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Diarrhea
- a flowing through
- passage of frequent watery stools
- accute <14 days
- chronic >30 days
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Epidemiology of Diarrhea
- Chronic affects 5% of adults and 3-20% of children
- leading cause of illness and death in developing countries
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Etiology of diarrhea
- drugs
- ID
- Food intolerance
- Endocrine Disorders
- Radiation Colitis
- Hyperthyroidism
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Osmotic Diarrhea
- Increased osmotic pressure in the lumen of the intestines
- water move in
- lactase deficiency
- divalent ions
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Secretory Diarrhea
- fat
- laxitives
- toxins
- hormones
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Exudative/Inflammatory diarrhea
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Altered intestinal transit
- drugs
- bacterial overgrowth
- surgery
- - bariatric surgery = no time to absorb fluid
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Clinical Presentation of Diarrhea
- N & V
- abdominal pain
- headache
- fever, chills, malaise
- dehydration
- metabolic disorders
- cramps
- urgency
- strain (tenesmus)
- weight loss
- anorexia
- weakness
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Assessment of diarhea
- History
- -stool characteristics, acute or chronic, new meds, recent travel...)
- Physical exam
- -auscultation, tympany and palpation
- Laboratory tests
- -stool culture, colonoscopy, radiographic studies
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Prevention of Diarrhea
personal and environmental hygiene
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Non-pharmacologic treatment for diarrhea
- fluid replacement
- electrolyte replacement
- soft bland diet
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Pharmacologic treatment of diarrhea
- antimotility drugs
- adsorbents
- antisecretory drugs
- octreotide
- bacterial replacement
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Response time
improvement generally seen in 24-72 hours
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Constipation definition
infrequent or difficult passage of stools
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Epidemiology of Constipation
- 1.9-2.7%
- 2.2:1 female to male ratio
- pregnancy
- increased age
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Etiology of constipation
- opiates, antacids, anticholinergics
- inadequate fiber
- inactivity
- pregnancy
- metabolic and endocrine disorders (hypothyroidism)
- neuro and psychogenic disorders (PD or MS)
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Clinical presentation of constipation
- Hard, small dry stool
- bloated
- cramping
- straining
- feeling full
- N & V
- Fatigue
- Headache
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Assesment of constipation
- History - stool charictaristics
- Physical exam - generally not required
- Lab tests
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Lab tests for Constipation
- Proctoscopy
- Sigmoidoscopy
- Colonoscopy
- Barium enema
- Thyroid function test
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Non-pharmacologic treatment for constipation
- increase fluid intake
- increase fiber intake
- exercise
- surgery
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Pharmacological treatment for constipation
- stool softeners
- laxitive
- enema
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IBS
chronic abdominal pain and altered bowel habits in the absence of any organic cause
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Epidemiology of IBS
- 2:1 female:male
- 10-20% of US population
- most common GI diagnosis
- least understood
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Etiology & Pathophysiology of IBS
- impairment of intestinal motor function
- impairment of sensory function in CNS
- Hyperalgesia
- genetics
- immunological
- psychological
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Clinical Presentation of IBS
- Variety of GI and non GI problems
- Abd. pain
- altered bowel function
- flatulence, bloating
- nausea, anorexia
- constipation, diarrhea
- anxiety, depression
- stress
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Hallmark symptoms of IBS
- lower abdominal pain relieved by defecation
- change in stool frequency or consisitancy
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Assessment of IBS
- History
- PE - auscultation, palpation & tympany
- Lab Tests
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Lab Tests to diagnos IBS
- Fecal occult blood
- stool culture
- sigmoidoscopy
- colonoscopy
- radiographic images
- barium enema
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Not IBS if:
- weight loss
- blood in stool
- symptoms at night
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Nonpharmacologic Treatmend of IBS
- Stress management
- avoid offending agents
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Pharmacologic treatment of IBS
- Antispasmodics
- Antidepressents (SSRI and Tricyclic)
- Anticholinergics
- Alosetron (diarrhea predominant)
- Lubiprostone (women, constipation predominant)
- Tegaserod (constipation predominant, increase heart attack risk)
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IBD
- describes two inflammatory disorders of the GI tract
- Chrohn's disease
- Ulcerative colitis
- differentiated by areas and layers of GI involved
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Epidemiology of IBD
- Western countries
- 3-10 per 100,000 people annually
- ages 20-30 and 50-80
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Etiology of IBD
- infection
- genetic
- environmental
- psychological
- immunological
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Pathophysiology of IBD
- Genetic succeptibility
- trigger factors => immune response =>IBD
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Types of inflammation for CD
granulomatous
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Types of inflammation for UC
Ulcerative and exudative
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Layers involved in CD
- Submucosal
- Transmural
- Every layer
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Layers involved in UC
mucosal
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Extent of damage for CD
skip lesions
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Extent of damage of UC
continuous
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Areas involved for CD
- Primary - ileum
- Secondary - colon
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Areas involved in UC
rectum and or left colon
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Rectal bleeding in CD?
rare
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Rectal bleeding in UC?
common
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Perianal abscesses in CD?
common
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Perianal abscesses in UC?
rare
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Developement of cancer with CD?
uncommon
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Development of caner with UC?
relatively comon
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Assesment of IBD
- History
- Physical Exam
- -HR, BP, Temp, palpation, weight
- Lab tests
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Lab tests for IBD
- sigmoidoscopy
- colonoscopy
- stool cultures
- radiographic contrast
- biopsies
- CBC, BMP
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Gastroesphageal reflux disease
- from the gastric region
- to the esophagus
- return
- persistent/recurring
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Work to keep contents in the stomach
- Diaphragm
- Esophageal stricture
- saliva
- peristalsis
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Role of saliva in stomach
helps increase the pH
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Contributing factors to GERD
- Large meals
- Foods that reduce tone (caffeine, fat, chocolate)
- EtOH
- Smoking
- Weight
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Presentation of GERD
- "Heartburn"
- occurs 30-60 min after eating
- evening onset
- pain in epigastric area that radiates
- belching
- respiratory symptoms due to aspiration
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Diagnosis of GERD
- History
- - Rule out angina or musculoskeletal injury
- Selective Diagnostic Methods
- -Radiology
- -Esophagoscopy
- -Esophageal pH monitor (pH < 4 for 24hrs.)
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Non-pharmacologic treatment for GERD
- avoid large meals
- avoid alcohol and smoking
- remain upright
- avoid bending for long periods
- lose weight
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Pharmacologic treatment for GERD
- Antacids
- Alginic Acid (Gavascon)
- H2 blockers
- PPIs
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Acute Gastritis
- Acute mucosal inflammatory process
- may include hemmorrhage
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Causes of Gastritis
- Local irritants
- Severe illness/trauma
- Chemotherapy drugs
- Radiation
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Local irritants to mucosa
- NSAIDS
- Aspirin
- EtOH
- Bacterial toxins
- Steriods
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Acute Gastritis Patient Presentation
- Heartburn
- No symptoms
- bleeding and hematemesis
- abrupt violent onset
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Treatment for Acute Gastritis
- supportive treatment
- removal of causative agent
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Chronic Gastritis
- No visible erosions
- chronic inflammatory changes
- atrophy of epithelium
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Types of chronic gastritis
- H. pylori
- Autoimmune and multifocal
- Chemical
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H. Pylori Gastritis
- most common cause of gastritis
- worse in developing countries
- bacterial infections small G- rods
- secrete urease => ammonia buffer
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Patient presentation with H. Pylori
- asymptomatic
- stomach ache
- belching
- weight loss
- nausea
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Diagnosis of H.Pylori
- Carbon urea breath test
- stool antigen test
- edoscopic biopsy
- blood test
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Peptic Ulcer Disease
- group of disorders in upper GI exposed to acid-pepcin secretions
- Duodenal lesions
- gastric lesions
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Duodenal Peptic ulcer disease
- 5x more common
- 30-60 years
- Men > women
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Gastric peptic ulcer disease
- less common
- middle aged and elderly
- men=women
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Peptic ulcer tissue penetration
one mucosal layer or all the way to the muscle
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Risk factors for peptic ulcers
- H. Pylori
- NSAIDS
- Age
- warfarin with corticosteroids
- smoking
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Better drug for PUD
cox2 inhibitors
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Presentation of Duodenal Peptic ulcer
- burning or hunger like pain
- epigastric region
- several hours after eating when stomach is empty
- nocturnal symptoms
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Gastric peptic ulcers
- burning or hunger pain
- epigastric region
- within 30-60 minutes of eating a meal
- usually in the daytime
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Diagnosis of Peptic Ulcers
- Endoscopy
- Rule out H. Pylori
- fecal occult blood test
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complications of peptic ulcers
- hemorrhage
- obstruction (duodenal)
- perforation (extreme pain)
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Nonpharmacologic treatment of PUD
remove offeding agent
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Pharmacologic treatment of PUD
- H2 blockers
- PPIs
- Sucralfate
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Nausea
- unpleasant sensation
- stimulated by food or drug
- distention of duodenum
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Vomiting
sudden and forceful oral emptying of stomach contents
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Non pharmacologic treatment of vomiting
removal of trigger
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Pharmacologic treatment of vomiting
- dopamine antagonists
- serotonin antagonists
- anticholinergic properties
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