IBS, GI malignancy and colonoscopies Flashcards
1
Q
What is ulcerative colitis?
A
Diffuse mucosal inflammation involving only the COLON
involves rectum and extends proximally.
2
Q
What is Crohn’s disease?
A
Patchy, transmural inflammation affecting any segment of the GI TRACT
anywhere from mouth to anus
3
Q
is smoking assciated with the developement of chrons or UC?
A
Crohns disease
4
Q
What is the most commonly affected part of the GI tract in Crohn’s?
A
Terminal ileum, characterized by transmural inflammation and skip lesions
5
Q
How does Crohn’s present clinically?
A
- Chronic crampy RLQ pain
- Intermittent, non-bloody diarrhea
- Wt loss, weakness, fatigue
- Mass in RLQ = terminal ileum
6
Q
What are the extraintestinal manifestations of Crohn’s?
A
- Pyoderma gangrenosum
- Erythema nodosum
- Arthralgia
- Apthous ulcers (mouth)
- Fistulas, abscesses
Crohns is the creepy manifestations
7
Q
What are the 4 types of fistulas that can occur due to transmural inflammation in Crohn’s?
A
- Enterovesical (intestine to bladder)
- Enterocutaneous (intestine to skin)
- Enteroenteric (intestine to colon)
- Enterovaginal (intestine to vagina)
8
Q
Where does erythema nodosum occur in Crohn’s and what does it correlate with?
A
- Occurs on anterior lower legs
- Correlate with bowel symptoms
Red, hot lesions
9
Q
What is pyoderma gangrenosum?
A
Severe disease on dorsal surface of feet and legs usually, beginning as a pustule that spreads and turns necrotic
(seen with Chrons Disease)
10
Q
What is the gold standard to diagnose Crohn’s?
A
Colonoscopy with biopsy showing skip areas with a cobblestone appearance.
May also see focal ulceration adjacent to normal areas
11
Q
What is the management goal in Crohn’s?
A
Symptomatic relief
12
Q
How do we treat low-risk Crohn’s involving the ileum/cecum?
A
Step-up therapy with enteric coated budesonide and slowly increase it.
No improvement in 3-6 months => immunomodulator or biologic.
Alternative to budesonide is 5-ASA
13
Q
For mild-mod Crohn’s involving diffuse colitis or the left colon, what is the treatment?
A
- Oral prednisone with a tapering off
- Post tapering => ileocolonoscopy in 6-12 months
Alternative to prednisone will be 5-ASA. 5-ASA will be continued until scopy.
14
Q
If there is a remission in mild-mod Crohn’s, what is the new therapy we start?
A
Second course of glucocorticoid + azathioprine or biologic (infliximab)
15
Q
What is the overall therapy methodology in high-risk Crohn’s?
A
Step-down/Top-down
AKA starting with the big boys first
16
Q
What is the top-down therapy for high-risk Crohn’s?
A
Combination therapy of TNF blockers + immunomodulators
17
Q
What drug is NOT preferred for maintenance in Crohn’s?
A
Steroids
18
Q
Once remission is seen in Crohn’s, what is the next step?
A
Ileocolonoscopy in 6-12 months.
19
Q
What does UC most commonly involve?
A
Rectum and sigmoid colon
20
Q
What is the hallmark sign of UC?
A
Bloody diarrhea
21
Q
What is the common presentation of UC?
A
- Gradual onset
- Crampy lower abd pain that relieves with defecation
- Diarrhea with pus
- Bloody Diarrhea
- Fecal urgency
- Anemia
22
Q
What are the extraintestinal manifestations of UC?
A
- Arthritis
- Ankylosing spondylitis
23
Q
Who is UC ironically not as bad in?
A
Smokers
24
Q
What is the gold standard to diagnose UC?
A
Sigmoidoscopy showing a continuous friable mucosa, edematous, with pus, bleeding, erosions, and erythema
25
When should we NOT do a colonoscopy for suspected UC?
Severe or fulminant colitis due to risk of perf or megacolon.
26
What kind of cancer are patients with long-standing UC most at risk for?
* Colonic epithelial dysplasia
* Colonic epithelial Carcinoma
27
What lifestyle change is recommended to help with UC?
Cessation of caffeine
28
What is the treatment for mild-mod UC limited to the distal colon? (not past sigmoid)
Topical mesalamine (5-ASA) or hydrocortisone suppository (worse)
29
What is the treatment for mild-mod UC that extends past the sigmoid colon?
1. Oral mesalamine + topical mesalamine
2. Add-on oral corticosteroids if unresponsive after 4-8 weeks
30
For mod-severe UC, what is the treatment?
Prednisone +/- immunomodulators/TNF blockers
31
What is the curative treatment for UC?
Total proctocolectomy with placement of ileostomy.
32
When do we do maintenance therapy for UC and what is it?
1. More than 1 relapse in a year
2. Anyone with ulcerative proctosigmoiditis
3. Anyone with UC proximal to sigmoid (left-sided)
4. **Mesalamine**
33
What do 5-ASA/aminosalicylates do and their main SEs?
1. Indication: Induction and maintenance therapy of UC and CD
2. MOA: Inhibition of prostaglandin production
3. SEs: N/V, HA,
4. CI: Allergy to aspirin or sulfa
| Sulfasalazine and mesalamine
34
What are corticosteroids indicated for in IBD?
Induce remission in severe flares or for acute flares.
35
What are the two corticosteroids used in IBD?
* Prednisone: more potent
* Budesonide: poor systemic absorption, fewer SEs
36
What are the indications/MOA/SEs/AEs/BBW for immunomodulators/immunosuppressants?
1. Indication: Steroid dependent IBD or remission maintenance in severe IBD
2. MOA: Inhibition of DNA/RNA synthesis
3. SEs: Leukopenia, thrombopenia, anemia, infection, N/V/D, Malaise, myalgia
4. AEs: Lymphoma and severe infection
5. BBW: Mutagenic potential for rapidly growing malignancies
| Azathioprine or 6-mercaptopurine
37
When is methotrexate used for IBD?
Only in mild-mod CD for maintenance if azathioprine fails
38
When is cyclosporine used for IBD?
Severe refractory IBD that failed steroids
39
What are the indications/MOA/SEs/AEs/BBW for Anti-TNFs?
1. Indication: Mod-severe active IBD
2. **TOC for CD fistula (treatment of choice)**
3. MOA: MAB that binds to human TNF, interfering with cytokine inflammation
4. SEs: Fever, rigors, N/V, urticaria, hypotension
5. AEs: Severe infection/sepsis/Malignancy
6. BBW: Severe infection
## Footnote
ends in -mab
40
What ABX are used in IBD and when?
* Presence of fistula or abscess that makes patient susceptible to infection.
* Metronidazole or ciprofloxacin
41
What are the 5 common causes of IBD flare-ups?
1. Missing doses while in remission
2. NSAIDs (recommend tylenol)
3. Smoking (esp with CD)
4. Stress
5. Certain foods
42
What are the 4 pathologic colon polyp groups?
1. Mucosal adenomatous (MC)
2. Mucosal serrated
3. Mucosal non-neoplastic
4. Submucosal
| Serrated are 2nd MC
43
What causes adenomatous polyps?
DNA changes in lining of the colon
| 95% of colon adenocarcinomas are from these polyps
44
What are the risk factors of adenomatous polyps?
* Age > 50, MC in men
* High fat diets
* Obesity
45
What do adenomatous polyps look like?
* Flat, sessile, pedunculated
* Slow growing
46
How do you diagnose and workup adenomatous polyps?
* Colonoscopy
* Check all the polyp pathologies
47
What are the 3 types of adenomatous polyps and what is the most likely to be cancerous?
1. Tubular: least likely
2. Tubulovillous
3. Villous: Most likely (villain)
48
What general characteristics suggest that a polyp has a high likelihood of being cancerous?
1. > 1 cm
2. Villous histology
3. # of polyps
4. Flat polyps
49
What are the characteristics of a serrated polyp?
* Sessile, serrated polyps
* Varied types (adenoma, hyperplastic)
* Variable malignancy potential
50
What are the characteristics of a non-neoplastic polyp?
* MC non-neoplastic polyp but can develop to adenomatous
* MC found in rectosigmoid area
* MC very smol
51
What are the submucosal lesions?
Mesenchymal benign tumors.
* Lipoma
* Leiomyoma
* Neurofibroma
* Vascular lesions
| Usually made of **multiple tissue types**
52
What is the MC etiology of colon cancer?
Adenomatous polyps
53
What are the risk factors for colon cancer?
1. >50 y/o
2. FMHx
3. Diet (red meat and high fat)
4. Smoking
5. Obesity
54
When is colonoscopy screening recommended?
45 years for average risk individuals
55
How does proximal colon cancer tend to present?
* Anemia
* Weakness, fatigue
* Melena
* Positive FOBT
* Wt loss
56
How does distal colon cancer tend to present?
* Change in bowel habits
* Obstruction
* Hematochezia
* Tenesmus
57
How is colon cancer diagnosed and staged?
* Diagnose: Colonoscopy
* Staging: CT/MRI
58
What is the treatment for colon cancer?
1. Stage 1 = resection
2. Stage 2-4 = Resection + chemo/radiation
59
What is familial adenomatous polyposis?
| FAP
Genetic predisposition to making thousands of little polyps, often **developing by age 15 and cancerous by age 40.**
## Footnote
Can also make little growths everywhere like skin.
60
For someone with FAP, what surgery is needed to prevent cancer by age 50?
Prophylactic proctocolectomy with anastomosis is recommended by age 20!!
61
Who do we screen for FAP?
* Anyone with many polyps upon endoscopy
* Any first-degree family members with FAP
62
For someone with FAP, how often do we screen them?
EGD every 1-3 years
63
What does lynch syndrome predispose someone to?
Colorectal cancer
64
What does lynch syndrome present as?
Few adenomas, but they are flat and more villous
| Villous = highest likelihood to cause cancer
65
What is the three tool screening for Lynch syndrome?
1. 1st degree relative with colo-rectal cancer prior to age 50
2. Has the pt had colo-rectal cancer/polyps before 50
3. 3 or more relatives with colo-rectal cancer?
66
When is genetic counseling recommended for Lynch syndrome?
* Family/Personal Hx of CRC before 50
* Family history of multiple people with CRC
67
What is the treatment for Lynch syndrome?
* Subtotal colectomy with ileorectal anastomosis
* Prophylactic hysterectomy/oophorectomy by age 40
* Screening with EGD every 2-3 years starting at age 30
* Colonoscopies starting at age 25
68
What defines internal vs external hemorrhoids?
Dentate line
69
What are the primary causes of hemorrhoids?
* Constipation, low fiber
* Straining
* Pregnancy
* Obesity
| Venous pressure increases
70
Where exactly do internal hemorrhoids occur?
* Right anterior
* Right posterior
* Left Lateral
| RAPLL
## Footnote
definitely seems like a test question
71
What veins do external hemorrhoids originate from?
Inferior hemorrhoidal veins below the dentate line.
72
How do internal hemorrhoids tend to present?
* Bleeding, prolapse, Mucoid discharge
* Often not painful
73
How do we look for hemorrhoids?
* Perianal inspection
* Anoscopic evaluation
74
Table of internal hemorrhoid staging
75
How do you conservatively treat stage 1-2 hemorrhoids?
* Proper toileting
* High fiber, drink water, take laxatives
76
How do you treat stage 1-2 hemorrhoids that have recurrent bleeding or stage 3-4?
1. Rubber band ligation (preferred)
2. Injection sclerotherapy
77
For stage 4 or a severe stage 3 hemorrhoid, what is the surgery?
Hemorrhoidectomy
78
How do external hemorrhoids tend to present?
* Very painful
* Bluish nodule that looks poppable
79
How do you treat external hemorrhoids?
* Sitz baths
* Topical ointments
* Evacuation of clot
80
What are anal fissures and what usually causes them?
* Linear tears/ulcerations around the anus caused by hard stools.
* MC in **posterior midline**
* Any other lines might suggest IBD
81
If someone has chronic anal fissures, what could we recommend?
Surgical repair
82
What is the MCC of perianal abscesses?
Perianal fistulas
83
How does a perianal abscess present?
* Fluctuance
* Continuous pain
* Throbbing and swelling
84
How do you treat a perianal abscess?
* I&D
* Maybe use ABX
* Surgical excision
85
How do you treat a perianal fistula?
Fistulotomy under anesthesia
86
Is rectal prolapse normal?
It often reduces spontaneously once you are done defecating
87
If rectal prolapse is chronic/complete, what do we do?
Surgical correction
| Emergent
88
What are the risk factors for rectal prolapse?
* Age > 40
* Female
* Vaginal delivery
* Big baby delivery
* Anything that weakens your pelvic floor
* Dementia
89
How do you treat a rectal prolapse?
* Manual reduction
* Fluid/fiber
* Kegel exercises
* Surgical consult
90
What is pilondial disease?
An extra sinus opening?
91
what arethe screening reccomendations for colonoscopies in the average patient
screen starting at age 45 then every 10 years.
continue until 75 or until life expectancy is <10 years
92
what are contraindications to colonoscopies
acute diverticulitis documented.
93
what medications MUST be stopped prior to colonoscopies
oral iron (5 days)
94
what position is a colonoscopy completed in
left lateral decubitus position
95
what are the adverse events that could occur with colonoscopies
* gas explosion
* postpolypectomy syndrome
* perforation
* bleeding
96
what is the MC presentation of a bowel perforation
abdominal pain with diffuse abdominal tenderness post colonoscopy
97
how to diagnose perforation
abdominal xray
98
tx for perf
IV abx
IV fluids
surgery consult if big
99
what is pospolypectomy syndrome
results from electrocoagulation to bowel wall, causing a burn and peritonitis but NO perforation
100
what are symtpoms/presentation of postpolypectomy syndrome
abdominal pain, fever, abdominal tenderness, and leukocytosis after 5 days.
101
tx for postpolypectomy syndrome
IV fluids
IV antibiotics
bowel rest.
