Lecture 9b: GI disorders Flashcards

Question

GI: Small Bowel Obstruction (3 types + pathophysiology (3))

Answer 1

1) Adhesions (Abnormal union between adjacent tissue) - most common cause of SBO, occurring after laparotomy, radiation, ischemia, infection, or foreign body. - usually occurs with previous surgery 2) Hernias—strangulated 3) Tumors—uncommon in the small bowel 4) Pathophysiology: - Fluid and air accumulate proximal to obstruction causing distention. - Bowel wall becomes edematous and distended. - Peristalsis decreases and normal function halts.

Answer 2

Severity of symptoms is proportionate to severity of ischemia. Acute onset of intermittent, crampy, periumbilical pain Vomiting often relieves the pain. In strangulated SBO, the pain is localized, steady, severe. Fever, constipation, obstipation Hemodynamic instability Encoparesis- diarrhea leaking around the stool mass.

Answer 3

1) History of abdominal surgery/trauma, inflammatory bowel disease, diverticulitis, radiation, PUD, pancreatitis - Medication history 2) Physical examination: - Visible peristalsis and distention, epigastric/periumbilical/diffuse abdominal tenderness, hyperactive BS early then high-pitched tinkling - S & S of dehydration, palpable mass; palpate for inguinal hernia.

Answer 4

1) Labs for differential 2) Radiography - Dx of obstruction, perforation, barium 3) Computed tomography - Obstructive lesions, neoplasms, hernias, and ischemia 4) Endoscopy - Direct visualization of obstruction in colon or proximal SB (not common)

Answer 5

Medical management: - NPO, NGT, IVF, electrolyte repletion, I & Os, TPN, central line - Monitor for S & S of sepsis, perforation, ischemia, necrosis, gangrene Surgical management: - Strangulated bowel, volvulus, incarceration, or closed loop obstructions need immediate surgery. - Lysis of adhesions, resection, ostomy, bowel decompression

Answer 6

- Abdominal pain, distention, progressive obstipation - Colicky pain in peritonitis, severe constant pain in gangrenous bowel - Vomiting may occur late. - Changes in bowel habits - Dehydration - Diarrhea may be present if stool is leaking past an obstruction. - Dyspnea from abdominal distention

Answer 7

1) History of altered bowel movements, bloody stool, iron deficiency anemia, weight loss, anorexia, fever, pain 2) Physical examination - Abdominal distention, tympany, ascites - S & S of dehydration, hyperactive then hypoactive BS, mass, diffuse abdominal tenderness with guarding or rebound - Rectal exam

Answer 8

Fluid Flatus Feces Fetus Fat Fatal tumor

Answer 9

1) Iron deficiency, leukocytosis 2) Imaging: - Abdominal films identify site of obstruction. - CT distinguishes anatomic and pseudo-obstruction

Answer 10

Fluid and electrolytes, NPO, NGT, rectal tube Surgical management: - Excision and re-anastomosis or ostomy Endoscopic therapy: - Stents as a palliative measure until surgery - Used to de-bulk obstructing tumors

Answer 11

Post-op, metabolic abnormalities, medications, local/systemic inflammation, spinal cord injury, blood-borne toxins Pathophysiology: - Poorly understood - Peristalsis decreased or ceases; distention occurs as gas/fluid/electrolytes accumulate.

Answer 12

1) Diffuse abdominal pain, nausea/vomiting, constipation, hiccups, bloating 2) History of thyroid/parathyroid disease, heavy metal exposure, diabetes, scleroderma 3) Physical examination: - Abdominal distention - decreased/absent BS - resonant to percussion - tachycardia - orthostatic - S & S of dehydration 4) Labs—electrolyte abnormalities 5) Abdominal radiography shows colonic dilation; CT/abdominal Xray

Answer 13

Treat the underlying cause. NPO, IVF, electrolyte repletion, NGT Hold medications that affect motility (narcotics). ‘Entereg’ Neostigmine, prokinetic medications Colonoscopy Surgery for perforation

Answer 14

1) Open abdomen in severe cases 2) Require lots of fluids to correct hypovolemia - Implications for hemodynamic monitoring 3) Broad spectrum abx

Answer 15

1) Gallstones and excessive alcohol abuse in 70% to 80% 2) Hypercalcemia and hypertriglyceridemia, medications, infectious processes 3) Pathophysiology: - Pancreatic enzymes become prematurely activated. - Results in autodigestion of the pancreas and peripancreatic tissue - Substances released from injured pancreas cause a cascade of events that lead to systemic sequelae.

Answer 16

- Deep, boring midepigastric or periumbilical pain - Nausea/vomiting without pain relief, tachycardia, hypotension, abdominal distention, low-grade fever History of biliary disease, alcohol use, diabetes, medications, location of pain, weight loss, N/V Physical examination: - Diffuse abdominal tenderness and guarding, tympanic to percussion - Hypoactive BS, jaundice, ascites, S & S of dehydrations or hypovolemic shock - Grey Turner’s or Cullen’s sign tip: Jaundice- Inability to conjugate red blood cells. Grey- flank (side) bruising, pancreas Cullens- umbilicus, organ rupture (edward cullen sucking on my belly button) - both grey and cullen's sign are indications of peritoneal rupture

Answer 17

Labs: - Elevated serum amylase and lipase - electrolyte imbalance - hyperglycemia - LFTs elevated with concurrent liver disease - elevated ALT and alkaline phosphatase with biliary disease Imaging studies: - Radiographs exclude other causes. - CT is the preferred test. - MRCP for bile duct stones, ERCP locates and removes stones. tip: Amylase stays elevated longer Hypertriglyceridemiapa

Answer 18

Local—pancreatic necrosis, pseudocyst, abscess Pulmonary—atelectasis, ARDS, pleural effusion Cardiovascular—shock states Renal—ARF Hematological—DIC Metabolic—hyperglycemia, hypertriglyceridemia, hypocalcemia, metabolic acidosis Gastrointestinal—GIB

Answer 19

1) IVF, electrolyte repletion, pain management, rest pancreas with NGT to suction 2) NPO, TPN, bed rest 3) Surgical management: - With massive necrosis, pancreatic resection is done. - Broad-spectrum antibiotics

Answer 20

Noninfectious hepatitis: - Excessive alcohol use - Autoimmune disorders - Biliary obstruction - Medications (Tylenol) - Right-sided heart failure - sarcoidosis - lupus - RA

Answer 21

1) Highly contagious 2) Classified according to specific infecting agent and corresponding serology markers - Hepatitis A, B, C, D, E, F, and G 3) Present with nonspecific flu-like symptoms 4) Symptoms more severe in hepatitis B

Answer 22

1) Hepatocytes, blood vessels, and Kupffer cells are responsible for uptake and degradation of foreign and potentially harmful substances in the body. 2) In mild disease, hepatocytes may regenerate. 3) In severe disease, regeneration is incomplete and fibrosis leads to cirrhosis and impediment of blood flow through the liver. 4) Fulminant liver failure can progress to cerebral edema, coma, and death Ammonia based product from blood into urea nitrogen- ammonia will cause confusion- we give lactulose for that.

Answer 23

1) History of alcohol use, drug use, medications, herbal supplements, surgery and transfusion history, occupational and travel history, sexual history 2) Physical examination: Jaundice, hepatomegaly, splenomegaly Muscle wasting, ascites, peripheral edema Vitamin deficiencies, bruising, telangiectasis, spider nevi Abdominal wall vein dilation, bruit over the liver

Answer 24

1) Tests for evaluating hepatocellular injury - AST (Aspartate Aminotransferase), ALT (Alanince Aminotransferase) 2) Tests for evaluating liver synthetic function - Albumin, total protein, and PT 3) Tests for evaluating cholestasis (excretory function) - Serum bilirubin - Alkaline phosphatase and GGT tip: GGT- gamma glutamyltransferase (Alkaline phosphatase -ALP) AST- Aspartate Aminotransferase ALT – Alanine Aminotransferase

Answer 25

Treatment is supportive. Rest, hold harmful medications. Monitor hemodynamic status. Monitor hepatic enzymes, electrolytes. Strict I & O, daily weight, abdominal girth High-calorie, low-protein diet Monitor for bleeding. Avoid alcohol, narcotics, barbiturates. Treat encephalopathy by lowering ammonia levels tip: Binds to ammonia and excretes it via the bowel. Lactulose---

Answer 26

1) Complication of liver disease 2) Caused by: chronic Hepatitis infection, alcohol abuse, nonalcoholic steatohepatitis, hereditary hemochromatosis, Wilson’s disease, and alpha1-antitrypsin deficiency 3) Inflammation, fibrotic changes, and increased intrahepatic vascular resistance cause compression of the liver lobule - increased resistance or obstruction of normal blood flow through the liver, (which is normally a low-pressure system) 4) Results in splenomegaly, varices, hemorrhoids, cardiac dysfunction 5) Inability to perform normal function of liver

Answer 27

H & P reveals altered liver function. Altered glucose, carbohydrate, fat, and protein metabolism Decreased synthesis of albumin leads to interstitial edema and decreased plasma volume. Clotting dysfunction Ascites, lower extremity edema, hypotension

Answer 28

Monitor nutrition, fluid balance, urine output, electrolytes, PT/PTT, platelet function, hematocrit. Monitor LOC, abdominal girth. Manage ascites—paracentesis or VP shunt. TIPS (trans-hepatic portal vein stent) procedure to decompress portal venous system tip: 7Liters - - - we can give albumin pre and post paracentesis.

Answer 29

1) Hepatic encephalopathy: - Caused by accumulation of toxic agents absorbed in intestinal tract - Limit protein intake, - lactulose, neomycin, or metronidazole (Abx to kill NH3 producing bacteria) 2) Hepatorenal syndrome - Often fatal: treatment is supportive. - advanced liver disease causes low production of albumin, leading to third spacing and hypoperfusion to the kidneys, causing kidney damage 3) Spontaneous bacterial peritonitis - Infected ascitic fluid - treat with broad-spectrum antibiotics