Gastrointestinal Disorders: Diagnosis, Treatment, and Management, Exams of Medicine

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CMSRN Review Gastrointestinal System

Lower GI Bleed Treatment - ✔️ ✔️ Identification and Resolution of source of bleed

• Ligation
• Cauterization In EMERGENCY Decrease in 10 mmHg = 1000 ml of blood loss
• Fluid replacement = isotonic Crystalloids Peritonitis treatment - ✔️ ✔️ -Peritoneal lavage: sterile cleansing of the peritoneum.
• Intravenous fluids
• Intravenous antibiotics (Control Infection and Inflammation)
• Insertion of a nasogastric tube; decompress GI tract.
• Intestinal abscesses can be drained percutaneously or surgically removed Upper GI bleed location and conditions - ✔️ ✔️ Esophagus and Stomach Esophageal Varices Gastric/Duodenal Ulcers Cancer Mallory-Weiss Tears Types of Acute Abdomen - ✔️ ✔️ 1. Peritonitis

2. Appendicitis Require Surgical Intervention Peritonitis s/s: - ✔️ ✔️ pain tenderness rigid abdominal muscles fever nausea vomit bloating altered peristalsis chills fever loss of appetite Peritonitis Assessment and Diagnostic Findings - ✔️ ✔️ Based on patient history Results of Lab Studies Blood Cultures Ultrasound CT X-Ray studies of the abdomen Paracentesis

Appendicitis S/S - ✔️ ✔️ Periumbilical RLQ pain low grade fever nausea rebound tenderness at McBurney's point. appendicitis diagnosis - ✔️ ✔️ Blood and urine tests R/o Pregnancy Elevated WBCs X-ray CT scan Ultrasound Appendicitis Treatment - ✔️ ✔️ Antibiotic therapy (third gen. cephalosporins), Surgical removal of appendix Upper GI Bleed Risks Factors - ✔️ ✔️ Age Hx of GERD Use of NSAIDS and Steroids Alcoholism upper GI Bleed signs and symptoms - ✔️ ✔️ nausea hematemesis hematochezia heart burn/indigestion light-headedness melena (upper GI bleed) Upper GI Bleed diagnostics - ✔️ ✔️ Patient Hx CBC Coagulation Studies Endoscopy Chest Films (X-Ray) Upper GI Bleed Treatment - ✔️ ✔️ Treat Cause: Ex. Peptic Ulcer treated with appropriate ANTIBIOTIC and PPI Lower GI Bleed Location and Conditions - ✔️ ✔️ Large and Small Intestine Diverticulosis Ischemic events

• Radiation
• Cancer

• administration of antibiotics
• pain control with meperidine or morphine Complicated
• Laparoscopic Cholecystectomy Cirrhosis Risk Factors - ✔️ ✔️ Chronic Hepatitis due to Hep C NAFLD Diabetes Obesity Elevated Triglycerides Sarcoidosis Primary Biliary Cirrhosis Right Heart Failure Tricuspid Regurgitation Autoimmune Hep alpha 1 antrypsin Deficiency Cirrhosis symptoms - ✔️ ✔️ ascites abdominal pain portal hypertension hepatic encephalopathy drowsiness coma hepatorenal disease fever anorexia weight loss spider angioma jaundice coagulopathy Cirrhosis treatment - ✔️ ✔️ Treat according to cause: Hep C- Antivirals Cardiac Conditions-
• Diuretics
• Beta-Blockers
• Digoxin Autoimmune:
• Immunosuppressants Cirrhosis Treatment of Fibrotic Changes - ✔️ ✔️ Pruritis Zinc Deficiency Osteoporosis Donor Transplant diverticulitis s/s - ✔️ ✔️ Acute onset of LLQ pain

Nausea and vomiting Low grade fever Chills Tachycardia ESR & WBC increased (sign of infection) Hgb & Hct decreased Diverticulitis treatment - ✔️ ✔️ • For Mild Diverticulitis: broad spectrum antibiotics, mild analgesic, outpatient

• For More Severe Diverticulitis: hospitalization with IV antibiotics and pain meds.
  • Demerol not used for older adults because of adverse effects
• Bowel Rest
• Lab Studies (Coagulation Assay)
• Nasogastric Decompression
• Blood Cultures
• In acute phase, patient will be NPO then on clear liquids
• Surgical intervention in COLECTOMY and COLOSTOMY
• Risks: Hemorrhage, altered fluid volume, delay healing, impaired self-image, inflammatory attacks Diverticulitis Recovery Treatment - ✔️ ✔️ Progress clear liquid to low-fiber until symptoms subside Progress to High-fiber esophageal varices s/s - ✔️ ✔️ Asymptomatic If ruptured-->Hematemesis, melena, hematochezia, dizziness Sx of cirrhosis and portal HTN Esophageal Varices Prophylactic Treatment - ✔️ ✔️ Recommended for varices 5mm or more in diameter due to risk of hemorrhage Beta-Blocker Therapy to prevent hemorrhage and aim to keep HR at 55 Esophageal Varices Emergency Treatment - ✔️ ✔️ Endoscopy with litigation of varices Vasopressin Placement of transjugular intrahepatic shunt Surgery Crystalloid and Colloid Fluid Replacement Esophagitis causes - ✔️ ✔️ 1. Infection (in immunocompromised pts):
• Candida albicans
• HIV
• HSV
• CMV

2. Pill-induced:

• NSAIDs

Foreign Body Risk Population - ✔️ ✔️ Children 18 to 48 months People who use dentures Psychiatric Patients Prisoners Foreign body diagnosis - ✔️ ✔️ Identify and Treat Radiograph GI to locate and estimate size Ultrasound if patient is in respiratory distress and object is nonradiopaque or sharp Foreign Body Treatment - ✔️ ✔️ · Endoscopy · Small, nontoxic objects may be monitored for passing · Disc battery in esophagus and multiple magnets need emergent removal

• Promotility Medications
• High-Fowler Position Gastroenteritis symptoms - ✔️ ✔️ Nausea Vomiting Abdominal cramping Diarrhea Dehydration Hyperactivity of the intestine produces high-pitched bowel sounds = borborygmi. Hyponatremia possible Hypokalemia possible Metabolic acidosis possible Metabolic alkalosis possible Hypovolemic Shock in High-risk individuals: Children and Elderly gastroenteritis causes - ✔️ ✔️ Norovirus in 50 to 70 percent of all cases Rotavirus in children Salmonella is the second most common cause C. difficile leading cause of HAI Gastroenteritis complications - ✔️ ✔️ Pseudomembranous Colitis Toxic Megacolon Perforation of Colon Sepsis Gastroenteritis Treatment - ✔️ ✔️ Symptomatic and supportive; fluid/nutritional support, antidiarrheals, antiemetics Agent-Specific Antibiotics Gastritis Differential Diagnosis - ✔️ ✔️ Acute
• Erosive
• nonerosive Chronic

gastritis common causes - ✔️ ✔️ Acute

• Long-term NSAID use
• alcohol abuse
• coffee
• caffeine
• corticosteroids
• H. pylori Gastritis Diagnostic Tests - ✔️ ✔️ -Gastric analysis --Biopsy
• Hemoglobin, hematocrit, and red blood cell (RBC) indices
• Serum vitamin B12 levels
• Upper endoscopy
• Double-contrast barium studies Gastritis treatment - ✔️ ✔️ -surgery: vagotomy, gastroectomy
• antibiotics (course of 3 types of H. pylori)
• PPIs : pantoprazole
• histamine 2 receptor antagonists: famotidine (pepcid)
• antiacids: magnesium hydroxide (milk of mag)
• discontinue causative agents Emergency care of gastritis - ✔️ ✔️ Assess for hemorrage Restore Fluid volume status Pain management Types of Gastritis - ✔️ ✔️ Chronic Autoimmune Chemical/Reactive Gastritis Agents in hepatitis - ✔️ ✔️ HAV HBV HCV HDV HEV CMV Epstein-Barr Virus Adenovirus Hepatitis S/S - ✔️ ✔️ Acute: flu-like symptoms, malaise, muscle/joint aches, fever, n/v, diarrhea, headaches, jaundice, right upper quadrant pain Chronic: malaise, fatigue, jaundice, weight loss, easy bruising/bleeding, encephalopathy, deteriorating coagulation

• Left untreated, FATAL in 2-5 days Intussusception diagnostics - ✔️ ✔️ Diagnosed by xray, ultrasound, air or barium contrast enema, which sometimes reduces the obstruction without need for surgery Surgery is indicated when barium or air contrast enema does not reduce the intussusception Intussusception treatment - ✔️ ✔️ Nonoperative: Therapeutic enemas-barium, water-based contrast and air sufflation NG tube for decompression Nonoperative contraindications: peritonitis and perforation Operative: Laparoscopic operation to pull intestine out of itself; if necrotic, surgical resection and anastomosis obstructions of GI tract Diagnostics - ✔️ ✔️ Endoscopy Test for H. Pylori and Diabetic Gastric Paresis Flat Plate of Abdomen Assessment CT Obstruction treatment - ✔️ ✔️ -NG tube, NPO, IV therapy, pain control
• Possible surgery
• Specific to cause
• Colectomy
• Colostomy
• Decompression
• Bowel Rest
• Fluids pancreatitis s/s - ✔️ ✔️ Severe abdominal pain, N/V 24-48 hrs after heavy meal/alcohol ingestion, hypotension from shock, acute renal failure, elevated serum amylase and lipase, hyperglycemia, grey turner's sign, cullen's sign, fever, jaundice, steatorrhea, weight loss Pancreatitis diagnosis - ✔️ ✔️ -Labs:
• Amylase and lipase levels
• Liver enzymes (AST and ALT)
• Bilirubin
• CT of abdomen Pancreatitis Treatment: Acute - ✔️ ✔️ Rest pancreas. Withhold feeding, maintain hydration IV Elemental enteral nutrition to jejunum

Progress to easily digested food w/ low fat Pancreatitis Treatment: Chronic - ✔️ ✔️ PERT: pancreatic enzymes orally with meals and snacks to minimize fat malabsorption. MCTs do not require pancreatic lipase, so add Give max level of fat tolerated to maintain wt Fat sol. vitamins in water sol. form. Parenteral B Avoid large meals with fatty foods, alcohol Types of GI trauma s/s - ✔️ ✔️ Penetrating

• visible hemorrage
• altered LOC
• tachycardia
• hypotension Blunt Force
• abdominal pain
• tenderness
• hypotension
• Cullen's sign Diagnostics for GI Trauma - ✔️ ✔️ Penetrating
• Identify Weapon
• Estimated Loss of Blood Blunt
• Consider Domestic Violence
• Hx
• Labs
• Ultrasound
• CT
• Peritoneal Lavage
• Exploratory Laporotomy Treatment for GI Trauma - ✔️ ✔️ Penetrating and Blunt
• Restore and Maintain Fluid Volume
• Prevent Infection
• Surgical Repair Types of Ulcers - ✔️ ✔️ Gastic Peptic Gastric Ulcers s/s - ✔️ ✔️ Duodenal
• Abdominal Pain 2-4 hours after eating Hematemesis Melena