Paulson - Disorders of Lower GI Tract Flashcards
1
Q
constipation is defined as
A
< 3 stools/week
2
Q
constipation etiologies (8)
A
inadequate fiber/water
meds
neuro conditions
prolonged immobility
metabolic dz’s
functional fecal retention
anatomic abnormalities
functional abnormalities
3
Q
what meds are associated w. constipation
A
opioids
anticholinergic
CCBs
antacids
iron
4
Q
what neuro conditions are associated w. constipation (4)
A
MS
Parkinsons
dementia
stroke
5
Q
what metabolic dz’s are associated w. constipation (5)
A
DM
hypothyroidism
uremia
hypercalcemia
hypokalemia
6
Q
what is functional fecal retention
A
chronic stool withholding
think kids
7
Q
tx for constipation (4)
A
fiber
hyperosmolar agents → sorbitol, lactose
stimulant → glycerin suppository, dulcolax
enema → mineral or tap water
8
Q
when should you use an opioid antagonist for constipation
A
only in terminally ill pt
9
Q
what are 2 examples of opioid antagonists
A
relistor
naloxegol
10
Q
what is a complication of chronic constipation
A
fecal impaction
11
Q
fecal impaction is mc in
A
kids
elderly
12
Q
fecal impaction is mc found in
A
rectum
distal sigmoid colon
13
Q
what are 5 sx of fecal impaction
A
abd pain
bloating
overflow fecal incontinence
paradoxical diarrhea
increased urinary frequency
14
Q
what might you see on pe for fecal impaction
A
impacted feces on DRE
15
Q
what imaging is used for fecal impaction
A
xray or CT→ location of impaction and any associated obstruction
16
Q
tx for fecal impaction (4)
A
manual disimpaction
enema
osmotic laxatives
address underlying cause
17
Q
serious complication of fecal impaction
A
large bowel obstruction w. colonic perforation → high mortality
18
Q
celiac disease is same same
A
gluten insensitivity
nontropical sprue
19
Q
sx of celiac dz
A
diarrhea w bulky foul smelling bm
floating stools
steatorrhea
flatulence
wt loss
weakness
abd distension
FTT w/ infants/kids
IDA
osteopenia/porosis
20
Q
what conditions are associated w. celiac
A
dermatitis herpetiformis
DM1
Down’s syndrome
liver dz
menstrual/reproductive issues
21
Q
common presenting sign for celiac
A
dermatitis herpetiformis → grouped pruritic papules/vesicles
22
Q
rf for celiac (5)
A
1st/2nd degree relative w. confirmed CD
T1DM
AI thyroiditis
down syndrome
turner syndrome
23
Q
preferred serologic test for celiac
A
TTGIGA abs test
24
Q
2nd line dx test for celiac
A
EMA-IgA
25
test to confirm celiac
small bowel bx x 4
26
what do you think when you see: atrophic appearing mucosa w. loss of folds, visible fissures, nodularity, scalloping, prominent submucosal vascularity
small bowel bx findings for celiac
27
dx testing for pt w. high probability of CD (classic presentation + rf)
blood test
PLUS
bx
28
dx testing for pt w. low probability of CD (not classic presentation, no rf)
serologic testing
29
does negative serology r.o celiac
no!
30
tx for celiac
gluten free diet
RD referral
replete nutritional deficiencies
DXA
pneumococcal vaccination
screen family members
31
education regarding dermatitis for celiac pt
improvement of rash more delayed than intestinal manifestations
32
mc cause of anal fissures
local trauma
33
other causes of anal fissures
constipation
anal sex
diarrhea
vaginal delivery
34
causes of secondary anal fissures (3)
IBD
malignancy
STI
35
mc location for anal fissures
2nd mc location for anal fissures
posterior midline
anterior midline
36
acute anal fissures will appear
fresh
superficial
like a papercut
37
chronic anal fissures will appear
raised edges
fibrotic appearance
often w. skin tag (sentinel pile)
38
sx of anal fissures
anal pain → intensifies w. bm
ripping/tearing feeling → can last for hours
+/- anal bleeding
39
dx for anal fissures (2)
direct visualization
reproduce pain w. digital palpation of posterior anal verge
40
tx for anal fissures
fiber + water
+/- stool softeners
sitz bath
topical analgesics
topical vasodilators
41
2 ex of topical vasodilators
nifedepine gel
topical nitroglycerin
42
IBD includes
crohn's
uc
43
rf for IBD (4)
15-40 yo
jewish
1st degree relative w. hx
western diet
44
highest risk for IBD
western diet
45
smoking is protective for \_\_
and rf for \_\_
UC
crohn's
46
UC always starts __ at the rectum
and progresses \_\_
in a __ manner
distally
proximally
continuous circumferential
47
UC is characterized by no __ progression
skips
48
UC is characterized by inflammation in the mucosa of the
colon
49
onset of UC is
gradual/progressive
50
PE for UC is usually \_\_,
but might include (6)
ttp
fever
hypotn
tachycardia
pallor
blood on rectal exam
51
2 common sx of UC
bloody diarrhea
frequent BMs that are smaller in volume
52
if UC is mainly distal, symptoms may include (4)
constipation + frequent blood/mucus d.c
incontinence
colicky abd pain
systemic systems
53
systemic sx in UC include (3)
fever
weight loss
fatigue
54
extraintestinal sx affect what systems
joints
eyes
skin
bv
gallbladder
55
what joint sx are associated w. UC (2)
nondestructive peripheral arthritis of large joints
ankylosing spondylitis
56
what eye sx are associated w. UC
episcleritis
uveitis
57
what is this condition
episcleritis
58
what is this condition
uveitis
59
what skin sx are associated w. UC
erythema nodosum
pyoderma gangrenosum
60
what is this condition
pyoderma nodosum
61
what is this condition
erythema nodosum
62
what bv conditions are associated w. UC (3)
VTE
arterial thromboembolism
AI hemolytic anemia
63
what other GI condition has a strong association w. UC
primary sclerosing cholangitis
64
labs abnormalities associated w. UC (4)
anemia
elevated ESR/CRP
electrolyte abnormalities
fecal calprotectin
65
elevated fecal calprotectin is a marker of
active inflammation in the GI tract
66
is imaging required for dx of UC
no!
67
what imaging might you use in UC (4)
xray
double contrast barium enema
CT/MRI
bx
68
xray findings associated w. UC (3)
proximal constipation
mucosal thickening or "thumbprinting"
colonic dilation → if severe
69
what do you think of when you see, microulcerations, collar button ulcers, loss of haustra, pseudopolyps
UC findings on barium enema
70
what are pseudopolyps
mass of scar tissue from granulation
71
you should avoid barium enemas in \_\_
bc it can cause \_\_
severely ill
megacolon
72
what type of imaging is this and what is it showing
barium enema
loss of haustra → smooth featureless colon
**UC**
73
what are haustra
folds in sigmoid colon
74
what imaging is this and what is it showing
barium enema
microulcerations (white spots)
**UC**
75
what type of imaging is this and what is it showing
barium enema
pseudopolyps w. stricture
**UC**
76
what type of imaging is lower sensitivity for UC and is not used for dx
CT/MRI
77
what do you think when you see, loss of vascular markings from swelling of mucosa; petechiae; exudates, edema; erosions that are **friable to touch**; and spontaneous bleeding
endoscopic findings of UC
78
what imaging is this and what is it showing
endoscopy
petechiae
bleeding
**UC**
79
what is this endoscopy showing
pseudopolyps
## Footnote
**UC**
80
what do you think of when you see, crypt abscesses; shortenings and disarray; crypt atrophy; epithelial cell abnormalities; mucin depletion; paneth cell metaplasia; inflammatory features
bx findings of UC
81
4 dx factors for UC
1. chronic diarrhea x at least 4 weeks
2. e.o active inflammation on endoscopy
3. chronic changes on bx
4. exclusion of other causes
82
what do you think when you see, lamina propria cellularity, basal plasmacytosis, basal lymphoid aggregates, lamina propria eosinophios
inflammatory findings of bx for UC
83
in UC progression, there are no __ areas of mucosa
normal
84
mild UC parameters (3)
4 or less stool/day *without blood*
normal ESR
no systemic sx → severe abd pain, fever, wt loss, profuse bleeding
85
moderate UC parameters (5)
more than 4 bloody stools/day
mild anemia → *does not require transfusion*
moderate abd pain
minimal signs of systemic toxicity
no wt loss
86
severe UC parameters (4)
6 or more frequent, loos bloody stools/day
severe abd pain
systemic sx
+/- rapid wt loss
87
4 systemic sx considerations in US severity grading
fever
tachycardia
anemia
elevated ESR
88
first step in tx of UC
classify severity of dz
89
what is the most distal manifestation of UC
ulcerative proctitis or proctosigmoiditis
90
first line tx for ulcerative proctitis or proctosigmoiditis
topical 5-aminosalyclic acid (5-ASA)
91
5-ASA offers \_\_
and __ for UC
symptomatic relief
AND
decreased bleeding
92
5-ASA acts quickly and can cause complete healing in
4-6 weeks
93
if a pt has complete healing of UC following 5-ASA tx, how should you d.c med
continue 8 weeks longer → then taper
94
how should you administer 5-ASA for UC
suppository and/or enema
95
which suppository is used if UC is confined distally, and how is it administered
Mesalamine
suppository
96
how should mesalamine be administered if UC extends past the distal part of rectum
enema
PLUS
suppository
97
mesalamine is what class of drug
5-ASA
98
mesalamine should offer symptomatic relief in
a few days
99
maintenance therapy for UC is NOT recommended for
1st episode of proctitis
100
for UC, maintenance therapy is recommended for
proctosigmoiditis
1 or more relapses per year
101
alternative meds for UC (besides mesalamine) (2)
topica steroids
oral 5-ASA
102
tx for left-side colitis, extensive colitis, pancolitis
combo therapy:
oral 5-ASA, steroid suppositories
PLUS
5-ASA or steroid enemas
103
all pt w. left-sided colitis, extensive colitis, and pancolitis should receive
maintenance therapy
104
tx for refractory UC
refer for further oral immunosuppressants
105
2 complications of chronic UC
strictures
colorectal ca
106
strictures are mc in __ UC
and are __ until proven otherwise
via \_\_
rectosigmoid colon
malignant
bx
107
what GI d.o involves transmural inflammation of GI tract anywhere from mouth to perianal area
Crohn's Dz
108
2 mc locations in Crohn's
ileum
right colon
109
\_\_ areas are classic in Crohn's
skip
110
peak incidence of Crohn's occurs btw __ yo
15-35
*younger than UC*
111
5 common sx of crohn's (7)
crampy abd pain
strictures
diarrhea
fistulas
malabsorption
abscess formation
aphtous ulcers
112
what do you think when you see strictures with repeated obstruction
Crohn's
113
diarrhea in crohn's __ over time
and __ is less common then in UC
fluctuates
bleeding
114
4 common fistula sites Crohn's
enterovesical
enterocutaneous
enteroenteric
enterovaginal
115
enterovesical is bleeding to the
bladder
116
2 mc extraintestinal manifestations of crohn's
fatigue
arthritis of large joints
wt loss
117
eye sx related to crohn's
uveitis
iritis
episcleritis
118
skin manifestations associated w. crohn's
erythema nodosum
pyoderma gangrenosum
119
what other bowel condition is associated w. crohn's
primary sclerosing cholangitis
120
bv manifestations of crohn's
VTE
arterial thromboembolism
121
renal manifestation of crohn's related to steatorrhea and diarrhea
nephrolithiasis
122
what vitamin deficiency is related to crohn's
B12
123
does crohn's affect the lungs
yes!
124
what is secondary amyloidosis and what GI condition is it associated w.
build up of abnormal proteins in tissues and organs
crohn's
125
pe for crohn's is often \_\_
and can include (5)
perianal skin tags
sinus tracts
abd tenderness
wt loss
pallor
126
what labs might be helpful in crohn's
CBC
CMP
ESR/CRP
serum iron
vit D/B12
fecal calprotectin
abs test
127
CRP is higher in \_\_
than in \_\_
CD
UC
128
what test can help differentiate crohn's from IBS
fecal calprotectin
129
what abs tests can help dx IBD and distinguish CD from UC
pANCA
ASCA
130
what is used to establish dx in crohn dz
colonoscopy
131
what do you think when you see, focal ulcerations adjacent to areas of normal appearing mucosa; and polypoid mucosal changes that give a cobblestone appearance
colonoscopy findings of crohn's
132
in crohn's dz, __ areas
and __ sparing is common
skip
rectal
133
what do you think when you see, cobblestone appearance
crohn's dz
134
what do you think when you see, crypt abscesses, crypt branching, crypt atrophy, and paneth cell metaplasia
UC
135
what do you think when you see, thumbprinting
UC
136
besides colonoscopy, what is another way to visualize small bowel that does not involve radiation exposure
wireless capsule endoscopy
137
in what pt population should you avoid wireless capsule endoscopy
pt's with suspected stricture
138
what imaging is helpful in crohn's dz (3)
**xray →** upper GI series w.small bowel follow through
CT
MRI
139
what do you think when you see, narrowing of lumen w. nodularity and ulceration, string sign, cobblestone appearance, fistulas/abscess formation, bowel wall thickening, and stricturing
crohn's dz
140
what is this showing
nodular filling defects
xray finding of crohn's
141
what is this showing
cobblestoning
xray findings of crohn's
142
what is this showing
string sign
xray finding of crohn's
143
best imaging for crohn if abscess is suspected
CT
144
what do you think when you see, mural thickening, high mural signal intensity (edema), and layered pattern of enhancement
MRI findings of acute small bowel inflammation
crohn's dz
145
what are the 2 dz activity and rating scales for crohn's
crohn's disease activity index (CDAI)
harvey-bradshaw index (HBI)
146
what factors are included in the CDAI (7)
stool patterns
abd pain rating
general wellbeing
complications
abd mass
anemia
wt change
147
what factors are included in the HBI
general well being
abd pain
of liquid stools
abd mass
complications
148
according to the CDAI, clinical remission parameters
asymptomatic
no sequelae
achieved spontaneously or after medical or surgical intervention
149
according to CDAI, mild crohn's parameters (5)
ambulatory
tolerating oral diet
\<10% wt loss
no systemic sx
no s/s of obstruction
150
according to CDAI, mod-severe Crohn's parameters
have failed tx for mild-mod dz
have prominent sx: fever, wt loss, abd pain/tenderness, intermittent n/v, anemia
151
according to CDAI, severe-fulminant crohn's
persistent s/s despite steroids or biologic agents
high fever, persistent vomiting
intestinal obstruction, peritoneal signs
cachexia
e.o abscess
152
what are the 2 tx approaches to crohn's
step up therapy
top down therapy
153
step up therapy is used for
mild crohn's
154
top down therapy is used for
severe crohn's
155
in step up therapy, meds are __ potent,
but have fewer \_\_
less
side effects
156
in top-down therapy, the goal is to use more potent therapies early on before the patient becomes
glucocorticoid dependent
157
the goal for crohn's tx is to achieve remission, which includes __ (3)
evidence of of complete mucosal healing
endoscopic
histologic
clinical
158
tx for mild-mod crohn's w. ileum or proximal colon involvement
**budesonide x 4-8 weeks** → for induction → then taper for 8-12 weeks
can continue at lower dose **for no more than 3-6 mo**
*prednisone is alternative*
159
tx for mild-mod crohn's w. diffuse colitis or left colonic involvement
oral prednisone x 1 week → then taper
then clinically observe
*sulfasalazine is alternative*
160
tx for oral lesions in crohn's
topical meds → **triamcinolone acetonide**
161
what class of drug is budesonide (enterocort)
corticosteroid
162
s.e of budesonide
HA
acne
adrenal suppression
osteoporosis
immunosuppression
psychiatric disturbance
exacerbation of CV
hyperglycemia
163
\_\_ should be used to clinically observe pt's w. crohn's after induction therapy has been d.c
ileocolonoscopy q 6-12 mo
164
how do you tx relapse of mod-sev crohn's
2nd course of glucocorticoid
165
tx for severe crohn's
refer!
biologic + immunomodulatory for induction
+/- addition of glucocorticoid for acute relief
maintenance therapy w. biologic agent
166
what immunomodulatory drugs are used for severe crohn's
azathioprine
6-mercaptopurine
methotrexate
167
surgical indications for crohn's
perforation
abscess
fistula
hemorrhage
stricture
neoplasm
persistent sx despite medical management
168
2nd mc cause of cancer deaths in US (after lung ca)
colorectal ca
169
colorectal ca is often \_\_
and is dx \_\_
asymptomatic
incidentally w. routine colonoscopy
170
colorectal ca can be asymptomatic or present w.
acute event → obstruction, peritonitis, non acute GI bleed
171
mc non acute event sx associated w. colorectal ca
change in bowel habits
*also unexplained IDA, rectal mass, abd mass, abd pain*
172
procedure that is diagnostic and therapeutic for colorectal ca
colonoscopy
173
what do you think when you see, endoluminal masses; friable, nectrotic, ulcerated lesions; +/- bleeding
colonoscopy findings of colorectal ca
174
what is this showing
apple core → circumferential involvement of colorectal ca
175
alternative to colonoscopy for colorectal ca
CT colonography (aka virtual colonoscopy/CT cologaphy)
176
\_\_ is still required for CT colonography;
if results are abnormal, __ is required
bowel prep
real colonoscopy
177
CT colonography is not
therapeutic
178
tumor marker associated w. colorectal ca
CEA
179
CEA has __ diagnostic ability,
and is used for __ in colorectal ca
low
f/u
180
CEA is \_\_,
but level \> \_\_
os associated w. worse prognosis for colorectal ca
nonspecific
5
181
if CEA is still elevated post surgery, consider
refractory/recurrent colorectal ca
182
rf for colorectal ca that are NOT associated w. early screening recommendations
obesity
DM
red and processed red meat/high cooking temps
smoking
etoh
183
emergency admission for colorectal ca (3)
intestinal obstruction
peritonitis
acute GI bleed
184
tx for colorectal ca if carcinoma in a polyp (contained) → clear margins
endoscopic removal alone
185
tx for larger colorectal tumors
surgical resection → adjuvant chemo
186
xrt for colorectal ca is mc used for \_\_
and is not routinely used for \_\_
rectal ca
resected colon ca
187
rf associated w. increased risk/early screening (5)
personal OR fam hx CRC or adenomatous polyp
personal or fam hx of genetic syndromes that cause CRC
IBD
prior hx abd xrt for childhood malignancy
cystic fibrosis
188
what genetic syndromes are associated w. increased risk for CRC (5)
familial adenomatous polyposis
lynch syndrome
juvenile polyposis syndrome
peutz-jeaghers syndrome
MUYTH-associated dz
189
what 2 factors MAY influence screening guidelines for CRC (4)
HIV (+) men
AA
acromegaly
renal transplant + long-term immunosuppression
190
age to initiate screening in average risk pt
50 yo
+/- 45 yo for AA
191
when to d.c screening for average risk
screen through 75 yo if expected to live at least 10 more years
192
screening tests for CRC
colonoscopy
FIT (fecal immunochemical testing)
CT colonography
sigmoidoscopy + FIT
sigmoidoscopy alone
guaiac-based FOBT
stool DNA
193
choice of screening in pt's w. FH CRC or advanced polyp
**colonoscopy every 10 years**
FIT annually if pt refuses colonoscopy
194
when to start screening if pt has fam hx CRC
40 yo or 10 years before youngest FDRs dx
195
high risk syndrome pt's start screening for CRC (lynch, FAP, peutz-jeghers)
8-20 yo
196
swollen veins on rectum/anus can can lead to prolapse/bleeding
hemorrhoids
197
rf for hemorrhoids
anything that puts strain on abd area:
age
chronic constipation
pregnancy
pelvic tumors
diarrhea
anal sex
prolonged sitting
anticoags
198
3 classifications of hemorrhoids
external
internal
mixed
199
what landmark differentiates hemorrhoid classification
dentate line
200
pe findings of hemorrhoid
acute perianal pain w. palpable lump
protuberant purple nodules covered by mucosa
201
which type of hemorrhoid is painful
external
202
\_\_% of hemorrhoids are asymptomatic
40
203
sx associated w. hemorrhoids (6)
painless hemorrhoidal bleeding associated w. BM
bright red blood that coats stool
**pruritis/irritation of perineal**
mild fecal incontinence
mucus d.c
wet sensation
204
dx of hemorrhoids (2)
classic symptoms
PLUS
visualization
205
how do you visualize internal hemorrhoids
anoscopy
206
grade 1 hemorrhoid
no prolapse
207
grade 2 hemorrhoid
prolapse w. defecation → spontaneously reduces
208
grade 3 hemorrhoid
prolapse w. defecation or other times → needs manual reduction
209
grade 4 hemorrhoid
permanently prolapses → irreducible
visible externally
+/- strangulation
210
tx for hemorrhoids (5)
increase fiber/water
topical steroids → hydrocortisone or suppository
topical analgesics → lidocaine gel
sitz bath
nitroglycerin ointment
211
what drug reduces inflammation/edema for hemorrhoids
warm sitz bath
212
what med reduces sphincter spasm for hemorrhoids
antispasmotic → nitroglycerin
213
when to refer for hemorrhoids (3)
symptomatic low grade fever I or II that are refractory
symptomatic high grade III or IV
thrombosed hemorrhoids
214
office based procedures for hemorrhoids (3)
rubber band ligation
sclerotherapy
infrared coagulation
215
rubber band ligation should only be used for
internal hemorrhoids!
216
what in office therapy is good for pt at increased bleeding risk
sclerotherapy
217
surgery indications for external hemorrhoidectomy
large
refractory
mixed internal/external
218
surgery indications for internal hemorrhoidectomy
prolapsed
incarcerated
refractory
mixed internal/external
219
diverticulosis includes (5)
diverticular dz
diverticulitis
diverticular colitis
symptomatic
uncomplicated diverticular dz
220
sac-like protrusion of colonic wall at points of weakness
diverticulosis
221
rf for diverticulosis
increasing age
low fiber/high fat/red meat
lack of PA
BMI \>25
NSAIDs/steroids/opiates
222
clinically significant and symptomatic diverticulosis
diverticular dz
223
mc cause of brisk/painless hematochezia
diverticular dz
224
inflammation of diverticulum
diverticulitis
*4-15% of pt's*
225
inflammation of interdiverticular mucosa w.o involvement of diverticular orifices
diverticular colitis
226
persistent abd pain of interdiverticular mucosa w.o involvement of diverticular orifices
symptomatic uncomplicated divertiular dz aka smoldering diverticulitis
227
functional dz of GIT w. chronic pain, altered bowel habits
IBS
228
3 conditions associated w. IBS
fibromyalgia
chronic fatigue syndrome
dpn
anxiety
229
bowel symptoms of ibs are
highly variable → constipation, diarrhea, both etc
230
w. ibs, __ worsens pain
and __ improves pain
stress
bm
231
rome criteria
recurrent abd pain at least 1 week x 3 months
PLUS 2 of the following:
related to defecation
associated w. change in stool frequency
associated w. change in stool appearance
232
indications for GI referral for IBS
more than minimal rectal bleeding
wt loss
unexplained IDA
nocturnal sx
FH of CRC, celiac, IBD
233
tx for IBS
ex + reassurance
FODMAP
if constipation: more fiber, Miralax, Lubriprostone
diarrhea predominant: immodium, cholestramine
antispasmotics for postprandial pain: dicyclomine (Bentyl)
234
lubiprostone is a
promotility med
235
cholestramine is a
antidiarrheal
236
dicyclomine (Bentyl) is a
antispasmotic
