Gastrointestinal Specific Conditions

Right upper quadrant, below the liver

What is the location of the gallbladder?

3-4 inches

What is the size of the gallbladder?

Storage place for bile

What is the function of the gallbladder?

Liver

What produces bile?

Body digesting fats

What does bile help with?

Gallbladder contracts, pushes bile into common bile duct, to the small intestine for aid in breakdown of fats

What is the path of bile from the gallbladder?

Gallstones

pebble-like, hardening of bile, developed in gallbladder

1. Cholesterol

2. Pigment

What are the 2 most common types of gallstones?

1. Most cases are asymptomatic (found when imaging for another reason)

2. Pain may be intermittent or constant

2 facts to know about gallstones

Cholecystitis

inflammation of the gallbladder

Cholelithiasis

stones in the gallbladder

Choledocholithiasis

stones in common bile duct (or anywhere in bile system)

1. Family history OR fair complexion

2. Females

3. Fat

4. Forty

5. Fertile

Gallbladder disease risk factors (Classic 5 F's)

Signs

provider finds upon examination, objective

1. RUQ tenderness

2. Dehydration (if persistent vomiting)

3. Murphy's sign

What are 3 signs of gallbladder disease?

Cessation of breathing; press in on RUQ, take a deep breathe, if positive can't complete breathe

What is Murphy's sign?

Murphy's sign

cessation of deep inspiration secondary to pain

Symptoms

what pt complains about, subjective

1. Abdominal pain (RUQ or epigastric)

2. Abdominal pain timing

3. Associated symptoms

What are 3 symptoms of gallbladder disease?

1. Dull ache

2. Can be poorly localized

3. Might have pain that radiates to right shoulder or infrascapular region

Gallbladder disease symptoms: Describe abdominal pain (3)

1. 30-60 minutes after eating a meal

2. May last 1 hour or a couple (pt dependent)

Gallbladder disease symptoms: Describe abdominal pain timing (2)

1. Associated infection (fever/chills)

2. N/V

Gallbladder disease symptoms: Describe associated symptoms (2)

1. Hepatitis (inflammation of liver)

2. Right kidney issues

3. Gallbladder issues

What are 3 differential diagnoses of gallbladder disease (RUQ pain)?

1. Labs- elevated WBC count (CBC, complete blood count, indicates infection)

2. Abdominal ultrasound

3. Endoscopic retrograde cholangiopancreatography (ERCP)

4. Helical CT

5. Oral cholecystogram

6. HIDA (Hepatobiliary Iminodiacetic Acid Scan)

What are 6 tests to diagnose gallbladder disease?

Abdominal ultrasound

What is the first-line test for gallbladder disease?

Scope with light into duodenum, catheter through scope, dye injected, and images are taken to outline gallbladder

Describe an ERCP test

Images are taken in cross section, rather than overlapping

What is a helical CT?

Oral cholecystogram

x-ray of gallbladder after contrast tablets are taken the night before

HIDA

nuclear medicine scan; radioactive tracer is injected, scanner tracks flow of tracer

Watchful waiting

What is the management for asymptomatic gallstones like?

Cholecystectomy for recurrent, persistent symptoms

What is management like for symptomatic gallstones?

1. if pain is not constant, can wait to treat

2. low-fat diet or reduce risk factors

2 types of conservative treatment for symptomatic gallstones

Sits across back of abdomen, behind or adjacent to stomach

Where is the pancreas located?

6 inches (15 cm)

What is the size of the pancreas?

1. Produce insulin (hormones essential for sugar regulation)

2. Produces digestive enzymes

What are the 2 functions of the pancreas?

Islets of Langerhans

What cells in the pancreas produce insulin?

Amylase and lipase

What are the two digestive enzymes the pancreas produces?

Exocrine tissue and endocrine tissue

What are the 2 types of tissue the pancreas is made of?

digestive enzymes

What does the exocrine tissue of the pancreas produce?

Insulin and glucagon

What does the endocrine tissue of the pancreas secrete?

Pancreatitis

inflammation of the pancreas

When digestive enzymes, usually contained within ducts in the pancreas, leak into the rest of the pancreas and irritate it

When does pancreatitis occur?

1. Acute (sudden)

2. Chronic (occur over many years)

2 types of pancreatitis and description

1. Increased triglycerides

2. Excessive, persistent alcohol intake (most common cause of acute pancreatitis)

3. Gall stones

4. Certain medications

What are the 4 risk factors for pancreatitis?

1. Decreased bowel sounds

2. Abdominal rigidity (muscles tighten bc its so painful)

What are 2 common signs of pancreatitis?

1. Upper abdominal pain, often radiates to back (feels like knife through back)

2. 10/10 pain scale

3. Pain may increase with eating

4. Usually sudden onset, worsens with time

What are the 4 most common symptoms of pancreatitis?

1. Anorexia (lack of appetite)

2. N/V

3. Fever (if infection is present)

What are 3 other symptoms of pancreatitis?

1. Alcohol abuse

2. Gall stones

What are the 2 most common causes of pancreas disease?

1. Amylase and lipase levels (see if they are elevated)

2. CBC (see if WBC is elevated)

3. Liver function test

What are 3 labs to diagnose pancreatic disease?

1. CT of abdomen with contrast

2. Ultrasound of abdomen

What are 2 imaging techniques to diagnose pancreatic disease?

1. Admit patient

2. Pain management

3. IV hydration (esp. for N/V)

4. Put bowel to rest (nothing by mouth)

5. Prescribe antibiotics if it is infectious process

6. Begin to correct underlying problem after stabilization (cholecystectomy if gall stones; stop alc intake)

6 managements of pancreatic disease

Bowel Obstruction

any condition that prevents the flow of chyme through the intestine

80%; its longer and the loops flow over each other, the large intestine is more stationary

What percentage of bowel obstructions occur in the small bowel and why?

1. N/V

2. Diarrhea, constipation

3. Cramps

4. Distention

5. Absence of bowel movements

What are 5 symptoms of bowel obstructions?

Characteristic or indicative of a specific disease

What does pathognomic mean?

"string of pearls" (image with dilated bowel)

What is pathognomonic of small bowel obstruction?

1. Mechanical (something physical or anatomical causes it)

2. Functional (peristalsis isn't functioning)

What are the 2 types of causes of bowel obstruction?

1. Tumor

2. Adhesions

3. Volvulus

4. Intussusception

5. Hernia

6. IBD (irritable bowel diseases)

What are 6 types of mechanical causes of bowel obstruction?

Fibrous bands that cause sticking together

What are abdominal adhesions?

Twisting of bowel

What is volvulus?

Bowel invaginates within itself

What is intussusception?

1. Prior surgery with general anesthesia (bowel has to wake up after anesthesia)

2. Infection

3. Certain medications

4. Nerve or muscle disorders

What are 4 causes of functional blockages?

Death of intestinal wall (blood supply may also be obstructed)

What is a complication of bowel obstructions?

Put bowel at rest via NPO (nill per os), only liquids, no food, IV fluids

What is the treatment for partial mechanical obstruction (some food or liquid is getting through)?

Insert NG tube, get everything in stomach/bowel out, put bowel to rest

What is the first treatment for complete bowel obstruction?

Surgically remove the area

What is the final treatment option for complete bowel obstructions?

Appendix

finger-shaped pouch that projects from the very 1st part of the small intestine (cecum)

We don't know

What is the function of the appendix?

Pinkie

What is the size of the appendix?

1. Fecal obstruction (can backflow into appendix)

2. Infection

3. Excessive mucus secretion and retention

4. Tumors (new growth)

What are 4 causes of appendicitis?

Periumbilical or epigastric pain

What is the most common initial symptom of appendicitis?

appendicitis is very unlikely (chronology is important)

If vomiting proceeds pain...

RLQ, specifically McBurney's point

Where does appendicitis pain localize to? More specifically?

2/3's of the way from the umbilicus to anterior superior iliac spine

What is the McBurney's Point?

Kids

In what population is diarrhea a common sign of appendicitis?

1. Periumbilical or epigastric pain

2. Anorexia

3. N/V

4. Pain localizes to RLQ, specifically McBurney Point

5. Low-grade fever

6. Diarrhea

7. If it is in later stages or burst appendix, may have rigid abdomen (feels like washboard)

What are 7 clinical manifestations of appendicitis?

1. Do you have your appendix?

2. When did vomiting start? (if before pain, appendicitis is very unlikely)

What are two questions to ask regarding the possibility of appendicitis?

1. Ovarian cyst

2. Right ureter issues

3. Hernia

4. Right bladder infection

5. Testicular torsion

6. Muscle strain

7. Ectopic pregnancy

8. Diverticulitis

9. Gastroenteritis (virus in stomach or bowel)

10. Tumor/growth

What are 10 differential diagnoses for appendicitis?

1. Ultrasound (noninvasive, less costly)

2. Abdominal CT

3. CBC (to see elevated WBC count)

What are 3 tests to diagnose appendicitis?

Head, body, and tail

What 3 parts does the pancreas have?

1. Psoas sign

2. Obturator sign

What are 2 evaluatory tests for appendicitis?

1. pt lays on left side, provider extends right hip back

2. pt lays on back and flexes right hip up, provider applies resistance

Appendix test: Describe psoas sign (2)

Increased RLQ pain with movement

What is a positive psoas sign?

RLQ pain with internal rotation or flexed knee and hip

Appendix test: Describe obturator sign

1. Antibiotics (fever/chills for infection)

2. Appendectomy (removal of appendix, most common)

What are the two ways to manage appendicitis?

Diverticulosis

small, marbled-size pouches that protrude through colon wall; many pouches, asymptomatic

In naturally weak pouches in the colon; wall gives way to pressure as chyme comes through

Where do diverticula develop? How does this occur?

Diverticulum

single pouch that protrudes through colon wall

Diverticulitis

inflammation of diverticulum

Meckel's diverticulum

What is the most notable type of diverticulum?

Meckel's diverticulum

congenital sax in the lower ileum, represents the proximal end of the yolk stalk, developed into out pouch

2%

What % of population has Meckel's diverticulum?

Usually multiple diverticula present, usually less than 10 mm in size

Pathophysiology of diverticulitis: Number and size

In sigmoid and descending colon (LLQ)

Pathophysiology of diverticulitis: Where does it most commonly occur?

Ascending colon/RLQ

Pathophysiology of diverticulitis: Where does it commonly occur in Asians?

50% over the age of 60

Pathophysiology of diverticulitis: ___% over the age of ___ have diverticulosis

1. Age

2. Family history

3. Too low fiber (modifiable, results in hard large stools)

4. Lack of exercise (modifiable)

What are the 4 main risk factors of diverticulitis

1. Obesity

2. Smoking

3. Diabetes

What are 3 relative risk factors of diverticulitis?

1. LLQ pain

2. Fever

3. N/V

4. Palpable masses

What are the 4 signs/symptoms of diverticulitis?

- Severe

- Relived with bowel movements

- Usually worse with eating

- Usually associated with bloating and/or constipation

Describe the LLQ pain with diverticulitis (4)