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GI II Exam 2 EH > Lecture 10: Small Bowel and Colon Disorders > Flashcards

Lecture 10: Small Bowel and Colon Disorders Flashcards

1
Q

What is the Bristol Stool Chart and how does Type 1 differ from Type 7?

A
  • Type 1 is on the constipated end of the spectrum w/ stool equal to hard lumps, like nuts (hard to pass)
  • Type 7 is on the diarrhea end of the spectrum and is watery w/ no solid pieces (entirely liquid)
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2
Q

What is the major cause of death associated with diarrhea?

A

Dehydration

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3
Q

Diarrhea for >14 days is most commonly due to a (infectious/non-infectious) cause?

A

Likely non-infectious —> think meds!

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4
Q

If a workup is indicated for acute diarrhea which serum labs should you get?

A
  • CBC
  • Electrolytes
  • BUN
  • Cr
  • Blood culture?
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5
Q

Most routine (bacterial) stool cultures include which 4 organisms?

A
  • Salmonella
  • Shigella
  • E. coli (ask for shiga-like toxin detection for O157:H7 EHEC)
  • Most detect campylobacter (although may need to be requested)
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6
Q

Food poisoning from which bacteria is commonly seen after ingestion of potato salad, mayonnaise or cream pastries?

A

S. aureus = Gram (+) cocci

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7
Q

Food poisoning by which bacteria is most commonly associated with ingestion of lunch meat and unpasteurized dairy?

A

Listeria monocytogenes** –> **Gram (+) rod

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8
Q

What virulence factor does S. aureus contain that leads to the sx’s of food poisoning?

Type of diarrhea?

A
  • Preformed enterotoxins
  • Watery diarrhea
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9
Q

Which bacteria is associated with food poisoning from fried rice?

Type of diarrhea and what is the main symptom?

A
  • Bacillus cereus –> Gram (+) rod
  • Watery diarrhea
  • Vomiting is the main symptom!
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10
Q

Which gram-positive spore-forming rod is associated with food poisoning as a result of consuming inadequately cooked beef, ham, poultry, legumes, or gravy?

Type of diarrhea?

A
  • Clostridium perfringens
  • Watery diarrhea
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11
Q

Shigella spp. food poisoning is most commonly associated with what types of food?

A

Potato or egg salad, lettuce, raw vegetables

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12
Q

What type of diarrhea and symptoms are associated with Shigella spp. food poisoning?

A

Begins as watery —> intense colitis w/ fever and frequent small volume stools w/ blood and pus

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13
Q

Shigella spp. infection will have what finding in the stool of infected pt?

A

Fecal leukocytes (+)

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14
Q

What are post-infectious complications of Shigella spp.?

A
  • Reactive arthritis

- HUS

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15
Q

Complications associated with Salmonella typhimurium?

A
  • Reactive arthritis
  • Endocarditis
  • Septic arthritis
  • Osteomyelitis (sickle-cell pts)
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16
Q

Vibrio parahemolyticus is associated with food poisoning from the consumption of what?

What kind of diarrhea?

A
  • Seafood (i.e., shellfish, oysters, shrimp)
  • Watery —> bloody diarrhea
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17
Q

Where is Vibrio vulnificus found?

Most often infects people via what 2 routes?

Common symptoms associated with each route?

A
  • Warm, shallow, coastal salt water
  • Eating raw shellfish (oysters) –> vomiting and diarrhea
  • Open wounds in the water –> bullous skin lesions
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18
Q

Vibrio vulnificus infections are life threatening in which patients?

A
  • Immunocompromised
  • Especially cirrhosis and hemochromatosis pts
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19
Q

Aeromonas hydrophila is found in which enviornments?

Most often transmitted how?

A
  • Fresh water or brackish water (slightly salty)
  • Eating fish or shellfish
  • Wounded in the water or open wounds in water
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20
Q

Which type of diarrhea can be produced by Aeromonas hydrophila? (2 types)

A
  • Cholera-like: watery rice water stools
  • Bloody mucoid stools
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21
Q

If someone sustains a wound while in fresh water and then has a rapidly progressive wound infection (i.e., necrotizing fasciitis), which bacteria should be susepcted?

A

Aeromonas hydrophila

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22
Q

What are positive serum and fecal findings associated with EHEC infection?

A
  • Peripheral leukocytes (+) - CBC
  • Fecal leukocytes or lactoferrin (+)
  • Stool culture = shiga-like toxin
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23
Q

Antibiotic therapy for EHEC increases the risk for?

A

HUS

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24
Q

Infections by Yersinia enterocolitica poses a higher risk in which patients?

A
  • Pts w/ derangement of iron metabolism
  • Iron-overload syndromes, cirrhosis, hemochromatosis, aplastic anemia, and thalassemia
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25
Q

Infection by which bacteria can mimic appendicitis due to its localization to the terminal ileum?

A

Yersinia enterocolitica

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26
Q

Listeria monocytogenes can infect anybody, but has a predilection for whom?

A
  • Pregnant women
  • Extremes of age
  • Immunosuppressed
  • Those w/ Hemochromatosis
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27
Q

How is C. difficile diagnosed?

A

Stool culture - PCR for toxin (TcdA and TcdB)

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28
Q

Which 4 antibiotics are most commonly associated with infection with C. difficile?

A

1) Clindamycin
2) Ampicillin
3) Cephalosporins (3rd gens)
4) Fluoroquinolones

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29
Q

Best preventative measure for minimizing transmission and infection of C. difficile in a hospital setting?

A

Wash hands w/ soap and water + use of disposable gloves

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30
Q

How is Rotavirus detected?

Characteristic finding on electron microscopy?

A
  • Detected by viral culture PCR
  • “Wagon-wheel” appearance on electron microscopy
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31
Q

Who is most commonly affected by Adenovirus and what are the most common symptoms?

A
  • Children
  • Fever, chills, myalgias, sore throat
  • Watery diarrhea
  • Conjunctivits
  • Pharyngitis
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32
Q

How is the Dx of Strongyloides stercoralis made?

A

- Rhabditiform larvae in stool

- Eosinophils in stool

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33
Q

Which organism is the 2nd most common cause of Esophageal Varices in Africa?

What other complications?

A
  • Schistosoma mansoni
  • Bloody stools, bladder cancer, and liver cysts
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34
Q

Which organism can form cysts in the liver or lungs, which characteristically looks like free-flowing “hydatid sand” on CT?

A

Echinococcus granulosus

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35
Q

Which 2 bacteria are most often responsible for inflammatory diarrhea w/ fecal leukocytes and fecal lactoferrin but not typically bloody stools?

A
  1. Listeria monocytogenes
  2. Clostridium difficile
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36
Q

Anti-motility agents may be used in patients in whom no fever and non-bloody stools exist, but are not to be used if infection is due to which 2 organisms?

A
  • C. diff
  • EHEC
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37
Q

Chronic use of what can lead to melanosis coli, a benign hyperpigmentation of the colon?

A

Laxitives

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38
Q

The presence of abdominal pain with chronic diarrhea (>4 wks duration) suggests which 2 disorders may be present?

A

1) IBS
2) IBD

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39
Q

Before embarking on an extensive evaluation for the cause of someones chronic diarrhea the most common causes should be considered which include what 3 things?

A

1) Medications
2) IBS
3) Lactose intolerance

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40
Q

Which signs/symptoms and findings are inconsistent with the most common causes of chronic diarrhea (i.e., red flags) and warrant further evaluation?

A
  • Presence of nocturnal diarrhea
  • Weight loss
  • Anemia
  • Positive FOBT
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41
Q

Evaluation of chronic diarrhea showing a fecal elastase <100 mcg/g may point to what underlying problem?

A

Pancreatic insufficiency

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42
Q

Neuroendocrine tumors may be localized via what imaging modality?

A

Somatostatin receptor scintigraphy

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43
Q

A patient with chronic, high-volume watery diarrhea (>1L/day) with normal osmotic gap that persists during fasting should raise suspicion of which disorder?

A

Neuroendocrine tumor

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44
Q

Which non-invasive breath tests can be used for the diagnosis of small bowel bacterial overgrowth?

A

Glucose or lactulose or 14C-xylose breath tests

45
Q

Carbohydrate malabsorption is common and should be considered in all patints with chronic, postprandial diarrhea, and can be confirmed by which tests?

A
  • Elimination trial for 2-3 weeks
  • Hyrdrogen breath tests
46
Q

What are the 2 major subtypes of Microscopic Colitis?

A

1) Lymphocytic colitis
2) Collagenous colitis

47
Q

What are some of the meds that have been implicated in Microscopic Colitis (i.e., collagenous and lymphocytic colitis)?

A
  • NSAIDs
  • PPIs
  • Low-dose aspirin
  • SSRIs
  • AChE inhibitors
  • Beta-blockers
48
Q

What is the first line treatment for the diarrhea associated w/ Microscopic Colitis?

A

Antidiarrheal therapy w/ loperamide

49
Q

What is stool osmotic gap?

What is a normal value?

A
  • Difference between measured osmolality of the stool (or serum) and the estimated stool osmolality
  • Normally <50 mOsm/kg
50
Q

An osmotic gap >75 mOsm/kg implies that diarrhea is caused by what?

A

Ingestion or malabsorption of an osmotically active substance

51
Q

A person with diarrhea that has an increased stool osmotic gap and a stool volume that decreases with fasting is a clue for what type of diarrhea?

52
Q

In any patients with chronic, postprandial diarrhea what should alway be considered as a cause?

A

Carbohydrate malabsorption

53
Q

What are some of the most common causes of Osmotic Diarrhea?

A
  • CHO malabsorption (lactose, fructose, sorbitol)
  • Laxative abuse = Factitious (could be osmotic or secretory)
  • Medications: antacids, lactulose, etc..
54
Q

High-volume watery diarrhea (>1L/day) with a normal osmotic gap is characteristic of what type?

A

Secretory diarrhea

55
Q

What is the effect of fasting on Secretory Diarrhea?

A

Little change in stool output

56
Q

What are some common causes of Secretory Diarrhea?

A
  • Endocrine tumors: ZE syndrome, Carcinoid syndrome, VIPoma, Medullary thyroid carcinoma
  • Bile salt malabsorption
57
Q

What is one of the most common causes of chronic watery diarrhea in the elderly?

A

Microscopic colitis

58
Q

4 characteristic signs/symptoms of Malabsorptive Conditions?

A
  • Weight loss
  • Osmotic diarrhea
  • Steatorhhea
  • Nutritional deficiency
59
Q

The steatorrhea associated with Pancreatic Insufficiency is due to malabsorption of?

A

Triglycerides

60
Q

Characteristic skin rash consisting of pruritic papulovesicles over the extensor surfaces of the extremities and over the trunk, scalp, and neck is a cutaneous manifestation of what malabsorptive disorder?

A

Celiac disease —> dermatitis herpetiformis

61
Q

Recommended serological test for Celiac Disease is?

A

IgA tTG antibody

62
Q

Which serologic test has excellent sensitivity and specificity for Celiacs disease and can be useful in pts with IgA deficiency as well as young children?

A

IgG anti-deaminated gliadin peptides (DGP)

63
Q

What is the standard method for confirming the diagnosis of Celiacs in a patient w/ positive serologic tests?

A

Mucosal biopsy of prox. duodenum and distal duodenum

64
Q

Why is Dual-energy X-ray densitometry scanning recommended for all patients with sprue?

A

Screen for osteoporosis

65
Q

How is the diagnosis of bacterial overgrowth in the GI confirmed?

A

Jejunal aspiration w/ quantitative bacterial cultures

66
Q

Bacterial overgrowth is associated with what type of diarrhea(s)?

A

Osmotic and secretory + increased flatulence

67
Q

What are 6 of the most common causes of Short Bowel Syndrome in adults?

A

1) Chron disease
2) Mesenteric infarction
3) Radiation enteritis
4) Volvulus
5) Tumor resection
6) Trauma

68
Q

Which factors play a role in the type and degree of malabsorption associated with Short Bowel Syndrome?

A

- Depend on the length and site of the resection

- Degree of adaption of the remaining bowel

69
Q

Increased erythrocyte sedimentation rate or CRP in a patient with chronic diarrhea suggests which disorder?

70
Q

What is the most sensitive method for detecting Giardia and E. histolytica infection?

A

Fecal antigen test

71
Q

What does an adequate normal biopsy of a patient with suspected Celiac Disease mean?

A

Excludes the diagnosis

72
Q

Most patients with Celiac disease also have what other deficiency?

A

Lactose intolerance either temporarily or permanently and should avoid dairy until intestinal symptoms improve on glute-free diet

73
Q

What is the most common presenting symptom with Whipple Disease?

Others?

A
  • Weight loss = most common
  • Arthralgias = first sx’s
  • Diarrhea
  • Abdominal pain
74
Q

Whipple disease is established (90%) by endoscopic biopsy w/ histo evaluation of which part of the GI?

75
Q

What is the characteristic appearance of Whipple bacillus on electron microscopy?

A

Trilamellar wall

76
Q

Resection of over 50cm vs. 100cm of the ileum will lead to what deficiencies and what type of diarrhea associated with each?

What must be done as treatment?

A
  • >50cm = require monthly subcutanous or IM vit B12 shots; bile salt malabsorption will lead to watery diarrhea
  • >100 cm = ↓ bile salt pool –> steatorrhea and ADEK deficiency. Require a low-fat diet and vitamin supplements
77
Q

All of the unabsorbed fatty acids as a result of terminal ileal resection will bind to what and lead to what problem(s)?

Should be managed how?

A
  • Bind Ca2+, decreasing its absorption and increasing absorption of oxalate —> Oxalate kidney stones
  • Cholesterol gallstones due to decreased bile salts (common)
  • Ca2+ supplements should be given to bind oxalate and increase serum Ca2+
78
Q

What % of the small intestine can be resected and is usually well tolerated?

79
Q

Resection of the colon + 100 cm of proximal jejunum should be managed how?

Main goal?

A
  • Maintain adequate oral nutrition
  • Low-fat, high-complex CHO diet
80
Q

With a full colon resection + less than 100-200cm of jejunum left, how should this pt be managed nutritionally?

A

NEED parenteral nutrition

81
Q

Duodenal resection will lead to malabsorption of which vitamins?

A

Folate, iron, or calcium

82
Q

What is the most common cause of chronic diarrhea in young adults + the most common GI disease in clinical practice?

83
Q

What are the 3 types of clinical presentations for IBS?

A
  1. Spastic colon (chronic abdominal pain and constipation)
  2. Alternating constipation and diarrhea
    3) Chronic, painless diarrhea
84
Q

Pts presenting with IBS to a physician have an increased frequency of what type of disturbances?

A

Psychological –> Depression, hysteria, OCD

85
Q

Patients with IBS often report relief of abdominal pain with?

A

Bowel movements

86
Q

How long must the symptoms associated with IBS be present for a diagnosis and how long for it to be considered a differential?

A

Chronic > 6 months (sx’s for at least 3 mo. before considering it a differential)

87
Q

When assessing a patient with IBS you need to ask about “alarm symptoms,” which include what 6 things?

A
  • Acute onset of sx’s
  • Nocturnal diarrhea
  • Severe constipation or diarrhea
  • Hematochezia
  • Weight loss
  • Fever = incompatible w/ dx of IBS
88
Q

What are the 3 ROME diagnostic criteria for IBS?

A
  1. Improvement with defecation
  2. Onset associated w/ a change in frequency of stool
  3. Onset associated w/ a change in form (appearance) of stool

*Criteria filled for last 3 months with sx onset at least 6 months before diagnosis*

89
Q

In patients w/ IBS that have a lot of diarrhea, bloating, and flatulence which dietary restriction should be considered to improve symptoms (hint: mnemonic)?

A
  • Dietary restriction of “FODMAPS”
  • Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols
90
Q

XR or CT demonstrating colon dilation, confined to the cecum and proximal colon without signs of mechanical obstruction is consistent with what disorder?

A

Acute colonic pseudo-obstruction (Ogilvie Syndrome)

91
Q

A cecal diameter greater than _______ cm is associated with increased risk of colon perforation and requires intervention.

A

A cecal diameter greater than 10-12 cm is associated with increased risk of colon perforation and requires intervention.

*Ogilvie Syndrome

92
Q

How often should Cecal size be assessed with an abdominal radiograph in a patient with Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)?

A

Every 12 hours

93
Q

What are major differences between antibiotic-associated diarrhea and antibiotic-associated colitis?

A
  • ABx- assoc. diarrhea = most cases NOT due to C. difficile + Diarrhea typically occurs during period of ABx exposure and resolves spontaneously w/ discontinuation
  • ABx-assoc. colitis = almost always due to C. difficile and sx’s can be mild to fulminant
94
Q

Patients on antibiotics and what other drug in a hospital setting are at a higher risk of acquiring C. difficile and developing C. difficile-associated diarrhea?

95
Q

C. difficile should be considered in all hospitalized patients with unexplained?

A

Leukocytosis

96
Q

Which labratory findings (i.e., WBC’s, albumin, and others) are suggestive of severe disease in patient with C. difficile?

A
  • WBC >30,000/mcL
  • Albumin <2.5 g/dL (protein-losing enteropathy)
  • Elevated serum lactate
  • Rising creatinine
97
Q

In patients with severe C. difficile colitis what will be seen on flexible signoidoscopy?

Characteristic findings.

A
  • True pseudomembranous colitis
  • Classic “volcano” exudate of fibrin and neutrophils
98
Q

Diverticulitis is best staged and confirmed with what imaging modality?

Which imaging modality is contraindicated?

A
  • Best = CT with contrast
  • Endoscopy is contraindicated during initial stages of an acute attack due to risk of perforation
99
Q

Pts with weight loss, who have been experiencing a dull, crampy periumbilical pain 15-30 mins after a meal that lasts several hours and often report a “food fear” need to be evaluated for?

A

Chronic Mesenteric Insufficiency (aka “abdominal angina)

100
Q

What is the American Cancer Society guidelines for colorectal cancer screening for all people at average risk?

A
  • Start regular screening at age 45
  • Continue screening through age 75 (screening after 75 is based on personal preferences, life expectancy, overall health, and prior screening hx)
101
Q

What is the recommeded screening for CRC in a patient w/ a first-degree relative w/ CRC or adenomas diagnosed <60 yo or two first-degree relatives of any age?

A

Colonoscopy every 5 years, beginning at age 40 or 10 years before the age of the youngest affected relative (whichever is first)

102
Q

When should screening for CRC begin in someone with FAP?

103
Q

When should screening for CRC begin in someone with HNPCC?

A

Beginning at age 20-25 yo and every 1-2 years or 10 years younger than youngest age of CRC diagnosis in family

104
Q

What is a more sensitive test for CRC and advanced adenomas compared to FOBT?

A

FIT = fecal immunohistochemical test for hemoglobin

105
Q

What are ways that colonic polyps can be identified and treated?

Which are recommended and which are not?

A
  • Barium enema (not recommended) or CT colonography (okay, but only for low risk pt)
  • Colonoscopy = best choice –> diagnostic and therapeutic (polyectomy)
106
Q

What is the recommended treatment for FAP?

A

Prophylactic colectomy to prevent otherwise inevitable colon cancer

107
Q

Lynch syndrome (aka HNPCC) is due to mutations in genes essential in?

A

DNA base-pair mismatches: MLH1, MSH2

108
Q

The diagnosis of Lynch Syndrome (HNPCC) is suspected with what type of test/finding?

Diagnosis is confirmed via?

A
  • Diagnosis suspected by tumor tissue immunohistochemical staining for mismatch repair proteins or testing microsatellite instability
  • Confirmed by genetic testing!
109
Q

For woman with Lynch syndrome (HNPCC) at age 40 or once they have finished childbearing, what is the recommended treatment?

A

Prophylactic hysterectomy and oophorectomy

GI II Exam 2 EH (15 decks)

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