Profuse watery diarrhea, vomiting, vascular cramps, dehydrates A
Seen in daycare setting B
A.
Cholera and non-cholera
Sporadic cases that are self-limiting B
B.
E. Coli
Traveler’s diarrhea B
C.
Staphylococcal
Transmitted via mucous membrane B
D.
Botulism
Find on a cutting board, especially plastic C
E.
Viral Origin
Most common type of food poisoning C
F.
Salmonella
Symptomatology of 2-8 hours after ingestion C
Commonly transmitted via custards,
pastries, processed meats C
Neurotoxin D
High mortality rate D
Typhoid F
Poultry is most common cause F
Montezuma Revenge E
May produce septic joint disease F
Cecum is not descended with right sided sigmoid A
Presence gangrenous, atresia, stenosis B
Hirschsprung Disease C
Ten times more frequent in Down’s Syndrome C
Most common in high pressure areas of the colon (sigmoid)D
Occurs throughout the gut, excludes rectum D
Benign lesion arises from bowel wall and protrudes into
the lumen, usually asymptomatic E
May cause painless rectal bleeding E
A. Malrotations
B. Imperforated Anus
C. Megacolon
D. Diverticulitis
E. Polyps
Mimics appendicitis A
Congenital sacculation of the distal ileum A
Blind pouch maybe involved by inflammatory process A
Tendency toward ectopic tissue A
May cause obstruction and necrosis A
aka Abdominal Angina B
A. Meckel’s Diverticula
Atherosclerosis of the celiac and mesenteric arteries B
Weight loss, localized or generalized pain after meals
B. Chronic Vascular Lesion
Negative hemoccult, no blood in the stool B
C. Acute Vascular Lesion
Angiography confirms diagnosis B
Affects males in the fifth to sixth decade C
Tends to affect diabetics C
Abdominal distension, tenderness and rigidity C
Leukocytosis and hemoconcentration C
Restore fluids, colloid and electrolyte balance C
Include adhesions, hernias, intussusception and volvulus (Obstructive Lesions of Bowel)
Early colicky pain, later on more constant (Acute Obstruction)
aka Adynamic Ileus, Paralytic Ileus (Functional Obstruction)
Tends to occur post-surgical (Adhesions)
lasting 2-3 hours B
Second most common obstruction lesion in the bowel (Hernias)
Usually affects infants and children (Intussusception)
Complete twisting of the loop around the mesentery (Volvulus)
Pancreatic insufficiency, defect of bile salt A/B
Small Bowel Disease (celiac disease, Whipple’s disease,
lipodystrophy, Crohn’s disease) D A. Malabsorption Syndrome
Secondary presentation of a problem
B. Defective intraluminal hydrolysis
Disaccharide Deficiency C
C. Primary mucosal cell
abnormality
Bacteria overgrowth
D. Secondary mucosal cell
(1. Diverticula, 2. Fistula, 3. Blind loop)
abnormality
Abnormal fecal excretion of fat and variable fat soluble vitamins A
Floats briefly and then sinks E
E. Celiac Sprue
Remains afloat F
F. Fatty stool
Number one cause of Malabsorption Syndrome E
aka Non-tropical Sprue E
Bulky, frothy, foul smelling, greasy stool A
Symptoms may be delayed for months B
Classic triad of sore tongue, diarrhea, weight loss B
Affects females more than males A
A. Celiac Disease
Explosive and watery diarrhea B
B. Tropical Sprue
Diet high in protein and high calorie with low fat A
Strict elimination of gluten from diet A
Hypochromic or megaloblastic anemia A
Tends to affect the jejunum A
Two sugar test (lactulose/mannitol) used for diagnosis A
Steatorrhea occurs later and stools are fewer and more solid B
Presence of megaloblastic anemia
Wheat and rye are the most common, barely and oats are least common A
Hypersensitivity or antigen response to gluten or gliadin A
Presence of HLA-B8 antigen A
Flatulence, indigestion B
Vomiting, constipation, borborygmus A
Mild to moderate abdominal pain that is continuous B
Bowel sounds decrease or absent, vomiting may occur,
gas filled loops B
aka Crohn’s Disease C
May occur at any age, usually diagnosed in second
or third decade C
Most frequently begins in the distal ileum and
A. Acute Obstruction
crosses ileocecal valve C
B. Functional Obstruction
Diet high in calories, avoid raw fruit and vegetables, C. Regional Enteritis
supplement with Psyllium seed C
D. Ulcerative Colitis
Can be involved from mouth to anus C
Children often operated on with mistaken appendicitis C
Peak incidence between age 14-24 C
Symptoms increase by milk or mechanical irritating foods C
Skip lesions, fistulas C
Usually starts at the rectum D
Recurrent acute and chronic inflammation of the colon mucosa D
Symptoms appear in third and fourth decade D
NO skip lesion, abdominal pain in the LLQ D
Blood mucous diarrhea A
Abdominal pain and tenderness in LLQ A
Hemorrhage most common complaint A
Affects females more than males A
A. Ulcerative Colitis
Steroids, antibiotics, surgery A/B
B. Crohn’s Disease
Skip lesions, fistula B
String sign B
Colicky or steady abdominal pain in RLQ or periumbilical area B
Affects males and females evenly B
Presence of an abdominal mass B
Toxic megacolon B
Presence of occult blood in stool and may lead to anemia B
Systemic and infective disease involving fat intolerance B
Presence of acidic diarrhea A
Mediated by obstructing lumen by fecalith, inflammation C
Affects 70-80% Asian, Native and African Americans A
Inability to digest carbohydrates because of the lack
in intestinal enzyme A
A. Disaccharide Deficiency
Joints symptoms of polyarthralgia and arthritis B B. Whipple’s Disease
Diagnosis by suction biopsy
C. Appendicitis
Affects all ages and both sexes evenly, most common
age is 10-30 years old
Minor abdominal bloating, distention, flatulence, severe diarrhea A
Occurs primarily in males age 30-60 B
Begins with epigastric or periumbilical pain then
12-24 hours later shifts to RLQ C
Constipation is usual, but diarrhea occurs occasionally C
Most common complication is peritonitis post rupture C
Affects females more than males A
Pain over regions of colon that are colicky in nature C A. Irritable Bowel Syndrome
Urgent diarrhea occurs after a meal D
B. Gastroenteritis
Mucoid type of stool, not fatty D
C. Spastic Colon Type (IBS)
Alternating constipation and diarrhea A
D. Painless Diarrhea Type
String mucous stool A
LLQ pain, manual pressure decreases pain D
Possible history of congestion of potentially contaminated food B
Onset usually sudden B
Glucose-electrolyte solution, hydrate B
More common in males - Meckel’s Diverticula
Symptoms appear in third and fourth decade - Ulcerative Colitis
Peak incidence between 14-24 years of age - Crohn’s Disease
May occur at any age, but usually second and third decade - Crohn’s Disease
Affects females more than males - Ulcerative Colitis, Celiac Sprue and IBS
Affect males and females evenly - Crohn’s Disease
Affects males in the fifth and sixth decade - Acute Mesenteric Vascular Lesion
Occurs in males age 30-60 - Whipple’s Disease
GI/UG (07.21.97)
*NO barium in perforations or obstructive syndromes*
Constant abdominal pain, worse with movement because increase in abdominal pressure, localized then diffuse
to general is indicative of:
1. Peptic ulcers
2. Ruptured liver or spleen
3. Chronic diverticulum
4. Appendicitis (rupture that leads to abscess)
5. Penetrating trauma, mesenteric vascular accidents
6. Intra-abdominal bleeding
7. Pelvic organ infections
8. Severe pancreatitis
Complications of peritonitis is an abscess and eventual necrosis. Utilize CT, tagged WBC nucleotide, and/or
laparoscopy, but not for exploratory means.
GI/GU TEST 4 (Notes mostly from action)
Small Bowel Complications
Inflammation
Predisposed to malabsorption
Ulcerative inflammatory disease
Obstruction
Primary tumor (rare)
Small bowel diverticula (occur 1/10 as often as duodenal diverticula)
Congenital asymptomatic and usually may bleed into rectum*
Classification of Polyps
Hyperplastic- epithelial
Neoplastic-epithelial
Hamartomatous - overgrowth of tissues that belongs in the area
Inflammatory
Unclassified
Test: double contrast barium study, solid column hides especially small ones
Clinical Significance of Polyps
Common benign neoplasm usually asymptomatic
Painless rectal bleeding possible*
Single/multiple occurs most frequently in sigmoid/rectum
Resection only with changes in symptoms or hyperplasia
Treatment for Polyps
Small - just watch & wait, this includes visualization though at approximately 4-6 month intervals
< 0.5cm don’t operate unless malignant ie colors/vessels
1cm don’t operate
> 1cm operate
See Chart on page 49
Diagnosis for Polyps
Sigmoidoscopy (flexible or rigid)
Double contrast barium (not solid)
Colonoscopy
Rectal exam
See Chart on page 50
Colon Carcinoma Considerations
Males 3:2 (females are catheterized up though)
6th leading cause of death*
50% of all lesions are within reach of finger*
75% within reach of colorectal scope
Silent bleeding*
Test: barium enema (initial step)
Predisposition to Colon Carcinoma
Familial polyposis
Granuloma inguinale
Gardner syndrome
Ulcerative colitis*
Environmental influences
Lymphogranuloma venereum*
Diet*
Anatomic distribution of METS
1.
Rectal
2.
Sigmoid
3.
Ascending colon
4.
Descending colon
5.
Transverse colon
Clinical findings of Colon Carcinoma
Persistent changes in customary bowel habits*
Midline defect*
Abdominal - most common in adults with post surgery
Intussusception
Most common in infants & children (but over all is rare)
Telescoping of small bowel*
Trapped segment propelled into bowel by peristalsis
Differential diagnosis with tumor if in an adult
Test: Upper/Lower GI, X-ray shows "coil spring appearance"
Volvus
Twisting of loop around mesentery*
Rare, most occur in small bowel
May present with closed loop (trapped material)/open loop (communication present)
Acute Obstruction
Signs and Symptoms Acute Obstruction
Colicky pain around belly button, sensed during distention (in peristaltic pattern)*
Vomiting
Constipation
Borborygmus is rushing peristaltic sounds of gurgling*
Gas on x-ray
No fever*
Anxiety of restlessness and weakness, sweating
Treatment Acute Obstruction
Complications of Acute Obstruction
Strangulation/necrosis in bowel wall*
Fever (sudden) with high WBC count*
Perforation*
Peritonitis
Sepsis*
Prognosis for Acute Obstruction
Varies depending on cause and severity of necrosis
Test for acute obstruction with barium enema
Differential Diagnosis Acute Obstruction
Inflammatory or perforated viscus*
Renal colic
Gallbladder colic
Peritonitis
Mesenteric vascular occlusion*
Organ torsion ie. ovarian cyst
Functional Obstruction (AKA. Adynamic Ileus, Paralytic Ileus)
Neurogenic etiology (common causes of functional obstruction)*
Surgery
Ruptured viscus
Cord injury
Diabetes
Peritonitis
Subluxation
Back pain
CVA
Renal colic
Hemorrhage
Pancreatitis
Signs & Symptoms Functional Obstruction
Continous pain with symptoms in abdomen ranging from mild to moderate
NO borborygmus*
Moderate distention
Vomiting can lead to dehydration
Test for functional obstruction with x-ray, gas filled loops visible, KUB gives multiplanar fluid
Considerations for Functional Obstruction
Precipitating factors help with easy diagnosis
Restore fluid with vomiting
With compression (sympathetic response), surgery (maybe)
Regional Enteritis (AKA, Crohn’s Disease)
Considerations of Regional Enteritis
Chronic inflammation *
Cause unknown
Bowel wall affected
Distal ileum (usually starts here)*
Mouth to anus possible
Familial*
Mistaken for appendicitis in children*
Age 14-24 is peak incidence*
Entire thickness of bowel wall involved
Complications of Regional Enteritis (Crohn’s Disease)
Malignancy
Malabsorption
Ulceration- "cobble stone " appearance*
Perforation
Obstruction mechanical*
Nonspecific granulomas (< 50 %)
Thickened submucosa with lymphedema
Lymphoid hyperplasia*
Dehydration
Abscess (may lead to draining sinus)*
Fibrosing strictures*
Fistulas (Three types)
Perianal, ischiorectal, uterine
Systemic in nature and often associated with:
Arthritis*
Uveitis*
Liver inflammation*
Gallbladder*
Incidence of Crohn’s Disease, AKA Regional Enteritis
Any age*
Most common 2nd and 3rd decade
Males & female evenly
Whites most often*
Jewish 2-3 times more often
2-3 times more often with familial involvement*
Clinical Course of Crohn’s Disease, AKA Regional Enteritis
Variable
Diarrhea*
Fever
RLQ pain then, asymptomatic*
Return of above sign and symptoms
Intervals get closer together
Symptomatic Considerations for Crohn’s, AKA Regional Enteritis
Signs and symptoms increase with milk or mechanically irritating foods
Abdominal mass (maybe present)
Occult blood loss may lead to anemia*
Signs and Symptoms of Regional Enteritis, AKA Crohn’s
Exacerbation and remission*
RLQ pain of colicky nature or steady also periumbilical pain possible*
Diarrhea with constipation*
Anorexia
Malaise
Weight loss
Vomiting
Submucosa most commonly involved
Infrequently involves rectal area (as does ulcerative colitis)* - "string sign" seen with
barium enema x-ray
Diagnosis of Regional Enteritis (Crohn’s Disease)
Mucosal changes*
Stiff bowel
Ulcerations
Skip lesions*
Fistulas*
Biopsy (occasionally)
Non-specific lab findings like anemia, leukocytosis, hypoalbuminemia, C-reactive protein*
Treatment of Regional Enteritis (Crohn’s Disease)
High calorie diet
Avoid fruit & raw vegetables*
Treatment for dehydration, vitamin deficiency and anemia
Adjust
Antibiotics and surgery
Psyllium seed supplement*
Ulcerative Colitis
Considerations for Ulcerative Colitis
Colon inflammation, recurrent acute & chronic presentations (wall of distal ileum)*
Starts at the rectum, usually
NO skip lesions*
5-7 cases/100,00 in population*
3rd-5th decade
Physical and mental stress brings on episodes*
Signs & symptoms of Ulcerative Colitis
Bloody mucoid diarrhea*
30-40 bowel movements per day is possible*
Intermittent attacks
Anorexia, malaise, weakness, fatigue
Rectal involvement VERY common*
Females more than males*
Complications of Ulcerative Colitis
Dehydration*
Cancer (25%)*
Toxic megacolon (10-30% fatal)*
Hemorrhage most common*
Perforation
Anemia
Progression extends proximally
Erythema nodosum of face and arms
Arthritis (seronegative)*
Peritoneal inflammation*
Uveitis*
Fistula formation*
Treatment of Ulcerative Colitis
Hydration
Supplements
Adjust
Steroids
Antibiotics
Diet modification eg. avoid raw fruit and vegetables, trial dairy elimination
Chart on page 37 of Action notes Crohn’s vs. Ulcerative colitis
Malabsorption Syndrome
Involves disturbances of :
Digestion of nutrients/small molecules*
Decreased absorption capacity*
Transport of absorbed products*
Deficiency in Abnormal Fecal Excretion of
Fat
Fat soluble vitamins and minerals
Proteins
Carbohydrates
Water
Often idiopathic with signs vary and overlap with different causes
Diagnostic Test for Malabsorption:
Stool fat determination*
Xylase absorption*
UGI
LGI
Small bowel follow up
Biopsy (intestinal)
Etiology/Classification of Malabsorption Syndrome
Defective intraluminal hydrolysis*
Pancreatic insufficiency*
Bile salt (defect)*
Bacterial overgrowth*
Diverticula*
Fistula*
Blind loops*
Mucosal Cell Abnormality
Primary Cell Disorders
Disaccharidase deficiency (unavailable intrinsic cellular mechanisms) O.D.A.
A-Beta lipoproteinemia
Secondary Cell Disorders
Small Bowel Disease
Celiac Disease
Whipple’s Lipodystrophy
Crohn’s Disease
Lymphatic Obstruction
Multiple Surgical Defects
Short Bowel Syndrome
Obstruction due to fibrotic repair/replacement
Idiopathic/unexplained
Infection
Tropical Sprue
Drug Induced
Laxatives
Antibiotics
Clinical and laboratory manifestations of malabsorption
(See Chart on page 38 of Action notes)
Clinical Signs of Malabsorption Syndrome
Depends on severity of disease
Weight loss
Anorexia
Abdominal distention
Borborygmus*
Muscle wasting
Steatorrhea*
Common causes of Malabsorption Syndrome
1.
Celiac Sprue (AKA non-tropical sprue)
2.
Crohn’s disease
3.
Chronic pancreatitis
Other causes:
Whipple’s
Small bowel diverticulosis
Tropical sprue
Disaccharide deficiency
Post gastrectomy and blind loop syndromes
Celiac Sprue
Deficient of Celiac Sprue (AKA non-tropical sprue)
Chronic intestinal disorder caused by gluten, sensitivity reaction to gluten
Incidence of Celiac Sprue
Females more
Young adults (children)
Familial tendencies
Pathology of Celiac Sprue
Hypersensitivity of antigen response to gluten or gliadin*
Exposure causes massive Ig response*
Disaccharides deficiency*
Presence of HLA-B8 antigen (abnormal immune response suggested)
Jejunum (tends to be effected)
Striking loss of VILLI
Decrease in surface area*
Decrease in enzymes*
Decrease in absorption*
Signs and Symptoms of Celiac Sprue
Stool is bulky, foul, frothy, greasy*
Signs of fat soluble vitamin deficiency*
Protein loss*
Paresthesias*
Folate deficiency* (microcytic anemia)
Increased alkaline phosphatase*
Bone pain due to calcium loss and vitamin D deficiency
Osteomalacia
Bruising with hemorrhage
Weight loss
Calcium, potassium, sodium deficiency
Increased prothrombin time
In children:
Iron deficiency anemia*
Failure to thrive
Wasted buttock
Pot belly
Diagnosis of Celiac Sprue
Stool analysis via chemistry
Hypochromic or megaloblastic anemia (CBC)*
Test intestinal absorption pattern
Suction biopsy
Two sugar test (good indicator)
Osmotic filtration
Elimination diet*
Small bowel follow through
Treatment of Celiac Sprue
Strict elimination of gluten from diet*
Diet alterations
NO gluten*
High calories
High proteins
Low fat
Vitamin K and B12 until recovered
Prognosis of Celiac Sprue
Good response with diet alterations
Slightly increased risk of lymphoma, carcinoma
Eliminate and the reintroduce small amounts
Tropical Sprue
Unknown etiology
Symptoms maybe delayed for months/years after visit to endemic areas of tropical regions (excluding Jamaica)*
Signs & Symptoms of Tropical Sprue
Classic Triad: sore tongue, diarrhea, weight loss
Explosive and watery diarrhea*
Steatorrhea (later) also stool is fewer, pale, foul, frothy, greasy exacerbated by high fat diet*
Indigestion, gas, cramps, tenderness
Multiple nutritional deficiencies (causes glossitis & angular stomatitis)
Paresthesias
Muscle cramps
Asthenia (decreased energy, weakness) with irritability*
Diagnosis of Tropical Sprue
Presence of megaloblastic anemia
Serum iron decreased*
Increased PTT*
Normal pancreatic enzyme
Malabsorption*
History of travel to tropics*
Treatment of Tropical Sprue
Folic acid supplements
Tetracycline (250 mg/4X per day)
B12 and vitamin K supplements
Diet high in protein, high in calories and low in fat
Disaccharidase Deficiency - "diarrhea and abdominal distention caused by inability to digest carbohydrates because lack of
intestinal enzyme" (O.D.A.)
Primary in some children (congenital), but may be adult onset*
Occurs secondary to other intestinal diseases
Acidic diarrhea*
Utilize lactase intolerance test*
Treatment is by removal of offending sugar & the diet is curative
Incidence of Disaccharidase Deficiency
70-80 % affect Asian, Native and African Americans
10-15 % affect Northern and Western Europeans
Signs and Symptoms of Disaccharidase Deficiency
Minor abdominal bloating*
Distention*
Gas*
Severe diarrhea*
Whipple’s Disease - a systemic and infective disease involving fat intolerance and intestinal lipodystrophy
Incidence of Whipple’s Disease
Rare
Males 10:1 aged 30-60
Pathology of Whipple’s Disease
Unknown etiology
Systemic infectious disease
Intestinal mucosa inflammation (involved)
Signs & Symptoms of Whipple’s Disease
Gray to brown skin pigmentations*
Polyarthralgia and arthritis*
Steatorrhea*
Lymphadenopathy*
Hypoproteinemia*
Edema
Severe nervous system manifestations
Sores on angle of the mouth
Diarrhea
Weight loss
Anemia
Severe malabsorption ( uncommon cause)
Diagnosis of Whipple’s Disease
Upper GI with small bowel follow up
Biopsy (macrophages are foamy and PAS reactive)
Treatment of Whipple’s Disease - adjust and moderate antibiotics
Appendicitis - "an acute inflammation of the appendix", usually mediated by an obstruction of the lumen by:
Fecaliths*
Inflammation*
Foreign body*
Neoplasm*
Followed by infection, edema, infarction of the appendiceal wall
Signs & Symptoms of Appendicitis
Epigastric periumbilical pain*
1-2 episodes of vomiting*
Later 12-24 hours symptoms of pain shift to RLQ
Point tenderness
Aggravated by coughing or walking (changes in abdominal pressure)
Rebound tenderness*
Positive obturator and psoas sign*
Anorexia, moderate malaise and slight fever
Constipation is usual, but diarrhea occurs occasionally, as does nausea and vomiting
Quiet abdomen*
Lab Findings for Appendicitis
Moderate leukocytosis (<20,000)
Elevated neutrophils
Differential Diagnosis of Appendicitis
Meckel’s diverticulum*
Regional enteritis (Crohn’s)*
Perforated duodenal ulcer*
Mesenteric adenitis*
Mittelschmerz (painful ovulation)*
Urethral cyst*
Acute salpingitis*
Treatment of Appendicitis
Surgery (appendectomy)
Avoid laxatives
Irritable Bowel Syndrome (IBS) aka Mucous Colitis and Spastic Colon - Know this well*
Note: Not the same as IBD, IBD has blood and we expect changes
Considerations for IBS
A motility disorder of small and large bowel*
Stress reaction in susceptible person
Incidence of IBS
All age groups
Increased incidence young and middle aged females
Females more than males*
Associated with mental stress*
Not inflammatory or infectious*
Increased parasympathetic and decreased sympathetic*
Normal tissue, perhaps extra mucous (parasympathetic)
Pathology of IBS
Probable hyperreactive bowel syndrome*
Parasympathetic over reaction*
Increased peristalsis without effectiveness (uncoordinated on fluoroscopy)
Spastic segmentation of the colon
Excess mucous secretion stimulated sometimes consider a functional disorder
Signs and Symptoms of IBS
Variable
Intermittent/recurrent
Can last days, weeks, months
Pain triggered by eating - relieved by defecation or flatulence
Stringy, mucous stools*
Absence of nocturnal symptoms*
Characteristics of IBS
Abdominal pain*
Constipation and/or diarrhea
Hypersecretion of mucous*
Dyspeptic symptoms from gas, nausea, distention, anorexia*
Varying degrees of anxiety/depression, can manifest with cortisol level*
Autonomic imbalance
Unpredictable changes in stool consistency
Irregular bowel habits*
Hyperreactive to eating
Psychosocial and laboratory recommendations
Diagnosis via exclusion*
Eliminate viscerosomatic lesion
30 % recall symptoms as a child
Physical findings unreliable
Clinical Groups of IBS
Spastic Colon Type
Variable frequency of bowel movements*
Pain over regions of colon that is colicky*
Alternating constipation and diarrhea*
Association with fatigue, depression and anxiousness*
Symptoms triggered by eating
Painless Diarrhea Type
Urgent diarrhea right after meal*
Absence of nocturnal diarrhea*
Mucoid type of stool (not fatty)*
Non-specific physical findings of IBS
LLQ tenderness*
Tender colon*
Manual pressure diminishes the pain
Diagnosis of IBS
Characteristic history via exclusion
Cathartic abuse (runny stool)
Crohn’s disease
Parasites
Lactase deficiency
Ulcerative colitis
Treatment of IBS
Supportive/palliative
Enlist patient’s cooperation
Lifestyle changes
Food diet
Regular exercise
Stress reduction - walk x 2 5-7days/week
NO aerobic benefit
NO endorphin response
Just relax time
Adjust to effect viscerosomatic and somaticovisceral responses
Psyllium seed (adds to gas helps constipation) -soften or firms depending on condition*
Consider referral for psychological aspect of syndrome
Gastroenteritis (this is an umbrella term) - *know differentiating features
Considerations for Gastroenteritis
Group of clinical syndromes usually in upper GI
Nausea, vomiting, anorexia with diarrhea*
Abdominal pain*
Possible consumption of contaminated food/water*
Campylobacter infectious agent for diarrhea*
Can be epidemic
Monitor for complications
Pathology of Gastroenteritis
Mucosal embarrassment
Bacterial exotoxin*
Impairs intestinal absorption
Provokes secretion of electrolytes and water*
Immune compromised
Virus
Food toxin
Mucosal Invasion
Penetrates bowel wall
Ulceration, bleeding
Loss of protein, electrolytes and water*
Shigella*
Salmonella*
E. coli*
Idiopathic: viral, enterotoxins, intestinal flu, Montezuma revenge - travelers diarrhea
Others: food poisoning, chemicals, heavy metal ingestion (lead), antibiotic use (disturbs intestinal flora) an overgrowth
gastroenteritis
Signs and Symptoms of Gastroenteritis
Depends on etiology
Sudden onset usual*
Anorexia
Vomiting
Abdominal cramps
Diarrhea
Complications of Gastroenteritis
Electrolyte imbalance - alkalosis and hypochloremia (vomiting)*
Water imbalance - dehydration*
Febrile*
Shock*
Acidosis (diarrhea)*
Dependent edema in extremities*
Therapy for Gastroenteritis
Electrolyte replacement with dilute carbohydrates of < 8% concentration with fluid replacement
Glucose -electrolyte solution of warm sugar solute with 1 tablespoon of NaCl or baking soda
If acute use, clear liquids, if not vomiting eg. ginger ale*
Add soft cooked food when able
Avoid raw vegetables, fatty/greasy foods, roughage, alcohol, caffeine- decrease transit time may prolong*
Diarrhea*
Specific Examples of Gastroenteritis
Cholera and Non- Cholera
Acute infection of small bowel
Watery diarrhea, vomiting, vascular cramps, dehydration and death*
Common in Asia, Middle East, Africa, India, Bangladesh (not USA)
Most serious consequences associated with electrolyte imbalances and fluid loss*
E-Coli, aka Traveler’s Diarrhea
Self limiting 1-3 days*
Nursery school diarrhea
Baby to baby & worker to baby to baby transmission (worker should wash between changes)
Transmitted via mucous membranes*
Staphylococcal Food Poisoning
Most common food poison*
Short duration
Won’t kill you
Lots of vomiting with decrease vomit threshold
Enterotoxin formed in food at room temperature attacks neuroreceptor*
Common in custard, pastries, meat, fish
Symptoms 2-8 hours after ingestion
Botulism Neurotoxin
Associated with canning
Double vision (early on)*
Dyspnea*
Dysphagia*
Respiratory distress*
Rare GI
High mortality rate
To kill spore heat to 180 degrees for 15 minutes*
Increased mortality partially due to being away from facilities for help
Salmonella
Typhoid*
Feces, urine, food can all carry*
Very old, young, and ill are affected most
Poultry most common cause*
Don’t need blood sample
Take stool sample
NO leukocytosis*
Associated with septic arthritis*
Self limiting
Viral disorders
Intestinal flu*
Montezuma revenge*
Virus inflammation, fluid secretion, electrolyte loss and water*
Other poisons: mushrooms, house plants, fish poisoning, shellfish
Colon
Congenital anomalies of the colon
Malrotations
Associated with mid gut rotation
Usually third stage arrest*
Cecum isn’t descending with right sided sigmoid
Clinically silent - incidental finding*
Imperforated Anus
Presence of membrane covering - congenital - membrane tissue plug- benign
Presence of agenesis, atresia, and stenosis
Megacolon
Congenital aganglionic megacolon "Hirsprung’s disease"
Congenital absence of Meissner’s and Auerbach plexus -especially in large intestine
Lack of parasympathetic ganglion cells (does not dilate) narrow segment- abnormal
10 x more frequent in Downs Syndrome patients
Males more often
In babies with hyperperistalsis, cramping, vomiting and crying on and off
Megacolon test as mentioned in class - barium through upper GI with small bowel follow through
“Beak sign" = Point
Rectal exam: colon distal to obstruction = thin
Signs and Symptoms of Congenital Anomalies
Failure to pass stools
Abundant distension*
Vomiting*
Symptoms may appear later
Portal obstruction, with high grade, no passage of stool, with low grade , limited passage of stool*
Enterocolitis*
Explosive diarrhea*
Upon rectal exam, narrow anus with no presence of feces and colonic impaction above constricted area
Differential Diagnosis Congenital Anomalies
Celiac disease*
Hypogangloremia*
Immaturity of ganglionic cells
Neonatal intestinal obstruction
Treatment of Congenital Anomalies
Colostomy (rule out immature development first)
Ileostomy
With low grade obstruction, watchful waiting*
Diverticulitis - herniation through the mucosal membrane
Considerations for Diverticulitis
Condition of many diverticula (sacs or outpockets)
Tends to dissect along the course of the nutrient vessels
Increased frequency after 40-50 years of age*
Occur through out gut, excluding the rectum
Most common in high pressure areas of the colon (ie. sigmoid)*
Less common is the cecum*
Signs and Symptoms of Diverticulitis
May be asymptomatic/incidental finding*
LLQ pain maybe steady and severe and last days*
May be cramping and intermittent and relieved by bowel movement
Constipation (adynamic ileus) is usual, but diarrhea may occur*
Presence of occult blood in the stool*
KUB*
Complications of Diverticulitis
Imbalance of enterocolic bacteria, inflammation with fever
Perforation and fistula formation
Most common cause of free air in abdomen (between diaphragm and liver) is ruptured diverticulum*
Chills*
Sepsis*
Ileus (lack of peristaltic activity)
Partial or complete colonic obstruction ie fibrotic repair especially if recurrent
1.
Annular carcinoma
2.
Diverticulitis
3.
Volvus
Diagnosis of Diverticulitis
History proof by barium enema
Tagged WBC
Laproscopic
Endoscopic
Treatment of Diverticulitis
Antibiotic therapy
Surgery with perforation or fistula
Diet modification
Avoid irritants
Prevent with high fiber diet (introduce slowly)*
Avoid processed foods
Give patient bulk forming, not cathartics
Avoid berries due to small seeds*
Fiber laxative
Psyllium seed*
Note: diverticulosis has no blood, can see multiple fluid air levels
Note any persistent changes in customary bowel habits*