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gi: clin med iia > Intro N/V > Flashcards

Intro N/V Flashcards

1
Q

2 Major physiologic function of the GI system

A

Digest food
Absorb nutrient into the bloodstream

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2
Q

describe the physiology of digesting food and absorbing nutrients?

A
  1. Food moves slowly along the digestive tract and are broken down into ions and molecules = absorbed into body through intestinal wall and into blood or lymph system
  2. un-absorbed nutrients and wastes are collected in the large intestine for elimination
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3
Q

6 functions of the GI system

A
  1. Ingestion - Occurs when solid food and liquid enter the oral cavity
  2. Mechanical digestion and propulsion - crushing/shredding of food in oral cavity and mixing and churning in the stomach
  3. Chemical digestion - Chemical and enzymatic breakdown of food into small organic molecules that can be absorbed by the digestive epithelium
  4. Secretion - release of water, acids, enzymes, buffers, and salts by the digestive tract epithelium and by accessory digestive organs
  5. Absorption - Movement of nutrients across the digestive epithelium and into the bloodstream
  6. Defecation - Indigestible food is compacted into material waste that is eliminated by defecation
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4
Q

3 parts of the GI system

A
  1. Upper - mouth, esophagus, stomach
    - Where digestion starts
  2. Middle - duodenum, jejunum, ileum
    - Where most digestive & absorptive processes occur
  3. Lower - cecum, colon, rectum
    - Storage for elimination
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5
Q

why is the GI system lined with permanent ridges and temporary folds?

A

increases surface area for absorbing nutrients

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6
Q

what accessory organs produce secretions to aid in digestion?

A

salivary glands
liver
pancreas

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7
Q

what is nausea?

A
  • Subjective feeling of a need to vomit
  • Vague, intensely disagreeable sensation of sickness or “queasiness”
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8
Q

what spasmodic respiratory and abdominal movements usually follows nausea?

A

retching

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9
Q

Oral expulsion of gastrointestinal contents due to ?

A
  • contractions of gut and thoracoabdominal wall musculature

Multiple afferent and efferent pathways exist which induce vomiting

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10
Q

The effortless reflux of liquid or food stomach contents
“Burping up” food contents

what is this term

A

regurgitation

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11
Q

The chewing and swallowing of food that is regurgitated after meals

what is this term

A

rumination

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12
Q

Normal function of the upper GI tract involves an interaction between what two things?

A

the gut and the CNS

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13
Q

The motor function of the gut is controlled at three main levels:

A
  1. parasympathetic and sympathetic NS
  2. enteric brain neurons
  3. smooth muscle cells
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14
Q

which is more bothersome and disabling, nausea or vomitting?

A

nausea

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15
Q

what causes nausea?

A

Gastric Rhythmic Disturbance

  1. Nausea correlates with a shift in normal 3-cycle-per min gastric myoelectrical activity (muscle contraction and relaxation)
    - 3 cycles/min of smooth muscle contraction in stomach
    - This activity increases with a food bolus
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16
Q

In disorders of stomach motility, the rhythm is (regular/irregular)?

A

irregular

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17
Q

2 disorders of stomach motility, describe each

A
  1. Tachygastria: increased rate of electrical activity in the stomach
    - >4 cycles/min
  2. Bradygastria: decreased rate of electrical activity in the stomach
    - <2 cycles/min
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18
Q

Vomiting may be stimulated by 4 different sources:

A
  1. Afferent vagal fibers from GI viscera (serotonin 5-HT3)
    - GI distention, mucosal or peritoneal irritation, infections
  2. Fibers of vestibular system (histamine H1)
    - sea-sick, dizziness
  3. Higher CNS centers
    - sights, smells, or emotional experiences
  4. Chemoreceptor trigger zone
    - stimulated by drugs, chemo agents, toxins, hypoxia, uremia, acidosis, radiation therapy
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19
Q

what type and where are the chemoreceptor trigger zones that cause vomiting?

A
  1. opioid, serotonin 5-HT3, neurokinin 1 (NK1), and dopamine D2 receptors
  2. located outside blood-brain barrier in the area postrema
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20
Q

what are the likely microbes that cause vomiting? include incubation period and likely food sources

A
  1. s. aures
    - 1-6 h
    - prepared foods, salads, dairy, meat
  2. B. cereus
    - 1-6 h
    - rice, meat
  3. norwalk-like viruses
    - 24-48 h
    - shellfish, prepared foods, salads, sandwiches, fruit
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21
Q

In both urgent care and routine outpatient settings, the following 3 steps should be generally undertaken in pts with N/v

A
  1. find etiology, see if acute or chronic sx
  2. Correct any consequences/complications of N/V
    - fluid depletion, hypokalemia, and metabolic alkalosis
  3. Targeted therapy when possible
    - surgery for bowel obstruction or malignancy
    - symptomatic tx
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22
Q

causes of acute sx w/o severe abdominal pain

A
  1. Inquiry should be made into recent changes in meds, diet, other GI symptoms, or similar illnesses in family members
    - food poisoning
    - infectious gastroenteritis
    - drugs
    - systemic illnesses
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23
Q

causes of Acute onset of severe pain and vomiting

A
  • suggests peritoneal inflammation
  • acute gastric/intestinal obstruction
  • pancreatobiliary disease
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24
Q

causes of persistent vomiting?

A

suggests pregnancy
gastric outlet obstruction
gastroparesis
intestinal dysmotility
psychogenic disorders (think bulimia)
CNS/systemic disorders

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25
Q

recurrent episodes of N/V and abdominal discomfort in patients with prolonged marijuana use is called?
tx?

A

Cannabinoid Hyperemesis Syndrome
hot shower/bath

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26
Q

causes of morning vomiting?

A

pregnancy
uremia
alcohol intake
increased intracranial pressure

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27
Q

if a pt is Vomiting immediately after meals, what PE should you def do?

A

bulimia - TEETH EXAM

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28
Q

causes of Vomiting undigested food one to several hours after meals

A
  1. gastroparesis
  2. gastric outlet obstruction
    - may hear a succussion splash
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29
Q

Acute or chronic sx you should ask about neurologic sx (CNS cause) with vomiting?

A

HA
stiff neck
vertigo
focal weakness/paresthesias

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30
Q

Feculent vomiting would indicate what?

A

Intestinal obstruction

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31
Q

what is Hematemesis?

A

Vomiting of blood or coffee-like material

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32
Q

labs for vomiting?

A

Screening tests can direct clinical care: severe or protracted vomiting

  1. CBC - Infection, anemia
  2. CMP - lyte disturbances, liver function, azotemia, met alkalosis from loss of gastric contents
  3. Amylase, Lipase - Pancreatic enzymes
  4. b-hCG
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33
Q

imaging for n/v?

A

Flat and Upright abdominal films: with severe or suspicion of mechanical obstruction

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34
Q

on abd film shows intestinal air-fluid levels w/ reduced colonic air

what is this?

A

small bowel obstruction

35
Q

on abd film shows diffusely dilated air-filled bowel loops

what is this?

A

Ileus

36
Q

If initial testing is non-diagnostic for n/v, may require anatomic studies:

A
  1. EGD
    - MC chronic N/V that is unexplained after routine evaluation—often normal
  2. CT scan
  3. Colonoscopy
  4. US
  5. MRI
  6. GI motility testing
37
Q

what additional anatomic study Detects ulcers, malignancy, retained gastric food residue, gastric outlet obstruction

A

EGD
exception, emergent hematemesis

38
Q

what additional anatomic study Diagnoses partial SBO

A

CT scan

39
Q

what additional anatomic study Detects colonic obstruction, malignancy, inflammatory conditions

A

Colonoscopy

40
Q

what additional anatomic study Defines intraperitoneal inflammation, cholelithiasis

A

US

41
Q

what additional anatomic study Can show inflammation in Crohn’s disease

A

MRI

42
Q

what additional anatomic study Can detect an underlying motor disorder when anatomic abnormalities are absent (Gastroparesis)

A

GI motility testing

can detect delayed gastric emptying
however, sx overlap with other GI disorders such as functional dyspepsia

43
Q

complications of n/v

A

Volume Depletion/Dehydration
Electrolyte Disturbances
Aspiration
Mallory-Weiss Tear
Boerhaave Syndrome (Esophageal Rupture)

44
Q

what macromolecule delays gastric emptying therefore should be avoided in foods when treating n/v?

A

lipids
Foods high in indigestible residue are avoided because these prolong gastric retention

45
Q

tx for mild-moderate n/v?

A
  • Clear liquids (broths, tea, soup, carbonated beverages)
  • Advance to small quantities bland food (crackers)
  • Antiemetic medication

Most causes are mild, self-limited and require no specific treatment

46
Q

tx for moderate-severe n/v?

A

Hospitalization with IV (isotonic) fluids
Antiemetic medication
NG tube in certain situations (i.e. small bowel obstruction/gastric)

47
Q

tx for pediatric n/v?

A
  1. Infants and children with difficult IV/IO access may be hydrated with oral lyte solutions via NG tube
  2. oral rehydration w/ 50–100 mL/kg of glucose–electrolyte solution x 4 hrs.
  3. age-appropriate diet and breast-feeding may resume asap.

In either case, start with small doses of oral fluid and slowly increase the amount

48
Q

tx for Severe volume depletion or hypovolemic shock from n/v?

A

Rapid rate of 1-2 L of isotonic fluids ASAP - restore tissue perfusion.

49
Q

tx for Mild to moderate hypovolemia from n/v?

A
  1. Rapid fluid resuscitation is not necessary
  2. Induce positive fluid balance = give fluid 50-100 mL/hr > estimated fluid losses
50
Q

choices of replacement fluids?

A

Most pts are started initially on isotonic saline

  1. Hypernatremia and hyponatremia - SLOW correction
    - overly rapid correction is potentially harmful
  2. Potassium replacement - for potassium depletion
  3. sodium bicarbonate - met. acidosis
51
Q

Caution with parenteral fluid bolus doses in following patient populations when tx fluid depletion/N/V:

A

infants, poor systolic EF, kidney disease, chronic severe hyponatremia (w/o neuro deficits that require hypertonic saline) and DKA in children.

52
Q

indications for Ondansetron (Zofran)

A
  1. Acute N/V
  2. Postoperative N/V
  3. Chemotherapy related N/V
  4. Hyperemesis gravidarum?
    - avoid in 1st trimester (rare chance of cleft palate)
53
Q

caution with ondansetron (zofran) in who?

A

hepatic impairment
Pregnancy (1st trimester) - monitor
QT prolongation - monitor

54
Q

SE of ondansetron

A

HA
Diarrhea/Constipation
Fatigue, malaise
Dizziness
Pruritus

55
Q

class of Scopolamine (Transderm Scop)/Meclizine/doxylamine

A

Anticholinergic/antihistamines

56
Q

indications for Scopolamine (Transderm Scop)/Meclizine/doxylamine

A
  1. Motion Sickness, vertigo, migraines
  2. combined with oral Vitamin B6 and doxylamine for pregnancy
  3. Prevention postoperative N/V
57
Q

what medication is recommended by American College of OBGYN 1st line therapy N/V with pregnancy

A

Scopolamine (Transderm Scop)/Meclizine/doxylamine

58
Q

SE of Scopolamine (Transderm Scop)/Meclizine/doxylamine

A

xerostomia, urinary retention
dizziness
drowsiness, mydriasis

59
Q

which medication
- 1st gen antihistamine; blocks H1 receptors - antiemetic and sedative effects
- special mention for Dopamine Receptor Antagonist (Phenothiazine); with H1 blocking as well

A

Promethazine (Phenergan)

60
Q

which n/v med is available as a patch?

A

Scopolamine (Transderm Scop)/Meclizine/doxylamine

61
Q

which n/v med should be administered with food, water, or milk to reduce GI distress

A

Promethazine (Phenergan)

62
Q

PK of Promethazine (Phenergan)

A

Metabolized by the liver; CYP450

63
Q

Serious SE of Promethazine (Phenergan)

A

serious

  1. rsp Depression
  2. Seizures
  3. Leukopenia
  4. Thrombocytopenia
  5. Hallucinations
  6. Extrapyramidal SE
    - physical sx: tremors, uncontrolled muscle mvmts, slurred speech, akathisia (always moving), parkinsonism
  7. Bradycardia
64
Q

common SE of Promethazine (Phenergan)

A

Sedation
Blurred Vision
Confusion
Xerostomia
Dermatitis
Urinary retention
Constipation

65
Q

which med has a BBW for Respiratory Depression and Tissue Injury/Necrosis

A

Promethazine (Phenergan)

66
Q

CI of Promethazine (Phenergan)

A

rsp depression - children <2

67
Q

caution with Promethazine (Phenergan)

A

Elderly
CNS depression
Asthma/COPD
Glaucoma
BPH
Cardiac Ds
Hepatic Ds
Seizure Ds

68
Q

safety/monitoring for Promethazine (Phenergan)

A

Pregnancy Category: C
Obtain CBC, Ophtho exam with prolonged use

69
Q

MOA of Metoclopramide (Reglan)

A

Increases peristalsis primarily by inhibiting dopamine
enhances response to acetylcholine of tissue in upper GI
enhances motility and accelerated gastric emptying
increases lower esophageal sphincter tone

70
Q

which med is indicated for refractory GERD

A

Metoclopramide (Reglan)
N/V (adjunct), Gastroparesis, refractory GERD

71
Q

which n/v med is renally excreted?

A

Metoclopramide (Reglan)

72
Q

serious SE of Metoclopramide (Reglan)

A
  1. Extrapyramidal SE
  2. Neuroleptic malignant syndrome
    - life threatening reaction characterized by F, autonomic dysfunction, altered mental status and muscle rigidity
  3. Seizures
  4. Depression/Suicidal Ideations
  5. Leukopenia/Agranulocytosis
  6. CHF, arrhythmias
  7. HTN
73
Q

common SE of Metoclopramide (Reglan)

A

Diarrhea
Drowsiness
Restlessness
Anxiety/Insomnia/Depression
HA/Dizziness
Hormonal Disorders
HTN

74
Q

which med has a BBW of Tardive Dyskinesia

A

Metoclopramide (Reglan)

  1. caused by use of neuroleptic drugs
  2. involuntary, repetitive body movements, which may include
    - grimacing
    - eye blinking
    - lip smacking
    - abnormal mvmts of arms and legs
75
Q

CI for Metoclopramide (Reglan)

A

Seizure Ds, GI obstruction

76
Q

cautions with Metoclopramide (Reglan)

A

HTN
Parkinsons
CHF
Depression
DM
Renal Impairment

77
Q

safety/monitoring for Metoclopramide (Reglan)

A

Pregnancy Category: B

CrCl at baseline

Do not abruptly discontinue - taper

78
Q

what n/v med is used During chemotherapy with dexamethasone

A

Neurokinin receptor antagonists - Aprepitant (Emend)

79
Q

what n/v med is used for Postoperative N/V; Chemotherapy
Additive agent

A

Dexamethasone

80
Q

which med is use for anticipatory N&V with chemo?

A

Lorazepam - benzo (Xanax)

81
Q

what med is given along with Zofran to help with Chemotherapy induced vomiting

A

Lorazepam

82
Q

which n/v med is in the class of Serotonin 5-HT3 Receptor Antagonist?

A

Ondansetron (Zofran)

83
Q

which n/v med acts on
5-HT3 receptors present both peripherally and centrally
Blocks serotonin from binding to 5-HT3 receptors
Blocking stimulation of “vomiting center” in medulla

A

Ondansetron (Zofran)

gi: clin med iia (12 decks)

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