GI E1- Intro

What is another name for indigestion?

dyspepsia

Persistent or recurrent pain/burning centered in the upper abdomen (epigastric region), early satiety, or postprandial fullness is known as _______

Dyspepsia

Dyspepsia can also be described as _______

bloating, N/V

What is heartburn?

retrosternal burning

Dyspepsia must be distinguished from _______

heartburn

What is almost aways present w/ heartburn?

GERD

What is the most common cause of chronic dyspepsia?

functional dyspepsia → sx mild & intermittent, no obvious organic cause

What are the GI ALARM symptoms that warrant further evaluation?

• constant or severe pain

• unintentional weight loss

• persistent vomiting

• dysphagia; odynophagia

• hematemesis

• melena

• hematochezia

• abd mass

• unexplained IDA

• Fhx of upper GI cancer

T/F: History and PE allows you to differentiate between ulcer related and non-ulcer dyspepsia.

false

Which kind of dyspepsia?

• younger patients

• variety of abdominal / GI symptoms

• increased incidence of anxiety or depression or stress

non-ulcer

Which kind of dyspepsia?

• older patients (> 55)

• often smokers

• pain is changed w/ food or meds

peptic ulcer

what must always be done for abdominal complaints?

rectal exams

What is the workup for dyspepsia?

abdominal + rectal exams, labs, upper endoscopy EGD (study of choice), noninvasive H. pylori testing (urea breath test, fecal antigen, IgG serology)

What should be done in ALL pts > 60 w/ dyspepsia or < 60 w/ alarm symptoms (wt loss, recurrent vomiting, evidence of bleeding, anemia)?

upper endoscopy EGD

What should be done for dyspepsia pts < 60 yrs without alarm symptoms and negative PE?

lifestyle modifications and noninvasive H, pylori testing (urea breath, fecal antigen, IgG serology)

What should be given to a patient with dyspepsia who is positive for H. pylori?

4-6 weeks of PPI’s + abx

At what age should you refer for endoscopy in dyspepsia patients who are born in areas w/ increased incidence of gastric cancer?

> 45

What lifestyle modifications should be made for dyspepsia patients?

• D/C alcohol, caffeine, fatty foods, smoking

• avoid lying down after meals; no food 3 hrs before HS

• food diary → identify foods or drinks that exacerbates & WHEN pain/discomfort is worse

What are pharmacological treatment options for dyspepsia?

antacids, H2RAs, low dose antidepressants HS, PPIs, pro kinetic agents (metoclopramide, erythromycin), H. pylori triple drugs (prevpac, helidac)

What drug provides competitive inhibition of histamine at H2 receptors of gastric parietal cells, inhibiting gastric acid secretion?

H2RAs

What drug suppresses gastric acid secretion via inhibition of H+/K+ ATPase in the gastric parietal cell?

PPIs

What are SE of PPI therapy?

atrophic gastritis, fractures, osteoporosis, inc risk CV disease, CAP, c. diff infx

What should you always consider when prescribing PPIs?

shorter duration & lowest dose

What should be given along with PPis for those at risk of osteoporosis?

Ca, Vit D, and monitor bone status

What drug?

• prokinetic agent to treat dyspepsia & an antiemetic

• works to speed gastric emptying

• SE- tardive dyskinesia (black box warning)

Metoclopramide (Reglan)

What are the drugs in Prevpac to treat H. pylori?

Lansoprazole, amoxicillin, clarithromycin

A vague, intensely disagreeable sensation of sickness or “queasiness” that is a subjective experience is known as _____

nausea

The forceful expulsion of gastric contents through a relaxed upper esophageal sphincter and open mouth is known as _____

vomiting

The effortless reflux of liquid or food stomach contents is known as ____

regurgitation

Vomiting is controlled by ________

brainstem / medulla & vagus nerves

What are possible complications of vomiting?

dehydration, hypokalemia, metabolic alkalosis, pulm aspiration, boerhaave’s syndrome, mallory weiss tear, splenic /hepatic lacerations & intraabdominal bleeding (rare)

What is the non pharm management for acute mild and self limited vomiting?

clear oral fluids, broth, tea, soup, carbonated beverages, small feedings of toast or dry soda crackers

What antiemetics can be used to treat vomiting?

serotonin 5-HT₃ antags: ondansetron

dopamine antags: promethazine, prochlorperazine

antihistamines/anticholinergics: diphenhydramine, meclizine, scopolamine patch

steroids: dexamethasone

sedatives: benzodiazepines

What drug?

• antiemetic used for chemotherapy or post op nausea prophylaxis

• ex: ondansetron (zofran) 4-8 mg x 12h IV or PO

serotonin 5-HT3 antagonists

What drug?

• antiemetic

• avoid w/ CNS depressants such as alcohol

• ex: promethazine (phenergan), prochlorperazine (compazine)

dopamine antagonists

What is another name for hiccups?

singultus

How do hiccups happen?

diaphragm goes into spasm, forcing air into lungs → epiglottis snaps shut making sound

What is the workup for persistent hiccups?

detailed neuro exam, serum creatinine, LFTs, CXR

if unclear cause → CT of head, chest, or abd

What is the treatment for benign cases of hiccups?

tongue traction, 1 tsp dry granulated sugar, hold breath for several resp cycles, valsalva, rebreathing into a bag

meds: chlorpromazine, benzodiazepines, anticonvulsants

A perception of abnormal bowel movements such as hard stools, straining, decreased frequency or feeling of incomplete evacuation is known as ______

constipation

What is a spasm of anal sphincter associated with cramping and ineffective straining at stool?

tenesmus

How does defecation normally work?

puborectalis muscle and external sphincter relax in response to increased rectal pressure → BM

How does abnormal defecation / constipation happen?

muscle or sphincter fails to relax

What is the normal frequency of BMs?

3-21 per week; approximately 35 hrs colonic transit time

what is the medical criteria for constipation?

< 3 BMs per week & excessive straining with defecation

If constipation pain is relieved by defecation, this suggests _____

IBS

What kind of constipation?

• no structural abnormalities

• may have slow colonic transit time or anorectal dysfunction

• may be part of generalized dysmotility syndrome

primary

What kind of constipation?

• due to systemic disorders, meds, or obstructing colonic lesions

secondary

what must be done for new onset constipation in pts >45 with or without alarm sx (hematochezia, anemia, wt loss, +fecal blood test) and a FHX colon cancer or IBD?

work up to r/o colorectal cancer

what is the most common cause of constipation?

diet → inadequate fiber, fluids, or exercise

What is the workup for constipation?

PE w/ rectal exam → sphincter tone & anal wink reflex

stool testing for occult blood

labs

if alarm sx → colonoscopy, flex sig, barium enema

what is seen in this xray?

severe case of constipation showing a loaded colon

What are non pharmacological treatment options for constipation?

Diet: bulking agents (fiber supps), high fiber diet (25 g/day), fluids & exercise

Psych referral if hx sexual abuse or depression

What medications can be used to treat constipation?

osmotic lax: MgOH, non digestible carbs (sorbitol, lactulose), polyethylene glycol (miralax)

stimulant lax(cathartics): bisacodyl, senokot, cascara, castor oil

opioid receptor antags: methylnaltrexone, lubiprotone, naloxegol

What osmotic laxative should be avoided in pts w/ chronic renal insufficiency?

magnesium hydroxide

What should be AVOIDED in pts > 55 with known kidney disease or on meds that affect kidney function (NSAIDs, ACEIs, ARBS, diuretics)?

Sodium Phosphate (Osmoprep, Fleets phosphor-soda)

What drug?

• usually administered at HS to treat constipation

• stimulates fluid secretion and colonic contraction

• chronic use of these may result in loss of normal colonic muscular function

• ex: bisacodyl, senokot, cascara, castor oil

stimulant laxatives (cathartics)

what drug?

• block peripheral opioid receptors w/o affecting central analgesia

• approved for use in opioid induced constipation

• ex: methylnaltrexone, lubiprotone, naloxegol

opioid receptor antagonists

How do osmotic laxatives work to treat constipation?

increase water into intestinal lumen to soften stool

T/F: polyethylene glycol (miralax) does NOT cause fluid or electrolyte shifts

true

what are predisposing factors for fecal impactions?

meds (opioids), severe psychiatric dz, prolonged bed rest, neurogenic dz of colon/spine

what is the clinical presentation of a fecal impaction?

• dec appetite, N/V

• abd pain & distention

• diarrhea- liquid stool seeps out around impaction

• PE → firm feces are palpable

What studies can be done for fecal impactions?

DRE → diagnostic & therapeutic

Radiographs → megarectum, fecaloma

what is the treatment for fecal impactions?

impaction relief: DRE, enema (saline, mineral oil), disimpaction

prevention: maintain soft stools, avoid prolonged bathroom sessions, regular bowel schedule

An involuntary or voluntary release of gas from the stomach or esophagus is known as _____

belching / eructation

Passage of gas from the rectum caused by swallowed air or bacterial fermentation of undigested carbohydrates is known as _____

flatus

What is the treatment for GI gas?

lactose free diet, avoid gas producing foods, dec fatty food intake

probiotics & simethicone (gas-x, mylicon, beano, phazyme)

An increased liquidity / decreased consistency of stools is known as ____

diarrhea

A reduction as little as _____ in the water absorptive efficiency may lead to diarrhea.

1%

T/F: History can distinguish acute vs chronic diarrhea

true

What time frame classifies diarrhea as acute?

< 2 weeks

Which kind of acute diarrhea?

• watery, non bloody

• cramps, bloating, N/V, large volumes

• e.coli, s. aureus, b. cereus, viruses, giardia

• no tissue invasion (no fecal leukocytes)

• comps: hypokalemia, metabolic acidosis from loss of HCO3

non-inflammatory

what kind of acute diarrhea?

• fever + bloody (colonic tissue damage)

• small volumes, LLQ cramps, urgency, tenesmus

• shigella, salmonella, campylobacter, yersinia, c. diff, e. coli

• fecal leukocytes

• comp: HUS

inflammatory

What work up should be done for patients with diarrhea >7 days duration?

stool culture, O&P, fecal leukocytes

What is the treatment for acute noninflammatory diarrhea?

often self limiting

diet- bowel rest; avoid high fiber foods (BRAT diet), clear soups, crackers, no fats or milk products

rehydration- oral is best (pedialyte, gatorade), glucose, NaCl, K, bicarbonate or citrate, IV fluids if severe

What is the treatment for acute infectious diarrhea?

anti-diarrheal agents: kaopectate, peptobismol, ioperamide (immodium)

abx in select pts: rifaximin for traveler’s, cipro, azithro

What is the treatment for acute inflammatory diarrhea?

oral rehydration:, no high fiber/fatty foods, milk, caffeine, or alcohol

avoid antidiarrheal agents

abx usually not needed; can be used empirically while cultures pending or when specific organism found (*NOT w/ suspected STEC)

What time frame classifies diarrhea as chronic?

> 4 weeks

What kind of chronic diarrhea?

• poorly absorbable, osmotically active solute ingested, drawing enough fluid into lumen to exceed the colon’s resorptive capacity

• fecal water output increases in proportion to solute load

• stool volume decreases w/ fasting

• eti: meds (antacids, lactulose, sorbitol), lactose intolerance, factitious diarrhea (mg or na sulfate laxatives), carbohydrate malabsorption

osmotic

what kind of chronic diarrhea?

• deranged fluid & elyte transport across enterocolonic mucosa

• NO malabsorbed solute, so osmolality of stool w/in normal limits (no fecal osmotic gap)

• large, watery volumes (> 1 L/day),

• little change w/ fasting,

• painless

• eti: hormonal (carcinoid, zollinger-ellison, thyroid cancer), meds, factious (stimulant laxative abuse), bile salt malabsorption, chronic alcohol ingestion

secretory

what kind of chronic diarrhea?

• fever, hematochezia, abd pain

• eti: ulcerative colitis, crohns, microscopic colitis, malignancies, radiation enteritis

inflammatory

What kind of chronic diarrhea?

• wt loss

• stool analysis: fecal fat > 10 g/24 hrs

• anemia

• hypoalbuminemia

• eti: small bowel mucosa dz, lymphatic obstruction, pancreatic dz

malabsorption

what kind of chronic diarrhea?

• systemic dz or prior abdominal surgery

• eti: vagotomy, partial gastrectomy/gastric bypass, systemic disorders (scleroderma, DM, hyperthyroidism), IBS

motility induced

what kind of chronic diarrhea?

• immunosuppressed patients

• eti: parasites (giardia lamblia, entamoeba histolytic, cyclospora), AIDS, viral (CMV, HIV), bacterial (c. diff, m. avium), protozoal (microsporidia, cryptosporidium)

chronic infection

What is the workup for chronic diarrhea?

Labs, stool studies, serologic tests, endoscopic evaluation, imaging

what is that treatment for chronic diarrhea?

narcotic analogues: loperamide, bismuth subsalicylate (pepto bismol), diphenoxylate w/ atropine (lomotil)

narcotics (generally avoided): codeine, paregoric (tincture of opium), morphine, cholestyramine (used in bile acid malabsorption)

In a patient w/ chronic diarrhea, what should always be r/o as a cause?

cancer

_____ peritoneum is innervated by the ANS, ______ peritoneum is inverted by spinal somatic nerves

visceral, parietal

Which kind of pain?

• transmitted rapidly

• very sharp and localized

• a-delta neurons

somatic

what kind of pain?

• from distention of an organ

• poorly localized

• dull, achy

• C fibers transmit pain slowly

• innervation is b/l → pain refers to midline

visceral

what kind of pain?

• a vital, protective mechanism that permits us to live in our environment

acute

what kind of pain?

• a disease state, not a symptom

• pain that lasts beyond the normal duration of time that an injury or insult to the body needs to heal

• usually 4-6 wks, up to 3 mos (if longer, may be an irreversible and intractable condition)

chronic

what is the major goal when evaluating abdominal pain?

determine presence of life threatening surgical dz (dissecting aortic aneurysm, perforated viscus, bowel obstruction)

What kind of pain may be perceived in the right shoulder or scapula?

gallbladder

what kind of pain is referred to the back?

retroperitoneal processes such as pancreatitis

what kind of pain may be localized to RLQ?

ileum (Crohn’s)

Episodic abdominal pain with pain free intervals is known as ____

colicky

what is the key to determining presence/severity of pain?

facial expressions

Bowel sounds are ____ in peritonitis

absent

Bowel sounds are ____ in early obstruction

high pitched & hyperactive