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GI 1 > Colorectal 1 > Flashcards

Colorectal 1 Flashcards

1
Q

large bowel obstruction MC occurs where

A

sigmoid colon

bc site where stool becomes more solid

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2
Q

LBO cecum

A

most likely to perforate if obstruction here due to thinnest wall

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3
Q

LBO etiologies

A

MC 2/2 carcinoma

can be 2/2 diverticular dz, volvulus, hernia, benign growth

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4
Q

LBO pathophysiology

A

obstruction leads to massive dilation above obstruction

causes mucosal edema and impaired venous and arterial blood flow

ischemic bowel wall loses integrity and becomes compromised = mucosal permeability

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5
Q

mucosal permeability in LBO causes

A

bacterial translocation

systemic toxicity

dehydration

electrolyte abnormalities

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6
Q

symptoms of obstruction

A

deep, cramping pain

constipation/obstipation

abdominal distention

feculent vomiting

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7
Q

signs of obstruction

A

abdominal distention and tympany

high pitched metallic tinkles, w/ rushes and gurgles on auscultation

localized tenderness

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8
Q

what indicates an emergency LBO

A

fever, peritoneal signs and abdominal rigidity

might suggests peritonitis and perforation - surgical emergency

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9
Q

TOC for LBO

A

CT Abdomen/Pelvis, with IV and Oral contrast

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10
Q

CT findings in LBO

A

haustral markings

air fluid levels and dilated colon

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11
Q

CXR in LBO

A

air under the diaphragm

can show transition point

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12
Q

tx of LBO

A

initial stabilization and prep for possible surgery

I.e. fluid resuscitation, zosyn, NG tube

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13
Q

Ogilve’s syndrome

A

colonic dilation and ileum that mimics obstruction without transition point or mechanical obstruction

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14
Q

MC site of Ogilve’s syndrome

A

right colon and cecum commonly affected

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15
Q

risk factors of Ogilve’s syndrome

A

medical or surgical illnesses such as infection, trauma, cardiac disease

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16
Q

Ogilve’s syndrome tx

A

supportive - hydration and lytes and bowel rest

colonoscopic decompression may be attempted if supportive doesn’t work but surgical intervention is not encourage

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17
Q

medications that could cause Ogilve’s syndrome

A

opioids
anticholinergics
muscle relaxants

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18
Q

rotation of intestinal segment on mesenteric axis

A

volvulus

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19
Q

volvulus results in

A

partial or complete lumen obstruction

may compromise the blood supply = closed loop obstruction

can’t back up, rapid wall extension and increased risk of perforation

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20
Q

volvulus etiologies by country

A

chronic constipation (Western)

high fiber diet (developing nations)

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21
Q

volvulus pathophysiology

A

overloaded sigmoid colonic loop

stretching of mesentery and increasing susceptibility of torsion

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22
Q

populations predisposed to volvulus

A

institutionalized pts with neuropsychiatric disorders

MS, Parkinson disease, spinal cord injury

pts in nursing homes due to prolonged recumbency and chronic constipation

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23
Q

volvulus etiologies

A

excessive use of laxatives, cathartics, enemas (increased stimulation stretches it)

pregnancy or large pelvic tumors

chagas disease

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24
Q

s/s sigmoid volvulus etiologies

A

60-70% pts present acutely with LBO symptoms (cramping, obstipation, abdominal distention)

subacute or chronic symptoms (episodic constipation, less severe abdominal pain, distention, obstipation)

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25
Q

Xray sigmoid volvulus findings

A

massively dilated single bowel loop

concavity points to LLQ

coffee bean sign

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26
Q

s/s cecal volvulus

A

severe, intermittent colicky pain in RLQ , vomiting and obstipation ensues

less distention than sigmoid, more likely to have vomiting

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27
Q

cecal volvulus plain film

A

dilated kidney bean shaped cecum
concavity pointing to RLQ
cecal volvulus

inadequate for diagnostics

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28
Q

tx of cecal volvulus

A

operative detorsion

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29
Q

sigmoid volvulus tx

A

no strangulation or perforation = endoscopic decompression

strangulation or perforation = surgery

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30
Q

diverticulum

A

small finger like out-poaching of mucosa thru colonic wall at site of penetrating arteries

31
Q

where do most diverticula occur

A

sigmoid colon and left sided colon

due to pressure sites

32
Q

diverticula risk factors

A

increase with age

likely due to lack of fiber

obesity

33
Q

asymptomatic diverticula

A

found incidentally during C-scope or BE

diagnosed with diverticulosis

34
Q

diverticulosis tx

A

supplemental fiber in the diet

35
Q

diverticulitis pathophysiology

A
  1. erosion of the diverticular wall due to increased intraluminal pressure and thickened matter
  2. outlet obstruction by fecalith or undigested food
36
Q

diverticulitis epidemiology

A

mc in middle age to elderly population

right sided diverticula more common in asian population

37
Q

s/s diverticulitis

A

mild to moderate aching abdominal pain in LLQ

n/v, constipation, diarrhea, +/- BRBPR

fever

symptoms are usually mild, more acute with perforation

38
Q

diverticulitis on PE

A

generalized pain –> increased size causes localized pain

high fever

increased then decreased BP

painful heel tap

39
Q

TOC diverticulitis

A

CT abdomen/pelvis w/contrast

40
Q

diverticulitis evaluation

A

CT scan, barium enema contraindicated

Labs: CBC, chem panel, blood cultures x2 q 15 minutes

+/- amylase, lipase, liver enzyme, c-diff screen

41
Q

mild diverticulitis tx

A

mild symptoms and no peritoneal sings

clear liquid diet, ABX 7-10 days

42
Q

ABX used in mild diverticulitis

A

Cipro + Flagyl, Augmenting or Avelox

43
Q

inpatient medical diverticulitis tx

A

NPO with IVF

IV antibiotics (zosyn, unasyn) (3-5days switch to PO)

consult if severe or septic

IR percutaneous catheter

44
Q

who gets surgical tx diverticulitis

A

peritonitis, large abscess, fail to improve with medical management in 2-3 days

OR significant peritonitis/perforation at time of presentation

45
Q

surgical tx diverticulitis

A

NOP, fluid resuscitated

brand spectrum IV ABX begun

abdominal laparotomy + colostomy (elective takedown)

46
Q

repeated episodes of diverticulitis

A

episodes of 3+ diverticulitis

consider elective colon resection (no colostomy)

47
Q

colitis types

A

Infectious, ischemic, IBD

RARE: microscopic, necrotizing enterocolitis, allergic colitis

48
Q

C diff colitis

A

inflammation and infection of the colon

typically gotten from healthcare workers and contaminated clothing and equipment and ABX use kill off other natural gut flora causing C Diff to develop

49
Q

C diff colitis MC due to what ABX (4)

A
  1. ampicillin
  2. clindamycin
  3. 3rd gen cephalosporins
  4. fluorquinalones
50
Q

risk factors for developing C diff colitis

A

elderly, debilitated, immunocompromised

multiple abx/prolonged use

entereal feeding, PPI use, DI dz, surgery

51
Q

C diff colitis s/s

A

w/in 2 months of after ABX use

can occur after just ONE dose of ABX

watery green, foul smelling diarrhea w/mucus and cramping

SIGNIFICANT LEUKOCYTOSIS

52
Q

C diff colitis workup

A

Diarrheal stool samples ONLY:

enzyme immunoassay (EIA)

PCR assay of C diff toxin

flexible sigmoidoscopy

53
Q

tx of C diff colitis

A

stop abx that contribute to problem

ABX 10-14days

do NOT repeat

54
Q

ABX less likely to cause C diff colitis (5)

A 
vancomycin
sulfonamides 
macrolides
IV aminoglycoside 
tetracycline
55
Q

ABX used to tx C diff colitis

A

Flagyl/Metronidazole (PO, IV) 500 mg q8/250q6

Vancomycin (Oral) 125 PO

56
Q

C diff colitis recurrence

A

typically occurs in 1-3 weeks

repeat stool assays dont work

NOT related to drug resistance so can use same drug

call I&D, high chance of reoccurrence

57
Q

severe C diff colitis if:

A
  1. leukocytosis >15,000
  2. serum creatinine >1,5x pt baseline
  3. shock, hypotension
58
Q

C diff colitis tx

A

VANC preferred

rarely, total colectomy

fecal microbiota transplant

59
Q

fecal microbiota transplant

A

normal non pathogenic bacteria from donor stool can repopulate in tract of recipient and stop unchecked C Diff growth

60
Q

ischemic colitis

A

low blood flow to bowel causes mucosa to become ischemic and slough

typically 2/2 trauma, surgery, syncope

61
Q

areas most vulnerable to ischemic colitis

A

splenic flexure

rectosigmoid junction

62
Q

ischemic colitis s/s

A

LLQ pain, cramping tenderness

frankly blood diarrhea following inciting event

63
Q

ischemic colitis tx

A

supportive care (NPO, hydration)

daily labs to monitor progress

empiric ABX

64
Q

lower GI bleed epidemiology and etiologies

A

mc in men, elderly

  1. diverticular bleeding
  2. angiodypslasia/AVM
  3. benign anorectal dz
  4. IBD
  5. neoplasm
65
Q

lower GI bleed painless and copious

A

diverticular bleed

66
Q

lower GI bleed self limited, painless, slow and RECURRENT

A

AVM/angiodysplasia

67
Q

lower GI bleed painful bloody, weight loss, mucous

A

inflammatory colitis

68
Q

lower GI bleed painful, hx of event with low flow

A

ischemic colitis

69
Q

lower GI bleed insidious bleeding painless

A

colon ca

70
Q

lower GI bleed painful or painless, blood on toiled

A

anorectal disease

71
Q

lower GI bleed management

A

try to qualify loss (rectal exam)

lab work up: CBC, chem panel, PTT, PT/INR, T&C

GI consult

72
Q

how to determine if lower GI bleed is ongoing?

A

serial H&H to see rate of decline

remember fluids will decrease

73
Q

lower GI bleed workup

A

colonoscopy initially (tx and dx)

CT scan, bleeding scan, mesenteric angiography

GI 1 (12 decks)

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