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Internal Medicine > MGH PM - Gastroenterology III > Flashcards

MGH PM - Gastroenterology III Flashcards

1
Q

Nutrition in hospitalized patients - Pathophysiology:

A
  1. When acutely ill, catabolism > anabolism ==> Carbs preferred due to decr. fat metab.
  2. When recovering, anabolism > catabolism ==> Body restores protein and muscle loss.
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2
Q

Nutrition in hospitalized patients - Critical illness (JPEN 2009):

A

Goals not well validated but 18-30 kcal/kg/d and 1.2-1.5g/kg/d protein.

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3
Q

Nutrition in hospitalized patients - Critical illness - Enteral:

A

Start w/in 24-48hrs of admission, trend toward decr. infxns and mortality in early (<48h) feeding in critically ill Pts who are adequately nourished at presentation.

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4
Q

Nutrition in hospitalized patients - Critical illness - Enteral - Contraindic:

A
  1. Inadequate volume resusc.
  2. Intestinal obstruction.
  3. Major GIB.
  4. Severe vomiting.
  5. Ischemic bowel.
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5
Q

Nutrition in hospitalized patients - Critical illness - Parenteral:

A

Start if unable to tolerate enteral w/in 7d or evidence of protein/cal malnutrition on admission.

==> May be beneficial in those below calorie goal w/ enteral (Lancet 2013).

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6
Q

Nutrition in hospitalized patients - Critical illness - Parental - Contraindic:

A
  1. Hyperosmolality.
  2. Severe electrolyte disturbances.
  3. Severe hyperglycemia.

==> Sepsis is a RELATIVE contraindic.

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7
Q

Nutrition in hospitalized patients - End-stage liver disease (Clin Gastro & Hep 2012) - Nutrition status …?

A

Predicts morbidity/mortality malnutrition in 50-90% of cirrhotics.

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8
Q

Nutrition in hospitalized patients - End-stage liver disease (Clin Gastro & Hep 2012) - Protein req …?

A

HIGHER than healthy adults (1-1.5g/kg/d vs 0.8g/kg/d).

==> Restrict ONLY if acute hep encephalopathy.

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9
Q

Nutrition in hospitalized patients - End-stage liver disease (Clin Gastro & Hep 2012) - Supplements:

A

Vit ADEK + Zinc, Selenium.

==> Do NOT carb restrict.

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10
Q

Nutrition in hospitalized patients - Refeeding syndrome (BMJ 2008):

A

Fluid/electrolyte shifts in malnourished Pts receiving artificial nutrition.

==> Hypophosphatemia is HALLMARK, but also decr. K and Mg, hyperglycemia, decr. thiamine, hypervolemia.

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11
Q

Nutrition in hospitalized patients - Refeeding syndrome (BMJ 2008) - Prevention:

A
  1. Thiamine 300mg PO qd.
  2. Vit B complex tid.
  3. MVI.
  4. Start feeding at 10kcal/kg/d (or 25% of estim goal) and incr. over 3-5days.

==> Advance only when electrolytes are w/in nl range.

==> Follow electrolytes and volume status, rehydrating and repleting.

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12
Q

Diverticular disease - Diverticulosis (Lancet 2004) - Definition:

A

Acquired herniation of colonic mucosa and submucosa through the colonic wall.

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13
Q

Diverticular disease - Diverticulosis (Lancet 2004) - Pathobiology - Existing dogma:

A

Low-fiber diet ==> Incr. stool transit time and decr. stool volume ==> Incr. intraluminal pressure ==> Herniation where vasa recta penetrate, but now ?’d (Gastro 2012).

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14
Q

Diverticular disease - Diverticulosis - Epidemiology:

A

Prevalence higher w/ incr. age (10% if <40y; 50-66% if >80y).

==> “Westernized” societies.

==> Left side (90%, mostly sigmoid) > Right side of colon (EXCEPT in Asia, where R>L).

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15
Q

Diverticular disease - Diverticulosis - Clinical manifestations:

A
  1. Usually asx, but 5-15% develop diverticular hemorrhage and <5% diverticulitis.
  2. Nuts, etc. intake in asx diverticulosis does NOT incr. risk of diverticulitis (JAMA 2008).
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16
Q

Diverticulitis - Pathophysio (NEJM 2007):

A

Retention of undigested food and bacteria in diverticulum ==> Fecalith formation ==> Obstruction ==> Compromise of diverticulum’s blood supply, infection, perforation.

17
Q

Diverticulitis - Pathophysio (NEJM 2007) - Uncomplicates and complicated:

A

Uncomplicated ==> Microperforation ==> Localized infection.

Complicated (25%) ==> Macroperforation ==> Abscess, peritonitis, fistula (65% w/ bladder), obstruction, stricture.

18
Q

Diverticulitis - Clinical manifestations:

A

LLQ abd pain, fever, N/V, constipation.

19
Q

Diverticulitis - PEx:

A

Ranges from LLQ tenderness +/- palpable mass to peritoneal signs and septic shock.

20
Q

Diverticulitis - Ddx:

A
  1. IBD.
  2. Infectious colitis.
  3. PID.
  4. Tubal pregnancy.
  5. Cystitis.
  6. CRC.
21
Q

Diverticulitis - Diagnostic studies:

A
  1. Plain abd radiographs to r/o free air, ileus or obstruction.
  2. Abdominal CT (I+O+): >95% Se and Sp ==> Assess complicated disease (abscess, fistula).
  3. Colono contraindicated acutely ==> Incr. risk of perforation ==> Do 6wk after to r/o neoplasm.
22
Q

Diverticulitis - Tx (Am J Gastro 2008) - Mild:

A

OutPt Rx indicated if Pt has few comorbidities and can tolerate POs.

==> PO abx: (MNZ + FQ) or amox/clav for 7-10d.

==> Liquid diet until clinical improvement, though recent evidence suggest abx may be unnecessary (Br J Surg 2012).

23
Q

Diverticulitis - Tx (Am J Gastro 2008) - Severe:

A
  1. InPt Rx if cannot take POs.
  2. Narcotics needed for pain, or complications.
  3. NPO, IV fluids, NGT (if ileus).
  4. IV abx (GNR and anaerobic coverage): amp/gent/MNZ or pip/taz.
24
Q

Diverticulitis - Tx (Am J Gastro 2008) - Abscess:

A

> 4cm should be drained percutaneously or surgically.

25
Q

Diverticulitis - Tx (Am J Gastro 2008) - Surgery:

A

If progression despite med Rx, undrainable abscess, free perforation or possibly recurrent disease (>2severe episodes).

26
Q

Diverticulitis - Tx (Am J Gastro 2008) - Colonic stricture:

A

Late complication of diverticulitis.

==> Rx w/ endoscopic dilation vs. resection.

==> Colono after 6wk to exclude neoplasm.

27
Q

Diverticulitis - Prevention:

A
  1. LOW-fiber diet immediately after acute episode.
  2. HIGH fiber diet when >6wk w/o sx.

==> Consider mesalamine +/- rifaximin if multiple episodes.

28
Q

Diverticulitis - Risk fo recurrence:

A

10-30% w/in 10y of 1st episode.

==> More likely 2nd episode complicated.

29
Q

Diverticular hemorrhage - Pathophysio:

A

Intimal thickening and medial thinning of vasa recta as they course over dome of diverticulum ==> weaking of vascular wall ==> Arterial rupture.

30
Q

Diverticular hemorrhage - Diverticular hemorrhage:

A

Diverticula MORE COMMON in left colon.

==> But BLEEDING diverticula more often in RIGHT colon.

31
Q

Diverticular hemorrhage - Clinical manifestations:

A
  1. Painless hematochezia/ BRBPR; can have abdominal cramping.
  2. Usually stops spontaneously (-75%) but resolution may occur over hrs-days. 20% recur.
32
Q

Diverticular hemorrhage - Diagnostic studies:

A
  1. Colono ==> Rapid prep w/ PEG-based solution via NGT.

2. Arteriography +/- tagged RBC scan if severe bleeding.

33
Q

Diverticular hemorrhage - Tx:

A
  1. Colono: epinephrine inj +/- electrocautery (NEJM 2000), hemoclip, banding.
  2. Arteriography: Intra-arterial vasopressin infusion or embolization.
  3. Surgery: If above modalities fail and bleeding is persistent and hemodynamically significant.
34
Q

IBD - Definition:

A

UC ==> Idiopathic inflammation of the colonic MUCOSA.

CD ==> Idiopathic TRANSMURAL inflammation of the GI tract, skip areas.

Indeterminate colitis ==> In 5-10% of chronic colitis, cannot distinguish UC vs CD even w/ bx.

35
Q

IBD - Epidemiology and pathophysiology (NEJM 2009, Gastro 2011):

A
  1. 1.4million people in US.
  2. Prev 1/1000 UC and 1/3000 CD.
  3. Incr. incidence in Caucasians, Jews.
  4. Age of onset 15-30y in UC and CD; CD is BIMODAL and has a 2nd peak at 50-70y.
  5. Smokers incr. risk for CD, whereas nonsmokers + former smokers at incr. risk for UC.

Genetic predisposition + disruption of intestinal barrier (epithelial or decr. defenses) +/- Δ in gut microbiota ==> Acute inflam w/o immune downregulation or tolerance ==> Chronic inflam.

36
Q

UC (NEJM 2011, Lancet 2012) - Clinical manifestations:

A
  1. Grossly bloody diarrhea, lower abd cramps, urgency, tenesmus.
  2. Severe colitis (15%).
  3. Extracolonic manifestations (>25%).
37
Q

UC (NEJM 2011, Lancet 2012) - Clinical manifestations - Severe colitis (15%):

A
  1. Progresses rapidly over 1-2wk with decr. Ht.
  2. Incr. ESR.
  3. Fever.
  4. Hypotension.
  5. > 6 bloody BMs per day.
  6. Distended abdomen with absent bowel sounds.
38
Q

UC (NEJM 2011, Lancet 2012) - Clinical manifestations - Extracolonic (>25%):

A
  1. Erythema nodosum.
  2. Pyoderma gangrenosum.
  3. Aphthous ulcers.
  4. Uveitis.
  5. Episcleritis.
  6. Thromboembolic events. (esp. during a flare; Lancet 2010).
  7. AIHA.
  8. Seroneg arthritis.
  9. Chronic hep.
  10. Cirrhosis.
  11. PSC (incr. risk for cholangio CA, CRC).

Internal Medicine (106 decks)

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