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vomiting, diarrhea, constipation Flashcards

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1
Q

chronic nausea/vomiting, think what conditions??

A

gastroparesis: DM neuropathy, unable to digest
dx with a radio labeled egg that is undigested

tx: Reglan, metoclopromide (prokinetic)
erythromycin (but tachyphylaxis? effect: tolerance, stops working after several doses)
FYI can put in gastric pacemakers

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2
Q

with excessive vomiting, watch out for ??

A

rupture of esophageal varicose: can rupture

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3
Q

if drink drano, don’t induce vomiting because ??

A

will corrode esophagus 2x!!

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4
Q

induced vomiting can b ??

A

medication/iatrogenic in the hospital

on purpose

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5
Q

N/V mediated by

A

Brainstem mediated in medulla

stimulated by: 4 next cards

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6
Q

Afferent vagal fibers from GI viscera 5-HT3 receptors due to ??

A

biliary or GI distention, mucosal or peritoneal irritation, or infections. (pre-formed toxins)

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7
Q

Vestibular system, ??

A

H1 and muscarinic cholinergic receptors

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8
Q

Amygdala, ??

A

sights/smells/emotion

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9
Q

Chemoreceptor trigger zone (outside blood brain barrier)

A

Rich in opioid, serotonin 5-HT3, dopamine D2 receptors

effected by meds

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10
Q

mechanical obstructions

A

gastric outlet obstruction, PUD, Ca, gastric volvulus

small int. obstruction, adhesions, hernias, volulus Crohn’s, Ca

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11
Q

dysmotility

A

gastroparesis, DM, postviral, post vagotomy

sm. int: scleroderma, amyloidosis, chronic intestinal pseudo obstruction

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12
Q

peritoneal irritation

A

peritonitis: perforated viscus, appendicitis,(rebound tenderness) spontaneous bacterial peritonitis (bac from gut into peritoneal cavity: if cirrhotic, dec. immune system)

viral gastroenteritis: Norwalk, rotavirus

“food poisoning”: Bacillus cereus, S. aureus, C. perfringes

Hepatitis A, B
acute systemic infections

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13
Q

hepatobiliary or pancreatic disorders

A

acute pancreatitis

cholecystitis (inflamed GB) or choledocholithiasis (stone in common bile duct)

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14
Q

topical GI irritants

A

etOH, NSAIDs, oral abx (tetras)

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15
Q

postop

A

due to anesthesia

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16
Q

other causes of N/V

A

cardiac disease: acute MI, HF

urologic disease: stones, pyelonephritis

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17
Q

vestibular disorders

A

labyrinthitis, Menieres, motion sickness

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18
Q

CNS disorders

A

inc. ICP: CNS tumors (morning), subdural, SAH
migraine
infections: meningitis, encephalitis
psychogenic

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19
Q

irritation of CRTZ

A 
antitumor chemo
meds/drugs?? (nicotine gum misuse)
radiation tx
systemic disorders 
DKA
pregnancy
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20
Q

morning vomiting

A

Pregnancy, alcohol, increased ICP

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21
Q

after meals

A

biliary, GB issue

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22
Q

undigested foods?

A

Gastroparesis or gastric outlet obstruction

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23
Q

Green Emesis

A

Bowel obstruction, biliary emesis

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24
Q

examination

A

Rebound?
RUQ Pain? Murphy’s?
Pelvic Pain in Woman? (think gyne, ovarian pathology) PID, ovarian torsion

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25
vomiting CMP
Hypochloremic, hypokalemic, metabolic alkalosis (prolonged emesis
26
other testing
``` KUB, Obstructive Series NM Gastric Emptying Study Barium Upper GI Study EGD CT w or w/o, RARELY w and w/on (note that is 2 scans) (pick ONE typically) Head CT? (check for tumor) ```
27
slide 12 on left
stool seen on right on pt
28
slide 12 on right
see air bubbles: small bowel obstruction
29
most common dx
``` Viral Gastroenteritis Bacterial Gastroenteritis Ileus Small Bowel Obstruction Opiate Induced Gastroparesis Pregnancy Chemotherapy Anesthesia Gallstone Pancreatitis *Ascites (from inc. pressure) ```
30
complications of vomiting
Dehydration, electrolytes *aspiration* (into lungs: chemical inflammation, if have fever start on anaerobic abx coverage) Boerhaave’s Syndrome (rupture esophagus, emergency, rare, v. painful) Mallory Weiss Tears (more common, less serious, smaller tears from force of vomiting)
31
vomiting tx
Symptomatic management -Clear liquids to full liquids to soft diet Admit patient? NG tube? (swallow when going down to ensure not in lungs, XR to figure out in lungs, listen for gurgling sound with sterile saline) Antiemetic Medications
32
serotonin 5-HT3 antagonists
ondansetron (zofran) IV, oral granisetron (chemo?) dolasetron Palonosetron (chemo)
33
ondansetron
oral or IV | postop N/V
34
granisetron
IV for chemo
35
dopamine receptor antagonists
*metoclopramide* IV, oral *prochlorperazine IV, IM, oral, rectum *promethazine IV, oral, rectum trimethobenzamide oral, IV SEs: dyskinesias
36
marijuana: used as tx and causes vomiting
THC active ingredient, available by Rx as dronabinol Helps with nausea of chemo, has CNS side effects NOTE: some have paradoxical reaction, Cyclic Vomiting Syndrome, Canabis Hyperemesis Syndrome: Classic History: Improvement of symptoms of N/V with taking a hot shower
37
2nd Case: traveller's diarrhea
pepto bismol | Postinchain doesn't like cipro: risk of C. diff
38
Diarrhea
Range from acute self limiting to fatal (cholera) 10L approximately entering duodenum, all but 1.5 L absorbed, colon absorbs rest less than 200ml in stool lost Definition: 200-300g in 24 hour period Alternate Definition: more than 3 bowel movements per day (may be norm) or liquidity
39
acute diarrhea
``` less than 2 weeks -Non inflammatory: Watery, non bloody Self limited Virus or noninvasive bacteria -Inflammatory: Blood, pus or fever Invasive organism or toxin producing Clostridium difficile, E coli O157:H7 ```
40
risk for acute diarrhea
Pregnancy? Higher risk of listeriosis (avoid soft cheese) Day care? Hiking? Higher risk Giardia or Cryptosporidium Traveler’s diarrhea Antibiotics? C diff colitis (metronidazole, vanco SLD) (can have without C. diff) HIV? ie: CMV
41
med risk for acute diarrhea ??
Do NOT give immodium (loperimide) or diphenoxylate with atropine, risk of increased contact time with gut
42
virus causing diarrhea on cruiseship
norovirus | slide 24
43
slide 25
causes
44
slide 26
``` algorithm send for fecal leaks routine stoll cx C. diff assay o/p more ```
45
med Good for traveler’s
Bismuth subsalicylate
46
opioid receptor agaonist
Loperamide
47
IBD??
UC or Crohn's: affects terminal ileum
48
chronic diarrhea time
>4 wks
49
slide 29, 30
types/causes laxatives malabsorption: lactase deficiency, malfuncitoning pancreas
50
case 3: constipation
can add metamucil prune juice 10-15% of adults More common in women, elderly If bed bound, may be due to inability to get to toilet
51
dx constipation
History is key Physical examination: rectal exam, FOBT Labs: BMP, Mag, TSH ? Colonoscopy (only if thinking tumor)
52
slide 34 more causes
``` inadequate fluid hypothyroidism *hyperthyroidism: can lead to hyperCa2+ and cause constipation* neuro disorders CCBs ```
53
primary constipation
Normal transit time is 35 hours, more than 72 hours is abnormal Impaired relaxation of anal sphincter and/or pelvic floor muscles Irritable Bowel Syndrome (IBS) (pain relieved with bowel movement, can fluctuate C/D)
54
secondary constipation
Systemic disorders, medications, obstructing colonic lesions: Hypercalcemia, hypokalemia, hypothyroidism, calcium channel blockers (amlodipine/nifedipine)
55
secondary constipation: cancer: Warning signs:
Age >50 with: hematochezia, weight loss, anemia, FOBT +, family history of colon CA, IBD patients
56
constipation tx
Lifestyle measures Dietary changes Mineral oil Laxatives, Osmotic laxatives, Stimulant laxatives Magnesium citrate – AKA “liquid TNT” – Magnesium Mg “makes you go” Prune juice Opioid Induced Constipation: Methylnaltrexone (Relistor), subcutaneous injection Enema or Suppository Fecal Impaction Manual disimpaction OMT: colonic milking
57
most common
polyethylene glycol (miralax, golytely) stimulant lax: senna: ExLax, may cause cramps add with *docusate* (1st line) Lactulose: prevents buildup of ammonium, good for liver pts
58
Ogilvie syndrome
AKA Acute Colonic Pseudo-obstruction (ACPO) massive dilation of large intestine put tube in colon, suck air out, stop opiates, get pt to walk around
59
FA facts
Projective vomiting in 2-6 week old = palpable “olive” mass: Congenital pyloric stenosis Achalasia – bird’s beak on barium swallow, ? (pic) If from Chagas disease Boerhaave syndrome – esophageal rupture
60
FA facts 2
Diverticulosis vs. Diverticulitis (when it becomes INFECTED) (LLQ Pain, fever, leukocytosis) Intussusception – “currant jelly” stools

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