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A comprehensive overview of various gastrointestinal and bowel disorders, including acute gastroenteritis (age), irritable bowel syndrome (ibs), inflammatory bowel disease (ibd), diverticulosis, and colorectal cancer. It covers the common symptoms, diagnostic criteria, and treatment approaches for these conditions. The document delves into the etiology, pathophysiology, and management strategies for each disorder, equipping healthcare professionals with the necessary knowledge to effectively identify, evaluate, and manage patients presenting with gastrointestinal and bowel-related complaints. Additionally, the document addresses the role of advanced practice registered nurses (aprns) in the care of these patients, highlighting their scope of practice and the importance of appropriate referrals to gastroenterologists when necessary.
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What are common causes of N/V associated with gastritis? - answer Alcohol, NSAIDs, ASA, ABX, and illicit substances What is the most common cause of nausea and vomiting? - answer Acute Gastroenteritis (AGE) What are some manifestations of AGE? - answer Nausea, vomiting, and diarrhea, fever, abdominal pain. May also include fatigue, malaise, anorexia, tenesmus and borborygmus. How is the severity of AGE gauged? - answer Dehydration secondary to profuse watery diarrhea, fever greater than 101ºF (38.3ºC), vomiting, or dysentery. What are important parts of a patient's history when AGE is suspected? - answer Travel, dining locations, ABX history.. What happens to the pH of the stomach when antacids are taken and how does this affect bacteria? - answer High pH can make it easier for bacteria to survive and cause and infection. How does motility of the GI tract affect bacteria colonization? - answer Small bowel stasis as a result of obstruction, diverticulitis, or blind loop syndrome frequently develop an overgrowth of bacteria within the stagnant segment. Which immunoglobulin may protect the GI tract against invading organisms? - answer IgA...may also help protect against a future attack by the same pathogen. Onset of N/V begin within 6 hours after exposure. Is this bacterial or viral? - answer Bacterial: time frame suggests food poisoning resulting from the ingestion of a preformed toxin such as that of Bacillus cereus.
What two indications are highly suggestive of viral AGE? - answer Incubation periods greater than 14 hours and the initial symptom of vomiting. If a patient presents with AGE and reports bloody stools, what can be understood about the reason for blood in the stool/ - answer Mucosal damage and inflammatory process secondary to invasive pathogens. What do frothy stools and flatus suggest? - answer Malabsorption problem. Patients with prolonged AGE illness who are malnourished may present with edema. What is the reason? - answer Hypoalbuminemia T or F: Chronic diarrhea usually has a noninfectious etiology. - answer True T or F: Acute diarrhea usually is caused by infectious agents or toxins - answer True What is the most common viral pathogen causing AGE in adults? - answer Norovirus What is the most common viral pathogen causing AGE in pediatrics? - answer Rotavirus. This has been greatly reduced since the introduction of the rotavirus vaccine. T or F: Stool studies are indicated in the absence of bloody diarrhea or systemic disease - answer False T or F: A CBC will help distinguish between viral and bacterial AGE - answer False When are stool studies warranted? - answer Severe or prolonged diarrhea, a fever > 38.5ºC, bloody stools or stools that test positive for leukocytes or occult blood. What are common pathogens involved in Traveler's Diarrhea? - answer Shigella, Campylobacter, and E. coli.
What should the clinician do if the patient develops diarrhea after initiation of completion of antibiotic therapy? - answer Test for C. diff. What are some DDx of AGE, particularly in patients with persistent or chronic diarrhea and severe abdominal pain? - answer IBS, IBD, ischemic bowel disease, partial bowel obstruction, small bowel diverticulosis. What are some red flag symptoms that may indicate the need for hospitalization? - answer Hypovolemia, dehydration, abnormal electrolytes, decreased renal function, bloody stool/rectal bleeding, weight loss, severe abdominal pain, prolonged symptoms greater than 1 week, pregnancy, advanced age, history of hospitalization or antibiotic use in the last 3-6 months. What is the usual course of treatment for AGE? - answer Only supportive treatment is initiated since AGE is usually self-limiting and resolves within 1 week after onset of symptoms. How such patients with evidence of dehydration be treated initially? - answer Fluid repletion and nutrition. Sports drinks aren't as effective as specific electrolyte replenishing drinks. At what point should a patient be referred to the hospital for dehydration? - answer Signs of hypovolemia such as hypotension, tachycardia, pallor, and poor skin turgor. T of F: Empiric antimicrobial therapy is recommended for patients with severe diarrhea suspected form traveling. - answer True. Bactrim, Ciprofloxacin, Norfloxacin, Floxacin. T or F: Antibiotic prophylaxis for patients traveling to high-risk areas is appropriate. - answer True How effective is antibiotic prophylaxis for patients traveling to high-risk areas? - answer 90% effective What does antibiotic prophylaxis treatment consist of? - answer Bactrim, Ciprofloxacin, Norfloxacin, or Floxacin given once daily until 2 days after returning home.
What is an appropriate symptomatic treatment for patients < 65 years or age with moderate to severe diarrhea? - answer Two-day course of Loperamide (Imodium) What is an appropriate symptomatic treatment for patients < 65 years or age with significant vomiting? - answer Two-day course of Zofran or Phenergan. What is the best way to prevent AGE? - answer Hand washing. T or F: Kids can attend daycare with infectious diarrhea as long as they're separated from other children. - answer False! Not until the diarrhea has stopped. If pain is present in the right lower quadrant, what might be the etiology related to bowel disorders? - answer IBD, IBS, Infectious Colitis, and Constipation If pain is present in the left lower quadrant, what might be the etiology related to bowel disorders? - answer Diverticulitis, IBS, IBD, Constipation, and Infectious Colitis. If pain is present in the left upper quadrant, what might be the etiology related to bowel disorders? - answer Stomach ulcers, pancreatitis, and gastritis. If pain is present in the right upper quadrant, what might be the etiology related to bowel disorders? - answer Gall bladder, hepatitis, and pancreatitis. T or F: IBS is a disorder of bowel function in the absence of an atomic abnormality. - answer True What are common symptoms of IBS? - answer Changes in bowel habits such as diarrhea (IBS-D), constipation (IBS-C), abdominal pain, bloating, rectal urgency with diarrhea. What are some extra-intestinal (outside the intestines) symptoms of IBS? - answer Sexual dysfunction, loss of libido, dyspareunia, muscle aches and
pains, fatigue, fibromyalgia, headaches, back pain, urinary urgency, urinary hesitation, or bladder spasms. T or F: IBS results in serious medical consequences - answer False, prognosis for IBS is excellent. T or F: IBS is a risk factor for IBD (Crohn's and UC) and colon cancer. - answer False What are the two most common types of bowel disorders under the Inflammatory Bowel Disease (IBD) umbrella? - answer Ulcerative Colitis (UC) and Crohn's Disease In which part of the bowel is UC most commonly manifested? - answer Rectosigmoid T or F: UC extends into the small intestine. - answer False, UC is not present outside of the colon. T or F: Crohn's Disease can be present anywhere from mouth to anus. - answer True In Crohn's Disease there is a characteristic segmental presentation of the diseased bowel, separated by normal areas of mucosa. What are these areas referred to as? - answer Skipped lesions What is one characteristic of Crohn's that differentiates it from UC related to the bowel tissues themselves? - answer Crohn's affects the tissue to a deeper level and can affect any or all layers of the bowel. What is the theory behind the etiology of IBD? - answer An initiating factor such as a virus, allergic, or bacterial process occurs and inflames the intestine. Subsequently, those with a certain genetic predisposition may produce antibodies that chronically attack the intestine (autoimmune). Sometimes other relatives are found to also have IBD demonstrating a genetic component. Describe IBS as it pertains to its effect on the bowels... - answer Disordered sensation or abnormal function of the small or large intestine.
What is the most consistent characteristics of IBS? - answer Alteration in bowel habits alternating. Abdominal pain is also common. Painless diarrhea may occur. What are the three most common areas of abdominal tenderness for patients with suspected IBS? - answer LLQ, umbilicus, or epigastrium. T or F: The physical exam for patients with suspected IBS is usually abnormal - answer False: It's usually normal because there is no anatomical abnormality behind this condition. T or F: Digital rectal exams are usually normal in patients with suspected IBS but may exacerbate symptoms. - answer True T or F: Extensive testing such as thyroid testing, abdominal imaging, and stool studies are indicated in patients with suspected IBS - answer False: Start with basic labs such as CBC and ESR, although elevated ESR and leukocytosis is typically seen with IBD, not IBS. T or F: Colonoscopy and barium enema are abnormal in a patient with suspected IBS - answer False: Those tests would be normal because there is no anatomical abnormality behind this condition. What are 4 main points of diagnosis for patients with suspected IBS? - answer 1. Reveal an increase in bowel symptoms with the onset of pain.
T of F: There is proven treatment for IBS - answer False At what severity are pharmacological measures taken in patients with IBS? Mild, moderate, or severe? - answer Moderate to severe What is the first-line treatment for IBS-C? - answer 1. High fiber diet and hydration
T or F: Cross-sectional imaging and/or colonoscopy can usually detect signs of IBD. - answer True Crohn's Disease represents an abnormality in intestinal immune response. What is the result of this abnormality with regard to the bowel tissue and subsequent complications? - answer 1. Causes fibrosis which thickens the bowel wall
T of F: Periods of stress can exacerbate Crohn's symptoms - answer True T or F: Fatty, spicy, and dairy foods are well tolerated in patients with Crohn's Disease - answer False, they are usually poorly tolerated. T of R: Crohn's is characterized by periods of acute exacerbation alternating with complete remission. - answer True What is history of antibiotic use important when a patient presents with diarrhea? - answer Because antibiotics disrupt the normal balance of bacteria in the GI tract which in turn affects digestion. What are the most common presenting symptoms of ulcerative colitis (UC)? - answer 1. Rectal bleeding
What is the severity of Crohn's based on? - answer Level of inflammation and intestinal lumen obstruction caused by fibrosis. What might a physical exam reveal on a patient with suspected ulcerative colitis? - answer 1. Tenderness in the LLQ or across the entire abdomen
What medications are often use for moderate to severe IBD? - answer Anti-TNF therapy or "Biologics" including Remicade (infliximab), Humira (adalimumab), and Entyvio (vedolizumab). What disease is present when inflammatory changes within diverticula mucosa of the intestines arises? - answer Diverticular Disease What does diverticular disease, or diverticulosis, look like upon examination of the bowels? - answer Small outpouchings or sacs in the wall of the colon are present, usually at the location of weakened areas of the bowel wall where arterial vessels perforate the colon. T of F: Diverticulosis is typically asymptomatic until the diverticula become inflamed and/or bleed. - answer True Although diverticula con occur anywhere in the intestines, where is the most common place for them to arise? - answer Descending and sigmoid colon How does diverticulosis differ from diverticulitis? - answer The latter occurs when the former becomes inflamed and subsequently has the potential to rupture Where does acute diverticulitis usually show up during an abdominal exam? - answer LLQ abdominal pain and tenderness If a perforation of a diverticula occurs and is not isolated, signs and symptoms of _________________ may be present. - answer Peritonitis...think rebound tenderness! What are common signs and symptoms of diverticulitis? - answer 1. LLQ pain/tenderness
When testing for diverticulitis, what blood tests should be ordered and what would they show? - answer 1. CBC: can show mild to moderate leukocytosis
If you are at high risk for colorectal cancer based on family history, when should you start screenings? - answer BEFORE age 50 and/or be screened more often What makes a person at high risk for colorectal cancer? - answer 1. Personal history of CC or adenomatous polyps
What are the main endocrine functions of the pancreas? - answer Alpha and beta cells secret hormones into the bloodstream, namely glucagon and insulin, respectively. What are the endocrine functions fo the pancreas? - answer Acinar cells secrete digestive enzymes which are secreted into the duodenum which help break down carbohydrates, lipids, and proteins. How does the pancreas protect itself from its own enzymes? - answer By producing inactive forms of enzymes called proenzymes, known more specifically as zymogens. These zymogens are activated by proteases. Where is zymogen stored to keep it away from sensitive tissues? - answer In vesicles called zymogen granules. These are stored with protease inhibitors to prevent accidental activating for the zymogen. How are zymogens used to digest food? - answer They are secreted into the pancreatic duct and enter the duodenum where they are activated by the protease trypsin. What is trypsinogen? How, when, and to what is it converted? - answer Trypsinogen is a zymogen made by the pancreas. It is activated by enteropepidase which is produced in the duodenum. The active form of the enzyme is called trypsin. What is the results of trypsinogen and other zymogens becoming active prematurely? - answer Acute Pancreatitis Acute pancreatitis may be a result from what two physical circumstances? - answer 1. Injury to the acinar cells
in thick pancreatic juices that can form a protein plug in the pancreatic ducts and therefore cause a blockage.
What happens to the pancreas as a whole after the inflammatory response and proteases ravaging the tissues? - answer This causes blood vessels to leak and rupture causing edema which results in the swelling of the capsule of the pancreas. What happens when lipases are activated in the pancreas as a result of the inflammatory process? - answer They can destroy the fat surrounding the pancreas known as the peripancreatic fat. As the autodigestion and bleeding occur in the pancreas, what is the end result? - answer Liquification of pancreatic tissues known as: liquefactive hemorrhagic necrosis. One complication of acute pancreatitis is a pseudocyst. How does this occur and what are the symptoms? How is it best diagnosed? How is this problematic? - answer This occurs when fibrous tissue surrounds liquefactive necrotic tissue which fills with pancreatic juice. Symptoms: abdominal pain, loss of appetite, palpable mass, serum amylase/lipase/bilirubin elevation. CT scan for imaging As pseudocysts grow they may rupture releasing enzymes into the abdominal cavity causing massive inflammation. They can become infected, often by E. coli, which turns the pseudocyst into an abscess. How is a pancreatic pseudocyst distinguished from a pancreatic abscess since they present similarly in symptoms and imaging? - answer 1. High fever and WBC count since it is an infection What secondary complication results from damaged blood vessels as a result of acute pancreatitis? - answer Hemorrhage --> hypovolemic shock How does acute pancreatitis affect the body's ability to clot? - answer It affects the systemic activation of coagulation factors which may result in disseminated intravascular coagulation (DIC). How does acute pancreatitis affect the body's respiratory system? - answer May lead to acute respiratory distress syndrome (ARDS) where massive pancreatic inflammation leads to leaky blood vessels throughout
the body making it harder to breath. #1 killer in patients with acute pancreatitis. What are some general symptoms of acute pancreatitis? What about distinctive signs? - answer 1. N/V, epigastric pain radiating to the back
What is the main subjective s/s of acute cholecystitis? - answer Nausea & vomiting which can last a long time. How does the gall bladder become inflamed? - answer Since there a is a stone stuck in the cystic duct, the bile cannot escape the gallbladder. The bile becomes an irritant to the gallbladder mucosa which in turn secretes mucus and enzymes. These enzymes cause the walls of the gallbladder to become inflamed and pressure to rise. Where does pain caused from cholecystitis radiate? - answer Right scapula, shoulders Bacteria eventually make their way through the gall bladder wall and into the _____________ causing _____________. This results in ____________ tenderness. - answer 1. peritoneum
What complications arise if a gallstone becomes lodged in the common bile duct? - answer Bile backs up into the gallbladder and the liver. The pressure builds and causes bile to force its way through the cells that form the bile duct walls and allow it to enter the blood stream --> conjugated bilirubin --> jaundice. What markers in the blood can be used to assist in the diagnosis of cholecystitis? - answer ALT or alkaline phosphatase. This enzyme is found in high amounts in the cells of the bile ducts of the liver. The increased pressure of the bile in the ducts can cause the cells to rupture, releasing their ALP into the blood. What non-invasive diagnostic test can be used for cholecystitis? What are some of its findings? - answer 1. Ultrasound
What type of hearing loss involves the outer and middle ear to the level of the oval window that may results from a variety of structural abnormalities?
How is sensorineural hearing loss treated? - answer There's no proven treatment, but hearing aids and cochlear implants (for profound loss) can aide. T or F: Most type of conductive hearing loss are irreversible. - answer False, most are reversible. What are some possible causes of tympanic membrane (TM) rupture? - answer Impact, pressure change injury such as in an airplane of an explosive. Acute infection of the middle ear may cause a relative ischemia in drum concurrent with increased pressure in the middle ear space. What does this lead to? - answer Tear or rupture of the tympanic membrane. What are the signs and symptoms of a perforated tympanic membrane? - answer 1. Sharp ear pain which resides quickly
How is otitis externa treated? - answer Antibacterial ear drops with or w/o corticosteroids. No class is better than another. Consider cost, availability, and convenience. If the TM cannot be visualized in otitis externa _______________ drops much be used when treating. _______________ is the antibiotic class of choice. - answer 1. non-ototoxic
What is the differential diagnosis for eustachian tube disorder (ETD)? - answer 1. Acute, serous, or chronic otitis media