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Gastrointestinal > MDT Lower GI 2 > Flashcards

MDT Lower GI 2 Flashcards

1
Q

What are anal fissures?

A

Linear or rocket-shaped ulcers that are < 5 mm in length

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2
Q

Where do anal fissures most commonly occur?

A
  • Most common in posterior midline

- 10% occur anteriorly

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3
Q

What locations of fissures should raise suspicion and why?

A
  • Fissures that occur off the midline

- Could be symptomatic of more serious disease or sexual assault

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4
Q

Most anal fissures are believed to arise from what?

A

Trauma to the anal canal during defecation, caused by straining, constipation, or high sphincter tone

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5
Q

What are symptoms of anal fissures?

A
  • Severe tearing pain during defecation followed by throbbing discomfort
  • May lead to constipation due to fear of pain during shitting
  • Bright red blood may be seen on TP
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6
Q

How are anal fissures confirmed?

A
  • Visual inspection of the anal verge while gently separating buttocks
  • Looks like cracks in epithelium
  • Digital and anoscopic exam may cause severe pain and may not be possible
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7
Q

What do chronic fissures result in?

A

Fibrosis and development of skin tag on the outermost edge

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8
Q

What are some differential diagnosis for anal fissures?

A
  • Perianal abscess
  • Inflamed/thrombosed hemorrhoids
  • Condyloma acuminate
  • Skin tag
  • Chron’s disease
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9
Q

Lab/rad for anal fissure?

A

Unless a more serious disease is expected, Pt should be referred

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10
Q

Treatment of anal fissures?

A
  • Directed at promoting effortless, painless BM
  • Fiber supplements and sitz baths
  • Topical anesthetics (5% viscous lidocaine)
  • Oral analgesics (Tylenol/NSAIDS)
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11
Q

When does healing occur for anal fissures?

A

Within 2 months in up to 45% of Pt’s

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12
Q

When should fissures be referred and how can they be treated?

A
  • Chronic fissures

- Topical nitroglycerin (0.2-0.4%) or diltiazem (2%)

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13
Q

What is a anorectal abscess?

A

Obstruction occurs blocking the gland orifice resulting in infection and abscess

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14
Q

What spaces can an anorectal abscess happen in?

A
  • Perianal space
  • Intersphincteric space
  • Ischiorectal space
  • Deep postanal space
  • Supralevator or pelvirectal space
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15
Q

What is the most/least common anorectal abscess?

A
  • Most: Perianal abscess

- Least: Supralevator

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16
Q

Who are anorectal abscess more common in?

A

Young, middle-aged males

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17
Q

Symptoms of anorectal abscess?

A
  • Dull, aching, or throbbing pain that becomes worse before defecation, lessened after BM, persists between BM
  • Pain aggravated by straining, coughing, sneezing
  • Eventually interfere with sitting/walking
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18
Q

What easily palpable abscess in not usually accompanied by fever, leukocytosis, and sepsis?

A

Perianal abscess

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19
Q

Differential Diagnosis for anorectal abscess?

A
  • Pilonidal cysts
  • Hemorrhoid
  • Anorectal fistula
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20
Q

Rad for anorectal abscess?

A

Ultrasound for deep abscess

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21
Q

What is the treatment for anorectal abscess?

A
  • Surgical intervention
  • I&D early and often
  • Perirectal abscesses must be done in OR
  • Simple and isolated perianal abscess can be done outside OR
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22
Q

What are some post drainage considerations of an anorectal abscess?

A
  • No packing required (if done, do lightly and remove within 24 hours)
  • Cover with bulk dressing
  • Begin Sitz bath (3x/day)
  • Antibiotics ONLY needed for febrile, leukocytosis, valvular-heart disease, or cellulitis
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23
Q

Initial care of anorectal abscess?

A
  • I&D

- Refer to General Surgery for complicated case

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24
Q

What do anal crypts allow for?

A

Secretion of excess mucus otherwise found in the rectum and anus

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25
Q

What is an anorectal fistula?

A

The chronic manifestation of the acute perirectal process that forms an anal abscess which when ruptured or is drained, an epithelial track forms connecting the abscess in anus/rectum with perirectal skin
- also referred to as “fistula-in-ano”

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26
Q

What are symptoms of anorectal fistula?

A
  • “Nonhealing” anorectal abscess following drainage
  • Chronic purulent drainage and pustule-like lesion in perianal/buttock area
  • Intermittent rectal pain, particularly during defecation, but also sitting
  • Intermittent and malodorous perianal drainage and pruritus
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27
Q

What is differential diagnosis for anorectal fistula?

A
  • Perianal abscess
  • Hemorrhoid
  • Anal Fissure
  • Pilonidal Cyst
  • Colorectal Cancer
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28
Q

Treatment for anorectal fistula?

A
  • MEDEVAC, require higher echelon care

- Stabilize and prepare for transport

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29
Q

Initial care for anorectal fistula?

A
  • Based on vital signs and patient stability

- If Pt presents in pain, consider MEDEVAC and treat with pain medicationst

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30
Q

What is pilonidal disease?

A

Malfunction that describes a spectrum of clinical presentations, range from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region (some tendency to reocur)

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31
Q

Pilonidal cysts can occur in the presence of what?

A
  • Staph Aureus

- Can invade through openings caused by ingrown hair

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32
Q

Where do pilonidal cysts/sinuses occur?

A

Midline in the upper part of the anal cleft overlying the lower sacrum and coccyx

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33
Q

What type of disease is pilonidal disease and when does it most commonly occer?

A
  • Acquired condition

- Most commonly occur in 4th decade of life

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34
Q

An abscessed pilonidal cyst is always located where?

A
  • Midline

- Does not communicate with anorectum

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35
Q

What are symptoms of pilonidal disease?

A
  • Swelling
  • Pain
  • Persistent discharge
36
Q

What will be found on examination for pilonidal disease?

A
  • Area of inflammation in the midline of the gluteal crease, with 1+ opening
  • Most common finding is single opening with hair protruding
  • Spontaneous and ongoing drainage is common indicator
37
Q

When will a patient present for pilonidal disease?

A

When an abscess has formed that can no longer drain

38
Q

Labs for pilonidal disease?

A

CBC for Pt’s with systemic disease

39
Q

Treatment for pilonidal disease?

A
  • Surgical intervention

- mostly simple I&D

40
Q

Antibiotic therapy for pilonidal disease?

A
  • Considered only temporizing and palliative
  • If surrounding area has cellulitis
  • Keflex then Doxy
41
Q

Disposition for Pilonidal disease?

A
  • Retain on board if uncomplicated
  • MEDADVICE depending on Physician Sup
  • MEDEVAC for more complicated cases (refer to gen surgery)
42
Q

What is Inflammatory Bowel Disease?

A
  • Immune response disrupts the intestinal mucosa and leads to chronic inflammatory process
  • Lifelong illness
  • Includes ulcerative colitis and Chron’s disease
43
Q

What is Ulcerative Colitis?

A
  • Inflammation limited to the colonic mucosa

- Can have Pseudo-polyp

44
Q

What is an inflammatory pseudo-polyp?

A

Island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue

45
Q

What is Chron’s disease?

A
  • Can affect ANY portion of the GI tract from mouth to anus
  • “Skin lesions”
  • Transmural inflammation
46
Q

What are some extra-intestinal manifestations of Ulcerative Colitis AND Chron’s?

A
  • May be associated in 50% of Pts(esp. chron’s)
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Thromboembolic events
47
Q

What are some extra-intestinal manifestations of Ulcerative Colitis?

A
  • Peripheral arthritis
  • Spondylitis
  • Uveitis/Episcleritis
  • Hepatitis
48
Q

What are some extra-intestinal manifestations of Chron’s?

A
  • Oral Ulcers

- Anorectal disease

49
Q

What mucosal inflammation is indicative of ulcerative colitis?

A

Inflammation involving only the mucosal layer of the bowel wall

50
Q

What transmural inflammation is indicative of Chron’s?

A
  • “Complete” inflammation of all layers structure

- Inflammatory changes/ulceration of all layers of bowel

51
Q

What is the most common portion of the GI tract that Chron’s affects?

A

Terminal ilium

* can result in malabsorption of digested foods, B12, bile salts and sodium

52
Q

What disease is chronic and recurrent that involves all of the GI tract and involves “skip lesions”?

A

Chron’s Disease

53
Q

Pertinent history of Chron’s?

A
  • Fevers
  • Pt general sense of well-being
  • Weight loss
  • Presence of abdominal pain
  • Number of liquid bowels in a day
  • Surgical/hospitalization history
54
Q

Physical exam signs for chron’s?

A
  • Ileitis or ileo-colitis
  • Diarrhea (non-bloody and intermittent)
  • Low grade fever
  • Malaise
  • Weight loss
  • Cramping abdominal pain
55
Q

Obstructive bowel signs and symptoms?

A
  • Abdominal distension
  • Nausea/vomiting
  • Intermittent liquid stools and/or constipation
56
Q

Pertinent pathophysiology of chron’s?

A
  • Diffuse abdominal pain/discomfort
  • Radiographic evidence of ulceration, stricturing, or fistulas
  • 1/3 of all cases involve small bowel
  • 1/2 of all cases involve small bowel and colon
  • Cigarette smoking
57
Q

Imaging for Chron’s disease?

A
  • Endoscopy
  • Colonoscopy
  • CT Scan of abdomen
58
Q

Labs for Chron’s?

A
  • Poor correlation for labs

- CBC and serum albumin

59
Q

Treatment of Chron’s?

A
  • 5-aminosalicylic acid derivatives (5-ASA)
  • Corticosteroids
  • Immuno-modulating and biologic agents
  • Treatment directed toward symptomatic relief and controlling disease process
60
Q

Management of Chron’s?

A
  • Acute flairs may require surgical intervention (bowel perforation)
  • Discontinue tobacco
  • Consult GI/Gen surg
  • MEDEVAC (only for new onset case)
61
Q

Complications of Chron’s disease?

A
  • Intra-abdominal abscess formation
  • Small bowel obstruction
  • Fistulas
  • Anal fissures
62
Q

What is Ulcerative colitis?

A
  • Chronic, recurrent disease
  • Limited to colonic mucosa (large intestine)
  • More common in non-smokers and former smokers
63
Q

Ulcerative Colitis causes?

A
  • Ulceration
  • Edema
  • Bleeding (common, unlike Chron’s)
  • Fluid and electrolyte loss
64
Q

Symptoms of Ulcerative Colitis?

A
  • Bloody diarrhea (hallmark)
  • Lower abdominal cramps and fecal urgency
  • Anemia, low serum albumin
  • Negative stool cultures
65
Q

Mild ulcerative colitis?

A
  • Gradual onset of infrequent diarrhea (<5 movements/day)
  • Stools may be formed or loose consistency
  • Fecal urgency and tenesmus
  • Lower Left quadrant cramps
66
Q

Moderate ulcerative colitis?

A
  • Have more severe diarrhea with frequent bleeding
  • Abdominal pain and tenderness (not severe)
  • Mild fever, anemia, and hypoalbuminemia
67
Q

Severe ulcerative colitis?

A
  • More than 6-10 bloody BM/day
  • Severe anemia, hypovolemia, and impaired nutrition
  • Abdominal pain and tenderness
68
Q

Labs for ulcerative colitis?

A
  • CBC
  • ESR
  • CRP
  • Stool bacterial culture
  • C dif
  • Ova and parasites
  • Serum albumin
  • Electrolytes
69
Q

Imaging for ulcerative colitis?

A
  • CT Scan in suspected fistula, perforation, abscess, acute flares
  • Colonoscopy (screen for carcinoma)
  • Colonoscopy 8 years after initial Dx
70
Q

Two main treatment objectives of ulcerative colitis?

A
  • Terminate the acute, symptomatic attack

- to prevent recurrence of attacks

71
Q

Medication options for ulcerative colitis?

A
  • Mesalimine
  • Corticosteroid
  • 5-ASA
72
Q

Mild to moderate treatment of ulcerative colitis?

A
  • As recommended by GI

- Limit intake of caffeine and gas-producing vegetables

73
Q

Treatment of severe ulcerative colitis?

A
  • Hospitalization generally required
  • NPO for 24-48 hours
  • Discontinue all opioid and anticholinergic agents
  • Restore circulating volume with fluids
  • Serial abdominal exams
74
Q

What is the definitive way to diagnose Chron’s and ulcerative colitis?

A

Biopsy

75
Q

Disposition of Chron’s and Ulcerative Colitis?

A
  • MEDEVAC

- Refer to GI/Gen Surg

76
Q

What is Irritable Bowel Syndrome?

A
  • Chronic disease (at least 3 months)
  • Characterized by abdominal pain or discomfort that occurs in association with altered bowel habits
  • Not completely understood
  • Believed that mental health plays huge role
77
Q

Possible causes/associations of IBS?

A
  • Ovum and Parasite
  • Food poisoning via
  • Campylobacter
  • Shagella
  • Salmonella
  • E. coli
  • C. dif
  • Stress
  • Mental health
78
Q

Hallmarks IBS?

A

Abdominal discomfort relieved immediately after defecation with an otherwise normal physical exam

79
Q

Other symptoms IBS?

A
  • Usually begins late teens to twenties
  • Abnormal stool frequency
  • May have other somatic or psychological complaints
80
Q

Diagnosis of IBS?

A

At least two of the three features:

  • Relieved with defecation
  • Onsite associated with a change in frequency of stool
  • Onsite associated with a change in form of stool
81
Q

3 major categories of IBS?

A
  • IBS-C or IBS-D ( IBS-Constipation/IBS-Diarrhea)
  • Infrequent bowel movements (IBS-U)
  • IBS with mixed constipation and diarrhea (IBS-M)
82
Q

Alarm symptoms associated with IBS?

A
  • Acute onset of Sx (Esp in >40-50 yrs)
  • Nocturnal diarrhea
  • Severe constipation
  • Hematochezia/Unexplained IDA
  • Weight loss
  • Fever
  • FamHx: Cancer, IBD or celiac disease
83
Q

Physical exam IBS?

A
  • Usually normal
  • Should not have fever, rashes, blood in stool
  • Can have very mild abdominal tenderness in lower abdomen
84
Q

Labs for IBS?

A 
- Consider:
CBC
Chem
Serum albumin
Thyroid function test
*Only if alternate diagnosis is suspected
85
Q

Rad for IBS?

A
  • Colonoscopy only recommended for Pt’s >50yrs to check for malignancy
86
Q

Treatment for IBS?

A
  • Establish therapeutic relationship with patient
  • Diet (avoid caffeine and trigger foods)
  • Symptomatic treatment (loperamide, anticonstipation)
  • Potential for TCA’s (mental health Rx only)

Gastrointestinal (6 decks)

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