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- Fiber, Miralax, MOM, Anxiety- Ativan etc. Depression –SSRIs, Tricylcics, Pain-Antispasmodics, Anitcholanergics, Physical Therapy, muscle release. Avoid Narcotics. BRAT Diet: Bananas, Rice, Applesauce and Toast

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, post-surgical, 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/RnrsDrh.htm

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