GI MDT Glacken Flashcards
Diarrhea can be defined as
More than 3 bowel movements in a day
Liquidity of feces
Acute diarrhea lasting less than two week is most commonly caused by
Bacterial toxins
Infectious diarrhea can be transmitted by what
Fecal-oral contact
Food
Water
What is the incubation period of infectious sources of dire health
12-72 hours
Most common cause of acute gastroenteritis
Infectious agents
How is acute gastroenteritis as a diarrheal disease defined
3 pre more BM a day or at least 200g of stool a day
Rapid onset lasting less than 2 weeks and may be accompanied by nausea, vomiting, fever or abdominal pain
What are common findings on examination in patients with acute viral gastroenteritis
Mild diffuse abdominal tenderness on palpation
Abdomen is soft, but may be guarding
What is the treatment for viral gastroenteritis
Usually self limiting and supportive measures (fluid repletion)
No antivirals needed
What is the mechanisms for infectious gastroenteritis
Adherence
Mucosal invasion
Enterotoxin/cytotoxin production
Acute gastroenteritis as a diarrheal disease can lead to what
Dehydration and loss of electrolytes and nutrients
A diagnosis of gastritis requires what
Histopathologic evidence of inflammation
Gastritis only involves what
The stomach
What are the most common causes of gastritis
Chronic NSAID use
Chronic alcohol use
Trauma
If gastritis does not resolve with conservative management, refer for what
Endoscopy and H. Pylori testing
Chronic diarrheal diseases may be classified as
Osmotic
Inflammatory
Secretory
Chronic infections
Malabsorption syndromes
Motility disorders
What can cause osmotic diarrhea
Medications
Zollinger-Ellison syndrome
Inflammatory diarrhea occurs when
Mucosal lining of the intestine is inflamed
What is happening during Secretory diarrhea
Increase in secretory activity
Chronic infections if diarrhea can be caused by
Parasites
What are some malabsorption diseases
Celiac disease
Whipple
Crohn disease
Lactose intolerance
What is an example of a motility disorder
Irritable bowel syndrome
What is the difference between inflammatory diarrhea and non inflammatory
Inflammatory is bloody
Non-inflammatory is just watery
What is a common cause of inflammatory diarrhea
Shigella
Salmonella
E. coli
E. Coli O157:H7
Community outbreaks of diarrhea usually suggest what
Viral etiology or food source
Patients with recent family illness suggest what
Infectious origin
Acute non-inflammatory diarrhea is usually milder and caused by what
Virus
Common cause of acute non-inflammatory diarrhea
Rotavirus
Norwalk virus
The term “food poisoning” usually denotes what
Disease caused by toxins present in consumed food
Preformed toxin incubation period
1-6 hours
When incubation period is longer (8-16 hours) the toxin is usually produced when
After being ingested
Non-inflammatory diarrhea illness is
Mild and self-limited
If diarrhea worsens or persists for more than 7 days, stool should be
Sent for leukocyte, ovum and parasite eval with bacterial culture
Medevac for diarrhea when
Signs of inflammatory with fever, bloody diarrhea, or abdominal pain
6 or more stools in 24 hours
Signs of dehydration
Differential for diarrhea
Food poisoning
Inflammatory bowel disease
Malabsorption
Medication effect
Laxative abuse
Labs for diarrhea
CBC w diff
Fecal leukocyte
Fecal O/P
Stool culture
Initial care for diarrhea
Treat symptomatically
What are the categories of gastritis
Erosive and hemorrhagic
No erosive and non specific
Specific type
Uncommon causes of gastritis
Caustic ingestion and radiation
Symptoms of gastritis
Epigastric pain
Nausea vomiting
Upper GI bleed with “coffee ground” vom
Most sensitive method of diagnosis for gastritis
Endoscopy
Treatment for NSAID caused gastritis
D/C NSAIDs.
Proton pump inhibitor 2-4 weeks (omeprazole 20-40mg)
Treatment for alcohol caused gastritis
No alcohol
H2 receptor agonists
PPI
Disposition for gastritis
Medevac
Non erosive, non specific causes of gastritis
H. Pylori
Pernicious anemia
Eosinophil gastritis
Causes of constipation
Decrease in fiber intake with decrease fluid intake
Medications
Structural abnormalities
Slow colonic transport
IBS
Hirschsprung disease
How will getting an upright chest film for a patient who is constipated help
Detect the presence or absence of an obstruction
First line treatment for constipation
Strict diet changes
Increase water
Fiber supplementation (Metamucil)
Second line treatment for constipation
Emollients - colace 100mg 1-2x a day
Stimulants - bisacodyl 5-15mg PO daily
Saline laxative - milk of mag
Hyperosmolar agents - sorbitol
Third line treatment for constipation includes
Suppositories or enemas
If uncomplicated constipation disposition is what
Retain on board
Complicated or chronic cases of constipation disposition is
Refer to gastroenterologist
Stage I hemorrhoids are
Internal and confined to the anal canal
Stage II hemorrhoids defined
Gradually enlarge and protrude from anal opening
Stage III hemorrhoids
Require manual reduction after bowel movements
Stage IV hemorrhoids
Remain chronically protruding and unresponsive to manual reduction
What is the definitive care for internal hemorrhoids
Surgical banding or band ligation
Describe external hemorrhoids
Tense bluish nodule covered with skin.
Few centimeters in size
Type of diet for hemorrhoids
High fiber diet increase water intake
Treatment for external hemorrhoids
Warm sitz bath
Anesthetize skin with 1% lido, 30g needle
Eclipse of skin excised and clot evacuated
Describe what anal fissures look like
Linear or rocket shaped ulcers, usually < 5mm in length
Causes of anal fissures
Trauma from Straining, constipation, high internal sphincter tone
Symptoms of anal fissures
Sever, tearing pain during defecation
Bright Blood may be present
Difference is appearance between chronic and acute anal fissures
Acute looks like cracks in the epithelium
Chronic results in fibrosis and development of skin tags at outermost edge
Differential for anal fissures
Perianal abcess
Hemorrhoids
Skin tag
Crohn disease
Treatment for anal fissures
Fiber supplements and sitz baths
Topical anesthetics
Oral analgesics (Tylenol or NSAID)
Initial care for anal fissures
Consider stool softeners
Inform patient on importance of keeping clean
What is an obstruction of an anal gland that opens in the base of an anal crypt that drains into the anal canal
Anorectal abcess
Anorectal abscesses almost always begin with the involvement of?
An anal crypt and it’s gland
Most common space Anorectal abcesses occur
Perianal
Least common place Anorectal abcesses occur
Supralevator
As rectoanal abcesses persist what may happen
Fistula formation
Who is commonly affected by Anorectal abscesses
Young middle aged males
Symptoms of Anorectal abscesses
Dull, aching, throbbing pain immediately before defecation, lessened after defecation, persists between bowel movements
Aggravated by straining
Interfere with walking or sitting
Differential for Anorectal abscesses
Pilonidal cyst
Hemorrhoid
Anorectal fistula
Treatment for Anorectal abscesses
Surgical as soon as diagnosis is made
Packed with gauze (not required)
Patients with abscesses and fever should be give ?
Broad spectrum antibiotics (cephalexin (keflex), doxy)
Initial care for rectoanal abscesses
I&D
If more complicated refer to surgery
Anal crypts allow for secretion of
Excess mucus otherwise found in rectum and anus
Anal crypts become problematic when?
Obstruction occurs
An epithelialized track that can form to connect an abscess in the anus or rectum with perirectal skin
Anorectal fistula
Anorectal fistulas can be the result of?
Non-healing Anorectal abscess following drainage
Symptoms of Anorectal fistulas
Chronic purulent drainage
Pustule lesion in Perianal or buttock area
Rectal pain while pooping or sitting
Malodorous drainage
Disposition of Anorectal fistulas
If unstable medevac
Anatomy of pilonidal disease
Pilonidal sinus
Sacrum
Coccyx
Asymptomatic hair-containing cysts or abscess on the sacrococcygeal region that have tendency to recur
Pilonidal disease
Pilonidal abscess may occur in the presence of?
Staphylococcus aureus which invade through openings caused by ingrown hairs
Where do Pilonidal sinuses or cysts occur
Midline in upper part of the natal cleft overlaying the lower sacrum and coccyx
Symptoms of Pilonidal disease
Swelling, pain, discharge
Tender mass
Examination for Pilonidal disease genially reveals what?
Area of inflammation in midline gluteal crease with one or more sinus openings
Most common finding in Pilonidal disease
Single opening with protruding hair
Treatment for Pilonidal disease
Surgical treatment is treatment of choice
Acute Pilonidal abscess treatment
I&D, recurrence is common
Definitive treatment for persistent or complicated Pilonidal abscess
Surgical excision
Pilonidal abscess should be packed with what type of gauze
Moistened (wet to dry) changed daily
Disposition for Pilonidal disease
Retain for uncomplicated cases, refer to general surgery for definitive management
Med advice
Inflammatory bowel disease encompasses what disease processes
Ulcerative colitis
Crohn disease
In IBD what is happening with the immune response
It disrupts the intestinal mucosa leading to chronic inflammation
Hallmarks of ulcerative colitis
Limited to colonic mucosa
Pseudo polyps
Hallmarks of Crohn disease
Any segment from mouth to anus
Skip lesions
Transmural inflammation
Crohn disease may be associated with
Oral ulcers
Anorectal diseases
What is mucosal inflammation
Involves only the mucosal layer of bowel wall
Ulcerative colitis
What is transmural inflammation
Inflammation/ulceration of all layers of bowel wall
Crohn disease
Most common portion of GI tract affected by Crohn disease
Terminal ilium resulting in malabsorption of food, B12, bile salts and calcium
B12 deficiency causes
Macrocyclic anemia
Crohn disease
Common symptoms of macrocytic anemia
Numbness and tingling in distal aspects of upper and lower extremities
Crohn disease is a chronic and ______ disease
Recurrent
Intestinal cobble stoning is a finding of
Crohn disease
Pertinent history for Crohn disease
Fevers
General well being
Weight loss
Abdominal pain
Number of liquid BM a day
Surgical history/hospitalization
Symptoms of Crohn disease
Ileitis/ileo-colitis (most common)
Fistulas to bladder (UTI)
“Peeing out air”
Anal fissures
Perianal diseases
Oral aphthous lesions
Type of imaging useful for crohn disease
Endoscopy (not when inflamed)
Colonoscopy (not when inflamed)
CT
Crohn disease is a chronic lifelong illness characterized by
Exacerbations and periods of remission
Treatment for Crohn disease
Treat symptomatically toward improvement and controlling disease
Available therapies for Crohn disease
5-aminosalicylic acid derivatives (5-ASA)
Corticosteroids
Immuno-modulating and biological agents
Disposition for Crohn disease
DC tobacco
Consult to GI
Medevac
Complication of Crohn disease
Intra abdominal abscess
Small bowel obstruction
Fistulas
Fissures, skin tags
Bleeding
Increase colon carcinoma risk
Screening colonoscopy to detect dysplasia or cancer for patients with Crohn disease frequency
Patients with history of 8 or more years after initial diagnosis
Ulcerative colitis is a chronic and _____ disease
Recurrent
Ulcerative colitis is limited to what part of the GI tract
Large intestine
Inflammation of the mucosa of the colon can cause
Ulceration
Edema
Bleeding
Fluid and electrolyte loss
Ulcerative colitis manifests in periods of
Flare ups and remission
Ulcerative colitis is common in what demographic
Non smokers and former smokers
Appendectomy before the age of 20 is an increased risk of developing
Ulcerative colitis
Pertinent history for ulcerative colitis
Stool frequency and character
Rectal bleeding
Abdominal pain
Fecal urgency
Tenesmus (the feeling of needing to poop)
Hallmark of ulcerative colitis
Bloody diarrhea
Lower abdominal pain
Anemia
Negative stool culture
Mild Ulcerative colitis symptoms
Infrequent diarrhea (less than 5 a day)
Formed or loose consistency
Tenesmus
LLQ pain
Moderate ulcerative colitis symptoms
Severe diarrhea with frequent bleeding
Fever, anemia
Severe ulcerative colitis symptoms
More than six to ten BM per day
Severe anemia
Hypovolemia
Impaired nutrition
Abdominal pain
Initial assessment for patient with ulcerative colitis should focus on
Volume status by orthostatic BP, HR, urine output and mental status
Nutritional status
DRE of patient with ulcerative colitis may have
Red blood on DRE
Labs for ulcerative colitis
Blood, serology, stool culture
Degree of abnormality in HCT and albumin reflects severity
Colonoscopy screening for ulcerative colitis
8 years post initial diagnosis
Patients with ulcerative colitis have _______ risk of colon cancer than general population and Crohn disease
Greater
What are the two main treatments for ulcerative colitis
Terminate the acute attack
Prevent recurrent attacks
Medication options for ulcerative colitis
Mesalamine
Corticosteroids
5-ASA
Antidiarrheal agents if negative for Cdiff
What is the surgery called for ulcerative colitis
Total proctocolectomy
Taking out the large intestine (curative)
Mild to moderate ulcerative colitis should be referred to
GI or general surgery
Severe ulcerative colitis initial treatment
Hospitalize
DC oral intake for 24-48 hours
Serial abdominal exams
Disposition for ulcerative colitis
Medevac
Can ulcerative colitis be diagnosed in an outpatient setting
No, needs a biopsy
How is irritable bowel syndrome defined
Chronic disease (more than 3 months) with abdominal pain associated with altered bowel habits
IBS usually begins at what stage in life
Late teens to early twenties
Hallmark of IBS
Abdominal discomfort relieved immediately after defecation with a normal physical exam
What is needed to diagnose IBS
Two of three:
Relieved with defecation
Onset of change in frequency of stool
Onset with change in stool form
3 major categories of IBS
C - constipation
D - diarrhea
M - mix constipation and diarrhea
Rule out other diagnosis before concluding IBS in patients with these symptoms
Acute onset
40-50 years old
Nocturnal diarrhea
Severe constipation
Hematochezia
Weight loss
Fever
Family history of cancer
Physical exam for IBS are usually
Normal
Differential for IBS
Colonic neoplasia
IBD
Hypo/hyperthyroidism
Parasites
Malabsorption
Psych
What is definitive treatment for IBS
No definitive treatment
Adjust diet
Can antidepressants (TCA) be used in treatment of IBS
Yes
