DSA 4: Melena, Hematochezia Occult GIB Flashcards
what is the Hx and PE of crohns dz
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)
what is arteriovenous malformation (AVM) aka angioectasias
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)
how do you Dx and Tx Lynch syndome (HNPCC)
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)
what is considered avg risk for colorectal CA
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)
what is the work up for IBD
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
what is diagnostic of occult GI bleeds
how does evaluation change based on presentation and age?
(+) 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
what is etiology, Hx & PE for Lynch syndrome (aka HNPCC)
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
what is the Hx & PE of hemorrhoids
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
what are extra-intestinal manifestations of IBD
pyoderma gangrenosum
oral aphthous ulcer
toxic megacolon
iritis, anterior uveitis
ankylosing spondylitis
erythema nodosum
what are the treatments and complications of crohns
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
what is hereditary colorectal CA & polyposis syndrome
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
how do you Dx, treat and prevent colon CA
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
how do you Dx and Tx anal fissures
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
what are treatment options of IBD
5-aminosalicylic acid derivatives
corticosteroids
immunomodulating agents
biologic agents
what is the epidemiology of IBD
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
what is Dx and Tx of LGIB
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
what are dx factors of nonfamilial adenomatous & serrated polyps
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
what is the Diagnostic imaging used to work up IBD
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
what is the DDx of hematochezia/melena
Upper GIB (PUD & Varices) Infectious colitis
Intussusception
Meckel’s diverticulum
Varices (Colon)
Radiation colitis
NSAID-induced ulcers
Rectal ulcer
What is the Hx and PE for UC
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
what is the etiology of diverticulosis
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
what are complications of hemorrhoids
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
how can upper GIB present?
melena
hematochezia (if rapid presentation)
how do you dx & tx hemorrhoids
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
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
what is the DDx of LGIB in pt > 50 yo
malignancy
diverticulosis
angiectasias (AVM, angiodysplasia)
ischemic colitis
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
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)
what are hamartomatous polyposis syndromes
Peutz-Jeghers syndrome
familial juvenile polyposis
PTEN multiple hamartoma syndrome (Codwen dz)
how can lower GIB present
hematochezia
below (distal) of ligament of Treitz
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
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
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
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
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
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
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)
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)
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
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
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)
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
what is the DDx for LGIB in pt < 50 yo
infxous colits
anorectal dz (anal fissure, hemorrhoids)
IBD
meckel diverticulum
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 =
- neoplasm
- vascular abn (angioectasia)
- acid-peptic lesions (esophagitis, PUD, erosion of hiatal hernia)
- infxn (nematode, esp hookworm; TB)
- meds (esp NSAIDs or ASA)
- IBD (CD > UC)
what is cowden dz
hamartomatous polyps & lipomas throughout GI tract trichilemmomas, and cerebellar lesions
increased rate of malignancy - thyroid, breast, and urogenital tract
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
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
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
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
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
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
