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Gastroenterology and Hepatology - Coggle Diagram
Gastroenterology and Hepatology
Gastrointestinal assessment
Focused health history
ㆍ Diet, indigestion, swallowing ability.
ㆍ Appetite, weight loss, weight gain.
ㆍ Nausea and vomiting.
ㆍ Diarrhea,constipation, melaena.
ㆍ Abdominal pain
Focused physical assessment
Obvious signs of discomfort or distress.
Inability to lie flat or cough due to abdominal pain.
Nutritional assessment.
Fluid assessment.
Bowel assessment.
Gastrointestinal-focused assessment of the face and abdomen
Gastrointestinal monitoring
Gastric residual assessment
Normal gastric content
ㆍ Acceptable gastric residual volumes
ㆍ Normal gastric fluid color
Abnormal gastric content
ㆍHigh gastric residual volumes
ㆍ Fresh blood
ㆍCoffee-grounds appearance
ㆍFecal smell
Intra-abdominal pressure
The pressure within the abdominal cavity can be estimated by obtaining a pressure measurement in the bladder
Normal IAP
ㆍ 5-7 mmHg
ㆍ< 12 mmHg not significant (may be due to COPD, obesity, or ascites)
Diarrhea
Causes
ㆍFecal impaction
ㆍMedication
ㆍEnteral feeding via N& tube
ㆍAntibiotic-associated diarrhea (including C.difficile-associated diarrhea (CDAD))
ㆍIntra-abdominal inflammation
ㆍIntra-abdominal infection
Nosocomial Diarrhea
ㆍan acute episode of diarrhea in a hospitalized patient that was not present on admission, arises
after 23 days of hospitalization and for at least 1 day
Assessment findings
ㆍMore than 3 stools a day.
ㆍWatery, loose stools.
ㆍBristol Stool Chart-type 5, 6, or 7.
ㆍStool weight > 200 g/day.
Management
ㆍ Protect the skin from excoriation by means of:
careful washing
barrier cream or spray
a bowel management system (flexible rectal catheter with balloon seal and collection bag)
ㆍMonitor electrolytes and treat imbalances
ㆍMonitor fluid status and treat fluid deficit
ㆍReview current medications and discontinue laxatives or other diarrhea-inducing drugs that are not essential
ㆍPerform a rectal examination to rule out fecal impaction with overflow
ㆍObtain stool specimens for W/U causes
ㆍConsider fiber-containing enteral feeds, continuous infusion and probiotic additives
ㆍConsider semi-elemental feeds if malabsorption is suspected
ㆍMedication
Constipation
Definition
ㆍusually considered to be more than 3 days without abowel movement.
ㆍConstipation occurs in up to 70% of critically ill patients, and early initiation of enteral nutrition is associated with improved bowel function of mechanically ventilated patients.
Assessment
ㆍMore than 3 days without a bowel movement.
ㆍBristol Stool Chart-type 1 or 2.
ㆍAbdominal palpation-distension,firm or palpable fecal matter
Causes
ㆍOpiates.
ㆍImmobility.
ㆍDehydration.
ㆍVasoconstrictors.
ㆍHypoperfusion of the gastrointestinal tract.
Management
ㆍIdentify the patient's normal frequency of bowel movements
ㆍIf the patient is enterally fed, switch to fiber-containing feed
ㆍPerform a rectal examination to assess for stool in the rectum
ㆍFollow local bowel management protocol, including:
ㆍlaxatives
ㆍglycerine suppository
ㆍenema
Hypomotility
Definition
ㆍgastrointestinal motility becomes delayed
ㆍstomach contents accumulate
ㆍ leading to abdominal distension
Causes
ㆍMedications-opiates, catecholamines, B-2 agonists.
ㆍPost-operative ileus.
ㆍSepsis.
ㆍTrauma
ㆍ Increased ICP.
ㆍGastrointestinal ischemia.
ㆍCellular cytokines and kinases released during reperfusion injury
ㆍRelease of endotoxin or corticotropin (a stress response agent)
Assessment findings
ㆍHigh GRV-as defined by local protocol, which typically considers a GRV of > a number between 200 and 500 mL to be high.
ㆍVomiting.
ㆍAbdominal distension.
ㆍHypoactive or absent bowel sounds
ㆍMonitor GRV according to local protocol.
ㆍContinue low-volume enteral feeding.
ㆍSemi-recumbent positioning (head-up angle of 35-45%).
ㆍProkinetics-metoclopramide, erythromycin.
ㆍPost-pyloric feeding
Acute abdomen
Definition
ㆍthe rapid onset of clinically significant abdominal abnormalities when the underpinning problem is still unknown
Causes
ㆍObstruction
ㆍIschemia
ㆍ Perforation/Ruptured
ㆍInflammation
Assessment findings
ㆍSevere sudden pain < 24 h in duration.
ㆍPain before vomiting.
ㆍRaised temperature and heart rate.
ㆍDistended, firm, tender abdomen.
ㆍRaised WBC count
ㆍBowel sounds-hypoactive, absent, or high-pitched/tinkling.
ㆍPeritoneal signs-rebound tenderness, guarding, or rigidity
Management
ㆍInform the doctor urgently and refer the patient to the surgical team as indicated.
ㆍGive analgesia and anti-emetic for pain and nausea
ㆍGive fluid resuscitation and hemodynamics support as required
ㆍInvestigations as appropriate to the assessment findings
Blood
ㆍ Imaging study
Monitoring e.g., IAP
Pancreatitis
Definition
-Inflammation of the pancreas can result from an acute, chronic, or acute on chronic process
-Pancreatic enzymes are prematurely activated in the pancreas instead of within the duodenum, leading to autodigestion
-Resulting from this autodigestion triggers the release of cytokines, hormones, and other vasoactive substances as part of the inflammatory response
Causes
ㆍBiliary disease-gallstones or common bile duct obstruction.
ㆍAlcohol/toxins.
ㆍEndoscopic retrograde cholangiopancreatography (ERCP).
ㆍMedications-diuretics, sulfonamides, ACE inhibitors, valproic acid.
ㆍAbdominal trauma.
ㆍInfection.
ㆍTumor
ㆍAutoimmune
ㆍIdiopathic causes
Assessment findings
ㆍNausea and vomiting without relief.
ㆍAbdominal pain.
ㆍAbdominal distension and tenderness.
ㆍFever.
ㆍJaundice.
ㆍElevated serum pancreatic enzymes-amylase and lipase.
ㆍRaised WBC count, CRP, and lactate dehydrogenase (LDH)
ㆍElevated alkaline phosphatase (biliary disease).
ㆍHyperglycemia.
ㆍElectrolyte imbalances.
ㆍMetabolic acidosis.
ㆍRetroperitoneal bleeding-Cullen's sign (bruising near the umbilicus) and Grey Turner's sign (flank bruising).
ㆍSteatorrhea -oily, foul-smelling, grey faces secondary to excess fat in faces
Management
ㆍSeverity assessment
ㆍ Etiologies
ㆍFluid resuscitation with intensive monitoring
ㆍEnd organ failure surveillance e.g., Respiratory, Renal system and abdominal compartment syndrome
ㆍEnteral feeding with nutritional assessment
ㆍAnalgesic medication
ㆍ ERCP if indicated
Gastrointestinal hemorrhage
Definition
ㆍUpper gastrointestinal bleeding:
bloody or coffee-groundgastric aspirates or emesis
melena.
ㆍLower gastrointestinal bleeding-rectal passing of fresh blood or clots
Causes-1
ㆍPeptic ulcers.
ㆍVarices secondary to portal hypertension.
ㆍMallory-Weiss tear.
ㆍTumors.
ㆍIschemic colitis.
Caused-2
ㆍCrohn's disease.
ㆍUlcerative colitis.
ㆍDiverticulitis/Diverticular bleeding.
ㆍRectal ulcers.
ㆍInfection.
Assessment findings
ㆍSigns of hypovolemic shock
hypotension, tachycardia, prolonged capillary refill time, cool skin, and weak pulse
ㆍAbdominal distension and tenderness
ㆍbowel sounds
Management
ㆍHemodynamic monitoring to assess for hypovolemic shock
ㆍMonitor fluid status and treat fluid deficit
ㆍConfirm with doctor the enteral feeding regime, depending on the amount of bleeding and cause of bleeding
ㆍBlood investigations & Blood components as required
ㆍUse medication with a gastrointestinal vasoconstrictor effect-vasopressin, terlipressin, or octreotide as indicated
ㆍEndoscopy treatment
Acute liver failure
Definition
ㆍSignificant liver dysfunction with any degree of altered mentation (hepatic encephalopathy) in the absence of chronic liver disease indicates acute liver failure
Causes
ㆍParacetamol overdose.
ㆍAcute viral hepatitis or other viruses.
ㆍHepatotoxic substances-drugs, excessive alcohol, mushrooms, chemicals, herbal remedies.
ㆍVascular causes-ischemic hepatitis, Budd-Chiari syndrome.
ㆍPregnancy-acute fatty liver, HELLP syndrome.
ㆍAutoimmune hepatitis.
ㆍMetabolic causes-Wilson's disease, Reye's syndrome.
Assessment findings
ㆍHepatic encephalopathy
ㆍCerebral edema leading to raised ICP.
ㆍCoagulopathy and bleeding.
ㆍJaundice and raised LFTs.
ㆍAcute kidney injury.
ㆍMetabolic disturbances.
ㆍInfection
Management
ㆍHemodynamic monitoring to assess for distributive shock.
ㆍFluid resuscitation, avoiding excessive volume overload.
ㆍVasoconstrictor if hypotension does not respond to IV fluids.
ㆍInotropic support as required.
ㆍAntibiotics for prophylaxis or an identified infection.
ㆍBlood components as required-FFP is only given if the patient is actively bleeding or prior to invasive procedures (INR is a highly sensitive marker of liver function and helps to monitor the progression and severity of liver injury).
ㆍGive 50% glucose for hypoglycemia.
ㆍRenal replacement therapy for oliguria and/or significant acidosis
ㆍAvoid the use of sedatives, or give short-acting agents
ㆍMaintain cerebral perfusion pressure if cerebral edema develops:
ICP monitoring is required in severe cases
ㆍN-acetylcysteine infusion
ㆍ Paracetamol overdose
Consider for non-paracetamol-induced liver failure
Abdominal compartment syndrome
Definition
Abdominal compartment syndrome is defined as a continuous intra-abdominal pressure reading of > 20 mmHg with new organ failure.
Causes
ㆍCapillary leakage during fluid resuscitation
ㆍSystemic inflammatory response syndrome(SIRS).
ㆍSepsis.
ㆍBurns.
ㆍTrauma
ㆍIncreased abdominal contents
ㆍHemorrhage within the abdominal cavity.
ㆍ Ascites.
ㆍLiver disease.
ㆍ Pancreatitis.
ㆍIntra-abdominal mass
ㆍ Increased intra-luminal contents
ㆍBowel obstruction
ㆍDecreased abdominal wall compliance
ㆍPatient-ventilator dyssynchrony
ㆍHigh levels of intrinsic or extrinsic PEEP.
ㆍProne positioning
ㆍAbdominal surgery with tight closure
Assessment findings
ㆍIntra-abdominal pressure > 20 mmHg.
ㆍAbdomen distended, firm, and tender.
ㆍNausea and vomiting.
ㆍHigh gastric residual volumes.
ㆍAcute kidney injury.
ㆍAcute respiratory failure.
ㆍHypotension, tachycardia, and reduced cardiac output
Management
ㆍAvoid excessive fluid resuscitation.
ㆍ Improve abdominal compliance:
ㆍOptimize mechanical ventilation settings.
ㆍGive sedation, analgesia, and neuromuscular block as required.
ㆍOptimize patient positioning--avoid prone positioning and hip flexion
ㆍEvacuate intraluminal and abdominal contents:
ㆍAspirate oro- or nasogastric tube and leave on free drainage.
ㆍ Give enema.
ㆍGive prokinetics
ㆍDrain ascites
ㆍRenal replacement therapy for oliguria and/or significant acidosis
ㆍHemodynamic monitoring to assess preload and cardiac output.
ㆍSurgical decompression