GI concerns/Abdominal Pain

Question 1

Review normal anatomic and physiologic changes of the GI system

Answer 1

Gastric compression by gravid uterus

Increased serum progesterone → decreased lower esophageal sphincter tone, gastric acid secretion, bile and small bowel motility

Physiologic nausea and vomiting of pregnancy

Question 2

List the physiologic causes of abdominal pain

Answer 2

Without other symptoms or signs can be due to an enlarging uterus, fetal pressure against adjacent organs, and Braxton-Hicks uterine contractions

Pain is generally in the quadrant where the affected organ is located

Question 3

Differential diagnosis: common discomforts vs serious diagnosis

Answer 3

Pain intensity, nature, temporal pattern, radiation, exacerbating factors, and alleviating factors help narrow the differential dx

Common Discomforts

• —Round ligament pain
• —Nausea
• —Fetal position or movement
• —Acid reflux
• —Braxton hicks
• —Constipation

Serious Diagnosis

• —Celiac disease
• —Acute Fatty Liver of Pregnancy
• —Appendicitis
• —Pancreatitis
• —Cholecystitis
• —Peptic Ulcer disease

Question 4

Red flag symptoms

Answer 4

• —Moderate or severe pain associated with other symptoms (N/V, vaginal bleeding, HA)
• —Fever greater than 100.5°
• —N/V after 20 weeks
• —Hematemesis
• —Bloody diarrhea
• —Jaundice

Question 5

Discuss the management approach (work up) to pain

Answer 5

• —Lab work - keep in mind normal pregnancy changes
  
  • —CBC with DIFF
    
    • WBCs of 10 - 14K normal → diff helpful
  • —LFTs
    
    • ALP normally elevated
    • AST/ALT usually stay the same
  • —BMP
    
    • Low Na+ (129 - 143) normal
  • —Amylase/Lipase
    
    • Lipase more sensitive, stays higher longer
    • Both usually dont change during pregnancy
  • —UA
• —Imaging
  
  • —Ultrasound - preferred due to safety, not always best method
  • —MRI - safe, avoid contrast (but no evidence of teratogenicity)
  • —CT - only if life threatening
• —Collaboration

Question 6

Celiac disease

Definition, signs, and symtoms

Answer 6

• Autoimmune disorder in that attacks gut
  
  • Ingestion wheat, rye, barley → chronic inflammation of small intestine → shrink villi → malabsorbtion
  • Genetic component—
  • 1% of population
  • Can walk around with it for years without knowing
• Symptoms
  
  • Cramping
  • Gas
  • Wt loss
  • Nausea
  • Pale stools
  • Diarrhea
  • —Malabsorption
  • —Dermatitis Herpetiformis - very itchy, often on joints (elbows/knees)
    
    • 25% of people w/celiac

Question 7

Celiac Disease

Diagnosis and treatment

Answer 7

• —Best to do testing before starting gluten free diet
• Diagnosis (does not need to be us, can’t hurt to refer to GI)
  
  • —IgA tTg - low cost, serum test of choice
  • —*Small bowel biopsy* - gold standard, looks for atrophic villi
  • —Skin biopsy for dermatitis herpetiformis
  • —Genetic testing
    
    • 99% of celiac have HLA DQ2, DQ8 or both
• —Treatment
  
  • —Gluten free diet
  • —Dermatitis Herpetiformis: Dapsone (benefit outweighs risk. Use smallest amount for shortest amount of time possible)

Question 8

Celiac Disease

Effects on pregnancy and effects of pregnancy on CD

Answer 8

• Increased risk for:
  
  • Miscarriage
  • IUGR
  • LBW
  • Preterm delivery
• —Referral
• —Educate
  
  • Hidden sources of gluten, reading labels. “Modified food starch”
• —Monitor
  
  • Risk for anemia due to malabsorption, weight gain, higher rates of depression

Question 9

Acute Fatty Liver

Discuss incidence and signs and symptoms

Answer 9

• Rare, serious, specific to pregnancy.
  
  • 1 in 10,000
  • More common in primipara, multiple gestation, 3rd tri
• Accumulation of Microvesicular fat → takes over liver and prevents it from doing its job
• Signs/symptoms
  
  • —Nausea/vomiting
  • —Malaise
  • —Anorexia
  • —Epigastric pain
  • —Progressive jaundice
  • —Signs suggestive of Preeclampsia
    
    • can be misdiagnosed or have both

Question 10

Acute Fatty Liver

Diagnosis and treatment

Answer 10

• —Diagnosis
  
  • —Lab values
    
    • —CBC
    • —LFTs
    • —Creatinine
    • —Coagulation studies
      
      • Fibrinogen < 200 concerning
    • —Hypoglycemia*
      
      • *helps distinguish from other issues*
  • —Imaging
  • —Liver biopsy—
• —Treatment
  
  • —DELIVERY
  • —ICU
    
    • Many also have pancreatitis
    • Very sick patients
• REFER

Question 11

Appendicitis

Signs and symptoms

Answer 11

• —Nausea/Vomiting/Anorexia
• —RLQ pain (may start periumbilical first)
  
  • Most common presenting sx regardless of pregnancy
  • Gradual onset, may radiate to flanks/thighs
  • Appendix may migrate upward/laterally due to gravid uterus
• —Fever/tachycardia
• —Guarding/rebound tenderness
  
  • Dependent based on how hard you push
  • Abdominal wall laxity + interposition of the gravid uterus between the appendix and the anterior abdominal wall in late pregnancy may mask the classical signs of peritonitis

Question 12

Appendicitis

Diagnosis and treatment

Answer 12

• —Diagnosis
  
  • —Lab work
    
    • Elevated WBCs
  • —Imaging:
    
    • —Ultrasound
    • —MRI - better at dx
• —Treatment
  
  • Appendectomy
    
    • Safer during 2nd tri, but can do 1st if needed.
    • Can be laprascopic during 1st & 2nd, possibly 3rd

Question 13

Appendicitis

Morbidity/mortality related to delay in diagnosis

Answer 13

• Need prompt recognition of emergency
• Delay in diagnosis increases morbidity and mortality for both parent and fetus.
• Perforation associated with higher mortality (esp for fetus)

Question 14

Cholecystitis

Patho, signs, and symptoms

Answer 14

• 2nd most common surgical case after appendicitis
• Increased estrogen → increased cholesterol crystals and thicker sludgy bile → progesterone slows everything down
• —Symptoms
  
  • RUQ or epigastric pain (focal)
  • —Referred pain to right scapula, shoulder, or back
  • —Nausea, vomiting
  • —Fever
  • —Murphys sign
  • Post prandial pain – often ate something fatty/greasy and pain starts after

Question 15

Cholycystitis

Diagnosis and treatment

Answer 15

• —Diagnosis
  
  • —Labs - WBC, AST/ALT, ALP elevations suspicious
    
    • —CBC
    • —LFTs
  • —Imaging
    
    • —RUQ ultrasound - very helpful
• —Treatment
  
  • —Conservative - may lead to more ER visits, earlier induction/Cesarean
    
    • —Inpatient management
    • —Hydration
    • —Antibiotic therapy
  • —Surgical Intervention
    
    • —Laparoscopic cholecystectomy
    • —ERCP: endoscopic retrograde cholangiopancreatography

Question 16

Cholycystitis

CNM/WHNP role

Answer 16

• Known Hx of Cholelethiasis?
  
  • Education
    
    • Avoid fatty, greasy foods
  • Nutrition consult
• Prompt recognition of an emergency – get to ER/triage for evaluation early

Question 17

Pancreatitis

Signs and symptoms

Answer 17

• Similar regardless of pregnancy
• —Epigastric pain radiating to back
  
  • may be more severe with leaning forward due to position of the pancreas
• —Nausea /vomiting
• —Fever (low grade)
• —Abdominal distention
• —Hypoactive bowel sounds
• —Guarding

Question 18

Pancreatitis

Diagnosis and treatment

Answer 18

• Diagnosis
  
  • —Lab work - degree of raise does not correlate with severity
    
    • —Amylase
    • —Lipase – most reliable marker
    • —WBCs
  • —Imaging
    
    • —Ultrasound - Hard to dx via US due to size of uterus
    • —MRCP: magnetic resonance cholangiopancreatography
• Treatment
  
  • —IV fluids
    
    • May be inpatient longer, dehydration is generally harder to manage in pregnacy
  • —Analgesia
  • —Bowel rest/NPO
  • —Antibiotics with severe disease

Question 19

Pancreatitis

Disease effects of pregnancy on pancreatitis and pancreatitis on pregnancy

Answer 19

• Occurs in about 1 per 3000 pregnancies
• Most commonly during the 3rd tri
• Gallstones cause about 70% of cases during pregnancy
• Hyperlipidemia is 2nd most causative factor
• Pregnancy does not necessarily predispose the patient to pancreatitis, BUT pregnancy does:
  
  • Increase serum cholesterol
  • Cause biliary stasis
  • Induces gall stone formation.

Question 20

Inflammatory Bowel Disease

Signs and symptoms

Answer 20

• —Abdominal pain
• —Diarrhea
  
  • Bloody diarrhea main symptom of UC x 4 weeks
• —Fatigue
• —Weight loss
• —Fever
• —Extraintestinal symptoms
• —Arthritis - 20% have arthritis typically in large joints
• —Skin disorders - 10% have derm issues

Question 21

Inflammatory Bowel Disease

Diagnosis and treatment

Answer 21

• ——Diagnosis
  
  • Labs
    
    • Known diagnosis
      
      • —Iron
      • —B12
    • —Acute evaluation
      
      • —CBC
      • —CMP
  • —Ultrasound: r/o other dx
  • —Endoscopy with biopsy
    
    • gold standard → often delayed pp
• Treatment
  
  • —IV fluids
  • —Correction of electrolyte disturbances
  • —Antibiotics
  • —Anti-inflammatory and immunosuppressive agents
    
    • —Anti-tumor necrosis factor agents
    • —Glucocorticoids
    • Methotrexate often used as treatement → SUPER contraindicated during pregnnacy
      
      • Need to be off at least 3 months, preferrably 6 months before conception.

Question 22

Inflammatory Bowel Disease

Discuss effects of IBD on pregnancy and effects of pregnancy on IBD

Answer 22

• —Preconception Counseling – send to MFM
  
  • Timing conception is important – wait until in remission to become pregnant
  • Active disease doesn’t tend to get better during pregnancy
• —Management
  
  • At risk for antepartum hemorrhage and LBW, premature delivery
  • Manage/eval B12
    
    • *need 2g of folic acid a day
    • High risk in 3rd tri with active disease
• —Collaboration
• —Nutrition consult
• —Mode of delivery

Question 23

Peptic Ulcer

Discuss signs and symptoms

Answer 23

• —Symptoms less common during pregnancy despite increased GERD
• Most common causes: h. pylori, NSAIDS, ASA
• Epigastric pain #1 symptom
• —Nausea
• —Anorexia, early satiety
• —Heartburn

—

• Duodenal Ulcer
  
  • —Pain may improve when eating
  • —Pain: 2-5 hours postprandial
• —Gastric Ulcer
  
  • —Eating does not improve pain
  • —Pain: 30 min-2 hours postprandial

Question 24

Peptic Ulcer

Diagnosis and treatment

Answer 24

• —Diagnosis
  
  • —CBC
    
    • Lab work not super helpful
    • May see anemia that you would see anyway
  • —Upper Endoscopy
  • —Endoscopic biopsy
• —Treatment
  
  • —Antacids: 1st line
    
    • Avoid antacid with sodium bicarb to avoid fluid overload
    • Tums: dosage during pregnancy is different, read back of bottle
  • —H2 Receptors
  • —Proton-pump inhibitors
  • —H Pylori:
    
    • Timing is controversal. May delay tx until after 1st tri
    • —Amoxicillin 1000mg BID x 14 days WITH
    • —Clarithromycin 500mg BID
      
      • OR
    • Metronidazole 500mg BID

Question 25

Discuss the physiologic effects of pregnancy on abdominal disorders

Answer 25

* Displaced organs (ie appendix moved superior and lateral) * Abdominal wall laxity * Position of the gravid uterus btw appendix and anterior abdominal wall in late pregnancy may mask the classical signs of peritonitis * Extraintestinal abdominal conditions/disorders promoted by pregnancy. * Diminished muscle tone in urinary tract from elevated progesterone levels and mechanical obstruction from uterine compression → mild hydronephrosis and hydroureter * Common during pregnancy, particularly early 3rd trimester . * Hydronephrosis in pregnancy is usually asymptomatic, may have positional abdominal discomfort * Mucosal immunity may be attenuated as part of the physiologic immunologic tolerance for the foreign fetal antigens. * Combined with urinary stasis → increased rate of cystitis and pyelonephritis. * Increased cholesterol synthesis + gallbladder hypomotility → cholelithiasis

Question 26

List causes, signs, symptoms of upper and lower GI bleeding

Answer 26

Most common causes of Upper GI hemorrhage: * GERD * Gastritis * Mallory-Weiss tear - tear of mucus membrane near where the lower part of the esophagus joins upper part of the stomach (often from coughing/vomiting) * Ulcers Rare causes: * Esophageal varicies * Gastric cancer Most common rectal bleed: hemorrhoids

Question 27

**Ectopic pregnancy** Risk factors

Answer 27

* Previous ectopic * Prior PID * Previous tubal surgery or blockage * Abdominal surgery * Advanced maternal age * Cigarette smoking * Intrauterine device * Prior abortions * History of subfertility

Question 28

**Ectopic Pregnancy** Diagnostic modalities

Answer 28

* Quantitative serum hCG * increase by less than 50% during a 48-hour period → almost always nonviable * Transvaginal US * should see gestational sac (GS) when hCG level is above discriminatory zone (1500 - 2000). * Sometimes can definitively dx by showing an extrauterine GS with a yolk sac or embryo * More frequently only suggestive of ectopic * Adnexal mass = most common sono finding in ectopic * solid or complex saclike ring * Pelvic free fluid. * MR imaging * Excellent to confirm or better define suspected ectopic esp when US doesnt show ectopic focus or distinguish from incomplete AB. * Can help dx the rare or complicated form of EP * Can better distinguish btw GS and corpus luteum cyst (look similar on US)

Question 29

**Ectopic Pregnancy** Conservative management

Answer 29

* _Expectant management_ for clinically stable asymptomatic patients with: * US dx of EP and * Decreasing serum hCG initially \< 1000 mIU/mL * _Medical therapy_ (methotrexate) should be offered to: * serum hCG value \< 3000 mIU/mL, and * minimal symptoms * _Surgery_ is usually needed when: * Severe symptoms, bleeding, or high hCG levels are present. * Laparoscopic surgery is typically used. * Emergency laparotomy for ruptured ectopic