-
Causes of acute onset of GI pain
gastroenteritis, hepatitis, cholecystitis, pancreatitis, appendicitis, diverticulitis
-
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
-
Causes of RUQ abd pain
(Area of pain) hepatitis, cholecystitis, (pancreatitis)
-
Causes of Epigastric pain
cholecystitis, pancreatitis, GERD, PUD
-
Causes of LUQ pain
(Area of pain) splenic injury, gastritis
-
Causes of RLQ pain
(Area of pain) appendicitis, IBD (Crohn’s)
-
Causes of LLQ pain
(Area of pain) IBD (ulcerative colitis), diverticulitis
-
Causes of periumbilical pain
(Area of pain) early appendicitis, RAP
-
Causes of diffuse abd pain
- gastroenteritis, celiac disease, pancreatitis, IBS,
- constipation
-
Pancreatitis (HPI)
boring pain epigastrium to midback radiation
-
Cholecystitis (HPI)
epigastrium/RUQ to right shoulder radiation
-
GERD (HPI)
Epigastrium to retrosternal area, neck, throat, back radiation
-
Character of pain: Acute persistent pain
(Character of pain) appendicitis, cholecystitis, pancreatitis
-
Character of pain: intermittent
- diverticulitis, gastroenteritis, celiac disease, IBS, IBD,
- PUD, GERD, chronic abdominal pain
-
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)
-
GERD (Aggravating factors) (Relieving factors)
- (Aggravating factors) after meals, lying down, bending over
- (Relieving factors) antacids, sitting up
-
Pancreatitis (Aggravating factors) (Relieving factors)
- (Aggravating factors) alcohol, fatty meals
- (Relieving factors) Leaning forward
-
Gastroenteritis (Aggravating factors) (Relieving factors)
- (Aggravating factors) Meals
- (Relieving factors) vomiting, diarrhea
-
Celiac disease (Aggravating factors)
(Aggravating factors) Gluten
-
Appendicitis (Aggravating factors)
(Aggravating factors) vomiting, movement, coughing
-
IBS (Aggravating factors) (Relieivng factors)
- (Aggravating factors) stress, meals
- (Relieivng factors) bowel movements
-
Red flags GI history
- Loss of weight
- Blood (Emesis or stool)
- Early satiety
- Progression of symptoms
- New onset greater than 50 yo
-
Causes of Burning, gnawing pain:
(characteristic of pain) GERD, PUD
-
Causes of Crampy colicky pain
(characteristic of pain) cholecystitis, appendicitis, gastroenteritis, IBD, IBS
-
Common causes of GI pain in Eldery
(population) cancer, diverticulitis
-
Common causes of GI pain in children:
(population) GERD, gastroenteritis, appendicitis
-
Common causes of GI pain in females
(population) cholecystitis, IBS
-
Common causes of GI pain in males
(population) PUD
-
Common causes of GI pain in alcoholics
(population) PUD, pancreatitis
-
Medications to consider related to GI pain:
OCPs, laxatives, antacids, OTC H2-blockers, NSAIDs, Tylenol
-
ROS to consider for GI pain
- Cardiac
- Pulmonary
- Genitourinary
- Psychological
-
Murphy’s Test
- Text positive - Cholecystitis
- Halt intake of breath upon deep palpation under Right intercostal margin
-
Rebound Tenderness
- Test positive - peritoneal irritation
- Worse pain on release than deep palpation
-
Psoas Test
- Test positive - peritoneal irritation
- Abdominal pain on passive extension of thigh when lying on side with knees extended
-
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.
-
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
-
Punch Tenderness
- Test positive - hepatitis, splenic injury, nephrolithiasis
- Pain produced by tapping the costovertebral angle.
-
CBC with diff
Diagnostic test for anemia and infection
-
Liver Function Tests
- AST, ALT, Alk Phos, Bilirubin
- To screen for, detect, evaluate, and monitor for liver inflammation and damage
-
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
-
ALT (LFT)
ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose
-
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.
-
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.
-
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
-
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
-
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
-
Hepatitis Serologies
- diagnostic test
- Indicated to determine cause of HSM or immune status
-
Urinalysis
- diagnostic test
- metabolic and kidney disorders
-
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
-
Stool for Ova & Parasites
- Diagnostic testing
- Positive in parasitic infection
-
Fecal Occult Blood
- Diagnostic test
- Melena present in hemrrhoids, anal fissures, colon polyps, PUD, UC, GERD, Crohn's, NSAIDs
-
Stool for WBCs
- diagnostic test
- Smear observed under microscope for WBCs indicating infectious process.
-
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
-
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.
-
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.
-
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
-
Causes/cofactors of PUD
- –Helicobacter pylori
- –NSAID use
- –Zollinger-Ellison syndrome
- –Idiopathic
- –Smoking
- –Coffee
- –Stress
- Heredity
-
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
-
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.
-
GERD 1. Elderly 2. Neuro
- 1. Inc. risk due to dec. saliva production and dec. gastric emptying
- 2. Hypertonia, spasticity - Increase intra-abdominal pressure
-
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)
-
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
-
Medications that dec LES tone
- Smooth muscle relaxants
- Theophylline
- Nitrates
- Calcium channel blockers
- Verapamil
- Nifedipine
- Progesterone
- Transdermal Nicotine
- Diazepam
- Meperidine
- Anticholinergics
- Atropine
- Scopalamine
- Belladonna
-
Medications that may injure the esophageal mucosa
- Tetracyclines
- Quinidine
- Wax-matrix potassium chloride tablets
- NSAIDs
-
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
-
GERD Management Step 3:
- Promotility Therapy for those with persistent symptoms:
- Metoclopramide (Reglanâ)
- Bethanechol (Urecholineâ)
-
GERD Management Step 4:
- Antireflux Surgery for severe, difficult to control, or persistent symptoms
- Nissen fundoplication
- Endoscopic suturing
-
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.
-
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
-
Etiology of Gastroenteritis
- Viral – Rotavirus, Norwalk virus, Adenovirus
- Bacterial – Salmonella, Shigella, Campylobacter, C. difficile, E. coli 0157:H7,
- Parasitic – Giardia, Entamoeba histolytica, Cryptosporidium
-
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 _____
-
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
-
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
|
|