Gastrointestinal Exam 1 Flashcards
Afferent nerves
Towards CNS
Efferent Nerves
Away from CNS
Nausea
Feeling of needing of needing to vomit
Caused by an abnormality of gastric rhythmic disturbance
Vomiting
Emesis
Retching as well as other physiologic changes such as salivation, increased HR, etc.
Normal gastric rhythm
3 cycles per minute
4 sources of nausea
Afferent vagal fibers
Vestibular system fibers
Higher CNS centers - memory response
Chemoreceptor trigger rich zone
Succession splash
Heard in stomach indicating that food is not moving on
Early vs. Late obstruction
Hyperactive sounds early on
4 labs for nausea
CMC, CMP, Amylase and Lipase for pancreas, hCG
X-ray findings for nausea
Air filled bowel loops for ileus
EGD use in nausea
Often non-diagnostic but can rule out cancer or ulceration
Ondansetron (Zophran) class
5-HT3 receptor agonist
Ondansetron indications
Acute nausea vomiting
Postoperative
Chemo
Pregnancy AFTER 1st trimester
Contraindications/BBW for ondansetron
QT prolongation
1st trimester pregnancy
HA, COnstipation, Fatigue
Class of scopalamine
Anticholinergic/antihistamine
Indications for scopalamine
Motion sickness, vertigo, migraine
1st line in 1st trimester pregnancy when combined with B6 and doxylamine
Common side effects of scopalamine
Xerostomia, Urinary retention
Dizziness
Drowsiness
Pregnancy category C
Promethazine (Finnergan) MOA
Antihistamine, H receptor blocker
Can be given rectally
Indications of promethazine (Phenergan)
Acute N/V - can be given rectally
Side effects of phenergan
Respiratory depression
BBW - tissue injury or necrosis
CNS depression
Anticholinergic
Abnormal body movements
Metaclopramide MOA
Prokinetic - makes the GI tract move faster
Side effects of metaclopramide
Extrapyriamidal side effects/Tardive dyskenesia
Neuroplastic malignant syndrome
Diarrhea, drowsiness, restlessness
CI in seizures and GI obstruction
Other nausea meds - 3
Neurokinin - chemo with dexamethazone
Dexamethasone - Additive with chemo
Lorazepam - Benzo anticipatory to chemo
S. aureus food poisoning
Within 1-6 hours from prepared foods such as salads or dairy
B. cereus food poisoning
Within 1-6 hours from grains
Norwalk virus food poisoning
24-48 hours from shellfish or prepared foods
Acute, persistent and chronic diarrhea
Acute - under 2 weeks
Persistent - 2-4 weeks
Chronic - 4+weeks
MCC of acute diarrhea
Viral or bacterial infection
5 high risk groups for diarrhea
Travelers
Consumers of certain foods
Immunodeficient patients
Daycare members
Institutionalized people
Acute non inflammatory diarrhea presentation
No blood with peri-umbilical pain
Acute inflammatory diarrhea presetation
Blood - gross or occult, LLQ pain
Small bowel infections
Watery diarrhea - usually a viral infection
Large bowel infections
More often bacterial and inflammatory
5 non-inflammatory diarrhea bacteria
S. aureus
B. cereus
C diff
ETEC
Vibrio cholerae
1 viral and 1 protozoal cause of inflammatory diarrhea
CMV
Entomoeba histolitica
Raw eggs food borne illness
Staph aureus
Time for staph or B cereus infection to develop
1-6 hours
Time for a protozoal infection to develop
7-14 days to develop
Time for viral food infection to develop
24-48 hours
4 abx associated with C diff commonly
FQ, Clinda, Cephalosporins, Penicillins
Indication for stool studies
7+ days of diarrhea
Dietary treatment for diarrhea
BRAT diet, bowel rest
Rehydrate!! - pedialyte
When to admit for diarrhea
Sever dehydration, age extremes, organ failure
Antidiarrheal agents
Loperamide - inhibits peristalsis (not for inflammatory
Pepto bismol - Can cause black tongue
Lomotil (Diphenexolate)
ABX for diarrhea
FQ - Drug of choice
Vanc or Flagyl for C diff
Cholera - Z max
Listeria - Bactrim/ Amox
Giardia - Flagyl
Osmotic diarrhea
Carbohydrate malabsorption or laxative abuse - High osmotic gap resolves with fasting
Secretory diarrhea
Little change in stool output with fasting - Endocrine or bile salt malabsoption etiologies - Normal or low osmotic gap
Inflammatory diarrhea
Bloody with weight loss - IBF
Malabsorptive diarrhea
Caused by bacterial overgrowth or pancreatic insufficiency
Steatorrhea is common
Motility diarrhea
Caused by inflammatory diarrhea
No bleeding or nocturnal diarrhea
Hyperthyroid - Hypermotility
Hypothyroid - Hypomotility and bacterial buildup
Contraindications and adverse reactions for antidiarrheals
Bloody/C diff diarrhea
Under 2 years
Constipation, Cramps, Dizziness
Paralytic ileus, Toxic megacolon
Common reactions to Pepto bismol
Black tongue/stool
Tinnitus
Octreotide for diarrhea
For chronic secretory diarrhea, Gall bladder stones edema, cont. possible
Caution with DM, Thyroid, kidney, endocrine disorders
Somatostatin analog
Cholestryamine
Secretory and malabsorptive diarrhea
Take with food
Binds intestinal bile acids
After GI resections
Drugs for diarrheal symptoms of IBS
Hyoscyamine and Dicyclomine
Relaxes muscle to inhibit contractions
May cause ileus, dry mouth
Normal colonic transit time
35 hours, over 72 is abnormal
MCC of constipation
Poor bowel habits
Inadequate fluid/fiber intake
FOBT
Fecal occult blood test - always to with DRE
CI for stool bulking agents
GI obstruction
No systemic absorption
Stool softeners
Coats stool - more mild/moderate cases
Osmotic laxatives
Magnesium hydroxide
Miralax
Lactulose
Softens stools and pulls water into intestines
Used in the elderly for opioid induced constipation
Bowel cleansers
Stronger - Osmotic laxatives
Polyethylene glycol
Magnesium citrate
Sodium phosphate
Used prior to colonoscopies
Stimulant laxatives
Bisacodyl, Senna, Cascara
Rescue agents
Irritate intestinal walls
Not for long term use
Enemas
Tap water
Sodium phosphate
Mineral oil
Also used for colonoscopy
Stepwise approach to constipation treatment
Fiber supplements
Stool softeners
Osmotic laxatives
Stimulant laxatives
Presentations of fecal impaction
Paradoxical diarrhea
Decreased appetite
Treat via digital stimulation
3 common symptoms of esophageal dysfunction
Pyrosis - heartburn radiating to neck
Oropharyngeal dysphagia
Problems in the oral phase of swallowing - chewing, food feels stuck in throat, coughing and choking during meals
6 Causes of oropharyngeal dysphagia
Infectious disease - Polio, C bot, Lyme diptheria, tetanus
Structural disorders - Zenker
Motility disorders
Muscular disorders
Metabolic disorders - Thyrotoxicosis, amyloidosis
Esophageal disphagia
Inability of of food to move down esophagus
Mechanical obstructions
Solids, predictable, can have liquids
Motility disorder
Solids and liquids can’t pass down - less predictable
Odynophagia
Pain with swallowing
Infection in immune compromise
Pills - don’t lay down right away
Button batteries
3 types of GE Junction issues
Transient lower esophageal sphincter relaxation - belching
Anatomic disruption of GE junction - Hernia, etc.
Hypotensive esophageal sphincter - rise in intraabdominal pressure
Severity and GERD symptoms
Not necessarily correlated
Atypical GERD symptoms
Cough, Asthma, Chest pain, Sleep disturbances
Typical GERD presentation
Heartburn radiating to the neck
EGD
Upper endoscopy - documenting the type and degree of tissue damage and detecting complications
When to stop a PPI before EGD
Stop a PPI a week before
Hiatal hernia
Stomach pulled above diaphragm
Sliding hernia
Stomach slides up past the diaphragm
Paraesophageal hernia
Side hernia - rolling, also a hiatal hernia type
3 MC risk factors for hiatal hernia
50+
Obesity
Coughing heavy lifting
Presentation of sliding hiatal hernia
GERD with lack of clearance
Presentation of paraesophageal hernia
Epigastric pain, fullness, nausea, may be asymptomatic
Barrett’s esophagus
Esophagus epithelium becomes gastric
Salmon colored mucosa on endoscopy
Follow up for barretts esophagus
3-5 years check up is NO dysplasia
Resect and rechack in 6 months for low-grade dysplasia
Resect ALL and repeat EGD ASAP for HIGH grade dysplasia
Reflux disease treatment
Symptomatic releif and lesion healing
Mild reflux treatment
Lifestyle modifications - smaller more frequent meals, weight loss, smoking cessation, don’t lay down after eating
Antacids or H2 receptor antagonists
PPI if no success with above treatment
3 oral H2 antagonists
Cimetidine
Nizatidine
Famotidine
30 min delay of onset
PPIs for GERD
-Prazole
30 minutes before breakfast 8-12 weeks
Complicated cases can stay lifelong
May cause deficiency and bacterial overgrowth
Dementia??
Fundoplication
Wrap fundus around esophagus, helps create a new sphincter
Can be done laparoscopically
LINX system
Magnetic implant that helps with LES tone
When to refer for GERD
Considering surgery, Atypical presentation, Treatment resistance
Esophageal cancer
Adenocarcinoma - more associated with Barrett’s - Distal
SC carcinoma - More associated with alcohol and tobacco - Middle
Presentation of esophageal cancer
Usually very advanced when they come in
Weight loss is common
Hoarseness
PE normal
Treatment for esophageal cancer
Surgery if curable
May use chemo
5 year survival of under 20%
Zenker’s diverticulum
Outpouching of esophagus
Dysphagia, regurg, and halitosis that worsen over time
Detection of zenkers
Barium swallow
Treatment for Zenkers
Endoscopic stapling procedure - can come back
Achalasia
Failure of lower sphincter relaxation
Gradual solid AND liquid dysphagia
Regurg
Need to move around to get it down
Diagnosis of achalasia
Esophageal manometry - First line
Barium swallow with Bird beak sign
Treatment of achalasia
Baloon dilation - serially
Good response usually
Can also use botox or heller myotomy to relieve pressure if tx not working
Esophageal spasm
DES - mimics angina with episodic dysphagia for solids and liquids
Corkscrew esophagus on barium swallow
RULE OUT HEART DX
Treatment for DES
CCB for 3 months PRN
TCA
Nitroglycerin
Slidenafil
Botulinum
Scleroderma
Autoimmune disorder
Skin, lungs, heart, GI syndrome
Hardening of esophagus - has to sit up with eating
Treat like GERD can also use reglan
Mallory weiss tear
Mucosal tear at GE junction
Caused by retching and vomiting
Presentation of MW tear
History of straining to vomit
Red blood or coffee ground emesis
May have epigastric pain
Diagnosis of MW teard
Endoscopy, stat consult for GI doctor
Treatment for MW tear
Fluids and Blood
Most spontaneously stop bleeding
Epinephrine, Cautery or pressure if they don’t stop
Angiographic arterial embolization for failure of all treatments
PPI after
Esophageal webs
Thin - mid or upper esophagus
Esophageal rings
Distal esophagus like webs
Presentation and tx for esophageal rings and webs
Dilation - may have dysphagia depending on size
Esophageal varices
Can cause life threatening GI bleed
Due to portal hypertension from cirrhosis
Yearly endoscopy to check for them in cirrhosis patients
4 bleeding risk factors of EVs
Size (over 5cm)
Red wale markings (Dilated venules
Severity of liver disease
Active alcohol abuse
Presentation of EVs
Blood in vomit and stool, may present in shock
Management of bleeding EVs
ABCs
Rapid blood and fluid resucitation
May use baloon if needed or shunt ling term
Antibiotic prophylaxis - Rocephin or FQ
Octreotide to reduce portal pressure
Vitamin K - Clotting
Lactulose to prevent ammonia production
Endoscopy for esophageal varices
After stabilized, banding of varices for atrophy and death of varices
Prevention of bleeding in EV
Beta blocker to prevent from ever bleeding
Infectious esophagitis
Most common in immune compromised patients
Odynophagia and dysphagia
Fluconazole for candida
Acyclovir for herpes
Ambulatory esophageal pH monitoring
System for reflux - keeps track of stomach pH
Goblet cells
Musous production
Parietal cells
Acid
Cheif cells
Pepsinogen
Dyspepsia
Burining epigastrically, not retrosternal like heartburn - more suggestive of a stomach problem
Gastropathy
Any endothelial damage but no inflammation
Gastritis
Endothelial damage with inflammation
Errosive/Hemorrhagic or Nonerrosive (less acute)
Etiologies of gastritis
Medications (NSAIDs)
Alcoholic
Stress - burns, ventilation, etc.
NSAID induced gastritis
NSAIDs block prostaglandins that stimulate mucous production
Erosive gastritis symptoms
Coffee ground emesis - EGD for diagnosis
Absence of rugal folds
Treatment for errosive gastritis
Remove causative agent
IV PPI(Pantoprazole)
Endoscopy within 24 hours of admission
Celebrex or sucralfate for adjunct
Management for stress gastritis
Put on prophylactic PPI IV
Nonerosive gastritis etiology
H. pylori MC
Can be autoimmune
H pylori
Spread human to human - acute to chronic inflammation
Can be asymptomatic
Noninvasive diagnostics for nonerosive gastritis
Breath, blood, and stool test
Biopsy is definitive - use in 60+, alarm symptoms, no response, GI cancer hx
H. pylori therapy 1st line
Omeprazole 20mg BID
Amoxacillin 1g BID
Clarithromycin 500mg BID
H. Pylori 2nd line therapy if failure or PCN allergy
Omeprazole 20-40mg QD
Bismuth 300mg QID
Tetracycline 500mg QID
Metronidazole 500mg TID
Peptic ulcer disease
Duodenum younger - 30-55
Stomach ulcer in 55+ MC
Break in mucosa to muscularis - can be caused by H. pylori in duodenum, NSAIDs in Stomach
Presentation of PUD
Gnawing hunger-like pain that gets better with antacids and eating, wakes them up at time d/t circadian acid secretion
Procedure for suspected PUD
Endoscopy with biopsy
Assess for H. pylori
Tx for non H. Pylori PUD
Continue on PPI - for 4-6 weeks or lifelong if NSAID is being used
Confirmation for h pylori eradication
4 weeks after start - continue therapy in case of large ulcers
Management of PUD GI bleed
Fluids, IV PPI, Transfusion, Endoscopy to cauterize and assess
Clinical presentation of GI perforation
Severe abdominal pain, rigid abdomen
Leukocytosis
Sew shut
shows up as free air underneath the diaphragm
PUD penetration
Ulcer extends into contiguous substances such as the pancreas and liver
Gradual increasing pain radiating to the back
PPI and surgical therapy
Gastric outlet obstruction
Due to edema
Fullness and weight loss and vomiting
PPI, Endoscopy, Ballooning
CT for severe symptoms bc we are concerned about cancer
Misoprostol
NSAID gastritis/ulcer prevention
Oral tablets
Need to test for pregnancy!!!
Sucralfate
Stress gastritis and NSAID gastritis prophylaxis
Constipation MC SE
Can’t be taken within two hours of any other medication
Gastric obstruction etiologies
Postnatal muscular hypertrophy
PUD
Malignancy
Polyps
Pancreatitis
Presentation of gastric outlet obstruction
Vomiting - postprandial projectile vomit in children
Early satiety
Abdominal distension
Olive shaped mass
Succusission splash
Workup mfor GOO
EGD to confirm and abdominal ultrasound for children
Adult GOO management
NPO
IV fluids
NG tube
Treat underlying cause
Pylormyotomy if needed (esp. for children)
Gastroparesis
Delayed gastric emptying more common in women - many causes (viral, DM, etc)
Clinical presentation of gastroparesis
Pain, bloating, nausea and vomiting, regurg
PE for gastroparesis
Epigastric distension with NO guarding/rigidity
May have splash
Workup for Gastroparesis
Gastric emptying test confirms the diagnosis
r/o blockage
Management of gastroparesis
CHeck for underlying cause
Metoclopramide or erythromycin
May need a PEG tube if refractory
Zollinger-Ellison syndrome triad
Gastrinoma - tumors that secrete gastrin
Increased Gastric acid
Peptic ulcers
Gastinoma triangle
Cystic and common bile ducts, Neck of the pancreas 1st 2/3s of the duodenum
Workup for ZE syndrome
Get a serum gastrin level - 10x upper limit and gastric pH under 2 is diagnostic
Secretin stimulation test - secretin causes marked gastrin secretion
CT/MRI for tumors
Management of ZE disease
Surgical resection of tumors/mets
Gastric tumors
Benign - polyps
Malignant - Intestinal MC or DIffuse
Presentation of gastric adenocarcinoma
Vague epigastric pain - may have palpable masses - check left supraclavicular lymph node
Treatment for gastric cancers
Depends of severity/Mets
Classic presentation of celiac disease
Abdominal distension
Failure to thrive
Chronic diarrhea
Atypical presetation of celiac disease
Alopecia
Epilepsy
Psoriasis
Fatigue
Iron deficiency
Dermatitis herpetiformis
Itchy rash seen with celiac in some patients
Antibody test for Celiac
IgA TTG - can improve with dietary changes
Imaging for celiac
Endoscopy and biopsy
Atrophy of duodenal folds
Interepithelial leukocytes
Blunting or loss of intestinal villi - scalloping, fissuring, mosaic
Improvement window for celiac
Should improve in 1-2 weeks
Whipple disease
Malabsorptive infectious disease
Fecal oral with immune response
Presentation of whipple disease
Arthralgia, weight loss, Malabsorption with fatty stool can progress to neuro disease
Hyperpigmentation
Lymphadenopathy
Sero-negative arthritis
Diagnosis for whipple disease
Upper endoscopy followed by PCR testing
Treatment for whipple disease
IV Ceftriaxone for 2-4 weeks followed by bactrim for a year
Small intestinal bacterial overgrowth etiologies
Surgeries, reduced bowel mobility, Immune disorders
Presentation of bacterial overgrowth
Flatulence, Vitamin deficiency - Use lactulose followed by breath test for hydrogen
Treatment for SIBO
Cipro for 7-10 days
Short bowel syndrom
We have had to remove portion of small bowel
Malabsorption of vitamins - B12
Stabilize acutely w/ IV PPI and TPN
Manage diet and fluids chronically
Lactose intolerance
Lactase is absent
Hydrogen breath test with lactose loading dose
Lactaid or lactose free diet
Paralytic ileus
Neurogenic loss of peristalsis in the ABSENCE of mechanical onstruction
After surgery, Inflammation, Severe illness - ICE
Over 4 days is concerning
Presentation of paralytic ileus
N/V/C
Distension and tympany to percussion
Diffuse pain - r/o obstruction
Diagnosis of paralytic ileus
Gas filled loops of bowel, other tests to rule out other possibilities
Treat underlying cause, bowel rest and NG tube. Treat underlying cause gum chewing can also help
Small bowel obstruction
Hyperactive bowel sounds at beginning, Hypoactive bowel sounds later
Often due to adhesions
SBO presentation
N/V
Dehydration
Abdominal distension
Tinkling sounds on auscultation
Pain out of proportion to presentation
Treatment of small bowel obstruction
Immediate admission and surgery consult
TPN
Broad spectrum abx
Ogilvie syndromegilvie syndrome
Spontaneous massive dilation of the cecum and proximal colon without anatomic lesion. Associated with post-op
Presentation for Ogilvie syndrome
N/V
Distended abdomen
Some tenderness
Normal or decreased bowel sounds
Work up for Ogilvie
CBC, CMP, Plain readiograph
Treatment for Ogilvie syndrome
Ambulate or roll to get gas on, Adjust drugs away from opioids
NPO w/ IV fluids
Neostigmine to keep colon moving
IBS
Motility problems
Visceral hypersensitivity
Inflammation
Psychosocial factors
Presentation of IBS
1 day per week of pain related to defecation, stool frequency, form (must have two)
Pain and altered bowel habits
Crampy lower abd pain
Change in characteristics of stool
Not waking them up at night
3 IBS criteria
Defecation related
Change in frequency
Change in form
6 manning criteria for IBS
Pain releived with defecation
More frequent stools at onset of pain
Looser stools at onset of pain
Visible abdominal distension
Passage of mucus
Sensation of incomplete evacuation
Alarm symptoms NOT associated with IBS
Weight loss, Fever, Hematochezia
Workup for IBS
Stool studies, Celiac - colonoscopy if uncertain
Management of IBS
Avoid and identify food triggers
Low FODMAP diet
Physical activity
Fiber
Relaxation activities
FODMAP
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And’
Polyols
Pharm for IBS
Antispasmodics - Dicyclomine
Antidiarrheal - Loperamide
Specific IBS drugs
Antispasmodics for IBS
Diarrhea
Dicyclomine and Hyoscyamine
Anti-cholinergic SEs
Alosetron
For severe diarrhea in IBS
5HT3 antagonist
BBW for severe constipation and Ischemic colitis
Linaclotide
For IBS constipation
BBW for under 18
Guanylate cyclate agonist
Lubiprostone
IBS constipation drug
SE - Nausea, Fatigue, Dizziness
Selective chloride activator
Antidepressants for IBS
TCAs - Tryptiline
ABX colitis
C. diff infection
Alcohol does not kill
Caused by amp, clinda, Cephalosporines, FQs
May be delayed 8 weeks after abx
C. diff presentation
Foul mucus
LLQ tenderness
Over 3 loose stools in 24 hours with risk
Sever have even higher WBCs
Stool PCR or Immunoassay for diagnosis
Treatment for C. diff
d/c abx
Fidamoxacin or Vanc PO if mild
Vance and Flagyl if severe
Red flags for surgery with C diff
5 days without improvement
WBC over 20,000
Fever 38.5+
Organ failure
Surgery for c diff
Colectomy or ileostomy
Regimen for relapses of C diff
Same regimen the first time
7 week tapering dose of vance for second relapse
Ischemic colitis
Reduction of blood flow to the colon - splenic flexure and rectosigmoid junction are most common areas
Presentation of ischemic colitis
May appear after surgery/long distance runner/birth conrol pills
Acute or chronic presentation - cramping, left bowel tenderness, urgency with abd pain out of proportion (acute) chronic may have weight loss
Management and DIagnostics for Ischemic colitis
Double halo sign, colonoscopy emergently
Supportive care - NPO; Watch with no specific care
Evaluate by surgery with BS abx
Meckels diverticulum
Congenital abnormality of SB
2% of population, 2 feet from IC valve, 2% have symptoms
Presents like appendicitis - must resect
Diverticulosis
Can be caused by low fiber, chronic constipation, age. Diverticulitis if it gets inflamed
MC area of diverticulosis
L side of colon
Presentation and tx of diverticulosis
Often found through colonoscopy - increase fiber to help bulk stool
Acute diverticulitis dx and tx
Acute LLQ abdominal pain
Fever
Blood in stool
Leukocytosis
Abx - flagyl and FQ or Bactrim. liquid diet and colonoscopy after resolution
if not responding Pip and Taz IV (7days) then switch to Cipro and Flagyl 14 days
Diverticular bleed tx
May resolve on own
May need to do a colonoscopy
Ulcerative colitis
Diffuse mucosal inflammation only found in the colon and rectum - extends proximally - Male = MC
Crohn’s disease
Patchy transmural inflammation anywhere in the GI tract - Female = MC
MC area of crohns
Terminal ileum
Presentation of Crohns
Diarrhea
RLQ pain
Malabsorption
SYmptoms in other areas of the body - erythema nodosum
Workup for crohns
Colonoscopy with biopsy - Skip lesions with cobblestoning, pseudopolyps
Labs used to support diagnosis and see if interventions are working
Management of crohn’s disease
Goal to shorten flare ups
Diet, smoking
Step up therapy for mild or top down for serious
Treatment for mild crohn’s disease
Budesonide - Enteric coated 5-ASA for those who don’t want a steroid
Immunomodulator or biologic if not improvement in 3-6 months
Treatment for moderate crohn’s disease
Prednisone for 7 days PO and TAPER
May use 5-ASA as alternative
Colonoscopy may move onto immune mod or biologic
High risk crohn’s patient
Under 30
Tobacco use
hx of resection
Deep ulcerations
Fistula/Abcess
Treatment for high risk crohn’s
Start with biologic - TNF blocker and immune modulator - colonoscopy 6-12 months after remission
Remain of therapy for 1-2 years - can switch to glucocorticoid
MC area for UC
Rectum and sigmoid colon
Hallmarks of UC
Bloody diarrhea (not seen in crohns)
Fecal urgency
Fever/Fatigue
Mild UC classification
Under 4 stools per day
HR under 90
Normal HCT, Temp, and Albumin
No weight loss
ESR under 20
Severe UC classification
7+ stools per day (bloody)
HR 100+
HCT under 30
Weight loss over 10 lbs
ESR over 30
Albumin under 3
Temp over 100
Gold standard for UC diagnosis
Sigmoidoscopy - control first
Management of UC
Monitor diet etc.
Topical mesalamine - Mild
Oral Mesalamine with oral Mesalamine - Mild/Moderate
High dose steroids and taper then immune modulator/biologic with tx failure; hospitalize - Severe
Aminosalicylates
Sulfalazine and Mesalamine
N/V
Can’t have if allergic to aspirin or sulfa
Immune modulators for IBD
Azathioprine
6-Mercaptopurine
Methotrexate
Risk of severe infection or lymphoma
Anti-TNF biologics for IBD
Infliximab
Adalimumab (Humira)
Certolizumab
Risk of serious infections
Adenomatous polyps
95% of colon cancer - MC
Flat ones are more likely to be cancerous
Found through colonoscopy, removed and analyzied
Types of adenomatous polyp least and most likely to be cancerous
Tubular - least likely
Vilious -Most likely
Follow up if polyp found
5 year FU instead of ten start screenings at 45 end around 75
Risk factors for cancer in a polyp
Overweight
Over 1 cm
Villious
Flat
Submucosal lesions
Lipomas - usually benign
Tumor marker for colon cancer
Use carcinoembrionic antigen to see if treatment is working
Post op follow up for colon cancer
Colonoscopy 1 year after and then every 3 years
Familial adenomatous polyposis syndrome
Develop by 15, cancer by 40
Prophylactic colectomy
Screen endoscopically every 1-3 years
Lynch syndrome
Hereditary non-polyposis colon cancer
Autosomal dominant
Few, flat villous adenomas
1st degree relative, polyps before 50, 3+ relatives - 3 tool!
Management of lynch syndrome
Prophylactic hysterectomy with oophorectomy, colectomy
Screening for gastric cancer every 2-3 years at 25 and up
External hemorrhoids
Below dentate line, PAINFUL!! Inferior hemorrhoid vein
MC location of internal hemorrhoids
Right anterior, right posterio, left lateral
Causes of hemorrhoids
Pressure, Hard stools, Low fiber diet
Internal hemorrhoid staging
1 - Painless bleeding
2 - Itching
3 - Swelling and staining
4 - Prolapsed
Treatment for internal hemorrhoids
Conservative for 1-2 (High fiber, decreased sitting on toilet)
Rubber ban ligation or injection if not working
Cut off for larger 3-4
Treatment for external hemorrhoids
Sitz bath, topical ointment, evacuate blood clot
Anal fissures
Tears around the anus, usually less than 5mm and due to heard stools
MC on midline think crohns if not
Treatment for anal fissure
Proper toileting
Fiber
Sitz bath
Lidocaine
Miralax to soften stool
Perianal abcess/fistula treatment
Abcess - I&D may use abx
Fistula - surgical incision open tract up and keep it open
Rectal prolapse
Protrusion of the anus - can become chronic or complete (emergent if complete)
Due to pelvic weakness - birth, surgery, straining
Tx for rectal prolapse
Manual reduction
Surgery
Kegel exercises to prevent
Pilonidal disease
Sinus that can get infected - MC in adolescent male
Treat with surgery
