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Gastrointestinal tract (อ.นพ.นามศิริ ใบอดุลย์) (นางสาวศรินญา เมฆฉาย…
Gastrointestinal tract (อ.นพ.นามศิริ ใบอดุลย์)
(นางสาวศรินญา เมฆฉาย 603101091)
Peptic ulcer
1.1 Peptic ulcer disease (PUD)
Gastric ulcer
Duodenal ulcer
1.2 Pathophysiology
• increased aggressive factors
• decreased defensive factors
• most ulcers are caused by H. pylori
infection or NSAID use
1.3 Aggressive factors
hydrochloric acid secretion, Pepsins, ethanol ingestion, Smoking, duodenal reflux of bile, Ischemia, NSAIDs, Hypoxia, H. pylori infection
1.4 Clinical
Abdominal pain, nausea, bloating, weight loss, stool positive for occult blood, and anemia
1.5 Diagnosis
Dyspepsia and without alarm symptoms, it may be
appropriate to initiate empirical PPI therapy for PUD without upper endoscopy, NSAIDs and aspirin should be stopped
1.6 Complications
Bleeding, Perforate, Obstruction
1.7 Investigation
EGD, H.pylori testing
1.8 Treatment
1.8.1 acid suppressive therapy
1.8.2 Prokinetic drug ex: domperidone, plasil
1.8.3 Life style modification
Peptic perforate
2.1 Clinical
Sudden onset severe epigastric pain
2.2 Physical exam
2.2.1 Localized peritonitis
2.2.2 Diffuse peritonitis
2.3 Initial management
NPO
IV fluids
NG tube
Foley catheter
IV ATBs
2.4 Treatment
Surgery is almost always indicated for ulcer perforation
Sealed perforation
•Options for surgical treatment
Nonoperative management
Upper GI hemorrharge
3.1 Bleeding proximal to ligament of Treitz Esophagus, Stomach, Duodenum
3.2 Definition
Hematemesis
vomiting of blood and is usually caused by bleeding from the upper GI tract
Melena
black, tarry, and foul-smelling stool, generally suggests bleeding from the upper GI tract
3.2.3 Hematochezia
bright red blood from the rectum that may or may not be mixed with stool. Although this typically reflects a distal colonic source, magnitude is significant, even upper GI bleeds may produce hematochezia
3.3 Cause
3.3.1 Variceal bleeding
3.3.2 Non-variceal bleeding
ononvariceal causes account for approximately 80% of such bleeding, with peptic ulcer disease being the most common
3.4 Resuscitation
Airway + oxygen supplement
IV fluids : crystalloid solution
Nasogastric tube (NG tube)
Foley catheter
Lab + G/M for blood transfusion
Medication
3.5 การดูแล
ดูแลระบบทางเดินหายใจ ระวังสำลัก
ซักประวัติ และตรวจร่างกาย เพื่อหาสาเหตุ ของภาวะเลือดออก
ทางเดินอาหารส่วนต้น และประเมินความรุนแรงของโรค
พิจารณาใส่ สาย NG-tube เฉพาะในกรณีที่มีประวัติเลือดออก
ทางเดินอาหารไม่ชัดเจน หรือต้องการประเมินว่าผู้ป่วยยังคงมีเลือดออกทางเดินอาหารส่วนต้น ในขณะนั้นหรือไม่ (Active bleeding)
โดยสามารถนำสายออกได้ หลังได้รับการวินิจฉัย
ให้สารน้ำทางหลอดเลือดดำ เพื่อแก้ไขภาวะขาดน้ำ
เจาะเลือดเพื่อตรวจ CBC, coagulogram, BUN/Cr เพื่อประเมินโรคร่วม และ Glasgow-Blatchford score
ควรจองเลือดไว้ ถ้าผู้ป่วยมีแนวโน้มขาดเลือด
3.6 Endoscopic interventio
3.6.1 Diagnosis
3.6.2 Treatment
3.6.3 Time for endoscopy
Within 24 hour
Resuscitation àclinical stable
3.7 Endoscopic Therapeutic options
3.7.1 Injection therapy
3.7.3 Thermal coaptive therapy
3.7.2 Mechanical devices
SMALL BOWEL OBSTRUCTION
(Gut obstruction)
Etiology
5.1.1 Intraluminal (e.g., foreign bodies, gallstones, or meconium)
5.1.2 Intramural (e.g., tumors, Crohn's disease–associated
inflammatory strictures)
5.1.3 Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
5.1.4 Intra-abdominal adhesions related to prior
abdominal surgery account for up to 75%of cases of
small bowel obstruction.
Pathophysiology
5.2.1 With onset of obstruction, gas and fluid accumulate within the intestinal lumen proximal to the site of obstruction.
5.2.3 The intestinal activity increases in an effort
to overcome the obstruction, accounting for the
colicky pain and the diarrhea
5.2.2 With ongoing gas and fluid accumulation, the bowel distends and
intraluminal and intramural pressures rise.
5.2.4 If the intramural pressure becomes high enough, intestinal micro-vascular perfusion is impaired, leading to intestinal ischemia and, ultimately, necrosis.
Clinical Presentation
Colicky abdominal pain, Nausea, Vomiting, Obstipation (severe constipation)
Physical examination
Abdominal distend, Bowel sound,
Lab: Hemoconcentration, Electrolyte abnormalities, Mild leukocytosis is common
5.5 Diagnosis
5.5.1 Distinguish mechanical obstruction from ileus
5.5.2 Determine the etiology of the obstruction
5.5.3 Discriminate partial from complete obstruction
5.5.4 Discriminate simple from strangulating obstruction
Investigations
Film abdomen serie, Triad : Dilated small bowel loops (>3 cmin diameter), Air-fluid levels seen on upright films, Paucity of air in the colon
Treatment
Fluid resuscitation, Isotonic fluid should be given intravenously
Retain foley catheter may be placed to monitor urine output
Broad-spectrum antibiotics are given by some
The stomach should be continuously evacuated of air and fluid using a nasogastric (NG) tube
LOWER GI HEMORRHAGE
Definition
Bleeding below the ligament of Treitz
Small intestine ( jejunum - ileum )
Large intestine
Diagnosis
Hematochezia that can range from
bright red blood to old clot
Investigation
4.3.1 Colonoscope
4.3.2 Radionuclide Scanning
4.3.3 Computed Tomography Angiography
4.3.4 Mesenteric Angiography
Evaluation
Physical examination, Vital signs, Abdomen, Anorectal exam, Laboratory, CBC, BUN / Cr, Coagulation
Resuscitation
Airway management, IV fluid resuscitation, Monitoring, G/M blood transfusion, NG lavage : exclude UGIB, Foley catheter
4.6 Identify bleeding site
Anorectal examination : PR-Anoscopy
NG tube lavage : bile content, no bleeding
Treatment
4.7.1 Diverticular diseases
4.7.2 Angiodysplasia
4.7.3 Neoplasia
4.7.4 Anorectal disease
4.7.5 Colitis
4.7.6 Mesenteric ischemia
COLONIC OBSTRUCTION
(Gut obstruction)
Cause
6.1.1 Intraluminal
fecal impaction, inspissated barium, and foreign bodies
6.1.2 Intramural
carcinoma, include inflammation Hirschsprung's disease, ischemia, radiation, intussusception, and anastomotic stricture
6.1.3 Extraluminal
adhesionshernias, tumors in adjacent organs, abscesses, and volvulus
Pathophysiology
Obstruction-proximal dilatation
Bacterial overgrowth-translocation-sepsis
Fluid loss & electrolyte imbalance
Bowel wall ischemia-perforation
Sign and symptoms
Constipation /obstipation, Distension, Pain, Nausea & vomiting : feculent vomitus, Anorexia & Weight loss, Family Hx of colorectal cancer, Past Hx
Physical examination
Abdominal examination, Distension, Palpable mass, Tenderness, Generalize tenderness, Rebound tenderness-perforation
Management
NPO, IV fluids resuscitation, NG tube decompression, Foley catheter and monitor urine output, Laboratory, Corrected electrolyte and hydration, +- Central line