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Internal Medicine > MGH PM - Gastroenterology II > Flashcards

MGH PM - Gastroenterology II Flashcards

1
Q

Acute diarrhea means …?

A

<4wk.

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2
Q

Acute diarrhea - Acute infectious etiologies - Non inflammatory:

A

Predom. disruption small intestine absorp. and secretion.

==> Voluminous diarrhea, N/V, (-) fecal WBC and FOB.

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3
Q

Acute diarrhea - Acute infectious etiologies - Preformed toxin:

A

“Food poisoning”,

<24h dur. S.aureus (meats and dairy).

B. cereus (fried rice).

C.perfringens (rewarmed meats).

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4
Q

Acute diarrhea - Acute infectious etiologies - Viral - Rotavirus:

A

Outbreak person to person (PTP), daycare; lasts 4-8 d.

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5
Q

Acute diarrhea - Acute infectious etiologies - Viral - Norovirus:

A

50% OF ALL DIARRHEA.

Winter outbreaks; PTP and food/water. No immunity.

==> Lasts 1-3 d. Vomiting prominent.

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6
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - E.coli (toxinogenic):

A

> 50% of traveler’s diarrhea.

==> Cholera-like toxin; <7d.

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7
Q

Acute diarrhea - Acute infectious etiologies - V.cholerae (Lancet 2012):

A

Contam H2O, fish, shellfish.

==> 50 cases/y in US Gulf Coast.

==> Severe dehydration and electrolyte depletion.

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8
Q

Acute diarrhea - Acute infectious etiologies - Parasitic - Giardia:

A

Streams/outdoor sports, travel, outbreaks. Bloating.

==> Acute (profuse, watery) ==> Chronic (greasy, malodorous).

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9
Q

Acute diarrhea - Acute infectious etiologies - Parasitic - Cryptosporidia:

A

Water-borne outbreak; typically self-limited, can cause chronic infxn if immunosupp.

==> Abd pain (80%), fever (40%). (NEJM 2002).

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10
Q

Acute diarrhea - Acute infectious etiologies - Cyclospora:

A

Contaminated produce.

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11
Q

Acute diarrhea - Acute infectious etiologies - Inflammatory:

A
  1. Predom. colonic invasion.
  2. Small vol diarrhea.
  3. LLQ cramps.
  4. Tenesmus.
  5. Fever.
  6. Typically (+) fecal WBC or FOB.
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12
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Campylobacter:

A

Undercooked poultry, unpasteurized milk, travel to Asia.

==> Carried by puppies and kittens.

==> Prodrome; abd pain ==> Pseudoappendicitis;

==> c/b GBS, reactive arthritis.

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13
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Salmonella (non typhoidal):

A
  1. Eggs, poultry, milk.
  2. Bacteremia in 5-10%.

==> 10-33% of bacteremic Pts >50y develop aortitis.

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14
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Shigella:

A

Low inoculum; PTP spread. Abrupt onset.

==> Often gross blood and pus in stool; UP UP WBC.

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15
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - E.coli (O157:H7 and inv/hemorrhagic non-O157:H7):

A

Undercooked beef, unpasteurized milk, raw produce; PTP.

==> O157 and non-O157 sp. (40%) produce Shiga toxin ==> HUS (typically in children). Gross blood in stool.

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16
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - V.parahaem.:

A

Undercooked seafood.

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17
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Salmonella typhi:

A

Travel to Asia. Systemic toxicity, relative bradycardia, rose spot, rash, ileus ==>Pea-soup diarrhea, bacteremia.

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18
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Yersinia:

A

Undercooked pork; unpasteurized milk, abd pain ==> “Pseudoappendicitis” (aka mesenteric adenitis).

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19
Q

Acute diarrhea - Acute infectious etiologies - Bacterial - Aeromonas, Plesiomonas, Listeria:

A

Meats and cheese.

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20
Q

Acute diarrhea - Acute infectious etiologies - Parasitic - E.histolytica:

A

Contaminated food/water, travel (rare in US).

==> Liver abscess.

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21
Q

Acute diarrhea - Acute infectious etiologies - Viral - CMV:

A

Immunosuppressed; dx by shell vial cx of colon bx.

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22
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Hx:

A

Stool freq, bloody, abd pain, duration of sxs [1 wk for viral and bacterial (except C.diff), >1wk for parasitic], travel, food, recent abx.

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23
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - PEx:

A

Vol depletion (VS, UOP, axillae, skin turgor, MS), fever, abd tenderness, ileus, rash.

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24
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Further evaluation if WARNING SIGNS:

A
  1. Fever.
  2. Signific abd pain.
  3. Blood or pus in stools.
  4. > 6 stools/d.
  5. Severe dehydration.
  6. Immunosupp.
  7. Elderly.
  8. Duration >7 d.
  9. Hosp-acquired.
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25
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Etiology established in only …?

A

3% of community-acquired diarrhea.

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26
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Laboratory:

A
  1. Fecal WBC [high false (+) and (-)].
  2. Positive fecal calprotectin or lactoferrin Se/Sp >90%).
  3. Stool cx.
  4. BCx.
  5. Lytes.
  6. C.diff (if recent hosp or abx).
  7. Stool O&P (if >10 d, travel to endemic area, exposure to unpurified H2O, community outbreak, daycare, HIV(+) or MSM).

+/- Stool ELISAs (viruses, Crypto, Giardia), serologies (E.histolytica), special stool cx.

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27
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Imaging/endoscopy:

A

CT/KUB if ? toxic megacolon.

==> Sig/colo if immunosupp or cx (-).

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28
Q

Acute diarrhea - Evaluation (NEJM 2009, Gastro 2009) - Ddx:

A

Infx vs. preformed toxin vs. med-induced vs. initial presentation of chronic diarrhea.

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29
Q

Acute diarrhea - Treatment - If none of the above WARNING SIGNS and Pt able to take POs:

A

Supportive Rx only: Oral hydration, loperamide, bismuth subsalicylate (avoid cholinergics).

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30
Q

Acute diarrhea - Treatment - If moderate dehydration:

A

50-200 mL/kg/d of oral solution (1/2 tsp salt, 1 tsp baking soda, 8 tsp sugar, & 8 oz OJ diluted to 1L w/ H2O) or Gatorade, etc.

==> If severe, LR IV.

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31
Q

Acute diarrhea - Treatment - For traveler’s diarrhea:

A

Bismuth or rifaximin useful for prophylaxis and empiric Rx.

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32
Q

Acute diarrhea - Treatment - Non-hosp-acquired inflammatory diarrhea?

A

Empiric abx reasonable ==> FQ x 5-7 d.

==> Abx rec for Shigella, cholera, Giardia, amebiasis, Salmonella if Pt > 50y or immunosupp or hospitalized, ? Campylobcter (if w/in 4 d of sx onset).

==> AVOID abx if suspect E.coli O157:H7 as may increase risk of HUS.

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33
Q

C.diff-associated diarrhea (CDAD) - Pathogenesis:

A
  1. Ingestion of C.difficile spores ==> Colonization when colonic flora Dd by abx or chemo ==> Release of toxin A/B ==> Colonic mucosal necrosis + inflammation ==> Pseudomembranes.
  2. Incr. toxigenic strain (NAP 1/027) incr. mort. + LOS (esp. in elderly) (NEJM 2008).
  3. Additional risk factors: elderly, nursing home residents, IBD, PPI (CID 2011).
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34
Q

CDAD - Clinical manifestations (a spectrum of disease):

A
  1. Asx colonization: <3% healthy adults; 20% in hospitalized patients on abx.
  2. Acute watery diarrhea (occ bloody) +/- mucus often w/ lower abd pain, fever, UP UP UP WBC.
  3. Pseudomembranous colitis: Above sx + pseudomembranes + bowel wall thickening.
  4. Fulminant colitis (2-3%): TOXIC MEGACOLON (colon dilation >6cm on KUB, colonic atony, systemic toxicity) and/or bowel perforation.
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35
Q

CDAD - Diagnosis - Only test if …?

A

SYMPTOMATIC - Test LIQUID stool (unless concern for ileus).

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36
Q

CDAD - Diagnosis - Stool EIA:

A

Detects toxin B and/or A (1-2% strains make A).

==> Fast (2-6h).

==> Most often used.

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37
Q

CDAD - Diagnosis - PCR:

A

Quick, becoming test of choice (Mayo 2012).

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38
Q

CDAD - Diagnosis - Alternative:

A

2-step method:

==> Check glutamate dehydrogenase (GDH) EIA (high Se, (+) even if no toxin production) ==> Then if (+), check cytotoxin assay or toxinogenic cx.

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39
Q

CDAD - Diagnosis - Consider flex sig id …?

A

Dx uncertain and/or evidence of no improvement w/ standard Rx.

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40
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Start …?

A

==> Contact precautions.

==> If possible d/c abx ASAP.

==> Stop antimotility agents.

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41
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Mild-moderate (WBC <15k, Cr<1.5 x baseline, age <65y and no peritoneal sx):

A

MNZ 500mg PO tid x 10-14d.

42
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Severe (WBC >15k or Cr >1.5x baseline or age >65y):

A

Vanco 125mg PO qid x 10-14d.

43
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Complicated (ileus, malabsorption, shock, megacolon, peritonitis):

A
  1. Vanco 500mg PO q6h AND MNZ 500mg IV q8h.
  2. PR vanco if ileus, but avoid if evidence of toxic megacolon.
  3. Abd CT and urgent surg consult re: colectomy.
  4. ? IVIG fidaxomicin 200mg bid non inferior to vanco PO + Decr. rate of recurrence (NEJM 2011).
44
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - If Pt needs to stay on original abx …?

A

Continue C.diff. Rx for >7 d post-abx cessation.

45
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Stool carriage may persist …?

A

3-6wk postcessation of sx and should NOT trigger further Rx.

46
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Recurrent infection:

A

15-30% risk after d/c of abx, most w/in 2wk of stopping abx.

==> 1st relapse: if mild ==> repeat 14d course of MNZ or vanco.

==> 2nd relapse ==> PO vanco taper for 6wk.

==> >2 relapses: vanco taper and adjunctive Rx such as S.boulardii, probiotics, rifaximin, nitazoxanide, fidaxomicin or cholestyramine (binds vanco so cannot take concurrently).

47
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Fecal transplant:

A

In refractory disease appears safe and effective (Clin Gas Hep 2011, NEJM 2013).

48
Q

CDAD - Treatment (Infect Control Hosp Epidemiol 2010) - Probiotics:

A

May prevent CDAD by 66% in non immunosuppressed Pts (Annals 2012).

49
Q

Chronic diarrhea (>4wk; Gastro 2004) - Medications

A

Cause incr. secretion + incr. motility, Δ flora, incr. cell death or inflammation.

  1. PPI.
  2. Colchicine.
  3. Abx.
  4. H2RA.
  5. SSRIs.
  6. ARBs.
  7. NSAIDs.
  8. Chemo.
  9. Caffeine.
50
Q

Chronic diarrhea (>4wk; Gastro 2004) - Osmotic:

A
  1. Decr. diarrhea with fasting.
  2. (-) fecal fat.
  3. Incr. osmotic gap.
51
Q

Chronic diarrhea (>4wk; Gastro 2004) - Lactose intolerance:

A
  1. Seen in 75% nonwhites and in 25% whites.

2. Can be acquired after gastroenteritis, med illness, GI surgery.

52
Q

Lactose intolerance - Clinical:

A
  1. Bloating.
  2. Flatulence.
  3. Discomfort.
  4. Diarrhea.
53
Q

Lactose intolerance - Dx:

A

Hydrogen breath test or empiric lactose-free diet.

54
Q

Lactose intolerance - Rx:

A
  1. Lactose-free diet.
  2. Use of lactose-free dairy products.
  3. Lactase enzyme tablets.
55
Q

Osmotic diarrhea - Etiology:

A
  1. Lactose intolerance.

2. Other ==> Laxatives, antacids, sorbitol, fructose.

56
Q

Malabsorption - Main features:

A
  1. Decr. diarrhea with fasting.
  2. Incr. fecal fat.
  3. Incr. osmotic gap.
57
Q

Celiac disease (NEJM 2012) - Pathogenesis:

A

Immune rxn in genetically predisposed Pts (1% of pop) to gliadin, a component of gluten (wheat protein)

==> Small bowel inflammatory infiltrate.

==> Crypt hyperplasia, villus atrophy.

==> Impaired intestinal absorption.

58
Q

Celiac disease (NEJM 2012) - Other s/s:

A
  1. Fe/Folate def anemia.
  2. Osteoporosis.
  3. Dermatitis herpetiformis (pruritic papulovesicular).
  4. Incr. AST/ALT.
59
Q

Celiac disease (NEJM 2012) - Dx:

A

IgA tissue transglutaminase or endomysial Abs ==> 90% Se and >98% Sp (JAMA 2010).

==> Small bowel bx AND clinical/serologic response to gluten-free diet definitive.

60
Q

Celiac disease - Rx:

A

Gluten-free diet;

==> 7-30% do not respond to diet ==> ? wrong dx or non compliant.

61
Q

Celiac disease - Complications:

A

5% refractory (sx despite strict dietary adherence).

==> Risk of T-cell lymphoma and small bowel adenocarcinoma.

62
Q

Whipple’s disease (NEJM 2007):

A
  1. Infx w/ T.whipplei.
  2. S/s ==> Fever, LAN, edema, arthritis, CNS Ds, gray-brown skin pigmentation, AI + MS, oculomasticatory myorhythmia (eye oscillations + mastication muscle contract).
63
Q

Whipple’s disease - Rx:

A

(PCN + Streptomycin) or 3rd-gen ceph x 10-14 d ==> Bactrim for >1y.

64
Q

Small Intestinal Bacterial Overgrowth (SIBO; Inf Dis Clin 2010):

A
  1. Incr. SI bacteria from incompetent/absent ileocecal valve.
  2. S/p RYGB, scleroderma, diabetes, s/p vagotomy ==> Fat and CHO malabsorption.
65
Q

Small Intestinal Bacterial Overgrowth (SIBO) - Dx:

A

(+) 14C-xylose and H+ breath tests.

66
Q

SIBO - Rx:

A

Cycled abx (eg, MNZ, FQ, rifaximin).

67
Q

Pancreatic insufficiency:

A

Most commonly from chronic pancreatitis or pancreatic cancer.

68
Q

Other etiologies of malabsorption:

A
  1. S/p short bowel resection (short bowel syndrome.
  2. Crohn.
  3. Chronic mesenteric ischemia.
  4. Eosinophilic gastroenteritis.
  5. Intestinal lymphoma.
  6. Tropical sprue.
69
Q

Inflammatory diarrhea - Main features:

A
  1. (+) FOB.
  2. abd pain.
  3. (+) fecal WBC or lactoferrin or calprotectin.
70
Q

Inflammatory diarrhea - Etiologies:

A
  1. Infections ==> Parasitic (above pathogens and strongyloides), CMV, TB.
  2. IBD.
  3. Radiation enteritis, ischemic colitis, neoplasia (colon cancer, lymphoma).
71
Q

Secretory diarrhea - Main clinical features:

A
  1. Nocturnal diarrhea freq described.
  2. No Δ diarrhea after NPO.
  3. Normal osmotic gap.
72
Q

Secretory diarrhea - Etiologies:

A
  1. Hormonal.
  2. Laxative abuse.
  3. Neoplasm.
  4. Decr. bile absorption.
  5. Lymphocytic colitis, collagenous colitis (may be a/w meds, including NSAIDs).
73
Q

Secretory diarrhea - Hormonal:

A
  1. VIPoma (Verner-Morrison).
  2. Serotonin (carcinoid).
  3. Thyroxine.
  4. Calcitonin (Medullary thyroid carcinoma).
  5. Gastrin (Z-E).
  6. Glucagon.
  7. Substance P.
74
Q

Secretory diarrhea - Neoplasm:

A
  1. Carcinoma.
  2. Lymphoma.
  3. Villous adenoma.
75
Q

Motility diarrhea - IBS:

A

10-15% of adults (BMJ 2012, NEJM 2012).

76
Q

IBS (BMJ 2012, NEJM 2012) - Pathogenesis:

A

Due to altered intestinal motility/secretion in response to luminal or environmental stimuli w/ enhanced pain perception and dysregulation of the brain-gut axis.

77
Q

IBS (BMJ 2012, NEJM 2012) - Rome III criteria:

A

Recurrent abd pain >3d/mo over last 3 mo + at least 2 of the following:

  1. Improvement w/ defecation.
  2. Onset w/ Δ freq of stool.
  3. Onset w/ Δ in form of stool.
78
Q

IBS (BMJ 2012, NEJM 2012) - Rx:

A

Sx-guided (AJG 2009):

  1. Pain ==> Antispasmodics, TCA, SSRI.
  2. Bloating ==> Rifaximin (NEJM 2011), probiotics.
  3. Diarrhea ==> Loperamide, alosetron (5-HT3 antagonist) for women (incr. risk of ISCHEMIC COLITIS), rifaximin.
  4. Constipation ==> Incr. fiber 25g/d, lubiprostone (Cl- channel activator).
79
Q

Motility diarrhea - Other etiologies:

A
  1. Scleroderma.
  2. Diabetic autonomic neuropathy.
  3. Hyperthyroidism.
  4. Amyloidosis.
  5. s/p vagotomy.
80
Q

Workup for chronic diarrhea:

A
  1. Culprit meds ==> Med-induced.
  2. (+) fecal fat ==> Malabsorption ==> Based on hx check tissue transglut. Abs, stool elastase, H breath and 14C-xylose (if avail) tests, EGD w/ bx, EUS.
  3. (+)FOB, (+)WBC, (+)lactoferrin, calprotectin ==> Inflammatory ==> Check stool cx, colonoscopy.
  4. Stool osmotic gap <50 ==> Secretory/motility ==> CT scan, colo, hormone levels.
  5. Stool osmotic gap >50 ==> Check H breath test or empiric lactose-free diet, lax abuse.
81
Q

Stool osmotic gap = …?

A

Osm/stool (usu 290) - [2x (Na Stool - K stool)].

82
Q

Constipation (Gastro 2013) - Definition:

A

ROME III: At least 2 of the following during last 3mo at least 25% of time:

  1. Straining.
  2. Lumpy/hard stools.
  3. Incomplete evacuation.
  4. Sensation of anorectal obstruction.
  5. Manual maneuvers to facilitate defecation.
  6. Stool frequency <3 per wk.
83
Q

Constipation (Gastro 2013) - Etiology:

A
  1. Functional.
  2. Meds.
  3. Obstruction.
  4. Metabolic/endo.
  5. Neuro.
84
Q

Constipation (Gastro 2013) - Functional etiology:

A
  1. Normal transit.
  2. Slow transit.
  3. Pelvic floor dysfunction.
  4. Constipation-predom IBS.
85
Q

Constipation (Gastro 2013) - Etiology - Meds:

A
  1. Opioids.
  2. Anticholinergics (TCAs, antipsychotics).
  3. Fe.
  4. CCB.
  5. Diuretics.
  6. NSAIDs.
86
Q

Constipation (Gastro 2013) - Etiology - Obstruction:

A
  1. Cancer.
  2. Stricture.
  3. Rectocele.
  4. Anal stenosis.
  5. Extrinsic compression.
87
Q

Constipation (Gastro 2013) - Etiology - Metabolic/endo:

A
  1. DM.
  2. Hypothyroid.
  3. Uremia.
  4. Preg.
  5. Panhypopit.
  6. Porphyria.
  7. Up Ca.
  8. Down Mg.
  9. Down K.
88
Q

Constipation (Gastro 2013) - Etiology - Neuro:

A
  1. Parkinson.
  2. Hirschprung.
  3. Amyloid.
  4. MS.
  5. Spinal injury.
  6. Autonomic neuropathy.
89
Q

Constipation (Gastro 2013) - Dx:

A
  1. H/P w/ DRE.
  2. Labs: consider CBC, electrolytes w/ Ca, TSH.
  3. Colono if alarm sx ==> wt loss, (+) FOBT, fever, FHx of IBD or colon cancer.
  4. Sig if no alarm sx and <50y.
  5. For functional constipation: Sitzmark study, anorectal manometry, defecography.
90
Q

Constipation (Gastro 2013) - Tx - Steps:

A

Bulk laxatives (fiber 20g/d) ==> Osmotic laxatives ==> Stimulant laxatives.

91
Q

Constipation (Gastro 2013) - Tx - Bulk laxatives:

A
  1. Psyllium.
  2. Methylcellulose.
  3. Polycarbophil.

==> Incr. colonic residue, incr. peristalsis.

92
Q

Constipation (Gastro 2013) - Tx - Osmotic laxatives:

A
  1. Mg.
  2. Sodium Ph [avoid if CKD].
  3. Lactulose.

==> Incr. water in colon.

93
Q

Constipation (Gastro 2013) - Tx - Stimulant laxatives:

A
  1. Senna.
  2. Castor oil.
  3. Bisacodyl.
  4. Docusate sodium.

==> Incr. motility and secretion.

94
Q

Constipation (Gastro 2013) - Tx - Enema/suppository:

A
  1. Phosphate.
  2. Mineral oil.
  3. Tap water.
  4. Soapsuds.
  5. Bicasodyl.
95
Q

Constipation (Gastro 2013) - Tx - Other:

A
  1. Lubiprostone (see IBS).
  2. Methylnaltrexone and alvimopan for opioid-induced (AJG 2011).
  3. Linaclotide ==> Incr. stool freq, decr. straining/bloating (NEJM 2011).
96
Q

Acute pseudo-obstruction (adynamic ileus) - Definition:

A

Loss of intestinal peristalsis in absence of mechanical obstruction.

97
Q

Acute pseudo-obstruction (adynamic ileus) - Ogilvie’s?

A

Acute colonic adynamic ileus in presence of competent ileocecal valve.

98
Q

Acute pseudo-obstruction (adynamic ileus) - Precipitants:

A
  1. Intra-abd process (surgery, pancreatitis, peritonitis).
  2. Severe medical illness (Eg, PNA, sepsis).
  3. Intestinal ischemia.
  4. Meds (opiates, anticholinergics).
  5. Electrolyte abnl.
99
Q

Acute pseudo-obstruction (adynamic ileus) - Clinical manifestations:

A
  1. Abd discomfort.
  2. N/V.
  3. Hiccups.
  4. Abd distention.
  5. Decr. or absent bowel sounds.
  6. No peritoneal signs (unless perforation).

==> Cecum >10-12cm ==> Incr. risk of rupture.

100
Q

Acute pseudo-obstruction (adynamic ileus) - Dx:

A

Supine and upright KUB vs CT ==> Gas-filled loops of small and large intestine.

==> Must exclude mechanical obstruction (absence of gas in rectum).

101
Q

Acute pseudo-obstruction (adynamic ileus) - Tx:

A
  1. NPO.
  2. Mobilize (walk, roll).
  3. D/c Rxs that decr. intestinal motility, enemas.
  4. Decompression (NGT, rectal tube, colonoscope).
  5. Neostigmine (for colonic), methylnatrexone (for small bowel, ? colonic).

Internal Medicine (107 decks)

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