EOR GI part 9- IBD, HCC, jaundice Flashcards
At-risk population for Crohn’s dz
High in the Jewish population
Low in the African black population
Similar rates between AA and US white populations
Sex risk for Crohn’s
F>M
Distribution for age in Crohn’s
Bimodal
Peak incidence at 25-40 yrs
Second peak at 50-65 yrs
At-risk population for ulcerative colitis
High in the Jewish population
Low in the AA population
Pos FHx in 20% of cases
Sex risk for ulcerative colitis
M>F
Age distribution in ulcerative colitis?
Bimodal at 20-35 and 50-65
Initial sx of Crohn’s
Abdominal pain Diarrhea Fever Wt loss Anal dz
Initial sx of ulcerative colitis?
Bloody diarrhea (hallmark)
Fever
Wt loss
Anatomic distribution of Crohn’s
Mouth to anus
Small bowel only (20%)
Small bowel and colon (40%)
Colon only (30%)
Anatomic distribution of ulcerative colitis
Colon only
Route of spread of Crohn’s
Small bowel, colon or both with skip areas
Route of spread of ulcerative colitis
Almost always involves the rectum and spreads proximally always in a continuous route without skip areas
What is backwash ileitis?
Mild inflammation of the terminal ileum in ulcerative colitis
Thought to be backwash of inflammatory mediators from the colon into the terminal ileum
Bowel wall involvement in Crohn’s
Full thickness (transmural involvement)
Bowel wall involvement in ulcerative colitis
Mucosa/submucosa only
Anal involvement in Crohn’s
Common (fistulae, abscesses, fissures, ulcers)
Anal involvement in ulcerative colitis
Uncommon
Rectal involvement in Crohn’s
Rare
Rectal involvement in ulcerative colitis
100%
Mucosal findings in Crohn’s
Aphthoid ulcers Granulomas Linear ulcers Transverse fissures Swollen mucosa Full-thickness wall involvement
Mucosal findings in ulcerative colitis
Granular, flat mucosa Ulcers Crypt abscess Dilated mucosal vessels Pseudopolyps
Diagnostic tests for Crohn’s
Colonoscopy with bx
Barium enema
UGI with small bowel follow through
Stool cultures
Diagnostic tests for ulcerative colitis
Colonoscopy
Barium enema
UGI with small bowel follow through (to look for Crohn’s dz)
Stool cultures
Complications of Crohn’s
Anal fistula/abscess Fistula Stricture Perforation Abscesses Toxic megacolon Colovesical fistula Enterovaginal fistula Hemorrhage Obstruction CA
Complications of ulcerative colitis
CA Toxic megacolon Colonic perforation Hemorrhage Strictures Obstruction Complications of surgery
CA risk for Crohn’s
Overall increased risk, but about half that of ulcerative colitis
CA risk for ulcerative colitis
~5% risk of developing colon CA at 10 yrs; then risk increases ~1% per year
Indications for surgery in Crohn’s dz
Obstruction Massive bleed Fistula Perforation Suspicion of CA Abscess (refractory to medical tx) Toxic megacolon (refractory to medical tx) Strictures Dysplasia
Indications for surgery in ulcerative colitis
Toxic megacolon refractory to medical tx CA prophylaxis Massive bleed Failure of child to mature because of dz and steroids Perforation Suspicion of or documented CA Acute severe sx refractory to medical tx Inability to wean off of chronic steroids
What are the common surgical options for ulcerative colitis?
Total proctocolectomy, distal rectal mucosectomy and ileoanal pull through
Total proctocolectomy and Brooke ileostomy
What is toxic megacolon?
Toxic pt: sepsis, febrile, abdominal pain
Megacolon: acutely and massively distended colon
What are the medication options for treating IBD?
Sulfasalazine, mesalamine (5-aminosalicylic acid) Steroids Metronidazole Azathioprine 6-mercaptopurine Infliximab
What meds are used fro Crohn’s but not ulcerative colitis?
Methotrexate
Antibiotics
What are infliximab, adalimumab, certolizumab, anatlizumab?
Monoclonal antibodies versus TNF-alpha
What is the most common primary malignancy of the liver?
Hepatocellular carcinoma (HCC)
By what name is HCC also known?
Hepatoma
What is the incidence of HCC?
80% of all primary malignant liver tumors
What are the associated RFs of HCC?
Hep B
Cirrhosis
Aflatoxin
S/sx of HCC
Dull RUQ pain
Hepatomegaly
What tests should be ordered for HCC?
U/s
CT
Angiography
Tumor marker elevation
What is the tumor marker for HCC?
Elevated alpha-fetoprotein
What is the MC way to get a tissue dx with HCC?
Needle bx with CT scan, u/s, or laparoscopic guidance
What is the MC site of metastasis with HCC?
Lungs
Tx of HCC
Surgical resection , if possible
Liver transplant
What are the tx options if an HCC pt is not a surgical candidate?
Percutaenous ethanol tumore injection
Cryotherapy
Intra-arterial chemo
What are the indications for liver transplantation?
Cirrhosis and NO resection candidacy as well as no distant or LN metastases and no vascular invasion
The tumor must be single <5 cm tumor or have three nodules, with none >3 cm
At what level of serum total bilirubin does one start to get jaundiced?
2.5
Classically what is thought to be the anatomic location where one first finds evidence of jaundice?
Under the tongue
What are the s/sx of obstructive jaundice?
Jaundice Dark urine Clay-colored stools Pruritis Loss of appetite Nausea
What is obstructive jaundice?
Jaundice (hyperbilirubinemia >2.5) from obstruction of bile flow to the duodenum
DDx of proximal bile duct obstruction
Cholangiocarcinoma LAD Metastatic tumor Gallbladder carcinoma Sclerosing cholangitis Gallstones Tumor embolus Parasites Postsurgical stricture Heptatoma Benign bile duct tumor
DDx of distal bile duct obstruction
Choledocholithiasis Pancreatic carcinoma Pancreatitis Ampullary carcinoma LAD Pseudocyst Postsurgical stricture Ampulla of Vater dysfunction/stricture Lymphoma Benign bile duct tumor Parasites
Whatis the initial study of choice for obstructive jaundice?
U/s
What lab results are associated with obstructive jaundice?
Elevated alk phos
Elevated bilirubin with or without elevated LFTs
