GI & Nutrition

causes of upper GI bleeding

• tarry/dark blood, can look like coffee grounds

• duodenal ulcer

• esophageal or gastric varices

• gastric ucler

• mallory-weiss tear

causes of lower GI bleeding

• bright red/maroon blood (hematochezia)

• cancer

• diverticulosis

• hemorrhoids

• inflammatory disease

• polyps

• vascular ectasias

biggest risk factor of peptic ulcer

alcohol consumption!!

• H.pylori

• NSAIDS

• smoking

h.pylori infection

elevates levels of gastrin and pepsinogen and releases toxins and enzymes that promote ulceration and inflammation

melena

shiny, black, foul-smelling stool that results from the degradation of blood by stomach acids or intenstinal bacteria

causes of esophageal varices

• most common is liver cirrhosis » leading to portal HTN

• hepatitis B or C, or fatty liver disease

• Blood clots in the portal or splenic vein

S/S of esophgeal varices

• Varices usually cause no symptoms until they bleed. Vein walls are thin » rupture » bleeding can be severe and life-threatening

• Vomiting blood (bright red or like coffee grounds)

• Black, tarry, or bloody stools

• Lightheadedness, fainting, rapid heartbeat

• Pale skin

guaiac testing

• GI blood is occult (not visible) and is tested w a chemical reagant

• When blood is present in the stool, the heme in blood triggers a chemical reaction when a developer solution is added, and the spot turns blue (+)

pt signs of blood loss from upper GI tract

• boody emesis (hematemesis)

• hematochezia or melena

• ↑ bowel sounds

patho of upper GI bleed

diagnostic of upper GI issues

endoscopy: procedure can be done @ bedside, pt must be hemo stable, pt sedated

• preferred for suspected ulcers, GI bleeding, Barrett’s esophagus, cancer, and esophageal varice

stress ulcer prophylaxis

High-risk patients given H2 blockers or PPIs

• Mechanical ventilation for more than about 48 hours

• A coagulopathy (impaired clotting), such as from liver disease, low platelets, or anticoagulants

H. pylori treatement

• PPI (esomeprazole, lansoprazole, omeprazole, pantoprazole) plus two ABX (amoxicillin & clarithromycin)

vasopressin therapy

• lowers portal vein pressure by constricting splanchic arteriolar bed (often given w NTG)

• somatostatin or octreotide: reduce splanchnic blood flow by a different mechanism and have a much better safety profile than vasopressin

MOST COMMON cause of acute pancreatitis

alcohol ingestion and biliary disease

pancreatitis labs

S/S of acute pancreatitis

• abdominal guarding/distension

• cullen’s sign

• dehydration

• fever

• grey turner’s sign (ecchymosis in flanks)

• N/V

• pain

patho of acute pancreatitis

• Trigger: Acinar cell injury lets pancreatic enzymes (trypsin, chymotrypsin, elastase) leak into pancreatic tissue.

• Autodigestion: causing edema, vascular damage, hemorrhage, necrosis, and fibrosis.

• Systemic spread: Enzymes and inflammatory mediators enter the blood and injure distant organs

• Immune response: Local inflammation is followed by CARS → too much CARS → ↑ infection risk

common hepatotoxic meds

• APAP

• ABX

• NSAIDS

• MAOIs

• antiepileptics

• statins

common cause of liver failure

hepatitis

treatment/prophylaxis of chronic liver disease

• Avoid alcohol and unnecessary hepatotoxic medications (including excess acetaminophen)

• Adequate nutrition and hydration

• Monitoring liver enzymes and for chronic cases, screening for cirrhosis and liver cancer

S/S of acute liver failure

• Chills

• Convulsions

• ↓ LOC, coma

• Hyperexcitability

• Insomnia

• Irritability

• Jaundice

• Lethargy

• Nausea and vomiting

• Sudden onset of high fever

liver disease categories

1. portal HTN

2. impaired liver metabolic process

3. impaired bile formation and flow

high-output failure or hyperdynamic circulation

liver cell destruction » shunting of blood and ↑ CO + vasodilation » decreased perfusion to organs despite ↑ CO

• s/s related to those of HF, JVD, & pulmonary crackles

causes of fatty liver

• long-term alcohol abuse

• obesity

types of liver cirrhosis (scarring)

• alcoholic

• biliary (obstruction of bile ducts)

• cardiac (long term RHF)

• postnecrotic (exposure to hepatotoxins or chemicals)

ascites

• a complication of liver failure

• acculumation of fluid in the peritoneum

• assoc w/ low albumin levels

• Na + H2O retention + portal HTN » ascites

ascites treatment

• bed rest, low Na diet, fluid restriction, diuretic therapy

• paracentesis (percutaneous needle aspiration)

why is ammonia high in liver failure?

• The liver is the body’s main ammonia-detoxifying organ, and when it fails, ammonia builds up in the blood

• Normally, hepatocytes convert ammonia into urea through the urea cycle, and the kidneys excrete the urea in urine

hepatic encephalopathy

Excess ammonia crosses into the brain, where astrocytes convert it to glutamine. Glutamine draws water into the cells, causing swelling, and disrupts neurotransmission. The result ranges from sleep reversal and mild confusion to asterixis (flapping tremor), stupor, and coma. In acute liver failure, the swelling can cause dangerous brain edema and raised intracranial pressure.

treatment of hepatic encephalopathy

lactulose (acts as a laxative + converts ammonia » ammonium)