Nausea And Vomiting

 

Nausea

Can be simply described as an uncomfortable feeling or a sensation of sickness which may or may not be followed by vomiting.

Vomiting

Is an effortless regurgitation of  stomach contents.

Nausea and vomiting is caused by a wide variety of conditions which stimulate the vomiting receptors in the brain.

Vomiting may lead to dehydration, electrolyte imbalances, aspiration pneumonia.

How to Manage

A detailed history helps to identify the underlying cause.

-         Sudden onset of vomiting without any associated pain may suggest food poisoning, infectious gastroenteritis or use of any dugs

-         Vomiting along with abdominal pain may be caused by acute abdominal conditions like appendicitis, acute gastritis or intestinal obstruction.

-         Early weeks of pregnancy causes nausea, morning sickness and vomiting due to hormonal changes.

-         Migraine headaches are commonly associated with nausea and sometimes vomiting too.

Laboratory tests that should be done include

-         Serum Electrolytes

-         Blood glucose

-         Urea and Creatinine

-         Serum Amylase

-         Liver function tests

-         TSH

-         Pregnancy test

Imaging Studies that can help find out the cause include

-         Flat and upright abdominal X ray

-         Ultrasound of abdomen

-         CT scan abdomen

-         Barium studies

Medications that help includes different antiemetic medicines which are given to control vomiting.

For mild, self limited acute vomiting no treatment is needed , just give clear fluids and soft easily digestible small quantities of food.

In cases of severe vomiting IV fluids are needed to correct and prevent dehydration.

Gastritis - Inflammation Of The Stomach Lining

Gastritis

Simply defined as inflammation of the gastric mucosa.

It may occur as an Acute gastritis when symptoms appear within a few days or it may be chronic when it is present for a long time.

Clinical Features include

-         -vague symptoms like nausea, sometimes vomiting , loss of appetite, upper abdominal pain or discomfort.

-        - Upper gastrointestinal bleeding

-         -Mild epigastric tenderness on palpation which may or may not be present.

Underlying Causes include

-         -Stress

-         -Use of NSAIDs

-        - Alcohol

-         -H.pylori Gastritis

-         -Radiation therapy

-         -Any acute disease or surgery

-        - Cancer of the stomach or pancreas

Differential Diagnosis

-Peptic Ulcer disease.

- Functional or non ulcer dyspepsia

- GERD

- Viral gastroenteritis

- indigestion from iver eating, high fat food.

- Biliary Disease

- Pancreatitis

- Cholecystitis

- Angina (Ischemic heart disease )

 

How to Manage

Avoid the precipitating factors like NSAIDs, alcohol, caffeine, cigratte smoking and high fat diet.

Workup to look for the presence of H pylori, and treat if present.

Medicines like proton pump inhibitors (omeprazole) and H2 receptor blockers (Ranitidine) are helpful.

Introduction to Gastric cancer

Introduction

Common throughout the world, gastric cancer affects all races. However, unexplained geographic and cultural differences in incidence occur; for example, mortality is high in Japan, Iceland, Chile, and Austria. In the United States, incidence has decreased 50% during the past 25 years, and the death rate from gastric cancer is one-third that of 30 years ago.
The decrease in gastric cancer incidence in the United States has been attributed, without proof, to the balanced American diet and to refrigeration, which reduces the number of nitrate-producing bacteria in food.
Incidence is highest in men over age 40. The prognosis depends on the stage of the disease at the time of diagnosis; overall, the 5-year survival rate is about 15%.

Etiology
The cause of gastric cancer is unknown. 

This cancer is commonly associated with 

• gastritis, 
• chronic inflammation of the stomach, 
• gastric ulcers, 
• Helicobacter pylori bacteria, and 
• gastric atrophy. 

Predisposing factors include environmental influences, such as smoking and high alcohol intake.

Genetic factors have also been implicated because this disease occurs more frequently among people with type A blood than among those with type O; similarly, it’s more common in people with a family history of such cancer.
Dietary factors include types of food preparation, physical properties of some foods, and certain methods of food preservation (especially smoking, pickling, and salting).

Classification
According to gross appearance, gastric cancer can be classified as 

Introduction to Irritable bowel syndrome

Introduction

Also referred to as spastic colon or spastic colitis, irritable bowel syndrome is marked by chronic abdominal pain, alternating constipation and diarrhea, and abdominal distention. This disorder is extremely common; 20% of patients, however, never seek medical attention.

Etiology
The cause and pathogenesis of this functional disorder remain poorly understood. Generally associated with psychological stress, the disorder may result from physical factors, such as diverticular disease, ingestion of irritants (coffee or raw fruits or vegetables), lactose intolerance, abuse of laxatives, food poisoning, or colon cancer. Contributing factors include abnormal gut motor and sensory activity, central neural dysfunction, and luminal factors.

Clinical Features
Irritable bowel syndrome characteristically produces intermittent, crampy lower abdominal pain. The pain is usually relieved by defecation or passage of flatus. It typically occurs during the day. Pain intensifies with stress or 1 to 2 hours after meals. The patient may experience constipation alternating with diarrhea, with one being the dominant problem. Mucus is usually passed through the rectum. Abdominal distention and bloating are common.

Chronic Constipation - Causes , Signs&Symptoms And Management

Also known as lazy colon, colonic stasis, colonic inertia, and atonic constipation, chronic constipation may lead to fecal impaction if left untreated. It’s common in elderly and disabled people because of their inactivity and is commonly relieved with diet and exercise. Left untreated, it can result in hemorrhoids, fissures and megacolon.

Causes
Chronic constipation usually results from some deficiency in the three elements necessary for normal bowel activity: dietary bulk, fluid intake, and exercise. 

Other possible causes can include

•  habitual disregard of the impulse to defecate, 
• emotional conflicts, 
• overuse of laxatives, or 
• prolonged dependence on enemas, which dull rectal sensitivity to the presence of stool. 

Certain medications (tranquilizers, anticholinergics, opioids, antacids) can cause it, and patients with certain disorders (Parkinson’s disease, multiple sclerosis, hypothyroidism, scleroderma, lupus erythematosus) are more prone to develop it.

Signs and symptoms
The patient typically strains to produce dry, hard stool accompanied by mild abdominal discomfort. Straining can aggravate other rectal conditions such as hemorrhoids.

Ulcerative colitis - Special considerations

Patients with ulcerative colitis need special care and management. Following points are important to remember:.

• Accurately record intake and output, particularly the frequency and volume of stools.
• Watch for signs of dehydration and electrolyte imbalances, specifically signs of hypokalemia (muscle weakness, paresthesia) and hypernatremia (fever, tachycardia, flushed skin, dry tongue).
• Monitor hemoglobin and hematocrit, and transfuse if necessary.
• Provide good mouth care for the patient who is allowed nothing by mouth.
• After each bowel movement, thoroughly clean the skin around the rectum.
• Administer medication. Watch for adverse effects of prolonged corticosteroid therapy (moonface, hirsutism, edema, gastric irritation). Be aware that such therapy may mask infection.
• If the patient needs total parenteral nutrition, change dressings, assess for inflammation at the insertion site, and check blood glucose every 6 hours.
• Take precautionary measures if the patient is prone to bleeding. Watch closely for signs of complications, such as a perforated colon and peritonitis (fever, severe abdominal pain, abdominal rigidity and tenderness, and cool, clammy skin), and toxic megacolon (abdominal distention, decreased bowel sounds).
• Prepare the patient for surgery, and provide teaching related to the care of an ileostomy. Consult the enterostomal therapy nurse for preoperative teaching and stoma marking. Provide a bowel preparation.

Brief Summary of Gastroenteritis

Also called intestinal flu, traveler’s diarrhea, viral enteritis, and food poisoning, gastroenteritis is a self-limiting disorder characterized by diarrhea, nausea, vomiting, and abdominal cramping. It occurs in all age-groups and is a major cause of morbidity and mortality in underdeveloped nations.
It can also be life-threatening in elderly and debilitated people.

Causes
Gastroenteritis has many possible causes, including the following:

• bacteria (responsible for acute food poisoning)—Staphylococcus aureus, Salmonella, Shigella, Clostridium botulinum, Escherichia coli, Clostridium perfringens
• amoebae—especially Entamoeba histolytica
• parasites—Ascaris, Enterobius, Trichinella spiralis
• viruses (may be responsible for traveler’s diarrhea)—adenovirus, echovirus, or coxsackievirus
• ingestion of toxins—plants or toadstools (mushrooms)
• drug reactions—antibiotics
• enzyme deficiencies
• food allergens.

The bowel reacts to any of these enterotoxins with hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid.

Signs and symptoms
Clinical manifestations vary, depending on the pathologic organism and the level of GI tract involved. Gastroenteritis produces symptoms such as diarrhea, abdominal discomfort (ranging from cramping to pain), nausea, and vomiting. Other possible symptoms include fever, malaise, and borborygmi.
In children and elderly and debilitated people, gastroenteritis produces the same symptoms, but the inability of these patients to tolerate electrolyte and fluid losses leads to a higher mortality.

Brief Summary of Peptic ulcers

Peptic ulcer is a disruption in the gastric or duodenal mucosa when normal defense mechanisms are overwhelmed or impaired by acid or pepsin. Ulcers are circumscribed lesions that extend through the muscularis mucosa. Ulcers are five times more common on the duodenum.

Causes
Researchers recognize three major causes of peptic ulcer disease: infection with Helicobacter pylori, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and pathologic hypersecretory states such as Zollinger-Ellison syndrome.
H. pylori is the cause of the majority of duodenal and gastric ulcers. Following treatment with standard therapies, 70% to 85% of patients have a documented recurrence (by endoscopy) within 1 year.
Other causes include the use of certain drugs, such as salicylates and other NSAIDs, which encourage ulcer formation by inhibiting the secretion of prostaglandins (the substances that suppress ulceration). Certain illnesses— such as pancreatitis, hepatic disease, Crohn’s disease, Zollinger-Ellison syndrome, and preexisting gastritis — are also known causes. Additionally, having a type A personality increases autonomic nervous system effects on the gastric mucosa.

Predisposing factors
Ulcers are more common in smokers and those who regularly use NSAIDs. (Smoking increases the amount of hydrochloric acid in the stomach; nicotine reduces the bicarbonate content of pancreatic secretions and also decreases the degree of acid neutralization.) Diet and alcohol don’t appear to contribute to the development of peptic ulcer disease. It’s unclear whether emotional stress is a contributing factor.

Signs and symptoms
Symptoms vary with the type of ulcer.

Gastric ulcers
Gastric ulcers are usually signaled by pain that becomes more intense with eating. The pain is usually constant because the gastric mucosa is sensitive to acid secretion. Nausea or anorexia may occur.

Gallbladder and bile duct cancers

Introduction: Cancer of the gallbladder is rare, constituting less than 1% of all cancer cases. It’s usually found coincidentally in patients with cholecystitis; 1 in 400 cholecystectomies reveals cancer.
This disease is most prevalent in women over age 60. It’s rapidly progressive and usually fatal; patients seldom live 1 year after diagnosis. The poor prognosis is because of late diagnosis; gallbladder cancer usually isn’t diagnosed until after cholecystectomy, when it’s typically in an advanced, metastatic stage.
Extrahepatic bile duct cancer is the cause of about 3% of all cancer deaths in the United States. It occurs in both men and women between ages 60 and 70 (incidence is slightly higher in men). The usual site is at the bifurcation in the common duct.
Cancer at the distal end of the common duct is commonly confused with pancreatic cancer. Characteristically, metastasis occurs in local lymph nodes and in the liver, lungs, and peritoneum.

Causes
Many consider gallbladder cancer a complication of gallstones. This inference rests on circumstantial evidence from postmortem examinations: 60% to 90% of all gallbladder cancer patients also have gallstones. Postmortem data from patients with gallstones show gallbladder cancer in only 0.5%.
Adenocarcinoma accounts for 85% to 95% of all cases of gallbladder cancer; squamous cell carcinoma accounts for 5% to 15%. Mixed-tissue types are rare.
Lymph node metastasis is present in 25% to 70% of patients at diagnosis. Direct extension to the liver is common (46% to 89% of patients); direct extension to the cystic and the common bile ducts as well as the stomach, colon, duodenum, and jejunum produces obstructions. Metastasis also occurs through the portal or hepatic veins to the peritoneum, ovaries, and lower lung lobes.
The cause of extrahepatic bile duct cancer isn’t known, but statistics reveal an unexplained increased incidence of this cancer in patients with ulcerative colitis. This association may be attributed to a common cause —perhaps an immune mechanism or chronic use of certain drugs by the patient with colitis.

Signs and symptoms
Clinically, gallbladder cancer is almost indistinguishable from cholecystitis. The signs and symptoms of both disorders include pain in the epigastrium or right upper quadrant, weight loss, anorexia, nausea, vomiting, and jaundice. Chronic, progressively severe pain in an afebrile patient suggests cancer.

With simple gallstones, the pain is sporadic.
Another telling clue to cancer is a palpable gallbladder (in the right upper quadrant) with obstructive jaundice. Some patients may also have hepatosplenomegaly.

Acute pancreatitis

Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. Acute pancreatitis is sudden swelling and inflammation of the pancreas. In acute cases the gland heals without any impairment of function or any morphologic changes.

Acute pancreatitis can have severe complications and high mortality despite treatment. While mild cases are often successfully treated with conservative measures.

Etiology
The pancreas is an organ located behind the stomach that produces chemicals called enzymes, as well as the hormones insulin and glucagon. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food.

When these enzymes somehow become active inside the pancreas, they eat (and digest) the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels.

Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits makes more likely to develop this condition.

The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States). Genetics may be a factor in some cases. Sometimes the cause is not known, however.

Other conditions that have been linked to pancreatitis are:

• Autoimmune problems (when the immune system attacks the body)
• Blockage of the pancreatic duct or common bile duct, the tubes that drain enzymes from the pancreas
• Damage to the ducts or pancreas during surgery
• High blood levels of a fat called triglycerides.
• Injury to the pancreas from an accident

Other rare causes may include:

• Complications of cystic fibrosis
• Hyperparathyroidism.
• Reye syndrome
• Use of certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine)
• Viral infections, including mumps coxsackie B, and campylobacter.

Management Of Patient With GIT Bleeding

A patient with upper or lower GI bleeding after initial evaluation should be managed as follows:

1. Provide venous access with large bore IV (14-18 gauge); central venous line for major bleed and patients with cardiac disease; monitor vital signs, urine output. hematocrit. Gastric lavage is of unproven benefit but clears the stomach before endoscopy. Iced saline may lyse clots ; room temperature tap water may be preferable . Intubation may be required to protect airway.

2. Type and cross match blood (6 units may be needed for a major bleed).

3. Prepare the surgical team for standby when bleeding is massive.

4. Support blood pressure with isotonic fluids (normal saline); albumin and fresh frozen plasma in cirrhotics. Packed red blood cells when available (whole blood if massive bleeding) ; maintain Hct >25-30.

5. IV calcium (e.g upto 10-20 ml 10% calcium gluconate IV over 10 to 15 minutes) if serum calcium falls due to transfusion of citrated blood.

6. Start empirical drug therapy with antacids , H2 receptor blockers, omeprazole although they are of unproven benefit.

Causes Of Dysphagia

Dysphagia means difficulty in swallowing. It may or may not be associated with pain on swallowing. Dysphagia may be associated with ingestion of solids or liquids or both. It is important to know different medical conditions that lead to dysphagia and a simple list is given here:

Causes Of Dysphagia

Congenital

• Oseophageal atresia

Acquired

1.In the lumen

• Food bolus
• Foreign body

2. In the wall

• Inflammatory stricture
• Gastroesopahgeal reflux
• Caustic stricture
• Candidiasis
• Achlasia
• Carcinoma
• Plummer vinson syndrome
• Irradiation
• Scleroderma
• Chagas disease (rare)

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease also known as GERD, is a condition in which the stomach contents leak backwards from the stomach into the esophagus. It is a chronic digestive disorder and since the stomach has acidic contents it irritates the lining of the esophagus.

Pathophysiology: Normally when we eat, the food passes from our mouth through the esophagus to the stomach. A ring of muscle fibers in the lower esophagus that make up the lower esophageal sphicture (LES) normally prevent the gastric contents from backing up into the esophagus.
Reflux occurs when LES pressure is deficient or when the pressure within the stomach exceeds LES pressure.

Risk Factors: There are certain situations in which a person may be predisposed to develop GERD. These may include:

• Obesity
• Pregnancy
• Smoking
• Excess use of Alcohol
• Use of certain drugs  e.g : anticholinergics, diazepam, morphine, bronchodialtors.
• Hiatal hernia
• Scleroderma
• History of pyloric surgery 
• Long term nasogastric intubation.

Clinical Features: Include: