12) GI (Part 2) Flashcards
Acute pancreatitis most common causes/pathology
- Leakage of pancreatic enzymes into the interstitial space –> edema and inflammation
- Alcohol (inflammation)
- Gallstones/Biliary Pancreatitis (obstruction)
- Hypertriglyceridemia (> 1000 mg/dl)
Acute pancreatitis signs/symptoms
- Epigastric pain radiating to the back
- Cullen’s sign & Grey-Turner sign are consistent with severe necrotizing pancreatitis
- Elevated Amylase and Lipase (Lipase remains elevated longer)
Acute pancreatitis Tx
- IV FLUIDS, NPO
- Analgesics (Demerol does not constrict the sphincter of Oddi like morphine)
- Bowel rest
Most cases of chronic pancreatitis are due to
- ETOH
Chronic pancreatitis pathology
- Inflammation
- Fibrosis
- Irreversible loss of pancreatic cell function
Chronic pancreatitis signs/smyptoms
- Chronic abdominal pain
- Diarrhea
- Weight loss
Chronic pancreatitis diagnosis
- Amylase/lipase may be elevated or normal
- KUB: pancreatic calcifications
Chronic pancreatitis Tx
- Symptomatic with pancreatic enzyme replacement
Chronic pancreatitis complications
- Malabsorption, steatorrhea
- Diabetes may develop
Pancreatic cancer
- Most are adenocarcinoma
- Prognosis is poor as most have locally advanced or metastatic disease at Dx
- Biggest risk factor is cigarette smoking
Pancreatic cancer signs/symptoms
- Non-specific sxs
- “painless jaundice” (obstruction)
- Systemic pruritus
- Nausea, abd discomfort
- Weight loss
- Courvoisier’s sign (palpable GB in the presence of painless jaundice)
Pancreatic cancer diagnosis
- CT guided biopsy or EUS w/ biopsy
- Pancreatectomy (Whipple’s)
- Appropriate for only 10-20% of pts
Diverticulitis complications
- Acute Diverticulitis
- Diverticular Bleeds
Diverticulitis signs/symptoms
- Often elderly patients
- LLQ pain & tenderness
- Low grade fever
Diverticulitis diagnosis
- Often treated empirically
- CBC w/ elevated WBCs
- CT w/ contrast – most accurate
Diverticulitis Tx
- Ciprofloxacin + metronidazole (mild disease)
Irritable bowel syndrome pathology
- Related to gut-brain interaction
- Not due to structural or biochemical abnormalities
IBS signs/symptoms
- Abd pain and distension - worse after eating and relieved after BM*
- No weight loss or fever
IBS types (3)
- Constipation (IBS-C)
- Diarrhea (IBS-D)
- Constipation alternating with diarrhea (IBS-M)
IBS Tx
- Pain: antispasmodics, rifaximin, tricyclic antidepressants, probiotics
- Constipation: fiber/ psyllium, PEG, Lactulose, Lubiprostone, Linaclotide
- Diarrhea: loperamide, eluxadone, bile acid sequestrants, alosetron
Celiac disease pathology
- Gluten exposure causes formation of IgA antibodies directed against gliadin and tissue transglutaminase
- Causes atrophy and blunting of the villi in the small intestines –> malabsorption
Celiac disease signs/symptoms
- Chronic diarrhea, steatorrhea
- Weight loss
- Abd distension
- Dermatitis herpetiformis
- B12 deficiency
Celiac disease diagnosis
- Serologic Tests: + IgA Endomysial antibodies & tissue transglutaminase (tTG) antibodies (Antigliadin antibodies: lower sensitivity and specificity)
- Small bowel biopsy confirms Dx
Celiac disease Tx
- Gluten-free diet (reverses pathologic changes in the intestinal villi)
Acute mesenteric ischemia
- Acute onset of small intestinal hypoperfusion
Acute mesenteric ischemia pathology
- Embolic or thrombotic arterial or venous occlusion
- Nonocclusive processes (vasospasm or low cardiac output)
- Most commonly in those with atherosclerosis, A fib
- Associated with high mortality
Acute mesenteric ischemia signs/symptoms
- Acute severe abdominal pain “out of proportion”
Acute mesenteric ischemia diagnosis
- CT scan, MRI
- Doppler ultrasound
Acute mesenteric ischemia Tx
- O2, NPO, NG tube, IVF, analgesia
- STAT surgical or endovascular consult & Rx
Ischemic colitis
- Usually seen in elderly patients
- Diabetes mellitus, CAD, and PAD
Ischemic colitis pathology
- Same as AMI (hypoperfusion)
- Most prominent at the “watershed” area of colon
Ischemic colitis diagnosis
- Abd CT scan
- Colonoscopy (CT or MRI may assist in the diagnosis)
Ischemic colitis Tx
- Usually responds to conservative Rx
- NPO; IV fluids; correct electrolyte abnormalities, Abx
- Anti-embolic therapy
- Surgery is uncommon
Volvulus
- Higher incidence in elderly pts with other comorbidities
Volvulus pathology
- Sudden, twisting of the bowel on itself –> obstruction and ischemia
- Gangrene, necrosis and perforation can occur
- Associated with high morbidity and mortality
Volvulus signs/symptoms
- Abd pain, bloating, vomiting
- Bloody stool
Volvulus diagnosis
- Plain abd x-ray or KUB – “coffee bean” sign
Volvulus Tx
- Endoscopic reduction
- Surgery
Small bowel obstruction causes
- Surgical Adhesions (most common cause), hernias
Large bowel obstruction causes
- Colon CA – most common cause
Bowel obstruction signs/symptoms
- Abdominal pain
- Nausea, vomiting
- Constipation (with complete obstruction)
Bowel obstruction diagnosis
- KUB – air fluid levels, dilated bowel loops
- Abd Ct scan
Bowel obstruction Tx
- Decompression (NG tube), surgery
Toxic megacolon
- Rare, emergency case
Toxic megacolon pathology
- Non-obstructive widening of the large intestine (> 6 cm, loss of haustra)
Toxic megacolon etiologies
- UC
- C-diff colitis
- Colonic ischemia
Toxic megacolon signs/symptoms
- Abd distension
- Hypotension, tachycardia
- Fever
- Leukocytosis
- Altered mental status –> shock
Toxic megacolon diagnosis
- Abd X-ray - dilated colon >6cm
- Abd CT scan
Toxic megacolon Tx
- Bowel rest: IVF, NG tube/suction, NPO
- Steroids, Abx
- GI and Surgical Consult (partial or total colectomy)
Inflammatory bowel diseases (IBD)
- Crohn’s Disease
- Ulcerative Colitis
Crohn’s Disease
- Most commonly involves terminal ileum and adjacent colon
- Transmural (whole thickness of the colon) involvement with skip lesions
Ulcerative Colitis
- Most commonly involves the rectosigmoid colon
- Involves the mucosa and submucosa only
- Diffuse involvement (no skip lesions)
Crohn’s Disease (IBD) common presentation
- Diarrhea (usually non-bloody)
- RLQ pain
- Low grade fever
- Weight loss
- Perianal disease with fistula and abscess
- Almost never involves the Rectum
Ulcerative Colitis (IBD) common presentation
- Intermittent bloody diarrhea (lesions are friable)
- Tenesmus, Urgency
- Lower abdominal cramping
- Almost always involves the Rectum
Crohn’s Disease (IBD) lab tests and diagnostic studies
- ASCA (antisaccharomyces cervisiae antibody)
- Small bowel follow through: ulceration, fistulas, skip lesions
- Biopsy – Granulomatous lesions; focal ulcerations; acute and chronic inflammation.
Ulcerative Colitis (IBD) lab tests and diagnostic studies
- p-ANCA** (anti- neutrophil cytoplasmic antibody)
- Biopsy – crypt abscesses, crypt branching, shortening and disarray, and crypt atrophy
IBD treatment options
- 5-ASAs – PO, enema or suppository (sulfasalazine, mesalamine, etc.)
- PO antibiotics
- PO corticosteroids to decrease flare, sxs
- Immunomodulator drugs
- Biologic Therapy
- Surgery
PO antibiotics used to treat IBD
- Metronidazole & ciprofloxacin (if secondary infection is present)
Immunomodulator drugs used to treat IBD
- azathioprine (Imuran, Azasan)
- 6-MP, Purinethol
- cyclosporine A (Sandimmune, Neoral)
- tacrolimus (Prograf)
- Methotrexate
Biologic therapy used to treat IBD
- Infliximab (Remicade)
Surgeries to treat IBD
- UC - colectomy is curative
- Crohn’s disease – reserve ONLY for complications
IBD extra-intestinal manifestations
- Skin: erythema nodosum, pyoderma gangrenosum
- Eye: uveitis, episcleritis
- Joints: ankylosing spondylitis
Colon cancer (IBD complication)
- Management: Screening colonoscopy is recommended 8 yrs after Dx
- Then, annual surveillance
Toxic megacolon (IBD complication)
- Emergency
Primary sclerosing cholangitis (IBD complication)
- Suspect in a patient who has unexplained elevated liver enzymes
- Particularly an elevation in serum alkaline phosphatase
Colon polyps pathology
- Majority are adenomas
- Benign adenomatous polyps can undergo dysplasia & neoplastic changes
- Larger polyps & those with more villous characteristics are more likely to contain dysplasia (tubular, villous, tubulovillous)
Colon polyps signs/symptoms
- Are asx
Colon polyps diagnosis
- Found incidentally on colonoscopy or radiologic study
- FHx (genetic mutation)
- Sigmoidoscopy/ colonoscopy
- Barium study/ CT scan
Colon polyps Tx
- Endoscopic resection
- F/U surveillance by colonoscopy every 2-5 yrs
Colorectal cancer is nearly always
- Adenocarcinoma
Colorectal cancer risk factors
- First degree relative with colon cancer or adenomatous polyps
- Personal H/O breast, ovarian, or uterine cancer
- Genetic predisposition
- Ulcerative colitis > Crohn’s disease
Genetic predisposition to colorectal cancer
- Familial adenomatous polyposis (AKA: FAP, Gardner’s syndrome)
- Peutz-Jeghers Syndrome
Colorectal cancer signs/symptoms
- Change in bowel habits
- FOBT
- Intermittent melena or stool streaked with blood
- Recurrent hematochezia
Colon cancer diagnosis
- Colonoscopy with biopsy – test of choice
- Stool tests
Stool tests to screen for colon cancer
- Fecal immunochemical test (FIT)
- Multitarget stool deoxyribonucleic acid (MT-sDNA)
+ results require a colonoscopy for definitive Dx
Colon cancer Tx
- Surgical excision for early stage cancers
- Adjuvant chemotherapy and/or XRT
- Prognosis depends upon stage at Dx
Anal fissure pathology
- Split or tear in anal mucosa
Anal fissure signs/symptoms
- Tearing, burning, throbbing pain with defecation
- Blood streaks on stool &/or toilet paper
Anal fissure physical exam findings
- Crack in the epithelium
- External anal skin tag
Anal fissure Tx
- Sitz baths
- High fiber diet
- Stool softeners
- Hydrocortisone supp/ cream (Anusol HC, Proctofoam-HC)
Anal fistulas pathology
- Communication btwn an abscess with an opening within the anal canal
Anal fistulas are associated with
- Crohn’s disease
- Lymphogranuloma venereum
- Rectal cancer
Anal fistula signs/symptoms
- Drainage of blood, pus, mucous, stool
- Pruritus, tenderness, pain
Anal fistula Tx
- Surgery - I&D (under sedation or in office)
- Fistulotomy
- Broad spectrum Abx
- Sitz baths
Hemorrhoids
- Varices of the hemorrhoidal plexus
Hemorrhoids signs/symptoms
- Pruritus & rectal bleeding.
- BRBPR
- Dull, burning pain (internal rhoids)
- Rectal pain (if external and thrombosed)
Hemorrhoids Tx
- High fiber diet
- Sitz baths
- Local treatment (proctofoam, Tucks medicated pads, Preparation H)
- Rubber band ligation
- Sclerotherapy
- Surgical repair if severe
Hernias may present as
- Incarcerated
- Strangulated
Incarcerated hernia
- Reducible - a hernia that is not able to be reduced on exam
- The vascular supply of the bowel is NOT compromised
Strangulated hernia
- Irreducible
- Blood supply to the entrapped bowel has been cut off
- Results in small bowel obstruction and infarction
Types of hernias
- Direct
- Indirect (most common)
- Umbilical
- Incisional
- Ventral
- Hiatal or diaphragmatic
- Femoral
Indirect hernia (most common)
- Passes thru the internal inguinal ring down the inguinal canal
- May pass into the scrotum
Direct hernia
- Passes through the external inguinal ring at Hesselbach’s triangle
- Rarely enters the scrotum
Umbilical hernia
- Most often appear at birth
- Most resolve without treatment
- Surgery may be indicated
Incisional hernia
- Most often appear after vertical incisions
Ventral hernia
- Weakening in the anterior abdominal wall
- May be either incisional or umbilical
Hiatal or diaphragmatic hernia
- Herniation of the stomach through the esophageal hiatus
Femoral hernia
- Passes through the femoral ring
- Least common
- Occur almost exclusively in females
