Lecture 4 (GI)-Exam 1 Flashcards
- What are the risk factors of C-Diff colitis? (3)
- What is the pathophysio?
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
Clostridium difficile
* produces what?
* What type of diarrhea?
- Produces a toxin which causes mucosal damage (pseudomembranous colitis).
- Inflammatory diarrhea
Pseudomembranous Colitis
* What does it appear like?
Pseudomembranous colitis appears as a tan to yellow-green exudate over an erythematous bowel mucosa.
Treatment – Clostridium difficile Colitis
* Discont what?
* use what type of precaution?
* What is the oral drug of choice?
- Discontinue antibiotics if possible
- Use Contact Precautions until diarrhea stops!
- Dificid (fidaxomicin) – oral drug of choice
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?
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
C-diff Recurrence
* Risk of recurrence?
* What is the tx?
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.
Ischemic Colitis
* What is the physical exam?
PAIN OUT OF PROPORTION TO PHYSICAL EXAM. No tenderness, no guarding.
Ischemic Colitis
* Ischemia of the colon (GUT ANGINA) most often affect who?
* Thought to be caused by what?
* Ischemic colitis is almost always what?
- 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)
Ischemic Colitis
* What are the sxs? What is elevated?
* How do you dx it?
* What is the txt?
- 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.
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?
- 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)
Differential Diagnosis of Constipation
* What is the DDX of lifestyle (4), drugs (2) and metabolic (2)?
Lifestyle
* Inadequate fiber
* Little food intake
* Ignoring urge to defecate (children)
* Immobility (elderly)
Drugs
* Opiates
* Anti-cholingerics
Metabolic/Endocrinologic
* Hypothyroidism
* Hypercalcemia
Differential Diagnosis of Constipation
* What is the ddx for neurologic (4)?
* What is the ddx for GI tract (5)
Neurologic
* Parkinson’s disease
* Multiple Sclerosis
* Spinal lesions
* Autonomic neuropathy
Gastrointestinal tract
* Luminal obstruction
* Aganglionosis (Hirschsprung’s disease)
* Myopathy
* Neuropathy
* Systemic sclerosis (scleroderma)
Differential Diagnosis of Constipation
* What is the DDX for anotrectum
* What is the DDX for idiopathic consitipation
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
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?
Functional Ileus
* What is the clinical presentation?
- 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
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?
- 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
Hirschsprung Disease
* Stems from what? Rarely affects what?
* Lack of what?
* What is the MC coexisting cogenital anomaly?
- 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
Hirschsprung Disease
* Suspect if what?
* How do you dx it?
* How do you tx it?
* What is the outcome?
- 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
Constipation Work-up
* What is the work up?
Constipation Work-up
* Physical examination – including what?
* Tests to exclude systemic disease: (4)
* Tests to exclude structural disease:(2)
- 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
Constipation Treatment
* Eliminating what?
* What is offered first?
Eliminating the offending medication or treating the underlying medical condition
Nonpharmacologic Treatments – offered first
* High Fiber Diet, Adequate hydration, Regular exercise
Constipation Treatment: Pharm treatments
* What is first line?
* What is can be added?
* What are Primarily rescue treatments ?
Constipation Treatment: Pharm treatments
* What are the txt for opiate induced constipation?
Opiate induced Constipation
* Methylnatrexone (Relistor), Naloxegol (Movantik)
Diverticular Disease
* What is the pathology?
* Associated with what?
* Increase incidence with what?
* Located where?
- 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)
What is shown here?
* What is there?
Colon Diverticulosis
* Several diverticula are seen along length of descending colon.
* Focal weaknesses in bowel wall & increased lumenal pressure contribute to formation of diverticula.
Diverticulosis
* What is the clinical presentation?
* What is the treatment?
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.
What is going on here? When do you not do this?
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)
What are the Diverticulosis Complications? (2)
- Acute Diverticulitis
- Diverticular Bleeds
Painless Rectal Bleeding
* Usually stems from what? What is common?
* Occurs in how many ppl?
Usually stems from diverticulosis, NOT diverticulitis
* AVMs are internal hemorrhoids are common as well
Occurs in 15-40% of patients with diverticulosis
Painless Rectal Bleeding
* how do you dx?
* What is the txt?
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)
Acute Diverticulitis
* What it is?
* What are the sxs?
* What does the cbc show?
* how do you dx it?
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
What is going on here?
Acute Diverticulitis
* The white areas are the inflammation of the pt’s diverticulum…
* The black hole with other arrow marks a localized perforation.
Acute Diverticulitis Treatment
* What do you do for uncomplicated?
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
Acute Diverticulitis Treatment
* What do you do for complicated?(4)
- IV ABX (Levofloxacin OR Ceftriaxone + Metronidazole, or Piptazo alone)
- NPO
- Surgery consult
- Elective hemicolectomy is advised if >3 episodes in 12 month period
What is this?
Colon Diverticulitis with Perforation
Meckel’s Diverticulum
* One of the MC what? What is it?
* Occurs when?
* Usually what?
- 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.
Meckel’s Diverticulum
* What is the study of choice? Detects what?
* What are potentional complications? (2)
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
Sigmoid Volvulus
* Produced when?
* Most commonly occurs in who?
* Complications include what?
- 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.
Sigmoid Volvulus
* If obstruction is not complete, it may occasionally do what?
* High rate of recurrence usually warrants what?
- 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
- What is this?
Sigmoid Volvulus
* Air in dilated loops of colon and air-fluid levels can be seen in this patient with a sigmoid volvulus
How does Intussusception work??
Intussusception
* What is it?
* Most commonly occurs where?
* What are the sxs? (3)
* Most cases can be both diagnosed and treated with what?
- 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
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?
- 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)
Carcinoid Tumor
* What are the sxs? (4)
- Flushing
- Diarrhea
- Bronchospasm
- May have cardiac right-sided regurgitant valve involvement
Carcinoid Tumor
* How do you make the dx?
- Made by detecting site of tumor – imaging studies
- Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in urine
Carcinoid Tumor
* What is the treatment?
* What is the prognosis?
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
Insulinoma
* What is it?
* 90% are what?
* MCC of what?
* What are typical sxs?(6)
- Insulin secreting pancreatic tumors
- 90% are benign
- MCC of hypoglycemia through endogenous hyperinsulinism
- Typical symptoms are diaphoresis, tremor, palpitations, mentation changes, seizures and coma
Insulinoma
* How do you dx?
* What is the tx?
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
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 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
Zollinger-Ellison Syndrome/Gastrinoma
* Dx is by what?
* What is the secretin test?
* What is the therapy?
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
Colonic Polyps: tubular adenomas
* Present in who?
* What are the types?
* ususally what?
* 65% found where?
* 5 % cause what?
* May cause what?
- Present in 30% of adults
- Pedunculated or sessile
- Usually asymptomatic
- 65% found in rectosigmoid colon
- ~5 % cause occult blood in stool
- May cause obstruction
Colonic Polyps: Tubular adenomas
* Overall risk of malignant degeneration correlates with what?
* How do you dx?
Overall risk of malignant degeneration correlates with size
Diagnosis
* Sigmoidoscopy/Colonoscopy
* May also be detected on barium enema
Treatment of Tubular Adenomas
* What is used to detect the lesions?
* What is the txt?
* Follow up when?
- 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
Colorectal Cancer: Patho
* Nearly always what?
* 75% located where?
* A study by JAMA notes increasing incidence of colon cancer in who?
- 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
Colon Cancer Risk Factors
* What are all the risk factors? (7)
- 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
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?
- 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
Colon Cancer
* How do you dx it?
* How do you txt it?
What is this?
This is very late stage CA. the massive lesion lends to apple core appearance
Colon Cancer Screening
* What is the average risk patient screenings? African American?
* What is the increased risk patients screening?
Colon Cancer Screening
* Screening for Familial adenomatous polyposis/Gardner’s syndrome/Peutz-Jeghers Syndrome?
Start screening with colonoscopy at age 10-15
Hemorrhoids (Piles)
* What is it?
* What are the sxs?
* What is the txt?
- 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.
What is this?
- A – 1st degree internal
- B – 2nd degree internal hemorrhoid
- C - Thrombosed
What is the elliptical excision?
Anal Fissures
* What are the sxs?
* What is the txt?
Anal Fistulas
* What is it?
* Opening where?
* What are the sxs?
* What is it associated with?
* What is the tx?
- 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…
Anorectal Abscess
* What is it?
* What are associated disorders?
* What are the sxs?
* What does the PE show?
* What is the txt?
- 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
Rectal Foreign Bodies
* What is endless?
* Should consider what?
- Etiologies are endless
- Should consider removing if able, but admit for GI/Surgery consult if unable
Rectal Prolapse
* Prolaspe of what?
* Is seen in who?
- 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
Rectal Prolapse
* What are the etiologies? (3)
- Increased abdominal pressure
- Increased bowel motility (infections)
- Congenital problems (cystic fibrosis, myelomeningocele, Hirschsprung disease, spina bifida, congenital hypothyroidism)
Rectal Prolapse
* What is type one and two?
Rectal Prolapse Treatment
* What is the conservative management?
* In ED, what can be used?
* What is be used if persistent?
* Last resort is what?
