Clinical Nutrition; Acute Gi Sx Probs; Gi Bleeding

Front 1

What are the 3 salivary glands?

Back 1

Parotid, Sublingual, Submaxillary

Front 2

What enzymes does salivary fluid contain that starts digestion?

Back 2

α amylase; lingual lipase

Front 3

Approx. how long is esophagus?

Back 3

~25 cm

Front 4

How much salivary fluid is secreted/day?

Back 4

~1.5L

Front 5

How much gastric juice is secreted/day?

Back 5

up to 3 L

Front 6

Adult capacity of stomach

Back 6

~1.5 L (can distend to accomodate)

Front 7

Where does the mixing/grinding occur in stomach?

Back 7

Antrum where there are powerful contractions to force food against a closed pylorus

Front 8

Which macronutritient takes longest to empty from stomach?

Back 8

Fat

Front 9

What are the functions of the duodenum? (2 major)

Back 9

1) Secretion: bicarb from pancreas and Brunner's glands to neutralize; Proteases, lipases, amylases from pancreas to digest; Bile acids from biliary tract for fat

2) Absorption: Iron

Front 10

Where is Iron digested?

Back 10

Duodenum

Front 11

In what state is iron digested?

Back 11

Ferrous (Fe2+) state

Front 12

What is the amount of pancreatic juice secreted/day?

Back 12

1.5 - 2 L

Front 13

The (jejunum, ileum) has fastest transit time. What are implications?

Back 13

Jejunum. (ileal brake) Implications are that the ileum compensates more when there is surgical resection because it is slower. better to lose jejunum instead of ileum.

Front 14

The (jejunum, ileum) compensates better after resection.

Back 14

Ileum. Loss of jejunum will cause the ileum to compensate, though this takes some time.

Front 15

Where is B12 absorbed

Back 15

Ileum

Front 16

Where are bile salts reabsorbed?

Back 16

ileum

Front 17

The (crypt, villus) is at the top of the small intestinal lumen while the (crypt, villus) is at the bottom.

Back 17

Villus; crypt

Front 18

The (crypt, villus) is more specialized for net absorption while the (crypt, villus) is more specialized for secretion.

Back 18

Villus; Crypt

Front 19

What does the colon excrete?

Back 19

potassium, bicarb

Front 20

What does the colon absorb?

Back 20

Short chain fatty acids

Water

Sodium

Front 21

What does the terminal ileum absorb?

Back 21

B12 and bile salts

Front 22

What is intestinal failure?

Back 22

condition where patient can't absorb enough fluids and electrolytes to keep hydrated and cannot absorb enough nutrients to maintain a normal level of nutrition.

Front 23

Third spacing: defn

Back 23

Rapid internal shifts of fluid; space in the body where fluid does not normally collect in larger amounts

Front 24

What are urinary losses/day

Back 24

.8 - 1.5 L

Front 25

What are GI losses of water in stool/day?

Back 25

.1 - .2 L

Front 26

What are insensible losses of water/day (skin, lungs?)

Back 26

~1 L/day

Front 27

What will happen initially and over time with loss of the jejunum?

Back 27

Initially, there will be compromised nutrient absorption. (Crypts are deeper and villi taller in the jejunum).

Eventually, the ileum will adapt.

HOWEVER, at least 100 cm of jejunum must remain to maintain positive water and electrolyte balance.

Front 28

at least ___ cm of jejunum must remain to maintain positive water and electrolyte balance.

Back 28

100

Front 29

Loss of Ileocecal Valve: What happens?

Back 29

1) Transit from ileum to colon is too fast.

2) There is bacterial overgrowth.

Front 30

Anthropometric Measurements of nutrition status: how to measure body fat?

Back 30

Triceps Skin Fold – Fat Stores

Front 31

Anthropometric Measurements of nutrition status: how to measure muscle mass?

Back 31

Mid Arm Muscle Circumference – Protein stores

Front 32

Two main functions of Albumin

Back 32

1) Allows drug-binding for plasma transport

2) Provides 70% of blood's oncotic pressure.

Front 33

Marasmus: defn

Back 33

Starvation due to inadequate caloric intake.

Bradycardia, hypotension, and hypothermia
Thin, dry skin
Redundant skin folds caused by loss of subcutaneous fat
Thin, sparse hair that is easily plucked.

Front 34

Kwashiorkor: defn

Back 34

Inadequate protein intake but sufficient calories

Front 35

Kwashiorkor: Sx and Signs

Back 35

May be normal height and weight.

Anasarca
Rounded prominence of the cheeks ("moon-face")
Pitting edema in the lower extremities and periorbitally
Dry, atrophic, peeling skin with confluent areas of hyperkeratosis and hyperpigmentation
Hepatomegaly (from fatty liver infiltrates)
Distended abdomen with dilated intestinal loops

Front 36

What is the peripheral edema caused by in Kwashiorkor?

Back 36

Caused by hypoalbuminea which reduces the oncotic pressure of plasma and fluid leaks out of capillaries

Front 37

T/F Patients with Kwashiorkor are immunosuppressed

Back 37

T.

Front 38

What is mixed malnutrition?

Back 38

Combo of both marasmus and immunorepressive malnutrition (Kwashiorkor).

Front 39

Deficiency of vitamin ____ would cause the following symptoms:

Night blindness
Xerophthalmia
Bitot’s spot

Back 39

A

Front 40

Deficiency of vitamin ____ would cause the following symptoms:

Hemorrhagic tendencies

Back 40

K

Front 41

Deficiency of vitamin ____ would cause the following symptoms:

neuromuscular disorders, hemolysis
Spinocerebellar syndrome

Back 41

E

Front 42

Deficiency of vitamin ____ would cause the following symptoms:

Osteomalacia
rickets

Back 42

D

Front 43

Deficiency of vitamin ____ would cause the following symptoms:

Wet or dry beriberi
Wernicke - Korsakoff syndrome

Back 43

Thiamin (B1)

Front 44

Wet beriberi: what does it affect?

Back 44

Wet beriberi affects the heart; it is sometimes fatal, as it causes a combination of heart failure and weakening of the capillary walls, which causes the peripheral tissues to become edematous. It is also characterized by:

Vasodilation leading to increased arteriovenous shunt
Peripheral edema
Paroxysmal nocturnal dyspnea
Increased heart rate
Dyspnoea on exertion
Swelling of the lower legs

Front 45

Dry beriberi: what does it affect?

Back 45

Dry beriberi causes wasting and partial paralysis resulting from damaged peripheral nerves. It is also referred to as endemic neuritis. It is characterized by:

Difficulty walking
Tingling or loss of feeling (sensation) in hands and feet
Loss of muscle function or paralysis of the lower legs
Mental confusion/speech difficulties
Pain
Involuntary eye movements (nystagmus)
Vomiting

Front 46

EtOH and/or gastric bypass are associated with what type of beriberi?

Back 46

Wet

Front 47

Deficiency of vitamin ____ would cause the following symptoms:

Pellagra- diarrhea, dementia, dermatitis

Back 47

B3: Niacin

Front 48

Deficiency of vitamin ____ would cause the following symptoms:

Macrocytic anemia
Subacute combine degeneration of the dorsal and lateral spinal columns

Back 48

B12

Front 49

2 primary types of abdominal pain

Back 49

1) Splanchnic/visceral
2) Somatic/parietal

Front 50

pain fibers Travel with major blood vessels to sympathetic ganglia

Back 50

Splanchnic pain

Front 51

What is the ligament of treitz?

Back 51

The Suspensory muscle of duodenum or Ligament of Treitz connects the duodenum of the small intestines to the diaphragm.

This ligament is an important anatomical landmark of the duodenojejunal junction.

Front 52

Hematemesis (blood in the vomit) or melena (black tarry stools) usually indicate a gastrointestinal bleed from a location proximal to the _____. Hematochezia (bright red blood or clots in the stools) usually indicates a gastrointestinal bleed from a location distal to the ________

Back 52

Ligament of Treitz

Front 53

What is Murphy's sign?

Back 53

Patient stops inhalation with deep RUQ palpation due to pain

Front 54

What is difference between pain from biliary colic vs. Acute cholecystitis?

Back 54

Biliary colic from splanchnic nerve stretch from stone in cystic duct: usually felt as severe cramping with possible radiation; - Murphy's sign

Acute cholcystitis: Acute inflammation of gallbladder, RUQ tenderness, + Murphy sign. Fever and leukocytosis.

Front 55

Dull, poorly localized midline pain is aka

Back 55

Splanchnic/Visceral pain

Front 56

Duodenal ulcer, gastric ulcer, gallbladder, spleen, liver, pancreas
all cause pain that ravels on what artery?

Back 56

Celiac

Front 57

Left colon
Splenic flexure to rectum
Pelvic and genitourinary organs
all cause pain that travels on what artery?

Back 57

IMA

Front 58

Appendix
Small bowel
Colon to splenic flexure

All cause pain that travels on what artery?

Back 58

SMA

Front 59

What kind of abdominal processes cause somatic (parietal) pain?

Back 59

Ischemia, inflammation, stretching of parietal peritoneum

Front 60

Small bowel obstruction presents with what type of pain? What associated lab test abnormality?

Back 60

Intermittent cramping abdominal pain often with elevated amylase.

Front 61

SMA Thrombosis: what are signs and symptoms?

Back 61

Severe, sudden onset, diffuse pain out of proportion to physical findins.

Need high index of suspicion - h/o atrial fibrillation, peripheral vascular disease, intestinal angina (pain with meals).

Needs emergency angiogram and emergent surgery.

Front 62

Appendicitis: Signs and symptoms

Back 62

FIRST SPLANCHNIC PAIN: starts out as periumbilical discomfort, loss of appetite, and nausea.

SECOND SOMATIC PAIN: (only in 2/3) RLQ pain and tenderness with low grade fever, mildly elevated WBC.

Front 63

Why do 1/3 of patients with appendicitis never develop pain in RLQ (Somatic pain)?

Back 63

Their appendix is positioned anatomically such that it doesn't come into contact with the parietal peritoneum and not moved or irritated with pressing deeply at McBurney's point.

Front 64

Acute Pancreatitis: What is the pain usually like?

Back 64

Diffuse abdominal pain, usually radiating to back.

Patient sits in leaning forward position.

May be very sick.

Elevated lipase/amylase, tachycardia, fever, Cullen's sign, Gray Turner's sign

Front 65

Best test for acute pancreatitis

Back 65

Abdominal CT

Front 66

What estimates severity of acute pancreatitis?

Back 66

Ranson's score

Front 67

PERITONITIS: defn

Back 67

inflammation of peritoneum, thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.

Front 68

Peritonitis: PE findings

Back 68

Tenderness/guarding

Rebound tenderness

Front 69

T/F Peritonitis requires urgent surgery

Back 69

T

Front 70

Signs of inflamed appendix

Back 70

Low grade fever

Mild increase in WBC

Front 71

Sudden Onset Mid-epigastric pain
Rapid development diffuse abdominal pain
Boardlike, rigid abdomen


Characteristic of what?

Back 71

perforated duodenal ulcer

Front 72

What is the "acute abdomen" xray series?

Back 72

Upright chest x-ray
Upright abdomen x-ray
Supine abdomen x-ray

Front 73

What will be seen on acute abdomen xray series if there is a problem?

Back 73

Dx: “Free Air” on upright chest x-ray

Front 74

T/F A perforated duodenal ulcer does not need to be operated on emergently.

Back 74

F. Needs Emergent Laparotomy/Laparoscopy to close leak.

Front 75

SIGMOID DIVERTICULITIS: Pathogenesis

Back 75

Occurs if a diverticula becomes inflamed/infected.

Front 76

SIGMOID DIVERTICULITIS: Symptoms

Back 76

LLQ pain, localized tenderness

Front 77

SIGMOID DIVERTICULITIS: Treatment

Back 77

“Bowel Rest”
Gm- Aerobic, anaerobic antibiotic Rx: Cefoxitan
CT scan - if see abscess, need drainage.

Front 78

PERFORATED SIGMOID DIVERTICULITIS: Symptoms and Signs

Back 78

Diffuse abdominal pain, tenderness, guarding, rebound

May see free air

Front 79

PERFORATED SIGMOID DIVERTICULITIS: treatment

Back 79

Fluid resuscitation
Broad spectrum antibiotics
Emergent laparotomy, partial colectomy, colostomy, Hartmann pouch

Front 80

Elevated amylase

Borborygmus bowel sounds

Cramping periumbilical pain and vomiting


Are symptoms/signs or what?

Back 80

Small Bowel obstruction

Front 81

Elevated amylase can be caused by what?

Back 81

Pancreatitis

Blocked Gut
Hole in Gut
Dead Gut

Front 82

(Lower, Upper) GI bleeding occurs more frequently.

Back 82

UPper

Front 83

Mortality rates for Upper GI Bleeding (UGI) and Lower GI Bleeding (LGI)

Back 83

UGI: ~7%
LGI: ~2-5%

Front 84

How is UGI bleeding defined?

Back 84

Proximal to Ligament of Treitz

Front 85

How is LGI bleeding defined?

Back 85

Bleeding from the last 10 to 20 cm of the terminal ileum, colon or rectum (distal to ligament of treitz)

Front 86

Effect of acute volume of blood loss

15 to 20% of blood volume loss

Back 86

Orthostatic hypotension
(Systolic drop of > than 10 mmHg)

Front 87

Effect of acute volume of blood loss

30% blood volume loss

Back 87

Shock, tachycardia and hypotension

Front 88

Vomiting of fresh blood and clots

Back 88

Hematemesis

Front 89

most common cause of acute UGI hemorrhage

Back 89

Peptic ulcer disease

Front 90

(Gastric, duodenal) ulcers are more likely to hemorrhage.

Back 90

Duodenal

Front 91

bright red blood per rectum is aka

Back 91

hematochezia

Front 92

Independent (but additive) risk factors for ulcer hemorrhage

Back 92

1) older age >65 years
2) use of NSAIDs or aspirin
3) h/o prior peptic ulcer

Front 93

T/F Corticosteroid use alone is associated with increased risk for ulceration or bleeding.

Back 93

F

Front 94

T/F Corticosteroid use + NSAIDs is associated with increased risk for ulceration or bleeding.

Back 94

T

Front 95

T/F H pylori infection alone is associated with increased risk for ulceration or bleeding.

Back 95

F. Although it's a risk factor for development of peptic ulcer disease, it's not shown to be an indept risk factor for ulcer hemorrhage.

Front 96

What are the most common causes of UGI hemorrhage?

Back 96

1) Peptic ulcer

2) Esophageal or gastric varices

Front 97

T/F Hematochezia always indicates a lower GI bleed.

Back 97

F. Most are lower GI, but 18% are due to a brisk UGI source (especially when patient is hemodynamically unstable)

Front 98

Sx of UGI bleed

Back 98

hematemesis (30%)

Melena (20%)

Both (50%)

Front 99

What is the initial approach to the patient with UGI hemorrhage?

Back 99

STABILIZE the patient:

1) need large IV access
2) adequate assessment of blood loss
3) appropriate fluid and blood product infusion

Front 100

What does an NG aspirate that is grossly bloody in patients with hematochezia (no hematemesis) indicate?

Back 100

That there is an UGI bleeding source.

Front 101

Why is metoclopramide and/or erythromycin given prior to endoscopy?

Back 101

Increases gastric emptying and thus clears the stomach of clots to improve emergency endoscopic exams.

Front 102

After the patient is stabilized, what is the next step in an UGI bleed?

Back 102

Determine source of bleeding.

Then stop the bleeding.

Treat the underlying abnormalities or causes
Prevent recurrent bleeding

Front 103

T/F In most patients with a UGI bleed, it will stop on its own.

Back 103

T. 80% will stop, but in the remaining, it can be very serious.

Front 104

Why is endotracheal intubation for massive UGI bleeding a good idea?

Back 104

Good to prevent aspiration to protect the airways.

Front 105

T/F H2-receptor blockers are ineffective for acute UGI bleeds

Back 105

T

Front 106

T/F Proton pump inhibitors are ineffective at reducing rates of rebleeding.

Back 106

F. they ARE effective and are the medical therapy of choice for patients with ulcer hemorrhage after successful endoscopic hemostasis.

Front 107

In order of decreasing importance, what are Endoscopic appearance Predictors of Recurrent Ulcer Hemorrhage?

Back 107

Most to least important:
1) Active bleeding - will rebleed
2) Nonbleeding but visible vessel
3) Nonbleeding adherent clot
4) Oozing bleeding without clot
5) Gray slough, flat red or black spot
6) Clean ulcer base

Front 108

T/F Most UGI bleeds are arterial

Back 108

T (except esophageal varices)

Front 109

What are the 3 general types of endoscopic methods used to achieve ulcer hemostasis?

Back 109

1) Thermally active
2) Injection sclerotherapy
3) Mechanical - clips, ligation, loops

Front 110

What is the best way to treat ulcer endoscopically?

Back 110

A combination of 2 forms, not just one.

Ie, EPI injection and thermal therapy. Both have different mechanisms of action and combined they work better.

Front 111

Elecrocoagulation (Monopolar, Bipolar)
Laser
Argon plasma coagulator
Heater probe

All are examples of what type of therapy?

Back 111

Thermal

Front 112

When is GI surgery used?

Back 112

If endoscopic hemostasis fails. Want to avoid if possible.

The main purpose is to prevent exsanguination, with secondary aims of preventing recurrent hemorrhage.

Front 113

What is Angiographic Therapy?

Back 113

A technique for patients for whom endoscopy has failed to stop bleeding. Involves 2 different techniques:
1) Vasopressin infusion - causes vasoconstriction which stops ulcer hemorrhage in 1/2 of cases

2) Embolic materials - can be selectively injected thru a cathetic into bleeding artery.

Front 114

Angiographic Therapy Requires an active bleeding at a rate of at least _____.

Back 114

0.5 ml/ minute

Front 115

What are medical therapies for long-term prevention of ulcer hemorrhage?

Back 115

1) Acid suppression with H2RA and PPI
2) H pylori eradication
3) NSAID d/c

Front 116

Top 2 sources for lower GI bleeding

Back 116

1) Diverticulosis
2) Internal hemorrhoids

Front 117

Management of Severe Acute LGI Bleeding

Back 117

1) Stabilize patient
2) Look for UGI bleeding
3) Start prepping with Golytely for an urgent colonoscopy
If colonoscopy is not diagnostic then Scintigraphy (bleeding scan) followed by angiography

Front 118

Scintigraphy requires bleeding rate of _________ to be able to localize it.

Back 118

0.1mL/min

Front 119

Scintigraphy : what is it?

Back 119

is a form of diagnostic test used in nuclear medicine, wherein radioisotopes (here called radiopharmaceuticals) are taken internally, and the emitted radiation is captured by external detectors (gamma cameras) to form two-dimensional image.

Front 120

Angiography requires a bleeding rate of _____ to be able to localize it.

Back 120

0.5mL/min

Front 121

T/F Barium enema is useful in diagnosing acute bleeding

Back 121

F. Just gets in the way.

Front 122

In what one condition is CT scanning a good diagnostic tool?

Back 122

H/O AAA and there's a graft in place. Allows visualization of erosion.

Front 123

Diverticular bleeding originates most frequently from _____(about 70%)

Back 123

right colon, even though most diverticular involve sigmoid and descending colon.

Front 124

What is colon angiodysplasia?

Back 124

small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia

Front 125

What is the bleeding like in diverticulosis?

Back 125

Timing is abrupt.

There is painless large hematochezia

Front 126

Colonic Angiodysplasia or AVM (arterio-venous malformation) most often occurs where?

Back 126

Right colon

Front 127

What is the bleeding like in Colonic Angiodysplasia or AVM (arterio-venous malformation)?

Back 127

Usually intermittent and mild. Present with Fe deficiency anemia.

Front 128

T/F Inflammatory bowel disorders rarely present with abrupt GI bleeding

Back 128

T

Front 129

Most common cause of LGI bleeding in outpatient ambulatory adults

Back 129

Internal hemorrhoids.

Front 130

What is the bleeding like in internal hemorrhoids?

Back 130

Self-limited, mild bleeding manifested by bright red blood on toilet paper.

CAN bleed profusely and require emergent hospitalization and hemostasis.

Front 131

T/F Colonoscopy plays an important role in diagnosis but a limited role in therapy in LGI bleeds

Back 131

T