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PANCE GI (9%) > Colorectal Disorders > Flashcards

Colorectal Disorders Flashcards

1
Q

Constipation is a functional d/o. Name the 3 subtypes

A
  • slow colonic transit
  • obstructive defication
  • IBS-C
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2
Q

constipation ddx (etis)

A
  • MC: low fiber, sed lifestyle, inadequate fluid intake
  • systemic: ENDOCRINE (hypothyroid, hyperparathyroid, DM), METABOLIC (hypokalemia, hypercalcemia, uremia, porphyria), NEURO (Parkinson, MS, sacral nerve damage, paraplegia, autonomic neuropathy)
  • meds: opioids, diuretics, CCB, anticholinergics, psychotorpics, Ca, Fe, NSAID, clonidine, cholestyramine)
  • structural: anorectal, perineal descent, colonic mass/stricture, Hirschsprung
  • slowed transit: idiopathic, psychogenic, eating d/o, chronic pseudoobstruction
  • pelvic floor dyssynergia
  • IBS-C
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3
Q

constipation wu

A
  • rectal & abd exam

- if alarm sx: CBC, TSH, BMP, ref for EGD or flex sig

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4
Q

constipation mgmt

A
  • inc fiber intake gradually
  • inc # of daily meals
  • laxatives prn/chronically if refractory to lifestyle mods
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5
Q

Fiber laxatives

A
  • FIRST LINE

- bran powder (gassy), Metamucil, Citrucel, FiberCon (pill), Benefiber

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6
Q

osmotic laxatives

A
  • onset w/in 24 hrs
  • Mild of Mg, epsom salt, sorbitol/lactulose, Miralax,
  • AVOID IN RENAL DYSFXN (for whatever eti)
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7
Q

stimulant laxatives

A
  • onset in 6-12 hrs PO, 15-60 min rectal

- bisacodyl & senna (cramping, not daily)

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8
Q

opioid-receptor antagonists

A
  • does NOT affect central analgesia (good for pain pts)

- methylnaltrexone

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9
Q

stool surfactants/emollients

A
  • softens ONLY (avoid straining)

- mineral oil, docusate sodium (colace: marginal benefit)

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10
Q

definition of constipation (sx)

A

< 3 stools/wk, difficutl-to-pass stools, sense of incomplete evacuation, abd distension, bloating, pain

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11
Q

encopresis def

A

leaking of liquid stool around hard, impacted stool

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12
Q

pediatric constipation eti & s/s

A
  • self-perpetuating (don’t want to go after initial episode b/c of pain) = chronic rectal distention = desensitized to urgency
  • encopresis, UTIs, chronic abd pain, poor appetite, lethargy, rectal skin tags
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13
Q

pedi constipation ddx

A
  • imperforate anus
  • Hirschsprung
  • Crohn’s
  • tethered cord
  • spina bifida
  • anterior displacement of anus
  • CF
  • celiac
  • lead intoxication
  • botulism
  • cow’s milk constipation
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14
Q

pedi constipation wu

A
  • Rome III criteria: sx x 1 month in toddlers, 2 mos in older
  • labs only if refractory
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15
Q

pedi constipation mgmt

A
  • initially enema or Golytely, followed by Miralax (if > 2 yr)
  • goal = 1 soft stool qd
  • “rescue plan” = stimulant lax, enema, suppository if recurrence
  • behavioral mod: sit on toilet x 5-10 min after q meal, keep logs
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16
Q

diverticulosis eti/epi, s/s, mgmt

A
  • outpouching of sub/mucosa thru musc layer of wall
  • 20th century dz assoc w/ Western diet (low fiber, red meat, obesity, inc age
  • most asx/incidental, chronic C, abd pain, fluctuating bowel habits
  • fiber supps may reduce comps
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17
Q

diverticulitis s/s

A
  • LLQ or suprapubic pain +/- palpable mass
  • acute GIB that’s painless & maroon
  • F, malaise, C, D, cramps, bloating, N/V, dysuria/u freq
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18
Q

diverticulitis ddx

A

perf’d colonic CA, Crohn’s, appy, ischemic colitis, CDAD, ectopic preg, ovarian cyst/torsion

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19
Q

diverticulitis wu

A
  • CBC: leukocytosis w/ left shift (inc prod due to inf/inflam)
  • CT w/ contrast = IMG OF CHOICE to assess severity
  • XR (free air, ileus, obstruction)
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20
Q

diverticulitis mgmt

A
  • uncomplicated/simple: aerobic/anaerobic coverage (cipro + metro) x 7-10 days, clear liq diet until imp (2-3 d), surg consult if no imp/worsens in 3 d
  • complicated (peritonitis, obstruction, perf, abscess, fistula): admit w/ IV abx (amp, gentamicin, metro), IVF, pain mgmt, antiemetics
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21
Q

when to follow up acute diverticulitis

A

ref for CSY, CT, colonography, or barium enema w/ flex sig 2-6 wks s/p recovery (eval extent of damages & exclude malignancy, time avoids risk of perf)

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22
Q

diverticulitis prognosis

A
  • complications: lower GIB, intra-abdominal abscess/peritonitis (from perf), fistulas, obstruction
  • 30% recurrence
  • 30-40% will have episodic abd pain w/o inf
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23
Q

name both inflammatory bowel dz’s

A
  • crohn’s dz

- ulcerative colitis

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24
Q

IBD overview

A
  • autoimmune, runs in families
  • incidence highest if 15-40, > 60 y.o.
  • extraintestinal sx poss: eye, skin (erythema nodosum (tender subQ nodules), pyoderma gangrenosum (painful ulcers, lower legs)), liver, joints
  • dx via combo of endoscopy, histology, radiography, labs, clinical data
  • tx affected area (response 30-70%)
  • use steroids sparingly (flares: WBC, H/H, f/u w/ endoscopy ref if no improvement)
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25
Q

Crohn’s dz eti

A
  • ANY portion of GI tract (ileum = MC)
  • transmural involvement
  • skip lesions (skips parts of tracts)
  • bouts of flares & remission
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26
Q

Crohn’s dz s/s

A
  • prolonged D & abd pain, fatigue, wt loss
  • obstructions, perianal dz, fistulas, abscesses
  • worse w/ smoking
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27
Q

crohn’s wu

A
  • 1st img = upper GI series w/ small bowel follow thru
  • CSY shows cobblestoning & varying deg of ulceration
  • labs NOT specific/reliable
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28
Q

crohn’s ddx

A

UC, IBS, appy, diverticulitis w/ abscess, enteritis, NSAID-induced colitis, perianal fistula (lymphogranuloma venereum, CA, rectal TB)

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29
Q

crohn’s mgmt

A
  • flares: steroids (budesonide = less adr)
  • pain (sitz, gentle, pads)
  • low-roughage diet if obstructive
  • ref to rheum for pts unresponsive to steroids/need chronic steroids (will Rx immunomodulators: methotrexate)
  • CSY q yr (w/ 8+ yr h/o dz)
  • mesalamine & abx use are NOT effective in flares
30
Q

crohn’s comps

A
  • small bowel strictures
  • fistulae (bowel, bladder, vagina, skin)
  • high oxalate from malabsorption of injested fat (binds to Ca = kidney/gall stones)
  • surgery
31
Q

ulcerative colitis eti, s/s

A
  • begins in rectum, limited to colon, superficial penetration of mucosal wall, bouts of flares/remission
  • proctitis, tenesmus (rectal cramp/urgency w/wo small BM, strain), low abd/pelvic pain/cramp, bloody D, mucus/pus per rectum, F
32
Q

UC ddx

A

colitis (inf, ischemic, pseudomembranous/CDAD), crohn’s, diverticular dz, colon CA, inf proctitis (G/C, HSV, syphilis), s/p radiation

33
Q

UC wu

A
  • labs: low sAlbumin, anemia, high ESR
  • neg stool cx
  • dx via sigmoidoscopy w/ bx (crypt abscesses, chronic colitis)
  • barium enema (“stovepipe” colon: loss of haustra)
34
Q

UC mgmt

A
  • distal: DOC = mesalamine, hydrocortisone (suppository) prn - 2nd = PO sulfasalazine
  • mild/mod (above sigmoid): mesalamine PO +/- hydrocortisone foam, enema prn - ref to rheum for immunomod if no response
  • sev flare: ED for admission
  • CSY q 1-2 yrs for pts w/ h/o dz x 8+ yrs
35
Q

UC comps

A

toxic megacolon, ext of colonic dz, perf, strictures

36
Q

IBS eti, ddx

A
  • chronic abd pain & alt bowel habits in ABSENCE of organic cz (FUNCTIONAL)
  • dietary, inf, IBD, psychogenic, malabsorption, tumor, endometriosis
37
Q

IBS s/s

A
  • pain relieved w/ BM
  • more freq BM at onset of pain
  • mucus
  • bloating
  • sense of incomplete evacuation
  • urgency
38
Q

IBS wu

A
  • need to r/o IBD, inf, CA
  • FOBT
  • CBC, CMP, ESR, sAlbumin, +/- TSH
  • celiac panel if D
  • Manning and Rome criteria for DX
39
Q

Red flags for CSY (in IBS wu, aka, not IBS)

A
  • abnml exam
  • F
  • +FOBT
  • wt loss
  • onset in elderly
  • nocturnal awakening
  • anemic
  • high WBC and/or ESR
40
Q

IBS mgmt

A
  • elimination diet (gluten, lactose) if elevated IgG
  • psych for anxiety/depression
  • antispasmodic/depressant for abd pain
  • loperamide (caution) for D
  • bulking agents (fiber) for C
  • NO CURE
41
Q

ischemic bowel dz epi/eti/RF

A
  • most = acute
  • from low BP, clot, vasoconstriction, idiopathic
  • RF: age, atherosclerosis, low CO, arrhythmias, sev valve dz, recent MI, intra-abd malignancy
42
Q

ischemic bowel dz s/s

A
  • D, F
  • hyperactive phase: bloody BM, sev abd pain
  • paralytic phase: diffuse abd pain, tender abd, bloating, no more bloody BM, absent BS
  • shock phase: leaky colon = metabolic acidosis, dehydration, hypotension, tachycardia, confusion
43
Q

ischemic bowel dz wu, prog

A
  • mesenteric angiography = GS, consult surg

- most pts fully recover w/o sequelae

44
Q

ischemic bowel dz mgmt

A
  • restore blood flow
  • supportive
  • correct metabolic acidosis (bicarb, lytes)
  • broad spec AB (if mod/sev: cipor/metro)
  • NGT for gastric decompression
  • bowel rest
45
Q

anal fissure cz/prev

A
  • C/D, inf (TB, syphilis, HIV, abscess), IBD, anal sex, childbirth
  • high fiber/fluid to prev D, wipe w/ moist cloth
46
Q

anal fissure s/s

A
  • tearing pain w/ BM (less if chronic)
  • BRB on TP
  • MC at posterior midline
  • perianal pruritis/irritation
  • chronic lesions: raised edges w/ ext skin tags & hypertrophied villae
47
Q

anal fissure ddx

A

perianal ulcer (IBD, TB, STI), anorectal fistula

48
Q

anal fissure mgmt

A
  • stop C
  • sitz
  • 1% hydrocortizone cream, 2% NTG cream (vasodil, inc blood flow, dec internal anal sphinter pressure = can heal)
  • surg consult if not better in 6 wks (internal sphincterotomy)
49
Q

B9 colorectal neoplasms

A
  • non-neoplastic polyps: hyperplastic, hamartomatous, inflammatory, lymphoid = NO PRE-MAL
  • Neoplastic epithelial polyps: tubular/tubulovillous/villous adenomas = PRE-MAL (screen more freq)
  • leiomyoma: smooth muscle tumor in colon/rectum
  • others: lipoma, neuroma, hemangioma, lymphangioma
50
Q

Colorectal adenocarcinoma = MAL

eti/RF

A
  • 95% of primary colon CA
  • 30% rectum, 25% right colon
  • RF: age, FHx (30%), T2DM, metobolic synd, AA, IBD, high red/processed meats, inactivity, obesity, smoking, heavy EtOH
51
Q

Associated familial syndromes of colon CA

A
  • FAP (Familial adenomatous polyposis): inc risk of thyroid, pancreas, duodenal, and gastric CA
  • HNPCC (Hereditary Non-polyposis Colorectal Cancer): assoc w/ endometrial, ovarian, gastric, urinary, renal cell, biliary, and gallbladder CA
  • most occur > 50 y.o.
52
Q

colon CA screening

A
  • Assess risk at 20 y.o.
  • CSY q 10 yr starting at 45 (AA) or 50 OR 10 yrs sooner than age of dx of family member
  • stop when life exp < 10 yrs or pt is 85 y.o.
  • CT colonography or flex sig q 5 yrs
  • FOBT q yr if img not poss
53
Q

colon CA s/s

A

rectal bleeding, Fe def anemia, fatigue/wt loss, obstruction, change in stool quantity/caliber, abd mass/pain, weakness, met to liver/lung

54
Q

colon CA wu

A
  • CSY for bx
  • abd/pelvis CT for staging (“apple core” lesions)
  • CXR for mets
  • labs (CBC, CMP, baseline CEA)
  • PET
55
Q

colon CA mgmt

A
  • early stage tumors: endoscopic removal
  • hemicolectomy w/ lymph resect
  • local tx of mets
  • chemo for micromets
  • rad not typically used b/c of toxic effect in gut
56
Q

bowel obstruction can be mechanical or fxnl

A
  • mech: intrinsic, post-op

- fxnl: paralytic, lyte abnml, DM

57
Q

cause of lg bowel obst

A
  • MC = neoplasms

- tic dz, volvulus (sigmoid, cecal), adhesions

58
Q

cause of small bowel obst

A
  • MC = adhesions (prev surg)

- hernia, neoplasm, stricture, intussusception, Meckel’s tic, volvulus, intramural hematoma

59
Q

s/s of bowel obst

A

crampy/generalized abd pain/distension w/ diffuse midabd TTP (r/o ischemia), NO signs of peritonitis, reduced urine output, no flatus (can pass up to 12-24 hr s/p onset)

60
Q

bowel obst wu

A
  • chk lytes
  • lactate if concern for strangulation/ischemia
  • KUB (distended small B, air-fluid levels, free air under diaphragm (if perf’d), “swirl sign” (bowel twist on mesentary), “bird’s beak” or “corkscrew” (if volvulus)
  • CT for further localization
  • SBO in absence of prior abd surg = malignancy wu
61
Q

bowel obst mgmt

A
  • IVF
  • abx (cipro/metro?)
  • NPO, NGT decompression
  • volvulus: rectal tube decompression w/ surg repair
  • ischemia/perf: surgery
62
Q

Toxic megacolon def

A

potentially lethal. total/segmental nonobstructive colonic dilation + systemic toxicity

63
Q

toxic megacolon eti

A

IBD, inf/ischemic colitis, volvulus, diverticulitis, obst colon CA

64
Q

toxic megacolon s/s, wu

A

s/s: sev bloody D

wu: XR (R colon dil > 6 cm, dil of trans colon, abscence fo haustra)

65
Q

toxic megacolon mgmt

A

IVF, fix lytes, IV vanc/metro, bowel rest & decompress (NGT), surg consult (colectomy w/ end-ileostomy for refractory pts)

66
Q

rectal abscess eti, s/s, wu, mgmt

A

eti: inf anal glands

s/s: sev pain, F/malaise, +/- fistula

wu: pelvic MR if nonvisible/palpable (use Goodsall’s rull to asses tract location if suspect fistula)
mgmt: I&D w/ cx (for pain out of proportion on PE), OR for complex location, abx if valve dz/immunosupp’d/extensive cellulitis/DM, surgery for fistula

67
Q

Hemorrhoids

A
  • engorged venous plexus. classified based on relation to DENDRATE line (divides the upper two thirds and lower third of the anal canal).
  • czs: C/strain, portal HTN, preg
68
Q

external hems

A
  • rarely bleed, very painful (esp if thrombosed = lance/remove clot), itch, visible
  • sitz, 1% hydrocortisone, stool softener, surg if refractory
69
Q

internal hems grading

A

I: bulge into lumen, not below denate line
II: prolapse but spontaneously reduce
III: patient can reduce
IV: nonreducible (may strangulate, surg)

70
Q

internal hems s/s, mgmt

A

s/s: painless bleed s/p BM, visible w/ anoscopy, not palpable/painful on DRE

mgmt: 1% hydrocortisone, band lig (GI/surg) if prolapse

PANCE GI (9%) (12 decks)

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