Large Bowel Disorders

Question 1

What is the definition of a Diverticula?

Answer 1

small mucosal herniations protruding through intestinal and smooth muscle layer along natural openings of the vasa recta of the colon

Question 2

What is the most common area for a diverticula and why?

Answer 2

Sigmoid colon = highest intraluminal pressure

Question 3

What is the definition of Diverticulosis?

Answer 3

uninflamed diverticula associated with low fiber diet, constipation, and obesity

Question 4

What is the most common cause of acute lower GI bleeding?

Answer 4

Diverticulosis!

Question 5

What is the definition of Diverticulitis?

Answer 5

inflamed diverticula 2ry to obstruction/infection (fecaliths) leading to distention

Question 6

What are the clinical manifestations of diverticulitis?

Answer 6

1. fever
2. LLQ pain
3. N/V
4. diarrhea/constipation
5. flatulence

Question 7

What is the diagnostic test of choice for diverticulitis?

Answer 7

CT scan

Ba enema not done in acute phase!!

Question 8

What is the management of diverticulitis?

Answer 8

clear liquid diet

broad spectrum abx = cipro (or Bactrim) + Metronidazole

Question 9

What is the management of diverticulosis?

Answer 9

high fiber diet, fiber supplements

Question 10

What is the definition of a volvulus?

Answer 10

twisting of any part of bowel in itself

Question 11

Where does a volvulus most commonly happen?

Answer 11

sigmoid colon or cecum

Question 12

What are the clinical manifestations of a volvulus?

Answer 12

obstructive s/sxs —> abd. pain, distention, N/V, fever, tachycardia

Question 13

What is the management of a volvulus?

Answer 13

Endoscopic decompression initially!

Surgical correction is 2nd line

Question 14

What is the most common cause of obstruction of the appendix?

Answer 14

Fecalith (hardening of feces)

Question 15

What is the one clinical feature that can rule out appendicitis?

Answer 15

if the patient is hungry!!

Question 16

What is Rovsing sign?

Answer 16

RLQ pain with LLQ palpation

Question 17

What is obturator sign?

Answer 17

RLQ pain with internal and external hip rotation with bent knee

Question 18

What is Psoas sign?

Answer 18

RLQ pain with right hip flexion/extension (SLR)

Question 19

How is appendicitis diagnosed?

Answer 19

CT scan
US
leukocytosis

Question 20

What is the hallmark of irritable bowel syndrome?

Answer 20

Abdominal pain associated with altered defecation/bowel habits (diarrhea, constipation, or alteration between the 2)

Question 21

What is the clinical definition of IBS?

Answer 21

chronic, functional idiopathic disorder with NO organic cause

Question 22

Name some “alarming symptoms” of IBS?

Answer 22

Evidence of GI bleeding
Anorexia or weight loss
Nocturnal symptoms
Onset > 45 years
Persistent diarrhea causing dehydration OR
Severe constipation causing fecal impaction

Question 23

What are the possible pathophysiology of IBS?

Answer 23

1. Abnormal motility –> chemical imbalance in intestine causing abnormal movements and spasm
2. Visceral hypersensitivity –> lower pain thresholds to intestinal distention
3. Psychosocial interactions

Question 24

What specific chemicals can be imbalanced in the intestine to cause IBS?

Answer 24

Serotonin and Acetylcholine

Question 25

What is the Rome II Diagnostic Criteria for IBS?

Answer 25

Abdominal pain or discomfort with 2 of 3 features for at least 12 weeks during preceding 12 months 1. relief with defecation**** 2. onset associated with change in stool frequency 3. onset associated with change in stool formation

Question 26

What are the management options for IBS?

Answer 26

Lifestyle changes --> smoking cessation, eat low fat/unprocessed foods, sleep, exercise ``` Anticholinergics (Dicyclomine) Antidiarrheal (Loperamide) Prokinetics Bulk-forming laxatives Saline or osmotic laxatives ```

Question 27

What is acute mesenteric ischemia?

Answer 27

sudden decrease of mesenterial blood supply to the bowel GI EMERGENCY!!!

Question 28

Where is inadequate perfusion most common in acute mesenteric ischemia and why?

Answer 28

at the splenic flexure b/c less collateral blood perfusion

Question 29

What are the most common etiologies for acute mesenteric ischemia?

Answer 29

1. embolus (ex. pts with Afib) 2. thrombus (esp in pt with prior known atherosclerosis) 3. Non-occlusive causes (less common) --> shock, cocaine

Question 30

What are the clinical manifestations of acute mesenteric ischemia?

Answer 30

SEVERE abdominal pain out of proportion to physical findings

Question 31

What is the diagnostic test of choice for acute mesenteric ischemia?

Answer 31

Angiogram!

Question 32

What is the management for acute mesenteric ischemia?

Answer 32

Revascularization! (angioplasty with stenting or bypass) Surgical resection if bowel not salvageable

Question 33

What is chronic mesenteric ischemia?

Answer 33

mesenteric atherosclerosis of the GI tract leading to inadequate perfusion in post-prandial states (esp. at splenic flexure)

Question 34

What are the clinical manifestations of chronic mesenteric ischemia?

Answer 34

``` chronic dull abdominal pain worse after meals "intestinal angina" Weight loss (anorexia) ```

Question 35

What is the diagnostic test of choice for chronic mesenteric ischemia and what will it show?

Answer 35

Colonoscopy --> mucosal atrophy with loss of villi

Question 36

What is the management for chronic mesenteric ischemia?

Answer 36

bowel rest | revascularization (angioplasty with stenting or bypass)

Question 37

What is toxic megacolon?

Answer 37

non-obstructive, severe colon dilation > 6cm + signs of systemic toxicity

Question 38

What are the most common etiologies of toxic megacolon?

Answer 38

``` UC, Crohn's pseudomembranous colitis infectious XRT ischemic Hirschsprung ```

Question 39

What are the clinical manifestations of toxic megacolon?

Answer 39

``` Abdominal pain diarrhea N/V rectal bleeding or tenesmus fever, tachycardia, hypotension ```

Question 40

What is Hirschsprung?

Answer 40

a congenital aganglionic colon (neurogenic bowel obstruction)

Question 41

What is the diagnostic test of choice for toxic megacolon and what will it show?

Answer 41

Abdominal X-ray ---> large dilated colon > 6cm

Question 42

What is the management of toxic megacolon?

Answer 42

bowel decompression (NG tube) bowel rest broad spectrum abxs Colostomy if refractory

Question 43

What is the medical definition of tenesmus?

Answer 43

continual or recurrent inclination to evacuate the bowels

Question 44

What are the clinical manifestations of ischemic colitis?

Answer 44

LLQ pain with tenderness and bloody diarrhea Due to sloughing off of the colon

Question 45

What is the diagnostic test of choice for ischemic colitis and what will it show?

Answer 45

Colonoscopy ---> segmental ischemic changes in areas of low perfusion (ex. splenic flexure)