Chapter 31 Review

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Chapter 31 Review : 

Chapter 31 Review Gastrointestinal Emergencies

Slide 2: 

What is a Tilt Test? A Tilt Table Test or TTT is widely used in making the diagnosis of Neurally (pronounced new-rully) Mediated Syncope (pronounced syn-cup-ee) or NMS. Click Here for explanation.

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What is Neurally Mediated Syncope (NMS) and why do these patients pass out?

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1. A patient with a positive tilt test:  A) often requires atropine.  B) is severely hypotensive.  C) may faint upon standing.  D) has intra-abdominal bleeding.

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2. Intestinal strictures would MOST likely result in:  A) diarrhea.  B) gastroenteritis.  C) bowel obstruction.  D) ulcerative colitis.

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As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravity-dependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common)

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In addition, fluid may accumulate in the lungs, thereby causing shortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air.

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3. A 52-year-old man complains of vomiting and diarrhea for the past day. He is conscious and alert, has a blood pressure of 130/70 mm Hg, a heart rate of 120 beats/min and strong, and respirations of 20 breaths/min and regular. His past medical history is significant for anemia and congestive heart failure. Prior to administering isotonic crystalloid solutions to this patient, it is MOST important to:  A) check his blood sugar.  B) apply a pulse oximeter.  C) obtain a 12-lead ECG.  D) auscultate his lung sounds.

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Acute cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain. Symptoms The main symptom is abdominal pain the pain may: Be sharp, cramping, or dull Come and go Spread to the back or below the right shoulder blade Occur within minutes of a meal

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4. An obese 52-year-old woman who presents with severe pain in the right upper quadrant of her abdomen and pain in her right shoulder is MOST likely experiencing:  A) cholecystitis.  B) acute hepatitis.  C) Crohn's disease.  D) Mallory Weiss syndrome.

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5. A 38-year-old man presents with an acute onset of severe right upper quadrant abdominal pain, pain to his right shoulder, and nausea. He is conscious and alert, but is restless from the pain. His blood pressure is 150/86 mm Hg, pulse rate is 120 beats/min and strong, and respirations are 22 breaths/min and regular. In addition to administering supplemental oxygen, you should:  A) start an IV with normal saline and set it to keep the vein open, place him in a position of comfort, and administer 4 mg of morphine and 12.5 mg of promethazine.  B) encourage him to remain supine to relieve his pain, monitor his oxygen saturation level, and administer 10 to 20 mg of Nubain via the intramuscular route.  C) establish vascular access with a large-bore catheter, administer a 500 mL normal saline bolus, and avoid analgesics due to the potential for intra-abdominal bleeding.  D) perform a comprehensive abdominal exam, start at least one large-bore IV line, infuse normal saline at 125 mL/hr, and consider giving him an antiemetic medication.

Diarrhea : 

Diarrhea Osmotic diarrhea means that something in the bowel is drawing water from the body into the bowel. A common example of this is "dietetic candy" or "chewing gum" diarrhea, in which a sugar substitute, such as sorbitol, is not absorbed by the body but draws water from the body into the bowel, resulting in diarrhea. Secretory diarrhea occurs when the body is releasing water into the bowel when it's not supposed to. Many infections, drugs, and other conditions cause secretory diarrhea.

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6. If water is not reabsorbed in the colon:  A) diarrhea occurs.  B) constipation occurs.  C) the appendix may rupture.  D) waste material is solidified.

Protuberant abdomen : 

Protuberant abdomen Unusual or prominent convexity of the abdomen, due to excessive subcutaneous fat, poor muscle tone, or an increase in the contents of the abdomen.

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7. A protuberant abdomen would MOST likely be encountered in a patient with:  A) an abdominal evisceration.  B) peritoneal fluid accumulation.  C) decreased abdominal volume.  D) an acutely inflamed appendix.

Crohn’s Disease : 

Crohn’s Disease Similar to ulcerative colitis May affect the entire GI tract Immune system attacks the GI tract. Most likely site of inflammation is the ileum. Scarred, narrow, stiff, and weakened portion of the small intestine

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The inflammation of Crohn's disease is nearly always found in the ileocecal region. The ileocecal region consists of the last few inches of the small intestine (the ileum), which moves digesting food to the beginning portion of the large intestine (the cecum). However, Crohn's disease can occur anywhere along the digestive tract.

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8. The MOST likely cause of Crohn's disease is:  A) autoantibody destruction of the intestinal wall.  B) precancerous lesions in the lower intestinal tract.  C) chronically high triglyceride levels in the blood.  D) infection of the gastrointestinal tract with Helicobacter pylori.

Visceral Pain : 

Visceral Pain Visceral pain is the pain we feel when our internal organs are damaged or injured and it is, by far, the most common form of pain. It is very often difficult to localize.

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9. In contrast to somatic pain, visceral pain:  A) is well-localized.  B) indicates peritonitis.  C) is difficult to localize.  D) increases with movement.

Peptic Ulcer Disease : 

Peptic Ulcer Disease No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Ulcers can be caused by: Infection with a type of bacteria called Helicobacter pylori (H. pylori) Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others), and many others available by prescription. Even aspirin coated with a special substance can still cause ulcers. Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output; seen in Zollinger-Ellison syndrome.

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10. Chronic use of nonsteroidal anti-inflammatory drugs would MOST likely result in:  A) diverticulitis.  B) esophageal varices.  C) acute gastroenteritis.  D) peptic ulcer disease.

Coffee-ground Emesis : 

Coffee-ground Emesis Coffee ground emesis is when an individual has episodes of vomiting that resembles coffee grounds. During these episodes, the fluid the individual brings up will be dark brown or black. It will have a granular consistency much like coffee grounds. This type of vomiting is usually the result of bleeding into the stomach.

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11. Blood that has been digested by stomach acids manifests as:  A) hematochezia.  B) bright red vomitus.  C) gray-colored stool.  D) coffee-ground emesis.

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12. If a patient complains of left lower quadrant abdominal pain, you should FIRST palpate the:  A) right upper quadrant.  B) right lower quadrant.  C) left lower quadrant.  D) left upper quadrant.

Pancreas : 

Pancreas The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as an exocrine gland, secreting pancreatic juice containing digestive enzymes that pass to the small intestine. These enzymes help to further break down the carbohydrates, proteins, and fats in the chyme.

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13. The exocrine function of the pancreas produces:  A) insulin.  B) glucagon.  C) enzymes.  D) somatostatin.

Small Intestine : 

Small Intestine In vertebrates, the small intestine is the part of the gastrointestinal tract (gut) following the stomach and followed by the large intestine, and is where the vast majority of digestion and absorption of food takes place

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14. MOST of the digestive process occurs in the:  A) liver.  B) pancreas.  C) jejunum.  D) small intestine.

Mallory-Weiss Syndrome : 

Mallory-Weiss Syndrome In 1929, Kenneth Mallory and Soma Weiss first described a syndrome characterized by esophageal bleeding caused by a mucosal tear in the esophagus as a result of forceful vomiting or retching.

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15. The presentation of Mallory Weiss syndrome is linked to _________, and is caused by:  A) eating spicy foods, erosion of the lining of the gastrointestinal tract.  B) spastic coughing, rupture of esophageal veins due to portal hypertension.  C) severe vomiting, a tear at the junction between the esophagus and stomach.  D) blunt trauma, rupture of hollow organs with resultant peritoneal inflammation.

Pancreatitis : 

Pancreatitis Severe upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis. Nausea and vomiting (emesis) are prominent symptoms.

Slide 33: 

16. A patient with pancreatitis would MOST likely present with pain that:  A) radiates around to the right side of the back and angle of the scapula.  B) is severe and radiates from the flank to the groin and external genitalia.  C) is localized to the left upper quadrant and referred pain to the left shoulder.  D) goes straight through to the back in the midline of the lower thoracic area.

Bowel Obstruction : 

Bowel Obstruction Depending on the level of obstruction, bowel obstruction can present with abdominal pain, abdominal distension, vomiting, fecal vomiting, feculent breath odor, and constipation.

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17. A patient with an advanced bowel obstruction would MOST likely present with:  A) a feculent breath odor.  B) black, tarry stools.  C) bright red hematemesis.  D) deep, rapid respirations.

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18. A 62-year-old man presents with an acute onset of bright red vomiting. According to his wife, he ingests excessive amounts of alcohol each day. As you are assessing the patient, you note that his level of consciousness has decreased markedly. His mouth is full of blood, and his skin is pale and moist. You should  A) assist his ventilations for 2 to 3 minutes, insert a Combitube, suction his airway for up to 15 seconds, start two large-bore IV lines with normal saline, and administer 1 L fluid bolus.  B) perform immediate tracheal intubation, insert a nasogastric tube, establish IV or IO access, and administer 10 to 20 mL/kg normal saline or lactated Ringer's boluses to maintain a systolic blood pressure of at least 90 mm Hg.  C) turn him on his side and suction his oropharynx, intubate his trachea if the oral bleeding continues, establish at least one large-bore IV with normal saline, and administer enough fluids to maintain adequate perfusion.  D) suction his mouth for up to 20 seconds, insert a nasopharyngeal airway, ventilate him at a rate of 20 breaths/min, consider endotracheal intubation, start a large-bore IV line, and run the IV wide open until signs of improvement are noted.

Abdominal Pain : 

Abdominal Pain

Slide 38: 

19. Patients with abdominal pain MOST often present with:  A) deep breathing.  B) flexion of the hips.  C) signs of hypoperfusion.  D) either vomiting or diarrhea.

Appendicitis in the Elderly : 

Appendicitis in the Elderly Multiple factors contribute to the diagnostic difficulty and high incidence of complications seen in elderly patients. Immune function tends to decrease with advancing age. Many elderly patients have underlying conditions such as diabetes or malignancy, further suppressing immunity. Elderly patients often have underlying cardiovascular and pulmonary disease, which decreases physiologic reserve and predisposes them to conditions such as abdominal aortic aneurysm (AAA) and mesenteric ischemia. Elderly patients also have a high incidence of asymptomatic underlying pathology.

Appendicitis in the Elderly : 

Appendicitis in the Elderly Understanding that elderly patients may present very differently than their younger counterparts also is important. Elderly patients tend to wait much longer to seek medical attention than younger patients, and they are much more likely to present with vague symptoms and have nonspecific findings on examination

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20. Compared to a 21-year-old patient with acute appendicitis, a 74-year-old patient with the same condition would MOST likely present with:  A) periumbilical pain that radiates.  B) vague or diffuse abdominal pain.  C) localized abdominal pain and fever.  D) a body temperature well below 98.6°F.

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