GI

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Author:
cheflouie
ID:
86432
Filename:
GI
Updated:
2011-05-19 01:39:47
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GI symptoms primary care
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Description:
Common GI complaints
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  1. Causes of acute onset of GI pain
    gastroenteritis, hepatitis, cholecystitis, pancreatitis, appendicitis, diverticulitis
  2. Causes of gradual/intermittent onset of GI pain
    gastroesophageal reflux (GERD), peptic ulcer disease (PUD), chronic abdominal pain, celiac disease, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), diverticulosis, colon cancer
  3. Causes of RUQ abd pain
    (Area of pain) hepatitis, cholecystitis, (pancreatitis)
  4. Causes of Epigastric pain
    cholecystitis, pancreatitis, GERD, PUD
  5. Causes of LUQ pain
    (Area of pain) splenic injury, gastritis
  6. Causes of RLQ pain
    (Area of pain) appendicitis, IBD (Crohn’s)
  7. Causes of LLQ pain
    (Area of pain) IBD (ulcerative colitis), diverticulitis
  8. Causes of periumbilical pain
    (Area of pain) early appendicitis, RAP
  9. Causes of diffuse abd pain
    • gastroenteritis, celiac disease, pancreatitis, IBS,
    • constipation
  10. Pancreatitis (HPI)
    boring pain epigastrium to midback radiation
  11. Cholecystitis (HPI)
    epigastrium/RUQ to right shoulder radiation
  12. GERD (HPI)
    Epigastrium to retrosternal area, neck, throat, back radiation
  13. Character of pain: Acute persistent pain
    (Character of pain) appendicitis, cholecystitis, pancreatitis
  14. Character of pain: intermittent
    • diverticulitis, gastroenteritis, celiac disease, IBS, IBD,
    • PUD, GERD, chronic abdominal pain
  15. PUD (Aggravating factors) (Reliving factors)
    • (Aggravating factors) empty stomach, alcohol, caffeine, stress, after meals (1-2 hours) empty stomach, alcohol, caffeine, stress, after meals (1-2 hours)
    • (Reliving factors) antacids, food (initially)
  16. GERD (Aggravating factors) (Relieving factors)
    • (Aggravating factors) after meals, lying down, bending over
    • (Relieving factors) antacids, sitting up
  17. Pancreatitis (Aggravating factors) (Relieving factors)
    • (Aggravating factors) alcohol, fatty meals
    • (Relieving factors) Leaning forward
  18. Gastroenteritis (Aggravating factors) (Relieving factors)
    • (Aggravating factors) Meals
    • (Relieving factors) vomiting, diarrhea
  19. Celiac disease (Aggravating factors)
    (Aggravating factors) Gluten
  20. Appendicitis (Aggravating factors)
    (Aggravating factors) vomiting, movement, coughing
  21. IBS (Aggravating factors) (Relieivng factors)
    • (Aggravating factors) stress, meals
    • (Relieivng factors) bowel movements
  22. Red flags GI history
    • Loss of weight
    • Blood (Emesis or stool)
    • Early satiety
    • Progression of symptoms
    • New onset greater than 50 yo
  23. Causes of Burning, gnawing pain:
    (characteristic of pain) GERD, PUD
  24. Causes of Crampy colicky pain
    (characteristic of pain) cholecystitis, appendicitis, gastroenteritis, IBD, IBS
  25. Common causes of GI pain in Eldery
    (population) cancer, diverticulitis
  26. Common causes of GI pain in children:
    (population) GERD, gastroenteritis, appendicitis
  27. Common causes of GI pain in females
    (population) cholecystitis, IBS
  28. Common causes of GI pain in males
    (population) PUD
  29. Common causes of GI pain in alcoholics
    (population) PUD, pancreatitis
  30. Medications to consider related to GI pain:
    OCPs, laxatives, antacids, OTC H2-blockers, NSAIDs, Tylenol
  31. ROS to consider for GI pain
    • Cardiac
    • Pulmonary
    • Genitourinary
    • Psychological
  32. Murphy’s Test
    • Text positive - Cholecystitis
    • Halt intake of breath upon deep palpation under Right intercostal margin
  33. Rebound Tenderness
    • Test positive - peritoneal irritation
    • Worse pain on release than deep palpation
  34. Psoas Test
    • Test positive - peritoneal irritation
    • Abdominal pain on passive extension of thigh when lying on side with knees extended
  35. Obturator Sign
    • Test positive - peritoneal irritation
    • Abdominal pain on flexion and internal rotation of the hip. First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient's right ankle in his right hand. With his left hand, the examiner rotates the hip by moving the right knee inward.
  36. Rovsing’s Sign
    • Test positive - peritoneal irritation
    • If palpation of the left lower quadrant of a person's abdomen results in more pain in the right lower quadrant
  37. Punch Tenderness
    • Test positive - hepatitis, splenic injury, nephrolithiasis
    • Pain produced by tapping the costovertebral angle.
  38. CBC with diff
    Diagnostic test for anemia and infection
  39. Liver Function Tests
    • AST, ALT, Alk Phos, Bilirubin
    • To screen for, detect, evaluate, and monitor for liver inflammation and damage
  40. AST (LFT)
    raised in acute liver damage, but is also present in red blood cells, and cardiac and skeletal muscle and is therefore not specific to the liver
  41. ALT (LFT)
    ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose
  42. Alk Phos (LFT)
    • rise with large bile duct obstruction, intrahepatic cholestasis or infiltrative diseases of the liver.
    • Also present in bone and placental tissue, so it is higher in growing children (as their bones are being remodelled) and elderly patients with Paget's disease.
  43. Bilirubin (LFT)
    • Jaundice
    • If direct (i.e. conjugated) ______ is normal, then the problem is an excess of unconjugated _______, and the location of the problem is upstream of ______ excretion. Hemolysis, viral hepatitis, or cirrhosis can be suspected.
    • If direct ______ is elevated, then the liver is conjugating ______ normally, but is not able to excrete it. Bile duct obstruction by gallstones or cancer should be suspected.
  44. Amylase test
    • Diagnostic test
    • increase in pancreatic duct obstruction and cancer of the pancreas, obstructed intestine or decreased blood flow to the intestines (infarct).
    • decreased in cases of permanent damage to the amylase-producing cells in the pancreas
  45. Lipase
    • Diagnostic test
    • increased in acute pancreatitis, pancreatic duct obstruction, pancreatic cancer, and other pancreatic diseases.
    • decreased when cells are damaged, and in cystic fibrosis
  46. H. pylori testing
    • Diagnostic test
    • Indicated in PUD to identify infectious organism
    • Serum antibody IgG testing + test indicates active or prior infection
    • Stool antigen assay + test indicates active infection. Useful for test of cure
    • 13-14C urea breath testing + test indicates active infection
    • No longer recommended: Urine ELISA, Saliva ELISA
  47. Hepatitis Serologies
    • diagnostic test
    • Indicated to determine cause of HSM or immune status
  48. Urinalysis
    • diagnostic test
    • metabolic and kidney disorders
  49. Stool Culture
    • Diagnostic testing
    • 3 samples in 3 separate days
    • culture is positive for pathogenic bacteria, then that is the most likely cause of your prolonged diarrhea
  50. Stool for Ova & Parasites
    • Diagnostic testing
    • Positive in parasitic infection
  51. Fecal Occult Blood
    • Diagnostic test
    • Melena present in hemrrhoids, anal fissures, colon polyps, PUD, UC, GERD, Crohn's, NSAIDs
  52. Stool for WBCs
    • diagnostic test
    • Smear observed under microscope for WBCs indicating infectious process.
  53. Flat Plate of the Abdomen
    • Diagnostic test
    • Diagnose a pain in the abdomen or unexplained nausea
    • Identify suspected problems in the urinary system, such as a kidney stone or blockage in the intestine
    • Locate an object that has been swallowed
  54. Abdominal Ultrasound
    • Diagnostic test
    • Determine the cause of abdominal pain.
    • Determine the cause of kidney infections.
    • Diagnose a hernia.
    • Diagnose and monitor tumors and cancers.
    • Diagnose or treat ascites.
    • Learn why there is swelling of an abdominal organ.
    • Look for damage after an injury.
    • Look for stones in the gallbladder or kidney.
    • Look for the cause of abnormal blood tests such as liver function tests or kidney tests.
    • Look for the cause of a fever.
  55. Endoscopy
    • Diagnostic test
    • Investigate causes of digestive signs and symptoms. Determine what's causing nausea, vomiting, abdominal pain, difficulty swallowing and gastrointestinal bleeding.
    • Diagnose digestive diseases and conditions. (biopsy) samples to test for diseases and conditions, such as anemia, bleeding, inflammation, diarrhea or cancers of the digestive system.
    • Treat certain digestive system problems, such as bleeding from the esophagus or stomach and difficulty swallowing caused by a narrow esophagus, or to remove polyps. Can also be used to remove foreign objects lodged in your upper digestive tract.
  56. PUD Treatment plan
    • Dx: CBC w/diff, H. pylori testing, (EKG?)
    • Rx: Famotidine (Pepcid®) 40 mg q HS. DC Ibuprofen, consider COX-2 inhibitor or acetaminophen. Antacid of choice 1-3° pc, at HS, and prn
    • Pt.Ed: Need to avoid NSAIDs, discuss treatment options to DC cigarettes, avoid foods that trigger sx, stress reduction
    • F/U: RTC in 2 weeks for recheck/lab results. Will treat for H. pylori if test +. Recheck in 6-8 weeks; if sx persist, consider GI referral for endoscopy. Schedule for flexible sigmoidoscopy
  57. Causes/cofactors of PUD
    • –Helicobacter pylori
    • –NSAID use
    • –Zollinger-Ellison syndrome
    • –Idiopathic

    • –Smoking
    • –Coffee
    • –Stress
    • Heredity
  58. PUD (Rx)
    • Proton Pump Inhibitor BID x 7-14 days
    • Clarithromycin 500 mg BID x 7-14 days
    • Amoxicillin 1 gm BID x 7-14 days
    • Antacids prn for symptom control
  59. 1. -tidine
    2. -prazole
    • 1. H2 blockers - Inhibit histamine binding to H2-receptor on gastric parietal cell, Decreases acid secretion, QD to BID dosing, Relief within 2 weeks
    • 2. Proton pump inhibitors - Inhibit gastric parietal cell hydrogen-potassium ATPase, Inhibit gastric acid secretion, QD to BID dosing, Faster pain relief , Faster ulcer healing than with H2-blockers.
  60. GERD 1. Elderly 2. Neuro
    • 1. Inc. risk due to dec. saliva production and dec. gastric emptying
    • 2. Hypertonia, spasticity - Increase intra-abdominal pressure
  61. GERD Management Step 1
    • Elevate HOB on 6-8" blocks or wedge pillow
    • Weight loss if obese
    • Avoid restrictive clothing, bending over pc
    • Eliminate cigarettes, alcohol, caffeine
    • Small, frequent meals
    • Don’t eat within 3 hours of bedtime or exercise
    • Avoid substances/conditions that dec LES tone
    • Promote salivation (gum, oral lozenges)
  62. Substances/Conditions that dec LES tone/ Delay Gastric Emptying
    • High fat/CHO foods
    • Chocolate
    • Spicy foods
    • Acidic foods
    • Peppermint
    • Caffeine
    • Tobacco
    • Alcohol
    • Tight clothing
    • Obesity
    • Ascites
    • Pregnancy
    • CNS disease
    • Hiatal Hernia
    • DM
  63. Medications that dec LES tone
    • Smooth muscle relaxants
    • Theophylline
    • Nitrates
    • Calcium channel blockers
    • Verapamil
    • Nifedipine
    • Progesterone
    • Transdermal Nicotine
    • Diazepam
    • Meperidine
    • Anticholinergics
    • Atropine
    • Scopalamine
    • Belladonna
  64. Medications that may injure the esophageal mucosa
    • Tetracyclines
    • Quinidine
    • Wax-matrix potassium chloride tablets
    • NSAIDs
  65. GERD Management Step 2:
    • Decrease Gastric Acid Production:
    • Antacids - Low pH inactivates pepsin, dec. LES tone. Use before meals and at bedtime
    • Oral H2-blockers - BID dosing optimal
    • PPI
  66. GERD Management Step 3:
    • Promotility Therapy for those with persistent symptoms:
    • Metoclopramide (Reglanâ)
    • Bethanechol (Urecholineâ)
  67. GERD Management Step 4:
    • Antireflux Surgery for severe, difficult to control, or persistent symptoms
    • Nissen fundoplication
    • Endoscopic suturing
  68. GERD in children: 1.Reflux vs 2.Disease
    • 1. Regurgitation with normal weight gain. No esophagitis, respiratory or neurobehavioral symptoms
    • 2. Regurgitation with poor weight gain. Irritability, hematemesis, apnea, cyanosis, wheezing, aspiration, pneumonia.
  69. GERD Management (Children)
    • Position to dec. postprandial reflux
    • Upright holding
    • Trial of milk-free diet
    • Small, frequent feedings
    • Avoid foods that dec. LES tone
    • Thicken formula
    • 1 T. rice cereal/1 oz. formula
    • Medication if fail conservative management
    • H2-blockers, PPIs in age-appropriate dosing
    • Prokinetic agents
    • Anti-reflux surgery
  70. Etiology of Gastroenteritis
    • Viral – Rotavirus, Norwalk virus, Adenovirus
    • Bacterial – Salmonella, Shigella, Campylobacter, C. difficile, E. coli 0157:H7,
    • Parasitic – Giardia, Entamoeba histolytica, Cryptosporidium
  71. Clinical Characteristics of Viral Gastroenteritis
    • Gastroenteritis differential
    • Most common
    • Usually self-limited, requiring minimal intervention
    • Vomiting before diarrhea, large volume watery stools, no blood
    • Diarrhea in infants/children usually due to _____
  72. Clinical Characteristics of Bacterial Gastroenteritis
    • Gastroenteritis differential
    • Bloody stools common
    • More frequent stools but with less volume
    • Less vomiting, +/- fever
    • 80% of traveler’s diarrhea is bacterial
  73. Clinical Characteristics of Parasitic Gastroenteritis
    • Gastroenteritis differential
    • Symptoms of longer duration, wax and wane
    • Alternating constipation and diarrhea
    • Giardia is the most common parasite in US

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