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Primary Care Exam 4 > GI > Flashcards

GI Flashcards

1
Q

What are some causes of acute, abrupt onset, abdominal pain?

A
  • Perforation
  • Ruptured abscess
  • Obstruction
  • Intestinal infarction
  • Acute cardiac or pulmonary event
  • Ruptured ectopic pregnancy
  • Ruptured aortic aneurysm
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2
Q

What are some causes of acute, gradual onset, abdominal pain?

A
  • Acute inflammation
  • Strangulated hernia
  • Intestinal obstruction
  • Pelvic pathology
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3
Q

What are some causes of acute, intermittent, abdominal pain?

A
  • Partial obstruction

- Gastroenteritis

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4
Q

What are some causes of RUQ abdominal pain?

A
  • Pleurisy
  • Subdiaphragmatic abscess
  • Cholecystitis
  • Perforated duodenal ulcer
  • Appendicitis
  • Perforated colon
  • Ectopic pregnancy, TA
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5
Q

What are some causes of LUQ abdominal pain?

A
  • Pleurisy
  • Splenic rupture/infarct
  • Perforated gastric ulcer
  • Pancreatitis
    Diverticulitis (splenic flexure)
  • Perforated colon
  • Ectopic pregnancy, TA
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6
Q

What are some causes of RLQ abdominal pain?

A
  • Appendicitis
  • Acute cholecystitis
  • Acute Crohn’s
  • Incarcerated hernia
  • Ectopic, TA, torsion
  • PID
  • Cecal diverticulitis
  • Colon cancer
  • Leaking aortic aneurysm
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7
Q

What are some causes of LLQ abdominal pain?

A
  • Sigmoid diverticulitis
  • PID
  • Ectopic, TA
  • Perforated sigmoid carcinoma
  • Perforated gastric ulcer
  • Incarcerated inguinal hernia
  • Leaking aortic aneurysm
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8
Q

What are some characteristics of abdominal pain?

A
  • Crampy
  • Burning or gnawing
  • Sharp of constant
  • Change of the pain
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9
Q

What are some different types of abdominal pain?

A
  • Visceral
  • Parietal
  • Extra-abdominal
  • Referred pain
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10
Q

What are some commonly associate symptoms with abdominal pain?

A
  • Fever or chills
  • Nausea, vomiting
  • Constipation, diarrhea
  • Urinary symptoms
  • Vaginal bleeding, irregular, missed period
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11
Q

What are some common aggravating or relieving factors associated with abdominal pain?

A
  • Foods
  • Bowel activity
  • Urination
  • Sexual activity
  • Exertion
  • Position
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12
Q

What are some factors in the PMH do we want to ask about when evaluating abdominal pain?

A
  • Medications
  • Recent history immobilization, travel
  • Abdominal/gynecological surgery
  • Cardiovascular diseases
  • GI disorders
  • DM, anemia, bone/joint problems
  • Gynecological hx
  • FH
  • Diet or food intolerances, ETOH use
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13
Q

What are some worrisome features in abdominal complaints?

A
  • host
  • abrupt onset
  • awakens patient from sleep
  • unrelenting or worsening pain
  • weight loss
  • symptoms present < 24 hours
  • blood
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14
Q

What are some red flags about the physical exam in assessing abdominal pain?

A
  • shocky
  • peritoneal signs
  • abdominal distention
  • atypical presentation
  • change in bowel sounds
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15
Q

What are the features of PERITONITIS?

A
  • P lace: front, back, sides, shoulders
  • E lectrolytes fall, shock ensures
  • R igidity or rebound
  • I mmobile abdomen, patient
  • T enderness w/ voluntary guarding
  • O bstruction
  • N ausea and vomiting
  • I ncrease in pulse, decrease in BP
  • T emperature elevation, tachypnea
  • I ncrease in abdominal girth
  • S ilent abdomen
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16
Q

What is primary vs. secondary peritonitis?

A
  • primary spontaneous bacterial peritonitis = peritoneal infection in absence of precipitating factor
  • secondary peritonitis = spillage of GI or GU organisms into peritoneal space
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17
Q

what are some causes of abdominal distention?

A
  • fat
  • fluid
  • feces
  • fetus
  • flatus
  • fibroid
  • full bladder
  • fatal tumor
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18
Q

general diagnostic studies for abdominal pain

A
  • CBC with diff
  • UA
  • urine or serum HCG
  • CMP
  • KUB
  • abdominal/pelvic US
  • CT scan with contrast unless contraindicated
  • CXR
  • EKG
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19
Q

52 y/o woman with a vague epigastric pain since yesterday, low grade fever and today has nausea. Unable to eat breakfast. Pain has now radiated to RLQ. Slight loose stools.

  • vital signs T:100°, P 99, r 20, BP 140/90
  • abdomen: soft
    • McBurney sign
    • obturator sign
    • rosvig sign
  • tenderness right perirectal area

What are your differential diagnoses?

A
  • appendicitis
  • ruptured ectopic pregnancy
  • strangulated hernia
  • ovarian cyst
  • renal calculi
  • regional ileitis
  • acute salpingitis
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20
Q

atypical presentation of appendicitis in the elderly

A
  • unexplained weakness, anorexia
  • abdominal distention w/ little pain
  • sx may be mild, tachycardia
  • classic sequence may be absent
  • take serious even if rebound tenderness and guarding are absent
  • increase in bands without leukocytosis
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21
Q 
72 y/o male LLQ w/ low grade fever 99°F developed over the last couple of days. Nausea and increase in flatulence. Hx. of constipation and  diverticulosis. Pain has progressively gotten worse over the last 24 hours.
   VS: T 100°F, P 100, R 26 
   tenderness to palpation
   palpable mass LLQ
   bowel sounds decreased
   \+rebound tenderness
   \+ stool guaiac

What are your differential diagnoses?

A
  • diverticulitis
  • appedicitis
  • IBD, IBS (lactose intolerance)
  • colon cancer
  • urologic (pyelonephritis)
  • in females consider gynecologic
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22
Q

what is diverticulitis?

A
  • most common complication of diverticulosis
  • inflammation condition that involves 1 or more colonic diverticula
  • always symptomatic
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23
Q

diagnostic studies for diverticulitis

A
  • CBC, CMP
  • UA
  • stool guaiac
  • abdominal plain films
  • US abdomen
  • *CT with contrast
  • delay colonoscopy until after acute episode
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24
Q

treatment for diverticulitis

A
  • clear fluids for 1-2 days, bland diet
  • amoxicillin clavulanate 875 mg/125 mg BID or
  • ciprofloxacin 500 mg BID +
  • metronidazole 500 mg TID
  • 7-10 days or afebrile 2-3 days
  • dietary restrictions
  • indication for hospitalization
  • surgery
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25
Q
  • 55 y/o, woman w/ acute onset
  • epigastric, deep, steady pain for and improves after 15-20 minutes. Pain radiates to subscapular area. Nausea, vomiting and anorexia, not precipitated with any meal.
  • Pmhx dyspepsia
  • fever is low grade
  • localized tenderness in RUQ
  • +rebound
    • murphy’s sign
A
  • cholecystitis
  • appendicitis
  • hepatitis
  • pneumonia
  • MI
  • liver abscess
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26
Q

pathogenesis of cholecystitis

A
  • gallstone impacts in Hartmann’s pouch
  • edema of gallbladder wall
  • increased intraluminal pressure
  • gallbladder distention
  • increased fluid secretion
  • increased prostaglandin I2 and E2 secretion
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27
Q

diagnostic tests for cholescystitis

A
  • CBC with diff
  • CMP
  • EKG and CXR
  • US, CT abdomen
  • HIDA or PIPIDA scan
  • elevated AST, ALT, ALP, amylase
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28
Q

treatment for cholecystitis

A
  • based on patient risk
  • hospitalization
  • surgery or medical management
  • non-invasive procedure
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29
Q

what is a common chronic complication associated with cholecystectomy and how do we manage that?

A
  • 1 in 3 develop chronic diarrhea
  • cause unclear
  • could be increase in bile, especially bile acids entering large intestines act as laxative
  • treatment: imodium or meds that impair bile acids, i.e. Cholestryamine or Aluminum hydroxide
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30
Q

what is GERD?

A

chronic symptoms or mucosal damage produced by abnormal reflux of gastric contents into esophagus or beyond, into oral cavity (including larynx) or lung

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31
Q

what are some causes of increased exposure of esophagus to gastric refluxate

A
  • defective esophageal clearance
  • LES dysfunction
  • hiatal hernia
  • increased intra-abdominal pressure
  • delayed gastric emptying
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32
Q

which medications impair LES function?

A
  • beta-adrenergic agonists
  • theophylline
  • anticholinergics
  • TCAs
  • progesterone
  • alpha-adrenergic antagonists
  • diazepam
  • calcium channel blockers
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33
Q

which medications damage mucosa?

A
  • ASA and NSAIDs
  • tetracycline
  • quinidine
  • bisphophonates
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34
Q

how do you diagnose GERD?

A
  • presumptive dx of GERD in setting of typical sx of heartburn and regurgitation
  • empiric medical tx with PPI is recommended in this setting*
  • pts with non-cardiac chest pain suspected of GERD should have diagnostic eval before institution of therapy
  • cardiac cause needs to be excluded*
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35
Q

what diagnostic studies are not recommended first line for GERD?

A
  • barium radiographs
  • upper endoscopy (recommended in presence of alarm s/s and screening for high risk for complications)
  • screening for H. pylori not recommended
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36
Q

what are some indications for additional investigation of GERD?

A
  • atypical history
  • sudden s/s in a pt 50 years or older
  • sx frequent, long-standing, or don’t respond to therapy
  • alarm s/s present
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37
Q

what are some alarm s/s when assessing for GERD?

A
  • severe dysphagia
  • weight loss
  • bleeding
  • hematemesis
  • mass in upper abdomen
  • anemia
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38
Q

complications of GERD

A

prolonged exposure of the esophagus to gastric refluxate can cause

  • metaplasia
  • malignancy
  • ulceration
  • strictures
  • hemorrhage
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39
Q

what is Barrett’s esophagus and how is it managed?

A
  • premalignant condition associated with chronic esophageal injury (>5 years) due to reflux
  • risk for esophageal adenocarcinoma is 30-40x higher
  • periodic EGDs with biopsies recommended
  • surveillance EGD every 3 years
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40
Q

what is metaplasia of the esophagus?

A

change in the esophageal epithelium from squamous epithelium to columnar epithelium

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41
Q

what is the only reliable technique for detecting Barrett’s esophagus?

A

endoscopy

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42
Q

GERD management goals

A
  • provide complete relief from heartburn and other sx
  • heal underlying esophagitis
  • maintain symptomatic and endoscopic remission
  • tx or prevent complications
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43
Q

what are some lifestyle interventions for managing GERD?

A
  • weight loss
  • decrease meal size
  • HOB elevation
  • avoidance of meals 2-3 hours before bedtime
  • routine global elimination of food triggers such as chocoalte, caffeine, alcohol, acidic or spicy foods IS NOT RECOMMENDED
  • smoking cessation
  • reduced carbonated drink
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44
Q

how do you manage GERD?

A
  • PPI therapy initiated
  • 8 weeks duration
  • once a day 30-60 minutes before 1st meal
  • maintenance PPI for those who continue w/ s/s after PPI is discharged and those w/ erosive esophagitis or Barrett’s
  • pts w/ partial response may be given BID
  • H2RA can be used for maintenance therapy w/ erosive disease, or bed time for nighttime reflux
  • non-responders referred for evaluation
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45
Q

what are some potential risks associated with PPIs?

A
  • effects on vitamin and mineral absorption (iron, calcium, b12, magnesium)
  • can cause c.diff and should be used w/ caution in pts at risk
  • short term use PPI may increase risk for CAP
  • PPI does not need to be altered in concomitant use w/ clopidogrel users
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46
Q

what are some extraesophageal presentations of GERD?

A
  • asthma, chronic cough, and laryngitis
  • can be considered a co-factor in GERD
  • dx of reflux laryngitis should not be based solely on laryngoscopy findings
  • PPI is recommended to tx extraesophageal sx if pt has typical sx of GERD
  • pH reflux monitoring should be considered before PPI in pts with extraesophageal sx
  • non-responders to PPI should have upper EGD
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47
Q

what causes the cough associated with GERD?

A

acid refluxate entering the lung and/or stimulating the vagus nerve

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48
Q

what is the main cause of peptic ulcer disease?

A
  • 90% duodenal caused by H. pylori

- 85-90% gastric caused by H. pylori

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49
Q

what are some other causes of PUD?

A
  • NSAIDS
  • other meds: steroids, bisphosphonates, KCL, chemo
  • rare causes: Zollinger-Ellison syndrome, gastric cancer, lymphoma, lung cancers, stress
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50
Q

what are the characteristics of Helicobacter pylori?

A
  • gram negative, motile spiral rod found in 48% of patients with PUD
  • H. pylori bacteria adhere to gastric mucosa
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51
Q

what are the risk factors for PUD?

A
  • 50 years or older
  • drink alcohol excessively
  • smoke cigarettes or use tobacco
  • FH ulcer disease
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52
Q

what are the risk factors for NSAID induced PUD?

A
  • 60 years or older
  • past experiences with ulcers and internal bleeding
  • steroid use or anticoagulation
  • consume alcohol or use tobacco on a regular basis
  • chronic NSAIDs or taking higher than recommended
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53
Q

s/s of PUD

A
  • burning, gnawing pain in epigastric area
  • pain when stomach is empty, but may occur at any time
  • pain will last anywhere from a few minutes to several hours
  • pain may occur in the middle of the night
  • duodenal ulcer: food alleviates s/s
  • gastric ulcer: food worsens s/s
  • other: N?V, hemoptysis, melena, loss of appetite, anemia
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54
Q

atypical s/s in the elderly

A
  • discomfort may be vague
  • poorly localized
  • radiating inconsistently
  • dysphagia, fatigue, anorexia, and weight loss may be the first symptoms
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55
Q

ROS for PUD

A
  • NSAID use, PO coricosteroids
  • 1st degree relatives
  • COPD, cirrhosis, chronic renal disease
56
Q

tx for PUD with alarm s/s

A
  • EGD or barium studies
  • If ulcer present, abx for H. pylori, PPI, tx bleeding/other complications, biopsy gastric ulcer
  • If no ulcer, PPI or H2RA
57
Q

tx for PUD w/o alarm s/s

A
  • Detect and tx H. pylori, d/c NSAIDs/smoking/ETOH/drugs, PPI or H2RA
  • If good clinical response, observe and consider maintenance with H2RA or PPI if sx recur
  • If persistent s/s, continue H2RA or PPI for 4-8 weeks
  • If good response observe or maintenance with H2RA or PPI
  • If no response consider EGD, recheck and retreat for H. pylori, check for noncompliance, consider hypersecretory states
58
Q

what are some non-endoscopic methods for diagnosing H. pylori?

A
  • serology via ELISA IgG
  • urea breath test
  • fecal antigen test via ELIZA monoclonal
59
Q

what are some endoscopic methods for diagnosing H. pylori?

A
  • rapid usease test (1 antrum and 1 corpus)
  • histology (1 antrum and 1 corpus)
  • culture
60
Q

indications for early endoscopy

A
  • new onset s/s >50yo
  • anorexia
  • dysphagia
  • GIB
  • mass
  • unexplained anemia
  • unexplained weight loss
  • severe vomiting
61
Q

1st line H/ pylori tx for pts w/o PCN allergy and have not previously received a macrolide

A
  • PPI BID
  • clarithromycin 500 mg BID
  • amoxicillin 1000 mg BID for 10-14 days
62
Q

1st line H/ pylori tx for pts w/ PCN allergy and have not previously received a macrolide/metronidazole or unable to tolerate bismuth quadruple therapy

A
  • PPI BID
  • clarithromycin 500 mg BID
  • metronidazole 500 mg BID for 10-14 days
63
Q

1st line H/ pylori tx for pts w/ PCN allergy and failed one course of H. pylori tx

A
  • bismuth subsalicylate 525 mg QID
  • metronidazole 250 mg QID
  • tetracycline 500 mg QID
  • PPI BID 10-14 days
    OR
  • bismuth subcitrate 420 mg QID
  • metronidazole 375 mg QID
  • tetracycline 375 mg QID
  • PPI BID 10-14 days
64
Q

how do you select appropriate abx tx for H. pylori?

A
  • abx resistance
  • prior abx exposure
  • pt compliance
65
Q

tx for NSAID associate ulcers

A
  • d/c offending agent
  • pts over 60yo have a greater than 5% year developing an ulcer
  • COX2 selective agent preferred in high risk pts for limited time
  • PPI for 8 wks
  • misoprostol (Cytotec) 100-200 mcg QID
66
Q

H. pylori complications

A
  • GI bleeding
  • gastric outlet obstruction
  • perforation
  • pancreatitis
67
Q

when to refer someone with H. pylori infection

A
  • failure to response to therapy
  • relapse
  • weight loss
  • hematemesis
  • melena
  • dysphagia
  • odynophagia
68
Q

criteria for irritable bowel syndrome (IBS)

A

recurrent abdominal pain at least 1 day/week, on average, in the past 3mo associated w/ 2 or more of the following:
- defecation
- change in frequency of stool
- change in form of stool
s/s onset should occur at least 6mo prior to dx and s/s should be present during last 3mo

69
Q

pathophysiology of IBS

A
  • involves enteric nervous system, visceral smooth muscle, and neurohormonal control of gut fx
  • caused by malfunction of chemical messengers such as serotonin
  • measured alterations in bowel motility occur in response to such stimuli as eating, stress (physical and psychological)
70
Q

more likely to develop IBS: women or men?

A

women 2-3x more likely

71
Q

typical onset IBS

A

adolescence, but people don’t often seek care until 30-50yo

72
Q

what races less commonly affected by IBS?

A

asians and hispanics

73
Q

triggers for development of IBS

A
  • infection
  • trauma
  • cholecystectomy
74
Q

physical characteristics of IBS

A
  • crampy, flatulence, bloating, borborygmi
  • constipation and diarrhea
  • pain relieved by BM
  • urgency, straining, mucus in stool
  • dyspepsia
  • absence of constitutional sx
  • absence of nocturnal diarrhea
75
Q

d/dx for IBS

A
  • lactose intolerance
  • celiac disease
  • giardia (parasite)
  • IBD
  • hyperthyroidism
  • PUD
  • diverticulosis
  • laxative abuse
  • infectious colitis
  • neoplasm
76
Q

red flags when dx IBS

A
  • weight loss
  • age >50yo
  • fever
  • nocturnal sx
  • heme positive stools
  • anemia
  • dehydration
  • FH celiac disease, IBD, or colon cancer
  • failure to respond to therapy
77
Q

bristol stool chart

A
  • type 1: separate hard lumps, like nuts
  • type 2: sausage shaped but lumpy
  • type 3: like a sausage but with cracks on the surface
  • type 4: like a sausage or snake, smooth and soft
  • type 5: soft blobs w/ clear-cut edges (passed easily)
  • type 6: fluffy pieces with ragged edges, a mushy stool
  • type 7: watery, no solid pieces
78
Q

steps in diagnosing IBS

A
  • exclude red flags
  • CBC, CMP, TSH
    if warranted:
  • stool hemocult, culture, ova and parasites
  • IgA, IgG transglutaminase and endomysial antibody tests for celiac disease
  • r/o lactose intolerance
  • sigmoidoscopy, colonoscopy not necessary in absence of red flags
79
Q

tx IBS-C, constipation predominates

A
  • soluble fiber

- linaclotide, lubiprostone, PEG laxatives

80
Q

tx IBS-D, diarrhea predominates

A
  • dietary modification

- rifaximin, alosetron, loperamide

81
Q

common foods containing FODMAPs

A
  • excess fructose: fruits, sweeteners, large total fructose dose, honey
  • lactose: milk, cheeses
  • fructans: vegetables, cereals, fruits
  • galactans: legumes
  • polyols: fruits, vegetables, sweeteners
82
Q

what is inflammatory bowel disease (IBD)?

A

a chronic inflammatory condition

83
Q

2 types of IBD

A
  • ulcerative colitis (UC)

- crohn’s disease (CD)

84
Q

what is ulcerative colitis?

A

chronic inflammation of lining of colonic muscosa, beginning in rectum and may involve entire colon

85
Q

what is crohn’s disease?

A

chronic inflammation of all layers of intestinal tract and can involve any portion from mouth to anus

86
Q

s/s differences btwn IBS and IBD

A
  • IBS: constipation, gas,
  • UC+CD: vomiting, severe diarrhea, bloody stool, weight loss
  • CD: mucus in stool, higher likelihood of fistulae
87
Q

diagnostic finding differences btwn IBS and IBD

A
  • IBS: by elimination, colonoscopy/biopsy neg
  • UC: ulcer on interior wall large intestine, biopsy will show signs of disease
  • CD: inflammation of intestines, ulceration less likely, biopsy will show signs of disease
88
Q

different causes of IBS vs IBD

A
  • IBS: trauma to gut, i.e. food poisoning, stomach flu; micro-inflammation causing overproduction of histamines; bacterial overgrowth; nervous system disorders; psychosomatic causes
  • IBD: autoimmune
89
Q

differences in tx of IBS vs IBD

A
  • IBS: diet, probiotics, fiber, laxatives, antidepressants

- IBD: diet, abx, anti-inflammatories, corticosteroids, immunosuppressive drugs, surgery

90
Q

diagnostics of IBD

A
  • CBC with diff, CBC, CRP, ESR, B12, folate
  • celiac antibody panel
  • genetic testing
  • stool tests: C and S, O and P, fecal leukocytes
  • imaging/endoscopy: MRI, CT, small bowel capsule endoscopy, upper EGD, sigmoidoscopy, colonoscopy, barium enema
  • GI MDs are completing work up and tx of IBD pts*
91
Q

PCP considerations for IBD pts

A
  • managed by GI MD
  • ensure pts are f/u w/ GI MD and up to date w/ colonoscopies (more frequent)
  • nutritional needs (b12/folic acid supplementation and monitoring)
  • meds prescribed by GI MD may need lab monitoring and caution when prescribing other meds
92
Q

diagnostic criteria for functional constipation

A

must include 2 or more:

  • straining during > 25% of defecations
  • lumpy/hard stools (Bristol types 1-2) > 25% defecations
  • sensation of incomplete evacuation > 25% defecations
  • sensation anorectal obstruction/blockage > 25% defecations
  • manual maneuvers to facilitate > 25% of defecations (i.e. digital evacuation, support of pelvic floor)

loose stools rarely seen w/o use of laxatives

insufficient criteria for IBS

*criteria fulfilled for last 3 mo w/ sx onset at least 6 mo prior to dx

93
Q

primary cause of constipation

A

colonic transit and pelvic floor dysfunction

94
Q

secondary causes of constipation

A

medical and psychogenic conditions, meds, structural abnormalities, lifestyle

95
Q

common triggers of constipation in adults

A
  • low-fiber diet
  • inadequate fluid intake
  • sedentary lifestyle
  • ignoring gastrocolic reflex (urge to defecate)
  • travel- and scheduling-related factors (varying mealtimes, limited toilet availability)
  • poor toilet access (2/2 physical/functional limitations)
  • lack of privacy/comfort
  • med SE
  • anal pain/discomfort
96
Q

meds associated w/ constipation

A
  • opioids
  • NSAIDs
  • iron
  • calcium
  • antacids
  • TCAs
  • antipsychotics
  • gen anesthesia
  • diuretics (non-K sparing)
  • polystrene sodium sulfate
  • muscle relaxants
  • antiepileptics
  • anticholinergics
  • antiemetics
  • CCBs
  • ganglionic blockers
  • clonidine
  • barium
  • drugs for detrusor hyperactivity
  • polypharmacy (> 5 meds)
97
Q

ROS for constipation

A
  • acute vs chronic
  • diet
  • laxative use
  • straining, fecal soiling
  • incontinence feces or urine
  • hemorrhoids/other anorectal disease
98
Q

eval for pt with constipation

A
  • acute: r/o obstruction, ileus (flat and upright films, i.e. KUB)
  • constitutional sx present
  • FH colon CA, IBD
  • CBC, CMP, TSH, stool for occult blood
  • colonoscopy, sigmoidoscopy, barium enema
99
Q

tx options for constipation

A
  • phase 1 - lifestyle changes
  • phase 2 - bulk-forming laxatives
  • phase 3 - stool softeners
  • phase 4 - osmotic laxatives
  • phase 5 - stimulant laxatives
  • phase 6 - chloride channel activators
  • phase 7 - severe cases may require both oral laxatives and enemas
100
Q

colorectal cancer risks

A
  • colon cancer 2nd most lethal cancer
  • lifetime incidence of average risk approx 6%
  • 2-3x higher for persons w/ affected 1st degree relative
  • persons w/ IBD 5-6x higher
  • persons w/ familial polyposis risk 20-30x higher
101
Q

ppl w/ avg risk for colon cancer

A
  • age 50+ (45+ for AA or American Indian/Alaska native)
  • no personal hx polyps and/or colorectal cancer
  • no personal hx IBD
  • no FH colorectal cancer
  • no FH adenomatous polyps
102
Q

ppl w/ increased risk for colon cancer

A
  • FH colorectal cancer or polyps
  • 1st degree relative w/ colorectal cancer or advanced adenoma < age 60
  • 2nd degree relative w/ colorectal cancer or advanced adenoma (colonoscopy q 5yrs beginning age 40 or 10 years younger than age at dx of youngest affected relative)
  • personal hx colorectal cancer
  • personal hx IBD
103
Q

clinical manifestations of colon cancer

A
  • rectal bleeding
  • anemia
  • vague, poorly localized abdominal pain
  • change in bowel habits
    palpable mass
  • large bowel obstruction
  • asymptomatic
  • weight loss
104
Q

d/dx colorectal cancer

A
  • IBS
  • diverticular disease
  • ischemic colitis
  • IBD
105
Q

screening guidelines

A
  • ACA = age 45

- AAFP, USPSTF = ages 50-75

106
Q

yearly recommendations for colorectal cancer screening

A
  • gFOBT

- FIT

107
Q

3 year recommendations for colorectal cancer screening

A
  • fecal DNA
108
Q

5 year recommendations for colorectal cancer screening

A
  • CTC (CT colonography)
  • flexible sigmoidoscopy
  • barium enema
109
Q

10 year recommendations for colorectal cancer screening

A
  • colonoscopy
110
Q

what is celiac disease?

A

disorder of small bowel malabsoprtion

111
Q

pathophysiology of celiac disease

A
  • mucosal inflammation, villous atrophy, and crypt hyperplasia w/ exposure to gluten (wheat, barley, rye)
  • clinical and histological improvement w/ withdrawal of gluten from the diet
112
Q

associations w/ untreated celiac disease

A
  • nutritional derangements
  • anemia
  • reduced bone density
  • intestinal lymphoma
113
Q

risks for celiac disease

A
  • FH celiac disease
  • T1DM
  • iron deficiency anemia
  • low bone mass density
114
Q

what screening is done to detect celiac disease?

A
  • endomysial antibodies (EMA)

- tissue transglutaminase (tTG) antibodies (95% sensitivity, 100% specificity)

115
Q

definition of diarrhea

A

increase in stool frequency of > 3 stools/day, typically appearing loose or liquid

116
Q

acute vs chronic diarrhea

A
  • acute: lasting < 2 weeks, 10% is noninfectious

- chronic: continues for a month w/o improvement

117
Q

questions about history of diarrhea

A
  • character of stool
  • timing of stool
  • duration of sx
  • fever
  • weight loss
  • relationship to food
118
Q

ROS diarrhea

A
  • travel
  • occupational or residency
  • meds
  • FH
  • sexual history
  • PMH and PSH
119
Q

what diagnosis should we consider if someone has acute onset diarrhea for less than one week after recent travel?

A

traveler’s diarrhea

120
Q

what diagnosis should we consider if someone has acute onset diarrhea for less than one week after abx exposure?

A

C. difficile

121
Q

what diagnosis should we consider if someone has acute onset diarrhea for less than one week that is bloody with a fever, chills, and cramps?

A

bacterial or amebic dysentery

122
Q

what diagnoses should we consider if someone has acute onset diarrhea for less than one week that is watery?

A
  • viral gastroenteritis

- food poisoning

123
Q

what diagnosis should we consider if someone has acute onset diarrhea for less than one week after recent anorectal sex?

A

sexually transmitted GI infection

124
Q

what are some characteristics of non-inflammatory diarrhea?

A
  • watery, non-bloody
  • periumbilical cramps, bloating
  • nausea or vomiting (suggests small bowel enteritis)
  • typically mild, but may be voluminous
  • no tissue invasion, fecal leukocytes usually not present
125
Q

what are some inflammatory pathogens that cause diarrhea?

A
  • shigella
  • salmonella
  • campylobacter
  • E. coli
  • entamoeba histolytica
126
Q

when would you use loperamide to tx diarrhea?

A
  • mild watery diarrhea

- mod-severe non-travel-associated diarrhea

127
Q

when would you use abx tx for diarrhea?

A
  • mod-severe travel-associated diarrhea
  • mod-severe non-travel-associated diarrhea for more than 72hr with a fever of 101
  • dysenteric diarrhea (passage of grossly bloody stools)
128
Q

common tx for bacterial diarrhea

A
  • azithromycin
  • metronidazole
  • ciprofloxacin
  • doxycycline
129
Q

common tx for protozoal diarrhea

A
  • TMP/SMX (bactrim)
  • metronidazole
  • albendazole
130
Q

diagnostics in a patient with diarrhea

A
  • CBC with diff
  • CMP
  • stool for occult blood
    fecal leukocytes
  • stool for ova and parasites
  • culture for C. diff
    Imaging (if indicated):
  • KUB
  • CT abdomen
  • colonoscopy
  • upper endoscopy w/ small bowel follow through
131
Q

who is at risk for ova and parasite infection?

A
  • community waterborne outbreak
  • exposure to daycare center
  • HIV/AIDS
  • MSM
  • recent travel to developing countries, Russia, Nepal, or Rocky Mountain
132
Q

some characteristics of diarrhea from ova and parasites?

A
  • persistent diarrhea > 2 weeks

- stools blood but few leukocytes

133
Q

how is C. diff diagnosed?

A
  • fecal test on diarrheal (unformed) stool, unless ileus due to C. diff suspected
  • dx based on clinical and lab findings
  • hx abx or antineoplastic agents w/in past 8 weeks
134
Q

tx for acute mild to moderate diarrhea

A
  • stop soilds for 1st 48 hours
  • rehydrate
  • adsorbents
  • anti-motility
  • anti-secretory
  • abx
  • probiotics (if indicated)
135
Q

chronic causes of diarrhea

A
  • colon cancer
  • endocrine
  • HIV
  • IBD
  • IBS
  • malabsorption

Primary Care Exam 4 (3 decks)

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