clin med- first two lectures Flashcards
DiverticulOSIS
the presence of diverticula (sac like protrusion of colon wall)
Diverticulosis
prev increases w age
usually SIGMOID colon
often No sx, discovered incidentally
Worsening factors of Diverticulosis
Weak points in wall, vasa recta penetrate
Low fiber diet –> constipation –> increase pressure –> herniation
Diverticulosis sx (if present, usually not)
Abd cramp, constipation, diarrhea, bloating
DiverticulOSIS
Labs/imaging
Tx
Labs/image: none
Tx: High FIBER (and water)
Diverticulitis
ACUTE, symptomatic episode d/t inflammation of diverticula
Pathophys of DiverticulITIS
impaction obstructs the neck of diverticulum OR increased pressure —> erosion of wall –> inflammation and necrosis –> Perforation
(Micro vs Macro perforation)
Free air/peritonitis
result of Diverticulitis
Subtypes of Diverticulitis
Uncomplicated
Complicated: abscess, fistula, obstruction, perforation
ACUTE diverticulitis sx
Progressive, steady, ACHING pain (LLQ)
Fever/chills
maybe the following: n/v, change bowel habits, urinary sx,
Rectal/ Pelvic exam in Diverticulitis
Rectal may reveal mass or tender (GET STOOL GUIAIC)
Perform pelvic on women
Acute Diverticulitis labs
CBC: might show Leukocytosis
Also order: CMP, amylase, lipase, UA/culture, preg test, stool study (if diarrhea), stool occult
Imaging Test of choice for Diverticulitis
CT WITH contrast
CT (with contrast) of Diverticulitis will show
Wall thickening/fat stranding
Colonic diverticula
If worried about obstruction or perforation, can also order
X Ray (abd or CXR)
CONTRA tests in Diverticulitis
do NOT order these
Colonoscopy/flex sigmoid (could cause Perf)
Barium Enema (could worsen inflammation if Perf present)
Acute UNCOMPLICATED Diverticulitis tx
Gram neg/Anaerobic coverage x7-10d
Close F/u in 2 days
Acceptable regimens for Acute UNCOMPLICATED diverticulitis
Metronidazole + Cipro
Metronidazole + Bactrim
Augmentin, OR
Moxifloxacin
Gram neg/ Anaerobic
Acute Diverticulitis INPATIENT tx
NPO IVF Analgesics IV abx (transition to PO to complete total of 10-14d) GI, surgery, consult
Repeat imaging IF not improving in 2-3 d of abx
When to refer Acute diverticulitis to surgery
- Perforation with peritonitis
- Worsen or fail to improve within 3d of meds
- Complicated case
Acute diverticulitis Long term tx
High fiber (once acute episode resolved)
Colonoscopy 6-8 wks later (r/o CA or IBD)
Diverticular bleeding is common cause of
OVERT lower GI bleeding
Usually resolved spont
Which side of colon is usually involved with Diverticular bleeding?
RIGHT side
diverticulum are wider and vasa recta more exposed here
Clinical sx of diverticular bleeding
PAINLESS hematochezia (fresh blood in stool) Blood on rectal exam
May have bloating, cramping, TTP
Imp thing to do with diverticular bleeding
Once resuscitation complete, LOCATE source of bleeding w/ flex sig/ colonoscopy
Tx for diverticular bleeding
USUALLY resolves on its own
Main goal: maintain blood volume (transfuse prn)
Tx of bleeding site prn: Endoscopic, Angiographic, +/- surgery
Flat polyp
Sessile
Hyperplastic polyp
Non-CA
completely benign
Usually distal colon
Pseudopolyp
Non-CA
Inflammatory
usually d/t IBD
Adenoma
Neoplastic, “Pre-CA”
Adenoma subtypes
Tubular adenoma- most common
Tubulovillous adenoma
Villous adenoma
Sessile serrated polyps
emerging type of Pre-CA
Usually R side colon
Flat, few surface blood vess
difficult to see
70% of Colorectal CA arise from adenoma
Progression from Adenoma –> CA takes about 10 years
High Risk Adenoma (#, size, histoloty)
> 1 cm
Villous or tubulovillous
High grade dysplasia
Most common side of Colon CA
LEFT side
Risk factors CRC
not modifiable
IBD >8-10 yrs
>50 YO
African American
Personal or family hx:
- Adenoma or Colon CA
- Familial ademomatous polyposis
- HNPCC
Risk factors CRC
modifiable
TOBACCO alc diet (high fat, low fiber) red meat obesity DM
CRC usually A-sx, but RED FLAGS are:
Change bowel habit Hematochezia or occult blood in stool Iron def anemia Anorexia/weight loss Abd pain (refer to GI for Colonoscopy)
CRC sx (if present)
Cachectic Pallor Lymphadenopathy Abd distention, ascites, mass, organomegaly DRE: hemoccult + stool, rectal mass
CRC diagnostic
CBC: look for anemia
Liver test: ALP may be elevated w Liver METs
What is CEA (carcinoembryonic antigen) used for?
Prognostic indicator
Monitor recurrence
“apple core lesions”
Colon CA
Colonoscopy and CT
Colonoscopy: biopsy for pathologic confirmation
CT chest/abd/pelvis: show tumor extension/complication, METs
CRC staging “TNM” system
Tumor- depth
Node- regional lymph node involvement
METs- yes or no
stage 0-4
CRC tx options
Partial colectomy w wide margins and adjacent lymph node removal
Chemo (if METs)
Radiation (Rectal adenocarcinoma)
CRC surveillance
Serial CEA levels
Annual CT (depend on stage)
Colonoscopy periodically
Visualization tests
Colonscopy
Flex sig
CT colonography
Stool based tests
gFOBT (hemoccult SENSA)
FIT (fecal immuno test)
FIT-DNA (cologuard)
CRC screening Gold standard
Colonoscopy (diagnostic and therapeutic)
can remove polyps, take biopsy
Do you need bowel prep for Colonoscopy
Yes
CT Colonography
“Virtual colonscopy”
dont have to sedate, but CAN MISS FLAT OR SMALL POLYPS
still need bowl prep
cannot remove polyps
gFOBT stool test
“Hemoccult SENSA”
requires 3 consecutive stools
Annual use recommended (one time screening doesn’t tell us much)
FIT stool test*
test for human hgb
PREFERRED CRC detection test!
single specimen, non invasive
BUT annual use still recommended
FIT-DNA stool test
(Cologuard)
like the FIT but also test for DNA mutation biomarkers in cells shed by CRC
MAIN CONCERN: false positives
if +, get colonscopy ASAP rocky
requires entire bowel movement
Overall, stool tests
have lower sensitivity
sometimes miss polyps that don’t bleed
need to be annual (pt compliance)
If you have IBD, when should you have first Colonoscopy
8-10 yrs after sx onset
If 1st deg family hx of CRC or Advanced adenoma, when to get YOUR first colonscopy?
If relative <60 YO (or two 1st deg relatives any age)
-every 5 yrs starting at 40YO or 10 yrs younger than dx of relative
If relative >60 YO
-start at 40, if normal continue on as normal indiv
FAP (familial adenomatous polyposis)
tons of polyps!
>100 adenomatous poyps
Starts ~16 YO
nearly ALL polyps will become CA by age 39 if untreated
Tx for FAP
Prophylactic colectomy
Risk of extracolonic CA (stomach, duod, ampullary CA is common)
Screening for FAP who are gene carriers or have family hx (even without genetic confirmation)
Sigmoid/Colonoscopy start at 10-12 YO and repeat every 1-2 years
+Routine EGD
HNPCC
“lynch syndrome”
Inc risk for RIGHT sided CRC
age 45-60
HNPCC
“lynch synd”
multiple family members usually affected
Increased risk of other CA: Endometrial being most common
3-2-1 rule diagnosis
Amsterdam criteria for HNPCC
At least 3 relatives w Lynch syndrome assoc CA
At least 2 generations in a row
At least 1 before age 50
HNPCC screening
Annual Colonoscopy starting at age 20-25 OR
2-5 yrs before onset of earliest dx age in family
whichever comes first
Other screening to consider with HNPCC
Pelvic exam (endometrial CA) EGD (start 30-35 YO and every 2-3 yrs)
Consider familial Colon CA condition if
> 1 fam member hx CRC
Persona/ fmx CRC at age earlier than 50 YO
Personal/fmx of MULTIPLE adenomas (>10-20)
Personal/fmx of multiple Extracolonic CA
