vomiting, diarrhea, constipation Flashcards Preview

CSI > vomiting, diarrhea, constipation > Flashcards

Flashcards in vomiting, diarrhea, constipation Deck (60):
1

chronic nausea/vomiting, think what conditions??

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

2

with excessive vomiting, watch out for ??

rupture of esophageal varicose: can rupture

3

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

will corrode esophagus 2x!!

4

induced vomiting can b ??

medication/iatrogenic in the hospital
on purpose

5

N/V mediated by

Brainstem mediated in medulla
stimulated by: 4 next cards

6

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

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

7

Vestibular system, ??

H1 and muscarinic cholinergic receptors

8

Amygdala, ??

sights/smells/emotion

9

Chemoreceptor trigger zone (outside blood brain barrier)

Rich in opioid, serotonin 5-HT3, dopamine D2 receptors
(effected by meds)

10

mechanical obstructions

gastric outlet obstruction, PUD, Ca, gastric volvulus
small int. obstruction, adhesions, hernias, volulus Crohn's, Ca

11

dysmotility

gastroparesis, DM, postviral, post vagotomy
sm. int: scleroderma, amyloidosis, chronic intestinal pseudo obstruction

12

peritoneal irritation

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

13

hepatobiliary or pancreatic disorders

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

14

topical GI irritants

etOH, NSAIDs, oral abx (tetras)

15

postop

due to anesthesia

16

other causes of N/V

cardiac disease: acute MI, HF
urologic disease: stones, pyelonephritis

17

vestibular disorders

labyrinthitis, Menieres, motion sickness

18

CNS disorders

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

19

irritation of CRTZ

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

20

morning vomiting

Pregnancy, alcohol, increased ICP

21

after meals

biliary, GB issue

22

undigested foods?

Gastroparesis or gastric outlet obstruction

23

Green Emesis

Bowel obstruction, biliary emesis

24

examination

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

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