Colon Flashcards
For HOW LONG do symptom have to EXIST for the diagnosis of CHRONIC CONSTIPATION?
3 MONTHS
A CONGENITAL disorder of OBSTIPATION and COLONIC DILATION PROXIMAL to a SPASTIC, NON-PROPULSIVE segment of DISTAL BOWEL resulting in ARREST of CAUDAL MIGRATION?
HIRSCHPRUNG’s DISEASE
ANTICHOLINERGICS (antispasmodics, antidepressants, antipsychotics); IRON SUPPLEMENTS, ALUMINUM (antacids, sucralfate), OPIATES, ANTIHYPERTENSIVES, CALCIUM CHANNEL BLOCKERS, 5H3-AGONISTS?
CONSTIPATING DRUGS
WITHOUT ALARM SYMPTOMS (hematochezia, weight loss >10 lbs, FH of colon cancer or IBD, ANEMIA, positive FOBT and ACUTE ONSET of constipation), are flex sig, colonoscopy, barium enema, thyroid tests, etc. warranted for CHRONIC CONSTIPATION?
NO
What is the FIRST and most PHYSIOLOGIC approach to treating CHRONIC CONSTIPATION?
Dietary FIBER (WHEAT BRAN, PSYLLIUM) DAILY - if fiber intollerant, use stimulant laxatives 2-3 times per week or osmotic laxatives daily
Which are the PREFERRED SAFE LAXATIVES to use in PREGNANCY?
PEG and LACTULOSE
Is CHRONIC use of STIMULANT LAXATIVES harmful to the COLON?
NO (goal of 2-4 stools/week)
In patients who do NOT RESPOND to CONSERVATIVE therapy AFTER DEFECATION studies have been performed, what is the NEXT TEST?
COLONIC TRANSIT STUDY (SITZ markers) - normal is NO MARKERS on days 4 and 7 on x-ray
Delayed PASSAGE of radiopaque markers through the PROXIMAL COLON with a NORMAL COLON DIAMETER and NORMAL ANORECTAL FUNCTION is known as?
COLONIC INERTIA
SLOW RECTOSIGMOID colon transit with or without MEGARECTUM?
OUTLET DELAY (dyssynergia, weak force, short-segment Hirschprung’s, rectocele)
These parameters (rectal sensation and compliance, relaxation of the internal rectal sphincter and expulsion of a water-filled balloon) are checked for the FUNCTION of the RECTUM in what exam?
ANORECTAL MANOMETRY
In the ABSENCE of DELAYED BALLOON EXPULSION, can DYSSYNERGIC DEFECATION be diagnosed based on ANORECTAL MOTILITY?
NO
Barium thickened to the consistency of stool is monitored and evacuation monitored by imaging. This test can be used to test for DEFECATION DISORDERS where ANORECTAL MANOMETRY is NOT AVAILABLE?
DEFACOGRAPHY
FAILURE to RELAX of the PUBORECTALIS and EXTERNAL ANAL SPHINCTER, or INAPPROPRIATE CONTRACTION of these muscles are found in what DEFECATION DISORDER?
DYSSYNERGIC DEFECATION (narrows the ANORECTAL ANGLE)
When TWO of the following studies are positive (ANORECTAL MANOMETRY, DEFECOGRAPHY, INNABILITY to EXPEL a water BALLOON within 2 MINUTES), ONLY then this can be DIAGNOSED?
DYSSYNERGIC DEFECATION treat with BIOFEEDBACK - habit training
What treatments should be AVOIDED in the treatment of CHRONIC MEGACOLON?
FIBER SUPPLEMENTS and OSMOTIC LAXATIVES (often need surgery)
How is INTRACTABLE CONSTIPATION treated?
Manual disimpaction, then either BID ENEMAS or PEG until cleared bowles, then PEG to produce stool every other day, with HABIT TRAINING - if no defecation in 2 days, glycerin suppositry or enema
What is the FIRST STUDY to perform when evluating a patient for REFRACTORY CONSTIPATION?
ANORECTAL MANOMETRY and BALLOON EXPULSION (before ANY other study such as colonic transit studies or biofeedback)
What can be done for a patient that has CHRONIC, SEVERE and DISABLING SYMPTOMS from CONSTIPATION UNRESPONSIVE to medical therapy; has SLOW COLONIC TRANSIT of the INERTIA PATTERN; and does NOT HAVE INTESTINAL DYSMOTILITY?
SUBTOTAL COLECTOMY with ILEORECTAL ANASTOMOSIS
What TEST should be performed BEFORE REPAIR of a RECTOCELE thought to cause CONSTIPATION?
IMPROVED RECTAL EVACUATION after pressure is placed on the POSTERIOR VAGINAL WALL
What is the TREATMENT of CHOICE for Hirschprung’s Disease?
SURGERY - excision of affected segment of bowel
What FINDING demonstrates END-STAGE COLON FAILURE?
CHRONIC MEGACOLON
NALOXONE, NALOXEGOL, NALDEMEDINE and NALTREXONE are all what types of meds?
OPIOID ANTAGONISTS used in reversing the CONSTIPATION effect of opioid analgesics
In OPIOID-INDUCED CONSTIPATION, what are the FIRST-LINE agents recommended?
LAXATIVES followed by OPIOID ANTAGONISTS (naltrexone, etc.)
BEFORE performing a COLON TRANSIT STUDY (markers), what TESTING should be done first, to EXCLUDE DEFECATION problems FIRST?
BALLOON EXPULSION TEST and ANORECTAL MANOMETRY
In a patient with CHRONIC CONSTIPATION, REGARDLESS of OPIOID use, what MUST BE TRIED FIRST before using OPIOID ANTAGONISTS and other measures to relieve the constipation?
TRADITIONAL LAXATIVES (PEG)
If ANY TWO of the following are present: straining during defecations, lumpy, hard stools, incomplete evacuation, sense of anorectal obstruction, manual disimpaction the DIAGNOSIS of this can be made?
FUNCTIONAL CONSTIPATION
SLOW PROXIMAL COLON TRANSIT that best reponds to PEG and MISOPROSTOL is called what?
COLONIC INERTIA
Intractable or disabling symptoms of COLONIC INERTIA (proximal colon), NO intestinal PSEUDOOBSTRUCTION, NORMAL ANORECTAL FUNCTION (abdominal pain is NOT predominant feature). What can be done for treatment?
SUBTOTAL COLECTOMY
MEGACOLON and MEGARECTUM, besides in children with retentive soiling, can be seen in?
Institutionalized ELDERLY, those with PARKINSON’s disease and SCHIZOPHRENIA and other PSYCHOTIC DISORDERS (treat with LOW fiber diet, enemas, PEG or surgery)
Is PAIN (progressive, awakens or prevents sleep) associated with ANOREXIA, WEIGHT LOSS or MALNUTRITION a finsing in IBS?
NO
EXAGERRATED MOTOR RESPONSE to MEALS, STRESSORS, CCK, and IMPAIRED HANDLING of INTESTINAL GAS are seen in what condition?
IBS
This can be seen in 4-30% of patients after a BACTERIAL or VIRAL ENTERITIS with DIARRHEA predominance (women, anxiety, deoression, use of antibiotics)?
POST-INFECTIOUS IBS
Does PSYCHIATRIC DISTRESS CAUSE symptoms of IBS?
NO (but it can INFLUENCE THEM)
Is there a RELIABLE BREATH TEST for SIBO?
NO
Post LACTULOSE administration, what constitutes a POSITIVE HYDROGEN BREATH TEST for SIBO?
An INCREASE of >20 ppm by 90 min or 180 min (early or late)
What strategy results in FEWER IBS-RELATED FOLLOW-UP visits?
Physician-Patient relationship with REALISTIC EXPECTATIONS and CONSISTENT LIMITS - normal life span, FODMAP DIET, reduction of GAS-PRODUCING foods
Is FOOD ALLERGY testing HELPFUL for patients with IBS?
NO
In which patients should the IBS-D medication ELUXADOLINE NOT be used in?
Those S/P CHOLECYSTECTOMY, KNOWN PANCREATICO-BILIARY DISEASE, CIRRHOSIS or HEAVY ALCOHOL USE
LINACLOTIDE, LUBIPROSTONE, PLECANATIDE, PEG, TEGASEROD (in women <65 when ALL ELSE FAILS) are ALL used to treat this condition?
IBS-C
RIFAXIMIN, ALOSETRON, LOPERAMIDE and ELUXADOLIN are all used to treat what?
IBS-D
Which SMOOTH MUSCLE relaxants and ANTI-SPASMODICS work best in IBS (short-term use)?
DICYCLOMINE, PEPPERMINT OIL (good placebo effect)
Do TCAs and SNRIs work better than placebo in IBS?
YES
FRUCTANS (onions, wheat, artichokes); GALACTANS (legumes, cabbage, Brussles sprouts); LACTOSE, SORBITOL, XYLITOL, MANNITOL and SUCRALOSE?
FODMAP (Fermentable Oligo, Di, Mono And Polyols) - AVOID THESE (low-FODMAP diet) in IBS patients
What is the BEST DIET for improving the QUALITY of LIFE in IBS patients?
LOW-FODMAP
For MODERATE to SEVERE IBS, what ELSE helps SIGNIFICANTLY besides medications (rifaximin, etc.)?
Cognitive Behaviroal Therapy (self-administered)
What should be considered FIRST in IBS-D before other treatment options?
FECAL CALPROTECTIN and if POSITIVE, COLONOSCOPY with BIOPSY
What treatment for IBS has shown the GREATEST value over PLACEBO?
PHYSICIAN-PATIENT RELATIONSHIP
In a patient with IBS-D, if intolerant to one TCA, what should be done?
SWITCH to another TCA
If LINACLOTIDE (or PLECANATIDE - same mechanism) are ineffective in treating IBS-C, what should be tried next?
LUBIPROSTONE (approved for IBS-C)
CBC, FOBT, COLORECTAL CANCER SCREENING, CRP, FECAL CALPROTECTIN, STOOL CULTURES and COLONOSCOPY are tests that should be done when working up what?
IBS with NO ALARM SYMPTOMS
This class of meds Ondansetron, Alosetron, Prucalopride are used to treat IBS?
SNRIs
Which ADENOMAS of the colon are DYSPLASTIC?
ALL, by definition (hence, all must be removed)
What is considered an ADVANCED COLON ADENOMA?
>1 cm and with HIGH-GRADE DYSPLASIA
HYPERPLASTIC polyp, SESSILE SERRATED polyp and SERRATED ADENOMAs are all types of what?
SERRATED colon polyps (hyperplastic is the only benign polyp)
Distinguishing features of a polyp that has even A SINGLE DILATED or DISTORTED CRYPT designates it as what type of polyp?
SESSILE SERRATED polyp rather than a hyperplastic polyp
When a colon lesion INVADES into the SUBMUCOSA, only then is it termed what?
CANCER (carcinoma in situ and intramucosal adenocarcinoma are NOT cancer)
Which COLON POLYPS have the HIGHEST prevalence of HIGH-GRADE DYSPLASIA?
DEPRESSED lesions (usually RIGHT colon, whereas pedunculated lesions are predominantly in the left colon)
What differentiates SUPERFICIAL from DEEP SUBMUCOSAL INVASION of a dysplastic colon polyp?
Lesions with ≥1,000 microns of SUBMUCOSAL INVASION
On ENDOSCOPY with NBI, the appearance of a polyp with DISRUPTED or AMORPHIC VASCULAR and PIT structure is suggestive of what?
A polyp with features of DEEP SUBMUCOSAL INVASION and NOT removable ENDOSCOPICALLY
What are the THREE most common MOLECULAR PATHWAYS to COLON CANCER?
1. CHROMOSOMAL INSTABILITY (ADENOMAS tubular and villous, accumulating mutations - APC, K-ras, p53)
2. HYPERMETHYLATION pathway - SERRATED polyps (BRAF, MLH1 genes)
- LYNCH - germline mutations in mismatch repair genes (MLH1, MSH2, MLH6, PMS2) microsatellite instability
In a patient in which 1 - 2 CONVENTIONAL ADENOMAS have been found on colonoscopy, WHEN should they be SCREENED next?
5-10 YEARS
In a patient found to have ≥3 ADENOMAS of ANY SIZE or ONE ≥10 mm in size WITH VILLOUS elements or HIGH-GRADE DYSPLASIA, when should SURVEILLANCE be done next?
In 3 YEARS
In a patient found to have ≥10 ADENOMAS, when should SURVEILLANCE be done next?
In LESS than <3 YEARS
In a patient found to have an ADENOMA ≥2 cm in SIZE resected in a PIECEMEAL fashion, when should SURVEILLANCE be done next?
3 - 6 MONTHS, then 1 YEAR
In a patient found to have 1 - 2 SESSILE SERRATED POLYPS <10 mm in SIZE, when should SURVEILLANCE be done next?
5 YEARS
In a patient found to have ≥3 SESSILE SERRATED POLYPS or ONE ≥10 mm in SIZE or a SESSILE SERRATED POLYP with DYSPLASIA, when should SURVEILLANCE be done next?
3 YEARS
How should a SINGE HYPERPLASTIC POLYP be treated if ≥10 mm in SIZE?
As ONE SESSILE SERRATED POLYP
Are SERRATED type polyps PEDUNCULATED?
Almost NEVER
A colon POLYP’s features such as GRANULAR (bumpy) LATERAL SPREADING are different than non-granular lesions in what IMPORTANT manner?
These have a LOWER RISK of invasive CANCER and SUBMUCOSAL FIBROSIS - can be EASILY removed ENDOSCOPICALLY even if LARGE (4 cm, etc.)
What do STAGES 0-4 in COLORECTAL CANCER represent?
Stage 0 - mucosa only
Stage 1 - submucosa
Stage 2 - invades MP
Stage 3 - LN involvement
Stage 4 - near or distant organs
Which portrends a worse outcome, a POORLY DIFFERENTIATED lesion or a WELL DIFFERENTIATED one?
POORLY DIFFERENTIATED (also distance from resection margin 1-2 mm, tangential resection)
What do these terms (CARCINOMA-IN-SITU and INTRAMUCOSAL ADENOCARCINOMA) mean?
HIGH-GRADE DSYPLASIA
What part of the colon is at HIGHEST RISK for MISSED lesions?
RIGHT COLON
What is the RECOMMENDED ADR (Adenoma Detection Rate) by ASGE - % of patients >50 yo undergoinf first time screening colonoscopy who have one or more conventional adenomas detected and removed?
25% (but goal should be 50%) (if FIT POSITIVE, its 40% with goal of 70%)
What is Lynch Syndrome?
Inherited Colorectal Cancer Syndrome (hereditary non-polyposis colon cancer)
Is NBI better than WHITE LIGHT for ADR (adenoma detection rate)?
YES!
APC GENE mutation, HUNDREDS of POLYPS, 50% of those affected develop ADENOMAS by age 15 (colon, duodenum, stomach), lipomas, fibromas, sebaceous cysts, tumors everywhere..
FAP (5q21)
By what age on average would a patient with FAP develop colon cancer unless the had a TOTAL COLECTOMY?
39
FIRST DEGREE RELATIVES (at risk) of patients with FAP should be SCREENED with APC GENE TESTING (not colonoscopy)at what age?
10-12
If a FIRST DEGREE RELATIVE is screened for APC GENE testing and found to be NEGATIVE, what MUST be done next?
Test for the MUTYH GENE (the autosomal recessive variant)
What is recommended for SCREENING and SURVEILLANCE COLONOSCOPY for a patient with FAP?
SCREENING YEARLY at PUBERTY or the age of 12 - 24, then EVERY 2 YEARS from 25 - 34, then EVERY 3 YEARS from 35 - 44 and then evry 3-5 YEARS
What are the REALTIVE indications for COLECTOMY in pt’s with FAP?
Too many polyps
What is CRAIL’s SYNDROME?
A variant of FAP also with an APC GENE mutation which results in a BRAIN MEDULOBLASTOMA associated with ADENOMATOUS POLYPOSIS
A condition in FAP where the mutation is in the MUTYH GENE and presents with LESS polyps than FAP, similar surveillance but colon cancer develops LATER (51) if no colectomy rather than (39) as in FAP?
ATTENUATED FAP
What MUTATION in ASHKENAZI JEWS causes an INCREASED RISK of colorectal cancer?
I1307K MUTATION
What are the DIFFERENCES between MAP and FAP?
MAP - MUTYH GENE affected - presents like ATTENUATED FAP, autosomal RECESSIVE, and WITHOUT osteomas, dermoid tumors or thyroid cancer. At risk for BREAST, OVARIAN and URINARY cancers. Colonoscopy every 1-2 years starting at 25-30 yo and EGD at 30-35 every 6 mo - 4 years depending on findings
FAP - APC GENE affected, autosomal DOMINANT, multiple tumors
Newly-diagnosed disease, affecting POLE and POLD1 GENES with OLIGOADENOMATOUS POLYPOSIS (<100 colorectal adenomas) with ENDOMETRIAL, BRAIN and DUODENAL cancers?
Polymerase Proofreading Associated Polyposis (PPAP)
Autosomal Dominant condition caused by mutation of the STK11 GENE on chromosome 19p with ARBORIZING polyps in the COLON, SMALL INTESTINE and STOMACH with MELANIN on the LIPS, BUCCAL mucosa, FINGERS, FEET, EYELIDS?
PEUTZ-JEGHER’s Syndrome (breast, colon, pancreas, testicular, ovarian, lung cancers)
When should you test AT-RISK (1st degree relatives of affected individual) patients for PEUTZ-JEGHER’s Syndrome and how?
Test for STK11 GENE mutations at AGE 8 and EGD/COLONOSCOPY every 1-3 YEARS
Autosomal DOMINANT, HAMARTOMAS of the SKIN, THYROID, BREAST, GIT, and ADNEXA, PTEN GENE affected on chromosome 10q, with multiple FACIAL TRICHILEMMOMAS around MOUTH, NOSE and EYES (>90% of patients) with GI LIPOMAS, GANGLIONEUROMAS?
COWDEN SYNDROME (breast and thyroid cancer, ovary, uterus and urinary)
Present in INFANCY or EARLY CHILDHOOD (age 4) with ONE or TWO polyps in the RECTOSIGMOID colon, with RECTAL BLEEDING or ANAL PROLAPSE
SOLITARY JUVENILE POLYPS - NOT INHERITED, NO INCREASED RISK of COLON CANCER
At LEAST 3-5 but usually HUNDREDS of polyps in the COLORECTUM, SMALL INTESTINE or STOMACH (HAMARTOMAS with edematous mucosa and MUCUOUS-FILLED CYSTS) with mutations in the TGF/SMAD pathway and BMPR1A on chromosome 10q22-23 and DIAGNOSIS <6 yo with RECTAL BLEEDING, ANEMIA, FAILURE TO THRIVE?
JUVENILE POLYPOSIS (39% lifetime risk of colorectal cancer) - AVMs, cardiovascular complications
Multiple NEVOID BASAL CARCINOMAS, SKELETAL ABNORMALITIES, MACROCEPHALY, and CRANIOFACIAL ABNORMALITIES associated with JUVENILE POLYPS with PTCH GENE affected?
GORLIN SYNDROME
≥5 SERRATED (hyperplastic) POLYPS PROXIMAL to the SIGMOID COLON, with TWO of these >1 CM or in a patient with this FAMILIAL DISEASE or ≥20 such polyps?
SERRATED POLYPOSIS (HYPERPLASTIC POLYPS) - HIGH (56%) lifetime risk of COLON CANCER - ANNUAL (or 1-3 years) COLONOSCOPY surveillance
A VARIANT of COWDEN SYNDROME with PIGMENTED MACULES on GLANS and SHAFT of PENIS?
Bannayan-Zonana Syndrome
NON-FAMILIAL, multiple JUVENILE POLYPS with EDEMATOUS MUCOSA in BETWEEN polyps, mean age of onset is 59 YO, CUTANEOUS HYPERPIGMENTATION, HAIR LOSS, NAIL BREAKDOWN, with DIARRHEA, MALABSORPTION, WEIGHT LOSS and EDEMA?
CRONKHITE-CANADA Syndrome
COLITIS CYSTICA PROFUNDA, is found in IBD - polypoid regenerated mucosa, sessile, NON-NEOPLASTIC and require NO TREATMENT?
INFLAMMATORY POLYPS (pseudopolyps)
Found in the TERMINAL ILEUM of patients with FAP or COMMON VARIABLE IMMUNODEFFICIENCY 1-3 mm polyps, BENIGN?
Nodular Lymphoid Hyperplasia (also associated with GIARDIA)
How is COLON CANCER ranked as far as leading causes of DEATH?
2nd (after lung cancer)
What UROLOGICAL procedure increases the risk of COLON CANCER?
URETEROSIGMOIDOSTOMY
What do these STAGES (T0, Tis, T1, T2, T3, T4a, T4b) mean in COLON CANCER?
T0 - NO TUMOR
Tis - confined to MUCOSA (HG dyplasia)
T1 - confined to SUBMUCOSA
T2 - Invaded MP but not into the serosa
T3 - Invaded the SEROSA
T4a - direct invasion of ORGANS or STRUCTURES
T4b - PERITONEUM
What do these (Nx, N0, N1, N2) LYMPH designations mean in COLON CANCER STAGING?
Nx - lymph node involvement CANNOT BE ASSESSED
N0 - NO LN involvement
N1 - 1-3 REGIONAL LNs
N2 - >4 REGIONAL LNs
SHOULD DISSECT at least 7 LNs
What do (Mx, M0 and M1) mean in COLORECTAL CANCER STAGING?
Mx - distant metastases CANNOT BE ASSESSED
M0 - NO DISTANT METS
M1 - YES DISTANT METS (non-regional LNs - common iliac, external iliac, paraaortic and supraclavicular are considered mets)
What are the American College of Gastroenterology recommendations for COLORECTAL CANCER SCREENING?
STARTING at age 45-50, ENDING at age 75-85
COLONOSCOPY every 10 YEARS (ANNUAL FIT if refuses)
OR
FLEX SIG every 5-10 YEARS OR CT COLOGRAPHY every 5 YEARS OR ANNUAL HEMOCCULT OR FECAL DNA every 3 YEARS
What is the SEROLOGIC TEST for COLORECTAL CANCER SCREENING?
SEPTIN-9
People with COLORECTAL CANCER or ADVANCED ADENOMA in TWO 1st degree RELATIVES (any age) or COLORECTAL CANCER or ADVANCED ADENOMA in ONE 1st degree REALTIVE <60 yo, WHEN should colorectal cancer SCREENING BEGIN?
COLONOSCOPY every 5 YEARS beginning 10 YEARS BEFORE the age of diagnosis of the YOUNGEST AFFECTED or age 40, whichever is EARLIER
In patients who are GENETIC FAP (APC) CARRIERS, WHEN should they get SCREENED for colon cancer?
Beginning at PUBERTY (age 10-12)and offered a FLEX SIG YEARLY
People with colorectal cancer in MULTIPLE 1st DEGREE relatives, accross generations, young age, etc. should be handled HOW as far as SCREENING is concerned?
GENETIC COUNSELING and SCREENING COLONOSCOPY every 1-2 YEARS beginnig at AGE 20-25 or 2-5 YEARS EARLIER if youngest was BEFORE age 20
Which type of colon POLYP has the HIGHEST incidence of cancer according to SIZE?
VILLOUS (HIGHEST) > tubulovillous > tubular
In patients with IBD, what is the colon cancer SCREENING consensus?
Start 8-10 YEARS after diganosis (15 years if only LEFT SIDED) and perform every 1-2 YEARS with 4-QUADRANT biopsies every 10 CM
What is the STANDARD in testing ALL patients found to have COLORECTAL CANCER?
Test for LYNCH SYNDROME (immunohistochemistry for the abence of the MISMATCH REPAIR GENE or MICROSATELLITE INSTABILITY - MLH1, BRAF) and if POSITIVE, genetic COUNSELING
What is the STANDARD for SCREENING AFTER COLORECTAL CANCER SURGERY if STAGE I, II, III?
STAGE I At 1 YEAR and the 3 YEARS and 5 YEARS
STAGE II & 3 PHYSICAL EXAM & CEA every 3-6 MONTHS for 2 YEARS then every 6 MONTHS for 5 YEARS; CT C/A/P every 6 mo - 1 year for 5 YEARS and COLONOSCOPY at 1 YEAR, 3 YEARS, 5 YEARS after SURGERY
In what patients with STAGE III COLON CANCER are the drugs 5-FU + LEUCOVORIN, FOLFOX, CAPECITBINE + OXALIPATIN, CETUXIMAB (EGFR), PENITUMUMAB (EGFR), BEVACIZUMAB (VEGF), PEMBROLIZUMAB (PD-L1)
Post-OP ADJUVANT CHEMOTHERAPY
EPCAM gene mutation results in what SYNDROME?
Lynch Syndrome (HNPCC if same syndrome but NO MUTATION)
AD disorder, 3% of all COLON CANCER cases, 80% of lifetime risk of COLON CANCER, younger age at onset (44), RIGHT side of colon, polyps are VILLOUS, MUCIONOUS, POORLY DIFFERENTIATED and with a LYMPHOID host-response to the tumor?
Lynch Syndrome
Lynch Syndrome is ASSOCIATED with which extra-intestinal CANCERS?
ENDOMETRIAL, OVARIAN, stomach, small bowel, ovary, ureter and bilairy
What is REQUIRED to diagnose HNPCC?
≥3 relatives with COLON CANCER (one has to be a 1st degree relative); COLORECTAL CANCER involving at least 2 GENERATIONS and at least one case diagnosed BEFORE AGE 50
Which MISMATCH REPAIR GENES are associated with LYNCH SYNDROME?
MSH1, MSH2, MLH1 (MSH6 and PMS2 have less risk, “attenuated” form - but higher risk of ENDOMETRIAL cancer)
What is the advantage in MSI-positive (microsatellite inatability) tumors in HNPCC?
SURVIVAL ADVANTAGE
ALL patients diagnosed with COLORECTAL CANCER are screened for what?
LYNCH SYNDROME (absence of MISMATCHED GENE PROTEINS)
Besides COLORECTAL CANCER SCREENING yearly beginning at age 20-25 in pts with LYNCH SYNDROME, and EGD every 2 years with GASTRIC BIOPSIES starting at age 30-35, what ELSE should be screened for?
At age 30, ANNUAL ENDOMETRIAL CANCER screening and TV US for OVARIAN CANCER, URINALYSIS annualy and HYSTERECTOMY at age 40 or when childbearing is complete
What is a VARIANT of LYNCH SYNDROME with SEBACEOUS tumors?
Muir-Torre Syndrome
A VARIANT of LYNCH SYNDROME with BRAIN TUMORS (glioblastoma and astrocytoma)?
TURCOT SYNDROME
This VARIANT of LYNCH SYNDROME is AR and occurrs with tumors and polyps everywhere including the BRAIN and occurs in CHILDREN, such as SCREENING starts at 8 YO?
BMMRD (Biallelic Mismatch Repair Defficiency)
In this SYNDROME, there is MICROSATELLITE STABILITY in the COLON (only colon tumors) tumors?
Familial Colorectal Cancer Syndrome Type X
In a patient with FAP, what ANNUAL SCREENING must they have besides ANNUAL SIGMOIDOSCOPY for retained RECTUM as they are NOT at an increased risk of GYN or gastric cancers (LOW)?
ANNUAL THYROID CANCER SCREENING (4-10% risk)
At WHAT AGE is it recommended for women with LYNCH SYNDROME (MSH2) to have PROPHYLACTIC removal of the OVARIES and UTERUS?
40 (colonoscopy at age 20-25) - no associated increased breast cancer risk
Polyposis with polyps containing EDEMATOUS MUCOSA and DILATED CYSTIC CRYPTS (colon and stomach)?
JUVENILE POLYPOSIS (SMAD4 or BMPR1a)
A patient was found on colonoscopy to have 21 SESSILE SERRATED (hyperplastic) polyps, waht is the INHERITANCE RISK of this condition?
What do patients with JUVENILE POLYPOSIS (SMAD4 or BMPR1a) demonstrated by polyps with EDEMATOUS MUCOSA and DILATED CYSTIC CRYPTS have to be SCREEND for besides colonoscopy and EGD?
Hemorrhagic Telangiectasia Syndrome (AV malformations in LUNG and BRAIN)
What EXTRA-COLONIC manifestations are there in SERRATED POLYPOSIS SYNDROME (multiple hyperplastic polyps)?
Genetic MUTATIONS in the POLE and POLD genes are found in WHICH POLYPS?
ADENOMATOUS POLYPS (not in serrated ones)
OSTEOMAS (skull and long bones), FIBROMAS, LIPOMAS, EPIDERMOID CYSTS (skin), EYE, THYROID, SMALL BOWEL, LIVER (hepatoblastoma) and ANGIOFIBROMAS are all associated with this SYNDROME?
FAP (APC gene)
How OFTEN and at what AGE is SCREENING (colonoscopy) performed in patients with FAP?
Starting at AGE 12 - YEARLY
then EVERY 2 YEARS at 25
then EVERY 3 YEARS at 35
AFTER SURGERY (colectomy) in patients with FAP, what is still SCREENED for YEARLY?
RECTUM (ileorectal anastomosis)
EGD (upper GI)
THYROID
Desmoids
<100 POLYPS found, LATER onset of COLORECTAL CANCER (51 vs 39) HETEROGENEOUS?
ATTENUATED FAP (MUYTH gene, also in MAP - MUYTH-associated polyposis)
How is MAP (MUYTH-associated polyposis) different than FAP?
NO OSTEOMAS, NO THYROID CANCER, NO EYE involvement, NO DESMOIDS
What do CRALI’S (APC) and TURCOT’s (MMR) SYNDROMES have in common?
POLYPOSIS and BRAIN TUMORS
Associated with the STK11 GENE and SPARES this part of the GI tract?
PEUTZ-JEGHER’s
Which POLYPOSIS SYNDROME causes CANCERS in the STOMACH (remove small bowel polyps >15 mm), COLON (remove polyps >5 mm), BREAST, PANCREAS, OVARY, TESTICULAR and LUNG?
PEUTZ-JEGHER’S
On COLONOSCOPY, if you find >10 TUBULAR ADENOMAS, what is the recommended SCREENING INTERVAL?
<3 YEARS
AD, SMAD4 and BMPR1A, GASTRIC, DUODENAL, PANCREATIC tumors, SCREENING starting at AGE 12 and associated with LUNG and BRAIN AVMs, polyps are EDEMATOUS and have CYSTIC CRYPTS?
JUVENILE POLYPOSIS
Mutation in the PTEN gene, BREAST, THYROID, RENAL, CEREBELLAR cancers, HAMARTOMAS of the SKIN, MUCOUS MEMBRANES, THYROID, BREAST and COLON (GANGLIONEUROMAS), MACROCEPHALY and PAPILLOMATOSIS?
COWDEN DISEASE
On COLONOSCOPY, if you find NO POLYPS or HYPERPLASTIC POLYPS <10 mm, what is the recommended SCREENING INTERVAL?
10 YEARS
On COLONOSCOPY, if you find 1-2 TUBULAR ADENOMAS <10 mm, what is the recommended SCREENING INTERVAL?
5-10 YEARS
On COLONOSCOPY, if you find 3-10 TUBULAR ADENOMAS, what is the recommended SCREENING INTERVAL?
3 YEARS
On COLONOSCOPY, if you find TUBULAR ADENOMA >10 mm, what is the recommended SCREENING INTERVAL?
3 YEARS
On COLONOSCOPY, if you find a VILLOUS ADENOMA, what is the recommended SCREENING INTERVAL?
3 YEARS
On COLONOSCOPY, if you find an ADENOMA with HIGH-GRADE DYSPLASIA, what is the recommended SCREENING INTERVAL?
3 YEARS
AVERAGE RISK COLORECTAL CANCER SCREENING TEAR 1?
Colonoscopy every 10 YEARS, ANNUAL FIT
AVERAGE RISK COLORECTAL CANCER SCREENING TEAR 2?
Virtual Colonoscopy every 5 YEARS
Flexible Sigmoidoscopy every 5-10 YEARS
FIT/FECAL DNA every 3 YEARS
AVERAGE RISK COLORECTAL CANCER SCREENING TEAR 3?
CAPSULE Colonoscopy every 5 YEARS
What is the FDA-APPROVED SERUM test for COLORECTAL CANCER SCREENING?
SEPTIN-9
If a patient has a RELATIVE >60 YO, that was found to have COLON CANCER or an ADVANCED ADENOMA, wehn should they be SCREENED and HOW OFTEN?
Starting at AGE 40 and ROUTINE INTERVAL (not every 5 years)
What PART of th COLON do SPORADIC COLON CANCERS develop in, what about LYNCH SYNDROME CANCERS?
SPORADIC - LEFT COLON
LYNCH - RIGHT COLON
COLON CANCER arising from MISMATCH REPAIR GENE failure?
LYNCH SYNDROME (microsattelite, BRAF)
If COLORECTAL CANCER is found and you performe IMMUNOHISTOCHEMICAL TESTING (IHC) and ALL PROTEINS ARE PRESENT, what is done NEXT?
NOT LYNCH SYNDROME - no further testing
If COLORECTAL CANCER is found and you performe IMMUNOHISTOCHEMICAL TESTING (IHC) and there is LOSS of MLH1 and PMS2, what is done NEXT?
PROMOTER hypermethylation or BRAF TESTING - if PRESENT, NOT LYNCH, no further testing
If COLORECTAL CANCER is found and you performe IMMUNOHISTOCHEMICAL TESTING (IHC) and there is LOSS of MLH1 and PMS2, what is done NEXT?
PROMOTER hypermethylation or BRAF TESTING - if NOT PRESENT, POSITIVE for LYNCH SYNDROME - REFER TO GENETIC COUNSELING for germline mutation testing
If COLORECTAL CANCER is found and you performe IMMUNOHISTOCHEMICAL TESTING (IHC) and there is LOSS of OTHER PROTEINS (not MLH1 or PMS2) what is done NEXT?
POSITIVE for LYNCH SYNDROME - REFER TO GENETIC COUNSELING for germline mutation testing
In a patient with SESSILE SERRATED POLYPOSIS (not hyperplastic) with finding of POLYPS <10 mm PROXIMAL to SIGMOID and NO DYSPLASIA, what is the SCREENING INTERVAL?
EVERY 5 YEARS
In a patient with SESSILE SERRATED POLYPOSIS (not hyperplastic) with finding of POLYPS >10 mm OR with DYSPLASIA OR TRADITIONAL SERRATED ADENOMA, what is the SCREENING INTERVAL?
3 YEARS
In a patient with SERRATED POLYPOSIS (>20 hyperplastic), what is the SCREENING INTERVAL?
YEARLY
What is the RISK of RELAPSE of CROHN’S disease at 1 year and 5 years POST-SURGERY?
53% at 1 YEAR
85% at 5 YEARS
What is considered a HIGH-RISK patient with CHROHN’S DISEASE?
A patient who developed CROHN’S after the age of 40, has ILEAL INVOLVEMENT, is a SMOKER, requires STEROIDS or has a FISTULA in the FIRST FEW MONTHS of DIAGNOSIS
What CANCER are CROHN’S disease patients susceptible to besides COLON CANCER?
NON-HODGKINS LYMPHOMA
What role does the APPENDIX play in ULCERATIVE COLITIS?
An APPENDECTOMY performed for APPENDICITIS rather than abdominal pain has a PROTECTIVE role AGAINST DEVELOPMENT of UC
A patient with ULCERATIVE COLITIS that is >40 years old, has EXTENSIVE COLITIS, DEEP ULCERS, HIGH CRP and ESR, requires STEROIDS, HOSPITALIZATIONS, history of C. DIFF and CMV are at HIGH RISK for what?
Requiring a COLECTOMY
What AGE of ONSET is considered HIGH-RISK for a CROHN’S DISEASE patient?
Age <30 (young)
What GENETIC DEFECT is associated with IBD?
CARD15 (used to be NOD2)
What are genetic markers DNAse SENSITIVE pANCA, ASCA, OmpC and CBir-1 associated with?
IBD (DNAse sensitive pANCA is for UC & CD; whereas ASCA is for CD); OmpC (CD); CBir-1 (CD)
What is the REMAINING risk when a patient with UC has a total colectomy?
POUCHITIS (ileal pouch-anal anastomosis)
HIGH LEVELS of ASCA and DNAse SENSITIVE pANCA in a patient with CROHN’S DISEASE portrends what?
Aggressive SMALL INTESTINAL DISEASE
What is the recommended INITIAL THERAPY for ULCERATIVE COLITIS?
TOPICAL + ORAL 5-ASA drugs
6-MP is broken down by the TPMT enzyme into a therapeutically-active metabolite and one that is not, which is which?
6-MMPN is INACTIVE - can cause HEPATOTOXICITY
6-TGN is active - can cause MYELOTOXICITY
What should be done PRIOR to initating 6-MP or AZA treatment for IBD?
Test for the TPMT enzyme to determine MUTATIONS causing RAPID 6-TGN production and MYELOTOXICITY (neutropenia)
Which agent is HELPFUL in INDUCTION and MAINTENANCE of REMISSION as well as reduce IMMUNOGENICITY in CROHN’S disease (does NOT WORK in UC)?
METHOTREXATE
Infliximab (fistulas), Adalimumab (if failed infliximab), Certolizumab (CD only), Golimumab (UC only) are what tye of agents?
anti-TNF-alpha
What MUST be done BEFORE using anti-TNF-alpha agents?
Test for TB and HEPATITIS B for possible REACTIVATION
If a patient on an anti-TNF-alpha agent presents with FEVER and COUGH, what MUST be SUSPECTED?
INFECTION (FUNGAL)
In a patient on an anti-TNF-alpha agent presents with a PSORIAFORM rash, what should be done?
STOP THERAPY
What CANCER RISK exists with the anti-TNF-alpha agents?
LYMPHOMA (especially patients with RHEUMATOID ARTHRITIS)
Which anti-TNF-alpha agent does NOT have a RISK of LYMPHOMA nor JC-VIRUS REACTIVATION (pml)?
VEDOLIZUMAB (used for UC and CD)
What should IBD patients be treated with IMMEDIATELY POST-OP for BEST RATES of REMISSION?
anti-TNF-alpha (adalimumab best)
This CROHN’S DISEASE antibiologic targets INTERLUKINS IL-12 and IL-23 and is an INFUSION given every 8 WEEKS?
USTEKINUMAB
An antibiologic used for moderate to severe active ULCERATIVE COLITIS that targets JAK 1, 2, 3 and acts VERY RAPIDLY to stop bleeding is?
TOFACITINIB (adverse effects are HERPES ZOSTER and elevated CHOLESTEROL)
In what IBD cases is an ELEMENTAL DIET as EFFICACIOUS as STEROIDS?
CROHN’S DISEASE with SMALL BOWEL involvement
What INFECTION are IBD patients SUSCEPTILE to by virtue of the disease itself not treatment?
CLOSTRIDIUM DIFFICILE
What PREVENTS POUCHITIS and what is used to TREAT IT?
PROBIOTICS prevent it
METRONIDAZOLE treats it (or ciprofloxacin)
Flat SKIN lesions in IBD patients on the EXTENSOR surfaces of LOWER EXTREMITIES which turn painful and parallel GI symptoms
Eryhtema Nodosum
This lesion sarts out as a NODULE or ULCER in IBD patients on the EXTENSOR surfaces of LOWER EXTREMITIES which turns bigger with manipulation and time.
Pyoderma Gangrenosum
Joint arthralgias, arthritis, ankylosing spondylitis, uveitis and episcleritis (immediate ophthalmologist attention) are all extra-intestinal manufestations of what?
IBD (erythema nodosum and pyoderma gangrenosum as well)
PRE-MALIGNANT condition associated with IBD that can cause liver cirrhosis and need for transplantation, no other treatment available, what is this?
Primary Sclerosing Cholangitis (PSC) - persistently elevated alk phos
What is the INCREASED RISK for COLORECTAL CANCER in patients with UC over the general population?
INCREASE of 10% after 30 YEARS of DISEASE
Does IBD result in INFERTILITY?
UC - ONLY if had POUCH PROCEDURE
CD - scarring of fallopian tubes due to pelvic inflammation
BEST OUTCOMES - CONCEPTION when in REMISSION
What medication CANNOT be used in PREGNANCY to treat IBD?
METHOTREXATE (all other meds ok in LOWEST EFFECTIVE DOSE)
What is the RECOMMENDATION for VACCINATION of infants born to mothers actively treated for IBD?
NO LIVE VACCINATIONS (rotavirus, BCG) for the first 6 MONTHS of life)
In how many patients with UC is the RECTUM involved?
>99%
Which IBD disease is MORE COMMON in NON-SMOKERS or EX-SMOKERS?
ULCERATIVE COLITIS (smoking can induce remission but NEVER recommended)
Can REGULAR USE of HIGH-DOSE NSAIDs lead to disease flares in IBD?
YES
What is the BEST mode of treatment of LEFT-SIDED (most common) ULCERATIVE COLITIS and what is done for more ACTIVE disease?
TOPICAL (enemas, suppositories) meds, ADD ORAL ones for more active disease
THIOPURINES (azathioprine and 6-MP) have an INCREASED RISK of what?
NON-MELANOMA skin cancers (make the skin photosensitive), and LYMPHOMA, HPV
The RISK of WHAT returns to BASELINE if THIOPURINES (azathioprine and 6-MP) are DISCONTINUED?
LYMPHOMA
In patients with GOOD BLOOD LEVELS of anti-TNF-alpha inhibitors like INFLIXIMAB who DO NOT RESPOND to therapy, how MUST treatment be CHANGED?
Use of NON anti-TNF-alpha inhibitors such as vedolizumab, ustekinumab, natalizumab
How MUST treatment be CHANGED in a patient who PREVIOUSLY RESPONDED but developed ANTIBODIES to one anti-TNF-alpha inhibitor?
COMBINATION therapy with another anti-TNF-alpha inhibitor
Which IBD medications cause PALMAR PLANTAR PUSTULOSIS as an adverse effect?
anti-TNF-alpha inhibitors (adalimumab, infliximab) - change class of drug
Peripheral ARTHRITIS and ARTHRALGIAS are noted in IBD usually with what? How is it treated?
Active and more bothersome with ACTIVE DISEASE
Treat by TREATING ACTIVE DISEASE and INCREASE DOSAGE as needed
What drug is a CHIMERIC IgG1 Ab to TNF-alpha?
INFLIXIMAB
What drug is a FULLY HUMANIZED IgG1 Ab to TNF-alpha?
ADALIMUMAB
What drug is a HUMANIZED PEGYLATED FAB IgG1 FRAGMENT to TNF-alpha?
CERTOLIZUMAB
What drug is a alpha-1-INTEGRIN inhibitor IgG4 Ab?
NATALIZUMAB
What is the 10-YEAR risk from diagnosis of SURGERY need in Crohn’s disease?
40%
What has been proven as SUPERIOR for identification of NEOPLASIA in ULCERATIVE COLITIS?
DYE SPRAY CHROMOENDOSCOPY (methylene blue or indigo carmine) with STANDARD DEFINITION colonoscopes is superior to white lite standard definition colonoscopes
What should be done in a patient who develoops an anti-TNF-alpha PSORIAFORM RASH (palmar erythema with pruritus and peeling)?
HOLD the anti-TNF-alpha DRUG
When suspecting INITIAL episode of POUCHITIS (not recurrent), what is the recommended approach?
METRONIDAZOLE or CIPROFLOXACIN
In PREGNANT patients with CROHN’s disease, what occurs with the infants REGARDLESS of treatment?
PREMATURE babies, SMALL for GESTATIONAL AGE (more likely to have a C-SECTION)
In a patient with CROHN’s DISEASE who was NON-COMPLIANT with INFLIXIMAB INFUSION therapy and presnts with MYALGIAS, ARTHRALGIAS and FEVERS following his INFUSIONS likely because of what?
Developed DRUG-INDUCED IMMUNE HYPERSENSITIVITY to infliximab so START STEROIDS
If AZATHIOPRINE or 6-MP are NOT YET STARTED during a PREGNANCY, why should these NOT be started if possible?
Because of the risk of PANCREATITIS (which can severely affect pregnancy)
Which anti-TNF-alpha inhibitor does NOT CROSS the PLACENTA?
CERTOLIZUMAB PEGOL
THIOPURINES (azathioprine and 6-MP) increase the RISK of what type of cancers?
NON-MELANOMA skin cancers (BASAL CELL and SQUAMOUS)
Histomogically, NO EDEMA, CRYPT ABSCESSES, SHORT-BRANCHED CRYPTS, LESS SURFACE DAMAGE and DECREASED MUCIN are found in what condition?
ULCERATIVE COLITIS
In a patient with UC with EXTENSIVE COLITIS, DEEP ULCERS, AGE <40, HIGH CRP & ESR, STEROID-REQUIRING, HOSPITALIZATION history, C. DIFF and CMV infections all indicate a HIGH-RISK for what?
COLECTOMY
Is it RECOMMENDED to use FECAL CALPROTECTIN to assess the EFFECT of STRESS on IBD?
NO (no effect)
DNAse SENSITIVE pANCA?
ULCERATIVE COLITIS
ASCA, OmpC
CROHN’s DISEASE
What is the significance of HIGH IgG and IgA ASCA in Crohn’s Disease?
More AGGRESSIVE Small Bowel Disease
Are SEROLOGIC MARKERS recommended in DIAGNOSIS or PROGNOSTICATION of IBD?
NO
In which IBD is ABDOMINAL PAIN noted?
CROHN’s DISEASE (in UC its bleeding)
In which IBD condition is METHOTREXARTE used as it can INDUCE REMISSION and is effective for MAINTENANCE therapy as well as prevent ANTI-DRUG Ab’s when used in COMBINATION therapy?
CROHN’s DISEASE (does NOT WORK in UC) - NEEDS FOLIC ACID supplementation
What can be used as a SURROGATE to determine DISEASE ACTIVITY in an IBD patient whe ENDOSCOPY is not feasible to assess mucosal healing and disease activity?
Fecal CALPROTECTIN
What does “HISTOLOGIC REMISSION” in IBD refer to (as opposed to endoscopic remission)?
ABSENCE of NEUTROPHILS
What SIMPLE medication is EFFECTIVE for INDUCTION and MAINTENANCE of MILD to MODERATE ULCERATIVE COLITIS?
5-ASA (aminosalycilates)
What CORTICOSTEROID is EFFICACIOUS for achieving INDUCTION of REMISSION in MILD to MODERATE UC?
BUDESONIDE (enteric coated - ileum and cecum; extended release - throughout colon)
How should STEROIDS be used in treating IBD?
Use NON-SYSTEMIC first (budesonide), check VIT D and BONE DENSITY
What does having the NUDT15 mutation mean?
INCREASED SENSITIVITY to 6-MP (leukopenia)
Which IBD treatments INCREASE the RISK of LYMPHOMA?
THIOPURINES (azathioprine and 6-MP) and anti-TNF-alpha inhibitors
In a patient on 6-MP with SUB-THERAPEUTIC 6-TGN levels and elevated LFTs, what can be done?
Start ALLOPURIONOL (xanthine oxidase pathway rescue)
When using METHOTREXATE (never in pregnant women), what must be SUPPLEMENTED?
FOLIC ACID (monitor LFTs every 6 months)
BONE MARROW SUPPRESSION, MUCOSITIS, HYPERSENSITIVITY PNEUMONITIS, CIRRHOSIS are all adverse effect of this medication used to treat CROHN’s DISEASE?
METHOTREXATE
What is SWAPPING vs CYCLING when speaking of IBD drugs?
SWAPPING - using a completely DIFFERENT CLASS drug (ustekinumab for infliximab)
CYCLING - using a different drug within the SAME CLASS (adalimumab for infliximab)
What is ROUTINELY RECOMMENDED to guide THIOPURINE DOSE therapy in IBD patients?
TPMT testing and reactive thiopurine METABOLITE testing to guide therapy (TGN, MMPN)
What TESTS can be used to PREDICT RELAPSE in a patient with CROHN’s DISEASE if INFLIXIMAB therapy is WITHDRAWN?
CRP (>6) and FECAL CALPROTECTIN (>300)
In a patient with SURGICAL-INDUCED remission of CROHN’s DISEASE, what is the post-surgical surveillance recommendation?
COLONOSCOPY every 6-12 months
In a patient with SURGICAL-INDUCED remission of CROHN’s DISEASE, what is the post-surgical TREATMENT recommendation?
anti-TNF-alpha inhibitor (infliximab) +/- additional agent (methotrexate, etc)
What treatment for IBD is HIGH-RISK for POST-OPERATIVE complications?
STEROIDS
Are the DISEASE OUTCOMES modified in ULCERATIVE COLITIS, when the STEP-UP approach is used and 5-ASA is ADDED to BIOLOGICS?
NO (no need to add the 5-ASA)
Which are the ANTI-INTEGRIN DRUGS (still need to check for TB and HBV before use - insurance issues no elevated risk) used in IBD treatment?
NATALIZUMAB (CROHN’s ONLY) and VEDOLIZUMAB (CROHN’s & UC) no PML danger, LOW malignancy risk)
This is an anti-INTERLUKIN (IL12/23) medication APPROVED for CROHN’s DISEASE (induction and maintenance of remission for MODERATE-SEVERE and REFRACTORY DISESE) only?
USTEKINUMAB (for CROHN’s ONLY)
This JAK-INHIBITOR was approved for MODERATE-SEVERE UC and can flare HERPES ZOSTER?
TOFACITINIB
What is the BEST therapeutic indicator in IBD therapy that utilizes INFLIXIMAB whether monotherapy or combination?
INFLIXIMAB LEVELS
When ESCALATING therapy to anti-TNF-alpha inhibitors, does the addition of 5-ASA make a difference?
NO
Do USTEKINUMAB and VEDOLIZUMAB benefit from COMBINATION therapy?
NO
What DIET has been shown in CROHN’s DISEASE to be as beneficial as STEROID treatment?
ELEMENTAL DIET
Any patient presenting with a FLARE of IBD should be tested for what initially?
C. DIFF (if positive, treat with PO vancomycin)
What should be offered to patients with IBD and RECURRENT C. DIFF infections?
Fecal Microbiota Transplant (FMT)
What can be used as MAINTENANCE therapy for patients with POUCHITIS?
PROBIOTICS
MALE gender, longer DURATION of disease, YOUNGER age of diagnosis, GREATER EXTENT of colonic involvement, FAMILY HISTORY, PSC are all risk factors in UC for what?
COLORECTAL CANCER
If DYSPLASIA is found on SURVEILLANCE colonoscopy in a patient with IBD, what is the recommendation?
COLECTOMY or CLOSE surveillance very 6 months with biopsies
Can PREGNANCY cause RELAPSE of UC in an INACTIVE patient?
YES
Does PREGNANCY significantly affect DISEASE ACTIVITY in ACTIVE UC?
NO
Is there a risk for CONGENITAL abnormalities in patients with IBD?
NO (only prematurity and small gestational age with or without thiopurines)
Which anti-TNF-alpha drugs can be detected in infant up to 6-MONTHS postpartum?
INFLIXIMAB and ADALIMUMAB
Can METHOTREXATE or THALIDOMIDE be used in PREGNANCY?
NO
Which VACCINES are PREFERRED before starting anti-TNF-alpha inhibitor therapy?
PNEUMOVAX and ZOSTER
Which VACCINES must be AVOIDED once on IMMUNOSUPPRESSION therapy?
All LIVE vaccines (MMR, ROTAVIRUS, SMALLPOX, CHICKENPOX, YELLOW FEVER)
ANNUAL DERMATOLOGIC screening and PAP smears, HPV vaccination and COLORECTAL CANCER screening, BONE health, SMOKING CESSATION are recommeneded for all patients being treated for what?
IBD (especially if on immunosuppressants)
WANING INFLIXIMAB effect with LOW ATI (anti-infliximab antibodies) and LOW TROUGH levels indicate what?
UNDER-DOSING of INFLIXIMAB
POOR INFLIXIMAB effect with LOW ATI (anti-infliximab antibodies) and good TROUGH levels indicates what?
MECHANISTIC ESCAPE (immune system override of drug)
What is the HIGHEST-RISK with INFLIXIMAB?
INFECTION (by far and way over non-melanoma skin cancer)
What RISK factor with METHOREXATE THERAPY can occur at ANY TIME during treatment?
HYPERSENSITIVITY PNEUMONITIS
What should be done when a patient on an anti-TNF-alpha inhibitor therapy develops PSORIATIC LESIONS?
CHANGE AGENT (50% chance of recurrence with next agent)
ACTIVE IBD is associated with what THREE main RISKS in PREGNANCY?
LOW BIRTH WEIGHT
PREMATURE BIRTH
SPONTANEOUS ABORTION
In a patient with STEROID-RESISTENT UC, what should be thought of?
CMV or C. DIFF infection
Can C. DIFF present in patients with IBD without PSEUDOMEMBRANES on colonoscopy?
ABSOLUTELY YES
When should you perform a SURVEILLANCE COLONOSCOPY for a patient who underwent SURGERY for CROHN’s DISEASE?
Within 6-12 MONTHS after the SURGERY (look for evidence of recurrence)
In a patient with SYMPTOMS of POUCHITIS but they have a NROMAL-APPEARING POUCH, what is the issue?
IRRITABLE POUCH SYNDROME (IPS)
Where is POUCHITIS normally located?
DISTAL POUCH ONLY
If POUCHITIS TRACKS up the AFFERENT LIMB, what is the issue?
CROHN’s DISEASE, not UC
If POUCHITIS is LIMITED to the ANAL TRANSITION ZONE, what is the issue?
CUFFITIS
What VACCINATIONS should patients with IBD get?
MENINGOCOCCAL, Tdap, HPV, etc.
Which TWO agents are responsible for the HIGHEST INCIDENCE of DEATH related to INFECTIOUS DIARRHEA?
C. DIFF and NOROVIRUS
How do ENTEROTOXINS (VIBRIO cholera, ENTEROTOXIGENIC E. COLI) cause diarrhea?
Secrete toxin which causes villi that IMPAIR SECRETION or ABSORPTION
This common enteric bacteria makes CYTOTOXIN which causes CELL INJURY and inflammation?
C. DIFF
These bacteria produce PREFORMED TOXINS causing diarrhea?
Staph AUREUS and Bacillus CEREUS
These organisms produce ENTEROADHERENT TOXINS which adhere to the intestinal mucosa and EFFACE MUCOSAL CELLS?
ENTEROPATHOGENIC, ENTEROHEMORRHAGIC, ENTEROAGGREGATIVE and DIFFUSELY ADHERENT E. COLI
These organisms result in MUCOSAL INVASION, with INFLAMMATION and ULCERATION as they penetrate to mucosa and cause erosions and ulcerations?
SHIGELLA, ENTEROINVASIVE E. COLI, CAMPYLOBACTER JEJUNI
These organisms PENETRATE the MUCOSA and PROLIFERATE in the SUBMUCOSA?
SALMONELLA, YERSINIA ENTEROCOLITICA
ARACHIDONIC ACID, metabolites and KININS, as well as VASOACTIVE substances are all what types of agents?
Inflammatory SECRETOGOGUES
What is the MOST COMMON vehicle for FOOD POISONING?
GREEN LEAFY vegetables
When a patient presents with INITIAL and PREDOMINANT NAUSEA and VOMITING, what type of substance were they exposed to as far as FOOD POISONING?
PREFORMED TOXIN (staph aureus, bacillus cereus)
When a patient presents with INITIAL and PREDOMINANT WATERY DIARRHEA, what type of organism were they exposed to as far as FOOD POISONING?
NON-INVASIVE pathogen
When a patient presents with INITIAL and PREDOMINANT BLOODY DIARRHEA, what type of organism were they exposed to as far as FOOD POISONING?
INVASIVE pathogen
For agents that have PREFORMED TOXINS, what is the presentation TIMELINE post INGESTION?
1-12 HOURS for bacteria (staph aureus - protein rich, creamy foods, bacillus cereus - starchy foods, rice) - food sits at ROOM TEMP
24-48 HOURS for VIRUSES
FOOD POISONING with this agent results in INCUBATION period of 12-24 hours, SYMPTOMS of NAUSEA, VOMITING, WATERY DIARRHEA, FEVER that last from 1-3 DAYS and pt can be INFECTIOUS from 5 DAYS to 4 WEEKS?
NOROVIRUS
WATERY DIARRHEA from food poisoning can be either INFLAMMATORY or NON-INFLMMATORY, which are the NON-INFLAMMATORY AGENTS?
CLOSTRIDIUM PERFRINGENS (spores in meat, gravy), ENTEROTOXIGENIC E. COLI, NOROVIRUS and ROTA VIRUS as well as PARASITES (giardia, cryptosporidium, cyclospora - water, produce, milk - diarrhea can last a month)
How can you DIAGNOSE PARASITES as the food poisoning agents?
ACID-FAST STOOL test (giardia - daycare, streams or rivers - stool antigen test, cryptosporidium, cyclospora)
WHICH individuals are more susceptible to GIARDIA infections (fresh water streams and rivers, daycare workers)?
Those with an IgA DEFICIENCY
When BLOOD and MUCOUS is noted in DIARRHEA, severe ABDOMINAL PAIN and FEVER, what type of diarrhea is this?
INFLAMMATORY - stool LEUKOCYTES or LACTOFERRIN
INFLAMMATORY diarrhea (BLOOD and MUCOUS) is generally caused by these agents in which the INCUBATION period is 3-5 DAYS?
SALMONELLA, SHIGELLA, CAMPYLOBACTER (poultry)- undercooked MEAT and contaminated PRODUCE
This TOXIN is found in UNDERCOOKED MEAT, UNPASTEURIZED JUICES, CONTAMINATED FRUITS and VEGETABLES and has an INCUBATION period of 1-7 DAYS, starts out with WATERY diarrhea that TURNS BLOODY?
SHIGATOXIN produced by E. coli 0157:H7 (Hemolytic Uremic Syndrome - HUS)
What toxin is associated with WATERY diarrhea that TURNS BLOODY and causes Hemolytic Uremic Syndrome (HUS)?
SHIGATOXIN caused by E. coli 0157:H7
This organism can cause ILEO-COLITIS, is found in UNDERCOOKED PORK and PORK INTESTINES, as well as UNPASTEURIZED MILK and causes an INFLAMMATORY (BLOODY) DIARRHEA?
YERSINIA ENTEROCOLITICA
These TWO organisms are known to cause CHRONIC ILEO-COLITIS?
PLESIOMONAS and AEROMONAS
48 HOURS after ingesting SHELLFISH, a patient develops DIARRHEA and these can be DEADLY in patients who are IMMUNOCOMPROMISED or have LIVER DISEASE?
VIBRIO (parahaemolyticus; vulnificus - associated skin infection)
Achlorhydria, Sickle Cell Disease, RAW EGGS, PETS (reptiles, chicks, ducklings, hamsters) predispose to an INFECTION with this bacteria and treatment is ONLY RECOMMENDED in those IMMUNOCOMPROMISED?
SALMONELLA
An INFECTION with this bacteria causes COLONIC INFLAMMATION and DYSENTERY and ALL CASES SHOULD BE TREATED?
SHIGELLA (QUINOLONES, CEPHALOPSPORINS, AZITHROMYCIN)
An INFECTION with this bacterial agent causes WATERY to BLOODY diarrhea, is most COMMONLY contracted from POULTRY and presents with ILEOCOLITIS (can mimic appendicitis) and can cause GUILLAIN-BARRE SYNDROME?
CAMPYLOBACTER
Which FOUR (4) E. coli bacteria types affect the SMALL INTESTINE?
ENTEROTOXIGENIC
ENTEROPAHTOGENIC
ENTEROADHERENT
DIFFUSELY ADHERENT
Which are the TWO (2) E.coli baterial types that affect the COLON?
ENTEROINVASIVE
ENTEROHEMORRHAGIC (shiga, 0157:H7)
How must ENTEROHEMORRHAGIC (shiga, 0157:H7 - undercooked beef, salad, sprouts, unpasteurized cider) E.coli NEVER be TREATED?
NEVER TREAT with ANTIBIOTICS or ANTIDIARRHEALS
The INCREASE in use of what ANTIBIOTICS can select for a very VIRULENT strain of C. DIFF (NAPI/B1)?
QUINOLONES (as well as CLINDAMYCIN, CEPHALOSPORINS)
Which MEDICATION TYPES are CONTRAINDICATED in the treatment of C. DIFF?
ANTIDIARRHEALS (decreased stool transit times lengthen the illness course)
ONLY which patients should be tested by PCR for C. DIFF as this is the BEST test but also VERY SENSITIVE (can detect carriers)?
ONLY patients with DIARRHEA
HOW is C. DIFF best treated and for how long?
ORAL METRONIDAZOLE or VANCOMYCIN or FIDAXOMICIN for 10 DAYS
Do PROBIOTICS help in treatment of C. DIFF?
NO
Which ANTIBIOTIC is the BEST for the treatment of SEVERE C. DIFF?
ORAL VANCOMYCIN (125 mg PO QID)
How are CRITICALLY ILL (pseudomembranes, high leukocytosis, colon wall thickening ascites) patients with C. DIFF treated?
ORAL VANCOMYCIN at 500 mg PO QID and IV METRONIDAZOLE 500 TID
WHEN is a TOTAL COLECTOMY with ILEOSTOMY required for C. DIFF infection?
When there is a HIGH-RISK of DEATH (marked leukocytosis, serum lactate >5, rising Cr)
What DETERMINES whether an episode of C. DIFF is MILD or SEVERE?
MILD C. DIFF (WBC <15,000; Cr <1.5)
SEVERE C. DIFF (WBC ≥15, 000; CR ≥ 1.5)
How do you treat C. DIFF in patient has an ILEUS?
VANCOMYCIN ENEMAS
In HOW mant patients will C. DIFF recur?
10-20% (low IgG to TOXIN A) and occurs 5-8 DAYS after antibiotics are stopped
How is RECURRENT C. DIFF treated?
Repeat Vancomycin 125 mg PO 4x/day for 10 DAYS, then 125 mg PO every 3 DAYS for 10 more DAYS
When is the TREATMENT with FECAL MICROBIOTA TRANSPLANT (FMT) appropriated for C. DIFF?
When there has been at lease THREE RECURRENCES
When SHOULD a PROBIOTIC (and WHICH ONE) be used in C. DIFF treatment?
Saccharomyces boulardii and ONLY in COMBINATION with HIGH-DOSE VANCOMYCIN
Should IVIG be used to treat C. DIFF?
NO (not efficacious)
Which BACTERIAL agent acts like C. DIFF (antibiotic-associated colitis), C. DIFF NEGATIVE, BLOODY diarrhea involving the RIGHT colon and CECUM with RECTAL SPARING and NO PSEUDOMEMBRANES?
Klebsiella oxytoca
This organism MIMICS APPENDICITIS and CROHN’s disease with ACUTE or CHRONIC COLITIS, with ESENTERIC ADENITIS and is grown on COLD ENRICHMENT MEDIUM, it is usually transmitted from undercooked PORK and PORK INSTETINES?
YERSINIA
These TWO organisms are transmitted from RAW SHELLFISH or WATER, they can cause CHRONIC COLITIS as well as TRIGGER IBD in SUSCEPTIBLE patients?
AEROMONAS hydrophila and PLESIOMONAS shigelloides
These TWO organisms have a PREDILECTION for the ILEO-COLONIC area, BIOPSY, CULTURE and PCR are best and only 50% of patients also have the PULMONARY manifestations?
TUBERCLOSIS and HISTOPLASMOSIS
Often found in OUTBRAKES of WATERY DIARRHEA with FEVER, HEADACHE and MENINGITIS and found in LUNCH MEAT, UNPASTEURIZED CHEESE, CANTALOUPES and ICE CREAMS and can be FATAL in IMMUNOCOMPROMISE as well as cause FETAL DEATH in pregnant women?
LISTERIA MONOCYTOGENES
What PHASES of ENTAMOEBA HISTOLYTICA (abd pain and watery diarrhea) MUST be TREATED?
TISSUE and LUMINAL PHASES (diagnose with SEROLOGY)
WATERBORNE parasite that affects the SMALL INTESTINE and BILIARY TRACT and is treated with NITAZOXANIDE?
CRYPTOSPORIDIUM
Parasite transmitted from imported RASPBERRIES and BASIL, and causes WATERY diarrhea for 4-6 WEEKS?
CYCLOSPORA
What is the MOST COMMON finding in parasitic infection with WORMS?
EOSINOPHILIA
What WORM parasite can cause APPENDICITIS and BILIARY OBSTRUCTION and is the MOST COMMON worldwide?
ASCARIS
This WORM parasite causes IRON DEFFICIENCY ANEMIA and OCCULT GI BLOOD LOSS?
HOOKWORMS
Stepping on contaminated animal FECES when this parasite makes contact with the SKIN, the larvae penetrate the skin and travel to the LUNGS, up the bronchial tree and are SWALLOWED, burrow into the SMALL BOWEL mucosa and live for years. The eggs are passed in the stool and can also AUTOINFECT the HOST?
STRONGYLOIDES STERCORALIS - SKIN, PULMONARY and GI manifestations - IVERMECTIN or ALBENDAZOLE
Infection with this PARASITE causes ANAL ITCHING but NOT DIARRHEA?
PINWORM
What is the MOST COMMON CAUSE of DIARRHEA world-wide?
ROTAVIRUS (children) and NOROVIRUS (everyone) - vaccines (rotavirus), WASHING HANDS (preventative), REHYDRATION (treatment)
What should be done for ALL patients presenting with DYSENTERIC DIARRHEA (BLOOD and MUCOUS)?
STOOL TESTING
What should be done ALL patients presenting with DYSENTERIC DIARRHEA (BLOOD and MUCOUS) who have RECENTLY TRAVELLED?
EMPIRIC AZITHROMYCIN (can use RIFAXIMIN too)
What should be done with a patient infected with these agents SHIGELLA, CHOLERA, C. DIFF, PARASITES, SEVERE TRAVELLER’s DIARRHEA, VIBRIO, YERSINIA, CAMPYLOBACTER, AEROMONAS and PLESIOMONAS?
Pathogens that SHOULD BE TREATED
How should a patient be TREATED if presenting with MILD WATERY DIARRHEA or MODERATE TO SEVERE DIARRHEA WITHOUT FEVER (EXCEPT 0157:H7 or C. DIFF)?
REHYDRATION and LOPERAMIDE (EXCEPT 0157:H7 or C. DIFF)
What is the MOST COMMON CAUSE of DEATH from GI INFECTIONS in the US?
C. difficile
Which FOOD is the most COMMON CAUSE of EPIDEMICS?
GREEN LEAFY VEGETABLES
HIGHLY-CONTAGIOUS agent with NO LIFELONG IMMUNITY, transmitted via fecal-oral route, aerosolized vomitus and fomites. This can spread quickly especially in institutionalized patients with MALAISE, LOW-GRADE FEVER, WATERY DIARRHEA?
NOROVIRUS
How LONG does an ilness from a PREFORMED TOXIN last?
6-24 HOURS (nor days)
In a patient with TRAVELER’s DIARRHEA watery at first, then with mucous and blood, whether PREGNANT or not, what is the best empiric treatment?
AZITHROMYCIN (NOT quinolones - resistence and pregnancy contraindication)
DELAYED INCUBATION PERIOD 4-7 DAYS, WATERY DIARRHEA and BLOATING, STOOL TEST is DIAGNOSTIC?
CYCLOSPORA (raspberries)
A patient with CHRONIC DIARRHEA tests POSITIVE for BLASTOCYSTIS HOMINIS and ENDOLIMAX NANA in stool O&P, what do you do?
These are NOT PATHOGENS but CAN BE TREATED (to get rid of symptoms)
TRABELERS who develop WATERY or BLOODY diarrhea are treated how?
EMPIRICALLY with AZITHROMYCIN
BLOODY DIARRHEA in the USA (not treveler’s) indicates what TYPE of PATHOGEN and what must be done?
INVASIVE pathogen requiring a STOOL CULTURE and NOT EMPIRIC THERAPY
In the USA (not traveler), WHEN is a STOOL CULTURE required for WATERY (non-bloody) DIARRHEA rather than empiric treatment?
When there is FEVER >101F and DURATION >72 HOURS
Eating FISH that is NOT FRESH can cause a HISTAMINE RASH (scombroid fish poisoning) that manifests as a PAINLESS red rash on the FACE and UPPER CHEST, how do you TREAT?
ANTIHISTAMINES (increase dose until they work)
What HISTOLOGIC feature DISTINGUISHES UC from INFECTIOUS COLITIS?
BRANCHING of the BASE of the CRYPTS
What can occur after FMT is used to treat C. diff in a patient with CROHN’s (or UC) DISEASE?
IBD FLARE
Which E. coli species AFFECT THE COLON (not small bowel)?
EIEC (ENTERO INVASIVE) - DYSENTERY
EHEC (ENTERO HEMORRHAGIC) - 0157:H7
Severe abdominal pain, bloody stools with mucus, causes HUS - DO NOT USE ANTIBIOTICS or ANTIDIARRHEALS
Caused by TROPHERYMA WHIPPLEI - CADIAC, JOINT and NEUROLOGIC SYMPTOMS (memory loss) with small bowel biopsies that show ACID-SCHIFF (PAS) - positive FOAMY MACROPHAGES?
WHIPPLE’s DISEASE (treat with IV PCN/Ceftriaxone and ORAL METRONIDAZOLE for 1 YEAR)
Diarrhea that is WATERY, LARGE VOLUME, with MID-ABDOMIAL PAIN, can have MALABSORPTION without INVASION or INFLAMMATION of the mucosa?
SMALL BOWEL INFECTIOUS DIARRHEA
CRUISE ship diarrhea, with ABRUPT onset of N/V/Abd pain, fever and MYALGIAS, lasts <72 hours, VERY INFECTIOUS, CONTAGIOUS for 3 WEEKS and NO LIFE-LONG IMMUNITY?
NOROVIRUS
ALCOHOL HAND-GEL does NOT PREVENT transmission of these TWO DIARRHEA-CAUSING agents?
ROTAVIRUS, C. DIFF
What is available PREVENTATIVELY for ROTAVIRUS for infants?
VACCINE
What are the RECOMMENDED attributes of ORAL REHYDRATION therapy for DIARRHEA?
LOW OSMOLARITY (245), LESS GLUCOSE and SALT, and RICE CEREAL, diluted APPLE JUICE
What DOES NOT work as ORAL REHYDRATION THERAPY?
SPORTS DRINKS, SODA, COFFEE (recommend salty crackers, pretzels, mineral water, chicken broth, yogurt, fruit juices)
What bacterial E.coli organism is involved in TRAVELER’s DIARRHEA?
ETEC (EnteroToxigenic E. Coli) - 1-3 DAYS incubation, <3 WEEKS and treat with RIFAXIMIN (MILD) or AZITRHOMYCIN (cipro too) if SEVERE or DYSENTERY
What can be used as PROPHYLAXIS for TRAVELER’s DIARRHEA (65% effective)?
BISMUTH SUBSALYCILATE (pepto-bismol)
What are the BEST TESTS for SMALL INTESTINAL PARASITES?
STOOL Giardia and ACID-FAST TEST
RECURRENT GIARDIA episodes?
HYPOGAMMAGLOBULINEIA (IgA)
WATERBORNE parasite, causes WATERY DIARRHEA?
CRYPTOSPORIDIUM - treat with NITAZOXANIDE
Transient EOSINOPHILIA, check BEFORE TRANSPLANT, ENDEMIC areas (AFRICA), with ITCHING, COUGH and abdominal pain?
STRONGYLOIDES STERCORALIS (eosinophils, SEROLOGY, ELISA, STOOL cultures)- TREAT with IVERMECTIN
SOLID ORGAN TRANSPLANT, HTLV-1, HIV and HIGH-DOSE STEROIDS all increase the RISK of this PARASITIC infection?
STRONGYLOIDES STERCORALIS
Which VIRUS can cause INFECTIOUS COLONIC DIARRHEA?
CMV
Campylobacter, Salmonella, Shigella, E.coli 0157:H7 (EIEC), C. diff, Yersinia, Aeromonas, Plesiomonas, Vibrio and Listeria all have what in COMMON?
These are ALL INFECTIOUS agents that cause INVASIVE ILEO-COLONIC DIARRHEA
Entamoeba Histolytica, Trichuris (whipworm) and Schistosomiasis are all parasites that cause what in COMMON?
INVASIVE ILEO-COLONIC infectious DIARRHEA
RAW CHICKEN, N/V/WATERY to BLOODY DIARRHEA, causes ILEOCOLITIS and GUILLAIN-BARRE?
CAMPYLOBACTER - erythromycin, cipro
REPTILES, CHICKEN or DUCK EGGS are associated with this DIARRHEA-CAUSING agent?
SALMONELLA
ALWAYS TREAT DIARRHEA (watery-to-bloody) with FEVER caused by this organism as it is HIGHLY-INFECTIOUS?
SHIGELLA (azithromycin)
INCUBATION period of 1-3 DAYS, WATERY DIARRHEA - to - BLOODY DIARRHEA and SEVERE CRAMPS, FEVER, similar symptoms to ischemic colitis and causes HUS?
STEC (ShigaToxin E. coli) - 0157:H7
Hemolytic ANEMIA, RENAL FAILURE, THROMBOCYTOPENIC PURPURA, what is it and what is it caused by?
HUS (hemolytic uremic syndrome) caused by STEC (0157:H7)
If STEC is suspected (shiga-toxin E.coli) whether 0157:H7 or not, what is RECOMMENDED?
CULTURE for SHIGA TOXIN
In STEC (shiga-toxin E. coli) why are ANTIBIOTICS and ANTIDIARRHEALS CONTRAINDICATED?
Because they can precipitate HUS
ILEITIS, MESENTERIC ADENITIS, GRANULOMATOUS APPENDICITIS, DIARRHA and 2-3 WEEKS later with REACTIVE ARTHRITIS?
YERSINIA (cold enrichment medium) - NO TREATMENT needed
Which DIARRHEA-causing ORGANISMS can result in REACTIVE ARTHRITIS 2-3 WEEKS post infection?
YERSINIA, CAMPYLOBACTER, SALMONELLA and SHIGELLA
Usually from RAW SHELLFISH, with COLON INVASION, N/V/D x 1 DAY, SELF-LIMITED and sometimes with BULLOUS SKIN LESIONS?
VIBRIO (vulnificus - skin lesions)
UNPASTEURIZED CHEESE, LUNCH MEAT, HOT DOGS, DELI MEAT, CANTALOUPES, ICE CREAM, resists salt, acid and cold (multiplies in refrigerator)?
LISTERIA - WATERY DIARRHEA, FEVER, HEADACHE, SELF-LIMITED
PREGNANT WOMEN are at HIGH-RISK for FETAL LOSS and MORTALITY if infected with this WATERY-DIARRHEA causing organism?
LISTERIA
90% are ASYMPTOMATIC CARRIERS, with INFECTIOUS CYSTS and INVASIVE TROPHS and cause colon ULCERS?
ENTAMOEBA HISTOLYTICA - STOOL ANTIGEN (best)
On colonoscopy you find THIS which causes CHRONIC DIARRHEA, COLITIS and DYSENTERY, how do you treat?
TRICHURIS TRICHURIA (whipworm) - ALBENDAZOLE
Campylobacter, Salmonella, Yersinia (can mimic appendicitis and Crohn’s), TB and Amoebas are found usually WHERE in the colon?
ILEO-CECAL
WHERE in the COLON is STEC (shiga-toxin producing E.coli - 0157:H7) found and it MIMICS ISCHEMIC COLITIS?
RIGHT COLON
WHERE in the COLON is SHIGELLA found and it MIMICS UC?
DISTAL COLON
How do you TREAT MILD DIARRHEA?
Oral REHYDRATION Therapy (ORT) and LOPERAMIDE
How do you TREAT MODERATE TO SEVERE TRAVELER’s DIARRHEA?
ANTIBIOTICS (azithromycin)
How do you TREAT MODERATE to SEVERE NON-TRAVELER’s DIARRHEA with NO or LOW grade FEVER (<101 F)?
Oral REHYDRATION Therapy (ORT) and LOPERAMIDE
How do you TREAT MODERATE to SEVERE NON-TRAVELER’s DIARRHEA with FEVER (>101 F) and <72 HOURS DURATION?
Oral REHYDRATION Therapy (ORT) and LOPERAMIDE
How do you TREAT MODERATE to SEVERE NON-TRAVELER’s DIARRHEA with FEVER (>101 F) and >72 HOURS DURATION?
STOOL CUTURES
How do you TREAT NON-TRAVELER’s DYSENTERY (BLOODY DIARRHEA) with or without FEVER?
STOOL CULTURES + ANTIBIOTICS (azithromycin)
How do you TREAT TRAVELER’s DYSENTERY (BLOODY DIARRHEA)?
EMPIRIC ANTIBIOTICS (azithromycin)
What COLONIC manifestations does HSV cause?
DISTAL PROCTITIS
What is found on COLON BIOPSY in patients with COLITIS (vs. IBD)?
NORMAL ARCHITECTURE (distorted in IBD)
ACUTE INFLAMMATION (acute and chronic in IBD)
NO BASAL INFLAMATION (present in IBD)
What is the GOLD STANDARD DIAGNOSTIC TEST for C. DIFF?
PCR
How many adults are HEALTHY CARRIERS of C. DIFF?
3-7% and if HOSPITAL EXPOSED (4-15%) - test ONLY patients with DIARRHEA
How LONG do CULTURES and TOXINS stay POSITIVE after treatment of C. diff?
ONE MONTH (so DON’T TEST for CURE)
ELDERLY patient >75 with LACTATE >5, WBC >20, SHOCK, on PRESSORS due to C. diff colitis, what do you do?
COLECTOMY (survival benefit) or LOOP ILEOSTOMY with PEG and VANCOMYCIN LAVAGE - colon preserving
In a patient ON IBD THERAPY and diagnosed with C. diff DIARRHEA, what should be done for treatment?
HOLD IBD TREATMENT while C. diff is being treated (if IBD severe, treat BOTH)
WHEN do you use FMT for treatment of RECURRENT C. diff?
After the THIRD RECURRENCE
What can develop CHRONICALLY in patients with DIVERTICULOSIS?
IBS-LIKE SYMPTOMS
OBESITY, SMOKING, NSAIDs, CORTICOSTEROIDS and OPIATES are risk factors for this condition of the COLON?
DIVERTICULITIS
What is the STANDARD of CARE for DIVERTICULITIS?
ANTIBIOTICS
What is RECOMMENDED after a DIVERTICULITIS EPISODE?
In a patient who has NOT HAD a RECENT COLONOSCOPY, one is recommended 6-8 weeks AFTER the EPISODE
When is the ONLY time SURGERY is recommended after DIVERTICULITIS?
ONLY if COMPLICATIONS like PERFORATION or PERITONITIS
An inflammatory-appearing colon polyp with CYSTIC architecture and MUCUS-FILLED GLANDS on histology and usually occurr in patients <10 years of age and present with PAINLESS BLEEDING. These are NOT associated with SYNDROMES and if COMPLETELY REMOVED do not NEED SPECIAL SURVEILLANCE?
JUVENILE POLYP (if >5 of these polyps - JUVENILE POLYPOSIS SYNDROME)
A HAMARTOMATOUS (AD) polyposis syndrome with 50% risk of CANCER by AGE 30 (COLON, STOMACH, DUODENUM, PANCREAS) - BMPR1A, DPC4 and SMAD4
JUVENILE POLYPOSIS SYNDROME (>5 JUVENILE POLYPS)
What is the RECOMMENDED SURVEILLANCE for JUVENILE POLYPOSIS SYNDROME?
COLONOSCOPY every 3 YEARS from SYMPTOM OCCURRENCE (or EALY TEENS if family histroy but no symptoms) and EGD every 2 YEARS
What is the DIFFERENCE in SURVEILLANCE between post-treatment COLON CANCER and RECTAL CANCER?
RECTAL CANCER requires more FREQUENT SURVEILLANCE due to HIGHER RATE of LOCAL RECURRENCE (especially with TRANSANAL surgery)
What is the GOLD STANDARD treatment of APPENDICITIS?
APPENDECTOMY (HIGH CRP and WBCs)
What are the PREFERRED IMAGING modalities for diagnosing APPENDICITS in a CHILD and in an ADULT?
CHILD - US
ADULT - LOW-DOSE, NON-CONTRAST CT
PREGNANCY - MRI
What MEDICATIONS can cause MICROSCOPIC COLITIS?
NSAIDs (STOP THE NSAIDs)
What is the RECOMMENDATION for ANTIBIOTIC PROPHYLAXIS for pts undergoing COLONOSCOPY with PERITONEAL DIALYSIS?
AMPIILLIN 1g + AMINOGLYCOSIDE with or without METRONIDAZOLE IV IMMEDIATELY before procedure AND that the abdomen be EMPTIED of FLUID BEFORE procedure
What is the RECOMMENDED treatment for VOLVULUS after fluids and antibiotics if NO PERITONEAL SIGNS?
FLEXIBLE SIGMOIDOSCOPY (only then followed by surgical repair)
PAIN focally, at site of ABDOMINAL HERNIA REPAIR that can be REPRODUCED by tensing the RECTUS SHEETH (situp) is CAUSED by what and TREATED HOW?
Caused by ENTRAPMENT (by scar tissue) of the ANTERIOR CUTANEOUS NERVE - LIDOCAINE/XYLOCAINE INJECTION followed by long-acting steroid like TRIAMCINOLONE
Intussusception usually caused by a POLYP, LYMHADENOPATHY or CANCER (focal area of traction) or infections, adhesions, Crohn’s or ulcers with resulting EDEMA and ISCHEMIA resulting in NECROSIS or PERFORATION. HOW is the TREATED?
SURGERY (gas between segments on imaging, with CRESCENT, TARGET or DONUT sign) - NO ENDOSCOPIC REDUCTION as can cause PERFORATION
What TYPE of INTUSUSSCEPTION is ALWAYS caused by a MALIGNANCY?
ILEO-COLIC INTUSUSSCEPTION (cecal adenocarcinoma)
EXCESSIVE STRAINING and EXCESSIVE time sitting on the toilet with SINGLE ULCER?
SOLITARY RECTAL ULCER SYNDROME (HIGH-FIBER diet with LAXATIVES)
What is the RECOMMENDED INITIAL EVALUATION for acute LOWER GI BLEEDS usually caused by DIVERTICULI, with SUDDEN HEMATOCHEZIA with CLOTS (not likely UGIB source if clots and RED blood)?
COLONOSCOPY - after RAPID BOWEL PURGE and REUSSCITATION within 24 HOURS and INR 1.5-2.5 (if INR >2.5, reverse FIRST)
HEMATOCHEZIA presenting with HEMODYNAMIC INSTABIITY, what is the likely SOURCE?
UGIB (HIGH BUN:Cr) - ENDOSCOPY or LAVAGE first
For OBSCURE-OVERT GIB, what is the BEST initial modality to LOCALIZE the BLEED?
CT ANGIOGRAPHY (over bleeding scan)
What is the RECOMMENDED INITIAL TREATMENT for OPIOID-INDUCED CONSTIPATION?
TRADITIONAL LAXITIVES (PEG), PAMORA’s (Peripherappy Acting Mu Opioid Receptor Antagonists) are SECOND LINE THERAPY
CHLAMYDIA TRACHOMATIS can cause a proctitis-type picture especially in GAY MEN with SYSTEMIC INFECTION, what MUST BE DONE for DIAGNOSIS?
LYMPHOGRANULOMA VENERUM (LGV SEOLOGY) - tenesmus, proctitis - DOXYCYCLINE 100 mg PO BID x 21 DAYS
What is a classic CROHN’s DISEASE MIMIC (DIARRHEA, abdominal pain, SORE THROAT, arthralgias, erythema nodosum, TI inflammation, MESENTERIC ADENOPATHY, fecal leukocytes) and HOW is it TREATED?
YERSINIA ENTEROCOLITICA - TMP-SMX or DOXYCYCINE, aminoglycosides or fluoroquinolones (PROLONGED DIARRHEA - 4 WEEKS) - DEVELOPS REACTIVE ARTHRITIS when DIARRHEA SUBSIDES
What is the PREFERRED TREATMENT for PELVIC FLOOR DYSFUNCTION (constipation, incomplete evacuation, straining, WEAK PUSH)?
Pelvic Floor RETRAINING and BIOFEEDBACK
Which TYPE of ISCHEMIC COLITIS is the most SERIOUS and why?
ISOLATED RIGHT-COLON ISCHEMIA (IRCI) - A-fib, CAD, CKD - assess RISK for MESENTERIC ISCHEMIA before SURGERY with CT ANGIOGRAPHY
What is the INITIAL RECOMMENDED therapy for MILD-to-MODERATE C. diff DIARRHEA?
VANCOMYCIN 125 mg PO 4x/day OR FIDAXOMYICIN 200 mg PO BID x 10 days
Colonic MUCOSA and SUBMUCOSA HERNIATE through MUSCULARIS PROPRIA?
DIVERTICULOSIS
What is the RECOMMENDED SURVEILLANCE for RECTAL CANCER once surgically removed?
FLEXIBLE SIGMOIDOSCOPY or EUS every 3-6 MONTHS for the FIRST 2-3 YEARS after surgery
What BACTERIAL DIARRHEA can cause ULCERS of the COLON which can result in INTUSUSSCEPTION?
YERSINIA
Single 1 cm ANTERIOR RECTAL WALL ULCER within 10 cm of the rectal verge, mucosal thickening with elongation and gland distortion, edema of the lamina propria and fibrosis and extention of the smooth muscle fibers between the crypts?
SINGLE RECTAL ULCER SYNDROME (HIGH-FIBER DIET + LAXATIVES)
In a patient with GIB, if CT ANGIOGRAPHY (preferred over bleeding scan) demonstrates bleed, what is RECOMMENDED to be done NEXT?
INITIAL or REPEAT ENDOSCOPY; IR; or SURGERY
PROLONGED DIARRHEA (3-4 weeks) and PHARYNGITIS?
YERSINIA enterocolitica
What ARTERY is OBSTRUCTED in RIGHT-COLON ISCHEMIA?
SMA (evident on CTA)
What MEDICATION should NOT be used with NEW-ONSET BLOODY diarrhea?
LOPERAMIDE or ANY ANTI-DIARRHEALS
What should ANY YOUNG WOMAN be tested for when presenting with ABDOMINAL PAIN?
PREGNANCY TEST
In ALL patients with CROHN’s disease, where >⅓ of the colon is involved, WHEN should they get their FIRST colonoscopy?
After 8-10 years from DIAGNOSIS
At what AGE do patients develop CROHN’s disease?
YOUNG, <30
In which IBD disorder are non-caseating GRANULOMAS found?
CROHN’s Disease
What is INCREASING in INCIDENCE among IBD patients and should be TESTED for when they present with INCREASED bowel movements, even without recent antibiotics, etc.?
C.diff
What is CT ENTEROGRAPHY used for in CROHN’s DISEASE?
Assessment of SMALL BOWEL CROHN’s disease
This TEST used in diagnosis of CROHN’s DISEASE provides TRANSMURAL DISEASE ASSESSMENT, detects PENETRATING DISEASE and to diagnose EXTRAINTESTINAL MANIFESTATIONS where MANAGEMENT of the disease is altered by the results?
CT ENTEROGRAPHY (used mainly to assess SMALL BOWEL INVOLVEMENT)
What happens to WOMEN who are in REMISSION BEFORE PREGNANCY once they become PREGNANT?
They are MORE LIKELY to REMAIN in REMISSION during their pregnancy
In a woman with CROHN’s who wants to become PREGNANT, when should METHOTREXATE be DISCONTINUED?
3 MONTHS before CONCEPTION
WHEN throughout PREGNANCY are IBD FLARES most common?
FIRST TRIMESTER and POSTPARTUM
What is the PREGNANCY course like for a woman with INACTIVE IBD who have NOT had ABDOMINAL or PELVIC OPERATIONS?
NORMAL
What DIETARY RESTRICTIONS do IBD patients have?
NONE
In a patient with SMALL BOWEL STRICTURES, what would be the most appropriate DIET?
LOW-RESIDUE (low fiber) diet
Which SEX has a HIGHER RISK for CROHN’s disease?
WOMEN
What DIETARY intolerance is COMMON among CROHN’s patients?
LACTOSE intolerance
What are ALL REASONABLE tests in a patient suspected to have a CROHN’s FLARE?
CT ENTEROGRAPHY, COLONOSCOPY, CRP, C.diff
In a patient with NEW presentation of BLOODY DIARRHEA, with colonoscopy demonstrating INFLAMMATION around the APPENDIX and sigmoid and rectum with “mild CHRONIC ACTIVE COLITIS,” what is the diagnosis?
ULCERATIVE COLITIS (appendiceal PATCH)
PERIANAL PAIN with a BOIL in a patient with CROHN’s disease suggests WHAT? HOW do you test for it?
FISTULA and/or ABSCESS - PELVIC MRI
What IMAGING STUDY is NOT good for assessing PERIANAL CROHN’s disease such as FISTULAS or ABSCESSES?
CT or CT ENTEROGRAPHY
What is the RECOMMENDED STARTING DOSE for AZATHIOPRINE in MANAGEMENT of IBD?
2.0 - 2.5 mg/kg DAILY (NOT 5)
In a patient with CROHN’s and ARTHRITIS (joint pain) SYMPTOMS, what is the BEST OPTION for a MEDICATION CHOICE to start?
METHOTREXATE 25 mg SC WEEKLY (best for joint pains)
When a patient on an anti-TNF-alpha drug begins to require DOSE ESCALATIONS, what should be DONE?
CHANGE to ANOTHER anti-TNF-alpha AGENT
What is the RISK of INCREASING AZATHIOPRINE DOSAGE?
BONE MARROW TOXICITY
How can development of anti-INFLIXIMAB Ab’s be PREVENTED (but once they exist, this will have no effect)?
By PRE-MEDICATING with METHYLPREDNISOLONE and DIPHENHYDRAMINE
What is NATALIZUMAB (IBD anti-TNF) DANGEROUS FOR?
RE-ACTIVATION of JC POLYOMAVIRUS (do NOT use in patients with antibodies to JC polyomavirus)
What is the BEST MEDICATION to start for a patient with IBD who is NOT RESPONDING to STEROIDS?
An anti-TNF-alpha agent or CYCLOSPORINE (2-4 mg/kg NOT 5)
Pt with IBD and BACK PAIN (worse on awakening and improves throughout the day) HLA-B27 POSITIVE, is WHAT? How do you BEST TREAT?
ANKYLOSING SPONDYLITIS - PHYSICAL THERAPY
What DOES the DIAGNOSIS of PSC in a patient with UC increase the RISK for?
COLON CANCER and cholangiocarcinoma
How OFTEN should patients with UC and PSC receive SURVEILLANCE COLONOSCOPY at time of PSC DIAGNOSIS?
YEARLY
In a patient with IBD, who develops LE EDEMA, LOW ALBUMIN, with CONGO RED STAINING will be likely to find WHAT on EXTRACELLULAR TISSUE DEPOSITION?
Serum AMYLOID A protein (secondary amyloidosis)
What is the FIRST LINE THERAPY for PYODERMA GANGRENOSUM (IBD) and what should NEVER be done?
CORTICOSTEROIDS or TOPICAL TACROLIMUS - NEVER SURGERY (any trauma makes it WORSE)
What is the DIFFERENCE between a patient with UC and EYE involvement in ACTIVE and INACTIVE disease and HLA-B27 association?
ACTIVE DISEASE (NO HLA) - EPISCLERITIS. SCLERITIS
INACTIVE or ACTIVE DISEASE (HLA-B27 POSITIVE) - IRITIS
Fecal LEUKOCYTES, WATERY then BLOODY DIARRHEA NO DAYCARE history (shigella)?
CAMPYLOBACTER
48 HOURS, N/V/WATERY DIARRHEA, CHINESE RESTAURANT?
BACILUS CEREUS
FOOD POISONING from SOFT CHEESES and LUNCH MEATS of HIGH-RISK in PREGNANT WOMEN and IMMUNOCOMPROMISED?
LISTERIA
FOOD POISONING with MAIN SYMPTOMS of N/V and NO RICE exposure?
STAPH AUREUS
FIRST LINE THERAPY for C.diff with MILD DISEASE (WBC <15, Cr <1.5 x baseline)?
METRONIDAZOLE 500 mg PO TID x 10 DAYS
FIRST LINE THERAPY for C.diff with MOD-SEVERE DISEASE (WBC >15, Cr >1.5 x baseline)?
VANCOMYCIN 125 mg PO 4x/day x 10 DAYS
What MEDICATIONS are to be AVOIDED in INFECTIOUS DIARRHEA?
ANTI-DIARRHEALS
1 WEEK LARGE-VOLUME WATERY DIARRHEA and GAS, CAMPING, STREAM WATER?
GIARDIA (affects the small bowel)
LARGE-VOLUME WATERY DIARRHEA with NAUSEA, BLOATING, FLATULENCE, CRAMPING and has RECENTLY EATEN RASPBERRIES?
CYCLOSPORA (raspberries) - TMP-SMX
ACUTE-ONSET VOMITING and DIARRHEA, muscle aches, fatigue, CHILDREN in DAYCARE, NO FOOD ASSOCIATION?
VIRAL GASTROENTERITIS
In WHAT RACIAL or ETHNIC GROUP is the INCIDENCE and MORTALITY of COLORECTAL CANCER the HIGHEST?
AFRICAN AMERICANS
Can BOTH BRAF and KRAS MUTATIONS EXIST in the same COLON CANCER?
NO
WHAT MUTATION in COLORECTAL CANCER is ASSOCIATED with METHYLATION of MLH1?
BRAF
In a patient with COLORECTAL CANCER POSITIVE for BRAF MUTATION WITHOUT MLH1 MUTATION, FIRST DEGREE RELATIVES DO NOT need to be SCREENED, WHY?
DOES NOT meet DIAGNOSTIC CRITERIA for LYNCH SYNDROME
COLORECTAL CANCER POSITIVE for BRAF MUTATION AND MLH1 MUTATION is considered WHAT?
LYNCH SYNDROME
METHYLATION of MLH1 is ASSOCIATED with WHAT MUTATION?
BRAF
Is there a ROLE for SURVEILLANCE with COLONOSCOPY in a patient with APC (FAP)?
BEGINNING at AGE 10, YEARLY, UNTIL COLECTOMY (hundreds of adenomatous polyps)
SIBLINGS and CHILDREN of those with APC MUTATIONS should be OFFERED what?
GENETIC TESTING
Pt presents with HUNDREDS of polyps on colonoscopy and biopsies show adenomas, what is the RECOMMENDATION?
GENETIC COUNSELING for APC GENE MUTATION and COLECTOMY (FAP)
A SINGLE (<10) HAMARTOMATOUS POLYP noted on COLONOSCOPY means WHAT?
JUVENILE POLYP (cancer risk NOT increased) - REASSURANCE ONLY
MULTIPLE (>10) HAMARTOMATOUS POLYPS noted on COLONOSCOPY means WHAT?
LIKELY JUVENILE POLYPOSIS - GENETIC TESTING for SMAD4, BMPR1A, ENG (SURVEILLANCE for AT-RISK RELATIVES BETWEEN AGES 15-70 WITH BOTH EGD AND COLONOSCOPY)
In the TREATMENT of METASTATIC COLON CANCER, TESTING for WHAT MUTATION is DONE to GUIDE the CHOICE of CYTOTOXIC chemotherapy?
KRAS
METASTATIC COLON CANCER to WHICH ORGANS indicates that pt may still be CURABLE with SURGERY and CHEMOTHERAPY?
LIVER and LUNG
In a patient who presents with COLORECTAL POLYPOSIS (1-100 ADENOMAS) in the ABSENCE of FAMILY HISTORY should be EVALUATED for what?
ATTENUATED FAP (MYH-associated polyposis)
WHICH PATIENTS with ATTENUATED FAP (MYH) REQUIRE COLONOSCOPY and EGD SURVEILLANCE?
Only BI-ALLELIC MYH MUTATION (monoallelic mutations do not require special surveillance)
In a patient with ATTENUATED FAP (MYH), how do you DETERMINE the RISK of BI-ALLELIC MYH MUTATIONS (disease not carrier) in the CHILDREN?
MOTHER should be tested for MYH
DYSSENERGIC DEFECATION (pelvic floor dysfunction) - lifelong constipation, infrequent BMs, excessive straining and difficulty passing stools with manual disimpaction, even with SOFT STOOLS with elevated digital anal sphincter pressure and tenderness, how do you DIAGNOSE?
ANORECTAL MANOMETRY with BALLOON EXPULSION (pelvic floor RETRAINING with BIOFEEDBACK therapy)
What are KEGEL EXERCISES RECOMMENDED for?
FECAL INCONTINENCE
WOMAN >50 YO with 2-YEAR history of ABD PAIN, CRAMPING, WATERY DIARRHEA and BLOATING with NORMAL SCREENING COLONOSCOPY (for polyps) and NORMAL LABS. What is the NEXT STEP?
IBS-D (microscopic colitis can mimic this) - so REPEAT COLONOSCOPY with RANDOM BIOPSIES
How is MEDICALLY-REFRACTORY SLOW-TRANSIT CONSTIPATION (sitz-marker study) treated?
SUBTOTAL COLECTOMY with ILEORECTAL ANASTOMOSIS (ileorectostomy) - segmental resection is NOT HELPFUL
What is the surgical procedure of CHOICE for a patient with RECTAL PROLAPSE?
RECTOPEXY
WOMAN YOUNGER <50 YO with a 2-YEAR HISTORY of crampy lower ABDOMINAL PAIN associated with BLOATING and FREQUENT LOOSE STOOLS (IBS-D), what is the NEXT TEST of CHOICE in such a patient?
SCREEN for CELIAC DISEASE with IgA TTG Ab
What is the MECHANISM of ACTION of LUBIPROSTONE?
CHLORIDE-CHANNEL ACTIVATOR
What is the MECHANISM of ACTION of LINACLOTIDE?
GC-C AGONIST (guanylate cyclase C agonist) - increases cGMP
What is the HIGHEST-RISK FACTOR for developing POST-INFECTIOUS IBS?
PROLONGED DURATION of INITIAL ILLNESS
PELVIC FLOOR DYSFUNCTION with a DEFECATORY DISORDER (constipation, infrequent stools, strains even with soft stools, sense of blockage and incomplete evacuation with defecation, negative flex sig), what’s the NEXT STEP?
ANORECTAL MANOMETRY and RECTAL BALLOON EXPULSION test
Can ANORECTAL TESTS have FALSE-POSITIVE RESULTS?
YES (due to embarrassment, etc.)
What is the FIRST CHOICE of treatment for YOUNG patients with CONSTIPATION WITHOUT ALARM SYMPTOMS?
OTC LAXATIVES
For patients with SIGNIFICANT SYMPTOMS of FECAL INCONTINENCE that have NOT IMPROVED with MEDICAL THERAPY, what is RECOMMENDED NEXT?
SACRAL NERVE STIMULATION
Is SURGICAL SPHINCTER DEFECT REPAIR a good LONG-TERM SOLUTION for patients with FECAL INCONTINENCE?
NO, works short-term only
Is PELVIC FLOOR RETRAINING by BIOFEEDBACK THERAPY SUPERIOR to KEGEL EXERCISES?
NO
SYMPTOMS of INCREASED BOWEL FREQUENCY and INCONTINENCE after CHOLECYSTECTOMY are treated HOW?
BILE-ACID BINDING RESIN (cholestyramine)
Do ANAL PRESSURES VARY with AGE and SEX?
YES (should be compared with NORMAL values with the same technique in age and sex-matched asymptomatic people)
Can ANAL RESTING and SQUEEZE functions be accurately assessed with a DIGITAL RECTAL EXAM?
YES
What is a SAFE, FIRST-LINE CATEGORY A MEDICATION that can be used in PREGNANCY in patients with FIRST-TRIMESTER NAUSEA (without alarm symptoms)?
PYRIDOXINE (Vit B6)
Is SODIUM BICARBONATE SAFE to use in PREGNANCY?
NO (causes milk-alkali syndrome and electrolyte imbalance in fetus)
What HEARTBURN MEDICATION is safe to use during ALL TRIMESTERS of PREGNANCY?
PPIs
What SHOULD a PREGNANT WOMAN do if she is on AZATHIOPRINE or 6MP for IBD which is controlling her disease well, BEFORE SHE GOT PREGNANT?
CONTINUE, DO NOT STOP AZATHIOPRINE or 6MP
In a PREGNANT patient on TACROLIMUS for a TRANSPLANT who is STABLE, what is done with the TACROLIMUS?
It is CONTINUED
FUNCTIONAL CONSTIPATION, a COMMON OCCURRENCE during PREGNANCY is treated how (first-line treatment)?
FIBER SUPPLEMENT -THERAPY (can also use docusate)
