Lower GI- Paulson Flashcards
1
Q
__________ & ________- make up inflammatory bowel disease
A
Chrons & Ulcerative colitis
2
Q
This disease is an inflammatory condition involving the mucosal surface of the colon that starts distally and progresses proximally without skip areas
A
ulcerative colitis (UC)
3
Q
What are sxs of UC?
A
- **Bloody diarrhea
- Frequent urge to defecate
- constipation, frequent blood and mucus discharge
- colicky abdominal pain
- onset usually gradual and progressive
4
Q
What are some extraintestinal manifestations of UC?
A
- Arthritis, ankylosing spondylitis
- uveitis, episcleritis
- erythema nodosum
- pyoderm gangrenosum
5
Q
What are some lab abnormalities in UC?
A
- Anemia
- inc ESR/CRP bc inflammation
- Electrolyte abnormalities
- Fecal calprotein inc (tells you if intestinal inflamm or not
6
Q
Is imaging required for UC?
A
No but you can get xray, barium enema, CT/MRI
7
Q
How to dx UC?
A
- Chronic diarrhea ≥4 weeks
- Evidence of active inflammation on endoscopy
- Chronic changes on biopsy
*must exclude other causes of colitis
8
Q
What would an endoscopy find on UC?
A
- Loss of vascular markings
- Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
9
Q
Are there normal areas of mucosa in UC?
A
No it is continuous (no skippage areas)
10
Q
What characterizes mild UC?
A
- Less than or eq to 4 stools/day with or without blood
- normal ESR
- no severe abd pain, fever, weight loss, or bleeding
11
Q
What characterizes moderate UC?
A
- > 4 loose stools/day
- mild anemia
- mod abd pain
- low grade fever
- no weight loss
12
Q
What characterizes severe UC?
A
- frequent loose bloody stools >6/day
- severe abd pain
- systemic sxs
- could have rapid weight loss
13
Q
Treatment for UC if the dz is confined to the distal part of rectum?
A
Topical 5-ASA:
Mesalamine 1 PR BID
-topical you put on distal rectum
14
Q
Treatment for UC if the dz extends further than the distal part of rectum?
A
Mesalamine enema + suppository
15
Q
Treatment for more extensive colitis past sigmoid or left-sided colitis or pancolitis?
A
Oral and topical 5-ASA combo
16
Q
In patients with UC, we should be careful about __________ and consider what test if there is a stricture of the colon?
A
Colorectal CA and biopsy
17
Q
This is a disease that causes inflamm of the GI tract with inflammation and skip areas in the colon
A
Chron’s disease
18
Q
What are some clinical manifestations of chron’s?
A
- crampy abd pain
- malabsorption
- less gross blood than UC
- diarrhea
- fistulas and ulcers common
19
Q
What clinical manifestation could distinguish UC from Chrons?
A
UC has more gross blood than Chrons
20
Q
People with chrons often feel better if they _______
A
don’t eat
21
Q
What lab finding could distinguish chrons from UC?
A
In chrons there will be an elevated ESR/CRP more so than in UC
22
Q
What other lab test could help diagnose IBD and distinguish CD from UC?
A
Antibody tests-
pANCA and ASCA may be + in Chrons
23
Q
How can you dx chrons?
A
colonoscopy- may show cobblestone appearance and skipping
24
Q
String sign is in what disease?
A
Chrons
25
What imaging should you do for chrons and abscess?
CT
26
If a patient is totally asymptomatic, what stage of chrons is this?
Clinical remission
27
If a patient is fine, no systemic symptoms, what stage of chrons is this?
mild chrons
28
If a pt has prominent symptoms, what stage of chrons is this?
mod-severe
29
A pt with chrons in which tx doesnt work and systemic sxs, what stage chrons is this?
Severe-fulminant disease
30
What is step-up therapy for chrons?
* Start with less potent meds (but fewer side effects)
| * Use more potent meds if initial therapies not effective
31
What is top-down therapy for chrons
• Start with more potent therapies early in the course of the disease before they
become glucocorticoid-dependent
32
What is the tx for mild-mod and ileum or proximal colon chrons disease?
Budesonide
33
What is the tx for diffuse colitis or left colonic involvement?
Pred
34
Tx for oral chrons lesions
Triamcinolone acetonide
35
What are some adverse effects of Budesonide?
since it is a corticosteroid, can cause osteoporosis, immunosuppression
36
What if a patient with chrons relapses?
Begin another dose of corticosteroid
37
For more severe chrons we will usually refer, but what is the top-down med approach we would use?
Biologic + immunomodulatory for induction
"umab" and methotrexate
-may also get a glucocorticoid for symptom relief
38
Constipation is caused by inadequate ______ & _______ consumption
fiber, water
39
What are some clinical manifestations of constimation?
- Hard/lumpy stools
- feeling of incomplete voiding
- straining
- abdominal discomfort and bloating
40
Treatment for constipation?
- Fiber (metamucil, citrucel)
- Hyperosmolar agent (miralax)
- Stimulant (senna/colase)
- Enema
41
A mass of compacted feces in the large intestine that can’t be evacuated spontaneously common in the elderly?
Fecal impaction
42
Signs and symptoms of fecal impaction?
- Rectal discomfort
- abd pain or cramping
- overflow fecal incontinence
- could hit something hard on DRE (feces)
43
Treatment for fecal impaction
- Manual disimpaction
- Enema
- Osmotic laxatives
- address underlying cause
44
Inflammation of the small bowel (small intestine) due to ingesting gluten-containing foods (wheat, barley, rye, oats)
Celiac disease
45
What are some symptoms of celiac?
- Diarrhea with bulky, foul-smelling floating stools (steatorrhea)
- weight loss & weakness
- IDA
- osteoporosis
46
What is a common manifestation of celiac not in the intestines?
Dermatitis herpetiformis
47
T/F: All celiac testing should be done while a patient is on a gluten containing diet?
True!
48
What are the testing options for celiac?
Low probability= serologic testing
high probability= serologic testing + small bowel bx with endoscopy
49
What is the preferred serologic test for celiac?
tTG IgA test
50
If tTG IgA test is positive, what is the next step?
If serology positive -> small bowel biopsy needed to confirm diagnosis
51
Endoscopy for celiac disease may show _____ & _____
scalloping & nodules
52
T/F: One biopsy can confirm dx of celiac?
False! 4 bx are needed to confirm dx. They will be from different sites
53
Management of celiac?
- Refer
- Gluten-free diet
- Need pneumococcal vaccine
- DXA scan
**INCREASED RISK FOR MALIGNANCY
54
A leading cause of cancer deaths in the US
Colorectal cancer
55
What are RF that don't influence colorectal CA screening?
- Obesity
- DM
- Red & processed meat
- Smoking
- Alcohol consumption
56
What are suspicious sx/sxs of colorectal CA?
* Change in bowel habits
* Unexplained IDA
* Rectal bleeding + change in bowel habits
* Rectal mass or abdominal mass
* Abdominal pain
57
How do you dx colorectal CA and what finding might you expect?
Colonoscopy with apple core lesions
58
Apple core
Colorectal CA on colonoscopy
59
What marker do we use to tract and follow progression of someone with colorectal CA?
CEA
60
How to treat colorectal cancer?
- If carcinoma in a polyp, then endoscopic removal
| - if CA then surgical resection then chemo/radiation
61
At what age do we initiate colorectal CA screening in a person without RF? How often do we get colonoscopies?
50 yrs
Every 10 years
62
When do you d/c screening for colorectal CA?
age 75
63
Other options besides colonoscopy?
FIT testing, CT colonography "virtual colonoscopy," sigmoidoscopy
64
If you have a first-degree relative (FDR) diagnosed at age <60 years when should you start screening for colorectal CA?
age 40 or 10 years before FDR's dx and then a colonoscopy every 5 years
65
If you have ≥2 FDRs diagnosed at any age, when do you start screening?
age 40 or 10 years before FDR's dx and then a colonoscopy every 5 years
66
If you have one FDR diagnosed at age ≥60 years, when do you start screening?
begin screening at age 40
67
When do you screen for Lynch Syndrome?
20-25 years old or 2-5 years prior to the earliest age of CRC diagnosis in the family
68
When do you start screening for 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
69
When do you start screening for Peutz-Jeghers syndrome?
EGD, video capsule endoscopy, and colonoscopy starting at age 8
70
Tear, cut or crack in the lining of the distal half of the anal canal
Anal fissures
71
Clincial manifestations of anal fissures?
- Anal pain
- "papercut of anus" feeling
- Pain worsens w/ defecation
72
What is the mc location of anal fissure?
Posterior midline and anterior midline 2nd mc
73
Acute anal fissure appearance?
fresh like a papercut
74
Chronic anal fissure appearance?
Raised edges, fibrotic appearance often accompanied by a skin tag (sentinel pile)
75
How do you dx anal fissures?
history + physical exam (either direct visualization or reproduce the pain)
76
Treatment for anal fissures?
- Fiber + water and/or stool softeners
- Sitz bath
- lidocaine jelly topical
- Nifedipine gel or topical nitroglycerin
77
Swollen veins in the rectum and anus that can lead to discomfort, prolapse and bleeding
Hemorrhoids
78
This type of hemorrhoid is distal (below) to the dentate line?
external hemorrhoid
* Somatic innervation
- >more sensitive to pain/irritation
79
This type of hemorrhoid is proximal (above) to the dentate line?
internal hemorrhoid
*Visceral innervation -> less sensitive to pain/irritation
80
Clinical manifestations of hemorrhoids?
- bleeding that is painless and associated with a bowel mvmt
- BRBPR
- mild fecal incontinence, mucus d/c, wet sensation
81
How do you dx hemorrhoids?
Classical symptoms + visualization of hemorrhoids
82
How are you able to dx and see internal hemorrhoids?
Anoscopy
83
What grade hemorrhoid is this?
| Prolapse with defecation or other times, needs manual reduction
Grade III
84
What grade hemorrhoid is this?
No prolapse
Grade I
85
What grade hemorrhoid is this?
Prolapse with defecation, spontaneously reduces
Grade II
86
What grade hemorrhoid is this?
Permanently prolapsed/irreducible, Visible externally, may strangulate.
Grade IV
87
What is the first line treatment for hemorrhoids besides increasing fiber and water intake to produce soft stools?
- Topical steroids: hydrocortisone cream
- Lidocaine gel
- Warm sitz baths
- Nitroglycerin ointment
88
When to refer a patient with hemorrhoids?
Low grade that has been refractory to 6-8 wks tx and any grade higher
89
What are potential surgical options for hemorrhoids?
- Rubber band ligation
- Sclerotherapy
- Infrared coagulation
Grade III to IV
90
What is the difference between a diverticulum and diverticulosis?
Diverticulum: a sac-like protrusion of the colonic wall
Diverticulosis: defined by the presence of diverticula
91
Difference between diverticulosis and diverticulitis?
Diverticulosis is small pouches called diverticula in the colon
Diverticulitis is infection or inflammation in diverticula
92
Painless hematochezia is what type of diverticular disease?
Diverticular bleeding
93
Inflammation of a diverticulum
Diverticulitis
94
Inflammation in the interdiverticular mucosa, without involvement of the diverticular orifices
Diverticular colitis
95
Persistent abdominal pain attributed to diverticula without overt colitis or diverticulitis?
Symptomatic uncomplicated diverticular disease
96
RF for diverticular disease?
- Low fiber, high fat diet
- Nuts, seeds and corn NOT associated with increased risk
- lack of physical activity
- Smoking
- NSAIDs, opoids, steroids
97
Functional disorder of the GIT with chronic abdominal pain and altered bowel habits
IBS
98
A hallmark of this disease is worse with stress and better with bowel movements
IBS
99
What are clinical manifestations of people with IBS?
* Diarrhea
* Constipation
* Alternating diarrhea and constipation
* Normal bowel habits alternating with diarrhea and/or constipation
100
What is the diagnostic criteria of IBS?
Rome Criteria which basically says that you have to have recurrent abd pain on avg at least once/wk in past 3 months associated with 2 or more of the following:
- related to defication
- associated with change in stool frequency
- change in stool appearnace
101
Treatment for IBS?
Education & reassurance
- Diet modification (FODMAPs)
- Increased fiber (Miralax)
- Antidiarrheals (imodium)
102
Tx for IBS and abd pain?
- Antispasmodics: Dicyclomine, Hyoscyamine ("amines")
| * helps improve post-prandial abd pain, bloating, fecal urgency
103
What treatment for IBS can slow intestinal time (dec diarrhea) and help abd pain?
TCAs: "triptylines"
104
Do you use abx in someone with IBS?
In mod-severe IBS without constipation if failed to respond to other therapies, can try rifaximin (this is a 3rd, 4th line therapy)
