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Lower GI pathology Flashcards

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1
Q

The following abdominal x-ray shows _

A

The following abdominal x-ray shows air-fluid levels suggesting bowel obstruction
* The obstruction point appears to be in the descending colon, possibly sigmoid colon

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2
Q

A “bowel obstruction” typically refers to a
(mechanical/non-mechanical) blockage of the bowels

A

A “bowel obstruction” typically refers to a
mechanical blockage of the bowels

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3
Q

A non-mechanical obstruction of the bowels is called _

A

A non-mechanical obstruction of the bowels is called ileus

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4
Q

Ileus is a non-mechanical bowel obstruction due to _

A

Ileus is a non-mechanical bowel obstruction due to lack of movement or peristalsis of the bowel
* Presents like a bowel obstruction
* Common after surgery

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5
Q

Bowel obstruction is more common in the (small/large) bowel

A

Bowel obstruction is more common in the small bowel
* Roughly 80% of B.O
* The small bowel has a smaller lumen so it is easier to obstruct

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6
Q

The most common overall cause of small bowel obstructions in adults is _

A

The most common overall cause of small bowel obstructions in adults is adhesions
* Other causes: hernias, malignancy, stricture, volvulus

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7
Q

Incarcerated hernias are also common causes of bowel obstructions, most commonly in the (small/large) bowel

A

Incarcerated hernias are also common causes of bowel obstructions, most commonly in the small bowel

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8
Q

Volvulus is a more common cause of a bowel obstruction in the (small/large) bowel

A

Volvulus is a more common cause of a bowel obstruction in the large bowel

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9
Q

The most common site of volvulus in adults is the _

A

The most common site of volvulus in adults is the sigmoid colon
* The sigmoid colon becomes “droopy” and loops around itself

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10
Q

The most common cause of bowel obstruction in children is _

A

The most common cause of bowel obstruction in children is intussusception
* Usually in children < 3 years old

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11
Q

_ can predispose children to intussusception

A

Meckel’s diverticulum can predispose children to intussusception

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12
Q

Aside from intussusception, _ and _ are two common causes of bowel obstruction in children

A

Aside from intussusception, volvulus and foreign body ingestions are two common causes of bowel obstruction in children
* Crohn’s disease with strictures is also possible
* Adhesions and malignancy are uncommon in kids

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13
Q

Volvulus in children is more often due to _

A

Volvulus in children is more often due to congenital malrotation

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14
Q

Clinical signs of bowel obstruction:

A

Clinical signs of bowel obstruction:
* Colicky abdominal pain
* Abdominal distension
* Nausea
* Vomiting
* Lack of stool output
* Lack of flatus

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15
Q

On physical exam, bowel obstructions may present with distended abdomen, _ on percussion, and _ bowel sounds

A

On physical exam, bowel obstructions may present with distended abdomen, tympany on percussion, and high pitched bowel sounds

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16
Q

Initial management of bowel obstruction includes _

A

Initial management of bowel obstruction includes:
1. NPO in case of surgery
2. NG tube for suction to decompress the bowel
3. IV fluids to maintain intravascular hydration

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17
Q

Further evaluation of a bowel obstruction following NG tube decompression involves:

A

Further evaluation of a bowel obstruction following NG tube decompression involves:
1. CT imaging
2. Surgical consultation

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18
Q

(True/False) GI motility drugs/ laxatives may be utilized in the case of an acute mechanical bowel obstruction

A

False; GI motility drugs/ laxatives may be utilized in the case of an acute mechanical bowel obstruction

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19
Q

Individuals with a history of _ have a risk for adhesions and bowel obstructions

A

Individuals with a history of prior abdominal surgery have a risk for adhesions and bowel obstructions
* Adhesions are fibrous bands outside the bowel that cause the bowel to be tethered

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20
Q

Bowel torsion or twisting is called _

A

Bowel torsion or twisting is called volvulus

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21
Q

Adults tend to have _ volvulus; children tend to have _ volvulus

A

Adults tend to have sigmoid volvulus; children tend to have cecal volvulus

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22
Q

Coffee bean sign on abominal xray is pathopneumonic for _

A

Coffee bean sign on abominal xray is pathopneumonic for sigmoid volvulus

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23
Q

Scarring inside the bowel is called a _
Scarring outside the bowel is called _

A

Scarring inside the bowel is called a stricture
Scarring outside the bowel is called adhesion

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24
Q

Colon cancer is the _ most common cancer in the US

A

Colon cancer is the third most common cancer in the US
* It is the second deadliest cancer in the US

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25
Risk factors of colon cancer:
Risk factors of colon cancer: * Hereditary * Male * Type 2 diabetes * IBD * Smoking * Alcohol * Obesity * Abdominal radiation
26
Positive factors that improve colon cancer risk:
Positive factors that improve colon cancer risk: * Aspirin/ NSAID use * Menopausal hormone therapy * Statin use * Physical activity * Whole grains, dietary fiber * Fish, nuts, calcium
27
There are two pathways for the pathogenesis of colon cancer, _ and _
There are two pathways for the pathogenesis of colon cancer: 1. **Conventional adenoma-carcinoma pathway** 2. **Microsatellite instability pathway**
28
70-90% of colon cancers develop via the _ pathway
70-90% of colon cancers develop via the **adenoma-carcinoma pathway** (polyps)
29
It is easier to screen for colon cancer that develops via the (adenoma- carcinoma pathway/ microsatellite instability pathway)
It is easier to screen for colon cancer that develops via the **adenoma-carcinoma** * This is the slower growing form (10-20 years)
30
The colon cancers that develop via microsatellite instability pathway are harder to screen because they develop in _ years
The colon cancers that develop via microsatellite instability pathway are harder to screen because they develop in **1-5 years**
31
The following shows an adenoma with _ histology
The following shows an adenoma with **villous** histology
32
The following shows an adenoma with _ histology
The following shows an adenoma with **tubular** histology
33
The following shows an adenoma with _ histology
The following shows an adenoma with **tubulovillous** histology
34
Low- grade dysplasia (adenoma) is characterized by _ and _
Low- grade dysplasia (adenoma) is characterized by **loss of mucin** and **increased mitotic figures**
35
36
Characterize by the stage of carcinoma
Early adenoma --> late/ high-grade adenoma --> carcinoma
37
The first line testing option for colon cancer is either direct visualization of the colon via _ or stool based test via _
The first line testing option for colon cancer is either direct visualization of the colon via **colonoscopy** or stool based test via **fecal immunohistochemistry**
38
FIT stands for _ and "cologuard" is a _ test
FIT stands for **fecal immunohistochemistry** and "cologuard" is a **stool DNA test**
39
If FIT or cologuard comes back abnormal, _ is still needed
If FIT or cologuard comes back abnormal, **colonoscopy** is still needed
40
Why is colonoscopy beneficial over FIT?
Colonoscopy offers... * Higher sensitivity * Diagnostic and therapeutic (polyp removal) * Less frequent
41
FIT testing is done every _ years, colonoscopy is done every _ years
FIT testing is done every **1-3** years, colonoscopy is done every **5-10** years * Colorectal cancer screening starts at age 45
42
Lynch syndrome has _ inheritance pattern
Lynch syndrome is **autosomal dominant**
43
(Lynch syndrome/ familial adenomatous polyposis) has a dramatic phenotype
**Familial adenomatous polyposis** has a dramatic phenotype
44
FAP is inherited in _ pattern
FAP is **autosomal dominant**
45
FAP involves the _ gene and _ signaling pathway
FAP involves the ***APC*** gene and **Wnt** signaling pathway * We get too much wnt signaling
46
Lynch syndrome is also called _
Lynch syndrome is also called **hereditary nonpolyposis CRC**
47
Lynch syndrome increases the risk of the following (3) cancers:
Lynch syndrome increases the risk of: 1. **Colorectal** 2. **Endometrial** 3. **Ovarian** *Also associated with pancreaticobiliary, gastric, small bowel, GU, skin, brain*
48
Colorectal cancer on colonoscopy
49
FAP, gross specimen
50
FAP
51
(True/ False) Lynch syndrome is also called hereditary non-polyposis colorectal cancer because it does not involve polyps
False; **Lynch syndrome can have few polyps** but it does not involve ***polyposis***
52
The mutations in lynch syndrome are in _ genes
The mutations in lynch syndrome are in **mismatch repair genes** * MLH1, MSH2, MSH6, PMS2
53
Patients with (lynch syndrome/ FAP) tend to present at a very young age with cancer
Patients with **FAP** tend to present at a *very young age* with cancer (20s, 30s) * Patients with lynch syndrome are typically middle aged or older
54
Patients with (FAP/ Lynch syndrome) have 100% lifetime risk of cancer
Patients with **FAP** have 100% lifetime risk of cancer
55
Patients who present with hundreds of polyps in the colon may have _
Patients who present with hundreds of polyps in the colon may have **FAP**
56
FAP associated cancers include (3):
FAP associated cancers include: 1. Gastric 2. Duodenal 3. Thyroid
57
Expected physical exam findings for peritonitis include:
Peritonitis: * Rigidity * Rebound tenderness * Pain with movement * Pain with "stretching" of the peritoneal cavity
58
Primary peritonitis is _
Primary peritonitis is **direct infection of the peritoneum** * This is typically a bacterial infection * Called *spontaneous bacterial peritonitis* SBP
59
Primary peritonitis is typically seen in patients with _
Primary peritonitis is typically seen in patients with **cirrhosis**
60
We treat primary peritonitis with _
We treat primary peritonitis with **antibiotics** * Recall that this is a direct infection of the peritoneum
61
Secondary peritonitis is due to _
Secondary peritonitis is due to **severly inflamed or infected abdominal organ that comes in contact with peritoneum**
62
Causes of secondary peritonitis include:
Causes of secondary peritonitis include: * **Appendicitis** * **Cholecystitis** * **Severe/perforated diverticulitis** * **Bowel perforation** * **Ovarian torsion or abscess** * **Perforated peptic ulcer**
63
Hematemesis suggests (upper/lower) GI bleed
Hematemesis suggests **upper GI bleed**
64
Coffee ground emesis suggests (upper/lower) GI bleed
Coffee ground emesis suggests **upper GI bleed**
65
Bright red blood per rectum suggests (upper/lower) GI bleed
Bright red blood per rectum suggests **lower GI bleed**
66
Melena suggests (upper/lower) GI bleed
Melena suggests **upper GI bleed**
67
Hematochezia suggests (upper/lower) GI bleed
Hematochezia can suggest **either upper or lower GI bleed**
68
Upper vs lower GI bleeding is delineated by _ landmark
Upper vs. lower GI bleeding is delineated by **ligament of Treitz**
69
The ligament of Treitz offers support at the end of the _ and beginning of the _
The ligament of Treitz offers support at the end of the **duodenum** and beginning of the **jejunum**
70
Causes of upper GI bleeding:
71
Causes of lower GI bleeding:
72
Small bowel ("mid bowel") bleeding may present with _ colors
Small bowel ("mid bowel") bleeding may present with **maroon, black, or bright red** stool
73
Anal fissures are small cuts/breaks in the _
Anal fissures are small cuts/breaks in the **anorectal mucosa** (anoderm) * *Like a paper cut in the anus*
74
Anal fissures will cause _ type of bleeding
Anal fissures will cause **bright red** bleeding on the *outside* of the stool
75
Anal fissures can be caused by _
Anal fissures can be caused by **trauma/stretching of anal mucosa** * Ex: hard stool
76
Deep anal fissures can cause _ spasm
Deep anal fissures can cause **anal sphincter** spasm
77
First line treatment for anal fissures includes treating the underlying cause with _ , or soothing measures like _
First line treatment for anal fissures includes treating the underlying cause with **fiber, water, laxatives (constipation)** , or soothing measures like **sitz baths, topical analgesic**
78
We can use a smooth muscle relaxant like _ or _ to reduce anal sphincter spasms
We can use a smooth muscle relaxant like **nifedipine** or **nitroglycerin** to reduce anal sphincter spasms
79
Refractory cases of anal fissures may require _
Refractory cases of anal fissures may require **botox**
80
What are hemorrhoids?
**Hemorrhoids** are *normal* vascular structures in the anal canal
81
Hemorrhoids arise from a channel of _ that drains into the superior and inferior _ veins
Hemorrhoids arise from a channel of **arteriovenous connective tissue** that drains into the superior and inferior **hemorrhoidal (rectal)** veins
82
Hemorrhoids are only considered pathologic when they become _
Hemorrhoids are only considered pathologic when they become **enlarged, cause pain, or bleed** * Possibly caused by straining or constipation
83
(External/ Internal) hemorrhoids are more likely to bleed
**Internal hemorrhoids** are more likely to bleed
84
(External/Internal) hemorrhoids are more likely to cause pain
**External hemorrhoids** are more likely to cause pain
85
External hemorrhoids have _ innervation
External hemorrhoids have **somatic afferent innervation** (why they are painful)
86
Internal hemorrhoids are less likely to cause pain because they are innervated by _
Internal hemorrhoids are less likely to cause pain because they are innervated by **pelvic splanchnic afferent (visceral) nerves**
87
What does it mean that irritable bowel syndrome is a *functional disorder*?
There is *no organic cause of IBS nor is it related to any structural abnormalities* * Instead it is a functional disorder liely related to **gut-brain axis disorder**
88
Irritable bowel syndrome is associated with an increase in _ leading to osmosis into the gut lumen
Irritable bowel syndrome is associated with an increase in **short chain carbohydrates (lactose, sucrose)** leading to osmosis into the gut lumen
89
How do short chain carbohydrates lead to the gas and cramping associated with IBS?
1. Short chain carbohydrates get **metabolized by gut bacteria** --> gas 2. **An increase in luminal water expands the GIT**, causes abdominal pain and intestinal smooth muscle spasms
90
IBS is associated with an increase in visceral hypersensitivity; this is why abdominal pain is often relieved _ when?
IBS is associated with an increase in visceral hypersensitivity; this is why abdominal pain is often relieved **following bowel movements**
91
IBS often presents with:
IBS often presents with: * Abdominal pain * Consipation, diarrhea * Changes in stool consistency and frequency
92
IBS is diagnosed using the _ criteria
IBS is diagnosed using the **Rome IV** criteria
93
What is the Rome IV criteria for IBS?
1. **Recurrent abdominal pain** (at least once per week for 3 months) And at least 2 of the following: a. **Symptoms related to defecation** b. **Change in stool frequency** c. **Change in stool form/ appearance**
94
Create a ddx for RUQ pain
95
Create a ddx for LUQ pain
96
Create a ddx for RLQ pain
97
Create a ddx for LLQ pain
98
IBS-D is _
IBS-D is **diarrhea predominant** * This means that the bowel pattern is diarrhea 25% of the time
99
IBS-C is _
IBS-C is **constipation predominant** * This means that the bowel pattern is constipation 25% of the time
100
IBS-M is _
IBS-M is **mixed diarrhea and constipation** * Alternating periods
101
The first line treatment for IBS with abdominal pain is _
The first line treatment for IBS with abdominal pain is an **anti-spasmodic** like **hyoscyamine** or **dicyclomine** * These have anti-cholinergic effects
102
How do we manage IBS?
103
IBS directed therapies (overview)
104
_ is a congenital failure of neural crest cell migration to the myenteric and submucosal plexus in the rectum
**Hirshsprung disease** is a congenital failure of *neural crest cell migration* to the *myenteric and submucosal plexus* in the rectum
105
A baby with hirschsprung disease may present with:
A baby with hirschsprung disease may present with: * Abdominal distention * **Failure to pass meconium within 48 hours** * Constipation * **Bilious vomiting**
106
Hirschsprung disease causes defective relaxation and peristalsis of the rectum and distal sigmoid colon leading to _
Hirschsprung disease causes defective relaxation and peristalsis of the rectum and distal sigmoid colon leading to **proximal megacolon**
107
Hirschsprung disease can present with _ sign on digital rectal exam
Hirschsprung disease can present with **squirt sign** on digital rectal exam * *Explosive expulsion of feces with empty rectal vault*
108
Hirschsprung disease is diagnosed via absence of _ cells on _ biopsy
Hirschsprung disease is diagnosed via absence of **ganglion cells** on **rectal suction biopsy**
109
Hirschsprung disease is associated with _ syndrome and _ mutations
Hirschsprung disease is associated with **down syndrome** and **RET mutations**
110
Necrotizing enterocolitis is a condition in which the bowel becomes _
Necrotizing enterocolitis is a condition in which the bowel becomes **gangrenous, we see inflammation and ischemic necrosis of ileum and colon**
111
Necrotizing entercolitis is associated with _ infants
Necrotizing entercolitis is associated with **premature, low-birth-weight, formula-fed** infants * Babies with immature immune systems and get overgrowth of bacteria from formula
112
Acute mesenteric ischemia is _
Acute mesenteric ischemia is **critical blockage of arterial blood flow to the intestines --> necrosis**
113
The most common cause of mesenteric ischemia is an embolic occlusion of the _ artery
The most common cause of mesenteric ischemia is an embolic occlusion of the **superior mesenteric artery** * Supplies the small intestine * Caused by valvular disease, atrial fibrillation
114
Signs of acute mesenteric ischemia:
Signs of acute mesenteric ischemia: * **Pain out of proportion to physical exam** * **Red currant jelly stools** * **Decreased bowel sounds** *Can progress to transmural infarction, perforation, shock*
115
Atherosclerosis of the celiac artery, SMA, or IMA may lead to _
Atherosclerosis of the celiac artery, SMA, or IMA may lead to **chronic mesenteric ischemia**
116
Chronic mesenteric ischemia is associated with _ type pain
Chronic mesenteric ischemia is associated with **postprandial epigastric pain** * Need increased blood flow after consuming a meal --> pain
117
Colonic ischemia most often occurs in _ areas
Colonic ischemia most often occurs in **watershed areas**
118
_ and _ are two watershed areas of the colon that are more likely to experience ischemia
**Splenic flexure** and **rectosigmoid junction** are two watershed areas of the colon that are more likely to experience ischemia
119
Colonic ischemia may be diagnosed by cramping abdominal pain, hematochezia, and _ sign on abdominal xray
Colonic ischemia may be diagnosed by cramping abdominal pain, hematochezia, and **thumbprint sign** on abdominal xray
120
Normal colonic mucosa is lined by _ epithelium and is rich in _ cells
Normal colonic mucosa is lined by **simple columnar epithelium** and is rich in **goblet cells**
121
Increase number of cells is _
Increase number of cells is **hyperplasia**
122
Change in the physiologic cell type is called _
Change in the physiologic cell type is called **metaplasia**
123
Disordered cell growth is called _
Disordered cell growth is called **dysplasia**
124
(Sessile/ pedunculated) polyps are more likely to be malignant or have malignant potential
**Sessile** polyps are more likely to be malignant or have malignant potential * Villous = sessile
125
A serrated polyp can often progress to colon cancer via the _ pathway
A serrated polyp can often progress to colon cancer via the **microsatellite instability** pathway
126
Adenoma-Carcinoma sequence (3):
Adenoma-Carcinoma sequence (3): 1. Loss of APC 2. Mutation of KRAS 3. Loss of TP53
127
Apple core constriction = colorectal cancer
128
The most common location for colon cancer is in the _
The most common location for colon cancer is in the **rectosigmoid** * Causes reduced stool caliber
129
_ is a GI pathogen that may increase the risk of colon cancer
**Streptococcus bovis** is a GI pathogen that may increase the risk of colon cancer
130
The most common location of colon cancer metastasis is the _
The most common location of colon cancer metastasis is the **liver**
131
Lynch syndrome involves a mutation in DNA mismatch repair genes which leads to _ pathway of colorectal cancer
Lynch syndrome involves a mutation in DNA mismatch repair genes which leads to **microsatellite instability**

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