Nausea, Vomiting, & Diarrhea Flashcards by Dylan Null

Nausea and Vomiting Treatments (More Common)

Clear Liquids
Ginger

Ondansetron
Dexamethasone

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Neurokinin Receptor Antagonist

(Nausea and Vomiting Treatment)

Aprepitant
Fosaprepitant
Rolapitant

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Dopamine Antagonist

(Nausea and Vomiting Treatment)

Promethazine
Prochlorperazine

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Antihistamines + Anticholinergics

(Nausea and Vomiting Treatment)

Meclizine
Scopolamine
Dimenhydrinate

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Nausea and Vomiting Treatment during Pregnancy

Oral B6 + Doxylamine

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Cannabinoids

(Nausea and Vomiting Treatment)

Dronabinol

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What is the most common type of Hiatal Hernia?

Sliding (Type 1)

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What is commonly used to diagnose Hiatal Hernias?

Upper Endoscopy + Barium Swallow with Contrast

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What are some common risk factors of Hiatal Hernias?

Age
Obesity
Power-lifting Athletes

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Diaphragmatic hiatus dilation permits upward herniation of STOMACH CARDIA and GE JUNCTION

Type 1
- SLIDING Hiatal Hernia

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How do you treat a Type 1 (Sliding) Hiatal Hernia?

Same as GERD

H2 Blockers + Antacids
PPIs

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Results from localized defect in phrenoesophogeal membrane.

GE JUNCTION STAYS FIXED TO PREAORTIC FASCIA AND ARCUATE LIGAMENT

GASTRIC FUNDUS HERNIATES ADJACENT TO ESOPHAGUS

Type 2
- ROLLING Hiatal Hernia

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How do you treat a Type 2 (Rolling) Hiatal Hernia?

Surgical Repair
- due to high chance of strangulation

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Most common type of Paraesophageal Hiatal Hernia.

Results from Mixed Types 1 + 2

BOTH GE JUNCTION AND FUNDUS HERNIATE THROUGH HIATUS

Type 3
- MIXED Hiatal Hernia

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How do you treat a Type 3 (Mixed) Hiatal Hernia?

Surgical Repair

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PRESENCE OF STRUCTURE OTHER THAN STOMACH within the Hernia Sac

Type 4
- LARGE DEFECT Hiatal Hernia

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How do you treat Hiatal Hernia’s Types 2 - 4?

Surgical Repair

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Signs and Symptoms of Hiatal Hernias

Epigastric Discomfort
Postprandial Bloating
Dysphagia
Shortness of Breath
Nausea and Vomiting
Anemia secondary to gastric erosions
Reflux Symptoms

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How do you diagnose Hiatal Hernias?

Barium Swallow

Endoscopy
- determine inflammation + rule out cancer

Manometry + pH Monitoring
- if reflux symptoms

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What are some complications of Hiatal Hernias?

Hemorrhage
Incarceration
Obstruction
Strangulation
Volvulus
Shortness of Breath
- due to restricted lung capacity

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What procedure is performed during surgical repair of a Hiatal Hernia?

Laparoscopic Repair
+
Nissen Fundoplication

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Hesselbach’s Triangle

Rectus Abdominus
(medial)

Inferior Epigastric Vessels
(supero-lateral)

Inguinal Ligament
(inferior)

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What are the 2 types of Inguinal Hernias determined by?

Relation to the Inferior Epigastric Vessels

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Inguinal hernia that protrudes through the internal inguinal ring, LATERAL to the inferior epigastric vessels.

Indirect Inguinal Hernia
(most common → may reach scrotum)

Right-sided is most common
Seen in children + young adults
Often Congenital

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Inguinal hernia that protrudes through the posterior wall of the inguinal canal, MEDIAL to the inferior epigastric vessels.

Direct Inguinal Hernia (does not reach the scrotum)

Type of Inguinal Hernia that causes: Severely painful bowel movement, to the point where the patient may refrain from defecation.

Strangulated Hernia - Surgical Emergency

Type of Inguinal Hernia that causes: Painful enlargement and is irreducible. Can be accompanied by nausea and vomiting if a bowel obstruction is present.

Incarcerated Hernia

Protrusion of the abdominal cavity contents below the inguinal ligament through the femoral canal. Can be hard to differentiate from lymph nodes.

Femoral Hernias → Highest rate of Incarceration and Strangulation

Protrusion of abdominal content through the umbilical fibromuscular ring - congenital. Most resolve on their own by age 2.

Umbilical Hernia

If an Umbilical Hernia does not resolve on its own, what age should you perform surgical repair?

5 Years Old

20% of Abdominal Operations result in this type of Hernia.

Incisional (Ventral) Hernia

How do you treat Small Incisional Hernias?

Should be treated early! - Direct Fascia to Fascia Repair → non-absorbable sutures Non-surgical → elastic corset

How do you treat Large Incisional Hernias?

Hernia Sac is Dissected Free Non-absorable mesh Remove excess or scar tissue

What are the two types of Acute Diarrhea?

Inflammatory + Non-Inflammatory

What time frame allocates diarrhea as being Acute?

< 2 weeks

What are the causes of Acute Diarrhea?

Viruses Bacteria Protozoa Medications Food Toxins 80% are infectious

What time frames allocates diarrhea as being Chronic?

> 2 - 4 weeks

What are the common causes of Chronic Diarrhea?

Medications Osmotic Secretory Conditions Malabsorption Motility Disorders Chronic Infections

A community outbreak of diarrhea would most likely be caused by what?

Virus

A pregnant patient with diarrhea could be caused by what type of infection?

Listeriosis

Diarrhea outbreaks during Camping, Swimming, or at a daycare.

Giardia or Cryptosporidium

Diarrhea with a recent history of ABX use.

C. diff

Diarrhea in an immunosuppressed patient would most likely be caused by what?

Viral CMV

Characteristics of Non-Inflammatory Diarrhea (Non-Invasive)

Watery (non-bloody) Small Bowel → Large Volumes Self-Limiting Vomiting Fecal Leukocytes (-) Caused by a toxin-producing bacterium

Characteristics of Inflammatory Diarrhea (Invasive)

DO NOT GIVE ANTI-MOTILITY DRUGS Destruction of Intestinal Epithelium Blood Pus + Fever Large Bowel → Many Small Volumes Minimal Vomiting Fecal Leukocytes (+)

What are some worrisome features of diarrhea that would require further work-up?

High Fever Dehydration Frequent Bloody Stools Severe Pain Immunosuppression No improvement after 3-4 days of supportive treatment

What is the most common cause of Acute Gastroenteritis in the United States? Transmitted via fecal-oral route. → Shellfish Seen in daycares, nursing homes, schools, and cruise ships

Norovirus

How do you treat Norovirus?

Supportive

Most common cause of diarrhea in infants and young children (6 months - 2 years old) Incidence has decreased since Vaccine was introduced in 2006 → Rotarix

Rotavirus

Signs and Symptoms of Rotavirus

Watery Diarrhea (4 - 8 days)

Protozoal Diarrhea Found in mountain stream water, camping/backpacking, and on beavers.

Giardia Lamblia

Signs and Symptoms of Giardia Lamblia

Weight Loss (up to 10% of body weight) Watery-yellow stools that are foul smelling and greasy. Usually clears in 6 weeks but may have residual symptoms.

How do you diagnose Giardia Lamblia?

Trophozoites or Cysts in Stool - Microscopy with Antibody Testing

How do you treat Giardia Lamblia?

Tinidazole Metronidazole Nitazoxanide

Parasitic diarrhea. Most common in tropical or subtropical regions. Outbreaks in the United States are linked to IMPORTED PRODUCE

Cyclospora

How do you treat Cyclospora?

Bactrim

Bacterial food borne illness → meat, dairy, eggs, and bakery products. Produces enterotoxin Symptoms occur VERY FAST (30 minutes to 6 hours)

Staph. aureus

How do you treat gastrointestinal symptoms caused by Staph. aureus?

Supportive

Bacterial food borne illness that is transmitted via food left out too long. Fried rice sitting under a heat lamp. Typically lasts for 24 hours.

Bacillus Cereus - Supportive

Bacterial food borne illness. Found in raw meat and poultry. Bacterium grows in rewarmed meat and poultry dishes and produces enterotoxin. Abrupt onset of profuse diarrhea with only occasional vomiting.

Clostridium perfringens - Supportive

Traveler's Diarrhea Unpeeled Fruits and Unsanitary Drinking Water

Enterotoxigenic E.coli (ETEC)

How do you diagnose ETEC?

Stool Culture

How do you treat ETEC?

Fluids Fluoroquinolones - if severe

Bacterial related. History of travel to endemic areas with ingestion of contaminated food & water - Fish, Shellfish, Street Vendor Food

Vibrio Cholera

Signs and Symptoms of Cholera

Massive amounts of diarrhea Non-bloody Grey and without odor "Rice Water Stools"

How do you treat Cholera?

Doxycycline Fluids

Viral cause of diarrhea that is transmitted via body fluids. Healthy persons may have very few symptoms - once infected, virus remains dormant for life. Symptoms are seen in immunosuppressed and AIDS patients.

Cytomegalovirus

How do you treat Cytomegalovirus?

Valganciclovir

Protozoal GI infection. Low-income countries with suboptimal sanitation in: Asia, Central and South America

Entamoeba histolytica

Signs and Symptoms of Entamoeba Histolytica

Asymptomatic Cyst carriage in 90% of cases 2 - 4 week incubation Gradual onset of abdomen pain and diarrhea

What are some potential consequences of Entamoeba Histolytica?

Amebic Liver Abscess Colitis + Dysentery Toxic Megacolon Pancolitis → emergency colectomy

How do you treat Entamoeba Histolytica?

Metronidazole + Luminal Agent - Diloxanide - Iodoquinol - Paromomycin

Shiga Toxin producing E.Coli. - cytotoxin

Enterohemorrhagic E.Coli (EHEC)

Sources of EHEC Infection

Contaminated Meat Unpasteurized Milk or Apple Cider Vinegar Daycares Contaminated Water

Symptoms of EHEC

Watery diarrhea that becomes bloody

How do you treat EHEC?

Fluid Replacement ABX NOT RECOMMENDED → HUS Devlopment

Cytotoxin producing bacteria Associated with raw seafood and shellfish. - Especially in the Gulf of Mexico

Vibrio Parahaemolyticus - Supportive

Infection usually occurs 7-10 days follow use of antibiotics.

Clostridium Difficile

What ABX are most likely to cause C.diff?

Clindamycin Beta-Lactams

How do you treat Clostridium Difficile

Vancomycin Fulminant → Oral Vancomycin + IV Metronidazole

Bacteria that causes mucosal invasion. Highly virulent Abrupt onset of explosive diarrhea.

Shigella

How is Shigella diagnosed?

Stool Culture

How do you treat Shigella?

Azithromycin Ciprofloxacin Ceftriaxone

Bacteria that causes mucosal invasion. Largely from undercooked poultry or unpasteurized milk. Commonly associated with Guillain-Barre

Campylobacter Jejuni

How do you treat Campylobacter Jejuni?

Self-Limiting Azithromycin

Bacteria that causes mucosal invasion. Most commonly from poultry products and exotic pets. More common in summer months.

Salmonella

What is a major complication of Salmonella?

Typhoid Fever - Headache - Pharyngitis - Pea Soup Stool - Bradycardia - "Rose Spots" appear in 2nd week (slight raised spots that fade on pressure)

How do you treat Salmonella?

Ceftriaxone Ciprofloxacin Amoxicillin Bactrim

Bacteria that causes mucosal invasion. Most commonly found in: - unpasteurized dairy products - hot dogs - deli meats - cantaloupes - ricotta cheese

Listeria monocytogenes

Who does Listeria most commonly infect?

Pregnant Women Older Adults

How do you treat Listeria?

Ampicillin - add gentamicin PCN Allergy → Bactrim

Bacteria that causes mucosal invasion. Most commonly found in undercooked pork and tofu. Symptoms may mimic acute appendicitis.

Yersinia Enterocolitica

What infection has been described as causing Necrotizing Enterocolitis in infants?

Yersinia Enterocolitica

What are 2 extra manifestations of Yersinia Enterocolitica?

Reactive Arthritis Erythema Nodosum

How do you treat Yersinia Enterocolitica?

Self-Limited Bactrim if Severe

What medications are most likely to cause Medications Induced Diarrhea?

SSRIs Metformin PPIs NSAIDs ARBs Cholinesterase Inhibitors Allopurinol Orlistat

Decreased stool volume with fasting. Increased Stool Osmotic Gap.

Osmotic Diarrhea

Large Volumes of Diarrhea ( > 1L per day) Little Change with Fasting. NORMAL Stool Osmotic Gap

Secretory Diarrhea

Fever Hematochezia Abdominal Pain Chronic Diarrhea

Inflammatory Conditions - Ulcerative Colitis - Crohn's disease - Malignancy - Radiation Enteritis

Weight Loss Abnormal Lab Values Fecal Fat > 10g per 24 hours Chronic Diarrhea

Malabsorption Syndromes

Prior abdominal surgery Diabetes Scleroderma Chronic Diarrhea

Motility Disorders

What are two common causes of Chronic Infections leading to Diarrhea?

Parasites AIDS-related

How do you treat diarrhea? (non-pharmacologic)

Bowel Rest Drink Tea + "Flat" Carbonated Drinks Pedialyte or Gatorade

How do you treat diarrhea? (pharmacologic)

Bismuth Subsalicylate (Pepto-Bismol) Diphenoxylate + Atropine (Lomotil) Loperamide (Imodium)

What is a common side effect of Bismuth Subsalicylate? (Pepto-Bismol)

Dark Stools

What patient population should not receive Bismuth-Subsalicylate?

Children with Viral Illnesses - risk of Reye Syndrome

When should you NOT give Antidiarrheal or Anti-motility agents?

Invasive Diarrhea

What anti-diarrheal medication is safe in patients with dysentery?

Bismuth Subsalicylate (Pepto-Bismol)

What medications are used to empirically treat Chronic Diarrhea?

Fluoroquinalones Azithromycin

When do you Admit Patients with Diarrhea?

- Severe Dehydration - Bloody diarrhea that is worsening - Severe abdomen pain - Signs of sepsis or severe infection - Worsening symptoms in patients 70+ or immunocompromised

Nausea, Vomiting, & Diarrhea Flashcards

(110 cards)