GI CIS Flashcards
Describe type of bleeding associated with hemorrhoids
Painless bleeding, usually associated with BM, coats the stool at end of defecation. Blood may drip into toilet or stain toilet paper
Describe type of bleeding associated with anal fissures
Small amount on toilet paper or surface of stool; usually dx on history of tearing pain with passage of BM
Describe type of bleeding associated with diverticula
Painless, profuse bleeding
Which is more likely to exhibit hematochezia — UC or crohns?
UC
Describe presentation of infectious colitis
Similar clinical presentation and endoscopic appearance of UC; excluded with stool and tissue cultures, stool studies, and on biopsies of the colon (EHEC)
What condition may present as abdominal pain followed by profuse hematochezia?
Ischemic colitis
T/F: polyps are typically symptomatic and result in intermittent large amounts of bleeding
False, they are typically asymptomatic and most often detected by colon cancer screening tests as occult bleeding
Describe type of bleeding associated with proctitis
Insidiously with intermittent rectal bleeding, passage of mucus, and mild diarrhea associated with fewer than 4 small loose stools per day (like mild UC)
Describe type of bleeding associated with rectal ulcers
Can present with bleeding, passage of mucus, straining during defecation, and sense of incomplete evacuation
Important hx and PE points to ask/perform on GIB patient
Prior episodes of GI bleeding?
Chance of pregnancy in females
PMH of IBD, cancer, CV dz, diverticulosis, PUD
Medications — ask about NSAIDs, ACs, antiplatelet agents
PE: assess hemodynamic stability, general exam, CV, skin, abdominal, DRE
How is smoking related to IBD?
Stopping smoking is risk factor for UC
Starting smoking is risk factor for Crohns, continued smoking = poorer prognosis
BUN:Cr ratio seen in upper GIB
30:1
AST:ALT ratio in alcoholic
2:1
Anatomical division of an upper GIB vs lower GIB
Ligament of Treitz
Recognize what abruptly stopping a beta blocker can lead to
Rebound sinus tachycardia
How fast can KCl be given through a peripheral IV?
10 mEq/hr (otherwise it is irritating the vein)
How many g/dL would you expect the Hgb to rise from 1 unit of PRBCs?
1g/dL
Primary tx for acute IBD flare
Corticosteroids (IV or PO)
Condition often seen with IBD characterized by red nodular areas on shins
Erythema nodosum
Initial management of acute lower GIB
Supportive: IV access, admit to appropriate setting, O2, IVF, blood products, assessment/management of coagulopathies
In cases of ongoing bleeding or high risk features: colonoscopy should be done w/i 24 hours of presentation after adequate colon prep (typically 4-6 L polyethylene glycol — may require NG tube)
Considerations for blood transfusion with PRBCs (type and screen vs. type and cross), what are Hgb requirements of special pt populations?
First type and screen in Hgb is stable and no acute bleed
Type and cross for young pts without comorbidities (may not require transfusion until Hgb <7), older pts who have severe comorbid conditions like CAD require Hgb of >9
Obtain iron studies if desired BEFORE transfusion, otherwise inaccurate
T/F: pts with active bleeding and hypovolemia may require transfusion even if they have a normal Hgb
True
Diagnostic test for GIB that is noninvasive, sensitive to low rates of bleeding, and can be repeated for intermittent bleeding, BUT it has to be performed during active bleed, has poor localization, not therapeutic, and not widely available
Radionuclide imaging
Diagnostic test for GIB that is noninvasive, accurately localizes bleeding source, provides anatomic detail, and is widely available; BUT it has to be performed during active bleeding, is not therapeutic, and may require IV contrast+radiation exposure
CT angiography
Diagnostic test for GIB that accurately localizes bleeding source, therapy possible with super-selective embolization, and does not require bowel prep; BUT has to be performed during active bleeding and has potential for serious complications
Angiography
Pros and cons to colonoscopy
Pros: precise dx and localization regardless of active bleeding or type of lesion; endoscopic therapy is possible
Cons: need colon prep for optimal visualization, risk of sedation in acutely bleeding pt, definite bleeding source (stigmata) infrequently identified
Complications/risks in pts with UC
Toxic megacolon (emergency — surgery for colectomy)
Primary sclerosing cholangitis (M>F)
Ankylosing spondylitis
Pyoderma gangrenosum
Complications/risks in crohns
Fistulas/strictures
Fissures
Pigmented gallstone formation
Malabsorption
Kidney stones
Complications seen with BOTH UC and crohns
Colon cancer, DVT
Signs of retroperitoneal hemorrhage on PE
Cullen sign — periumbilical ecchymosis
Grey turner sign — flank ecchymosis
American cancer society guidelines for colorectal cancer screening for ppl at average risk
Start regular screening at age 45, continue through age of 75
For people age 76-85, base decision on person’s preferences, life expectancy, overall health, and prior screening hx
People over 85 should no longer get screened
Recommended colorectal cancer screening for first-degree relative with colorectal cancer or adenomas dx at age <60 or two first-degree relatives dx at any age
Begin colonoscopy at age 40 or 10 years before age of youngest affected relative, repeat q5y
Recommended colorectal cancer screening for first-degree relative with colorectal cancer or adenomas dx at age >60y or two second degree relatives with colorectal cancer
Same options as average risk, but begin at age 40
Recommended screening for pts with FAP
Refer for genetic testing or annual screening by sigmoidoscopy beginning at age 10-12
Recommended screening for pts with HNPCC
Refer for genetic testing, or colonoscopy every 1-2 years beginning at age 20-25 years, or 10 years younger than youngest age of colorectal ca dx in family
Frequency of gFOBT screening for colorectal cancer
Every year
FIT is a colorectal cancer screening used annually just like gFOBT, which one is more accurate?
FIT
What stool-based colorectal cancer screening method can be done every one or three years?
FIT-DNA
[specificity is lower than for FIT, resulting in more false-positive results, more diagnostic colonoscopies, and more associated adverse events; improved sensitivity compared with FIT per single screening test]
Direct visualization tests for colon cancer and the frequency with which they must be done
Colonoscopy = GOLD STANDARD — every 10 years if normal
CT colonography = q5y
Flexible sigmoidoscopy = q5y
Flexible sigmoidoscopy with FIT = flex sig q10, with FIT every year
UC or Crohns?
Mucosal lesions
UC
[crohns is transmural]
UC or Crohns?:
Anywhere along GI tract with most common site being TI
Crohns
[UC most common in rectum]
UC or Crohns?:
ASCA positive
Crohns
[UC is pANCA positive]
Which type of IBD has skip lesions, non-caseating granulomas, and creeping fat?
Crohns
Which type of IBD commonly has bloody diarrhea and crypt abscesses?
UC
Methods for DVT prophylaxis in IBD pts
SCDs
TED hose (compression stockings)
Anticoagulation
Early ambulation
Before starting an immunomodulatory or biologic medication, what should be checked?
TPMT enzyme activity (before azathiopurine)
PPD skin test or Quantiferon gold (+/- CXR) — checks for TB
Viral hepatitis serology
Abdominal aortic exam
Press firmly deep into upper abdomen, slightly to left of midline, and identify aortic pulsations
In pts 50+, assess width by pressing deeply in upper abdomen with one hand on each side (nml is not more than 3 cm wide)
Ease of feeling aortic pulastions varies greatly with the thickness of the abdominal wall and with the anteroposterior diameter of the abdomen
IV order for SL
Saline lock — not hooked up to any infusion, flushed with saline and then locked
IV order for HL
Heparin lock, not hooked up to any infusion, flushed with heparin and then locked
IV order for KVO
Keep vein open, hooked up to infusion at slow rate (~30 cc/hr)
Maintenance rate for IVF
IVF at NS 125 cc/hr
IVF orders for rapid re-hydration
IVF at NS 1 liter bolus
What patients might refuse blood products?
Jehovah’s witness
Chapmans reflex lateral, proximal 1/5th of right high, anteriorly on tensor fascia lata
Cecum
Chapmans point on right lateral middle 3/5ths of thigh, anterior distribution of IT band
Ascending colon
Chapmans point proximal to knee, anterolateral aspect of thigh bilaterally
Transverse colon
Chapmans point lateral, proximal 1/5th of left thigh, anteriorly on tensor fascia lata
Sigmoid colon
Anterior chapmans point left lateral middle 3/5ths of thigh, anterior distribution of IT band
Descending colon
Chapmans point medial aspect of proximal thigh over lesser trochanters bilaterally
Rectum
Posterior chapmans point transverse process L2 to transverse process L4, extending laterally to iliac crest
Colon
Posterior chapmans point - sacrum at lower end of SI articulation bilaterally
Rectum
Collateral ganglia inhibition at superior and inferior mesenterics = relevant regions for ______ _____ (condition)
Ulcerative colitis
Normal bowel sound frequency
5-34 clicks/min
Abnormal is high pitched, decreased, or absent
Where should you hear dullness on percussion of abdomen?
Liver and spleen
Expected liver span
6-12 cm at midclavicular line on R
Expected spleen span
From ribs 6-10 at midaxillary line on L
What is courvoisiers sign
Enlarged, nontender gallbladder secondary to pancreatic dz or cancer
