GI #2 Flashcards
Management of fecal impaction
- Digital disimpaction followed by warm-water enema with mineral oil
- Polyethylene Glycol
MCC of anorectal abscess
-Staphyloccus Aureus
MC site of anorectal abscess
Posterior rectal wall
Symptoms of an anorectal abscess
- Swelling
- Rectal pain worse with sitting, coughing, defecation
- Focal edema, induration, and fluctuance
Treatment for anorectal abscess/fistula
- Incision and drainage
- -Followed by WASH (warm water cleaning, analgesic, sitz baths, high-fiber diet)
Causes of anal fissures
- Low-fiber diet
- Passage of large hard stools
- Constipation
- Other anal trauma
Symptoms of anal fissures
- Severe rectal pain with bowel movements
- bright red blood per rectum
Describe the MC type and location of anal fissure
-Longitudinal tear at posterior midline
True or False: 80% of anal fissures resolve spontaneously
True
However, what is the treatment for an anal fissure if it does not resolve?
Supportive measures (warm water sitz baths, analgesics, high fiber diet, laxatives, mineral oil)
-Topical vasodilators, Nitroglycerin, Botox injections, Surgery for refractory cases
Internal hemorrhoids originate from ________ and what symptoms do they have?
Proximal (above) the dentate line
-Bleed and are painless
Describe the four grades of internal hemorrhoids
- Grade I: does not prolapse
- Grade II: prolapses with defecation but spontaneously reduces
- Grade III: Requires manual reduction
- Grade IV: Irreducible and may strangulate
External hemorrhoids originate from ________ and have symptoms such as
- Distal (below) dentate line
- Do not bleed and are painful
Management of hemorrhoids
- Conservative treatment: high fiber, increased fluids, warm sitz baths, topical corticosteroids
- Rubber band ligation, sclerotherapy, infrared coagulation
- Hemorrhoidectomy: for Stage IV or non responsive to other therapy, or external hemorrhoids
Regarding diverticulosis, what is the MC area for occurrence and what is the MC area for bleeding?
- Left colon (MC in incidence)
- Right colon (MC in bleeding)
Risk factors for diverticulosis
- Low fiber diet
- Constipation
- Obesity
What is the MCC of acute lower GI bleeding (Painless hematochezia) in adults?
Diverticulosis
What is the diagnostic of choice for diverticulosis?
Colonoscopy
If bleeding is not visualized on colonoscopy for diverticulosis, what is the next diagnostic step?
Radionuclide imaging followed by arteriography
In most cases of diverticulosis, the bleeding stops spontaneously. However, if it does not, what should you do?
-Resuscitation (2 large bore IVs, fluids, blood products)
Asymptomatic diverticulosis can be followed by (3 things)
- High fiber diet
- Psyllium
- Use of Bran
MC area of diverticulitis
-Sigmoid colon (due to high intraluminal pressure)
Symptoms of diverticulitis
- LLQ abdominal pain
- Low grade fever
- Nausea, vomiting
- Constipation, Diarrhea
- Changes in bowel habits
Diagnostic of choice for diverticulitis
-CT scan (initial)
What is the criteria for admission with diverticulitis?
- Perforation, abscess, obstruction or fistula
- High fever, sepsis, immunocompromised, increased age, unable to tolerate oral intake
Treatment for uncomplicated diverticulitis
- Treat as outpatient with oral antibiotics (Metronidazole + Ciprofloxacin or Levofloxacin) for 7-10 days
- Metro + Bactrim (alternative)
What is toxic megacolon?
-Nonobstructive, extreme colon dilation > 6 cm + signs of systemic toxicity
What are some common etiologies of toxic megacolon?
-Complications of IBD, C. diff, radiation, volvulus
Symptoms of toxic megacolon
- Profound bloody diarrhea
- Lower abdominal tenderness
- Distention
- Signs of toxicity: AMS, fever, tachycardia, hypotension, dehydration
What is the initial imaging of choice for toxic megacolon?
Abdominal radiographs
What do the abdominal radiographs for toxic megacolon usually show?
-Radiologic evidence of colon > 6 cm
Treatment for toxic megacolon
Supportive mainstay: bowel rest, bowel decompression with NG tube, Ceftriaxone + Metro, fluid and electrolyte replacement
What is Olgivie Syndrome?
-Colonic pseudo-obstruction (no mechanical obstruction present)
What are some etiologies of olgivie syndrome?
- Postoperative state
- Medications (opiates)
- Metabolic (hypokalemia, hypercalcemia)
- Hypothyroidism
- DM
Symptoms of Olgivie Syndrome
- Abdominal distention!
- Tympanitic abdomen
Although abdominal radiographs are the initial test for Olgivie Syndrome, what is the most accurate test?
CT scan
Treatment for Olgivie Syndrome
- Conservative: electrolyte and fluid repletion (if < 12 cm)
- Medical decompression: Neostigmine (if > 12 cm or failed 24-48 hours of conservative)
- Colonoscopic decompression: if failed conservative and Neostigmine
- Surgical decompression: if all other options fail
Name risk factors for IBD
- Jewish population, Caucasians
- 15-35 years old
- UC in males, Crohn’s in females
- Smoking bad for Crohn’s and protective in UC
- Western diet
- Medications: NSAIDs, OCP
Name some extra-intestinal manifestations for IBD
- Anterior uveitis/iritis
- B12 and iron deficiency
- Increased risk of thromboembolism
- Arthritis, osteoporosis
Name 8 factors about UC
- Limited to colon, rectum always involved, contiguous spread
- Mucosa and submucosa only
- LLQ pain, bloody diarrhea
- Smoking decreases risk
- Uniform inflammation and pseudopolyps (colonoscopy)
- Stovepipe sign (barium studies) - no haustral markings
- P-ANCA labs
- Surgery is curative
Name 8 factors about Crohn’s Disease
- Any segment of GI tract, MC in terminal ileum
- Transmural
- RLQ pain, no bloody diarrhea
- Smoking does not decrease risk
- Perianal disease (fistulas, abscesses, granulomas) and B12/Fe deficiency common
- Skip lesions and cobblestone appearance (Colonoscopy)
- String sign (barium studies)
- ASCA (labs)
- Surgery is noncurative
Initial test of choice for Crohn’s Disease and UC
-Upper GI series
Treatment for Crohn’s Disease
- Limited ileocolonic disease: 5-ASA (Mesalamine) or oral glucocorticoids
- Ileal and proximal: Glucocorticoids (Pred, Budesonide)
- Severe: Azathioprine, Methotrexate, Infliximab
What is shown on the following imaging studies for Crohn’s Disease?
- Upper GI series:
- Endoscopy:
- Biopsy:
- Labs:
- Upper GI series: string sign
- Endoscopy: Skip areas, cobbles-toning
- Biopsy: Transmural inflammation, noncaseating granulomas
- Labs: ASCA, B12 and Iron Deficiency
What is shown on the following diagnostics for UC?
- Flexible sigmoidoscopy:
- Biopsy:
- Barium Enema:
- Labs:
- Flexible sigmoidoscopy: uniform erythema and ulceration
- Biopsy: crypt abscesses and atrophy, contiguous involvement
- Barium Enema: stovepipe or leadpipe sign
- Labs: P-ANCA
What are some maintenance therapy options for Crohn’s and UC?
- Azathioprine
- Methotrexate
- Cyclosporine
- Tacrolimus
- Anti-TNF agents (Infliximab, Adalimumab)
For mild to moderate UC and Crohn’s, what is the first-line therapy?
-5-ASA (Mesalamine) Topical
Oral if needed, can be added
