GI Precision & Pearls #2 Flashcards
By definition, toxic megacolon is…
What are some symptoms of this condition?
Nonobstructive colonic dilation > 6 cm + signs of systemic toxicity
-Profound bloody diarrhea, vomiting, pain, diarrhea
-Distention
-Fever, AMS, tachycardia, hypotension, dehydration, peritonitis signs
You need three things to diagnose a patient with toxic megacolon. Name them.
-Abdominal radiographs
-3 of the following: fever, pulse > 120, leukocytosis, anemia
-1 of the following: dehydration, AMS, hypotension, lyte abnormalities
Treatment for toxic megacolon
-Supportive: decompression with NG tube, bowel rest, ABX (Metro + Ceftriaxone)
-Correct fluid/electrolyte problems
-Steroids if UC is the cause
Diverticulosis is outpouchings due to herniation of mucosa into the wall of the colon. What are some risk factors for this condition?
Symptoms?
Constipation, low fiber, obesity
-May be asymptomatic
-Painless hematochezia (MCC of lower GI bleed)
What is the MCC of a lower GI bleed?
Diverticulosis
Diverticulosis is MC an incidental finding on a colonoscopy. However, if the bleed is NOT seen on colonoscopy, what diagnostic can you do for this condition?
Radionuclide imaging (tech-99)
Treatment for diverticulosis
-Most spontaneously resolve
–Resuscitation (2 large bore IV lines/blood products if needed)
-high fiber diet, bran, Psyllium
On the other hand, diverticulitis is infection/inflammation of the diverticulum. What part of the colon does this MC occur in?
What are the symptoms of this condition?
Sigmoid colon
LLQ pain, fever, change in bowel habits, n/v
What imaging study is done for diverticulitis?
What oral ABX are used in treatment for diverticulitis?
CT scan
-Labs show leukocytosis
Oral ABX: Metro + Cipro/Levofloxacin for 7-10 days
With diverticulitis, when should you admit the patient?
If complicated (abscess, fistula, perforation) = CT guided percutaneous drainage
If uncomplicated with high risk (sepsis, high fever, old age, immunocompromised)
A small bowel obstruction, or blockage of the small intestine, MC occurs due to what? Other etiologies, though, include…
Post-surgical adhesions (MC)
Others: Malignancy, hernias, volvulus, intussusception
Symptoms of a small bowel obstruction include CAVO, as well as…
Crampy abdominal pain
Abdominal distention
Vomiting
Obstipation (no flatus)
-High pitched tinkles on auscultation
-Visible peristalsis (early) –> hypoactive bowel sounds (late)
Diagnostics done for a small bowel obstruction. What is shown on them?
Upright abdominal XR:
CT scan:
XR: multiple air fluid levels in a step ladder appearance
CT: transition zone = dilated loops with contrast to area without contrast
Management for nonstrangulated and strangulated small bowel obstruction
Nonstrangulated: NPO, IVF, bowel decompression
Strangulated: Surgery!
A paralytic ileus is ________. A few etiologies of this are
-Decreased peristalsis without mechanical obstruction
-Postoperative state, Opioids, DM, hypothyroidism, hypokalemia, hypercalcemia
What are the symptoms of a paralytic ileus (how does it differ from a SBO)?
Decreased or absent bowel sounds, symptoms like SBO
-However, this is painLESS
What do abdominal XR’s show for a paralytic ileus?
Dilated loops of bowel without a transition zone (there is no mechanical obstruction in this case)
Treatment for a paralytic ileus?
Supportive: NPO, electrolyte and fluid replacement
NG suction if persistent nausea/vomiting
Encourage walking to get the bowels moving!
What is intussusception? Where does it MC occur?
Telescoping of an intestinal segment into adjoining segment –> obstruction
Ileocolic junction
Intussusception is the MCC of bowel obstruction in kids < 4 years old. What are risk factors associated with this condition? What is the MCC of this?
Children, males, post infections
Idiopathic (MCC), Meckel Diverticulum, Foreign body, Tumors
What symptoms are associated with intussusception?
What diagnostics should you do and what is seen on them?
Triad: Vomiting + Abdominal pain + Passage of blood per rectum (currant jelly stools)
-Sausage shaped mass in RUQ
-Emptiness in RLQ (Dance’s Sign)
-Pull knees to chest due to pain
US (initial) = target/donut sign
Air or contrast enema: diagnostic and therapeutic
Management for intussusception
-Fluid and electrolyte replacement then
-Pneumatic or hydrostatic NG decompression
-Admit for observation
A volvulus is twisting of part of the bowel at the mesenteric attachment site. This MC involves what two parts of the colon?
Sigmoid colon or cecum
Symptoms of a volvulus in an adult.
Symptoms in a neonate
-Tympanic abdomen, tenderness, crampy pain, distention, n/v, colicky
-Fever, tachycardia, guarding, rigidity
Neonate: non bilious vomiting within first weeks of life
What diagnostics can you do for a volvulus and what is seen?
Abdominal CT: bird beak appearance at site of volvulus
Abdominal XR: bent inner tube = U shaped appearance. Closed loop with loss of haustral markings
Contrast enema: bird beak appearance
Treatment for volvulus
-Endoscopic decompression (proctosigmoidoscopy)
Then, elective surgery due to recurrence
What is acute mesenteric ischemia?
What is the MCC and what are other causes?
Symptoms of mesenteric ischemia?
Abrupt onset of small intestine hypoperfusion
Emboli from A-fib (MC)
Others: Thrombotic (atherosclerosis) = Superior mesenteric artery MC, shock, vasopressors, cocaine
Symptoms: Severe abdominal pain out of proportion (poorly localized), n/v, diarrhea
Initial diagnostic for acute mesenteric ischemia
Definitive diagnostic
Labs show leukocytosis and lactic acidosis (elevated lactate is associated with ischemia)
CT angiography initially
Arteriography definitive
Management for acute mesenteric ischemia
-Surgical revascularization (embolectomy, angioplasty with stent, etc.)
-Possible resection
-Anticoagulation if associated with A-fib
Explain the pathology behind chronic mesenteric ischemia
MC it is due to atherosclerotic disease
Decreased supply of blood during times of increased demand (eating)
Symptoms of chronic mesenteric ischemia
-Chronic dull abdominal pain worse after meals
-Aversion to eating (anorexia) –> weight loss
Again, the definitive diagnostic for chronic mesenteric ischemia is….
Treatment?
Angiography
Revascularization is the treatment
Inflammatory bowel disease includes UC and Crohn’s Disease. What are some risk factors for these conditions?
Ashkenazi Jews, 15-35 years old, genetics, infections, western diet, Smoking, Meds (NSAIDs, OCPs, hormone replacement)
When thinking about IBD as a whole, what are some extra-intestinal symptoms you should watch for?
Anterior uveitis/iritis
Osteoporosis, MSK pain
Erythema nodosum
B12 deficiency
Explain the following for Ulcerative Colitis
-Where it takes place
-Is rectum always involved?
-How deep?
-Symptoms (location)
-Smoking risk
-What is seen on colonoscopy
-What is seen on Barium study
-Labs
-Treatment (is surgery curative as well)
-Limited to colon (begins in rectum with contiguous spread, proximally to colon)
-Rectum ALWAYS involved
-Mucosa and submucosa only
-LLQ pain, colicky, tenesmus, bloody diarrhea
-Smoking decreases risk
-Colonoscopy: uniform inflammation and pseudopolyps
-Barium: Stovepipe sign = decreased haustral markings
-Labs: P-ANCA
-Treatment: MILD: Topical 5-aminosalicylic acid (ASA) +/- Topical corticosteroids; SEVERE: Oral glucocorticoids + high dose 5-ASA + topical steroids
-Surgery is curative in this condition
Explain the following for Crohn’s Disease
-Where it takes place
-Is rectum always involved?
-How deep?
-Symptoms (location)
-Smoking risk
-What is seen on colonoscopy
-What is seen on Barium study
-Labs
-Treatment (is surgery curative as well)
-Any segment of the GI tract (from mouth to anus)
-MC in terminal ileum
-Transmural (includes all layers)
-RLQ pain, crampy pain, diarrhea (no blood). Perianal disease: fistulas, granulomas, B12/iron deficiency
-Colonoscopy: skip lesions and cobblestone appearance
-Barium: String sign
-Labs: ASCA
-Treatment: 5-ASA (Mesalamine) or oral glucocorticoids; SEVERE: Azathioprine, Methotrexate, anti-TNF (-mab) drugs
-Surgery NOT curative in this condition
Name some symptoms of IBS, as well as some Alarm Symptoms
Although this is a diagnosis of exclusion, what is the ROME IV Criteria and what are the components of it?
Abdominal pain with altered bowel habits, diarrhea/constipation alternating, pain relieved with defecation
Alarm: GI bleeding, anorexia, weight loss, dehydration
ROME IV: Abdominal pain 1 day/week for the last 3 months, plus 2 of the following 3
–Related to defecation
–Change in stool frequency
–Change in stool appearance
What is the treatment for IBS (initially, for constipation, and for diarrhea)
Initially: Lifestyle and diet changes (low fat, high fiber, unprocessed foods). Sleep hygiene. No smoking.
Constipation: Fiber, Psyllium, Poly-Glycol
Diarrhea: Loperamide, Dicyclomine
What is the pathophysiology of celiac disease (Sprue)?
What are the symptoms that occur as a result of this patho?
Remember the skin finding as well…
Autoimmune-mediated inflammation of the small bowel due to reaction with alpha-gliadin in gluten foods –> loss of villi –> malabsorption
Diarrhea, bloating, pain, growth delays
Dermatitis herpetiformis: pruritic, papular rash on extensor surfaces, neck, trunk, scalp
Screening diagnostic for celiac
Definitive diagnostic for celiac
-Transglutaminase IgA antibodies (endomysial IgA antibodies)
Small bowel biopsy = atrophy of the villi
Treatment for celiac disease
-Gluten free diet (wheat, rye, barley)
-Vitamin Supplementation
Explain the types of colon polyps
-Pseudopolyps:
-Hyperplastic:
-Adenomatous:
Pseudopolyps due to IBD are not cancerous
Hyperplastic: low risk of malignancy (MC non neoplastic type)
Adenomatous: MC neoplastic type.
–Tubular Adenoma: MC type. Least risk
–Villous Adenoma: highest risk
Name three genetic disorders that predispose you to having colon polyps
Lynch Syndrome = MC
FAP: 100% risk before age 40
Peutz-Jegher’s: benign transform to malignant
Most colorectal cancers arise from adenomatous polyps. What are other risk factors associated with colon cancer?
What are some PROTECTIVE factors?
RF: Age > 50, UC, diet (low fiber, high red meat), obesity, FH, smoking, EtOH
Protective: Physical activity, Aspirin, NSAIDs
Explain the three genetic disorders to colon polyps
-Lynch Syndrome
-FAP
-Peutz-Jeghers
-Lynch: Nonpolyposis CRC. Due to loss of function of DNA mismatch repair genes
FAP: mutation of APC gene. Adenomas in childhood. Cancer by 45 years old 100% chance. Colectomy prophylatically is recommended.
Peutz-Jeghers: hamartomatous polyps, mucocutaneous hyperpigmentation, risk of breast and pancreatic cancer
Symptoms of colorectal cancer
-Fatigue, weakness (iron deficiency anemia)
-Change in bowel habits, bleeding, abdominal pain
-large bowel obstruction (CRC MCC)
-Right side (proximal): Chronic bleeding
-Left side (distal): bowel obstruction, change in stool diameter
What is the diagnostic of choice for CRC?
What is the best tumor marker for colon cancer?
Colonoscopy with biopsy
CEA
What is seen on barium enema if the patient has colon cancer?
Apple core lesion
Treatment for colon cancer
Surgical resection then chemotherapy if localized
Palliative chemotherapy if metastatic
Describe the screening recommendations for colon cancer
For an average risk, family history risk, Lynch Syndrome, FAP
-Screened until age 75
-Average Risk
–Fecal occult test (annually at 50)
–Colonoscopy Q10 years of Flex Sigmoidoscopy Q5
-1st degree relative with colon cancer > 60 years old
–Fecal occult test (annually at 40)
–Colonoscopy Q10 years
-1st degree relative with colon cancer < 60 years old
–Fecal occult test (annually at 40 or 10 years before diagnosis)
–Colonoscopy: Every 5 years
-Lynch Syndrome
-Start at 20-25 years old via colonoscopy Q1-2 years
-FAP
-Start at 10-12 years with flexible sigmoidoscopy yearly!
