GI Conditions 1

what is contained in the RUQ?

liver, gallbladder, duodenum, pylorus, hepatic flexure, right adrenal gland

what is contained in the RLQ?

cecum and appendix, right ovary/fallopian tube, right ureter, ascending colon

what is contained int he LUQ?

spleen, stomach, left lobe of liver, body of pancreas, splenic flexure, left adrenal gland

what is contained in the LLQ?

sigmoid colon, left ovary/fallopian tube, left ureter, descending colon

what do most clinicians use when assessing the abdominal structures?

a combination of the four quadrant (a horizontal and vertical line directly through the umbilicus) and nine region systems

what vascular structures are included in the abdominal cavity?

abdominal aorta (branches into common iliac at the level of the umbilicus), renal arteries, iliac arteries

9 Region system:

Midclavicular Line: 1 (Right hypochondrium) 2 (Epigastrium) 3 (Left hypochondrium)

Transpyloric Plane: 4 (Right flank) 5 (Umbilical) 6 (Left flank)

Intertubercular Plane: 7 (Right groin) 8 (Pubic) 9 (Left groin)

Flank

Lumbar region

Groin = Inguinal aka iliac region

Public = Suprapubic aka Hypogatric region

what is swallowing?

(deglutition)

a complex process involving voluntary and involuntary neuromuscular contractions coordinated to permit breathing and swallowing through the same anatomical pathway

what are the two stages of swallowing?

oropharyngeal (transforming food from the mouth to the throat) and esophageal phases (Food through throat into the stomach)

what is the oropharyngeal stage?

process of chewing food and mixing with saliva to form a bolus

what is the esophageal stage?

passage of the bolus past the upper esophageal sphincter

what is dysphagia?

difficulty swallowing

what is odynophagia?

painful swallowing

what is globus?

sensation of a food in the throat. It feels stuck but it is not

what is considered oropharyngeal dysphagia?

difficulty transferring food from the mouth into the pharynx and esophagus or initiating the swallowing process

what is esophageal dysphagia?

difficulty passing food down the esophagus that can be due to a mechanical or motility issue or progressive or nonprogressive

what is progressive dysphagia?

starts with food and progresses to liquids

what is nonprogressive dysphagia?

difficulty with both solids and liquids from the beginning

what are intrinsic mechanical lesions that can cause esophageal dysphagia?

- benign/malignant tumors

- strictures, rings, and webs

- esophagitis

what are motility disorders that can lead to esophageal dysphagia?

achalasia (lower esophageal sphincter fails to relax), esophageal spasms, functional dsyphasia

what is dyspepsia?

indigestion

VERY VAGUE, must give more information

what can be included in the feeling of dyspepsia?

feeling of fullness with very little food intake (early satiety), feeling of uncomfortable fullness following meals, vague discomfort

Pyrosis

Heartburn caused by GERD

what is visceral abdominal pain?

caused by distention of a hollow organ and is usually dull and aching, poorly localized and palpable at midline

what is parietal abdominal pain?

caused by peritoneal irritation and is usually sharp and well localized, location typically over involved location

(Can point with a singular finger)

what is the difference between radiation of pain and referred pain?

radiation of pain refers to at the site of injury and somewhere else. referred pain represents pain that is somewhere other than the pathology

what are examples of life-threatening causes of abdominal pain?

- AAA (abdominal aortic anyeursims)

- acute bowel obstruction

- organ rupture

- acute MI

- perforation of GI tract

- ectopic pregnancy, placental abruption

what is key in narrowing down the differential diagnosis list when dealing with abdominal pain?

the history

what is the anatomical dividing point to determine upper GI bleeding vs lower GI bloeeding?

the ligament of treitz (above is upper GI bleeding vs below is lower GI bleeding)

what is hematemesis?

regurgitation of blood or blood mixed with stomach contents (appears red or brown (coffee ground color)

The hematemesis brown coffee ground color if not thrown up and is released as a stool can be what?

Melena

what is melena?

dark, black, and tarry feces that typically has a strong characteristic odor caused by the digestive enzyme activity and intestinal bacteria on hemoglobin (Mixture of color)

what does upper GI bleeding usually present with?

hematemesis or melena

what does lower GI bleeding usually present with?

bright red blood per rectum (BRBPR) or hematochezia

what is the definition of hematochezia?

passing of bright red blood via the rectum

what are examples of upper GI bleeding?

- upper GI tumors

- peptic ulcer diseases

- esophagitis

- gastritis

- foreign body ingestion

- mallory-weiss tears

- post-surgical bleeds

- varices

(peg my vip)

what are examples of lower GI bleeding?

- diverticulosis

- colon cancer

- ischemic colitis

- anal fissures

- infectious colitis

- inflammatory bowel disease

- hemorrhoids

- post-surgical bleeds

(dic a ship)

what is nausea?

queasiness, feeling that one may vomit

what is emesis?

vomiting - forceful upward movement of the stomach contents

what is the difference between regurgitation and retching?

regurgitation is the effortless expulsion of contents from the mouth whereas retching is dry heaving

What must be taken note of in emesis?

The presence of bright red blood or coffee grounds

what does the vomitous appearance of undigested food suggest?

reflux from esophagus/stomach

what is the appearance of bilious vomitus?

yellow-green color that is associated with obstruction

what does fecal material vomit suggest?

a bowel obstruction

how does hematemesis appear and suggest?

bright red or "coffee ground" appearance, suggesting upper GI bleeding

what is diarrhea?

stool with increased water content, volume, or frequency

how is acute vs chronic diarrhea considered?

acute is less than 14 days, chronic is more than 14 days

What does it mean if there are red blood and very dark stools in diarrhea?

melena

what does diarrhea with blood suggest?

GI bleeding

what does diarrhea with mucus suggest?

infection or inflammation

what does diarrhea with steatorrhea suggest?

malabsorption

what is constipation?

less than 3 bowel movements per week or incomplete elimination, difficulty passing or both BM at least 3 times per week

what is the difference between primary and secondary constipation?

primary is considered functional, whereas secondary is due to medication use, chronic diseases process, and psychosocial issues

what system is utilized to assess a patient's stool?

bristol stool chart

what should be included in the physical exam of the GI systeM?

- vitals

- general assessment of pt

- inspection of skin, hair and nails

- HEENT

- abdominal exam

- pelvic/genital and rectal exam

what should be included in the general assessment of the GI exam?

body position, body habitus, acute distress, toxic looking

what should be inspected of the skin, hair and nails?

jaundice or pallor, skin lesions, or nail changes

what should be evaluated in the eyes and mouth of the HEENT exam?

• Eyes - scleral icterus (yellowish color in sclera occurs first), conjunctival pallor

• Mouth- lesions, hydration status

what is inspection in the abdominal exam?

contour of abdomen, scars, surface motion, lesions

what is auscultation of the abdominal exam?

bowel sounds, vascular abnormalities

what is percussion in the abdominal exam?

assesses for density, helps evaluate solid organs and tumors

what is palpation in the abdominal exam?

evaluation for masses, tenderness, solid orgnas

abdominal distention

an observable swelling or increase in the size of the belly

Peristalsis

a series of involuntary, wave-like muscle contractions that move food, fluids, or waste through hollow organs of the body

what test can be done to identify appendicitis?

obturator sign

what is the obturator sign?

Patient is supine - internal and external rotation of the hip with knees and hips at 90/90, pain is present in the suprapubic area

what palpation can be conducted to identify appendicitis?

point tenderness at McBurney's Point - the point is 2/3 of the way form the umbilicus to ASIS

what test can be conducted for acute cholecystitis?

Murphy's sign

what is murphy's sign?

RUQ pain and abrupt cessation of inspiration

what is the main usage of x-ray for diagnostic of abdominal conditions?

perforations. Can see air present

what is a HIDA scan?

hepatobiliary iminodiacetic acid scan that evaluates for the correct movement of the gallbladder

what is a barium swallow test?

use of radioactive dye to visualize anatomy where images are taken of the esophagus

what is an esophagogastroduodenoscopy (EGD)?

a scope of the upper GI tract structures through the mouth and down

what is a colonoscopy?

scope of the lower GI structures through the anus and up

What is the last resort?

Laparotomy - opening the patient up

what lifestyle changes can be completed for abdominal conditions?

- weight loss

- alteration in timing of food consumption

- change in sleeping position

- avoidance of medications

- avoidance of tobacco, drugs, alcohol

what are common medication classes to utilize for GI conditions?

- antibiotics

- antacids/Proton pump inhibitors - reducing acid recreation

- histamine 2 blockers

- promotility agents - Improve peristalsis

- stool softeners

- laxatives - trigger bowel movements

- antiemetics - anti nausea

- antimotility agents - for diarrhea

- antispasmodic agents - decrease cramping

Surgeries for GI

Laparoscopic - camera with an incision of 1-2 in (heal faster and less pain

Open surgery - large incision in pathology

what is gastroenteritis?

inflammation of the bowel secondary to infection with virus, bacteria, or parasite resulting in non-bloody diarrheal disease of rapid onset lasting less than 2 weeks, usually with nausea, vomiting, fever, or abdominal pain

what is the most common cause of viral gastroenteritis?

norovirus

peaks in winter/spring

what is viral gastroenteritis also known as?

the stomach flu

what is bacterial gastroenteritis also known as?

food poisoning

(some organisms cause specific clinical syndromes)

how does viral gastroenteritis present?

- rapid onset of non-blood diarrhea, N/V, fever, and abdominal pain

- look for signs of dehydration

how is viral gastroenteritis diagnosed?

clinical

how is viral gastroenteritis treated?

- BRAT diet and fluids

- antiemetics

- anti-motility agents

what foods are considered to be apart of the BRAT diet?

bananas, rice, apple sauce, and toast

what are the causes of bacterial/parasitic gastroenteritis?

salmonella and campylobacter (bacteria) (USA) and giardia (parasite)

what are the two basic subtypes of bacterial/parasitic gastroenteritis?

inflammatory (more severe bloody or mucus) and watery

how does the CDC track bacterial/parasitic gastroenteritis?

FoodNet

giardia species causes ________ gastroenteritis?

watery

salmonella and campylobacter causes _______ gastroenteritis?

inflammatory

Closteridium difficile

Post-antibiotic or long term antibiotic use

Strong odor!

Watery

Giardia lamblia

Parasite

Check water source - well water

watery

Listeria monocytogenes

Travel/Large gatherings

Concern with pregnancy

watery

Nontyphoidal salmonella

inflam

travel to resoirces- limited setting “travlers diarrhea”

Campylobacter spp

inflam

Travel to resource limited settings

Enterohemorrhagic E. coil

Ground beef

High complication rate- Hemolytic Uremic Syndrome

Inflam

how does bacterial gastroenteritis present?

same as viral but more severe symptoms

Some bacterial have specific clinical symptoms

how does parasitic gastroenteritis present?

chronic diarrhea is most common