Powerpoint
dixiechelsey
DiagnosisPPT.pptxOverview Nausea/Vomiting/Diarrhea
Emergency Departments treat 136 million people each year
Common grouping of Symptoms: Nausea, Vomiting, and Diarrhea
Can present as the complaint (CC)
Can accompany other complaints
Abdominal pain
Accounts for 10% of emergency dept visits
Over 13 million individuals
Increasing cost to patient and facility
Within this presentation I want it to be informative as well as useful;. The best way that I know how to do this is to speak about the nausea, vomiting, and diarrhea as a whole and narrow it down to specific differential diagnosis that providers can rule out when a patient presents with these symptoms.
The focus of symptoms is mainly going to be focused on the Gi tract and issues that can cause dysregulation of the GI tract. An example of how often healthcare workers see GI tract related issues can be seen with the emergency room. Each year emergency rooms in the United States assess and treat 136 million people. Of this number, approximately 10% of those are GI related abdominal pain driven complaints (Cervellin, et al., 2016). That means that approximately 13,600,000 individuals have this as their chief complaint (The Emergency Center, 2020). Often times in centers such as emergency departments, broad nets of laboratory work and radiological studies are performed to attempt to make an accurate diagnosis, save time, and decrease a hospitals liability. However, this can bring increased monetary cost to a patient as well as increase radiological risk factors. The skill of the physical assessment and interpretation of symptoms cannot be overstated. The physical exam allows for a calming, professional, and competent approach to patient care that allows a connection between technology and critical thinking (Hyman, 2020).
Overview and Objectives
Diagnostic process
Artform
Complex
Patient centered
Objectives
Identify the assessment process
Identify mechanisms of nausea
Identify mechanisms of diarrhea
Identify differential diagnosis of nausea and vomiting together
With the information from the previous slide in mind, it is apparent that it takes skill and practice to be able to use the diagnostic process. The diagnostic process itself is a patient centered process that is very complex (Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors, 2015). For example, individual symptoms can be part of many different disease processes, but when they are combined together and viewed as a symptom grouping, then the identification of multiple symptoms can help add in or add out a diagnosis. Nausea and vomiting can be a symptom of multiple different disorders ranging from medication side effects, pregnancy, cardiac issues, stress, brain injury or tumor, or even cancer (Khatri, 2020). Another symptom to evaluate can be diarrhea, Diarrhea can be a symptom of infections, intestinal obstructions, stress, and even food intolerances or chronic disorders (Guandani, 2020).
Anatomy & Physiology of Upper GI
Upper GI tract
Hollow tube
Mouth to Anus
Mouth
Mechanical digestions
Chemical/Enzymatic Digestion
Esophagus
Stomach
Chemical digestion into chyme
Mechanical digestion
Empties into small intestine
(Science photo Library, 2021)
When looking at the symptoms of nausea, vomiting, and diarrhea as group, they are usually occurring because of dysfunction of the GI tract. The GI tract is for lack of a better term a hollow tube that from mouth to anus. The Gi tract is a very important tool used for both digestion and absorption. The digestion first occurs within the mouth. The mouth performs a combination of mechanical and enzymatic digestion and the food traveling from the mouth to the esophagus to the stomach. The stomach is where there is a mixture of mechanical and chemical breakdown of food. The chemical breakdown occurs from stomach acids produced by chief cells. The breakdown of the food is digested into chyme. This chyme travels through the pyloric sphincter into the small intestines.
Anatomy & Physiology of Lower GI
Lower GI Tract
Small intestines
Large intestines
Rectum
Small Intestine
Duodenum
Jejunum
Ileum
Large Intestine
Cecum
Ascending Colon
Transverse Colon
Descending Colon
Sigmoid Colon
(NIH, 2019)
A small amount of digestion occurs in the stomach, but most of the absorption happens in the small intestine accounting for 90% of the body’s absorption. The small intestines have 3 areas called the duodenum, jejunum, and ileum. After the chyme travels through the duodenum into the jejunum. The jejunum is a pivotal role for the chemical digestive and absorption process of the body. The remainder of water and materials that are not absorbed move into the large intestines. The large intestines are made up of 5 parts: the cecum, ascending colon, descending colon, and the sigmoid colon. The large intestines make a final attempt for the body to absorb more water as well as producing microbes to further break down food material. Along with water and nutrient absorption there is also the production of vitamin K and absorption of vitamin K. When the remaining digestive material move into the large intestines it is then reffered to as feces. The now feces is then moved into the rectum and excreted out of the body by the relaxation of the internal and external anal sphincter (Ogobuiro, Gonzales, & Tuma, 2021).
Pathophysiology of Vomiting
Common Symptoms
Complex systems
Variety of causes
Nausea and Vomiting Center
Medulla Oblongota
Noxious stimulation pathways
Multiple Sources
CNS
Intra GI Tract- abdominal distention and peristalsis
Organs outside GI Tract- Heart injury, Common Bile Duct
(Becker, 2010)
Vomiting and diarrhea is something that every human has experienced but do not completely understand how complex the anatomy and physiology is.
Vomiting is a very complex and still not completely an understood process. The process can be broken down into 3 parts: Nausea, Retching, and Emesis. Vomiting includes anatomy separate the GI tract. The nervous system has some structures that can contribute to nausea and vomiting. The vomiting center is located within the medulla oblongota. This area of the brain sends signals down nerve pathways that innervate with the GI tract, vagus nerves and diaphragm and other muscles (Becker, 2010). When a noxious stimulus is introduced to the vomiting centers, it can be from multiple sources such as Visceral afferents from the GI tract such as abdominal distention, visceral afferents form outside the Gi tracts such as surrounding organs like the heart and bile duct and peritoneum. The stimulation can also occur from within the central nervous system such as stress, being startled, smells, balance and movement events, and chemical abnormalities can trigger the vomiting centers or the chemo receptor trigger zone in the brain (Bowen, 2019). The nervous system then causes a very physical reaction. Nausea in and of itself is a noxious feeling and not tolerated well by individuals. When the connection is made between nausea and vomiting the patient may have a retching action. Organs involved are the glottis, esophagus, stomach, and intestines. When the retching progresses to vomiting the diaphragm is also involved, which has a sharp contraction causing a contraction of the stomach. When this happens, the pyloric sphincter remains closed while the esophageal sphincter opens allowing a route of exit for gastric contents (Bowen, 2019).
Pathophysiology of Vomiting Continued
Noxious Stimuli triggers Vomiting Center
3 Step Vomiting Process
Nausea initiated
Sends signals for retching action
Retching Action
Dry heaves
Glottis Closed
Esophageal sphincter relaxes
Pyloric sphincter is closed
Vomiting Action
Sharp contraction of abdomen
Sharp contraction of diaphragm
Only 1 exit for gastric content
(Becker, 2010)
The nervous system then causes a very physical reaction. Nausea in and of itself is a noxious feeling and not tolerated well by individuals. When the connection is made between nausea and vomiting the patient may have a retching action. Organs involved are the glottis, esophagus, stomach, and intestines. When the retching progresses to vomiting the diaphragm is also involved, which has a sharp contraction causing a contraction of the stomach. When this happens, the pyloric sphincter remains closed while the esophageal sphincter opens allowing a route of exit for gastric contents (Bowen, 2019).
Pathophysiology of Diarrhea
Involving Small intestines, Large intestines and Rectum
Different durations
Acute
Prolonged
Chronic
Osmotic Diarrhea
Secretory Diarrhea
Inflammatory Diarrhea
Deranged Motility
While vomiting involves mostly the upper Gi tract in the pre pyloric sphincter area, diarrhea is primarily involving the post pyloric area of the intestines such as the small and large intestines. It is true that occasionally vomiting can include the duodenum of the small intestines. however, the intestines are mainly involved in the diarrhea process. With the small and large intestines having different lengths and functions, there are differences in the amounts and causes of diarrhea based on the physiologic process of the intestines. Diarrhea can be broken into 4 subsets: Osmotic, Secretory, and Inflammatory and deranged motility (Bowen, Pathophysiology of Diarrhea, 2018).
Osmotic diarrhea is caused when a larger number of solutes are left in the intestines from an inability for the body to absorb the solutes. This changes the osmotic pressure and results in the intestines holding water. Example used for this is a patient that is lactose intolerant and can cause osmotic changes and give a person spasms and diarrhea from the passing of the water that was unable to be absorbed in the small intestines (Bowen, Pathophysiology of Diarrhea, 2018).
Secretory Diarrhea is a result of toxins released from bacteria such as Vibrio cholerae and E. Coli. When these toxins are released they contribute to uncontrolled secretion of water. This can lead to death if the hydration Is not done aggressively (Bowen, Pathophysiology of Diarrhea, 2018).
Inflammatory and the Infectious diarrhea is caused by bacteria, viruses, and protozoa. In contrast to the secretory diarrhea, infectious diarrhea doesn’t produce an excess of fluid, but instead the inflamed tissue that normally will absorb fluid can no longer absorb water efficiently. This occurs when the toxins produced by these organisms cause cellular death to the epithelial cells in the intestines and replaces them with less effective immature cells (Bowen, Pathophysiology of Diarrhea, 2018).
Lastly, Diarrhea associated with deranged motility causes water to pass through the small intestines and into the large intestines at an increased rate and decreases the small intestine’s ability to absorb water and nutrients (Bowen, Pathophysiology of Diarrhea, 2018).
When assessing the cause or causes of the diarrhea it is also important to assess the onset and duration and differentiate between acute diarrhea, persistent diarrhea and chronic diarrhea.
Acute diarrhea is the most common lasting a few days. Persistent diarrhea can continue for a few weeks. Chronic diarrhea can persist for an extended period of time (Cleveland Clinic, 2020).
Differential Diagnosis
Acute Differentials
Bacterial Gastroenteritis
Viral Gastroenteritis
Food poisoning
Diverticulitis
Chronic Differentials
Chrones Disease
Celiac Disease
The combination of nausea, vomiting, and diarrhea together as a set of symptoms can help rule out disease processes that only have one or two of these symptoms. Some of these differentials can be acute and some chronic. Some acute differential diagnosis for these symptoms are viral gastroenteritis, bacteriasl gastroenteritis, food poisoning, and diverticulitis. Some chronic diagnosis are Chrohn’s disease and celiac disease (Sethi, 2020).
Assessments for gastroenteritis
Symptoms
Nausea
Vomiting
Mild, Moderate, Severe
Diarrhea
Mild, Moderate, Severe
Fever-
Low grade vs. high
Dehydration
Severity
Urine color/concentration/amount
No urine output
Heart rate/blood pressure
ALOC
An example of clinical assessment can be for suspected gastroenteritis as a differential diagnosis. Common findings for bacterial gastroenteritis is Nausea and vomiting and diarrhea. There csn also be accompanying fever and abd pain. Vomiting and Diarrhea can be viewed as mild, moderate, or severe based on the number of vomiting and diarrheal episodes per day (Seattle Children's , 2021). Assess the color of the urine and frequency or urination. If the patient does not produce urine in 8 hours the patient is showing signs of dehydration. Assess mucous membranes and skin for signs of dehydration as well (Seattle Children's , 2021). Other signs of dehydration from excessive vomiting and diarrhea and decreased oral intake can be tachycardia, dry mucous membranes, hypotension, and even altered mental status in advanced stages of dehydration (Sattar & Singh, 2021).
Treatment Approaches
Two pronged approach
Treat Symptoms
Treat Underlying cause
Treat dehydration
Oral fluids
IV fluids
Treat Vomiting to prevent water loss
Antiemetics
Serotonin blocking – Zofran
Increase GI function- Metoclopramide
Dopamine blocking- Haldol, prochlorperazine
Antihistamine- Benadryl
Typical treatments- One of the biggest dangers with varying severities of vomiting and diarrhea is the risk of the patient becoming dehydrated. This can be especially dangerous with pediatrics and elderly patients. Special support and education is necessary with families that have children with illnesses that have nausea, vomiting, and diarrhea. Children will not want to drink fluids when they are ill and techniques for keeping a child hydrated is important. One technique is the use of a syringe for helping the child get enough fluid without causing GI upset. New parents may also be very timid with taking care of a sick child so office follow up may be necessary to decrease anxiety and offer guidance and education(Lorenzo, 2021).
There needs to be a two-pronged approach to treating these patients, treating symptoms and treating the underlying cause. To prevent dehydration it is important to encourage fluid intake orally and if fluid is not tolerated then IV fluids may be necessary. Mitigating fluid loss is important by treating the patient’s vomiting and diarrhea. For vomiting a patient can take Dramamine over the counter or take Zofran if prescribed by a provider. Much of the treatment for vomiting can be an attempt to disrupt the pathway that is causing the vomiting center to be activated. For example, Serotonin-blocking medications such as the Zofran mentioned above attempts to block activity from serotonin that causes nausea. Metoclopramide is a medication that works directly on the GI tract that can produce the peristalsis movement to help with gastric emptying. Dopamine-blocking medications, such as haloperidol or prochlorperazine, have been used increasingly for nausea caused by cyclical vomiting by blocking some dopamine activity causing nausea and vomiting. Antihistamines have also been use dot block the histamine receptors for histamine that can cause nausea in the patient (Sampson, 2021).
Treatment Approaches
Treat Diarrhea to decrease water loss
Antidiarrheal- Loperamide with caution
Decrease oral intake of food
BRAT DIET- Bland diet
Probitiocs
Treat the underlying infection
Antibiotics
Oral Vancomycin
IV Metronidazole
Cipro
(Parakh, 2017)
For diarrhea the patient treatment direction is to prevent water and electrolyte loss and allow the intestines decrease inflammation in order to more adequately and efficiently absorb water and nutrients. A patient can take loperamide to stop the spasmodic episodes of diarrhea, as long as they do not have a fever or blood in their stool (Santos-Longhurst, 2018) In the example of bacterial gastroenteritis, antibiotic therapy may need to be initiated. Examples antibiotics are oral vancomycin and/or IV metronidazole and Ciprofloxacin. During the symptomatic and treatment phase a patient should also adhere to education focused on decreasing intestinal irritating food intake or use the BRAT diet to decrease irritation to the intestinal lining.
Treatment Innovations/Trends
Bimodal Release Ondansetron
Orally administered
6mg immediate release
18 mg 24 hour release
24mg total daily dose
(Cunha, 2021)
As healthcare providers it is critical to assess for trends in healthcare and search for best treatment options for patients. One of these trends is the ineffective oral ondansetron. For some individuals that are suffering from nausea and vomiting, the use of Zofran does not always work efficiently for nausea when given through the oral route. However, there is evidence that an innovative treatment option is a combination ondansetron can work to decrease nausea and vomiting. This is called bimodal release ondansetron. This ondansetron formulary has been show to increase effectiveness over the placebo groups. It releases 6 mg of immediate release Zofran and 18mg of 24 hour release Zofran. This is a daily amount of 24 mg (Silverman, House, & Meltzer, 2019). Having a 24 hour tablet allows a patient to be able to be compliant with medication and have better control of their nausea symptoms.
References
Becker, D. (2010). Nausea, Vomiting, and Hiccups: A Review of Mechanisms and Treatment. Anesthesia Progress.
Bowen, R. (2018). Pathophysiology of Diarrhea. Retrieved from vivo.colostate.edu: http://www.vivo.colostate.edu/hbooks/pathphys/digestion/smallgut/diarrhea.html
Bowen, R. (2019). Physiology of Vomiting. Retrieved from Vivo.colostate.edu: http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/vomiting.html
Cervellin, G., Mora, R., Ticinesi, A., Meschi, T., Comelli, I., Catena, F., & Lippi, G. (2016). Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Annals of Translational Medicine, 362.
Cleveland Clinic. (2020, April 13). Diarrhea. Retrieved from my.clevelandclinic.com: https://my.clevelandclinic.org/health/diseases/4108-diarrhea
Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors. (2015). Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US).
Cunha, J. (2021, May 14). Zofran. Retrieved from rxlist.com: https://www.rxlist.com/zofran-drug.htm
Guandani, S. (2020, January 31). Diarrhea Differential Diagnoses. Retrieved from emedicine.medscape.com: https://emedicine.medscape.com/article/928598-differential
References
Hyman, P. (2020, August 24). The Disappearance of the Primary Care Physical Examination—Losing Touch. Retrieved from jamanetwork.com: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769550
Khatri, M. (2020, December 06). Nausea and Vomiting. Retrieved from webmd.com: https://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomiting
Lorenzo, C. D. (2021, January 06). Patient education: Nausea and vomiting in infants and children (Beyond the Basics). Retrieved from uptodate.com: https://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics
NIH. (2019, August). About the Lower GI Tract. Retrieved from niddk.nih.gov: https://www.niddk.nih.gov/health-information/digestive-diseases/anatomic-problems-lower-gi-tract/about-lower-gi-tract
Ogobuiro, I., Gonzales, J., & Tuma, F. (2021). Physiology, Gastrointestinal. Treasure Island (FL): StatPearls Publishing.
Parakh, D. M. (2017, February 6). Treating Diarrhea & Vomiting in Kids. Retrieved from rdx.in: https://www.rxdx.in/treating-kids-diarrhea-and-vomiting/
Ramani, A. (2013, December 20). Gastroenteritis/ Stomach Flu. Retrieved from medindia.net: https://www.medindia.net/patients/patientinfo/gastroenteritis.htm
Sampson, S. (2021, August 24). What to know about vomiting. Retrieved from medicalnewstoday.com: https://www.medicalnewstoday.com/articles/vomiting
Santos-Longhurst, A. (2018, December 18). What Causes Concurring Diarrhea and Vomiting, and How to Treat It. Retrieved from healthline.com: https://www.healthline.com/health/diarrhea-and-vomiting
Sattar, S. B., & Singh, S. (2021). Bacterial Gastroenteritis. Treasure Isalnd (FL): StatPearls Publishing.
References
Science photo Library. (2021). Gastrointestinal Tract Illustration. Retrieved from sciencephoto.com: https://www.sciencephoto.com/media/995536/view/gastrointestinal-tract-labelled-illustration
Seattle Children's . (2021, March 11). Vomiting With Diarrhea. Retrieved from seattlechildrens.org: https://www.seattlechildrens.org/conditions/a-z/vomiting-with-diarrhea/
Sethi, S. (2020, September 3). What can cause nausea and diarrhea? Retrieved from medicalnewstoday.com: https://www.medicalnewstoday.com/articles/nausea-and-diarrhea
Silverman, R., House, S., & Meltzer, A. (2019). Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults. JAMA Network Open.
The Emergency Center. (2020). Emergency Room Visit Statistics. Retrieved from theemergencycenter.com: https://www.theemergencycenter.com/emergency-room-visit/
