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Clin Med: GI (block 3) > Colorectal Disorders > Flashcards

Colorectal Disorders Flashcards

1
Q

Diverticular Dz is most common in which part of the colon?

A

sigmoid colon

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2
Q

What is diverticula?

A

small outpouching in the colon

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3
Q

When diverticular gets inflamed its called….

A

diverticulitis

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4
Q

RFs of development of diverticular

A
  • incr age
  • obesity
  • lack of exercise
  • lack of fiber
  • NSAID and/or ASA
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5
Q

Average age of dx for diverticular dz

A

62 yo

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6
Q

Diverticulosis Patho

A

Chronic constipation/straining leads to pressure gradient in the abdomen, causing outpouchings

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7
Q

Diverticulitis Main S/S

A
  • abdo pain (LLQ)
  • fever (sometimes)
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8
Q

Diverticular Dz other S/S

A
  • constipation
  • N/V
  • diarrhea
  • dysuria
  • Anorexia
  • rectal bleeding
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9
Q

When do you refer a patient w/ diverticular dz?

A
  • Failure to improve w/n 72 hrs of medical management
  • (+) peridiverticular abscesses (4 cm or larger) req poss. drainage
  • Generalized peritonitis or sepsis
  • Recurrent attacks
  • Chronic complications
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10
Q

Diverticulitis patho

A

Inflammation of a diverticula caused by irritation from fecal material

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11
Q

Diverticular Dz Dx

A
  • CBC
  • CMP
  • Lipase
  • UA
  • UCG
  • CT abd/pelvis w/ IV contrast
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12
Q

Diverticular Dz PE

A
  • Fever
  • LLQ tenderness
  • (+/-) palpable mass
  • Distension
  • +/- blood on rectal or occult blood
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13
Q

Diverticular Dz Tx for mod cases

A
  • bowel rest
  • IV fluids
  • IV antibiotics
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14
Q

Diverticular Dz Tx for mild cases

A

Outpatient treatment
- Clear liquid diet
- cipro/metro
- close FU

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15
Q

Diverticular Dz Tx for severe cases

A

Surg indicated for
- generalized peritonitis
- Large abscesses that can’t be drained
- Clinical deterioration despite medical management & drainage

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16
Q

When do you admit a patient w/ diverticular dz?

A
  • Severe pain or inability to tolerate oral intake
  • Signs of sepsis or peritonitis
  • CT scan showing signs of complicated dz (abscess, perforation, obstruction)
  • Failure to improve w/ outpt management
    Immunocompromised or frail, elderly pt
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17
Q

Diverticulitis Patient Edu

A

high fiber diet

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18
Q

What are the 2 separate disease entities for IBD?

A
  • Crohn’s dz
  • Ulcerative colitis
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19
Q

Crohn’s Dz is an inflammatory dz of the…

A

GI tract

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20
Q

Patient after having Crohn’s for how long are at incr risk of colon cancer?

A

8-10 yrs

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21
Q

Where is Crohn Dz most commonly found?

A

terminal ileum

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22
Q

Crohn Dz affects which part of the GI tract

A

any segment of the GI tract
“mouth to anus”

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23
Q

Crohn Disease onset age & gender prevalence

A
  • 10-30 years old
  • women > men
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24
Q

Crohn Dz RFs

A
  • FHx
  • Smoking
  • Lower levels of physical activity
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25
Crohn Dz pathophys
- not exactly known ~ environmental, genetic, gut microbiome, immune response
26
Crohn Dz S/S
- Insidious onset - Intermittent low-grade fever, diarrhea, & RLQ pain - RLQ mass & tenderness - Malaise - Diarrhea (usually non bloody)
27
Crohn Dz PE
- RLQ tenderness/mass - Perianal dz (fistula, stricture, abscesses)
28
How does Crohn Dz look upon visualization?
"skin lesions" w/ "cobblestone appearance" - Transmural lesions
29
Crohn Dz Dx Labs
Obtain CBC, ESR/CRP, serum albumin - Anemia b/c chronic inflammation, blood loss, iron deficiency, or vitamin B12 malabsorption - Leukocytosis occurs w/ abscesses - ESR/CRP elevated Fecal calprotectin - Excellent noninvasive test - Elevated levels correlated w/ active inflammation as seen on ileocolonoscopy or radiologic CT or MR enterography
30
Crohn Dz Dx Imaging
- CT w/ IV and oral contrast - Colonoscopy w/ biopsy (skin lesions, cobblestone appearance)
31
UC peak onset age & gender prevalence
- 10-40yo - men = women
32
Crohn Dz Tx for maintenance
- Mesalamine (oral or rectal) - Sulfasalazine - Immune modifying agents (Methotrexate) - Anti-TNF agents
33
Crohn Dz Indication for surg
- No response to medical therapy - Intra-abdominal abscess - Massive bleeding - Obstruction w/ fibrous stricture - Fistula formation
34
Complications of Crohn Dz
- Abscess - Small bowel obstruction - Fistulas - Perianal dz - Carcinoma - Hemorrhage (unusual) - Malabsorption
35
UC Dz is an inflammatory condition of the...
mucosal surface of the rectum & colon
36
Crohn Dz Tx for acute flare
corticosteroids
37
UC RFs
- FHx - High fat intake - Inconsistent evidence regarding UC & NSAIDS
38
What is a condition characterized an abdo pain or discomfort that occurs w/ altered bowel habits?
Irritable Bowel Disease (Syndrome)
39
List subtypes of IBS
- IBS w/ constipation - IBS w/ diarrhea - Mixed (unsubtyped) IBS
40
IBS gender prevalence & age?
- women > men - 20-30 yo
41
IBS RFs
- Depression - Anxiety - Migraines - Fibromyalgia
42
IBS Patho
- There's a link b/t the brain & gut b/c serotonin is made in the gut.
43
IBS S/S
- subj abdo distention - Abdo pain, intermittent, crampy, in the lower abdomen, that may be improved or worsened by defecation - More frequent or less frequent stools w/ the onset of abdo pain - Looser stools or harder stools w/ the onset of pain - Constipation, diarrhea, or alternating constipation & diarrhea
44
IBS PE
- usually normal - maybe non specific lower abdo tenderness
45
IBS Dx
- rule out other patho prior to making dx - dx based on Hx, PE, & absence of "alarm symptoms"
46
ACG Dx Criteria for IBS syndrome
recurrent abdo pain or discomfort for >/=3 days/month in past 3 months w/ >/=2 - improvement w/ defeacation - onset assoc. w/ change in stool freq or appearance
47
IBS alarm symptoms
- >60 yo w/ change in bowel habits to looser and/or more freq stools > 6wks - unintentional & unexplained weight loss - rectal bleeding - FHx of bowel or ovarian cancer - anemia - inflammatory markers for IBD - abdo or rectal mass
48
IBS Tx
- For abdo pain/spasm: antispasmodics (dicyclomine, hyoscyamine) - SSRI - Antidiarrheal if needed (loperamide) - Fiber supplements, osmotic laxatives for constipation - Ondansetron for nausea
49
IBS Pt. Edu
- Reassure pt - Consider behavioral modification w/ relaxation techniques, hypnotherapy - Recommend moderate exercise as helpful - Restrict dietary “FODMAPS” (to improve bloating, flatulence, & diarrhea in some pts)
50
Abx Associated Colitis is caused by...
C. diff
51
Route of transmission for Abx associated colitis?
- person-to-person via fecal-oral - contaminated surfaces or equipment
52
How long can c. diff spores survive on dry inanimate surfaces?
up to 5 months
53
Abx associated colitis RFs
- abx exposure - hospitalization or exposure to other healthcare setting - incr age - higher # of comorbidities - IBD - immunodeficiency - use of PPI
54
Abx Associated Colitis Patho
Abx disrupts the colon microflora--> C. diff gets ingested & colonized--> either are a carrier or get the clinical dz
55
Abx associated colitis S/S
- abdo pain, profuse watery diarrhea w/ up to 30 stools/day - stools may have mucus but seldom gross blood - usually low-grade fever
56
Abx associated colitis PE
non-specific
57
Abx associated colitis Dx options
- glutamate dehydrogenase assay - enzyme immunoassays, which detect toxin A or toxin B - nucleic acid amplification tests - CT
58
Abx associated colitis CT may show
- inflammation - bowel wall thickening - dilated colon - perforation
59
Abx associated colitis Standard Tx
- Metronidazole (10-14 days) OR - Vanc
60
In Abx associated colitis, Tx w/ Vanc is reserved for...
- Pts who are intolerant of metronidazole - Pts w/ IBD - Pregnant women - Children
61
Abx associated colitis Tx if severe
- Intravenous metronidazole: - Supplement w/ vanc nasoenteric tube or enema - Total abdo colectomy or loop ileostomy w/ colonic lavage may be required in pts w/ toxic megacolon, perforation, sepsis, or hemorrhage
62
Abx associated colitis investigational therapy
- Fecal microbiota transplantation (FMT)
63
Abx associated colitis Prevention & screening
- Abx stewardship - Infx control - Hand washing > alcohol hand sanitizer - Probiotics while taking antibiotics (DanActive twice daily)
64
What is toxic megacolon?
toxic colitis w/ dilation of the colon
65
What are the qualifications of toxic megacolon?
nonobstructive colonic dilation larger than 6 cm & signs of systemic toxicity
66
Dx Criteria for toxic megacolon
- Radiographic evidence of colonic dilatation - The classic finding is > 6 cm in the transverse colon - Any 3 of the following - Fever (>101.5°F), tachycardia (>120 beats/min), leukocytosis (>10.5 x 103/µL), or anemia - Any 1 of the following - Dehydration, AMS, electrolyte abnormality, or HPTN
67
Causes of toxic megacolon
- Inflammatory - Infectious - Other
68
Inflammatory causes of toxic megacolon
69
Infectious causes of toxic megacolon
Bacterial - C. diff - Salmonella - Shigella - Campylobacter - Yersinia Parasite - Entameba histolytica - Cryptosporidium Viral - CMV colitis
70
Other causes of toxic megacolon
- Pseudomembranous colitis 2ndary to methotrexate therapy - Kaposi's sarcoma
71
Ischemic colitis gender prevalence & age onset
- female > men - esp > 49yo
72
Is ischemia colitis occlusive or non-occlusive?
non-occlusive
73
Ischemic colitis precipitating events
- HPTN - MI - Sepsis - Heart failure - Aortic surg - cocaine
74
Ischemic Colitis Pathophys
Due to inflammation/ischemia the colon receives less blood supply compared to the rest of the GI tract *most vulnerable during systemic HPTN
75
Watershed areas during ischemic colitis
- Splenic flexure - Rectosigmoid junction
76
Ischemic colitis S/S
- acute onset of mild, crampy, left sided abdo pain - tenesmus - diarrhea - passage of red or maroon blood w/n 12-24 hours of onset - symptoms of systemic response: fever, tachypnea, tachycardia, fever
77
Ischemic colitis PE
- tenderness - increasing abdo tenderness, guarding & rebound tenderness w/ gangrenous colitis - abdo distention
78
Ischemic colitis Dx
- CT scan may show segmental circumferential wall thickening or be normal - Colonoscopy to confirm
79
Ischemic colitis primary goal of tx
maintaining perfusion of the colon for mild symp w/ no perf or infarction
80
In Ischemic colitis tx for maintaining perfusion of the colon
- digestive rest to reduce O2 requirements of colon - fluid & electrolyte replacement to optimize CO - prevention of venous thromboemb
81
When is bowel resection indicated in ischemic colitis?
- if peritoneal signs - symp persisting > 2wks or - severe complications (perf or infarction on CT or colonoscopy)
82
Most LBO are due to...
neoplasm (usually colon, but can be ovary, pancreatic, or lymphoma)
83
LBO tx
most require surg intervention
84
What are colon polyps?
growths that arise from epithelial cells lining the colon
85
Which type of colorectal polyps put pts are higher risk of colon cancer?
adenomatous polyps
86
Colon polyps epidemiology
- middle aged & elderly - screening & autopsy
87
Colon polyps RFs
- Older age - FHx - Diet: Animal fats in red meat, incr conversion of normal bile acids to carcinogens - UC - Excess body weight - Mod to heavy etoh consumption
88
Colon polyps S/S
- Usually asymp - Pts may experience overt or occult rectal bleeding. - Change in bowel habits
89
For colon polyps, repeat colonoscopy depends on...
type & number of polyps
90
Describe repeat colonoscopy requirement for colon polyps
- Every 5-10 yrs for those w/ 1-2 small tubular adenomas w/ low-grade dysplasia after initial polypectomy - Every 3 yrs for pts w/ 3-10 adenomas or 1 adenoma > 1 cm or any adenoma w/ villous features or high-grade dysplasia - > every 3 years for pts w/ > 10 adenomas - At 2 to 6 months to verify complete removal in pts w/ sessile adenomas that are removed piecemeal
91
What is Familial Adenomatous  Polyposis?
An inherited condition characterized by early development of 100s to 1000s of colonic adenomatous polyps & adenocarcinoma
92
Familial Adenomatous  Polyposis Tx
Prophylactic colectomy recommended to prevent otherwise inevitable colon cancer
93
Colorectal cancers are almost all...
adenocarcinomas
94
Colorectal age seen & gender
>/= 60 yo men > women
95
Colorectal cancer RFs
- age - FHx - IBD - high meat/low fiber diet,
96
Colorectal cancer pathophys
growths that arise from epithelial cells of the colorectal mucosa
97
Colorectal Cancer primary symptoms
- rectal bleeding w/o anal symp (soreness, discomfort, itching, lumps, or pain) - occult blood in stool - change in bowel habit to looseness or incr frequency
98
Colorectal Cancer other non-specific symptoms
- fatigue - weight loss - generalized or localized abdo pain - symp of iron deficiency & anemia, such as shortness of breath & pale appearance
99
Colorectal Cancer PE
- abdo mass - signs of intestinal obstruction, such as distention or pain - assess for lymphadenopathy - assess for hepatomegaly & ascites - may present w/ palpable rectal mass
100
Colorectal Cancer Dx
- CBC may reveal IDA - Elevated liver biochemical tests, esp serum ASP, are suspicious for metastatic dz - Carcinoembryonic antigen (CEA) may be elevated & is used to monitor colorectal cancer - Colonoscopy for dx & biopsy/staging - CT or MRI chest/abdo/pelvis for staging
101
Colorectal Cancer Tx
- Surgery ---> resection of primary colonic or rectal cancer ---> regional lymph node removal to determine staging ---> for metastatic dz, resection of liver or lung metastases - Chemotherapy - Tx largely dependent on TNM staging
102
5-year survival rates w/ dz at all stages
65%
103
5-year survival rates w/ localized dz
90%
104
5-year survival rates w/ regional dz
71%
105
5-year survival rates w/ distant stage dz
14%
106
Constipation description
persistent, difficult, infrequent, or seemingly incomplete defecation
107
Types of Constipation
- functional - slow transit - Defacatory dysfunction/disorder
108
Constipation alarm symp for colorectal cancer
- rectal bleeding - change in caliber of stools - blood in stool - weight loss - anemia - FHx of colorectal cancer
109
Constipation PE
- Usually unremarkable - May have abdo distension - May have firm stool on rectal exam
110
In healthy pts w/ constipation, under age 50 w/o alarm symp it is reasonable to initiate...
a trial of empiric treatment without diagnostic tests
111
Further dx tests for constipation should be performed in...
- Pts age > 50 yo - Pts of any age w/ --> Severe constipation --> Hematochezia --> Weight loss --> (+) fecal occult blood or fecal immunochemical tests - (+) FHx of colon cancer or IBD - No response to empiric tx
112
Constipation Dx
- Anorectal manometry - Colonic transit study - Colonoscopy if alarm symptoms - Abdo XR & CT
113
Constipation Tx
- Fiber (psyllium, bran) - Stool Surfactants (Docusate sodium, mineral oil) - Osmotic Laxatives (PEG, magnesium hydroxide) - Stimulant Laxatives (Senna) - Enemas (sodium phosphate, mineral oil) - “special enemas”: soap suds, milk & molasses
114
Constipation Pt Edu
- High fiber diet - Incr activity - Regular toileting - Do not hold defecation
115
Define fecal impaction
severe bowel condition where hard, dry mass of stool becomes stuck in the colon or rectum
116
What doesn't treat fecal impaction?
laxatives or enemas
117
Can you have diarrhea w/ fecal impaction?
yes
118
Fecal impaction dx
rectal exam
119
Fecal impaction tx
dis-impacted
120
Differentiate internal vs external hemorrhoids
- internal--> dilation above the dentate line - external--> dilation below the dentate line
121
Hemorrhoids peak prevalence age, common during?
- 45 - 65yo - preg & childbirth
122
Hemorrhoids patho (commonly cited factors)
- exact etiology unknown - constipation & chronic straining at defecation - factors that incr intra-abdo pressure (pregnancy or cirrhosis w/ascites, straining
123
Hemorrhoids S/S
- Bright red blood on the toilet paper or in the toilet after BM - Internal hemorrhoids (painless) - External hemorrhoids (painful) esp if thrombosed - Anal itching - Feeling of mass or fullness
124
Hemorrhoids Dx
- typically made clinically in pts w/ hx of anal symp (bleeding, itching, or prolapse of tissue - Visual inspection - anoscopy is req to confirm or exclude dx of internal hemorrhoids
125
Hemorrhoids Tx
Conservative measures - 1st line--> adequate fiber & fluids   - Behavior modifications _--> avoid straining & reading while on toilet ---> lose weight & incr exercise ---> good perianal hygiene - topical ointments, suppositories - Excision of thrombosed hemorrhoids - Rubber band ligation & sclerotherapy - Hemorrhoidectomy
126
What is an anal fissure?
linear fissure, usually <5mm
127
Anal fissure arises from...
trauma during defecation
128
Anal Fissure S/S
- Pts report tearing sensation & bright red blood - Very painful
129
Anal Fissure Dx
inspection
130
Anal Fissure Tx
- topically - stool softeners - incr fiber
131
What are the 2 types of anorectal abscesses?
- perianal - perirectal
132
Types of Perirectal abscesses
- Ischiorectal abscess - Intersphinteric abscess - Supralevator abscess
133
Anorectal Abscess age onset & gender prevalence
- 30-50yo; peak 40yo - men > women
134
List the Aerobic & anaerobic bacteria
- Bacteroides fragilis - E. coli - Clostridium spec. - Fusobacterium - Peptostrepto - Porphyromonas - Prevotella - S. aureus - Strep
135
Anorectal Abscess Pathophys
136
Anorectal abscess S/S
- acute rectal pain (may be deep-seated) - swelling - tenderness or redness - fluctuant mass - fever
137
Anorectal Abscess PE
- redness - signs of 2ndary cellulitis - large skin tags or multiple fistulas = Crohn Dz
138
Which abscesses tyically a have tender, fluctuant mass?
- perianal - ischiorectal
139
Which abscesses may have a normal external exam or tenderness or fluctuance on digital exam?
- intersphincteric - supralevator
140
Anorectal Abscess Dx
- CBC - CMP - poss blood cultures - poss would cultures - lactate - CT--> extent of abscess - MRI--> track fistula
141
What type of perirectal abscesses can be drained in the operating room?
- ischiorectal - submucosal - intersphincteric - supralevator
142
What type of perianal abscesses can be drained in the ED or office by gen surg?
- simple - isolated - fluctuant
143
Tx for perianal anorectal abscess
- Augmentin or Cipro/Flagyl if being discharged/treated as outpt
144
Tx for perirectal anorectal abscess
- BSAbx (Zosyn or Invanz)
145
What is a pilonidal cyst/abscess?
formed by the penetration of the skin by an ingrown hair--> causes a foreign body granuloma rxn
146
Tx for pilonidal cyst/abscess
- I&D - Abx (if cellulitis)
147
What is the definitive tx for pilonidal cyst/abscess?
referral to surgeon - surgery
148
Timeframe for acute diarrhea
> 2 wks
149
Timeframe for persistent diarrhea
2-4 wks
150
Timeframe for chronic diarrhea
> 4wks
151
More than 90% of acute diarrhea is caused by....
infectious agents
152
Symptoms that accompany acute diarrhea
- vomiting - fever - abdo pain
153
Acute noninflammatory diarrhea S/S
- Watery, nonbloody. - Usually mild, self-limited. - Caused by a virus or noninvasive bacteria. - Dx evaluation is limited to pts with diarrhea that is severe or persists beyond 7 days.
154
Acute inflammatory diarrhea S/S
- Blood or pus, fever. - Usually caused by an invasive or toxin-producing bacterium. - Dx evaluation req routine stool bacterial testing (including E coli) in all & testing as clinically indicated for C. diff toxin and ova & parasites. - **Can also be caused by IBD**
155
Acute Diarrhea (Infectious) Non-inflammatory causes...
- Viral: Rotavirus, norovirus, adenovirus - Toxin producing bacteria: E. coli, Staph aureus, clostridium perfingens - Parasitic: Giardia
156
Acute Diarrhea (Infectious) inflammatory causes...
- bacterial invasion of colonic tissue: shigellosis, salmonella, campylobacter, **Yersinia**, **invasive e. coli**
157
Name the at risk groups for Acute Diarrhea (infectious)
- travelers - consumers of certain foods - daycare attendees & their fam
158
Describe the travelers at risk of Acute Diarrhea (infectious).
- Latin America/Africa/Asia- E coli, campylobacter, shigella, salmonella - Campers/backpackers/swimmer- giardia - Cruise ships- norovirus
159
Describe the foods that put you at risk of Acute Diarrhea (infectious).
- Food left out (picnic)- salmonella, campylobacter - Mayo- staph aureus or salmonella - Eggs- Salmonella - Soft cheese- Listeria - Seafood (esp raw)- Vibrio, salmonella, hep A
160
Describe the daycare attendees & family at risk of Acute Diarrhea (infectious).
- shigella - giardia - rotavirus
161
Acute Infx Diarrhea Dx
Stool studies - Fecal Leukocytes - Culture - Ova & Parasites - Immunoassays for C.diff, rotavirus, giardia
162
Acute Infx Diarrhea Tx
- Oral rehydration - Antidiarrheal agents (loperamide, bismuth) ** - Avoid high fiber, high fat foods, milk products
163
Acute Infx Diarrhea Empiric Abx Tx if...
- Fever, tenesmus, bloody stools, presence of fecal leukocytes, immunocompromised pts - Quinolone, Bactrim, or doxy - Zithromax--> alt for traveler’s diarrhea - Once cultures return, tailor to results
164
Mild Dehydration volume lost
5%
165
Mild Dehydration symptoms
thirsty
166
Moderate Dehydration volume lost
6-9%
167
Moderate Dehydration symptoms
- dry mucous membranes - sunken eyes - decr urine output - tachypnea - tachycardia
168
Severe Dehydration volume lost
>10%
169
Severe Dehydration symptoms
- very dry mucous membranes - decr skin turgor - cool limbs - anuria - significant tachypnea & tachycardia
170
What makes diarrhea chronic?
present longer than 4 wks
171
Chronic diarrhea causes...
- Meds (metformin - Osmotic Diarrheas (malabsorption of lactose) - Secretory conditions (endocrine tumors) - Inflammatory conditions (IBD) - Irritable bowel syndrome - Chronic infections (giardia)
172
Chronic Diarrhea Tx
- treat underlying cause - antidiarrheal as needed
173

Clin Med: GI (block 3) (8 decks)

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