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HOME CARE PADA

PENYAKIT
GASTROINTESTINAL
FA R DA H A KI L
DI V I SI G E H DE PA RTEMEN I P D F K UN HAS
2016

Pelatihan Home Care Dokter Umum, RSUH 22 September 2016


Introduction
Major function of GI tract :
Processing the fluid and
nutrition consume with
efficiency
Elimination of wasting
products

Disturbance of the function



Symptoms & Sign of GI tract
Sign & Symptoms of GI tract
Heartburn & Non-cardiac chest pain
Dysphagia & odynophagia
Dyspepsia
Nausea & Vomiting
Bloating & Early satiety
Abdominal pain
Diarrhea
Constipation
Anorexia & Eating disorders
Bleeding Intrinsic properly from gastrointestinal tract or
manifestation of systemic disease
HC pada Penyakit Saluran Cerna
GEH
Keluhan :
- Perdarahan Saluran Cerna Atas
Disfagia
- Perdarahan Saluran Cerna Bawah
Dispepsia
- Diare Akut
Diare akut
- Akut ileus Paralitik
Perdarahan GI : hematemesis-melena-
hematokezia - Akut Obstruksi Kolon
Nyeri abdomen
Dysphagia & Odynophagia
DYSPHAGIA: difficulty or delay in preparation and/or passage of a liquid or
solid food bolus that is sensed by patient within 10s of the initiation of a
swallow attempt
Divided into oropharyngeal & esophageal

ODYNOPHAGIA : a pain or burning sensation directly associated with


swallowing especially acidic and spicy foods or those at temperature extremes.

Globus sensation : constant or intermittent


sensation of a lump, fullness or pressure in
the throat or neck
oropharyngeal dysphagia esophageal dysphagia
- inability to initiate the swallowing process - involves disorders of the smooth muscle of
the esophagus
- may involve disorders of striated muscle
- symptoms within seconds of the Initiation of
- There may be a sensation of solids or liquids swallowing
left in the pharynx.
Etiology of
oropharyngeal
dysphagia
Etiology of
esophageal dyphagia
Diagnostic
algorithm for the
symptomatic
assessment of the
patient with
dysphagia
Approach to
management of total
dysphagia
Nausea & Vomiting
NAUSEA : unpleasant VOMITING : the forceful
sensation of the imminent oral expulsion of gastric
need to vomit. - usually contents associated with
comprise epigastric contraction of the
discomfort as well as abdominal & chest wall
generalized feeling of muscle.
sickness - Usually preceded by and
associated with retching
Causes of
acute
vomiting.
Examination
Signs of dehydration dry tongue, decreased Other important clinical features to look out
skin turgor, postural hypotension. for include:
Smell of alcohol or ketones on the breath. Signs of uremia sallow appearance,
pericardial rub.
Abdominal examination for signs of
peritonism, gastric stasis, or acute intestinal Signs of hypoadrenalism pigmentation,
obstruction. A succession splash is postural hypotension.
suggestive of gastric outlet obstruction.
Characteristic skin blisters of acute
CNS signs of meningism, nystagmus or intermittent porphyria.
papilledema.
Management of acute nausea
and vomiting
A threestep approach is advocated:
1 Correction of any complications of vomiting such as dehydration and
acid/electrolyte abnormalities.
2 Targeted therapy of identified cause of vomiting.
3 Symptomatic treatment if necessary.
Fluid replacement Antiemetic drugs
If the patient is dehydrated and cannot These agents are useful in the acute phase in
tolerate oral fluids, intravenous fluid the majority of cases of acute vomiting where
replacement using normal saline should be the underlying etiology is not clear but urgent
started. symptomatic relief is necessary.
Potassium supplements may be required in In some cases, more than one agent may be
patients with gastric outlet obstruction or if required.
the vomiting has been associated with
prolonged diarrhea.
Classes of antiemetic drug and Clinical uses of different antiemetics
Prochlorperazine Cyclizine
- Oral prochlorperazine 20 mg initially It can cause drowsiness and should be used
followed by 10 mg after 2 hours. For with caution in the elderly
prevention, give 510 mg 23 times daily.
- severe vomiting or in patients who cannot
- Sublingual (BuccastemR) a 3 mg tablet can tolerate oral medication, give 50 mg stat either
be placed high up between the upper lip and by intramuscular or intravenous injection and
gums and left to dissolve. Recommended this can be repeated 8hourly.
dosage is 12 tablets twice daily.
- less severe vomiting, oral dose 50 mg
- Suppository: 25 mg suppository followed by 8hourly can be given.
oral dose after 6 hours if necessary.
- Injection give 12.5 mg stat by deep im
followed by oral dose after 6 hours if
necessary
Domperidone and metoclopramide Ondansetron
Also function as prokinetic agents. If all above fail
Metoclopramide is contraindicated in
gastrointestinal obstruction and perforation. - 4 mg dose either by intramuscular or
intravascular injection.
- Domperidone can be given orally (1020 mg)
or rectally (3060 mg) every 48 hours. - 16 mg suppositories

-Alternatively, give metoclopramide 10 mg, - If vomiting is controlled after the initial dose,
either oral or injections the oral form can be given up to a daily
(intramuscular/intravenous) every 8 hours. maximum dose of 32 mg in the 4 or 8 mg
tablet form.
DYSPEPSIA

A board spectrum of symptoms consist of pain or discomfort


centered in the upper abdomen (UGI tract), for at least 12
weeks in the last 12 months (ROME III Criteria)
The term of dyspepsia are not used if the symptoms
occur outside of UGI disorders, such as :
Biliary disease
Pancreatitis
Malabsorbsion syndrome
Metabolic syndrome
CLASSIFICATION 2. FUNCTIONAL DYSPEPSIA/
NON-ULCER DYSPEPSIA
1. ORGANIC DYSPEPSIA The absence of any organic,
systemic, or metabolic disease
Peptic ulcer, (include upper endoscopy) that
Gastroduodenitis, UGI cancer could explain the symptoms.
2 subtype (Rome III criteria) :
1. Post-prandial distress syndrome
(bothersome post-prandial
fullness, early satiation)
2. Epigastric pain syndrome
(pain & burning intermitten-
localized to the epigastrium)
DIAGNOSIS Discomfort refers a subjective
sensation not interpret as pain
which may characterized by or
Anamnesis : chronic/recurrent associated w/ abdominal fullness,
pain/discomfort centered in early satiety, bloating, belching,
upper abdomen nausea, vomiting.
Centered refers to pain or discomfort
Diagnostic study : Endoscopy in or around the midline
UGI as gold standard

ENDOSCOPIC examination was using an


Alarm Symptoms as criteria guide
ALARM SYMPTOMS
Age treshold 45 years old
Persistent anorexia/ vomiting
Bleeding UGI (haematemesis/melena) or anemia without knowing the
source
Unintentional weight loss
Dysphagia-odynophagia
jaundice
Abdominal mass or lymphadenopathy
Patients anxious because of the symptoms appearing off and on or
persistent (psychoneurosis)
DIFFERENTIAL DIAGNOSIS
1. GERD and Nonerosive reflux disease
2. Peptic ulcer disease
3. Upper GI malignancy
4. Chronic intestinal ischemia
5. Pancreatobiliary disease
6. Motility disorders

24
MANAGEMENT

GENERAL MEASURES

1. Education & reassurance


2. Diet alteration and lifestyle modification
- avoid fatty or heavilly spiced food & excessively large meal
- smaller, more frequent meals
- minimize alcohol and caffein intake
- reguler exercise & adequate restful sleep
- cognitive behavioral therapy (CBT), psychotherapy
25
PHARMACOTHERAPY

- Antisecretory agents (4-8 weeks)


H2 receptor antagonis (ranitidine, cimetidine, famotidine)
Proton Pump Inhibitor (omeprazole,lansoprazole, rabeprazole,
pantoprazole, esomeprazole) >> H2RA
block acid secretion, suppress acid production
- Promotility agents (Prokinetic)
Metoclopramide, domperidone, cisapride, tegaserod
help increase stomach emptying or relaxation.
- Low-dose Antidepressants
Tricyclic antidepressant (amytriptylin, fluoxetin, desipramine)
affect how the brain and nerves process pain, improve stomach emptying and expansion to accommodate
food (these potential effects are being studied).

26
GUIDELINES FOR Dyspepsia, without heartburn

MANAGING DYSPEPSIA IN
Alarm symptoms
PRIMARY CARE Hp test and treat
Or > 45 y.o
Or empirical therapy

Empirical therapy, Specialist referral


Hp test and treat Endoscopy

a. Lifestyle modification
b. Empiric therapy :
PPI or H2RA x2-4 wk Hp negative Hp +ve (Eradication)

No adequate respons
Adequate respons Follow up not
Follow up Modify therapy Follow up treatment
succesfull succesfull

- Step up therapy : Increase dose or shift


to another drug class Alternative
- Prokinetic therapy regimen

Adequate respons : Succesfull No succesfull :


No adequate respons
Follow up treatment Specialist referral
Specialist referral Endoscopy
Regimen Eradication of Hp
PPI - PO bid + Clarithromycin 500
mg PO bid + Amoxicillin 1000 mg PO Alternative regimen after initial
bid or metronidazole 500 mg PO bid failure :
(10-14 days) PPI - PO bid + colloidal bismuth
Alternative regimen : subsalicylate/subcitrate 120mg PO
PPI - PO bid + Amoxicillin 1000 mg bid + Metronidazole 400-500mg PO
PO bid x 5 days, followed by bid + Tetracycline 500mg PO qid x 7
PPI-PO bid + Claritromycin 500mg + days
tinidazole 500 mg PO bid
FOLLOW UP
Offer low dose w/limited number of prescriptions or stopping
treatment
dyspepsia is remitting & relapsing disease, continuous medication is not necessary
after eradication of symptoms unless there is an underlying condition requiring
treatment
Continue to avoid known precipitants of dyspepsia including
smoking, alcohol, coffee,chocolate, fatty food and weight
bearing
Monitor for appearance of alarm sign/symptoms
When to consider referring a
dyspeptic patient to a specialist

If prompt investigation is required (such as


recent onset of alarm symptoms)
Severe pain
Failure of symptoms to resolve or
substantially improve after appropriate
treatment
Progressive symptoms
Acute Diarrhea
Diarrhea of < 2 weeks duration is most commonly caused by invasive or noninvasive pathogens
and their enterotoxins.
Acute noninflammatory diarrhea Acute inflammatory diarrhea

Watery, nonbloody. Blood or pus, fever.

Usually mild, self-limited. Usually caused by an invasive or toxin-


producing bacterium.
Caused by a virus or noninvasive bacteria.
Diagnostic evaluation requires routine stool
Diagnostic evaluation is limited to patients with bacterial cultures (including E coli O157:H7)
diarrhea that is severe or persists beyond 7 days. in all and testing as clinically indicated for
Clostridium difficile toxin, and ova and
Responding within 5 days to simple rehydration parasites.
therapy or antidiarrheal agents
Evaluation
If diarrhea worsens or persists for more than 7 days, stool should be sent for fecal leukocyte or
lactoferrin determination, ovum and parasite evaluation, and bacterial culture.
In patients with diarrhea that persists for more than 10 days, who have a history of travel to
areas where amebiasis is endemic, or who engage in oral-anal sexual practices, three stool
examinations for ova and parasites should also be performed.
Prompt medical evaluation is indicated in the following :
(1) Signs of inflammatory diarrhea manifested by any of the following: fever (> 38.5C), bloody
diarrhea, or severe abdominal pain.
(2) The passage of six or more unformed stools in 24 hours.
(3) Profuse watery diarrhea and dehydration.
(4) Frail older patients.
(5) Immunocompromised patients (AIDS, posttransplantation).
(6) Hospital-acquired diarrhea (onset following at least 3 days of hospitalization).
(7) Systemic illness.
Physical examination pays note :
- patients level of hydration, Hospitalization is required in patients with :
- mental status, and severe dehydration, marked abdominal pain,
- the presence of abdominal tenderness or or altered mental status.
peritonitis (Peritoneal findings may be
present in infection with C difficile or STEC).
Stool specimens should be sent for
examination for routine bacterial cultures
Treatment
Diet
Most mild diarrhea will not lead to dehydration provided the patient takes adequate oral fluids
containing carbohydrates and electrolytes.
Patients find it more comfortable to rest the bowel by avoiding high-fiber foods, fats, milk
products, caffeine, and alcohol.
Frequent feedings of tea, flat carbonated beverages, and soft, easily digested foods (eg, soups,
crackers, bananas, applesauce, rice, toast) are encouraged.
Rehydration
In more severe diarrhea, dehydration can occur quickly, especially in children, the frail, and the
elderly.
Oral rehydration with fluids containing glucose, Na+, K+, Cl, and bicarbonate or citrate is
preferred when feasible. A convenient mixture is . tsp salt (3.5 g), 1 tsp baking soda (2.5 g
NaHCO3), 8 tsp sugar (40 g), and 8 oz orange juice (1.5 g KCl), diluted to 1 L with water.
Alternatively, oral electrolyte solutions (eg, Pedialyte, Gatorade) are readily available.
Fluids should be given at rates of 50200 mL/kg/24 h depending on the hydration status.
Intravenous fluids (lactated Ringer injection) are preferred in patients with severe dehydration
Antidiarrheal Agents
Antidiarrheal agents may be used safely in patients with mild to moderate diarrheal illnesses to
improve patient comfort.
Opioid agents help decrease the stool number and liquidity and control fecal urgency. However,
they should not be used in patients with bloody diarrhea, high fever, or systemic toxicity and
should be discontinued in patients whose diarrhea is worsening despite therapy.
Loperamide is preferred, in a dosage of 4 mg orally initially, followed by 2 mg after each loose
stool (maximum: 16 mg/24 h).
Bismuth subsalicylate (Pepto-Bismol), two tablets or 30 mL orally four times daily, reduces
symptoms in patients with travelers diarrhea by virtue of its anti-inflammatory and antibacterial
properties. It also reduces vomiting associated with viral enteritis.
Anticholinergic agents (eg, diphenoxylate with atropine) are contraindicated in acute diarrhea
because of the rare precipitation of toxic megacolon.
Antibiotic Therapy
Empiric treatmentEmpiric antibiotic treatment of all patients with acute diarrhea is not
indicated. Even patients with inflammatory diarrhea caused by invasive pathogens usually have
symptoms that will resolve within several days without antimicrobials
Empiric treatment may be considered in patients with :
- nonhospital-acquired diarrhea with moderate to severe fever,
- tenesmus, or bloody stools or the presence of fecal lactoferrin while the stool bacterial culture
is incubating, provided that infection with STEC is not suspected.
- It should also be considered in patients who are immunocompromised or who have significant
dehydration.
The oral drugs of choice for empiric treatment are:
fluoroquinolones (eg, ciprofloxacin 500 mg, ofloxacin 400 mg, or norfloxacin 400 mg, twice daily,
or levofloxacin 500 mg once daily) for 57 days
Alternatives include trimethoprim-sulfamethoxazole, 160/800 mg twice daily; or doxycycline,
100 mg twice daily
Macrolides and penicillins are no longer recommended because of widespread microbial
resistance to these agents.
Rifaximin, a nonabsorbed oral antibiotic, 200 mg three times daily for 3 days, is approved for
empiric treatment of noninflammatory travelers diarrhea
Specific antimicrobial treatmentAntibiotics are not recommended in patients with
nontyphoid Salmonella, Campylobacter, Shiga-toxinproducing E coli, Aeromonas, or Yersinia,
except in severe disease, because they do not hasten recovery or reduce the period of fecal
bacterial excretion.
The infectious diarrheas for which treatment is recommended are shigellosis, cholera,
extraintestinal salmonellosis, listeriosis, travelers diarrhea, C difficile infection, giardiasis, and
amebiasis.
When to Admit
Severe dehydration for intravenous fluids, especially if vomiting or unable to maintain sufficient
oral fluid intake.
Bloody diarrhea that is severe or worsening in order to distinguish infectious versus
noninfectious cause.
Severe abdominal pain, worrisome for toxic colitis, inflammatory bowel disease, intestinal
ischemia, or surgical abdomen.
Signs of severe infection or sepsis (temperature > 39.5C, leukocytosis, rash).
Severe or worsening diarrhea in patients who are > 70 years old or immunocompromised.
Signs of hemolytic-uremic syndrome (acute kidney injury, thrombocytopenia, hemolytic
anemia).
Gastrointestinal Bleeding
Management
Check ABCs If upper GI bleed:
Airway Nasogastric tube and lavage (optional)
Breathing Check CBC, PT, PTT, INR, type and screen
Circulation Liver disease: FFP
2 large bore IVs: Kidney disease: DDAVP
Isotonic fluid or blood On anticoagulation: Stop
GI consult
Ligament of Treitz
Above = upper GI bleed Below = lower GI bleed
Hematemesis Bright red blood per rectum
Melena Hematochezia
Coffee ground emesis
Bright red bold per rectum (very rapid bleed)
Treatment
Initial stabilization, blood replacement, and triage are managed in the same manner as Acute
Upper Gastrointestinal Bleeding.
Therapeutic Colonoscopy
High-risk lesions (eg, angioectasias or diverticulum, rectal ulcer with active bleeding, or a visible
vessel) may be treated endoscopically with epinephrine injection, cautery (bipolar or heater
probe), or application of metallic endoclips or bands.
In diverticular hemorrhage with highrisk lesions identified at colonoscopy, rebleeding occurs in
half of untreated patients compared with virtually no rebleeding in patients treated
endoscopically.
Radiation proctitis is effectively treated with applications of cautery therapy to the rectal
telangiectasias, preferably with an argon plasma coagulator.
Intra-arterial Embolization
When a bleeding lesion is identified, angiography with selective embolization achieves immediate
hemostasis in more than 95% of patients. Major complications occur in 5% (mainly ischemic colitis)
and rebleeding occurs in up to 25%.
Surgical Treatment
Emergency surgery is required in < 5% of patients
indicated in patients with ongoing bleeding that requires more than 6 units of blood within 24 hours
or more than 10 total units in whom attempts at endoscopic or angiographic therapy failed. Most
such hemorrhages are caused by a bleeding diverticulum or angioectasia.
patients with two or more hospitalizations for diverticular hemorrhage depending on the severity of
bleeding and the patients other comorbid conditions.
Initial Evaluation & Treatment
Stabilization
assessment of the hemodynamic status. A systolic blood pressure < 100 mm Hg identifies a high-
risk patient with severe acute bleeding. A heart rate over 100 beats/min with a systolic blood
pressure over 100 mm Hg signifies moderate acute blood loss. A normal systolic blood pressure
and heart rate suggest relatively minor hemorrhage.
two 18-gauge or larger intravenous lines should be started prior to further diagnostic tests.
Blood is sent for complete blood count, prothrombin time with international normalized ratio
(INR), serum creatinine, liver enzymes, and blood typing and screening (in anticipation of need
for possible transfusion).
Patients with evidence of hemodynamic compromise are given 0.9% saline or lactated Ringer
injection and crossmatched for 24 units of packed red blood cells.
Central venous pressure monitoring is desirable in some cases, but line placement should not
interfere with rapid volume resuscitation.
Placement of a nasogastric tube is not routinely needed but may be helpful in the initial
assessment and triage of selected patients with suspected active upper tract bleeding.
Erythromycin (250 mg) administered intravenously 30 minutes prior to upper endoscopy
promotes gastric emptying and may improve the quality of endoscopic evaluation when
substantial amounts of blood or clot in the stomach is suspected.
Efforts to stop or slow bleeding by gastric lavage with large volumes of fluid are of no benefit
and expose the patient to an increased risk of aspiration.
Blood Replacement
The amount of fluid and blood products required is based on assessment of vital signs, evidence
of active bleeding from nasogastric aspirate, and laboratory tests.
packed red blood cells should be given to maintain a hemoglobin of 79 g/dL, based on the
patients hemodynamic status, comorbidities (especially cardiovascular disease), and presence
of continued bleeding.
the hemoglobin should rise approximately 1 g/dL for each unit of transfused packed red cells.
Transfusion of blood should not be withheld from patients with massive active bleeding
regardless of the hemoglobin value. It is desirable to transfuse blood in anticipation of the nadir
hematocrit.
In actively bleeding patients, platelets are transfused if the platelet count is under 50,000/mcL
and considered if there is impaired platelet function due to aspirin or clopidogrel use (regardless
of the platelet count).
Uremic patients (who also have dysfunctional platelets) with active bleeding are given three
doses of desmopressin (DDAVP), 0.3 mcg/kg intravenously, at 12-hour intervals.
Fresh frozen plasma is administered for actively bleeding patients with a coagulopathy and an
INR > 1.8; massive bleeding, 1 unit of fresh frozen plasma should be given for each 5 units of
packed red blood cells transfused.
Overtransfusion should be avoided as it leads to increased central and portal venous pressures,
increasing the risk of rebleeding.
Many patients with bleeding esophageal varices have coagulopathy due to underlying cirrhosis;
fresh frozen plasma (20 mL/kg loading dose, then 10 mg/kg every 6 hours) or platelets should be
administered to patients with INRs > 1.82.0 or with platelet counts < 50,000/mcL in the
presence of active bleeding.
Rockall Score for upper gastrointestinal bleeding.
Initial Triage : Clinical predictors of increased risk of rebleeding and death include age > 60
years, comorbid illnesses, systolic blood pressure < 100 mm Hg, pulse > 100 beats/min, and
bright red blood in the nasogastric aspirate or on rectal examination.
High riskPatients with active bleeding manifested by hematemesis or bright red blood on
nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid resuscitation,
serious comorbid medical illness, or evidence of advanced liver disease require admission to an
intensive care unit (ICU).
After adequate resuscitation, endoscopy should be performed within 224 hours in most
patients but may be delayed in selected patients with serious comorbidities (eg, acute coronary
syndrome) who do not have signs of continued bleeding.
Low to moderate riskAll other patients are admitted to a step-down unit or medical ward
after appropriate stabilization for further evaluation and treatment. Patients without evidence
of active bleeding undergo nonemergent endoscopy usually within 24 hours.
Subsequent Evaluation & Treatment
bleeding source is correct in only 40% of cases. Signs of chronic liver disease implicate bleeding
due to portal hypertension, but a different lesion is identified in 25% of patients with cirrhosis.
history of dyspepsia, NSAID use, or peptic ulcer disease suggests peptic ulcer. Acute bleeding
preceded by heavy alcohol ingestion or retching suggests a Mallory-Weiss tear, though most of
these patients have neither.
Upper Endoscopy all patients with upper tract bleeding should undergo upper endoscopy within
24 hours of arriving in the emergency department. The benefits of endoscopy in this setting are
threefold.
1. To identify the source of bleeding
2. To determine the risk of rebleeding and guide triage
Patients with a nonbleeding Mallory-Weiss tear, esophagitis, gastritis, and ulcers that have a
clean, white base have a very low risk (< 5%) of rebleeding. who are < age 60 years, without
hemodynamic instability or transfusion requirement, without serious coexisting illness, and who
have stable social support may be discharged from the emergency department or medical ward
after endoscopy with outpatient follow-up.
All others with one of these low-risk lesions should be observed on a medical ward for 2448
hours. Patients with ulcers that are actively bleeding or have a visible vessel or adherent clot, or
who have variceal bleeding usually require at least a 3-day hospitalization with closer initial
observation in an ICU or step down unit.
3. To render endoscopic therapy Hemostasis can be achieved in actively bleeding lesions with
endoscopic modalities such as cautery, injection, or endoclips.
Acute Pharmacologic Therapies
1. Acid inhibitory therapyIntravenous proton pump inhibitors (esomeprazole or
pantoprazole, 80 mg bolus, followed by 8 mg/h continuous infusion for 72 hours) reduce the risk
of rebleeding in patients with peptic ulcers with high-risk features (active bleeding, visible
vessel, or adherent clot) after endoscopic treatment.
Oral proton pump inhibitors (omeprazole, esomeprazole, or pantoprazole 40 mg; lansoprazole
or dexlansoprazole 3060 mg) once or twice daily are sufficient for lesions at low-risk for
rebleeding (eg,esophagitis, gastritis, clean-based ulcers, and Mallory-Weiss tears).
2. OctreotideContinuous intravenous infusion of octreotide (100 mcg bolus, followed by 50
100 mcg/h) reduces splanchnic blood flow and portal blood pressures and is effective in the
initial control of bleeding related to portal hypertension. It is administered promptly to all
patients with active upper gastrointestinal bleeding and evidence of liver disease or portal
hypertension until the source of bleeding can be determined by endoscopy.
terlipressin 12 mg intravenous every 4 hours, may be preferred to octreotide for the treatment
of bleeding related to portal hypertension because of its sustained reduction of portal and
variceal pressures and its proven reduction in mortality.
Contraindicated in patients with significant coronary, cerebral, or peripheral vascular disease.
Antibiotic prophylaxisCirrhotic patients admitted with upper gastrointestinal bleeding have a >
50% chance of developing a severe bacterial infection during hospitalization such as bacterial
peritonitis, pneumonia, or urinary tract infection.
Most infections are caused by gram-negative organisms of gut origin.
Prophylactic administration of oral or intravenous fluoroquinolones (eg, norfloxacin, 400 mg
orally twice daily) or intravenous third-generation cephalosporins (eg, ceftriaxone, 1 g/d) for 57
days reduces the risk of serious infection to 1020% as well as hospital mortality.
Other Treatment
1. Intra-arterial embolizationAngiographic treatment is used in patients with persistent
bleeding from ulcers, angiomas, or Mallory-Weiss tears who have failed endoscopic therapy and
are poor operative risks.
2. Transvenous intrahepatic portosystemic shunts (TIPS)Placement of a wire stent from the
hepatic vein through the liver to the portal vein provides effective decompression of the portal
venous system and control of acute variceal bleeding. It is indicated in patients in whom
endoscopic modalities have failed to control acute variceal bleeding.
Abdominal Pain
Abdominal Pain by the Quadrant
Comparison of
symptoms of
common causes
of acute
abdominal pain.
Management
Management
If the patient is shocked, he or she will need antibiotic therapy directed against gram
the following: negative and anaerobic bacteria. Regimens
can Include
- vigorous fluid resuscitation, initially via a
peripheral intravenous line with colloid 500 mL - cefotaxime 1 g 8hourly intravenously or
over 1530 minutes and then guided by Tazocin (piperacillin/tazobactam) 4.5 g 8
measurement of the central venous pressure; hourly plus gentamicin 80 mg 8hourly
intravenously (reduce dose in renal
- monitoring of urine output with a urinary impairment) plus metronidazole 500 mg
catheter; 8hourly intravenously;
- Give oxygen if the patient has severe pain, is an urgent surgical consult.
breathless, or if oxygen saturation by pulse
oximetry is less than 90%.
- Relieve severe pain with diamorphine or
pethidine
Acute Paralytic Ileus
Ileus is a condition in which there is neurogenic failure or loss of peristalsis in the intestine in the
absence of any mechanical obstruction.
1) intra-abdominal processes such as recent gastrointestinal or abdominal surgery or peritoneal
irritation (peritonitis, pancreatitis, ruptured viscus, hemorrhage);
2) severe medical illness such as pneumonia, respiratory failure requiring intubation, sepsis or
severe infections, uremia, diabetic ketoacidosis, and electrolyte abnormalities (hypokalemia,
hypercalcemia, hypomagnesemia, hypophosphatemia); and
3) medications that affect intestinal motility (opioids, anticholinergics, phenothiazines).
Following surgery, small intestinal motility usually normalizes first (often within hours), followed
by the stomach (2448 hours), and the colon (4872 hours).
Postoperative ileus is reduced by the use of patientcontrolled or epidural analgesia and
avoidance of intravenous opioids as well as early ambulation, gum chewing, and initiation of a
clear liquid diet.
Symptoms and Signs conscious report mild diffuse, continuous abdominal discomfort with
nausea and vomiting. Generalized abdominal distention is present with minimal abdominal
tenderness but no signs of peritoneal irritation (unless due to the primary disease). Bowel
sounds are diminished to absent.
Laboratory Findings Serum electrolytes, including potassium, magnesium, phosphorus, and
calcium, should be obtained to exclude abnormalities as contributing factors
Imaging Plain film radiography of the abdomen demonstrates distended gas-filled loops of small
and large intestine. Air-fluid levels may be seen. A CT scan may be useful in such instances to
exclude mechanical obstruction, especially in postoperative patients.
Treatment
The primary medical or surgical illness that has precipitated adynamic ileus should be treated.
restriction of oral intake with gradual liberalization of diet as bowel function returns
Severe or prolonged ileus requires nasogastric suction and parenteral administration of fluids
and electrolytes.
Alvimopan is a peripherally acting mu-opioid receptor antagonist with limited absorption or
systemic activity that reverses opioid-induced inhibition of intestinal motility.
Acute Colonic Pseudo-obstruction
(Ogilvie Syndrome)
Severe abdominal distention : an increase in gut sympathetic activity or a decrease in sacral
parasympathetic activity of the distal colon, or both, is hypothesized to impair colonic motility.
Arises in postoperative state (mean 35 days), or with severe medical illness (respiratory failure,
metabolic imbalance, malignancy, myocardial infarction, heart failure, pancreatitis, or a recent
neurologic event (stroke, subarachnoid hemorrhage, trauma)
May be precipitated by electrolyte imbalances, medications.
Absent to mild abdominal pain; minimal tenderness, up to 40% of patients continue to pass
flatus or stool.
Massive dilation of cecum or right colon
Laboratory Findings Serum sodium, potassium, magnesium, phosphorus, and calcium should be
obtained. Significant fever or leukocytosis raises concern for colonic ischemia or perforation.
Treatment
Conservative treatment first step for patients with no or minimal abdominal tenderness, no fever,
no leukocytosis, and a cecal diameter < 12 cm
A nasogastric tube and a rectal tube should be placed.
Patients should be ambulated or periodically rolled from side to side and to the knee-chest
position in an effort to promote expulsion of colonic gas.
All drugs that reduce intestinal motility, such as opioids, anticholinergics, and calcium channel
blockers, are discontinued if possible.
Enemas may be administered judiciously if large amounts of stool are evident on radiography.
Oral laxatives are not helpful and may cause perforation, pain, or electrolyte abnormalities.
Follow Up
Conservative treatment is successful in over 80% of cases within 12 days. Patients must be
watched for signs of worsening distention or abdominal tenderness. Cecal size should be
assessed by abdominal radiographs every 12 hours.
Intervention should be considered : (1) no improvement or clinical deterioration after 2448
hours of conservative therapy; (2) cecal dilation > 10 cm for a prolonged period (> 34 days); (3)
patients with cecal dilation > 12 cm.
Neostigmine injection single dose (2 mg intravenously) results in rapid (within 30 minutes)
colonic decompression in 7590% of patients, unless contraindicated.
Colonoscopic decompression is indicated in patients who fail to respond to neostigmine. Colonic
decompression with aspiration of air or placement of a decompression tube is successful in 70%
of patients. However, the procedure is technically difficult in an unprepared bowel and has been
associated with perforations in the distended colon.
In patients in whom colonoscopy is unsuccessful, a tube cecostomy can be created through a
small laparotomy or with percutaneous radiologically guided placement.