GI Part 2 Flashcards
1
Q
Nausea and Vomiting
A
2
Q
N/V Clinical Presentation
A
3
Q
N/V Associated Symptoms
- Abdominal p____
- H______, D____ness
- Ti_____
- Di______
- F______
- ______ status changes
- Pr______
- An_______
A
- Abdominal pain
- Headache
- Dizziness
- Tinnitus
- Diarrhea
- Fever
- Mental status changes
- Pregnancy
- Anxiety
- If a patient has NO symptoms of abdominal pain this may be indicative of serious illness, especially if they have neuro symptoms*
- Neuro symptoms: Headache, visual disturbances, ataxia, vertigo*
4
Q
Acute Emergencies
(5)
Usually accompanied by f___ or p___
A
Acute pancreatitis
Appendicitis
Bowel obstruction (SBO or Ileus)
Peritonitis
Cholecystitis
*Usually accompanied by fever or pain
5
Q
Chronic or Recurrent N/V
- May be p______
- Result of r____ or ch_____
- G_____ disorders
- M_____ headaches (aura)
- Diabetic gastrop_____
- M_____ or e_____ abnormality
A
- May be psychogenic
- Result of radiation or chemotherapy
- Gastric disorders
- Migraine headaches (aura)
- Diabetic gastroparesis
- Metabolic or endocrine abnormality
6
Q
N/V Physical
- W_____, t______; _____ BP, p___ rate
- Skin exam to assess t____, co____, mo_____, ra___
- C_ exam
- Abdominal exam to assess for dis_______, per_____, _____ness, ri____, re_____, m______
- M____ status, g____, C_ function
- Additional exam in children to include: Presence of t____, Urination or # wet (1)
A
- Weight, temperature; orthostatic VS; pulse rate
- Skin exam to assess turgor, color, moisture, rash
- CV exam
- Abdominal exam to assess for distention, peristalsis, tenderness, rigidity, rebound, masses
- Mental status, gait, CN function
- Additional exam in children to include: Presence of tears, Urination or # wet diapers
- Abdominal exam includes abnormal BS, peritoneal signs, focal or flank tenderness*
- Neuro exam includes retinopathy and papilledema, nystagmus, stiff neck, ataxia of gait*
7
Q
N/V Diagnostic
Diagnostics depend on differentials
- If N/V is <24 hours =
- Lab tests may include = (2)*
- (1) if obstruction or peritonitis suspected
A
- If N/V is <24 hours = no labs are generally needed; Presentation, history and diff dx will guide testing
- Lab tests may include = UA or urine dipstick (SGravity), serum electrolytes, glucose, BUN, Scr, serum ketones, amylase (r/o pancreatitis), LFT’s (alk phos and AST r/o acute cholecystitis, choledocholithiasis) drug levels, Hcg, CBC with diff, TSH
- Abd X-ray if obstruction suspected
8
Q
N/V Non-Pharm Management
- No _____ for at least 24 hours and ____ liquids for 24 hours; start with (1) (15mLs) every __ minutes
- Hydration status should be assessed by pt’s ability to _____ every 2-3 hours
- Followed by (1) diet for 24 hours
- (1) diet approx 1 week
A
- No solids for at least 24 hours and clear liquids for 24 hours; start with 1 tbsp. (15mLs) every 10 minutes
- Hydration status should be assessed by pt’s ability to void every 2-3 hours
- Followed by BRAT (bananas, rice, applesauce, toast) diet for 24 hours
- Bland diet approx 1 week
- Most n/v is self-limited and supportive therapy is all that is indicated; although must look at cause to dictate therapy
- No solids for 8-12 hours in children
- Advance diet as tolerated: if vomiting does not occur, double fluids every hour, if vomiting occurs, allow stomach to rest briefly and then start again
- May use glucose-electrolyte solutions for infants and small children such as Pedialyte or Rehydralyte
- Regular diet may resume as tolerated: usually 4 hours after vomiting stops
- For children, advance to BRAT diet
9
Q
N/V Pharm Management
Pharm management should be started if pt is too nauseated or does not respond to PO intake, IV hydration should be started
Antiemetics in children?
- (1) for motion sickness
- (1) for gastroparesis, GERD, chemo SE
- (1) for cancer, RT, surgery (preg class B)
- (1) for migraine induced vomiting (preg class C)
A
Antiemetics should not be given routinely in children
- Dramamine for motion sickness
- Reglan for gastroparesis, GERD, chemo SE
- Zofran for cancer, RT, surgery (preg class B)
- Promethazine (Phenergan) for migraine induced vomiting (preg class C)
10
Q
N/V in Infants and Children
- Usually mild, short-lived _____
- Weight loss may indicate an _____ problem
- Weight gain may indicate over-_____
- Any child with emesis plus colicky abdominal pain or fever >24 hours must be?
A
- Usually mild, short-lived virus
- Weight loss may indicate organic problem
- Weight gain may indicate over-feeding
- Any child with emesis plus colicky abdominal pain or fever >24 hours must be evaluated immediately in the ED (acute abdomen?)
Infancy: consider pyloric stenosis: projectile vomiting, epigastric mass
11
Q
Oral Rehydration and Diet in Peds
- _____ to eat or drink for _-_ hours after vomiting; then start with 1 ___ (sip) of ____ liquid every __-__ min
- If clear liquids tolerated for 2-3 hours may advance diet to _____ diet and ___ liquid as tolerated
A
- Nothing to eat or drink for 2-3 hours after vomiting; then start with 1 tsp (sip) of clear liquid every 10-15 min
- If clear liquids tolerated for 2-3 hours may advance diet to bland diet and full liquid as tolerated
12
Q
Oral Rehydration and Diet in Peds
Type of liquids that should be avoided?
Type of food that should be avoided?
Recommended foods include a combination of complex _______ (r____, wh____, p____, br____), ____ meats, yo___, fr___, and v______
A
Apple, pear, and cherry juice, and other beverages with high sugar content, including sports drinks (Gatorade), should be avoided since they have too much sugar and have inappropriate electrolyte levels
High fat foods are difficult to digest and should be avoided
Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables
13
Q
GI Bleeding
- (1) esophageal (varices, ulceration, esophagitis), Gastritis, Cancer, PUD, neoplasm
- (1) Meckel’s diverticulum, Crohn’s, Ulcer disease, Varices
- (1) hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD
A
- Hematemesis esophageal (varices, ulceration, esophagitis), Gastritis, Cancer, PUD, neoplasm
- Melena Meckel’s diverticulum, Crohn’s, Ulcer disease, Varices
- Hematochezia hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD
14
Q
GI Bleeding Physical Exam
- Vital signs: postural ______
- C______ exam
- Skin: p____, e____moses, pet____, tel______, stigmata of chronic ____ dx
- Nose/Pharynx: source of _____
- Lymph nodes: enlarged in ______
- Abdomen: masses, He______
- R___ exam
A
- Vital signs: postural hypotension
- Cardiovascular exam
- Skin: pallor, ecchymoses, petechiae, telangiectases, stigmata of chronic liver dx
- Nose/Pharynx: source of bleeding
- Lymph nodes: enlarged in malignancy
- Abdomen: masses, hepatosplenomegaly
- Rectal exam
15
Q
GI Bleeding Diagnostics
- Labs: ____ (Hgb may not reflect acute loss), Co____ studies, R____ (elevated BUN) and L____ function
- Hematochezia (fresh blood per anus) if >50yo, _____ is warranted
- Hematemesis: En_____ + B______ to r/o (1) diagnosis
- Melena: decide location first, probably ____
- Occult bleeding: do a ________
A
- Labs: CBC (Hgb may not reflect acute loss), Coag studies, Renal and Liver function
- Hematochezia (fresh blood per anus) if >50yo, Colonoscopy is warranted
- Hematemesis: Endoscopy + Biopsy to r/o H.Pylori diagnosis
- Melena: decide location first, probably upper
- Occult bleeding: do a colonoscopy
16
Q
GI Bleeding Diagnosis
- (1): cirrhosis, chronic liver disease, alcoholism, meds, epigastric pain
- IBD sx: d_____, ur_____, cr_______
- _____ rectal bleeding: diverticular, ulcerative colitis, rectosigmoid disease
A
- Hematemesis: cirrhosis, chronic liver disease, alcoholism, meds, epigastric pain
- IBD sx: diarrhea, urgency, cramping
- Frank rectal bleeding: diverticular, ulcerative colitis, rectosigmoid disease
17
Q
GI Bleeding Management
- Ulcer/gastritis: (2) Rx
- I____ replacement
- Anal bleeding: cause- hemorrhoids (if secondary to constipation-tx: f____ supplements or stool softener)
- (1) or (1) to prevent bleed in known varices (goal pulse < 70) secondary to ______
- Refer for ____ bleed, those who need en_____, un____ etiology of bleed
A
- Ulcer/gastritis: H2 blockers, omeprazole
- Iron replacement
- Anal bleeding: cause- hemorrhoids (if secondary to constipation-tx: fiber supplements or stool softener)
- Nadolol or Propanolol to prevent bleed in known varices (goal pulse < 70) secondary to cirrhosis
- Refer for acute bleed, those who need endoscopy, unclear etiology of bleed
18
Q
Appendicitis
Appendicitis is defined as an inflammation of the _____ lining of the _____ appendix that _____ to its other parts
- Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the ______ of the appendiceal ____
- Left untreated, appendicitis has the potential for severe complications, including ______ or ____, and may even cause _____
A
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts
- Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the obstruction of the appendiceal lumen
- Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death
19
Q
Appendicitis
- Most common in ages ___-___
- No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation, and the classic history of an_____ and p______ pain followed by n_____, (1) quadrant pain, and v_____ occurs in only 50% of cases
- PE: do a full (2) exam
- Labs will show (1)
A
- Most common in ages 10-15yo
- No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation, and the classic history of anorexia and periumbilical pain followed by nausea, RLQ quadrant pain, and vomiting occurs in only 50% of cases
- PE: do a full abdominal and rectal exam
- Labs will show elevated WBC (may be mildly high)
20
Q
Appendicitis Presentation in Children
=
- Younger children have (2) more often
- Exam: look for __Q tenderness, and m___ on rectal exam
- Treatment: if pain is Periumbilical, you may _____ the pt in __ hours in the clinic or ER, depending on the patient and family
A
The younger child is irritable, lies still, quiet with flexed hips
- Younger children have perforation and peritonitis more often
- Exam: look for RLQ tenderness, and mass on rectal exam
- Treatment: if pain is Periumbilical, you may re-evaluate the pt in 4 hours in the clinic or ER, depending on the patient and family
21
Q
Appendicitis Provocative Tests
(2)
A
Psoas and Obturator Sign
22
Q
Psoas Sign
=
What indicates a positive sign?
A
Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip.
Place your hand above the patient’s right knee. Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign
23
Q
Obturator Sign
=
What indicates a positive sign?
A
Raise the patient’s right leg with the knee flexed. Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign.
24
Q
Appendicitis Diagnostics
(2)*
- Diagnosis of acute appendicitis is suggested by the (1)
- CBC with diff (1) supports diagnosis
- U__, Beta ____, QN
- Imaging (1) or US if indicated
A
WBC and CT*
- Diagnosis of acute appendicitis is suggested by the H&P
- CBC with diff (WBC 10,000-16,000 supports diagnosis)
- UA, Beta HCG, QN
- CT scan or US if indicated
25
Appendicitis CT Results
Will show (2)
**Dilated fluid-filled appendix**
**Fat stranding** (Minimal inflammatory changes are also present in the adjacent mesenteric fat)
26
Appendicitis Management
**All cases of appendicitis require?**
(1) standard of care for acute uncomplicated appendicitis, give (1) pre-op
(1) has been studied as an alternative for uncomplicated appendicitis, however (1)
**Surgical consultation**
**Laparoscopic appendectomy,** give broad spectrum abx w gram - and anaerobic coverage
**Non op management with antibiotics** has been studied, however carries a recurrent appendicitis rate of 14-20% in 1st year
(Patients who present late (\>4-5 days after symptom onset may be treated initially with antibiotics, bowel rest and drainage if any abscess. Later (4- 10wks) appendectomy can then be performed in this subgroup only)
27
Inflammatory Bowel Disease
Refers to (2) chronic diseases that cause inflammation of the intestines
Increases incidence of (1) CA
* Peak onset __ to **\_\_** yo
* Second ‘peak’ incidence: ___ to __ yo
* Males vs. Females?
* (1) is greaest risk factor
* Ethnicity: (1) \> (1) \> (1)
**Ulcerative Colitis, Crohn's Disease**
Risk for Colorectal CA
* Peak onset 15 to 25 yo
* Second ‘peak’ incidence: 50 to 65 yo
* Approximately equal between males and females
* Family history is greatest risk factor
* Jewish \> Non-Jewish and Caucasian \> African American
28
Ulcerative Colitis
=
Diffuse inflammatory disease of bowel mucosa***, superficial and only in colon***
29
Crohn's Disease
Chronic relapsing inflammation-autoimmune
Distribution of disease is segmented **(skip lesions)**
**Extends through all layers of bowel wall, entire GI tract can be affected** ***(mouth to anus) , most commonly effects _ileocecal_ junction (between small and large intestine)***
30
Crohn's Disease Systemic Complications
* *E\_\_\_ inflammation*
* *Lower ____ density, g\_\_\_\_ failure in children*
* *Liver and B\_\_\_\_duct inflammation, gall\_\_\_\_\_*
* *S\_\_\_ lesions*
* *Kidney \_\_\_\_*
* *Subf\_\_\_\_\_ (more so in females)*
* *Ar\_\_\_\_\_, j\_\_\_\_ pain*
* *Eye inflammation*
* *Lower bone density, growth failure in children*
* *Liver and Bile duct inflammation, gallstones*
* *Skin lesions*
* *Kidney stones*
* *Subfertility (more so in females)*
* *Arthritis, Joint pain*
31
Ulcerative Colitis Presentation
**\_\_\_\_ diarrhea, ur\_\_\_\_\_, fecal in\_\_\_\_\_** (*from chronic diarrhea not the UC), **abdominal p\_\_\_\_\_***
**May have f\_\_\_\_, an\_\_\_\_\_, ____ loss**
Extracolonic manifestations include: (2) itis, j\_\_\_\_\_, skin \_\_\_\_\_
**Bloody diarrhea, urgency, fecal incontinence, abdominal pain**
**Fever, Anorexia, Weight loss**
Arthritis, uveitis, jaundice, skin lesions
32
Ulcerative Colitis
Frequently involves what parts of the GI tract? (2)
Diagnosis may be done by (1)
90% go into _____ after 1st attack
Distal Colon and Rectum
Diagnosis may be done by Sigmoidoscopy
90% go into remission after 1st attack
33
Ulcerative Colitis Management
**Mainstay =**
Initial tx/prophylaxis =
During inactive disease =
During flareup
Screen for (1)
**Biologics**
Mesalamine (5-ASA)- *NSAID that treats and prevents flare ups in UC* (other 5-ASAs include Asacol, Pentasa, Lialda)
1-2 tsp of Metamucil per day
Reduce dietary fiber during flare-up
Screen for Colon CA
Others: steroids, immunosuppression (6-MP, AZA, CsA), opiates, psychological support, surgery
34
Biologics used in UC
**(2)\***
+ others
**Vedolizumab (Amjevita), Golimumab (Simponi)**
* **_Adalimumab_ (_Humira_)**
* **_Infliximab_ (_Remicade_)**
* adalimumab-atto (Amjevita)
* adalimumab-adbm (Cyltezo)
* **_certolizumab_ pegol (_Cimzia_**)
* Infliximab-abda **(_Renflexis_)**
* infliximab-dyyb (**_Inflectra_)**
* **_tofacitinib_ (_Xeljanz_)**
35
Crohn's Disease Diagnosis
**Involves mostly (2) parts of the GI tract**
Diagnostics (3)
**Mostly small intestine, terminal ileum**
Colonoscopy/Tissue biopsy, EGD, Barium Enema
36
Crohn's Disease S/S
* D\_\_\_\_\_, abdominal p\_\_\_ (\_\_Q) or dis\_\_\_\_, weight \_\_\_, food \_\_\_\_\_, n\_\_\_, v\_\_\_\_\_, f\_\_\_\_, p\_\_\_anal pain /drainage, recurrent \_\_\_\_’s, pneumaturia, psoas ab\_\_\_\_
* **Extraintestinal**: \_\_\_itis, ankylosing spondylitis, \_\_\_i**tis**, aphthous o\_\_\_\_ ulcers, sclerosing cholangitis
* May have discreet RLQ \_\_\_\_
* Diarrhea, abdominal pain (RLQ) or distention, weight loss, food avoidance, nausea, vomiting, fever, perianal pain /drainage, recurrent UTI’s, pneumaturia, psoas abscess
* **Extraintestinal**: arthritis, ankylosing spondylitis, **uveitis**, aphthous oral ulcers, sclerosing cholangitis
* May have discreet RLQ mass
37
Crohn's Disease Diet Modifications
Adequate p\_\_\_\_\_ and calories, (1) for those with diarrhea, decreased \_\_\_, no \_\_\_\_\_
Supplemental (1)
May need bowel ____ or T\_ \_
Adequate protein and calories; fiber for those with diarrhea, decreased fat; no milk
Vitamins
May need bowel rest or TPN
38
Crohn's Disease Pharm Management
Rx (1)-(3) for control/prophylaxis
Others =
(1) reserved for intractable disease - most pts have to get it at some time
5-ASA agents (Asacol aka Mesalamine, Pentasa, Apriso)
Antibiotics, steroids, immunosuppression (6-MP, AZA), biologics, opiates, psychological support
Surgery
39
Biologics used in Crohn's Disease
(6)
Adalimumab (Humira) + other variations
Certolizumab (Cimzia)
Infliximab (Remicade) + other variations
Natalizumab (Tysabri)
Ustekinumab (Stelara)
Vedolizumab (Entyvio)
40
**Chronic benign GI disorder: abdominal pain, bloating, and disturbed defecation that is classified as functional bc there are no structural/biochemical abnormalities**
Irritable Bowel Syndrome
41
Irritable Bowel Syndrome
* Gender ___ \> ___ (2:1)
* Most common presentation: abdominal p\_\_\_ and bl\_\_\_\_\_; d\_\_\_\_\_ &/or c\_\_\_\_\_
* (1) criteria can help make diagnosis
* Women affected more than men (2:1)
* Most common presentation: abdominal pain and bloating; diarrhea &/or constipation
* Rome criteria can help make diagnosis
42
Rome IV Criteria for IBS
New definition
Functional GI disorders have a new definition. Rome IV defines them as follows: “Functional GI disorders are disorders of **gut-brain interaction.**
It is a group of disorders classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.
43
Rome IV Criteria for IBS
A person may experience problems with:
1. **(1):** The movement of food and waste through the GI tract
2. **(1):** Heightened experience of pain in the internal organs
3. **(1):** Changes in the gut’s immune defenses
4. **(1):** Changes in the community of bacteria in the gut
5. **(1):** Changes in how the brain sends and receives from the gut
1. **Motility disturbance**
2. **Visceral hypersensitivity**
3. **Altered mucosal and immune function**
4. **Altered guy microbiota**
5. **Altered central nervous system processing**
44
Rome Criteria for IBS
**\_\_\_\_\_ abdominal pain,** on average, at least __ days/week in the last\_\_ months associated with 2 or more of the following
1. Related to def\_\_\_\_\_\_\_
2. Change in _____ of stool
3. Change in _____ of stool
****Criteria fulfilled for the last __ months with symptom onset at least** __ **months before diagnosis.***
**Recurrent abdominal pain,** on average, at least 1 days/week in the last 3 months associated with 2 or more of the following
1. Related to defecation
2. Change in frequency of stool
3. Change in appearance/form of stool
****Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.***
45
IBS Work Up
* Weight -usually \_\_\_\_\_
* Abdominal exam: tenderness (usually \_\_Q) guarding, bowel sounds, masses, H\_ \_
* R\_\_\_\_ exam: tenderness, masses, blood
* Diagnostics: CBC, E\_\_\_, TSH, glucose, lytes, BUN/Scr Fecal o\_\_\_\_ ; stool for O&P x 3; stool culture, U\_\_\_ breath test
* May have imaging: Abd u/s and x-ray, KUB = , BE
* If severe symptoms or unsure-proceed w/ **(1)**
* Weight -usually stable
* Abdominal exam: tenderness (usually LLQ) guarding, bowel sounds, masses, HSM
* Rectal exam: tenderness, masses, blood
* Diagnostics: CBC, ESR, TSH, glucose, lytes, BUN/Scr Fecal occult ; stool for O&P x 3; stool culture, Urea breath test
* May have imaging: Abd u/s and x-ray, KUB (kidney, ureter, bladder), BE
* If severe symptoms or unsure-proceed w/ **colonoscopy**
46
IBS Management
Rome IV emphasizes that the best management for functional GI disorders requires a ______ approach which takes into consideration
* **Early life influences**: g\_\_\_\_\_, c\_\_\_\_\_, en\_\_\_\_
* **Psychosocial factors**: st\_\_\_\_, per\_\_\_\_\_\_, psychological state, cop\_\_\_, social su\_\_\_
* **Physiology**: m\_\_\_\_, sen\_\_\_\_, i\_\_\_\_\_ function, microf\_\_\_\_, food, diet
**Biopsychosocial Approach**
* **Early life influences**: genetics, culture, environment
* **Psychosocial factors**: stress, personality, psychological state, coping, social support
* **Physiology**: motility, sensation, immune function, microflora, food, diet
47
IBS Management
Treatment is purely symptomatic and includes dietary modifications, medications, behavioral therapy, education and reassurance
* Establish effective relationship with pt: ed\_\_\_\_\_ and re\_\_\_\_ is key
* Symptom d\_\_\_\_ (timing, associated sx, feelings)
* Predominate diarrhea: f\_\_\_\_ to bulk stool; **lo\_\_\_\_\_** 2-4 mg QID (45 min before meals) can be helpful
* Constipation: dietary fiber; laxative- **M\_\_\_\_\_** preferred
* Establish effective relationship with pt: education and reassurance is key
* Symptom diary (timing, associated sx, feelings)
* Predominate diarrhea: fiber to bulk stool; **loperamide** 2-4 mg QID (45 min before meals) can be helpful
* Constipation: dietary fiber; laxative- **Miralax** preferred
48
IBS Management Cont.
* Gas/Bloating: diet
* Abdominal \_\_\_\_\_\_: Bentyl 10-20mg TID, Levsin sl TID prn or Levbid
* St\_\_\_\_\_ reduction, \_\_\_feedback, ex\_\_\_
* Moderate to severe IBS, consider Rx (1)
* Follow-up in \_*-*\_ weeks then every \_*-*\_ mos
* Gas/Bloating: diet
* Abdominal cramping: Bentyl 10-20mg TID, Levsin sl TID prn or Levbid
* Stress reduction, biofeedback, exercise
* Moderate to severe IBS, consider SSRI
* Follow-up in 3-6 weeks then every 3-6 mos
49
Role of Serotonin in IBS
Serotonin is a neurotransmitter and a hormone that plays an important role in numerous life processes, including mood, sleep, appetite, temperature regulation, pain perception, sexual behavior, and the secretion of other hormones.
Although most of the body's serotonin is found in the ___________ system and in \_\_\_\_\_\_, its most well-known effects are in the \_\_\_\_\_.
Serotonin is an important signaling molecule in the gastrointestinal (GI) system, where it functions to initiate gut m\_\_\_\_\_, allow the stomach to ex\_\_\_\_, and transmit information to the \_\_\_\_.
Although most of the body's serotonin is found in the gastrointestinal system and in blood platelets, its most well-known effects are in the brain.
Serotonin is an important signaling molecule in the gastrointestinal (GI) system, where it functions to initiate gut motility, allow the stomach to expand, and transmit information to the CNS.
50
**Defined as a decrease in the frequency of bowel movements**
Most commonly occurring gastrointestinal complaint
This disorder does affect the pediatric population but is a common complaint among older adults and more prevalent in \_\_\_\_\_
Constipation
women
51
Common Causes of Constipation
**Common causes (mostly functional)**
* ______ urge to defecate (most common)
* inadequate f\_\_\_\_ and fl\_\_\_\_ in diet; sed\_\_\_\_\_
* met\_\_\_, en\_\_\_\_, n\_\_\_\_, colorectal disorder
**Elderly patients:**
* Diminished vit\_\_\_\_, decreased act\_\_\_\_, consequence of _____ illness and medications, poor d\_\_\_\_ habits, and decreased fl\_\_\_ intake
**Common causes (mostly functional)**
* ignoring urge to defecate (most common)
* inadequate fiber and fluids in diet; sedentary
* metabolic, endocrine, neuro, colorectal disorder
**Elderly patients:**
* Diminished vitality, decreased activity, consequence of chronic illness and medications, poor dietary habits, and decreased fluid intake
52
Rome Criteria for Constipation
Functional constipation categorized under new Rome criteria IV
* IBS subtypes (constipation and diarrhea) are now based on abnormal _____ type occurring at least \_\_% of days
* IBS subtypes (constipation and diarrhea) are now based on abnormal stool type occurring at least 25% of days
New diagnoses added to this edition include reflux hypersensitivity syndrome, cannabinoid hyperemesis syndrome (CHS), opiod-induced constipation (OIC), and narcotic bowel syndrome (NBS). \*\*
\*\*“Many purists would say [these] are not really functional because [they have] a cause, but we have to rethink ... this in the 21st century,” Drossman said. “What we’re really saying is that these are conditions that will mimic other so-called functional GI conditions, which ... may have specific etiologies, and [they are] also consistent with our [new] definition [for functional GI disorders].”
53
Rome IV IBS Subtypes
* Subtypes are based on how _____ you experience very ____ or very ____ stools.
* The percentages are now based on stool ___ on days with at least one (1)
* In Rome III, the percentages were based on ____ stools.
* Subtypes are based on how frequently you experience very loose or very hard stools.
* The percentages are now based on stool form on days with at least one abnormal bowel movement.
* In Rome III, the percentages were based on total stools.
54
Constipation Eval: History
Pt def\_\_\_\_ of constipation; stool p\_\_\_\_ and recent changes, d\_\_\_, act\_\_\_\_, medication and lax\_\_\_\_\_ use, PMH, P\_H
* *Rectal exam =*
* *Check for im\_\_\_\_\_--esp in elderly or those with chronic constipation*
History: pt definition of constipation; stool pattern and recent changes, diet, activity, medication and laxative use, PMH, PSH
* *Rectal exam: fissures, hemorrhoids, irritation, guiac disease*
* *check for impaction--esp in elderly or those with chronic constipation*
55
Meds Associated with Constipation
* O\_\_\_\_\_ and related narcotics
* Nonsteroidal anti-inflammatory drugs
* At\_\_\_\_\_, dicyclomine, hyoscyamine, clidinium,
* Tricyclic anti\_\_\_\_\_, Antip\_\_\_\_ and neuroleptic , Anti-par\_\_\_\_\_ drugs,
* Calcium channel antagonists, Central alpha adrenergic agonists, Hy\_\_\_\_\_
* MAO inhibitors, Methyl-\_\_\_\_\_,
* Aluminum (ant\_\_\_\_, sucralfate), I\_\_\_\_ supplements, Calcium supplements, Barium sulfate,
* Heavy m\_\_\_\_ intoxication (lead, mercury, arsenic), V\_\_\_\_ alkaloid, Cholestyramine, Sodium polystyrene sulfate
* Opioids and related narcotics
* Nonsteroidal anti-inflammatory drugs
* Atropine, dicyclomine, hyoscyamine, clidinium,
* Tricyclic antidepressants, Antipyschotic and neuroleptic , Anti-parkinsonian drugs,
* Calcium channel antagonists, Central alpha adrenergic agonists, Hydralazine
* MAO inhibitors, Methyl-DOPA,
* Aluminum (antacids, sucralfate), Iron supplements, Calcium supplements, Barium sulfate,
* Heavy metal intoxication (lead, mercury, arsenic), Vinca alkaloid, Cholestyramine, Sodium polystyrene sulfate
56
Constipation PE
* Not uncommon to have _____ findings
* Orthostatic hypotension and/or tachycardia implies \_\_\_\_\_\_\_
* Wt loss suggests an\_\_\_\_\_ or ca\_\_\_\_\_
* O\_\_\_\_ exam
* G\_, G\_\_\_, R\_\_\_\_\_ exam
* N\_\_\_\_\_ exam
* Not uncommon to have normal findings
* Orthostatic hypotension and/or tachycardia implies dehydration
* Wt loss suggests anorexia or carcinoma
* Oral exam
* GI, GYN, Rectal exam
* Neuro exam
57
Constipation Diagnostics
* Labs (3)
* (2) urine and stool
* Imaging (4)
* C\_\_\_\_\_\_ or Flex Sig
* Anorectal manometry (measures _____ of anal sphincter muscles)
* Colonic tr\_\_\_\_\_\_ studies
* Electromyelogram (assess _____ of muscles and nerve cells that control them)
* CBC with diff, Chemistry profile, TSH
* UA, Stool for occult blood/Stool culture
* AXR/ KUB, Abdominal u/s, BE
* Colonoscopy or Flex Sig
* Anorectal manometry (measures pressure of anal sphincter muscles)
* Colonic transport studies
* Electromyelogram (assess health of muscles and nerve cells that control them)
58
Constipation Management
* Keep stool d\_\_\_\_
* Increase f\_\_\_\_ intake
* Increase dietary fiber and supplements: Meta\_\_\_\_, Fiberall or Fibercon, stool s\_\_\_\_\_, or os\_\_\_\_\_ agents;
* If straining still present a l\_\_\_\_\_ is indicated (3)
* _____ if \> 50 years old: unresponsive to tx, positive hemoccult, or weight loss
* Keep stool diary
* Increase fluid intake
* Increase dietary fiber and supplements: Metamucil, Fiberall or Fibercon, stool softeners, or osmotic agents;
* If straining still present a laxative is indicated
* Senna, Bisacodyl, Miralax
* Refer\> 50 years old: unresponsive to tx, positive hemoccult, or weight loss
59
FDA Approved Meds for Constipation
1. **(1)** (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
2. **(1)** *(linaclotide)* is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
3. **(1)**, a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
4. **(1)** (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
5. **(1)**, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
6. **(1)** (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
7. **(1)** (Ibsrela) ADULTS only
1. **Amitiza** (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
2. ***Linzess** (linaclotide)* is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
3. **Lactulose**, a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
4. **Miralax** (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
5. ***Trulance***, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
6. **Tegaserod** (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
7. **Tenapanor** (Ibsrela) ADULTS only
60
Diarrhea
=
1. **Acute diarrhea** usually has ab\_\_\_\_\_ onset and lasts \< ___ weeks, s\_\_\_\_-limiting
* Most cases of acute diarrhea are _____ and occur within hours of exposure; most common etiology is (1)
2. **Chronic diarrhea** lasts longer than __ to __ weeks, can be intermittent or continuous, and is classified as inf\_\_\_\_, os\_\_\_\_, sec\_\_\_\_, fac\_\_\_\_\_ or related to altered intestinal motility (1)
* Medications, particularly ch\_\_\_therapeutic agents, en\_\_\_\_ feedings, laxatives, antib\_\_\_\_, caf\_\_\_\_, magnesium antacids, alcohol may cause diarrhea
**Defined as an increase liquidity and frequency of stools**
1. Acute diarrhea usually has abrupt onset and lasts \< 1 week, self-limiting
1. Most cases of acute diarrhea are infectious and occur within hours of exposure; most common etiology is viral gastroenteritis
2. **Chronic diarrhea** lasts longer than 2 to 3 weeks, can be intermittent or continuous, and is classified as inflammatory, osmotic, secretory, factitious or related to altered intestinal motility (IBS)
* Medications, particularly chemotherapeutic agents, enteral feedings, laxatives, antibiotics, caffeine, magnesium antacids, alcohol may cause diarrhea
61
Diarrhea Presentation
* ______ is the most helpful tool in determining etiology of illness
* D\_\_\_\_\_ of illness, fr\_\_\_\_\_ and l\_\_\_\_\_ of stool, presence of b\_\_\_ or m\_\_\_\_
* Social history including tr\_\_\_\_, al\_\_\_, emp\_\_\_\_, residence, st\_\_\_\_\_, se\_\_\_\_ practices
* Similar illness in f\_\_\_\_
* **Assoc sx’s =**
* **History** is the most helpful tool in determining etiology of illness
* Duration of illness, frequency and liquidity of stool, presence of blood or mucus
* Social history including travel, alcohol, employment, residence, stress, sexual practices
* Similar illness in family
* **Assoc sx’s:** N/V, abd pain or cramping, fever, malaise
* Increase thirst, oliguria, dizziness, tenesmus, wt loss, previous or current diagnosed condition (DM, thyroid, CA), current medications, dietary supplement
62
Diarrhea PE
* VS (2)
* CV (1)
* HEENT (1)
* Abdominal =
* Rectal =
* Temperature, Weight
* Cardiovascular status- postural hypotension
* Skin for color, turgor, rash, joint inflammation
* HEENT: conjunctivitis (Reiter’s)
* Abdominal exam: tenderness, distention, rigidity, tympany, bowel sounds, HSM
* Rectal exam: tenderness, masses, ? fecal impaction, occult blood
63
Diarrhea Diagnostics
* If duration 24-48 hours =
* **Labs** =
* **(1)**: Think inflammatory factor such as toxin producing bacteria (*Campylobacter, Shigella, Salmonella, C Diff, enterohemorrhagic E coli, Yersinia, E. histolytica*)
* If duration 24-48 hours, no tests indicated
* **Labs =** Stool culture, including occult blood, fecal leukocytes, CBC with diff, electrolytes, glucose, BUN, Scr, for fever \>24 hours
* **+ leukocytes**: Think inflammatory factor such as toxin producing bacteria (*Campylobacter, Shigella, Salmonella, C Diff, enterohemorrhagic E coli, Yersinia, E. histolytica*)
64
Diarrhea Management
Usually \_\_\_-limiting, treatment measures should be directed toward ______ relief
\_\_\_\_\_ fluid replacement
\_\_ hydration for severe hydration or for young, old or immunocompromised patients
1. **Viral =**
2. **Bacterial =**
Usually self-limiting, treatment measures should be directed toward symptomatic relief
Oral fluid replacement
IV hydration for severe hydration or for young, old or immunocompromised patients
1. **Viral**: no specific therapy; handwashing, keep children from day care until resolved
2. **Bacteria**l: Treat according to organism
65
Oral Rehydration Solution for Diarrhea
Pre-formulated solution such as (1) is recommended in the pediatric population
If pre-formulated solution is unavailable, you can make your own oral rehydration solution by (3)
Be sure to measure accurately because incorrect amounts can make the solution less effective or even harmful. (2)
Pre-formulated solution such as Pedialyte is recommended in the pediatric population
½ teaspoon salt + 6 teaspoons sugar + 1 liter of safe drinking water
Too much sugar makes diarrhea worse, Too much salt is dangerous
66
Diarrhea Management Cont.
* Follow-up if diarrhea not resolved in Supportive therapy: maintain adequate hydration status (same as vomiting); pro\_\_\_\_ (saccharomyces boulardii lyo-Florastor)
* Antimotility agents should be avoided in pts with ____ diarrhea, but loperamide/simethicone may improve symptoms in pts with ____ diarrhea
* Chronic: treat _____ cause
* Follow-up in office if diarrhea has not resolved in ___ hours
* Follow-up if diarrhea not resolved in Supportive therapy: maintain adequate hydration status (same as vomiting); pro\_\_\_\_ (saccharomyces boulardii lyo-Florastor)
* Antimotility agents should be avoided in pts with bloody diarrhea, but loperamide/simethicone may improve symptoms in pts with watery diarrhea
* Chronic: treat underlying cause
* Follow-up in office if diarrhea has not resolved in 48 hours
67
**Pseudomembranous colitis, caused by an enterotoxin or cytotoxin that alters the patient’s normal intestinal flora after antibiotic therapy**
* Can occur up to __ months after the medication has been taken
* Treatment of choice **(1) or (1)** for intolerance or no response
Clostridium Difficile
* Can occur up to 3 months after the medication has been taken
* **Metronidazole** (250-500mg QID in adults) or **Vancomycin** (125-500mg in adults) for intolerance or no response to Flagyl
68
Diverticular Disease
=
1. Prevalence \<5% for age \_\_years, increases with \_\_
2. Peak incidence of occurrence in (3) decades of life
* May cause **divert\_\_\_\_\_** if plugged and inflamed: 10-30% will present with this
* **D\_\_\_\_\_\_\_** usually asymptomatic
* **D\_\_\_\_\_\_\_\_**: LLQ pain, fever, and leukocytosis (Asian patients usually have ___ sided disease)
* **Complications (4)**
**Abnormal herniations of colonic mucosa**
1. Prevalence \<5% for age \< 40 years
2. Peak incidence of occurrence in 6th, 7th and 8th decades of life
* May cause **diverticulitis** if plugged and inflamed: 10-30% with disease will present with diverticulitis
* **Diverticulosis** usually asymptomatic
* **Diverticulitis**: LLQ pain, fever, and leukocytosis (Asian patients usually have Rt sided disease)
* Complications: **perforation, fistulas, obstruction, hemorrhage**
69
Diverticulosis vs. Diverticulitis
1. **D\_\_\_\_\_\_:** usually incidental finding
2. **D\_\_\_\_\_\_\_:** mild f\_\_\_\_\_ (\<101F, WBC \_\_\_-\_\_)
* bed\_\_\_\_ and (1) diet
* non\_\_\_\_ analgesics for pain
* May have abd pain, n/v/d
* if febrile, give ___ spectrum \_\_\_\_\_
* **Diagnostic test (1)**
* Barium enema ______ performed
* **(1)** If temperature \> 101oF despite antibiotics, pain worsens, peritoneal signs develop or WBCs rise
* **(1)** Once symptoms subside to rule out cancer
1. **Diverticulosis**: usually incidental finding
2. **Diverticulitis**: Mild (fever \<101oF, WBC 13,000-15,000)
1. bedrest and clear liquid diet
2. nonopiate analgesics for pain
3. May have abd pain, n/v/d
4. if febrile, broad spectrum antibiotic
5. **CT is diagnostic tool of choice using oral, IV and rectal contrast (although oral and IV most commonly done)**
6. Barium enema NEVER performed
* **Hospitalize -** If temperature \> 101oF despite antibiotics, pain worsens, peritoneal signs develop or WBCs rise
* **Lower GI endoscopy-** Once symptoms subside to rule out cancer
70
Diverticulosis Management
* Inc risk of symptomatic diverticular disease: ___ fiber, ____ fat and red meat
* ____ laxatives, enemas, and opiates
* Anti\_\_\_\_\_\_\_ may help but constipate
* Pt \_\_\_\_: report fever, tenderness, bleeding ASAP
* ______ research on avoiding seeds, nuts, popcorn, cucumbers, tomatoes, figs, corns, strawberries, caraway seeds to prevent diverticular complications
* JAMA 2008 large prospective study: __ associations were seen between nut, corn, popcorn consumption
* low fiber, high fat and red meat assoc with inc risk of symptomatic diverticular disease
* avoid laxatives, enemas, and opiates
* anticholinergics may help but constipate
* Pt Ed: report fever, tenderness, bleeding ASA
* Conflicting research on avoiding seeds, nuts, popcorn, cucumbers, tomatoes, figs, corns, strawberries, caraway seeds to prevent diverticular complications
* JAMA 2008 large prospective study: no associations were seen between nut, corn, popcorn consumption
71
Diverticulitis Management
Diverticulitis: Mild ____ ( - \_\_
* bed\_\_\_\_ and (1) diet
* (1) for pain
* monitor temp, a\_\_\_\_, ___ cells
* if febrile (1)
* (1) If temperature \> 101oF despite antibiotics, symptoms worsens, intolerance to oral fluids, peritoneal signs develop or WBCs rise
* If treating as outpatient re assess \_-\_ days after _____ of abx and ____ thereafter until resolution of all symptoms
Diverticulitis: Mild fever (\<101F), WBC 13,000-15,000
* bedrest and clear liquid diet
* Non opiate analgesics for pain
* monitor temp, abd, WBCs
* if febrile, broad spectrum antibiotic
* If temperature \> 101oF despite antibiotics, symptoms worsens, intolerance to oral fluids, peritoneal signs develop or WBCs rise: hospitalize
* If treating as outpatient re assess 2-3 days after initiation of abx and weekly thereafter until resolution of all symptoms
72
Broad Spectrum Antibiotics in Diverticulitis
(1) + (1) OR
(1) + (1) OR
(1) + (1) OR
(1) OR
(1)
**Cipro + Flagyl**
**Levofloxacin + Flagyl**
**Bactrim + Flagyl**
**Augmentin**
**Moxifloxacin**
73
Diverticulitis seen on CT
(4) Complications
* Diverticulitis. CT scan obtained with oral and intravenous contrast material shows wall _____ in the sigmoid colon (arrows) with adjacent inflammatory changes in the pericolic \_\_\_\_.*
Perforation, Abscess, Fistula, Obstruction
*Diverticulitis. CT scan obtained with oral and intravenous contrast material shows wall thickening in the sigmoid colon (arrows) with adjacent inflammatory changes in the pericolic fat.*
74
**Masses of vascular tissue that, along with connective and muscular tissue, form a cushion in the submucosal layer of the anal canal**
One of their functions is to maintain ____ of the anus
They are part of _____ human anatomy and therefore symptomatic hemorrhoids can potentially develop in all adults
Hemorrhoids
One of their functions is to maintain closure of the anus
They are part of normal human anatomy and therefore symptomatic hemorrhoids can potentially develop in all adults
75
Hemorrhoids Presentation
* (1) bleeding
* anal dis\_\_\_\_\_
* pr\_\_\_\_\_
* pro\_\_\_\_\_ or p\_\_\_\_
* painless bleeding
* anal discomfort
* pruritis
* protrusion or pain
76
Hemorrhoids Differentials
* Anal f\_\_\_\_
* C\_\_\_\_\_ disease
* Anal skin \_\_\_\_
* Con\_\_\_\_\_
* Rectal pro\_\_\_\_\_ (more common elderly)
* Anorectal ab\_\_\_\_\_
* Perianal t\_\_\_\_/rectal po\_\_\_\_
* Anal fissure
* Crohn's disease
* Anal skin tags
* Condyloma
* Rectal prolapse (more common elderly)
* Anorectal abscess
* Perianal tumors/rectal polyps
77
Mild Hemorrhoids Management
* high ____ diet, b\_\_\_\_-forming agents, *stool softener*
* (1) pads or baby wipes
* _____ baths 1-2x/day
* Rx (2) QID x7days
* high fiber diet, bulk-forming agents, *stool softener*
* witch hazel pads (Tucks) or baby wipes
* sitz baths 1-2x/day
* Anusol or PrepH QID x7days
78
Moderate Hemorrhoids Management
* \_\_\_\_Cream-HC 2.5% cream or A\_\_\_\_\_-HC 2.5% cream
* Anal\_\_\_\_-HC/ pram\_\_\_\_ 1%/1% or 2.5%/1% supp
* Severe: refer for \_\_\_\_\_\_
* ProctoCream-HC 2.5% cream or Anusol-HC 2.5% cream
* Analpram-HC/ pramoxine 1%/1% or 2.5%/1% supp
* Severe: refer for surgery
79
Colorectal Cancer
* Colon cancer is the ___ leading cause of cancer related deaths men and women (2nd most common cause of death gender combined)
* B\_\_\_\_\_ and His\_\_\_\_ are less likely to present with ____ stages and have a 50% greater chance of ____ from the disease
* Colon cancer is the 3rd leading cause of cancer related deaths men and women (2nd most common cause of death gender combined)
* Blacks and Hispanics are less likely to present with early stages and have a 50% greater chance of dying from the disease
80
Colorectal Cancer Risk Factors
* Prior C\_ \_
* Inflammatory ___ \_\_\_
* Hereditary and G\_\_\_\_\_ factors, familial \_\_\_\_\_posis syn
* Hx of br\_\_\_\_ or female g\_\_\_\_\_ cancer
* high \_\_\_, low ____ diet
Lifetime risk of developing is 2.5% in the general population, and 5 to 10% in persons who have a first-degree relative with ad\_\_\_\_\_\_ colon p\_\_\_\_ or colon ca\_\_\_\_
* Prior CRC
* IBD
* Hereditary and Genetic factors, familial polyposis syn
* Hx of breast or female genital cancer
* High fat, low bulk diet
Lifetime risk of developing is 2.5% in the general population, and 5 to 10% in persons who have a first-degree relative with adenomatous colon polyp or colon cancer
81
Polyps and Colorectal CA
* Between 70 to 90% of colorectal cancers arise from **(1)** (tubular adenoma, tubular villious, or villous adenoma).
* Polyps greater than **\_\_ cm** make the possibility of malignancy greater
* Those with ___ \_\_\_ ____ (FAP) syndrome have an almost 100% chance of developing cancer by age \_\_
* The adenomatous polyposis ___ (APC) increases susceptibility to the development of adenomatous polyps
* Between 70 to 90% of colorectal cancers arise from adenomatous polyps (tubular adenoma, tubular villious, or villous adenoma).
* Polyps greater than 1 cm make the possibility of malignancy greaterThose with familial adenomatous polyposis (FAP) syndrome have an almost 100% chance of developing cancer by age 40
* The adenomatous polyposis gene (APC) increases susceptibility to the development of adenomatous polyps
*The average time from onset of a polyp to onset of carcinoma is 10 to 15 years*
82
Colorectal CA Screening
Normal population =
Family history =
FAP syndrome =
New USPSTF guidelines =
For those with IBD (risk of carcinoma) =
Start at 50-75, 76-85 individual decision, dc at 85
Start at 40 or 10 years younger than diagnosis
Start at 10 years old
Offer screening starting at 45, continue from 50-75
Annual colonoscopy for IBD
83
Colorectal CA Screening Frequency
FOBT =
Colonoscopy =
Flex sigmoidoscopy =
Virtual colonoscopy =
Q 1-3 years depending on test
Q 10 years
Q 5-10 years (with FIT?)
Q 5 years
84
Colon CA Screening Details
(3) types of stool tests approved by FDA
* *(1) exam has low sensitivity*
* *Fecal occult testing: must do pt ed re: (1) x 3 days*
* *(1) is preferred test if fecal occult blood is positive*
* *Can also do air contrast (1)every 5-10 years, but not as sensitive as colonoscopy*
1. **gFOBT** (Guaiac FOBT)
2. **FIT, also known as iFOBT** (Fecal immunochemical or immunohistochemical test)
3. **FIT-DNA** (Multitargeted stool DNA testing)
* *Digital rectal exam has low sensitivity*
* *Fecal occult testing: must do pt ed re: restricted diet x 3 days*
* *colonoscopy is preferred test if fecal occult blood is positive*
* *Can also do air contrast barium enema every 5-10 years, but not as sensitive as colonoscopy*
85
GI Disorders seen in Pediatrics
1. Abdominal p\_\_\_\_
2. C\_\_\_\_\_ disease
3. Col\_\_\_
4. D\_\_\_\_\_/C\_\_\_\_\_\_\_
5. Failure to \_\_\_\_\_
6. F\_\_\_\_\_\_ aversion/disorder
7. G\_ *\_* \_
8. (1) infection
9. L\_\_\_\_\_ Intolerance
10. V\_\_\_\_\_\_\_
1. Abdominal pain
2. Celiac disease
3. Colic
4. Diarrhea/Constipation
5. Failure to thrive
6. Feeding aversion/disorder
7. GERD
8. H. pylori
9. Lactose Intolerance
10. Vomiting
86
Constipation in Peds
Defined as a de\_\_\_ or di\_\_\_\_\_\_ in defecation, present for _\>_ __ or more weeks and responsible for ~ 3-5 % of visits
1. Constipation in children usually is _____ and the result of stool \_\_\_\_\_\_
2. Constipation often causes more distress to (1) than to the affected child
Defined as a delay or difficulty in defecation, present for _\>_ 2 or more weeks and responsible for ~ 3-5 % of visits
1. Constipation in children usually is functional and the result of stool retention
2. Constipation often causes more distress to parents and other caregivers than to the affected child
87
Constipation in Peds Red Flags
Organic causes
* Hirs\_\_\_\_\_\_ disease (congenital aganglionic megacolon)
* Pseudo\_\_\_\_\_\_
* S\_\_\_\_\_ cord abnormality
* H\_\_\_thyroidism
* Diabetes in\_\_\_\_\_
* C\_\_\_\_\_ Fi\_\_\_\_\_
* Glu\_\_\_\_ enteropathy
* Con\_\_\_\_\_ anorectal mal\_\_\_\_\_
* Hirschsprung's disease (congenital aganglionic megacolon)
* Pseudoobstruction
* Spinal cord abnormality
* Hypothyroidism
* Diabetes insipidus
* Cystic fibrosis
* Gluten enteropathy
* Congenital anorectal malformation
88
Normal Frequency of BM's in Infants and Children
Mean # BMs/week, BMs/day
1. 0-3m
2. 6-12m
3. 1-3y
4. \>3y
1. 5-40, 2.9
2. 5-28, 2
3. 4-21, 1.4
4. 3-14, 1.0
89
Functional Constipation
95% of cases (in peds)
* Continence is maintained by (2) muscle contractions.
* (1) anal sphincter has an involuntary resting tone that decreases when stool enters the rectum.
* (1) anal sphincter is under voluntary control.
* If a child does not wish to defecate, he or she ______ the external anal sphincter and squeezes the gluteal muscles. These actions can push feces _____ in the rectal _____ and reduce the ____ to defecate. If a child frequently avoids defecating, the rectum eventually ______ to accommodate the retained fecal mass, and the pro\_\_\_\_\_ power of the rectum is diminished.
* The longer that feces remains in the rectum, the _____ it becomes
* Continence is maintained by involuntary and voluntary muscle contractions.
* internal anal sphincter has an involuntary resting tone that decreases when stool enters the rectum
* External anal sphincter is under voluntary control.
* If a child does not wish to defecate, he or she tightens the external anal sphincter and squeezes the gluteal muscles. These actions can push feces higher in the rectal vault and reduce the urge to defecate. If a child frequently avoids defecating, the rectum eventually stretches to accommodate the retained fecal mass, and the propulsive power of the rectum is diminished.
* The longer that feces remains in the rectum, the harder it becomes
90
Organic Causes of Constipation in Peds
Match the symptoms to the diagnosis
1. (1) Passage of meconium more than 48 hours after delivery, small-caliber stools, failure to thrive, fever, bloody diarrhea, bilious vomiting, tight anal sphincter, and empty rectum with palpable abdominal fecal mass
2. (1) Abdominal distention, bilious vomiting, ileus
3. (1) Decrease in lower extremity reflexes or muscular tone, absence of anal wink, presence of pilonidal dimple or hair tuft
4. (1) Abnormal position or appearance of anus
5. (1) Fatigue, cold intolerance, bradycardia, poor growth
6. (1) Polyuria, polydipsia
7. (1) Diarrhea, rash, failure to thrive, fever, recurrent pneumonia
8. (1) Diarrhea after wheat is introduced into diet
1. **Hirschsprung's disease**
2. **Pseudo-obstruction**
3. **Spinal cord abnormalities**
4. **Congenital anorectal malformations**
5. **Hypothyroidism**
6. **Diabetes insipidus**
7. **Cystic Fibrosis**
8. **Gluten enteropathy**
91
Constipation PE
* (1) should be performed to assess rectal tone and determine presence of rectal distension or impaction
* (2) findings that suggest diagnosis of functional constipation
* Digital rectal exam
* Rectal impaction, anal fissures (or papillae indicative of chronic anal fissures)
92
Constipation Diagnostics
If the rectal exam reveals fecal impaction?
If a rectal exam is not possible or is too traumatic for the child?
No imaging needed
Abdominal radiography may be considered
93
Disimpaction
1. Rx (1) for infant
2. Rx (3) for child
1. Rx (1) may also be required, caution dt SE of abdominal cramping
1. Glycerin Suppository or Enema
2. Saline, Mineral Oil, or 1:1 Milk Molasses enema
1. Oral laxative
94
Constipation Management (\>1yo)
Rx (3)
Lactulose
Senna
Polethylene Gylcol
95
Miralax Dosing Peds
\_\_\_-\_\_\_ g/kg/day
Higher initial dose of __ g/kg
Max ___ g/day
Once daily BM's achieved, ____ dose
Educate patient that once stool occurs?
0.2-0.8 g/kg/day
Higher initial dose of 1 g/kg
Max 17 g/day
Once daily BM's achieved, titrate dose
DO NOT stop med once stooling occurs
96
Differentials for Acute Pain in Children
1. M\_\_\_\_\_\_ diverticulum (congenital abnormality, occurs in 2% of the population. Diverticulae of atresia, usually found 2 feet from ileocecal valve)
2. Incarcerated h\_\_\_\_\_ or intestinal ob\_\_\_\_\_
3. T\_\_\_\_\_\_ torsion
4. Hir\_\_\_\_\_ disease
5. Con\_\_\_\_\_\_\_
6. App\_\_\_\_\_
7. Int\_\_\_\_\_\_\_
8. _____ common: pancreatitis, pneumonia, IBD, diabetic ketoacidosis, GYN, UTI, trauma
1. Meckel’s diverticulum (congenital abnormality, occurs in 2% of the population. Diverticulae of atresia, usually found 2 feet from ileocecal valve)
2. Incarcerated hernia or intestinal obstruction
3. Testicular torsion
4. Hirschsprung’s disease
5. Constipation
6. Appendicitis
7. Intussusception
8. Less common: pancreatitis, pneumonia, IBD, diabetic ketoacidosis, GYN, UTI, trauma
97
**When one portion of the bowel slides into the next, much like the pieces of a telescope.**
* Can result in (1) with the walls of the intestines pressing against one another
* This in turn leads to sw\_\_\_\_\_, in\_\_\_\_\_, and decreased ____ flow to the intestines involved
Intussusception
* Can result in obstruction with the walls of the intestines pressing against one another
* This in turn leads to swelling, inflammation, and decreased blood flow to the intestines involved
98
Intussusception Prevalence
* **\_\_\_\_\_ cause of pain & obstruction in infancy and childhood-up to age , ___ 80% occur before a child is** ___ **months old**
* 3 to 4 times more common in what gender?
* **Common cause of pain & obstruction in infancy and childhood-up to age 6, 80% occur before a child is 24 months old**
* 3 to 4 times more common in boys than girls
99
Intussusception Symptoms
Classic symptom =
* Pain onset, severity, quality =
* Periods of ____ alternating with \_\_\_\_\_
* May have v\_\_\_\_\_
Currant Jelly Stools (blood and mucus)
* Sudden onset of severe, colicky pain
* Periods of screaming alternating with quiet
* May have vomiting
100
Intussusception Treatment
(2)
Untreated can lead to?
Refer for surgery immediately
Barium enema may reduce if done within 24 hours of onset
Untreated, can lead to loss of bowel dt ischemia
100
Intussusception Treatment
(2)
Untreated can lead to?
Refer for surgery immediately
Barium enema may reduce if done within 24 hours of onset
Untreated, can lead to loss of bowel dt ischemia
101
**A congenital pouch (diverticulum) located about 2 ft from the end of the small intestine. It is about 2 inches in length, occurs in about 2% of the population, is twice as common in males as females, and can contain two types of ectopic tissue—stomach or pancreas**
* Many never have trouble but those that do present do so in the?
* Three possible complications: In\_\_\_\_\_, B\_\_\_\_\_, O\_\_\_\_\_\_
Meckel's Diverticulum
* First 2 years - first 2 decades of life
* Infection, Bleeding, Obstruction
102
Recurrent Pain in Children
* Usually occurs ages __ to \_\_; more in what gender (1)
* Over 14 suggests diagnosis of (1)
* Pain usually d\_\_\_, co\_\_\_\_, generalized or peri\_\_\_\_\_\_ pain
* Occurs daily with complete ______ between episodes
* May have low grade fever, pallor, HA, vomiting or constipation (\_\_\_\_\_somatic-bodily symptoms caused by emotional disturbances)
103
Failure to Thrive
FTT in childhood is a state of _______ dt inadequate caloric (2) or excessive caloric (1)
Defined as a weight for age that falls below the ___ percentile on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart
* In the US, it is seen in 5-10% of children in primary care settings
* Most cases involve inadequate caloric intake caused by be\_\_\_\_\_ or psy\_\_\_\_\_ issues
* The most important part of the outpatient eval is obtaining accurate amount of a child's eating _____ and (1)
FTT in childhood is a **state of malnutrition** dt inadequate caloric intake or absorption or excessive caloric expenditure
Defined as a weight for age that falls **below the 5th percentile** on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart
* In the US, it is seen in 5-10% of children in primary care settings
* Most cases involve inadequate caloric intake caused by behavioral or psychosocial issues
* The most important part of the outpatient eval is obtaining accurate amount of a child's eating habits and caloric intake
104
Failure to Thrive Management
* Routine laboratory testing?
* Reasons to hospitalize a child for further evaluation include ____ of outpatient management, suspicion of a\_\_\_\_ or n\_\_\_\_\_, or severe psychosocial impairment of the \_\_\_\_\_.
* A ______ approach to treatment, including home nursing visits and nutritional counseling, has been shown to improve weight gain, parent-child relationships, and cognitive development.
* The long-term effects of failure to thrive on cognitive development and future academic performance are \_\_\_\_\_\_.
* Routine laboratory testing rarely identifies a cause and is not generally recommended.
* Reasons to hospitalize a child for further evaluation include failure of outpatient management, suspicion of abuse or neglect, or severe psychosocial impairment of the caregiver.
* A multidisciplinary approach to treatment, including home nursing visits and nutritional counseling, has been shown to improve weight gain, parent-child relationships, and cognitive development.
* The long-term effects of failure to thrive on cognitive development and future academic performance are unclear.
105
Bariatric Surgery Types
1. **(1)** - restricts amt of food ingested
* Dec a\_\_\_\_\_, Early s\_\_\_\_, Slows di\_\_\_\_\_
* (3)
2. **(1)** - limits digestion and absorption
* Decreases ____ of intestine exposed to digested food
* 25% of ___ is absorbed
* Biliopancreatic Diversion/ duodenal Switch (least commonly performed)
* All operations can be performed open or laparoscopically
1. **Restrictive** - restricts amt of food ingested
* Dec appetite, Early satiety, Slows digestion
* Sleeve gastrectomy, Adjustable gastric banding, Roux-en Y gastric bypass
2. **Malabsorptive** - limits digestion and absorption
* Decreases length of intestine exposed to digested food
* 25% of fat is absorbed
* Biliopancreatic Diversion/ duodenal Switch (least commonly performed)
* All operations can be performed open or laparoscopically
106
**Surgical wt loss in which the stomach is reduced to 25% of its original size, by surgical removal of a large portion of the stomach along the greater curvature (most common)**
* Limits amount of food eaten and reduces hunger sensation because portion of stomach that produces \_\_\_\_\_\_, hunger stimulating hormone, is removed
* Fastest growing wt loss sugery in North America and Asia
* May be converted to gastric bypass or duodenal switch for ____ wt loss
* Quicker wt loss than lap band
* Reversible?
Gastric Sleeve
* Limits amount of food eaten and reduces hunger sensation because portion of stomach that produces Ghrelin, hunger stimulating hormone, is removed
* Fastest growing wt loss sugery in North America and Asia
* May be converted to gastric bypass or duodenal switch for additional wt loss
* Quicker wt loss than lap band
* Not reversible
107
**A silicone band is placed around the upper part of the stomach, a small pouch is created; slows down gastric pouch emptying**
* Early feeling of satiety/ surgical appetite suppressant; requires more patient effort for initial (1) than with gastric bypass or duodenal switch
* Purely restrictve
* Ad\_\_\_\_\_\_ restriction through mediport
* Reversible?
* Complications: sl\_\_\_\_\_, er\_\_\_\_\_, tubing dis\_\_\_\_\_\_ – *outdated*
Lap Band System
* Early feeling of satiety/ surgical appetite suppressant; requires more patient effort for initial wt loss than with gastric bypass or duodenal switch
* Purely restrictve
* Adjustable restriction through mediport
* Reversible (if necessary)
* Complications: slippage, erosion, tubing disconnect – *outdated*
108
Roux-en Y Gastric Bypass
=
* Inacc\_\_\_\_\_\_ gastric remnant
* Requires life long **(1) supplements**
* Complications: d\_\_\_\_ing, stomal str\_\_\_\_\_, per\_\_\_\_\_
* Reversible?
**A Gastric pouch of 15-20ml and 2 anastomoses are created to bypass 95% of the stomach an duodenum**
* Inaccessible gastric remnant
* Requires life long vitamin supplements
* Complications: dumping, stomal stricture, peritonitis
* Theoretically reversible, but very difficult
109
Which of the following is NOT a considered red flag when it comes to patients with acid reflex and dyspepsia?
1. Weight loss
2. Trouble swallowing liquids
3. Trouble swallowing solids
4. Reflux after meals
5. Nocturnal symptoms
4. Reflux after meals
110
All of the following are TRUE regarding Barrett Esophagus EXCEPT:
1. Males are more likely to have Barrett esophagus than females
2. Barrett esophagus occurs in 10-15% of pts with erosive esophagitis
3. Barrett esophagus is due to a change in the esophageal mucosa from columnar to squamous epithelium
4. Patients with Barrett esophagus should undergo periodic endoscopy
5. Barrett esophagus increases the risk of adenocarcinoma by up to 30 fold
3. Barrett esophagus is due to a change in the esophageal mucosa from columnar to squamous epithelium
Changes from squamous to columnar
111
Pollev Question
Insect/bee stings
112
Pollev Question
Peaks in 6th, 7th, 8th decade
Also true is D
113
Pollev Question
Viral gastroenteritis
114
Pollev Question
Serum IgG antibody titers
115
Pollev Question
Alopecia
116
Pollev Question
UC appears as transmural, whereas Chrons disease involves only the mucosal and submucosal layers
117
Pollev Question
TTG antibodies
118
Pollev Question
Endoscopy (EGD) looking for evidence of food after a restaurant meal is a good test for diagnosing gastroparesis
(not a restaurant meal)
