GI Re-Up #2 Flashcards
What is the criteria for toxic megacolon?
Name two common etiologies for this condition
Nonobstructive extreme colon dilation > 6 cm + signs of systemic toxicity
Complications of IBD (UC), Infectious Colitis (C. diff)
Symptoms of toxic megacolon
What is the initial imaging study of choice and what is seen?
-Profound bloody diarrhea, abdominal pain/distention, nausea, vomiting, tenesmus
-Lower abdominal tenderness and distention
-Signs of toxicity: AMS, fever, tachycardia, hypotension, dehydration. Rigidity, guarding, rebound tenderness.
-Initial: Abdominal radiographs show colon > 6 cm
You need 3 of the following 4 things to diagnose toxic megacolon.
Plus, 1 of the following…
-fever, pulse > 120, neutrophilic leukocytosis > 10,500, anemia PLUS 1 of the following
-hypotension, dehydration, lyte abnormalities, AMS
Treatment for toxic megacolon
-Supportive: bowel rest, NG decompression, Ceftriaxone + Metronidazole, fluid replacement, lyte replacement
What is Ogilvie Syndrome?
What are some etiologies (think about ileus)
Colonic pseudo-obstruction in absence of any mechanical obstruction
-Etiologies: postoperative state, meds (opiates), hypokalemia, hypercalcemia, hypothyroidism, DM
What is the main symptom of Ogilvie Syndrome?
What is the most accurate test for this and what is shown?
-Abdominal distention, tympanitic abdomen
-Abdominal CT scan: proximal right colonic dilation
Management for Ogilvie Syndrome
-IVF and electrolyte repletion if colon dilation < 12 cm
-Neostigmine if at risk for perforation or > 12 cm or if failed conservative therapy after 24-48 hours (medical decompression)
-Colonoscopic decompression is next option
-Surgical decompression if everything else fails
Name some risk factors for IBD (includes Crohn’s and Ulcerative Colitis)
-Ashkenazi Jews, Caucasians
-15-35 years old
-UC in Males, Crohn’s in Females
-Genetics, Family History
-Smoking (increased in Crohn’s, Decreased in UC)
-Western Style Diet
-Infections
-NSAIDs, OCPs, Hormone Replacement Therapy
Explain some extra-intestinal manifestations of IBD
-Dermatologic
-Ocular
-Hematologic
-Rheumatologic
-Derm: Erthema Nodosum
-Ocular: Conjunctivitis, Anterior Uveitis, Episcleritis
-Hematologic: B12 and Iron Deficiency
-Rheumatologic: MSK pain, ALS, osteoporosis
Regarding Ulcerative Colitis, explain the following findings, symptoms, or labs.
-Area affected
-Depth
-Symptoms
-Complications
-Colonoscopy Findings
-Barium Study Findings (Upper GI series)
-Labs
-Surgery
-Limited to colon (begins in rectum with contiguous spread proximally to colon). Rectum ALWAYS involved.
-Mucosa and Submucosa Only
-LLQ pain, Tenesmus, urgency, bloody diarrhea**
-Toxic Megacolon, Colon Cancer (complications)
-Uniform inflammation and pseudopolyps on colonoscopy
-Stovepipe sign: loss of haustral markings on barium’
- + P-ANCA
-Surgery is curative
Regarding Crohn’s Disease, explain the following findings, symptoms, or labs.
-Area affected
-Depth
-Symptoms
-Complications
-Colonoscopy Findings
-Barium Study Findings (Upper GI series)
-Labs
-Surgery
-Any segment of GI that from mouth to anus. MC in terminal ileum (RLQ pain)
-Transmural
-RLQ pain, weight loss, diarrhea without blood
-Perianal disease (fistulas, abscesses, strictures, granulomas, Iron and B12 deficiency) complications
-Skip lesions (normal between inflamed areas, cobblestone appearance on colonoscopy)
-String sign: barium flow through narrowed transmural stricture on barium study
- + ASCA
-Surgery is noncurative
For UC and Crohn’s, what is the first line treatment if mild to moderate disease?
5-ASA (Topical 5-aminosalicylic acid) Mesalamine
For Crohn’s, explain the treatments for…
-Limited ileocolonic disease:
-Ileal and proximal colon disease:
-Severe and refractory:
-Limited: 5-ASA and oral glucocorticoids
-Proximal: Glucocorticoids (Prednisone, Budesonide)
-Severe: Azathioprine, Methotrexate, anti-TNF agents
For UC, explain the treatments for…
-Mild to moderate distal:
-Severe:
-Surgery:
-Mild to moderate: Topical 5-ASA. Topical corticosteroids may be added in some.
-Severe: Oral glucocorticoids + high dose 5-ASA + topical 5-ASA or steroids
-Surgical resection in some cases
Hemorrhoids, which are engorgement of venous plexuses, have two types (internal and external). Internal hemorrhoids originate from the _________ vein and are proximal (above) the dentate line. What symptoms are unique to this type?
-Superior hemorrhoid vein
-Tend to bleed and are painless
There are four grades of internal hemorrhoids. Explain each one.
-Grade I: Does not prolapse. May bleed with defecation.
-Grade II: Prolapses with defecation or straining but spontaneously resolve.
-Grade III: Prolapses with defecation or straining, requires manual reduction.
-Grade IV: Irreducible and may strangulate.
On the other hand, external hemorrhoids originate from the ______ vein and are distal (below) the dentate line. What are symptoms associated with this type?
-Inferior hemorrhoid vein
-Tend to be painful and don’t usually bleed
Risk Factors for hemorrhoids
How do you diagnose these?
-Straining during defecation (constipation), pregnancy, obesity, prolonged sitting, cirrhosis with portal hypertension
-Visual inspection, DRE, fecal occult blood testing
-Anoscopy for internal allows for direct visualization
Symptoms of internal hemorrhoids:
Symptoms of external hemorrhoids:
Internal: intermittent rectal bleeding (painless BRBPR). Rectal itching, fullness, mucus discharge.
External: perianal pain aggravated with defecation. Tender palpable mass. +/- Skin tags.
Treatment for hemorrhoids
-Conservative: high fiber diet, increased fluids, warm sitz baths. Analgesics.
-Rubber band ligation (MC used), Sclerotherapy, infrared coagulation. Excision of thrombosed external may be performed.
-Hemorroidectomy for Stage IV not responsive to other therapies. Surgical treatment for external only.
What is constipation defined as?
What are some etiologies?
-Infrequent bowel movements (<2/week), straining, hard stools, feeling of incomplete evacuation.
-Hypothyroid, DM, Verapamil, Opioids, Hirschsprung’s Disease
Medications used for constipation.
-Fiber
–MOA
Retains water and improves GI transit
Osmotic Laxatives
-Names
-MOA
-Adverse Effects
-Polyethylene Glycol (PEG), Lactulose, Sorbitol, Milk of Magnesia, Magnesium Citrate
-H20 retention in stool
-Bloating, flatulence, hypermagnesemia
Bisacodyl and Senna, which are stimulant laxatives, work how?
Increases acetylcholine-regulated GI motility (peristalsis) and alters electrolyte transport in the mucosa
Can cause diarrhea and abdominal pain though
Management for fecal impaction
-Digital disimpaction followed by warm-water enema with mineral oil
-Polyethylene glycol either orally or via NG tube
Explain the pathophysiology of Duodenal Ulcers vs Gastric Ulcers
-Duodenal Ulcers: increased aggressive factors (H. Pylori)
-Gastric Ulcers: decreased protective mechanisms (mucus, bicarb, etc.)
Etiologies of PUD
Symptoms of both types of ulcers.
Symptoms of duodenal ulcers.
Symptoms of gastric ulcers
-H. Pylori (MCC), NSAIDs, Aspirin, Zollinger-Ellison Syndrome (gastrin producing tumor), ETOH, smoking, stress, males, elderly, steroids, gastric cancer
-Both: Dyspepsia (burning, gnawing, epigastric pain), nausea, vomiting
-Duodenal: dyspepsia relieved with food, worse before meals or 2-5 hours after meals, nocturnal symptoms
-Gastric: symptoms worse with food (especially 1-2 hours after meals), weight loss.
True or False, PUD is the MCC of upper GI bleed?
What are some symptoms of a perforated ulcer?
-True!
-Sudden onset of severe abdominal pain, may radiate to the shoulder. Rebound tenderness, guarding, rigidity may be peritonitis.
Diagnostic test of choice for PUD
Upper endoscopy with biopsy
–All gastric ulcers need repeat UE to document healing
What diagnostics are done to test for H. Pylori?
What’s the gold standard one?
-Urea breath test: H. Pylori converts urea into carbon dioxide.
-H. Pylori Stool Antigen (HpSA): confirm eradication after therapy
-Serologic antibodies: only useful in confirming H. Pylori
-Endoscopy with biopsy: GOLD STANDARD
Treatment for PUD if H. Pylori Positive (think 4 and 3)
-Quadruple Therapy: Bismuth + Tetracycline + Metro + PPI x 14 days
–or CAMP (Clarithromycin + Amoxicillin + Metro + PPI for 10-14 days)
-Triple Therapy (CAP): Clarithromycin + Amoxicillin + PPI for 10-14 days (Metronidazole if PCN allergic)
If H. Pylori negative, what treatment should you give for PUD?
If refractory, what is the treatment?
-PPI, H2 blocker, Misoprostol, antacids
-Refractory: Bilroth II surgery (associated with Dumping Syndrome)
Duodenal ulcers are MC in ______ whereas gastric ulcers are MC in ________
Duodenal: younger patients (30-55)
Gastric: older patients (55-70)
A volvulus is _______ and it MC involves the _________.
What are some symptoms of this condition?
-Twisting of any part of the bowel at it’s mesenteric attachment site. MC involves the sigmoid colon and cecum.
Symptoms (obstruction): crampy pain, tympanitic abdomen with tenderness to palpation. Distention, nausea, vomiting, constipation. (Impaired vascular supply): fever, peritonitis, tachycardia.
What is seen on the following diagnostics with a volvulus?
-Abdominal CT
-Abdominal Radiograph
-Contrast enema
-Abdominal CT: dilated sigmoid colon, bird beak appearance at site of volvulus
-Abdominal Radiograph: bent inner tube or coffee bean sign. U shaped appearance of the air-filled closed loop of distended colon with loss of haustral markings
-Contrast enema: Bird’s beak appearance
Management for a volvulus
-Endoscopic decompression (proctosigmoidoscopy) and then elective surgery due to high rate of recurrence
Which organ is the most common organ injured during trauma?
What are some symptoms?
-Spleen
-Abdominal pain, Hypotension, Shock.
-Kehr Sign: referred left shoulder pain due to irritation of diaphragm and phrenic nerve
Management for a splenic rupture or laceration if:
-Incomplete rupture:
-Complete rupture or intractable bleeding:
-Endovascular embolization
-Splenectomy
A small bowel obstruction is partial or complete mechanical blockage of the small intestine. What is the MC etiology and what are some others you should remember?
What are some symptoms?
-Think of early and late findings as well
-Post-surgical adhesions (MC)
-Others: Incarcerated hernias, Crohn’s, Malignancy, Intussusception.
-Symptoms (CAVO): Crampy abdominal pain, abdominal distention, vomiting, and obstipation (no flatus)
-High pitched tingles on auscultation and visible peristalsis (early findings). Hypoactive bowel sounds (late in obstruction)
What is seen on abdominal radiographs for a small bowel obstruction?
What is seen on a CT scan?
-Abdominal radiographs: multiple air-fluid levels in a step ladder appearance, dilated bowel loops
-CT scan: transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast.
Management for a SBO
-Nonstrangulated: NPO (bowel rest), IVF. Bowel decompression (NG suction) if severe vomiting
-Strangulated: Surgical intervention
What is a paralytic (adynamic) ileus?
What are some etiologies of this?
Name some symptoms.
-Decreased peristalsis WITHOUT structural obstruction
-Postoperative state, Opiates, Hypokalemia, Hypercalcemia, Hypothyroidism, DM
-Symptoms: Abdominal distention, obstipation, vomiting, nausea, decreased or absent bowel sounds (unlike SBO). No peritoneal signs
What is seen on plain radiographs in a paralytic ileus?
-Dilated loops of bowel with no transition zone
Management for paralytic ileus
-Supportive care: NPO or dietary restriction (clear fluids) Electrolyte and fluid repletion.
-NG suction if needed
One more time, explain the difference on abdominal radiographs of a SBO and a paralytic ileus?
SBO: multiple air fluid levels in a step ladder appearance, dilated bowel loops
Paralytic ileus: dilated loops of bowel with NO transition zone
Duodenal atresia, which is __________, has risk factors such as _____ and _______
Complete absence or closure of a portion of the duodenum, leading to gastric outlet obstruction
-Polyhydramnios (increased amniotic fluid), Down Syndrome
Symptoms of duodenal atresia
What is seen on abdominal radiographs?
-Neonatal intestinal obstruction: within the first 24-38 hours of life, bilious vomiting, abdominal distention
-Abdominal XR: double bubble sign (distended air-filled stomach + smaller distended duodenum separated by pyloric valve)
Management for duodenal atresia
-Decompression of GI tract, electrolyte/fluid replacement
-Duodenoduodenostomy is definitive treatment
A hiatal hernia is herniation of structures from the abdominal cavity through the esophageal hiatus of the diaphragm. There are two types. Which is the MC. Explain both types.
-Sliding (Type I): MC type: GE junction slides into the mediastinum.
-Paraesophageal (Type II): Rolling hernia. Fundus of stomach protrudes through diaphragm with the GE junction remaining in normal location.
Symptoms of a hiatal hernia
What is the management for both types?
-Asymptomatic incidental finding most times. Intermittent epigastric pain, postprandial fullness, retching, nausea.
-Sliding: Manage GERD: PPI’s + weight loss
-Paraesophageal: surgical repair reserved for complications
