diseases of intestine Flashcards
what portion of the GI tract can Crohns disease affect
any portion mouth to anus
50% include terminal ilium and colon
30% with terminal ilium only
20% with colon only
<5% with upper GI tract involvement
what id dysbiosis
alternation in normal flora of the gut
how do you describe inflammation with Crohns
tranmural - aka full thickness
‘cobblestoning’ or ‘skip lesions’
what is the presentation of Crohns
variable - depending on location and severity of dz
many have RUQ pain + diarrhea
+/- systemic symptoms (fever, weight loss, fatigue)
may present with obstruction from strictures, parianal or other GI tract manifestations or extra-intestinal manifestations
what is the workup for crohns disease
no lab testing specific for Crohns
stool studies to r/o other causes of diarrhea
+/- elevated ERC/CRP and evidence of malabsorption
Mainstay of dx is colonoscopy with biopsy
what is ulcerative colitis
like crohns, inflammatory condition but pathogenesis unknown
hereditary risk, environmental risk
what can lower the severity of UC
smoking
where is UC located in the GI tract
confined to colon
25% isolated to recosigmoid region
50% have disease extending to splenic flexure
25% have disease extending more proximally
what is inflammation confied to the mucosa
ulcerative colitis
what is the presentation of UC
variable based on location and severity of dz
-MOST with bloody diarrhea +/- mucus
LLQ, abdominal cramping, fecal urgency, tenesmus
+/- fever, weight loss
+/- extraintestinal manifestations
what is the workup for UC
mainstay of dx is colonoscopy with biopsy
when is colonoscopy with biopsy contraindicated
acute disease - risk for bowel perforation
What is the pharmacologic treatments of crohns and UC
5-aminosalicylates: (5ASA; sulfasalazine, mensalamine, balsalazide)
Corticosteroids
Immunomodulators (Mercaptopurine, azathioprine, methotrexate)
Biologic agents: TNF inhibitors, Anti-integrins, anti-IL antibody
what is the treatment of acute crohns
ensure adequate nutrition
antidiarrheal agents (loperamide)
pharmacotherapy:
mensalamine
+/- oral abx
corticosterioids (budesonide first line)
what is maintenance therapy for crohns
pts usually on zathioprine or mercaptopurine + infliximab
what is the treatment of acute UC
normal oral intake if mild/moderate
AVOID anti-diarrhea (loperamide)
pharmacologic:
topical mesalamine (first line: suppository or enema)
what is fulminant UC disease
severe, rapidly progressive (1-2 weeks) and toxic
fever, hypovolemia, hemorrhage, abdominal distension and tenderness
risk for bowl perforation and toxic megacolon
what is the treatment of fulminant UC disease
NPO 24-48 hours
resuscitation: fluid, blood products, correct electrolytes
topical hydrocortison -> infliximab +/- cyclosporine
R/o Toxic Megacolon with abd xr
what is the first line maintenance tx of UC
continue 5-ASA agent: topical or oral
if no improvement in 4-8 weeks: add pred or methylpred
when is surgical intervention recommended for UC/Crohn’s
refractory UC/Crohns
what are the indications for bowel resection with crohn’s and UC
refractory
hemorrhage
abscess
obstruction
fistulas
bowel perforation
fulminant colitis
toxic megacolon
carcinoma
what is an immunogenic response to gluten
celiac disease
what are gene associations with celiac disease
HLA-DQ2 gene
what is the result of the antibodies with celiac disease
damage to intestinal mucosa (villi)
tissue transflutaminase (tTG) antibodies
anti-gliadin antibodies
anti-endomysial antibodies (EMA)
what is the presentation of celiac disease
classic symptoms: chronic diarrhea, dyspepsia, flatulence +/- steatorrhea
malabsorption: weight loss, abdominal distention, weakness, muscle wasting, delayed growth
what is the workup for celiac disease
first line for dx testing is serology
what is the most specific and sensitive test for celiac disease
serology - IgA tissue transgluraminase (IgAtTG)
what is the definitive diagnostic test for celiac disease
mucosal biopsy
-atrophy or scalloping of duodenum, blunting of intestinal villi, hypertrophic of intestinal crypts, lymphocytes in lamina propria
what is the tx of celiac disease
TRUE gluten free diet (lifestyle modification)
what is a herniation of the intestinal mucosa and submucosa through the muscularis
diverticulum
what is the presence of diverticula
diverticulosis
what is inflammation and/or infection or the diverticula
diverticulitis
what are diet and lifestyle factors that contribute to inflammation with diverticulitis
high fat, high protein, refined grain diet (western diet)
red meat consumption
eating nuts and seeds
obesity
smoking
immunosuppression
NSAID use
what is the presentation of diverticulitis
acute ssx
LLQ or suprapubic abdominal pain
+/- palpable mass
abdominal tenderness
N/V
fever
change in bowel habits
etc
what is the workup for diverticulitis
CBC
ABD CT is test of choice
after resolution of acute episode - colonoscopy, barium enema or CT colonography
what are complications of diverticulitis
abscess formation
ruptured diverticulum
fistula
hemorrhage
what is the tx of diverticulitis
mild: rest and liquid diet, abx no necessary
mod/complicated/comorbidities: NPO plus oral abx (metronidazole + fluoroquinolone preferred)
if severe: admit and IV abx
large abscess: drainage
perforation: surgical intervention
what is the most common cause of an acute surgical abdomen
appendicitis
if appendicitis is left untreated, within 24-36 hours what does it lead to
perforation
gangrene
abscess
what is the presentation of appendicitis
acute onset constant and worsening abd pain
other non-specific symptoms: dyspepsia, N/v, anorexia, diarrhea, constipation, low grade fever
what is suggestive of perforation, abscess or gangrene with appendicitis
peritoneal signs, fever, tachy or other signs of sepsis
what is seen on PE with appendicitis
guarding and rigidity
tendernss at McBurneys point
rebound tenderness
Rovsing’s sign
Psoas sing
Obturator sign
what is the diagnostic test of choice for appendicitis
CT scan for adults
What is the tx of appendicitis
laparaoscopic appendectomy
abx
what is the inability of contents to pass through the bowels
bowel obstruction
where are bowel obstructions more common
small bowel obstruction
what are risk factors for bowel obsturctions
prior abdominal surgery
malignancy
IBD
hernias
radiation to the area
mostly things that increase risk for adhesions, strictures
what can the accumulation of contents within the bowel cause
increase in intraluminal pressure and dilation
what is the presentation of small bowel obstruction (SBO)
hx abd surgery or hernia
crampy, intermittent abd pain
periumbilical or diffuse abd pain
vomiting, early onset, that is bilious
no BM or flatusus
abdominal distenstion
what is the presentation of LBO
+/- hx of CA (caricnoma #1)
crampy, intermittened abd pain
hypogastric abd pain
vomiting, late onset, that is later feculent
No BM or flatus
abdominal distention
what is seen on PE with bowel obsturction
abdominal distention
abdominal tenderness
tympanic to percussion
decreased BS
high pitched BS
+/- peritoneal signs
what is the first diagnostic tests run for concern with bowel obstruction
abdominal x-ray
-absence of air or stool in rectal vault, bowel distention, air-fluid levels
what is the test of choice for bowel obstruction
abdominal CT (confirms obstruction and location)
what is the initial treatment for bowel obstruction
NPO
fluid resuscitation
electrolyte management
NG tube insertion for decompression
pain management
anti-emetics
+/- prophylactic abx
what is the definitive treatment for bowel obstruction
treat the underlying cause
if partial obstruction or SBO without complications: NG decompression
Next step if no perf: endo/colonoscopic decompression
if unstable or perf: surgical management, exlap with bowel resection
what occurs when the bowel twists on itself anc causes strangulation
volvulus
where is vulvulus most common
sigmoid colon: elderly males, pts with chronic constipation
Cecum is second most common: young females
in kids: small intestines
what is the presentation of vulvulus
most with acute onset of symptoms
abdominal pain/distention
vomiting
constipation/obstipation
hematochezia
hemodynamic instability
if the patient has an associated perforation with volvulus what is this presentation
abdominal tenderness
rigidity
guarding
what is the initial study of choice for vulvulus
abdominal x-ray:
characteristic coffee bean appearance
what will be seen on a barium enema with volvulus
birds beak appearance
what can be diagnostic and therapeutic for vulvulus
flexible sigmoidoscopy
what is the initial treatment of volvulus
sigmoidoscopy: insufflation at site of rotation, decompression with rectal tube
what is the refractory treatment of volvulus
surgical management - bowel resection due to risk for recurrence
what is the most common cause of bowel obstruction in young children
intussesception
what is telescoping of the intestines
intussesception
what is the presentation of intussesception
sudden onset colicky abdominal pain: reoccurs every 15-20 min
abdominal pain later becomes constant
vomiting
bloody stools; ‘currant jelly’ colored
lethargy
palpable mass: “sausage shaped”
what is the test of choice for intussusception
US
what is seen on US with intussesception
‘target sign’
what test can be diagnostic and therapeutic for intussesception
barium enema - risk for peritonitis if performation present
what is the treatment of intussusception
air or barium enema is the tx of choice
if air enema is unsuccessful: surgical reduction
what is ischemic colitis
hypo-perfusion through the IMA - sloughing of the intestinal mucosa
who is at a increased risk of ischemic colitis
IBS or COPD 2-4x increased risk
more common in pts with pre-existing cardiac or peripheral vascular disease or coagulopathy
what is the presentation of ischemic ocolitis
LLQ abdominal pain
abdominal tenderness
abdominal cramping
diarrhea, usually bloody
low grade fever
what is the first line for assessing ischemic colitis
Ct scan
what is the tx of ischemic colitis
tx underlying cause
main adequate BP
IV fluids
prophylactic abx
bowel rest (NPO except clear liquids)
in full thickness necrosis - surgical intervention
if there is a bleed proximal to the ligament of treitz it is what type of bleed
Upper GI bleed
if there is a bleed distal to the ligament of treitz it is what type of bleed
lower IG bleed
what is occult
often asymptomatic, no visible blood
who is at an increased risk of mortality with GI bleeding?
patients over 60 and hospitalized patients
what can cause UGI bleeding
PUD
portal HTN (varices)
mallory-weiss tear
vascular anomalies
gastric/esophageal CA
erosive gastritis/esophagitis
hiatal hernia
coagulopathy
what can cause LGI bleeding
diverticulosis
vascular anomalies (angioectasias)
colonic/anal CA
IBD
anorectal disease
ischemic colitis
inflammatory diarrhea
hemorrhoids
lower abdominal or anorectal trauma
what is the presentation of UGI bleed
anemia
hematemesis
melena
+/- hematochezia
+/- hemodynamic instability
what is the presentation of LGI bleed
anemia
+/- melena
hematochezia
+/- hemodynamic instability
what are the diagnostic tests that can be done for GI bleeding
endoscopy /colonoscopy
nuclear scans
angiography
capsule imaging
what is the treatment for GI bleeding
endoscopic tx
pharmacologic options: IV or oral PPI, octreotide if liver disease
intra-arterial embolization
surgical management
TIPS for variceal bleeds
what are common causes of occult GI bleeding
neoplasms
angiogenectasis
PUD
infection
meds
IBD
what are the diagnostic tests of choice for occult bleeding
Fecal occult blood test (FOBT)
fecal immunochemical test (FIT; cologuard)
if FOBT or FIT positive -> colonoscopy and EGD
