GI Flashcards
what is acute cholecystitis caused by?
sustained obstruction of cystic duct
how is acute cholecystitis different from acute cholangitis?
by lack of biliary obstruction & jaundice (cholangitis has this)
what are the s/s of acute cholecystitis?
localizing constant RUQ pain/epigastrium
pain lasts >3-4 hrs
N/V, systemic sx’s of infam -> fever, tachycardia
pt stays still b/c pain aggravated by movement
what is a sign of perforation in acute cholecystitis?
hypoactive bowel sounds
what is Boas sign?
radiation of pain d/t phrenic nerve irritation in acute cholecystitis
(pain radiates from RUQ to scapula)
what are the labs like for acute cholecystitis?
LEUKOCYTOSIS W/ LEFT SHIFT
mild incr. in AST/ALT
what’s the initial test of choice for acute cholecystitis?
U/S (shows distended gallbladder and thickened GB wall)
what’s the GOLD STANDARD to dx acute cholecystitis?
HIDA scan (aka cholescintigraphy) - see non visualization of GB suggesting cystic duct obstruction
what’s the tx for acute cholecystitis?
NPO, IVFs, IV abx (3rd gen CPN & Flagyl)
Lap chole (after IVF and abx tx)
Cholecystostomy (if too ill for cholecystectomy)
what is the MOST COMMON bacteria in acute cholecystitis? other bacteria?
MC = E. coli
others: Klebsiells, enterococci, b. frag, clostridium
what can chronic cholecystitis lead to?
gallbladder cancer (d/t chronic inflammation of GB)
what’s the s/s of chronic cholecystitis?
Biliary colic = classic & MC sx
NO FEVER/CHILLS (NO INFECTION)
which has FEVER/CHILLS - signs of infection…acute or chronic cholecystitis?
acute cholecytitis
what’s the labs like for chronic cholecystitis?
normal CBC w/diff (no leukocytosis)
LFTs normal
how is chronic cholecystitis distinguished from acute cholecystitis?
by sx’s and absence of leukocytosis
what’s the preferred imaging for dx of chronic cholecystitis?
U/S
what’s the tx of chronic cholecystitis?
IV analgesics & observation
Elective cholecystectomy (after confirm dx)
Intra-op cholangiogram
Lithotripsy w/ bile salts (chenodeoxycholic & ursodeoxycholic acid) -> takes 2 years, if can’t do surgery
what’s the MC cause of acute pancreatitis? after that?
MCC is gallstones
after is ETOH abuse (chronic)
what’s the s/s of acute pancreatitis?
abrupt onset of non-cramps, epigastric abd pain that radiates to the back
pain alleviated by sitting forward or standing
N/V, anorexia, jaundice (d/t biliary obstruction)
the pain in acute pancreatitis is alleviated by what?
sitting forward or standing
what’s the labs like for acute pancreatitis?
Amylase/Lipase >3x ULN
-or elevated amylase 1.5x ULN w/ lipase of 5x ULN
Fasting Tg >1,000
Leukocytosis
what imaging is done to dx acute pancreatitis?
CT w/ IV contrast
what’s the tx for acute pancreatitis?
dmit to hospital, NPO, IVFs, analgesia with Meperidine (not morphine b/c incr. spasm of sphincter of Oddi), antiemetic IV
when is surgery done for acute pancreatitis?
if dx uncertainty and to prevent further attacks of acute pancreatitis
what surgeries are done for acute pancreatitis?
If mild-mod pancreatitis d/t cholelithiasis → undergo cholecystectomy during admission
If choledocholithiasis → ERCP w/ sphincterotomy & stone extraction done pre-op to clear CBT
what is chronic pancreatitis?
irreversible damage to pancreas
occurs after multiple acute attacks, causing pancreatic ductal system to become permanently damaged
what insufficiencies occur in chronic pancreatitis?
endocrine & exocrine and are manifested by DM and steatorrhea
causes of chronic pancreatitis?
ETOH abuse = MC
smoking, CF, autoimmune
what are the s/s of chronic pancreatitis?
dull epigastric pain that radiates tot he back (improved by leaning forward) that starts out intermittent, then becomes constant
malnutrition & fat-soluble vit. deficiencies d/t malabsorption 2/2 exocrine insufficiency and steatorrhea
what are the labs for chronic pancreatitis?
Secretin test -> Abnl if >60% dysfxn (checks digestive enzyme fxn b/c secretin stimulates their secretion from the pancreas)
what’s the tx for chronic pancreatitis?
change diet to decrease fat and ETOH
***pancreatic enzyme replacement for steatorrhea
what are the MC anal abscesses?
perianal and ischiorectal
what is a perianal abscess?
early intersphincteric abscess increases in size
what is a ischiorectal anal abscess?
in ischiorectal fossa located outside external sphincter & below elevator ani muscles
what’s a supralevator anal abscess?
abscess spreads above elevators (hard to dx)
what’s an intersphincteric anal abscess?
abscess b/w external and internal anal sphincters
what are the s/s of anal abscess?
***Cardinal signs of infection present: fever, redness, swelling
***Extreme perirectal pain that won’t let pt sit down or have BMs
Hard to see swelling on early intersphincteric and supralevator
what are the classic PE findings for anal abscess?
rubor, dolor, calor, tumor (heat, pain, redness, swelling)
what’s the tx for anal abscess?
I&D of abscess
-if perianal or ischiorectal abscess -> drain thru skin (simple)
-if perirectal, intersphincteric, supralevator abscess -> draining OR (complicated)
what are anal fistulas?
from anal abscess ater drainage
Abnl. communication b/w anus at level of dentate line & the perirectal skin, thru the bed of a the previous abscess
what is an intersphincteric fistulae?
results of perinanal abscess
what is a transsphincteric fistulae?
result of ischiorectal abscess
what is a suprasphincteric fistulae?
result of supralevator abscess
what’s the sx’s of anal fistulas?
chronic drainage of pus, fecal soiling, occasional perineal discomfort
what’s goodsall’s rule?
to predict trajectory of the fistulous tract & location of the internal anal opening
Fistulas w/ext. opening anteriorly to anal line, connect to internal opening by short radial straight tract
Fistulas w/ext. opening posteriorly to anal line connect to internal opening by curvilinear fashion to posterior midline
Exception: ant. fistulas lying >3 cm from anus, may have curved track (sim. to post. fistulas)
what’s the tx for anal fistulas?
Fistulotomy (unroof fistula tract) - careful about cutting sphincter -> incontinence (use seton stitch to avoid incontinence)
where are most anal fissures located?
posterior midline
what’s the tx for anal fissures? (acute and chronic fissures)
Acute fissures:
-conservative tx, avoid diarrhea/constipation, bulk laxative, top. nitro, top. procainamide, botox, sitz bath, top. CCB
Failure of conservative tx or chronic fissures:
-Surgery -> partial lateral internal sphincterotomy
what are the two types of anorexia?
restrictive type and purging type
what’s the BMI or body weight to dx anorexia?
BMI < 17.5 kg/m2 or body weight <85% of ideal weight
what is seen on PE for anorexia?
emaciation, hypotension, bradycardia, skin/hair changes (ex. lanugo), dry skin, salivary gland hypertrophy, amenorrhea, arrhythmias, osteoporosis
what’s the labs like for anorexia?
leukocytosis, leukopenia, anemia; hypokalemia, incr. BUN (dehydration), hypothyroidism
what syndrome can occur in anorexia?
refeeding syndrome
what’s the HALLMARK and predominant cause of refeeding syndrome?
hypohosphatemia
what’s the tx for anorexia?
- Medical stabilization: hospitalization for <75% expected body weight or pts who have medical complications
- Psychotherapy: CBT, supervised meals, weight monitoring
- Pharmacotherapy: if depressed → SSRIs; atypical antipsychotics +/- b/c can also help w/ weight gain
when do you hospitalize a pt for anorexia?
for <75% expected body weight or pts who have medical complications
what’s the pre-op abx for appendicitis if not perfed?
single dose Cefotetan 2g IV
(covers GN aerobic bacteria)
if PCN/CPN allergy -> Clinda + Cipro or Levo or Gentamicin or Aztreonam
when do you NOT operate for appendicitis?
peritonitis, appendicular mass, resolved
what’s the most common complication of appendectomy?
post-op wound infection
what are the most important vitamin deficiencies in bariatric surgery?
iron, vit B12, folic acid, thiamine, Ca, vit D
what’s the MOST COMMON vitamin deficiency in gastric bypass patients?
iron deficiency
what’s the MC cause of SBO in first world? MC in third world??
post-surgical adhesions = MC cause in 1st world
incarcerated hernia = MC cause in 3rd world
what are the top 3 MC causes of SBO?
post-surgical adhesions, incarcerated hernia, metastatic peritoneal cancer
what’s the MC cause of large bowel obstructions?
malignancy
which type of SBO is at high risk for strangulation and requires IMMEDIATE surgery?
Closed loop SBO (lumen occluded at 2 points, reducing blood supply, causing strangulation, necrosis & peritonitis)
what’s the difference b/w distal and partial SBO’s on presentation?
distal presents more with abdominal distention & less vomiting
what are the 4 hallmark sx’s of SBO?
- Cramping abdominal pain (colicky abd pain in periumbilical region that becomes more severe & constant)
- Abdominal distention (the more distal the more prominent)
- Vomiting (may be bilious if proximal, follows the abdominal pain)
- Obstipation (late finding)
what are signs of high grade obstruction?
constipation and obstruction
what’s the PE like for SBO?
abdominal distention, hyperactive bowel sounds in early obstruction -> HIGH-PITCHED TINKLES ON AUSCULTATION & VISIBLE PERISTALSIS
No bowel sounds occur late in obstruction
what’s the initial dx study for SBO?
abdominal (KUB) x-ray
-see air fluid levels in step ladder pattern
what imaging is done after abd x-ray for SBO for further localization?
CT with water soluble PO contrast
-failure of contrast to reach cecum in 4 hrs -> SURGERY
SBO in the absence of prior abdominal surgery should trigger what type of work-up?
a malignancy work-up
what electrolyte abnormality is common in SBO?
hypokalemia, “contraction” alkalosis w/ advanced dehydration
what’s the tx for SBO if non-strangulated?
IVF, NPO with NGT decompression
what’s the tx for SBO if strangulated?
surgery
if pt with SBO doesn’t get surgery, but there’s no improvement of sx’s in = 24-48 hrs, what’s the tx?
surgery (d/t incr. risk of bowel ischemia)
what abx are used for SBO with surgery?
3rd gen CPN like cefdinir, cefpodoxime + flagyl (covering GN aerobes and anaerobes)
what is the MC cause of large bowel obstruction? others?
adenocarcinoma = MCC
Others = Scarring a/w diverticulitis and volvulus
what’s the s/s of large bowel obstruction?
abd distention, cramping abd pain in hypogastrium, N/V, obstipation
what’s the dx for large bowel obstruction?
Plain abd films (if see obstruction, no barium enema)
Water-soluble contrast barium enema confirms dx and show exact location
what’s the tx for partial LBO?
NGT decompression and IVF
what’s the tx for complete LBO?
emergent surgery
what is a volvulus?
twisting of any part of the bowel (at its mesenteric attachment site)
what’s the MC site of a LBO?
sigmoid colon
what’s the MC sites of volvulus?
sigmoid (70%) and cecum (30%)
what’s the 2nd MC cause of complete colonic obstruction?
volvulus
what are risk factor for volvulus?
stretching and elongation of sigmoid w/ age
common >/= 65 y/o
what’s the s/s of volvulus?
Obstructive sx’s:
-massive abd distention, vomiting, abd pain, obstipation, tachypnea
what’s the PE like for volvulus?
distention, tympany, high-pitched tinkling sounds and rushes
what’s the dx imaging for volvulus?
Abd x-rays
-show massively dilated cecum or sigmoid w/out hausfrau that assume a KIDNEY BEAN APPEARANCE
Water-soluble contrast enema
-shows exact site of obstruction -> characteristic funnel-like narrowing that resembles BIRD’S BEAK OR AN ACE OF SPADES
what do the abd x-rays show for volvulus?
kidney bean appearance (no hausfrau on cecum or sigmoid and they are dilated)
what does water-soluble contrast enema show for volvulus?
shows exact site of obstruction -> characteristic funnel-like narrowing that resembles BIRD’S BEAK OR AN ACE OF SPADES
kidney bean appearance on abd x-rays means what?
volvulus
bird’s beak or ace of spades appearance on water-soluble contrast enema means what?
volvulus
what’s the initial tx for volvulus?
sigmoidoscopy with rectal tube insertion to decompress sigmoid volvulus
how are cecal volvulus treated?
always treated surgically with right hemicolectomy with ileotransverse colostomy
how are sigmoid volvulus treated?
easily decompressed and req. elective resection, except for high-risk elderly pts
what is cholangitis?
biliary tract infection from obstruction (occurs from choledocholithiasis)
what’s the clinical manifestations of cholangitis?
Charcot’s triad:
-jaundice, RUQ pain, fever
Reynold’s Pentad:
-Charcot’s triad + hypotension & AMS
Light colored stools, dark tea-colored urine
when does Reynold’s Pentad occur?
in cholangitis if pus (in addition to the stones) develops -> acute suppurative cholangitis
what are the strongest risk factors for gallbladder disease?
Native American and family history
what’s the PE like for Cholangitis?
RUQ pain
what’s the labs like for cholangitis?
Leukocytosis (very high)
Elevated total bilirubin (d/t bile duct obstruction)
Elevated ALP (means inflammation/irritation of ductal system) and GGT
Mild elevation of AST/ALT
what’s the gold standard imaging for cholangitis?
Cholangiography via ERCP -> draining the CBD
do PTC if can’t do ERCP
what’s the tx for cholangitis?
URGENT INTERVENTION & MONITORING IN ICU
IVFs, NPO, abx (broad spectrum covering GN rods)
-Ampicillin/Sulbactam, Piperacillin/tazobactam or Ceftriaxone + Metronidazole or FQ + Metro
***ERCP → CBD decompression/stone extraction
when will patient with cholangitis get a cholecystectomy?
after they recover from the acute cholangitis episode
what’s the risk factors for cholelithiasis?
Fat, fertile, forty, female, fair
Native American
what d/o’s produce pigment stones instead of cholesterol stones?
hemolytic d/o’s & alcoholic cirrhosis
what are the labs like for cholelithiasis?
all normal
what’s the initial study of choice for cholelithiasis?
U/S
what’s the tx for choelithiasis?
Lap cholecystectomy if symptomatic
Elective cholecystectomy if asymptomatic
Lithotripsy w/ bile salts (chenodeoxycholic & ursodeoxycholic acid) → takes 2 years, if can’t do surgery
what is choledoclithiasis?
when stones pass thru cystic duct & enter CBD
what’s the s/s of choledoclithiasis?
If stone obstructs bile duct → jaundice w/ light-colored stools and dark, tea-colored urine
Jaundice may fluctuate in intensity (vs progressive jaundice caused by malignant disease)
Same sx’s as cholelithasis
what are 3 causes of total bilirubin increase?
hemolytic anemia (sickle cell), Gilbert Syndrome, Cholangitis (obstruction)
what’s the PE like for choledoclithiasis?
abd unremarkable or tenderness in RUQ if cholangitis is present
what’s the labs like for choledoclithiasis?
Significant elevation in serum bilirubin
Increased ALP, GGT
Mild elevation of AST/ALT
what’s the dx test of choice for choledoclithiasis?
ERCP (can be used for both dx and stone extraction)
transabdominal U/S (for initial dx)
what’s the treatment for choledoclithiasis?
Elective (if no cholangitis) ERCP and sphincterotomy for removal of stones from common bile duct
Elective cholecystectomy
what are congenital “true” diverticula and where in the colon are they found?
full wall thickness in the diverticular sac
uncommon, but when present are found in the cecum and ascending colon
what are acquired (False) diverticula and where are they found?
common in western countries
involve the sigmoid colon
mucosal herniations thru the muscular wall
what is diverticulosis?
presence of multiple FALSE diverticula int he colon
what’s the MC cause of LGIB?
diverticulosis
what’s the s/s of diverticulosis?
Recurrent abdominal pain, localized to the LLQ (sigmoid area)
Functional changes in bowel habits - bleeding, constipation, diarrhea, alternating constipation and diarrhea
what’s the PE like for diverticulosis?
Unremarkable (usually), may show mild tenderness in LLQ
what’s the dx like for diverticulosis?
NO LEUKOCYTOSIS OR FEVER
Segmental spasm and luminal narrowing on radiograph
Endoscopic eval shows openings of diverticula
what’s diverticulosis a/w?
low fiber diet, constipation, obesity
what area is the most common for diverticulosis?
sigmoid colon
what’s the tx for diverticulosis?
high fiber diet, fiber supplements (psyllium)
what is diverticulitis initiated by?
obstruction of the neck of the diverticulum by a fecalith
what’s the HALLMARK s/s of diverticulitis?
LLQ pain (subacute onset), alteration in bowel habits (constipation or diarrhea), fever
***LLQ pain = MC
where is the pain localized in diverticulosis/diverticulitis?
LLQ (sigmoid area)
what are complications of diverticulitis?
perf, abscess, obstruction, fistula
what’s the PE like for diverticulitis?
LLQ pain, fever, palpable mass (MC PE finding)
what’s the imaging test of choice for diverticulitis?
CT scan
increased ___ cells in diverticulitis
white blood cells
what’s the tx for diverticulitis?
admit pt, NPO clear liquid diet, IV antibiotics (Cipro or Bactrim + Metro) for 5-7 days
do patients with diverticulitis need surgery?
most pts don’t need surgery unless they have recurrent bouts several times a year or a fistula
what’s the s/s of diverticular bleeding?
BRBPR
***PAINLESS HEMATOCHEZIA
from where does diverticular bleeding occur?
distal to ligament of Treitz
how do you determine if LGIB or UGIB?
NGT
if diverticular bleeding, what dx test is done?
colonoscopy
what’s the tx for diverticular bleeding?
most diverticular bleeding stops out intervention
MESENTERIC ANGIOGRAPHY is useful in detecting source (can also be used in tx w/ Vasopressin
what’s the MC cause of esophageal cancer worldwide and in AAs and males?
squamous cell carcinoma
what’s the MC cause of esophageal cancer in US, younger pts, NAs, whites, Europe?
adenocarcinoma
which type of esophageal cancer is a/w Barrett’s esophagus from GERD?
adenocarcinoma esophageal cancer
where in the esophagus does SCC occur?
upper 1/3 of esophagus
what are the RF’s for SCC esophageal cancer?
tobacco/ETOH use, exposure of esophagus to noxious stimuli, AA’s
where in the esophagus does adenocarcinoma esophageal cancer occur?
lower 1/3 (distal esophagus)
what is adenocarcinoma esophageal cancer a complication of?
GERD leading to Barrett’s esophagus
what are the MC sites of mets for esophageal cancer?
LNs, liver, and lungs
what’s the s/s of esophageal cancer?
***progression of dysphagia from solid foods to liquids
weight loss, chest pain
h/o GERD for adenocarcinoma
h/o smoking and alcohol abuse for SCC
what’s the difference in presentation b/w adenocarcinoma and SCC esophageal cancer?
Adenocarcinoma pts have h/o GERD
Pts usually healthier, less advanced disease (b/c undergoing surveillance endoscopy of Barrett’s)
SCC present more with advanced disease, greater weight loss, and h/o smoking and alcohol abuse
what’s the initial dx study for esophageal cancer?
barium swallow to evaluate the cause of dysphagia
what’s the dx test of choice for esophageal cancer?
upper endoscopy with biopsy for histologic confirmation
what’s the tx for esophageal cancer?
surgical resection of tumor = best chance for cure
do complete local resection of the tumor w/ reconstruction of the alimentary tract by using stomach (MC), or left colon, or jejunum
chemotherapy
what are esophageal strictures?
narrowing of lumen of esophagus
what’s the MC cause of esophageal strictures?
untreated GERD -> peptic strictures
what’s the s/s of esophageal strictures?
***Slowly progressive food DYSPHAGIA, odynophagia, heartburn, heart burn, and episodic food impaction
what’s dx imaging for esophageal strictures?
***endoscopy = initial test
barium esophagram = initial test ONLY if h/o or sx’s of a proximal esophageal lesion or known stricture from XRT tx or caustic ingestion
what’s the tx for esophageal strictures?
***PPIs
Diet - GERD restrictions, weight loss, small meals & eat slowly, avoid meds that cause pill esophagitis
***Esophageal dilation and resection of cancer
***treat the underlying cause
what are causes of esophageal strictures/
GERD (peptic strictures), Zollinger-Ellison, Tumor (adenocarcinoma), Caustic ingestion, XRT, infectious esophagitis, pill esophagitis
what’s the MC type of gastric cancer world wide?
adenocarcinoma
what’s the most frequent type of gastric cancers?
ulcerative carcinomas
what’s the most important RF for gastric cancer?
H. pylori
what are RFs for gastric cancer?
H. pylori (most impt.), salted, cured, smoked, pickled foods containing nitrites/nitrates
what are the 2 types of gastric adenocarcinoma?
intestinal and diffuse
what’s intestinal gastric adenocarcinoma?
Well differentiated w/ glandular elements
More common in regions w/ a high incidence of disease
Occurs in older pts & spreads hematogenously
what’s diffuse gastric adenocarcinoma?
Poorly differentiated w/ characteristic signet ring cell
Occurs in younger pts and a/w w/ blood type A
Spreads via lymphatics and local extension
what’s the s/s of gastric adenocarcinoma?
***Dyspepsia, weight loss, early satiety, epigastric pain, unexplained weight loss
***Hematemesis, melena
***New onset Fe def. anemia (d/t bleeding
***Signs of Mets
what are the signs of Mets for gastric adenocarcinoma?
***supraclavicular LN (virchows node)
***umbilical LN (sister Mary Josephs node)
palpable nodule on rectal exam (Blumer’s shelf)
Ovarian METS (Krenburg tumor)
left axillary LN (Irish sign)
what’s the dx for gastric adenocarcinoma?
upper endoscopy with biopsy
what is Linitis plastica?
diffuse thickening of the stomach wall (“leather bottle” appearance) d/t complete cancer infiltration of the stomach
***WORSE TYPE OF GASTRIC ADENOCARCINOMA
what’s the tx for gastric adenocarcinoma?
gastrectomy, XRT, and chemo (both adenocarcinoma & lymphoma) -> poor prognosis
what’s the MC site of extra nodal mets in NHL?
stomach (gastric lymphoma)
what is Barrett’s esophagus?
complication of GERD
esophageal squamous epithelium replaced by columnar epithelium cells from the stomach
what are the typical sx’s of GERD?
- **HEARTBURN = hallmark
- incr. w/supine pos. & relieved w/ antacids
Regurgitation (sour taste in mouth), dysphagia, cough at night (acid going into lungs and irritating them)
what are the atypical sx’s of GERD?
hoarseness, aspiration pneumonia, “asthma” (bronchospasm from acid contact w/ the lung
Noncardiac chest pain (MC cause of non cardiac chest pain)
what’s the MCC of non-cardiac chest pain?
GERD
what are the ALARM sx’s of GERD?
dysphagia, odynophagia, weight loss, bleeding (suspect malignancy)
how do you dx GERD?
- Clinical dx based on hx
- Endoscopy: often used 1st* if persistent sx’s or complications of GERD (ex. Malignancy, etc.)
- Esophageal Manometry: decr. LES pressure* - may be used if upper EGD nml
- 24h ambulatory pH monitoring: gold standard* - only needed if sx’s are persistent and dx uncertain
what dx test is used first for GERD?
endoscopy (if persistent sx’s or complications of GERD like malignancy)
what’s the GOLD STANDARD for dx GERD?
24h ambulatory pH
what’s the tx for GERD?
- Lifestyle Mods:
- Elevate HOB, avoid supine pos. for 3 hrs after eating, etc. - PRN Pharm Tx:
- H2-receptor antagonists (ex. ranitidine)***
- if alarm of atypical sx’s -> upper EGD - Scheduled Pharm Tx:
- H2 blockers, PPI & pro kinetic agents (Cisapride)
- ***PPIs = drug of choice in mod-severe disease
when is Nissan fundoplication done for GERD?
if lifestyle mods and pharm tx’s are not working and pt still having sx’s
what’s the difference b/w internal and external hemorrhoids in terms of location?
internal hemorrhoids = proximal to the dentate line
external hemorrhoids = distal to the dentate line
how do you dx hemorrhoids?
Visual inspection
Anoscopy (esp. to see 1st degree)
what do internal hemorrhoids look like on anoscopy?
bulging purple/blue veins
what do prolapsed internal hemorrhoids look like on anoscopy?
dark pink, glistening, sometimes tender
what do thromboses external hemorrhoids look like on anoscopy?
acutely tender, purple/blue
what’s the tx for 1st degree hemorrhoids that are asymptomatic?
bulking agents (e.g. psyllium derivatives, high fiber diet, warm sitz bath)
what’s the tx for 1st degree hemorrhoids that are symptomatic?
topical agents (e.g. hydrocortisone cream, lidocaine, witch hazel, zinc oxide paste)
***Bleeding: rubber band ligation or injection sclerotherapy
what’s the tx for bleeding 1st degree hemorrhoids?
rubber band ligation (or injection sclerotherapy)
what’s the tx for 2nd degree hemorrhoids?
Conservative management or rubber-band ligation
what’s the tx for 3rd degree hemorrhoids?
rubber-band ligation; maybe surgical hemorrhoidectomy
what’s the tx for 4th degree hemorrhoids?
surgical hemorrhoidectomy
what’s the tx for external hemorrhoids if thromboses?
<72 hrs thrombosed excision and clot evacuation
> 72 hrs thromboses = conservative tx
what’s the tx for external hemorrhoids?
conservative tx -> if fail this or interferes w/perianal hygiene (have pruritus) then excision
what is HCC a/w?
cirrhosis, Hep B, and Hep C
what’s the dominant cause of HCC?
Hep B
what are RF’s for HCC?
NAFLD, ETOH, Hep B and C
what’s the s/s of HCC?
known cirrhosis, worsening jaundice, encephalopathy, increasing ascites, weight loss, hepatosplenomegaly, abd pain
what’s the screening like for HCC?
HBV testing recommended → vaccine
Cirrhosis from HBV, HCV, alcohol
US/CT/MRI and AFB q6 months
who MUST be investigated for possible HCC?
Any mass >1 cm in pt w/ cirrhosis
what are the labs to dx HCC?
***increased AFP (>500-1000 mg/dL)
HBsAg (pos. Hep B)
what’s the imaging to dx HCC?
***U/S; MRI
CT shows localization & extent
if pt has <1cm lesion on liver, what do you do?
f/u q3 months
if pt has 1-2 cm lesion on liver, what do you do?
biopsy the lesion
if pt has >2 cm lesion on liver, w/ cirrhosis, characteristic imaging findings, increased AFP, what do you do?
don’t bx -> has HCC
what’s the tx for HCC?
surgical resection w/clear margins if confined to a lobe & not a/w cirrhosis
SURGERY = ONLY LONG-TERM CURE
what’s the liver transplant criteria?
single tumor <5cm or up to 3 tumors all = 3 cms, no vascular invasion
what’s the medical/palliative tx for HCC?
Sorafenib (VEGF inhibitor) → slows progression w/ advanced HCC
Large or multifocal tumor via hepatic a.
- Chemoembolization (TACE)
- Radioembolization (TARE)
- Bridge to liver transplant
who do you NOT do surgery on for HCC? what tx do they get?
comorbid factors, >3 lesions or any >6 cm, gross vascular invasion, mets, or LN(+)
get palliative care/medical tx
MC malignant tumors found in the liver are from what?
mets!!! - MC from a GI source!!!
what is cholangiocarcinoma?
Arises from mucosa of the biliary tree
Present in periphery of the liver, centrally w/in the liver, or involving the extrahepatic bile ducts
what are the sx’s of peripheral cholangiocarcinoma tumors?
asx
what are the sx’s of central/hilar cholangiocarcinoma tumors?
cause obstructive jaundice & a bile duct stricture on endoscopic retrograde cholangiopancreatography (ERCP)
what’s the tx for cholangiocarcinoma?
liver resection
what side of the body are indirect inguinal hernias the MC on?
right side
where do indirect inguinal hernias protrude? where do they exit?
internal inguinal ring LATERAL to the inf. epigastric artery
go thru the internal ring into the inguinal canal and follow the testicle tract into the scrotum
what’s the cause of indirect inguinal hernias?
Often congenital d/t persistent patent processus vaginalis
who are indirect inguinal hernias MC in?
MC in young children & young adults
what’s the MC type of hernia overall in men & women?
indirect inguinal hernias
where do direct inguinal hernias protrude? where does it exit?
Protrude MEDIAL to the inferior epigastric vessels w/in Hesselbach’s triangle
can go through the superficial ring (doesn’t reach the scrotum)
what are the borders of Hesselbach’s triangle?
“RIP”
Rectus Abdominis (medial)
Inferior epigastric vessels (lateral) &
Poupart’s (inguinal) ligament (inferiorly)
what’s the cause of direct inguinal hernias?
d/t weakness in the floor of the inguinal canal
what are s/s of incarcerated hernias?
painful, enlargement of an irreducible hernia +/- N/V if bowel obstruction present
what are s/s of strangulated hernias?
ischemic* incarcerated hernias with systemic toxicity* (irreducible hernia w/ compromised blood supply)
Severe painful bowel movement (may refrain defecation)
what are RFs of inguinal hernias?
delayed descent of testicles
where does femoral hernias protrude?
femoral canal below the inguinal ligament
what’s the tx for femoral hernias?
Often become incarcerated or strangulated compared to inguinal → surgical repair often done
what are incisional (ventral) hernias? d/t what?
Herniation through weakness in the abdominal wall through previous fascial incision, usually from laparoscopy
Usu. d/t deep wound infection
incisional (ventral) hernias are MC with what types of incisions and patients?
MC with vertical incisions and in obese patients
what are RFs for incisional (ventral) hernias?
obesity/anything that incr. abd pressure
what’s the tx for asx hernias?
observation
what’s the palliative tx for hernias?
a truss
what’s the tx for strangulated hernia?
manual reduction by putting pt in trendelenburg position and applying pressure to hernia
what’s the tx for hernias if sx?
surgical reduction and placement of mesh to prevent reoccurrence
what are the 4 types of hiatal hernias?
Type 1 = “sliding hiatal hernia”
Type 2 = “rolling hernia: (paraesophageal)
Type 3 = combo of type 1 & 2
Type 4 = herniation of other organs including the colon & spleen
what’s the MC type of hiatal hernia?
Type 1 (sliding hiatal hernia)
what is Type 1 sliding hiatal hernia a/w?
GERD
what is Type 1 sliding hiatal hernia?
Gastroesophageal junction slides in and out of the chest (mediastinum) thru the esophageal hiatus → increases reflux
what does Type 1 sliding hiatal hernia increase?
reflux
what’s the tx for Type 1 sliding hiatal hernia?
Asymptomatic can be observed b/c no risk for incarceration
Surgical tx is determined by sx’s of GERD
Management similar to GERD
Surgery = fundoplication
what’s Type 2 paraesophgeal (rolling) hiatal hernia?
Fundus of stomach protrude thru diaphragm w/ the GE junction remaining in its anatomic location
what can Type 2 paraesophgeal (rolling) hiatal hernia lead to?
strangulation
what’s the tx for Type 2 paraesophgeal (rolling) hiatal hernia?
Surgical repair of the defect to avoid complications such as strangulation and ischemia
what’s the difference b/w Type 1 sliding hiatal hernia and Type 2 rolling paraesophageal hiatal hernia?
in sliding hiatal hernia, the stomach remains in its position (vs paraesophageal it doesn’t b/c the funds protrude thru the diaphragm)
what remains in place in paraesophageal hernia?
GE junction
what areas are affected in Crohn’s disease?
ANY SEGMENT OF THE GIT from MOUTH TO ANUS
MC site is the TERMINAL ILEUM -> RLQ PAIN
how much of the colon is affected in Crohn’s disease?
TRANSMURAL INFLAMMATORY
what type of lesions are seen in Crohn’s disease?
skip lesions with cobblestone appearance
what are complications a/w Crohn’s disease?
Perianal dz: fistulas, strictures, abscess, NONCASEATING GRANULOMAS
Malabsorption: Fe & B12 deficiency
what’s the s/s of Crohn’s disease?
Abd pain: RLQ pain MC (kramp) & weight loss
Diarrhea with NO VISIBLE BLOOD
Perianal involvement (fistulae, fissures, abscesses)
Extra-intestinal manifestations
what are the nutritional losses with Crohn’s disease?
hypoalbuminemia, fat soluble vit (A, D, E, K) def., and vit B12 def (b/c affect terminal ileum)
d/t diminished PO intake and impaired absorption
what does barium study show for Crohn’s?
String sign -> barium flow through narrowed inflamed/scarred area d/t transmural strictures
what lab is positive in Crohn’s disease?
+ ASCA
is surgery curative for Crohn’s or UC?
surgery is curative for UC, but NOT curative Crohn’s
what’s the imaging test of choice for dx of Crohn’s? what are the findings on it?
colonoscopy w/ bx (gold standard for dx)
-findings are aphthoid, stellate, linear ulcers
what are Crohn’s patients counseled to quit?
smoking
what’s the tx for Crohn’s for mild disease and for maintenance of disease?
5-ASA (Mesalamine - preferred for maintenance; Sulfasalazine)
-released in the terminal ileum and ascending colon
what’s the tx for Crohn’s for flares?
Corticosteroids (esp. when unresponsive to sulfasalazine/mesalamine)
-Budesonide (greatest effect on terminal ileum & R-sided colonic disease)
when are immunosuppressants used for Crohn’s and what are they?
good for pts unresponsive to steroids or to minimize steroid use
- Azathioprine/6-MP (3-6 months to achieve effect)
- Methotrexate (remission sustaining)
- Cyclosporine (used in fistulous Crohn’s unresponsive to steroids & abx)
when is Cyclosporine used in Crohn’s? wha are you concerned about with it?
used in fistulous Crohn’s unresponsive to steroids & abx
concern for nephrotoxicity and need ppx for Pneumocystis carinii pneumonitis
what do the immunosuppressants prevent in Crohn’s?
relapse of disease once in remission
when are TNF alpha-blockers (anti-biologics) used for Crohn’s? what are the names?
if steroid-resistant, mod-severe Crohn’s
Infliximab, Adalimumab, Certolizumab, Natalizumab
when is surgery indicated for Crohn’s? is it curative for Crohn’s?
Reserved for complicated disease and disease refractory to medical management
Perforation, fistulae, obstruction (fibrotic stricture)
***SURGERY IS NOT CURATIVE
what are complications of surgery in Crohn’s?
short bowel syndrome d/t resection in surgery
who is UC most common in?
Jews and family hx
what areas are affected in UC?
LIMITED TO COLON
-mucosa and submucosa of the large bowel and rectum
ALWAYS INVOLVES THE RECTUM (begins in rectum and spreads proximally to colon)
what is seen on colonoscopy for UC?
uniform inflammation - friable, reddish mucosa w/no skip areas, mucosal exudate, and PSEUDOPOLYPS
what are the s/s of UC?
abdominal pain: LLQ MC,* colicky
Tenesmus,* urgency
BLOODY DIARRHEA = HALLMARK (stools w/mucus/pus), hematochezia
also, extra intestinal sx’s (ankylosing spondylitis, peripheral arthritis, uveitis, sclerosing cholangitis)
what’s the HALLMARK sx of UC?
BLOODY DIARRHEA W/PUS AND MUCUS
how do you dx UC?
Colonoscopy w/ bx (gold standard) - friable, reddish mucosa w/no skip areas, mucosal exudate, and pseudo polyps
serologic markers -> pANCA
barium study (2nd line)
what are complications of UC?
primary sclerosing cholangitis, colon cancer, toxic megacolon (MC in UC)
what is seen on the barium study for UC?
“stovepipe sign” (loss of haustral markings)
what’s the tx for mild UC?
symptomatic tx, with antidiarrheal agents that slow gut transit (e.g. loperamide) and bulking agents (e.g. psyllium)
what’s the tx for mod. UC?
Sulfasalazine or mesalamine → induce remission
what’s the tx for severe UC?
steroid taper (d/t adrs)
what’s the maintenance tx for UC?
PO mesalamine or sulfasalazine for maintenance and budesonide for flares
when is surgery indicated for UC?
indicated when medical therapy fails or surgically treatable complications occur (e.g., hemorrhage, perforation, obstruction, dysplasia, carcinoma)
long-standing UC is an indication for surgery b/c of increased risk of carcinoma
what do people with LONG-STANDING UC have an increased risk of?
increased risk of carcinoma
what’s the surgery of choice for UC?
Total colectomy w/ proctectomy and ileoanal pull-through
at what levels of bilirubin does jaundice occur?
> 2.5 mg/dL
increased direct (conjugated) bilirubin causes what symptoms?
dark urine & light-colored stools
what are causes of jaundice?
hemolytic (incr. bilirubin overproduction)
hepatocellular (e.g. hepatitis) - der. hepatic bilirubin uptake, impaired conjugation
Obstructive (biliary obstruction)
increased bilirubin w/out increased LFTs, what should you suspect?
familial bilirubin d/o’s (Dubin-Johnson Syndrome, Gilbert Syndrome) & hemolysis
what is elevated in hemolytic jaundice? dx?
Low level (bilirubin of 6 or 8), and all the elevated bilirubin is unconjugated (indirect), no elevation of the direct
no bile in urine
dx: work-up to determine what is causing hemolysis
what is elevated in obstructive jaundice?
Elevations of both fractions of bilirubin
Modest elevation of AST/ALT
Very high ALP
what’s the first step in the dx of obstructive jaundice?
sonogram (looking for dilatation of the biliary ducts and other clues of cause of obstruction)
what is elevated in hepatocellular jaundice?
Elevation of both fractions of bilirubin and very high levels of AST/ALT
Modest elevation of the ALP
what’s the MC cause of hepatocellular jaundice?
Hepatitis
what’s the MC histology of pancreatic cancer?
adenocarcinoma - ductal MC
where is the MC place for pancreatic cancer to occur in the pancreas?
the head of the pancreas
what are the RFs for pancreatic cancer?
**smoking, **>60 y/o (doubles risk), ***fam hx (>2 1st degree relatives)
chronic pancreatitis, ETOH, DM, males, obesity, AA
what is the MC genetic mutation a/w pancreatic cancer?
K-ras oncogene
what are the s/s of pancreatic cancer?
Usu. have mets by time of presentation (to LNs and liver)
Painless jaundice* classic → 2/2 CBD obstruction
Weight loss, CONSTANT abd pain → back (may be relieved w/ sitting up & leaning forward)
Pruritus (d/t incr. bile salts in skin)
what is Trousseau’s malignancy sign?
migratory phlebitis a/w malignancy
what are PE signs for pancreatic carcinoma?
Courvoisier’s sign* = palpable, NON-tender, distended, gallbladder* a/w jaundice (CBD obstruction)
what are labs like for pancreatic carcinoma?
increased tumor markers: CEA, **CA 19-9
what’s the initial imaging study for pancreatic carcinoma? what’s the most sensitive?
CT scan = initial dx test of choice
ERCP = most sensitive test
what’s the surgery for pancreatic cancer head tumors?
Whipple procedure = pancreaticoduodenectomy resection
-Resection of distal CBD, duodenum, and head of pancreas
what’s the surgery for pancreatic cancer body & distal tumors?
distal pancreatectomy (includes a splenectomy)
what’s the tx for advanced or inoperative pancreatic cancer?
ERCP w/ stent placement as palliative tx for intractable itching
what’s the prognosis like for pancreatic cancer?
very poor, most lesions unresectable
what is the MC complication of pancreatitis?
pancreatic pseudocyst
what is pancreatic pseudocyst? caused by what?
Development of fluid in the peripancreatic area or retroperitoneum
Caused by disruption of the pancreatic duct → enzymatic fluid collects around the pancreas and is walled-off by surrounding viscera
Most acute fluid collections resolve spontaneously, but those that persist become pseudocysts
what can pancreatic pseudocysts become?
communicating or non-communicating, based upon whether the cyst is connected to the pancreatic duct
what are the s/s of pancreatic pseudocysts?
Occur when pseudocysts grow large
Epigastric pain, N/V, early satiety
Most sx’s related to compression of adjacent structures including mechanical obstruction of stomach, duodenum, or CBD
how do you dx pancreatic pseudocysts?
CT - show cyst walls and their relation to surrounding structures
what’s the tx of pancreatic pseudocyst of non-communicating with pancreatic duct?
Aspirated or drained percutaneously
what’s the tx of pancreatic pseudocyst of communicating with pancreatic duct??
Internal drainage into the stomach, duodenum, or Roux limb to prevent formation of a pancreatic fistula, since they directly communicate w/ the pancreatic duct
Goal is to avoid fluid draining back into the pancreas to prevent formation of pancreatic fistula
what is PUD d/t?
2/2 imbalance of decr. mucosal protective factors in gastric ulcer & incr. damaging factors (acid, pepsin) in duodenal ulcer
what are the MC type of peptic ulcers? where do they form?
duodenal ulcers
-form in duodenal bulb
what’s the MC cause of PUD?
H. pylori
what’s the 2nd MC cause of PUD?
NSAIDs
what are the 2 MC causes of PUD?
H. pylori - 1st MC
NSAIDs - 2nd MC
what are other causes of PUD besides H. pylori and NSAIDs/
Zollinger-Ellison syndrome (gastrin producing tumor)
ETOH, smoking, stress, et.c
when should you suspect GI malignancy like ZES or gastric cancer in a/w a gastric ulcer?
in non-healing gastric ulcer
what are the s/s of PUD?
- Dyspepsia (epigastric pain that’s burning)
2. UGIB (PUD = MC cause of UGIB)
what’s the MC cause of UGIB?
PUD
when is the dyspepsia in PUD worse, at night or in the morning?
worse at night
what are duodenal ulcer s/s like? what pts are they the MC in?
Relief w/ food, antacids &/or anti-secretory agents
Worse before meals or 2-5 hrs after meals
Nocturnal sx’s = classic
Younger patients MC
what are gastric ulcer s/s like?
Pain 1-2 hrs after meals & weight loss (b/c pain a/w w/food)
Older patients MC
which ulcers are relieved with food, duodenal or gastric?
duodenal ulcers
what ulcers are worse before meals or 2-5 hrs after meals?
duodenal ulcers
what sx’s are classic of duodenal ulcers?
nocturnal sx’s
what ulcers are food-provoked?
gastric ulcers
what ulcers are worse 1-2 hrs after meals and weight loss?
gastric ulcers (b/c pain a/w with food)
what’s the GOLD STANDARD to dx PUD?
Endoscopy (bx to r/o malignancy if GU present and if alarm sx’s)
when is barium upper GI series used to dx PUD?
in pts unable to do EGD
what’s the dx tests for PUD?
Endoscopy (w/ bx if have GU or H. pylori)
Barium Upper GI series (in pts unable to do EGD)
what must GU ulcer be dx with?
endoscopy w/ bx
what’s the GOLD STANDARD to dx H. Pylori?
EGD w/ bx
what’s the dx tests for H. Pylori (cause of PUD)?
EGD w/ bx = GOLD STANDARD***
- + rapid urease test: direct stain of bx for H. pylori
- Urea breath test: (used for testing if EGD can’t be done, but can also be used to confirm eradication after therapy)
- H. Pylori stool antigen (HpSA): >90% specific
- Useful for dx H. pylori & confirming eradication after therapy
- H. Pylori stool antigen (HpSA): >90% specific
- Serologic antibodies: only useful in confirming H. pylori infection (NOT eradication)!*
what tests for H. pylori are useful to confirm eradication after tx?
Urea breath test and H. pylori stool antigen (HpSA)
when is urea breath test used to dx H. Pylori?
if EGD can’t be done, also to confirm eradication after therapy
what H. pylori test is >90% specific and useful for dx of H. pylori and confirming eradication after tx?
H. Pylori stool antigen (HpSA)
what H. pylori test is NOT for eradication and only for confirmation of H. pylori infection?
Serologic antibodies
what’s the triple therapy for H. Pylori tx?
Clarithromycin + Amox + PPI* (CAP)
Metro if PCN allergic
what’s the quadruple therapy for H. Pylori tx?
PPI + Bismuth subsalicylate + Tetracycline + Metronidazole
what’s the tx for PUD if H. pylori is NOT the cause?
PPI (drug of choice) - most effective drug to treat PUD
-take 30 min before meals
H2 blocker, Misoprostal, antacids, bismuth subsalicylate, sucralfate
what is the drug of choice to treat PUD if H. pylori is NOT the cause? when do you take it?
PPI - take 30 min before meals
what’s adr can you get from PPIs?
B12 deficiency
what are causes of Small bowel carcinoma?
Adenocarcinoma, Carcinoid tumors, Lymphoma, GI stromal tumors
what’s the MC small bowel tumor? where is it found?
adenocarcinoma - usu. found in the duodenum
where do carcinoid tumors arise from?
Kulchitsky cells in the crypts of Lieberkuhn
where is carcinoid tumors the MC?
in the ileum
what’s the MC site of extranodal lymphoma?
small bowel - int he ileum
what are GI stroll tumors? where are they found? what do they respond well to?
Mesenchymal tumors of the GIT
Found anywhere in the small bowel
Poor prognosis, but responds well to tyrosine kinase inhibitors
what are the s/s of small bowel carcinoma?
obstruction sx’s (MC)
anorexia, fatigue, weight loss
how do you dx small bowel carcinoma?
Laparotomy, enteroclysis, capsule endoscopy, or Ct enterography
what’s the tx for small bowel carcinoma?
Colectomy/surgical resection of tumor
what is toxic megaton?
Non-obstructive, extreme colon dilation >6cm + signs of systemic toxicity*
what are causes of toxic megacolon?
UC, Crohn’s, pseudomembranous colitis, infectious, radiation, ischemic
what are s/s of toxic megacolon?
Fever, abd pain, diarrhea, N/V, rectal bleeding, tenesmus, electrolyte d/o’s
what’s the PE like for toxic megacolon?
Abd tenderness, rigidity, tachycardia, dehydration, hypotension, AMS
how do you dx toxic megacolon?
Abd radiographs: large dilated colon >6cm
what’s the tx for toxic megacolon?
Bowel decompression
Bowel rest, NG tube, abx
Electrolyte repletion
Colostomy for refractory cases
how do you dx gastritis?
endoscopy
what are the sx’s of gastritis if symptomatic?
epigastric pain
what is celiac disease?
small bowel AUTOIMMUNE inflammation 2/2 alpha-gliadin in GLUTEN -> loss of villi & absorptive area -> impaired fat absorption
who is at increased risk of celiac disease?
females, European descent (Irish & Finnish)
what are the s/s of celiac disease?
malabsorption: diarrhea
Dermatitis herpetiformis (pruritic, paplovesicular rash on extensor surfaces, neck, trunk, & scalp)
how do you dx celiac disease?
+ Endomysial IgA antibiody & transglutaminase antibody
Small bowel bx = definitive dx
how do you definitively dx celiac disease?
small bowel bx
what’s the test of choice for lactose intolerance?
hydrogen breath test (performed after a trial of lactose free diet)
what’s type of diet is a RF for small bowel carcinoma?
***diet high in salt-cured foods
diet high in refined sugar, red meat, and smoked foods
ETOH use
what d/o’s are RF for small bowel carcinoma?
FAP, Lynch, Peutz-Jeghers syndromes, IBD
how do you dx UGIB?
endoscopy
when does screening for colorectal cancer begin for average-risk pts and when does it end? when do you stop screening?
at 50 y/o and ends at 75 y/o
Stop screening when pts lifespan is < 10 years
when does screening for colorectal cancer begin for high-risk pts?
40 y/o (<50 y/o)
what are the indications to do EGD for pt with dyspnea?
< 60 y/o if:
-clinically significant weight loss, alarm sx’s, overt GI bleeding (ex. melena), >/= 1 alarm sx’s present
all pts >/= 60 y/o with new dyspepsia
what are the sx’s of a strangulated hernia? what’s the tx?
tenderness, pain, bd distention, N/V, erythema over hernia site, fever, peritonitis
tx: surgery (surgical emergency)
what test do you run to establish dx of jaundice?
fractionated bilirubin
when is watchful waiting an option for Crohn’s disease?
if asx and found to have CD incidentally on routine colonoscopy
what’s the best long-term tx for chronic pilonidal disease?
surgical excision of all sinus tracts
what’s the MC post-surgical complication by pts undergoing surgery tx for PUD?
weight loss
what med is administered to pt undergoing unilateral/bilateral adrenalectomy and why?
IV hydrocortisone (glucocorticoid) to prevent hypotension
what’s the MOST IMPORTANT FIRST step in tx for GI bleed? what’s done next?
IV access = first step
NGT is done next
what imaging study is done to assess disease extent and respectability of pancreatic cancer?
Abd CT w/ contrast
what’s the BEST approach for adrenalectomy when malignancy is suspected/
open trans abdominal approach -> allows more visualization
if doing bilateral adrenalectomy, what’s the best approach?
posterior retroperitoneoscopic
how do you dx colonic polyps?
colonoscopy (can also remove them)
what are s/s of colon polyps?
typically asymptomatic, GI bleeding, intestinal obstruction
BRBPR, rectal tenesmus, change in bowel habits
what are non-neoplastic colonic polyps?
mucosal, inflammatory, pseudopolyps, hyperplastic, submucosal, hamartomas
what are mucosal colonic polyps?
small <5mm, resemble adjacent tissue
histologically normal, no clinical significance
what are inflammatory pseudopolyps?
common in IBD, not malignant
what are Hyperplastic colonic polyps?
MOST COMMON NON-NEOPLASTIC COLONIC POLYPS
low risk for malignancy
serrated/sawtooth pattern
most found in rectosigmoid and <5mm
what are the MOST COMMON non-neoplastic colonic polyps?
Hyperplastic colonic polyps
what are Hamartomas colonic polyps?
Grow in disorganized fashion
seen in FAP - juvenile polyps & Peutz-Jeghers syndrome
low malignancy, often spontaneously regress/auto-amputate; observe
what are Neoplastic colonic polyps?
adenomatous polyps
what are adenomatous polyps?
tumors overtime that may become malignant -> 7-10 yrs avg time to transition to adenocarcinoma
personal hx of colon adenomas increases risk of CRC
what are the 3 types of Adenomatous colonic polyps?
Tubular adenoma: nonpedunculated (MC & least risk of malignancy of the 3 types of adenomatous polyps)
Tubulovillous (mixture) adenoma: intermediate risk of malignancy - pedunculated
Villous adenoma: highest risk of becoming cancerous - sessile
what is the tx of colonic polyps?
Polypectomy
when should IBD pts tha have had IBD for >/= 10 years have colonoscopy?
every year colonscopic surveillance w/ bx
how often is flexible sigmoidoscopy done?
every 5 years
how often is conoscopy done
every 10 years
how often is double-contrast barium enema done?
every 5 years
how often is FOBT done for colonic polyp screening?
every year
how often is FIT done for polyp screening?
every year
what pts are at high risk of developing colorectal cancer?
those with familial colorectal cancer syndromes and pts who’ve had IBD for >/= 10 years
what’s the most important risk for colorectal cancer?
family h/o in 1st degree relatives
what lab value indicates pancreatic cancer?
CA 19-9
what is achalasia?
loss of Auerbach’s plexus -> INCREASED LES PRESSURE***
what is the pathophysiology of achalasia?
failure of LES relaxation (increased LES tone) -> obstruction and lack of peristalsis
what are the s/s of achalasia?
dysphagia to BOTH solids and liquids
what’s the GOLD STANDARD to dx achalasia? what does it show?
esophageal manometry
shows increased LES pressure >40 mmHg
what do you see on double-contrast esophageal with achalasia?
bird’s beak appearance of LES (LES narrowing)
what’s the treatment for achalasia?
decrease LES pressure -> botox, nitrates, CCBs
what tumor marker is used to monitor recurrence of colon cancer?
CEA
what medication is used to control acute variceal bleeding?
octreotide
what treatment decreases the risk of rebreeding in a pt with esophageal varices?
Sclerotherapy
what are the s/s of anal fissures?
Pain increased during BMs & a/w streaks of blood in stool (bright red)
what’s the MC RF for esophageal varices in adults?
cirrhosis
what’s the s/s of esophageal varices?
UGIB (hematemesis, melena)
how do you dx esophageal varices?
upper endoscopy -> enlarged veins
what’s the tx for management of acute active bleeding varices?
- stabilize with 2 large bore IV lines, IVFs
- Endoscopic ligation = TOC
- Octreotide = med of choice in acute bleeding or vasopressin
when do you use saloon tamponade to control active bleeding varices?
to stabilize bleeding NOT controlled by endoscopic or pharmacologic intervention
when do you use TIPS for active bleeding varices?
if bleeding despite endoscopic or pharmacologic tx
what’s the TOC for active bleeding varices?
endoscopic ligation
what’s the tx to prevent rebreeds of varices?
- Non-selective beta blockers -> TOC in primary ppx to prevent rebleed (propranolol, nadolol)
- Isosorbide -> long acting nitrate (vasodilator)
NOT GIVEN IN ACUTE BLEEDS
what’s the TOC for ppx of rebleeding varices?
non-selective BBs -> propranolol, nadolol
what is boerhaave syndrome?
full thickness rupture of the DISTAL esophagus that’s a/w repeated, forceful vomiting
what’s the s/s of boerhaave syndrome?
retrosternal chest pain rose with deep breathing and swallowing
what’s the PE like for boerhaave syndrome?
crepitus on chest auscultation d/t PNEUMOMEDIASTINUM (air in the mediastinum) -> see on CXR or chest CT
what’s the definitive dx for boerhaave syndrome?
contrast esophageal with gastrografin swallow
what’s mallory-weiss syndrome?
UGIB from LONGITUDINAL MUCOSAL lacerations at the GE junction or the gastric cardia (occurs in submucosal layer)
how do you dx mallory-weiss syndrome?
upper endoscopy = TOC -> see SUPERFICIAL LONGITUDINAL MUCOSAL EROSIONS
what’s the tx for mallory-weiss syndrome?
- Supportive (most cases stop w/out tx)
2. if severe bleeding -> epinephrine injection
