Lecture 6 (GI)-Exam 2 Flashcards
(71 cards)
1
Q
Obesity:
* Defined as what?
* Disease is multifactorial stemming from what?
A
- Defined as abnormal accumulation of adipose tissue that may impair health (via contribution to CAD/DM/HTN/HLD).
- Disease is multifactorial stemming from mismatch of calories intake versus expenditures and further influenced by genetic (obesity os very heritable), social and societal factors.
One-thirdof adults and about 17% of adolescents in the UnitedStates are obese
2
Q
Obesity
* What is a genetic syndrome associated with extreme obesity?
* What is the gene implicated with obesity ?
A
- Prader-Willi is the most common genetic syndrome associated with extreme obesity
- FTO gene is implicated with obesity
3
Q
- What is leptin?
- What is ghrelin?
A
- Leptin – adipocyte hormone that reduces food intake via appetite suppression and therefore reduces body weight
- Ghrelin is an appetite stimulant hormone and works as an antagonist to leptin
4
Q
What does leptin resistance cause?
A
Leptin resistance on cellular level increases obesity and promotes free fatty acid secretion that increases inflammation and cause triglyceride levels to rise and increase insulin secretion (NIDDM basic-> T2D)
5
Q
What happens with leptin and ghrelin levels before and after eating?
A
6
Q
- What is Metabolic obese normal weight (MONW) ?
- What is Metabolically healthy obese (MHO) ?
A
Metabolic obese normal weight (MONW)
* Subjects with normal BMI suffer from metabolic complications normally found in obese individuals
Metabolically healthy obese (MHO)
* Individuals have BMI over 30 kg/m2 but do not have the characteristics of insulin resistance or dyslipidemia
7
Q
He said low yield
What are the BMI ranges?
A
- Underweight: less than 18.5 kg/m2
- Normal range: 18.5kg/m2to 24.9 kg/m2
- Overweight: 25kg/m2to 29.9 kg/m2
- Obese, Class I: 30 kg/m2 to 34.9 kg/m2
- Obese, Class II: 35 kg/m2 to 39.9 kg/m2
- Obese, Class III: more than 40 kg/m2
8
Q
What should be measured for obesity dx and what are the values for males and females?
A
Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:0.8 is considered significant.
9
Q
Obesity Treatment: Multiprong individualized approach
* Manage what?
* Provide what supportive treatment? (4)
* Who are the medications for?
A
- Manage contributing conditions (hypothyroidism, dietary and behavioral modifications)
- Provide supportive treatment: physical activity, exercise, nutrition, and weight maintenance.
- Medications: reserved for patients with BMI >30 or >27 + comorbid condition
10
Q
What are the examples of obesity medications?
A
Orlistat, phentermine, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine
11
Q
Obesity
* What is surgery reserved for?
* What are the types of surgery?
* What are the SE of surgery?
A
Surgery: reserved for BMI >40 or 35 + severe comorbid conditions
* Adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy
* Rapid weight loss can lead to gallbladder problems
* Chronically may lead to malabsorption refeeding or dumping syndrome.
12
Q
What are the 5 types of GI bleeding?
A
- Acute
- Chronic
- Overt – clinical signs/symptoms present
- Occult – not clinically evident (+ FOBT and/or iron deficiency anemia)
- Obscure – routine evaluation (upper and lower endoscopy has not revealed source)
13
Q
Gastrointestinal Bleeding
* Upper GI vs. Lower GI location is determined by what?
A
the Ligament of Treitz
14
Q
What are locations of UGI and LGI bleeds?Dx by?
A
UGI – proximal to Ligament of Treitz
* Esophagus
* Stomach
* Duodenum
* Dx by EGD
LGI – distal to Ligament of Treitz
* Jejunum and Ileum
* Colon
* Dx by colonoscopy
15
Q
GI Bleed Presentation
* What can happen with vomit that is probably an UGI source?
A
Hematemesis (vomiting blood) – probably an UGI source
* Bright Red Blood with or without clots
* Coffee grounds – blood accumulates in stomach
16
Q
Stool color, consistency, frequency:
* Wha tis melena and hematochezia? What do they indicate?
A
- Melena (black tarry stools) – Typically suggests upper GI source, but can be seen with LGI small bowel or proximal colon bleeds.
- Hematochezia (bright red blood per rectum) – Typically suggests a lower GI source on left side, however, but can be seen with brisk UGIB
17
Q
Hemodynamic Changes: GI bleed
* What can happen with BP? what can be some sxs?
A
- Orthostatic drop in BP > 10 mm Hg or HR > 20 bpm - usually indicates > 20% reduction in blood volume(+/- syncope, lightheadedness, nausea, sweating, thirst)
- Shock, BP < 100 mm Hg systolic - usually indicates > 30 % reduction in blood volume(+/- pallor, cool skin)
18
Q
Work-up of GI Bleeds
* What do you need to do?
A
- Vital Signs + orthostatic BP
- Physical Exam w/ Rectal Exam
- Labs: CBC, PT/INR/PTT/LFTs, Electrolytes/renal function
19
Q
Work-up of GI Bleeds
* Why do we have to get CBC?
* Why PT/INR/LFTs?
* Why electrolytes/renal function?
A
CBC
* Check and monitor hemoglobin and hematocrit
* Crossmatch 2 – 6 units PRBC depending on level of active bleeding
* Platelet count (< 50,000/mcl with active bleeding requires transfusions of platelets and FFP to replete lost clotting factors)
PT/INR/PTT/LFTs to r/o advanced liver disease (coagulopathy)
* INR must be kept less than 1.5
Electrolytes/renal function
* Prerenal changes (i.e. azotemia)
20
Q
Early Management of GI Bleeds
* What do you need to check, place and give?
A
- ABCs (airway, breathing, circulation)
- Bilateral 14/16-gauge upper extremity peripheral IV (need large bore IV)
- Resuscitation: IV Fluids, PRBCs after type and cross and Correct underlying coagulopathies
- Foley catheter to monitor renal perfusion
- NG Tube lavage (for UGIB)
21
Q
NG tube/gastric lavage
* What is the aspirate if UGIB and LGIB?
* WHat is nondiagnostic?
A
- UGIB - Fresh blood or coffee-ground aspirate
- Probable LGIB – Non-bloody, bilious aspirate
- Clear, non-bilious aspirate is NONDIAGNOSTIC (May miss duodenal source of bleeding)
* Bile is aspirated in duodenum, not gastrum
22
Q
A 28 year old patient has been passing tarry stools for two days. Blood pressure in the supine position is 110/70 mm Hg with pulse of 98 bpm. In the sitting position blood pressure is 96/72 mm Hg with pulse of 110 bpm. Nasogastric aspirate is negative for blood. The most likely location of this bleed is:
A. Esophageal
B. Duodenal
C. Rectal
D. Large Bowel
E. Posterior nasopharynx
A
Duodenal
23
Q
Causes of Upper GI Bleeding
* What are the different types of esophagus bleeds? (4)
A
- Esophageal varices (#3 cause) – present with Portal HTN
- Esophagitis
- Esophageal Ulcer
- Mallory-Weiss tear (mucosal tear at GE junction due to retching-ETOH, Bulimia, sick) (#4 cause)
24
Q
Causes of Upper GI Bleeding
* What are the examples of stomach bleeds? (3)
A
- Gastric ulcer (#2 cause)
- Gastritis
- Gastric antral vascular ectasia – Longitudinal erythematous stripes on gastric mucosa (known as Watermelon Stomach) (rare)
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Causes of Upper GI Bleeding
* What is a dieulafoy's lesion?
Dieulafoy's Lesion - Artery at gastric fundus erodes to surface and may bleed heavily (rare)
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Causes of Upper GI Bleeding
* What is an duodenum cause?
* What are two other cuases of UGIBs?
* Duodenum: Duodenal ulcer (#1 cause)
* Coagulopathy (liver, drugs, bleeding disorders)
* Arteriovenous malformations
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Upper GI Bleed management
* _
* Keep what? Why?
* What do you need to give for meds?
* What do you need to do EARLY?
* Resuscitation
* **Keep NPO – prevent aspiration**
* High dose Proton Pump Inhibitors – prevent acidity to ulcer.-> Consider loading dose and drip of Protonix
* EARLY esophagogastroduodenoscopy (EGD) to identify the source of the bleeding & for therapeutic intervention
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Lower GI Bleeds
* What are the small bowel causes? (4)
* Neoplasm
* IBD
* Aortoenteric Fistula
* Mesenteric ischemia
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Lower GI Bleeds
* What are the colon causes? (6)
* Diverticuli – most common cause
* Angiodysplasia/AVM
* Inflammatory Bowel Disease
* Neoplasm
* Infectious
* Radiation Proctitis
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Lower GI Bleeds
* What are the perianal examples? (3)
* What is another reason?
Perianal
* Hemorrhoid
* Fissure
* Fistula
Coagulopathy (drugs, liver disease, etc.)
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Suspected LGIB
* What will happen 80% of the time?
* Exclude waht?
* What is the primary option?
* Bleeding stops spontaneously 80% of the time
* Exclude upper GI source 1st
* Colonoscopy is the primary option
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If the patient has massive ongoing bleeding with hemodynamic instability, what is indicated?
If the patient has massive ongoing bleeding with hemodynamic instability, urgent angiography vs emergent endoscopy is indicated
* Colonoscopy Prep Emergently: Purge with 4 – 8L of polyethylene glycol solution given orally or per NG tube
33
Additional Studies if Needed
* New CT scan guidelines request what?
* If both CT or colonoscopy do not reveal a source, but bleeding continues, what should be ordered?
* New CT scan guidelines request oral and IV contrast when evaluating lower GI bleeding with CT abdomen and Pelvis, which can help identify site of extravasation
* If both CT or colonoscopy do not reveal a source, but bleeding continues – tagged RBC scan should be done to localize bleeding +/- angiography if positive
34
Nuclear bleeding scan
* How does it work?
“Red blood cells are labeled with 15 mCi of technetium-99m (in vitro) and reinfused into the patient. Images are then acquired sequentially at one minute intervals in the anterior projection. Early in the study, a focus of increased activity appears in the left lower quadrant of the abdomen. Activity then progresses in a curvilinear fashion approximating the course of the sigmoid colon. “
35
* If colonoscopy does not reveal a source, but bleeding stops do what?
* Consider what?
* If colonoscopy does not reveal a source, but bleeding stops, observe the patient
* Consider small bowel evaluation (Capsule endoscopy)
36
Surgery: GI bleeds
* Who is surgery reserved for? (2)
* Every effort should be made to do what?
Surgery is reserved for patients
* Who have failed medical, colonoscopic, & angiographic intervention
* Who have ongoing bleeding >4U PRBC per 24 hr
Every effort should be made to localize the source of bleeding prior to surgery (especially in diverticular disease)
37
Diarrhea
* What is the criteria?
* Increase in stool weight (>200 g/day)
* Decreased stool consistency
* Increased stool frequency, urgency, fecal incontinence
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The Intestines
* How much ingested fluid and secretions enter the intestines each day
* How much is absorbed in small and large intestines?
* What is normal fluid in normal stool day?
* 10 liters of ingested fluid and secretions enter the intestines each day
* 90% is absorbed in the small intestines
* Of the fluid that remains, 90% is further absorbed in the large intestines
* 80-100ml of fluid is in normal stool day
39
Diarrhea
* How long is acute? What are the two types?
* How long is chronic?
Acute – lasting less than 4 weeks
* Infection (most common)
* Medications (Metformin)
Chronic – lasting more than 4 weeks
40
What are the different pathophysiologies of diarrhea?(5)
* Osmotic
* Secretory
* Malabsorption/Maldigestion
* Altered Motility
* Inflammatory
* Inflammatory Bowel Diseases
* Infectious Diarrhea
41
* What is the osmotic gap for serum?
* Feces is normally in osmotic equilibrium with what?
* 290 mOsm/kg - 2 ([Na]+ + [K]+) – for serum
* Feces is normally in osmotic equilibrium with blood serum, which the human body maintains between 290–300 mOsm/kg.
42
Fecal Osmotic Gap
* What is osmotic and secretory diarrhea level? Why does this happen?
* Osmotic diarrhea >125 – high fecal osmotic gap (can be due to lactulose)
* Secretory diarrhea <50- cholera – massive excretion (Na, K, HCO3, Cl) and low absorption of electrolytes. It doesn’t stop if patient fasts.
43
What is functional diarrhea? Typically in who?
Functional Diarrhea – Normal Gap >50 but <125 – Typically IBS or Altered Motility Type Disorder
44
Osmotic Diarrhea
* What is the definition?
Definition: Increased amounts of poorly absorbed, osmotically active solutes in gut lumen interferes with absorption of water
45
Osmotic Diarrhea
* What are Solutes are ingested that are osmotic? (4)
* Magnesium sulfate or citrate or magnesium containing antacids
* Sorbitol – sugar free gum
* Lactulose – Tx constipation
* PEG (polyethelane glycol) – Tx constipation
46
Osmotic Diarrhea
* besides the solutes, what is another cause?
Malabsorption of food
* Lactose intolerance
47
Lactose Intolerance
* What is this?
* Lactose remains where and what does that cause?
* Congenital or acquired deficiency in the brush border disaccharidase lactase that leads to malabsorption of lactose
* Lactose remains in the intestinal lumen and acts as a strong osmotic substance leading to osmotic diarrhea, flatulence, bloating
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Lactose Intolerance
* what is the txt?
Treatment: Avoid lactose containing foods and/or supplement oral intake of dairy products with liquid or tablet form of the lactase enzyme
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Osmotic Diarrhea
* what is the cause?
Nonabsorbable molecules accumulate in the gut lumen
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Osmotic Diarrhea
* What are the clinical features?
Diarrhea stops with fasting
Electrolyte absorption is not affected, only water is affected
Fecal osmotic gap is high
* Test checks stool electrolytes
* Stool water is low in electrolytes
51
Secretory Diarrhea
* What is it?
Abnormal ion transport in intestinal epithelial cells -> increased secretion &/or decreased absorption of electrolytes
52
Secretory Diarrhea
* What are the clinical features?
Fasting does not stop diarrhea
Electrolyte absorption is affected
* Increased secretion and/or decreased absorption of Na+ and Cl-
Fecal osmotic gap is low
* Stool water is high in electrolytes
53
Secretory Diarrhea
* What are the bacterial or viral enterotoxins?
* What are the causes of Intestinal resection?
Bacterial or viral enterotoxins: Cholera, enterotoxigenic E. coli, B. cereus, S. aureus, Rotavirus, Norwalk virus (BRENCS)
Intestinal resection
* Decreased absorptive surface for not only nutrients but also electrolytes and fluid
* Combined malabsorption and secretory component
54
Secretory Diarrhea
* What type of laxatives?
* Circulating agents by what?
Non-osmotic laxatives (castor oil, senna)
Circulating agents by neuroendocrine tumors such as:
* Carcinoid Syndrome
* Zollinger-Ellison syndrome
55
Infectious Diarrhea
* Hx of what?
* _ contacts?
* Food?
* Can be what?
* is there what use?
* History of travel
* Sick contacts and their progression
* Food exposure history
* Could it be Hepatitis A or B or something non infectious
* Is there drug use or homelessness history
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Infectious Diarrhea: essential of dx
* Acute:
* Chronic:
* Mild diarrhea:
* Moderate diarrhea:
* Severe diarrhea:
* Acute diarrhea: < 4 weeks
* Chronic diarrhea: > 4 weeks.
* Mild diarrhea: /= 4 stools per day w/ local symptoms (cramps, nausea, tenesmus)
* Severe diarrhea: >/= 4 stools per day w/ systemic symptoms (fever, chills, dehydration)
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Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Bloody, THINK what?
* Recent hospitalization or antibiotic use (MC: Clindamycin)->
* Foreign travel->(5)
* Bloody, THINK Bacteria
* Recent hospitalization or antibiotic use (MC: Clindamycin)->C. diff
* Foreign travel-> Salmonella, Shigella, Campylobacter, E coli or V cholerae (VECSS)
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Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Outbreak on cruise ship, school, LTCF->
* Recurrent C. diff =
* Undercooked hamburgers ->
* Outbreak on cruise ship, school, LTCF-> Norovirus
* Recurrent C. diff = Fecal microbiota transplantation
* Undercooked hamburgers -> Enterohemorrhagic Escherichia coli, including Shiga-toxin–producing E coli strains (STEC)
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Infectious Diarrhea: Classification of inflammatory/bloody diarrhea
* What is involved?
* What are common sxs?
* What are common causes?
* What is often postive? What is required for definitive etiology?
* Colonic involvement (bacteria, parasites, toxins)
* Common symptoms: Frequent bloody, small-volume stools, often with fever, abdominal cramps, tenesmus and fecal urgency
* Common Causes: Shigella, Salmonella, Campylobacter, Yersinia, invasive strains of E.coli, Entamoeba histolytica and C. difficile (CCEESSY)
* Fecal leukocytes are often positive, stool culture required for definitive etiology
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Infectious Diarrhea: Classification of noninflammatory, non-bloody or watery
* Milder, caused by what?
* interferes with what?
* Common sxs:
* Common causes:
* Milder, caused by viruses or toxins that affect small intestine
* Interferes w/ salt & water balance resulting in large-watery diarrhea
* Common Symptoms: Nausea, vomiting, cramps
* Common Causes: Rotavirus, norovirus, astrovirus, enteric viruses, vibriones, enterotoxin-producing E. coli, Giardia lamblia, crystosporidia & agents that cause food-borne gastroenteritis
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Acute Gastroenteritis
* What is it?
* May include what?
* Temperature?
* Signs of what?
* What is a late sign?
* Consider waht?
* Flu-like illness with GI component
* May include Melena, or hematochezia depending on organism
* High fever
* Signs of dehydration
* Altered mental status -> late sign
* Consider hypovolemic shock (hemorrhagic and non-hemorrhagic)
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AGE work up
* What type of tests? (3)
* What are the labs? (4)
* what is the imaging?
* R/O what?
* Blood cultures, stool culture, O and P specific tests
* CBC with differential
* CMP
* Fecal leukocytes
* Hemoccult vomit
* CT (with or without contrast depending on oral tolerance and Cr) if abdomen tender or you have guarding or rebound tn
* R/O Clostridium difficile via toxin test
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Treatment AGE
* Most cases are what?
* What for fever?
* What is the diet?
* What do you give for pain?
* Most cases are self-limited
* Acetaminophen for fever
* Clear liquids until symptoms better, BRAT diet
* Pain: Ketorolac
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Treatment AGE
* What do you give for anti-emetics?
* Fluids?
* Avoid what?
* If abnormal labs, then do what?
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Treatment AGE: general measures
* Most cases of acute gastroenteritis are what?
* Txt usually consists of what?
* Most cases of acute gastroenteritis are self-limited and do not require therapy other than supportive measures
* Tx usually consists of replacement of fluids and electrolytes and, very rarely, management of hypovolemic shock and respiratory compromise
68
Treatment AGE: General measures
* mild diarrhea, increase what? May increase risk for what?
* What do you need to do severe dehydration?
Mild diarrhea, increase juices and clear soups
* May increase risk for osmotic diarrhea
Severe dehydration (postural light-headedness, decreased urination), oral glucose-based rehydration solutions (Ceralyte, Pedialyte
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Treatment AGE: Specific Measures
* Immunocompetent adults->Empiric antimicrobial therapy for bloody diarrhea while waiting for results is recommended only with the following circumstances? (2)
* (1) documented fever, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella
* (2) returning travelers with a temperature of at least 38.5°C or signs of sepsis
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Treatment AGE: Specific Measures
* What is the empiric antimicrobial therapy for bloody diarrhea?
* Empiric antibacterial treatment should be considered in who?
* Fluoroquinolone or azithromycin as empiric antimicrobial therapy for bloody diarrhea
* Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea
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Treatment AGE: Specific Measures
* Loperamide may be given to who? When should it be avoided?
* Loperamide may be given to immunocompetent adults with acute watery diarrhea, but should be avoided with Shigella infection or in suspected or proven toxic megacolon
* Generally avoid loperamide unless you confirm lack of infection (viral or bacterial)
