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IPAP > GI: Block 2- 10 11 12 15 16 > Flashcards

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
Q

If diverticulosis is identified, what is the next step?

A

Recommended inc fiber and water

Do not need to avoid seeds, nuts, popcorn

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26
Q

S/Sx of diverticular bleeding

A

Painless hematochezia
BRB squirting into toiler
Typically no other S/Sx

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27
Q

What is the next step for PTs with diverticular bleeds?

A

Active- resuscitate and stabilize, endoscopy

No active bleeds- refer for scope

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28
Q

What causes diverticulitis

A

Inflammation and perforation of diverticulum

“Micro-perf” causing intra-abdominal infection

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29
Q

How will PTs with diverticulits present?

A

Abd pain and tenderness, classically in LLQ
Fever
N/V

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30
Q

What will a PE on PT with diverticulitis show?

What will labs show?

A

LLQ TTP
20% w/ LLQ mass
Fever

Leukocytosis on CBC
+/- occult blood

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31
Q

What diagnostic imaging is used for Diverticulitis

What type of Diverticulitis does NOT need imaging?

A

Abdominal CT

Not necessary for mild dz (mild ttp, no fever)

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32
Q

What imaging test is NOT performed on PT with Diverticulitis?

A

No endoscopy (Flex or C-scope)- risk of exacerbating inflammation and/or perf

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33
Q

What is the treatment plan for mild diverticulitis?

A 
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
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34
Q

What is the criteria for Inpatient/Severe diverticulitis

A 
IF 102 SOCIALS 
Complicated diverticulitis on CT
Sepsis
Fever >102
Leukocytosis
Adv age
Immunocompromised
Comorbities
PO intolerant Or, failure of outpatient treatment
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35
Q

What is the treatment plan for severe disease inpatient management

A 
NPO
IV broad ABX- inflammation stabilized= transition to PO ABX
IV fluid/E+
IV pain
Surgical consult
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36
Q

What are potential complications for PTs with diverticulitis?

A

Perforation
Abscess formations
Fistulization
Obstruction- result of severe inflammation

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37
Q

When are complications such as abscesses in diverticulitis PTs considered?
What is your next step?

A

Fails to improve on ABX regimen, obtain CT is suspicion exists

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38
Q

When is Ogilvie Syndrome seen?

How does it present on imaging?

A

S/Sx of obstruction w/out mechanical lesions

Bowel dilation on imaging usually in cecum or righ hemicolon

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39
Q

When/who does Ogilvie Syndrome occur in?

A

Hospitalized PT that are:
Post-Surgical
Post-Traumatic
Medical inpatient (resp failure, MI, CHF)

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40
Q

Ogilvie Syndrome is AKA ?

What are the S/Sx?

A

Acute Colonic Pseudo-Obstruction

Abdominal distension
Abdominal pain
N/V

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41
Q

Define Volvulus

A

Torsion of segment of the alimentary tract that leads to an obstruction most commonly in the sigmoid colon but can occur at any point

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42
Q

How does a Sigmoid Volvulus present

A

Insidious onset of progressive abdominal pain that’s continuous and severe
N/V
Abd distension
Constipation

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43
Q

What will a PE of a Sigmoid Volvulus present as?

A

Distended abdomen w/ tympany to percussion
Tenderness to palpation
Unremarkable labs
Plain-film/CT

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44
Q

How are Sigmoid Volvulus cases treated?

A

Detorsion via flexible sigmoidoscopy

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45
Q

Define Polyp

A

Protuberance extending into lumen of colon that are usually A-Sx but can cause:
Bleeding
Tenesmus
Obstruction

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46
Q

What are the four major pathologic groups of colonic polyps?

A

Mucosal Adneomatous
Mucosal Serrated
Mucosal Non-Neoplastic
Submucosal Lesions

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47
Q

Define an Adenomatous Polyps

A

Most common, dysplastic by definition that has malignant potential
Can be tubular, villous or tubulovillous

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48
Q

Define Serrated Polyps

A

Display a lumen with a serrated or stellate architecture that include hyperplastic polyps

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49
Q

Define Mucosal Non-Neoplastic Polyp

A

No clinical significance but includes hamartomas- benign tumor like malformations made of cells and tissue

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50
Q

Define Submucosal lesions

A

Creat a polypoid appearance of overlying mucosa

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51
Q

What type of polyp characteristics are bad to see on a pathology report?

What results are not considered as bad?

A

Adenoma or adenomatous
Dysplasia or dysplastic

Hyperplastic or hyperplasia

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52
Q

Define Polyposis Syndromes

A

Familial Adenomatous Polyposis

Inherited disorder that causes 100s-1000s of polyps to develop before 15y/o but is a marker for inevitable colon cancer

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53
Q

Due to the inevitable diagnosis of colon cancer, what management/treatment steps are taken for PTs with Polyposis Syndromes?

A

Prophylactic total colectomy

Annual colonoscopy until colectomy

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54
Q

Define Hamartomatous Polyposis Syndromes

A

Peutz-Jeghers Syndrome- hamartomas and oral lesions from familial juvenile polyposis with an increases risk of colon and Cowden Disease

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55
Q

Define Hereditary Nonpolyposis Colon Cancer

A

AKA Lynch Syndrome

Audtosomal Dominant condition that has increased risk of cancers

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56
Q

What is the name of the criteria used for screening for Hereditary Nonpolyposis Colon Cancer

A

Bethesda Criteria

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57
Q

What are the risk factors that contribute to development of Colorectal Cancer

A 
IBDz
Smoking
FamHx to 1*
Age, inc risk after 45
Diet high in fat and red meat
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58
Q

Why are PTs that are A-Sx at time of colorectal cancer dx given a low prognosis?

A

Slowly growing tumor that doesn’t present w/ Sx until years later

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59
Q

Colorectal Cancer screening is the delineation between ?

A

Cancer Prevention Tests: Colonoscopy, Flexible Sigmoidoscopy
CT Coloangiography

Cancer Detection Tests: Fecal Immunochemical Test, Hemoccult SENSA or Fecal DNA

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60
Q

What is the preferred CRC prevention and detection tests for average risk PTs?

A

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

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61
Q

What type of PTs are at higher risk for colorectal dz?

A

FamHx Pos
Dx <60yrs
Two 1* relatives w/ CRC
Adv adenomas

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62
Q

Define the Colorectal Cancer screening method “CEA”

A

Carcinoembryonic Ag

NOT an actual screening test but is useful for prognosis AFTER Dx to serve as a marker of recurrence after treatment

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63
Q

What are the S/Sx of a colorectal cancer in the right colon?

A

Fe deficiency anemia
Weakness
Fatigue

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64
Q

What are the S/Sx of colorectal in the left colon?

A

Change in bowel habits
Blood streaked stool
Obstructive Sx- constipation w/ inc frequency and loos stool, colicky pain

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65
Q

What are the S/Sx of colorectal disease in the rectum?

A

Hematochezia
Tenesmus
Urgency
Ribbon stool- decrease in caliber of stool

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66
Q

What are the signs of advanced or metastatic disease?

A

Complete obstruction- apple core lesion
Weight loss
F/C/Ns

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67
Q

What does the work up for colorectal cancer include?

A 
FOBT- Guiac or FIT
CBC
CMP
UA
Colonoscopy
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68
Q

What are the treatment steps for colorectal cancer?

A

Surgical resection- full/partial colectomy
Chemo
Radiation

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69
Q

What are the prognosis stages of colorectal cancers?

A

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

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70
Q

What are the Alternate CRC prevention and Detection tests:

A

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

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71
Q

How does family history positive affect CRC recommendations?

A

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

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72
Q

IBDzs include what 3 diseases?

A

Crohn’s
Ulcerative colitis
Microscopic colitis

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73
Q

Where does Crohn’s affect the majority of the intestines?

Where does UC mainly effect?

A

RLQ and scattered

Ulcerative colitis- LLQ and rectum

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74
Q

What are some of the extraintestinal manifestations of IBDz?

A 
MSK- arthritis, hypertrophic osteroarthropathy, osteoporosis, aseptic necrosis, polymyositis, osteomalacia
Skin/Mouth- 
Hepatobiliary-
Ocular-
Metabolic-
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75
Q

How is Crohn’s IBDz characterized?

What type of PT is it worse for?

A

TIERSS
Transmural inflammation
Skip lesions
Exacerbations and remission

Smokers

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76
Q

Crohn’s may involve ? GI tract

What can it lead to?

A

Entire, mouth to anus

Ulceration, stricturing, fisulization, abscesses

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77
Q

General presenting Sx of Crohn’s may include?

A

Fatigue
Prolonged intermittent diarrhea, usually no blood
Weight loss
Fever

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78
Q

What is the most common presentation of Crohn’s dz?

A

Chronic inflammatory Dz
Attacks terminal ileum
Cramping RLQ pain/mass
PTs c/o ileitis or ileocolitis

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79
Q

What is the most common Symptoms of chronic inflammatory Crohn’s dz?

A

Malaise
Weight loss
Fatigue
Non-bloody intermittent diarrhea

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80
Q

What causes Crohn’s Dz intestinal obstructions?

What are the S/Sx?

A

Narrowing of lumen as result of chronic inflammation

Postprandial bloat
Cramping abd pain
Loud borborygmi

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81
Q

What is the pathophysiology of pentrating/fistulization of Crohn’s Dz?

A

Transmural bowel inflammation associated w/ development of sinus tracts

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82
Q

Characteristics of the Penetrating Dz of Crohn’s Dz?

A

Sinus tracts penetrate bowel wall presents as phlegmon: walled off inflammatory mass w/out bacterial infection

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83
Q

Is phlegmon seen on PE and how does it often present?

A

May be palpable

Indolent process and not as an acute abdomen issue

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84
Q

Crohn’s Dz penetration may also lead to ?

A

Intrabdominal abscess: acute presentation of localized peritonitis w/ fever, abd pain and tenderness

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85
Q

Characteristics of Fistulization Crohn’s Dz

A

Sinus tracts penetrate serosa and give rise to fistula: tracts that connect two epithelial lined organs

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86
Q

What are common sites of Crohn’s Fistulas

A

Bladder- enterovesical
Skin- entercutaneous
Small bowel- enterenteric
Vagina- entervaginal

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87
Q

What are the S/Sx of an Enterovesical Fistula

A

Recurrent UTI

Pneumaturia

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88
Q

Define Enterocutaneous Fistula

A

Bowel contents that drain to surface of skin

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89
Q

Define Enteroenteric fistula

A

ASx or palpable mass

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90
Q

Define Enterovaginal fistula

A

Passage of gas/feces through vagina

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91
Q

Crohn’s fistula to retroperitoneum may lead to ? issues

A

Psoas abscesses

Uteral obstruction w/ hydronephrosis

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92
Q

What are common clinical constellations of Crohn’s Dz

A 
Perianal Dz:
Large painful skin tags
Anal fissures at lateral location
Perianal abscess
Fistula
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93
Q

What are some of the extraintestinal manifestations of Crohns Common Clinical Constellations?

A 
Arthralgia/arthritis
Iritis/uveitis
Pyoderma Gangrenosum
Erythema nodosum
Oral aphthous ulcers
Inc prevalence of gallstones due to malabsorption of bile salts in terminal ileum
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94
Q

What are two derm Signs of Crohn’s issues?

A

Pyoderma Gangrenosum

Erythema Nodosum

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95
Q

What lab tests does a Crohn’s Work up include?

A 
No specific lab test
CBC- anemia or leukocytosis?
CMP
Fe/B12
Albumin
ESR
CRP
Stool culture and O&amp;P
96
Q

What test/imaging establishes a Crohn’s Dx?

A

Colonoscopy first to evaluate colon and terminal ileum

Endoscopy- Dx

97
Q

Why would a barium swallow be ordered in a PT w/ Crohn’s?

What additional image test may be ordered?

A

Evaluate for ulcerations, strictures or fistulas

Capsule endoscopy to look for small bowel involvement

98
Q

How is Crohn’s Dz severity categorized by their CDAI scores?

A

ASx remission- <150
Mild-Mod- 150-220
Mod to Severe- 221
Severe-Fulimant >451

99
Q

What type of extraintestinal Crohn’s Manifestations require a surgical consult and treatment?

A

Abscess
Obstruction
Fistulization

100
Q

How are Crohn’s treatments planned?

A

Treatment of GI Sx directed to symptomatic improvement and control

101
Q

What meds are used for Symptomatic Crohn’s?

A

Anti-Diarrheals:
Loperamide
Bile Acid Sequestrants- if terminal ileum is involved
Kenalog in orabase (Triamcinolone)- for aphthous ulcers

102
Q

What are the Non-Systemic Corticosteroids used for Crohn’s treatment

A

Mild to Mod Dz

Budesonide- 9mg daily x 8-16wks (taper by 3mg over 2-4wks)

103
Q

What are the Systemic Corticosteroids used for Crohn’s Disease

A

Severe Disease
Prednisone- 40-60mg/day until Sx resolution and weight gain resumes (7-28 days)
Avoid long term use

104
Q

When/why would a Crohn’s PT be considered for hospital admission during treatment?

A

Failure to respond to oral corticosteroid therapy

105
Q

What is the relapse rate of Crohn’s w/out maintenance therapy?

A

80% in 1yr

106
Q

What are the immunomodulators used for Crohn’s treatment?

Why are they used?

A

Maintain remission/induce remission in PT w/ severe dz and fail oral steroids or have refractory dz

Azathioprine
6-Mercaptopurine
Methotrexate

107
Q

What A-TNF agents are used for Crohn’s treatment?

Why is this class of drug used?

A

Induce/maintain remission in PTs with moderate to severe dz including fistulizing dz

Infliximab
Adalimumab
Certolizumab

108
Q

What are the surgical indications for a PT with Crohn’s?

A 
Therapy failure- primary indication
Intestinal obstruction
Abscess formation
Perianal
Enterocutaneous fistula
109
Q

PTs w/ Crohn’s need to be admitted if what is suspected or what criteria exist?

A

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
Q

How many specialties need to be consulted for a PT w/ Crohn’s?

A

GI
Dietician
Crohns/Colitis Foundation of America
Surgery

111
Q

Define Ulcerative Colitis

A

Idiopathic inflammation limited to mucosal layer of colon causing diffuse friability and erosions w/ bleeding

112
Q

What are 3 unique characteristics of Ulcerative Colitis

A

1/3 in retrosigmoid region- proctosigmoiditis
1/3 extend to splenic flexure (L sided colitis)
1/3 extends proximally (extensive colitis)

113
Q

What are the five types of Ulcerative Colitis and where does it inhabit the large intestine?
(Look at Pics)

A 
Proctitis
Proctosigmoiditis
Distal Colitis
Extensive colitis
Pancolitis
114
Q

What is a characteristic of Ulcerative Colitis that Crohn’s also has?

A

Exacerbations and periods of remission

115
Q

What are the ranges of Ulcerative Colitis

What are the ranges of Crohn’s Dz?

A

Mild colitis - Fulminant Colitis (risk of Toxic Megacolon)

Crohns: mild to severe/fulminant

116
Q

Ulcerative Colitis has extraintestinal manifestations similar to Crohn’s but ?

What is a unique/bizarre characteristic of UC?

A

Significantly fewer UC PTs develop fistulas

UC severity is lower in active smokers and may worse in PTs who stop

117
Q

How is UC characterized?

A

Universal involvement of rectum and sigmoid colon w/ continuous erythema and ulceration of mucosal surface

118
Q

What is the Hallmark Sx of UC?

A

Bloody Diarrhea but presentation depends on severity

look at chart and know

119
Q

Characteristics of Mild to Moderate UC

A

Gradual onset of diarrhea w/ blood and mucus
Fecal urgency
Tenesmus
LLQ pain that’s relieved w/ defecation

120
Q

Characteristics of Severe UC?

A 
Hypoalbuminemia**
>6 bloody bowel movements/day
Hypovolemia
Anemia
LLQ pain
TTP on exam
121
Q

UC bowel movements are what size and frequency?

A

Frequent and small volume due to inflammation

122
Q

What lab tests are ordered during a UC work up?

A 
CBC
CMP
Serum Albumin
CRP and ESR
Stool Culture
OandP
STI tests
123
Q

How is UC diagnosed?

A

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
Q

What type of histology report is suggestive of UC?

A

Crypt abscesses
Crypt branching
Crypt atrophy
Shortening/disarray

125
Q

What imaging modality is used to assess for colonic dilation or toxic megacolon?

A

Plain film

126
Q

How is UC treated?

A

Similar to Crohn’s
Treat acute, active disease and prevent recurrence to maintain remission
Differentiated by Dz severity

127
Q

What is the main difference of UC treatment than Crohn’s?

A

UC- 5- Aminosalicylic acid agents are mainstays of treatment

128
Q

After UC is dx, what is the next step?

A

Anatomic extent is assessed w/ endoscope
Distal inflammation= topical therapy
Proximal to descending colon= systemic medications

129
Q

Mild-Moderate Distal UC means that it is confined to ? and how is it treated?

A

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
Q

How is Mild-Moderate Distal colitis that’s refractory treated?

A

Co-therapy with oral and topical 5-ASA

Prednisone is added if Sx persist

131
Q

What happens if Mild-Moderate Distal Colitis relapses?

A

Maintenance dose of topical/PO mesalamine nightly/every other day
PO less effective at preventing remission

132
Q

Mild-Moderate Extensive UC means that it is confined to ? and how is it treated?

A

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
Q

How is Mild-Moderate Extensive colitis that’s refractory treated?

A

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
Q

Severe or Fulminant UC means that it is confined to ? and how is it treated?

A

Pancolitis or Fulminant

In PT Care- early surgical consult, NPO, IV fluids/E+ and corticosteroids

135
Q

What is used/given as UC maintenance therapy?

A

Oral Mesalamine or Sulfasalazine daily

Mercaptopurine or Azathioprine- for PTs w/ >2 relapses/year

136
Q

PTs w/ UC have significantly higher risk of developing ? so ? steps are taken as precautions?

A

Colorectal cancer

Colonoscopy w/ biopsy every 1-2yrs starting at 8yrs post-Dx

137
Q

What are the absolute surgical indications for UC? What are the Relative indications?

A

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
Q

Who is consulted for PTs w/ UC?

When are they considered for admission to the hospital?

A

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
Q

Define Microscopic Colitis

A

Chronic inflammatory dz of colon characterized by chronic watery diarrhea but normal appearing colonic mucosa on colonoscopy

140
Q

How is Microscopic Colitis Dx’d?

A

Histopathologic exam of biopsy specimen

141
Q

What are the two major sub-types of microscopic colitis?

A

Lympocytic- intraepithelial lymphocytic infiltrate

Collagenous- colonic subepithelial collagen band >10um thick

142
Q

What is the etiology of Microscopic Colitis?

A 
NSAIDs
Sertraline
Paroxetine
Lansoprasole
Lisinopril
Simvastatin
143
Q

How does Microscopic Colitis present clinically?

A 
Chronic non bloody watery diarrhea w/ 4-9 stools/day
Abd pain
Fatigue
Dehydration
Weight loss
144
Q

How is Microscopic Colitis diagnosed and treated?

A

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
Q

How is IBS characterized?

A

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
Q

How is IBS diagnosed?

A

No biological markers to confirm, Dx off of Sx criteria

147
Q

What are the multifactorial natures that make up IBS?

A 
Abnormal motility
Visceral hypersensitivity
Intestinal inflammation
Enterif infection
Psychosocial abnormalities
148
Q

What are the S/Sx of IBS

A

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
Q

Criteria for IBS-C/D

A

C: w/ < 3 BMs/week w/ straining
D: > 3 BMs/day w/ urgency or incontinence

150
Q

What somatic/psychological complaints are common IBS extraintestinal manifestations

A 
Dyspepsia
Heartburn
Chest pain
HA
Fatigue
Myalgia
Gynecologic- impaired sex, dysmenorrhea, dyspareunia
Uro- inc freq/urge
Anxiety/depression
151
Q

What are atypical Sx that are not compatible with IBS?

A

Rectal bleeds
Nocturnal/progressive Abd pain
Weight loss
Lab abnormals: anemia, inc inflammatory markers, E+ disturbance

152
Q

What is the next step if PTs present with any of the atypical Sx that are not compatible with IBS?

A

Further imaging studies and/or colonoscopy

153
Q

How is IBS Dx?

A

Exclude organic etiologies
It’s a chronic condition so acute onset is odd and indicative of non-IBS etiology
PT/FamHx is critical

154
Q

What questions are asked for info gathering to Dx IBS?

A 
Hx GI neoplasm
IBD
Hyper/pothyroid
Malabsorption
Psychiatric disorders
Meds/diet/exercise
Travel or illness
155
Q

What is the Dx criteria for IBS?

A

> /= 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
Q

What is some of the supporting criteria for an IBS Dx

A

Abnormal:

Freq, form, passage, mucus or bloating/distension

157
Q

What will PE for IBS show?

A

Unremarkable

Mild Abd TTP that can be exaggerated is psychosomatic component is present (cycles- anxiety of Sx= worse Sx)

158
Q

What diagnostic tests are ran for IBS?

A

CBC CMP UA
IBS-D is screened for Celiac Dz
Plain Abd films for IBS-C

159
Q

What type of diet is recommended for IBS?

A

Regular meal patterns
Avoid large meals
Reduce fat, fiber, caffeine and gas-producing foods
Low FODMAPS

160
Q

What dietary mods are made for IBS-D and C

A

D: lactose/gluten elimination
C: Inc fiber and fluids

161
Q

What treatment strategy is recommended and useful in all subtypes of IBS?
What psychological therapies is recommended?

A

Inc exercise

Cognitive behavioral therapy
Hypnotherpay
Relaxation techniques

162
Q

What adjunct pharmacologic therapies are recommended for IBS treatment?

A 
Dietary and Lifestyle mods FIRST
Antispasmodic
Anti-constipations
Antidiarrheals- SSRA, ABX
Psychotropics
163
Q

What anti-spasmodics are used for IBS?

What anti-constipations meds are used for IBS-C?

A

Dicyclomine, Hyosycamine

Osmotic laxatives- FIRST
Lubiprostone- Fem>18y/o
Linaclotide

164
Q

What anti-diarrheals are used in IBS-D

A

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

165
Q

What psychotropics are used in IBS pharamacologic treatment?

A

Most useful in PTs w/ Abd pain/bloating as main complaint
Usefule in IBS-D due to anticholinergic effect
TCAs: Amitriptyline, Nortriptyline, Desipramine, Imipramine

166
Q

When/why are probiotics used in BIS therapy?

A

No clinical value, may offer psychological effect leading to Sx improvement

167
Q

Successful Sx improvement in PTs w/ IBS is result of what factors?

A

PT/Provider relationship
PT education and compliance
Trial and error

168
Q

Define Primary Biliary Cirrhosis and what is it AKA

A

Primary Biliary Cholangitis
Autoimmune destruction of small intrahepatic bile ducts and cholestasis involving T-Cell mediated attack on small intralobular bile ducts

169
Q

What is the pathologic sequence of Primary Biliary Cirrhosis?

A

Destruction of bile duct epithelial cells
Loss of Intralobular ducts
Cholestasis
Cirrhosis/liver failure

170
Q

What type of PT usually has Primary Biliary Cirrhosis

A

Insidious onset in majority of women w/ Dx in 40-50

171
Q

Primary Biliary Cirrhosis is associated with what other Autoimmune Disorders?

A

Sjogren Syndrome
Autoimmune thyroid Dz
Raynaud Syndrome
Scleroderma

172
Q

What are the S/Sx of Primary BIliary Cirrhosis

A 
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
173
Q

What are the lab findings of Primary Biliary Cirrhosis

A

Cholestatic pattern
Inc Alk Phos, Bilirubin, Lipids and Transaminases
Markers of autoimmune Dz: Antimitochondrial Abs
Antinuclear Abs

174
Q

How is Primary Biliary Cirrhosis treated?

A

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

175
Q

PBC PTs usually/likely progress to what end treatment plan?

A

Liver transplant

176
Q

Define Hemochromatosis

A

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

177
Q

What are the S/Sx of Hemochromatosis

A

Clinical onset after 50y/o

Incidental finding w/ elevated AST, Alk Phos, plasma iron and serum Ferritin

178
Q

How is Hemochromatosis diagnosed?

A

Genetic testing in PTs w/ Fe overload or FamHx

179
Q

What treatment measures are used for Hemochromatosis PTs?

A

Deferoxamin- chelation
Phlebotomy
Liver transplant

180
Q

Define Wilson Disease

A

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

181
Q

How does Wilson Dz clinically present?

A

Liver Dz
Neurologic/Psych Sx
Pathognomonic Sign- Kayser Fleischer rings

182
Q

What diagnostic testing is done for Wilson Diz?

How is it treated?

A

Dec serum ceruloplasmin
Inc urinary excretion of Cu
Inc Cu concentration in liver

Tx w/ chelation of Cu

183
Q

Define Budd-Chiari Syndrome

A

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

184
Q

What are the clinical manifestations and Rad tests for Budd-Chiari Syndrome?

A

Tender/pain hepatomegaly
Jaunidce
Splenomegaly
Ascites

Color Doppler US

185
Q

How is Budd-Chiari Syndrome treated?

A

Directed to underlying cause and ascite complications

Admit any PT w/ suspected obstruction

186
Q

What are the different types of Pyogenic Hepatic Abscesses?

A

Bile duct- ascending cholangitis
Portal vein- pylephlebitis
Direct extension of infection
Traumatic bacteria implantation

187
Q

What is the clinical presentation of Pyogenic Hepatic Abscess?

A 
Fever
RUQ pain/TTP
Jaundice
N/V
Anorexia, weight loss, fatigue
188
Q

What are the lab findings in PTs with Pyogenic Hepatic Abscesses

A

Leukocytosis on CBC
+ blood cultures
Abnormal hepatic panel

189
Q

What are the diagnostic imaging modalities for Pyogenic Hepatic Abscess?

A

CT scan
Hepatic US
CT guided percutaneous drainage w/ culture of aspirate

190
Q

Define Benign Liver Neoplasm

A

Cavernous hemangioma

191
Q

What type of cancer is associated w/ 80% of cirrhosis?

A

Hepatocellular carcinoma

192
Q

What are the other risk factors that can lead to Hepatocellular Carcinoma

A 
Hep B/C
NAFLD
Tobacco/ETOH
Diabetes
Obesity
Hemochromatosis/Wilson Dz
193
Q

What are the S/Sx of Hepatocellular Carcinoma

A

F/C
Weight loss
Bone pain from metastases

194
Q

What lab tests are done for suspected Hepatocellular Carcinoma

What imaging is ordered?

A

Leukocytosis on CBC
Sudden and Sustained inc of Alk Phos
Inc AFP

CT or MRI then Biopsy

195
Q

How is Hepatocellular treated?

A

Surgical resection

Liver transplant

196
Q

How often is screening recommended for PTs with Hepatocellular Carcinoma

A

Recommended for PTs w/ cirrhosis, HBV/HCV or FamHx of HCC

US and AFP every 6mon

197
Q

Define Cholelithiasis

A

Presence of stones in gallbladder made of cholesterol or Ca bilirubinate

198
Q

What are the risk factors of cholelithiasis

A 
Age +40
Femal
Pregnancy
OCP/Estrogen
FamHx
Obese
Rapid weight loss
Diabetes
Cirrhosis
Crohn's
199
Q

What are the 5 F’x of cholelithiasis

A 
Fat
Fair 
Forty
Fertile
Flatulent
200
Q

What are the protective factors of Cholelithiasis

A

Coffee
Statins
PT
Diet rich in poly/monosaturated fats

201
Q

Gall stones are often ASx, but are often found how?

A

Incidentally on X-ray or US

Causing RUQ- Biliary Colic

202
Q

What is the treatment of Cholelithiasis?

A

None if ASx
NSAIDs
Cholecystectomy- if pain or frequent cholecystitis

203
Q

90% of acute cholecystitis is due to gallstones, the other cases are due to ?

A

Acalculous Cholecystitis- consider in critically ill PTs due to association w/ high mortality

204
Q

How does acute cholecystitis clinically present?

A

Sudden onset of steady RUQ pain that radiates to shoulder
Non resolving biliary colic affter 4-6hrs
N/V
Fever

205
Q

How does Acute Cholecystitis present on PE?

A

Laying still, looking ill
RUQ TTP w/ guarding
Pos Murphy’s
Jaundice is uncommon

206
Q

What are the lab findings in a PT with Acute Cholecystitis?

A

Leukocytosis
Inc serum bilirubin- UNCOMMON
Inc ALP/AST/ALT
Modest inc of amylase

207
Q

What are the diagnostic images for Acute Cholecystitis?

A

RUQ US

HIDA scan- cholescintigraphy

208
Q

What are the complications of Acute Cholecystitis

A

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

209
Q

One of the compliations of acute cholecystitis is Chronic Cholecystitis which is defined as ?

A

Repeated episodes in PTs that are poor surgical candidates and can result in Porcelain Gallbladder

210
Q

What are the treatment steps for Acute Cholecystitis

A

Admit

Laparoscopic cholecystectomy

211
Q

Define Choledocholithiasis

A

Gallstones in CBD as a result of stone from the gallbladder causing obstruction and cholangitis (infection)

212
Q

How does Choledocholithiasis clinically present?

A

Severe biliary colic
RUQ/epigastric pain
N/V
Jaundice- during attacks or intermittent

213
Q

What labs and diagnostic images are used for choledocholithiasis

A

Cholestatic pattern of hepatic panel- AlkPhos and bilirubin higher than AST/ALT

RUQ US- FIRST
ERCP

214
Q

How is choledocholithiasis trested?

What complications can occur if left untreated?

A

Endoscopit stone remoaval even in ASx PTs follow by laparoscopic cholecystectomy to prevent recurrences

Cholangitis and pancreatitis

215
Q

What is Charcto’s Triad?

A

RUQ pain
Fever/chill
Jaundice
AKA- ascending cholangitis from bacteria rising from duodenum through bile duct

216
Q

Define Reynold’s Pentad

A 
RUQ pain
Figor- fever/chills
Jaundice
Altered mental
HOTN
217
Q

What does Reynolds Pentad indicate

A

Acute Suppurative Cholangitis which is a surgical emergency

218
Q

What lab tests are pulled for Acute Cholangitis

A 
CBC for leukocytosis
Hepatic panel
Inc amylase
Blood cultures
CRP
219
Q

How is Acute Cholangitis treated?

A

Admit
ERCP
Surgery
Cholecystectomy

220
Q

Define Primary Sclerosing Cholangitis

A

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

221
Q

How does Primary Sclerosing Cholangitis present?

A

Progressive obstructive jaundice w/ fatigue, pruritus, anorexia and indigestion

222
Q

ASx gallstones is called?

Gallstone + fever/pain = ?

A

Cholelithiasis

Cholecystitis

223
Q

Gallstone + juandice = ?

Gallstone jaundice fever = ?

A

Choledocholithiasis

Cholangitis

224
Q

What S/Sx combine to form Suppurative Cholangitis

A 
Gallstone
Jaundice
Fever
AMS
HOTN
225
Q

Define cholangiocarcinoma

A

Cancer of bile duct usually Dx by incidence during surgery and has poor prognosis

226
Q

How does Cholangiocarcinoma present?

A

Obstructive jaundice
Painless
Dilated biliary tree

227
Q

Define Courvoisier Sign

A

Palpable gallbladder with painless obstructive jaundice but can also be associated with jaundice

228
Q

How is carcinomas of the biliary tracts diagnosed?

A

Sx of biliary obstruction- jaundice, abnormal liver tests, bile duct dilation or,
No alternative explanation such as choledocholithiasis or pancreatic head lesion

229
Q

Carcinomas of the biliary tract diagnosis’ should be considered in what type of pPTs?

A

Isolated intrahepatic mass on imaging and a NORMAL serum level of AFP

230
Q

What pieces of information are important when considering screening colonoscopy?

A

Hx

Age

231
Q

50 y/o male ASx with no FamHx of colon CA and denies initial screening colonoscopy should be offered what second option?

A

CT colonography every 5 yrs

FIT is equivalent

232
Q

What Sx/lab finding is not consistent with IBD and indicates cancer?

A

Iron deficient anemia

233
Q

Normal AST/ALT levels?

A

AST: 14-36
ALT: 9-50

234
Q

What lab markers may be seen in PTs with active Hep B infection?

A

Anti-Hep C Ab

Anti Hep B Surface Ag

235
Q

Stopped on

A

26 of review

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