NURS 6501 Knowledge Check: Gastrointestinal and Hepatobiliary Disorders
The case study concerns DC, a 46-year-old woman with RUQ pain that has lasted 24 hours. The onset of the RUQ pain was roughly 1 hour after having a large family dinner. She reports having nausea and one episode of vomiting. The purpose of this paper is to discuss the patient’s diagnosis and recommend an appropriate medication therapy.
Diagnosis
The likely diagnosis for this patient is Acute Cholecystitis. Gallaher and Charles (2022) define Acute cholecystitis as an acute inflammatory disorder of the gallbladder, usually resulting from gallstone obstruction at the cystic duct. The classic clinical presentation of acute cholecystitis includes acute right upper quadrant (RUQ) pain, fever, and nausea associated with eating (Bridges et al., 2018). Physical exam findings include RUQ tenderness. Diagnostic findings in acute cholecystitis include elevated white blood cell count (WBC), Liver enzymes, and bilirubin levels. The patient has RUQ pain, nausea, and vomiting after eating. She also has an elevated WBC count and Direct and indirect serum bilirubin levels.
Appropriate drug therapy
The recommended drug therapy for DC will comprise analgesics, antiemetics, and IV antibiotics. Ketorolac IV 30 mg STAT dose, followed by 10 mg OO QID, will be recommended to relieve RUQ pain (Mou et al., 2019). The antiemetic of choice will be IV Promethazine 12.5 mg QID to manage nausea and vomiting. IV antibiotics will include Levofloxacin 500 mg IV once daily and Flagyl, 1 g IV loading dose followed by 500 mg IV QID (Markotic et al., 2020).
Conclusion
Cholecystitis mainly develops as a complication of gallstone disease but can occur without gallstones. The patient has positive symptoms of Acute Cholecystitis, including RUQ pain, nausea, vomiting, and elevated WBC and bilirubin. Treatment will include antibiotics, antiemetics, and analgesics.
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References
Bridges, F., Gibbs, J., Melamed, J., Cussatti, E., & White, S. (2018). Clinically diagnosed cholecystitis: a case series. Journal of surgical case reports, 2018(2), rjy031. https://doi.org/10.1093/jscr/rjy031
Gallaher, J. R., & Charles, A. (2022). Acute cholecystitis: a review. Jama, 327(10), 965-975. doi:10.1001/jama.2022.2350
Markotic, F., Grgic, S., Poropat, G., Fox, A., Nikolova, D., Vukojevic, K., Jakobsen, J. C., & Gluud, C. (2020). Antibiotics for adults with acute cholecystitis or acute cholangitis or both. The Cochrane Database of Systematic Reviews, 2020(6), CD013646. https://doi.org/10.1002/14651858.CD013646
Mou, D., Tesfasilassie, T., Hirji, S., & Ashley, S. W. (2019). Advances in the management of acute cholecystitis. Annals of gastroenterological surgery, 3(3), 247–253. https://doi.org/10.1002/ags3.12240
Question 1
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Scenario 1: Peptic UlcerA 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain has been persistent for two weeks. The pain described as burning, non-radiating and worse after meals. Denies N&V, weight loss or obvious bleeding. She admits to frequent belching with bloating. PMH: seasonal allergies with Chronic Sinusitis, positive for osteoarthri  tis, Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain Family Hx-non contributary Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and 6-7 cups of coffee per day. She denies illicit drug use, vaping or unprotected sexual encounters. Breath test in the office revealed + urease. The healthcare provider suspects the client has peptic ulcer disease. Questions:1. Explain what contributed to the development from this patient’s history of PUD? |
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Question 2
Scenario 1: Peptic Ulcer
A 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain
NURS 6501 Knowledge Check Gastrointestinal and Hepatobiliary Disorders has been persistent for two weeks. The pain described as burning, non-radiating and worse after meals. Denies N&V, weight loss or obvious bleeding. She admits to frequent belching with bloating.
PMH: seasonal allergies with Chronic Sinusitis, positive for osteoarthritis,
Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain
Family Hx-non contributary
Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and 6-7 cups of coffee per day. She denies illicit drug use, vaping or unprotected sexual encounters.
Breath test in the office revealed + urease.
The healthcare provider suspects the client has peptic ulcer disease.
Question:
1. What is the pathophysiology of PUD/ formation of peptic ulcers?
Selected Answer: This is in two part, which is decreased mucosal protection and increased acid production. The causative factor most likely is the H.pyloris that destroy the mucosal lining, causing inflammatory process that increased gastric acid production that erode the liniing ,The increasesd acid create open sore that bleed.
Correct Answer: 
Chronic use of NSAIDS causes suppresses of mucosal prostaglandin and direct irritative topical effect. High gastrin level and excessive gastric acid production often seen in Zollinger-Ellison syndrome which can caused by gastrinoma. Smoking impairs healing by vasoconstriction. H Pylori causes gastritis and interferes with mucosa
Response Feedback: [None Given] -
Question 3Scenario 2: Gastroesophageal Reflux Disease (GERD)
A 44-year-old morbidly obese female comes to the clinic complaining of “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. She says she has started coughing at night which has been interfering with her sleep. She denies palpitations, shortness of breath, or nausea.
PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)
FH:non contributary
Medications: Lisinopril 10 mg po qd, Bentyl 10 mg po, ibuprofen 800 mg po q 6 hr prn
SH: 20 PPY of smoking, ETOH rarely, denies vaping
Diagnoses: Gastroesophageal reflux disease (GERD).
Question:
1. If the client asks what causes GERD how would you explain this as a provider?
Selected Answer: Gastroesophageal reflux disease is the backflow of acid from stomach to the esophagus causing irriation of the mucousa lining.
The symotoms are heartburn,reguritation,and pain with swallowing. The lower end of the oesphaus there is a circular ring of muscle called the spinicter that prevent the backflow of food and acid from escaping into the oesphagus, as a result of the relaxaton of sphinicter muscle from pressure from the stomach. There are riak factor for GERD. Hiatus hernia,obesity, pregnancy,lifestyle factors, like smoking,alchol consumption, excessive intake of nonsteriodal antinflammatory drugs , Certains steps can be taken to relief the sysptoms. The GERD can be manged with theses steps,Loose weight, stop smoking, Decrease alcohol intake,decrease meal size, avoid eating late. Avoid lieing down 2hours to 3hours after eating,
Correct Answer: GERD manifestations result directly from gastric acid reflux into the esophagus. Pyrosis, the classic symptom, is a substernal burning sensation typically described as heartburn. It may be accompanied by regurgitation, particularly in someone who has recently eaten. The lower esophageal sphincter (LES) relaxes due to certain medications (calcium channel blockers), hiatal hernia, and obesity allows stomach contents to enter the lower esophagus causing inflammation and possibly erosion of the esophagus.
Response Feedback: [None Given] -
Question 4
Scenario 3: Upper GI Bleed
A 64-year-old male presents the clinic with complaints of passing dark, tarry, stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.
Question:
1. What are the variables here that contribute to an upper GI bleed?
Selected Answer: The major causes of upper GIB include esophageal varices, gastritis, peptic ulcers.The variaiable to upper GIBleed is the history of the patient about epigastric pain several weeks, passing of dark tarry stool , Now presenting with signs of shock from bleeding.
Correct Answer: UGI bleeds can be caused by Peptic ulcer disease (PUD) which remains the most common cause of UGIB. Esophageal bleeding from a Mallory-Weiss tear (caused by repeated vomiting, retching, erosions of the mucosa), gastric carcinomas.
Response Feedback: [None Given] -
Question 5
Scenario 4: Diverticulitis
A 54-year-old schoolteacher is seeing your today for complaints of passing bright red blood when she had a bowel movement this morning. She stated the first episode occurred last week. The episode today was accompanied by nausea, sweating, and weakness. She states she has had some LLQ pain for several weeks but described it as “coming and going”. She says she has had a fever and abdominal cramps that have worsened this morning.
Diagnosis is lower GI bleed secondary to diverticulitis.
Question:
1. What can cause diverticulitis in the lower GI tract?
Selected Answer: Diverticulosis occur in the large intestine,caused by lack of fiber in the diet that cause constipation,this exert pressure on the wall of the colon and cause pouch known as the diverticula , This pouch are formed in weak area of the colon. Diverticulitis occur when the pouch is inflammed and infected due to erosion of the wall . This can also result in lower GI bleed.
Correct Answer: Diverticulitis is defined as an inflammation of one or more diverticula. Fecal material or undigested food particles may collect in a diverticula causing obstruction. The obstruction can cause vascular compromise. Increased intraluminal pressure or food particles cause erosion of the diverticular wall, resulting in inflammation, localized necrosis, and perforation.
Response Feedback: [None Given]
QUESTION 3
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Scenario 2: Gastroesophageal Reflux Disease (GERD)
A 44-year-old morbidly obese female comes to the clinic complaining of “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. She says she has started coughing at night which has been interfering with her sleep. She denies palpitations, shortness of breath, or nausea.
PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)
FH:non contributary
Medications: Lisinopril 10 mg po qd, Bentyl 10 mg po, ibuprofen 800 mg po q 6 hr prn
SH: 20 PPY of smoking, ETOH rarely, denies vaping
Diagnoses: Gastroesophageal reflux disease (GERD).
Question:
- If the client asks what causes GERD how would you explain this as a provider?
I would explain to the client that GERD is caused by excessive relaxation of the lower esophageal sphincter (LES). This allows reflux of gastric contents into the esophagus and exposes the esophageal mucosa to acidic gastric contents. Nighttime reflux usually causes prolonged exposure of the esophagus to acid since the supine position reduces peristalsis and the benefit of gravity (Maret-Ouda et al., 2020). The refluxed gastric contents are then returned to the stomach through a combination of gravity, saliva, and peristalsis. However, the inflamed esophagus cannot remove the refluxed material as quickly as a healthy one. Thus, the length of exposure to gastric acid increases with each reflux episode (Maret-Ouda et al., 2020). Consequently, increased blood flow and erosion occur in the esophagus in response to the chronic inflammation.
4 points
QUESTION 4
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Scenario 3: Upper GI Bleed
A 64-year-old male presents the clinic with complaints of passing dark, tarry, stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.
Question:
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What are the variables here that contribute to an upper GI bleed?
The patient’s variables contributing to the upper GI bleed (UGIB) include sex, advanced age, history of upper GI bleeding, use of high-dose NSAID, and anticoagulant use. Wilkins et al. (2020) explain that UGIB is twice more common in males than females, and its prevalence increases with age. Persons aged 60 years and older have the highest risk. The common medical causes of UGIB include esophagitis, peptic ulcer bleeding, gastritis, variceal bleeding, and gastric cancer. The patient has a history of mild epigastric pain, which points to gastritis. His gender, advanced age, and possible gastritis can be attributed to the upper GI bleed (Wilkins et al., 2020).4 points
QUESTION 5
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Scenario 4: Diverticulitis
A 54-year-old schoolteacher is seeing your today for complaints of passing bright red blood when she had a bowel movement this morning. She stated the first episode occurred last week. The episode today was accompanied by nausea, sweating, and weakness. She states she has had some LLQ pain for several weeks but described it as “coming and going”. She says she has had a fever and abdominal cramps that have worsened this morning.
Diagnosis is lower GI bleed secondary to diverticulitis.
Question:
- What can cause diverticulitis in the lower GI tract?
Diverticulitis is inflammation of a diverticulum with or without infection. It can occur when there is a micro or macro perforation in a diverticulum, which causes the release of intestinal bacteria that triggers inflammation (Barbaro et al., 2022). If bacteria get trapped in a diverticulum, the blood supply to that diverticulum is reduced. Bacteria invade the diverticulum, causing diverticulitis, which then can perforate and progress to a local abscess.
References
Barbaro, M. R., Cremon, C., Fuschi, D., Marasco, G., Palombo, M., Stanghellini, V., & Barbara, G. (2022). Pathophysiology of diverticular disease: from diverticula formation to symptom generation. International Journal of Molecular Sciences, 23(12), 6698. https://doi.org/10.3390/ijms23126698
Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease. The American journal of medicine, 132(4), 447-456. https://doi.org/10.1016/j.amjmed.2018.12.009
Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease: a review. Jama, 324(24), 2536-2547. https://doi.org/10.1001/jama.2020.21360
McEvoy, L., Carr, D. F., & Pirmohamed, M. (2021). Pharmacogenomics of NSAID-induced upper gastrointestinal toxicity. Frontiers in pharmacology, 1302. https://doi.org/10.3389/fphar.2021.68416
Wilkins, T., Wheeler, B., & Carpenter, M. (2020). Upper Gastrointestinal Bleeding in Adults: Evaluation and Management. American family physician, 101(5), 294–300.