Gastrointestinal diseases Flashcards
Presentation of dysmenorrhea?
Chronic pelvic pain in a woman of reproductive age. It is a cause of cyclical pelvic pain, it comes and goes in predictable intervals which may be known or unbeknownst to the patient.
What is primary dysmenorrhea?
Cyclical menstrual pain with no identifiable underlying cause
What is secondary dysmenorrhea?
Cyclical menstrual pain with an underlying cause.
Risk factors for primary dysmenorrhea?
- Earlier age at menarche
- Longer menstrual period
- Higher BMI
- Smoking
- Parity appears to be associated with decreased incidence of primary dysmenorrhea
Pathophysiology of primary dysmenorrhea
During menstruation, endometrial cells releaseprostaglandins. Women with primary dysmenorrhea appear to release higher levels of prostaglandins.
What is the #1 cause of secondary dysmenorrhea?
Endometriosis
Primary dysmenorrhea vs secondary dysmenorrhea?
Primary: Age: 16-26 Onset of pain: just prior to menses Symptoms: pain only Response: Responds to NSAIDs and COCs Physical exam: Unremarkable
Secondary: Age: 30-45 years Onset of pain: Often progresses through late luteal phase Symptoms: other sx usually present Response: Resistance to NSAIDS and COCs Physical exam: Depend on cause
Secondary dysmenorrhea should be strongly suspected in women who?
- Have onset of dysmenorrhea after 25 y
- Have abnormal pelvic exam findings
- Have infertility or menstrual abnormalities
- Have dyspareunia
- Do not respond to conventional therapy for primary dysmenorrhea.
Treating primary dysmenorrhea?
- NSAIDS = first line
- COC or progestin-only contraceptives may be used in patients who do not respond to NSAIDs or as a first-line in patients also desiring contraception.
Mittelschmerz, what is this?
German for “middle pain”. Classically, one-sided lower abdominal pain that coincides with ovulation.
Precise mechanism of pain is unknown. Possibly due to release of fluid or blood from the follicule which irritates the lining of the abdomen. May last from minutes to up to 48h. Treatment is OTC analgesics.
Benign vs malignant trophoblastic disease
- Benign (75%)
- Complete molar pregnancy (90%)
- Partial molar pregnancy (10%) - Malignant (25%)
- Persistent/invasive mole (75%)
- Choriocarcinoma (25%)
- Placental site trophoblastic tumor (PSTT) (<1%).
What is gestational trophoblastic disease?
The presence of abnormal tissue derived from fetal cells. Also known as “molar pregnancy” or “hydatidiform moles”
What is the most common “form” of GTD?
Complete (classic) moles are most common (90%). The rest are partial (incomplete) moles 10%.
Risk factors of benign GTD?
Hx of previous molar pregnancy Extremes in age Nulliparity Diet Smoking Hx of OCP use
hCG-level of complete molar pregnancy, and symptoms?
VERY high hCG.
- Most women will present when they notice cherry-like clusters per vagina.
- Nausea, vomiting, irritability, dizziness, photophobia, nervousness, anorexia, tremor
- Larger uterus
- Pre eclamptic signs may be noted (Htn, Swelling etc)
!NB: Pre-eclampsia before 20 weeks is pathognomic for molar pregnancy !
Treatment of complete molar pregnancy?
Immediate D&C under general anesthesia.
What should you follow up on after D&C in complete molar pregnancy?
- Obtain quantitative hCG titer 48hrs P/O
- Serial quantitative hCGs weekly until levels are normal for three consecutive weeks
- After hCG levels normalized, serial quantative hCGs monthly for 6 months
What should you put the patient on after D&C in complete molar pregnancy?
Barrier contraception should be used until hCG normalizes. Hormonal contraception may be used thereafter.
What is Partial Molar Pregnancy characterized by?
Arises from dispermic fertilization.
Characterized by focal hydropic villi and proliferation of cytotrophoblasts. There is often a fetus, though many abnormalities will usually be apparent, e.g IUGR, hydrocephaly, syndactyly.
! Oligohydramnios !
Hihger malignant potential compared to partial molar pregnancies.
How will the levels of hCG be in a partial molar pregnancy?
As the cytotrophoblast does not produce hCG, levels in partial molar pregnancy will be “normal”.
Clinical presentation of a partial molar pregnancy?
Usually presents as a spontaneous abortion around the late first to early second semester. May be diagnosed at routine ultrasound for pregnancy. Exam is typically unremarkable.
What will Pelvic US show in partial molar pregnancy?
May reveal fetus with abnormalities, or simply an gestational sac. Low amniotic fluid. Enlarged placenta with “swiss cheese” appearance.
Treatment of partial molar pregnancy?
Immediate D&C under general anesthesia
What should you follow up on after D&C in partial molar pregnancy?
- Obtain quantitative hCG titer 48hrs
- Serial quantitative hCG weekly until levels are normal for three consecutive weeks
- After hCG levels normalized, serial quantitative hCGs montly for 6 months.
What should you put the patient on after D&C in partial molar pregnancy?
Barrier contraception should be used until hCG normalizes. Hormonal contraception may be used thereafter.
Development of molar pregnancy to malignant gestational trophoblastic disease?
About 50% of malignant GTD occurs months to a year after a molar pregnancy.
- 25% occur after a miscarriage/ectopic pregnancy
- 25% occur after a normal pregnancy
Most malignant GTDs that follow a molar pregnancy are the persistent/invasive GTD, while those that follow a nonmolar pregnancy are usually choriocarcinoma.
Staging of malignant gestational trophoblastic disease (GTD)
Stage 1: confined to uterus
Stage 2: metastasis to pelvis, vagina
Stage 3: Metastases to lung
Stave 4: Distant metastases (brain, liver, etc).
Persistent/Invasive Mole
When it happens, it almost always follows the evacuation of a molar pregnancy. Complete mole - 15%, Partial mole 5%.
Clinical presentation: hx of molar pregnancy w/hcG rise or plateau on follow-up.
Most common presentation of a persistent/invasive mole?
Most common symptom is abnormal uterine bleeding.
Treating Persistent/Invasive mole?
Chemotherapy.
Low-risk: methotrexate alone
High-risk: Methotrexate, actinomycin D and etoposide.
How to follow up on persistent/invasive mole?
Continue monitoring w/serial hCGs every week until normal for 3 consecutive weeks. Then montly hCGs for one year.
Barrier contraception should be used until hCGs are normalized. Hormonal contraception may be used until normalized for at least one year. Pt should avoid pregnancy for one year after finishing chemotherapy.
What is choriocarcinoma?
Malignancy of placental tissue. May occur in nulliparous women (ovary) and in men (testes) but gestational-related choriocarcinoma is the most common.
Clinical presentation of choriocarcinoma?
Late postpartum bleeding (> 6-8w PP).
Often presents in metastatic stage;
- Lungs: cough, dyspnea, resp.distress, hemoptysis
- CNS: headache, dizziness
Px: uterine enlargement, signs of metastatic disease - vaginal mass, B/L theca lutein cysts, neuro sx.
How to diagnose choriocarcinoma?
The best first test when suspecting choriocarcinoma is hCG level. This is followed by pelvic sono and appropriate imaging.
Treating choriocarcinoma?
Stage 1: Methotrexate
Stages 2-4: Methotrexate, actinomycin D, etoposide.
Follow up with continuous monitoring w/serial hCGs every week until normal for 3 consecutive weeks. Then montly hCGs for one year.
What is Placental Site Trophoblastic Tumor (PSTT)?
Very rare, malignant tumor derived from cytotrophoblasts at the placental implantation site. Little propensity to spread outside the uterus.
Clinical presentation of PSTT?
Chronic, persistent, irregular bleeding occuring weeks to years after a pregnancy.May note an enlarged uterus.
Diagnosing PSTT?
Pelvic sono is the best test to diagnose PSTT, but hCG level may be drawn to exclude choriocarcinoma. HCG levels will be < 100 mlU/ml
Treating PSTT?
Hysterectomy is the best treatment choice, followed by chemotherapy 1 week later.
What can cause infectious vaginitis?
- Trichomoniasis
- Candida Vaginitis
- Bacterial vaginosis
What is the most prevalent non-viral STD?
Trichomoniasis.
Trichomoniasis is a clinical marker of high risk sexual activity! (high co-incidence of infectionw/other STDs)
Symptoms of trichomoniasis?
Foul, thin yellow-green discharge. Also dysuria, dyspareunia and vulvar itching and burning.
Physical sx of trichomoniasis?
Erythematous, edematous vulva, excoriations, “strawberry spots”
Diagnosing trichomoniasis?
Saline prep revealing trichomonads:
- Vaginal pH will often be elevated (> 4.5)
- Rapid assays are available
- May be picked up on Pap
Treating Trichomoniasis?
Metronidazole
- Test for other STDs
- Refer sexual contacts.
Risk factors of Candida Vaginitis
DM
Immunosupression
Recent antibiotic use
Pregnancy
Symptoms of candida vaginitis (yeast infection) ?
Cottage cheese-like or “curdy” discharge; vulvar/vaginal itching and burning.
Physical: erytematous, edematous vulva, excoriations.
Diagnosing Candida Vaginitis
10% KOH prep revealing buds and hyphae. Vaginal pH is normal (4.0-4.5)
Which cases of Candida vaginitis are “complicated cases”?
Those which are:
- Recurrent (>4 cases/year)
- Severe
- Non-albicans infections
- Occur in pt who si diabetic, immunosuppressed, debilitated or pregnant.
Treating Candida Vaginitis?
Tx of uncomplicated cases is a topical azole antifungal such as miconazole (Monistat) or Clotrimazole
Complicated cases:
- Recurrent: prolonged tx w PO fluconazole
- Pregnant: Nystatin vaginal tablets
- Non albicans: Boric acid vaginal capsule
Bacterial vaginosis - Risk factors
Vaginal douching Oral sex Sex during menses Sexual activity w/other women Early age of sexual intercourse IUD placement Black race Smoking
Sx of bacterial vaginosis?
Malodorous (“fishy”) vaginal discharge
Diagnosing Bacterial vaginosis?
Saline prep revealing “Clue cells”
- Positive KOH “whiff” test
- Vaginal pH usually elevated (> 4.5)
Treating bacterial vaginosis?
Metronidazole, alternatively clindamycin.
