GI: Block 2- 10 11 12 15 16 Flashcards

1
Q

When are Virtual Endoscopy’s indicated?

A

Failed colonoscopy
Eval colon proximal to obstructing lesion
CRC screening in PTs w/ contraindications to endoscopy
PTs refusing other screening options

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2
Q

What two test/imaging modalities are specific to anorectal pathology?

A

Rigid sigmoidoscope

Anoscope

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3
Q

Antibiotic associated colitis is AKA ?

A

Pseudomembranous colitis, not the same is diarrhea

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4
Q

True colitis is nearly always a result of an infection from ?

When is it most commonly seen?

A

C Diff- Sx of mild diarrhea up to fulminant dz w/ toxic megacolon

Nosocomial- cause of diarrhea in 20% hospitalized PTs for +3 days

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5
Q

What are the most common causative agents that allow C Diff to flourish?

A
Ampicillin
Clindamycin
3rd Generation Cephalosporins
Fluoroquinolons
Almost all ABX have been implicated
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6
Q

What are the S/Sx of mild-moderate antibiotic associated colitis?

A

Mild/Moderate diarrhea- watery/green/foul/mucus
Cramping
CBC showing mild leukocytosis <15K

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7
Q

What are the S/Sx of severe antibiotic associated colitis?

A
Profuse diarrhea 
Fever <101.3
Hypoalbuminemia
One of the following:
Ab pain w/ diffuse TTP or,
CBC leukocytosis >15K
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8
Q

Criteria for Antibiotic Associated Colitis: Fulminant Disease

A
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
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9
Q

Define Antibiotic Associated Colitis: Pseudomembranous Colitis

A

Pseudo membrane formations on mucosal surface of bowel causing severe inflammation that may manifest as yellow/off-white plaques up to 2cm in diameter

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10
Q

How is C Diff toxin identified

A

Stool Assays:
PCR- study of choice
Enzyme Immunoassay- reqs 2 sample testing

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11
Q

When is imaging indicated for Antibiotic Associated Colitis

A

Contrast enhanced CT of abdomen and pelvis

PTs w/ evidence of fulminant dz to evaluate for toxic megacolon, perforation or surgical indications

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12
Q

What are some complications of fulminant disease?

A
Hemodynamic instability
Hypoalbuminemia causing hypercoagulability
Resp Failure
Metabolic acidosis
Toxic Megacolon
Bowel perforation
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13
Q

What are the treatment steps for antibiotic associated colitis?

A

Admit
D/c ABC offenders
Infection control/prevent spread
Correct fluid/E+ loss

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14
Q

What is the first line treatment option for antibiotic associated colitis?

A

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

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15
Q

What is the cost difference between Metronidazole and Vancomycin?

A
Metron= $22
Vanvomycin= $680
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16
Q

What is the preferred treatment regime for severe antibiotic associated colitis?

A

Vancomycin 125mg PO QID x 10 days

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17
Q

What are the treatment regimes for fulminant diseases?

A

Vancomycin 500mg PO QID
Metronidazole 500mg IV q8hrs
Vancomycin 500mg PR QID in 500mL NS enema
AND, early surgical consult

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18
Q

What are the characteristics of antibiotic associated colitis treatment relapse?

A

25% will relapse in 14 days
Repeat PO ABX
Relapse req 7 day taper of Vancomycin
Adjuncts: probiotics, fecal transplant

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19
Q

Define Toxic Megacolon

A
Acute Toxic Colitis/Toxic Colitis
Total/segmental colonic dilation
Non-obstructive
Larger than 6cm
Systemic Toxicity- toxemia
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20
Q

Toxic Megacolon may be a complication of ?, usually what form?

A

IBDz

Ulcerative Colitis

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21
Q

What is the diagnostic criteria for Toxic Megacolon?

A
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
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22
Q

How is Toxic Megacolon treated?

A

Reduce distension to prevent perforation
Correct fluid/E+ disturbance
Treat toxemia/precipitating factors
Surgical consult

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23
Q

Define Diverticulum

A

Sac-like protrusion of colonic wall that is the same color as the tissue around it

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24
Q

Characteristics of Colonic Diverticula

A
Most are A-Sx, various sizes
Sigmoid/Descending dominant
Pathogenesis- inc intraluminal pressure
Low fiber
Dec water intake
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25
If diverticulosis is identified, what is the next step?
Recommended inc fiber and water | Do not need to avoid seeds, nuts, popcorn
26
S/Sx of diverticular bleeding
Painless hematochezia BRB squirting into toiler Typically no other S/Sx
27
What is the next step for PTs with diverticular bleeds?
Active- resuscitate and stabilize, endoscopy No active bleeds- refer for scope
28
What causes diverticulitis
Inflammation and perforation of diverticulum | "Micro-perf" causing intra-abdominal infection
29
How will PTs with diverticulits present?
Abd pain and tenderness, classically in LLQ Fever N/V
30
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
31
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)
32
What imaging test is NOT performed on PT with Diverticulitis?
No endoscopy (Flex or C-scope)- risk of exacerbating inflammation and/or perf
33
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 ```
34
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 ```
35
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 ```
36
What are potential complications for PTs with diverticulitis?
Perforation Abscess formations Fistulization Obstruction- result of severe inflammation
37
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
38
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
39
When/who does Ogilvie Syndrome occur in?
Hospitalized PT that are: Post-Surgical Post-Traumatic Medical inpatient (resp failure, MI, CHF)
40
Ogilvie Syndrome is AKA ? What are the S/Sx?
Acute Colonic Pseudo-Obstruction Abdominal distension Abdominal pain N/V
41
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
42
How does a Sigmoid Volvulus present
Insidious onset of progressive abdominal pain that's continuous and severe N/V Abd distension Constipation
43
What will a PE of a Sigmoid Volvulus present as?
Distended abdomen w/ tympany to percussion Tenderness to palpation Unremarkable labs Plain-film/CT
44
How are Sigmoid Volvulus cases treated?
Detorsion via flexible sigmoidoscopy
45
Define Polyp
Protuberance extending into lumen of colon that are usually A-Sx but can cause: Bleeding Tenesmus Obstruction
46
What are the four major pathologic groups of colonic polyps?
Mucosal Adneomatous Mucosal Serrated Mucosal Non-Neoplastic Submucosal Lesions
47
Define an Adenomatous Polyps
Most common, dysplastic by definition that has malignant potential Can be tubular, villous or tubulovillous
48
Define Serrated Polyps
Display a lumen with a serrated or stellate architecture that include hyperplastic polyps
49
Define Mucosal Non-Neoplastic Polyp
No clinical significance but includes hamartomas- benign tumor like malformations made of cells and tissue
50
Define Submucosal lesions
Creat a polypoid appearance of overlying mucosa
51
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
52
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
53
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
54
Define Hamartomatous Polyposis Syndromes
Peutz-Jeghers Syndrome- hamartomas and oral lesions from familial juvenile polyposis with an increases risk of colon and Cowden Disease
55
Define Hereditary Nonpolyposis Colon Cancer
AKA Lynch Syndrome | Audtosomal Dominant condition that has increased risk of cancers
56
What is the name of the criteria used for screening for Hereditary Nonpolyposis Colon Cancer
Bethesda Criteria
57
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 ```
58
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
59
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
60
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
61
What type of PTs are at higher risk for colorectal dz?
FamHx Pos Dx <60yrs Two 1* relatives w/ CRC Adv adenomas
62
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
63
What are the S/Sx of a colorectal cancer in the right colon?
Fe deficiency anemia Weakness Fatigue
64
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
65
What are the S/Sx of colorectal disease in the rectum?
Hematochezia Tenesmus Urgency Ribbon stool- decrease in caliber of stool
66
What are the signs of advanced or metastatic disease?
Complete obstruction- apple core lesion Weight loss F/C/Ns
67
What does the work up for colorectal cancer include?
``` FOBT- Guiac or FIT CBC CMP UA Colonoscopy ```
68
What are the treatment steps for colorectal cancer?
Surgical resection- full/partial colectomy Chemo Radiation
69
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
70
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
71
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
72
IBDzs include what 3 diseases?
Crohn's Ulcerative colitis Microscopic colitis
73
Where does Crohn's affect the majority of the intestines? Where does UC mainly effect?
RLQ and scattered | Ulcerative colitis- LLQ and rectum
74
What are some of the extraintestinal manifestations of IBDz?
``` MSK- arthritis, hypertrophic osteroarthropathy, osteoporosis, aseptic necrosis, polymyositis, osteomalacia Skin/Mouth- Hepatobiliary- Ocular- Metabolic- ```
75
How is Crohn's IBDz characterized? What type of PT is it worse for?
TIERSS Transmural inflammation Skip lesions Exacerbations and remission Smokers
76
Crohn's may involve ? GI tract What can it lead to?
Entire, mouth to anus Ulceration, stricturing, fisulization, abscesses
77
General presenting Sx of Crohn's may include?
Fatigue Prolonged intermittent diarrhea, usually no blood Weight loss Fever
78
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
79
What is the most common Symptoms of chronic inflammatory Crohn's dz?
Malaise Weight loss Fatigue Non-bloody intermittent diarrhea
80
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
81
What is the pathophysiology of pentrating/fistulization of Crohn's Dz?
Transmural bowel inflammation associated w/ development of sinus tracts
82
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
83
Is phlegmon seen on PE and how does it often present?
May be palpable | Indolent process and not as an acute abdomen issue
84
Crohn's Dz penetration may also lead to ?
Intrabdominal abscess: acute presentation of localized peritonitis w/ fever, abd pain and tenderness
85
Characteristics of Fistulization Crohn's Dz
Sinus tracts penetrate serosa and give rise to fistula: tracts that connect two epithelial lined organs
86
What are common sites of Crohn's Fistulas
Bladder- enterovesical Skin- entercutaneous Small bowel- enterenteric Vagina- entervaginal
87
What are the S/Sx of an Enterovesical Fistula
Recurrent UTI | Pneumaturia
88
Define Enterocutaneous Fistula
Bowel contents that drain to surface of skin
89
Define Enteroenteric fistula
ASx or palpable mass
90
Define Enterovaginal fistula
Passage of gas/feces through vagina
91
Crohn's fistula to retroperitoneum may lead to ? issues
Psoas abscesses | Uteral obstruction w/ hydronephrosis
92
What are common clinical constellations of Crohn's Dz
``` Perianal Dz: Large painful skin tags Anal fissures at lateral location Perianal abscess Fistula ```
93
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 ```
94
What are two derm Signs of Crohn's issues?
Pyoderma Gangrenosum | Erythema Nodosum
95
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 ```
96
What test/imaging establishes a Crohn's Dx?
Colonoscopy first to evaluate colon and terminal ileum | Endoscopy- Dx
97
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
98
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
99
What type of extraintestinal Crohn's Manifestations require a surgical consult and treatment?
Abscess Obstruction Fistulization
100
How are Crohn's treatments planned?
Treatment of GI Sx directed to symptomatic improvement and control
101
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
102
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)
103
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
104
When/why would a Crohn's PT be considered for hospital admission during treatment?
Failure to respond to oral corticosteroid therapy
105
What is the relapse rate of Crohn's w/out maintenance therapy?
80% in 1yr
106
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
107
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
108
What are the surgical indications for a PT with Crohn's?
``` Therapy failure- primary indication Intestinal obstruction Abscess formation Perianal Enterocutaneous fistula ```
109
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
110
How many specialties need to be consulted for a PT w/ Crohn's?
GI Dietician Crohns/Colitis Foundation of America Surgery
111
Define Ulcerative Colitis
Idiopathic inflammation limited to mucosal layer of colon causing diffuse friability and erosions w/ bleeding
112
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)
113
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 ```
114
What is a characteristic of Ulcerative Colitis that Crohn's also has?
Exacerbations and periods of remission
115
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
116
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
117
How is UC characterized?
Universal involvement of rectum and sigmoid colon w/ continuous erythema and ulceration of mucosal surface
118
What is the Hallmark Sx of UC?
Bloody Diarrhea but presentation depends on severity | look at chart and know
119
Characteristics of Mild to Moderate UC
Gradual onset of diarrhea w/ blood and mucus Fecal urgency Tenesmus LLQ pain that's relieved w/ defecation
120
Characteristics of Severe UC?
``` Hypoalbuminemia** >6 bloody bowel movements/day Hypovolemia Anemia LLQ pain TTP on exam ```
121
UC bowel movements are what size and frequency?
Frequent and small volume due to inflammation
122
What lab tests are ordered during a UC work up?
``` CBC CMP Serum Albumin CRP and ESR Stool Culture OandP STI tests ```
123
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
124
What type of histology report is suggestive of UC?
Crypt abscesses Crypt branching Crypt atrophy Shortening/disarray
125
What imaging modality is used to assess for colonic dilation or toxic megacolon?
Plain film
126
How is UC treated?
Similar to Crohn's Treat acute, active disease and prevent recurrence to maintain remission Differentiated by Dz severity
127
What is the main difference of UC treatment than Crohn's?
UC- 5- Aminosalicylic acid agents are mainstays of treatment
128
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
129
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
130
How is Mild-Moderate Distal colitis that's refractory treated?
Co-therapy with oral and topical 5-ASA | Prednisone is added if Sx persist
131
What happens if Mild-Moderate Distal Colitis relapses?
Maintenance dose of topical/PO mesalamine nightly/every other day PO less effective at preventing remission
132
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
133
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)
134
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
135
What is used/given as UC maintenance therapy?
Oral Mesalamine or Sulfasalazine daily | Mercaptopurine or Azathioprine- for PTs w/ >2 relapses/year
136
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
137
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
138
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
139
Define Microscopic Colitis
Chronic inflammatory dz of colon characterized by chronic watery diarrhea but normal appearing colonic mucosa on colonoscopy
140
How is Microscopic Colitis Dx'd?
Histopathologic exam of biopsy specimen
141
What are the two major sub-types of microscopic colitis?
Lympocytic- intraepithelial lymphocytic infiltrate | Collagenous- colonic subepithelial collagen band >10um thick
142
What is the etiology of Microscopic Colitis?
``` NSAIDs Sertraline Paroxetine Lansoprasole Lisinopril Simvastatin ```
143
How does Microscopic Colitis present clinically?
``` Chronic non bloody watery diarrhea w/ 4-9 stools/day Abd pain Fatigue Dehydration Weight loss ```
144
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
145
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
146
How is IBS diagnosed?
No biological markers to confirm, Dx off of Sx criteria
147
What are the multifactorial natures that make up IBS?
``` Abnormal motility Visceral hypersensitivity Intestinal inflammation Enterif infection Psychosocial abnormalities ```
148
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
149
Criteria for IBS-C/D
C: w/ < 3 BMs/week w/ straining D: > 3 BMs/day w/ urgency or incontinence
150
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 ```
151
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
152
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
153
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
154
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 ```
155
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
156
What is some of the supporting criteria for an IBS Dx
Abnormal: | Freq, form, passage, mucus or bloating/distension
157
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)
158
What diagnostic tests are ran for IBS?
CBC CMP UA IBS-D is screened for Celiac Dz Plain Abd films for IBS-C
159
What type of diet is recommended for IBS?
Regular meal patterns Avoid large meals Reduce fat, fiber, caffeine and gas-producing foods Low FODMAPS
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What dietary mods are made for IBS-D and C
D: lactose/gluten elimination C: Inc fiber and fluids
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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
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What adjunct pharmacologic therapies are recommended for IBS treatment?
``` Dietary and Lifestyle mods FIRST Antispasmodic Anti-constipations Antidiarrheals- SSRA, ABX Psychotropics ```
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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
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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
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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
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When/why are probiotics used in BIS therapy?
No clinical value, may offer psychological effect leading to Sx improvement
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Successful Sx improvement in PTs w/ IBS is result of what factors?
PT/Provider relationship PT education and compliance Trial and error
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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
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What is the pathologic sequence of Primary Biliary Cirrhosis?
Destruction of bile duct epithelial cells Loss of Intralobular ducts Cholestasis Cirrhosis/liver failure
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What type of PT usually has Primary Biliary Cirrhosis
Insidious onset in majority of women w/ Dx in 40-50
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Primary Biliary Cirrhosis is associated with what other Autoimmune Disorders?
Sjogren Syndrome Autoimmune thyroid Dz Raynaud Syndrome Scleroderma
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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 ```
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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
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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
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PBC PTs usually/likely progress to what end treatment plan?
Liver transplant
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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
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What are the S/Sx of Hemochromatosis
Clinical onset after 50y/o | Incidental finding w/ elevated AST, Alk Phos, plasma iron and serum Ferritin
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How is Hemochromatosis diagnosed?
Genetic testing in PTs w/ Fe overload or FamHx
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What treatment measures are used for Hemochromatosis PTs?
Deferoxamin- chelation Phlebotomy Liver transplant
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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
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How does Wilson Dz clinically present?
Liver Dz Neurologic/Psych Sx Pathognomonic Sign- Kayser Fleischer rings
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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
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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
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What are the clinical manifestations and Rad tests for Budd-Chiari Syndrome?
Tender/pain hepatomegaly Jaunidce Splenomegaly Ascites Color Doppler US
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How is Budd-Chiari Syndrome treated?
Directed to underlying cause and ascite complications | Admit any PT w/ suspected obstruction
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What are the different types of Pyogenic Hepatic Abscesses?
Bile duct- ascending cholangitis Portal vein- pylephlebitis Direct extension of infection Traumatic bacteria implantation
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What is the clinical presentation of Pyogenic Hepatic Abscess?
``` Fever RUQ pain/TTP Jaundice N/V Anorexia, weight loss, fatigue ```
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What are the lab findings in PTs with Pyogenic Hepatic Abscesses
Leukocytosis on CBC + blood cultures Abnormal hepatic panel
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What are the diagnostic imaging modalities for Pyogenic Hepatic Abscess?
CT scan Hepatic US CT guided percutaneous drainage w/ culture of aspirate
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Define Benign Liver Neoplasm
Cavernous hemangioma
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What type of cancer is associated w/ 80% of cirrhosis?
Hepatocellular carcinoma
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What are the other risk factors that can lead to Hepatocellular Carcinoma
``` Hep B/C NAFLD Tobacco/ETOH Diabetes Obesity Hemochromatosis/Wilson Dz ```
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What are the S/Sx of Hepatocellular Carcinoma
F/C Weight loss Bone pain from metastases
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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
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How is Hepatocellular treated?
Surgical resection | Liver transplant
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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
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Define Cholelithiasis
Presence of stones in gallbladder made of cholesterol or Ca bilirubinate
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What are the risk factors of cholelithiasis
``` Age +40 Femal Pregnancy OCP/Estrogen FamHx Obese Rapid weight loss Diabetes Cirrhosis Crohn's ```
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What are the 5 F'x of cholelithiasis
``` Fat Fair Forty Fertile Flatulent ```
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What are the protective factors of Cholelithiasis
Coffee Statins PT Diet rich in poly/monosaturated fats
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Gall stones are often ASx, but are often found how?
Incidentally on X-ray or US | Causing RUQ- Biliary Colic
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What is the treatment of Cholelithiasis?
None if ASx NSAIDs Cholecystectomy- if pain or frequent cholecystitis
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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
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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
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How does Acute Cholecystitis present on PE?
Laying still, looking ill RUQ TTP w/ guarding Pos Murphy's Jaundice is uncommon
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What are the lab findings in a PT with Acute Cholecystitis?
Leukocytosis Inc serum bilirubin- UNCOMMON Inc ALP/AST/ALT Modest inc of amylase
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What are the diagnostic images for Acute Cholecystitis?
RUQ US | HIDA scan- cholescintigraphy
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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
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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
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What are the treatment steps for Acute Cholecystitis
Admit | Laparoscopic cholecystectomy
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Define Choledocholithiasis
Gallstones in CBD as a result of stone from the gallbladder causing obstruction and cholangitis (infection)
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How does Choledocholithiasis clinically present?
Severe biliary colic RUQ/epigastric pain N/V Jaundice- during attacks or intermittent
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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
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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
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What is Charcto's Triad?
RUQ pain Fever/chill Jaundice AKA- ascending cholangitis from bacteria rising from duodenum through bile duct
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Define Reynold's Pentad
``` RUQ pain Figor- fever/chills Jaundice Altered mental HOTN ```
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What does Reynolds Pentad indicate
Acute Suppurative Cholangitis which is a surgical emergency
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What lab tests are pulled for Acute Cholangitis
``` CBC for leukocytosis Hepatic panel Inc amylase Blood cultures CRP ```
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How is Acute Cholangitis treated?
Admit ERCP Surgery Cholecystectomy
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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
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How does Primary Sclerosing Cholangitis present?
Progressive obstructive jaundice w/ fatigue, pruritus, anorexia and indigestion
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ASx gallstones is called? Gallstone + fever/pain = ?
Cholelithiasis Cholecystitis
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Gallstone + juandice = ? Gallstone jaundice fever = ?
Choledocholithiasis Cholangitis
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What S/Sx combine to form Suppurative Cholangitis
``` Gallstone Jaundice Fever AMS HOTN ```
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Define cholangiocarcinoma
Cancer of bile duct usually Dx by incidence during surgery and has poor prognosis
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How does Cholangiocarcinoma present?
Obstructive jaundice Painless Dilated biliary tree
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Define Courvoisier Sign
Palpable gallbladder with painless obstructive jaundice but can also be associated with jaundice
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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
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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
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What pieces of information are important when considering screening colonoscopy?
Hx | Age
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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
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What Sx/lab finding is not consistent with IBD and indicates cancer?
Iron deficient anemia
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Normal AST/ALT levels?
AST: 14-36 ALT: 9-50
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What lab markers may be seen in PTs with active Hep B infection?
Anti-Hep C Ab | Anti Hep B Surface Ag
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Stopped on
#26 of review