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GI > Lecture 6: Disorders of the Colon & Rectum > Flashcards

Lecture 6: Disorders of the Colon & Rectum Flashcards

1
Q

What are the two autoimmune conditions that make up IBD?

A
  • Crohn’s
  • Ulcerative colitis
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2
Q

What is ulcerative colitis?

A

Diffuse inflammation involving only the COLON

Often extends proximally.

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3
Q

What is Crohn’s disease?

A

Patchy, transmural inflammation affecting the GI TRACT

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4
Q

Who is IBD MC in?

A

Caucasians and western diet

Females: Crohn’s (football club)
Males: UC

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5
Q

What lifestyle/risk factor is extremely associated with Crohn’s development?

A

Smoking

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6
Q

What is the most commonly affected part of the GI tract in Crohn’s?

A

Terminal ileum, characterized by transmural inflammation and skip lesions

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7
Q

How does Crohn’s present clinically?

A
  • Chronic RLQ pain
  • Crampy abd pain
  • Intermittent, non-bloody diarrhea
  • Wt loss, weakness, fatigue
  • Mass in RLQ = terminal ileum
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8
Q

What are the extraintestinal manifestations of Crohn’s?

A
  • Pyoderma gangrenosum
  • Erythema nodosum
  • Arthralgia
  • Apthous ulcers (mouth)
  • Fistulas, abscesses

Crohns is the creepy manifestations

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9
Q

What are the 4 types of fistulas that can occur due to transmural inflammation in Crohn’s?

A
  • Enterovesical
  • Enterocutaneous
  • Enteroenteric
  • Enterovaginal
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10
Q

What are the clinical manifestations of fistulas in Crohn’s?

A
  • Infection
  • Abscess
  • Personal hygiene issues
  • Wt loss
  • Malnutrition
  • Diarrhea
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11
Q

Where does erythema nodosum occur in Crohn’s and what does it correlate with?

A
  • Occurs on anterior lower legs
  • Correlate with bowel symptoms

Red, hot lesions

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12
Q

What is pyoderma gangrenosum?

A

Severe disease on dorsal surface of feet and legs usually, beginning as a pustule that spreads and turns necrotic

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13
Q

What is the gold standard to diagnose Crohn’s?

A

Colonoscopy with biopsy showing skip areas with a cobblestone appearance.

May also see focal ulceration adjacent to normal areas

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14
Q

What is the management goal in Crohn’s?

A

Symptomatic relief

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15
Q

What is considered low risk Crohn’s?

A
  • Normal/mild CRP
  • Dxd > 30yo
  • Limited inflammation
  • Little to no ulcerations
  • No perianal complications
  • No prior resections
  • No penetration or strictures.
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16
Q

How do we treat low-risk Crohn’s involving the ileum/cecum?

A

Step-up therapy with EC budesonide and slowly increase it.

No improvement in 3-6 months => immunomodulator or biologic.

Alternative to budesonide is 5-ASA

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17
Q

For mild-mod Crohn’s involving diffuse colitis or the left colon, what is the treatment?

A
  • Oral prednisone with a tapering off
  • Post tapering => ileocolonoscopy in 6-12 months

Alternative to prednisone will be 5-ASA. 5-ASA will be continued until scopy.

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18
Q

If there is a remission in mild-mod Crohn’s, what is the new therapy we start?

A

Second course of glucocorticoid + azathioprine or biologic (infliximab)

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19
Q

What is the overall therapy methodology in high-risk Crohn’s?

A

Step-down/Top-down

AKA starting with the big boys first

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20
Q

What is the top-down therapy for high-risk Crohn’s?

A

Combination therapy of TNF blockers + immunomodulators

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21
Q

What drug is NOT preferred for maintenance in Crohn’s?

A

Steroids

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22
Q

Once remission is seen in Crohn’s, what is the next step?

A

Ileocolonoscopy in 6-12 months.

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23
Q

What does UC most commonly involve?

A

Rectum and sigmoid colon

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24
Q

What is the hallmark sign of UC?

A

Bloody diarrhea

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25
Q

What are the common complications of UC?

A
  • Gradual onset
  • Crampy lower abd pain that relieves with defecation
  • Diarrhea with pus
  • Bloody Diarrhea
  • Fecal urgency
  • Anemia
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26
Q

What are the complications of UC?

A
  • Severe bleed
  • Lots of diarrhea
  • Toxic megacolon
  • Perfd colon
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27
Q

What are the extraintestinal manifestations of UC?

A
  • Arthritis
  • Ankylosing spondylitis
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28
Q

Severity table for UC

Adkins said MUST KNOW!!!

A
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29
Q

Who is UC ironically not as bad in?

A

Smokers

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30
Q

What is the gold standard to diagnose UC?

A

Sigmoidoscopy showing a continuous friable mucosa, edematous, with pus, bleeding, erosions, and erythema

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31
Q

When should we NOT do a colonoscopy for suspected UC?

A

Severe or fulminant colitis due to risk of perf or megacolon.

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32
Q

What kind of cancer are patients with long-standing UC most at risk for?

A
  • Colonic epithelial dysplasia
  • Colonic epithelial Carcinoma
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33
Q

What lifestyle change is recommended to help with UC?

A

Cessation of caffeine

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34
Q

What is the treatment for mild-mod UC limited to the distal colon? (not past sigmoid)

A

Topical mesalamine (5-ASA) or hydrocortisone suppository (worse)

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35
Q

What is the treatment for mild-mod UC that extends past the sigmoid colon?

A
  1. Oral mesalamine + topical mesalamine
  2. Add-on oral corticosteroids if unresponsive after 4-8 weeks
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36
Q

For mod-severe UC, what is the treatment?

A

Prednisone +/- immunomodulators/TNF blockers

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37
Q

What is the curative treatment for UC?

A

Total proctocolectomy with placement of ileostomy.

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38
Q

When do we do maintenance therapy for UC and what is it?

A
  1. More than 1 relapse in a year
  2. Anyone with ulcerative proctosigmoiditis
  3. Anyone with UC proximal to sigmoid (left-sided)
  4. Mesalamine
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39
Q

What do 5-ASA/aminosalicylates do and their main SEs?

A
  1. Indication: Induction and maintenance therapy of UC and CD
  2. MOA: Inhibition of prostaglandin production
  3. SEs: N/V, HA,
  4. CI: Allergy to aspirin or sulfa

Sulfasalazine and mesalamine

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40
Q

What are corticosteroids indicated for in IBD?

A

Induce remission in severe flares or for acute flares.

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41
Q

What are the two corticosteroids used in IBD?

A
  • Prednisone: more potent
  • Budesonide: poor systemic absorption, fewer SEs
42
Q

What are the indications/MOA/SEs/AEs/BBW for immunomodulators/immunosuppressants?

A
  1. Indication: Steroid dependent IBD or remission maintenance in severe IBD
  2. MOA: Inhibition of DNA/RNA synthesis
  3. SEs: Leukopenia, thrombopenia, anemia, infection, N/V/D, Malaise, myalgia
  4. AEs: Lymphoma and severe infection
  5. BBW: Mutagenic potential for rapidly growing malignancies

Azathioprine or 6-mercaptopurine

43
Q

When is methotrexate used for IBD?

A

Only in mild-mod CD for maintenance if azathioprine fails

44
Q

When is cyclosporine used for IBD?

A

Severe refractory IBD that failed steroids

45
Q

What are the indications/MOA/SEs/AEs/BBW for Anti-TNFs?

A
  1. Indication: Mod-severe active IBD
  2. TOC for CD fistula (treatment of choice)
  3. MOA: MAB that binds to human TNF, interfering with cytokine inflammation
  4. SEs: Fever, rigors, N/V, urticaria, hypotension
  5. AEs: Severe infection/sepsis/Malignancy
  6. BBW: Severe infection

ends in -mab

46
Q

What ABX are used in IBD and when?

A
  • Presence of fistula or abscess that makes patient susceptible to infection.
  • Metronidazole or ciprofloxacin
47
Q

If we want to give a live vaccine prior to IBD treatment, how early should it be?

A

4 weeks prior

48
Q

Image of CD vs UC

A
49
Q

What are the 5 common causes of IBD flare-ups?

A
  1. Missing doses while in remission
  2. NSAIDs (recommend tylenol)
  3. Smoking (esp with CD)
  4. Stress
  5. Certain foods
50
Q

What are the 4 pathologic colon polyp groups?

A
  1. Mucosal adenomatous (MC)
  2. Mucosal serrated
  3. Mucosal non-neoplastic
  4. Submucosal

Serrated are 2nd MC

51
Q

What causes adenomatous polyps?

A

DNA changes in lining of the colon

95% of colon adenocarcinomas are from these polyps

52
Q

What are the risk factors of adenomatous polyps?

A
  • Age > 50, MC in men
  • High fat diets
  • Obesity
53
Q

What do adenomatous polyps look like?

A
  • Flat, sessile, pedunculated
  • Slow growing
54
Q

How do you diagnose and workup adenomatous polyps?

A
  • Colonoscopy
  • Check all the polyp pathologies
55
Q

What are the 3 types of adenomatous polyps and what is the most likely to be cancerous?

A
  1. Tubular: least likely
  2. Tubulovillous
  3. Villous: Most likely (villain)
56
Q

What general characteristics suggest that a polyp has a high likelihood of being cancerous?

A
  1. > 1 cm
  2. Villous histology
  3. # of polyps
  4. Flat polyps
57
Q

How do we manage and screen for polyps?

A
  1. Removal via colonoscopy w/ polypectomy
  2. FOBT, fecal immunochemical and fecal DNA annually
  3. Colonoscopy screenings
  4. Diet and wt loss
58
Q

What are the characteristics of a serrated polyp?

A
  • Sessile, serrated polyps
  • Varied types (adenoma, hyperplastic)
  • Variable malignancy potential
59
Q

What are the characteristics of a non-neoplastic polyp?

A
  • MC non-neoplastic polyp but can develop to adenomatous
  • MC found in rectosigmoid area
  • MC very smol
60
Q

What are the submucosal lesions?

A

Mesenchymal benign tumors.

  • Lipoma
  • Leiomyoma
  • Neurofibroma
  • Vascular lesions

Usually made of multiple tissue types

61
Q

What is the MC etiology of colon cancer?

A

Adenomatous polyps

62
Q

What are the risk factors for colon cancer?

A
  1. > 50 y/o
  2. FMHx
  3. Diet (red meat and high fat)
  4. Smoking
  5. Obesity
63
Q

When is colonoscopy screening recommended?

A

45 years for average risk individuals

64
Q

How does proximal colon cancer tend to present?

A
  • Anemia
  • Weakness, fatigue
  • Melena
  • Positive FOBT
  • Wt loss
65
Q

How does distal colon cancer tend to present?

A
  • Change in bowel habits
  • Obstruction
  • Hematochezia
  • Tenesmus
66
Q

How is colon cancer diagnosed and staged?

A
  • Diagnose: Colonoscopy
  • Staging: CT/MRI
67
Q

What is the treatment for colon cancer?

A
  1. Stage 1 = resection
  2. Stage 2-4 = Resection + chemo/radiation
68
Q

For curative resections of colon cancer, what is the follow-up screening/treatment protocol?

A
  • H&P and CEA
  • Annual CT if high-risk
  • Colonoscopy 1 year post-op then 3 years if clean
  • If CEA starts going up; colonoscopy
69
Q

What tests are used to screen for colon cancer?

A
  1. FOBT or FIT test
  2. Flexible sigmoidoscopy
  3. Colonoscopy
  4. CT Colonography
70
Q

What is familial adenomatous polyposis?

FAP

A

Genetic predisposition to making thousands of little polyps, often developing by age 15 and cancerous by age 40.

Can also make little growths everywhere like skin.

71
Q

For someone with FAP, what surgery is needed to prevent cancer by age 50?

A

Prophylactic proctocolectomy with anastomosis is recommended by age 20!!

72
Q

Who do we screen for FAP?

A
  • Anyone with many polyps upon endoscopy
  • Any first-degree family members with FAP
73
Q

For someone with FAP, how often do we screen them?

A

EGD every 1-3 years

74
Q

What does lynch syndrome predispose someone to?

A

Colorectal cancer

75
Q

What does lynch syndrome present as?

A

Few adenomas, but they are flat and more villous

Villous = highest likelihood to cause cancer

76
Q

What is the three tool screening for Lynch syndrome?

A
  1. 1st degree relative with colo-rectal cancer prior to age 50
  2. Has the pt had colo-rectal cancer/polyps before 50
  3. 3 or more relatives with colo-rectal cancer?
77
Q

When is genetic counseling recommended for Lynch syndrome?

A
  • Family/Personal Hx of CRC before 50
  • Family history of multiple people with CRC
78
Q

What is the treatment for Lynch syndrome?

A
  • Subtotal colectomy with ileorectal anastomosis
  • Prophylactic hysterectomy/oophorectomy by age 40
  • Screening with EGD every 2-3 years starting at age 30
  • Colonoscopies starting at age 25
79
Q

What defines internal vs external hemorrhoids?

A

Dentate line

80
Q

What are the primary causes of hemorrhoids?

A
  • Constipation, low fiber
  • Straining
  • Pregnancy
  • Obesity

Venous pressure increases

81
Q

Where exactly do internal hemorrhoids occur?

A
  • Right anterior
  • Right posterior
  • Left Lateral

RAPLL

definitely seems like a test question

82
Q

What veins do external hemorrhoids originate from?

A

Inferior hemorrhoidal veins below the dentate line.

83
Q

How do internal hemorrhoids tend to present?

A
  • Bleeding, prolapse, Mucoid discharge
  • Often not painful
84
Q

How do we look for hemorrhoids?

A
  • Perianal inspection
  • Anoscopic evaluation
85
Q

Table of internal hemorrhoid staging

A
86
Q

How do you conservatively treat stage 1-2 hemorrhoids?

A
  • Proper toileting
  • High fiber, drink water, take laxatives
87
Q

How do you treat stage 1-2 hemorrhoids that have recurrent bleeding or stage 3-4?

A
  1. Rubber band ligation (preferred)
  2. Injection sclerotherapy
88
Q

For stage 4 or a severe stage 3 hemorrhoid, what is the surgery?

A

Hemorrhoidectomy

89
Q

How do external hemorrhoids tend to present?

A
  • Very painful
  • Bluish nodule that looks poppable
90
Q

How do you treat external hemorrhoids?

A
  • Sitz baths
  • Topical ointments
  • Evacuation of clot
91
Q

What are anal fissures and what usually causes them?

A
  • Linear tears/ulcerations around the anus caused by hard stools.
  • MC in posterior midline
  • Any other lines might suggest IBD
92
Q

If someone has chronic anal fissures, what could we recommend?

A

Surgical repair

93
Q

What is the MCC of perianal abscesses?

A

Perianal fistulas

94
Q

How does a perianal abscess present?

A
  • Fluctuance
  • Continuous pain
  • Throbbing and swelling
95
Q

How do you treat a perianal abscess?

A
  • I&D
  • Maybe use ABX
  • Surgical excision
96
Q

How do you treat a perianal fistula?

A

Fistulotomy under anesthesia

97
Q

Is rectal prolapse normal?

A

It often reduces spontaneously once you are done defecating

98
Q

If rectal prolapse is chronic/complete, what do we do?

A

Surgical correction

Emergent

99
Q

What are the risk factors for rectal prolapse?

A
  • Age > 40
  • Female
  • Vaginal delivery
  • Big baby delivery
  • Anything that weakens your pelvic floor
  • Dementia
100
Q

How do you treat a rectal prolapse?

A
  • Manual reduction
  • Fluid/fiber
  • Kegel exercises
  • Surgical consult
101
Q

What is pilondial disease?

A

An extra sinus opening?

GI (17 decks)

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