McGowan DSA Week 2 Flashcards
How do upper GI bleeds present typically?
How do lower GI bleeds present?
Melena, hematochezia if rapid onset
Hematochezia
What are several causes of upper GI bleeds?
PUD
Varices
Gastritis
MW tear
Boerhaave syndrome
Aortoenteric fistula
AV malformations
Cancer
Swallowed blood
Anticoag Drugs
What are several causes of lower GI bleeds?
IBD
Ischemic Colitis
Diverticulosis
Anal Fissures
Polyps
Cancer
Infectious colitis
AV malformations
Varices
NSAID ulcers
Rectal ulcers
Intussusception
What is an occult GI bleed?
What is the etiology of an occult GI bleed?
Bleeding that is not apparent to the patient
chronic GI blood loss of less than 100ml per day with no visible change in stool
What is the H/P of occult GI bleed?
Fatigue
bleed can come from anywhere in GI tract
Common cause: Neoplasm, vascular abnormalities, Chron’s Disease
How is an occult GI bleed diagnosed?
+ Fecal Occult blood test
+ Fecal imunochemical test
Iron deficient anemia
Colonoscopy if asymptomatic
Colonoscopy and EGD if symptomatic
IgA anti-tissue transglutaminase or duodenal bx (Celiac’s)
In a patient under 60 with unexplained occult bleeding or iron deficiency what further examination should be done?
examination of the small intestine to exclude a small intestine neoplasm or IBD
In patients over 60 with occult bleeding and normal endoscopy and no other concerning sx, what is the likely diagnosis?
blood loss due to angioectasias
In a person over 45 with IDA, what is your main concern?
Colon Cancer
What is the treatment for occult GI bleed?
supportive, transfusion if indicated
treat underlying cause
What are the DDx for a Lower GI bleed in someone under age 50?
Infectious colitis
Anorectal Disease (fissures, hemorrhoids)
IBD
Meckel Diverticulum
What are the DDx for Lower GI bleed in patients over 50?
Malignancy
Diverticulosis
Angiectasis
Ischemic Colitis
What percentage of hematochezia is due to upper GI source?
10%
What is the H/P for lower GI bleed?
possible hematochezia or pain
history of NSAID/anticoag use
Red Dye and beets (pink/red stool, no blood)
How is a lower GI bleed diagnosed?
Colonoscopy in stable patients
vitals/CBC/anoscope
massive bleeds require sigmoioscopy, EGD, angiography or nuclear bleeding scan
What is the treatment for Lower GI Bleed?
CBC/Chem, INR,PT, PTT, Type+screen+cross
Fluids (2 LB IV)
transfusion id needed
endoscopic treatment, rarely surgery
What is the etiology for diverticulitis?
herniation of mucosa through the muscularis at points of artery entry
most common cause of major lower tract bleed
common in sigmoid colon
What is the H/P for diverticulosis?
acute, painless large volume maroon or bright red hematochezia in patients over age 50
What are the diagnostics for diverticulosis?
evaluation with colonoscopy in stable patients, once bleeding subsides
(panel of labs)
Treatment for diverticulosis?
high fiber diet, anticholinergics
supportive care
fluid/transfusion if needed
What is IBD?
chronic state of dys-inflammation
disruption of normal homeostasis by environment or genetics
What are some risks for developing IBD?
environment and genetics
bimodal distrubitions (20s+90s)
appendectomy before age 20 can be protective
Abx in first year of life increases IBD risk by 2.9%
What are the labs for IBD?
ANCA
ASCA
What will be seen on a barium enema with IBD?
string sign (narrowing from inflammation or stricture in CD)
Lead Pipe (loss of haistra in UC)
What is the H/P for Chron Disease?
RLQ pain
diarrhea with or without blood
Acute ileitis (looks like appy)
What are the diagnostics for Chron Disease?
ASCA
imaging (CT/MRI/Colonoscopy/Barium Enema)
What is the treatment for Chron Disease?
Corticosteroids
immunomodulating agents /biologics
Antibiotics
What are some complications of Chron Disease?
Fistula/Abscess
Bile salt malabsorption
gallstones/kidney stones
colon cancer
What is the H/P of ulcerative colitis?
Bloody Diarrhea
Tenesmus/fecal urgency
hx of recent smoking cessation
What are the diagnostics of Ulcerative colitis?
labs (pANCA, fecal calprotectin)
anoscopy
sigmoid/colonoscopy with bx
barium enema
What is the treatment for Ulcerative Colitis?
corticosteroids
immunomodulating/biologic agents
What are the complications of Ulcerative Colitis?
hemorrhage
perforation
cancer
What are some extraintestinal manifestations of IBD?
aphthous ulcer
toxic megacolon
uveitis/iritis
erythema nodosum
ankylosing spondylitis
What is the CD related gene for Chron disease?
card15/NOD2
ch. 16p
What type of cancer is increased in chrons and uclerative colitis?
Colon cancer
What are some specific features of ulcerative colitis that differentiates it from chron disease?
Colon only
continuous lesions
bloody diarrhea
smoking protective
What is the history of ischemic colitis?
What is seen on imaging?
Managment?
sudden cramping LLQ abd pain with urge to defecate
passage of blood or bloody diarrhea
“Thumb Printing” on imaging
stabilize and surgery
Up to ___ % of all cololorectal cancers are caused by what?
4%; germline genetic mutations
Due to genetic mutations causing colorectal cancers, who should be screened for colon cancer?
persons with:
Fmhx of colorectal cancer in more than one relative
personal or Fmhx of colorectal cancer under age 50
personal or fmhx of more than 20 polyps
personal or fmhx of multiple extracolonic cancers
What is the etiology of FAP?
100-1000s of adenomatous polyps and adenocarcinoma
What is the H/O for FAP?
polyps
congenital hypertrophy of the retinal pigment epithelium detected at birth
What are the diagnostics of FAP?
90% have AD mutation in APC gene
8% have AR mutation in MUTYH gene
What is the treatment for FAP?
proctocolectomy with ileoanal anastomosis before age 20
prophylactic colectomy to prevent inevitable colon cancer
What is the etiology of Lynch Syndrome(HNPCC)
polyps that undergo rapid transformation over 1-2 years to adenoma and then to cancer
Colorectal cancer risk (22-75%)
endometrial cancer (30-60%)
other cancers develop at a young age
What is the H/P for Lynch syndrome? (HNPCC)
based on fmhx, Bethesda Criteria
All colorectal cancers should undergo testing for Lynch syndrome with either immunohistochemistry or microsatellite instability
what are the diagnostics for Lynch sydndrome?
AD
DNA base-pair mismatch genetic testing for MLH1, MSH2
What is treatment for Lynch Syndrome? (HNPCC)
subtotal colectomy with ileorectal anastomosis with surveillance
prophylactic hysterectomy and oophorectomy is recommended to women at age 40 or once they have finished childbearing
What is the H/P for Peutz-Jeghers syndrome?
hamartomatous polyps
not malignant
pigmented macules on lips/buccal mucosa and skin
What is the H/P for familial juvenile polyposis?
several juvenile hamartomatous polyps located in colon
increased risk for adenocarcinoma
What is the H/P for PTEN (Cowden Disease)
hamartomatous polyps and lipomas in GI tract
increased risk for malignnacy is demonstrated in thyroid, breast and urogenital tract
What are the diagnostics of peutz-jeghers sydrome?
AD
serine threonine kinase 11 gene testing
What are the diagnostics of familial juvenile polyposis
AD
genetic defects ID’ed on loci 18q and 10q
What is the H/P for nonfamilial adenomatous and serrated polyps?
mostly completely asymptomatic
What are the treatments for nonfamilial adenomatous and serrated polyps?
colonoscopic polypectomy
post-polypectomy surveillance 3-10 years depending on type of polyp
What are the diagnostics for nonfamilial adenomatous and serrated polyps?
barium enema or CT or CT colonography that are diagnostic but not therapeutic
Colonoscopy remains the best test because it is diagnostic and therapeutic (polypectomy)
What are the guidelines for colon cancer screening?
start at age 45 and continue until age 75
75-85 screen based on preference, health, life expectancy
85 stop screening
What is the etiology for colon cancer?
over 45
S. bovis bacteremia
second most common internal cancer in humans
What is the H/p for colon cancer?
Left sided: presents with rectal bleeding, changes in bowel habits
Right sided: anemia, blood loss, weight loss
What are the diagnostics for colon cancer?
early diagnosis by screening asymptomatic persons with fecal blood testing
What is the treatment/prevention for colon cancer?
surgery/chemo/radiation for treatment
prevent with colonoscopies at age 45 and screening should start at 40 or ten years earlier than 1st degree relative if fmhx
What are AV malformations/angioectasias?
painless bleeding to occult blood loss
melena if proximal to ligament of trietz
common in those with chronic renal failure or aortic stenosis
What is the H/P for hemorrhoids?
bright red blood per rectum, usually only drops
What are the diagnostics for hemorrhoids?
treatment?
visualized externally or anoscopy
laxatives, stool softeners, band ligation
What is a complication of hemorrhoids?
thrombosed external hemorrhoid
onset after cough/sneeze, strain
acute pain, bluish perianal nodule
pain eases over 2-3 days
What is the etiology of anal fissures?
linear or rocket shapped ulcers from trauma to anal canal
What is the H/P for anal fissures?
treatment?
severe tearing pain with defecation followed by throbbing pain
hematochezia, blood on stool/paper
fiber, sitz baths, Botox of anal canal or Nitro ointment
What are the DDx for RUQ abdominal pain?
Gallbladder
Duodenal ulcer
hepatitis
pancreatitis
budd chiari syndrome
What are the DDx for epigastric abdominal pain?
Ruptured aortic aneurysm
PUD
Hiatal hernia
GERD
gastritis
esophagitis
pancreatitis
cholecystitis
When do we worry about an aortic aneurysm rupturing?
risk of rupture increases with size
greater than 5cm is the most concerning
unruptured will commonly have no symptoms, may be found on routine exam
ruptures are usually spontaneous and always life-threatening
acute pain and hypotension occur with rupture and requires surgery
What is a good screening tool for abdominal aortic anerysms?
US
esp. in men over 65 who have eber smoked
What are the sx of aortic aneurysm dissection?
tear in intima of vessel
creates a false lumen
causes atypical chest pain, wide medistinum
What are the DDx for LUQ pain?
gastric ulcer
gastritis
pancreatitis
perf. subdiaphragmatic viscus
What are the DDx for RLQ pain?
appendicitis
ectopic pregnancy
ovarian torsion
IBD
Ogilvie syndrome
Meckel’s diverticulitis
What is the etiology for appendicitis?
between ages 10-30 common
obstruction of appendix by fecolith, inflammation, etc
What is the H/P for appendicitis?
vague colicky periumbilical pain that moves to RLQ within 12 hrs
+psoas sign
+obturator sign
+heel strike
+rebound tenderness
What are the diagnostics for Appendicitis?
moderate leukocytosis, US or CT scan
What is the treatment for appendicitis?
Complications?
surgery
abx
gangrene and perforation within 36hrs
What is the etiology of ectopic pregnancy?
risks include hx of infertility, PID, ruptured appendix, prior tubal surgery
most common cause of maternal death in first trimester
What is the H/P for ectopic pregnancy?
severe lower quadrant pain in almost every case 6-8 wks after LMP
What are the diagnostics for ectopic pregnancy?
positive pregnancy test with serum bHCG greater than 2000 and NO intrauterine pregnancy on transvag US
What is the etiology of ovarian torsion?
right sided 70% of the time due to increased length of utero ovarian ligament on right and sigmoid on left
What is the H/P for ovarian torsion?
diagnostics?
sudden severe unilateral abdominal pain after exertion
transvag US with doppler
(typically ovary >4cm is most common finding in assx with torsion)
What is the treatment for ovarian torsion?
surgery
What is the etiology of acute colonic pseudo-obstruction? (ogilvie syndrome?)
spontaneous massive dilation of cecum or right colon without mechanical obstruction
What is seen on xray due to which common H/P finding in acute colonic pseudo obstruction?
abdominal distension prompts xray which shows colonic dilation
What are the diagnostics for acute colonic pseudo-obstruction?
xray or CT
upper limit of normal for cecal size is 9, so will see closer to 10-12 cm associated with an increased risk for colonic perforation
What is the treatment for acute colonic pseudo obstruction?
conservative treatment if less than 12cm while treating underlying illness, NG tube
D/C drugs that reduce colon mobility
Cecal size reassessed every 12 hrs
if not improving, or over 12cm, consider neostigmine, colonoscopic decompression, surgery
What are the rules of 2s for Meckel’s Diverticulum?
2ft from ileocecal valve
2% of pop. effected
2in long
2 types of ectopic tissue (Gastric and pancreatic)
2x more common in males
symptomatic by age 2
What are the sx of meckel’s diverticulum?
rectal bleeding, intussuscption, perfoation
can’t be distinguised clincally from appendicitis
best to diagnose with technetium-99m scan
manage with surgery
What are the DDx for LLQ?
diverticulitis
ischeimc colitis
ectopic pregnancy
ovarian torsion
ibd
colon cancer
What is the etiology for diverticulitis?
inflammation of a diverticulum leading to microperforations and macroperforations with abscess or generalized peritonitis
What is the H/p for diverticulitis?
acute LLQ pain
fever
constipation
mild LLQ tenderness with thick palpable sigmoid and descending colon (like a small mass)
What is the treatment for diverticulitis
can diagnose with barium enema or colonoscopy 4-6 weeks after recovery
IV fluids, NPO, abx inpatient or abx and liquid diet outpatient
surgical resection if young, immunosuppressed
sigmoidectomy for abscesses
What are the Ddx for periumbilical abd pain?
early appendicitis
mesenteric artery ischemia
ruptured aortic aneurysm
bowel obstruction
IBD
What are the sx of acute mesenteric ischmia?
Imaging results?
Post-op anticoagulation?
periumbilical pain out of proportion to tenderness
N/V, GI bleed
Thumbprinting on xray and CT angio is test of choice to see vasculature
Yes if venous thombosis, controversial in arterial occlusion
what are the symptoms in chronic mesenteric ischemia?
abdominal angina with crampy periumbilical pain 15-30 min after eating and lasting several hours
leads to “food fear”
evaluate with mesenteric arteriography
What is the most common cause of intestinal obstruction?
What is the diagnosis?
treatment?
peritoneal adhesions
Xray or Ct with dilated bowel and air fluid levels
NG tube, fluids
urgent laparotomy for lysis of adhesions before ischemia sets in
What is the H/P for SBO?
Diagnosis?
treatment?
N/V, feculent
KUB/abdominal series, CT scan
NG tube/surgery if NG isn’t enough
What are the DDx for diffuse abdominal pain?
IBS
Mesenteric artery ischemia
peritonitis
intestinal obstruction
IBD
Toxic megacolon
constipation
Primary bacterial peritonitis is most common among whom?
what is the pathogen?
pts with cirrhosis
enteric gram- bacilli like E. coli or gram+ like strep, enteroccoi, penumococci
typically a single organism is isolated
How is primary bacterial peritonitis diagnosed?
peritoneal fluids contain >250 PMN cells
blood cultures done because bateremia is common
prophylaxis with fluoroquinolines or TMP-SMX or ceftriaxone or piperacillin
what is secondary peritonitis?
What is the pathogen?
How will pt present?
bacteria contaminate the peritoneum as a result of spillage from an intraabdominal viscus
mixed flora
pt lies still with knees up to avoid stretching/irritating nerves of peritoneal cavity
What is the diagnosis of secondary peritonitis?
treatment?
radiographic studies to find source or immediate surgery
antibiotics and surgery
What is toxic megacolon?
lethal comlication of IBD or C. diff
total or segmental nonobstructive colonic dilation plus systemic toxicity
clinical diagnosis in pts with abdominal distension and acute or chronic diarrhea and enlarged dialted colon on abd. imaging + severe systemic toxicity
What are the DDx for fatigue?
occult GIB
cancer
IBD
chronic liver disease
malnutrition/malabsorption
What are the DDx for unintentional weight loss?
cancer
malabsorption syndromes
IBD
poor dentition
What is unintentional weight loss?
loss of 5-10% of body weight over 6 months should prompt further evaluation
rapid fluctuations of weight over days indicates loss/gain of fluid, while long term changes involve mass loss/gain
What questions should you ask of a pt with unintentional weight loss?
What should the exam include?
ask about GI sx including eating/bowel changes
obtain pt’s weight
rectal exam for men, pelvic exam for women
stool occult blood exam
*50% of claims of weight loss cannot be substantiated*
What should you make sure to check in a patient with unintential weight loss?
check their teeth during physical exam and ask about oral health
What can stool appearance suggest about underlying conditions?
greasy/malodorous indicates malabsorption issue
blood/pus indicates inflammation
water indicates secretory process
What does diarrhea plus abdominal pain indicate?
IBS
IBD
What should the physical exam assess for in patients with diarrhea?
signs of malnutrition, dehydration, IBD
What is diarrhea?
What nutrients are lost from diarrhea?
3+ loose or watery stools per day
OR
decrease in consistency and increase in frequency of BM daily
bicarb and potassium
How long does acute diarrhea last?
2 weeks or less
What are noninflammatory causes of acute diarrhea?
virus, bacteria
don’t need work up
(watery, mild)
What are inflammatory causes of acute diarrhea?
invasive/toxic bacteria
(blood/pus, fever)
consider stool cultures in all patients and C.diff/ova+parasite panels as indicated
How long does noninfectious diarrhea typically last?
>14 days
What is the most common cause of noninfectious diarrhea?
medications, mainly Abx
also NSAIDs, antidepressents, chemo, antacids and laxatives
What foods often cause diarrhea?
sweetners, sorbitol
found in Gum
Is antibiotic associated diarrhea due to C. diff?
not typically
Abx associated diarrhea occurs during the period of abx exposure
What is osmotic diarrhea?
stool volume decreases with fasting
increased stool osmotic gap over 50 (75 mosm/kg)
assx with intake of dairy, fruit, sweetners and ETOH
What are the most common causes of osmotic diarrhea?
medications
disaccharidase def./carb malabsorption
laxative abuse
malabsorptive syndromes
What are sx of secretory diarrhea?
stool volume doesn’t improve with fasting
nromal osmotic gap
high volume watery diarrhea over 1l per day
What are the causes of secretory diarrhea?
endocrine tumors
bile salt malabsorption
factitious diarrhea (laxativeS)
villous adenoma
How to approach diarrhea?
consider the most common causes of chronic diarrhea (meds, IBS, lactose intolerance) and then consider red flags like nocturnal diarrhea, weight loss, anemia, etc as those warrant more evaluation
What are some initial labs for chronic diarrhea?
CBC/CMP
Vit. A+D
TSH
ESR/CRP
IgA TTG
Stool studies for diarrhea?
stool electrolytes (osmotic gap)
sudan stain (fat malabsorption)
occult blood
lactoferrin, calprotectin, leukocytes (IBD)
ova/parasites, Giardia, E. histolytica fecal antigen (more senstivie and specific)
A colonoscopy with mucosal biopsy will exclude?
IBD
microscopic colitis
colonic neoplasia
EGD with SI bx is done to rule out?
celiac/whipple disease
protozoa in AIDS patients
Pancreatic elastase less than ____ indicates?
calcifications seen on plain abd radiograph indicates ?
100; pancreatic insuffieciency
chronic pancreatitis
breath tests for glucose or lactulose indicate what?
small bowel bacterial overgrowth
confirmed with aspirate
carb malabsorption is diagnosed how?
elimination trial for 2-3 weeks or
hydrogen breath test
Neuroendocrine tumors can be diagnosed how?
VIP
calcitonin
gastrin
5-HIAA
(serological test)
If someone has nocturnal diarrhea, weight loss, anemia, or +FOBT is this consistent with meds, IBS, or lactose intolerance?
NO, needs further testing
Common specific meds that cause diarrhea?
cholinesterase inhibitors
SSRIs
Angiotensin II receptor blockers
PPIs
NSAIDs
metformin
allopurinol
What is the etiology of IBS?
altered motility (colonic or small bowel)
enhanced visceral sensation
increased psychiatric sx
What are the three types of clinical presentation for IBS?
spastic colon
alternating constipation and diarrhea
chronic, painless diarrhea
What are some alarm symptoms concerning the bowel
*these are NOT consistent with iBS and wararnt further testing
acute onset of sx
nocturnal diarrhea
severe constipation or diarrhea
hematochezia
weight loss
fever
fmhx of cancer
What is the history of IBS?
altered bowel habits
abdominal pain, distension, mucus/loose stools, incomplete evacuation
no detectable organic pathology
pasty/ribbony or pencil tin stools
how is IBS diagnosed?
chronic > 6 months of sx (must have sx at least 3 months before considering IBS in ddx)
Rome IV criteria
treatment for IBS?
meds for diarrhea, constipation and pain
avoid stress, consider low FODMAPS diet
(fermentable, oligosaccharides, monosaccharides, disaccharides, and polyols)
what pathogens are commonly associated with chronic diarrhea?
Protozoa: Giardia, E. histolytica, cyclospora
Nemotode: S. stercoralis
Bacteria: C. diff
AIDS: CMV, HIV, C. diff, M. Avium, Microsporida, Crypto, I. belli, Cyclospora
What is the ost common cause of Abx associated colitis?
What is the microbiology?
C. Diff
aneaerobic Gram + spore forming bacillus
cytotoxin A and B
Who is at high risk of C. diff?
hospitalized for more than three days
multiple abx for more than ten days
ampicillin
clindamycin
3rd gen cephalosporins
fluoroquinolines
PPIs
HOw is C. diff diagnosed?
Stool assay for A and B toxins
PCR
Leukocytosis >15k
pseudomembranousis colitis with volcano exudate
How to avoid spreading C diff?
What is a complication of c diff?
wash your hands you filthy animal
toxic megacolon and hemodynamic instability leading to death
What are symptoms of malabsorption syndromes?
weight loss
osmotic diarrhea
steatorrhea
nutritional def.
What can cause malabsorption syndromes?
small bowel mucosal disorders
pancreastic disease
bacterial overgrowth
lymphatic obstruction
What is the etiology for celiac disease?
diffuse damage to proximal small intestinal muncosa with malabsorption of nutrients due to glut intolerance
most cases are undiagnosed or asymptomatic
What is the haplotypes for celiac disease?
HLA DQ2 and DQ8
Antibodies to gluten, ttG
What are the sx for celiac?
weight loss
chronic diarrhea
growth retardation
fatigue
dermatitis herpetifromis
IDA
osteoporosis
depression
amenorrhea
reduced fertility
How is celiac dianosed?
abnormal serologic findings, small bowel bx
Iga tTG antibody (become undetectable after 3-12 months after gluten withdrawal)
atrophy or scalloping of duodenal folds on biopsy
complete loss of intestinal villi
treatment for celiac?
lifelong removal of all gluten
Significant steatorrhea can be due to?
chronic pancreatitis or pancreatic cacner
(malabsorption of triglycerides)
What is bile salt malabsorption?
normally resorbed in terminal ileum but resection or chron’s disease can lead to a decrease
causes mild steatorrhea and imparied ADEK absorption
causes water diarrhea
What is whipple disease?
rare multisystem disease due to infection with G+ T. Whipplei
source of infection unknown
What is H/P for whipple disaese?
weight loss
malabsorption
chronic diarrhea
how is whipple disease diagnosed?
treatment?
prognosis?
endoscopy with duodenal bx
PAS + with macrophages
abx
untreated, fatal, neuro signs can be permanent
What is pseudo-diarrhea
what are the sx?
what is the cause?
small volume stool with frequent passage
rectal urgency, tenesmus, incomplete evacuation
IBS or proctitis
What is overflow diarhea?
severe constipation and only liquid oozes out
commonly in elderly patients with fecal impactions
What is the etiology of constipation/impaction?
opioids, bed rest, neurogenic disease or spinal cord injuries
What is the H/P of fecal impaction?
paradoxical overflow diarrhea
DRE with palpable feces in rectal vault
DO NOT DO DRE if Leukopenia present
What can caus malanosis coli?
a benign hyperpigmentation of the colon can be caused by chronic use of laxatives
