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GI 2 Exam 1 > DSA 5: Melena, Hematochezia > Flashcards

DSA 5: Melena, Hematochezia Flashcards

1
Q

what are the differential diagnoses for lower gastrointestinal bleed (LGIB) in patients UNDER 50?

A
  • infectious colitis
  • anorectal disease (anal fissures, hemorrhoids)
  • inflammatory bowel disease
  • meckel diverticulum
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2
Q

what are the differential diagnoses for lower gastrointestinal bleed (LGIB) in patients OVER 50?

A
  • malignancy
  • diverticuLOsis (outpouchings in colon wall, painless)
  • angiectasis
  • ischemic colitis (profuse, painful bleeding)
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3
Q

LGIB is defined as that arising below/distal to what?

A

ligament of Treitz

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4
Q

LGIB is less likely to present with what, when compared to UGIB?

A

shock or orthostasis requiring transfusions

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5
Q

what is the dx and tx of LGIB?

A
  • dx: colonoscopy in stable patients, vitals, CBC

- tx: 2 large bore IV’s, fluid bolus if signs of shock

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6
Q

what is the most common cause of major LGIB?

A

diverticulosis

  • herniation or saclike protrusions of the mucosa through the muscularis (painless)
  • most common in sigmoid colon
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7
Q

what is the dx and tx of diverticulosis?

A
  • dx: colonoscopy in stable patients, once bleeding subsides

- tx: self-limited, high-fiber diet, large bore IV’s

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8
Q

chronic relasping idiopathic inflammation of the GI tract

  • genetics and immune mechanisms play important role
  • increased intestinal permeability
  • irreversible impairment of GI structure/function
A

IBD

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9
Q

what is characterized as a Th1- and Th17-type disease?

A

Crohn’s

- driven by the production of TNF/IFN-gamma (Th1) and IL17 (Th17)

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10
Q

what is viewed as a Th2-type disease?

A

Ulcerative colitis

- increased mucosal expression of IL5 and IL13 (Th2 cytokines) produced by natural killer T cells

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11
Q

what region does Crohn’s usually present?

A

ileum and colon (may affect the entire GI tract)

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12
Q

what region does Ulcerative Colitis (UC) usually present?

A

**limited to the colon*

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13
Q

what is the wall appearance in Crohn’s?

A

thick, with strictures and fat-wrapping
- deep, knife-like ulcers

“skip lesions” primarily in small intestine and colon (most commonly in ileum and cecum)

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14
Q

what is the wall appearance in UC?

A

thin

  • superficial, broad-based ulcers
  • loss of haustra, crypt distortion

originates in the rectum and progresses proximally

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15
Q

what is seen during endoscopy of Crohn’s disease?

A

cobblestoning

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16
Q

what is seen during endoscopy of UC?

A

pseudopolyps

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17
Q
  • mucosal
  • colon only
  • continuous lesions
  • bloody diarrhea
  • tenesmus/fecal urgency*
  • crypt abscess
  • toxic megacolon (complication)
  • smoking protective**
A

UC

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18
Q
  • transmural
  • anywhere along GI tract
  • skip lesions
  • often without blood
  • acute ileitis (mimics appendix)
  • strictures (obstruction)
  • aphthous ulcers intervening with normal mucosa -> cobblestoning
  • smoking worsens disease**
  • CARD15/NOD2 on xsome 16p
A

Crohn’s

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19
Q

70% of patients with UC have antibodies against what serum marker?

A

ANCA

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20
Q

60-70% of patients with Crohn’s have antibodies against what serum marker?

A

saccharomyces cerevisiae (ASCA)

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21
Q

what is the tx for Crohn’s?

A
  • corticosteroids, immune-modulating agents, biologic agents

- antibiotics

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22
Q

what is the tx for UC?

A

corticosteroids, immune-modulating agents, biologic agents

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23
Q

what are the 3 mainstays of therapy for IBD?

A
  • 5-aminosalicylic acid derivatives
  • corticosteroids
  • immunomodulating agents
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24
Q

acute vascular obstruction that leads to sudden onset of cramping/left lower abd pain, desire to defacate, passage of blood or bloody diarrhea (hematochezia or bright red blood per rectum)

  • older pts with atherosclerotic dz most common
  • young pts with vaso-occlusive recreational drug use (cocaine)
  • abd Xray shows thumb-printing thickening of colonic wall
A

ischemic colitis

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25
Q

what is the most common area for ischemic colitis?

A

watershed area of splenic flexure

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26
Q

what is the tx of ischemic colitits?

A

NPO, IV fluids, surgical resection

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27
Q

periumbilical pain out of proportion to tenderness (physical exam isn;t impressive, but they are writhing in pain)*

  • food fear (abd pain worse after eating)
  • thumb-printing on abd Xray
A

acute mesenteric ischemia

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28
Q

what is the dx and tx of acute mesenteric ischemia?

A
  • dx: CT angiography diagnostic study of choice
  • tx: laparotomy indicated to restore intestinal blood flow obstructed by embolus or thrombosis
  • post-op anticoagulation indicated in mesenteric venous thrombosis
29
Q

associated with straining during bowel movements (constipation or pregnancy)

  • bright red blood per rectum, usually only drops on tissue or in toilet
  • seen on anal inspection or anoscopy
A

hemorrhoids

30
Q

what are the tx of hemorrhoids?

A
  • tx: bulk laxatives, stool softeners, sitz bath, witch hazel
  • bleeding may require rubber band ligation, or surgery
31
Q

what is the main complication of hemorrhoids?

A
  • *thrombosed external hemorrhoid**
  • may be precipitated by coughing, heavy lifting, or straining
  • acute onset very painful, gradually eases over 2-3 days
32
Q

severe, tearing pain during defecation followed by throbbing discomfort that may lead to constipation d/t fear of recurrent pain

  • may be associated hematochezia, with blood on stool or toilet paper
  • confirmed by visual inspection of the anal verge (DRE may be painful and may not be possible)
A

anal fissures

33
Q

what is the tx of anal fissures?

A

goal is to promote effortless, painless bowel movements

  • fiber supp
  • sitz baths
  • topical anesthetics may provide temporary relief
  • surgery in extreme cases
34
Q

how are most cases of proctitis transmitted?

A

sexually, especially by anal-receptive sex

35
Q

where should Neisseria gonorrhoeae swab specimens be taken from?

A
  • rectal swab
  • pharynx and urethra in men
  • pharynx and cervix in women
36
Q

how is Treponema pallidum diagnosed?

A

SYPHILIS!

  • dx: dark-field microscopy or fluorescent antibody testing from the chancre or condyloma
  • VDRL (STI test - venereal disease research lab) or RPR (rapid plasma reagent) is positive in 75% of primary cases and 99% of secondary cases
37
Q

what is a common cause of anorectal infection, that is diagnosed by viral culture, PC, or antigen detection assays of vesicular fluid

A

HSV type 2

38
Q

condylomata ACUMINATA, aka anal condylomas, aka genital warts must be distinguished from what?

A

condyloma LATA (secondary syphilis) or anal cancer

- biopsies should be obtained from large or suspicious lesions

39
Q

bleeding, pain, perianal mass

  • HPV is etiologic
  • W > M, but MSM at increased risk
A
  • anal cancer*
  • tx: radiation plus chemotherapy
  • abdominal-perineal resection with permanent colostomy for recurrent lesions
40
Q

poor anal hygiene associated with fistulas (also overzealous cleaning), fissures, prolapsed hemorrhoids, skin tags, minor incontinence

  • perianal itching and discomfort
  • dx on external inspection or anoscopy
A

perianal pruritus

41
Q

what is the tx of perianal pruritus?

A
  • *education**
  • avoid spicy foods, coffee, chocolate
  • appropriate cleaning after BM
  • topical glucocorticoid, antifungal agent if indicated
42
Q

what are the four major pathologic groups of polyps?

A
  1. mucosal adenomatous polyps (70%)
  2. mucosal serrated polys
  3. mucosal nonneoplastic polyps
  4. submucosal lesions
43
Q

adenomatous polyps and serrated polyps have what?

A

significant clinical implications

44
Q

what 4 criteria are important to consider for hereditary colorectal cancer and polyposis syndromes?

A
  • family hx of colorectal cancer, more than 1 family member
  • personal or family hx of colorectal cancer at an early age (under 50)
  • personal or family hx of multiple polyps (more than 20)
  • personal or family hx of multiple extracolonic malignancies
45
Q
  • *hundreds to thousands** of colonic adenomatous polyps and adenocarcinoma
  • 90% have mutation in APC gene (AD)
  • 8% have mutation in MUTYH gene (AR)
  • soft tissue tumors of the skin, congenital hypertrophy of retinal pigment epithelium (detected at birth)
A

familial adenomatous polyposis (FAP)

46
Q

what is the tx of FAP?

A
  • *complete proctocolectomy with ileoanal anastomosis** before the age of 20
  • prophylactic colectomy recommended to prevent otherwise inevitable colon cancer
47
Q

early onset colorectal cancer, polyps undergo rapid transformation over 1-2 years from normal tissue -> adenoma -> cancer
- DNA base-pair mismatches (MLH1, MSH2, MSH6, PMS2)

A

Lynch syndrome (Hereditary nonpolyposis colon cancer)

48
Q

what is the tx of Lynch syndrome?

A

subtotal colectomy with ileorectal anastomosis (followed by anal surveillance of the rectal stump)
- prophylactic hysterectomy and oophorectomy is recommended in women older than 40, or once they have finished child bearing d/t high risk of other cancers

49
Q

completely asymptomatic polyps

  • chronic occult blood loss may lead to iron deficiency
  • large polyps may ulcerate, resulting in intermittent hematochezia
A

non-familial adenomatous and serrated polyps

50
Q

what is the gold standard diagnostic tool for polyps?

A

colonoscopy

- remains the best test in most patients to detect and treat (polypectomy) colorectal polyps

51
Q

hamartomatous polyps throughout the GI tract, not malignant, may become large and bleed
- mucocutaneous pigmented macules on the lips, bucal mucosa and skin

A

Peutz-Jeghers syndrome (AD)

- serine threonine kinase 11 gene

52
Q

more than ten juvenile hamartomatous polyps located most commonly in the colon
- increased risk adenocarcinoma

A

familial juvenile polyposis (AD)

- loci on 18q and 10q (MADH4 and BMPR1A)

53
Q

hamartomatous polyps and lipomas throughout GI tract

- trichilemmomas (benign warty papules) and cerebellar lesions

A

PTEN multiple hamartoma syndrome (Cowden disease)

54
Q

when does the American Cancer Society recommend to start regular colorectal cancer screening?

A

age 45, colonoscopy every 10 years

- people in good health, with life expectancy more than 10 years

55
Q

what does the American Cancer Society recommend for colorectal cancer screening in patients ages 76-85?

A

decision to screen in based on a person preferences, life expectancy, overall health, and prior screening history

NOTE: people over age 85 should no longer get screened

56
Q

what is the recommended screening timeline for pt with first degree relative with colorectal cancer, or adenomas diagnosed at age <60, or two first-degree relatives at any age?

A

colonoscopy every 5 years, beginning at age 40**

- or 10 years before the age of the youngest affected relative

57
Q

what is the recommended screening timeline for pt with first-degree relative with colorectal cancer diagnosed at age >60, or by two second-degree relatives with colorectal cancer?

A

same as average-risk (colonoscopy every 10 years), but begin at age 40

58
Q

what is the recommended screening for pt with family hx of familial adenomatous polyposis?

A

annual screening by sigmoidoscopy, beginning age 10-12

59
Q

what is the recommended screening for pt with family hx of hereditary nonpolyposis colorectal cancer?

A

colonoscopy every 1-2 years, beginning at age 20-25, or 10 years younger than youngest age of colorectal cancer diagnosis in family

60
Q

what is the second most common internal cancer in humans?

A

colon cancer

61
Q

what do most colon cancers arise from?

A

adenomatous polyps

62
Q

there is a high prevalence of colon cancer in patients with what type of bacteremia?

A
  • *Streptococcus bovis**

- MUST screen for colon cancer!

63
Q

how does left-sided colon cancer usually present?

A
  • rectal bleeding
  • altered bowel habits (narrowing, constipation, diarrhea, tenesmus)
  • abdominal or back pain
64
Q

how does right-sided colon cancer usually present?

A
  • anemia
  • occult blood in stool
  • weight loss
  • perforation, fistula, volvulus, inguinal hernia
65
Q

what causes painless bleeding ranging from melena or hematochezia to occult blood loss
- is most commonly in pts over 70 years old, with chronic renal failure or aortic stenosis

A

arteriovenous malformations (AVM)

66
Q

what is the dx for AVM?

A

CBC with iron studies (will show iron deficient anemia)

- triggers us to do endoscopy, upper EGD, lower colonoscopy, capsule

67
Q

what is intussusception?

A

telescoping bowel

  • rare, more common in kids
  • causes jelly consistency BM currant jelly stool
68
Q

remnant of Vitelline duct

  • Rule of 2’s
  • adults may present with intestinal obstruction, rectal bleeding, intussusception, perforation, or diverticular inflammation
  • dx: technetium-99m scan
A

Meckel’s diverticulitis

GI 2 Exam 1 (22 decks)

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