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GI block > GI goljan IBD, bowel polyps, colon cancer, acute appendicitis > Flashcards

GI goljan IBD, bowel polyps, colon cancer, acute appendicitis Flashcards

1
Q

MC inflammatory bowel disease?

A

ulcerative colitis

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2
Q

define ulcerative colitis

A

chronic relapsing ulcerinflammatory disease w/ ulcerations in continuity and limited to mucosa and submucosa of rectum and colon

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3
Q

Define Crohn’s disease

A

chronic noncaseating granulomatous, ulceroconstrictive disease

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4
Q

characteristics of Crohn’s diseae

A

transmural inflammation;

discontinous spread throughout GI tract

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5
Q

What is indeterminate colitis?

A

features of UC and crohn’s

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6
Q

Epidemiology of UC

A

whites > blacks;
no sex predilection;
early teen to 40y/o;
lower incidence if previous appendectomy

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7
Q

smoking relationship to UC

A

lower incidence in smokers and other nicotine users

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8
Q

extent of inflammation in UC

A

mucosal and submucosal

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9
Q

epidemiology of Crohn’s disease (CD)

A

whites > blacks;
jews > non-Jews;
no sex predilectation;
majority from age 10-35

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10
Q

smoking relationship to CD

A

smoking is risk factor

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11
Q

extent of inflammation for CD

A

transmural

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12
Q

location of UC

A

mainly rectum and extends CONTINUOUSLY INTO LEFT COLON;

does NOT involve other areas of GI tract

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13
Q

location of CD

A

ileum and colon (50%), terminal ileum alone (30%), colon alone (20%);
MAY involve other areas of GI tract (mouth to anus)

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14
Q

gross features of UC

A

inflammatory pseudopolyps;
areas of friable, bloody residual mucosa;
ulceration and hemorrhage

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15
Q

gross features of CD

A

thick bowel wall and narrow lumen (leads to obstruction);
apthous ulcers in bowel (early sign);
skip lesions, strictures, fistulas;
deep linear ulcers w/ cobblestone pattern;
Fat creeping around serosa

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16
Q

Micro features of UC

A

ulcers and crypt abscesses containing neutrophils;

dysplasia or cancer may be present

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17
Q

micro features of CD

A

noncaseating granulomas (60%);
lymphoid aggregates;
dysplasia or cancer less likely

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18
Q

clinical findings w/ UC

A

recurrent L sided abdominal cramping w/ bloody diarrhea and mucus;
fever, tenesmus, weight loss

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19
Q

ExtraGI findings of UC

A

primary sclerosing cholangitis (UC > CD), erythema nodosum, iritis/uveitis (CD > UC);
pyoderma gangrenosum;
HLA-B27+ arthritis

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20
Q

Lab and radiograph findings in UC

A

p-ANCA Abs > 45% cases;

“lead pipe” appearance in chronic disease

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21
Q

complications of UC

A 
toxic megacolon (hypotonic and distended bowel);
adenocarcinoma (greatest risks are pancolitis, early onset and duration of disease > 10yrs)
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22
Q

Tx of UC

A

sulfasalazine or mesalamine;
corticosteroids for severe disease;
nicotine patch;
immunosuppressants : azathiprine or cyclosporine;
surgery=> colectomy w/ ileostomy usually cures

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23
Q

How does sulfasalazine or mesalamine help in UC and CD by their mechanism of action?

A

5-ASA active metabolite;
O2 free radicical scavenger;
inhibits lipoxygenase pathway in arachidonic acid metabolism

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24
Q

clinical findings of CD

A

recurrent RLQ colicky pain (obstruction) w/ diarrhea;
bleeding occurs only w/ colon or anal involvement (fistulas or abscesses);
apthous ulcers in mouth

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25
Q

extraGI findings in CD

A 
erythema nodosum; 
sacroiliitis (HLA-B27 assoc);
pyoderma gangrenosum;
iritis (CD > UC);
primary sclerosing cholangitis (UC > CD)
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26
Q

radiographical findings in CD

A

“string” sign in terminal ileum from luminal narrowing by inflammation and/or fistulas

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27
Q

complicaitons of CD

A

fistulas, obstruction, colon cancer (UC > CD);
Ca+ oxalate renal calculi (increased reabsorption of oxalate through inflamed mucosa);
malabsorption due to bile salt deficiency;
macrocytic anemia due to vit B12 deficiency

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28
Q

Tx for CD

A

sulfasalazine or mesalamine (5-ASA; oral salicylate)
corticosteroids for mod to severe disease;
steroid analogues that target areas of GI tract;
immunosuppressants: azathioprine or cyclosporine

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29
Q

What is used for Tx of complications of CD?

A

metronidazole for colonic fistulas;
TNF-i for enterocutaneous fistulas;
Surgery for obstruction, fistulas, toxic megacolon, refractory disease

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30
Q

What are the non-neoplastic or hamartomatous polyps?

A

hyperplastic polyp;
Juvenile (retention) polyp;
Peutz-Jeghers polyposis

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31
Q

Where is the most common adult non-neoplastic polyp located? How does it appear on histo?

A

hyperplastic polyp usually occurs in sigmoid colon;

Histo=> sawtooth appearance

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32
Q

Where is the most common polyp in children located? risks associated

A

Juvenile (retention) polyp is located in rectum and may prolapse out of rectum and bleed

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33
Q

How does a juvenile polyp present grossly?

A

solitary polyp w/ smooth surface w/ enlarged cystic spaces on cut section

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34
Q

Genetic associated w/ juvenile polyposis?

A

AD or nonhereditary

35
Q

How will nonhereditary polyposis syndrome present and what is it called?

A

Cronkhite-Canada syndrome => polyps + ectodermal abnormalities of nails

36
Q

A patient presents w/ mucosal melanin pigmentation of buccal mucosa and lips. where and how does this disease present?

A

Peutz-Jeghers polyposis that is AD;

hamartomatous polyps predominate in small bowel and less common in stomach and colon

37
Q

What is the risk associated w/ PJP?

A 
increased risk (>50%) for colorectal, breast, gynecologic cancers;
this is true even if polyps are hamartomas
38
Q

Neoplastic polyps are called what?

A

adenomas

39
Q

Epidemiology of premalignant dysplastic colonic polyps

A

increase w/ age;

equal sex incidence

40
Q

Where is the most common polyp found? How does it look grossly and micro?

A

tubular adenoma MC site is sigmoid colon;

stalked polyp w/ complex branching glands

41
Q

How does a tubulovillous adenoma present?

A

usually stalked polyp;

adenomatous and villous change (similar to small bowel villi)

42
Q

How common is a villous adenoma? MC location? and presentation on micro/gross? potential for malignancy?

A

villous adenoma (10% of polyps);
rectosigmoid location;
sessile polyp w/ primarily villous component;
30-40% risk for malignancy

43
Q

What is different about villous adenomas compared to others? risks associated

A

secrete protein and K+ rich mucus => can produce hypoalbuminemia and hypokalemia

44
Q

Risk factors for malignancy in adenomas

A

adenoma > 2cm (40% risk of malignancy);
multiple polyps;
polyps w/ increased villous component

45
Q

Etiology of FAP

A

AD disease where ALL patients develop tubular adenomas and cancer;
polyps begin developing bw 10-20y/o

46
Q

pathogenesis of FAP

A

inactivation of adenomatous polyposis coli (APC) suppressor gene

47
Q

clinical findings in FAP

A

malignant transformation usually bw 35-40y/o;

assoc w/ congenital hypertrophy of retinal pigment epithelium

48
Q

What should be done if FAP is diagnosed?

A

prophylactic colectomy recommended

49
Q

Differentiate 2 syndromes associated w/ FAP

A

Gardner’s=> AD polyposis w/ benign osteomas and desmoid tumors

Turcot’s=> AR polyposis w/ malignant brain tumors such as astrocytoma and medulloblastoma

50
Q

Epidemiology for colon cancer

A

3rd MC cancer related death in adults and in men and women;
rates have been decreasing due to screening;
typically elderly disease

51
Q

How are rectal and colon cancers Dx?

A

rectal => 50% detected from DRE

colon=> 50% detected by flexible sigmoidoscopy

52
Q

risk factors for colon cancer

A 
Age >50y/o;
smoking;
obesity, physical inactivity, heavy alcohol intake;
hereditary polyposis syndromes;
hereditary nonpolyposis colon cancer;
family cancer syndrome;
1st degree relatives w/ colon cancer;
IBD (UC > CD);
diet (low fiber, increased sat fats, reduced veggies)
53
Q

2 pathways for the carcinogenesis of colon cancer

A

Adenoma-carcinoma sequence (80% sporadic cases)=> sequential mutations of different genes (APC, RAS, p53)

MSI sequence=> inactivation of DNA mismatch genes

54
Q

MC locations for colon cancer

A

rectosigmoid (50%);
ascending colon (15%);
descending colon (15%);
transverse colon and cecum (10%)

55
Q

Screening tests for colon cancer in order of best tests

A

colonoscopy (gold standard) > fecal occult blood > barium enema

56
Q

When should screening of colonoscopy be started?

A

age 50 w/ no risk factors and 3-5yrs if Hx of polyp removal;

age 40 if 1st degree relative has polyps or colorectal cancer

57
Q

What is the basis for fecal occult blood test? how good is the test?

A

peroxidase activity of heme in Hb but myoglobin has peroxidase activity causing color change
=> not sensitive or specific for colon cancer

58
Q

What accounts for the varying levels of sensitivity and specificity in fecal occult blood test?

A

false pos=> myoglobin in met, plant peroxidase (radish)

59
Q

Colon cancer presents differently depending on site of tumor. Describe if it is Left sided cancer

A

tend to obstruct => smaller diameter than R colon & lesions will have annular (“napkin-ring”) look;

change in bowel habits w/ constipation & diarrhea w/ or w/o bleeding (bright red blood coating stool)

60
Q

Colon cancer presents differently depending on site of tumor. Describe if it is right sided cancer

A

tend to bleed => may lead to Fe deficiency
tumors are polypoid in appearance;
Blood is mixed w/ stool

61
Q

Sites of mets for colon cancer

A

liver (MC);
lungs;
bone;
brain

62
Q

6 ways of preventing colon cancer

A

ASA and other NSAIDs (decreases adenomas);
annual fecal occult blood testing;
estrogens and progestins;
diet alterations (decrease fat intake, increase fiber, fruit and vegs);
statin Tx (inhibit growth of cancer lines);
cessation of smoking

63
Q

Tx of colon cancer

A

surgery => CTX => targeted monoclonal Ab Tx

64
Q

Px for colon cancer and what is used to detect recurrences?

A

5yr=> 65%;

serum CEA detects recurrences

65
Q

Epidemiology of acute appendicitis

A

10% of population;

MC abdominal surgical emergency

66
Q

Pathogenesis of acute appendicitis in children

A

lymphoid hyperplasia secondary to viral infection (adenovirus, measles virus infection/immunization)

67
Q

pathogenesis of acute appendicitis in adults

A

fecalith obstructs proximal lumen (increased intraluminal pressure causes mucosal injury and bacterial invasion);
seeds (sunflower, persimmons);
pinworm infection

68
Q

What are the primary pathogens causing acute appendicitis?

A

E. coli (MC);

Bacteroides fragilis

69
Q

Clinical findings of acute appendicitis IN SEQUENCE

A

initial colicky periumbilical pain (50%);
fever;
pain then N/V;
cutaneous hyperesthesia at T12 level;
pain shifts to RLQ in 12-18hrs;
may have signs of lower UTI (increased freq, dysuria)

70
Q

Why is colicky periumbilical pain associated w/ acute appendicitis?

A

irriration of unmyelinated afferent C fibers on visceral peritoneal surface => referred pain to midline

71
Q

What is a key sign for ID’ing children w/ abdominal pain suspected of acute appendicitis?

A

fever

72
Q

Why does pain shift to RLQ in 12-18hrs?

A

irritation of A-(S) fibers on parietal peritoneum that localizes pain to exact location

73
Q

What are some clinical signs of acute appendicitis?

A

rebound tenderness at McBurney’s point;
Psoas sign;
Rovsing’s sign (LLQ pain referred to RLQ)

74
Q

Lab findings in acute appendicitis?

A 
neutrophilic leukocytosis w/ L shift;
abnormal urinalysis (increased protein, hematuria, pyuria)
75
Q

How will a rectocecal appendicitis present?

A 
radiograph sows sentinal loop in RLQ;
localized ileus (lack of motility) from subjacent appendicitis
76
Q

Complications of acute appendicitis

A

periappendiceal abscess w/ or w/o perforation;
pyelophlebitis;
subphrenic abscess

77
Q

Why does the most common complication of acute appendicitis occur?

A

periappendiceal abscess w/ or w/o perforation may develop subphrenic abscess due to Bacteroides fragilis

78
Q

Describe pyelophlebitis complication of acute appendicitis

A

infection of portal vein w/ thrombosis danger;

radiograph shows gas in portal vein

79
Q

Describe subphrenic abscess complication of acute appendicitis

A

persistent fever postop;
diaphragm fixed on Right w/ R-sided pleural effusion;
tenderness over lateral 7th or 8th ribs

80
Q

How is subphrenic abscess Dx and Tx?

A

Dx=> ultrasound, CT, gallium scan;

Tx=> extraperitoneal drain and ABx

81
Q

How is acute appendicitis diagnosed?

A

clinical exam;
spiral CT RLQ after Gastrografin enema;
plain CT w/ rectal contrast;
Ultrasound

82
Q

Tx for acute appendicitis

A

appendectomy;

cefoxitin (prophylactic in periop if perforation is suspected)

83
Q

What disorders mimic appendicitis?

A 
viral gastroenteritis;
ruptured follicular cyst;
ruptured ectopic pregnancy;
mesenteric lymphadenitis;
Meckel's diverticulitis

GI block (11 decks)

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