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Clinical Medicine 4 > Lecture 4 (GI)-Exam 1 > Flashcards

Lecture 4 (GI)-Exam 1 Flashcards

1
Q
  • What are the risk factors of C-Diff colitis? (3)
  • What is the pathophysio?
A

Pts taking a lot of PPIs may get this…lots of acid suppression may lead to it.

The broader the spectrum the ABX (ex: Clindamycin), the more likely.

Transmitable! Anaerobic G+ spore-forming bacteria, spores not killed by EtOH, so need to actually wash your hands in soap and water if come into contact with C. diff pt. Also bleach

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2
Q

Clostridium difficile
* produces what?
* What type of diarrhea?

A
  • Produces a toxin which causes mucosal damage (pseudomembranous colitis).
  • Inflammatory diarrhea
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3
Q

Pseudomembranous Colitis
* What does it appear like?

A

Pseudomembranous colitis appears as a tan to yellow-green exudate over an erythematous bowel mucosa.

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4
Q

Treatment – Clostridium difficile Colitis
* Discont what?
* use what type of precaution?
* What is the oral drug of choice?

A
  • Discontinue antibiotics if possible
  • Use Contact Precautions until diarrhea stops!
  • Dificid (fidaxomicin) – oral drug of choice
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5
Q

Treatment – Clostridium difficile Colitis
* What is used for alternative or recurrence c. diff?
* Oral or IV Metronidazole can be added to vancomycin if what?
* What has recently been approved for recurrent infections?

A

Alternative or recurrence -> ORAL Vancomycin
* If patient has failed to respond to fidaxomicin
* If patient is critically ill because of C. difficile colitis

Oral or IV Metronidazole can be added to vancomycin if it is a fulminant episode with hypotension or with ileus

Bezlotoxumab has recently been approved for recurrent infections

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6
Q

C-diff Recurrence
* Risk of recurrence?
* What is the tx?

A

20-30% risk of recurrence (diarrhea)

TX:
* 14 day course of Fidaxomicin or PO Vancomycin
* Fecal transplant if all else fails

with these pts, do NOT give Flagyl in relapse but Vanco or Fidaxo
* concomitant probiotics MAY help

if recurrent relapse, May do fecal transplant.

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7
Q

Ischemic Colitis
* What is the physical exam?

A

PAIN OUT OF PROPORTION TO PHYSICAL EXAM. No tenderness, no guarding.

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8
Q

Ischemic Colitis
* Ischemia of the colon (GUT ANGINA) most often affect who?
* Thought to be caused by what?
* Ischemic colitis is almost always what?

A
  • Ischemia of the colon (GUT ANGINA) most often affects the elderly (90% of patients > 60 y/o ).
  • Thought to be caused by small vessel atherosclerosis
  • Ischemic colitis is almost always non-occlusive. (emboli are the most common cause of occlusive acute mesenteric ischemia)
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9
Q

Ischemic Colitis
* What are the sxs? What is elevated?
* How do you dx it?
* What is the txt?

A
  • Symptoms – postprandial abdominal pain followed by rectal bleeding.
    * Lactic acid is elevated >2
  • Diagnosis – CTA Abdomen and Pelvis
  • Treatment – Supportive (bowel rest, IV fluids, ABX, blood thinners) - surgery is rarely required.
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10
Q

under notes

Ischemic Colitis
* CP worse with what?
* ischemia to aa that affect bowel. More common in elderly pts with what?
* almost always what? More of what type of process? Acute mesenteric ischemia pts usu have what?

A
  • CP worse with eating (like with heart, worse with walking) b/c more blood is required then
  • ischemia to aa that affect bowel. More common in elderly pts with CAD risks…HTN, cholesterol, etc.
  • almost always NONOCCLUSIVE. Another disorder—acute mesenteric ischemia that is ACUTE
  • IC more of a chronic process over time b/c of atheroscelrotic process. (thrombotic process over time)
  • Acute mesenteric ischemia pts usu have A fib; clots form in A fib, can embolize to arteries of gut. (acute embolic process)
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11
Q

Differential Diagnosis of Constipation
* What is the DDX of lifestyle (4), drugs (2) and metabolic (2)?

A

Lifestyle
* Inadequate fiber
* Little food intake
* Ignoring urge to defecate (children)
* Immobility (elderly)

Drugs
* Opiates
* Anti-cholingerics

Metabolic/Endocrinologic
* Hypothyroidism
* Hypercalcemia

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12
Q

Differential Diagnosis of Constipation
* What is the ddx for neurologic (4)?
* What is the ddx for GI tract (5)

A

Neurologic
* Parkinson’s disease
* Multiple Sclerosis
* Spinal lesions
* Autonomic neuropathy

Gastrointestinal tract
* Luminal obstruction
* Aganglionosis (Hirschsprung’s disease)
* Myopathy
* Neuropathy
* Systemic sclerosis (scleroderma)

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13
Q

Differential Diagnosis of Constipation
* What is the DDX for anotrectum
* What is the DDX for idiopathic consitipation

A

Anorectum
* Anal atresia
* Anal stenosis
* Large rectocele
* Weak pelvic floor
* Rectal prolapse

Idiopathic constipation
* Irritable bowel syndrome
* Slow colonic transit (colonic inertia)
* Outlet delay:
* Megarectum
* Fecal impaction
* Pelvic floor dysfunction

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14
Q

Functional Ileus
* Intolerance of oral intake due to what?
* What has to be ruled out? How?
* Presents similar to what?
* Usually presents on 3rd/5th day after what? Prolonged ileus is when what?

A
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15
Q

Functional Ileus
* What is the clinical presentation?

A
  • Initially abdominal distention and bloating leading to diffuse abdominal pain, then N/V, anorexia and inability to pass flatus
  • Bowel sounds are usually absent, but no peritoneal signs
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16
Q

Ileus Management
* What do you depress and how?
* Rest what and give what?
* What is is supportive to improve bowel motility ?
* What anx can be used?
* Ultimately, treat what?
* Prolonged ileus may require what?

A
  • GI decompression via NG tube
  • Bowel rest and IV fluids
  • Some studies show that chewing gum is supportive to improve bowel motility (stimulates cephalocaudal reflex)
  • Erythromycin can be used (although outcomes are mixed)
  • Ultimately, treat the underlying cause
  • Prolonged ileus may require TPN
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17
Q

Hirschsprung Disease
* Stems from what? Rarely affects what?
* Lack of what?
* What is the MC coexisting cogenital anomaly?

A
  • Stems from congenital anomaly of innervation of colon (aganglionosis of Meissner/Auerbach plexus)
  • Rarely affects small bowel
  • Lack of peristalsis leads to obstipation and distention
  • Down’s syndrome most common coexisting congenital anomaly

M>F 4:1

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18
Q

Hirschsprung Disease
* Suspect if what?
* How do you dx it?
* How do you tx it?
* What is the outcome?

A
  • Suspect if meconium is not passed in the first 48hrs of life (50-90%)
  • Dx: Enema, biopsy or manometry
  • Tx: Surgery to excise section after bowel clean out
  • Outcome: if not fixed, toxic megacolon can develop
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19
Q

Constipation Work-up
* What is the work up?

A
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20
Q

Constipation Work-up
* Physical examination – including what?
* Tests to exclude systemic disease: (4)
* Tests to exclude structural disease:(2)

A
  • Physical examination – including digital rectal examination
  • Tests to exclude systemic disease: Hemoglobin, erythrocyte sedimentation rate, thyroid function, calcium.
  • Tests to exclude structural disease:Barium x-rays & Colonoscopy
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21
Q

Constipation Treatment
* Eliminating what?
* What is offered first?

A

Eliminating the offending medication or treating the underlying medical condition

Nonpharmacologic Treatments – offered first
* High Fiber Diet, Adequate hydration, Regular exercise

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22
Q

Constipation Treatment: Pharm treatments
* What is first line?
* What is can be added?
* What are Primarily rescue treatments ?

A
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23
Q

Constipation Treatment: Pharm treatments
* What are the txt for opiate induced constipation?

A

Opiate induced Constipation
* Methylnatrexone (Relistor), Naloxegol (Movantik)

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24
Q

Diverticular Disease
* What is the pathology?
* Associated with what?
* Increase incidence with what?
* Located where?

A
  • Herniation of mucosa and submucosa of colon through muscularis
  • Associated with low fiber diet
  • Increased incidence with age
  • Located commonly on the left side of the colon.
    * So usually see LLQ pain

Worry about 2 things in these pts:
* Bleeding – can have massive BRBPR
* Diverticulitis when the diverticula b/c inflamed (can potentially rupture->peritonitis)

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25
Q

What is shown here?
* What is there?

A

Colon Diverticulosis
* Several diverticula are seen along length of descending colon.
* Focal weaknesses in bowel wall & increased lumenal pressure contribute to formation of diverticula.

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26
Q

Diverticulosis
* What is the clinical presentation?
* What is the treatment?

A

Clinical Presentation
* Most: Asymptomatic in terms of pain (detected by BE or colonoscopy)
* Intermittent abdominal bloating, pain is uncommon

Treatment
* High fiber diet/fiber supplements
* Avoidance of nuts and seeds—No longer an issue.

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27
Q

What is going on here? When do you not do this?

A

NEVER do a Barium enema in a pt with acute diverticulitis b/c may rupture (they’re already inflamed and the Barium enema puts more Pressure on them, as does a colonoscopy)

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28
Q

What are the Diverticulosis Complications? (2)

A
  • Acute Diverticulitis
  • Diverticular Bleeds
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29
Q

Painless Rectal Bleeding
* Usually stems from what? What is common?
* Occurs in how many ppl?

A

Usually stems from diverticulosis, NOT diverticulitis
* AVMs are internal hemorrhoids are common as well

Occurs in 15-40% of patients with diverticulosis

30
Q

Painless Rectal Bleeding
* how do you dx?
* What is the txt?

A

Diagnosis – colonoscopy, nuclear studies, angiography
* Dx: go right to GI bleed management—Airway first, order blood tests, large-bore IVs to get fluid resuscitation while type and cross-match; ultimately angiogram

Treatment
* Conservative – most stop spontaneously
* Angiography
* Surgery (rarely)

31
Q

Acute Diverticulitis
* What it is?
* What are the sxs?
* What does the cbc show?
* how do you dx it?

A

Inflammation of diverticulum

SXS – Fever and LLQ pain

CBC – elevated WBC count

DX – Clinical, CT Abd and Pelvis with contrast
* During the acute episode
* NO COLONOSCOPY
* NO BARIUM ENEMA

32
Q

What is going on here?

A

Acute Diverticulitis
* The white areas are the inflammation of the pt’s diverticulum…
* The black hole with other arrow marks a localized perforation.

33
Q

Acute Diverticulitis Treatment
* What do you do for uncomplicated?

A

PO ABX
* Cipro or Sulfa/Bactrim or Amox/Clavulanic acid and Metronidazole x 10-14 days
* May use 3rd Gen cephalosporin (not cephalexin)

Conservative measures – liquid diet

34
Q

Acute Diverticulitis Treatment
* What do you do for complicated?(4)

A
  • IV ABX (Levofloxacin OR Ceftriaxone + Metronidazole, or Piptazo alone)
  • NPO
  • Surgery consult
  • Elective hemicolectomy is advised if >3 episodes in 12 month period
35
Q

What is this?

A

Colon Diverticulitis with Perforation

36
Q

Meckel’s Diverticulum
* One of the MC what? What is it?
* Occurs when?
* Usually what?

A
  • One of the most common congenital abnormalities.
    * Outpouching of the small intestine
  • Occurs when the connection between the intestine and the umbilical cord does not completely close off during fetal development.
  • Usually asymptomatic, but can present with currant jelly stools painless rectal bleedingin a patient <2yo.

If younger pt with diverticul, think Meckel’s. location and age different – RLQ pain, younger.

37
Q

Meckel’s Diverticulum
* What is the study of choice? Detects what?
* What are potentional complications? (2)

A

Tc-99Mnuclear scintigraphy is the study of choice
* Detects gastric mucosa within the diverticula

Potential Complications
* Acute Diverticulitis – usually RLQ pain
* Diverticular bleed – suspect in a younger pt who presents with acute LGI bleed

38
Q

Sigmoid Volvulus
* Produced when?
* Most commonly occurs in who?
* Complications include what?

A
  • Produced when a long redundant sigmoid twist about its mesenteric axis in either direction & forms a closed loop obstruction
  • Most commonly occurs in elderly & psychiatrically disturbed patients
  • Complications include bowel ischemia & perforation if not promptly decompressed

– Increased incidence in psych pts, elderly.
– worry about these pts getting bowel ischemia and/or perforation.
– if incomplete obstruction, could try Barium enema to undo it, but otherwise Sx.

39
Q

Sigmoid Volvulus
* If obstruction is not complete, it may occasionally do what?
* High rate of recurrence usually warrants what?

A
  • If obstruction is not complete, it may occasionally be reduced during a barium enema examination
  • High rate of recurrence usually warrants resection of redundant sigmoid
40
Q
  • What is this?
A

Sigmoid Volvulus
* Air in dilated loops of colon and air-fluid levels can be seen in this patient with a sigmoid volvulus

41
Q

How does Intussusception work??

A
42
Q

Intussusception
* What is it?
* Most commonly occurs where?
* What are the sxs? (3)
* Most cases can be both diagnosed and treated with what?

A
  • Telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.
  • Most commonly occurs at the terminal ileum
  • SXS – abdominal pain, vomiting, “currant jelly” stools
  • Most cases can be both diagnosed and treated with Barium Enema
43
Q

Endocrine Tumors of The GI Tract: Carcinoid tumor
* MC what?
* Most commonly where?
* Rarely be found where?
* Carcinoid tumors of what?
* Zollinger-Ellison is associated with what?

A
  • Most common GI endocrine tumor
  • Most commonly the appendix, ileum, & rectum
  • Rarely be found arising in bronchi of lung (wheeze, SOB)
  • Carcinoid tumors of small bowel & bronchus have a more malignant course
  • Zollinger-Ellison is associated with peptic ulcer (1% of PUD)
44
Q

Carcinoid Tumor
* What are the sxs? (4)

A
  • Flushing
  • Diarrhea
  • Bronchospasm
  • May have cardiac right-sided regurgitant valve involvement
45
Q

Carcinoid Tumor
* How do you make the dx?

A
  • Made by detecting site of tumor – imaging studies
  • Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in urine
46
Q

Carcinoid Tumor
* What is the treatment?
* What is the prognosis?

A

Treatment
* Surgical resection where feasible
* Symptoms may be controlled with histamine blockers (flushing) & somatostatin (octreotide) 150-1500 mg/d in 3 doses

Prognosis
* 95% 5-yr survival for localized disease to 20% 5-yr survival for those with liver METS

47
Q

Insulinoma
* What is it?
* 90% are what?
* MCC of what?
* What are typical sxs?(6)

A
  • Insulin secreting pancreatic tumors
  • 90% are benign
  • MCC of hypoglycemia through endogenous hyperinsulinism
  • Typical symptoms are diaphoresis, tremor, palpitations, mentation changes, seizures and coma
48
Q

Insulinoma
* How do you dx?
* What is the tx?

A

Diagnosis via Whipple’s Triad
* Hypoglycemia (<50 mg/dL)
* Neuroglycopenic symptoms
* Relief of symptoms following glucose administration

Treatment: Surgical resection is the only curative procedure

49
Q

Zollinger-Ellison Syndrome/Gastrinoma
* A condition affecting what?
* ~20% associated with what?
* Associated with other “PPP” tumors:
* 90% have what? 35% have what?
* Most are found where?

A
  • A condition affecting about 1% of patients with peptic ulcer
  • ~20% associated with multiple endocrine neoplasia type 1 or MEN 1 (gastrinoma, hyperthyroidism, pituitary neoplasm)
  • Associated with other “PPP” tumors: parathyroid/pituitary/pancreatic
  • 90% have ulcer; 35% diarrhea
  • Most are found in the pancreas or duodenum
50
Q

Zollinger-Ellison Syndrome/Gastrinoma
* Dx is by what?
* What is the secretin test?
* What is the therapy?

A

Diagnosis is by elevated serum gastrin level in ulcer patient or someone with unexplained chronic diarrhea and/or malabsorption

Secretin test: gastrin levels with increase >200 pg/mL when given secretin

Therapy
* Surgical resection (EGD, CT, or MRI may localize the tumor)
* Acid suppression with very high doses of proton pump inhibitor

51
Q

Colonic Polyps: tubular adenomas
* Present in who?
* What are the types?
* ususally what?
* 65% found where?
* 5 % cause what?
* May cause what?

A
  • Present in 30% of adults
  • Pedunculated or sessile
  • Usually asymptomatic
  • 65% found in rectosigmoid colon
  • ~5 % cause occult blood in stool
  • May cause obstruction
52
Q

Colonic Polyps: Tubular adenomas
* Overall risk of malignant degeneration correlates with what?
* How do you dx?

A

Overall risk of malignant degeneration correlates with size

Diagnosis
* Sigmoidoscopy/Colonoscopy
* May also be detected on barium enema

53
Q

Treatment of Tubular Adenomas
* What is used to detect the lesions?
* What is the txt?
* Follow up when?

A
  • Full colonoscopy to detect synchronous lesions
  • Endoscopic resection(surgery if polyp large or inaccessible by colonoscopy)
  • Follow-up surveillance by colonoscopy every 2-5 years
54
Q

Colorectal Cancer: Patho
* Nearly always what?
* 75% located where?
* A study by JAMA notes increasing incidence of colon cancer in who?

A
  • Nearly always adenocarcinoma
  • 75% located distal to splenic flexure (except in association with polyposis or hereditary cancer syndrome)
  • A study by JAMA notes increasing incidence of colon cancer in patients <40yo, where cases have doubled; which is now the number one type of killer cancer in that age group.

ADENOCARCINOMA = most common colon, gastric, and pancreatic type of cancer

55
Q

Colon Cancer Risk Factors
* What are all the risk factors? (7)

A
  • Personal history of adenomatous polyps or colorectal cancer
  • Peutz-Jeghers Syndrome (left)
  • Familial adenomatous polyposis/Gardner’s syndrome (right)
  • Ulcerative colitis > Crohn’s disease
  • First degree relative with colon cancer or adenomatous polyps
  • Personal history of breast, ovarian, or uterine cancer.
  • Some studies note connection to dietary choices

  • Peutz-Jeghers on the left image
  • Gardner syndrome on the right image
56
Q

Colon Cancer – Signs/Symptoms
* Chronic what? What can that cause?
* Lesion where? What does that provoke?
* Change in what?
* Intermittent what?
* What type of cancer?

A
  • Chronic blood loss from right-sided colon cancers may cause Iron Deficiency anemia (Low Ferritin, Low serum Iron, Elevated or Normal TIBC or Transferrin)
  • Lesions of the left colon may provoke obstructive symptoms as the left colon has a smaller diameter and the stool is hard
  • Change in bowel habits - Constipation alternating with loose stools
  • Intermittent melena or stool streaked with blood
  • Rectal Cancer – tenesmus, urgency, and recurrent hematochezia
57
Q

Colon Cancer
* How do you dx it?
* How do you txt it?

A
58
Q

What is this?

A

This is very late stage CA. the massive lesion lends to apple core appearance

59
Q

Colon Cancer Screening
* What is the average risk patient screenings? African American?
* What is the increased risk patients screening?

A
60
Q

Colon Cancer Screening
* Screening for Familial adenomatous polyposis/Gardner’s syndrome/Peutz-Jeghers Syndrome?

A

Start screening with colonoscopy at age 10-15

61
Q

Hemorrhoids (Piles)
* What is it?
* What are the sxs?
* What is the txt?

A

  • Internal hemorrhoids usually not painful. Can bleed
  • External, if thrombosed, can present with rectal pain.
  • Usually no pain unless thrombosed.
  • Tx: Sitz bath to decrease inflammation, some topical treatments. If severe, surgical repair. If thrombosed, can excise them in the ER to relieve pain.
62
Q

What is this?

A
  • A – 1st degree internal
  • B – 2nd degree internal hemorrhoid
  • C - Thrombosed
63
Q

What is the elliptical excision?

A
64
Q

Anal Fissures
* What are the sxs?
* What is the txt?

A
65
Q

Anal Fistulas
* What is it?
* Opening where?
* What are the sxs?
* What is it associated with?
* What is the tx?

A
  • Hollow fibrous tracts
  • Opening inside anal canal or rectum and another orifice to perianal skin
  • SXS – Drainage of blood, pus, mucous, stool
  • Associated disorders: Crohn’s Disease, Rectal/Anal Cancer, Prior XRT
  • TX – Surgery, ABX

Who’s at risk? CROHN’S DISEASE.
– anyone with prior radiation to anal area, immunocompromised…

66
Q

Anorectal Abscess
* What is it?
* What are associated disorders?
* What are the sxs?
* What does the PE show?
* What is the txt?

A
  • Tissue space infection near rectum and anus
  • Associated Disorders: Crohn’s Disease, immunodeficiency states
  • SXS – Pain, fever, tenderness
  • PE – Tender Induration
  • TX – I&D (likely in OR) and ABX
67
Q

Rectal Foreign Bodies
* What is endless?
* Should consider what?

A
  • Etiologies are endless
  • Should consider removing if able, but admit for GI/Surgery consult if unable
68
Q

Rectal Prolapse
* Prolaspe of what?
* Is seen in who?

A
  • Prolapse of rectal mucosa through anal ring
  • Is seen in children up to 4yo (highest incidence at 1yo) and is usually self limiting, after 4yo, surgical repair will most likely be required to correct issue
69
Q

Rectal Prolapse
* What are the etiologies? (3)

A
  • Increased abdominal pressure
  • Increased bowel motility (infections)
  • Congenital problems (cystic fibrosis, myelomeningocele, Hirschsprung disease, spina bifida, congenital hypothyroidism)
70
Q

Rectal Prolapse
* What is type one and two?

A
71
Q

Rectal Prolapse Treatment
* What is the conservative management?
* In ED, what can be used?
* What is be used if persistent?
* Last resort is what?

A

Clinical Medicine 4 (13 decks)

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