Gastrointestinal Problems

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Gastrointestinal Problems

  1. 1. Gastrointestinal Problems The Acute Abdomen Bowel Obstruction Bowel Cancer
  2. 2. The Acute Abdomen <ul><li>Acute onset of abdominal pain </li></ul><ul><li>Many different causes </li></ul>
  3. 3. Causes of Acute Abdominal Pain <ul><ul><li>Abdo penetrating trauma </li></ul></ul><ul><ul><li>Bowel obstruction with perforation or necrosis </li></ul></ul><ul><ul><li>Acute ischaemic bowel </li></ul></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Pelvic inflammatory disease </li></ul></ul><ul><ul><li>Inflammatory bowel conditions (Chron’s, ulcerative colitis) </li></ul></ul><ul><li>- Gastroenteritis </li></ul><ul><li>Peptic Ulcer </li></ul><ul><li>Ruptured ectopic pregnancy </li></ul><ul><li>Ruptured ovarian cyst </li></ul><ul><li>Cholecystitis </li></ul><ul><li>Ruptured abdominal aneurysm </li></ul>
  4. 4. The Acute Abdomen <ul><li>Signs & Symptoms </li></ul><ul><ul><li>Pain: most common presenting symptom </li></ul></ul><ul><ul><li>Abdominal tenderness </li></ul></ul><ul><ul><li>Nausea/Vomiting </li></ul></ul><ul><ul><li>Diarrhoea </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Flatulence </li></ul></ul><ul><ul><li>General unwell/fatigue </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Increased abdominal girth (distension) </li></ul></ul>
  5. 5. The Acute Abdomen <ul><li>Diagnostic </li></ul><ul><ul><li>Complete history </li></ul></ul><ul><ul><li>Physical examination (including rectal & pelvic exam) </li></ul></ul><ul><ul><li>Blood tests (FBC, U&E’s,) </li></ul></ul><ul><ul><li>Urinalysis </li></ul></ul><ul><ul><li>Abdominal x-ray </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Pregnancy test </li></ul></ul><ul><ul><li>Abdominal USS + - CT scan </li></ul></ul>
  6. 6. Bowel Obstruction <ul><li>Occurs when intestinal contents cannot pass through the GI tract </li></ul><ul><li>Obstruction maybe partial or complete </li></ul><ul><li>Causes classified as mechanical or non-mechanical </li></ul>
  7. 7. Bowel Obstruction <ul><li>Mechanical Obstruction </li></ul><ul><ul><li>Account for 90% of all bowel obstructions </li></ul></ul><ul><ul><li>Affects the lumen of the bowel </li></ul></ul><ul><ul><li>Caused by an occlusion of the lumen </li></ul></ul><ul><ul><li>Most occur in the small intestine </li></ul></ul><ul><ul><li>Mainly caused by adhesions, hernias or neoplasms </li></ul></ul><ul><ul><li>Carcinoma is the most common cause of large bowel obstruction </li></ul></ul>
  8. 8. Bowel Obstruction <ul><li>Non-Mechanical Obstruction </li></ul><ul><ul><li>May result from neuromuscular or vascular disorders </li></ul></ul><ul><ul><li>Related to peristalsis </li></ul></ul><ul><ul><li>Paralytic ileus (lack of intestinal peristalsis) is the most common </li></ul></ul><ul><ul><ul><li>Occurs after surgery </li></ul></ul></ul><ul><ul><ul><li>Electrolyte abnormalities </li></ul></ul></ul><ul><ul><ul><li>Spinal fractures </li></ul></ul></ul><ul><ul><li>Vascular obstructions </li></ul></ul><ul><ul><ul><li>Due to interference to blood supply to a portion of intestines </li></ul></ul></ul>
  9. 9. Pathophysiology of Bowel Obstruction <ul><li>Normally 6-8 L of fluid enters small bowel daily </li></ul><ul><li>Approx 75% of intestinal gas is swallowed air </li></ul><ul><li>Bacterial metabolism produces methane & </li></ul><ul><li>hydrogen gases </li></ul><ul><li>Fluid, gas & intestinal contents accumulate </li></ul><ul><li>proximal to the intestinal obstruction </li></ul><ul><li>This causes distention, reduces the absorption of fluids & stimulates intestinal secretions </li></ul>
  10. 10. Pathophysiology (cont.) <ul><li>The increase in fluid increases the pressure in </li></ul><ul><li>the lumen </li></ul><ul><li>Increased pressure leads to increase capillary permeability & extravasion of fluids electrolytes </li></ul><ul><li>peritoneal cavity </li></ul><ul><li>Oedema, congestion & necrosis from impaired blood supply can occur </li></ul><ul><li>Retention of fluid in the intestine & peritoneal cavity can lead to severe hypovolaemia & shock </li></ul>
  11. 11. Bowel Obstruction <ul><li>Signs & Symptoms </li></ul><ul><ul><li>Vary depending on the location of the obstruction </li></ul></ul><ul><ul><li>Nausea/Vomiting </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><ul><li>Small bowel: colicky, cramp-like & intermittent </li></ul></ul></ul><ul><ul><ul><li>Large bowel: low grade cramp </li></ul></ul></ul><ul><ul><li>Abdominal distension (greater in large bowel) </li></ul></ul><ul><ul><li>Bowel Sounds </li></ul></ul><ul><ul><ul><li>Rapid, high-pitched tinkling </li></ul></ul></ul><ul><ul><ul><li>Absent </li></ul></ul></ul><ul><ul><li>Inability to pass flatus </li></ul></ul><ul><ul><li>Constipation </li></ul></ul>
  12. 12. Bowel Obstruction <ul><li>Treatment of Bowel Obstruction </li></ul><ul><ul><li>Aim to decompress the intestine </li></ul></ul><ul><ul><ul><li>Removal of gas & fluid </li></ul></ul></ul><ul><ul><ul><li>Use of nasogastric &/or intestinal tubes </li></ul></ul></ul><ul><ul><li>Maintain fluid & electrolyte balance </li></ul></ul><ul><ul><ul><li>6-8L fluid rich in sodium, potassium & chloride moves through the bowel each day </li></ul></ul></ul><ul><ul><ul><li>Normally most of it is reabsorbed </li></ul></ul></ul><ul><ul><ul><li>Retention of fluid in intestine & peritoneal cavity </li></ul></ul></ul><ul><ul><ul><li>Dehydration & electrolyte imbalances occur rapidly in small bowel obstruction </li></ul></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>l </li></ul></ul>
  13. 13. Bowel Cancer <ul><li>Colorectal cancer </li></ul><ul><li>One of the most common types of cancer in NZ </li></ul><ul><li>Diagnosed & treated early survival rate of 5 years + is approx 50% </li></ul><ul><li>Often undetected in early stages as asymptomatic </li></ul><ul><li>Prevention & early screening </li></ul>
  14. 14. Bowel Cancer <ul><li>Cause </li></ul><ul><li>Exact cause unknown </li></ul><ul><li>Risk factors include </li></ul><ul><li>- History of intestinal polyps, inflammatory bowel </li></ul><ul><li> disease </li></ul><ul><li>- Hereditary disposition </li></ul><ul><li>- Aged 50+ </li></ul><ul><li>- Obesity, sedentary lifestyle </li></ul><ul><li>- Diet high in animal fat </li></ul><ul><li>- Smoking </li></ul>
  15. 15. Bowel Cancer <ul><li>Signs & symptoms </li></ul><ul><ul><li>Vary with anatomic location of the tumour </li></ul></ul><ul><ul><li>Initially may be asymptomatic </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Loss of appetite </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Blood in stool </li></ul></ul>
  16. 16. Bowel Cancer <ul><li>Ascending colon & caecum tumours </li></ul><ul><ul><li>Abdominal pain R) lower quandrant </li></ul></ul><ul><ul><li>Iron deficiency anaemia </li></ul></ul><ul><ul><li>Occult blood in stool </li></ul></ul><ul><ul><li>Palpable mass </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Tumours may be large before causing changes in bowel habit </li></ul></ul>
  17. 17. Bowel Cancer <ul><li>Transverse colon tumours </li></ul><ul><ul><li>Including the R) & L) flexures </li></ul></ul><ul><ul><li>Occult blood in the stool </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Altered frequency bowel movements </li></ul></ul><ul><ul><li>Abdominal fullness </li></ul></ul><ul><ul><li>Cramp adominal pain </li></ul></ul>
  18. 18. Bowel Cancer <ul><li>Descending colon </li></ul><ul><ul><li>Bright red rectal bleeding </li></ul></ul><ul><ul><li>Ribbon shaped stools </li></ul></ul><ul><ul><li>Colicky abdominal pain </li></ul></ul><ul><ul><li>Alternating constipation & diarrhoea </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>These tumours may be ulcerative & infiltrate the bowel </li></ul></ul>
  19. 19. Bowel Cancer <ul><li>Sigmoid colon & rectum </li></ul><ul><ul><li>Dull or aching pain in sacrum or rectum </li></ul></ul><ul><ul><li>Feeling of rectal fullness </li></ul></ul><ul><ul><li>Bright red blood from rectum </li></ul></ul><ul><ul><li>Narrow stools </li></ul></ul><ul><ul><li>Tenesmus ( painful, ineffective straining to empty bowel ) </li></ul></ul><ul><ul><li>Anaemia </li></ul></ul>
  20. 20. Bowel Cancer <ul><li>Diagnostic Studies </li></ul><ul><ul><li>History & physical examination </li></ul></ul><ul><ul><li>Rectal examination (PR) </li></ul></ul><ul><ul><li>Sigmoidoscopy </li></ul></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>Barium enema </li></ul></ul><ul><ul><li>Faecal occult blood specimen </li></ul></ul><ul><ul><li>Blood tests (FBC’s, U&E’s, LFT’s) </li></ul></ul><ul><ul><li>Abdominal x-ray </li></ul></ul><ul><ul><ul><li>Show presence of gas & fluid in intestines </li></ul></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>Abdominal USS/CT </li></ul></ul>
  21. 21. Bowel Cancer <ul><li>Diagnostic </li></ul><ul><ul><li>History & physical examination </li></ul></ul><ul><ul><li>Rectal examination (PR) </li></ul></ul><ul><ul><li>Sigmoidoscopy </li></ul></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>Barium enema </li></ul></ul><ul><ul><li>Faecal occult blood specimen </li></ul></ul><ul><ul><li>Blood tests (FBC’s & U&E's, LFT’s) </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>Abdo USS </li></ul></ul>
  22. 22. Bowel Cancer <ul><li>Duke’s modified classification & prognosis </li></ul><ul><ul><li>Duke’s A </li></ul></ul><ul><ul><ul><li>Confined to the bowel wall </li></ul></ul></ul><ul><ul><ul><li>72% survive 5yrs </li></ul></ul></ul><ul><ul><li>Duke’s B </li></ul></ul><ul><ul><ul><li>Extended through bowel wall </li></ul></ul></ul><ul><ul><ul><li>56% survive 5yrs </li></ul></ul></ul><ul><ul><li>Duke’s C </li></ul></ul><ul><ul><ul><li>Regional lymph node involvement </li></ul></ul></ul><ul><ul><ul><li>35% survive 5yrs </li></ul></ul></ul><ul><ul><li>Duke’s D </li></ul></ul><ul><ul><ul><li>Distant metastases </li></ul></ul></ul><ul><ul><ul><li>0% survive 5yrs </li></ul></ul></ul>
  23. 23. Bowel Cancer <ul><li>Treatment </li></ul><ul><ul><li>Surgery: first line </li></ul></ul><ul><ul><li>Type depends on the location & extent of tumour </li></ul></ul><ul><ul><li>R) Hemicolectomy: tumours of the caecum & ascending colon </li></ul></ul><ul><ul><li>L) Hemicolectomy: tumours of the descending & sigmoid colon </li></ul></ul><ul><ul><li>Transverse colectomy: middle or L) transverse colon </li></ul></ul>
  24. 24. Bowel Cancer <ul><li>Surgery </li></ul><ul><ul><li>Anterior resection: proximal & mid rectal tumours </li></ul></ul><ul><ul><li>Anterior-posterior resection: advanced disease </li></ul></ul><ul><ul><li>Abdominoperineal resection: malignant tumours of the lower sigmoid colon, rectum & anus. Too low for anastomosis </li></ul></ul>

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