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*PANCE by subspecialty > GI > Flashcards

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

A

LLQ

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
Q

Presence of constitutional symptoms UC?

A

Rarely seen, more likely in CD

26
Q

Presence of constitutional symptoms CD?

A

Yes - low grade fever, weight loss, fatigue, malaise

27
Q

Extraintestional manifestations in UC?

A

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
Q

Extra-intentional manifestations in UC?

A

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
Q

D/dx UC/CD

A

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
Q

Diagnosis UC

A
  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
Q

Colonoscopy features UC

A

Diffuse confluent disease from entate proximally

Friable, edematous, erythematous mucosa w/ erosions, ulcerations, & spontaneous bleeding

32
Q

CD Dx/Labs

A

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
Q

Colonoscopy features CD

A

Colonoscopy will show segmental skip lesions, aphthoid stellate linear ulcers, strictures, especially in the terminal ileum and colon

34
Q

Medical treatment mild disease UC vs moderate vs severe

A

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
Q

UC: Elective vs urgent vs emergent surgical indications

A

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
Q

CD: Surgical indications

A

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
Q

Prevention & Screening UC

A

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
Q

Prevention & Screening CD

A

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

*PANCE by subspecialty (22 decks)

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