GI Packet #5

Gastrointestinal (GI) Bleeding

Bleeding from any site between the esophagus and anus

Occult

Hidden

Hematemesis

Vomiting blood

Hematochezia

Gross blood via the rectum

Melena

Black tarry stool

How do you recognize if it is internal?

You DON'T!; Recognize Sx that accompany GI bleed b/c Sx depend on site of bleed

An upper GI bleed occurs where in the GI tract?

Down to and including the duodenum

Pts with an upper GI bleed complain of what Sx? (3)

1. Vomiting bright red blood (Hematemesis)

2. Passing black tarry stools (Melena)

3. Vomiting coffee ground like vomit

A lower GI bleed occurs where in the GI tract?

Remaining small intestine through the colon and to the rectum

Pts with a lower GI bleed complain of what Sx? (1)

1. Passing pure blood or mixed blood with stool (Hematochezia)

Ligament of Treitz

Musculo fibrous band extending from the duodenum to the diaphragm

What does the ligament of Treitz separate?

Upper and lower GI tract

What kind of muscle is the ligament of Treitz and what does it do?

-Suspensory muscle

-Suspends abdominal contents & keeps them in place

What type of bleeding occurs from the esophagus? (2)

1. Vomiting bright red (blood) or coffee ground material

2. Black stools

What is the possible reason of bleeding from the esophagus? (2)

1. Ulcers

2. Varices

What type of bleeding occurs from the stomach? (2)

1. Vomiting bright red (blood) or coffee ground material

2. Black stools

What is the possible reason of bleeding from the stomach? (2)

1. Ulcer

2. Gastritis

What type of bleeding occurs from the small intestine?

Bright red/maroon rectal bleeding

What is the possible reason of bleeding from the small intestine? (2)

1. Ulcer

2. Tumor

What type of bleeding occurs from the large intestine?

Blood in stool

What is the possible reason of bleeding from the large intestine? (3)

1. Colon tumor

2. Polyps

3. Inflammatory Bowel Disease

What type of bleeding occurs from the rectum?

Bright red bleeding

What is the possible reason of bleeding from the rectum? (2)

1. Hemorrhoids

2. Tumor

What do most GI bleeds come from?

Ulcer formation

Risk Factors of GI bleeding (5)

1. Age

2. Chronic use of NSAIDs

3. Prior ulcer

4. Chronic alcohol use

5. Anticoagulants (blood thinners) put Pt at risk

What is the bench mark alcohol "recommendation" for males and females?

Males: 2 drinks/day

Females: 1 drink/day

TRUE OR FALSE: Healthcare providers can force Pts to stop using alcohol.

False, providers can only recommend avoidance of alcohol.

Diagnostics of GI Bleeding (8)

1. Rectal (Digital) Exam

2. FOBT

3. FIT

4. Cologuard

5. Upper endoscopy

6. Drink medium and take scans

7. Sigmoidoscopy

8. Shield Test

What can be observed during a rectal exam?

Lumps, bumps, masses, and tenderness

FOBT

Fecal Occult Blood Test

What is the brand name for FOBT?

Hemocult

What color does the stool turn during an FOBT if it is positive for blood?

Blue

FIT

Fecal Immunochemical Test

What kind of test is an FIT and what can it identify?

-Antibody test

-identifies occult (hidden) blood

How does Cologuard work?

DNA test identifying blood in stool

What part of the GI tract does the upper endoscopy examine?

Mouth to duodenum

What part of the GI tract does a sigmoidoscopy examine?

Rectum to sigmoid

What differentiates a sigmoidoscopy and a colonoscopy?

Sigmoidoscopy: Rectum to sigmoid

Colonoscopy: Rectum to cecum (large intestine)

What does the Shield Test detect?

Detects DNA fragments of cancer in the blood

Diarrhea

Abnormally frequent and liquid stools

Why is "frequent" a deceiving term?

Because defining frequency is based off what is normal for the Pt

Acute diarrhea

Lasts a few days

Chronic diarrhea

Greater than a month

Common causes of diarrhea (7)

1. Viral

2. Bacterial & Parasitic

3. Digestive disorders

4. Medications

5. Use of artificial sweeteners

6. High anxiety and stress

7. Sensitivity to certain foods

What is the #1 cause of diarrhea?

Viral

What is the most common cause of viral diarrhea in the U.S., especially in children?

Norwalk Virus

What is the most common cause of viral diarrhea worldwide?

Rotavirus

Why do we not see Rotavirus in the U.S.?

Kids are vaccinated in the U.S.

What is the transmission mechanism for diarrhea via bacteria and parasites?

Contaminated food or water

What are examples of bacterial causes of diarrhea? (5)

1. Salmonella

2. E. coli

3. Cholera

4. C. diff

5. Shigella

What is the most common bacterial cause of diarrhea?

C. diff

What is an example of a parasitic infection that causes diarrhea?

Giardia lamblia AKA Giardia

Examples of digestive disorders that can cause diarrhea (2)

1. IBS

2. Lactose intolereance

Examples of artificial sweeteners (3)

1. Aspartame

2. Saccharin

3. Sucralose

Pertinent Tests/Exams for diarrhea (5)

1. Detailed Pt Hx

2. Abdominal exam

3. Rectal exam if possible

4. Evaluate dehydration via skin

5. Stool cultures

What kind of questions should health care providers be asking Pts with diarrhea? (4)

1. Recent travel? Especially outside of the U.S.

2. What are you doing differently?

3. Any change in diet?

4. Any new medications?

How can you evaluate for dehydration on P.E.?

Skin tenting and dry mouth

What test would you likely order for a stool culture?

Stool for O & P

-"O" meaning "ova" or eggs

-"P" meaning "parasites"

Tx of Diarrhea (3)

1. Most cases clear up on their own (self-limited)

2. Replace any lost fluid (Pt dehydrated, if severe admit Pt for IV hydration)

3. Extremes of age (young and old, must be overly cautious)

Constipation

Common digestive problem which includes Sx of infrequent (according to Pt normal) BM's, passage of hard stools, or straining during BM

BM

Bowel movement

What happens to the stool, the longer it sits in the colon?

More fluid is absorbed by the large intestine, stool sits in colon, becomes too hard

Sx of constipation (3)

1. Passage of hard stool fewer than 3 times/week

2. Strain frequently during BM

3. Abdominal bloating or discomfort

Contributing factors of constipation (6)

1. Decreased/Inadequate water intake (especially in elderly and peds)

2. Low fiber diet

3. Not responding to bowel urges

4. Lack of physical exercise (sedentary lifestyle)

5. Medication

6. Pregnancy

What kinds of medications contribute to constipation?

1. Narcotics

2. Depression medication

3. Parkinson's medication

Dx testing for constipation (2)

1. Sigmoidoscopy

2. Colonoscopy

Tx of Constipation (3)

1. Lifestyle changes & Pt education (increase water and physical activity)

2. Stool softeners

3. Other Tx will depend on the cause

Colon Cancer

Cancer that arises in the colon (cecum to anus)

How does colon cancer start?

As a polyp that progresses

TRUE OR FALSE: Colon cancer is slow growing.

True

Why is screening so effective in reducing cases of colon cancer?

Due to the slow growth of colon cancer

Sx of colon cancer (6)

1. Rectal bleeding/blood in stools

2. Change in bowel habits

3. Pain with BM

4. None/Asymptomatic (detected by screening)

5. Persistent abdominal gas or discomfort

6. Unexplained weight loss

Which of these Sx is a "red flag"?

Change in bowel habits

Risk factors of colon cancer (9)

1. Age

2. Personal family Hx of colon cancer or polyps

3. Diet

4. Sedentary lifestyle

5. Diabetes

6. Obesity (possible)

7. Smoking (possible)

8. Alcohol

9. Long standing IBD

Types of IBD (2)

1. Crohn's Disease

2. Ulcerative colitis

Dx tests for colon cancer (4)

1. Fecal Occult Blood Test (FOBT)

2. Sigmoidoscopy/Colonoscopy

3. Barium Enema

4. Rectal Exam via P.E.

Tx for colon cancer (3)

1. Surgical excision of cancerous tumor or growth

2. Chemotherapy

3. Radiation

Do all of the Tx for colon cancer have to be given separately, or can they be used in a combination?

Can be used in combination

What does the Tx of colon cancer depend on?

Staging of the cancer

Prevention of colon cancer (5)

1. Regular screening

2. Increase fruits, vegetables, and whole grains in diet

3. Regular exercise

4. Limit alcohol

5. Stop smoking

What age does screening for colon cancer begin at?

45 years old

Stage 0 Colon Cancer

Earliest stage, confined to inner layer of the colon

Stage 1 Colon Cancer

Through mucosa, but not spread beyond colon wall; Still confined and treatable

Stage 2 Colon Cancer

Through colon wall, but not yet spread to lymph nodes

Stage 3 Colon Cancer

Through and to lymph nodes, but not any other body part

Stage 4 Colon Cancer

Spread to distant sites outside the GI tract

What does it mean for the Pt if colon cancer spreads to the lymph nodes?

Becomes more lethal

What are selective sites of metastasis for colon cancer? (3)

1. Liver

2. Lungs

3. Bones

How do we classify cancer staging?

TNM classification

What does the "T" in TNM stand for?

Size and extent of primary tumor (where it began)

What does the "N" in TNM stand for?

Number of nearby lymph nodes that have cancer

What does the "M" in TNM stand for?

Cancer that has metastasized or spread to other sites