Gastrointestinal Part 1 Flashcards
Define anal fissure and describe the surface that will become involved if it is untreated.
Painful, linear lesions in the distal anal canal –> may involve full thickness of the mucosa if untreated.
State the most common location of an anal fissure and describe common S/S.
Location: posterior midline.
S/S: pain on defecation, hematochezia, skin tags if chronic
What testing is done to diagnose anal fissure?
None, it is a clinical diagnosis –> rectal pain, constipation, bright red blood on DRE.
What counseling should be provided to a patient with an anal fissure?
High fiber diet.
T/F: All anal fissures require pharmacotherapy.
False: 80% resolve on their own.
Describe 1st and 2nd line treatment options for anal fissure.
1: Sitz bath, bulking agents, inc fluids (loosen stool)
2: Topical NTG, topical silver nitrate, gentian violet solution, nifedipine ointment, botox.
Define appendicitis and state the most common causes.
Def: Inflammtion/infection of the appendix caused by obstruction
Causes: Fecalith (most common), inflammation, malignancy, foreign body
What is the most common surgical emergency?
Appendicitis
Describe S/S of appendicitis.
Anorexia, periumbilical pain that migrates to RLQ, N/V, rebound tenderness, low fever
How common is perforation in appendicitis and what are the S/S of its occurrence?
20% of cases –> high fever, generalized abdominal pain, increased leukocytosis
In what age patients is appendicitis most common?
10 - 30
Describe Rovsing’s, Obturator, Psoas, and McBurney’s signs that indicate appendicitis.
R: RLQ pain with LLQ palpation
O: Internal hip rotation with bent knee causes RLQ pain
P: Raising leg against resistance causes RLQ pain.
M: Point tenderness 1/3 of distance from ASIS to umbilicus.
What imaging studies are used to diagnose appendicitis?
US initially –> CT is more sensitive and will help identify abnormally placed appendix.
What abnormal lab value is expected in appendicitis?
Leukocytosis 10,000 - 20,000 –> higher if perforation
How is appendicitis managed?
Surgery –> broad spectrum abx before and after if perforation is suspected.
What are the common causes of small and large bowel obstruction?
Sm: adhesions or hernias (most common), neoplasms, IBD, volvulus
Lg: neoplasm (most common), strictures, hernias, volvulus, intussusception, fecal impaction
What is primary concern s/p strangulation of bowel?
Infarction, necrosis, peritonitis
What are the cardinal S/S of bowel obstruction?
Abdominal pain and distension
Describe three H&P findings that indicate late or severe small bowel obstruction.
High pitched tinkles on auscultation
Visible peristalsis
Absent bowel sounds
Define obstipation and state what condition it is associated with.
Severe constipation –> associated with severe small bowel obstruction
What S/S are associated with small bowel obstruction that is less severe?
Crampy pain followed by vomiting, diarrhea
What may be found on labs or H&P in a bowel obstruction?
Dehydration and electrolyte imbalance
What imaging is used to diagnose bowel obstruction and what is the hallmark finding?
Abdominal X-ray –> air fluid levels in stepladder pattern and dilated loops of bowel.
CT with contrast if X-ray is not definitive.
Describe the management of bowel obstruction.
NPO, IV fluids, pain management.
Partial: Nasogastric suctioning
Complete: surgery –> esp if large bowel or strangulated
Define cholecystitis.
Infection or inflammation of the gallbladder –> usually s/p obstruction by a stone.
What pathogen is most commonly responsible for cholecystitis?
E. Coli
What S/S are most commonly associated with cholecystitis?
Post-prandial RUQ pain, N/V, low fever.
Define Murphy’s Sign and Boas Sign as signs of cholecystitis.
Murph: Push on GB during exhalation and maintain during inhalation –> positive if pain on inspiration.
Boas Referred pain to subscapular area
What imaging studies are used to diagnose cholecystitis and what are positive findings?
US: initial TOC –> thickened GB, stones, etc.
Abdominal X-ray: 10% of stones seen
HIDA scan: gold standard –> nonvisualization of GB
ERCP: to determine cause, location, and extent of obstruction
What narcotic is preferred for pain control in cholecystitis and why?
Meperidine –> morphine associated with increasing tone at sphincter of Oddi.
Describe the medical management of cholecystitis and name the meds if appropriate.
NPO, IV fluids, Abx –> 3rd gen ceph + metronidazole
Define acalculous cholecystitis and describe its severity.
Cholecystitis not caused by a stone –> usually more severe than that caused by a stone.
Describe two exam findings of chronic cholecystitis with gallstones.
Strawberry GB: surface looks like the surface of a strawberry s/p cholesterol aggregatiokn –> can be seen on US
Porcelain GB: inner wall is crusted with Ca –> seen on US/CT/X-ray and considered to be pre-malignant
Define cholelithiasis.
Stones in the GB with no inflammation –> 90% are made up of cholesterol.
Describe 5 risk factors associated with cholelithiasis.
Five F’s: fair, fat, female, forty, fertile
What are the common S/S associated with cholelithiasis?
Usually asymptomatic –> incidental finding
What imaging is used to diagnose cholelithiasis?
US –> test of choice
Describe the management of cholelithiasis.
Asymptomatic: observe
Symptomatic: cholecystectomy
List and define two complications of cholelithiasis (other than cholecystitis).
Choledocolithiasis: Gall stones in biliary tree
Cholangitis: Biliary tract infection s/p obstruction by gall stone
What is the treatment for choledocolithiasis?
Stone removal by ERCP
How is cholangitis diagnosed and treated?
Dx: ERCP
Tx: ERCP stone extraction and Abx –> PCN + aminoglycoside
What is Charcot’s Triad and Reynold’s pentad for acute cholangitis?
Char: fever, RUQ pain, jaundice
Reyn: Charcot + shock and ALOC
Define cirrhosis.
Irreversible fibrosis and nodular regeneration throughout the liver
What is the most common cause of cirrhosis and what are some other causes?
MC = ETOH. Other: Hep B/C, NAFD (obesity, DM, inc triglycerides), autoimmune, sclerosing cholangitis, drug toxicity
What skin manifestations are associated with cirrhosis?
spider angioma, caput medusa, palmar erythema, jaundice, muscle wasting
What S/S are most commonly associated with early cirrhosis?
Weakness, fatigue, hepatomegaly, weight loss, muscle cramps, anorexia
What S/S are more commonly associated with late stage cirrhosis?
Ascites, preural effusion, peripheral edema, esophageal varices, hepatic encephalopathy.
Describe the pathophysiology of hepatic encephalopathy and state the S/S.
Inc serum ammonia s/p the cirrhotic liver unable to breakdown ammonia into urea. S/S = confusion, lethargy, fetor hepaticus (strong, musty smell of breath), asterixis (liver flaps), tremor, dysarthria
What modalities are used in the diagnosis of cirrhosis?
Serums labs are near normal until late in disease
CBC –> anemia is common
US/CT/MRI to determine size and number of nodules and eval for carcinoma
Biopsy
What abnormalities in serum labs are expected in cirrhosis?
All minimally abnormal –> inc AST, inc alk-phos, inc gamma globulin, dec albumin, abnormal coags.
What may be used in the management of cirrhosis?
Cease ETOH use
Lactulose and neomycin for encephalopathy
Na restriction and paracentesis for ascites
Cholestyramine for pruritis
Spironolactone 100mg QD for diuresis
Liver transplant in select patients
What screening should be performed on patients diagnosed with cirrhosis?
Screen for carcinoma every 6 months
List risk factors for colorectal cancer.
Age > 50 (peak at 65), US/Crohn’s, polyps, genetics, diet (low fiber, high red meat), smoking, ETOH, Lynch syndrome.
What is the most common cause of inherited colorectal cancer?
Lynch Syndrome –> AKA hereditary non-polyposis colorectal cancer (HNPCC)
What gene mutation leads to a 100% chance a patient will develop colorectal cancer by age 40?
Mutation of APC gene (familial polyposis)
What is peutz-jehgers syndrome?
Genetic development of hamartomatous polyps early in life that have a high risk of developing to cancer.
Differentiate the presentation of right sided (proximal) colorectal lesions from that of left sided (distal lesions).
Rt: tend to bleed and cause diarrhea
Lt: present later and cause bowel obstruction
Identify important staging benchmarks for colorectal cancer and the associated prognosis of each.
I: only mucosa involved –> 90% survival at 5 years
II: transmural lesion or regional lymph node involvement –> 70-80% survival at 5 years
IV: Distant mets –> 5% survival at 5 years
What modalities are used in the diagnosis of colorectal cancer?
FOBT = can be early marker
Inc carcinoembryonic antigen (CEA) is a risk factor
Colonoscopy, barium enema to evaluate masses
CT, X-ray to detect mets
Biopsy
Describe the management of colorectal cancer.
Surgical resection
Chemo for stage III or higher
Monitor CEA
State the screening recommendations for colorectal cancer.
No risk factors: Annual DRE and colonoscopy q 10 years starting at age 50
Family Dx age >60: Annual DRE and q10y colonoscopy starting at age 40
Family Dx < age 60: Annual DRE and q5y colonoscopy starting at age 40
How long does it usually take an adenomatous polyp to develop into cancer (adenocarcinoma)?
10 - 20 years
What are the three leading causes of cancer death in the US?
- Lung
- Skin
- Colorectal
What procedure can significantly reduce the risk of colon cancer?
Removal of precancerous polyps
Describe S/S associated with colon polyps.
Usually asymptomatic –> May cause bleeding which can cause iron deficiency anemia.
Differentiate between hyperplastic and adenomatous polyps.
Hyp: Low risk of cancer –> 90% of all polyps
Aden: Pre-cancerous –> 10-20 years to progress to cancer.
List and describe the three types of adenomatous polyps.
Tubulous: non-pedunculated –> most common
Villous: highest cancer risk, most are sessile (immobile)
Tubulovillous: mix of the above
List the types of polyps from lowest cancer risk to highest.
Hyperplastic –> Tubulous –> Tubulovillous –> Villous
What is the recommended frequency of follow up after polyps removal?
Villous = 3 years
All others = 5 years
What information is particularly important to obtain in a patient with diarrhea?
Medications and illnesses of all people patient has recently shared a meal with
Travel history
Differentiate between secretory and inflammatory diarrhea.
Sec: Large volume, non-inflammatory –> non-bloody. Caused by: infection, pancreatic insufficiency, laxative use, ingestion of pre-formed bacterial toxins.
Inf: diarrhea with blood and/or mucus (dysentery). Fever also usually present. Caused by: invasive organism or IBD.
What is indicated by the finding of WBCs in the stool of a diarrhea patient?
Inflammatory process
What diagnostic modalities are used to evaluate diarrhea?
Stool culture, microscopy for parasites
What is the mainstay of treatment in diarrhea?
Fluid repletion –> PO preferred bu IV if necessary
What are the diet recommendations for a diarrhea patient?
Bland, low residue foods –> crackers, applesauce, soups, boiled vegetables. Avoid spicy, fried, and processed foods.
Which patients with diarrhea are candidates for therapy with anti-motility agents
Age < 65 with severe volume depletion
What type of diarrhea should not be given anti-motility agents and why?
Patients with invasive (salmonella, shigella, campylobacter) diarrhea –> may cause toxicity from bacteria
List three types of anti-motility agents used to treat diarrhea.
Bismuth Salicylate (Pepto/Kaopectate): dysentery
Opioid Agonists: noninvasive diarrhea
Anticholinergics
What are contraindications for use of Bismuth-Salicylates and for Opioid Agonists in diarrhea patients?
B-S: children s/p Reyes Syndrome risk
Opioid: Dysentery
What antibiotics are best for patients with severe infectious diarrhea from Shigella, campylobacter, C-diff, etc?
PO Vancomycin, metronidazole, fidaxomicin
Define constipation in relation to normal bowel function.
Normal: 3 stools per day to 3 per week. Constipation is a decrease in volume and increase in firmness accompanied by straining.
What is the primary concern in a patient older than 50 with new onset constipation?
Evaluate for colon cancer
What is the best therapy for constipation?
Increase insoluble fiber and fluid intake with increased exercise.
List causes of esophagitis.
GERD = most common
Infections in immunocompromised = 2nd MC
Radiation, ingestion of corrosive substances or some meds, eosinophilic (associated with food allergies and atopic disease/eczema)
List risk factors for esophagitis.
Pregnancy, smoking, obesity, ETOH, chocolate, spicy foods, meds (NSAIDs, BBs, CCBs)
Define two common symptoms associated with esophagitis.
Odynophagia: painful swallowing
Dysphagia: difficulty swallowing
State diagnostic and therapeutic modalities used in esophagitis.
Dx: endoscopy, double contrast esophogram
Tx: treat underlying cause
