Chronic GI Flashcards
UC vs Crohn
UC - continuous inflammation, usually only lower GI, less chances of remission
Crohn - ‘skip’ lesions of inflammation, can go all the way to mouth, fistulous tracks can occur, inflammation is in all layers of intestinal wall
Inflammatory Bowel Symptoms
Abd pain, diarrhea for some time is common - usually cramping pain
Rectum spasms, urgency, incontinece can occur
Fatigue, weight loss, anorexia, chills, joint pain, mouth sores, bloating
Elevated CRP or ESR is common, but non-specific
Test stool for other causes
CT scans can detect inflammation, etc.
Endoscopy is diagnostic
IBD Differentials
Consider: Infectious cause of diarrhea Lactose intolerance / gluten intolerance bacterial overgrowth diabetes bile acid problem
IBD Treatment
Antibiotics, 5-aminosalicytes, glucocorticoids, immunosuppresants, immunomodulators
Mesalamine for mild CD, sulfasalazine for UC
Steroids may be used for flares
Immunosuppresants - methotrexate and cyclosporine - are risky and take 6 months to work and indicated if others fail
Monoclonal antibodies (-fab drugs)
Metronidazole or Cipro for CD patients
Irritable Bowel
IBS - C = constipation predominant
IBS - D = diarrhea predominant
IBS - M = mixed
GI Refer
patients with a change in bowel habits after age 50; a family history of celiac disease, colon cancer or inflammatory bowel disease; evidence of gastrointestinal bleeding; weight loss; fever; nocturnal symptoms; recent antibiotic therapy; or continuing symptoms.
IBS Presentation and Diagnosis
Abdominal pain (must be present for diagnosis) - often LLQ, intermitten cramping Diarrhea or constipation or pattern of alternation between the two must be present for diagnosis
Always ask about recent travel, eating habits, bowel habits, other abdominal causes - assess for GYN causes in women
ROME IV Diagnostic Tool
Abdominal pain that occurred a minimum of once each week for the previous 3 months, in combination with two or more of the following features:
• Defecation-related pain
• Pain related to change in stool frequency
• Pain associated with change in appearance of stool (lumpy and hard or loose and watery)
IBS Treatment
Get KUB imaging
If diagnosis unclear, trial lactose-free then gluten-free diets
Key is therapeutic relationship with provider, IBS can be psychologically problematic for the patient (embarrassment)
IBS Medications
Dicyclomine 10-40mg qid, 30-60 min before meals - reduces motility
Loperamide 2-4mg 45 min before meals - decrease transit time
Lubiprostone 8mcg bid, can reduce constipation
What is the probable underlying pathology of irritable bowel syndrome (IBS), according to research over the last decade?
Recent research has yielded information about alterations in sensory processing that are different in persons with IBS.
GI Tumor Risks
smoking
alcohol
Tylosis (genetic disease)
GERD (risk for Barrett esophagus)
GI Tumor Presentation
Dysphagia and weight loss are classic presenting symptoms of esophageal carcinoma. More than 90% of patients will have solid food dysphagia which progressively worsens. Later signs are anorexia, abd pain, N/V, bowel changes, anemia
NEW ONSET DYSPHAGIA IS RED FLAG
Metastasis to trachebronchial can cause back or chest pain
Colorectal Cancer Risks
Risk factors for the development of colorectal cancer include age greater than age 50, prior colorectal cancer, ulcerative colitis, hereditary and genetic factors, familial polyposis syndromes, long-term cigarette smoking, and a high-fat high-caloric diet
A patient is diagnosed with cancer of the colon and is scheduled for surgical resection. A carcinoembryonic antigen (CEA) test prior to surgery is not elevated.
What is the significance of this finding?
A negative CEA indicates that this test is not informative and will not be useful postoperatively.
What is the initial step in treating a patient who has been taking an NSAID for osteoarthritis pain and develops peptic ulcer disease?
Recommend an H2 receptor antagonist
Prescribe a proton pump inhibitor
Discontinue the NSAID
Order prostaglandin therapy
The first step in treating a medication-induced peptic ulcer is to discontinue the medication.
peptic ulcer disease
ulceration of the gastric and duodenal mucosa. The two common causes of peptic ulcers in the United States are Helicobacter infections (Helicobacter pylori) and the use of nonsteroidal antiinflammatory drugs (NSAIDs)
PUD Risk Factors
family history smoking COPD major trauma oral steroids biphosphonate therapy caffeine use alcohol cirrhosis stress
PUD Presentation
most common presenting chief complaint is epigastric pain or dyspepsia. Upper abdominal pain or discomfort is the most common presentation, with pain centered in the epigastrium. This discomfort is often described as a sharp, burning, aching, gnawing pain occurring 2 to 5 hours after meals or in the middle of the night. The patient will report that the pain is usually relieved with the ingestion of food or antacids
H. pylori tests
Endoscopy can exlcude malignancy and test
stool tests - can’t take PPIs for 14 days prior
Serum antigen/antibody
H. pylori tests
Endoscopy can exlcude malignancy and test
stool tests - can’t take PPIs for 14 days prior
Serum antigen/antibody
Zollinger-Ellison
Zollinger-Ellison syndrome is a condition of excessive acid production. This should be considered if the individual does not respond to the traditional diet, smoking cessation, and pharmacologic therapy.
PUD Treatment
Stop NSAIDs / COX-2 inhibitors
Refer to GI if bleeding, anemia, noew onsety dyspesia in 50+ year olds, weight loss
H2RA and PPis reduce acids to let ulcer heal
Sucralfate to coat ulcer for healing / preventative
Misoprostol for patients who cannot stop NSAIDs
H. pylori treatment
PPI + antibiotics for 14 days typical
PPI + Clarithromycin + amoxicillin
PPI + clarithromycin + metronidazole
PPI + metronidazole + tetracycline + bismuth
