GI Flashcards
Characteristics of Crohns
Transmural, gum-bum, skip lesions, mostly ileal
How does Crohns present?
Pain, diarrhea, abscess/fistula, wt loss
What are the features of UC?
Mucosal, extends from rectum, colon only
Symptoms of UC
Urgency, tenesmus, bleeds/diarrhea, nocturnal, fever, wt loss
How is ASUC defined?
> 6 bloody BM/day, systemic toxicity
Extra-GI manifestations of IBD
Oral ulcers, uveitis, erythema nodosum, pyroderma gangrenosum, sweet’s (fever, neutrophilia, red papules), arthropathy, PSC, CRC
What should you not give patients with IBD?
NSAIDS
What concurrent infections indicate high risk UC?
CMV, C diff
Why is structuring Crohns a surgical emergency?
Can cause complete obstruction
What is the nature of UC surgery?
Curative
What are indications that surgery is required in UC?
Toxic mega colon, fulminant colitis, sepsis, perforation, hemorrhage
What is fulminant colitis?
Doesn’t respond to medical therapy
When is dysplasia in UC an indicator for surgery?
Lesions cannot be remixed endoscopically, high grade dysplasia confirmed by 2 pathologists, CRC
What does Truelove&Jewell state about patient conditions after medical therapy?
Improvement-stay the course
Deteriorate-surgery
Unchanged-biologics/surgery
How can you tell if medical management for UC is unsuccessful?
> 8bm/day, CRP>45, blood, formless stool, clinical deterioration, no improvement by day 5
What major risk is associated with extended steroid use?
Immune suppression
What disease location of crohns has the highest risk of relapse post-op?
Ileocolic
What are endoscopic hallmarks of Crohns?
Cobblestoning, creeping fat, transmural inflammation
What is the nature of surgery for Crohns?
Non-curative
What should you be mindful of when performing surgery from Crohns?
Preserve length to avoid morbidities
What are indications for surgery in Crohns?
Obstruction, fistula, perforation, bleeding, stricturing
How does the likelihood of Crohns and UC needing surgery change with age?
Increased surgical need if younger when diagnosed
How does smoking affect IBD?
Worse for Crohns, better for UC
What extraGI manifestations of Crohns will NOT improve with resection?
PSC, cirrhosis
How is perianal Crohns treated?
Drain abscess, sew seton in place to fight infection
What are vascular cushions?
Blood vessel, connective tissues, smooth muscles along anal canal, protect against hemorrhoids
Causes of hemorrhoids
FHx, increase intra-abd pressure, vascular enforcement, stretching of muscular support
How do you treat hemorroid disease?
Fiber (Metamucil)
Rubberband ligation (sclerotherapy), hemorrhoidectomy
What is the dentate/pectinate line?
Transition zone from rectal mucosa (columnar) to perianal skin (squamous)
Where is the internal hemorrhoidal plexus located?
Above dentate line, no pain
What are the features of internal hemorrhoids?
Prox dentate line, columnar epithelial, visceral innervation (bleed, prolapse, protrude, no pain)
What is stage IV internal hemorrhoid?
Protrusion that cannot be manually pushed back
What are the features of external hemorrhoids?
Distal dentate line, squamous epithelium, somatic innervation (localized pain, swelling, thrombose)
What is an anal fissure?
Tear in anoderm by hard stool/dry skin, cause irritation and spasm of internal sphincter (ischemia)
How do you treat TEH (thrombosed external hemorrhoids)?
Fiber, sitz bath
What are features of chronic anal fissure?
Sentinel tag, hypertrophic anal papilla, exposed internal sphincter fibers
Causes of acute anorectal pain
Fissure, TEH, abscess (or cancer)
Don’t do DRE
What is pilonidal disease?
Chronic infection of skin and subcutaneous tissues of upper natal cleft
Do hyperplastic polyps have dysplasia?
No
What are invasive adenocarcinomas?
Invasive glands
Are are post-op UTIs treated?
Cipro
What is thumb printing an indication of?
Bowel inflammation
Overgrowth of what organism causes psrudomembrane colitis? Where does this happen?
C diff, large intestine
How is pseudomembrane colitis treated?
Vancomycin
The visceral nervous system is sensitive to which stimuli?
Stretch, contraction, inflammation, ischemia
What is the nature of visceral pain?
Diffuse, dull, colic, unaffected by movement
What is the nature of somatic pain?
Sharp, localized, worse with movement
Peritonitis, appendicitis, diverticulitis are all examples of
Somatic pain
What is the most common cause of acute abd pain?
Appendicitis
What is the pathophysiology of appendicitis?
Obstruction, increased lumen pressure, ischemia, bacterial invasion, irritation, parietal peritoneum involvement, necrosis, perforation with peritonitis and abscess
Causes of appendix obstruction
Fecalith, lymphoid hyperplasia, fibrosis, foreign body, neoplasia
Symptoms of appendicitis
Anorexia, periumbilical pain—>RLQ, nausea, high WBC (bandemia)
What is the best imaging for appendicitis?
CT
What is obstipation?
Inability to pass gas
Colonic diverticula are true/false diverticula?
False diverticula (mucosa and submucosa)
What signs on auscultation indicate bowel obstructions?
High pitched sounds, lack of sounds
What is the most common cause of bowel adhesion?
Surgery
What imaging should be following after percussion a tympanic abdomen? Dull?
CT, US
What are some presentations of bowel volvulus?
Bloody stool, no sepsis (septic fluid cannot leave twist)
What is the most common form of bowel obstruction?
Adhesion
What is intussusception?
Telescoping of two segments of bowels that cause obstruction
If strictures are seen in UC, what should we suspect?
Cancer (mucosal damage should not cause stricturing)
How do symptoms of distal and proximal bowel obstructions differ?
Distal: more pain and distension
Proximal: more emesis, less tenderness
What is an ileus?
Lack of bowel movement
What can cause an ileus?
Acute peritonitis, intestinal dysmotility, severe constipation
What laboratory results point towards a bowel obstruction?
Hypokalemia, hypochloremia, metabolic acidosis (Lose ions bc body tried to conserve water)
Increased hematocrit, Hb, WBC
How do the causes of SB and LB obstructions differ?
SB: adhesion, hernia
LB: cancer, IBD, diverticulitis
What type of bowel obstruction is associated with aortic aneurysms?
Ischemic colitis
What part of the bowel is the earliest to be affected by ischemia?
Antimesenteric mucosa
What are symptoms of ischemic colitis?
Pain out of proportion with physical findings, distension, NV, bloody stool if colonic or rectal, sepsis if transmural
Tx for ischemic colitis
Thrombolysis, heparin, antibiotics, hydration, resection if full thickness necrosis
Where does an arterial embolus cause obstructions?
Proximal jejunum to mid transverse colon (obstruct SMA at mid colic artery)
What is portal venous gas associated with?
Full thickness necrosis
What dietary modifications should IBS patients implement?
Gluten free, low FODMAPS, probiotics
IBSD tx
Rifaximin, antispasmodics
IBSC tx
Linaclotide(Increase fluids secretion and transit, decrease pain)
Bloating vs distension
Bloating: feeling full/gassy
Distension: increased girth
Ascites Tx
Low Na diet, diuretics (spironolactone), paracentesis
What are the causes of exudate ascites (<11)?
Malignancy, pancreatitis, nephrotic, infection
what are the two pathways of visceral sensation?
vagal and spinal
what is the vagal pathway responsible for?
secretion, absorption, peristalsis
parasympathetic sensing
what is the spinal pathway responsible for?
pain sensation
sympathetic sensing
what is referred pain?
convergence of visceral and somatic afferents at same spinal level
what pain stimuli are the guts sensitive to?
contraction, stretching, injury, ischemia, inflammation
what is hyperalgesia?
exaggerated response to noxious stimuli
what is allodynia?
innocuous stimulus perceived as noxious
what nerve plexus is located between the two muscle layers of the esophagus? what is its role?
myenteric plexus (auerbach), regulate peristalsis
what nerve plexus is located between the circular muscular layer and the submucosa? what is its role?
submucosal plexus (meissner’s), digestion control
what role does the interstitial cells of cajal play?
perpetuate nerve signals
5HT serotonin is release by what cell?
ECM cells
what is gastroparesis?
impaired gastric emptying
what red flag must we look for when dealing with motility disorders?
GIB, nighttime stooling, B symptoms
what is the major difference between IBS and motility disorders in regards to pain?
IBS is defined by pain, motility problems do not include pain
what are osmotic laxatives?
not absrobed in SB, cause water/electrolyte secretion, increase stool mass
include PEG, lactulose, milk of magnesia
what are stimulant laxatives?
cause direct irritation of smooth muscle, lead to water/electrolyte secretion
diphenylmethane derivatives and anthrquinones
how does linactotide work?
pro-secretory drug, activate CAMP and cause Cl- excretion (like cholera)
decrease abd pain (CAMP interact with nerves)
how do bile acid sequestrants help with IBSD?
resorption of bile acids
what drug class do opioids fall under?
Mu receptor agonists
how do Mu receptors work on IBSD?
decrease Ach, increase NO (decrease paristalsis and slows motility, thus preventing stretch related pain)
what drug classes help with nausea?
anti-histamine, ondansetron, prokinetics, D2RA, erythromycin
what area of the brain is targeted by anti-nausea drugs?
CTZ
what are the symptoms of gastroparesis?
early satiety, NV, bloating, upper bad pain, burning
which form of nutrient is the preferred energy source?
carbs
what is the most energy dense macronutrient?
lipids
what is recommended daily intake of proteins?
10-35% of diet (0.6-0.8g)
how many essential amino acids are there?
9
what is the difference between soluble and insoluble fibre?
soluble: dissolves, slows gastric emptying/digestion, increase stool volume
insoluble: passes through bowels unchanged, speeds transit, increase stool wt
what is the normal BMI range?
18.5-25
which fatty acid is required to prevent EFAD?
linoleic acid
when considering enteral feeding, when should bolus feeding never be used?
if feeding to jejunum
which micronutrients will not be found in parenteral feeding?
Vit ADK, Fe
what is the refeeding symdrome and what are its implications?
sudden increase in kcal in chronically malnourished patient
electrolyte abnormalities, volume overload, insuline resistance, cardiac arrhythmia
prevent by starting at 50% kcal needs
where is ghrelin secreted from and what does it do?
stomach, increase appetite and lead to fat storage
where is CCK released and what does it do?
SB, reduce intake
where is PYY produced?
L cells throughout gut
what is the result of leptin deficiency?
increased appetite and obesity
which cytokine leads to decreased adiponectin secretion?
IL6
what is the pathophysiology of cholera?
vibrio cholerae toxin activates CAMP, lead to Cl- efflux, draw water out of stool (secretory diarrhea)
what combo is usually given to rehydrate patients?
water, glucose, sodium
what components of digestion happen in the stomach?
pepsin (protein)
iron conversion to ferrous
IF production
where is most fat absorbed in the body?
jejunum
what transporter is responsible for the absorption of fluids?
Na+/glucose
how does the laboratory testing for acute and chronic pancreatitis differ?
acute: elevated lipase
chronic: decreased lipase, elastase in stool
where are bile salts resorbed?
ileum
where do carb, protein, and lipid digestion start?
carb-mouth (amylase)
protein-stomach
lipids-SB
how do function and organic abd diseases differ?
functional: disease of gut-brain interaction, no structural/metabolic abnormalities
organic: related to gut structure, disease based
how is failure to thrive in children identified?
wt fall, ht fall, head circumference low
should acid blockers be given to infants with GERD?
no
how is EoE treated in kids?
steroids, dilatation
what are the PE findings for celiac disease in kids?
FTT, distended stomach, Fe deficiency signs, diarrhea
what increases the risk of celiac disease in kids?
trisomy 21, type 1 DM
how does the presentation of peds IBD differ from adult IBD?
peds-more extensive disease
adults-more localized
how are peds functional disorders treated?
clean out with PEG 3350 (osmotic laxative), include fiber in diet, dietary and behavioral changes
what is the most common form of toddler’s diarrhea?
osmotic (surgar)
