Vomiting, Diarrhea, Constipation Flashcards Preview

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Flashcards in Vomiting, Diarrhea, Constipation Deck (77)
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1
Q
Nausea and vomiting pathway
A
Brainstem mediated in medulla, stimulated by:
-Afferent vagal fibers from GI viscera 5-HT3 receptors due to biliary or GI distention, mucosal or peritoneal irritation, or infections.
-Vestibular system, H1 and muscarinic cholinergic receptors
-Amygdala (sights/smells/emotion)
-Chemoreceptor trigger zone (outside blood brain barrier; rich in opioid, serotonin 5-HT3, dopamine D2 receptors)
2
Q
Visceral afferent stimulation caused by Mechanical obstruction
A
malignancy, gastric volvulus, peptic ulcer disease, adhesions, hernias, Crohns,
carcinomatosis
3
Q
With abdominal/epigastric pain, always think
A
cardiac (MI)
4
Q
Pancreatitis causes epigastric pain that radiates to
A
back (will see increased lipase on blood tests)
5
Q
Cholelithiasis
A
gallstones
6
Q
Cholecystitis
A
inflamed gallbladder
7
Q
Choledocholithiais
A
stone on common bile duct
8
Q
Visceral afferent stimulation caused by dysmotility
A
gastroparesis (from diabetes, post viral, post vagotomy), scleroderma, amyloidosis, familial myoneuropathies
9
Q
Visceral afferent stimulation caused by peritoneal irritation
A
peritonitis, perforated viscus, appendicitis, spontaneous bacterial peritonitis, viral gastroenteritis, Norwalk agent, rotavirus, food poisoning toxins from Bacillus cereus, Staph aureus or clostridium perfringens, Hep A or B, acute systemic infection
10
Q
Visceral afferent stimulation caused by Hepatobiliary or pancreatic disorders
A
acute pancreatitis, cholecystitis/lithiasis
11
Q
Visceral afferent stimulation caused by topical GI irritants
A
alcohol, NSAIDs, antibiotics (Tetracyclines- take with milk or crackers)
12
Q
Visceral afferent stimulation caused by Post op/other
A
cardiac disease, acute MI, heart failure, urologic disease, stones, pyelonephritis
13
Q
Vestibular disorders that can cause N/V
A
Labyrinthitis, Meniere syndrome, motion sickness
14
Q
CNS disorders that can cause N/V
A
Increased intracranial pressure (CNS tumors, subdural/subarachnoid hemorrhage)
Migraine infections (meningitis, encephalitis)
Psychogenic- anticipatory vomiting, anorexia/bulimia, psych disorders
15
Q
Irritation of CRTZ
A
-Antitumor & Chemo/ Radiation meds
-Meds/Drugs (opioids, anticonvulsants, antiparkinsons, Bblockers, antiarrhythmics, digoxin, nicotine, BC pills, cholinesterase inhibitors, diabetes meds)
16
Q
Systemic disorders that can irritate CRTZ
A
Diabetic ketoacidosis, uremia, adrenocortical crisis, parathyroid disease, hypothyroidism, pregnancy, paraneoplastic syndrome
17
Q
History clues- morning vomiting?
A
Pregnancy, alcohol, increased ICP
18
Q
History clues- after meals?
A
Biliary (think gallstone or gallbladder issue possibly)
19
Q
History clues- undigested food?
A
Gastroparesis or gastric outlet obstruction
20
Q
History clues- green emesis?
A
Bowel obstruction, biliary (classic presentation)
21
Q
Rebound pain?
A
Peritonitis
22
Q
RUQ pain? Murphy's sign?
A
appendicitis
23
Q
Pelvic pain in woman?
A
gyn/ovarian pathology
24
Q
CMP will show
A
CLASSIC: Hypochloremic, hypokalemic, metabolic alkalosis (prolonged emesis)
-Could be from vomiting, diuretics
25
Q
Other Tests to order
A
-KUB (kidney, urinary, bladder), Obstructive Series (xrays standing, sitting, laying, to check air fluid levels)
-NM Gastric Emptying Study
-Barium Upper GI Study (up to small intestine)
-EGD (put camera in mouth/down throat to look into stomach)
-CT w or w/o, RARELY w and w/on (note that is 2 scans)  usually only WITH or WITHOUT
-Head CT? to rule out tumor
26
Q
Small bowel obstruction on Xray
A
MUST KNOW FOR TEST!!
-air fluid levels (and stool on X-ray)
27
Q
Complications
A
Dehydration, electrolytes, aspiration, Boerhaave’s Syndrome, Mallory Weiss Tears
28
Q
Aspiration- if someone throws up look for complications; if they throw up and take deep breath, vomit goes into lungs, causes chemical inflammation- may show up hours or days later- if they spike a fever- start on ________
A
antibiotic for anaerobic coverage (bacteria from gut is in lungs)
29
Q
Mallory Weiss Tears
A
small tear in esophagus and you throw up blood- from force of throwing up (bulimics and alcoholics)
30
Q
Boerhaave’s Syndrome
A
esophageal rupture (in FA)
31
Q
Treatment
A
-Symptomatic management
(clear liquids to full liquids to soft diet)
-Admit patient?
-NG tube? Tube from nose to stomach
-Antiemetic Medications
32
Q
Antiemetics- Serotonin 5-HT3 antagonists
A
Ondansetron (most common), Granlsetron (chemo patients), Dolasetron, Palonosetron
33
Q
Antiemetics- Dopamine receptor antagonists
A
Metoclopramide, Prochlorperazine, Promethazine, Trimethobenzamide
34
Q
Marijuana as antiemetic
A
-THC active ingredient, available by Rx as dronabinol
-Helps with nausea of chemotherapy, 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**
35
Q
Diarrhea
A
200-300g in 24 hour period or more than 3 bowel movements per day or liquidity
36
Q
Non-inflammatory Acute Diarrhea
A
37
Q
Inflammatory Acute Diarrhea
A
-Blood, pus or fever (BAD- invasive pathogen)
-Invasive organism or toxin producing
-Clostridium difficile, E coli O157:H7 (Isolation, spore forming, hard to kill, not hand sanitizer, only soap and water, test for this in stool)
38
Q
What food to avoid during pregnancy and why
A
Avoid soft cheese- higher risk of Listeriosis
39
Q
Day care and hiking cause higher risk of
A
Giardia or cryptosporidium
40
Q
Using antibiotics (like Cipro from travelers diarrhea)
A
May cause C diff colitis
41
Q
Antibiotics for C diff
A
metronidazol (first line)- Vanco if that doesn’t work
42
Q
For pt with C diff or E coli DO NOT GIVE
A
Do NOT give immodium (loperimide) or diphenoxylate with atropine, risk of increased contact time with gut (increased risk for systemic infection, body can’t get rid of it)
43
Q
Stomach virus from cruise ship
A
Norovirus
44
Q
Noninflammatory diarrhea is from
A
-norovirus, rotavirus
-giardia, cryptosporidium, cyclospora
-preformed enterotoxins (s. aureus, bacillus cereus, clostridium perfringens)
-enterotoxin production (enterotoxogenic E coli, vibrio cholerae)
45
Q
Inflammatory diarrhea is from
A
-CMV
-entamoeba histolytica
-Cytotoxin production (vibrio parahaemolyticus, EHEC O157:H5, C. diff)
-Mucosal invasion (shigella, campy, salmonella, EIEC, aeromonas, pleisomonas, yersinia, chlamydia, n. gonorrhea, listeria)
46
Q
Treatment
A
-Bismuth subsalicylate (Pepto- can turn stool black), good for traveler’s

-Loperamide: opioid receptor agaonist

-Inflammatory Bowel Disease?
UC (ulcerative colitis) vs. Crohn’s (terminal ilea)
47
Q
Osmotic diarrhea
A
-stool volume decreases w/ fasting, increased stoop osmotic gap
-from meds (antacids, lactulose, sorbitol)
-from dissacharidase deficiency (lactose intolerance)
-factitious diarrhea (magnesium in antacids/laxatives)
48
Q
Secretory diarrhea
A
-large volume (> 1L/day), little change with fasting, normal stool osmotic gap
-hormonally mediated (carcinoid, zollinger ellison syndrome-gastrin)
-factitious diarrhea (laxative abuse)
-villous adenoma
-bile salt malabsorption (idiopathic, crohns ileitis, post- cholecystectomy)
-meds
49
Q
Inflammatory conditions
A
-fever, hematochezia, abdominal pain
-UC, crohns, microscopic colitis
-malignancy (lymphoma, adenocarcinoma with obstruction and pseudodiarrhea(
-radiation enteritis
50
Q
Meds causing diarrhea
A
-SSRIs, cholinesterase inhibitors, NSAIDs, PPIs, ARBs, metformin, allopruinol
51
Q
Malabsorption syndromes
A
-weight loss, abnormal lab values, fecal fat > 10g/24 hrs
-small bowel mucosal disorders (celiac sprue, tropical sprue, whipple dx, eosinophilic GItis, small bowel resection, crohns)
-Lymphatic obstruction (lymphoma, carcinoid, infectious (tuberculosis), Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis)
-Pancreatic dx (chronic pancreatitis, cancer)
-Bacterial overgrowth (motility disorder like diabetes or vagotomy, scleroderma, fistulas, small int diverticula)
52
Q
Motility disorders
A
-systemic disease, prior abdominal surgery
-postsurgical (vagotomy, partial gastrectomy, blind loop with bacterial overgrowth)
-systemic disorders (scelroderma, DM, hyperthyroidism)
-IBS
53
Q
Chronic infections
A
-parasites (giardia, e. histolytica, strongyloidiasis, capillaria)
-AIDS related (CMV, HIV, C diff., mycobacterium avium complex, microsporidia, cryptosoiridium, Isospora belli)
54
Q
A 90 year old male with PMH of HTN, DM presents to your office with complaint of constipation. He reports normally would have a BM every day, but now often goes 2 days without one.
What do you tell the patient?
A
Prune juice- start with this- natural laxative

55
Q
Constipation overview
A
-10-15% of adults
-More common in women, elderly
-If bed bound, may be due to inability to get to toilet
-History is key
-Physical examination: rectal exam, FOBT (fecal occult blood testing)
-Labs: BMP, Mag, TSH
-Colonoscopy? not usually, unless you think tumor
56
Q
Most common causes of constipation are from
A
1. inadequate fiber/fluid intake
2. poor bowel habits
57
Q
System diseases that can cause constipation are
A
-endocrine (hypothyroidism, hyperparathyroidism, DM)
-metabolic (hypokalemia, hypercalcemia, uremia, porphyria)
-neuro (parkinsons, MS, sacral nerve damage from prior pelvic surgery or tumor, parapalegia, autonomic neuropathy)
58
Q
Meds that can cause constipation
A
-opioids, diuretics, calcium channel blockers, anticholinergics, psychotropics, calcium/iron supplements, NSAIDs, clonidine, cholestyramine)
59
Q
Structural abnormalities causing constipation
A
-Anorectal (rectal prolapse, rectocele, rectal intussusception, anorectal stricture, anal fissure, rectal ulcer syndrome)
-Perineal descent
-Clonic mass with obstruction/adenocarcinoma
-Hirschsprung disease
-Colonic stricture (radiation, ischemia, diverticulosis)
-Idiopathic megarectum
60
Q
Slow colonic transit can cause constipation from
A
-idiopathic
-psychogenic
-eating disorders
-chronic int pseudo-obstruction
61
Q
Other things causing constipation
A
Pelvic floor dyssynergia or IBS
62
Q
Zollinger Ellison syndrome
A
gastin secreting tumor
63
Q
Primary Constipation description
A
-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)- chronic abdominal pain, gets BETTER with bowel movement- sign of IBS, alternate diarrhea and constipation
64
Q
Secondary Constipation
A
-Systemic disorders, medications, obstructing colonic lesions
(Hypercalcemia, hypokalemia, hypothyroidism, calcium channel blockers like amlodipine/nifedipine)
-Cancer (Warning signs: Age >50 with hematochezia, weight loss, anemia, FOBT +, family history of colon CA, IBD patients-->refer to gastroenterologist)
65
Q
Treatment options
A
-Lifestyle measures
-Dietary changes
-Mineral oil
-Laxatives, Osmotic laxatives, Stimulant laxatives
(Magnesium citrate – AKA “liquid TNT” – Magnesium Mg “makes you go”)
-Prune juice
-Enema or Suppository
-For fecal Impaction use manual disimpaction
-OMT: colonic milking
66
Q
For Opioid Induced Constipation use
A
Methylnaltrexone (Relistor):
subcutaneous injection, expensive, blocks opioid receptors in gut only
67
Q
Examples for stool surfactants
A
-Docusate sodium, mineral oil
68
Q
Examples of Osmotic laxatives
A
-Magnesium oxide, lactulose or sorbitol, polyethylene glycol
69
Q
Examples of stimulant laxatives
A
bisacodyl, cascara, senna
70
Q
First line therapy (note from class)
A
Senna and docusate may come in combined pill- may cause cramping --> first line therapy
71
Q
Drug good for constipated pts with liver problems
A
Lactulose- good for liver patients, prevents ammonia build up in blood
72
Q
Ogilvie Syndrome
A
-AKA Acute Colonic Pseudo-obstruction (ACPO)
-Massive dilation of large intestine- electrolyte imbalances- older patients
-Tube in rectum to suck air out
-Stop opioid use
XRAY pic in slides
73
Q
Projective vomiting in 2-6 week old = palpable “olive” mass, think of
A
Congenital pyloric stenosis
74
Q
Bird’s beak on barium swallow, ? if from Chagas disease
A
Achalasia
75
Q
Boerhaave syndrome
A
esophageal rupture
76
Q
Diverticulosis vs. Diverticulitis - pain location and s/s
A
LLQ Pain, fever, leukocytosis
77
Q
Intussusception (intestine collapses on itself) will present with
A
“currant jelly” stools