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GI II Midterm > Chapter 17 - SI And Colon; Peritoneal Cavity > Flashcards

Chapter 17 - SI And Colon; Peritoneal Cavity Flashcards

1
Q

What are the most common causes of intestinal obstruction?

A

Hernias, adhesions, volvulus, intussusception

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2
Q

What are sx of bowel obstruction?

A

Abdominal pain, Distention (tympanic), vomiting, constipation/obstipation, sx of ischemic bowel

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3
Q

What is the most common cause of obstruction worldwide? Describe it

A

Hernia: part of an organ is displaced and protrudes through the wall of the cavity containing it
Acquired and congenital types
Complications: obstruction, incarceration (entrapment), strangulation (blood compromise)

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4
Q

What is the most common cause of obstruction in the US? Describe them

A

Adhesions: fibrous bands/bridges btwn bowel segments, abdominal wall, or operative site
Etiology: surgical procedures, infection, or other causes of peritoneal inflammation, such as endometriosis
Same complications as hernia

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5
Q

What is volvulus?

A

Twisting of a loop of bowel about its mesenteric point of attachment
Luminal and vascular compromise -> obstruction and infarction
Rare!
Sigmoid colon MC
Lots of tympanic sounds and distention in question stem

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6
Q

What is the most common cause of intestinal obstruction in children younger than 2? Describe it

A

Intussusception: inversion of one portion of the intestine w/i another
Idiopathic or after viral infection/rotavirus vaccine peds; mass or tumor in adults
Dx and Rx: barium enema

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7
Q

What are the causes of acute obstruction to flow leading to ischemic bowel disease?

A 
Severe atherosclerosis (ostium)
AAA
Embolization (cardiac valves/atheroma)
Hypercoagulation
Mesenteric thrombosis 
OCP
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8
Q

What are the chronic/hypoperfusion states that results in Ischemic bowel disease?

A 
Cardiac failure 
Shock
Dehydration
Drugs (cocaine, vasoconstrictors)
Vasculitides
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9
Q

What are the three major variables of the pathogenesis of ischemic bowel disease? What causes the majority of the damage?

A

Severity of vascular compromise
Duration
Vessels affected
Majority of damage: reperfusion injury-> leakage gut lumen bacterial products, inflammatory mediators into systemic circulation

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10
Q

What is the clinical setting and presentation of Ischemic bowel disease? What is the Rx?

A

Ischemic colitis most common
>70, slightly > F
Fq seen co-existing cardiac and/or vascular disease
Acute obstruction->s/o of cramping LEFT lower abdominal pain, desire to defecate, passage of blood
Rx: surgery if decreased bowel sounds (paralytic ileum), guarding or rebound tenderness

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11
Q

What is the outcome of Ischemic bowel disease?

A

Mucosal and non transmural infarcts may not be fatal
Transmural-> 10% mortality first 30 days
Superior mesenteric occlusion worse outcome - supplies both right side colon and much of SI (right sided more severe course)
Coexisting COPD - poor prognosis

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12
Q

What is the most common site of GI ischemia?

A

Colon

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13
Q

What is angiodysplasia?

A 
Tortuous, ecstatic dilations of mucosal or submucosal veins 
1% of pop 
Right colon 
After age 60
20% of major lower GI bleeds
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14
Q

How does malabsorption most commonly presents? How is it characterized?

A

Presents s chronic diarrhea
Characterized by defective absorption of fats, fat and water soluble vitamins, proteins, carbs, electrolytes and minerals, and water

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15
Q

What are the S/Sx of malabsorption ?

A

Chronic diarrhea, flatus, abd pain, borborygmi, anorexia and WL, mm wasting
Hallmark of malabsorption is steatorrhea: excessive feat fat and bulky, frothy, greasy, yellow or clay-colored stools

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16
Q

Describe the symptoms of vitamin deficiency:
Vit B, A, D
Ca and Mg

A

B6 (pyridoxine), folate, B12 - anemia and muscositis
Vit K - bleeding
Ca, Mg, Vit D - osteopenia and tetany
A, B12 (cobalamin) - peripheral neuropathy

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17
Q

What are the most commonly encountered chronic malabsorptive disorders in the US?

A

Pancreatic insufficiency
Celiac disease
Crohn disease

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18
Q

What is diarrhea? What are the classifications

A

Increase stool mass, fq, or fluidity, typically greater than 200 g/day
Secretory: isotonic stool
Osmotic: d/t excessive osmotic forces
Malabsorptive: steatorrhea
Exudative: inflammatory disease, purulent, bloody stools

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19
Q

How does Cystic fibrosis involve the GI tract?

A

Absence of CFTR->defective luminal hydration->intestinal obstruction
Pancreatic duct obstruction->low-grade chronic autodigestion of pancreas, eventual exocrine pancreatic insufficiency in majority
Failure of intraluminal phase of nutrient absorption**: Rx oral enzyme supplement

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20
Q

What is celiac disease? How common is it?

A

Spruce, celiac spruce, gluten sensitive enteropathy
Immune-mediated enteropathy via gluten (gliadin) (wheat, rye, barley)
Association with other autoimmune diseases
Increased intraepithelial CD8+ T cell #s
1% of population: Class II HLA-DQ2, DQ8

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21
Q

What are the clinical features of celiac disease?

A

Adults: 30-60s, >F, Classic and atypical
Adults Sx: chronic diarrhea, bloating, chronic fatigue, malabsorption, or asymptomatic
Children: M=F
Infant Sx: irritability, abd distension, chronic diarrhea, FTT, WL, mm loss
Child: abd pain, N/V, bloating, constipation
10% of pts with blistering skin disorder: dermatitis herpetiformis

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22
Q

What is the most sensitive diagnosis for Celiac disease and what is the treatment? What may have occurred if Sx return?

A

IgA tTG abs or IgG to deamidated gliadin
Change of diet - gluten free
Sx return: fell off diet or malignancy: adenocarcinoma or enteropathy-associated T lymphoma (EALT)

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23
Q

Environmental enteropathy pearls

A

Setting: areas of poor sanitation - parts of Africa, South America, Asia; areas of impoverished communities - Brazil, Guatemala, India, Pakistan
No Dx criteria
Cause unknown
Global impact - esp children: diarrhea, defects in physical and cognitive development
Terminal digestion and transepithelial transport defects

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24
Q

Autoimmune enteropathy pearls

A

Terminal digestion and Transepitheial transport defects
Rare, X-linked
MC children: persistent diarrhea and autoimmune disease
Severe IPEX form d/t FOXP3 TF of CD4+ T reg cell mutation
Autoabs - enterocytes, goblet cells, parietal cells, islet cells

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25
Q

Lactase deficiency pearls

A

Congenital - rare, autosomal recessive
Explosive watery diarrhea frothy stools
Abdominal distention upon milk ingestion

Acquired - down-reg lactose gene
Native A, AA, and Chinese
Follows Enteric viral and bacterial infections

terminal digestion defects

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26
Q

Abetlipoproteinemia pearls

A 
Transepitheial transport defects
Rare autosomal recessive 
Inability to process and secrete TG-rich lipoproteins 
MTP mutation 
Presents in infancy -> FTT, steatorrhea 
Dx: acanthocytic red cells: burr cells 
Intracellular lipid accumulation
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27
Q

Infectious enterocolitis - Cholera

A

Vibrio cholera: comma-shaped, gram-negative bacteria
India, Africa, Gulf of Mexico (shellfish)
Fecal-oral (drinking water)
Rice Water stools - severe watery diarrhea
Small Intestines
Toxin A: Gs pathway ->Surge of cAMP opens CFTR

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28
Q

Infectious Enterocolitis: Campylobacter

A

Campylobacter spp: comma-shaped, flagellated, gran-negative
C. Jejuni - MC enteric pathogen in developed countries
Important cause of traveler’s diarrhea (food poisoning - chicken, milk, water)
Erythema nodosum, HLA-B27 and reactive arthritis, Guillain-Barre syndrome (abs cross react with gangliosides)
Bloody or watery diarrhea
Colon

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29
Q

Infectious Enterocolitis: Shigellosis

A

Gram-negative unencapsulated, nonmotile, facultative anaerobes, enterobacteriaceae fam: closely related to E.coli
Lactose nonfermenter
Humans - reservoir: daycare centers, migrant workers, travelers to developing countries, nursing homes
one of MC causes of bloody diarrhea worldwide
Fecal-oral low dose
Self limited: prominent in left colon, ileum may be involved
Sterile reactive arthritis, urethritis, conjuctivitis (HLA-B27-positive men 20-40 YOA)
Bloody diarrhea

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30
Q

Infectious Enterocolitis: Salmonella non-typhoid type

A 
Enterobacteriaceae family 
G - bacilli, Lactose nonfermenter, 
S. Enteriditis 
Young children, elderly 
Contaminated food 
Stool cultures to ID 
Loose stools to cholera-like diarrhea to dysentery
Usually self-limited: sepsis, abscess 
At risk: malignancies, immunosuppresssion, alcoholism, cardiovascular dysfunction, Sickle cell disease, hemolytic anemia 
Colon and Si
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31
Q

Infectious Enterocolitis: Salmonella typhoid type

A

G - bacteria
Salmonella enterica: subtypes typhoid (endemic countries kids) and paratyphi (travelers)
India, mexico, philippines, pakistan, el salvador, haiti
Gall bladder stones
Peyer patches in terminal ileum
Anorexia, abd pain, bloating, N/V, bloody diarrhea
Short asymptomatic phase
Bacteremia, fever, flulike sx,
Pain mimic appendicitis
Encephalopathy, meningitis, seizures, endocarditis, myocarditis, pneumonia, cholecystitis
Liver - typhoid nodules
Disseminate vial lymphatics and blood vessels
SI

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32
Q

Infectious Enterocolitis: Yersinia

A

Yersinia Enterocolitis a and pseudotuberculosis: G-, lactose nonfermenter
Ileum, Appendix, right colon
Europe
Reservoir: pigs, cows
Abdominal pain, fever, diarrhea, mimic appendicitis
Reactive arthritis, erythema nodosum

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33
Q

E. coli microbiology

A

Gram - bacilli
Healthy GI tract
Lactose fermenter, fast = McConkees agar

34
Q

ETEC

A 
Enterotoxigenic E coli 
MC of travelers diarrhea 
Toxins: Heat-labile (cAMP), Heat-stable (cGMP) - both block intestinal fluid absorption 
Infants, adolescents, travelers 
Severe watery diarrhea 
SI
35
Q

EPEC

A 
Enteropathogenic E coli 
Pediatric 
A/E lesions 
Effacement of microvilli 
Watery diarrhea 
SI
36
Q

EHEC

A 
Enterohemorrhagic E coli 
O157:H7 and non-O157:H7
Shigalike toxin 
Contaminated milk and veggies 
Cows natural reservoir 
Hemolytic-Uremic syndrome - anemia, thrombocytopenia, RF
Bloody diarrhea
Colon
37
Q

EIEC

A 
Enteroinvasive E coli 
Similar to Shigella but no toxin 
Food, water, p2p transmission
MC in children
Colon
Bloody diarrhea
38
Q

EAEC

A 
Enteroaggregative E coli 
Children
Colon
Nonbloody diarrhea
Produce shigalike toxin
39
Q

Pseudomembranous colitis pearls

A

C diff
Pathognomonic
Lamina propria has dense infiltrate of neutro, surface epithelium denuded
Eruption, volcano crypts - exudates coalesce = pseudomembranes
RF: age, hospitalization, antibiotics
CF: fever, leukocytosis, abdominal pain, cramps, watery diarrhea, dehydration

40
Q

Wipple disease pearls

A

Rare
Caucasian male farmers
Soil/animals
Gram + actinomycete: Tropheryma wippelii
Diarrhea, WL, malabsorption
The only cause of malabsorption due to lymphatic transport
Laden Mo in LNs, joints and brain

41
Q

Most common cause of viral gastroenteritis outbreaks? Describe the virus and key features

A

Norovirus: small icosahedral viruses with ssRNA; caliciviridae
Most common cause of acute gastroenteritis requiring medical attention
Contaminated food and water, P2P MC
Immunocompetent: self limited watery diarrhea
Spreads on school, cruise
Immunocompromised: airborne

42
Q

What is the most common cause of severe childhood diarrhea? Describe the virus and clinical features

A 
Rotavirus: encapsulated segmented dsRNA 
6-24 mo
Low dose for infection 
Daycare/hospital common 
Damage to enterocytes NSP-4
Vomiting, watery diarrhea 
Vaccine associated w/ intussusception
43
Q

What is the second MC cause of pediatric diarrhea? Details

A

Adenovirus
SI epithelial degeneration
Nonspecific villa us atrophy
Self limited diarrhea, vomiting, abd pain

44
Q

Enterobius vermicularis

A 
Enterobiasis, Parasitic enterocolitis 
Pinworms 
Migrate anus at night, lay eggs -> rectal and perineal pruritis 
Scotch tape test 
Fecal oral 
Do not invade host tissues 
No serious illness
45
Q

Giardia lamblia

A

Parasitic enterocolitis
Most common parasitic pathogen in humans
Unfiltered public water, campers, swimming
Decrease lactase
Trophozoites ID in duodenal biopsies - pear shape and 2 equal sized nuclei
Immunofluorescent detection of cysts in stool samples
Damage microvilli brush border
IgA and IL-6 for clearance

46
Q

What is IBS? Who is it most prevalent in? And what are the clinical features?

A

Chronic, relapsing abdominal pain, bloating, and changes in bowel habits
Females 20-40
CF: Dx using clinical criteria that require the occurrence of abdominal pain/discomfort for at least 3 days per month over 3 months w improvement after defecation and change in stool fq or form
No pathologic abnormality*
Rome III criteria diagnosis

47
Q

What is Inflammatory bowel syndrome ?

A

Chronic condition related to inappropriate mucosal immune activation: Crohn disease or ulcerative colitis

48
Q

What is the epidemiology of IBD?

A

Presents teens/early 20’s
More common in Caucasians and Ashkenazi jews
Developed countries

49
Q

What is the pathogenesis of IBD?

A

Results from the combined effects of alterations in host interactions with intestinal micfrobiota, intestinal epithelial dysfunction, aberrant mucosal immune responses, and altered composition of the gut microbiome
Genetics: More common in twins
TNF - increase Tight jxn permeability

50
Q

Describe the Key features of Crohn disease

A 
MC in Small intestine, can include colon 
Skip lesions
Transmural inflammation ->creeping mesenteric fat, strictures, perforation, and perianal fistula
Aphthous ulcers - deep 
Fissure formation
Cobblestone appearance 
Non-caseating granulomas 
Abs - Sacccharomyces cerevisiae 
Wall - thick and rubbery 
Abundant neutrophils 
Recurrence after surgery 
Malignant potential with colonic involvement
51
Q

What are the symptoms of Crohn disease? Potential therapy?

A

Variable
RLQ pain, fever, bloody diarrhea - mimic acute appendicitis or bowel perforation
Malabsorption and malnutrition, vit B12 deficiency
Extra-intestinal manifestations - Erythema nodosum, clubbing of fingertips, iron deficiency anemia, uveitis, migratory polyarthritis, sacroiliitis, ankylosing spondylitis

Reactivation from emotional stress, smoking
Anti-TNF abs - therapy option

52
Q

Describe key features of Ulcerative colitis

A 
Colon only - always involves rectum
Slightly more common in females 
Diffuse 
No strictures
Wall - thin, pseudopolyps and mucosal bridges 
Mucosal inflammation 
Ulcers - superficial, broad based
No recurrence after surgery 
Crypt abscesses 
Toxic megacolon 
Malignant potential: higher if pancolitis 
P-ANCA
53
Q

What are the clinical features of Ulcerative colitis

A

Pt at greatest risk for developing Primary sclerosing cholangitis
Relapsing disorder: bloody diarrhea, stringy, mucous material. Lower abdominal pain and cramps relieved by defecation
Triggers - infectious enteritis, psychological stress, some d/t smoking CESSATION
Extra-intest: migratory polyarthritis, sacroiliitis, ankylosing spondylitis, uveitis, and skin lesions - same as Crohn

54
Q

What are the three factors of neoplasia in IBD?

A

Duration of disease: increases after 8 years
Extent of disease: pancolitis greater risk
Nature of the inflammatory response: Increase w severity and duration of active inflammation

55
Q

What is indeterminate type colitis

A

Does not involve small bowel, Colonic disease in continuous pattern - maybe ulcerative colitis
BUT - key features of CD: fissures, patchy, FH of CD, perianal lesions, onset after initiating use of cigarettes

56
Q

How is IBD monitored?

A

Surveillance biopsies 8 years after dx
High grade - colectomy
Low grade - colectomy or surveillance depending on age and # of foci

57
Q

What is diversion colitis? What is the treatment?

A

Creating of blind distal colonic pouch following intestinal surgery
Colitis d/t change in microbiome or irritation from diverted fecal stream
Histo: look like IBD - crypt abscesses, mucosal distortion, rarely granulomas
Rx: enemas w SCFA from bacterial digestion

58
Q

What is microscopic colitis

A

Middle-aged women, chronic watery diarrhea w abd pain
Endoscopic findings grossly normal
Two forms:
Collagenous: intraepithelial lymphocytes and a dense subepithelial collagen band
Lymphocytic: intraepithelial lymphocytes without bandlike collagen

59
Q

Key features of GVHD

A

Hx of hematopoietic stem cell transplant
Epithelial apoptosis
Watery diarrhea that may become bloody in severe cases

60
Q

What is diverticular disease? Who is it most prevalent in?

A

Acquired pseudo-diverticulum outpouchings of the colonic mucosa
Prevalence - common after age 60, western population; low fiber diets - MC in sigmoid (most weak point)
Right sided in Africa and Asia
Pathogenesis: unique structure of the colonic muscularis propria and elevated intraluminal pressure in the sigmoid colon

61
Q

What are the clinical features of Diverticular disease?

A

Symptomatic in about 20%: intermittent cramping, continuous lower abdominal discomfort, constipation, distention, or a sensation of never being able to completely empty the rectum
Symptoms can mimic IBS
Rare blood loss or hemorrhage
Obstruction of diverticula leads to diverticulitis->possible performation

62
Q

What is the most common polyp in the GI tract?

A

Hyperplastic polyp

63
Q

Key features of hyperplastic polyp

A 
Nonneoplastic - no malignant potential 
MC
Left colon 
Single or multiple 
6-7th decade
Less than 5 mm 
Histo: epithelial crowding produces serrated architecture when crypts are cut in x-section
64
Q

Key features of inflammatory polyp

A

Non neoplastic
Part of solitary rectal ulcer syndrome (SRUS)
Triad: rectal bleeding, mucus discharge, anterior rectal wall location

65
Q

What is a hamartomatous?

A

Non neoplastic polyp
Recognized to be syndrome associated with germline mutations in tumor suppressor genes or protooncogenes
Syndromes associated with cancer, extra-intestinal manifestations
Juvenile polyps and Peutz-Jeghers syndrome

66
Q

Key features of Juvenile polyps (retention polyps)

A

Focal hamartomatous malformations of SI and colon mucosa
< 5 YOA
Sporadic or syndromic
Rectal location
Syndrome: rare autosomal dominant disorder: 100 hamartomatous polyps, SMAD4, Pulmonary arteriovenous malforamtions, Increassed risk of bowel malignancy (adenocarcinoma by age 45, 50%)
Congenital malformations, digital clubbing

67
Q

Peutz-Jeghers syndrome key features

A

Rare AD syndrome
Age 11
Multiple GI harmartomatous polyps
Mucoccutaneous hyperpigmentation: dark blue to brown macules on lips, nostrils, buccal mucosa, palmar surfaces of the hands, genitalia, and perianal regions
Multiple polyps->intussusception in SI
LOF mutations in STK11/LKB1
Lifetime risk of malignancies in multiple organs (SI>colon>stomach adenocarcinoma; breast, lung, pancreatic cancer)
Complex glandular architecture and presence of smooth muscle

68
Q

What are colonic adenomas?

A

Benign polyp precursors to the majority of colorectal carcinomas
Most do NOT progress to malignancy
Risk of malignancy correlated to size and severity of dysplasia
Intraepithelial neoplasms that range from small, often pedunculated polyps to large sessile lesions
30% by age 60
Males >

69
Q

What is the hallmark of epithelial dysplasia?

A

Nuclear hyperchromasia, elongation, and stratification

70
Q

FAP key features

A

Autosomal dominant
100-1000 colorectal adenomatous polyps as teenager
APC gene
Risk of cancer 100%***** often before age 30, always by 50
Classic: congenital hypertrophy of retinal pigment epithelium, age 10-15
Attenuated: 40-50 YOA
Gardner: 10-15 YOA, osteomalacia, thyroid and Desmond tumors, skin cysts
Turbot: 10-15 YOA - medulloblastoma, glioblastoma

71
Q

HNPCC key features

A 
Lynch syndrome 
2-4% of all colorectal cancer 
MC syndromic form 
Earlier age 
RIGHT SIDED location 
Family history
MMR and MSI molecular defects 
Genes: MSH2, MLH1
72
Q

What should be considered in pts 65 and older or postmenopausal women with unexplained iron loss?

A

Colonic adenocarcinoma - MC GI malignancy

73
Q

Key features of colonic adenocarcinoma

A

60-70 YOA, North America, low veggies, high CHO’s, high fat
Methylation-induced epigenetic event
Classic: APC/B-catering pathway->activated MYC and cyclin D1, Left sided, annular lesions - napkin ring constrictions
MMR: right sided - polyploid, exophytic masses, MSI high

74
Q

Clinical features of right-sided colon adenocarcinoma

A

Fatigue, weakness d/t iron deficiency anemia

Fe Def anemia older man/postmen woman = GI cancer

75
Q

Clinical features of left sided colorectal adenocarcinoma

A

Occult bleeding, changes in bowel habits,, or cramping and left lower quadrant discomfort

76
Q

What are the two most important prognostic factors of colon adenocarcinoma?

A

Depth of invasion and the presence of LN metastases

Metastasis: regional LN, lungs, bones, LIVER MC

77
Q

Describe carcinomas of the anal canal

A

May have typical glandular or squamous, or basaloidpatterns of differentiation
Pure squamous cell carcinoma is fq associated with HPV infections (HIV related) which also causes precursor lesions such as condylomata acuminatum

78
Q

What are the risk factors and cause of Hemorrhoids? Clinical presentation?

A

RF: straining at defecation bc of constipation, and venous stasis of pregnancy, and cirrhosis (portal HTN)
Secondary to persistently elevated venous pressure within the Hemorrhoidal plexus - varices dilations
Presentation: pain and rectal bleeding, bright red blood on toilet tissue, Rarely <30 y/o except pregnancy

79
Q

Key features of acute appendicitis

A

MC acute abdominal condition requiring surgery
MC adolescents and young adults, M>F
Most associated with obstruction d/t small mass of stool (fecalith), tumor, worms -> stasis and favorable bacterial proliferation/ischemia/inflammation
McBurney sign
Morph: neutrophilic infiltration of muscularis propria

80
Q

What is the MC tumor of the appendix?

A

Carcinoid - neuroendocrine tumor w solid bulbous swelling distal top of appendix

81
Q

Describe primary tumors of the peritoneum

A

Rare
Mesothelioma: asbestos exposure
Desmoplastic small round cell tumor: translocation (11,22) Ewing sarcoma and Wilms tumor
Most are malignant

82
Q

Describe secondary tumors of Peritoneum

A

Most are malignant
More common than primary
MC: ovarian and pancreatic adenocarcinomas

GI II Midterm (5 decks)

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