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GI Exam 3 > Nausea, Vomiting, Diarrrhea > Flashcards

Nausea, Vomiting, Diarrrhea Flashcards

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1
Q

______: Unpleasant sensation that may,
but not necessarily, precede vomiting

A

Nausea

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2
Q

Emesis (vomiting)

A

Forceful oral expulsion of gastric contents
* Can allow for removal of toxins/poison
* Mechanism: Stimulation of multiple
pathways (see next slide)

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3
Q

Nausea mechanism

A

Gastric rhythm disturbance
* Gastric myoelectrical activity = 3
cycle/min
* ↑ (tachygastria) or ↓ (bradygastria)
frequency = NAUSEA

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4
Q

Nausea can cause autonomic changes:

A
  • Increased (↑): salivation, heart rate,
    respiratory rate
  • Decreased (↓): gastric tone, mucosal
    blood flow
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5
Q

The physiological mechanisms of vomiting (Prepartory and expulsion steps)

A

Preparatory Steps
➢ The pyloric sphincter relaxes to allow entry of contents from the intestines
➢ The glottis closes
➢ Contractions begin in the duodenum and stomach
Expulsion Steps
➢ The lower esophageal sphincter relaxes
➢ Vomitus can move into the esophagus.
➢ Inspiratory (diaphragm, intercostals) and abdominal muscles contract
➢ The pylorus closes
➢ Vomitus is expelled into the mouth

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6
Q

DDx for causes of N&V

A

● Infectious Causes
● GI Disorders
● Endocrine Causes
● Misc. Causes
● Medications
● CNS Causes

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7
Q

Diarrhea

A

Passage of loose or watery stools:
* At least three times in a 24-hour period
* >200 g/day (difficult to measure)

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8
Q

Diarrhea pathophysiology

A

↑ water content of the stool
due to:
* Impaired water absorption
* Active water secretion by the bowel
* Acute
* Persistent
* Chronic

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9
Q

Diarrhea can generally be classified as:

A
  1. Infectious or noninfectious
  2. Inflammatory or noninflammatory
  3. Acute or chronic
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10
Q

Inflammatory Diarrhea

A
  • Can be due to infectious (Invasive infections) and noninfectious causes.
  • Symptoms include:
  • Diarrhea with visible blood or mucus (invading tissue). Dysentery = bloody diarrhea
  • Frequent, small-volume, and bloody stools
  • May be accompanied by tenesmus, fever, or severe abdominal pain
  • Stool will often contain leukocytes or leukocyte proteins
  • If chronic, it is likely Inflammatory Bowel Disease
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11
Q

Non-inflammatory Diarrhea:

A

Most often caused by enterotoxin-producing organisms such as Vibrio cholerae and E.
coli, or by viruses that adhere to the mucosa and disrupt the absorptive and/or
secretory processes without causing acute inflammation or mucosal destruction

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12
Q

Symptoms of Non-inflammatory Diarrhea

A
  • Watery
  • No blood/pus (symptoms are due to osmotic and secretory effect)
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13
Q

Acute diarrhea:

A

<14 days

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14
Q

Persistent diarrhea duration

A

14-29 days

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15
Q

Chronic diarrhea duration

A

> 30 days

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16
Q

Diarrhea - Risk Factors

A
  • Person to person exposure (ill contacts, daycare or senior-care centers)
  • Exposure to contaminated food or water
  • Exposure to animals (birds, reptiles often harbor salmonella)
  • Medications
  • Iatrogenic: Recent hospitalization within the last 3 months
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17
Q

Diarrhea - Emergent/Urgent Risk Factors

A
  • Signs of inflammatory diarrhea: Fever, ↑ WBC, Bloody diarrhea, Severe abdominal pain
  • Passage of > 6 unformed stools/24h
  • Profuse watery diarrhea & dehydration
  • Frail older patient (> 65 yrs)
  • Immunocompromised pts
  • HIV, DM
  • Recent exposure to antibiotics
  • Weight loss
  • Pregnancy
  • Sx > 7 days
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18
Q

Acute Diarrhea - Etiology

A
  • Lasts < 2 weeks (~5-7 days)
  • Acute onset
  • Most commonly caused by:
  • Infectious agents
  • Medications
  • Can be non-inflammatory or
    inflammatory diarrhea
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19
Q

Acute Diarrhea - non inflammatory

A
  • Watery, Non-bloody
  • Caused by virus or non-invasive bacteria
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20
Q

S/S non-inflammatory acute diarrhea

A
  • Periumbilical cramping
  • Bloating
  • Nausea
  • Vomiting
  • Prominent
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21
Q

Enterotoxigenic E Coli
(traveler’s diarrhea) is a common cause of ___

A

Acute non-inflammatory diarrhea

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22
Q

Inflammatory acute diarrhea etiology

A
  • Fever
  • Bloody (dysentery)
  • Small volume < 1L/day
  • B/C predominantly involves the colon
  • Caused by virus or invasive bacteria: Shigella, Salmonella, Campylobacter, Amebiasis, C. diff, Enterohemorrhagic E. coli
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23
Q

S/S Inflammatory acute diarrhea

A
  • LLQ cramping
  • Urgency
  • Tenesmus
  • Fever
    • fecal leukocytes present
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24
Q

Infectious dysentery MUST be distinguished from _____

A

acute ulcerative colitis

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25
the Initial goal of the practitioner evaluating diarrhea is to Distinguish between _____
mild disease & those with serious disease * >90% of pts = mild/self-limited
26
If diarrhea worsens & lasts > 7 days, labs:
* Fecal leukocyte * Bacterial cx * Obtain THREE samples of O&P * > 10 days * Hx of fairly recent travel * HIV positive * Oral-anal sex
27
General Nausea, Vomiting, & Diarrhea - Treatment
1. Diet 2. Rehydration 3. Antiemetics 4. Antidiarrheal Agents 5. Antibiotic Therapy 6. Admit
28
Diet in treating N/V/D
1. Generally, diet should consist of softer, more easily digested foods, given in smaller amounts (BRAT diet) 2. Bowel rest (i.e. - avoid): * Large meals * High-fiber food * Fats * Milk products * Caffeine * Alcohol
29
1st line rehydration treatment in N/V/D
Oral rehydration * If feasible the solution should contain the following: * Glucose, Na+, K+, Cl-, HCO3 , Citrate * Oral electrolyte solutions: * Pedialyte, Gatorade, Oral rehydration tablets * Ice chips * IV fluids – SEVERE dehydration (1 liter Normal Saline (NS) or Ringer's Lactate (RL) IV over 60-90 min)
30
The most critical therapy in diarrheal illness is
Hydration
31
Antimicrobial Therapy
* NOT warranted for all patients * Administered either empirically (based on likely causes) or targeted (based on testing)
32
Targeted abx treatments for giardia
metronidazole
33
Targeted abx treatments for amebiasis
metronidazole
34
Targeted abx treatments for travelers diarrhea
Cipro or azithromycin
35
Targeted abx treatments for E. coli
Supportive
36
Targeted abx treatments for C. Diff
Metronidazole or vancomycin
37
Chronic Diarrhea
* Diarrhea present > 4 weeks
38
Most common causes of chronic diarrhea
* Medications * Lactose Intolerance * Irritable bowel syndrome
39
Chronic Diarrhea - labs
* CBC, TSH, CMP (albumin, calcium, LFT’s) TSH, vitamin A & D, INR, ESR, CRP, celiac serologic testing
40
Routine stool studies:
* O&P * Fecal Electrolytes (osmotic gap- secretory) * Qualitative staining for fat (sudan stain) * Occult blood (FOBT) * Leukocytes * Stool culture: routine identifies Salmonella, shigella, campylobacter
41
Staphylococcus aureus
Gram positive cocci in clusters (grapes) ● Facultative anaerobe (ATP via O2 or fermentation) ● Can cause many infections including gastroenteritis ● Can grow in food ● Produces Enterotoxin ● Ingested toxin → 12-24 hours of: ● Abdominal pain ● Nausea ● Vomiting (Q15-30 min X 12-24hrs) ● Diarrhea
42
Bacillus cereus
Gram positive rods * Aerobic, spore forming, toxin-producing * Deposits spores in food which survive initial cooking * Heat activates the spores → causes bacteria dump their enterotoxin into the food (the bacteria are killed by the heat) * Ingested toxin = nausea, vomiting, abdominal pain, & diarrhea * Lasts 12-24 hours usually, self-limited * Fried rice is an important cause of Bacillus cereus
43
Clostridium difficile
“C Diff” or Pseudomembranous Enterocolitis * Small amount normally found in the intestine (controlled) * Gram stain: Gram Positive Rod * Anaerobic bacteria, spore-forming, toxin-producing * Spores are often found in hospitals & nursing homes * Fecal-oral ingestion of spores → intestinal colonization
44
Escherichia coli
* Part of normal colon flora * If it gains virulence factor (mutation, plasmid exchange, etc), E coli can cause human disease. * Diarrhea, UTIs, neonatal meningitis, Gram negative sepsis * Outbreaks can occur with fecal contamination of water
45
3 important strains of E. Coli
* Enterotoxigenic: Non-invasive, toxin induces watery diarrhea (travelers diarrhea) * Enterohemorrhagic Escherichia coli (EHEC) : Invasive diarrhea due to Shiga-like toxin. * Enteroinvasive: Invasive diarrhea
46
HUS triad (hemolytic uremic syndrome)
Hemolytic anemia Acute renal failure Thrombocytopenia Triad is life Threatening 1% in adults 3% in children
47
Vibrio cholerae (Cholera)
● Similar action to E. Coli but much more severe ● Influx of Na+ into lumen pulls water with it ● Copious watery diarrhea (up to 1 L / hr) ● “Rice Water Diarrhea” ● Fishy odor
48
Treatment for cholera
Cipro® or azithromycin
49
Salmonella
* Salmonella Gastroenteritis- * Most common form of Salmonella * Sx - occur 8-48 hr post ingestion: * Fever * Abdominal pain * Mucous * Bloody diarrhea
50
Treatment of Salmonella
* Supportive * Abx do NOT shorten dz course
51
Severe form of salmonella
Typhoid Fever * Rx: Cipro (1st line), azithromycin, cephalosporins or trimethoprim/sulfamethoxazole
52
A MAJOR complication of Salmonellosis = _____
Enteric fever (Typhoid fever)
53
Symptoms of typhoid fever
○ SYSTEMIC - gets into the bloodstream ■ Meningitis ■ Endocarditis ■ Osteomyelitis ○ Weight loss ○ Rose spots (transient rash on abd/back) ● Culprits are Salmonella typhi & Salmonella paratyphi
54
Shigella
“Shigella dysenteriae” * NEVER found in normal GI flora * Shiga toxin: Cytotoxic to intestinal epithelium
55
S/S shigella
* HIGH Fever * Bloody/mucoid diarrhea (invasive) * Purulent * Abdominal cramping * Tenesmus & rectal spasms
56
Treatment of shigella
* Supportive treatment * Severe = Ciprofloxacin or TMP-SMX
57
Intestinal Complications of Shigella
* Proctitis * Rectal Prolapse * Toxic Megacolon * Intestinal obstruction * Colonic perforation
58
Campylobacter Jejuni S/S
* Fever * Bloody diarrhea * Possible association with Guillain-Barre Syndrome * Caution - can mimic appendicitis: often severe abdominal pain occurs PRIOR to onset of diarrhea * Key = Rebound/guarding usually absent * Can mimic inflammatory bowel disease colitis: starts in jejunum & progresses to cecum & colon. * Acute colitis & bloody diarrhea
59
How do differentiate campylobacter jejuni from appendicitis
Rebound/guarding usually absent
60
The two most common GI viruses are:
* Rotaviruses * Norwalk Virus
61
Leading cause of dehydrating gastroenteritis in children worldwide
Rotaviruses
62
= Most Common Sources of Transmission for norovirus
Food handlers
63
Treatment of CMV
* Antiretrovirals (in HIV pts) * Ganciclovir * Prophylaxis in HIV pts when CD4 < 50
64
Amebiasis Tx:
* Metronidazole + Iodoquinol
65
Giardiasis Tx
metronidazole

GI Exam 3 (5 decks)

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