Download document

Gastroenterology Pathology
Conrad Ross, PA-C SMDC GI
History
 Nature & course of abdominal symptoms
Pneumonic: OLD CARTS
 Associated s/s
 Past medical, family & surgical Hx
 Medications
 Could you be pregnant?
Pain








Onset
Location
Duration
Character
Aggravating / Alleviating Factors
Radiation
Treatments
Signs/Symptoms Associated
Physical Assessment
 Inspection
 Auscultation
 Percussion
Physical Examination
 Palpation
 Abdominal Quadrants
(Further Diagnostic Areas)
 Referred Pain
 Special Tests
(Murphy’s sign, Carnett’s Sign)
Abdominal Pain DDX












Appendicitis
Cholelithiasis
Irritable Bowel Syndrome
Inguinal Hernia
Esophageal Reflux/Indigestion
Colitis
Ulcer
Diarrhea/constipation
Gastroenteritis
Gastritis
Crohn’s Disease
Trauma – spleen, liver, hollow viscous
Appendicitis
 Pain usually (70%) starts centrally (umbilical
region) and moves to Mcburney’s Point
 The RLQ becomes tender in 65%-95% of cases
 Most common acute surgical condition of the
abdomen
 Occurs in about 7% of population, between age
10-30 yrs old
Appendicitis: Pathogenesis
 Long finger-like process that extends from the
inferior tip of the cecum
 Obstruction of the narrow lumen initiates the
clinical illness
 D/T viral illness or fecal obstruction (fecaliths)
Appendicitis
 S/S: Periumbilical abdominal pain, nausea,
fever, pain with motion, advanced stage
sepsis due to bowel perforation.
 Tests: inspection normal to immobile
patient, can look quite ill. Labs abnormal
elevated CRP, WBCs, abnormal palpation
 Tx/Complications: Immediate surgical
referral, if septic life threatening.
Appendicitis-Tests
 Psoas Sign
Appendicitis - Tests
 Obturator Sign
Irritable Bowel Syndrome
 Common disorder, cause unknown,
diagnosis of exclusion
 S/S: intermittent loose stools, intermittent
constipation, relation to foods, relation to
stress (anxiety and depression), distention
of bowel causing pain.
 GI Bleeding, fever, weight loss, and
persistent severe pain are NOT s/s of IBS
IBS – cont.

Diagnosis: Again of exclusion, Rome III diagnostic criteria* for irritable bowel syndrome
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3
months associated with 2 or more of the following
(1) Improvement with defecation
(2) Onset associated with a change in frequency of stool
(3) Onset associated with a change in form (appearance) of stool
•
Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to
diagnosis. Discomfort means an uncomfortable sensation not described as pain. In
pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2
days a week during screening evaluation for subject eligibility.
Reproduced with permission from Longstreth, GF, et al. Gastroenterology 2006; 130:1480.

TX: Treatment is directed at symptoms not cause. Diarrhea- antidiarrheal, Constipation-

BRAT Diet: Bananas, Rice, Applesauce and Toast
Fiber, Miralax, MOM, Anxiety- Ativan etc. Depression –SSRIs, Tricylcics, PainAntispasmodics, Anitcholanergics, Physical Therapy, muscle release. Avoid Narcotics.
Inguinal Hernia
 Definition: A hernia is the protrusion of a portion of an
organ or tissue through an abnormal opening in the wall
that normally contains it. In this case the Inguinal area.
Can be direct or indirect.
 s/s: painless to painful bulge in RLQ,LLQ, worse with
motion, lifting. If no bowel movements worrisome for
incarcerated bowel (surgical emergency).
 Tx: referral to surgeon
 Can be difficult to diagnose. Common when born
Ulcers
 Excessive secretion of gastric acids, inadequate
protection of mucus membrane, stress, heredity,
medications
 s/s: mid epigastric, gnawing abdominal pain
radiating to back, improved with eating, tarry
stools, anemia
 Dx: Exam, UGI x-ray, CBC, EGD
 Tx: Hold offending meds (NSAIDS), twice
daily PPI. Treat h. Pylori if present.
Reevaluate
Esophageal Reflux
 Heartburn
 Cause: Transient relaxation of the lower esophageal
sphincter intrinsic pressure, angle of cardioesphygeal
junction, action of diaphragm, gravity.
 s/s: Retro sternal, non exertional chest pain, with or
without episodes of regurgitation.
 Dx: Based on symptoms, sometimes seen on UGI.
 Tx: If no alarm symptoms then PPI and re-evaluate. If
alarm sxs: dysphagia, GI bleeding or weight loss then EGD
needed.
Diarrhea
 Causes: infection, drug-induced, food related, postsurgical, psychological, exercise (runner’s trot)
 s/s: Three or more bowel movements per day are
considered to be abnormal, and the upper limit of stool
weight is generally agreed to be 200 g per day in Western
countries.
 Dx: Multiple studies, stool o&p, stool culture, stool c.diff
toxin, stool fecal fat and if no cause and chronic then
colonoscopy and blood work, watch electrolytes.
 Tx: Aim at underlying cause, mostly supportive with low
glucose electrolyte solution, watered down Gatorade.
 BRAT diet: Avoid lactose, bland diet. No ETOH.
Runners Diarrhea



Incidence
–
Runners Diarrhea affects 35% of
runners in 10k race
Mechanism
–
Increased intestinal motility with
intense Running
–
Caused by gastrointestinal
peptide
–
Possibly related to bowel
ischemia
Symptoms and Signs
–
Watery Diarrhea

Increased stool frequency

Large volumes
–
Bloody stool in 12% of patients
–
Diffuse nonlocalized low
Abdominal Pain
–
Tenesmus

Recommendations
– Establish pre-run ritual
– Avoid eating 2 to 3 hours before Running
– Decrease dietary sugars
 Lactose
 Fructose
 Aspartame (Nutri-sweet)
 Sorbitol
– Decrease Dietary Fiber or use liquid meals
before race
– Decrease caffeine intake
– Avoid mints or gum containing Sorbitol
– Avoid large Vitamin Doses (especially
Vitamin C)
– Switch training time of day to evening
– Stay conditioned
– Consider anti-Diarrheal drugs
– Consider temporary decrease in miles or
intensity
 Initially decrease program by 20-25%
 Slowly re-increase Exercise program
– Consider rice-based electrolyte solution
(CeraSport)
 Anecdotal evidence only
Constipation
 Definition: Three or less bowel movement weekly
 S/S: bloating, early satiety, bulging abdomen,
painful defecation, nausea, abdominal pain
 Dx: History, KUB with sitz marker study
 Tx: Fiber, water, exercise, Miralax, Amitiza, MOM,
think about pelvic floor dysfunction, biofeedback
Gastroenteritis
 Definition: Literally inflammation of gastrointestinal
system resulting in a plethora of symptoms from N/V to
diarrhea. Usually attributed to viral or bacterial cause.
 Cause: E. Coli infection, staphylococcal food poisoning,
botulism, viral, chemical or drug related
 S/S: N/V, steatorrhea, bloody stools, dehydration,
weakness, abdominal pain relieved by bowel movements.
 Dx: Stool studies, O&P, Stool cultures, stool for fat, c.diff
toxin, stool for fat. BMP
 Tx: Usually supportive, fluids, water down Gatorade, let
run it’s course avoid anti diarrheals, consider pepto, if
longer than two weeks further investigation. Bland diet
(BRAT) avoid milk products.
Ulcerative Colitis
 Cause: Unknown, ?autoimmune
 S/S: Loose stools w/ w/o blood, nocturnal stools,
iron deficiency anemia, LLQ abdominal pain.
 Dx: Usually on colonoscopy, some IBD serology
 Tx: prednisone, asacol
Crohn’s Disease
 S/S: Will present with diarrhea, blood in
stool, pain nonspecific to generalized.
 Dx: Labs, colonoscopy
 Tx: Immunosuppressive medications. Last
resort surgical removal of ulcerated portion
Abdominal Trauma
 Common sports
 Key is immediate recognition, monitoring &
management
Abdominal Trauma
 Screening tools: exam and History observe for
abdominal distention or falling BP rising pulse
without explanation
 Ultrasound: +/ Diagnostic Peritoneal Lavage: +/ Computed Tomography: +/-
Splenic Injuries
 Most commonly injured organ in abdomen
 Deceleration causes a shearing force on vessels
and capsule
 Blunt trauma to LUQ
Splenic Injuries
 S/S: LUQ pain radiating to back, severe,
sharp unrelenting to dull ache after trauma,
some ecchymosis
 Tx: avoid surgery if possible
 Return to play: 6-8 weeks depending on
recovery and sport activity.
 Al Harris- DB Green Bay
Liver Injuries
 2nd most common injured
 Blunt trauma to RUQ, lower chest from front or
back
 s/s: RUQ ache radiating to back, usually contusion
of ribs, achy in character.
 Tx: Usually supportive with monitoring.
Still more options
 Are you pregnant?, reproductive diseases
 Ovarian Cysts, PID, Endometriosis
 UTI or bladder infection, Kidney stones
– Can be secondary to appendicitis
– Pylonephritis
Summary
 If fever, bloody stool/urine, pallor, distress,
no body movement, unexplained weight loss
or severe pain are present, something
serious is wrong!!
Resources
 http://www.fpnotebook.com/Sports/GI/RnrsD
rh.htm
???Questions???