DSA WL and FAtigue Flashcards
What nutrients are absorbed in the proximal SI?
- Iron
- Ca2+
- Folate
- Fats
- Carbs
- TAGS
What nutrients are absorbed in the distal SI?
- Vitamin B12
- Bile salts
- Water
What nutrients are absorbed in the colon?
- Water
- Electrolytes
______________ difficulty initiating or maintaining voluntary mental or physical activity.
Fatigue
Differential Dx Fatigue
- Occult GI Bleed
-
Cancer
- Esophageal
- Gastric
- Colon
- Pancreas
- Liver (HCC and Cholangiocarcinoma)
- GB
- IBD
- Chronic liver disease
-
Malnutrition/malabsoprtion
- Celiac
- Chronic Pancreatitis/ Pancreatic insufficieny/ CF
- Bile salt malabsorption
- Whipple Disease
Differential Dx: Unintentional WL
- Cancer
- Malabsorption Syndromes
- IBD
- Poor dentition
When diagnosing Fatigue
- What is CRITICAL?
- What must we distinguish, review and what is neecessary to understand the patients experience and gauge recovery and success of treatment?
- What can raise our suspicions o_f occult infection_ or malignancy?
- DETAILED HISTORY is CRITICAL
- In ROS, we must distinguish fatgue from excessive sleepiness, dyspnea on exertion, excercise intolerance and muscle weakness.
- Review patients meds/drugs/alcohol, life stressors, sleep habits and sleep hygeine.
- ASK how fatigue is impacting daily functioning => understand experience and used to to compare treatments
- Fever, chills, night sweats, WL = occult infection or malignancy.
How is fatigue diagnosed?
- Lab testing will only diagnose chronic fatigue 5% of the time => let H&P guide labs.
What labs should we run, based on the H&P, for fatigue?
- CBC + differential (anemia, infection and cancer)
- Electrolytes (K, Na , Ca, glucose, liver and renal fx)
- Thyroid function
- HIV
- Adrenal function
- ESR (Erythrocye sedmentation rate); looks for mimics
__________ =not informative in isolation in patients with fatigue and is + at low titers in healthy people
_________ are not indicated in patients with fatigue because inconentient, risk, costly and show unrelated findings.
- Routine screening with antinuclear antibody (ANA)
- Whole-body image scans
Rapid fluctuations of weight over days = ___________, whereas long-term changes = _________
Rapid fluctuations of weight over days suggest loss or gain of fluid, whereas long-term changes usually involve loss of tissue mass.
Loss of _____ of body weight over ____ months should prompt further evaluation.
Loss of 5-10% of body weight over 6 months should prompt further evaluation.
Common causes of unintentional weight loss:
In older persons
- Cancer (lung cancer and GI cancers)
- Benign GI disease
- Depression
Common causes of unintentional weight loss:
In younger persons
- DM
- Hyperthyroidism
- Anorexia nervosa
- Infection (HIV)
When taking a history in unintentional weight loss, what should you ask?
A history of GI symptoms, including difficulty eating, dysgeusia (distorted sense of taste), dysphagia, anorexia, nausea, and change in bowel habits.
When taking a PE in unintentional weight loss, what should you do?
- START with weighing them
-
All men = rectal and prostate exam
- cancer
-
All women = pelvic exam
- cancer
- Both = stool for occult blood
Before extensive evailation is done for unintentional WL, what must be done?
Confirm WL HAS occured (up to 50% of claims cannot be proven); if no docutmention, changes in clothes or belt size
What GI disorders can cause WL?
- Malabsorption
- Obstriction
- Peptic Ulcer
- Celiacs
- IBD
- Pancreatitis
- Perncious anemia
Occult GI Bleed = bleeding that is not apparent to patient.
- Symptoms
- MCC causes occult bleeding with iron deficiency
- Symptoms can be similar to signs of anemia: Fatigue, shortness of breath
- The most common causes of occult bleeding with iron deficiency are
- (1) neoplasms
- (2) vascular abnormalities (angioectasias)
•(3) acid-peptic lesions (esophagitis, peptic ulcer disease, erosions in hiatal hernia)
- (4) infections (nematodes, especially hookworm; tuberculosis)
- (5) medications (especially NSAIDs or aspirin)
- (6) inflammatory bowel disease (CD > UC)
Common causes of occult blood loss
- Nonfamilial adenomatous & serrated polyps
- Familial Adenomatous Polyposis (FAP)
- Lynch Syndrome
- Angioectasias (angiodysplasias)
You will need to remember: In premenopausal women, iron deficiency anemia is most commonly attributable to
- menstruation
- pregnancy-associated iron loss
Dx Occult GI Bleed (3)
- positive (fecal occult blood test) FOBT,
- (fecal immunochemical test) FIT,
- Iron deficiency anemia in the absence of visible blood loss.
Patients with iron deficiency anemia should be evaluated for possible:
Celiac disease with either:
- IgA anti-tTG
- Duodenal biopsy
In patients, younger than 60 years, with unexplained occult bleeding or iron deficiency anemia
it is recommended to pursue,
Further evaluation of the small intestine for a source of obscure-occult bleeding in order to exclude a small intestinal neoplasm or IBD
1st thing you think of person over 45 with iron-def anemia think ________
Colon Cancer
Patients over age 60 with occult bleeding who have a NL initial endoscopic evaluation and no other worrisome symptoms or signs (eg, abdominal pain, weight loss) most commonly have ____________.
blood loss from angioectasias
NONFAMILIAL ADENOMATOUS & SERRATED POLYPS
Clinical Findings:
Diagnosis:
-
Clinical Findings
- Completely Asymptomatic
-
Diagnosis
- Endoscopy = Colonoscopy = best test to treat and detect polypectomy colorectal polyps
- Radiology
- CT colonscopy = (okay for low risk pts)
*
- CT colonscopy = (okay for low risk pts)
NONFAMILIAL ADENOMATOUS & SERRATED POLYPS
CT Colonoscopy
- Detection polyps larger = _____mm (diagnostic but NOT therapeutic)
- Accuracy for detection of polyps _____ size is significantly lower
- Detection polyps larger > 10mm (diagnostic but NOT therapeutic)
- Accuracy for detection of polyps 5–9 mm in size is significantly lower
NONFAMILIAL ADENOMATOUS & SERRATED POLYPS
Treatment and Management?
Complication of the treatment?
-
Colonoscopic Polypectomy = colonoscopic removal with biopspy foreceps
- Complications: perforation and BAD bleedings
- Postpolypectomy surveillance for 3-10 years.
-
Familial Adenomatous Polyposis (FAP) = Early development 100s to 1000s of colonic adenomatous polyps and adenocarcinoma
- What are extraintestinal manifestions you see in H&P that can be an early sign for surveillance?
- congenital hypertrophy of the retinal pigment epithelium (detected at birth)
In FAP, 90% of people have a _____ disorder where there is a mutation in _______ gene;
8% have a ______ disorder where there is a mutation in ______ gene.
- In FAP, 90% of people have a AD disorder where there is a mutation in APC gene;
- 8% have a AR disorder where there is a mutation in MUTYH gene.
How do you treat and manage FAP?
- Complete proctocolectomy with ileoanal anastomosis is recommended usually before age 20 years.
- Prevention of colon cancer= Prophylactic colectomy
Lynch Syndrome (HNPCC) poses a lifetime risk of what?
Who quickly do the polyps progress to cancer?
- Colorectal cancer (22-75%); endometrial cancer (30-60%); other cancers develop at a young age.
- Rapidly; 1-2 years from NL => adenoma => cancer
Multisociety guidelines recommend that ALL colorectal cancers should undergo testing for__________ with either _________ or _______
- Multisociety guidelines recommend tha tall colorectal cancers should undergo testing for Lynch syndrome with either immunohistochemistry or microsatellite instability.
Lynch syndrome: mutation in ogenes that are important in the detection and repair of ______________
Lynch syndrome => defect in one of several genes that are important in the detection and repair of DNA base-pair mismatches (MLH1, MSH2)
Lynch Syndrome;
- Diagnosis suspected:
- Diagnosis confirmed:
- Diagnosis suspected:
- tumor tissue immunohistochemicalstaining for mismatch repair proteins
- testing for microsatellite instability
- Diagnosis confirmed:
- genetic testing
Lynch Syndrome:
- Treatment and management?
- Subtotal colectomy with ileorectal anastomosis (followed by annual surveillance of the rectal stump)
What screenings should be done in patients with HNPCC?
- Beginning at 30–35YO: W screened for endometrial and ovarian cancer
- 40 or stop having children: recommended for women to have prophylactic hysterectomy and oophorectomy.
- @ 30-35YO: Gastric cancer with upper endoscopy => every 2–3 years
Familial juvenile polyposis increases risk ______
Adenocarcinoma by 50%.
PTEN multiple hamartoma syndrome (Cowden disease) has what findings on PE?
Increases risk of what?
- Harmatomatous polyps and lipomas t/o GI tract, trichemmonas and cerebellar lesions.
- Thyroid, breast and GU tract cancers
Angioectasias (angiodysplasias) cause what kind of bleeding?
Who is it most common in?
Painless bleeding ranging from [melena = hematochezia = occult blood loss]
- Melena if above ligament of trietz
Chronic renal failure or aortic stenosis.
Esophageal cancers:
Esophageal SqCC = Most common type of esophageal cancer in the world
- Who is it found in?
- RF?
- Symptoms?
- Dx
- Located?
- AA Males >50
-
Smoking + alcochol
- Esopheageal disorders: achalasia, HPV, Plemmer Vinson syndrome, Tyolsis
- Progressive dysphagia, WL, anorexia, bleeding, hoarsness and cough
- EGD + biospy
- 50% in the middle 1/3)
*
Esophageal cancers:
-
Esophageal Adenocarcinoma
- Who is it found in?
- RF?
- Dx
- Located?
- Caucasian Males
- Barrets metaplasia => dysplasia => adenocarcinoma
- EGD + biopsy
- Distal 1/3
Gastric Adenocarcinoma
- Histology:
- Signs:
- RF:
- Signet ring cells
- Linitis plastica, virchows node
- RF
- Dietary factors
Colon cancer (adenocarcinoma)
- Age of onset: ___
- Occurs in high prevelance in people with ___________.
- When should we start screening?
- >45YO
- Strep bovis bacteremia
- 45 YO: If 1st degree relative = starts at 40YO or 10 years earlier than 1st degree relative diagnosed.
In patients with Colon Cancer, early diagnosis is done how?
Screen asympmatic patienst with fecal occult blood testing
- Rectal bleeding, altered bowel habits, abdominal or back pain
- Anemia, occult blood in stool, WL; perforation, fistula, volvulus, inguinal hernia
What kind of colon cancers?
- L
- R
Painless jaundice, N/V, WL, Steatorrhea. If pain, typically mid epigastric that radiates to the back, hurts most at night when laying down.
Sxs of ______
Pancreatic cancer
Treatment and managment of patient with Liver cancer: hepatocellualr caricnoma
- Surgical resection or liver transplant = therapeutic but rarely successful
- Radiofrquency ablation
- TACE (transcathetic arterial embolization)
LIVER (BILE DUCT) CANCER: CHOLANGIOCARCINOMA
Classic risk factor is _______.
Primary sclerosingcholangitis (PSC)
- Which of the following usually has non-bloody diarrhea?
- Mimic appendicits?
- Treated with corticosteroids, corticosteroids, immunomodulating agents, and biologic agents, ABX
- One question we should ask in Crohns
UC/Crohns?
- Crohns; MC in TI =>
- RLQ => Acute iletis => mimic appendicits
- recently started to smoking?
_______ is associated with the cessation of smoking.
UC: Bloody diarrhea + fecal urgency
What is the treatment of UC?
- Corticosteroids, immunomodulatingagents, and biologic agents
- Surgery = curative
Chronic hepatitis
- What is it?
- Common symptoms?
- What is seen in HBV HCV?
- Diagnosis
- Chronic inflammtion of the liver for at least 6 months.
- Fatigue, Malaise
- HBV = polyartertis nodosa
- HCV = mixed cryoglobinemia
- Dx: Biopsy for Histology
_____________ and/or _____________ can tell us whether or not we have fibrosis (cirrhosis) in chronic hep
- Serum FibroSure
- US elastography
SAAG >1.1 g/dL indicates _______
Cirrhosis
What are signs of Cirrhosis?
- Spider telangiectasias (on the upper half of the body)
- Palmar erythema (mottled redness of the thenar and hypothenar eminences)
- Dupuytren contractures
- Vit def (glossitis and cheilosis)
- Jaundice
- Caput medusa = obstruction of protal BF => superfical veins of abdomen and thorax = dilated
How can we definitively diagnose cirrhosis?
- Biopsy => histological classification (grade and stage), telling us degree of fibrosis
- Serum fibrosure
- US elastography
Cirrhosis, what do we see on the following?
- CBC
- INR
- Chemistry
- Serum
- US
- CBC
- Microcytic anemia d/t blood loss; macrocytic due to folate def
- Pancytopenia (hypersplenism) = Low platelet count
- pa
- Prolonged PT on INR
- Chemistry
- Glucose disturbances
- Hypoalbuminemia
- Serum
- Viral etiology => HBsAg, anti-HBc, anti-HBs, anti-HCV, anti-HDV
- •Fe, total iron-binding capacity, ferritin (Hemochromotosis)
- Antimitochondrialantibody (AMA) [Primary Biliary Cirrhosis]
- Smooth-muscle antibody (SMA), anti-liver/kidney microsomal (anti-LKM) Ab, ANA (Autoimmune)
- Ceruloplasmin(Wilson’s Disease)
- α1antitrypsin (and phenotyping) [α1antitrypsin deficiency]
Abdominal US with doppler stufy for Cirrhosis will show what?
establish patency of the splenic, portal, and hepatic veins
Patients with Cirrhosis
- ___________ is the most important in in tx and management of cirrhosis
- Receive the following vaccines:
- ______ are CI
- Avoid the following drugs:
- ABSTAIN FROM ALCOHOL
- HAV, HBV, pneumococcal and yearly influenza shot
- NSAIDS are CI
- ACE-I and Angiotensin II ANT should be avoided.
How do we treat ascities and edema seen in Cirrhosis?
- BEd rest and low Na diet
- If not => Sprinolacton (watch for hyperkalemia) + furosomaide
Surgical internvention for acites and edema in cirrhosis?
Complications
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS/TIPSS)
- hepatic encephalopathy, infection, shunt stenosis, shunt occlusion
Malabsorption Symptoms
1. Steatorrhea
2. OSmotic diarrhea
3. WL
4. Nutritiona defiiency
Significant diarrhea WITHOUT _________ NOT likely to be due to malabsorption
WL
Malabsorption disorders: small bowel mucosal disorders
- Celiacs
- Whipple
- Bile salt malabsorption
- Crohns Disae
Pancreatic disease/insufficiency caues of malabsorption
- CF
- Pancreatic carcinoma
- chronic pancreatitit
Only 10% have a clinical diagnosis of celiac disease => most cases are______
undiagnosed or asymptomatic
Celiac Sprue only develops in people with ________ (95%) or _____ (5%) class II molecules (40% of population)
Only develops in people with the HLA-DQ2(95%) or -DQ8 (5%) class II molecules (40% of population)
Celiac atypical symptoms
- Dermatitis herpetiformis
- iron deficiency anemia
- osteoporosis
Older children and adults are _____ likely to manifest signs of serious malabsorption in Celiacs
less
In celiacs, Many adults have minimal or no gastrointestinal symptoms but present with extraintestinal:
- Fatigue
- Depression
- Iron deficiency anemia
- Osteoporosis
- Short stature
- Delayed puberty
- Amenorrhea
- Reduced fertility
How do we diagnose celiacs?
What can exclude diagnosis?
- Abnormal serology
- Small bowel biopsy
Exclude: NL biopsy
- In patients with IgA deficieny with celiacs: measure ______ antibodies to _________.
- When do all AB become undectable?
- IgG antibodies to deamidatedgliadin peptides (anti-DGP)
- 3-12 months after dietary withdrawal
What do we see on endoscopy + biopsy in celiac disease?
- atrophy or scalloping of the duodenal folds may be observed
- complete loss of intestinal villi
Most common reason for treatment failure in Celiacs is ____.
is incomplete removal of gluten.
____________ scanning is recommended for all patients with celiac sprue to screen for osteoporosis.
Dual-energy x-ray densitometry scanning
PAncreatic Insuffiency
- MC causes
- leads to
- Chronic pancreatitis, cystic fibrosis, or pancreatic cancer
- Significant steatorrhea(due to malabsorption of triglycerides
Levels of what are DECREASED in pancreatic insufficiency?
- Decreased fecal chymotrypsin
- Decreased Pancreatic fecal elastase (<100mcg/gram)
Bile salts are resorbed in the _________. This area is removed in _______ => ______
- Terminal ileum
- Crohns
- Insuffiencnet intraliminal bile salts
Sx in Bile salt malabsorption
- Mild steatorrhea
- Watery secreteory diarrhea
- WL is minimal
- Cannot absorb vit ADEK
- => bleeding, osteoporis and hypocalcemia
Sx of Whipple Disease
- Chronic Diarrhea
- Malabsorption
- WL
Dx Whipples
Tx?
Endoscopy with Duodenal biopsy
•periodic acid Schiff (PAS)-positive macrophages with characteristic bacillus
ABX that dont cross BBB
