Important Differentiation in Small Bowel Obstruction (SBO)

Small Bowel Obstruction

There are 3 main pts of differentiation to consider with SBO...

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Free GI Textbook

First Principles of Gastroenterology, 5th Edition

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This is a FREE textbook.  

Nasogastric Tubes

On the general surgery rotation we place a good number of nasogastric tubes (NGTs). Today's educational topic during our pm rounds will be the NG tube so I thought I'd share what I have studied up on...

What do NGTs do? 

Gain access to the stomach and its contents. It will also allow for drainage and/or lavage in drug over-dosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.

Indications

• To drain gastric contents
• To decompress the stomach
• To obtain a specimen of the gastric contents
• To introduce a passage into the GI tract. 
• Treatment of gastric immobility and bowel obstruction 

Contraindications

Severe facial trauma (cribriform plate disruption) -  because you might insert the tube intracranially.

Precautions/Protection

High potential for contact with pt fluids. Wear gloves and face/eye protection!

Basic Needs

Personal protective equipment
NG/OG tube
Catheter tip irrigation 60ml syringe
Water-soluble lubricant, preferably 2% Xylocaine jelly
Adhesive tape
Low powered suction device OR Drainage bag
Stethoscope
Cup of water (if necessary)/ ice chips
Emesis basin
pH indicator strips

How to do it

*Directly from Univ of Ottawa's Emergency Medicine page 2003

1. Gather equipment
   
   
2. Don non-sterile gloves
   
   
3. Explain the procedure to the patient and show equipment
   
   
4. If possible, sit patient upright for optimal neck/stomach alignment
   
   
5. Examine nostrils for deformity/obstructions to determine best side for insertion
   
   
6. Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel
   
   
7. Mark measured length with a marker or note the distance
   
   
8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort.
   
   
9. Pass tube via either nare posteriorly, past the pharynx into the esophagus and
   then the stomach.
   
   Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.
   
   If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force.
   
   
10. Withdraw tube immediately if changes occur in patient's respiratory status, if
    tube coils in mouth, if the patient begins to cough or turns pretty colours
    
    
11. Advance tube until mark is reached
    
    
12. Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube.
    
    
13. Secure tube with tape or commercially prepared tube holder
    
    
14. If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed.
    
    
15. Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

 Source: Univ of Ottawa's Emergency Medicine page 2003

PANCE REVIEW: Stomach

The PANCE need-to-knows for the stomach are: GERD, gastritis, neoplasms, peptic ulcer dz, pyloric stenosis. That's it for the stomach! Studying seems so much more manageable once you see lists broken down.

I am going to set today's blog up a little differently. I will pose the questions and then you can try to answer them. Scroll down to find the answers.

Gastritis

1. What is gastritis?
2. What causes it?
3. What might you see clinically?
4. What labs/tests might you consider ordering?
5. How do you treat it?

1. inflammation of the stomach
2. imbalance of the "protective" factors in the stomach such as: mucus, bicarb, prostaglandins, mucosal blood flow, etc. - this can be due to autoimmune conditions, H.Pylori, NSAIDs, stress, ETOH
3. dypepsia, abdominal pain, other s/sx that reflect the underlying cause
4. a) endoscope with biopsy b) Urea breath test (looking for H.Pylori) c) condition-specific tests
5. treat the underlying cause + remove caustic factors (ETOH, NSAIDs)




Source: AAPA/PAEA Exam Review book

PANCE REVIEW: Esophageal Dysmotility

 Esophageal Dysmotility in a nutshell.

6 types that you need to know about:

1- Neurogenic dysphagia

• caused by brain stem injury
• difficulty swallowing BOTH solids and liquids

2- Zenker's Diverticulum

• Regurgitation of undigested solids/liquids several HRS after eating

3-Esophageal Stenosis

• hard to swallow SOLIDS
• slow progress = usually benign (rings)
• fast progress = usually malignant

4- Achalasia

• global motor dysfunc of esophagus
• decrease peristalsis, increase sphincter tone
•  SLOW, PROGRESSIVE dysphagia with episodic regurg and chest pain
• **Parrot-beak** on barium swallow

 5- Esophageal spasms

• intermit chest pain and dysphagia
• may or may not be associated with eating

6- Scleroderma

• often dz progression to esophagus
• decrease in peristalsis, decrease in sphincter tone
• s/sx of reflux

Question: What are the definitions of odynophagia and dysphagia?

Labs:
A. Barium swallow: good for both structural and motility problems
B. Esophagoscopy: must be done to clarify strictures
C. Esophageal manometry: looks at peristalsis

Tx:
Neurogenic? Treat underlying cause.
Stricture? BENIGN = dilation, MALIGNANT = resection



Answer: Odynophagia = painful swallowing, Dysphagia = difficulty swallowing





Pic: http://www.umm.edu/imagepages/19507.htm, http://www.bristolsurgery.com/page.aspx?id=184
Source: AAPA/PAEA Exam Review Book

PANCE REVIEW: Varices

Let's head north of the heart for a while - I'm CV-system'd out for a bit. The esophagus. The must-know topics about the esophagus are below. I won't get to all of them on my blog... but you should def get to them in your studies!

Esophagitis

Motility d/o's

Mallory-Weiss tears

Neoplasms

Strictures

Varices

Let's chat about Varices today...

Def:

Dilations of veins (generally found distally)

Causes:

-Usual underlying cause is portal HTN which is usually secondary to cirrhosis

-Chronic viral HEP and NSAIDS can worsen bleeding

-*Budd-Chiari Syndrome may cause thrombosis of portal vein which can lead to varices

Dx:

-Usually diagnosed clinically

-Asymptomatic until they start to bleed - then they are LIFE THREATENING!

Tx:

-Hemodynamic support

-High vol IVF

-Vassopressors

-Endoscopic therapy+Pharm vasoconstriction

**30% of pts die during the 1st bleed, 50% of those that survive will die during the 2nd bleed**

Picture: http://www.bio.ri.ccf.org/Henderson/port.html

Source: AAPA/PAEA Exam Review Book

PANCE REVIEW: Pancreas

Need to knows about the pancreas:

1. Acute pancreatitis

Notes:
Causes = ETOH abuse, cholelithiasis, hyperlipidemia, trauma, drugs, 2ndary to HIV meds
Clinical:

Classic presentation = epigastric pain radiates to back, N/V/F, pain alleviated by fetal position or leaning forward, leukocytosis, severe hypOvolemia

Labs/Tests:
-Increase serum amylase (not very helpful because it can be nl after 48-72hrs)
-Serum LIPASE = more sensitive/specific, but only with increases of 3x+
-Increase in liver enzymes if biliary obstruction
-Ranson's Criteria
Treatment:
-NPO
-IVF
-TPN
-pain management (MEPERIDINE (Demerol))
-consider antibx
-monitor for complications

2. Chronic pancreatitis

Notes:
-90% caused by ETOH abuse
- Triad only seen in 20% of pts [pancreatic calcification, steatorrhea, DM]

Clinical:
-same as Acute Pancreatitis +  steatorrhea (poor fat absorption)
Labs/Tests:
-serum lipase
-Abd film shows calcification in 20-30% of pts

Treatment: 
 -same as Acute Pancreatitis
-low fat diet at discharge
-NO ETOH

3. Pancreatic neoplasms

Notes:
-5th leading cause of CA related death in US
-Risks = incr age, obesity, tobacco, chronic pancreatitis, abd radiation, fam hx

Clinical:
-abdominal pain
-COURVIER'S SIGN (palpable gall bladder)

Labs/Tests:
-CT of abdomen
-angiography

Treatment: 
-surgical resection if no mets (Whipple procedure)
-POOR PROGNOSIS



Source: AAPA and PAEA Exam Review Book