melena and hematochezia Flashcards
clinical
differentiate between the sx of upper and lower GI
upper= melena, can present to hematochezia
lower= hematochezia
ddx for pts under 50 yo w lower gi bleed
infectious colitis
anal fissures, hemorrhoids
IBD
meckels
ddx for patients over 50 with lower gi bleed
malignancy
diverticulitis
angiectasias
ischemic colitis
define the location of a LGIB
below the Lig of Treitz (past duodenum part 3)
prognosis of UGIB vs LGIB
LGBI is more likely to be benign, less likely to present w shock, 75% spontaneously stop bleeding
serious LGIB is more common in who
older men
increased risk of LGIB in patients taking
aspirin, other antiplatelets, NSAIDs
multivitamin w iron, peptobismol
LGIB with hx of EtOH abuse
colonic varices
increased risk of UGIB in patients taking
aspirin glucocorticoids NSAIDs anticoag MVI w iron, peptobismol
octreotide consumption can inhibit secretion of ___, reduce ____ to the gastroduodenal mucosa, and cause ____ vasoconstriction in patient with varices
gastric acid
blood flow
splanchnic
etiology of diverticulosis, most common location
herniations or sac like protrusions of the mucosa at the points of nutrient A penetration
sigmoid colon
most common cause of major LGIB
diverticulosis
sx, dx, trx of diverticulosis
sx= acute, painless, large volume maroon or red blodd in pts over 50, hemorrhage, but 90% are asx
dx= colonoscopy in stable pts, INR/pt/Ptt, CBC
trx=if uncomplicated, high fiber intake and antichol, hemorrhage, also fluid bolus or blood transfusion as needed
patients with IBD have been shown to have ___ intestinal permeability, and ____ impairment of structure and function
increased, irreversible
T cell types and interleukins in crohn vs UC
Crohn= Th1 + Th17, TNF/IFN-g, IL17
UC= Th2 type, IL-5, IL-13
UC= L_Q pain and Crohn= L_Q pain
UC= LLQ Crohn= CRQ
crohn
pattern of lesions
locations of lesions
complications
histo
skip lesions, transmural
anywhere in GI trat, discontinuous, mostly in terminal ileus and colon, perianal ds is common
fistulas, strictures, “string sign” on US, bile salt malabsorption, gallstones,
coble-stoning on scope, thickened wall, fat wrapping of colon
ulcerative colitis
pattern of lesions
locations of lesions
complications
histo
continuous, superficial
from rectum proximal, not the entire colon
lead pipe sign on xray
loss of haustra, crypt distortion, ulceration, severe hemorrhage, pseudopolyps, toxic megacolon
while smoking is ___ in ulcerative colitis, it ____ crohn’s
protective
worsens
gene mutation related to crohn
CARD15/NOD2
populations in which IBD is present
bimodal age= 20s-40s and then 70s-90s
jewish + whites
high SES, hx of abx use in the first year of life
increase risk of what infectious agents with IBD
salmonella
shigella
campylobacter
C Dif
serum Ag levels of ___ are seen with ulcerative colitis, and of ___ in crohn
ANCA
ASCA
what does fecal lactoferrin indicate
intestinal inflammation (think IBD)
what does fecal calprotectin indicate
predict relapses and detect pouchitis
diagnostic imaging for IBD
single contrast barium enema
CT w contrast, CT/MR Enterography
sigmoidoscopy, colonoscopy
EGD
sx of crohn
RLQ pain fever diarrhea no blood growth retardation acute ileitis looks like appendicitis anorectal rissure
trx for crohn and ulcerative colitis
5-aminosalicylic acid derivatives corticosteroids, immunomodulating agents, biologic agents
(for Crohn also add abx, IVF w NGT suction)
sx of ulcerative colitis
6+ bloody BMs/day, tenesmus/fecal urgency, systemic vasculitis,
sx and dx of toxic megacolon
super sick
shock, sicker than they have ever been
dont want to increase the P or will perforate, so get a plain Xray and call surgery
extra-intestinal manifestations of IBD (7)
pyoderma gangrenosum (UC) oral aphthous ulcer (early sx in crohn) iritis anterior uveitis toxic megacolon (UC) erythema nodusum ankylosing spondylitis
hx of ischemic colitis
sudden onset of cramping LLQ pain, desire to defecate, passage of bloody diarrhea
in older patients with atherosclerotic ds
in younger patients with cocaine use
dx and trx of ischemic colitis
thumb printing on abd xray,
sigmoidoscopy w submucosal hemorrhage, friability, and ulceration
trx= NPO, IV fluids, surgical resection
hx of acute mesenteric ischemia
periumbilical pain out of proportion to tenderness
writhing in pain but physican exam isn’y impressive
“food fear”, abd pain worsens after eating
dx and trx of ischemic colitis
dx= thumb printing on xray, submucosal edema
CR angiography
trx= restore intestinal blood flow past an obstruction via laparotomy, post op anticoag in mesenteric venous thrombosis
hx, dx, trx of hemorrhoids
hx= increased P in venous plexus with straining to poop or pregnancy, bright red blood drops on tissue,
dx on anal inspection or anoscopy
trx= bulk laxative and stool softeners, analgesics, rubber band ligation or injection sclerotherapy
complications of hemorrhoids
thrombosed external hemorrhoid
acute, exquisite pain, tense, bluish perianal nodule
etiology of an anal fissure
linear or rocket shaped ulcers due to trauma to the anal canal during defecation
hx, dx, trx of anal fissure
hx= severe, tearing pain during defecation followed by throbbing discomfort
maybe a little bit of blood
dx= external anal inspection or anoscopy
trx=fiber supplements, sitz baths, topical anesthetics, relaxation of anal canal w nitroglycerin ointment,
internal anal sphincterotomy in refractory cases
anaorectal infections can lead to __, characterized by anorectal discomfort, tenesmus, constipation, and discharge
proctitis
most cases of proctitis are transmitted ___, especially ___
sexually
anal receptive
dx of N. gonorrhea anorectal infection
cultures from pharynx urethra (M) / cervix (F)
dx of treponema pallidum anorectal infection
dark field microscopy or flourescent Ab, VDRL or RPR test
dx of chlamydia trachomatis
serology, culture, PCR
hx with chlamydia anorectal infection
proctocolitis w fever, bloody diarrhea, perianal ulcerations, anorectal strictures, fistulas, inguinal adenopathy, MSM
dx of herpes simplex type 2 anorectal infection
viral culture, PCR, or Ag detection
viral shedding for several weeks after resolution
anal CA can be associated with chronic irritation from
condyloma acuminata perianal fissures/fistulas chronic hemorrhoids leukoplakia trauma from anal intercourse
etiology of anal ca
HPV virus
populations and hx associated with anal CA
women and MSM
bleeding, pain, perianal mass
trx and complications of anal CA
trx= radiation therapy plus chemo
complications= tumors may spread to the lung early on
etiology of pruritis ani
poor anal hygeine, or overzealous cleansing with soaps
hx, dx, trx of pruritis ani
hx= perianal itching and discomfort
dx= external anal inspection or anoscopy
trx=education, premoistened wipes, topical glucocorticoid, and anti-fungal agent if indicated
most polyps are what kind
mucosal adenomatous polyps
FAP sx and dx and trx
early development of 100s-1000s of polyps
detect w gene detection of APC and/or MUTYH gene
trx= complete proctocolectomy with ileoanal anastomosis
prophylactic colectomy
etiology of lynch syndrome
lifetime risk of colorectal cA, endometrial CA, and other CAs developing at a young age
polyps undergo rapid transformation over 1-2 years from normal tissure –> adenoma –> CA
dx, trx of lynch syndrome
dx= genetic counseling to look for x mismatch repair mechanism, immunohistochemical staining
trx= subtotal colectomy w ileorectal anastomosis with annual surveillance of the rectal stump
women undergo screening for endometrial/ovarian CA at 30
prophylactic hysterectomy
hx, dx, trx w nonfamilial adenomatous & serrated polyps
hx= mostly asx but all the bleeding can cause anemia
dx= barium enema, CT colongraphy, COLONOSCOPY IS THE BEST = most sensitive
trx= postpolypectomy surveillance
three syndromic presentations in which you will see hamartomous polyps
peutz-jeghers syndrome= HP throughout GI tract, may lead to gelatinous stools (s/p intussusception), mucocutaneous pigmented macules on the lips, buccal mucosa, and skin
familial juvenile polyposis= more than juvenile HPs most commonly in colon, increase risk of adenocarcinoma
PTEN multiple hamartoma syndrome (Cowden)
- HPs and lipomas throughout the GI tract, and cerebellar lesions
- increased rate of malignancy in thyroid, breast, and urogenital tract
what makes someone have an above avg risk for colorectal CA
- get a colonoscopy every 5 years starting at 40 or 10 yrs before the staring age of youngest relative w it if have
- first degree relative, dx at<60 or two first degree relatives at any age
- get colonoscopy every 5 years starting at 40 if
- first degree relative w colorectal CA or adenoma dx at >60, or teo second degree relatives with colorectal CA
screening and tests for colorectal CA
FOBT, FIT, and fecal DNA tests
strep bovi bacteremia in ppl >45 is associated with
adenocarcinoma of the colon
left sided colon CA presents with
vs right sided colon CA presenting with
left= rectal bleeding, altered bowel habits, abd/back pain
right= anemia, occult blood, weight loss, other
hx and dx of AVM
= angiodysplasia
-painless bleeding/occult blood loss,
-common hx of chronic renal failure or aortic stenosis
if proximal to Lig or Treitz, can present with melena
dx=
CBC, iron studies, endoscopic workup
TIPS procedure is for
long term decreased portal HTN
trx for stomach ulcer
IV pantoprazole (PPI)
normally, start transfusion therapy if Hgb is less than
in CAD, start transfusion therapy if Hgb is less than
7
10
giving someone iron can cause what s.e.
constipation
darker colored urine
