Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2590_Библиотеки_им_академика_М_И_Перельмана
.pdf
328
ID:c0011-ti0045
ID:c0011-p0250
ID:c0011-p0255
ID:c0011-p0260
ID:c0011-p0265
ID:c0011-p0270
ID:c0011-p0275
ID:c0011-p0280
ID:c0011-p0285
ID:c0011-p0290
ID:c0011-p0295
ID:c0011-p0300
ID:c0011-p0305
ID:c0011-p0310
ID:c0011-p0315
ID:c0011-p0320
ID:c0011-p0325
ID:c0011-p0330
ID:c0011-p0335
ID:c0011-p0340
ID:c0011-p0345
ID:c0011-p0350
ID:c0011-p0355
ID:c0011-p0360
ID:c0011-p0365
ID:c0011-p0370
ID:c0011-p0375
ID:c0011-p0380
ID:c0011-p0385
ID:c0011-p0390
ID:c0011-p0395
ID:c0011-p0400
ID:c0011-p0405
ID:c0011-p0410
ID:c0011-p0415
ID:c0011-p0420
ID:c0011-p0425
ID:c0011-ti0050
ID:c0011-p0430
ID:c0011-p0435
ID:c0011-p0440
ID:c0011-p0445
ID:c0011-p0450
ID:c0011-p0455
ID:c0011-p0460
ID:c0011-p0465
ID:c0011-p0470
ID:c0011-p0475
ID:c0011-p0480
ID:c0011-p0485
ID:c0011-p0490
ID:c0011-p0495
ID:c0011-p0500
ID:c0011-p0505
ID:c0011-p0510
ID:c0011-p0515
ID:c0011-p0520
ID:c0011-p0525
ID:c0011-p0530
ID:c0011-p0535
ID:c0011-p0540
ID:c0011-p0545
ID:c0011-p0550
ID:c0011-p0555
ID:c0011-p0560
https://t.me/med1917
11: GASTROINTESTINAL GUIDELINES
SUBJECTIVE
Evaluate
DATA
for a “surgical abdomen,” defined as a rapidly worsening
prognosis in the absence of surgical intervention. Clients should not eat
or drink while a diagnosis of a surgical abdomen remains under consideration. Once a surgical abdomen has been excluded, the remainder of
the evaluation will be guided by the chronicity of symptoms along with
the location of pain.
A.
Review the onset, duration, course, and quality of pain:
1.
When did the pain start?
2.
What were you doing when the pain started?
3.
What does the pain feel like?
4.
Has this ever occurred before?
5.
What was the primary diagnosis?
6.
What was the previous treatment and was it effective?
7.
Is there anyone else in your home having the same
symptoms?
8.
Review the progression of pain.
B.
Determine the pain rating on a 10-point scale, with 0 being
no pain and 10 being equivalent to the worst pain the client
has ever felt.
C.
Qualify the duration of pain in minutes, hours, days,
weeks, or months. Does the pain interfere with sleep?
D.
Review the pattern of pain:
1.
Review aggravating factors.
2.
Review alleviating factors.
3.
Does the pain radiate?
4.
Does the pain have any relationship to food intake?
5.
What other symptoms occur with pain?
E.
Questions specic to females:
1.
Determine the client’s last menstrual period.
2.
Have they had a hysterectomy or tubal ligation?
3.
Do they have a recent history of dyspareunia or dys-
menorrhea that suggests pelvic pathology?
4.
Is there any history of physical abuse?
5.
What type of contraception is used? Specically eval-
uate for an intrauterine device.
F.
Review the client’s current medications and drug history,
especially antibiotic, laxative, acetaminophen, aspirin, and
nonsteroidal anti-inammatory drug (NSAID) use. Pain may
be signicantly masked in clients taking corticosteroids.
G.
Rule out abdominal trauma from domestic violence, motor
vehicle accidents, falls, or assaults.
H.
Review bowel habits and note changes: constipation, diar-
rhea, change in bowel pattern, urgency, color of stools.
I.
Review the client’s history for sickle cell disease. Any indi-
vidual of African or Mediterranean descent presenting with
leg or abdominal pain should be questioned regarding sickle
cell disease or trait.
J.
Review urinary function. Is there any urinary frequency,
urgency, dysuria, ank pain, or back pain? If the client is
male, do they have any hesitancy, difculty starting the urine
stream, nocturia, low urinary volume, or any lower abdominal distention indicating urinary retention?
K.
Review alcohol intake/history.
L.
Has the client had any unexplained weight loss?
M.
Review recent travel history.
N.
Ask about any sick contacts.
O.
Evaluate sexual activity to rule out potential sexually
transmitted infection (STI):
1.
Evaluate whether the client has new partners.
2.
Are the partners experiencing any symptoms?
PHYSICAL
A.
Check temperature, pulse, respirations, and blood pres-
EXAMINATION
sure (BP); include orthostatic BP.
Tachycardia
rysm, septic shock, gastrointestinal (GI) hemorrhage, or volume depletion. Absence of a fever in the elderly or immunosuppressed client does
not exclude a serious illness.
B.
Inspect:
1.
or hypotension may be signs of a ruptured aortic aneu-
Observe general appearance: facial expressions, gait,
skin turgor, andrefusal to move/writhing; note grimace
or guarding during the examination.
2.
Perform eye and mouth examination to rule out iritis
and aphthous ulcers of the mouth (extraintestinal manifestations of IBD). Examine eyes for jaundice.
3.
Examine the abdomen for presence of hernia at the
umbilicus, groin, or near the site of prior surgical incisions.
4.
Examine the abdomen for overt masses or pulsations.
5.
Examine the skin for jaundice. Observe for any bruis-
ing or other signs of domestic violence in the “bathing
suit” areas—breasts, abdomen, and back—that would be
easily covered with clothes.
C.
Auscultate:
1.
Auscultate for bowel sounds in all four quadrants of
the abdomen.
2.
Evaluate the heart and lungs.
3.
Check for aortic, iliac, and renal bruits.
D.
Percuss:
1.
Abdomen for tympany and dullness.
E.
Palpate:
1.
Abdomen for masses, rebound tenderness, hepato-
megaly or splenomegaly, and peritoneal signs.
a.
Before palpating the abdomen, ask the client to
bend the knees to help with relaxation of the wall
musculature.
b.
Elderly clients may lack the classic peritoneal signs
of rebound and guarding.
c.
Begin palpation gently, starting from the area of the
least pain and advancing to the area of the greatest pain.
2.
Check the abdomen for a tender pulsatile mass at mid-
line; it may indicate abdominal aortic aneurysm (AAA).
3.
Examine the back, assessing for costovertebral angle
tenderness (CVAT).
4.
Perform a bimanual examination in females regard-
less of whether the client has had a hysterectomy or is
postmenopausal.
a.
Evaluate the size and symmetry of the uterus.
b.
Evaluate the adnexal areas for presence of appro-
priately sized mobile ovaries. A xed, painful adnexal
mass is suggestive of an endometrioma or tubo-ovarian
abscess.
c.
Endometriosis is suggested by localized tenderness
in the cul-de-sac or uterosacral ligaments, palpable tender nodules, pain with uterine movement, and tenderness xation of adnexal mass or uterus in a retroverted
position.
5.
Check for the obturator sign, which is abdominal pain
in response to passive internal rotation of the right hip
from a 90° angle knee–hip exion position; perform this
when an inamed appendix is suspected.
6.
Check for the psoas sign, which is a pain response
to the iliopsoas group of hip exor muscles when an
ABDOMINAL PAIN
ID:c0011-p0565
ID:c0011-ti0055
ID:c0011-p0570
ID:c0011-p0575
ID:c0011-p0580
ID:c0011-p0585
ID:c0011-p0590
ID:c0011-p0595
ID:c0011-p0600
ID:c0011-p0605
ID:c0011-p0610
ID:c0011-p0615
ID:c0011-p0620
ID:c0011-p0625
ID:c0011-p0630
ID:c0011-p0635
ID:c0011-p0640
ID:c0011-p0645
ID:c0011-p0650
ID:c0011-p0655
ID:c0011-p0660
ID:c0011-p0665
ID:c0011-p0670
ID:c0011-p0675
ID:c0011-p0680
ID:c0011-ti0060
ID:c0011-p0685
ID:c0011-p0690
ID:c0011-p0695
ID:c0011-p0700
ID:c0011-p0705
ID:c0011-p0710
ID:c0011-p0715
ID:c0011-p0720
ID:c0011-p0725
ID:c0011-p0730
ID:c0011-p0735
ID:c0011-p0740
ID:c0011-p0745
ID:c0011-p0750
ID:c0011-p0755
ID:c0011-p0760
ID:c0011-p0765
ID:c0011-p0770
ID:c0011-p0775
ID:c0011-p0780
ID:c0011-p0785
ID:c0011-p0790
ID:c0011-p0795
ID:c0011-p0800
ID:c0011-p0805
ID:c0011-p0810
ID:c0011-p0815
ID:c0011-p0820
ID:c0011-p0825
ID:c0011-p0830
ID:c0011-p0835
ID:c0011-p0840
ID:c0011-p0845
ID:c0011-p0850
ID:c0011-p0855
ID:c0011-p0860
ID:c0011-p0865
ID:c0011-p0870
ID:c0011-p0875
ID:c0011-p0880
ID:c0011-p0885
ID:c0011-p0890
ID:c0011-p0895
ID:c0011-p0900
ID:c0011-p0905
ID:c0011-p0910
ID:c0011-p0915
ID:c0011-p0920
https://t.me/med1917
329
inamed appendix is suspected. A positive psoas sign is
the presence of lower quadrant pain noted as the supine
client raises their right leg from the hip while the examiner
pushes downward against the client’s lower thigh.
F.
Perform a rectal examination, including testing of stool
for occult blood. Failure to perform a rectal examination
in clients with abdominal pain may be associated with an
increased rate of misdiagnosis and should be considered a
medicolegal pitfall.
DIAGNOSTIC
A.
Diagnostic testing is ordered based on the following differ-
TESTS
ential diagnoses:
1.
In all females of childbearing age, assume the cli-
ent is pregnant until proven otherwise. Vaginal bleeding with or without abdominal pain should prompt a
transvaginal ultrasound and a serum human chorionic
gonadotropin (HCG) test. HCG should be tested before
performing the transvaginal ultrasound.
B.
Complete blood count with differential.
C.
Electrolytes.
D.
Complete metabolic panel.
E.
Blood urea nitrogen.
F.
Amylase and lipase.
G.
Aminotransferases, alkaline phosphatase, and bilirubin.
H.
Serum iron, total iron binding capacity, and ferritin.
I.
Urinalysis; save the sample for culture.
J.
Free erythrocyte protoporphyrin or zinc protoporphyrin if
lead poisoning is suspected in adults.
K.
Plain x-ray lms of the abdomen to rule out obstruction.
L.
CT of the abdomen with or without contrast.
M.
Abdominal ultrasonography.
N.
GI series radiography.
O.
Upper endoscopy; consider Helicobacter pylori testing.
P.
Sigmoidoscopy.
Q.
Barium enema: Avoid with suspected obstruction.
R.
Stool guaiac test for occult blood.
S.
Consider endoscopic retrograde cholangiopancreatogra-
phy to visualize the distal common bile duct.
T.
EKG to rule out cardiac pain.
U.
Consider blood cultures for elderly clients who present
with abdominal pain associated with either fever or hypothermia or when sepsis is suspected.
V.
Chest radiography.
DIFFERENTIAL
A.
The location and duration of abdominal pain can often sig-
DIAGNOSES
nicantly help in narrowing the differential diagnosis.
1.
Right upper quadrant (RUQ) pain:
a.
Acute cholecystitis and biliary colic:
i.
Biliary tract disorders: biliary duct stones, gall-
stones, tumor, and sphincter of Oddi dysfunction. A
slightly increased serum amylase of 140 IU/L may
suggest bile duct obstruction associated with acute
cholecystitis; however, a level ≥500 IU/L might
indicate pancreatitis. In acute pancreatitis, serum
amylase is three times the upper limit of the normal.
ii.
Ascending cholangitis presents with fever and
jaundice in a client with RUQ pain.
In acute cholecystitis, the typical pain is maximal
iii.
in the RUQ or epigastrium, radiating to the scapular
region, and is accompanied by nausea, vomiting, and
fever without jaundice. Murphy sign, or inspiratory
arrest in response to upper quadrant palpation, may
be seen with acute cholecystitis. RUQ tenderness to
percussion or pressure of the gallbladder is also a
suggestive nding.
b.
Acute hepatitis.
c.
Hepatic abscess.
d.
Hepatomegaly due to congestive heart failure.
e.
Perforated duodenal ulcer (DU):epigastric and gen-
eralized abdominal pain.
f.
Acute pancreatitis: bilateral pain—RUQ and left
upper quadrant (LUQ) pain.
g.
Herpes zoster.
h.
Myocardial ischemia.
i.
Pleural or pulmonary pathology (e.g., pneumonia,
pulmonary embolism, or empyema).
2.
RLQ pain:
a.
Appendicitis often begins with symptoms of dull,
steady, periumbilical pain, and anorexia before localizing to the RLQ at McBurney point.
b.
Regional enteritis.
c.
Leaking aneurysm.
d.
Ruptured ectopic pregnancy.
e.
Ovarian cyst.
f.
Ovarian torsion.
g.
Pelvic inammatory disease (PID).
h.
Ureteral calculi.
i.
Incarcerated, strangulated inguinal hernia.
j.
Endometriosis.
k.
Meckel diverticulitis.
l.
Abdominal wall hematoma.
m.
Pyelonephritis.
n.
Infectious colitis.
3.
LUQ pain:
a.
Gastritis.
b.
Acute pancreatitis: epigastric pain that is relatively
sudden, bores in to the back, and is associated with
nausea, vomiting, and anorexia.
c.
Splenic enlargement, rupture, abscess, infarction,
aneurysm.
d.
Myocardial ischemia.
e.
Left lower lobe pneumonia.
f.
Renal colic: radiates to the groin.
4.
Left lower quadrant pain:
a.
Sigmoid and/or descending diverticulitis.
b.
Regional enteritis.
c.
Leaking aneurysm.
AAA
may present with a tender pulsatile mass at the abdominal midline.
Vascular disorders such as acute arterial insufficiency due to atherosclerosis or embolus may present with severe abdominal pain; however, mild, constant pain may be the only symptom for several days.
Dissection or rupture of an AAA produces severe acute abdominal pain
and often radiates to the back or genitalia.
d.
Ruptured ectopic pregnancy.
Rupture
of the fallopian tube generally causes sudden, acute, and localized abdominal pain. Internal hemorrhage causes syncope and referred
shoulder pain, caused by phrenic nerve irritation. Diagnosis before
tubal rupture may be difficult because symptoms and physical findings
mimic other conditions such as appendicitis.
Ovarian cyst.
e.
f.
Ovarian torsion.
g.
PID.
h.
Ureteral calculi.
i.
Incarcerated, strangulated inguinal hernia.
330
ID:c0011-p0925
ID:c0011-p0930
ID:c0011-p0935
ID:c0011-p0940
ID:c0011-p0945
ID:c0011-p0950
ID:c0011-p0955
ID:c0011-p0960
ID:c0011-p0965
ID:c0011-p0970
ID:c0011-p0975
ID:c0011-p0980
ID:c0011-p0985
ID:c0011-p0990
ID:c0011-p0995
ID:c0011-p1000
ID:c0011-p1005
ID:c0011-ti0065
ID:c0011-p1010
ID:c0011-p1015
ID:c0011-p1020
ID:c0011-p1025
ID:c0011-p1030
ID:c0011-p1035
ID:c0011-p1040
ID:c0011-ti0070
ID:c0011-p1045
ID:c0011-p1050
ID:c0011-ti0075
ID:c0011-p1055
ID:c0011-p1060
ID:c0011-p1065
ID:c0011-ti0080
ID:c0011-p1070
ID:c0011-p1075
ID:c0011-p1080
ID:c0011-p1085
ID:c0011-p1090
ID:c0011-p1095
ID:c0011-p1100
ID:c0011-p1105
ID:c0011-p1110
ID:c0011-p1115
ID:c0011-p1120
ID:c0011-p1125
ID:c0011-p1130
ID:c0011-p1135
ID:c0011-p1140
ID:c0011-p1145
ID:c0011-p1150
ID:c0011-p1155
ID:c0011-p1160
https://t.me/med1917
5.
11: GASTROINTESTINAL GUIDELINES
j.
Pyelonephritis.
k.
Infectious colitis.
Generalized abdominal pain:
a.
Trauma:
i.
Any person with a possible blow to the abdo-
men should have orthostatic BP taken, careful palpation of the abdomen, and measurement of serial
abdominal circumferences, and should be considered for abdominal imaging. Serial hemoglobin
(Hgb) and hematocrit (Hct) measurements should
be obtained if necessary.
ii.
In abdominal trauma, the spleen is the most
commonly injured organ, especially in blunt abdominal trauma; the onset can be immediate or delayed.
iii.
Nontraumatic splenic rupture is often associ-
ated with acute infectious mononucleosis.
b.
Intestinal obstruction: Obstruction that develops
slowly over weeks to months may be relatively subtle
in presentation.
Acute
obstruction presents with severe “colicky” pain or pain that is
wavelike in nature; it makes the pain relentless.
c.
Peritoneal irritation: severe pain due to the rich
innervation of the parietal peritoneum. Focal injury
results in well-localized discomfort that is described as
a sharp aching or burning sensation.
d.
Metabolic disturbances may mimic intra- abdominal
etiologies.
Porphyria
because they can cause cramping, abdominal pain, and hyperperistalsis.
and lead poisoning sometimes simulate bowel obstruction
e.
Nonspecic dysfunctional abdominal pain and psy-
chogenic abdominal pain are diagnoses of exclusion.
f.
Mesenteric ischemia: Clients may present with acute
onset of severe diffuse abdominal pain, often described
as pain out of proportion to examination.
g.
IBD: ulcerative colitis (UC) and Crohn’s disease
(CD).
h.
Ketoacidosis: Clients may have diffuse abdominal
pain in diabetic/alcoholic ketoacidosis.
i.
Viral gastroenteritis.
PLAN
A.
General interventions:
1.
If necessary, prepare the client for emergency transport
and hospitalization.
2.
Management and follow-up of other causes of abdomi-
nal pain are variable and depend on diagnosis.
B.
Client teaching: See Client Teaching Guides for this chapter,
“Abdominal Pain: Adults” and “Abdominal Pain: Children.”
1.
Counsel the client to keep a pain diary including infor-
mation on activity, foods, and other pain triggers (duration
of pain and what provides relief of symptoms).
C.
Pharmaceutical therapy:
1.
Treatment depends on the ndings from the history,
physical examination, and testing, as well as the clinical
diagnosis.
FOLLOW-UP
A.
Variable: depends on diagnosis.
B.
Review the pain diary.
CONSULTATION/REFERRAL
A.
Consult the physician for the client with acute abdominal
pain and pain related to abdominal trauma. Consider referral
to gastroenterologist.
B.
For obstetrical clients, consult a obstetrician for any bleed-
ing or abdominal pain.
C.
Surgical consultation when a surgical abdomen is
suspected.
INDIVIDUAL
A.
Pregnancy: There is no evidence that acute intra-abdominal
CONSIDERATIONS
surgical emergencies are more common during pregnancy if
ectopic pregnancy is excluded.
1.
The presence of peritoneal signs, rebound tenderness,
and abdominal guarding is never normal in pregnancy.
2.
Bleeding complications include the following:
a.
First trimester: miscarriage and ectopic pregnancy.
b.
Second and third trimesters: abruptio placenta.
3.
Physiologic changes of pregnancy may affect the pre-
sentation and evaluation of abdominal pain. The enlargement of the uterus can impede physical examination, affect
the normal location of pelvic and abdominal organs, and
mask or delay peritoneal signs.
4.
Severe preeclampsia: The clinical manifestations of
liver involvement include RUQ or midepigastric pain,
elevated transaminases, and in severe cases subcapsular
hemorrhage or hepatic rupture.
B.
Pediatrics:
1.
The caregiver’s lap makes the best examining surface.
It is much better than having the child lie xed and supine
on a table.
2.
Observe the child’s interaction and gait prior to exami-
nation. If able to stand, ask the child to hop as an assessment of peritoneal irritation. If the child is unwilling to
stand, then shaking the examination table or pelvis can
also evaluate for peritoneal signs.
3.
An infant’s abdomen should be examined during a
time of relaxation and quiet. It is often best to do this at the
start of the overall examination, especially before initiating
any procedure that may cause distress.
4.
Allowing an infant to suck on a pacier may help relax
them.
5.
Tenderness or pain on palpation may be difcult to
detect in an infant. However, pain and tenderness are
assessed by such behaviors as change in the pitch of crying, facial grimacing, rejection of opportunity to suck, and
drawing the knees to the abdomen with palpation.
6.
Urinary tract infections (UTIs) can cause abdominal
pain; often the child with a UTI does not complain of dysuria and frequency as adults typically do.
7.
Young children have inaccurate body perceptions and
are inaccurate historians. The practitioner must rely on the
caregiver and the examination for data. Consider psychosocial aspects of childcare and possible abuse.
8.
Appendicitis is the most common pediatric surgical
emergency. The diagnosis can be difcult because the classic symptoms are often not present.
9.
Intestinal malrotation must be considered when a
healthy infant suddenly refuses to eat, vomits, becomes
inconsolable, and develops abdominal distention.
10.
Intussusception presents as paroxysmal, colicky pain,
and the infant often has currant-jelly stools, a palpable
RUQ abdominal mass, and ultimately distention.
11.
Young male clients may hesitate to report testicular pain.
12.
ID:c0011-p1165
ID:c0011-p1170
ID:c0011-p1175
ID:c0011-p1180
ID:c0011-p1185
ID:c0011-p1190
ID:c0011-p1195
ID:c0011-p1200
ID:c0011-p1205
ID:c0011-p1210
ID:c0011-p1215
ID:c0011-p1220
ID:c0011-p1225
ID:c0011-p1230
ID:c0011-p1235
ID:c0011-p1240
ID:c0011-p1245
ID:c0011-p1250
ID:c0011-p1255
ID:c0011-p1260
ID:c0011-p1265
ID:c0011-ti0085
ID:c0011-p1270
ID:c0011-ti0090
ID:c0011-ti0095
ID:c0011-ti0100
ID:c0011-p1275
ID:c0011-ti0105
ID:c0011-p1280
ID:c0011-ti0110
ID:c0011-p1285
ID:c0011-ti0115
ID:c0011-p1290
ID:c0011-p1295
ID:c0011-p1300
ID:c0011-p1305
ID:c0011-ti0120
ID:c0011-p1310
ID:c0011-p1315
ID:c0011-p1320
ID:c0011-p1325
ID:c0011-p1330
ID:c0011-p1335
ID:c0011-p1340
ID:c0011-p1345
ID:c0011-p1350
https://t.me/med1917
Use of toys and distracting objects and pictures helps
in gaining cooperation of young children, infants, and
toddlers.
C.
Adults:
1.
Obesity distorts the abdominal examination, making
organ palpation or pelvic examination difcult.
2.
With males older than age 40 and females older than
age 50, suspect cardiac origin when presenting with epigastric pain. Consider obtaining an EKG for clients in this
age group.
Although
chest pressure or pain, the client may also have a gastritis or heartburn
sensation, coupled with nausea and diaphoresis.
D.
myocardial infarction (MI) “classically” presents with anterior
Geriatrics:
1.
Elderly clients may have a vague or atypical presenta-
tion of pain, varying in location, severity, and presence of
a fever or nonspecic ndings on examination.
a.
Classic ndings of acute peritonitis, rebound ten-
derness, and local rigidity occur less often in the
elderly.
b.
After abdominal palpation, look for responses in
facial expressions: confusion, surprise, or worry. Often
geriatrics may not physically feel discomfort, yet they
sense something is not normal for them.
2.
Elderly clients have a diminished sensorium, which
may allow pathology to advance to a dangerous point
prior to symptom development.
a.
The level of pain is much less severe at presentation
and continues to be at a lower level of pain.
b.
Elderly clients may present with altered mental
status.
3.
In an older client, a presentation similar to IBD with
abdominal pain and a change in bowel habits can be the
rst sign of colon cancer.
4.
AAA is observed almost exclusively in elderly clients.
Maintain a high index of suspicion in clients who present
with a clinical picture suggestive of renal colic or musculoskeletal back pain.
a.
Approximately 5% of males 65 years and older have
AAA.
b.
Maintain a high index of suspicion in clients who
present with a clinical picture suggestive of renal colic
or musculoskeletal back pain.
5.
Elderly clients with UTI are less likely to have dysuria,
frequency, or urgency.
6.
Clients older than 65 years have a 30% to 50% risk
of gallstones and may not present with signicant pain;
fewer than half have fever, vomiting, or leukocytosis.
7.
Fever and an elevated white blood cell (WBC) count
occur in fewer than half of all elderly clients with diverticulitis. Only about 25% of the elderly with diverticulitis
present with a guaiac-positive stool.
8.
The incidence of PUD is more common in the elderly
due to the availability and use of NSAIDs. The most common presenting symptom with PUD in the elderly is
melena.
9.
The chance of misdiagnosis of acute abdominal pain
in the elderly is high and associated with higher mortality
compared with younger clients.
RESOURCE
Rome
Foundation: https://theromefoundation.org
APPENDICITIS
331
BIBLIOGRAPHY
American College of Obstetricians and Gynecologists. (2018).
Tubal ectopic pregnancy. Clinical Management Guidelines for
Obstetrician–Gynecologists, 193(2018), 1e–10e. https://www.acog.
org/Clinical-Guidance-and-Publications/Practice-Bulletins/
Committee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregna
ncy?IsMobileSet=false
Penner, R. M., & Fishman, M. B. (2021, May 10). Evaluation of the adult
with abdominal pain. UpToDate. https://www.uptodate.com/contents/
evaluation-of-the-adult-with-abdominal-pain#H552587793
Vakil, N.B. (2020, January 14). Peptic ulcer disease: clinical manifestations and diagno-
sis. https://www.uptodate.com/contents/peptic-ulcer-disease-clinicalmanifestations-and-diagnosis?sectionName=CLINICAL%20
MANIFESTATIONS&topicRef=6860&anchor=H3&source=see_link#H3
Vege, S. S. (2019, January 9). Etiology of acute pancreatitis. UpToDate.
https://www.uptodate.com/contents/etiology-of-acute-pancreatitis
APPENDICITIS
DEFINITION
A.
Appendicitis is acute inammation of the appendix caused
by obstruction of the appendiceal lumen. Perforation is rare in
the rst 12 hours, but the rate of possible perforation increases
after 72 hours. Prompt, early diagnosis and intervention is the
goal of treatment. The differential diagnoses for appendicitis
include all abdominal sources of pain.
INCIDENCE
A.
The incidence of appendicitis is 100 per 100,000 person
years in North America. It is the most common condition in
children (1%–8%) and during pregnancy (0.06%–0.1%) that
requires emergency abdominal surgery. One in every 2,000
adults older than age 65 years will develop appendicitis.
PATHOGENESIS
A.
Foreign bodies, fecal material, tissue hypertrophy, stric-
tures, undigested food, parasites, or a bend or twist on the
organ may cause obstruction of the appendix. The obstruction
causes colicky pain. Bacterial invasion causes inammation
and leads to gangrene and perforation. The most common
bacteria are Escherichia coli, Pseudomonas, Bacteroides fragilis,
and Peptostreptococcus species.
PREDISPOSING
A.
Pregnancy.
B.
Torsion.
C.
Abdominal trauma.
D.
Male; ages 10 to 30 years.
COMMON
The
classic history of anorexia and periumbilical pain followed by nausea,
right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
A.
Adults:
1.
Generalized or localized abdominal pain in the epigas-
tric or periumbilical areas. Within 2 to 12 hours, pain localizes in RLQ at McBurney point and intensity increases.
2.
The location of the appendix is altered in pregnancy
and with anatomic variations.
3.
Pain typically develops before vomiting.
4.
Nausea and/or vomiting (may be projectile).
5.
Anorexia signals an organic cause of abdominal pain.
6.
Elderly clients may present with confusion. The dura-
tion of symptoms is longer than 48 hours in elderly persons.
7.
Clients may complain of indigestion, atulence, diar-
rhea, and generalized malaise in nonclassic presentation.
FACTORS
COMPLAINTS
332
ID:c0011-p1355
ID:c0011-p1360
ID:c0011-p1365
ID:c0011-p1370
ID:c0011-p1375
ID:c0011-p1380
ID:c0011-p1385
ID:c0011-p1390
ID:c0011-p1395
ID:c0011-p1400
ID:c0011-ti0125
ID:c0011-p1405
ID:c0011-p1410
ID:c0011-p1415
ID:c0011-p1420
ID:c0011-ti0130
ID:c0011-p1425
ID:c0011-p1430
ID:c0011-p1435
ID:c0011-p1440
ID:c0011-p1445
ID:c0011-p1450
ID:c0011-p1455
ID:c0011-p1460
ID:c0011-p1465
ID:c0011-p1470
ID:c0011-p1475
ID:c0011-p1480
ID:c0011-p1485
ID:c0011-p1490
ID:c0011-p1495
ID:c0011-p1500
ID:c0011-p1505
ID:c0011-ti0135
ID:c0011-p1510
ID:c0011-p1515
ID:c0011-p1520
ID:c0011-p1525
ID:c0011-p1530
ID:c0011-p1535
ID:c0011-p1540
ID:c0011-p1545
ID:c0011-p1550
ID:c0011-p1555
ID:c0011-p1560
ID:c0011-p1565
ID:c0011-p1570
ID:c0011-p1575
ID:c0011-p1580
ID:c0011-p1585
ID:c0011-p1590
ID:c0011-p1595
ID:c0011-p1600
ID:c0011-p1605
ID:c0011-p1610
ID:c0011-p1615
ID:c0011-p1620
ID:c0011-p1625
ID:c0011-ti0140
ID:c0011-p1635
ID:c0011-p1640
ID:c0011-p1645
ID:c0011-p1650
ID:c0011-p1655
ID:c0011-p1660
ID:c0011-p1665
ID:c0011-p1670
https://t.me/med1917
B.
Pediatrics:
1.
2.
OTHER
A.
Rigid abdomen.
B.
Changes in pulse (tachycardia), breathing (tachypnea), or
11: GASTROINTESTINAL GUIDELINES
Children younger than 2 years:
a.
Abdominal distention.
b.
Irritability.
c.
Lethargy.
d.
Fever.
Children older than 2 years:
a.
Vomiting is often the rst symptom.
b.
Abdominal pain in RLQ.
c.
Fever.
SIGNS AND SYMPTOMS
skin temperature.
C.
Involuntary guarding.
D.
Rebound tenderness.
SUBJECTIVE
A.
Evaluate for a “surgical abdomen,” dened as a rapidly wors-
DATA
ening prognosis in the absence of surgical intervention. Clients
should not eat or drink while a diagnosis of a surgical abdomen
remains under consideration. Once a surgical abdomen has been
excluded, the remainder of the evaluation will be guided by the
chronicity of symptoms along with the location of pain.
B.
Review the onset, duration, course, and quality of pain. Has
pain ever occurred before? If so, what was the primary diagnosis?
What was the previous treatment and was it effective? Qualify
the duration of pain in minutes, hours, days, weeks, or months.
Does it interfere with sleep? Is there a pattern to the pain?
C.
Have the client rate the pain on a 10-point pain scale, with 0
being no pain and 10 being the worst pain the client has ever felt.
D.
Review the pattern of pain:
1.
Review aggravating factors.
2.
Review alleviating factors.
3.
Does the pain radiate?
4.
Does the pain have any relationship to food?
E.
Questions specic to females:
1.
Determine the client’s last menstrual period to rule out
pregnancy.
2.
What type of contraception is used? Specically evalu-
ate for an intrauterine device (IUD).
3.
Has the client had a hysterectomy or tubal ligation?
4.
Does the client have a recent history of dyspareunia or
dysmenorrhea that suggests pelvic pathology?
F.
Review current medications and drug history, especially
antibiotic and laxative use. Clients taking corticosteroids may
have a signicant masking of pain.
G.
Rule out abdominal trauma, motor vehicle accidents, falls,
and assault.
H.
Discuss bowel habits, including any changes, such as con-
stipation or diarrhea, anorexia, food intolerance, nausea and
vomiting, and bloating.
I.
Ask the client about urinary frequency, urgency, dys-
uria, ank pain, and back pain. In males, ask about hesitancy,
difculty starting the urine stream, nocturia, low urinary
volume, or lower abdominal distention (urinary retention).
PHYSICAL
A.
Check temperature, pulse, respirations, and blood pres-
EXAMINATION
sure (BP), including orthostatic BP.
B.
Inspect:
1.
Observe general appearance: facial expressions (gri-
mace during examination), walk, skin color and turgor,
level of consciousness, and acuity level of pain.
2.
Inspect the abdomen for surgical scars.
3.
Observe for any bruising or other signs of domestic
violence in the “bathing suit” area—breasts, abdomen, or
back—that would be easily covered by clothes.
C.
Auscultate:
1.
Abdomen for bowel sounds in all quadrants.
2.
Heart and lungs.
D.
Percuss:
1.
Abdomen for tympany.
E.
Palpate:
1.
Palpate at the end of the examination because a posi-
tive response produces pain and muscle spasm that can
interfere with subsequent examination. Note guarding
during the exam.
2.
Ask the client to bend their knees to help relax abdomi-
nal wall musculature.
3.
Assess for McBurney point tenderness: tenderness at
1.5 to 2 in. on a straight line from the anterior superior iliac
spine to the umbilicus.
4.
Check for Murphy sign, which is inspiratory arrest in
response to right upper quadrant (RUQ) palpation, seen in
acute cholecystitis.
5.
Check for rebound tenderness.
6.
Check for jar tenderness: pain elicited in the lower
area of the abdomen when the standing client drops from
standing on toes to the heels with a jarring landing.
7.
Palpate the back; note costovertebral angle tenderness.
8.
Check for the obturator sign, or abdominal pain in
response to passive internal rotation of the right hip from
a 90° angle hip–knee exion position. A positive sign indicates pain secondary to irritation of the obturator muscle
with an inamed appendix.
9.
Assess for the psoas sign, or increased abdominal pain
occurring when the client attempts to raise their right
thigh against the pressure of the clinician’s hand placed
over the client’s right knee. Pain is caused by inammation of the psoas muscle in acute appendicitis.
10.
Check for the Apley rule: The farther the pain from the
navel, the more likely it is organic in origin.
11.
Check for Rovsing sign, or pain in the RLQ on palpa-
tion of the left side, suggesting appendicitis.
12.
Anatomic variations of the appendix may lead to
differences in the location of the pain. For example,
the location of the appendix changes with pregnancy
(Figure 11.1); a retrocecal appendix (inflamed appendix located behind thececum) may lead to right groin
pain.
13.
Perform rectal or pelvic examination if needed. Clients
may have right-sided pain with a subcecal or pelvic
appendix.
DIAGNOSTIC
A.
Serum human chorionic gonadotropin: Pregnancy should
TESTS
be excluded in all clients of childbearing age. Assume that
the client is pregnant until proven otherwise.
B.
Complete blood count with differential.
C.
C-reactive protein.
D.
Urinalysis to rule out urinary disorders.
E.
Abdominal ultrasonography; any person with trauma to
the abdomen should have an abdominal ultrasound.
F.
CT scan with or without contrast.
G.
MRI may be used as an alternative diagnostic test in preg-
nancy to avoid exposure to ionizing radiation.
H.
Stool guaiac test for occult blood.
ID:c0011-ti0145
ID:c0011-p1675
ID:c0011-p1680
ID:c0011-p1685
ID:c0011-p1690
ID:c0011-p1695
ID:c0011-p1700
ID:c0011-p1705
ID:c0011-p1710
ID:c0011-p1715
ID:c0011-p1720
ID:c0011-p1725
ID:c0011-p1730
ID:c0011-p1735
ID:c0011-p1740
ID:c0011-p1745
ID:c0011-p1750
ID:c0011-p1755
ID:c0011-p1760
ID:c0011-p1765
ID:c0011-p1770
ID:c0011-p1775
ID:c0011-p1780
ID:c0011-ti0150
ID:c0011-p1785
ID:c0011-p1790
ID:c0011-p1795
ID:c0011-p1800
ID:c0011-p1805
ID:c0011-p1810
ID:c0011-p1815
ID:c0011-p1820
ID:c0011-ti0155
ID:c0011-p1825
ID:c0011-ti0160
ID:c0011-p1830
ID:c0011-ti0165
ID:c0011-p1835
ID:c0011-p1840
ID:c0011-p1845
ID:c0011-p1850
ID:c0011-p1855
ID:c0011-p1860
ID:c0011-p1865
ID:c0011-p1870
ID:c0011-p1875
ID:c0011-p1880
ID:c0011-p1885
ID:c0011-p1890
ID:c0011-p1895
ID:c0011-p1900
9 months
ID:c0011-p1630
https://t.me/med1917
6 months
X
3 months
APPENDICITIS
2.
Surgical management: Open versus laparoscopic
appendectomy is the standard treatment for acute
appendicitis.
B.
Client teaching: See Client Teaching Guides for this chapter,
“Abdominal Pain: Adults” and “Abdominal Pain: Children.”
C.
Pharmaceutical therapy:
1.
Antibiotics are used to treat uncomplicated, nonsurgi-
cal appendicitis; however, there is a 5% to 15% rate of complications and a 15% to 30% recurrence rate. More studies
are needed to determine the efcacy of antibiotic therapy
alone. Prophylactic antibiotics are also used perioperatively and postoperatively to prevent wound infection and
intra-abdominal abscess following appendectomy.
2.
Do not give antipyretics to mask fever.
3.
Do not administer cathartics because they may cause
rupture.
FOLLOW-UP
A.
Postoperative follow-up is with the surgeon.
333
McBurney’s
point
FIGURE
11.1 The position of the appendix is
altered during pregnancy, and likewise for the
site of incision to gain access.
DIFFERENTIAL
A.
The appendix has no xed position. The duration of pain
DIAGNOSES
can signicantly help in narrowing the differential diagnosis.
Nonspecic dysfunctional abdominal pain and psychogenic
abdominal pain are diagnoses of exclusion.
1.
Appendicitis.
2.
Regional enteritis.
3.
Leaking aneurysm.
4.
Ruptured ectopic pregnancy.
5.
Ovarian cyst.
6.
Ovarian torsion.
7.
Pelvic inammatory disease.
8.
Mittelschmerz (ovulatory bleeding or pain).
9.
Endometriosis.
10.
Ureteral calculi.
11.
Incarcerated, strangulated groin hernia.
12.
Meckel diverticulitis.
13.
Abdominal wall hematoma.
14.
Bowel obstruction.
15.
Intestinal malrotation.
16.
Intussusception.
17.
Testicular torsion.
18.
Inammatory bowel disease.
19.
Parasites.
20.
IUD.
21.
Constipation.
PLAN
A.
General interventions:
1.
Consult with the surgeon and prepare the client for
admission to the hospital for surgery.
CONSULTATION/REFERRAL
A.
Surgical consultation and possible emergency transport
and hospitalization are often required.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Any abdominal pain or bleeding in the rst 8 weeks
after a missed menstrual period must be considered a
symptom of possible ectopic pregnancy.
2.
The identication of intra-abdominal masses may be
compromised by the enlarged uterus, but this problem
may be partially obviated by examining the client in the
lateral position.
3.
The intestinal tract is progressively displaced upward,
outward, and backward during pregnancy; bowel sounds
are best heard lateral or superior to the uterus.
B.
Pediatrics:
1.
The caregiver’s lap makes the best examining surface.
It is much better than having the child lie xed and supine
on a table.
2.
If possible, examine the infant’s abdomen during a
time of relaxation and quiet. It is often best to do this at the
start of the overall examination, especially before initiating any procedure that might cause distress. Allowing the
infant to suck on a bottle or pacier may help relax them.
3.
Tenderness or pain on palpation may be difcult to
detect in the infant. However, pain and tenderness are
assessed by such behaviors as change in the pitch of crying, facial grimacing, rejection of the opportunity to suck,
and drawing knees to the abdomen with palpation.
4.
Intestinal malrotation must be considered when a
healthy infant suddenly refuses to eat, vomits, becomes
inconsolable, and develops abdominal distention.
5.
Young children have inaccurate body perceptions and
are inaccurate historians, so rely on caregivers and examination for data, and consider psychosocial aspects such as
childcare and child abuse.
6.
Intussusception presents as paroxysmal, colicky pain,
and the infant often has currant-jelly stools, a palpable
RUQ, abdominal mass, and ultimately distention.
C.
Adults:
1.
Obesity distorts the abdominal examination, making
organ palpation or pelvic examination difcult.
2.
Immunocompromised clients are susceptive to infec-
tion. They may not exhibit the typical signs and symptoms
334
ID:c0011-p1905
ID:c0011-p1910
ID:c0011-p1915
ID:c0011-p1920
ID:c0011-p1925
ID:c0011-p1930
ID:c0011-ti0170
ID:c0011-ti0175
ID:c0011-ti0180
ID:c0011-p1935
ID:c0011-p1940
ID:c0011-p1945
ID:c0011-p1950
ID:c0011-p1955
ID:c0011-p1960
ID:c0011-ti0185
ID:c0011-p1965
ID:c0011-p1970
ID:c0011-p1975
ID:c0011-ti0190
ID:c0011-p1980
ID:c0011-p1985
ID:c0011-p1990
ID:c0011-p1995
ID:c0011-p2000
ID:c0011-p2005
ID:c0011-p2010
ID:c0011-ti0195
ID:c0011-p2015
ID:c0011-p2020
ID:c0011-p2025
ID:c0011-p2030
ID:c0011-p2035
ID:c0011-p2040
ID:c0011-p2045
ID:c0011-p2050
ID:c0011-p2055
ID:c0011-p2060
ID:c0011-p2065
https://t.me/med1917
11: GASTROINTESTINAL GUIDELINES
of appendicitis, but rather show only mild tenderness on
examination.
3.
To make a diagnosis in the immunocompromised cli-
ent, a CT examination is useful.
D.
Geriatrics:
1.
The elderly tend to have a diminished inammatory
response, resulting in a less remarkable history and physical examination. Be aware of vague symptoms, such as
milder pain, less pronounced fever, and leukocytosis with
shift to left on differential.
2.
Confusion is a common presenting symptom.
3.
A redundant sigmoid colon may also cause right-sided
pain from sigmoid disease.
4.
Prompt CT scan is used for diagnosis and differential.
BIBLIOGRAPHY
American College of Obstetricians and Gynecologists. (2018). Tubal
ectopic pregnancy. Clinical Management Guidelines for Obstetrician–
Gynecologists, 193(2018), 1e–10e. https://www.acog.org/Clinical-
Guidance-and-Publications/Practice-Bulletins/Committeeon-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy?
IsMobileSet=false
Martin, R. F. (2021, January 19). Acute appendicitis in adults: Clinical mani-
festations and differential diagnosis. UpToDate. https://www.uptodate.
com/contents/acute-appendicitis-in-adults-clinical-manifestationsand-differential-diagnosis
Smink, D., & Soybel, D. I. (2019, April 1). Management of acute appendi-
citis in adults. UpToDate. https://www.uptodate.com/contents/
management-of-acute-appendicitis-in-adults?topicRef=1386&source
=see_link
Wickramasinghe, D.P., Xavier, C., & Samarasekera, D.N. (2021). The
Worldwide epidemiology of acute appendicitis: An analysis of the
global health data exchange dataset. World Journal of Surgery, 45, 1999–
2008. https://doi.org/10.1007/s00268-021-06077-5
CELIAC
DISEASE
DEFINITION
A.
Celiac disease, previously known as celiac sprue, is an auto-
immune disorder triggered by a well-dened environmental
factor, gluten. Celiac disease is a permanent sensitivity to gluten; specically, affected people are unable to tolerate gliadin,
the alcohol-soluble fraction of gluten. Three cereals contain
gluten and are considered toxic to clients with celiac disease:
wheat, rye, and barley. The disease primarily affects the small
intestine and is characterized by mucosal inammation, villous atrophy, and crypt hyperplasia that occur upon exposure
to dietary gluten. Onset of symptoms depends on the amount
of gluten in the diet. Dietary nonadherence is the chief cause
of persistent or recurrent symptoms (see Appendix B, Table
B.5).
B.
Celiac disease is one of the most common causes of chronic
malabsorption as a result of injury to the small intestine,
with loss of absorptive surface area, reduction of digestive
enzymes, and consequential impaired absorption of micronutrients such as fat-soluble vitamins, iron, and potentially vitamin B12 and folic acid.
C.
Celiac disease is strongly associated with autoimmune
conditions, including type 1 diabetes, Addison disease, and
thyroiditis, as well as genetic syndromes, including Down
syndrome, Williams syndrome, and Turner syndrome.
Complications from celiac disease include osteopenia, osteoporosis, infertility, short stature, delayed puberty, anemia, gastrointestinal (GI) malignancies, and non-Hodgkin lymphoma
(NHL).
D.
After GI symptoms, the second most common manifesta-
tion of celiac disease in clients with type 1 diabetes is diminished or impaired bone mineralization.
E.
Celiac disease is the most common cause of steatorrhea
in people older than 50 years and the second most common
cause in people older than 65 years.
F.
A substantial number of clients are misdiagnosed as hav-
ing irritable bowel syndrome (IBS) for years before the diagnosis of celiac disease is made.
INCIDENCE
A.
Celiac disease can occur at any stage of life. The preva-
lence of celiac disease in children is unknown. Its prevalence is approximately 1% of the general population in
North America. The highest incidence (5%) is noted in the
sub-Saharan African population. The true incidence is undetermined due to asymptomatic disease and underdiagnosis.
It is estimated that 75% of those affected by celiac disease
remain underdiagnosed or misdiagnosed.
B.
Screening of the general population is not recommended.
C.
Newly diagnosed clients with celiac disease should inform
their rst-degree family members of their increased risk of
celiac disease and the American College of Gastroenterology
(ACG) recommendation for testing.
PATHOGENESIS
A.
Interactions between gluten and immune and genetic fac-
tors result in celiac disease. Gluten is poorly digested. The
enzyme tissue transglutaminase (tTG) is the autoantigen
against which abnormal immune response is directed. The
immune responses promote an inammatory reaction. Celiac
disease primarily affects the mucosal layer of the small intestine. The classic celiac lesion is noted in the proximal small
intestine.
B.
A hallmark on histology is the presence of villous atro-
phy. The Marsh classication is used to describe the progressive histologic stages of celiac disease. Marsh 1 and Marsh 2
may be seen in sow and cow’s milk allergies:
1.
Marsh 0: preinltrative stage (normal).
2.
Marsh 1: inltrative lesion (increased intraepithelial
lymphocytes).
3.
Marsh 2: hyperplastic lesion (type 1 plus hyperplastic
crypts).
4.
Marsh 3: destructive lesion (type 2 plus villous atrophy of
progressively more severe degrees [termed 3a, 3b, and 3c]).
5.
Marsh 4 (atrophic-hypoplastic): total villous atrophy,
crypt hypoplasia.
PREDISPOSING
A.
Female.
B.
May be precipitated by an infectious diarrheal episode or
FACTORS
other intestinal disease (e.g., rotavirus).
C.
Genetic disorders:
1.
Down syndrome (8%–12%).
2.
Type 1 diabetes (10%).
3.
Turner syndrome (2%–10%).
4.
Williams syndrome (8.2%).
D.
Strong hereditary component (10% in rst-degree
relatives).
E.
The introduction of gluten before 4 months of age is associ-
ated with increased disease development.
F.
Autoimmune thyroiditis.
G.
Selective immunoglobulin A (IgA) deciency.
COMMON
ID:c0011-ti0200
ID:c0011-p2070
ID:c0011-p2075
ID:c0011-p2080
ID:c0011-p2085
ID:c0011-p2090
ID:c0011-p2095
ID:c0011-p2100
ID:c0011-p2105
ID:c0011-p2110
ID:c0011-p2115
ID:c0011-ti0205
ID:c0011-p2120
ID:c0011-p2125
ID:c0011-p2130
ID:c0011-p2135
ID:c0011-p2140
ID:c0011-p2145
ID:c0011-p2150
ID:c0011-p2155
ID:c0011-p2160
ID:c0011-p2165
ID:c0011-p2170
ID:c0011-p2175
ID:c0011-p2180
ID:c0011-p2185
ID:c0011-p2190
ID:c0011-p2195
ID:c0011-p2200
ID:c0011-p2205
ID:c0011-p2210
ID:c0011-p2215
ID:c0011-ti0210
ID:c0011-p2220
ID:c0011-p2225
ID:c0011-p2230
ID:c0011-p2235
ID:c0011-p2240
ID:c0011-p2245
ID:c0011-ti0215
ID:c0011-p2250
ID:c0011-p2255
ID:c0011-p2260
ID:c0011-p2265
ID:c0011-p2270
ID:c0011-p2275
ID:c0011-p2280
ID:c0011-p2285
ID:c0011-p2290
ID:c0011-p2295
ID:c0011-p2300
ID:c0011-p2305
ID:c0011-p2310
ID:c0011-p2315
ID:c0011-p2320
ID:c0011-ti0220
ID:c0011-p2325
ID:p20211001ID:c0011-p2330ID:c0011-p2335ID:c0011-p2340ID:c0011-p2345ID:c0011-p2350ID:c0011-p2355ID:c0011-p2360ID:c0011-p2365ID:c0011-p2370ID:c0011-p2375ID:c0011-p2380ID:c0011-p2385ID:c0011-p2390ID:c0011-p2395ID:c0011-p2400ID:c0011-p2405ID:c0011-p2410ID:c0011-p2415ID:c0011-p2420ID:c0011-p2425ID:c0011-p2430ID:c0011-p2435ID:c0011-p2440ID:c0011-p2445ID:c0011-p2450ID:c0011-p2455ID:c0011-p2460ID:c0011-p2465ID:c0011-p2470ID:c0011-p2475ID:c0011-p2480ID:c0011-p2485ID:c0011-p2490
ID:c0011-p2495
ID:c0011-p2620
ID:c0011-p2625
https://t.me/med1917
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
OTHER
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
SUBJECTIVE
A.
B.
C.
COMPLAINTS
Asymptomatic.
Chronic diarrhea or explosive watery diarrhea.
Foul-smelling voluminous stools.
Anorexia.
Abdominal distention.
Abdominal pain.
Poor weight gain or weight loss.
Vomiting.
Steatorrhea (malabsorption of ingested fat).
Refusal to eat (children).
SIGNS AND SYMPTOMS
Behavioral changes, including irritability.
Dehydration.
Lethargy.
Constipation.
Failure to thrive (FTT).
Short stature and delayed puberty.
Dermatitis herpetiformis.
Arthritis.
Seizures.
Weakness and fatigue.
Dental enamel hypoplasia of permanent teeth.
Iron-deciency anemia unresponsive to treatment.
Bruising/bleeding tendency.
Osteopenia/osteoporosis.
Hair loss.
Lactose intolerance.
Aphthous stomatitis.
Ataxia.
Neuropathy.
Migraines/headaches.
DATA
Review the onset, duration, course, and type of symptoms.
Review the client’s weight history.
Evaluate family history for celiac disease or members with
similar histories.
D.
Review current medications and drug history, especially
antibiotic, laxative, and herbal products.
E.
Review bowel habits and note changes: constipation, diar-
rhea, anorexia, and/or food intolerance.
F.
Review the client’s tolerance of lactose products.
PHYSICAL
A.
Check vital signs, including height and weight. Follow
EXAMINATION
serial weights and plot serial height/weight on growth charts.
CELIAC DISEASE
B.
Inspect:
1.
Observe general overall appearance.
2.
Oral examination to evaluate for glossitis, dry mucosal
335
membranes (dehydration), and presence of oral aphthae.
3.
Examine the skin for presence of dermatitis herpeti-
formis: a blistering rash involving the scalp, neck, elbows,
knees, and buttocks.
4.
Evaluate the abdomen for presence of bloating and
protuberant “potbelly.”
5.
Evaluate the client’s weight loss, including muscle
wasting.
C.
Auscultate:
1.
Bowel sounds in all four quadrants of the abdomen.
D.
Percuss:
1.
Abdomen: may present with tympanic sounds, espe-
cially in children.
E.
Palpate:
1.
Palpate the abdomen for masses, rebound tenderness,
and peritoneal signs.
a.
Before palpating the abdomen, ask the client to
bend their knees to help with relaxation of the wall
musculature.
2.
Perform a rectal examination, including testing stool
for occult blood.
DIAGNOSTIC
A. The
TESTS
conrmation of a diagnosis of celiac disease is based
on the combination of ndings from the medical history, physical examination, serology, and upper endoscopy, with histologic
analysis of multiple biopsies of the duodenum. All testing should
be performed while clients are following a gluten-rich diet.
1. Endoscopy for duodenal biopsies is the standard and a
critical component for diagnosing celiac disease.
2. Screening and monitoring tests for celiac disease (see
Table 11.1 for celiac disease tests and possible results):
a. tTG antibody, IgA class:
i. Primary test ordered to screen for celiac disease.
ii. Used for monitoring and evaluating the effec-
tiveness of treatment 6 to 12 months after initial
diagnosis and yearly thereafter.
iii. Antibody levels should fall when gluten is
removed from the diet.
b. Anti-tTG antibodies, immunoglobulin G (IgG).
c. Anti-tTG, IgG class.
d. Deamidated gliadin peptide antibodies (anti-DGP,
IgA).
e. Antigliadin antibodies (AGAs) IgG (gliadin is a
component of wheat-storage protein gluten).
TABLE
11.1 SOME CELIAC DISEASE TESTS AND POSSIBLE RESULTS
tTG, IgA Total IgA tTG, IgG DGP, IgA DGP, IgG Diagnosis
Positive Normal Not performed Not performed Not performed Presumptive celiac disease
Negative Normal Negative Negative Negative Symptoms not likely due to celiac
Negative Low Positive Negative Positive Possible celiac disease (false-negative
DGP,
deamidated gliadin peptide; IgA, immunoglobulin A; IgG, immunoglobulin G; tTG, tissue transglutaminase.
Source:
From American Association for Clinical Chemistry. (2018, October 28). Celiac disease antibody tests. Lab Tests Online. https://labtestsonline.org/tests/
celiac-disease-antibody-tests. Reprinted with permission from Lab Tests Online.
disease
anti-tTG, IgA, and anti-DGP, IgA are
due to total IgA deficiency)
336
ID:c0011-ti0225
ID:c0011-p2630
ID:c0011-p2635
ID:c0011-p2640
ID:c0011-p2645
ID:c0011-p2650
ID:c0011-p2655
ID:c0011-p2660
ID:c0011-p2665
ID:c0011-p2670
ID:c0011-p2675
ID:c0011-p2680
ID:c0011-p2685
ID:c0011-p2690
ID:c0011-ti0230
ID:c0011-p2695
ID:c0011-p2700
ID:c0011-p2705
ID:c0011-p2710
ID:c0011-p2715
ID:c0011-p2720
ID:c0011-p2725
ID:c0011-p2730
ID:c0011-p2735
ID:c0011-p2740
ID:c0011-p2745
ID:c0011-p2750
ID:c0011-p2755
ID:c0011-p2760
ID:c0011-p2765
ID:c0011-p2770
ID:c0011-p2775
ID:c0011-p2780
ID:c0011-p2785
ID:c0011-p2790
ID:c0011-ti0235
ID:c0011-p2795
ID:c0011-p2800
ID:c0011-p2805
ID:c0011-p2810
ID:c0011-p2815
ID:c0011-ti0240
ID:c0011-p2820
ID:c0011-p2825
ID:c0011-p2830
ID:c0011-ti0245
ID:c0011-p2835
ID:c0011-p2840
ID:c0011-p2845
ID:c0011-p2850
ID:c0011-p2855
https://t.me/med1917
11: GASTROINTESTINAL GUIDELINES
f. AGA IgA.
g. IgA endomysial antibody (EMA): less frequently
ordered; measures the same thing as the anti-tTG test.
h. Antireticulin antibody (ARA): rarely ordered.
i. Anti-F-actin: ordered if the disease has been diag-
nosed; evaluates the severity of intestinal damage; may
be used for monitoring.
3. Complete blood count and electrolytes.
4. Aspartate transaminase (AST) and alanine transami-
nase (ALT): Liver enzymes normalize on a gluten-free diet.
5. Prothrombin time (PT): may be prolonged with malab-
sorption of vitamin K.
6. C-reactive protein.
7. Erythrocyte sedimentation rate (ESR).
8. Total protein.
9. Albumin.
10. Calcium.
11. Iron, transferrin, and ferritin.
12. Vitamin B
and folate levels.
12
13. Thyroid screen: Autoimmune thyroid disorders and
hypothyroidism are common in the elderly.
14. Stool tests: culture, ova, and parasites; 72-hour fecal fat
collection to detect steatorrhea.
15. Fecal fat.
16. Bone density: Bone mineral density improves on a
gluten-free diet.
17. Human leukocyte antigens (HLA) haplotypes.
18. Colonoscopy if the client has bloody stools or symp-
toms of colitis.
19. Sweat test to exclude cystic brosis (CF).
20. Other testing specic to nutritional deciencies as
needed (vitamins D, B12, folate).
21. Radiograph, including barium swallow study with a
small bowel follow-through, is usually nonspecic and is
not indicated.
DIFFERENTIAL
A.
IBS.
B.
Lactose intolerance.
C.
Food allergies.
D.
Inammatory bowel disease:
1.
Crohn’s disease.
2.
Ulcerative colitis.
E.
Immunodeciency disorders.
F.
Gastroenteritis (viral or bacterial).
G.
Parasites.
H.
Fungal infection.
I.
Small intestinal bacterial overgrowth.
J.
Malabsorption.
K.
Lymphomas of the small intestine.
DIAGNOSES
PLAN
A.
General interventions:
1.
Nutritional therapy is the only accepted treatment for
celiac disease.
2.
Gluten-free dietary instructions should be given and
clients advised of the need to read all food labels.
3.
Genetic testing does not diagnose celiac disease.
4.
Screen for osteoporosis: As many as 70% of adult and
elderly clients with celiac disease have osteopenia.
5.
Gluten rechallenge is not generally recommended
unless the diagnosis remains uncertain.
a.
The rechallenge is not mandatory for clients with
good improvement of symptoms.
b.
HLA-DQ2/DQ8 genotyping for genetic risk factors
should be used to try to exclude celiac disease prior to
a formal gluten challenge.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Celiac Disease.”
1.
The ACG recommends a referral to a registered dieti-
tian so that the client can receive a thorough nutritional
assessment and education on a gluten-free diet. Stress that
“wheat-free” is not the same as “gluten-free.”
2.
A gluten-free diet should be maintained for life.
3.
Nutriguides “nutrition guides” apps are available from
the iTunes Store for iPhone and iPad and from Google Play
for Android products.
4.
Monitor for iron and vitamin deciencies because sub-
stitute ours are not fortied with B vitamins. Supplement
with iron, folate, and vitamin B12 as needed.
5.
Keep a food/symptom diary to help identify and elim-
inate trigger foods. See Appendix B, Table B.5.
6.
Gluten has been identied in dietary supplements,
over-the-counter medications, and nonfood items such
as lipstick and envelope adhesive, and in food items with
gluten additives such as condiments.
C.
Pharmaceutical therapy:
1.
Corticosteroids may be prescribed for rapid control of
symptoms: prednisone (Deltasone, Orasone, Sterapred):
a.
Adults: 30 to 40mg/d; taper off completely in 6 to 8
weeks.
b.
Pediatrics: 1 mg/kg/d; not to exceed 30 mg/d.
Taper off completely in 6 to 8 weeks. Children with
celiac disease are rarely given steroids.
2.
Bisphosphonates for osteoporosis should be addressed
for long-term therapy.
FOLLOW-UP
A.
After the diagnosis of celiac disease is made and a strict
diet has been started, follow up in 4 to 8 weeks or earlier if the
client has other comorbidities.
B.
The Celiac Disease Guideline Committee recommends the
measurement of tTG after 6 months of a gluten-free diet.
C.
Newly diagnosed clients with celiac disease should
undergo testing and treatment for micronutrient deciencies.
Deciency testing should include, but not be limited to, iron,
folic acid, vitamin D, and vitamin B12.
D.
Refer the client for dietary consultation with a nutritionist
with experience in gluten-free diets.
E.
Consider allergy testing.
CONSULTATION/REFERRAL
A.
If the gluten-free diet fails or the client experiences new
symptoms, a systematic evaluation is required.
B.
Endocrine consultation for clients with Hashimoto thy-
roiditis and celiac disease.
C.
Consultation with an adult/pediatric gastroenterologist.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Females with untreated celiac disease are at risk for
preterm birth, low birthweight babies, recurrent loss, and
reduced fertility.
B.
Pediatrics:
1.
Children may appear to have a “potbelly” with muscle
wasting from malnutrition.
2.
Monitor growth and development. Utilize a growth
chart to plot growth rates. As many as 10% of children
with idiopathic short stature may have celiac disease.
CHOLECYSTITIS
ID:c0011-p2860
ID:c0011-p2865
ID:c0011-p2870
ID:c0011-p2875
ID:c0011-p2880
ID:c0011-p2885
ID:c0011-p2890
ID:c0011-p2895
ID:c0011-p2900
ID:c0011-ti0250wID:c0011-p2905
ID:c0011-p2910
ID:c0011-p2915
ID:c0011-p2920
ID:c0011-ti0255
ID:c0011-ti0260
ID:c0011-ti0265
ID:c0011-p2925
ID:c0011-ti0270
ID:c0011-p2930
ID:c0011-p2935
ID:c0011-ti0275
ID:c0011-p2940
ID:c0011-p2945
ID:c0011-p2950
ID:c0011-p2955
ID:c0011-p2960
ID:c0011-ti0280
ID:c0011-p2965
ID:c0011-p2970
ID:c0011-p2975
ID:c0011-p2980
ID:c0011-p2985
ID:c0011-p2990
ID:c0011-p2995
ID:c0011-p3000
ID:c0011-p3005
ID:c0011-p3010
ID:c0011-p3015
ID:c0011-p3020
ID:c0011-p3025
ID:c0011-p3030
ID:c0011-p3035
ID:c0011-p3040
ID:c0011-p3045
ID:c0011-p3050
ID:c0011-p3055
ID:c0011-p3060
ID:c0011-p3065
ID:c0011-p3070
ID:c0011-p3075
ID:c0011-ti0285
ID:c0011-p3080
https://t.me/med1917
337
3.
Breastfeeding has a protective role even if gluten is
introduced while breastfeeding.
4.
Biliary sludge and/or gallstones are likely to form in
one in ve children with hemolytic anemia before the adolescent years.
C.
Geriatrics:
1.
The elderly may present with nonspecic GI symp-
toms, abdominal discomfort, bloating, constipation, or
dyspepsia.
2.
Diarrhea may be mild or intermittent in the elderly.
3.
Iron-deciency anemia may also be a presenting symp-
tom. Anemia is present in 60% to 80% of elderly clients
with celiac disease.
4.
The elderly are at increased risk for falls related to
osteopenia, ataxia, and neuropathy.
5.
Autoimmune thyroid disorders are common with
elderly clients with celiac disease. The majority present
with hypothyroidism.
6.
The risk for NHL is increased in people with celiac dis-
ease aged 50 years and older.
RESOURCES
ww.celiac.com
w
ww.celiac.com/categories/Gluten-Free--Recipes-c-3400.html
w
ww.celiac.org
w
ww.gluten-freedrugs.com
BIBLIOGRAPHY
Hammer, H., & Hogenauer, C. (2020). Lactose intolerance: Clinical mani-
festations, diagnosis, and management. UpToDate. https://www.upt
odate.com/contents/lactose-intolerance-clinical-manifestationsdiagnosis-and-management
Husby, S., Murray, J. A., & Katzka, D. A. (2019). AGA clinical prac-
tice update on diagnosing and monitoring of celiac disease:
Changing utility of serology and histologic measures: Expert review.
Gastroenterology, 156(4), 885–889. https://doi.org/10.1053/j.gastro.20
18.12.010
Kelly, C. P. (2021, March 4). Diagnosis of celiac disease in adults. UpToDate.
https://www.uptodate.com/contents/diagnosis-of-celiac-diseasein-adults
University of Chicago Celiac Disease Center. (n.d). Gluten free diet. http://
www.celiacdisease.net/glutenfree-diet
CHOLECYSTITIS
DEFINITION
A.
Cholecystitis is acute or chronic inammation of the
gallbladder. Acute cholecystitis has associated stone formation (cholelithiasis) in 90% of all cases, causing obstruction and inammation. Biliary sludge is a feature of chronic
cholecystitis.
INCIDENCE
A.
Gallstones affect approximately 10% to 20% of Americans,
and one-third of these people develop acute cholecystitis.
The exact frequency of cholecystitis in children is not known,
but the overall incidence in children has increased in the past
three decades due to high fat consumption. Most clients with
an acute attack of cholecystitis have complete remission in
1 to 5 days; however, approximately 20% require surgical
intervention. Mortality related to acute cholecystitis is 5% to
10%, with the highest risk in clients older than 60 years. The
most common complication is the development of gallbladder
gangrene in up to 20% of cases, with the potential for subsequent perforation in approximately 10% of cases. Gangrenous
cholecystitis is most common in older clients, clients with diabetes, and clients who delay treatment.
B.
Cholecystectomy for recurrent biliary colic or acute cho-
lecystitis is the most common major surgical procedure performed by general surgeons.
PATHOGENESIS
A.
Cholecystitis occurs subsequent to bile stasis, bacterial
infection, ischemia, or obstruction by a gallstone. Acute cholecystitis is related to the impaction of a calculus in the neck of
the gallbladder in approximately 90% of cases. This can lead
to gallbladder distention and compromise of blood ow and
lymphatic drainage, leading to mucosal ischemia and necrosis. Spontaneous resolution may occur after the reestablishment of cystic duct patency.
B.
Escherichia coli is the primary microorganism in 80% of
cholecystitis infections.
C.
Estrogen-induced alteration in bile salts may favor stone
formation. Stones occur when cholesterol supersaturates
the bile in the gallbladder and precipitates out of the bile.
Cholesterol stones are the most common type of gallstones in
the United States.
D.
Pigment stones occur when free bilirubin combines with
calcium. Pigment stones are found in clients with cirrhosis,
hemolysis, and infections in the biliary tree.
E.
Acalculous cholecystitis is associated with infection and
local inammation. Formation of gallstones is not necessary
for the obstruction of the bile duct.
PREDISPOSING
A.
Female.
B.
Ethnic groups: Northern European and Hispanic.
C.
Sudden starvation/prolonged fasting.
D.
Medications:
1.
Cholesterol-lowering drugs: Stone formation increases
FACTORS
in users of cholesterol-lowering drugs, which are known
to increase biliary cholesterol saturation.
2.
Estrogen usage (oral contraceptives [OCPs] and hor-
mone replacement therapy [HRT]): Stone formation
increases in users of contraceptives and estrogens, which
are known to increase biliary cholesterol saturation.
3.
Furosemide.
4.
Ceftriaxone.
5.
Cyclosporine.
6.
Opiate narcotic analgesics.
7.
Octreotide.
E.
Bile acid malabsorption.
F.
Genetic predisposition: Native Americans and those of
Chinese or Japanese descent have a high incidence.
G.
Total parenteral nutrition (TPN).
H.
Obesity.
I.
Status post bariatric surgery.
J.
Pregnancy secondary to elevated progesterone.
K.
Increased age.
L.
Hemolytic anemia.
M.
Diabetes.
N.
High serum triglyceride and low high-density lipoprotein
(HDL) levels.
O.
High-caloric and rened-carbohydrate diet.
P.
Cirrhosis, Crohn’s disease, and gallbladder stasis.
COMMON
A.
COMPLAINTS
Abrupt, severe abdominal pain lasting 24 hours.
Соседние файлы в папке Библиотека им академика М.И. Перельмана