Disease of the intestines Flashcards
When does IBD typically present
30
*crohns more common than UC
Where in the world is IBD more common
Developed countries
*northern climates
What is dysbiosis
alterations in normal flora of the gut
What doubles the risk for crohns disease
Cigarette smoking
Where in the body does Crohns effect
Anywhere from mouth to anus
What type of disease are skip lesions associated with
Crohns
What are the common presentations of crohns disease
Dependent on location involved and disease severity
RUQ pain and diarrhea
+/- extra intestinal manifestations
What is the mainstay diagnosis for crohns disease
colonoscopy with biopsy
What lowers the risk of UC
smoking
How is the inflammation different between crohns and UC
UC inflammation is confined to the mucosa
Crohns inflammation involves the entire bowel wall
Where is UC found in the body
confined to the colon
What is the difference in stool presentation with crohns vs UC
UC generally has bloody diarrhea
Crohns generally has normal diarrhea
What may be seen on xray with UC
Thumbprinting
lead-pipe colon
colonic dilation
What is the mainstay of diagnosis for UC
Colonoscopy with biopsy
Will have contiguous inflammation
When is a colonoscopy with biopsy contraindicated with UC
Why?
During acute disease
Risk for bowel perf
Where is the pain usually located with UC
LLQ
What are the treatment options for crohns and UC
Aminosalicylates (sulfasalazine) oral or topical
Steroids for acute tx (IV, Oral, Topical)
Immunomodulators (Methotrexate)
biologics
Which immunomodulators increase risk for non-hodgkin lymphoma
Mercaptopurine
azathioprine
Monitor with CBC
If a patient is prescribed methotrexate, what needs to be given as adjunct therapy
Folic Acid
What biologics can be given for UC and Crohns
TNF inhibitors (inflixumab)
Anti-integrins (natalizumab)
Anti-IL antibody agents (Usetkinumab)
only used once they have failed all other therapy
What is the first pharmacological option in the tx of Crohns disease
mesalamine
What is the maintenance therapy for crohns disease
azathioprine or mercaptopurine + inflixumab
If someone has a UC acute attack what drugs should they be given and what should be avoided
Topical mesalamine (suppository/enema)
-move to oral if topical fails
avoid antidiarrheals (loperamide)
What is the greatest risk with fulminant UC
toxic megacolon
How do you r/o toxic megacolon
KUB
What is the maintenance therapy for UC
First line is to continue 5-ASA
oral is better if there is more proximal involvment
steroids are added if there is no improvement in 4-8 weeks
When is surgery done for UC and crohns
What type of surgery
Refractory disease
bowel resection
What is the first line steroid for treatment of crohns
budesonide
What is celiacs disease
Immunologic response to gluten
Different from gluten intolerance
What is the gene mutation with celiac
HLA-DQ2
What are the classic symptoms for celiac disease
Chronic diarrhea
dyspepsia
flatulence
steatorrhea
What symptoms are seen in kiddos with celiac
weight loss
abdominal distention
weakness
muscle wasting
delayed growth
What atypical symptoms may appear with celiac disease
dermatitis herpetiformis
Pruritic papulovesicules on extensor surfaces
What is the first line diagnostic test for celiac
What specific test
Serology
IgA levels are more sensitive and specific
What is the definitive diagnosis for celiac
Mucosal bx
What is the primary treatment for celiac
lifestyle modification
*true gluten free diet
What should be avoided until the celiac is under control
Dairy
What is the difference between diverticulitis and diverticulosis
Diverticulosis is the presence of diverticula (asymptomatic)
Diverticulitis is infection/inflammation of the diverticula
What is one of the most common intestinal disorder
Diverticulitis
increasing prevelance with age
Men m/c until 50y/o then women m/c
What helps decrease the risk of diverticulitis
high fiber diet
<4 servings of red meat/week
physical activity
nuts and seeds can contribute to inflammation
What are the symptoms of diverticulitis
LLQ / suprapubic pain
abdominal tenderness
N/V/F
change in bowel habits
What are some complications with diverticulitis
abscess formation
ruptured diverticulum
fistula
hemorrhage
How do you treat moderate diverticulitis
NPO + oral abx
- cipro is preferred
What is the most common cause of acute surgical abdomen
appendicitis
If appendicitis is left untreated for 24-36 hours, what happens
perforation
gangrene
abscess
What is the patient presentation with appendicitis
peritoneal signs, fever, tachycardia
+/- other signs of sepsis
What is Rovsings sign and what is it used for
Appendicitis
palpate LLQ and have rebound tenderness on opposite side
What may be seen on US with appendicitis
target sign
What is the imaging of choice in adults with appendicitis
CT
What is the preferred tx of appendicitis
laparoscopic appendectomy
Where are obstructions most common
small bowel
can be mechanical or movement issue
if movement issue = paralytic ileus
What are signs of a bowel obstruction
Crampy w/ intermittent abdominal pain
no BM or flatus
abdominal distention
What is the most common cause of SBO
Surgery
hernia
What is the most common cause of LBO
History of cancer
#1 is carcinoma
What will be seen on physical exam with a bowel obstruction
Tympanic to percussion
decreased BS
high pitched BS
What is the workup like for a bowel obstruction
imaging specific
KUB first (2 view)
TOC = abdominal CT
What pathology is indicative of an apple core lesion on an abdominal film
colonic carcinoma
What is the initial tx for a bowel obstruction
Definitive tx?
NGT
definitive is to treat underlying cause and decompress the bowel
What is a volulus
Where is it most common
bowel twists on itself, causing strangulation
1. signmoid colon m/c, then cecum, in kids-> small intestine
what is the patient presentation of a volvulus
What about if there is a perf
Acute onset
hematochezia
abdominal pain / distention
abdominal tenderness, rigidity, guarding
What is the first line tx for a volvulus
What would be seen with a BE
Abdominal Xray
*coffee bean appearance”
Birds beak appearance
What type of test can be diagnostic and therapuetic for a volvulus
Flexible signmoidoscopy
What is the initial treatment for a volvulus
What about if refractory?
Sigmoidoscopy
Surgical management
What is the most common cause of bowel obstruction in young kiddos
What age
Intussesception
most cases before age 2
*if over 4y/o its typically boys
If a child is over 6 with an intussusception, what should be a big differential
Lymphoma
When in the year does intussusception generally occur
Viral enteritis season
What is the presentation of an intussusception
sudden onset of colicky abd pain
vomiting
bloody stool (currant jelly color)
lethargy
palpable abd mass (sausage shape)
What is the test of choice to dx intussusception
US is test of choice
*target sign is seen
BE is diagnostic and therapeutic
What is the treatment of choice for an intussusception
Air or barium enema
if unsuccessful -> surgical reduction
Which patients have an increased risk of ischemic colitis
IBS or COPD
What is the patho behind ischemic colitis
Hypoperfusion through the IMA
When might ischemic colitis present
post op from aortic procedures
females more common
generally >65
What is the presentation of ischemic colitis
LLQ pain / tenderness/cramping
bloody diarrhea
low grade fever
What is first line imaging for ischemic colitits
What can confirm dx
CT
colonoscopy
When is surgery needed with ischemic colitis
When full thickness necrosis is present
What is overt vs. occult
Overt: symptomatic w/ obvious presentation
occult: asymptomatic, no visible blood
Where do GI bleeds typically occur
Which patients have a higher mortality rate
usually UGI
over 65 and hospitalized
What are the common causes of UGI bleed
how about LGI bleed
Gastric
esophageal
colonic, anal
What is a different presenting symptoms between UGI and LGI bleeds
UGI will have hematemesis
How do you treat a GI bleed if its a secondary cause from liver disease
octreotide
How do you treat a GI bleed
embo
surgical mngmnt
TIPS if variceal
What are common causes of occult bleeding
Neaoplasms
PUD
IBD
What is the diagnostic test of choice of occult GI bleed
if positive?, if less than 60?, if greater than 60?
Fecal occult blood test (FOBT)
Colonoscopy & EGD
check small bowel is less than 60
over 60 + neg = iron
