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Rosens > 81. Large intestine > Flashcards

81. Large intestine Flashcards

1
Q

IBS: what is this?

A

abdo pain, bloat, altered bowel habits - unclear pathophys but includes intestinal permeability, immune function, alt gut microbiome, motility and psychosocial status

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2
Q

IBS: Rome IV criteria dx

A

recurrent abod pain >1 day/week in previous 3mo, onset >6mo pre dx:
Abdo pain + at least 2:
pain in defection
change in freq stool
change in form

NONE of:
age >50
recent change in bowel habits
overt GIB sx
nocturnal pain or passage of stool
unintentional w loss
family hx CRC or IBD
palpable abdo mass or lymphadenopathy
evidence IDA
+ FOBt

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3
Q

Red flags of GI sx: list 8

A

age >50
recent change in bowel habits
overt GIB sx
nocturnal pain or passage of stool
unintentional w loss
family hx CRC or IBD
palpable abdo mass or lymphadenopathy
evidence IDA
+ FOBt

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4
Q

DDX IBS: 3 main categories

A

IBS with constipation vs diarrhea with mixed

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5
Q

IBS with constipation ddx - 5

A

Bowel obstruction
Malignancy
Adult-onset Hirschsprung disease
Rectocele
Paradoxical closure of the anus during defecation

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6
Q

IBS with diarrhea ddx - 5

A

Bacterial or parasitic intestinal infection Inflammatory bowel disease
Lactose intolerance
Malabsorption
Radiation proctocolitis
Celiac disease

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7
Q

IBS With Mixed Symptoms - ddx 6

A

Inflammatory bowel disease Ureteral colic
Bowel obstruction
Diverticular disease Gastroesophageal reflux of ulcer Liver or pancreatic disease
Lead toxicity Porphyria

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8
Q

management of IBS

A

low fodmap diet (fermentable, oligosacc, disacc, monosac and polyols diet (wheat, rye, garlic, onions, lactose containing, figs, honey, blackberries, lychee)

ondans

cbt

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9
Q

RF of diverticular disease

A

smoking
nsaid
PinA
Obese
red meat
high refined carb diet

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10
Q

Diverticular disease pathophys

A

diverticulosis: asx multiple divertiula (herniation of inner mucosa and submucosa layers of intestinal wall through muscular layers - often sigmoid colon

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11
Q

What 4 main factors contribute to development of colonic diverticula (4 categories)

A

weakness bowel wall
high intraluminal pressure
other assoc factors - seasonal, smoke, age
obesity

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12
Q

Diverticulititis: what is this?

A

inflamm of diverticula (typ sigmoid so LLQ)
low grade fever
nausea/emesis
altered bowel habits in 24h
abdo distensin possible

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13
Q

DDX of diverticulitis

A

colitis (either inflammatory or ischemic), ureteral stones, inguinal hernia, or pelvic or ovarian pathology, including an ectopic pregnancy or pelvic inflammatory disease. Appendicitis should be considered when symptoms are predominantly right-sided.

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14
Q

Diagnostic testing for diverticulitis and ddx

A

cbc
urinalysis if worry colovesical fistula
abdo ct with contrast for “itis” disease

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15
Q

Findings of diverticulitis on CT scan:

A

colonic wall thickening
pericolonic fat stranding
localized perf
abscess
free air or fluid

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16
Q

Management of Diverticulosis in general

A

high fiber diet
PA

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17
Q

Uncomplicated diverticulitis tx

A

hospitalization for IV abx and bowel rest if immuncom, elderly, mult moboridities, poor social support, unable to tolerate PO

oral therapy for outpt:
* Ciprofloxacin, 500 mg PO bid and metronidazole, 500 mg PO q8h or
* Amoxicillin-clavulanate, 875 mg–125 mg PO BID

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18
Q

Complicated diverticulitis tx:

A

bowel rest
IV abx:
Mild to Moderate Infection
* Pediatric:
*Metronidazole7.5mg/kgIVq6hANDceftriaxone50mg/kgIVoncedaily
OR
* Gentamicin 2.5 mg/kg IV q8h AND metronidazole 7.5 mg/kg IV q6h
* Adult:
* Metronidazole 500 mg IV q8h plus
* Ceftriaxone 1 g IV q24h or
* Ciprofloxacin, 400 mg IV q12h or * Levofloxacin 750 mg IV q24h or
* Ampicillin-sulbactam, 3g IV q6h

Severe/Complicated Infection
* Piperacillin/tazobactam 3.375 g IV q6h or 4.5 g (100 mg/kg) IV q8h OR
* Metronidazole 500 mg IV q8h (7.5 mg/kg IV q6h) PLUS Cefepime 2 g (50 mg/
kg) IV q12h OR
* Ertapenem,1gIVq24h(weight-baseddoseinpediatrics:15mg/kg/dose
IV BID)or imipenem/cilastatin, 500 mg IV q6h (weight-based dose in pedi- atrics: 60 to 100 mg/kg/day divided q6h) or meropenem, 1 g IV q8h (weight-based dose in pediatrics: 20 mg/kg/dose IV q8h)
concern for perf, sepsis, decline despite conservative - see surgery for consideration perc drain (esp if larger abscess >5cm)

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19
Q

Causes of LBO

A

CRC malignancy
IBD
ischemia
adhesions
endometriosis
radiation

extrinsic: impingement intestinal lumen - ovarian ca, hernia

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20
Q

MC location for LBO?

A

sigmoid due to smaller lumen of sig and desc colon
-imp distinction distal or proximal to splenic flexure (tumor mc distal to this)

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21
Q

What is Ogilvie’s syndome?

A

may mimic LBO
acute colonic distension w/o evidence mech obstruction
functional due to incr symp tone or decr parasymp

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22
Q

top 4 causes of LBO

A

CRC ca
volvulus
diverticulits
compression from other malignancy or met disease

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23
Q

Initial imaging for LBO?

A

supine and upright plain film for assessment distended colon >6cm diameter, but small bowel may be >3cm
-to look for perf in particular

then ct for location and cause

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24
Q

Management of LBO and Ogilvie’s in the ED

A

IVF
lyte replacement
IV pain control, antiemetic
NPO
NG tube

conservative unsuccessful 3d - consider neostigmine 2mg IV or colonic decomp:

if volvulus or fails conservative - surg/endoscopic decompression

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25
Q

How does neostigmine work for LBO?

A

incr ach for colonic motility but risk of ?toxic megacolon?

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26
Q

Volvulus age group in elderly?

A

60-70

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27
Q

What is volvulus?

A

loop of bowel twisting around itself and mesentery –> obstruction, also maybe ischemia if tight enough

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28
Q

Where does most volvulus occur?

A

sigmoid, cecum > transverse colon > splenic flexure

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29
Q

Complications of volvulus

A

ischemia
gangrene
perf
death

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30
Q

Who is at risk for volvulus at sigmoid?

A

residents LT care
neurologic/psych disease due to alt in colonic motility
chr constipation also possible issue

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31
Q

How much twisting can mesentery of sigmoid handle?

A

180

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32
Q

Cecal voluvlus - mc causes fo this?
RF?

A

congenital incomplet fusion of cecal mesentary in posterior abdo wall
RF: chr constip, high fiber diet, laxative use, hx lap, pregnancy, pelvic surg, colonoscopy, Long distance running

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33
Q

Sigmoid volvulus appearance on xr?

A

coffee bean sign - bowel bent inner tube appearnace

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34
Q

Differentiation cecal volvulus vs sigmoid: example of tool to help

A

contrast enema

“whirl sign” on ct

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35
Q

Management of sigmoid volvulus

A

IVF
Lytes, coagulopathy addressed
abx if gangene or perf

endo decompression - or if gangrene, doesn’t work, surg

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36
Q

Cecal volvulus management?

A

IVF
coagulopathy addressed, lytes addressed

surgery - cannot do endoscopy here

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37
Q

What is intussusception?

A

lead point changes motility allowing proximal aspect of intestine to telescope into another

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38
Q

What age. in childre in intusseception common? vs adults?

A

4-10y

rarer - concern for neoplasm/malignancy (mean age 50)

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39
Q

Sx of intussusception in kids and diagnostic tool of choice

A

acute onset, intermittent abdo pain, crying, pulling up knees and emesis

u/s

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40
Q

Sx of intussusception in adults and diagnostic tool of choice

A

acute onset abdo pain, vomit, rectal bleed

ct

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41
Q

Management intuss kids vs adult

A

kid - reduction - hydrostatic or pneumatic

adult: surg

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42
Q

Where does most intuss occur in kids?

A

ileum through ileoceccal valve into cecum

idiopathic cause or related to Peyer’s patch in infection

43
Q
A
44
Q

Peds intuss management:

A

In pediatric intussusception, the treatment of choice for the stable child is a trial of pneumatic reduction with x-ray guidance, or hydro- static reduction with ultrasound guidance when appropriate radiologic facilities are available.12 The choice of hydrostatic or pneumatic reduc- tion is largely dependent on institutional preference. Both have higher reduction rates when compared to barium. The reduction procedure is typically performed by a radiologist and may prevent the need for surgery. Reduction of pediatric intussusception is sufficient treatment in 80% of patient

45
Q

When might need to do surgery in ped intuss?

A

ischemic bowel necrosis
pathologic lead point

46
Q

IBD Crohn’s vs UC: inflamm type and location

A

C: transmural inflam, skip lesion in GI tract
UC: Superifical, cont colon or rectum

47
Q

IBD Crohn’s vs UC: mc extraintestinal sx

A

C: athritis, apthous stomatitis, uveitis, erythema nodosum, ank spond

UC: inflamm athropathies, PSC, skin/eye/bone issues possible

48
Q

IBD Crohn’s vs UC: dx

A

endoscopy, elevated fecal calprotectin, stool lacterferrin
crohn: ASCA vs UC: p-anca

49
Q

IBD Crohn’s vs UC: tx

A

C: uleal release budesonide, systemic steroids, immunomod, biologics, mult surg

UC: rectal/oral aminosalicyyclate, steroids, immunomod, biologics, surg (colectomy) can be curative

50
Q

General pathophys of IBD

A

dysreg of host immune system so no longer tolerates normal gut flora/bacteria

51
Q

Typical presenting sx of IBD

A

abdo pain/tenesmus
bloody diarrhea
w loss

52
Q

IBD children sx

A

diarrhea, growth or pubertal delay, weight loss, rectal bleeding, anemia, pallor, fatigue, perianal skin tags, fistulae or abscesses, erythema nodusum or pyoderma gangrenosum, seronegative rheumatic joint pain, or family history of IB

53
Q

Toxic megacolon: what is this?

A

pathologic dilation of colon from inflamm of sm layers in intestine –> m paralysis, dilation, perfoation if untx

54
Q

RF meds for toxic megacolon

A

anticholinergics
antimotility agents
narcotics
antidep

55
Q

Extraintestinal manifestations of IBD: skin

A

erythema nodosum
pyoderma gangrenosum

56
Q

Extraintestinal manifestations of IBD: eyes

A

episcleritis
scleritis
uveitis

57
Q

Extraintestinal manifestations of IBD: joints

A

arhtritis
sacroilitis

58
Q

Extraintestinal manifestations of IBD: bone

A

osteoporosis

59
Q

Extraintestinal manifestations of IBD: spine

A

ank spond

60
Q

Extraintestinal manifestations of IBD: liver

A

primary sclerosing cholangitis

61
Q

Extraintestinal manifestations of IBD: heme

A

dvt/pe

62
Q

Confirmatory testing for IBD

A

endoscopy with bx

63
Q

UC mild disease defn

A
  • Fewer than four stools/day
  • Stools may contain some blood
  • No systemic signs of toxicity (e.g., fever, tachycardia, anemia, elevated
    erythrocyte sedimentation rate)
64
Q

UC mod disease defn

A
  • More than four stools/day
  • Minimal signs of toxicity
65
Q

UC sev disease defn

A
  • More than six bloody stools/day
  • Signs of systemic toxicity
66
Q

Crohn disease: mild to mod disease sx

A
  • Patient ambulatory and able to eat
  • Nodehydration
  • Notoxicity
  • No significant abdominal pain or mass
  • Weight loss of 10%
67
Q

Crohn disease: mod to seve disease sx

A
  • Mild disease that has failed to respond to treatment
  • Patient may have some systemic toxicity, significant weight loss, anemia
  • Fever, some abdominal pain or tenderness, intermittent nausea or vomiting
68
Q

Crohn disease: sev disease sx

A
  • Persistence of symptoms during corticosteroid or biologic (e.g., infliximab) therapy
  • High fever, persistent vomiting
  • Intestinalobstruction
  • Reboundtenderness
  • Cachexia
  • Abscess
69
Q

Crohn’s: tx mild mod disease:

A

In general, mild disease can be treated by budesonide or oral steroids, whereas more severe disease often requires systemic IV corticosteroids, immunomodulators, or an anti- tumor necrosis factor (TNF) biologic strategy.

-bud 9mg PO daily x8 weeks (ileal release in particular)
-mild-mod GI: PPI
-extensive includes anti TNF, systemic corticosteroids induction 0.5-0.75mg/kg/day PO pred - higher if severe 40-60

70
Q

Crohn’s: tx mod to severe disease:

A

systemic steroids, early introduction to an immunomodulator, such as thiopurines or methotrexate, can be considered to reduce the risk of flare when steroids are withdrawn. Immunomodulators have a relatively slow onset, so are used adjunctively, and have limited use as monotherapy. Azathioprine 1.5 to 2.5 mg/kg/day PO or mercaptopurine 0.75 to 1.5 mg/kg/day PO may be used as an adjunctive therapy or steroid sparing agent. Methotrexate 25 mg/week subcutaneously or intramuscularly is the standard induction dose, with measurement of CBC and liver function tests prior to the initiation of therapy.

71
Q

Severe/fluminant Crohn disease amangeemnt

A

aggressive therapy, gastroenterology consultation, and often hospitalization. For patients with symptoms suggestive of obstruction, mass, or abscess, surgical consultation is prudent. Evaluation includes CBC, complete metabolic panel, blood cultures, stool culture, C difficile toxin antigen, urinalysis, and abdominal CT or MRI.

72
Q

When surgery in Crohn disease?

A

-fail medical therapy
-serious complications including abscess (perc drain if 5cm or greater)
-strictureplasy if resection <10cm

73
Q

UC: mild-mod tx

A

5-asa including mesalazine and sulfasalazine
proctitis PR of above
not responding to above: budesonide
if fail: sys predn: 0.5-1mg/kg PO pregn

74
Q

UC: mod severe dis tx

A

Cyclosporine, but given complications including (myelosupp, electrolyte disturbances, hepatic tox, nephro toxic, risk PCP) more likely inflximab

avoid antichol, antidiarrheas, or procedures like colonsocpy barium enema as may risk toxic megacolon

surg if refractory to above

75
Q

Pregnancy and IBD: how to manage?

A

-avoid cipro and metronidazole first trimester
-steriods incr risk DB
-5-ASA, immunomod and anti TNF safe in pregnancy

76
Q

Toxic megacolon tx:

A

IVF
IV corticosteroids
abx
tx lyte abn
assess for intestinal infection

77
Q

Colonic ischemia: how does this occur?

A

nonoccusive: hypoperfusion and reperfusion injury - see bowel wall edema nad subepithelium hemorrhage so mucosa ulcerates

78
Q

Colonic ischemia: primary insults?

A

-Cardiac: arrh, HF, shock
- vascular: AS, embolic, thrombotic, vasculitis
-infection: ecolo 0157:h7, hep b, cmv
-iatrogenic: surg on aorta
-physiologic : LD running
-coke/meth

79
Q

Colonic ischemia: weird RF?

A

copd

80
Q

Colonic ischemia: RRF diseases

A

copd, ibd, collagen vascular disease, heme disorders, ld running
meds: anti htn, vascon, antipsychotic, OCP, antidiarrheal, pseudophed, immunosuppressive agent

81
Q

Colonic ischemia: why is colon so at risk?

A

lowest flow state of all splancnhic organs, limited collaterals

usually L sided correlating with IMA

82
Q

Colonic ischemia: features of presentation

A

mild crampy abdo pain
n/v
may have rectal bleed

83
Q

Colonic ischemia: lab tests?

A

none sp but check wbc, lactate, decr hb, bicarb, incr LDH

84
Q

Colonic ischemia: ct features consistent?

A

mes fat stranding
abn colon wall enh
thumbprinting
wall thickening
luminal narrowing
inner wall hypoperfusion

sev: pneumatosis linearis, bowel dilation, pericolonic free fluid

85
Q

Colonic ischemia: best diagnostic testing?

A

colonoscopy for bx

86
Q

Colonic ischemia: absence of surgical complications, tx?

A

bowel rest
hydration
pain management

sign fx - abx

87
Q

Sterocoral colitis: what is this?

A

rare complication of chronic constipation and fectal impaction leading to inc intraluminal pressure wall necrosis, ischemic olitis, stercoral ulcer formation and concern for perf

88
Q

Stercoral colitis: common where (ie which part of colon)?

A

anterior rectum
rectosigmoid junction
apex of sigmoid colon

89
Q

Stercoral colitis: dx?

A

ct - fecal impaction with hard calcified fecal mass, colon dilation, colon wall thickening, mucosal discontinuity, pericolonic fat stranding, extraluminal free air

90
Q

Stercoral colitis: tx

A

bowel regimen
enemas
manua dismpaction

as long as no perf or peritonitis - if so - endoscpic guided disimpaction, consider abx or surg if perf

91
Q

Radiation proctocolitis: what is this?

A

acute begins within 12 weeks vs chronic 8-12mo: damages rapidly growing intestinal cells, mucosa injury = loss N barrier function - inflamm = further damage

can lead to stricture, fibrosis, ischemia

92
Q

Radiation proctocolitis: highest risk areas?

A

colon
cecum
rectum

93
Q

Radiation proctocolitis: acute vs chronic dx

A

acute - hx
chronic - dx exclusion - endoscopy

94
Q

Acute Radiation proctocolitis: management

A

supportive care: take to rad onc, nutrition imporvement, steroid enema?

95
Q

Radiation proctocolitis: chronic management

A

supportive - stool softner, analgesia, antiinflamm like sulfasalazine, mesalalzine

?hyperbaric therapy shows improvement?

96
Q

Neutropenic enterocolitis: what is this?

A

“typhlitis” - rare but important in all immunosupp with ac abdo pain
- intestinal mucosal injury typically at cecum and terminal ileum
-damage from chemo?

97
Q

Neutropenic enterocolitis: u/s vs ct fndings (aside from usual neutropenic testing)

A

u/s in peds particularly: bowel wall thickening >0.5cm

ct - bowell wall thciekning, cecum dilation, pericolonic inflamm, pericecal fluid, pneumatosis intestinalsis, perf

98
Q

Neutropenic enterocolitis: tx?

A

iperacillin-tazobactam (3.375 g IV, every 6 hours for adult patients, or 100 mg piperacillin/12.5 mg tazobactam per kilogram every 8 hours in pediatric patients), imipenem-cilastatin (500 mg IV every 6 hours or 1 g IV every 6 to 8 hours for adults, or 15–25 mg/kg every 6 hours in pediatric patients). Dual therapy can be used with cefepime (1g IV every 8 hours in adults, or 50 mg/kg every 8 hours) with metronidazole (1 g IV every 6 hours in adults or 30 mg/kg/day divided every 6 hours in pediatric patients). Antifungal treatment targeting candida albicans should be used in severe cases or in patients not showing any improvement after 72 hours of antibiotic treatment (fluconazole)

99
Q

A 59-year-old man with a past history of diverticular disease pres- ents with his second episode of left lower quadrant (LLQ) abdom- inal pain. He is afebrile, and laboratory examination is remarkable for a leukocytosis of 13,800/mm3. Physical examination reveals moderate LLQ tenderness without masses or rebound. A com- puted tomography (CT) scan of the abdomen reveals a small (4 cm) abscess adjacent to the sigmoid colon, with moderate diverticulitis. Which of the following would be the most appropriate treatment?
a. Admission for intravenous antibiotics
b. Confirmation with double-contrast barium enema
c. Discharge on oral antibiotics with 2-day follow-up
d. Radiology consultation for percutaneous drainage
e. Surgical consultation for laparotomy

A

a

100
Q
  1. What is the most common cause of large bowel obstruction in the US.?
    a. Adhesions
    b. Colon cancer
    c. Diverticulitis
    d. Intussusception
    e. Volvulus
A

b

101
Q
  1. Which of the following statements regarding intussusception is true?
    a. Bowel obstruction typically occurs.
    b. CT scans have a high sensitivity for detection of intussuscep-
    tion.
    c. Most adult cases involve the large bowel.
    d. Most adult cases require surgery.
    e. Most children have a causative lesion.
A

d

102
Q

A 29-year-old woman presents with a 4-month history of inter- mittent abdominal pain with bloating and diarrhea. The diarrhea has been watery, nonbloody, and often nocturnal. Physical exam- ination is remarkable for mild diffuse abdominal tenderness and brown, guaiac-positive stool. Rectal examination also demonstrates a small anal fissure at the 3-o’clock position. Laboratory evaluation is remarkable only for a normocytic anemia with a hemoglobin level of 11.5 g/dL. The diagnosis would most likely be confirmed by which of the following?
a. Colonoscopy
b. CT scan of the abdomen
c. Erythrocyte sedimentation rate
d. Mesenteric angiography
e. Response to a high-fiber diet

A

a - IBD

103
Q

5.
Which of the following statements regarding colonic ischemia is true?
a. CT scanning of the abdomen is diagnostic
b. It is rarely associated with bloody stool.
c. It is typically due to nonocclusive disease.
d. Isolated right-sided ischemic colitis is associated with compara-
tively lower mortality.
e. Specific serum biomarkers may be helpful.

A

c

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