Gastrointestinal

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Gastrointestinal symptoms

As with other chronic diseases, most women with gastrointestinal diseases will have had symptoms that antedate the pregnancy. However, it is certainly possible both to develop the new onset of a gastrointestinal disease during pregnancy and/or to develop gastrointestinal symptoms associated with pre-eclampsia during a pregnancy. As a result, a careful and accurate history is essential for the correct interpretation of gastrointestinal symptoms during pregnancy. This includes specific inquiries about previous episodes of the current symptoms as well as any previous diagnoses (including the method(s) by which the diagnoses were established) and any history of abdominal surgery. In addition, specific descriptions of the duration, nature and location of the symptoms and connections, if any, between the waxing and waning of symptoms and external factors such as eating, fatigue, activity or stress can be vitally important to establishment of the correct diagnoses.

Nausea

Certain clinical entities associated with the new onset of nausea in late pregnancy require specific evaluation for their exclusion. These include intra-abdominal (most common), intracranial and metabolic diseases. It must be emphasized that the onset of nausea beyond the first trimester should NEVER be ascribed to hyperemesis.

Nausea due to intra-abdominal conditions is usually associated with other gastrointestinal symptoms, characteristically vomiting and/or abdominal pain. Nausea that is exacerbated by food intake should suggest the possibility of cholelithiasis and/or cholecystitis, as this condition is a relatively common cause for non-obstetric surgical intervention during pregnancy. The nausea, vomiting and abdominal pain associated with acute cholecystitis is characteristically exacerbated by food intake and may radiate to the back, particularly if there is common duct obstruction (and associated pancreatitis).

Intracranial hypertension is commonly associated with nausea. While classically associated with early morning projectile vomiting, the nausea can occur at any time and these women should have a fundoscopic examination to exclude papilledema.

A careful history will often identify the concurrent ingestion of other medications, herbal preparations or toxins (recognized or unrecognized) that may be responsible for nausea.

Vomiting

In pregnant women with vomiting a careful history can often be very helpful in identifying or excluding concurrent gastrointestinal disease. Concurrent medications or ingestion of toxins, recognized or unrecognized, may be associated with vomiting, as can concurrent psychogenic disorders.

When a patient vomits during or immediately after a meal it is frequently psychogenic in origin, although the possibility of pyloric obstruction, usually due to an associated ulcer, must be considered. The possibility of structural distortion of the pancreas by a pseudocyst or tumor could also be considered. These women would be expected to have concurrent pain that, in contradistinction to women with ulcer disease, would not be relieved by vomiting.

Vomiting that occurs an hour or more after eating is characteristic of pancreatitis, gastric outlet obstruction or motility disorders such as gastro-paresis diabetacorum. These individuals may have enlarged stomachs that can be palpated or percussed on physical examination.

Idiopathic intracranial hypertension, previously called pseudotumor cerebrii, is also associated with vomiting, as can be other causes of increased intracranial pressure such as mass lesions. While classically associated with early morning projectile vomiting, vomiting can occur at any time. These patients can be easily identified by examination of the optic fundus, where papilledema should be readily apparent.

The contents of the vomitus should also be evaluated. Undigested food would suggest a gastric outlet obstruction, whereas the presence of bile should suggest a postpyloric condition. Likewise, the presence of blood should suggest an inflammatory, or rarely malignant, origin although prolonged vomiting in pregnancy may also lead to hematemesis secondary to gastroesophogeal junction lacerations (Mallory-Weiss syndrome).

Finally, consideration must be given to the possibility of iatrogenic causes of vomiting, primarily as side effects of concurrently administered medication. Magnesium sulfate is notorious for causing nausea and vomiting in pregnant women, whether administered for seizure prophylaxis or for treatment of premature labor. The list of additional medications is lengthy and can arguably include many of the medications commonly used in the treatment of pre-eclampsia and/or eclampsia.

Abdominal pain

The abdominal pain classically associated with pre-eclampsia is epigastric and/or right-upper quadrant in location and is not characteristically affected by food intake. The pain associated with visceral and/or hepatic ischemia is characteristically epigastric in location and does not radiate. The pain associated with hepatic hemorrhage may be more localized if the hemorrhage is contained within the liver parenchyma or may be diffuse if it has progressed to hemoperitoneum.

Patients, as well as their friends and families, all recognize that abdominal pain is abnormal and tend to report more promptly for evaluation of this symptom than for many others. Pain resulting from hollow viscera is characteristically dull, poorly localizable but described as midline and associated with nausea and/or vomiting. Esophageal pain may be confused with chest pain (see Chest Pain under Pulmonary Signs). As mentioned above, the pain associated with biliary tract disease is characteristically right-upper quadrant and postprandial in nature and is not associated with hypertension or proteinuria. The pain associated with cholecystitis is more constant, may radiate to the back (should suggest secondary pancreatitis) and is often accompanied by fever. Viral hepatitis may be associated with right-upper quadrant abdominal pain but is almost always associated with clinically apparent jaundice and is not characterized by proteinuria or hypertension. Pain from small bowel involvement (ischemia, obstruction, etc.) is characteristically periumbilical in location whereas pain from colonic sources is characteristically lowered abdominal in location. Pregnancy does not increase the risk of appendicitis over that expected in non-pregnant women of reproductive age. However, appendicitis in pregnant women is more likely to be associated with complications.

While recent cautions about vaginal delivery following previous Cesarean delivery have resulted in fewer attempts at subsequent vaginal birth, uterine rupture following previous Cesarean is still a recognized complication of subsequent pregnancies. In contrast to the gradual onset of pre-eclampsia, uterine rupture is an acute, often catastrophic, event generally occurring in labor and with maternal shock, fetal distress and vaginal bleeding. The sudden onset during labor and associated vaginal bleeding generally make this distinction obvious.

Pre-eclampsia clearly predisposes pregnant women to placental abruption. Abruption may also present as abdominal pain. However, physical examination generally identifies the uterus, rather than the upper abdomen, as the source of pain. Likewise, vaginal bleeding, although not invariably present, generally directs diagnostic consideration away from maternal visceral ischemia.

It must be emphasized that pain caused by conditions restricted to the viscera, i.e. without peritoneal involvement, is NOT affected by coexistent pregnancy and will be perceived in the same manner and locations as in the non-pregnant state.

As visceral inflammation and/or ischemia progresses, however, abdominal pain will characteristically shift from poorly localized visceral descriptions to the site of the involved peritoneal irritation. Appendicitis in pregnancy represents an instructive example. While the condition is no more or less common in pregnancy than during any other interval for women of reproductive age, it is likely to be more serious if it occurs during pregnancy, in part because of reluctance to perform the appropriate diagnostic and therapeutic interventions in a timely fashion because of concerns for the pregnancy, in part because the peritoneal irritation associated with the condition is characteristically right-upper quadrant in location, at least in late pregnancy, and is frequently confused with cholelithiasis/cholecystitis, and in part because the peritonitis associated with appendiceal rupture is less likely to be contained by the omentum because of the enlarged uterus.

Specific attention must also be directed to the patient's behavior during the pain. Pain caused by the stretching of smooth muscle (not only the intestinal tract but also the biliary tract and the ureter) is colicky in nature, not affected by movement, and affected patients tend to be restless. In contradistinction, patients whose pain is associated with peritoneal irritation tend to avoid movement, since this makes their pain worse.

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