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GI Flashcards

1
Q

Acute cholecystitis RF

A

RF:
Native American
Mexican American
Family history

Fertile, fat, forty, fair - not as much but still RF

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2
Q

Acute cholecystitis pathophysiology

A

Inflammation of gallbladder & infection of the bile in most - 90% of cases caused by obstruction from stone in cystic duct

Remember - gallstones can also cause obstructive cholangitis 2/2 choledocolithiasis or gallstone pancreatitis

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3
Q

CP acute chole

A

PERSISTENT, severe, steady RUQ pain, + Murphy’s sign, fever, N/V, anorexia, + Courvoisier’s sign (palpable gallbladder)

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4
Q

Dx acute chole

A

Labs:
Increased T.bili -

Labs:
Small increase in LFTs (AST/ALT, alk phos) released by hepatocytes - only section of liver inflamed is section GB is touching = small transaminitis)

Leukocytosis
Increased amylase

Imaging:
HIDA scan = most sensitive but VERY expensive, ultrasound used more frequently

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5
Q

Initial treatment acute chole

A

NPO, IVF, pain control, ABX (3rd gen ceph & flagyl or cipro & flagyl (GNR anaerobes & aerobes)

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6
Q

Treatment for acute cholecystitis in low risk surgical patient (ASA I-II) w/ clinical improvement after supportive care and antibiotics

A

Based on surgical risk:

- Low surgical risk w/ clinical improvement - elective cholecystectomy

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7
Q

Treatment for acute cholecystitis in low risk surgical patient (ASA I-II) w/ clinical deterioration after supportive care and antibiotics

A
  • Low risk w/ clinical deterioration - emergent cholecystectomy
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8
Q

Treatment for acute cholecystitis in HIGH risk surgical patient (ASA III-V) w/ clinical improvement after supportive care and antibiotics

A
  • High surgical risk w/ clinical improvement - discharge & refer for nonsurgical gallstone therapy
  • High surgical risk w/ clinical deterioration - percutaneous cholecystostomy (GB tube/drainage) & referral for nonsurgical gallstone therapy
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9
Q

Treatment for acute cholecystitis in HIGH risk surgical patient (ASA III-V) w/ clinical deterioration after supportive care and antibiotics

A
  • High surgical risk w/ clinical deterioration - PERCUTANEOUS CHOLECYSTOSTOMY (GB tube/drainage) & referral for nonsurgical gallstone therapy
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10
Q

Chronic cholecystitis definition & what it can lead to

A

Chronic episodes of biliary colic caused by:

  • Recurrent obs. of cystic duct by gallstones (acute cholecystitis)
  • Irritation of the gallbladder by stones contacting epithelium
  • Chronic inflammation of the gallbladder can lead to porcelain gallbladder (fibrosis of gallbladder) & = Inc r/o gallbladder CA
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11
Q

CP Chronic cholecystitis

A

Poorly localized pain (visceral so localize to midline but no peritoneal inflam/pain that’s at a specific point) commonly after eating, resolves spontaneously

Labs normal

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12
Q

CD or UC more common

A

UC

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13
Q

Parts of GIT affected UC

A

Colon & Rectum only

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14
Q

Parts of GIT affected CD

A

Terminal ileum = MC but can affect anywhere in GIT

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15
Q

Most important RF UC

A

Family History

Also Hx prior serious GI infection (shigella, salmonella, camplyobacter, esp as an adult)

Western Diet

Ashkanazi jews 5x prevalence

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16
Q

Location of ABD pain UC

17
Q

Location of ABD pain CD

A

RLQ/periumbilical

18
Q

Quality of diarrhea UC

A

Bloody & mucoid (can be non-bloody)

19
Q

Quality of diarrhea Crohn’s

A

Non-bloody

20
Q

Most important RF CD

A

FAMILY HISTORY

Hx of a more MILD GI infection - gastroenteritis etc
Western diet, sedentary, air pollution, tobacco

21
Q

Effect of smoking on UC

A

Lower risk & milder UC disease

22
Q

Effect of smoking on CD

A

Exacerbation

Remember one RF = pollution…

23
Q

CD: A/w perianal disease?

A

YES - remember normally no rectal involvement of crohns but a/w tons of other perianal complications whereas UC involves the rectum but is NOT a/w perianal complications

Abscess, sinus tracts, fistulae, strictures, adhesions, SBO

24
Q

UC: A/w perianal disease?

A

Very rarely seen in UC

25
Presence of constitutional symptoms UC?
Rarely seen, more likely in CD
26
Presence of constitutional symptoms CD?
Yes - low grade fever, weight loss, fatigue, malaise
27
Extraintestional manifestations in UC?
YES - remember CD a/w perianal comp & UC a/w extra-intestinal comp ``` Mouth - aphthous ulcers Eyes - iritis, uveitis, episcleritis Biliary - PSC - male Heme - AIHA MSKL - seronegative arthritis, ankylosing spondylitis (check for fam hx AS) ``` UC - starts w/ vowel, a/w all comp start w/ vowel - UC = AAAAIUE Note: All extra-GI manifestations improve post-colectomy EXCEPT the PSC :/
28
Extra-intentional manifestations in UC?
YES - remember CD a/w perianal comp & UC a/w extra-intestinal comp ``` Mouth - aphthous ulcers Eyes - iritis, uveitis, episcleritis Biliary - PSC - male Heme - AIHA MSKL - seronegative arthritis, ankylosing spondylitis (check for fam hx AS) ``` UC - starts w/ vowel, a/w all comp start w/ vowel - UC = AAAAIUE Note: All extra-GI manifestations improve post-colectomy EXCEPT the PSC :/
29
D/dx UC/CD
Must rule out other causes of diarrhea - infectious (yersinia, enterovirus) and non-infectious ( IBS, bechet's syndrome) Infectious colitis - stool cultures Ischemic colitis - in elderly, dehydrated - MC form of bowel ischemia CMV colitis - immunosuppressed
30
Diagnosis UC
1. Careful history 2. Colonoscopy 3. Biopsy Labs: CBC (H/H - anemic (microcytic hypo-chromic), albumin - dec 2/2 malabsorption, ESER/CRP elevated in flares - used to trend Imaging: CT ABD/pelvis - will show colitis in rectum- wall thickening - but what kind? Cannot differentiate between infectious, inflammatory & ulcerative - Need colonoscopy w/ biopsy to tell - bx will show crypt abscess/distortion lamina propria w/ pasma cells, eisoniphils, lymphoid cells & mucin depletion
31
Colonoscopy features UC
Diffuse confluent disease from entate proximally | Friable, edematous, erythematous mucosa w/ erosions, ulcerations, & spontaneous bleeding
32
CD Dx/Labs
COLONOSCOPY & BX = GOLD STANDARD Labs: H/H, albumin, WBC, fecal calprotectin, CT/MRI enterography Colonoscopy will show segmental skip lesions, aphthoid stellate linear ulcers, strictures, especially in the terminal ileum and colon
33
Colonoscopy features CD
Colonoscopy will show segmental skip lesions, aphthoid stellate linear ulcers, strictures, especially in the terminal ileum and colon
34
Medical treatment mild disease UC vs moderate vs severe
Mild: 5-ASA (sulfasalazine PO & mesalazine PR) Moderate: 5-ASA failure - oral steroids - taper over 60 days, re-transition to 5-ASA for maintenance - 6-MP (azathioprine) if failure of 5-ASA Severe: Hospitalization for IV steroids - IVF - steroid failure - try biologics TNF alpha blockers (inflixumab, adalimumab, golimumab) --> failure of TNF-alpha - use VEGF blocker fedolizumab - if inducted on Mab then keep on that for maintenance Medical failure --> surgery
35
UC: Elective vs urgent vs emergent surgical indications
Surgical treatment - 20-30% of UC pt require colectomy which is curative - done when medical management fails Emergency surgery - toxic megacolon unresponsive to meds Urgent surgery - admitted & not responding to intense medical treatment Elective surgery - long term steroid dependence or colorectal dysplasia/CA
36
CD: Surgical indications
Surgery = NOT curative like it is in UC Indications: abscess, intractable fistula, toxic megacolon, fibrotic strictures with obstruction, recalcitrant sx despite high dose steroids, perforation, intractable hemorrhage
37
Prevention & Screening UC
Colonoscopy to check for CRC 8 years post-dx - if rectosigmoid involvement only - follow age guidelines If left-sided colitis or pancolitis, repeat q 1-2 years Pt w/ PSC - annual screenings (risk of cholangiocarcinoma)
38
Prevention & Screening CD
CRC screening in pt w/ more thtan 1/3 colon affected (L3), first screening colonoscopy 8 years after dz onset, repeated every 1-2 years then every 1-3 years once normal

Surgery EORE (3 decks)

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