Gastrointestinal Disorders

Front 1

Term for a group of EPIGASTRIC symptoms that includes:
Pain, bloating, nausea, burping, early satiety, heartburn, regurgitation

Back 1

Dyspepsia

Front 2

Dyspepsia, Nausea and Vomiting, Constipation, GI Gas, Diarrhea, Acute Upper and Lower GI Bleed, Occult GI Bleed

Back 2

Signs and Symptoms of GI Disorders

Front 3

aka INDIGESTION

1. Very common presented in about 25% of population.
2. One of the MOST COMMON COMPLAINTS presented to general practitioners, even though most that experience this never seek medical attention.

Back 3

Dyspepsia

Front 4

Etiology:

Luminal GI Tract Dysfunction
1. GERD
2. PEPTIC ULCERS
3. Neoplasms
4. Parasitic infection
5. Lactose intolerance

Back 4

Dyspepsia

Front 5

Etiology:

Drugs/Medications
1. ETOH
2. Caffeine
3. NSAIDS (i.e. Aspirin-induced)
4. Antibiotics (i.e. Erythromycin, Metronidazole--Flagyl)

Back 5

Dyspepsia

Front 6

Etiology:

Pancreatic Disease
1. Carcinoma
2. Chronic Pancreatitis

Back 6

Dyspepsia

Front 7

Etiology:

Biliary Disease:
1. Cholelithiasis (Gallstones)
2. Choledocholithiasis (5% of ALL Gallstones formed DE NOVO-in ducts)

Back 7

Dyspepsia

Front 8

Etiology:

Functional Dyspepsia
1. When NO EXPLANATION for the sx can be found (in 50%: no explanation can be found)
2. Disordered Gastric Motility
3. Psychogenic factor

Other
1. Pregnancy
2. Diabetes Mellitus

Back 8

Dyspepsia

Front 9

Clinical Findings:

1. Sx of NONSPECIFIC nature
2. Clinical Hx has limited us, but is still important
3. There are some correlated sx and a "more likely" dx: (GERD, PUD, Biliary Disease, Pancreatic Disease)

Back 9

Dyspepsia

Front 10

Sx of Heartburn and Regurgitation

Back 10

GERD

Front 11

Sx of Postprandial episodic EPIGASTRIC pain

Back 11

Peptic Ulcer Disease (PUD)

Front 12

Sx of Postprandial Right Upper Quadrant pain

Back 12

Biliary Disease

Front 13

Sx of Weight loss and constant vague EPIGASTRIC pain

Back 13

Pancreatic Disease

Front 14

Initial Exam and Tests:

1. Complete physical exam is MANDATORY
2. Testing for occult blood in stool a MUST (Guiac Test)
3. CBC
4. Liver Chemistry Profile

Back 14

Dyspepsia

Front 15

Special Examinations:

1. ENDOSCOPY (1st study performed w/GI bleed present)NOT barium study
2. Serology testing for H. pylori (peptic and duodenal ulcers)
3. ABDOMINAL ULTRASOUND (1st imaging modality if Cholecystitis suspected)--Suspected Biliary or Pancreatic Disease

Back 15

Dyspepsia

Front 16

Treatment:

Always directed at the UNDERLYING CAUSE if one is found.

Most have mild dz so most will respond to lifestyle changes and reassurance.

Back 16

Dyspepsia

Front 17

Treatment:

Functional Dyspepsia
1. Avoidance of certain foods
2. Reassurance
3. Food-symptom diary (i.e. IRB)

Back 17

Dyspepsia

Front 18

Treatment:

Pharmacological Agents
1. Placebo?? (30% successful)
2. H2 Receptor Blockers (Ranitidine--Zantac)
3. Proton Pump Inhibitors (Omeprazole)--More effective than H2 receptor blockers
4. Promobility Agents
a. Metoclopramide (Reglan)
b. Cisapride (Propulsid)

Back 18

Dyspepsia

Front 19

Vague, Disagreeable sensation of sickness

Back 19

Nausea

Front 20

"Reverse Peristalsis", in most cases preceded by nausea and retching

Back 20

Vomiting

Front 21

Effortless reflux of stomach contents (liquid or solid)

Back 21

Regurgitation

Front 22

Vomiting w/out nausea b/c specific brain centers may be affected.

Back 22

Meningitis

Front 23

Complications:

1. Dyhydration (IV required)
2. Hypokalemia
3. Metabolic Alkalosis (vomiting OUT HCl--so alkalosis results)
4. Pulmonary Aspiration (Pepsin in lungs aspirated to avoid lund destruction)
5. Esophageal Rupture

Back 23

Complications of Vomiting

Front 24

Clinical Findings:

H&P Important in Etiologies
1. Drug
2. Food; esp. acute sx without abdominal pain (Suspect food poisoning-vomiting w/out ab pain)
3. Infection; acute or chronic
4. Acute onset of pain and vomiting:
a. peritoneal irritation
b. acute intestinal obstruction

Back 24

Nausea and Vomiting

Front 25

Clinical Findings:

Associated Symptoms
1. Headache
2. Vertigo

Back 25

Nausea and Vomiting

Front 26

Special Examinations:

1. X-rays
2. NG (Nasogastric) tube
3. Liver Function Test
4. Ultrasound
5. CT Scan (with or without contrast)

Back 26

Nausea and Vomiting

Front 27

Treatment:

1. Tx underlying cause
2. MOST cases are SELF-LIMITING and require no special tx
3. GENERAL MEASURES
a. Clear liquids
b. Dry food (BRAT Diet)

Back 27

Nausea and Vomiting

Front 28

Treatment:

Antiemetics
1. To prevent or control
2. No one is best for all pts, leading to COMBO at times
3. AVOID IN PREGNANCY
a. Serotonin 5-HT3 (Chemotheraphy induced vomiting)
b. Corticosteroids--additive w/above (Dexmethasone--Decadron)
c. Dopamine Antagonist (Phenothiazines)
d. Antihistamines--effective in motion sickness (Benedryl)

Back 28

Nausesa and Vomiting

Front 29

Treatment:

Sedatives
1. Diazepam (Valium)
2. Lorazepam (Antivan)--psychogenic and anticipatory vomiting

Back 29

Nausea and Vomiting

Front 30

General Information:

1. Two or fewer BM per week
2. Excessive difficulty or straining at defecation

Back 30

Constipation

Front 31

Common Identifiable Causes:

1. POOR DIETARY HABITS (Lack of Fiber and Fluid in diet; i.e. Meat & Potato diet)
2. BEHAVIORAL HABITS (family, not going with urge)
3. STRUCTURAL ABNORMALITIES (obstruction of fecal passage)
4. Systemic disease

Back 31

Constipation

Front 32

Evaluation of Patients with this disorder:

First Level:
1. Careful H&P
2. Routine Lab tests
3. Test occult blood
4. Addition of fiber (Tx Trial)
5. Colonoscopy or Flexible sigmoidoscopy & Barium enema w/blood or failed conservative therapy

Back 32

Constipation

Front 33

Evaluation of Patients with this disorder:

Second Level:
1. Colonic transit studies
-Radiopaque plastic markers given for 3 days on days 4 & 7 radiographs taken, # left in colon remaining counted
2. Studies of pelvic floor
-Defecography to dx outlet disorders

Back 33

Constipation

Front 34

Treatment:

1. Dietary measures
a. Bran
b. Pharm supplements (Psyllium--Perdie; Methylcellulose--Citruel)
2. Osmotic laxatives
a. Used to soften stool
b. Nonabsorbale sugars
c. Magnesium hydroxide (Avoid in renal insuff.)
3. Stool surfactant agents
4. Enemas (Empty GI Tract)

Back 34

Constipation

Front 35

1. Normal reflex and occurs commonly after meals
2. Virtually all stomach gas derived from swallowed air (each swallow: 2-5 mL air ingested)
3. Increased by rapid eating and carbonated drinks
4. Chronic Excessive Gas is almost always caused by AEROPHAGIA, seen in anxious and institutionalized pts

Back 35

Gastrointestinal Gas
BELCHING (ERUCTATION)

Front 36

1. Normal occurrence:
a. 500-500 mL/day
b. 6-20 times per day
2. Source:
a. Swallowed air that has not been belched passes thru and leaves as this
b. BACTERIAL FERMENTATION(of undigested carbs)--Hydrogen and Methane from plant carb

Back 36

Gastrointestinal Gas
FLATUS

Front 37

BACTERIAL FERMENTATION

1. Majority in colon
2. Increased by
a. Malabsorptive states (diarrhea and weight loss)
b. Increased ingestion of NON-ABSORBABLE CARBS (Lactose, Lactulose, Sorbitol--in non-calorie foods)

Back 37

Gastrointestinal Gas
FLATUS

Front 38

Treatment:

1. Initial trial of Lactose-free diet
2. Avoid gas-producing foods
3. Eliminated complex carbs

Back 38

Gastrointestinal Gas

Front 39

General Information:

1. COMMON SX that has a range of severity (depends on pt's bowel habits)
2. SUBJECTIVE (increased freq, stool fluidity, urgency, incontinence?)

Back 39

Diarrhea

Front 40

Increased stool frequency (>2-3 per day) or liquidity of feces and a stool weight >250g/24 hrs

Note: Normally only about 100mL of water is lost in the stool each day

Back 40

Diarrhea

Front 41

General Information:

When ACUTE in onset, and persists for 3 weeks or less it is:
a. infectious
b. bacterial toxin
c. drugs

Back 41

Acute Diarrhea

Front 42

H&P provides valuable for Etiology:

1. Recent travel (Traveler's Diarrhea)
2. Family members (Infectious origin)
3. Ab Therapy (Clostridium difficile colities)
4. Recent Diet (change in diet)

Back 42

Acute Diarrhea

Front 43

Nature of Condition:

Non-Inflammatory
1. Small bowel enteritis (toxin, disruption)
2. Enterotoxigenic E. coli, Staph aureus
3. No tissue invasion, no leukocytes
4. Watery non-bloody
5. Periumbilical pain (location of small intestines)
6. Bloating
7. Nausea & Vomiting
8. May be large in volume; small bowel

Back 43

Acute Diarrhea

Front 44

Nature of Condition:

Inflammatory (mucosa inflamed)--common in colds
1. Colonic tissue damage (Salmonella, Shigellosis)
2. Fever
3. Bloody diarrhea (Dysentery)
4. Damage by mucosal invasion
5. Involve mostly colon, thus diarrhea small in volume
6. Few leukocytes in stool

Back 44

Acute Diarrhea

Front 45

Nature of Condition:

Enteric fever by Salmonella
1. Severe systemic
2. Abdominal tenderness
3. Diarrhea
4. Rash
5. High fever

Back 45

Acute Diarrhea

Front 46

Evaluation:

1. DISTINGUISH CAUSES AND NATURE OF DIARRHEA
2. >90% MILD and SELF-LIMITING
3. Microscopic exam of stool for leukocytes (inflammatory only)
a. Stool bacterial culture
b. Inflammatory (High fever, Bloody diarrhea >5days, Ab pain)
4. Wet mount of stool for amebiasis in dysentary & hx of travel to endemic area

Back 46

Acute Diarrhea

Front 47

Treatment:

1. DIET (mild case, oral fluids w/carbs & electrolytes, AVOID high fiber foods)
2. REHYDRATION (oral hydration; Na+, K+, Cl-, Bicarbonate)

Back 47

Acute Diarrhea

Front 48

Treatment:

ANTIDIARRHEAL AGENTS (mild to moderate, OPIOID AVOIDED w/bloody case)
a. loperamide (CHOICE)
b. bismuth subsalicylate (Pepto-Bismol) anti-inflamm & anti-bacterial

Back 48

Acute Diarrhea

Front 49

Treatment:

Antibiotics:
1. Empiric, use in all pts with ACUTE case NOT WARRANTED
2. Inflammatory case (bloody stool, fever, tenesmus, fecal leukocytes)
3. Ciprofloxacin
4. Trimethoprin-sulmethoxazole
5. Erythromycin

Back 49

Acute Diarrhea

Front 50

Cause of Chronic Diarrhea
1. Increased Osmotic Gap
2. Resolves during fasting
3. Malabsorptive conditions

Back 50

Osmotic Diarrhea

Front 51

1. Ingestion or malabsorption of an osmotically active substance
2. Disaccharide deficiency
3. Laxative abuse (Lactose intolerance)
4. Malabsorptive syndromes

Back 51

Increased Osmotic Gap in Osmotic Diarrhea

Front 52

1. Weight loss
2. Osmostic Diarrhea
3. Nutritional deficits
4. Qualification of fecal fat should be performed

Back 52

Malabsorptive Conditions in Osmotic Diarrhea

Front 53

1. Osmotic Diarrhea
2. Secretory Conditions
a. Increased intestinal secretion
b. Decreased absorption
c. Large volume watery diarrhea
d. No change in diarrhea during fasting
e. NO OSMOTIC GAP
3. Inflammatory Diarrhea
4. Motility disorders
5. Chronic infections (Giardia, E. histolytica)
6. Factitial Diarrhea (about 15%, laxative use, stool dilution)

Back 53

Chronic Diarrhea

Front 54

Evaluation:
1. Careful H&P
2. Stool Analysis (24 hr stool for wt and fat, stool osmolality, stool laxative screen, fecal leukocytes, ova or parasites)
3. Blood tests (Routine; Specific--Secretory diarrhea: gastrin, cortisol)
4. Proctosigmoidoscopy w/bx
5. Imaging (if needed)--Calcification on plain film: pancreatic dz; Endoscopy

Back 54

Chronic Diarrhea

Front 55

Treatment:
1. Tx underlying condition
2. Ioperamide (Imodium)
3. Diphenoxylate w/atropine (Lomotil)
4. Codeine/Paregoric
a. only in cases of chronic intractable diarrhea
b. Best to avoid its use
5. Clonidine (Catapres patch)
6. Octreotide (Sandostatin)

Back 55

Chronic Diarrhea

Front 56

Histology:

1. Mucosa-stratified squamous epithelium
2. Lamina propria
3. Muscularis Mucosa-irregular layer of smooth muscle
4. Submucosa-Secretory Glands
5. Muscularis Externa-inner circular and outer longitudinal layer
6. Adventitia-Anchors structure to dorsal body

Back 56

Esophagus

Front 57

Histology:

1. Mucous Epithelium (Secretory Cells)
2. Lamina propria
3. Muscularis mucosae (Smooth mm.)
a. Submucosa (BV, Lymphatics)
b.Oblique Muscle
c.Circular Muscle
d.Longitudinal Muscle
8. Serosa

Back 57

Stomach

Front 58

Histology: (Goblet cells and Brush Border)

1. Mucosa (Villi-->Plica)
2. Muscularis mucosaee
a. Submuscoa (BV, Lymphatics, Plexus)
b. Muscularis externa (Circular layer and Longitudinal layer of smooth m.)
3. Serosa

Back 58

Small Intestines

Front 59

Histology: (Lack of Villi)

1. Columnar Epithelium
2. Abundant Goblet Cells
3. Muscularis Mucosae
4. Submucosa (BV, Plexus)
5. Muscularis externa
a. Longitudinal layer (taenia coli)
b. Circular layer

Back 59

Large Intestines

Front 60

Anatomy:

1. Superior 1/3-Skeletal muscle
2. Middle 1/3-Mixed Skeletal & Smooth muscle
3. Inferior 1/3-Smooth muscle

Back 60

Esophagus