GI-GU – 9/9/08
Co-management, Refer, Self-Treat
3 keys to the class…when to co-manage, when to self-treat (in office), when to refer
*** 5 exams with the final exam not cumulative and less than 1/5 of the material ***
*** Cecil’s is a reference book (you may not need to purchase it…use it only as a reference) ***
*** Take a look at various paper’s for each exam…In the front is the testable material and the back is the additional info, usually not tested on ***
*** First test is 5-6 weeks away and then every 2-3 weeks ***
*** Tests are usually 8:15 Tuesday – They will be multiple choice and fill in the blanks ***
*** 5 Exams each are 20% ***
PRE-TEST
Briefly outline an organized procedure for the evaluation of abdominal complaints.
History: It will give us a ton of information. Somethings come fast, somethings come slow. History allows us to find out ths infomraiton. We want family history, history of chief complaint, and past medical history.
Exam: Abdominal exam (inspection, auscultation, palpation)…We always want to inspect first, ausultate second and palpate third…We listen for bowel sounds and bruits. Peristalsis is segmentally controlled stretch receptors. Activatin of receptors sends signals to cord and the message ascends to brain. The brain then sends the signal via parasympathetics triggering peristalctic wave to squeeze fecal material proximal to distal, pushing feces downstream into a new section wchih dilates and causes a stretch reaction. The stretch receptors cannot tell the difference from inside-out stretch to outside in stretch, so a stretch to the body via palpation can create bowel sounds which mask what we attempt to hear. So we look first, listen second and palpate third. We need to pay attention to lack of sounds, and that occurs by absence of bowel sounds. We always listen to multiple sites in each quadrant. To document a peristalsis it takes 5 minutes.
We then go into light palpation. We check for spasm. Spasm is a reflex action. Spasm attempts to hold in place the structures. WE then go into deep palpation. After deep palpation, we go into percussion. Percussion is one of the least reliable. When we deal with fluid/ascites, we deal with percussion. We can also do KUB. KUB films is usually lower to increase contrast and observation of kidneys. Ascites can give us a bigger liver by percussion, but the radiograph gives us the observable size. Ascites percusses big and shows as normal size liver. True enlargement percusses big and looks big.
List some signs and symptoms of GI disease.
Blood in the stool. There are various relationships of blood in the stool. Occult blood in the stool cannot be seen. We can use a hema-occult/GUIAC test. GUIAC mixed with hemoglobin and hydrogen peroxide turns blue. Frank blood in the stool comes in 2 colors (red – source is likely to be distal like the sigmoid colon and beyond) & (black-melena stool – black tarry stool, the source is more proximal and is mixed in). The hypertonic, black stool liberates blood and it degrades to a black color.
Another sign and symptom of GI disease is pain. Cramping or colicky pain can ensue. Cramping/colicky pain is linked with unsatisfied contraction. BIliary colic, renal colic or GI colic are 3 types. Cramping pain can be explained by obstruction. All the systems are in place and the system is interfered with. This is not very satisfying. Tyring to clear the area with an obstruction is unsatisfied contraction. Each system is intact, but something prevents its operation. This information helps to limit, making the diagnosis.
Indigestion…Irregularity in bowel movements, reverse peristalsis, vomiting, diarrhea, cramping, acid reflux (burning pain),
Nauseua…It can exist alone or with other symptoms. Nausea can relieve pain and discomfort
Low Back Pain: Sclerotogenous pain with referral can happen. You can poke around the abdomen and sometimes generate the low back pain.
Abnormal Bowel Sounds: Absence of bowel sounds is a problem.
Gas: Belching or flatulence…Ask the patient what is normal for them…A long list of things cause flatulence (celiac disease – icomplete digestion due to organ problems….enzyme deficiency (cannot break things down – flatulence)…Bad food can cause flatulence
Obstruction:
Sharp Pain: It hurts right here (pt. points to one spot)…What you don’t want to hear is that it hurt right here and then all of a sudden just got better (indicates bursting) – subsequently this may cause peritonitis
Diarrhea: Frequent watery stools
Weight Loss: Ask about how they lost the weight? Ask about time frame? Ask about if weight loss was intended?
Colon Cancer: The #2 cause of death in the United States.
Abdominal Swelling: Puffy and maybe not limited to the stomach. Ascites and lymphedema and common reasons. Abdominal and LE retention is usually lymphedema. The more distributed the gain the greater the chance of proximal lymphatic obstruction.
Hepatomegaly can lift the ribs up.
Anorexia: Appetite suppression is true anorexia. Anorexia nervosa does not show appetite suppression. Anorexia nervosa shows body image distortion. You see too skinny and they look at themself as I need to lose more.
Painful Defacation: Anal Fissures can be a cause as well as perinanal abscess or tearing of the sigmoid colon. They can have a large, hard stool which can tear the sigmoid as it forces stool through. Anal fissures can be painful.
Cholecystitis: Pain follows an activity. Inspiration and expriation changes intra-abdominal pressure. Cholecystitis inflames the gallbladder. Usually a fat load provokes a prominent contraction of gallbladder.
Pus in the Stool: Invasion of the wall of the intestine. The further down, the more likely you’ll observe the pus. Infections affect nobody and no boundaries.
Hurts to Swallow: Esophageal ulcer…Hurts and eating makes it feel better (stomach ulcer)…Hurts 45-50 minutes after eating (small intestine and duodenum)….Usually esophageal and pyloric ulcers are predictable.
Lower L Quadrant Pain: Diverticulitis
Lower R Quadrant Pain: Appendicitis
Fatigue: Anemia (loss of cells by GI)….
Gallstone: R Upper Quadrant Pain
Pancreatitis: Severe Pain with posture of bending forward. The pancreas is more posterior in the abdominal cavity…Inflammed pancreas do not like to lie down, so they like to lay down.
Hernias:
Difficulty Swallowing: One of the more common signs and symptoms.
Describe the pathway a button would take if swallowed. (Normal Anatomy)
1. Oral Cavity,
2. Throat – Pharynx (Oro, Naso, Pharynx Proper) – everything travels down the pharynx…The epiglottis, protects the trachea
3. Esophagus, Trachea and Epiglottis (Upper Esophagus is under somatic control vs. the lower esophagus is under autonomic control)
4. LES – Lower Esophageal Sphincter (also called GE junction – gastro-esophageal junction)…The sphincter is a bad one and that is why we have GERD
5. Stomach (the last part of the stomach is called the antrum)…The antrum is a busy area for disease
6. Pyloric Sphincter – Good sphincter…Slowly allows release of contents…Reactive to stomach contents…Heavy fat meals are delayed due to the pyloric sphincter…Water is allowed to pass through easily…It is under neurologic and hormonal control
7. Duodenum – C-Sweep of Duodenum (first return to mid-line)… Pancreas is cradled in the middle of the C-sweep
8. Jejunum (no valve between duodenum and jejunum)
9. Ileum (No valve between jejunum and ileum)
10. Iliocecal Valve – Pretty good valve (
11. Cecum
12. Ascending Colon
13. Transverse Colon (we can differentiate where it changes over based on direction…The colon is kept up by suspensory ligaments…The suspensory ligament end signals the beginning of the ascending colon)…The transverse colon can loop
14. Splenic Flexure & Descending Colon
15. Sigmoid
16. Rectum
17. Anus
Calcification in the R Upper Quadrant could be from which sources?
Calcified Gallstones, Kidney Stones, Athersclerosis (renal artery, hepatic artery), costal cartilage (physiologic calcification), Dystrophic Calcification (liver, pancreas, kidney)…Pancreatic calcification is very devastating (no good reason for calcification in the pancreas)…Ureter (stone), Supra-Renal/Adrenal Gland Calcification
Duodenum (calcium pills can pass through and break up)
LUQ : Similar concept, but add spleen, aorta calcification
RLQ & LLQ are smaller lists of calcifications
List some organs that play an ancillary role in the physiology of the GI tract?
Pancreas (enzymes)
Kidney (hydration status)
Parotid Gland
Teeth (mechanically break down food exposing food for chemical action)
List Several Kidney Functions.
Filter Waste from Blood: Filter blood and filter out toxins and waste products
Water Balance and Regulation: Conservation or Removal of water…Kidney can recover 99% of what you drink (at best)
Electrolyte Balance: Gets rid or keeps potassium, hydrogen, etc.
RAA System: Dehydration, thick blood shows reduction in GFR…The kidney needs blood to pass through it so that it creates high BP to increase pressure in the efferent tubule to increase GFR
Vitamin D Activation: We need active vitamin D. Bad kidneys and we lose ability to make D.
Erythropoietin: They have anemia of underproduction iwhtouh kidneys.
GU Signs and Symptoms
Blood: Occult and Frank Hematuria. It has to deal with quantity and resent event. High vs. low also has to deal with
casts. Casts are from the tubular cells of the kidney (only).
LBP: Tends to be unilateral in presentation when from kidney stone.
Puss: Cloudy urine in color. Can be infection. Urethral infection presents with frequency, urgency, painful urination, and cannot fully void.
Incontinence:
Murphy’s Punch: Hydronephrosis and pyelonephritis
Polyuria: Many trips to the bathroom….Diuresis: A large volume of urination….Polyuria is increased frequency vs. iduresis is increased volume (more than 2 L a day)
Odor; Pee in a cup. The doctor tests color, clarity and odor. Ketones can cause change in urine scent. Asparagus and cabbage can change the odor.
Color: Pale to Straw Yellow is normal. You don’t want to see brown urine (hematuria).
Glucose: Often linked to polyuria, nocturia. Poluria and nocturia is linked with diuresis.
Hesitancy: Troube to initiate flow and stop flow (mechanical problem aand can be BPH or prostate cancer in males)
Dehydration: Dark Urine (polyuria, polydipsia, heat and humidity)
Painful Urination:
Urgency, Hurt when they fill, Hurt whey they empty: Hurts in all 3 phases indicates bladder infection…urethritis only hurts for brief time. Higher up indicates flank pain and upper UTI.
Hypospadias: New born problem.
List 4 Studies used to evaluate the GU system.
KUB (drop KVP and increase the mass), Dip Stick (urine is a fluid biopsy), Physical Exam, Diagnostic Ultrasound, PSA Test, Urethrocystocope - Cystoscopy (flexible fiberoptic) , Contrast Studies (Excretory Urogram), MRI (kidneys are nicely imaged on MRI…MRI’s can comment on physiology), CT Scan (Helical CT’s are faster, relatively inexpensive and give good slices), Manometers (pressure testing)
List 4 Disease Processes that may be associated with anormal urinalysis.
Diabetes, Glomerulonephritis (casts produced and renal cells), Pyelonephritis, Prostatic Cancer (history is important)
GI-GU – 9/15/08
KIDNEY
Cortical region (outer)
Medullar region (inner area)
These are the 2 big regions of the kidney. All of the glomeruli lie within the cortical region and all bowman’s capsule is in the same area. We have varying prox and distal convoluted tubule in the cortical area.
We have some unusual circumstances that damage both areas of the kidney.
Layered Organization of the Kidney
1.Bulk of the functional unit as the combo of Glomerulus, Bowman,s PcT, DCT and loop of henle between = functional unit to perform filtration and concentration
2. PCt and DCT, Bowmna’s and Glomerulus – The bulk of the loop dives deep into the medullary cavity
It takes billions of units working together to perform bodily functions.
Glomerulus (wrap around area in the pictures)….Show a hand in glove relationship. The Glomerulus is part of the circulatory system and specifically the arterial system. Filtered by the kidney is blood IN the Glomerulus, this is a specialized vascular structure designed to leak. We don’t want leakage anywhere else in the vascular system.
Size
The afferent arteriole is the entrance. The efferent arteriole is the eixt and should hae less particles. The Glomerulus is binary (it fits through the hole or it doesn’t). We have moleculues of all sizes (we lose waste and “cherished” moleculues). We do need a system to return moleculues. Particularly, bicarbonate is important. 7-8,000 Daltons is the cutoff for what makes it through and what doesn’t make it through.
Lipids and lipoproteins can be very large (20,000 or more Daltons). 7-8,000 allows waste to go through. We do have a way later to recover molecules we need.
For our purposes, 100% of glomeruli lie in cortical region
Arterial vs. Venous System
Some differences: Tunica Media (resistance and elasticitiy – it changes diameter and reacts)….The Tunica Media is not important in the Glomerulus (designed to leak). Another difference between the environments of venous vs. arterial is pressure. The highest pressure is the arterial. Moving products from Glomerulus to Boman’s (venous like – low pressure) there must be a gradient. The Glomerulus pushes by higher pressure. The pressure behind moves particiles.
Glomerulus
1. Kitchen Tools (Glomerular Like) – Strainer
2. Bowman’s Caspule – Captures everything that comes out…Bowman’s takes what the Glomerulus dishes out…Funnel (Bear Bong)…Funnel’s are not selective (just like Bowman’s)
PCT
Very important component. Without the PCT, kidney function cannot be accomplished. Passive and active transport take place here. Active transport requires energy. Mitochondria creates the energy to drive active processes forward. The more mitochondria the greater the engery requirement and the greater the active transport. The mitochondria density in the PCt is great as the PCt is the most active component on the kidney.
The segregation process begins in the PCT. Waste re-enters the vascular tree. Waste comes back into the system and is not desirable. The waste molecule most notable urea is destabilizing to normal membranes. It renders the cells leaky (urea). Not everything that comes back through the wall of the PCT is desirable, but it does occur. Urea comes back in the blood. It can be normal or abnormal amounts in the blood.
Sodium, potassium, cholidrd, glucose, bicarbonate are important items to retain. The PCt also allows for entrance of waste molecules.