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GI/GU II Exam 1 > DSA 4: Melena, Hematochezia Occult GIB > Flashcards

DSA 4: Melena, Hematochezia Occult GIB Flashcards

1
Q

what is the Hx and PE of crohns dz

A

insidious onset, intermittent bouts of fever

Cramping or steady right RLQ or periumbilical pain

Diarrhea (w/ or w/o blood), fatigue, malaise, wt loss, growth retardation in kids

acute ileitis (mimics appendicitis), abscesses

strictures (obstruction), fistulas, anorectal fissures

smoke tobacco_/recent onset of cigarette smoking_

PE: Vital signs (fever) RLQ ttp & possible mass (thickened bowel)

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2
Q

what is arteriovenous malformation (AVM) aka angioectasias

A

Usually a form of occult gib; Fe def anemia
Angioectasias (angiodysplasias)–> painless bleeding (melena or hematochezia to occult blood loss); if proximal to ligament of trietz = melena

MC > 70 years and pts w/ chronic renal failure or aortic stenosis

Diagnostics: CBC w/ iron studies (trigger for endoscopy, upper EGD, lower colonoscopy, capsule)

Endoscopic workup as above ; (capsule endoscopy canNOT be diagnostic and therapeutic)

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3
Q

how do you Dx and Tx Lynch syndome (HNPCC)

A

AD- evaluate families 1st by genetic counselor & give informed consent before genetic testing is performed

detection defect of DNA base-pair mismatches: MLH1, MSH2, MSH6, and PMS2.

Diagnosis suspected by tumor tissue immunohistochemical staining for mismatch repair proteins or microsatellite instability

confirmed by genetic testing

Subtotal colectomy w/ ileorectal anastomosis (followed by annual surveillance of the rectal stump)

Women - screen for endometrial and ovarian CA beginning at 30–35 yo w/ pelvic examination, transvaginal US, and endometrial sampling - Prophylactic hysterectomy & oophorectomy recommended - women @ 40 yo or once finished childbearing yrs

Screen for gastric CA w/ upper endoscopy considered every 2–3 years starting at 30–35 yo

Genetic testing + Lynch syndrome gene mutation:

Affected relatives screened w/ colonoscopy every 1–2 yrs beginning at age 25 (or 5 yr younger than age of Dx of the youngest affected family member)

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4
Q

what is considered avg risk for colorectal CA

A

pt that DO NOT have

personal Hx of colorectal CA or certain polyps, IBD, radiation to the abd/pelvic area

FHx of colorectal CA

confirmed/suspected hereditary colorectal CA syndrome (FAP or Lynch Syndrome)

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5
Q

what is the work up for IBD

A

blood work - CRP > ESR; CBC (anemia, leukocytosis, thrombocytopenia); iron studies; chemicstry (electrolytes; renal/live; albumin)

serum (anti-neutrophil cytoplasmic Ab) ANCA 70% UC & (Ab to sacchoromyces cerevisiae) ASCA 60-70% CD

stool studies: stool culture, c. diff toxin, ova/parasite, fecal lactoferrin (intestinal inflam) & calprotectin (correlate w/ histological inflam)

diagnostic imaging

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6
Q

what is diagnostic of occult GI bleeds

how does evaluation change based on presentation and age?

A

(+) fecal occult blood test (FOBT), fecal immunochem test (FIT) or Fe def anemia in absence of visible blood loss

if labs (+) and pt asymp –> colonoscopy

if labs (+) & pt symp –> evaluate GI tract w/ colonoscopy and upper endoscopy

pt w/ Fe def anemia –> evaluate for possible celiac dz

if <60 yo w/ unexplained bleeding/anemia –> further evaluation exclude SI neoplasm or IBD

>60 w/ normal endoscopic evaluation (1st think colon CA in person >45) and if no worrisome signs MC = angioectasias

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7
Q

what is etiology, Hx & PE for Lynch syndrome (aka HNPCC)

A

risk of colorectal CA (22-75%); Endometrial CA (30-60%); Other CA (ovarian, renal or bladder, hepatobiliary, gastric, andsmall intestinal cancers) develop at a young age

evaluate pt w/ persona; Hx of early-onset colorectal cancer or FHx colorectal, endometrial, or other Lynch syndrome-related CA at young age or in multiple members

polyps undergo rapid transformation over 1–2 yrs: normal tissue → adenoma → CA

Hx/PE

thorough FHx of CA, identify families that may be affected, appropriate genetic/colonoscopic screening

Multisociety guidelines recommend- all colorectal CA should undergo testing for Lynch syndrome w/ either immunohistochemistry/ microsatellite instability.

Universal testing = greatest sensitivity fx Dx and is cost-effective

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8
Q

what is the Hx & PE of hemorrhoids

A

due to increased hydrstatic pressure in hemorrhoidal venous plexus (associated w/ constipation or pregnancy)

may be external, internal, thrombosed, acute (prolapse/strangulation) or bleeding

BRB per rectum - usually only drops on tissue or in toilet

protrustion w/ discomfort (pain/itch)

DRE: palpated, possible gross blood

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9
Q

what are extra-intestinal manifestations of IBD

A

pyoderma gangrenosum

oral aphthous ulcer

toxic megacolon

iritis, anterior uveitis

ankylosing spondylitis

erythema nodosum

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10
Q

what are the treatments and complications of crohns

A

corticosteroids, immunomodulating agents & biologic agents, ABx

blood transfusion if needed, colon CA surveillance, IVF w/ NGT suction, percutanoues drainage of abscesses, SRG ONLY if necessary

complication: fistula, abscess, stricture, obstruction, bile salt malabs (secretory diarrhea) –> gallstones or oxalate kidney stones, colon CA

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11
Q

what is hereditary colorectal CA & polyposis syndrome

A

up to 4% of all colorectal CAs bc germline mutation

imp to cosiders in pts w/

  • FHx colorectal CA - affected > 1 person
  • personal or FHx colorectal CA @ early age (<50 yo)
  • personal or FHx of multiple polyps (>20)
  • personal or FHx of multiple extracolonic malignancies
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12
Q

how do you Dx, treat and prevent colon CA

A

early Dx aided by screening asymp ppl - FOBT

(>50% cases w/i reach of 60 cm flexible sigmoidoscope) - 85% that are not w/i reach dx by air contrast barium enema

SRG: duke’s classification (degree of invasion) = best predictor of prognosis’ chemo/radiation

prevention: colonoscopy starting at 45 yo (most sensitve & specific - tumor Bx & removal of synchronous polyps - prevent neoplastic conversion) & screening at 40 or 10 yrs before age of first degree relative when diagnosed)

routine screening of stool, annual DRE

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13
Q

how do you Dx and Tx anal fissures

A

external anal inspection or anoscopy

Goal = effortless, painless bowel movements==> fiber supplements & sitz baths ; topical anesthetics - temporary relief

relaxation of anal canal w/ nitroglycerin ointment or botulinum toxin type A

SRG: Internal anal sphincterotomy in refractory cases

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14
Q

what are treatment options of IBD

A

5-aminosalicylic acid derivatives

corticosteroids

immunomodulating agents

biologic agents

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15
Q

what is the epidemiology of IBD

A

Westernized nations; Urban>Rural; Higher SES > lower SES

environmental factors + similar genetic backgrounds

bimodal distribution (20-40 & 70-90); not gender specific

Jewish > Non-Jewish Caucasian > African Americans > Hispanic > Asian

OCP –> increase incidence of CD

Appendectomy for confirmed appendicitis (< 20 yo) may protect against developing UC

ABx use w/i 1st yr of life –> 2.9 x increased risk of IBD in childhood

Breastfeeding may be protective

infxn with - Salmonella, Shigella, Campylobacter or C. Diff increases risk of IBD 2-3 x

diet- high in animal protein, sugars, sweets, oils, fish and shellfish, high omega 6 & low omega 3 dietary fat

5-10% familial association

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16
Q

what is Dx and Tx of LGIB

A

vital signs, CBC, anoscopy, evaluation w/ colonoscopy in stable pt, sigmoidoscopy, EGD, angiography or nuclear bleeding scan

identify & stablize unstable pt; fluids if signs of shock, blood transfusion if indicated, endoscopic Tx

2 large bore IVs

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17
Q

what are dx factors of nonfamilial adenomatous & serrated polyps

A

radiologic tests:

  • barium enema (not recommended) or CT colonography - 2D, 3D immage of colon (only for low risk pts) - require bowel cleansing prep
  • detection of polyps > 10 mm (accuracy lower for 5-9mm) - Diagnostic but NOT therapeutic
  • • Abd CT imaging –> radiation exposure –> small risk of CA

endoscopic test :Colonoscopy: Remains the best test in most pt to detect and treat (polypectomy) colorectal polyps

  • requires colon prep; Diagnostic and therapeutic;
  • all pt w/ (+) FOBT, FIT, fecal, or DNA tests or Fe def anemia
  • increases prevalence of colonic neoplasms
  • polyps detected on radiologic imaging studies (barium enema or CT colonography); adenomas detected on flexible sigmoidoscopy
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18
Q

what is the Diagnostic imaging used to work up IBD

A

single contrast barium enema :

string sign - narrowing from inflam/stricture in CD

lead pipe colon - loss of haustra in UC

CT w/ IV & oral contrast, CT or MR enterography oral and IV contrast, MR > CT for CD pelvic lesion, sigmoidoscopy, colonoscopy, esophagoduodenoscopy

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19
Q

what is the DDx of hematochezia/melena

A 
Upper GIB (PUD & Varices)
Infectious colitis

Intussusception

Meckel’s diverticulum

Varices (Colon)

Radiation colitis

NSAID-induced ulcers

Rectal ulcer

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20
Q

What is the Hx and PE for UC

A

bloody diarrhea, tenesmus/fecal urgency, recently stopped smoking

mucus, fever, abd pain (diffuse, periumbilical, L-sided), wt. loss, lower abd cramps relieved by defecation

erythema nodosium, pyoderma ganglrenosum, primary sclerosing cholangitis

severe - 6+ bloody BM/day - dehydration, hypovolemia, anemia, hypoK, fulminant colitis –> rapidly worsen –> signs of toxicity –> may lead to toxic megacolon

PE: vitals (fever, tachycardia, hypotension, LLQ, periumbilical or diffuse ttp, DRE -gross bright red blood

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21
Q

what is the etiology of diverticulosis

A

herniation or saclike protrusions of mucosa through muscularis at points of nutrient A penetration

MCC = major lower tract bleeding

MC sigmoid colon

possibly due to increase intraluminal pressure, low fiber diet

incidence increase w/ age

pt w/ abn CT –> develop diverticulosis, ehlers-danlos syndrome, marfans syndrome & scleroderma

90% uncomplicated

22
Q

what are complications of hemorrhoids

A

Thrombosed External Hemorrhoid

precipitated by coughing, heavy lifting, or straining at stool

acute onset= painful, tense and bluish perianal nodule covered w/ skin

pain is most severe w/in first few hours & gradually eases over 2–3 days as edema subsides

relieved w/ warm sitz baths, analgesics, &

ointments.

if evaluated in first 24–48 hrs, removal of clot may hasten symptomatic relief

23
Q

how can upper GIB present?

A

melena

hematochezia (if rapid presentation)

24
Q

how do you dx & tx hemorrhoids

A

external anal inspection or anoscopy

Tx pain w/ bulk laxative & stool softeners, sitz baths, witch hazel compresses, analgesics

bleeding may require rubber band ligation or injection sclerotherapy, or surgery

25
differentiate the histology and gross presentation fo crohns & UC
crohns: cobblestoning, fat-wrapping, fissures, thickened wall, non-caseating granuloma UC: ulcerations, survivng mucosa (pseudopolyps), loss of haustra
26
what is the DDx of LGIB in pt \> 50 yo
malignancy diverticulosis angiectasias (AVM, angiodysplasia) ischemic colitis
27
what are characteristic of LGIB
severity - mild anorectal bleed --\> massive large-vol hematochezia tend be benign (BUT can still get hypovolemia) spontaneous cessation of bleeding in 75% & hospital mortality \< 4% mixed w/ solid brown stool = mild, usually from angiorectosigmoid _MC serious LGIB - older males_ increased risk LGIB bleeding in pts taking ASA, nonaspirin antiplatelet agents, _NSAIDS_
28
what are the clinical findings and tx's of nonfamilial adenomatous& serrated polyps
most pts completely asymp chronic occult blood loss --\> Fe def anemia large polyps - ulcerate --\> intermittent hematochezia Tx: colonoscopy polypectomy: colonoscopic removal w/ Bx forceps or snare cautery; Complications= perforation and **significant bleeding** **postpolypectomy surveillance**- periodic colonoscopic surveillance _recommended_ bc no bleeding (3-10 yrs depending on type of polyp, histologic features, and how many)
29
what are hamartomatous polyposis syndromes
Peutz-Jeghers syndrome familial juvenile polyposis PTEN multiple hamartoma syndrome (Codwen dz)
30
how can lower GIB present
_hematochezia_ below (**distal**) of **ligament of Treitz**
31
what is familial juvenile polyposis
AD =several (\> 10) juvenile hamartomatous polyps **MC in colon** increased risk (up to 50%) of adenoCA- bc synchronous adenomatous polyps or mixed hamartomatous- adenomatous polyps Defects = 18q and 10q (MADH4 and BMPR1A) Genetic testing available
32
who has abv avg risk for colorectal CA (CRC)
**1st degree relative** **w/ CRC or adenoma diagnosed \< 60 yo OR 2 1st degree relatives at any age** - screen every 5 yrs, beginning at 40 yo OR _10 years before the age of youngest diagnosed fam member_ **if relative \> 60 yo at diagnosis;** start screening at 40 yo **FAP**- genetic test/annual screening by sigmoidoscopy begining @ **10-12 yo** **HNPCC:** genetic test/ colonoscopy beginning at _20-25 yo_ or _10 years before the age of youngest diagnosed fam member_
33
what is the imaging & tx used for ischemic colitis
_abd x-ray:_ colonic dilation; **thumb-printing** _sigmoidoscopy:_ submucosal hemorrhage, friability, ulceration; *rectum often spared* Tx: NPO, IV fluids, blood products; surgival resection for infarction/post-ischemic stricture
34
what are the american cancer society guidelines for colorectal cancer screening
**start regular screening at 45 -** continue _thru 75 yo_ **75-85**- pts preference **\> 85 no longer**
35
how do you tx diverticulosis
uncomplicated: High-fiber diet, psyllium extract, anticholinergics hemorrhage: self-limited, hemodynamic support if needed Identify and stabilize unstable pt - fluid if under shock; blood transfusion if needed CBC, Chemistry Profile, INR/Pt/Ptt 2 large bore IV’s
36
what is the etiology colon Ca (adenoCA) how does it present
2nd MC internal CA; 10% of cancer-related deaths in USA **\>45 yo** freq located R colon (present before 50); (main side of metastasis = liver) most from adenomatous polyps pts with **Streptococcus bovis bacteremia**. (aka **Streptococcus gallolyticus** ) **L-sided CA: = MC** - rectal bleeding, altered bowel habits (narrowing, constipation, intermittent diarrhea, tenesmus), abdback pain **R-sided CA** (cecal & ascending colon CA) - sxs of anemia (50%), occult blood in stool, wt loss; other complications: perforation, fistula, volvulus, inguinal hernia
37
what are tests & screening techniques used for CRC
FOBT fecal DNA test FIT= Hbg thats more sensitive than FOBT dna test & FIT combo approved by FDA (cologaurd)
38
what is the etiology, Hx and PE of familial adenomatous polyposis
Early development- **100-1000s** colonic adenomatous polyps and adenoCA 1:10,000 people & = 0.5% of colorectal cancer Hx/PE Adenomatous polyps of duodenum and periampullary area develop; extracolonic ( duodenal adeonma, desmoids and osteomas) Extraintestinal manifestations:: soft tissue tumors- skin, desmoid tumors, osteomas, and **congenital hypertrophy of retinal pigment epithelium (detected at birth)**
39
how do you Dx & Tx FAP
90% mutations= **APC gene** (inherited, AD) 8% mutations = **MUTYH gene** (inherited, AR) de novo- 15% pts Genetic counseling/testing should be offered to pts found to have multiple adenomatous polyps at endoscopy and to 1st-degree family members **Tx: Complete proctocolectomy w/ ileoanal anastomosis recommended before age 20 years. _Prophylactic colectomy_ recommended to prevent inevitable colon cancer**
40
what is the etiology, Hx and PE of anal fissure
Linear or rocket-shaped ulcers (\< 5 mm) in length trauma to anal canal during defecation, maybe bc straining/constipation Posterior midline severe, tearing pain during defecation --\> then **throbbing discomfort --\> may lead to constipation** due to _fear of recurrent pain_ _mild associated hematochezia, w/ blood on stool or toilet paper_ confirmed by visual inspection of the anal verge while gently separating the buttocks DRE - severe pain and may not be possible
41
what occurs in IBD
chronic state of dys-inflam normal homeostasis btn - microbiota, epithelial cells that line interior of intestines (intestinal epithelial cells), immune cells w/ tissues disrupted by environment (Abx, smoking, enteropathogens, diet, NSAIDs); genetic (polygenic)
42
what are types of crohns dz fistulas
* colovesical- colon - bladder * enterovesical- small bowel - bladder * colovaginal- colon - vagina * enterovaginal- small bowel - vagina * enterocolonic- small bowel - colon * colocutaneous- colon - skin * enterocutaneous- small bowel - skin * entero-enteral- small bowel - small bowel * anorectal- rectum - anus
43
what is the DDx for LGIB in pt \< 50 yo
infxous colits anorectal dz (anal fissure, hemorrhoids) IBD meckel diverticulum
44
what is the Hx & PE of occult GI bleed
_signs of anemia_ - **fatigue**, SOB may arise from anywehere in GI tract **MCC of occult bleeding w/ Fe def =** 1. **neoplasm** 2. vascular abn (_angioectasia)_ 3. acid-peptic lesions (esophagitis, PUD, erosion of hiatal hernia) 4. infxn (nematode, esp hookworm; TB) 5. meds (esp NSAIDs or ASA) 6. IBD (**CD** \> UC)
45
what is cowden dz
hamartomatous polyps & lipomas throughout GI tract _trichilemmomas_, and cerebellar lesions increased rate of malignancy - thyroid, breast, and _urogenital tract_
46
what is Peutz-Jeghers syndrome & how do you Dx
=AD = hamartomatous polyps throughout the GI tract (esp SI) May become large, leading to bleeding, intussusception, or obstruction Not malignant Mucocutaneous pigmented macules on the lips, buccal mucosa, and skin ser/thr kinase 11 gene and genetic testing
47
what is the Hx and PE of LGIB
**hematochezia** abd pain PMHx: prior bleeds, Hx of IBD, diverticular dz, aortic stenosis/renal dz (AVM, angtioectasia, telangictasia, angiodysplasia), liver dz (portal htn cause varices) SHx: alc abuse; colonic varies Meds: NSAIDs & anticoag; meds w/ iron/bismuth; **liquid med or certain foods w/ red dye (kool-aid & beets) can stimulate hematochezia**
48
What is the Hx, PE and Dx of diverticulosis
hematochezia, maroon stool, abd pain **acute, PAINLESS, large vol maroon or bright red** hematochezia in pt \> 50 yo *hemorrhage:* _absence of diverticulitis_ - from ascending colon & typically self-limited Dx: vital, clincal Hx, CBC, chem profile, INR, PT/PTT **evaluation w/ colonoscopy in stable pt, once bleeding _subsides_**
49
what are the signs of ischemic colitis
acute vascular obstruction --\> **sudden onset of cramps LLQ, desire to defecate, pass blood or blood diarrhea (hematochezia or BRB/rectum)** _MC: older pts_ (atherosclerotic dz) young pt on vaso-occlusive recreational drug (cocaine), pts w/ vasculitis, coag disorder, estrogen therapy, **long-distance running** **watershed area of splenic flexure**
50
What are the Tx and complications for UC
**corticosteroids, immunomodulating agents & biologic agents** blood transfusion if indicated, colon CA surveillance, SRG can be curative complication: sever hemorrhage, _toxic megacolon_, colonic perforation, colon dysplasia, _colon CA_
51
if you have a premenopausal F presenting w/ Fe def anemia, what do you think it is?
MC attributable to mentrual & preg-associated Fe loss

GI/GU II Exam 1 (16 decks)

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