week 13 - GI and delirium

order of assessment of GI system

inspection

auscultation

percussion

palpate

UC location

large intestine/colon only

UC inflammation

continuous inflammation with no patches

innermost intestinal lining

UC complicaations

hemorrhage

toxic megacolon

UC smoking

decreased risk in smokers

crohn’s location

anywhere in GI tract

crohn inflammation

patches of inflammation

entire thickness of intestinal lining

bleeding UC

common in BM

bleeding crohn’s

uncommon

upper GI bleed causes

PUD

erosive gastritis

mallory-weiss tears

esophagogastric varices

tumors

AVMs

stress ulcers

hematochezia

bloody diarrhea, blood, clots from rectom

most common symptoms of acute GI bleeding

hematochezia

clinical manifestations of GI bleeding

occult blood

hematemesis

hematochezia

occult blood

blood present in GI tract but not visible → colon cancer

hematemesis

vomiting of bright red blood or coffee grounds color

PUD

most common cause of GI bleeds

occurs in stomach/proximal duodenum

sore on the lining of the stomach or duodenum

risk factors of PUD

h. pylori infection

NSAIDs

protective factors against PUD

mucosal prostaglandins and bicarbonate

mucosal blood flow

mucosal production

hostile factors leading to PUD

essentially anything that compromises blood flow to the gut

NSAIDs → aleve

malperfusion

gastric acid

pepsin

norepi

drinking

stressfu

function of stomach

B12 absorption

break down food fibers

kill microorganisms

activate pepsin

HCl leading to PUD

HCl can erode at stomach lining if nothing in stomach to increase pH

if blood vessels get impacted → arterial bleed → Hgb drops

duodenal ulcers

pain relieved by meal

occurs 2-3 hours after meal

dark, tarry stools

most common ulcer

duodenal

gastric ulcers

pain increased by meal

occurs 30-1hr after meal

vomiting occurs

PUD sx

burning in stomach

nausea

pain

vomiting

anorexia

wt loss

bloating

hematemesis

melena

hematochezia

tx PUD with GI bleed

abx

PPIs (-azole)

prostaglandins

bismuth subsalicylate (pepto)

sucralfate

antacids

eliminate foods that cause distress

active gastritis

inflammation of stomachac

acute erosive or hemorrhagic gastritis

transient inflammation of gastric mucosa

common causes of erosive gastritis

H. pylori

nsaids

alcohol

acute stress

test for erosive gastritis

stool test

blood test

endoscopy

fecal testG

GI bleed causes due to non-ulcers

acute erosive or hemorrhagic gastritis

acute gastritis

s/x erosive gastritis

asymptomatic

epigastric pain

N/V

slow blood loss - hematemesis, melena

tx erosive gastritis

endoscopy

surgical resection of involved portion

h2 blockers

PPIs

antacids

Upper GI bleed s/x

hematemesis

coffee ground emesis

bloody aspirate with NG suction

melena

prevention/tx upper GIB

maintain gastric pH above 4

H2RAs (famotidine), PPIs, sucralfate

esophageal and gastric varices

dilated vessels in esophagus and high pressure results in massive bleeding

what are esophageal and gastric varices associated with

cirrhosis

portal hypertension

portal or splenic vein thrombosis

mallory weiss tears

small linear laceration in mucosa at gastroesophageal junction

non-perforatin tear

resolves on own

causes of mallory-weiss tears

retching/vomiting

fluctuations in intra abdominal pressure

alcohol abuse

bleeding esophageal varies

develop secondary to portal hypertension

airway protection in PRIORITY

tx bleeding esophageal varices

blakemore tube to tamponade bleed

prepare for hemorrhage → fluids, PRBCs, blood products, type and cross, consent

IV access

ICU for hemodynamic monitoring

GI bleed diagnostic tests

stool sample (guaiac fobt)

EGD (esophagogastroduodenoscopy)

colonoscopy

Upper GIB causes

PUD or stress ulcers

erosive gastritis

mallory weiss tears

esophageal varices

causes lower GIB

ulcerative colitis

AVM

diverticulosis

internal hemorrhoids

rectal ulcers

neoplasms

ischemic bowel disease

IBD

diverticular bleeding

most common etiology of major lower GIB

can lead to diverticulitis and rupture

risk factors diverticular bleeding

60+ YO, chronic constipation

IBD

UC and crohns

bloody diarrhea most common symptom for UC

diagnosed by colonoscopy and biopsy

neoplasms and polyps

colorectal cancers associate with occult bleeding

bleeding is slow, chronic, self-limiting

ischemic bowel disease

ischemia of color d/t interruption of colonic blood supply

emergency!

causes of ischemic bowel disease

aortic dissection leading to mesenteric infarct

vasopressors

shock

bleeding from anticoagulant use

any with poor perfusion to gut

tx ischemic bowel disease

restore blood circulation to intestines

s/x ischemic bowel disease

high lactate

high WBC

febrile

hemodynamically unstable

mgmt of GI bleeds

assess severity of blood loss

admin fluid

assist in determining cause of bleeding

fluids for acute GIB

NS, LR, albumin, blood, platelets

primary goal of early mgmt of acute GIB

resuscitation if hemodynamically unstable

want to replace intravascular volume and tissue oxygenation

interventions for severe GI hemorrhage

vasopressin to induce vasoconstriction

somatostatin

octreotide

blakemore tube, mechanical tamponade

blood loss and symptoms with BP

by the time BP drops, 1.5-2 liters of blood is already lost

types of acute intestinal obstruction

surgical complications

incarcerated hernias

volvulus

intussusception

tumors

paralytic ileus

incarcerate hernia

intestines push out past peritoneum and tissue becomes strangled → ischemic

volvulus

twisting of bowels

intussusception of bowels

tunneling, folded in section

paralytic ileus

most common after surgery

duodenum

uses bile from gallbladder, liver, and pancreas to help digest food

jejunum

middle section of small intestine that carries food rapidly

ileum

most of nutrients of food are absorbed before emptying into large intestine

bulk forming agents

absorbs water in GI tract to pulk up stool

stool softeners

decreases surface tension between water and fat to help make stool softer

docusate

stimulant laxatives

stimulates wall of intestine to contract

senna

bisacodyl

acute small bowel obstruction

swallowed air is major cause of distention

strangulation can lead to bowel ischemia/necrosis/perforation/peritonitis

large bowerl obstrcutions

neoplasms most common cause

want to make patient NPO to prevent further obstruction

provide IV abx

tinkling bowel sounds

finding in pt with bowel obstruction

high-pitched and occur when intestines are tightly stretched

causes of tinkling bowel sounds

tension of air or fluid in a dilated bowel loop → obstruction

acute intestinal obstruction interventions

abd xr, lactic acid, CT, NPO, NG to LIS

t/x acute intestinal obstruction

fluid resuscitation

broad spectrum abx

early surgical consult advised in high-risk pt

intra-abdominal hypertension

abnormally high pressure within abd cavity

repeat pathological eval of IAP 12+

abdominal compartment syndrome

results from acute expansion of abdominal contents

IAH 20+

dysfunction improved by abd decompression or decompressive laparotomy

pancreatitis

inflammation of pancreas r/t escape of enzymes into surrounding tissues → autodigesting pancreas

acut pancreatitis

abd pain but usually self-limiting

causes of acute pancreatitis

alcohol abuse - 1

gall stones - 2

s/sx pancreatitis

abrupt onset of steady, severe epigastric pain

pain is worse with walking/laying supine

pain radiates to back

NV

weakness, sweating, anxiety

objective findings pancreatitis

upper abd tender to palpation

abd distention

absent bowel sounds if paralytic ileus

fever

tachycardia

pallor/cool skin

mild jaundice

hemorrhagic pancreatitis symptoms

grey turners

cullens sign

grey turners

flack discoloration d/t bleeding in retroperitoneal cavity

cullens sign

umbilical discoloration

labs in pancreatitis

leukocytosis

high amylase

high lipase

low calcium

gold standard to diagnose pancreatitis

CT

mgmt pancreatitis

bed rest

NPO

fluid replacement

NGT to LIS

pain control

once no pain and bowel sounds return → clear liquid diet

ERCP

endoscopic retrograde cholangiopancreatography

diagnose and treat problems of biliary/pancreatic ductal systems

supportive therapy for pancreatitis

stabilize hemodynamics

pain control

minimize pancreatic stimulation

LIS

correct underlying problem

diagnosis of acute pancreatitis

abd pain characteristic of acute pancreatitis

serum amylase and/or lipase more than 3 times to the upper limit of normal OR

characteristic findings of acute pancreatitis on imaging

pain with acute pancreatitis

sudden onset of sharp, knifelike, twisting, deep, upper abd pain

radiates to back and associated with nausea and vomiting

assessments of pt with acute pancreatitis

chovostek

trousseau

calcium becomes trapped as fat necrosis occurs, leading to hypocalcemia

medical mgmt of pancreatitis

fluids

inotropic therapy to stabilize hemodynamics

fentanyl, morphine, hydromorphone

complications of acute pancreatitis

decreased cardiac output

hypovolemia

gas exchange impaires

pain

NV

impaired nutrition

increased risk infection

anxiety

increased risk injury

electrolyte imbalance

palliative care

patient and family centered care that optimized quality of life by anticipating and treating suffering

hospice

focus is on comfort, not cure

when pt is advanced to end-stage disease or significant functional decline

communication strategies for goals of care

ask-listen-ask

strategic silence

active listening

types of pain

nociceptive pain - somatic, visceral

neuropathic pain

somatic pain

bones, joints, muscles

sharp, dull, aching, localizable

visceral pain

organs

crampy, dull, referred pain