Intestine 3 Flashcards
abdominal pain disproportionate to exam findings
Severe, steady, diffuse pain w/o focal findings
Late findings: elevated WBC, lactic acidosis, HOTN, abdominal distention
acute mesenteric (ischemic bowel disease)
> 45 years old, atherosclerotic history, epigastric/periumbilical postprandial pain lasting 1-3 hours
Anorexia and fear of eating
Weight loss
Abdominal bruit
chronic mesenteric (ischemic bowel disease)
LLQ pain and tenderness, abdominal cramping, mild diarrhea, bloody or non, more common >60
ischemic colitis
“Visceral artery insufficiency” or intestinal angina
Mesenteric ischemia can be chronic (flow demands not met, commonly from atherosclerotic disease or RF affecting at least ⅔ major vessels) or acute (occlusion like embolism or thrombus from a fib)
ischemic bowel disease
IMA, similar to IBD, after aortic surgery, from a transient and sudden reduction in blood flow
ischemic colitis
CT w/ contrast, angiography
– nonocclusive = “Pruned tree” appearance of distal visceral vascular bed
US = elevated flow velocities if severe, proximal obstructing lesions
acute/chronic mesenteric ischemia
CT of abdomen → “thumbprinting” wall edema and thickening
flexible sigmoidoscopy confirms diagnosis
→ needed to assess grade of ischemia that occurs in recto-sigmoid + splenic flexures
ischemic colitis
how do you treat acute mesenteric ischemia?
Acute - surgical exploration to determine bowel viability
Arterial bypass w/ prosthetic conduit
Bypass with bowel resection
Angioplasty and stenting
how do you treat chronic mesenteric ischemia?
Chronic: surgery
Angioplasty and stenting
Aorto-visceral artery bypass
Endarterectomy
Asymptomatic = modification of RF
how do you treat ischemic colitis?
Ischemic colitis - maintenance of BP + perfusion until circulation is well established, monitoring closely for perforation
70% with tubular MC, (low risk of malignancy), villous* (MC in rectum, increased risk), and tubulovillous*
– >30% in men and 20% women >50
Advanced if >1cm (at risk), >4 polyps
~10 years to become cancer
85% of colon cancer from adenomas
adenomatous colon polyps
large number of serrated polyps and at increased risk:
1) 20+ in colon
2) at least 5 proximal to sigmoid
3) At least 2 of which are 10mm or greater
Serrated polyposis syndrome
juvenile, hamartomas, inflammatory polyps, from UC or Crohn’s
nonneoplastic colon polyps
lipomas, lymphoid aggregates, carcinoids, pneumatosis cystoides intestinalis
submucosal colon polyps
colon polyps RF
genetic, >50
Discrete mass lesions protruding into intestinal lumen, MC sporadic, and can progress into cancer through gene mutation
colon polyps
consider what in those with family history of colorectal cancer affecting more than 1 family member, personal or family history of colorectal cancer at an early age, those with personal/family hx of multiple polyps, and those with extracolonic malignancies
Hereditary colorectal cancer and polyposis syndromes
how to monitor serrated polyposis syndrome
Surveillance colonoscopy recommended every 1-2 years with removal of serrated lesion >3-5mm in size
Can also watch for
Chronic occult blood loss = iron deficiency anemia
Large polyps that ulcerate → intermittent hematochezia
how to dx colon polyps
FOBT (bleeding)
FIT (cancer)
Cologuard (high sensitivity for cancer) - FIT + DNA
CT colonography
Endoscopy – colonoscopy (best means of evaluating entire colon + removing polyps)
→ capsule endoscopy for those who cannot tolerate above
what’s the best means of evaluating entire colon and removing polyps?
colonoscopy
— is performed in all patients who have + FOBT, FIT, or fecal DNA tests or iron deficiency anemia
colonoscopy
how do you treat colon polyps
Colonoscopy polypectomy
normal colonoscopy or <20 hyperplastic polyps <10 mm in distal colon or rectum
repeat colonoscopy every 10 years
5-10 adenomas or sessile serrated polyps <10 mm
1+ adenomas or sessile serrated polyp 10mm or greater
Adenoma containing villous features or high grade dysplasia
Sessile serrated polyp with dysplasia
When do you repeat colonoscopy?
repeat colonoscopy every 3 years
> 10 adenomas
repeat colonoscopy every year
Soft tumors of skin, desmoid tumors (locally invasive fibromas, MC intra-abdominal) → SBO, ischemia, hemorrhage
Osteomas, congenital hypertrophy of retinal pigment
~15 years and cancer by age 40
familial adenomatous polyposis
development of hundreds-thousands of colonic adenomatous polyps + variety of extracolonic manifestations →
APC gene variant
familial adenomatous polyposis
Genetic counseling and testing should be offered when multiple adenomatous polyps are found on endoscopy
14-67 hereditary cancer genes (APC and MUTYH)
Current guidelines = considered in individuals with as little as 10 adenomas to exclude diagnosis in 50-60 years
familial adenomatous polyposis
considered in individuals with as little as – adenomas to exclude diagnosis in 50-60 years
10
how do you treat familial adenomatous polyposis
Prophylactic proctocolectomy before age of 20
– Colonoscopy every 1-2 years with polypectomy with low number of polyps
Upper endoscopy every 1-3 years to look for polyps of upper GI
Sulindac + celecoxib have shown to decrease number/size in rectum
Peutz-Jeghers syndrome – small intestine and fecal mucosa (hamartomatous polyps, mucosal hyperpigmentation)
Familial juvenile polyposis – colon
Cowden disease (PTEN multiple hamartoma syndrome) – throughout GI tract, hair, brain
hamartomatous polyposis syndromes
Benign growth that can grow almost anywhere including the heart, lungs, and GI tract. Consists of surrounding tissues but grows in disorganized pattern
hamartomatous polyposis syndromes
Including peutz-jeghers syndrome, familial juvenile polyposis, and cowden disease (PTEN multiple hamartoma syndrome)
genetic screening for hamartomatous polyposis syndromes at ages
10-12
Increased risk of developing colorectal cancer as well as other cancers, including: endometrial, ovarian, kidney, bladder, hepatobiliary, prostate, brain, gastric, small intestine
lynch syndrome
Hereditary nonpolyposis colon cancer
Autosomal dominant condition (MLH1, MSH2, PMS2, EPCAM)
Genetic evaluation in those with:
- Personal or family history of colorectal cancer <50 years of age
- History of multiple family members with cancer
- >5% PREMM5 model predicted chance of Lynch syndrome
lynch syndrome
A few adenomas, flat and more often contain villous features or high grade dysplasia → rapid transformation into cancer over 1-2 years
lynch syndrome
3 question tool for lynch syndrome risk
Have you had colorectal cancer or polyps diagnosed before age 50?
Do you have 3+ relatives with colorectal cancer?
DO you have a first degree relative with colorectal cancer or another Lynch syndrome-related cancer diagnosed before age 50?
How do you treat lynch syndrome?
Colonoscopy every 1-2 years beginning at age 25 or 5 years younger than the age of diagnosis at youngest affected family member
Subtotal colectomy with ileorectal anastomosis (followed by surveillance)
Women = screen endometrial/ovarian cancer beginning at age 30-35 years w/ pelvic exam, TV US, sampling
– hysterectomy and oophorectomy recommended at age 40 or when finished with children
Screen for gastric cancer w/ upper endoscopy every 2-3 years starting at age 30-35
Right sided = chronic blood loss → iron deficiency anemia (fatigue and weakness)
Left sided = obstructive symptoms → colicky abdominal pain and change in bowel habits, bloody stool
Rectal = tenesmus, urgency, recurrent hematochezia
Rectal bleeding, change in bowel habits
colorectal cancer
chronic blood loss → iron deficiency anemia (fatigue and weakness)
right sided colon cancer
obstructive symptoms → colicky abdominal pain and change in bowel habits, bloody stool
left sided colon cancer
tenesmus, urgency, recurrent hematochezia
rectal cancer
RF for colon cancer
Age >50
Family history
Smoking
Consumption of red and processed meat
Alcohol intake
DM
Physical inactivity
Obesity
IBD
Primary sclerosing cholangitis
African americans
75% in no known predisposition
Almost all are adenocarcinomas, from malignant transformation of an adenomatous (MCC) or serrated polyps
colon cancer
> / 1 cm in size
Adenomas w/ villous features or high grade dysplasia
Serrated polyps with dysplasia
polyps at greater risk
Change in BM or hematochezia
Unexplained iron deficiency anemia
Occult blood in stool samples
What must you exclude?
neoplasms must be excluded in any patient
+Fecal occult blood
+Multitarget stool DNA assay
PE normal until advanced disease
Hepatomegaly
Digital rectal exam – if at distal rectum, determine extension into anal sphincter/fixation indicating spread
Labs:
CBC - anemia
CMP - elevated liver enzymes (metastatic)
CEA measured once confirmed diagnosis (>5 = poor prognosis)
Colonoscopy w// biopsy
CXR, abdominal XR, pelvic CT w/ IV contrast for staging
Rectal = pelvic MRI or endorectal US
colon cancer
— – is required with history suggesting cancer or with abnormality suspicious of cancer
& upper endoscopy with new onset iron-deficiency anemia
colonoscopy w biopsy
Average risk individuals colorectal cancer screening at – and older w/ annual labs (FOBT, FIT, fecal DNA) and colonoscopy every – years, CT and sigmoidoscopy every -
at 45 years
every 10
every 5
If relative was diagnosed 60+, begin screening at
40 years
If relative was diagnosed <60, begin screening at
40 years or 10 years younger than diagnosed relative
How do you treat colon cancer? (By stages)
Surgical resection of tumor
Curative for stages I-III
Regional dissection of at least 12 lymph modesto determine staging
Chemo following resection to improve survival
Stage 1 = no chemo needed
Stage 2 = not beneficial unless high risk
Stage 3 = chemo recommended
Stage 4 = radiation, systemic therapy. Biological and or immunotherapy
Rectal: small <4 = resection, may need chemoradiation pre or post op
Hematemesis, melena, hematochezia
Occult: fatigue, dizziness, incidental iron deficiency anemia, early satiety, nausea, intermittent abdominal pain
→ abdominal pain, weight loss, family history of cancer, fatigue, chest pain, DOE, dizziness
GI bleeding
hematemesis, melena, hematochezia
UGIB
hematochezia (quantify)
Diverticular = cherry pie jelly chunky
RF: NSAID, antiplatelet, anticoagulant use
LGIB
Gross = visible
Occult = not visible, detected by FOBT (mostly from upper GI tract, from cancer, vascular lesions, gastritis, ulcers, IBD, polyps)
GI bleed
PUD
Portal HTN
Mallory-weiss tear
Vascular anomaly
Gastric neoplasm
causes of UGIB
diverticulosis/diverticulitis (painless)
Infectious colitis
Hemorrhoids
Neoplasms
Angioectasias
IBD
ulcers
causes of LGIB
+ Colon cancer screening w/ FOBT
Workup for iron deficiency anemia
Take adequate history!
Assess Stability (high risk SBP<100 or HR >100)
2 large-bore IVs in separate limbs
DRE
CBC, INR, CMP, type and screen
Troponin and EKG
Continuous telemetry
Serum lactate
Differentiate from other causes
GI bleeding
What’s additional workup for a GI bleed?
Additional workup:
EGD (diagnostic + therapeutic)
Anoscopy and sigmoidoscopy
- In otherwise healthy patients w/o anemia <45 years of age w/ small volume bleeding
Colonoscopy
- Requires prep
CT angiography
- massive lower GI bleeding, instability
Push enteroscopy (w/ balloon)
Capsule endoscopy
How do you treat GI bleeding?
Fluid bolus if HOTN
Consent for blood
Stop anticoags/platelets
Consider reversing
IV PPI now (continuous)
Fluid resuscitation
Admit to ICU
