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Clin Med semester 2 > Lower GI disorders- Paulson (exam 3) > Flashcards

Lower GI disorders- Paulson (exam 3) Flashcards

1
Q

Inflammatory Bowel Disease (IBD)= consists of which 2 disease conditions

A

Crohn’s disease & Ulcerative colitis make up IBD

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2
Q

Risk factors for IBD:

A
  • Age of onset: 15-40 years old
  • More common in those of Jewish descent
  • First degree relative with IBD
  • Smoking: Increases risk of Crohn’s disease
  • “Western diet” ↑ risk
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3
Q

What is a protective factor against Ulcerative colitis?

A

smoking

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4
Q

Ulcerative Colitis (UC)= an inflammatory condition involving the ______

A

mucosal surface of the colon

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5
Q

UC= diffuse ____ areas and erosions of bleeding

A

friable

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6
Q

T/F: UC usually starts distally and progresses proximally

A

True! starts distally at rectum and progresses proximally

–>*Disease is continuous (no skipped areas)

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7
Q

UC Clinical Manifestations

A

Bloody diarrhea
BMs often frequent and small volume
-**Tenesmus
-Those with mainly distal disease may have constipation + frequent blood and mucus discharge
-Incontinence
-Colicky abdominal pain
-Onset of symptoms usually gradual & progressive
-Systemic symptoms (fever, weight loss, fatigue) possible

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8
Q

Tenesmus=

A

the urge to deficate

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9
Q

Colicky pain=

A

comes and goes

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10
Q

UC: PE findings

A 
-Often normal
Possibly:
Abdominal pain with palpation
Fever
Hypotension
Tachycardia
Pallor
Blood on rectal exam
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11
Q

UC: Extraintestinal Manifestations

A 
Arthritis
Nondestructive peripheral arthritis of large joints
Ankylosing spondylitis
Uveitis/episcleritis
Erythema nodosum
Pyoderma gangrenosum
VTE
Arterial thromboembolism
Autoimmune hemolytic anemia
Primary sclerosing cholangitis
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12
Q

UC: Labs

A

Anemia
↑ ESR/CRP
Electrolyte abnormalities from diarrhea/dehydration
***↑ Fecal calprotectin

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13
Q

What lab can be used to differentiate IBS from IBD?

A

increased Fecal calprotectin in IBD, NOT IBS

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14
Q

Imaging: UC

A
  • -Not required for diagnosis
  • Xray findings:
  • Proximal constipation
  • Mucosal thickening or **“thumbprinting” from edema
  • Colonic dilation if severe
  • Double contrast barium enema:
  • -**Diffusely reticulated pattern with punctate collections of barium in microulcerations
  • -**Collar button ulcers
  • Shortening of colon
  • -Loss of haustra
  • -Polyps or pseudopolyps
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15
Q

Avoid double contrast barium enema in which Pts?

A

Avoid in those severely ill –>can cause toxic megacolon

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16
Q

Other imaging studies for UC

A
  • CT or MRI
  • -have Lower sensitivity than barium enema at detecting subtle early disease
  • they show Thickening of bowel wall
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17
Q

Dx: UC (4 things)

A
  • **Chronic diarrhea ≥4 weeks
  • Evidence of active inflammation on endoscopy
  • **Chronic changes on biopsy

-Exclusion of other causes of colitis

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18
Q

Endoscopy findings for Ulcerative Colitis (2)

A
  • Loss of vascular markings from swelling of mucosa–> looks erythematous
  • Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
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19
Q

Ulcerative colitis: biopsy findings

A

-Crypt abscesses
Crypt branching
Shortening & disarray
Crypt atrophy

  • Epithelial cell abnormalities: mucin depletion, Paneth cell metaplasia
  • Inflammatory features: ↑ lamina propria cellularity, basal plasmacytosis, basal lymphoid aggregates, lamina propria eosinophils
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20
Q

Ulcerative colitis: patterns

A
  • Involves rectum
  • Extends proximally in a continuous, circumferential manner
  • No normal areas of mucosa
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21
Q

UC: Severity of Disease (3)

A
  • mild
  • moderate
  • severe
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22
Q

UC: mild disease (criteria)

A
  • ≤ 4 stools/day (with or without blood)
  • Normal ESR
  • No severe abdominal pain, fever, weight loss, or profuse bleeding
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23
Q

UC: moderate disease

A
  • > 4 loose, bloody stools/day
  • Mild anemia (not requiring transfusions)
  • Moderate abdominal pain
  • Minimal signs of systemic toxicity ie: low-grade fever.
  • No weight loss
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24
Q

UC: Severe disease (criteria)

A
  • Frequent loose bloody stools ≥6/day
  • Severe abdominal pain
  • Systemmic symptoms (fever, tachycardia, anemia, or ↑ESR)
  • May have rapid weight loss
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25
Q

UC: tx

  • for ulcerative proctitis or proctosigmoiditis?
  • for distal part of rectum?
A
  • **Topical 5-aminosalicylic acid (5-ASA) is first-line
  • Suppositories and/or enemas
  • -Use a Suppository if disease confined to distal part of rectum: Mesalamine 1 PR BID
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26
Q

UC tx:

-if disease extends farther than distal part of rectum?

A
  • Enema + suppository if disease extends further

- -Enema BID + suppository BID

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27
Q

UC tx:

-how quickly does tx provide relief?

A
  • Symptomatic relief and decreased bleeding in only a few days
  • Complete healing takes ≥4-6 weeks –> continue for 8 weeks then taper
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28
Q

UC:

  • who needs maintenance therapy?
  • who doesnt
A

–Maintenance therapy not recommended for 1st episode of proctitis
–Maintenance therapy is recommended for:
Proctosigmoiditis patients
Those with ≥1 relapse/year

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29
Q

UC: alternative tx

A

Topical steroids
Oral 5-ASA

*not as effective

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30
Q

UC: tx

-For Left-sided colitis, extensive colitis, pancolitis?

A

Combo therapy with oral 5-ASA, 5-ASA or steroid suppositories, and 5-ASA or steroid enemas
–All should have maintenance therapy

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31
Q

UC: Tx of refractory dz

A

Refer!

Likely will use further oral immunosuppressants

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32
Q

UC: chronic complications

A

Strictures: MC in rectosigmoid colon

  • Can cause obstruction
  • Consider malignant until proven otherwise (by biopsy)

Colorectal Cancer:

  • UC Pts are at ↑ risk for colorectal cancer
  • ↑ Duration of illness and ↑ extent of disease ↑ risk
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33
Q

UC: prognosis

A

-With treatment:
Exacerbations/flares alternating with long periods of symptomatic remission
Some unable to achieve remission

-Disease extension may be seen
-Some may need colectomy
20-30%
For acute complications or intractable disease

-Mortality: Slightly higher than the general population

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34
Q

Crohn Disease= transmural inflammation of the ____

A

GI tract that can occur anywhere from the mouth to perianal area

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35
Q

Crohn disease:

-MC involved areas?

A
  • Ileum & right colon most commonly involved

- Skip areas are classic**

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36
Q

Crohn disease:

  • etiology
  • peak incidence?
A

-Cause is unknown

Peak incidence between 15-35 years old

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37
Q

Crohn disease:

-Sx

A
  • Crampy abdominal pain
  • Strictures–> can have repeated obstruction
  • Diarrhea: Fluctuating over time, Gross bleeding less common than in UC (may be microscopic)
  • Fistulas
  • malabsorption
  • absecess formation
  • apthous ulcers (in the mouth)
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38
Q

Crohn Disease:

-common sites for fistulas?

A
  • Enterovesical (to bladder)
  • Enterocutaneous (to skin)
  • Enteroenteric (to bowel)
  • Enterovaginal (to vagina)
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39
Q

Crohn disease:

-extra-intestinal manifestations

A

Fatigue very common
Weight loss
Arthritis
Eye involvement: Uveitis, iritis, episcleritis
Skin: Erythema nodosum, pyoderma gangrenosum
Primary sclerosing cholangitis
-VTE & arterial thromboembolism
-Nephrolithiasis (from steatorrhea & diarrhea)
-Vitamin B12 deficiency
-Pulmonary involvement
-Secondary amyloidosis

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40
Q

Crohn disease: Physical exam findings

A
  • Often normal
  • Perianal skin tags
  • Sinus tracts
  • Abdominal tenderness
  • Weight loss
  • Pallor
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41
Q

Crohn disease: Labs

A
  • CBC
  • CMP
  • ESR/CRP–>CRP higher in CD than UC
  • Serum iron
  • Vitamin D level
  • Vitamin B12 level
  • **Fecal calprotectin may help differentiate from IBS
  • Antibody tests: pANCA and ASCA may help diagnose IBD and distinguish CD from UC
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42
Q

pANCA and ASCA stand for?

A

perinuclear antineutrophil cytoplasmic (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA)–> positive in crohn’s dz

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43
Q

How can a colonoscopy be useful in Crohn’s Pts?

A
  • Colonoscopy can be used To establish the diagnosis***
  • Focal ulcerations adjacent to areas of normal appearing mucosa
  • Polypoid mucosal changes that give a cobblestone appearance
  • Skip areas typical
  • Rectal sparing common
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44
Q

Wireless Capsule Endoscopy:

A
  • Another way to visualize small bowel
  • No radiation exposure
  • Don’t perform in those with suspected stricture***

-helps to dz crohn’s disease

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45
Q

Crohn’s disease: imaging (endoscopy findings)

A
  • Upper GI series with small bowel follow through
  • Narrowing of lumen with nodularity & ulceration
  • **“String sign”
  • Cobblestone appearance
  • Fistulas/abscess formation
  • Bowel wall thickening
  • Stricturing
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46
Q

“cobblestone appearance”–

A

think crohn’s!!! since the barium gets dispersed and settles into the inflamed areas

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47
Q

Crohn disease: CT scan

-when is a CT the best study?

A

CT (with ingestion of a neutral contrast agent to distend small bowel)
-Best study if abscess suspected**

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48
Q

Crohn disease: MRI

-findings?

A

-Mural thickening, high mural signal intensity (edema), and layered pattern of enhancement = acute small bowel inflammation

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49
Q

Crohn’s Disease Activity Index (CDAI)

A

Stool patterns, abdominal pain rating, general wellbeing, complications, abdominal mass, anemia, weight change

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50
Q

Harvery-Bradshaw Index (HBI)

A

-General wellbeing, abdominal pain, number of liquid stools, abdominal mass, complications

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51
Q

Crohn Disease:

-Clinical Remission

A

Asymptomatic, no sequelae. Achieved spontaneously or after medical or surgical intervention

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52
Q

Crohn Disease:

-Mild Crohn Disease

A

Ambulatory, tolerating oral diet. <10% weight loss, no systemic symptoms. No s/s of obstruction

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53
Q

Crohn Disease:

-Mod-severe Crohn disease

A

Have failed treatment for mild-mod disease, or have prominent symptoms like fever, weight loss, abdominal pain/tenderness, intermittent n/v, anemia

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54
Q

Crohn disease:

-Severe-fulminant disease

A

Persistent s/s despite steroids or biologic agents, or have high fever, persistent vomiting, intestinal obstruction, peritoneal signs, cachexia, or evidence of an abscess

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55
Q

Crohn disease:

-Treatment- general approaches

A
  • step up therapy

- Top-down therapy

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56
Q

Describe Step-up therapy

A
  • Start with less potent meds (but fewer side effects)
  • Use more potent meds if initial therapies not effective

(use step up tx for MILD crohn’s disease)

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57
Q

Describe Top-down therapy

A
  • USE for Pts with SEVERE crohn’s disease

- Start with more potent therapies early in the course of the disease before they become glucocorticoid-dependent

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58
Q

Goal of tx: Crohn’s disease

A

Goal: Achieve remission (endoscopic, histologic, and clinical) by demonstrating complete mucosal healing

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59
Q

Treatment of Mild-Mod Disease: Crohn Disease

A
  • Ileum or Proximal Colon Involvement–> Budesonide 1st line for induction. Budesonide 9 mg daily x 4-8 weeks, then taper Q2-4 weeks for 8-12 weeks total
  • Alternatives to budesonide: prednisone, oral 5-ASA (controversial)
  • Diffuse Colitis or left colonic involvement: Oral prednisone 40 mg daily x 1 week, then taper. Sulfasalazine is alternative

-Tx of Oral lesions:
Topical steroid medications ie: triamcinolone acetonide

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60
Q

Budesonide (aka _______

A

enterocort

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61
Q

Budesonide: pharmocologic category

A

corticosteroid

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62
Q

Budesonide:

-adverse reactions

A

headache, acne, adrenal suppression, osteoporosis, immunosuppression, edema, psychiatric disturbances, exacerbation of CV disease, hyperglycemia

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63
Q

After induction therapy is complete (crohn disease):

A
  • If prednisone used for induction:
  • -Taper and discontinue
  • -Then clinically observe, ileocolonoscopy in 6-12 months
  • If 5-ASA or sulfasalazine used:
  • -Continue the same med for long-term maintenance
  • -Ileocolonoscopy in 6-12 months

-If budesonide used:
Goal is to stop the med, but can continue at lower dose (6 mg) for no more than 3-6 months

  • Immunomodulator may be used
  • -More common for those with mod-severe disease
  • -Azathioprine, methotrexate, 6-mercaptopurine
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64
Q

For Relapse of Crohn disease- tx

A

-Begin a second course of a glucocorticoid

65
Q

Tx of more severe disease- crohn’s disease

A
  • Top-down approach
  • Refer!
  • Biologic + immunomodulatory for induction
  • -TNF-inhibitor: infliximab (Remicade), adalimumab (Humira), or certolizumab (Cimzia)
      • azathioprine, 6-mercaptopurine, or methotrexate
  • Some patients may also get a glucorticoid (up to 8 weeks) for more immediate symptom relief
  • Maintenance therapy
  • -Continue long-term treatment with a biologic agent
66
Q

Surgical Management: Crohn disease

A

Required for Pts with complications:

  • Perforation
  • Abscess
  • Fistula
  • Hemorrhage
  • Stricture
  • Neoplasm
  • Or those who have persistent symptoms despite medical management
67
Q

Prognosis: Crohn disease

A
  • Intermittent exacerbation followed by periods of remission
  • Over half develop structuring or penetrating disease
  • Up to 80% require at least 1 hospitalization
  • Many will require surgery
  • Predictors of severe course:
  • -Age < 40
  • -Perianal or rectal disease
  • -Smoking
  • -Low education level
  • -Initial need for glucocorticoids
68
Q

Constipation: list the causes

A

-Inadequate fiber & water consumption
-Medications: Opiates, anticholinergic meds, CCBs, antacids, iron
-Neurologic conditions:
MS, Parkinson disease, dementia, stroke

-Prolonged immobility
SCI, complete bed rest

-Metabolic diseases:
DM, hypothyroidism, uremia, hypercalcemia, hypokalemia

-Functional fecal retention:
Chronic stool-withholding behavior. Most common in kids

  • Anatomic abnormalities:
  • -Neoplams
  • -Anal fissures, lesions, proctitis, perirectal abscess
  • -Anorectal stenosis
  • Functional abnormalities:
  • -Increased rectal compliance
  • -Pelvic floor dysfunction (ie: rectocele, enterocele, ie pregnancy)
69
Q

Clinical manifestations of constipation

A
  • “Hard or lumpy stools”
  • Feeling of incomplete voiding
  • Straining
  • Abdominal discomfort and bloating
  • Manual maneuvers
  • Fewer than 3 defecations per week
  • Loose stools rare without laxative use
70
Q

Constipation: tx

A 
-Fiber--> Psyllium (Metamucil), methylcellulose (Citrucel), 
calcium polycarbophil (FiberCon)

-Hyperosmolar agent:
Sorbitol, lactulose, PEG (Miralax)

  • Stimulant: Glycerin suppository, bisacodyl (Dulcolax), senna (Senakot), senna/Colace
  • Enema: Mineral oil, tap water enema, sodium phosphate (Fleet)

-Opioid antagonist:
Methylnaltrexone (Relistor), naloxegol (Movantik)

71
Q

Fecal impaction

A
  • A mass of compacted feces in the large intestine that can’t be evacuated spontaneously
  • ->Usually in rectum or distal sigmoid colon

-Common in chronic constipation–> Especially elderly

72
Q

Fecal impaction: clinical presentation and imaging

A
  • Rectal discomfort
  • Abdominal pain & cramping
  • Bloating
  • Overflow fecal incontinence or paradoxical diarrhea
  • Increased urinary frequency, incontinence, or obstruction
  • May detect impacted feces on rectal examination

-Xray or CT shows location of impaction and any associated bowel obstruction

73
Q

Fecal impaction: tx

A
  • Manual disimpaction
  • Enema administration
  • Osmotic laxatives
  • Address underlying cause of constipation
  • ->Adequate fiber & water intake
  • ->Bulking agents, stool softeners
74
Q

Fecal impaction: complications

A
  • Large bowel obstruction with colonic perforation

- High mortality

75
Q

Celiac Disease: aka ________

-inflammation of?

A
  • AKA gluten-sensitive enteropathy and nontropical sprue
  • Inflammation of the small bowel secondary to ingesting gluten-containing foods
  • ->Wheat, barley, rye, some oats
76
Q

Celiac disease- pathogenecity

A
  • Immune disorder triggered by an environmental agent (the gliaden in gluten) in people who are genetically predisposed
  • Mostly in Caucasian patients with northern European ancestry
  • Many undiagnosed
  • More prevalent than recognized

-Usually presents between ages 10-40 (dx mostly in their 20’s)

77
Q

Celiac disease: Sx

A
  • Diarrhea with bulky, **foul-smelling, **floating stools
  • -Steatorrhea, flatulence
  • Weight loss
  • Weakness
  • Abdominal distension
  • Infants & kids may present with FTT
  • Iron deficiency anemia
  • Osteopenia & osteoporosis
78
Q

Conditions associated with Celiac disease:

A

-Dermatitis herpetiformis
-Diabetes Mellitus Type 1
Down Syndrome
Liver Disease
-Menstrual & reproductive issues

79
Q

Steatorrhea=

A

fatty stools

80
Q

Describe dermatitis Herpetiformis

A

=Grouped pruritic papules and vesicles. Commonly associated with Celiac disease
-on Elbows, dorsal forearms, knees, scalp, back, & buttocks common sites

81
Q

Describe Menstrual and reproductive issues

A

Recurrent miscarriage, infertility, later menarche, earlier menopause, preterm delivery, low birth weight

82
Q

Who should have serologic testing (for celiac dz)?

A
  • Pts with Suggestive GI symptoms
  • Extraintestinal S/S suggestive of Celiac disease

-All testing should ideally be done while patient is on a gluten-containing diet

83
Q

Describe low probability Serologic testing vs high probability serologic testing

A

low probability–> serologic testing:

  • No significant s/s of malabsorption
  • No FH of celiac disease
  • Chinese, Japanese, or Sub-Saharan African descent

High probability–> serologic testing and small bowel biopsy

  • Classic presentation
  • Risk factors: 1st or 2nd degree relative with confirmed CD, -Type 1 DM, autoimmune thyroiditis, Down syndrome, Turner syndrome
84
Q

Serologic testing must be done while the Pt is ____

A

eating gluten

85
Q

Serologic testing

A

-Tissue transglutaminase ***(tTG)-IgA antibody is **preferred test
90-98% sensitivity
-Anti-endomysial (EMA-IgA) levels also measured

86
Q

IF serologic testing is (+), a _____ biopsy is needed to confirm dx of celiac

A

small bowel biopsy (with endoscopy)

87
Q

T/F: negative serology doesnt 100% exclude celiac disease

A

True. Could be negative because of:
IgA deficiency
Low gluten/gluten free diet
-False negative more common in mild disease

88
Q

Endoscopy with Small Bowel Biopsy: what is seen on endoscopy?

A
  • Atrophic appearing mucosa with loss of folds
  • **Visible fissures
  • Nodularity
  • Scalloping
  • Prominent submucosal vascularity
89
Q

Small bowel biopsy: findings associated with celiac

A
  • Graded using Marsh-Oberhuber classification
  • At least **4 biopsies are recommended to confirm dx:
  • -Increased intraepithelial lymphocytes
  • -**Atrophic mucosa with villi loss
  • -Epithelial apoptosis
  • -Crypt hyperplasia
90
Q

Management of Celiac disease

A
  • Gluten-Free diet
  • Refer to a RD! (registered dietitian)
  • Replete any nutritional deficiencies
  • Evaluate for bone loss with DXA
  • Pneumococcal vaccination
  • Improvement of dermatitis herpetiformis may be more delayed than the response to intestinal manifestations
  • Consider screening family members
91
Q

Celiac disease: prognosis

-which cancers are they at higher risk for??*

A
  • Increase in overall mortality
  • -Mostly due to CV disease and malignancy
  • Increase risk for malignancy–> Lymphoma most common**
  • GI cancers also common
92
Q

Colorectal cancer is the leading cause of..

A

deaths in the US

93
Q

Risk factors that influence screening recommendations for colorectal cancer?

A
  • Hereditory syndromes: Familial adenomatous polyposis (FAP) & Lynch syndrome (HNPCC)
  • IBD
  • Abdominal radiation
  • Cystic fibrosis
94
Q

Colorectal cancer: demographic (& risk factors that MAY influence screening recommendations)

A
  • African Americans highest rates of CRC–> Mortality 20% higher than Caucasians
  • Male gender–>25% higher mortality
  • Acromegaly
  • Renal transplantation + long-term immunosuppression
95
Q

RISK factors for colorectal cancer that DONT influence screening recommendations:

A
  • Obesity
  • Diabetes
  • Red & processed meat–>High cooking temperature also implicated
  • Smoking
  • Alcohol consumption
96
Q

Colorectal cancer: s/sx

A 
-Suspicious signs & symptoms:
Change in bowel habits
Unexplained IDA
Rectal bleeding + change in bowel habits
Rectal mass or abdominal mass
Abdominal pain
97
Q

Can Pts with colorectal cancer be asymptomatic?

A

yes. but discovered on routine screening

- -Most patients with early stage cancer don’t have symptoms

98
Q

Some Colorectal cancer Pts may need an emergency admission due to..

A

intestinal obstruction, peritonitis, or an acute GI BLEED

99
Q

Colorectal cancer dx:

A

-Colonoscopy
Colonoscopy findings:
-Endoluminal masses- arise from mucosa and protrude into lumen
-Friable, necrotic, or ulcerated lesions may bleed
-“Apple core” description may be seen with circumferential involvement

100
Q

CT colonography= aka _____

A

“virtual colonoscopy” or CT colography
=Computer-simulated endoluminal perspective of the air-filled distended colon
–Still requires a bowel prep
—Stool can simulate polyps
-Abnormal results should be followed up by colonoscopy for excision & tissue dx

101
Q

tumor markers for colorectal cancer:

A

=CEA–> **Low diagnostic ability to detect primary colorectal cancer

  • has Significant overlap with benign disease: ie Gastritis, PUD, diverticulitis, liver disease, COPD, diabetes, any acute or chronic inflammatory state
  • **Low sensitivity for early-stage disease
102
Q

CEA is useful for..

A

follow-up of patients with diagnosed CRC

  • -If levels >5 preoperatively–> worse prognosis
  • -If levels don’t normalize after surgery–> look for persistent disease
103
Q

Management of colorectal cancer: (3 things)

A
  • Carcinoma in a polyp–>Endoscopic removal alone as long as margins are clear
  • Larger tumors–>Surgical resection. Then adjuvant chemotherapy

-Radiation therapy: Most commonly used for rectal cancer. Not routine for completely resected colon cancer

104
Q

Colonoscopy Screening guidelines:

-who is at increased risk?

A

Personal history of CRC or an adenomatous polyp

-Family member with CRC or a documented advanced polyp

-Personal or family history of genetic syndromes that cause CRC:
Familial adenomatous polyposis
Lynch syndrome
Juvenile polyposis syndrome
Peutz-Jeghers syndrome
MUTYH-associated polyposis
  • Inflammatory bowel disease
  • Prior history of abdominal radiation for childhood malignancy
105
Q

Other risk factors that may influence colorectal cancer screening (2)

A

HIV positive men

African American

106
Q

Age to Initiate Screening in those at average risk of colorectal cancer

A
  • 50 years old for average-risk adults
  • Some will start at age 45 for African American adults
  • ->Recommendations vary
107
Q

When to Discontinue Screening in those of average risk for colorectal cancer

A

-Screen through age 75 in average risk patients, as long as they are expected to live ≥10 years

  • Between ages 76-85, individualize decision based upon:
  • Patient preferences
  • Prior testing results
  • Comorbidities
108
Q

Choices of Screening Tests (3)

A
  • colonoscopy
  • Fecal immunochemical teting (FIT)
  • CT colonogrpahy (aka virtual colonoscopy)
109
Q

Colonoscopy:

  • how often is it needed?
  • sensitivity?
A

BEST TEST!!! diagnostic and allows you to remove lesions simultaneously.

  • Every 10 years for those at average risk
  • Highest sensitivity for CRC and adenomatous polyps of the screening methods
  • Allows lesion removal
  • Associated with reduced incidence and mortality from CRC
110
Q

Fecal immunochemical testing (FIT)=

-what does it measure?

A
  • Screen for occult blood yearly using 1 stool sample
  • *Measures hemoglobin in the stool
  • If positive, patient needs colonoscopy ASAP
111
Q

CT colonography:

-how often is it needed?

A
  • Every 5 years
  • If polyps or findings suggestive of CRC, need colonoscopy ASAP
  • Still need bowel prep
112
Q

Other screening tests for colorectal cancer (list 4) (not preferred)

A
  • Sigmoidoscopy + FIT: Recommendations regarding timing vary
  • Sigmoidoscopy alone–> Every 5-10 years. Minimal patient prep and no sedation required

-Guaiac-based FOBT:
3 samples given yearly

-Stool DNA testing (aka Cologuard):
One stool sample, performed every 3 years

113
Q

Choice of screening test in those with FH of CRC or advanced Polyp=

A

colonoscopy

-If patient refuses, FIT testing annually is the alternative

114
Q

When to Start Screening (FH of CRC or advanced Polyp) (3 things)

A
  • One first-degree relative (FDR) diagnosed at age <60 years:
  • -Begin screening at age 40 or **10 years before FDR’s diagnosis (whichever is earlier)
  • -Colonoscopy every 5 years
  • ≥2 FDRs diagnosed at any age:
  • -Begin screening at age 40 or 10 years before the youngest FDR’s diagnosis (whichever is earlier)
  • -Colonoscopy every 5 years
  • One FDR diagnosed at age ≥60 years:
  • -Begin screening at age 40
  • -Same screening options as average-risk patients
  • -Same frequency as average-risk patients
115
Q

PT with 1 FDR diagnosed at 45 and another relative diagnosed at 43, when should this Pt start getting screened for colorectal cancer?

A

33 yo (10 years prior to youngest relative’s dx)

116
Q

High Risk Syndrome Screening for colorectal cancer: list Some Examples

A
  • Lynch syndrome: 20-25 years old or 2-5 years prior to the earliest age of CRC diagnosis in the family
  • Familial adenomatous polyposis (FAP): yearly colonoscopy starting at age **10-12 years old if classic FAP and colonoscopy every 1-2 years starting at age 25 for attenuated FAP
  • Peutz-Jeghers syndrome: EGD, video capsule endoscopy, and colonoscopy starting at *age 8
117
Q

When to discontinue screening in higher risk patients? with colorectal cancer

A
  • No direct evidence but:
  • 1 FDR diagnosed after age 50: end at 79
  • ≥2 FDRs diagnosed before age 40: end at 85
  • If the patient has a life expectancy of <10 years–> reassess this plan
118
Q

Anal fissures= a tear, cut, or crack in the lining of the ____

A

distal half of the anal canal

119
Q

Anal fissures MC affect?

A

infants and middle aged adults

120
Q

Anal fissures: etiology

  • Primary?
  • Secondary?
A

Most are primary from local trauma:

  • Constipation
  • Anal sex
  • Diarrhea
  • Vaginal delivery

Secondary:

  • IBD
  • Malignancy
  • STI
121
Q

Anal fissures:

  • clinical Sx?
  • MC location?
  • 2nd MC location?
A
  • Anal pain
  • Pain intensifies with defecation
  • May feel like ripping/tearing
  • Often lasts for hours afterwards
  • May have associated anal bleeding (mild)
  • MC location: posterior midline. -2nd most common: anterior midline
  • ->Doesn’t usually extend above the dentate line
122
Q

anal fissures:
-acute looks ____
vs
-chronic fissure appearance:

A

-Acute: looks fresh, superficial, like a papercut

Chronic fissure: raised edges, fibrotic appearance often accompanied by a skin tag (sentinel pile)

123
Q

Anal fissures:

diagnosis

A
  • History + physical exam
  • Direct visualization (thinner patients) –or-
  • Reproduce the pain with (gentle) digital palpation of the posterior anal verge
124
Q

Anal fissure: tx

A
  • Fiber + water and/or stool softeners: prevents hard BMs which can cause reinjury
  • Sitz bath: anus is immersed in warm water for 10-15 minutes BID-TID–>Relaxes the anal sphincter & improves blood flow to mucosa
  • Topical analgesics: for pain control–> Ie: 2% lidocaine jelly

-Topical vasodilators: promote healing by ↑ local blood flow & ↓ anal sphincter pressure: —Nifedipine gel BID-QID
—Topical nitroglycerin BID: Si/E HA & hypotension
Don’t use within 24 hours of Viagra, Cialis, or Levitra!

125
Q

Anal fissure: Follow-up after?

A

-Reevaluate after 1 month.
If symptoms persist–> complete 1 more month of the same treatment

-If sx persist after 2 months–> refer for endoscopy to R/O Crohn disease

-If Crohn disease–> refer to GI
If no Crohn disease–> refer to colorectal surgeon
—Botox or lateral sphincterotomy recommended

126
Q

Hemorrhoids are swollen veins in the rectum and anus that can lead to ______

A

discomfort, prolapse, and bleeding

127
Q

Describe external hemorrhoids

A
  • (located) distal to the dentate line
  • Arise from the superior hemorrhoidal cushion
  • Somatic innervation –> more sensitive to pain/irritation
128
Q

Describe Internal hemorrhoids

A
  • (located) proximal to the dentate line
  • Arise from the inferior hemorrhoidal plexus
  • Visceral innervation –> less sensitive to pain/irritation
129
Q

Describe mixed hemorrhoids

A

both above and below the dentate line

130
Q

Risk factors for developing symptomatic hemorrhoids

A
  • Advancing age
  • Chronic constipation, straining
  • **Pregnancy (after pregnancy this is common)
  • Pelvic tumors
  • Diarrhea
  • **Prolonged sitting
  • Anal sex
  • Anticoagulants and antiplatelet medications
  • Obesity
  • Low fiber diet
131
Q

Hemorrhoids: clinical sx

-about ___% of Pts are asymptomatic

A

40%

132
Q

Clinical Sx: hemorrhoidal bleeding

A
  • Painless
  • Associated with a BM
  • Typically bright red & coats the stool at the end of defecation
133
Q

Clinical Sx: hemorrhoids

A
  • Pruritis or irritation of perineal area very common
  • Mild fecal incontinence, mucus discharge, or wet sensation
  • Acute onset of perianal pain possible with palpable “lump” from thrombosis
  • Appear like protuberant purple nodules covered by mucosa
134
Q

Diagnosis: Hemorrhoids

A
  • Classic symptoms + visualization of hemorrhoids

- Anoscopy: allows visualization of internal hemorrhoids

135
Q

How do we classify internal hemorrhoids? (list grades)

A

Grade I: No prolapse (aka below the dentate line)

Grade II: Prolapse with defecation, spontaneously reduces

Grade III: Prolapse with defecation or other times, needs manual reduction (aka you have to manually push the hemorrhoid back in)

Grade IV: Permanently prolapsed/irreducible, Visible externally, may strangulate.

136
Q

Hemorrhoids: tx?

A

-Increase fiber & water intake to produce soft stools

  • Topical steroids: may shrink hemorrhoids & relieve pruritis:
  • -Hydrocortisone cream BID x 7 days
  • -Hydrocortisone suppository BID x 7 days
  • Topical analgesics:
  • -Lidocaine gel

-Warm sitz baths: reduce inflammation & edema and relax sphincter muscles
BID-TID

  • Antispasmodic agents: reduce anal sphincter spasm:
  • -Nitroglycerin ointment
137
Q

When to Refer to Colorectal or General Surgeon for a Pt with hemorrhoids:

A
  • Symptomatic low grade (grade I or II) hemorrhoids refractory to 6-8 weeks of medical treatment
  • Symptomatic high grade (III or IV) hemorrhoids
  • Thrombosed hemorrhoids
138
Q

Office-based procedures for hemorrhoids:

-Describe rubber band ligation

A
  • MC procedure
  • Rubber band rings are placed on the internal hemorrhoids (NOT FOR EXTERNAL hemorrhoids)
  • Bleeding & pain MC complications
139
Q

Office-based procedures for hemorrhoids:

-describe Sclerotherapy

A
  • Injecting a solution that causes an inflammatory reaction, destroying tissue
  • Can be used for those who have an elevated bleeding risk
140
Q

Office-based procedures for hemorrhoids:

-describe Infrared coagulation

A

infrared light waves are applied to the hemorrhoid, causes necrosis

141
Q

Surgical Procedures:

-List indications for external hemorrhoidectomy:

A
  • Symptomatic & refractory to conservative measures
  • Symptomatic and refractory to office-based procedures
  • Large or severely symptomatic external hemorrhoids
  • Patients with substantial external skin tags
  • Combined internal and significant external hemorrhoids
142
Q

Surgical procedures:

-indications for internal hemorrhoidectomy?

A

-Prolapsed internal hemorrhoids that can be manually reduced (Grade III)

  • Prolapsed and incarcerated internal hemorrhoids (Grade IV)
  • Symptomatic internal hemorrhoids refractory to conservative measures
  • Symptomatic internal hemorrhoids refractory to office-based procedures
  • Combined internal and external hemorrhoids
143
Q

Diverticulosis:

  • a diverticulum is a sac-like protrusion of the _____
  • develops at points of _____
  • diverticulosis is defined by the presence of a _____
A
  • colonic wall
  • weakness
  • **diverticula–> may be symptomatic or asymptomatic
144
Q

Diverticular Disease= clinically significant and ______

A

symptomatic diverticulosis

145
Q

Paulson’s takeaway for hemorrhoids:

-outpatient setting?

A
  • topical steroids + suppository

- if no relief refer to colorectal

146
Q

Describe Diverticular disease:
-Diverticular bleeding=

  • diverticulitis=
  • diverticular colitis=
A
  • Diverticular bleeding= Painless hematochezia (BRBPR that is painless)–>MC cause of brisk hematochezia
  • Diverticulitis= Inflammation of a diverticulum–>4-15% develop diverticulitis
  • Diverticular colitis= Inflammation in the interdiverticular mucosa, without involvement of the diverticular orifices
147
Q

Describe Symptomatic uncomplicated diverticular disease

A

=persistent abdominal pain attributed to diverticula without overt colitis or diverticulitis.
–AKA smoldering diverticulitis

148
Q

diverticulosis: risk factors?

A
  • Increasing age
  • Low fiber, high fat, red meat diet
  • Nut, seeds, and corn diet are **NOT associated with increased risk in diverticulosis, diverticulitis, or diverticular bleeding

-Lack of physical activity:
Risk is inversely related to level of activity

  • BMI ≥25
  • Smoking ≥40 pack year hx
  • Meds: NSAIDs, opiates, steroids
149
Q

IBS= a functional disorder of the ____

A

GIT with chronic abdominal pain and altered bowel habits

150
Q

IBS: epidemiology

A
  • Women > men
  • Prevalence about 10-15% in North America
-Associated with:
Fibromyalgia
Chronic fatigue syndrome
Depression
Anxiety
151
Q

IBS: clinical Sx

A
  • **Chronic abdominal pain
  • Usually crampy
  • Variable intensity
  • Location and character can vary widely
  • **Defecation often improves the pain
  • **Stress can worsen the pain
  • Altered bowel habits**
152
Q

IBS:

-describe altered bowel movements

A

Altered bowel habits:

  • Diarrhea
  • Constipation
  • Alternating diarrhea and constipation
  • Normal bowel habits alternating with diarrhea and/or constipation
153
Q

Describe Bristol Stool Form Scale:

  • Type 1
  • type 2
  • type 3
  • type 4
  • type 5
  • type 6
  • type 7
A

type 1: separate hard lumps, like nuts (hard to pass)

Type 2: sausage-shaped but lumpy

type 3: like a sausage but w/ cracks on the surface

type 4: like a sausage or snake, smooth and soft

type 5: soft blobs with clear cut edges

6= fluffy pieces with ragged edges, mushy

7= watery, NO solid pieces, entirely liquid

dont memorize- general idea

154
Q

IBS: diagnostic criteria

A
  • Recurrent abdominal pain on average at least once a week in the past 3 months associated with ≥2 of the following:
  • -Related to defecation
  • -Associated with a change in stool frequency
  • -Associated with a change in stool appearance
155
Q

Alarm Symptoms (**Refer to GI):

A
  • More than minimal rectal bleeding
  • Weight loss
  • Unexplained IDA
  • Nocturnal symptoms
  • FH of colorectal cancer, celiac disease, inflammatory bowel disease
156
Q

IBS: tx

A
  • Education & reassurance
  • Dietary modification: some patients may benefit from excluding gas-producing foods- a diet low in **FODMAPs (fermentable oligo- di- and monosaccharides and polyols) and lactose and gluten avoidance
  • Increased fiber (psyllium) for those with constipation-predominant IBS:
  • -Miralax another option
  • -Lubiprostone for constipation-predominant IBS despite miralax
  • Antidiarrheals for those with diarrhea-predominant IBS:
  • -Imodium (Loperamide)
  • -Bile acid sequestrant if failed: cholestramine (Questran)
157
Q

FODMAPS

A
  • fermentable:
  • Oligosaccharides: wheat/barely, artichokes, pasta
  • Disaccharides: milk, custard, icecream yogurt
  • Monosaccarides: appples, pears, mangos, asparagus
  • and

-Polyols:

158
Q

IBS: Treatment for Abdominal Pain

A
  • Antispasmodics: inhibits gastrointestinal smooth muscle –> significant improvements to postprandial abdominal pain, bloating, and fecal urgency
  • Dicyclomine (Bentyl)= #1
  • Hyoscyamine (Levsin)
159
Q

IBS: other tx options

A

-TCAs: slow intestinal time (because of their anticholinergic properties) and help with abdominal pain:
Amytriptyline, nortriptyline, imipramine

-Antibiotics: In mod-severe IBS without constipation if failed to respond to other therapies, can try rifaximin

Clin Med semester 2 (24 decks)

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