Melena and Hematochezia DSA Flashcards
What structure designates a LGIB vs. UGIB?
Which are more worrisome?
Ligament of Treitz
Generally UGIB are more worrisome
DDx of LGIB in a patient >50 y/o
DDx of LGIB in a patient <50 y/o
> 50 y/o: malignancy, diverticulosis, angiectasia, ischemic colitis
<50 y/o: infectious colitis, anorectal fissures, IBD, Meckel’s diverticulum
Dx of LGIB usually requires…
Colonoscopy, only in stable patients
What meds can cause a GI bleed?
NSAIDs
Aspirin
Glucocorticoids
Anti-coagulants
**Meds with iron or bismuth (pepto bismol)
Most common cause of major LGIB is:
Where does it occur most commonly?
90% of patients are…
Diverticulosis
Sigmoid colon
Asx - detected on barium enema or colonoscopy
Sx of bleed with diverticulosis
Acute, painless, large-vol maroon or bright red stool
Tx of divericulosis
Diet change - increase fiber, etc.
Hemodynamic support if hemorrhage
2 large bore IVs
Crohn disease is associated with which finding on XR?
UC?
String sign (strictures)
Lead pipe sign (loss of haustra)
Which IBD: CD or UC?
Usually bloody diarrhea
UC
Which IBD: CD or UC?
Toxic megacolon
UC
Which IBD: CD or UC?
CARD15/NOD2
CD
Which IBD: CD or UC?
Ulcerated pseudopolyps
UC
What is seen on histology/colonoscopy of CD?
Aphthous ulcers intervening with normal mucosa
“Cobble-stoning”
Thickened bowel wall
“Creeping fat”
Which IBD: CD or UC?
Rectal involvement (almost always)
UC
Which IBD: CD or UC?
Most common site of involvement is terminal ileum
CD
What antibodies are tested in IBD?
Which diseases are they more specific for?
ANCA - UC
ASCA - CD
+ stool fecal lactoferrin indicates..
Intestinal inflammation
+ stool fecal calprotectin
Predicts relpases and detectes pouchitis
Sx of CD
RLQ pain Diarrhea (w/o blood) Acute ileus (mimics appendicitis) Abscesses Strictures Fistulas
Fist-line of treatment for IBD
Corticosteroids, then immunomodulating/biologics
Complications of Crohn disease include…
Gallstones
Kidney stone
Colon CA
Which IBD: CD or UC?
Fistulas are common
Fistulas are common in CD!
Sx of UC
Bloody diarrhea Tenesmus/fecal urgency Recently stopped smoking? (smoking tends to be protective) Wt loss Eryhthema nodosum
Complications of UC
Hemorrhage
Colon CA
Toxic megacolon
Colon perforation
Extra-intestinal complications of IBD at the following locations:
Eyes Kidneys Skin Mouth Liver Biliary tract Joints Circulation
Eyes: uveitis, episcleritis
Kidneys: stones, fistula, UTI
Skin: erythema nodosum, pyoderms gangrenosum
Mouth: aphthous ulcers, stomatitis
Liver: steatosis
Biliary tract: gallstones, sclerosing cholangitis
Joints: spondylitis, sacrolitis, arthritis
Circulation: phlebitis
Onset of ischemic colitis
What is the major risk factor?
What ages?
Sudden onset of cramping in LLQ
Desire to defecate
Passage of blood/bloody stool
Atherosclerosis is major risk factor
Older patients
Thumb-printing on XR is seen in what disease?
Ischemic colitis
Imaging used for iscemic colitis (2)
Abdominal XR - thumb-printing
Sigmoidoscopy
Acute mesenteric ischemia presentation:
What is a unique symptom?
What is the study of choice?
What is the treatment?
Perimubilical pain out of proportion of tenderness (lots of pain, but PE is unremarkable)
“Food fear” - pain is worse after eating
CT angiography
Laparotomy to restore blood flow
Hemorrhoids major presenting sign:
How do they occur?
What is the major complication?
BRBPR - in drops or on toilet paper
Increased hydrostatic pressure in hemorrhoidal venous plexus
-straingin at stool (associated w/ pregnancy)
Thrombosed external hemorrhoid: onset by heavy cough, lifting, straining
Anal fissures definition:
What is the presentation?
Linear/rocket-shaped ulcers usually 5 mm in length
Severe, tearing pain during defecation followed by throbbing discomfort, which may lead to constipation
Possible hematochezia
What is the major cause of proctitis?
What symptoms characterize it?
Sexually transmitted, usually by anal intercourse
Anorectal discomfort, tenesmus, constipation and mucous/bloody discharge
What 5 bugs can cause anorectal infections? Where should cultures come from?
N. gonorrheae Treponema pallidum Chlamydia trachomatis HSV-2 Condylomata acuminata (HPV - genital warts)
How is N. gonorrheae cultured?
Anal culture, as well as pharynx and urethra in men, and pharynx and cervix in women
Treponema pallidum is diagnosed with…
Dark-field microscopy or fluorescent Ab testing
Chalmydia trachomatis may cause…
There have been increasing cases in which patients?
What establishes a Dx?
Lymphogranuloma venereum - proctocolitis with fever and bloody diarrhea, perianal ulcers, strictures and fistulas, and inguinal adenopathy.
Gay men
Serology, culture or PCR testing of rectal discharge
HSV-2 symptoms onset how long after exposure?
How it is diagnosed?
When does it resolve?
4-21 days
Viral culture, PCR or Ag detection
Within 2 wks, but viral chedding may continue for a few wks.
Anal warts (HPV) should be distinguished from which pathogies?
Where should Bx come from?
Who should get vaccinated for it?
Conyloma lata (secondary syphilis) or anal cancer
Large or suspicious lesions
All people from ages 9-26 (especially women and gay men)
Anal cancer is predominantly caused by:
Which patients are at a greater risk?
What is it associated with?
What is the presentation?
HPV is etiologic
Women and gay men
Chronic irritation (infection, anal sex, hemorrhoids, leukoplakia, etc.)
Bleeding, pain and perianal mass
What are some treatments for anal cancer?
Radiation and chemo
Abdominoperineal resection with permanent colostomy is reserved for patients with large lesions or reoccurence post-chemo
What is the most common organ that anal cancer metastasizes to? Why?
Lungs, due to the paravertebral venous drainage
Perianal pruritis etiologies:
Treated by…
Poor hygiene
Contact dermatitis, atopic dermatitis, bacterial infections, STD, skin conditions, etc. can cause pruritis and should be excluded.
Education is important, but otherwise, topical glucocorticoids and anti-fungals if indicated.
What are the 4 major pathologic polyps?
Which one is most common?
Which have significant clinical implications?
Mucosal adenomatous polyps - tubular, tubulovillous, villous - 70% (most common) and clinically important
Mucosal serrated polyps - clinically important
Mucosal non-neoplastic polyps - juvenile, hamartomatous, inflammatory polyps
Submucosal lesions - lipomas, lymphoid aggregates, etc.
What 4 things might suggest that a patient has an increased risk of having a familial colon cancer?
Family Hx of colorectal cancer in more than 1 person
Personal or family hx of colorectal cancer <50 y/o
Personal or family hx of multiple polyps (>20)
Personal or family hx of multiple extra-colonic malignancies
Familial adenomatous polyposis (FAP) is indicated by the presence of…
What is the major extra-intestinal manifestation?
90% have a mutation in which gene in what kind of inheritance?
8% have a mutation in what other gene in what kind of inheritance?
Hundreds to thousands of colonic adenomatous polyps
Congenital hyperplasia of the RPE (detected at birth)
90% - APC gene in AD fashion
8% - MUTYH gene in AR fashion
What are the 2 manners of treatment for FAP?
Complete proctocolectomy w/ ileoanal anastomosis before age 20
Prophylactic colectomy to prevent inevitable colon cancer
Lynch syndrome (HNPCC) is associated with which 2 major malignancies?
How fast do polyps become malignant?
What genes are implicated and what is their function? Inheritance?
Colorectal cancer (22-75%) and endometrial cancer (30-60%) - other cancers can develop at a young age
Rapid transformation from normal tissue to adenomas - cancer in 1-2 years
MLH1 and MSH2 - DNA mismatch repair genes - AD
Multisociety guidelines recommend that all colon cancers should undergo…
Testing for Lynch syndrome, with either immunohistochemistry or microsatellite instability
What is the treatment for Lynch syndrome?
What should women have done?
When should screening be done for gastric cancer and how frequently should it be done?
Subtotal colectomy w/ ileorectal anastomosis (w/ annual surveillance)
Women should have a prophylactic hysterectomy and oopherectomy at 40 y/o or after they are done having kids
Upper endoscopy for gastric cancer every 2-3 yrs beginning at 30 y/o
Clinical findings in non-familial adenomatous and serrated polyps include:
What is the main way they are treated and monitored?
They are completely asymptomatic, but may show some blood loss and lead to iron deficiency anemia
Colonoscopic polypectomy if needed, but there is risk for bleeding and perforation
Postpolypectomy surveillance - periodic colonoscopies post removal of polyps
What endoscopic test is most useful in diagnosing non-familial adenomatous and serrated polyps?
Colonoscopy - best test to detect and treat colorectal polyps
Hamatomatous polyps include which 3 disease?
What are some characteristics of each?
Peutz-Jeghers
- hamartomatous polyps throughout GI, mostly in SI
- mucocutaneous pigmented macules in lips, buccal mucosa and skin*
Familial juvenile polyps
- > 10 polyps in colon
- 50% increased risk for colon cancer, but to synchronous adenomatous polyps or mixed hamartomatous-adenomatous polyps
PTEN hamartoma syndrome (Cowden disease)
- hamartomas and lipomas throughout GI tract, and trichilemmomas (benign skin neoplasm on neck and head) and cerebellar lesions
- increased rate of malignancies in thyroid, breast and GU tract
What is the inheritance and genes associated with Peutz-Jeghers syndrome and Familial juvenile polyposis?
J-P syndrome: AD - STK11 gene
FJP - AD - MADH4 and BMPR1A genes
Gardner’s syndrome is associated with which polyps?
What are extra-intestinal manifestations?
Inheritance?
Adenomatous colon polyps
Osteomas of mandible, skull and long bones
Supernumerary teeth
Thyroid and adrenal tumors
AD
Turcot’s syndrome is associated with which polyps?
What is the major extra-inestinal manifestation?
What is another major association?
Inheritance?
Adenomatous colon polyps
Brain tumors
Colorectal cancer in 100% of pts. over 40 y/o
AD
ACS guidelines for colorectal screening for patients at average risk
Begin regular screening at 45 y/o, and continue until 75 y/o
For pts. > 75 y/o, screening is done based on pt. preference
Pts. > 85 should not be screened, unless they have:
- hx of cancer/multiple polyps
- hx of IBD
- confirmed Lynch syndrome, FAP, etc.
- hx of radiation to belly
ACS guidelines for colorectal screening for patients at above-average risk
For FAP?
For Lynch syndrome?
First-degree relatives with colorectal cancer or adenomas <60 y/o
-colonoscopy every 5 yrs, beginning at 40 y/o or 10 yrs prior to the age tha the youngest family member was diagnosed
FAP: genetic testing or annual sigmoidoscopy beginning at 10-12 y/o
Lynch syndrome: genetic testing or colonoscopy every 1-2 yrs beginning at 20-25 y/o, or 10 yrs younger than the age the youngest family member was diagnosed
Colon adenocarcinoma is most common at what age?
Pts. with a strong family history of malignancy generally have tumors where? What infection has a high prevalence?
What is the major site of metastasis?
> 45 y/o
Right colon, Strep. bovis bacteremia
Liver
What are symptoms more common to right sided and left sided colon cancers?
Right: anemia, occult blood in stool, weight loss, perforation, fistulas
Left: rectal bleeding, abn. bowel habits (GI complaints), abdominal/back pain
What helps with early Dx of colon adenocarcinoma?
Screening Asx patients with fecal occult blood testing
Arteriovenous malformations (AVM - Angioectasias)
Symptoms?
Pts. with what other 2 diseases are commonly implicated? What age?
Diagnostics include (2)
Painless bleeding, ranging from melena to hematochezia (if proximal to ligament of Trietz it will be melena, etc.)
> 70 y/o with aortic stenosis or chronic renal failure
CBC with iron studies
Endoscopic evaluation
