GI Packet #3

Diverticulosis

Small marble sized pouches that protrude though the colon wall (large bowel); presence of many pouches

Is diverticulosis symptomatic or asymptomatic?

Asymptomatic

Diverticulum

A single pouch

How do these pouches form?

Develop in naturally week places in the colon that give way to pressure

Diverticulitis

Inflammation of a diverticulum

TRUE OR FALSE: There is usually only one diverticulum present.

False

How big is a diverticulum?

10 mm

Where are diverticulum most commonly found, and what population presents an exception to this?

Usually found in the sigmoid and descending colon (LLQ pain); Except in the Asian population, more commonly found in the ascending colon (RLQ pain)

Meckel's Diverticulum

Congenital sack (from birth) in the lower ileum (small intestine/bowel), representing the proximal end of the yolk sac

What percentage of the population has Meckel's diverticulum?

2%

What percentage of people >60 y/o have diverticulosis?

50%

Risk factors of diverticulitis (7)

1. Age

2. Family Hx

3. Too little fiber

4. Lack of exercise

5. Obesity

6. Smoking

7. Diabetes

What happens when there is too little fiber in one's diet?

Stool becomes hardened and large, affecting the weak area of the muscle

Signs and Sx of diverticulitis (4)

1. LLQ pain

2. Fever

3. N/V

4. Palpable mass

How is the LLQ pain described with diverticulitis?

-Severe

-Relieved with a BM

-Worsens with eating

-Associated with bloating and constipation

Where would a palpable mass be located on a Caucasian Pt with diverticulitis vs. an Asian Pt with diverticulitis

Caucasian: LLQ

Asian: RLQ

What are some other organs that can present as a differential Dx of diverticulitis? (3)

-Left ovary

-Left ureter

-Sigmoid colon

*All are locations of LLQ pain

What are some other disease processes that can present as a differential Dx of diverticulitis? (6)

-Ovarian cyst

-Stone in ureter

-PID (pelvic inflammatory disease)

-IBD (inflammatory bowel disease)

-Ectopic pregnancy

-Endometriosis

Diagnostic test of choice for diverticulitis

CT of abdomen

The type of Tx for diverticulitis depends on what?

The severity of the attack

What are mild Sx of diverticulitis defined as?

Uncomplicated cases in Pts who can still tolerate fluids

What is the Tx protocol for mild diverticulitis?

-Antibiotics are given outpatient for 7-10 days

-Clear liquids only; after 2-3 days Pt can advance diet (easy foods)

-Continue to slowly advance diet as Sx decrease

What are significant Sx of diverticulitis defined as?

Pts who cannot tolerate fluid or >85 y/o

What is the Tx protocol for significant diverticulitis?

-Pt is admitted

-Bowel is completely at rest

-IV Fluid therapy

-IV Antibiotics for 7-10 days (may switch to oral)

-Wait for improvement to advance diet

The amount of inflammation in Pts with diverticulitis depends whether or not they can get what surgery?

Bowel resection

What can also be a reason a Pt requires surgical Tx for diverticulitis?

Pt is not responding to IV fluids and antibiotics

Lifestyle recommendations for Pts with diverticulitis

-Increase fiber (20-30g/day)

-Increase water intake

-Respond to bowel urges

-Exercise (30 minutes/day)

What does exercising do for the colon?

Reduces pressure

Irritable bowel syndrome (IBS)

Syndrome of gut sensitivity and motility

TRUE OR FALSE: IBS can affect any part of the GI tract.

True

Types of IBS (2)

IBS-C and IBS-D

What are the signs and Sx of IBS? (3)

1. Abdominal pain and cramping

2. Bloating

3. D/C

What are the possible (theoretical) causes of IBS? (3)

1. Altered GI motility (normal peristaltic activity changed)

2. Luminal irritation (inside lining of the gut)

3. Possible hormonal changes

Triggers of IBS (3)

1. Foods

2. Stress

3. Other illnesses

IBS specific testing for Dx

No specific testing

IBS has a diagnosis of _________.

Exclusion (meaning process of elimination and ruling out other diseases; usually a default Dx)

Criteria for IBS Dx

Abdominal pain and discomfort lasting 12 weeks (not consecutive) plus 2 of the following:

1. Change in frequency or consistency of stools

2. Urgency of incomplete emptying

3. Mucus in stool

4. Bloating and or distension

What are the red flags for additional testing? (3)

1. New onset after age 50 (can indicate colon cancer)

2. Significant weight loss

3. High fever

Additional testing for IBS (4)

1. Flexible sigmoidoscopy

2. Colonoscopy

3. CT of abdomen

4. Stool studies (check for infection; bacteria & parasites)

Tx of IBS depends on Pt ___________.

Presentation

Most cases of IBS can be controlled by learning to ___________.

Manage stress along with diet and lifestyle changes

Forms of Tx for IBS-C (2)

1. Fiber supplements

2. Laxatives (NOT TO BE TAKEN LONG TERM)

Forms of Tx for IBS-D (1)

Antidiarrheals; Ex. Imodium

General Tx for IBS (2)

1. Having small meals (limiting triggering foods like dairy)

2. Avoid caffeine

Medicinal Tx of IBS (3)

1. Lubiprostone (Amitiza): IBS-C

2. Alosetron Hydrochloride (Lotronex): IBS-D

3. Antidepressants (SSRIs): Psychosocial component

Lubiprostone (Amitiza) does what to GI motility and treats what type?

Enhances it; IBS-C

Alosetron Hydrochloride (Lotronex) does what to GI motility and treats what type>

Decreases it; IBS-D

Methods of prevention for IBS (7)

1. Counseling (Anxiety)

2. Regular exercise, yoga, massage

3. Deep breathing

4. Acupuncture

5. Peppermint

6. Ginger

7. Hypnosis

What is FMT?

Fecal Microbiota Transplantation

How is FMT done?

Restores healthy gut bacteria by giving Pt stool from a donor with a healthy gut microbiome

What diseases is FMT used to treat?

IBS and C-diff

What are the functions of the liver? (6)

1. Produce bile

2. Produce cholesterol

3. Converts excess glucose into glycogen for storage

4. Filters the blood; detoxifies drugs and chemicals

5. Regulates clotting

6. Produce bilirubin

Anatomy of the Liver

4 lobes: Right, Left, Caudate, & Quadrate

How much does the liver weigh?

3 lbs

Why are alcoholics able to damage their liver heavily and still continue to live?

The liver can lose 3/4 of its cells and still function; alcoholics can live with 1/4 of their liver

Hepatitis

Inflammation of the liver, usually caused by exposure to an infectious agent, toxin, or a drug

Types of (viral) Hepatitis (6)

A, B, C, D, E, & G

Other types of Hepatitis (2)

Autoimmune & Toxic

Hepatitis A

Contagious infection caused by the Hepatitis-A virus

How is Hep A spread?

By fecal contamination of food or water OR by close personal contact

Does Hep A require medical Tx, if so, why or why not?

No Tx; Most recover completely without permanent liver damage

What type of Tx does Hep A require, although it does not require medical Tx?

Supportive Tx; Maintaining fluids and rest based on what Pt presents with

TRUE OR FALSE: Hep A develops into chronic hepatitis.

False

Prevention of Hep A (2)

Frequent handwashing and vaccination (routine childhood vaccine)

Does Hep A have any specific Sx?

No

Sx of Hep A (9)

1. None (asymptomatic)

2. Fatigue

3. N/V

4. Abdominal pain, especially RUQ

5. Loss of appetite

6. Low grade fever

7. Dark urine (excess bilirubin)

8. Muscle pain

9. Jaundice (yellowing of skin and sclera)

Signs of Hep A (2)

1. Enlarged, tender liver (via palpation)

2. "I feel like I have the flu" -Pt

Myalgia

Muscle ache

Specific transmission routes of Hep A (4)

1. Fecal oral route

2. Drinking contaminated water

3. Eating raw shellfish from polluted water

4. Can be transmitted via intercourse or needle sharing (rare)

What do blood tests measure when detecting Hep A?

Bilirubin and enzyme levels

What enzymes are specifically measured?

AST and ALT

AST

Aspartate amino transferase

ALT

Alanine amino transferase

What does the special blood test for Hep A measure specifically via radioimmunoassay?

IGM anti-Hep A antibodies

What is the main focus for Hep A Tx since there is no medical Tx that exists?

Adequate nutrition & prevention of permanent liver damage

How long does it take most Pts to recover from Hep A?

6 weeks

Sequela (not seen in Pts with Hep A)

Permanent damage

What is recommended to Pts with Hep A to avoid?

Alcohol

Hepatitis B

Caused by the Hepatitis B virus

Hep B CAN become chronic leading to...? (3)

1. Liver cirrhosis

2. Liver failure

3. Liver cancer

Do most adults fully recover from Hep B?

Yes

Is there a vaccine available for Hep B?

Yes

What are 2 overlooked transmission routes for Hep B?

1. Mother-infant transmission during delivery

2. Asymptomatic Pts

Non-specific Sx of Hep B (8)

1. None (asymptomatic)

2. Loss of appetite

3. N/V

4. Fatigue

5. Abdominal pain, RUQ

6. Dark urine

7. Jaundice

8. Joint pain

Transmission of Hep B

Contact with blood or other bodily fluids

- Birth

- Intercourse

- Sharing needles, razors, toothbrushes, etc.

TRUE OR FALSE: Transmission of Hep B does NOT occur through casual contact, telephone, or toilet seat.

True

What kind of labs can be taken to test for Hep B? (2)

1. Hepatitis B surface antigen (HBsAg)

2. Antibody to Hep B surface antigen (anti-HBs)

Positive and negative meaning for Hep B surface antigen test

Positive: Pt can pass virus to others

Negative: Pt not currently infected

Positive meaning for antibody Hep B surface antigen

Antibodies present via prior infection or vaccine; Pts cannot infect others, secondary to natural immunity from prior exposure or vaccination

Tx for Hep B (3)

1. Interferon (synthetic protein administered; immune modulators)

2. Antiviral medications

3. Liver transplantation (if damage to liver is severe)

A Pt with acute Hep B will eventually......

Clear on its own

Pts with chronic Hep B need what kind of medication?

Antivirals and immune modulators

Antivirals

Drugs slow or stop virus from reproducing; 7 available

Immune modulators

Boost immune system to stop viral replication

Even though Pts of Hep B may be asymptomatic, lab values can still be.....

High

Recommend to Pt to avoid what?

Alcohol

How can a strain of Hepatitis be figured out?

Via lab work

Hepatitis C

Most serious viral liver disease that can lead to liver cirrhosis, failure, or cancer

Are there Sx in the acute infection of Hep C?

No

TRUE OR FALSE: Most Pts with Hep C progress to viral disease.

True