GI: Block 2- 10 11 12 15 16 Flashcards
When are Virtual Endoscopy’s indicated?
Failed colonoscopy
Eval colon proximal to obstructing lesion
CRC screening in PTs w/ contraindications to endoscopy
PTs refusing other screening options
What two test/imaging modalities are specific to anorectal pathology?
Rigid sigmoidoscope
Anoscope
Antibiotic associated colitis is AKA ?
Pseudomembranous colitis, not the same is diarrhea
True colitis is nearly always a result of an infection from ?
When is it most commonly seen?
C Diff- Sx of mild diarrhea up to fulminant dz w/ toxic megacolon
Nosocomial- cause of diarrhea in 20% hospitalized PTs for +3 days
What are the most common causative agents that allow C Diff to flourish?
Ampicillin Clindamycin 3rd Generation Cephalosporins Fluoroquinolons Almost all ABX have been implicated
What are the S/Sx of mild-moderate antibiotic associated colitis?
Mild/Moderate diarrhea- watery/green/foul/mucus
Cramping
CBC showing mild leukocytosis <15K
What are the S/Sx of severe antibiotic associated colitis?
Profuse diarrhea Fever <101.3 Hypoalbuminemia One of the following: Ab pain w/ diffuse TTP or, CBC leukocytosis >15K
Criteria for Antibiotic Associated Colitis: Fulminant Disease
One of these: Admit to ICU HOTN- >100mm SBP Fever >101.3/38.5*C Ileus/abdominal distension Changes in mental status WBC >35K Serum Lactate >2.2mmol End organ failure/mechanical ventilation
Define Antibiotic Associated Colitis: Pseudomembranous Colitis
Pseudo membrane formations on mucosal surface of bowel causing severe inflammation that may manifest as yellow/off-white plaques up to 2cm in diameter
How is C Diff toxin identified
Stool Assays:
PCR- study of choice
Enzyme Immunoassay- reqs 2 sample testing
When is imaging indicated for Antibiotic Associated Colitis
Contrast enhanced CT of abdomen and pelvis
PTs w/ evidence of fulminant dz to evaluate for toxic megacolon, perforation or surgical indications
What are some complications of fulminant disease?
Hemodynamic instability Hypoalbuminemia causing hypercoagulability Resp Failure Metabolic acidosis Toxic Megacolon Bowel perforation
What are the treatment steps for antibiotic associated colitis?
Admit
D/c ABC offenders
Infection control/prevent spread
Correct fluid/E+ loss
What is the first line treatment option for antibiotic associated colitis?
Metronidazole 500mg PO TID x 10days
If PT unable to take metronidazole= Vancomycin 125mg PO QID x 10 days
If no improvement on Metron x 5-7 days, switch to Vancomycin
What is the cost difference between Metronidazole and Vancomycin?
Metron= $22 Vanvomycin= $680
What is the preferred treatment regime for severe antibiotic associated colitis?
Vancomycin 125mg PO QID x 10 days
What are the treatment regimes for fulminant diseases?
Vancomycin 500mg PO QID
Metronidazole 500mg IV q8hrs
Vancomycin 500mg PR QID in 500mL NS enema
AND, early surgical consult
What are the characteristics of antibiotic associated colitis treatment relapse?
25% will relapse in 14 days
Repeat PO ABX
Relapse req 7 day taper of Vancomycin
Adjuncts: probiotics, fecal transplant
Define Toxic Megacolon
Acute Toxic Colitis/Toxic Colitis Total/segmental colonic dilation Non-obstructive Larger than 6cm Systemic Toxicity- toxemia
Toxic Megacolon may be a complication of ?, usually what form?
IBDz
Ulcerative Colitis
What is the diagnostic criteria for Toxic Megacolon?
Radiographic evidence of colon distension >6cm plus three of: FLAP Fever HR +120bpm Leukocytosis >10.5 Anemia AND one of: HEAD Dehydration Altered mental status E+ abnormality HOTN
How is Toxic Megacolon treated?
Reduce distension to prevent perforation
Correct fluid/E+ disturbance
Treat toxemia/precipitating factors
Surgical consult
Define Diverticulum
Sac-like protrusion of colonic wall that is the same color as the tissue around it
Characteristics of Colonic Diverticula
Most are A-Sx, various sizes Sigmoid/Descending dominant Pathogenesis- inc intraluminal pressure Low fiber Dec water intake
If diverticulosis is identified, what is the next step?
Recommended inc fiber and water
Do not need to avoid seeds, nuts, popcorn
S/Sx of diverticular bleeding
Painless hematochezia
BRB squirting into toiler
Typically no other S/Sx
What is the next step for PTs with diverticular bleeds?
Active- resuscitate and stabilize, endoscopy
No active bleeds- refer for scope
What causes diverticulitis
Inflammation and perforation of diverticulum
“Micro-perf” causing intra-abdominal infection
How will PTs with diverticulits present?
Abd pain and tenderness, classically in LLQ
Fever
N/V
What will a PE on PT with diverticulitis show?
What will labs show?
LLQ TTP
20% w/ LLQ mass
Fever
Leukocytosis on CBC
+/- occult blood
What diagnostic imaging is used for Diverticulitis
What type of Diverticulitis does NOT need imaging?
Abdominal CT
Not necessary for mild dz (mild ttp, no fever)
What imaging test is NOT performed on PT with Diverticulitis?
No endoscopy (Flex or C-scope)- risk of exacerbating inflammation and/or perf
What is the treatment plan for mild diverticulitis?
Conservative- Out PT management PO ABX: Metronidzaole 500mg and Ciprofloxacin 500mg/TMP-SMX DS 160/800 Amoxicillin-Clavulance 875/125 Both for 7-10 days Clear liquid diet for 48-72hrs
What is the criteria for Inpatient/Severe diverticulitis
IF 102 SOCIALS Complicated diverticulitis on CT Sepsis Fever >102 Leukocytosis Adv age Immunocompromised Comorbities PO intolerant Or, failure of outpatient treatment
What is the treatment plan for severe disease inpatient management
NPO IV broad ABX- inflammation stabilized= transition to PO ABX IV fluid/E+ IV pain Surgical consult
What are potential complications for PTs with diverticulitis?
Perforation
Abscess formations
Fistulization
Obstruction- result of severe inflammation
When are complications such as abscesses in diverticulitis PTs considered?
What is your next step?
Fails to improve on ABX regimen, obtain CT is suspicion exists
When is Ogilvie Syndrome seen?
How does it present on imaging?
S/Sx of obstruction w/out mechanical lesions
Bowel dilation on imaging usually in cecum or righ hemicolon
When/who does Ogilvie Syndrome occur in?
Hospitalized PT that are:
Post-Surgical
Post-Traumatic
Medical inpatient (resp failure, MI, CHF)
Ogilvie Syndrome is AKA ?
What are the S/Sx?
Acute Colonic Pseudo-Obstruction
Abdominal distension
Abdominal pain
N/V
Define Volvulus
Torsion of segment of the alimentary tract that leads to an obstruction most commonly in the sigmoid colon but can occur at any point
How does a Sigmoid Volvulus present
Insidious onset of progressive abdominal pain that’s continuous and severe
N/V
Abd distension
Constipation
What will a PE of a Sigmoid Volvulus present as?
Distended abdomen w/ tympany to percussion
Tenderness to palpation
Unremarkable labs
Plain-film/CT
How are Sigmoid Volvulus cases treated?
Detorsion via flexible sigmoidoscopy
Define Polyp
Protuberance extending into lumen of colon that are usually A-Sx but can cause:
Bleeding
Tenesmus
Obstruction
What are the four major pathologic groups of colonic polyps?
Mucosal Adneomatous
Mucosal Serrated
Mucosal Non-Neoplastic
Submucosal Lesions
Define an Adenomatous Polyps
Most common, dysplastic by definition that has malignant potential
Can be tubular, villous or tubulovillous
Define Serrated Polyps
Display a lumen with a serrated or stellate architecture that include hyperplastic polyps
Define Mucosal Non-Neoplastic Polyp
No clinical significance but includes hamartomas- benign tumor like malformations made of cells and tissue
Define Submucosal lesions
Creat a polypoid appearance of overlying mucosa
What type of polyp characteristics are bad to see on a pathology report?
What results are not considered as bad?
Adenoma or adenomatous
Dysplasia or dysplastic
Hyperplastic or hyperplasia
Define Polyposis Syndromes
Familial Adenomatous Polyposis
Inherited disorder that causes 100s-1000s of polyps to develop before 15y/o but is a marker for inevitable colon cancer
Due to the inevitable diagnosis of colon cancer, what management/treatment steps are taken for PTs with Polyposis Syndromes?
Prophylactic total colectomy
Annual colonoscopy until colectomy
Define Hamartomatous Polyposis Syndromes
Peutz-Jeghers Syndrome- hamartomas and oral lesions from familial juvenile polyposis with an increases risk of colon and Cowden Disease
Define Hereditary Nonpolyposis Colon Cancer
AKA Lynch Syndrome
Audtosomal Dominant condition that has increased risk of cancers
What is the name of the criteria used for screening for Hereditary Nonpolyposis Colon Cancer
Bethesda Criteria
What are the risk factors that contribute to development of Colorectal Cancer
IBDz Smoking FamHx to 1* Age, inc risk after 45 Diet high in fat and red meat
Why are PTs that are A-Sx at time of colorectal cancer dx given a low prognosis?
Slowly growing tumor that doesn’t present w/ Sx until years later
Colorectal Cancer screening is the delineation between ?
Cancer Prevention Tests: Colonoscopy, Flexible Sigmoidoscopy
CT Coloangiography
Cancer Detection Tests: Fecal Immunochemical Test, Hemoccult SENSA or Fecal DNA
What is the preferred CRC prevention and detection tests for average risk PTs?
Prevention: Colonoscopy every 10yrs starting at 50y/o
AfAm should begin at 45y/o- Grades 2C
Detection: PTs that deny colonoscopy- recommended detection is annual FIT for blood
What type of PTs are at higher risk for colorectal dz?
FamHx Pos
Dx <60yrs
Two 1* relatives w/ CRC
Adv adenomas
Define the Colorectal Cancer screening method “CEA”
Carcinoembryonic Ag
NOT an actual screening test but is useful for prognosis AFTER Dx to serve as a marker of recurrence after treatment
What are the S/Sx of a colorectal cancer in the right colon?
Fe deficiency anemia
Weakness
Fatigue
What are the S/Sx of colorectal in the left colon?
Change in bowel habits
Blood streaked stool
Obstructive Sx- constipation w/ inc frequency and loos stool, colicky pain
What are the S/Sx of colorectal disease in the rectum?
Hematochezia
Tenesmus
Urgency
Ribbon stool- decrease in caliber of stool
What are the signs of advanced or metastatic disease?
Complete obstruction- apple core lesion
Weight loss
F/C/Ns
What does the work up for colorectal cancer include?
FOBT- Guiac or FIT CBC CMP UA Colonoscopy
What are the treatment steps for colorectal cancer?
Surgical resection- full/partial colectomy
Chemo
Radiation
What are the prognosis stages of colorectal cancers?
1: +90%
2: 70-85%
3: w/ <4 +nodes - 67%
3: w/ >4 +nodes - 33%
4: 5-7%
Rectal cancer have worse prognosis for each stage
What are the Alternate CRC prevention and Detection tests:
Prev: Flex Sig every 5-10 Grade 2B
CT colo- every 5yrs Grade 1C
Detect: annual Hct Sensa Grade 1B
Fecal DNA every 3 yrs
How does family history positive affect CRC recommendations?
Same as average risk Grade 2B
Single 1st degree w/ CRC or adv adenoma dx at <60 or,
Two 1st degree relatives w/ CRC or adv adenomas
Recommend screening colo ever 5yrs starting at 40 or 10yrs younger than age at Dx of youngest affected relative
IBDzs include what 3 diseases?
Crohn’s
Ulcerative colitis
Microscopic colitis
Where does Crohn’s affect the majority of the intestines?
Where does UC mainly effect?
RLQ and scattered
Ulcerative colitis- LLQ and rectum
What are some of the extraintestinal manifestations of IBDz?
MSK- arthritis, hypertrophic osteroarthropathy, osteoporosis, aseptic necrosis, polymyositis, osteomalacia Skin/Mouth- Hepatobiliary- Ocular- Metabolic-
How is Crohn’s IBDz characterized?
What type of PT is it worse for?
TIERSS
Transmural inflammation
Skip lesions
Exacerbations and remission
Smokers
Crohn’s may involve ? GI tract
What can it lead to?
Entire, mouth to anus
Ulceration, stricturing, fisulization, abscesses
General presenting Sx of Crohn’s may include?
Fatigue
Prolonged intermittent diarrhea, usually no blood
Weight loss
Fever
What is the most common presentation of Crohn’s dz?
Chronic inflammatory Dz
Attacks terminal ileum
Cramping RLQ pain/mass
PTs c/o ileitis or ileocolitis
What is the most common Symptoms of chronic inflammatory Crohn’s dz?
Malaise
Weight loss
Fatigue
Non-bloody intermittent diarrhea
What causes Crohn’s Dz intestinal obstructions?
What are the S/Sx?
Narrowing of lumen as result of chronic inflammation
Postprandial bloat
Cramping abd pain
Loud borborygmi
What is the pathophysiology of pentrating/fistulization of Crohn’s Dz?
Transmural bowel inflammation associated w/ development of sinus tracts
Characteristics of the Penetrating Dz of Crohn’s Dz?
Sinus tracts penetrate bowel wall presents as phlegmon: walled off inflammatory mass w/out bacterial infection
Is phlegmon seen on PE and how does it often present?
May be palpable
Indolent process and not as an acute abdomen issue
Crohn’s Dz penetration may also lead to ?
Intrabdominal abscess: acute presentation of localized peritonitis w/ fever, abd pain and tenderness
Characteristics of Fistulization Crohn’s Dz
Sinus tracts penetrate serosa and give rise to fistula: tracts that connect two epithelial lined organs
What are common sites of Crohn’s Fistulas
Bladder- enterovesical
Skin- entercutaneous
Small bowel- enterenteric
Vagina- entervaginal
What are the S/Sx of an Enterovesical Fistula
Recurrent UTI
Pneumaturia
Define Enterocutaneous Fistula
Bowel contents that drain to surface of skin
Define Enteroenteric fistula
ASx or palpable mass
Define Enterovaginal fistula
Passage of gas/feces through vagina
Crohn’s fistula to retroperitoneum may lead to ? issues
Psoas abscesses
Uteral obstruction w/ hydronephrosis
What are common clinical constellations of Crohn’s Dz
Perianal Dz: Large painful skin tags Anal fissures at lateral location Perianal abscess Fistula
What are some of the extraintestinal manifestations of Crohns Common Clinical Constellations?
Arthralgia/arthritis Iritis/uveitis Pyoderma Gangrenosum Erythema nodosum Oral aphthous ulcers Inc prevalence of gallstones due to malabsorption of bile salts in terminal ileum
What are two derm Signs of Crohn’s issues?
Pyoderma Gangrenosum
Erythema Nodosum
What lab tests does a Crohn’s Work up include?
No specific lab test CBC- anemia or leukocytosis? CMP Fe/B12 Albumin ESR CRP Stool culture and O&P
What test/imaging establishes a Crohn’s Dx?
Colonoscopy first to evaluate colon and terminal ileum
Endoscopy- Dx
Why would a barium swallow be ordered in a PT w/ Crohn’s?
What additional image test may be ordered?
Evaluate for ulcerations, strictures or fistulas
Capsule endoscopy to look for small bowel involvement
How is Crohn’s Dz severity categorized by their CDAI scores?
ASx remission- <150
Mild-Mod- 150-220
Mod to Severe- 221
Severe-Fulimant >451
What type of extraintestinal Crohn’s Manifestations require a surgical consult and treatment?
Abscess
Obstruction
Fistulization
How are Crohn’s treatments planned?
Treatment of GI Sx directed to symptomatic improvement and control
What meds are used for Symptomatic Crohn’s?
Anti-Diarrheals:
Loperamide
Bile Acid Sequestrants- if terminal ileum is involved
Kenalog in orabase (Triamcinolone)- for aphthous ulcers
What are the Non-Systemic Corticosteroids used for Crohn’s treatment
Mild to Mod Dz
Budesonide- 9mg daily x 8-16wks (taper by 3mg over 2-4wks)
What are the Systemic Corticosteroids used for Crohn’s Disease
Severe Disease
Prednisone- 40-60mg/day until Sx resolution and weight gain resumes (7-28 days)
Avoid long term use
When/why would a Crohn’s PT be considered for hospital admission during treatment?
Failure to respond to oral corticosteroid therapy
What is the relapse rate of Crohn’s w/out maintenance therapy?
80% in 1yr
What are the immunomodulators used for Crohn’s treatment?
Why are they used?
Maintain remission/induce remission in PT w/ severe dz and fail oral steroids or have refractory dz
Azathioprine
6-Mercaptopurine
Methotrexate
What A-TNF agents are used for Crohn’s treatment?
Why is this class of drug used?
Induce/maintain remission in PTs with moderate to severe dz including fistulizing dz
Infliximab
Adalimumab
Certolizumab
What are the surgical indications for a PT with Crohn’s?
Therapy failure- primary indication Intestinal obstruction Abscess formation Perianal Enterocutaneous fistula
PTs w/ Crohn’s need to be admitted if what is suspected or what criteria exist?
Intestine obstruction
Intra-abdominal abscess
Perirectal abscess
Serious infectious complication- especially immunocompromised PTs due to Corticosteroids, Immunomodulators or A-TNFs
Severe Sx- diarrhea, dehydration, weight loss or abd pain
Severe/persisting Sx despite treatment w/ corticosteroids
How many specialties need to be consulted for a PT w/ Crohn’s?
GI
Dietician
Crohns/Colitis Foundation of America
Surgery
Define Ulcerative Colitis
Idiopathic inflammation limited to mucosal layer of colon causing diffuse friability and erosions w/ bleeding
What are 3 unique characteristics of Ulcerative Colitis
1/3 in retrosigmoid region- proctosigmoiditis
1/3 extend to splenic flexure (L sided colitis)
1/3 extends proximally (extensive colitis)
What are the five types of Ulcerative Colitis and where does it inhabit the large intestine?
(Look at Pics)
Proctitis Proctosigmoiditis Distal Colitis Extensive colitis Pancolitis
What is a characteristic of Ulcerative Colitis that Crohn’s also has?
Exacerbations and periods of remission
What are the ranges of Ulcerative Colitis
What are the ranges of Crohn’s Dz?
Mild colitis - Fulminant Colitis (risk of Toxic Megacolon)
Crohns: mild to severe/fulminant
Ulcerative Colitis has extraintestinal manifestations similar to Crohn’s but ?
What is a unique/bizarre characteristic of UC?
Significantly fewer UC PTs develop fistulas
UC severity is lower in active smokers and may worse in PTs who stop
How is UC characterized?
Universal involvement of rectum and sigmoid colon w/ continuous erythema and ulceration of mucosal surface
What is the Hallmark Sx of UC?
Bloody Diarrhea but presentation depends on severity
look at chart and know
Characteristics of Mild to Moderate UC
Gradual onset of diarrhea w/ blood and mucus
Fecal urgency
Tenesmus
LLQ pain that’s relieved w/ defecation
Characteristics of Severe UC?
Hypoalbuminemia** >6 bloody bowel movements/day Hypovolemia Anemia LLQ pain TTP on exam
UC bowel movements are what size and frequency?
Frequent and small volume due to inflammation
What lab tests are ordered during a UC work up?
CBC CMP Serum Albumin CRP and ESR Stool Culture OandP STI tests
How is UC diagnosed?
Endoscopy
Fex Sigmoid if acute Dz
Avoid full colonoscopy due to perforation risk and inciting Toxic Mega Colon, consider performing after Sx improvement to assess extent
What type of histology report is suggestive of UC?
Crypt abscesses
Crypt branching
Crypt atrophy
Shortening/disarray
What imaging modality is used to assess for colonic dilation or toxic megacolon?
Plain film
How is UC treated?
Similar to Crohn’s
Treat acute, active disease and prevent recurrence to maintain remission
Differentiated by Dz severity
What is the main difference of UC treatment than Crohn’s?
UC- 5- Aminosalicylic acid agents are mainstays of treatment
After UC is dx, what is the next step?
Anatomic extent is assessed w/ endoscope
Distal inflammation= topical therapy
Proximal to descending colon= systemic medications
Mild-Moderate Distal UC means that it is confined to ? and how is it treated?
Rectosigmoid colon
Topical mesalamine- DOC
5-ASA drug that’s administered as a suppository/enema for 4-12wks
Topical corticosteroids- hydrocortisone
Oral mesalamine- PTs unwilling/unable to use topicals
How is Mild-Moderate Distal colitis that’s refractory treated?
Co-therapy with oral and topical 5-ASA
Prednisone is added if Sx persist
What happens if Mild-Moderate Distal Colitis relapses?
Maintenance dose of topical/PO mesalamine nightly/every other day
PO less effective at preventing remission
Mild-Moderate Extensive UC means that it is confined to ? and how is it treated?
Extends proximal to sigmoid
Oral 5-ASA x 3-6wks: Mesalamine, Sulfasalazine but reqs co-admin w/ Folic Acid
Oral corticosteroids added to 5-ASA if no improvement occurs in 4wks- Prednisone of Methylprednisolone
How is Mild-Moderate Extensive colitis that’s refractory treated?
Immunomodulators- PTs that experience flares despire 5-ASA and corticosteroids
Anti-TNFs- Infliximab, Adalimumab, Golimumab
Anti-Integrin- Vedolizumab (PTs that are unresponsive/intolerant to other therapies)
Severe or Fulminant UC means that it is confined to ? and how is it treated?
Pancolitis or Fulminant
In PT Care- early surgical consult, NPO, IV fluids/E+ and corticosteroids
What is used/given as UC maintenance therapy?
Oral Mesalamine or Sulfasalazine daily
Mercaptopurine or Azathioprine- for PTs w/ >2 relapses/year
PTs w/ UC have significantly higher risk of developing ? so ? steps are taken as precautions?
Colorectal cancer
Colonoscopy w/ biopsy every 1-2yrs starting at 8yrs post-Dx
What are the absolute surgical indications for UC? What are the Relative indications?
Absolute: severe hemorrhage, perforation, carcinoma
Relative: colitis unresponsive to max medical therapy, less severe colitis but medically intractable Sx or intolerable medication side effects
Who is consulted for PTs w/ UC?
When are they considered for admission to the hospital?
GI and Surgery
Severe Dz w/ frequent bloody stool, anemia, weight loss and fever
Fulminant Dz w/ rapid progression of Sx, worsening Abd pain, distension, high fever or tachycardia
Define Microscopic Colitis
Chronic inflammatory dz of colon characterized by chronic watery diarrhea but normal appearing colonic mucosa on colonoscopy
How is Microscopic Colitis Dx’d?
Histopathologic exam of biopsy specimen
What are the two major sub-types of microscopic colitis?
Lympocytic- intraepithelial lymphocytic infiltrate
Collagenous- colonic subepithelial collagen band >10um thick
What is the etiology of Microscopic Colitis?
NSAIDs Sertraline Paroxetine Lansoprasole Lisinopril Simvastatin
How does Microscopic Colitis present clinically?
Chronic non bloody watery diarrhea w/ 4-9 stools/day Abd pain Fatigue Dehydration Weight loss
How is Microscopic Colitis diagnosed and treated?
Routine lab tests rule out other etiologies of chronic diarrhea
Clinical suspicion leads to colonoscopy w/ biopsy
D/c offending meds, antidiarrheals, Budesonide if persistent past 4wks
How is IBS characterized?
Idiopathic GI syndrome w/ chronic abd pain, altered bowel habits and in the absence of an organic cause but still a functional bowel disorder w/ common extraintestinal manifestations
How is IBS diagnosed?
No biological markers to confirm, Dx off of Sx criteria
What are the multifactorial natures that make up IBS?
Abnormal motility Visceral hypersensitivity Intestinal inflammation Enterif infection Psychosocial abnormalities
What are the S/Sx of IBS
Crampy, intermittent abd pain usually in lower quadrants that is relieved by defecation
Change in stool form/frequency
Bloating w/ or w/out distension
Criteria for IBS-C/D
C: w/ < 3 BMs/week w/ straining
D: > 3 BMs/day w/ urgency or incontinence
What somatic/psychological complaints are common IBS extraintestinal manifestations
Dyspepsia Heartburn Chest pain HA Fatigue Myalgia Gynecologic- impaired sex, dysmenorrhea, dyspareunia Uro- inc freq/urge Anxiety/depression
What are atypical Sx that are not compatible with IBS?
Rectal bleeds
Nocturnal/progressive Abd pain
Weight loss
Lab abnormals: anemia, inc inflammatory markers, E+ disturbance
What is the next step if PTs present with any of the atypical Sx that are not compatible with IBS?
Further imaging studies and/or colonoscopy
How is IBS Dx?
Exclude organic etiologies
It’s a chronic condition so acute onset is odd and indicative of non-IBS etiology
PT/FamHx is critical
What questions are asked for info gathering to Dx IBS?
Hx GI neoplasm IBD Hyper/pothyroid Malabsorption Psychiatric disorders Meds/diet/exercise Travel or illness
What is the Dx criteria for IBS?
> /= 3mon of abd pain and altered bowel habits AND abd pain is associated w/ 2/3 of:
Relieved w/ defecation
Onset associated w/ change in defecation frequency/stool appearance
What is some of the supporting criteria for an IBS Dx
Abnormal:
Freq, form, passage, mucus or bloating/distension
What will PE for IBS show?
Unremarkable
Mild Abd TTP that can be exaggerated is psychosomatic component is present (cycles- anxiety of Sx= worse Sx)
What diagnostic tests are ran for IBS?
CBC CMP UA
IBS-D is screened for Celiac Dz
Plain Abd films for IBS-C
What type of diet is recommended for IBS?
Regular meal patterns
Avoid large meals
Reduce fat, fiber, caffeine and gas-producing foods
Low FODMAPS
What dietary mods are made for IBS-D and C
D: lactose/gluten elimination
C: Inc fiber and fluids
What treatment strategy is recommended and useful in all subtypes of IBS?
What psychological therapies is recommended?
Inc exercise
Cognitive behavioral therapy
Hypnotherpay
Relaxation techniques
What adjunct pharmacologic therapies are recommended for IBS treatment?
Dietary and Lifestyle mods FIRST Antispasmodic Anti-constipations Antidiarrheals- SSRA, ABX Psychotropics
What anti-spasmodics are used for IBS?
What anti-constipations meds are used for IBS-C?
Dicyclomine, Hyosycamine
Osmotic laxatives- FIRST
Lubiprostone- Fem>18y/o
Linaclotide
What anti-diarrheals are used in IBS-D
Loperamide- FIRST
Bile salt sequestrants- if no result w/ Loperamide
SSRA: Alosetron- if failed relief w/ other therapy and only use in females
Ondansetron- off label use
Rifaximin- (non-absorbable), in PTs w/ bloating
What psychotropics are used in IBS pharamacologic treatment?
Most useful in PTs w/ Abd pain/bloating as main complaint
Usefule in IBS-D due to anticholinergic effect
TCAs: Amitriptyline, Nortriptyline, Desipramine, Imipramine
When/why are probiotics used in BIS therapy?
No clinical value, may offer psychological effect leading to Sx improvement
Successful Sx improvement in PTs w/ IBS is result of what factors?
PT/Provider relationship
PT education and compliance
Trial and error
Define Primary Biliary Cirrhosis and what is it AKA
Primary Biliary Cholangitis
Autoimmune destruction of small intrahepatic bile ducts and cholestasis involving T-Cell mediated attack on small intralobular bile ducts
What is the pathologic sequence of Primary Biliary Cirrhosis?
Destruction of bile duct epithelial cells
Loss of Intralobular ducts
Cholestasis
Cirrhosis/liver failure
What type of PT usually has Primary Biliary Cirrhosis
Insidious onset in majority of women w/ Dx in 40-50
Primary Biliary Cirrhosis is associated with what other Autoimmune Disorders?
Sjogren Syndrome
Autoimmune thyroid Dz
Raynaud Syndrome
Scleroderma
What are the S/Sx of Primary BIliary Cirrhosis
ASx at time of Dx Dx detected by abmormal hepatic results and/or ASx hepatomegaly Fatigue- usual FIRST Sx Pruritus Xanthamatous lesion on skin/tendons Jaundice, steatorrhea, portal HTN LATER
What are the lab findings of Primary Biliary Cirrhosis
Cholestatic pattern
Inc Alk Phos, Bilirubin, Lipids and Transaminases
Markers of autoimmune Dz: Antimitochondrial Abs
Antinuclear Abs
How is Primary Biliary Cirrhosis treated?
FIRST: r/o other etiologies of bilary obstructions
Ursodeoxycholic acid- FDA approved for PBC that slows Dz progression
Sx treatment of pruritis w/ Bile Salt Sequestrants
PBC PTs usually/likely progress to what end treatment plan?
Liver transplant
Define Hemochromatosis
Autosomal recessive disorder resulting in accumulation of Fe as hemosiderin in liver, pancreas, heart, adrenals, testes, pituitary and kidneys
(Hemosiderin- intracellular Fe storage complex)
Leads to cirrhosis and/or liver failure
ETOH inc risk
What are the S/Sx of Hemochromatosis
Clinical onset after 50y/o
Incidental finding w/ elevated AST, Alk Phos, plasma iron and serum Ferritin
How is Hemochromatosis diagnosed?
Genetic testing in PTs w/ Fe overload or FamHx
What treatment measures are used for Hemochromatosis PTs?
Deferoxamin- chelation
Phlebotomy
Liver transplant
Define Wilson Disease
Autosomal recessive occurring in PTs under 40 as excessive absorption of Cu in small intestine w/ decreased hepatic excretion causing Cu deposits in cornea, liver and brain
How does Wilson Dz clinically present?
Liver Dz
Neurologic/Psych Sx
Pathognomonic Sign- Kayser Fleischer rings
What diagnostic testing is done for Wilson Diz?
How is it treated?
Dec serum ceruloplasmin
Inc urinary excretion of Cu
Inc Cu concentration in liver
Tx w/ chelation of Cu
Define Budd-Chiari Syndrome
Results in post-hepatic portal HTN
1- obstruction due to venous process (thrombus, phlebitis)
2- compression/invasion of hepatic veins/inf vena cava by lesion originating outside of vein
What are the clinical manifestations and Rad tests for Budd-Chiari Syndrome?
Tender/pain hepatomegaly
Jaunidce
Splenomegaly
Ascites
Color Doppler US
How is Budd-Chiari Syndrome treated?
Directed to underlying cause and ascite complications
Admit any PT w/ suspected obstruction
What are the different types of Pyogenic Hepatic Abscesses?
Bile duct- ascending cholangitis
Portal vein- pylephlebitis
Direct extension of infection
Traumatic bacteria implantation
What is the clinical presentation of Pyogenic Hepatic Abscess?
Fever RUQ pain/TTP Jaundice N/V Anorexia, weight loss, fatigue
What are the lab findings in PTs with Pyogenic Hepatic Abscesses
Leukocytosis on CBC
+ blood cultures
Abnormal hepatic panel
What are the diagnostic imaging modalities for Pyogenic Hepatic Abscess?
CT scan
Hepatic US
CT guided percutaneous drainage w/ culture of aspirate
Define Benign Liver Neoplasm
Cavernous hemangioma
What type of cancer is associated w/ 80% of cirrhosis?
Hepatocellular carcinoma
What are the other risk factors that can lead to Hepatocellular Carcinoma
Hep B/C NAFLD Tobacco/ETOH Diabetes Obesity Hemochromatosis/Wilson Dz
What are the S/Sx of Hepatocellular Carcinoma
F/C
Weight loss
Bone pain from metastases
What lab tests are done for suspected Hepatocellular Carcinoma
What imaging is ordered?
Leukocytosis on CBC
Sudden and Sustained inc of Alk Phos
Inc AFP
CT or MRI then Biopsy
How is Hepatocellular treated?
Surgical resection
Liver transplant
How often is screening recommended for PTs with Hepatocellular Carcinoma
Recommended for PTs w/ cirrhosis, HBV/HCV or FamHx of HCC
US and AFP every 6mon
Define Cholelithiasis
Presence of stones in gallbladder made of cholesterol or Ca bilirubinate
What are the risk factors of cholelithiasis
Age +40 Femal Pregnancy OCP/Estrogen FamHx Obese Rapid weight loss Diabetes Cirrhosis Crohn's
What are the 5 F’x of cholelithiasis
Fat Fair Forty Fertile Flatulent
What are the protective factors of Cholelithiasis
Coffee
Statins
PT
Diet rich in poly/monosaturated fats
Gall stones are often ASx, but are often found how?
Incidentally on X-ray or US
Causing RUQ- Biliary Colic
What is the treatment of Cholelithiasis?
None if ASx
NSAIDs
Cholecystectomy- if pain or frequent cholecystitis
90% of acute cholecystitis is due to gallstones, the other cases are due to ?
Acalculous Cholecystitis- consider in critically ill PTs due to association w/ high mortality
How does acute cholecystitis clinically present?
Sudden onset of steady RUQ pain that radiates to shoulder
Non resolving biliary colic affter 4-6hrs
N/V
Fever
How does Acute Cholecystitis present on PE?
Laying still, looking ill
RUQ TTP w/ guarding
Pos Murphy’s
Jaundice is uncommon
What are the lab findings in a PT with Acute Cholecystitis?
Leukocytosis
Inc serum bilirubin- UNCOMMON
Inc ALP/AST/ALT
Modest inc of amylase
What are the diagnostic images for Acute Cholecystitis?
RUQ US
HIDA scan- cholescintigraphy
What are the complications of Acute Cholecystitis
Gangrenous cholecystitis- present w/ sepsis and most common complication in DM or elderly
Perforation
Cholecystoenteric fistula
Gallstone ileus- stone passing through fistula in terminal ileum
One of the compliations of acute cholecystitis is Chronic Cholecystitis which is defined as ?
Repeated episodes in PTs that are poor surgical candidates and can result in Porcelain Gallbladder
What are the treatment steps for Acute Cholecystitis
Admit
Laparoscopic cholecystectomy
Define Choledocholithiasis
Gallstones in CBD as a result of stone from the gallbladder causing obstruction and cholangitis (infection)
How does Choledocholithiasis clinically present?
Severe biliary colic
RUQ/epigastric pain
N/V
Jaundice- during attacks or intermittent
What labs and diagnostic images are used for choledocholithiasis
Cholestatic pattern of hepatic panel- AlkPhos and bilirubin higher than AST/ALT
RUQ US- FIRST
ERCP
How is choledocholithiasis trested?
What complications can occur if left untreated?
Endoscopit stone remoaval even in ASx PTs follow by laparoscopic cholecystectomy to prevent recurrences
Cholangitis and pancreatitis
What is Charcto’s Triad?
RUQ pain
Fever/chill
Jaundice
AKA- ascending cholangitis from bacteria rising from duodenum through bile duct
Define Reynold’s Pentad
RUQ pain Figor- fever/chills Jaundice Altered mental HOTN
What does Reynolds Pentad indicate
Acute Suppurative Cholangitis which is a surgical emergency
What lab tests are pulled for Acute Cholangitis
CBC for leukocytosis Hepatic panel Inc amylase Blood cultures CRP
How is Acute Cholangitis treated?
Admit
ERCP
Surgery
Cholecystectomy
Define Primary Sclerosing Cholangitis
Strong association w/ IBD (UC>Crohn’s) causing an increased immune response to intestinal endotoxins causeing diffuse inflammation of biliary tract w/ fibrosis and stricture formation
How does Primary Sclerosing Cholangitis present?
Progressive obstructive jaundice w/ fatigue, pruritus, anorexia and indigestion
ASx gallstones is called?
Gallstone + fever/pain = ?
Cholelithiasis
Cholecystitis
Gallstone + juandice = ?
Gallstone jaundice fever = ?
Choledocholithiasis
Cholangitis
What S/Sx combine to form Suppurative Cholangitis
Gallstone Jaundice Fever AMS HOTN
Define cholangiocarcinoma
Cancer of bile duct usually Dx by incidence during surgery and has poor prognosis
How does Cholangiocarcinoma present?
Obstructive jaundice
Painless
Dilated biliary tree
Define Courvoisier Sign
Palpable gallbladder with painless obstructive jaundice but can also be associated with jaundice
How is carcinomas of the biliary tracts diagnosed?
Sx of biliary obstruction- jaundice, abnormal liver tests, bile duct dilation or,
No alternative explanation such as choledocholithiasis or pancreatic head lesion
Carcinomas of the biliary tract diagnosis’ should be considered in what type of pPTs?
Isolated intrahepatic mass on imaging and a NORMAL serum level of AFP
What pieces of information are important when considering screening colonoscopy?
Hx
Age
50 y/o male ASx with no FamHx of colon CA and denies initial screening colonoscopy should be offered what second option?
CT colonography every 5 yrs
FIT is equivalent
What Sx/lab finding is not consistent with IBD and indicates cancer?
Iron deficient anemia
Normal AST/ALT levels?
AST: 14-36
ALT: 9-50
What lab markers may be seen in PTs with active Hep B infection?
Anti-Hep C Ab
Anti Hep B Surface Ag
Stopped on
26 of review
