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GI > Lecture 5: Disorders of the SI/Colon > Flashcards

Lecture 5: Disorders of the SI/Colon Flashcards

1
Q

SI anatomy image review

A
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2
Q

What are the 3 phases of digestion?

A
  1. Intraluminal: dietary fats, proteins, carbs are hydrolyzed and solubilized by pancreatic and biliary enzymes
  2. Mucosal: brush border enzymes hydrolyze peptides and saccharides
  3. Absorptive
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3
Q

What is celiac disease?

A

Abnormal IMMUNE response to gluten/gliadin.

Permanent disorder.

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4
Q

Who is at highest risk for celiac disease?

A

Caucasians

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5
Q

What happens to the SI in celiac disease?

A

Atrophy of the SI villa and malabsorption of nutrients.

Antibody production will occur as well.

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6
Q

How does classic celiac disease present?

A
  • Diarrhea, steatorrhea, flatulence
  • Dyspepsia
  • Wt loss
  • Abd distension
  • Weakness, muscle wasting
  • Growth retardation in children
  • Resolution of symptoms upon not eating gluten food.
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7
Q

What skin findings are seen in celiac disease?

A

Dermatitis Herpetiformis (pruitic, papulovesicular rash)

If this is present, good chance they have celiac.

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8
Q

What serology test is the initial workup for celiac disease?

A

IgA TT antibody test

Extremely sensitive and specific.

Pt should make NO diet changes prior to this test!

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9
Q

What are the secondary serologic antibody tests we might order for celiac disease?

A
  • Total IgA
  • IgA anti-endomysial antibody
  • IgG DGP
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10
Q

What is the standard way of diagnosing celiac disease with a positive serologic test?

A

Endoscopic mucosal biopsy of both the proximal and distal duodenum.

Should show blunting or loss of intestinal villi.

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11
Q

What might endoscopy show on imaging for celiac disease?

A
  • Atrophy of duodenal folds
  • Nodular, scalloping of duodenal folds, fissuring, mosaic pattern
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12
Q

What causes whipple disease?

A
  • Tropheryma whipplei
  • G+, non-acid fast, PAS positive bacillus
  • Fecal-oral transmission
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13
Q

How does whipple disease typically present?

A
  1. Arthralgias (MC symptom reported first)
  2. Diarrhea
  3. Abd pain
  4. Wt loss (MC SYMPTOM OVERALL)
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14
Q

What PE findings are seen in whipple disease?

A
  • Low-grade fever
  • Evidence of malabsorption
  • Enlarged joints
  • LAN
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15
Q

What is the whipple disease mnemonic?

A
  • Weight loss
  • Hyperpigmentation of skin
  • Infection with tropheryma whipplei
  • PAS positive granules in macrophage
  • Polyarthritis
  • LAN
  • Enteric involvement
  • Steatorhhea

WHIPPLES

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16
Q

How do you diagnose whipple disease?

A

EGD with biopsy of duodenum showing macrophages with PAS bacilli/granules

PCR can confirm if inconclusive

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17
Q

How do you treat whipple disease?

A
  • IV rocephin or meropenem
  • Followed by Bactrim for 1 year
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18
Q

What is bacterial overgrowth?

A
  • Colonic bacteria seen in excess in SI.
  • Proximal short bowel normally has a small amt of bacteria.
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19
Q

What are the causes of bacterial overgrowth?

A
  • Motility disorders
  • Anatomic disorders (adhesions)
  • Diabetes
  • Immune disorders
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20
Q

What are the common symptoms of small intestinal bacterial overgrowth? (SIBO)

A
  • Nausea
  • Bloating
  • Gas
  • Abd pain
  • Fatigue
  • Cramps
  • Acne rashes
  • Wt loss
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21
Q

How do we confirm SIBO?

A
  • Small intestine aspiration w/ cultures (highly invasive)
  • Carbohydrate breath test with lactulose and carb cessation
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22
Q

How do you treat SIBO?

A
  • Ciprofloxacin 500mg BID
  • Augmentin
  • Bactrim

7-10 days

Also, correct anatomic defect if present (like adhesions)

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23
Q

What causes short bowel syndrome? (SBS)

A
  • Removal of a portion of the SI
  • Crohn’s, ischemia, tumor, trauma, mesenteric infarction, or volvulus
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24
Q

How does a terminal ileal resection present?

A

Malabsorption of B12 and bile salts

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25
Q

How does an extensive bowel resection present?

A
  • > 50% of SI removed
  • Wt loss and diarrhea d/t malabsorption
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26
Q

How do you manage the initial/acute phase of SBS?

A
  • Manage fluids/lytes
  • Acid suppression with PPIs
  • Parenteral nutrition
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27
Q

How do you manage the adaptation phase of SBS?

A
  • Transition to oral feedings
  • Complex carbs
  • Low fat
  • Fluids, PPIs, antidiarrheals, and ABX for SIBO
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28
Q

What is lactase?

A

Brush border enzyme that hydrolyzes lactose.

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29
Q

How is lactose intolerance confirmed?

A

Hydrogen breath test with 50g of lactose.

Must fast 8 hours prior.

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30
Q

What is paralytic ileus?

A

Neurogenic failure or loss of peristalsis in the SI without any mechanical obstruction.

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31
Q

Who is paralytic ileus MC in?

A

Hospitalized patients:

  1. Intra-abdominal processes such as recent GI or abd surgery
  2. Peritoneal irritation
  3. Severe medical illness
  4. Meds like opioids or anticholinergics
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32
Q

Post surgery, what is the order in which the GI system recovers?

A
  1. SI motility normalizes
  2. Stomach
  3. Colon
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33
Q

What occurs that causes paralytic ileus?

A
  • Inflammatory response to intestinal manipulation and trauma
  • Inhibitory neural reflexes increase sympathetic activity in the gut
  • Opioids inhibit motility
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34
Q

How does paralytic ileus present?

A
  • N/V/obstipation, abd discomfort
  • Abd distension w/ tympany to percussion
  • Diminished/absent bowel sounds
  • Diffuse abd pain
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35
Q

How do we workup and diagnose paralytic ileus?

A
  • Clinical dx if > 4 days
  • Plain films should show distended/dilated gas-filled loops
  • CT to distinguish between ileus and SBO.
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36
Q

What labs help r/o other causes of paralytic ileus?

A
  • CBC: r/o infection, ischemia, abscess
  • CMP: hypoK can worsen ileus
  • BUN/Cr: Uremia can cause ileus
  • LFTs, amylase, lipase: gallbladder/pancreatitis can cause ileus
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37
Q

How do we treat paralytic ileus?

A
  • Complete bowel rest via IV fluids and NG tube
  • Slowly advance diet
  • Activity
  • Remove any offending drugs
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38
Q

What preventative methods can aid with ileus?

A
  • Avoid IV opioids
  • Early ambulation
  • Clear liquid diet
  • GUM CHEWING (stimulates vagus nerve)
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39
Q

What is a small bowel obstruction? (SBO)

A
  • Impairment of the normal flow of intraluminal contents
  • Mechanical obstruction
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40
Q

What does a full SBO do? Partial?

A
  • Partial is only lumen
  • Full w/ strangulation will impair blood supply and cause necrosis
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41
Q

What secondary conditions can occur due to SBO?

A
  • SIBO
  • Distension
  • Hypovolemia
  • Dilation of intestines
  • Feculent emesis
  • Peritonitis (if no strangulation)

Everything getting clogged up

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42
Q

If SBO is prolonged, what could occur blood-flow wise?

A
  • Reduced perfusion
  • Tissue ischemia
  • Necrosis and perforation
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43
Q

What is the MCC of SBO?

A

Post-surgical adhesions

70%

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44
Q

What are the S/S of SBO?

A
  • Acute
  • Nausea/vomiting
  • Colicky abd pain
  • Obstipation (severe/complete constipation)
  • Proximal blockage: profuse emesis with undigested food
  • Diffuse blockage: Diffuse and poorly localized cramps with feculent vomiting
  • High-pitched tinkling sound
  • Fever
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45
Q

What is a hallmark sign of SBO?

A

Dehydration, which leads to tachycardia and hypotension

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46
Q

When are you more likely to hear hyperactive bowel sounds in SBO?

A

Early on, as the GI system attempts to overcome the block.

Hypoactive comes later as it gives up.

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47
Q

What are the signs that suggest intestinal ischemia?

A
  • Fever > 100F
  • Tachycardia
  • Peritoneal signs: guarding, rigid abdomen, rebound tenderness, disproportionate pain
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48
Q

How do we confirm a SBO?

A

Plain XRAYs of the abdomen showing dilated small bowel loops with air-fluid levels and a “ladder-like” appearance.

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49
Q

How do we treat SBO?

A
  • Admit and consult surgery
  • Fluid/lytes
  • NG tube
  • TPN
  • ABX for bowel compromise
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50
Q

Ileus vs SBO chart

A
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51
Q

What is Ogilvie syndrome?

Acute colon pseudo-obstruction

A

Spontaneous massive dilatation of the cecum and proximal colon in the absence of an anatomic lesion

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52
Q

Who is ogilvie syndrome MC in?

A

Severly ill, hospitalized patients (post-op is MC)

Most likely due to impaired autonomic response.

53
Q

What are the S/S of ogilvie syndrome?

A
  • Severely distended abdomen
  • Abd tenderness with guarding or rebound tenderness
  • Peritonitis will occur if perforation has occurred
  • Bowel sounds either normal or decreased
54
Q

How do we workup ogilvie syndrome?

A
  • Plain radiographs showing dilated colon, esp at the cecum to splenic flexure
  • CT can help establish and r/o other causes
55
Q

How do we treat ogilvie syndrome initially?

A
  1. Conservative treatment
  2. NG and rectal tube for colonic decompression
  3. Rolling patient side to side in fetal position
  4. NPO, IV fluids
  5. Neostigmine for severe
56
Q

Who is conservative treatment indicated in for ogilvie?

A
  • Little to no abd tenderness
  • No fever
  • No leukocytosis
  • Cecal diameter < 12cm
57
Q

What does neostigmine do?

A

Inhibits destruction of ACh, allowing impulses to move in the intestine.

58
Q

What are the essentials of diagnosing ogilvie syndrome?

A
  • Severe abd distension
  • Post-op or severely ill
  • Precipitated by lytes or meds
  • Absent to minimal abd pain; minimal tenderness
  • Massive dilation of cecum or right colon
59
Q

What is the primary cause of IBS?

A

Idiopathic

60
Q

What chronic GI symptoms typically result in IBS?

A
  • Abnormal motility
  • Visceral hypersensitivity
  • Enteric infection
  • Psychosocial
61
Q

Who is IBS MC in?

A

Young women

62
Q

What are the 4 pathogenesis things that result in IBS?

A
  • Abnormal motility
  • Visceral hypersensitivity
  • Intestinal inflammation
  • Psychosocial abnormalities
63
Q

How does IBS typically present?

A
  • Abd pain related to at least 2/3: defecation, stool frequency change, stool form change
  • Crampy, lower abd pain that relieves with defecation
  • 3 months of symptoms
  • Abd pain that DOES NOT OCCUR AT NIGHT (usually)
  • Abd distension, bloating
  • Dyspepsia, heartburn, fatigue
64
Q

What are the 4 IBS classifications?

A
  1. IBS with diarrhea
  2. IBS with constipation
  3. IBS with mixed constipation and diarrhea
  4. IBS that is not subtyped
65
Q

What is the Rome IV criteria for IBS?

A

Recurrent abd pain that averages out to at least 1 day a week in the past 3 months and is related to defecation, change in stool frequency, or change in stool form

2/3 must be present

66
Q

What is the manning criteria for IBS?

A

Higher likelihood with more symptoms

67
Q

What alarm symptoms suggest that a person is NOT having IBS?

A
  • Severe progressive pain
  • Pain associated with anorexia or wt loss
  • Severe constipation
  • Severe diarrhea
  • Hematochezia/rectal bleeding
  • Wt loss
  • Fever
68
Q

When is a colonoscopy indicated for IBS evaluation?

A

Anyone over 50 or ones that fail conservative treatment.

69
Q

How do we manage IBS?

A
  • Low FODMAP diet
  • Avoid alcohol, caffeine
  • Avoid fats, spicy, gas-producing foods
  • Relax
  • Therapy
  • Exercise
70
Q

What is FODMAP?

A
  • Fermentable
  • Oligosaccharides
  • Disaccharides
  • Monosaccharides
  • And
  • Polyols
71
Q

What are the drugs that may help with IBS?

Adjunctive therapy

A
  • Antispasmodics (Dicyclomine or hyoscyamine)
  • Loperamide
  • Laxatives (osmotics)
  • Specific IBS drugs (Linaclotide, lubiprostone, alosetron)
  • TCAs
  • SSRIs
72
Q

For IBS w/ diarrhea, what specifically might help the most in terms of meds?

A
  • Antispasmodics (Dicyclomine, hyoscyamine)
73
Q

When is alosetron used?

A
  • IBS w/ diarrhea in women
  • Diarrhea > 6 months
74
Q

What is alosetron?

A

5-HT3 receptor antagonist

Same class as ondansetron

75
Q

What is the BBW of alosetron?

A
  • Severe constipation
  • Ischemic colitis

Patients must sign consent prior to use

76
Q

What is linaclotide used for?

A

IBS w/ constipation

Clo = Con

77
Q

What is linaclotide?

A

Guanylate cyclase agonist

78
Q

What are the pros of linaclotide and the BBW?

A

Pros: stimulates intestinal fluid secretion and transit.

BBW: DO NOT USE IN CHILDREN < 18y + Risk of dehydration

Also pricey af

lubes ur insides

79
Q

What is lubiprostone used for?

A
  • IBS w/ constipation in women
  • Chronic constipation

Both IBS constipation drugs have an I in their name, like constipation.

They also both start with L and lube up ur insides for constipation

80
Q

What is lubiprostone and its CIs?

A
  • Selective chloride activator that activates channels, increasing fluid secretion and motility and reduces permeability.
  • CIs: Diarrhea, GI obstruction

also pricey af

lubes up ur SI

81
Q

What are antidepressants used for in terms of IBS subtype?

A

IBS w/ pain and bloating or diarrhea.

TCAs

82
Q

What is the bad kind of ABX associated colitis?

83
Q

How do you kill C diff?

A

Handwash with soap.

Sanitizers DO NOT WORK.

84
Q

What abx usually cause abx associated colitis?

A
  • Ampicillin
  • Clindamycin
  • 3rd gen cephalosporins
  • FQs
85
Q

How does mild-mod ABX associated colitis present?

A
  • Greenish, foul-smelling, watery diarrhea 5-15 times a day
  • LLQ tenderness
  • WBC > 15k
86
Q

How does severe/fulminant abx associated colitis present?

A
  • Fever
  • Hemodynamic instability
  • Abd pain, distension, tenderness
  • Profuse diarrhea (up to 30/day)
  • WBC > 30k
87
Q

What are the concerning complications of abx associated colitis?

A
  • Dehydration
  • Wt loss
  • Hemodynamic instability
  • Toxic megacolon
88
Q

What 3 things may suggest C. diff colitis?

A
  • Recent ABX use
  • Hospitalization
  • Advanced age
89
Q

When should we suspect C diff Colitis?

A

> = 3 loose stools in 24 hours

90
Q

How do we workup abx associated colitis?

A
  • Positive NAAT
  • Positive stool test
91
Q

How do we treat abx associated colitis?

A
  • D/c current abx
  • Contact precautions
  • Mild-mod: Fidaxomicin BID or Vanco 125mg PO QID
  • Severe: Vanco 500mg PO QID + Metronidazole IV

10d, fidaxomicin has lower recurrency

Severe would be WBC > 15k
Remember vanco must be ORAL for colitis

92
Q

When is surgery indicated for CDI?

C Diff infection

93
Q

What are the two surgeries for CDI?

A
  • Total abdominal colectomy (For bad cases)
  • Diverting loop ileostomy/colonic lavage (decreased risk)
94
Q

If CDI recurs once, what do we do?

A

Same regimen again or prolonged vanco tapering regimen.

95
Q

If CDI recurs twice, what do we do?

A

7 week tapering regimen of vanco

  1. QID for 14 days
  2. BID for 7 days
  3. QD for 7 days
  4. QOD for 7 days
  5. Q3d for 14 days

14-7-7-7-14

96
Q

What is ischemic colitis?

A

Reduction in blood flow that commonly occurs at watershed areas like the splenic flexure or rectosigmoid junction.

97
Q

What are the 3 arteries that supply the colon?

A
  • Superior mesenteric
  • Inferior mesenteric
  • Internal iliacs
98
Q

Who is ischemic colitis MC in?

A
  • Older
  • Atherosclerosis
  • Post-op
  • Cocaine
  • Extreme exercise
99
Q

What are the risk factors for ischemic colitis?

A
  • Any condition that lower perfusion to the intestine
  • Any condition that predisposes someone to mesenteric arterial embolism, thrombosis, or vasoconstriction
100
Q

What 4 things can cause colon ischemia in younger patients?

A
  • Vasculitis
  • Coag disorders
  • Estrogen
  • Long-distance running
101
Q

How does ischemic colitis typically present?

A
  • Rapid onset of mild, cramping abd pain
  • Tenderness over affected area (left side usually)
  • Diarrhea with hematochezia
  • Urgent desire to defecate
  • Mild-mod rectal bleeding
102
Q

How is acute ischemic colitis typically described as?

A

Abd pain out of proportion to the physical exam.

103
Q

How does chronic mesenteric ischemia typically present?

A
  • Recurrent abd pain after eating due to inability to increase abd perfusion to help digest.
  • Patients will often develop food fears and lose weight.
104
Q

What is the 1st imaging modality for ischemic colitis?

A
  • CT abd w/ con
  • Target/thumbprinting/double halo sign
  • Reflects initial episode of ischemia and the subsequent reperfusion injury.
105
Q

What should everyone suspected of ischemic colitis get in terms of diagnostics?

A

Diagnostic colonoscopy

CT abd
106
Q

How do you treat ischemic colitis?

A

Supportive care and NPO status

107
Q

When is surgical intervention recommended for ischemic colitis?

A
  • Ongoing pain
  • Persistent fever
  • Leukocytosis
  • Peritoneal irritation
  • GI bleeding
108
Q

What etiology would prompt us to use anticoags for ischemic colitis?

A

Mesenteric venous thrombosis

109
Q

What is the MC congenital abnormality of the small bowel?

A

Meckel’s diverticulum

Often found incidentally

110
Q

What is the rule of 2s for Meckel’s?

A
  • Present in 2% of the population
  • 2ft from ileocecal valve
  • Symptomatic in 2% of patients
111
Q

How does Meckel’s diverticulum present?

A
  • Crampy abd pain
  • N/V
  • Bleeding
113
Q

What is Meckel’s sign?

A

Ectopic gastric mucosa on nuclear medicine scan

114
Q

How do you treat Meckel’s?

A

Surgery is definitive.

115
Q

What is diverticulOSIS?

A
  • Outpouching of the colon.
  • MC in sigmoid/left colon
116
Q

What causes diverticulosis?

A
  • Chronic constipation
  • Low fiber
  • Hard stools

Increased intraluminal pressure

117
Q

What are the 3 forms of diverticulosis?

A
  • Uncomplicated
  • Diverticulitis
  • Bleeding diverticula
118
Q

How does uncomplicated diverticulosis present?

A
  • Asymptomatic usually
  • Abd pain, chronic constipation
  • Mild LLQ tenderness, palpable sigmoid colon
  • Normal labs
119
Q

How do you treat uncomplicated diverticulosis?

A

High fiber diet

120
Q

How does diverticulitis present?

A
  • ACUTE LLQ abd pain
  • Low grade fever
  • Bowel changes
  • N/V
  • Bloody stool
  • LLQ tenderness
  • Mild-mod leukocytosis

Diverticulitis means infection of the outpouchings

121
Q

What is the 1st line imaging for diverticulitis?

A

CT of abd to check 1st time or if its complicated.

122
Q

When is colonoscopy recommended for diverticulitis?

A

Anyone that responds to acute mangement should get one 4-8 weeks later.

Do not due initially due to risk of perf.

123
Q

For mild-mod symptoms of diverticulitis, what is the general OP tx?

A

Clear liquid diet and then high fiber after resolution

124
Q

For immunocompromised patients, what ABX might we use for diverticulitis?

A
  • Metro + quinolone
  • Metro + Bactrim
  • Augmentin

7-10

125
Q

For more complicated and IP tx of diverticulitis, what is the tx?

A
  • NPO with IV fluids
  • Piptazo IV followed by Cipro + metro PO
  • Surgery for severe disease or lack of improvement after 72 hours.
126
Q

When is hospitalization recommended for diverticulitis?

A
  • Increasing pain, fever, or PO intolerance
  • Immunocompromised
  • Significant comorbidities
  • Abscesses > 3-4cm
  • Signs of severe diverticulitis (high fever, leukocytosis, peritoneal signs)
127
Q

What is the criteria for inpatient treatment of diverticulitis?

A
  1. Complicated CT with perf
  2. Sepsis
  3. Immunosuppression
  4. High fever > 102.5F
  5. Severe abd pain
  6. Age > 70
  7. Significant comorbidities
  8. PO intolerance
  9. Failed OP tx
  10. Noncompliant

AKA really sick or really old

128
Q

What is the MCC of a lower GI bleed?

A

Diverticular bleed

Treated with colonoscopic cauterization or waiting.

GI (17 decks)

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