, milk power, or fatty liquids |
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Mouth Rinsing
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remove food particles
prevent bad taste alcohol - free, baking soda in warm water |
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Nutritional Intervention for Mouth Surgeries
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blenderized dieats
baby food add milk/butter to increase kCals and protein |
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National Dysphagia Diet 1
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Pureed
pudding like consistency, no lumps no gelatin, fruited yogurt, PB, cottage cheese, eggs |
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National Dysphagia Diet 2
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mechanicaly altered
soft and moist textured foods ground or finely diced meats, vegetables, cerals no bread, cake, rice, cheese, corn or peeas |
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National Dysphagia Diet 3
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regular foods, minus very hard sticky or crunch items
no hard fruit or vegetables, nuts or seeds |
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Foods that decrease LES pressure
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high fat
chocolate spearmint/peppermint alcohol caffine |
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Nutritional interventions for GERD
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foods that lower LES pressure
reduce acidity - stay away from spicey food, caffine, alcohol smaller more frequent meals remain upright after eating weight loss in obese patients |
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Nutrion, Nausea and vomiting
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results in inadequate nutrient intake, dehydration, and acid-base imbalances
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Nutritional intervention for Nausea and Vomiting
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cold foods best tolerated
small frequent low fat meals sip on ginger ale, tea, flat coke dry starchy or salty foods |
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Peptic Ulcer Disease Nutritional intervention
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restrict acid stimulation foods
peppers caffeine coffee alcohol stay away from milk and cheese - increases gastrin do not lie down after eating small meals MAY increase acid |
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Nutritional Implications
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reduced stomach capacity
change in gastric emptying and transit time possible intrinsic factor loss |
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Interventions for Dumping Syndrome
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small meals through out the day - less dramatic fluid shifts
high protein, moderate fat foods recommended avoid simple sugars - substutute complex carbohydrates fibrous foods slow transit, increase viscosity lying down an hour after eating may slow gastric emptying avoid liquids with meals avoid lactose evalute b12 |
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Gastric bypass
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people lose 60% of their weight
their DM, CAD, dyspilidemia, GERD, sleep apnea, HTN and OA first 3 months - unable to tolerate solid foods increased risk of obstruction clear liquids -> soft diet -> solid foods fluid intake is a problem (not enough) |
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Nutrition Intervention
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clear liquids - simple sugars
continue breastfeeding infants 1/2 strength formula pectins to thicken stool diet low in fiber no prune juice foods with prebiotics or probiotics |
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Nutritional Intervention for Constipation
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25-35 grams a day of fiber
adequate fluid |
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Nutritional Intervention for Malabsorption
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FAT: medium chain fatty acids - caprylic and capri acids
best incorporated into foods or recepies CARB: lactose - body can't use it, so bacteria do -> cramping diarrhea, gas |
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Nutritional Intervention for Celiac Disease
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omit wheat, rye, barley, malt, and oats
use, corn, potato, rice, soybean ect. common filler in OTC meds and toothpaste, be aware |
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Nutritional Intervention for Irritable Bowel Syndrome
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history of erratic eating - symptoms associated with stress and anxiety
establish regular pattern, food diaries adequate fiber and water prebiotics and probiotics avoid food that makes you gassey |
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Nutritional Intervention for Inflammatory Bowel Disease
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lactose free dieat
small meals reduce fat in cases with steatorrhea - add a MCFA add fiber and lactose in doses restrict gas producing foods, spicey foods, soda, Watch for B12 and Iron deficiencies |
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Nutritional Intervention for Diverticular Disease
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high fiber
avoid nuts, seed, hulls, popcorn bowel rest - clear liquids, low residue gradually increase fiber intake |
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Nutritional Intervention for Short Bowel Patients
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phase 1 - first 10 days - only parenteral
phase 2 - months - induce eating, include glutamine, nucleotides and SCFA for gut health phase 3 - more towards normal diet |
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Nutritional Intervention for hepatic steatosis
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well balanced diet
get patient to lose weight if necessary |
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Nutritional Intervention for Hepatitis
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improve nutritional status
enhance regeneration - high calorie, high protien, lots of fluids |
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Nutritional Intervention for Cirrhosis
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high calorie
high protein - dairy and vegetable sodium and water restriction |
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Nutritional Intervention for Hepatic Encephalopathy
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BCAA
sodium |
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Classic Acute Cholecystitis Clinical Presentation
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RUQ pain
fever leukocytosis gallstones blocking the cystic duct |
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Classic Acalculous Cholecystitis Clinical Presentation
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Sick ICU patient with RUQ pain
high mortality and morbidity |
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Classic Chronic Cholecystitis Presentation
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fibrosed thickened gallbladder
usually only diagnosed on autopsy |
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Pathogenesis of Cholecystitis
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inflammation
- lecithin -> lysolecithin by PLA2 - Lysolecithin is a mucosal irritant - stimulates inflammation PGE2 and 6K-PGF1 - involved in increased pressure in gallbladder and inflamation E coli, enterococcus, Klebsiella, and Enterobacter involved |
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Histology of Cholecystitis
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Edema
Inflammation Necrosis Gangrene Mucocele - white gallbladder |
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Symtoms/History of Patient with Cholecystitis
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RUQ or Epigastric pain
radiates to shoulder or back (confused with MI or AA) steady and severe pain N/V, anorexia look for questions with patients eating very fatty meals Biliary Colic |
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Biliary Colic
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GB contraction - presses against stone blocking outlet
crescendo pain that resolves after digestion less than 4 hrs of pain |
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Physical Exam of Patient with Cholecystitis
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ill appearing, febrile, tachycardic
voluntary/involuntary guarding Positive Murphy sign usually lie as still as possible due to peritoneal/parietal inflammation ELDERLY are typically ATYPICAL - be aware |
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Labs for Cholecystitis
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CBC
- leukocytosis, increased band forms, "left shift" - Alk Phos and Bilirubin are normally normal (can be increased though) - LFT's are increased transiently when stone or blockage is passed |
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Diagnostics for Cholecystitis
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ULTRA-SOUND
- may or may not have gallstones - but doesnt mean patient has Cholecystitis (can be assymptomatic cholelithiasis) - stones, with fever, RUQ, and Murphys sign AC is likely - also look for wall thickening |
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Cholescintigraphy or HIDA scan
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done if diagnostics are uncertain
HIDA is injected - if cystic block is open, gallbladder will be seen |
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Treatment for Cholecystitis
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hospital admission
IV hydration - correct electrolytes Ketorlac or Butorphanol Nothing by mouth NG tube Maybe AB's Cholecystectomy - Laproscopic removes need to cut rectus abdominus - Percutaneous, drain through skin, and flush with saline |
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Complications of Cholecystitis
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Gangrene - elderly, DM, delayed treatment
Perforation - cause peritonitits Cholecytoenteric Fistula - Gall stone ileus Emphysematous Cholecystitis - secondary inflammation C. welchii, E coli, staph, Strep, Pseudomonas - DM patients - Crepitus in Ab. wall |
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Cholangitis
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clinically - pain, fever, and jaundice
be aware of hypotension and confusion stasis and infection of the biliary tract - Charcot's triad |
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Pathogenesis of Cholangitis
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ascending from duodenum
rarely hematogenous spread - stasis usually do to biliary calculi or a benign stricture - pressue in GB promotes bacterial migration and defense mechs are altered Always thick recent procedures - Iatrogenic causes |
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Sphincter of Oddi and Cholangitis
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normally an effective mechanical barrier to ascending bacteria
bile flushes - bacteriostatic - maintains some degree of sterility IgA and mucus prevents bacterial adhesion and colonization bacteria use stones or stents to help colonize |
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Bacteriology
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E coli - common
Klebsiella Enterobacter Enterococcus Anerobes - bacteroides, clostridia |
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Diagnostics for Cholangitis
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Leukocytosis
LFT's are elevated - Alk phos, GGT, and conjugated billirubin Amylase can be elevated - due to associated pancreatitis ALT AST are high - seen with microabscesses draw blood for culture ERCP - take bile culture |
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Procedures for Cholangitis
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ULTRASOUND
and ERCP for confirmation - also fix sphincter with stone removal or stent placement |
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Treatment for Cholangitis
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AB's
establish bile drainage IV fluids close observation for Sepsis/shock |
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Antibiotics for Cholangitis
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Ampicillin-sulbactam
pipericillin-tazpbactam metrondiazole-ceftriaxone metrondiazole-cipro/levofloxacin imipinem |
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Biliary Drainage for Cholangitis
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if cholangitis fails to calm down over 24 hrs
and there is persistent pain, hypotension, fever, and mental confusion ERCP |
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DDx for diffuse, posterior-maxillary pain, w/o temp. sensitivity
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Sinusitis
Otitis Media TMJ Dental Decay Periodontal Disease |
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Acute Sinusitis (DDx for mandibular pain)
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facial pain or pressure, unilateral
nasal congestion post-nasal drip fever cough dental pain ear fullness |
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Otitis Media (DDx for Mandibular pain)
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URI symptoms
ear ache decreased hearing fever tooth pain |
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TMJ (DDx for Mandibular pain)
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chronic pain in the muscle of mastication
dull ache, unilateral jaw locking when mouth is opening Head aches/Jaw aches neck shoulder back pain teeth clenching MPD syndrome - increased muscle spasm - manifestation of psychological stress ID - articulating disease |
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Dental caries (DDx for Mandibular pain)
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loss of mineral and cavitation of tooth surdace
diet mediated, bacterial, infectious, transmissible oral disease Strep Mutans - major causative organism - virulence is changeable due to nutrient sources - acid production affected by fluoride - also affected by chlorhexidine, xylitol, nd MI paste |
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Pulpitis
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from untreated tooth decay or from a repair process
Reversible - mild inflammation of the tooth and pulp caused by caries Hot/Cold sensitivity but resolves within seconds of stimuli removal Irreversible - severe, spontaneous pain, persistent, poorly localized TX with root canal |
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Periapical Abscesses
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localized purulent apical periodotitis - w/p draining fistula - with regional lymphadenopathy
severe pain, spontaneous and persistent treat with Root Canal or Extraction - Pen VK (anti strep) - Cephalosporins or clindamycin on penicillin allergy |
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Cellulitis from Periodontal Abscesses
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diffuse soft tissue bacterial infection - lymphadenopathy - fever
can have life threatening consequences Ludwigs angina or cavernous sinus thrombosis requires immediate treatment, and IV Rocephin and oral AB's that include anerobe coverage |
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Periodontal Disease
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Chronic infection by gram negative anerobic bacteria - cause inflammation and destruction
(actinobacillus, actinomycetemcomitans, porphyromas, gingivalis, tannerella, forsythia, treponema) |
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Periodontal abscesses
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gram negatice anaerobes
throbbing pain with erythema, swellling and tooth mobility can progress to celluliis |
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Warning Signs for Periodontal Disease
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gums that bleed easily, tender, or swollen
receding gum lines puss between the gums halitosis loose teeth different bite |
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AB therapy for Periodontal Abscesses
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Doxycyline
augmentin in tetracycline allergy also can use amoxicillin and metrondiazole chlorhexidine to swish around after brushing |
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Periodontal Disease and DM
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DM patients have higher risk for periodontal disease, and more severe disease
increased tooth loss, proportional to DM BS control Chronic Periodontal disease can disrupt glycemic control inflamation contributes to cytokines that induce insulin resistance |
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Periodontal Disease and CV Disease
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cause thickened carotid arteries - indicator of stroke or MI
porphyroma gingivalis - attachement via fimbria - invade epithelial cells of Aorta - releases cytokines that promote clogging plaques - decreases PAF and enhances PAI |
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Periodontal Disease and Obesity
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obesity is a predictor of periodontal disease
might be mediated by insulin resistance |
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Periodontal Disease and Pregnancy
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treatment is not hazardous to women or their pregnancies
however no connection between treatment and reduced risk of preclamsia, pre term birth, ect. |
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Periodontal Disease and Cancer
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small but significant increase in overall cancer risk, even in non smokers
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DDx for painful lesion inside lower lip
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Herpes
Varicella Coxsackievirus Syphillis cryptosporidium, mucomycosis, histoplasma AI - Bechet's, Reiter's, IBD, SLE cyclic neutropenia Neoplasm - SCC |
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Apthous Ulcers (DDx for lip lesions)
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no fever
no lymphadenopathy no GI symptoms no skin or mucus membrane problems single or multople mucosa is non-keratinized and loosely attached Tx - Kenalog, Apthosol, dexamethason elixer miracle mouthwash - maalox, benedryl, lidocaine - swish and spit |
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DDx for non healing ulcer on lateral tongue
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White Nevus
Lichen planus SCC Candidiasis Traumatic Ulceration |
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White Nevus (DDx for non healing ulcer)
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lesions present since childhood
family history white folded plaques that can be pulled away |
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Squamous Cell Cacrinoma (DDx for non healing ulcer)
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males over 30
most common on tongue, outside of lip (#1) red, non healing ulcer - rolled borders |
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Candidiasis (DDx for non healing ulcer)
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immunocomprimised or infants
prengant femailes or debilitated patients also seen in people taking broad spectrum AB's white elevated plaque - it can be wiped off can develop into a chronic infection |
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Oral Lichen Planus (DDx for non healing ulcer)
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immune mediated disease
symmetrical bilateral confluent white plaque - mistaken for leukoplakia asspciated with AB's, antihypertensives, diuretics, |
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Heme Catabolism
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RBC's -> hemoglobin -> Heme -> unconjugated bilirubin -> to LIVER -> Conjugated -> excreted in urine (urobillogen) and in feces (Stercobillin)
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Causes of Increased Production of Biliruin (leads to jaundice)
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Hemolysis
Dyserythropoesis extravasation of blood into tissue |
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Causes of Impaired uptake (leads to jaundice)
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heart failure
sepsis drugs fasting portosystemic shunts |
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Causes of Impaired Conjugation (leads to jaundice)
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Congenital:
Gilbert Syndrome Crigler-Najjar Acquired: Neonatal Hyperthyroidism Ethinyl estradiol Liver Disease Sepsis |
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Most common causes of unconjugated hyperbilirubinemia
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Gilbert's
Hemolysis Heart Failure Sepsis |
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Conjugated hyperbilirubinemia with NORMAL LFT's
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systemic infection - hemolysis
Rotor syndrome Dubin-Johnson syndrome |
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Conjugated hyperbilirubinemia with Alk. Phos elevation
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biliary obstruction
intrahepatic cholestasis - viral/alcoholic hepatitis - Cirrhosis - Drugs and toxins |
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Conjugated hyperbilirubinemia with AST/ALT elevation
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viral hepatitis
alcoholic hepatitis cirrhosis drugs and toxins Hemochromotosis Wilson's disease A1AT deficiency |
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A patient has Alcoholic Hepatitis, what are the likely findings (positive and negative)
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Fever, Malaise, jaundice, and tender, enlarged liver
CT: shows enlarged nodular liver, ascites, normal pancreas Liver: steatosis -> steatohepatitis -> and cirrhosis Labs: negative Ab's and Ag's for Hep. A,B, and C low grade AST/ALT elevation AST/ALT ratio greater than 2 |
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treatment for Alcoholic Hepatitis
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Treat with Prednisolone
and Alcohol abstinence |
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What can you not miss when making a diagnosis of alcoholic hepatitis in a patient with jaundice and increase LFT's?
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biliary Obstruction due to Pancreatic Carcinoma
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Patient presents with Acute Hepatitis A, what are the likely findings (negative and positive)
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fatigue, achy RUQ pain, nausea, fever, chills, night sweats (all prior to jaundice), dark urine, palpable and tender liver
Labs: normal CBC AST/ALT generally greater than 1000 Bilirubin greater than 10 Alk Phos mildly elevated Serum IgM against Hep A elevated |
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In making the diagnosis of Hepatitis A, what other conditions must you not miss?
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Hepatitis B - high perinatal transmission, sexually transmitted
can be a chronic infection vaccine available see surgace antigen -> surgace antibody -> core antibody Hepatitis C - through blood contact, transfusion, tatoo, transplant acute infections often assymptomatic chronic infections may lead to cirrhosis and slight increase in carcinoma Test with anti-HCV and RIBA for confirmation |
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NAFLD
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most common cause of abnormal transaminases in US
risk factors: obesity diabetes, hypertriglyceridemia can develop to cirrhosis CT or Liver biopsy must exclude other to diagnose, stop offending medication or alcohol and recheck DDx; with Viral hepatitis and Hemochromatosis and AI hepatitis treat with weight loss and Vitamin E |
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Hereditary Chromotosis
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AR - more common with whites
excess iron absorption cirrhosis cardiomyopathy hypogonadism arthropathy diabetes hypothyroidism transferrin sat. > 45% Ferritin increased Liver Biopsy treat with phlebotomy |
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Risk Factors for Colorectal Cancer
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positive family history
smoking obesity/diabetes red meat/curred meat products IBD HIV disease |
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Symptoms for Colorectal Cancer
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tumors are asymptomatic in early stages
first sign is usually bleeding abdominal pain of fullness bowel character changes or bladder habbits weight loss is typically a late sign can cause bowel obstruction and metastasize to liver |
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Physical exam findings in Colorectal Cancer
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Physical exam is often normal
rectal exam may be positive for occult/trace blood abdomen can have masses and tenderness large liver, with nodular edge might indicate hepatic metastases |
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Labs in Colorectal Cancer
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often normal
anemia is common in advanced disease CEA may be useful in predicting recurrance but not useful for screening Abnormal LFT's may show up with hepatic metastases |
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Imaging Colorectal Cancer
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colonoscopy is test of choice
CT scan may pick up masses when people come into ER for abdominal pain CT will pick up liver mets if present |
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Treatment for Colorectal cancer
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Stage 1 and 2 - surgical resection
Stage 3 - surgery and chemo Stage 4 - candidates liver removal or surgery |
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Screening for Colorectal Cancer
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everyone should receive screening at age 50 - colonoscopy or FOBT and sigmoidoscopy every 5
high risk patients should be screened earlier and in shorter intervals |
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Small bowel tumors
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uncommon
adenocarcinomas mostly also can be carcinoid, lymphoma, GIST, harmatomas abdominal pain, bleeding and weight losss usually diagnosed late |
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Carcinoid tumors
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30% of small bowel tumors
can cause flushing and diarrhea due to serotonin release |
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Testing for Small Bowel Tumors
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carcinoid tumors - test urine for serotonin metabolites
negative upper and lower scopes and patient with bleeding 0 use capsule enteroscopy CT can pick up small bowel tumors |
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Presentation of Pacreatic Adenocarcinoma
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tumors in tail or body with present with pain
weight loss is usually present tumors of the pancreatic head are more likely to produce jaundice and steatorrhea unremarkable physical exam - jaundice and epigastric tenderness may be present |
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Associated Diseases with Pancreatic Adenocarcinoma
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Depression is an early symptom
VTE also present more common in patients with new onset diabetes (in thin patients) |
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Diagnosis of Pancreatic Adenocarcinoma
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Abdominal CT scan/US will demonstrate pancreatic mass or dilation of biliary ducts - indicates obstruction
might also show liver mets/elevated bilirubin masses can be resected surgically ERCP - involves cannulated the sphincter or Oddi and obtain samples via biopsy - may cause pancreatitis - MCRP also available |
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Treatment for Pancreatic Adenocarcinoma
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surgical resection is the only real hope
chemotherapy success is low, but still given in suitable patients |
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Livery Malignancy
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almost always metastatic tumors
primary tumors not common can have cholangiocarcinomas from intrahepatic biliary ducts |
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Liver Metastases
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mostly stage 4 cancer which is unresectable, usually
often discovered incidentally on a scan ordered because of abdominal complaints patients may have weight loss, nodular liver edge or be completely assymptmatic |
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Diagnosis of Liver Metasstases
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tissue diagnosis is needed, so do CT guided biopsy
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Cholangiocarcinoma
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uncommon
poor prognosis - similar to pancreatic adenocarcinoma causes dilation of the hepatic ducts use ERCP to diagnose |
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Hepatocellular Carcinoma
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more frequent in Asia and SS Africa
clear association with chronic viral hepatitis alcohol increases risk |
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Symptoms of Hepatocellular Carcinoma
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most patients have chronic liver disease/cirrhosis
some patients may have worsening ascites and jaundice |
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Physical Exam of Patient with Hepatocellular Carcinoma
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patients will develop chronic liver disease - ascites, muscle wasting, and spider angiomata
Liver may be enlarged Jaundice present |
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Diagnosis of Hepatocellular Carcinoma
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ultrasound is easy and safe
CT or MRI can be more accurate high AFP biopsy lesions |
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Treatment of Hepatocellular Carcinoma
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Resection of tumor is ideal
liver transplant is option for sever liver dysfunction embolization or ablation therapy for unresectable tumors chemotherapy not tolerated screen patients for Hep B, C, AFP |
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Differential Diagnosis of LLQ pain
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mesenteric thrombosis
epiploic infarction Kidney stone ovarian cyst salpingitis ectopic pregnancy strangulated hernia sciatic neuritis intestinal polyp intestinal obstruction regional ileitis Ulcerative colitis Crohn's disease diverticular disease Colorectal carcinoma |
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Differential Diagnosis for RUQ paim
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gallstone ileus
regional ileitis intussception appendicitis Meckel Divericulum messenteric thrombosis renal calculus sciatic neuritis salpingitis strangulated hernia iliac embolism |
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Differential Diagnosis for Epigastric pain
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cholecystitis
cholelithiasis duodenal ulcers carcinoma of the colon omental infarction omental hernia gastritis gastric ulcer carcinoma of the stomach hepatitis esophagitis |
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Pathogenesis of Proximal Bowel Obstruction
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swallowed air and gas accumulates - adding to dilation
emesis can smell feculent bowel becomes edematous - absorptive function is lost so fluid builds up - gut still secretes - loss of fluid in peritoneal cavity blood flow becomes comprimised - leads to necrosis - bowel can become perforated |
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Clinical Presentation of Patient with Proximal Bowel Obstruction
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dehydration and electrolyte abnormalities - from vomiting
decreased urine output tachycardic and hypotensive BUN and Creatinine levels increase |
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Electrolyte Abnormalities with Bowel Obstruction
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vomiting causes hypokalemia, hyponatremia
"alkali tide" - increase in blood pH - clinical picture is similar to pyloric stenosis - |
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History of Patient with Small Bowel Obstruction
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nausea, vomiting, abdominal distension
crampy pain - periumbilical - progresses to constant pain cannot pass gas history of abdominal surgery Crohn's Disease |
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Physical Exam with Small Bowel Obstruction
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abdominal surgical scars
guarding and tenderness high pitched bowel sounds hernias |
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Diagnostics for Small Bowel Obstruction
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CBC - shows leukocytosis
BUN, creatinine Na/K levels Lactate - buildup from ischemic bowel upright chest film - rule out free air from perforation abdominal film supine and upright CT with barium or water soluble contrast - look for bowel caliber discrepancy |
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Most Common causes of SBO
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Postoperative adhesions
malignant tumors hernias intussceptions, volvulus, Crohnns disease, Gallstones |
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Hernias
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indirect - internal inguinal ring - go into scrotum
direct - through Hesselbach's triangle femoral |
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Management of SBO's
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correct fluids and electrolytes
decide on need for surgery NG tube if necessary |
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Diverticulosis
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small mucosal hernoations through the intestinal wall
occur where blood vessels penetrate gut wall related to high intraluminal pressures RF: low fiber, constipation, and obesity |
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Diverticulitis
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inflammation of diverticuli - caused by blockage of opening to diverticuli
microabscesses form |
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Differential Diagnosis of LLQ pain
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colonic obstruction
volvulus constipation gastroenteritis IBD Irritable bowel syndrome bowel infarction nephrolithiasis ovarian cyst pelvic inflammatory disease ectopic pregnancy |
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Patient with Diverticulosis/Diverticulitis
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eldery LLQ pain
crampy and constant worse with movement - better lying still feverish, sweaty, fatigued loose bowels - no blood or nausea no sick contacts - shellfish no previous history no medications no alcohol or tobacco no previous surgeries |
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Physical Exam of Patinet with Diverticulosis/Diverticulitis
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slight increase in temperature, pulse
soft bowels, normal sounds pain in LLQ + guarding heme negative stool |
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What test is contrainidcated in Diverticulitis?
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Barium enema and colonoscopy are contraindicated due to increased risk for colon perforation
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Labs and Xray for diverticulitis
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CBC with differential - show left shift leukocytosis
chem profile is normal pancreatic enzymes normal urinalysis is normal can do Xray and CT - shows bowel wall thickening |
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Diverticulosis/Diverticulitits Facts
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2-4% of people under 40 have diverticulosis
1/3 over 50 have diverticulosis 2/3 over 85 have diverticulosis 1/4 of diverticulosis with get diverticulitis usually sigmoid and decending colon |
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Management of Diverticulitis
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outpatient management
-clear liquids -AB's to cover E coli, Klebsiella, Proteus, Strep, Enterobacter, B. Fragalis, Peptostreptococcus, clostridium -tell patients to return of condition does not improve inpatient unable to take PO, are immunocomprimised, fever, peritonitits or abscesses |
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Surgical complications of Diverticulitis
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large abscesses should be drained
perforation obstruction recurrent attacks fistulas |
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Summary of Diverticulosis/Diverticulitis
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Diverticulosis is common in people over 50
Diverticulitis occurs in about 1/4 of these patients sometimes can be managed as outpatient sometimes requires surgery consider colon cancer and IBD in differential |
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Irritable Bowel Syndrome
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GI problems without organic cause
10% of population - more common in women diffuse or localized pain - often vague, episodic and worse during stress |
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Symptoms of IBS
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Diarrhea is most common - usually with cramps
constipation can also occur, alternating with diarrhea bloating and flatulence is comon diarrhea most common right after eating |
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Associated Symptoms with IBS
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dyspepsia and heartburn
often have symptpms of depression and anxiety non specific musculoskeletal pain |
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Manning Criteria for IBS
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Tenesmus
more frequent stooks at the onset of pain looser stools at onset of pain abdominal distension passage of mucus sensation of incomplete evacuation |
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Rome Criteria for IBS
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Improvement with bowel movement
change in stook frequency change is stool appearance |
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Red Flags for IBS (factors pointing away from IBS)
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Bloody diarrhea
weight loss symptoms at night fever severe diarrhea |
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Physical Exam for IBS
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usually normal
mild abdominal distension sometimes sensitive to abdominal palpation |
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Diagnosis of IBS
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IBS is primarily a clinical diagnosis
patients with criteria and no red flags -> no serious workup patients with criteria but red flags -> should have stool study, endoscopy and colonoscopy |
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Pathogenesis of IBS
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increased sensitivity of gut receptors
increase response to stress hormones possible alteration of gut flora carbohydrate malabsorption |
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Post Infectious IBS
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typically occurs after a sever gastroenteritis
may be temporary or permanent microscopic mucosal inflammation present |
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Treatment for IBS
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individualized therapy
antidepressants antispasmidics serotonergic agents - to alter motility dietary changes |
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Summary of IBS
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waxing and waning course
depression is very common |
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Peptic Ulcer Disease
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erosions in the gastric or duodenal lining - through the muscularis mucosae
most are related to NSAIDS or H. Pylori mucosal injury extends itself in the presence of acid and pepsin |
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Helicobacter Pylori and PUD
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gram negative microaerophillic rod
produces urease adheres to gastric mucosal cells clear association with PUD and gastritis |
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NSAIDs and PUD
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taken chronically to treat arthritis
it impairs gastric prostaglandins - which inhibits bicarb and mucus |
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Acid Hypersecretion and PUD
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most patients with PUD dont have acid hypersecretion as a cause
many with H. Pylori induced PUD's do have an increased acid level increased gastrin secretion and inhibition of somatostatin may be involved |
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Zollinger Ellison syndrome
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uncommon
gastrinoma can be sporadic or apart of MEN syndrome gastrin is really high secretin stimulation test can metastasize |
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Other Risk Factors for PUD
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Bisphophonates
steroids cigarette smoking stress clopidogrel sirolimus SPICY FOODS NOT A RISK |
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Dyspepsia
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50% of cases related to IBS
related to GERD, PUD, and medicines |
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Testing for PUD
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Red Flag symptoms - weight loss, nocturnal symptpms, advanced age, blood in vomit, stool necessitate
testing not always necessary - can just give treatment |
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H. Pylori Testing
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test any patients with prior ulcers
test in areas of high prevalence serology is easy - but results may remain positibe for months stool antigen is sensitive and specific urea breath test endoscopy |
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endoscopy
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invasive but results are definitive - ulcer, gastritis, bleeding, malignancy can be identified
do on patient who are at high risk |
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H. pylori Treatment
|
Don't test if you are not going to treat
treat with PPI + amoxicillin + clarithromycin use metronidazole - used in PCN allergic patients treatment failure may occr in 20% reinfection may occur in endemic areas |
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NSAID Prophylaxis
|
prophylaxis with PPI in patients over 60, prior ulcer, who use steroids or warfarin
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Surgery and PUD
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not really done anymore
will be used in patients with perforation or life threatening bleed |
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Chronic PPI use
|
increased risk of osteoporosis
older studies suggested increased risk of gastric CA will change intestinal flora try to wean patients off unless they have GERD |
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Stress Ulcers
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Common in ICU patients
lack or oral intake leads to bile salt reflux and loss of gastric mucous layer uremia contributes to loos of gastric mucus layer associated wtih steroid use prophylaxis with acid suppressants recommended if patient is on mechanical ventilation oral feeding is recommended acid suppressants may allow bacterial growth in the proximal intestin |
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Upper GI Bleed
|
PUD is common and can be life threatening - ulceration of gastroduodenal artery
recognize the unstable patient DDx is AVM, portal hypertension give PPI and octreotide |
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Complications of PUD
|
gastric malignancy is rare, but can occur
may cause gastric outlet obstruction previous gastric surgery leads to increase risk of adhesions and other complications |
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Physiology of Intestinal Ischemia
|
collaterala provide circulatory redundancy
blood flow varies depending on need can compensate up to 70% vessel stenoses |
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Acute Gut Ischemia
|
rapid onset of abdominal pain
SMA arterial occlusion is most common - embolization of clot from left atrium (A fib) N/V and anorexia are common little finding on physcial exam - but patient in extreme pain patient may become ill with lactic acid buildup in bowel |
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Mesenteric Thrombosis
|
diffuse atherosclerosis
patients are typically elderly and have CAD and PAD smoking is a common risk factor |
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Non-Occlusive Disease
|
intestinal angina - from atherosclerosis
experience "food fear" and lose weight may be brought on by medications which decrease blood flow can lead to infarction |
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Venous Occlusion
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less common
hypercoagulability is a BIG risk factor (not a big deal in arterial occlusions) see with thrombosis of portal vein, trauma, and PNH treat with anticoagulants |
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Physical exam in Bowel Ischemia
|
look for SIRS and instability
look for acidosis and risk factors leads to abdominal distension, foul burping and feces |
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Imaging in Bowel Ischemia
|
plain films may be normal
can seem bowel wall edema and ileus if infarction happened CT of abdomen shows changes of ischemia or venous congestion angiography is diagnostic |
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Treatment for Bowel Ischemia
|
surgical resection in infarction
thrombosis can be treated with stenting or catheter restore volume and avoid vasoconstrictors can do arterial bypass with ischemia |
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IMA Ischemia
|
Do to hypoperfusion from atherosclerotic vascular disease
embolism is unlikely due to small caliber presents with large volume rectal bleeding with cramping DDx with colonic AVM and diverticular bleed - management is similar |
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Management of Treatment of IMA Ischemia
|
restore circulating volume - blood transfusion if necessary
colonoscopy is diagnostic - mucosa will be swollen may complicate aortic surgery may complicate acute MI some patients my have shock |
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Celiac Occlusion
|
Embolization is uncommon
thrombosis can occur in patients with atherosclerotic vascular disease celiac occlusion by compression by the arcuate ligament angiography is diagnostic |
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Vasculitis
|
common in small bowel
polyarteritis nodosa has higher incidence of GI involvment |
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Upper Abdominal Pain
|
check amylase, lipase, LFT's
consider hepatitis, pancreatitis, pneumonia, cholelithiasis |
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Lower Abdominal Pain
|
Check urine, pregnancy, CBC, Ultrasound
appendicitis, constipation, mesenteric adenitis UTI, ectopic pregnancy, pneumonia, obstruction, kidney stone |
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Diffuse periumbilical Pain
|
consider gastrienteritis
constipation mesenteric adenitis pneumonia appendicitis food poisoning |
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Referred Pain
|
do urinalysis, ultrasound
pyelonephritis constipation pancretitis splenic trauma |
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Appendicitis Presentation and Differential
|
periumbilical pain -> to RLQ
no recent bowel movements decreased right side bowel sounds, RLQ tenderness, dull, no radiation, worse with coughing flexed lower extremities DDx: gastroenteritis, constipation, pneumonia, UTI, Pacnreatitis |
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Treatment for Appendicitis
|
correct fluids and electrolytes
remove appendix broad spectrum AB's if perforated analgesia |
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Henoch Shonlein Purpura
|
low temp. joints pains, rash on back of legs
soft abdomen, active BS, diffuse mild tenderness no guarding no cyanosis, macules on back that blanch with pressure IgA mediated Vasculitis follows viral illness causes increased platelets, IgA and IgM supportive treatment, support renal function, watch for intussusception, give steroids |
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Intussusception
|
bloddy stool and mucus
attacks of back pain tenesmus and diarrhea and URI abdomend distended on deep palpation, sausage shaped mass in RUQ - no HSM Leukocytosis associtaed with Meckel's diverticulum air contrast enema and Xray is test of choice |
