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pulmonary > GI > Flashcards

GI Flashcards

1
Q

Crohn Dz - background

A

chronic INCURABLE transmural inflammatory dz that can affect ANY PART OF GI w/ SKIP lesions SPARING RECTUM!!!
chronic w/ flare-ups, progressively worse

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2
Q

crohn - pathology hallmarks

A
  1. terminal ileum most common site
  2. skip lesions
  3. transmural inflammation
  4. fistula, noncaseating granulomas, abscesses, strictures, mesenteric fat creeping, cobblestoning
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3
Q

crohn - pres

A
  • gradual fatigue, fever, malaise with NONBLOODY DIARRHEA, weight loss d/t malabsorption
  • crampy RLQ pain w/ n/v
  • perianal disease
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4
Q

crohn - extraintestinal sx

A 
ARTHRITIS - seronegative, migratory monoarticular, ankylosing spondylitis
UVEITIS / EPISLCERITIS
ERYTHEMA NEDOSUM, 
ORAL APTHOUS lesions
gallstones, kidney stones
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5
Q

crohn - dx

A
  • clinical picture + endoscopy
  • colonoscopy w/ bx
  • CT / MR enterography or barium upper GI for small bowel
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6
Q

treatment crohn

A
  • mild-mod: sulfasalazine and mesalamine - oral, first choice
  • antibiotics for active - oral flagyl 10 mg/kg/d or cipro 500 mg BID or rifaximin 800 mg BID x 6-12 weeks
  • corticosteroids: NOT longterm
    - Budesonide (entocort) 9 mg QD x 8-16 weeks w/ MILD-MOD dz- preferred b/c fewer SE
    • prednisone or methylprednisolone 40-60 mg/d for SEVERE x 8-16 weeks
    • if require long-term steroids, use IMMUNOMODULATORS
  • biologics if all else fails
  • bile acid sequestrants for terminal ileum disease - cholestyramine or colestipol
  • antidiarrheal: loperamide, diphenoxylate
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7
Q

immunomodulators for crohn

A

1st line: azathioprine, mercaptopurine, improve in 2-4 mo (not for exacerbations)
2nd / unresponsive: methotrexate x 12 weeks w/ folic acid

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8
Q

biologics for crohn

A

infliximab, adalimumab, certolizumab for mod-severe active crohn
*alays test for TB, HBV prior

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9
Q

mild and severe flare-ups for crohn

A

mild: sulfasalazine or oral mesalamine, reduce for maintenance dose
severe: hydrocortisone 100 mg, add cyclosporine if not responding then change to prednisone w/ response, then add back maintenance med and w/draw steroid in 1-2 mo

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10
Q

crohn - indications for surgery

A
  1. refractory dz
  2. intra-abdominal abscess
  3. massive bleed
  4. sx fistulas
  5. obstruction
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11
Q

ulcerative colitis - background

A

chronic CURABLE dz w/ CONTINUOUS SUBMUCOSAL / MUCOSAL INFLAMMATION OF COLON AND RECTUM!

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12
Q

UC - pathology

A

-continuous, submucosal ulcerations w/ erosions and friable tissue w/ crypt abscesses

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13
Q

UC - pres

A

BLOODY DIARRHEA, LLQ abominal pain w/ tenesmus and fecal urgency

  • more severe have anemia, hypovolemia, malnourished
  • arthritis, pyoderma gangrenosum - other sx same as crohn
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14
Q

UC - dx

A
  1. r/o infectious diarrhea w/ fecal leukocytes, ova/parasites, c. diff toxin
  2. sigmoidoscopy / colonoscopy (DO NOT DO COLONOSCOPY IN ACUTE D/T RISK OF PERF)
  3. KUB xray - for colonic dilation
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15
Q

UC - tx

A
  • AVOID NSAIDS AND LACTOSE - can precipitate flare
  • acute exacerbations: systemic corticosteroids - predinsone 40-60 mg/d
  • drug of choice: topical mesalamine suppository 1000 mg qHS or enema 4g
    • w/o response / w/ decline can do PO
    • can combine w/ hydrocortisone suppository if no response in 4-8 weeks, add systemic w/o further response
  • immunomodulators w/o response to above - mercaptopureine or azathioprine
  • anti-tnf: infliximab and adalimumab for mod-severe
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16
Q

toxic megacolon / colitis tx in UC

A

add antibiotics - broad spectrum against anaerobes / gram neg

17
Q

UC - indications for surgery

A

absolute: severe hemorrhage, perforation, documented carcinoma
- fulminant colitis / toxic megaolon not improving in 48-72 hr, flat dysplasai / nonresectable dysplasia, refractory dz

18
Q

UC - cure

A

proctocolectormy, most choose colectomy

-se: pouchitis in 40% - inflamm of ileal pouch, tx w/ oral flagyl or cipro

19
Q

prognosis

A

UC better controlled and curable than crohn

  • increased risk colon cancer and suppurative cholangitis in UC
  • *monitor w/ colonoscopy q 1-2 yrs in UC w/ dz >8 yrs
20
Q

diarrhea - acute and chronic def

A

acute: less than 2-3 weeks

chronic > 4weeks

21
Q

diarrhea - causes

A

acute: VIRAL infection, (rotavirus, norwalk virus), medications (antibiotics!)
chronic: IBS #1, IBD, meds, bacterial infection, colon cancer, diverticulitis, malabsorption, post-op, fecal impaction, lax, immunocompromised, meds (metformin)

22
Q

diarrhea - key sx

A
  • w/ assoc n/v - more like gastroenteritis or food poisoning
    - w/ food poisoning- occurs w/in hours
  • fever and blood - more likely shigella, campylobater, salmonella, e. coli (no fever / blood, more likely viral)
  • look for travel, family/friends sick, bloody / assoc sx, travel, new foods / new meds
23
Q

diarrhea - labs

A
  1. CBC - check for anemia (get FOBT), leukocytosis
    • w/ blood consider colonoscopy
  2. BMP - metabolic acidosis, hypokalemia, elevated BUN:crt (check vol status on exam)
  3. fecal leukocytes and FOBT
    • w/ neg leukocytes - dont need stool culture!
    • pos leukocytes common in salmonella, shigella, c diff, campylobacter and e. coli (not w/ staph / clostridial food poisoning or viral)
      - w/ pos send for stool culture and C. diff!
      - also get culture w/ fever and hospitalized
      - if suspect giardia (cramping, pale greasy stool) get ELISA
      - AXR if suspect obstruction / toxic megacolon!
24
Q

acute diarrhea treatment

A
  1. rehydrate, fix electrolytes
  2. hospitalize w/: dehydrated elderly, cannot tolerate PO, bloody, high fever / toxic
  3. sx of bacterial: FQ or macrolide
    * **avoid abx w/ E.coli 0157:H7 - increases toxin (HUS!)
  4. antimotility agents: loperamide (imodium): 2 mg after loose stool (max 16 mg/d) OR diphenoxylate-atropine (lomotil) 5-20 mg/d
    - probiotics w/ antibiotics
25
Q

abx for acute diarrhea…

  1. c diff
  2. giardia
A
  1. c diff - outpatient do flagyl (avoid alcohol) or inpatient do vanco po
  2. giardia (protozoan) - flagyl
26
Q

abx for diarrhea d/t…

  1. shigella
  2. campylobacter
  3. traveler’s
A
  1. shigella- bactrim DS or cipro
  2. campylobacter - erythromycin or cipro
  3. traveler’s: cipro or bactrim dS (same as shigella)
27
Q

toxic megacolon pres

A

*complication of ulcerative-

abdominal pain, distention, guarding, rebound, decreased bowel sounds, fever, tachycardia

pulmonary (16 decks)

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