GI Flashcards
Acute cholecystitis RF
RF:
Native American
Mexican American
Family history
Fertile, fat, forty, fair - not as much but still RF
Acute cholecystitis pathophysiology
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
CP acute chole
PERSISTENT, severe, steady RUQ pain, + Murphy’s sign, fever, N/V, anorexia, + Courvoisier’s sign (palpable gallbladder)
Dx acute chole
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
Initial treatment acute chole
NPO, IVF, pain control, ABX (3rd gen ceph & flagyl or cipro & flagyl (GNR anaerobes & aerobes)
Treatment for acute cholecystitis in low risk surgical patient (ASA I-II) w/ clinical improvement after supportive care and antibiotics
Based on surgical risk:
- Low surgical risk w/ clinical improvement - elective cholecystectomy
Treatment for acute cholecystitis in low risk surgical patient (ASA I-II) w/ clinical deterioration after supportive care and antibiotics
- Low risk w/ clinical deterioration - emergent cholecystectomy
Treatment for acute cholecystitis in HIGH risk surgical patient (ASA III-V) w/ clinical improvement after supportive care and antibiotics
- 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
Treatment for acute cholecystitis in HIGH risk surgical patient (ASA III-V) w/ clinical deterioration after supportive care and antibiotics
- High surgical risk w/ clinical deterioration - PERCUTANEOUS CHOLECYSTOSTOMY (GB tube/drainage) & referral for nonsurgical gallstone therapy
Chronic cholecystitis definition & what it can lead to
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
CP Chronic cholecystitis
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
CD or UC more common
UC
Parts of GIT affected UC
Colon & Rectum only
Parts of GIT affected CD
Terminal ileum = MC but can affect anywhere in GIT
Most important RF UC
Family History
Also Hx prior serious GI infection (shigella, salmonella, camplyobacter, esp as an adult)
Western Diet
Ashkanazi jews 5x prevalence
Location of ABD pain UC
LLQ
Location of ABD pain CD
RLQ/periumbilical
Quality of diarrhea UC
Bloody & mucoid (can be non-bloody)
Quality of diarrhea Crohn’s
Non-bloody
Most important RF CD
FAMILY HISTORY
Hx of a more MILD GI infection - gastroenteritis etc
Western diet, sedentary, air pollution, tobacco
Effect of smoking on UC
Lower risk & milder UC disease
Effect of smoking on CD
Exacerbation
Remember one RF = pollution…
CD: A/w perianal disease?
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
UC: A/w perianal disease?
Very rarely seen in UC
Presence of constitutional symptoms UC?
Rarely seen, more likely in CD
Presence of constitutional symptoms CD?
Yes - low grade fever, weight loss, fatigue, malaise
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 :/
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 :/
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
Diagnosis UC
- Careful history
- Colonoscopy
- 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
Colonoscopy features UC
Diffuse confluent disease from entate proximally
Friable, edematous, erythematous mucosa w/ erosions, ulcerations, & spontaneous bleeding
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
Colonoscopy features CD
Colonoscopy will show segmental skip lesions, aphthoid stellate linear ulcers, strictures, especially in the terminal ileum and colon
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
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
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
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)
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
