FNP 2 Module 14: Common Gastrointestinal Problems
Any women who presents with lower abdominal pain or pelvic pain and is age _______ should undergo a speculum exam
15-44
A norovirus gastroenteritis is usually self-limiting and lasts for how long _______
2 days
Functional dyspepsia affects about ___% of all adults every year
40
For a patient coming in with abdominal pain, what lab studies are you likely going to order?
CBC, CMP, urinalysis, STI testing, abdominal x ray, CT scan, ultrasound, also consider amylase or lipase testing if you're worried about gallstones or pancreatitis
____________ are used to classify groups of carbs that are notorious for triggering digestive symptoms like bloating, gas and stomach pain
FODMAPS
If a patient comes in complaining of pain in the umbilical or midline abdominal region of the abdomen, what is this most likely to be?
IBD, bowel obstruction or ischemia, appendicitis, AAA, IBS, DKA, gastroenteritis
What are the different subcategories of IBS?
IBS-C, IBS-D, and mixed dual pattern IBS where the patient will report a combo of both diarrhea and constipation
If a patient comes in complaining of pain in the epigastric or substernal region of the abdomen, what is this most likely to be?
MI, PUD, pancreatitis, biliary disease, hiatal hernia, hepatitis
What are the different drug classes of gastric acid suppressant medications?
PPIs, H2 blockers
What are the common s/s that a patient with cholecystitis may present with?
RUQ abdominal pain, nausea, vomiting, sometimes a low grade fever
What laboratory testing might you consider for someone who you are working up for PID?
STI testing and inflammatory marker tests such as sed rate or CRP
Explain the McBurney's Point test.
Used to assess for appendicitis; deeply palpate at a distance between the ASIS and umbilicus at about 2/3 away from the umbilicus. Pain elicited there is positive for appendicitis
Explain a positive Rosving sign
Used to assess for appendicitis; it is positive if there is pain elicited in the RLQ when the LLQ is palpated
Explain a positive Markle sign
Used to assess for appendicitis; it is positive if there is pain in the RLQ when the patient goes from standing on their toes to dropping down onto their heels
Explain a positive Psoas sign
Used to assess for appendicitis; it is positive if when the right hip is extended, it elicits pain in the abdomen
What is the recommended treatment for PID in women?
a one time IM injection of ceftriaxone plus doxycycline. All sexual partners within the last 60 days should be tested as well.
If your treatments are not effective for the management of IBS, then consider what?
a refer to gastroenterology
What is the criteria for abdominal pain to be recurrent in a patient with IBS?
abdominal pain for at least 1 or more days per week in the previous 3 months with an onset that was at least 6 months before diagnosis
What are the common s/s that a patient with IBS may present with?
abdominal pain, cramping, gas, bloating, constipation, diarrhea
What type of imaging may you order for a patient if you are worried about a bowel obstruction (although typically you will just refer them to the ED for this)?
abdominal x ray to assess bowel gas pattern
A rapid, sudden onset of abdominal pain
acute abdomen
What are the common s/s that a patient with a bowel obstruction may present with in clinic?
acute onset of abdominal distension and vomiting, may or may not have gas or bowel movements because of the obstructive process
What is the most common cause of bowel obstructions?
adhesions on the abdominal wall, which can be from previous abdominal surgeries
If a patient with abdominal pain also have a fever, then this is a sign that what is happening?
an acute infectious process
What are the signs and symptoms that a patient with appendicitis may present with?
anorexia, inability to eat, RLQ abdominal pain
What are some possible pharmacological treatments for diarrhea?
anticholinergics such as dicyclomine, antidiarrheals, TCAs, prokinetic agents, bulk forming laxatives, anti-spasmodics such as peppermint oil
What is the recommended first-line treatment for moderate IBS-C?
antispasmodic agents, peppermint, osmotic laxatives
What are the different possible causes of an acute abdomen?
appendicitis, bowel obstruction, cholecystitis, pancreatitis
If a patient comes in with abdominal pain that is dull but then it starts to increase in severity and localization, what should be on your differential list?
appendicitis, epididymitis
If a patient comes in complaining of pain in the right lower abdominal quadrant, what is this most likely to be?
appendicitis, ovarian disease, PID, ruptured ectopic pregnancy
For IBS-D patients, what dietary recommendations can we give to them?
avoid eating slowly, avoid chewing gum, avoid excessive alcohol intake or carbonated beverages, avoid legumes and foods containing fructose or sorbitol
How is PID diagnosed?
based on a thorough history and physical; a speculum exam and lab testing will also help with confirming the diagnosis
Functional abdominal pain differs from other functional bowel disorders how?
because it is just pain in the abdomen due to an unknown cause; it has nothing to do with gut function
Why is rotavirus not as common as it used to be?
because there is now a vaccine for it
If a patient comes in complaining of pain in the right upper quadrant, what is this most likely to be?
biliary disease, hepatitis, renal colic, diverticulitis
If a patient comes in complaining of pain in the midline subgastric region, what is this most likely to be?
bladder infection, prostatitis, diverticulitis, IBD, inguinal hernia, gynecological complaint
What are the common bacterial causes of acute gastroenteritis?
campylobacter, enterococcus faecalis, and c. diff
What is the recommended treatment for functional abdominal pain?
can be very challenging. Avoid narcotics. Screen for psych concerns such as depression and anxiety. May need to refer to Gastroenterology.
If a patient comes in with an acute abdomen, what is it super important that we first rule out?
cardiac pathology; esp. if the pain is epigastric as this could be a MI
What signs on a speculum exam would be indicative of PID?
cervical motion tenderness, uterine tenderness or adnexal tenderness
Which populations are the most susceptible to a rotavirus gastroenteritis?
children, the elderly, anyone who has not been immunized
Which types of STIs most commonly lead to PID and why?
chlamydia and gonorrhea because women can remain asymptomatic so they'll never know they have it and then it progresses to PID
What are the common s/s that patients coming in with functional abdominal pain will present with?
constant pain that is not associated with any PO intake or movement of their bowels, can also be associated with lower back pain, or chronic pain with gynecological or urological symptoms
If a patient has chronic abdominal pain and abnormal bowel patterns, what should you consider as a differential?
constipation and IBS
If a patient comes in with episodic/colicky abdominal pain, what should be on the top of your differential list?
constipation, gastroenteritis, intussusception, mesenteric adenitis
What are the common s/s of acute gastroenteritis?
diarrhea, nausea, vomiting, fever, abdominal pain
What is the recommended first-line treatment for mild IBS-D?
dietary changes such as excluding lactose and caffeine
What may be some aggravating or associated symptoms for a patient who has abdominal pain?
early satiety, nausea, vomiting
What are the common s/s that a patient with pancreatitis may present with?
epigastric and LUQ abdominal pain, pain that worsens with eating or drinking, anorexia, nausea and vomiting
According to the Rome IV criteria, functional dyspepsia has been divided into what two subcategories?
epigastric pain syndrome and postprandial distress syndrome
If a patient has any of these following warning signs present, then the abdominal pain they are presenting with is definitely not due to IBS:
evidence of GI bleeding, positive fecal occult blood test, unintentional weight loss, age older than 50 with no previous colon cancer screening, nocturnal pain or passage of stools, family history of colorectal cancer or IBD, iron deficiency anemia, palpable abdominal mass or lymphadenopathy
How is the rotavirus spread?
fecal-oral route
What are the FODMAP foods that should be avoided in IBS?
fermentable, oligosaccharide, disaccharide, monosaccharides, and polyols
What are the common s/s of a patient who has norovirus gastroenteritis?
fever, diarrhea, projectile vomiting, dehydration
What are the common s/s of acute gastroenteritis caused by rotavirus?
fever, diarrhea, vomiting, severe dehydration
What is the recommended first-line treatment for mild IBS-C?
guar fum, fiber, exercise, increased fluid intake
Vomiting of blood
hematemesis
If a patient comes in with complaints of diarrhea, they need to be evaluated for what warning signs and red flags?
hematemesis, melena, unintentional weight loss, coffee ground emesis, also all patients presenting with diarrhea should be tested for Helicobacter
What is the recommended first-line treatment for moderate IBS-D?
imodium or loperamide, antispasmodic agent, peppermint
For a patient with PID, you give the one time injection of ceftriaxone and doxy, and then when should you follow up?
in 3-5 days
What is a potential complication of untreated PID?
infertility
If a patient comes in with sudden, rapid onset abdominal pain, what should we consider in our differential list?
intussusception, incarcerated hernia, testicular or ovarian torsion, volvulus, perforated viscus
A functional bowel disorder where patients may report symptoms of abdominal pain, cramping, gas, bloating, constipation, diarrhea, or both
irritable bowel syndrome
What are the common s/s of PID?
lower abdomen or pelvic pain, lower back pain, nausea, or vomiting
Black tarry stools
melena
Should you ever prescribe narcotics to anyone with functional abdominal pain?
no, because they will not help that type of pain and can just further slow down the GI tract
Functional dyspepsia is also referred to as what?
non-ulcerative dyspepsia
The most common cause of viral gastroenteritis in humans
norovirus
Norovirus is highly contagious and often found where?
on cruise ships; so make sure to inquire about recent travel history
If a patient comes in complaining of pain in the left lower quadrant, what is this most likely to be?
ovarian disease, PID, ruptured ectopic pregnancy
IBS is classified when there is abdominal pain that is associated with at least two of what three following symptoms?
pain related to defecation, change in frequency of stool, change in form (appearance) of stool
A polymicrobial infection of the upper genital tract
pelvic inflammatory disease
In any female patient who is non-menopausal and comes in with abdominal pain, what do you need to make sure you do?
perform a urine pregnancy test because we do not want to risk missing this
What are the common s/s of functional dyspepsia?
postprandial fullness, early satiety, epigastric pain after eating
What is the etiology behind PID in women?
previous exposure to a STI
What is an OTC treatment that has been effective in treating patients with IBS?
probiotics
For patients with functional dyspepsia who report bloating or early satiety, what class of drugs can be helpful?
prokinetics such as metoclopramide. However, be careful because metoclopramide has a BBW for neurological conditions that can be irreversible
Patients with IBS should be screened for _________________ as they can significantly contribute to complaints of abdominal pain and diarrhea
psychological conditions, such as depression and anxiety
What does the typical timeline of gastroenteritis look like?
rapid onset and it lasts less than two weeks. Most cases will actually just last for a couple of days and then go away.
What is the Rome IV criteria for IBS?
recurrent abdominal pain, associated with at least 2 of the 3 main symptoms, and none of the warning signs
What is the recommended treatment for the causes of acute abdomen (bowel obstruction, appendicitis, cholecystitis, and pancreatitis)?
refer to the Emergency Department
What are the physical exam findings that a patient with appendicitis may present with?
rigid abdomen, low grade fever, positive Mcburney's tenderness, psoas sign, rovsing sign, and markle sign, vomiting with further progression of the disease
The most common cause of severe diarrhea among infants and children
rotavirus
What are the common viral causes of acute gastroenteritis?
rotavirus, norovirus, astrovirus, adenovirus
What are the potential complications that can arise from a rotavirus gastroenteritis?
severe dehydration and recurrent infection which can lead to malnutrition and possibly death
Most commonly bowel obstructions occur in the ___________.
small intestine
If a patient comes in complaining of pain in the left upper quadrant, what is this most likely to be?
splenic injury, renal colic, diverticulitis, stomach ulcer, pancreatitis, gastritis
What is the recommended treatment for functional dyspepsia?
the first line treatment is a gastric acid suppressant medication (first line is a PPI although you can try a H2 blocker instead), other pharm that has been shown to work is bismuth or peptobismol, and prokinetics in patients who report bloating or early satiety
What is the biggest difference between functional dyspepsia and heartburn or gerd?
the patient with functional dyspepsia will experience pain after eating, which is different than heartburn
What is important to note about elderly patients who come in with acute abdominal pain?
their threshold for pain may be higher, lethargy would be a red flag as well
Why should FODMAPS be avoided in those who have IBS?
they may draw water into the small intestine and cause diarrhea, can move into the large intestine undigested, are fermented by bacteria and can cause gas
For IBS-C patients, what dietary recommendations can we give to them?
they should follow an insoluble fiber diet such as root vegetables, bran, and whole wheat products
Acute gastroenteritis is defined as a diarrheal illness in which _____ or more times per day, ______ or more of stool occur.
three; 200 grams
Why would you order a CBC for a patient coming in with abdominal pain?
to assess WBC count, hemoglobin, hematocrit (to check for infection and dehydration)
Why would you order a CMP for a patient coming in with abdominal pain?
to assess electrolytes and liver function studies
What is commonly found on physical exam of a patient with a bowel obstruction?
tympany to percussion
What is the etiology of functional dyspepsia?
unknown; but there is some research that suggests that patients with functional dyspepsia also have coinciding IBS
How is norovirus transmitted?
via direct person to person contact and by ingestion of fecally contaminated food or water
Patients with functional abdominal pain usually come in when?
when it has lasted for more than 6 months and is causing a decrease in ability to perform daily activities
PID is most common in which population?
young women; although any woman who is sexually active is at risk
