Gastrointestinal disorders Flashcards
Peptic ulcer diease (PUD)
- A GI ulcer is a loss of enteric surface epithelium that extends deep enough to penetrate the muscularis mucosae, usually over 5mm in diameter.
- PUD referes to a chronic disorder where the pt has a lifelong underlying tendency to develop mucosal ulcers at sites that are exposed to peptic juice.
Most commons locations are the stomach and duodenum.
Causes of PUD
- H. Hylori is present in 90% of duodenal ulcers and 75% in gastric ulcers.
- Medications such as NSAIDs, ASA, glucocoritcoids.
- Most common in men.
- Duodenal ulcers are usually in youngr adults ages 30-55
- Gastric ulcers are usually in older adults age 55-65
- More common in smokers
- Alcohol and dietary factors do not appear to cause ulcer disease
- Role of stress is uncertain, type A personalities?
- Zollinger-Ellison syndrome (too much stomach acid due to pancreatic tumor).
- Cytomegalovirus
S/S of PUD
Gnawing epigastric pain.
“Feelings like something is eating me from the inside out.”
* Relief worsens with eating (gastrics)
* Relief of pain with eating (duodenal)
Physical findings are often unremarkable, may note some mild epigastric tenderness.
GI bleeding indicates melena, hematemesis, coffee ground emesis.
Perforation (acute abdomen): Severe epigastric pain, board like abdomen, quiet bowel sounds, rigidity.
Lab/diagnositcs of PUD
Normal, may note anemia on the CBC.
Consider endoscopy after 8-12 weeks of treatment.
Consider H.pylori testing.
Acid antisecretory agents
- PPIs- Suppress gastric acid secretion by inhibition of the hydrogen/potassium enzyme system at the secretory surface of the gastric parietal cells.
-Omeprazole, Pantoprazole, lansoprazole, rabeprazole
-Should be administered 30 minutes before meals.
-Safe for short term use but long term use can cause decrease B12, iron and calcium absorption, enteric infections (c-diff), pna, kidney disease and black box warning of increased incidence of osteoporotic hip fractures.
-If you suspect an ulcer regardless if it’s been diagnosed, start a PPI–mainstay of tx. PPI more effective at healing ulcers. - H2 Receptor Antagonists- Decrease gastric acid secretion by blocking histamine 2 receptors on parietal cells.
-Famotidine, cimetidine, nizatidine
-Works well with dyspepsia.
Mucosal Protective Agents
- Sucralfate (carafate)- Forms a protective barrier against acid, bile, and pepsin.
-Requires acidic environment so cannot be used with antacids, PPIs or H2 blockers.
-May bind some medications so should be given 2 hours before and after other meds.
-Can cause increase aluminum so dose adjustment for renal impairment.
-Associated with decreased incidence of nosocomial pna.
-May cause constipation - Bismuth subsalicylate (pepto-bismol)- Promotes prostaglandin production/stimulates gastric bicarbonate.
-Has direct antibacterial action again H.pylori. - Antacids (mylanta, Maalox, MOM)- Helps neutralize stomach contents and provide immediate relief.
-Low dose aluminum and magnesium containing antacids promote ulcer healing by stimulating gastric mucosal defenses, rather than neutralizing gastric acidity.
-High doses are associated with diarrhea, hyermag, and hypophos.
H.pylori eradication therapy
Two antibiotics + PPI w/or w/out bismuth for 10-14 days.
* Pts not allergic to penicillin and who have not previously recieved a macrolide:
-ECA- Esomeprazole + clarithromycin + amoxicillin or
-EBMT- Esomeprazole + bismuth + metronidazole + tetracycline or
-ECAM- Esomeprazole + clarithromycin + amoxicillin + metronidazole
- Pts who are allergic to penicillin and who have not previously recieved a macrolide or unable to tolerate bismuth:
-ECM: Esomeprazole + clarithromycin + metronidazole - Pts who are allergic to penicillin and who have previously recieve a macrolide:
-EBMT: Esomeprazole + bismuth + metronidazole + tetracycline
Antiulcer therapy is recommended following the previous regimens for 3-7 weeks to ensure symptoms relief.
-PPI continued for 7 additional weeks
-H2 blocker or sucralfate continued for 6-8 weeks
GERD
A chronic condition characterized by back flow of acidid gastric contents into the esophagus.
Can be due to anatomic factors such as an incompetent lower esophageal sphincter, hiatal hernia, delayed gastric empyting (gastroparesis)
S/S of GERD
Retrosternal burning
Bitter taste in mouth
Belching, hiccough, dysphagia (more commong in elderly)
Excessive salivation
Frequently occurs at night and/or in recumbant position
May be releived by sitting up, antacids, water or food.
Diagnostics for GERD
Consider referral for EGD to rule out cancer, barrets esophagus, PUD.
Management of GERD
- Non-pharmacologic measures:
- Elevate HOB, avoid alcohol/caffeine/ spices/peppermint, stop smoking, weight reduction if obese.
- Antacids PRN
- H2 blockers in high doses at night or divded twice a day.
- PPI if H2 blockers are ineffective.
- GI/surgical consult
Diverticulitis
Inflammation or localized perforation of one or more diverticula with abscess formation.
More common in women than men.
Caused is not clear but found in low dietary fiber and age.
S/S of diverticulitis
- Mild to moderate LLQ pain and fever are main clinical feature.
- Pts with free perforation present with more generalized pain and peritoneal signs.
- Constipation or loose stools may be present.
- N/V
Lab/diagnostics of diverticulitis
- Mild to moderate leukocytosis
- Elevated ESR, c-reactice protein and procalcitonin level
- Positive stool heme in 25% of pts.
- Sigmoidoscopy shows inflamed mucosa (avoid during acute phase)
- Plain abdominal films are obtained on all pts to look for evidence of free air (pneumoperitoneum)
- May consider CT scan to evaluate abscess
Management of diverticulitis
NPO dependent on condition
IV fluids to mantain hydration
If significant GI bleed present, treat as outline under PUD.
Surgical consult
Antibioitic therapy if needed with augmentin
Cholecystitis
Inflammation of the gallbladder, associated with gallstones in >90% of cases.
Gallstones become impacted within the cystic duct and inflammation occurs behind the impaction.
Acalculous cholecytitis-absence of stone, 5% of cases.
S/S of cholecystitis
Often precipitate a large and/or fatty meal.
A sudden appearance of steady, severe pain in epigastrium or right hypochondrium.
Vomiting in many pts provides relief.
Positive Murphy’s Sign: deep pain on inspiration while fingers are placed under the right rib cage.
RUG tenderness to palpation
Palpable gallbladder in 15% of cases.
Muscle guarding and rebound pain
Fever.