GI

Question 1

Hemorrhoids
Path:
Pt:
Tx:

Answer 1

Path: Arise from a plexus or cushion of dilated arteriovenous channels and connective tissue
Degree of prolapse internal hemorrhoids:
1st: do not protrude through anus
2nd: prolapse, reduce spontaneously 
3rd: prolapse, require manual reduction
4th: cannot be reduced, may strangulate 

Pt: bleeding, Pain (external), anal pruritus (internal), prolapse
External-> clinical inspection
Internal-> DRE, anoscopy, flexible sigmoidoscopy

Tx: Lifestyle modifications, sitz baths, analgesic creams, 
surgical excision (thrombosed) 
External : <72 hrs elliptical excision
Internal:
-Infrared coagulation
-Rubber band ligation

Question 2

Crohn's disease
Path:
Pt:
Dx:
Tx:

Answer 2

Path: Transmural inflammation of any part of the GI tract
15-30y/o, genetic, smoking correlation

Pt: intermittent, diffuse abdominal pain, morning/post meal diarrhea, perianal disease (fistula, abscess, fissure, rectal/anal skin tags)

Dx:

• Colonoscopy- full thickness inflammation of any portion of GI tract (skip areas); ulcerations commonly involving small bowel
• CT enterography, MR enterography, SBFT, capsule endoscopy, EDG

Tx:

• Steroids: induction only (budesonide- not absorbed concentrates in GI tract)
• Abx (abscess)- metronidazole, ciprofloxacin
• Immunomodulator- Azathioprine, 6-Mercaptopurine, methotrexate, cyclosporine
• Biologics- infliximab, adalimumab, certolizumab, vedolizumab
• Surgery- not curative, used to induce remission then control w/ medication

Complications:
Inc risk of colon cancer (not as significant as UC)
Less incidence of toxic mega colon

Question 3

Ulcerative Colitis
Pt:
Dx:
Tx:

Answer 3

Pt: Bloody diarrhea, mucus in stool, urgency, tenesmus, abdominal pain, fever, weight loss

Dx:
Anemia, iron deficiency
Colonoscopy- superficial inflammation, most severe in rectum, spreads continuously, improving proximally
bx: inflammatory infiltrates, ulcers +/- crypt accesses, cryptitis

Tx:
Induction: steroids (PO, IV)- budesonide, hydrocortisone, methylprednisolone
-mild: 5-ASAs (PO or rectally)- sulfasalazine, balsalazide, mesalamine
-moderate: immunosuppressants- azathioprine, 6-mercaptopurine, methotrexate, cyclosporine
-Severe: biologics
Anti-TNF-> infliximab, adalimumab, certolizumab
Anti-integrin-> vedolizumab
-Surgery: colectomy (curative)
Complications:
Inc risk of colorectal cancer
Toxic megacolon

Question 4

Gastric cancer
Path:
Pt:
Dx:
Tx:

Answer 4

Path: Gastric adenocarcinoma (MC)
Risks: diet, gastric ulcers, H pylori, blood type A

Pt:
Anorexia, N/V (pylorus), dysphasia (cardia)
Weight loss
Iron deficiency anemia

Dx: EDG & bx
METs to liver (MC)

Tx:
Endoscopic resection 
Surgery (gastrectomy with lymph node resection ) 
Chemotherapy 
Radiation therapy

Question 5

Phenylketonuria 
Path:
Pt:
Dx:
Tx:

Answer 5

PKU
Path: Autosomal recessive d/o of amino acid metabolism -> phenylketone neurotoxicity

Pt: After birth-> vomiting, mental delays
Children often blonde, blue-eyed w/ fair skin

Dx: Urine w/ musty odor

Tx: Lifetime dietary restriction of phenylalanine: milk, cheese, nuts, fish, chicken, meats, eggs, legumes, aspartame