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Clin Med III - GI > Polyps, Esophagitis, Surgical Abdomen > Flashcards

Polyps, Esophagitis, Surgical Abdomen Flashcards

1
Q

define polyp classifications

non-neo

neo

A
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2
Q

Smooth surface “cloud-like” appearance polyp

tx?

A

sessile serrated

Complete excision is recommended - due to their sessile nature and indistinct borders, special care is needed to ensure their complete removal endoscopically.

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3
Q

adenomas ≥10 mm in size or with villous components or high-grade dysplasia.

A

Advanced Adenomatous Polyps

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4
Q

Most common non-neoplastic polyp

•Normal cellular components but may be indistinguishable from adenomatous polyps

A

Hyperplastic Polyps

Look similar to tubular adenomas

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5
Q

Irregularly shaped islands of intact mucosa that forms as a result of mucosal ulceration and regeneration

•Seen in UC and Crohn’s Disease

A

Inflammatory Pseudopolyps

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6
Q

define high greade vs low grade dyplasia

A

Low-grade dysplasia – some cells are abnormal, but unlikely to spread

High-grade dysplasia- represents a step in the progression from a low-grade dysplasia to cancer - unlikely to metastasize

•applied to lesions that are confined to the epithelial layer and lack invasion into the lamina propria.

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7
Q

Recommend that CRC screening begin at

A
  • age 45 in African Americans, and that colonoscopy is the preferred test - More likely to develop right sided CRC
  • Age 50 for other races
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8
Q

CRC screening recc in

lynch syndrome

FAP

A

lynch

  • Age 20-25 or 10 years younger then youngest affected relative
  • Colonoscopy 1-2 years
  • Then yearly at age 40
  • Genetic testing recommended

FAP

  • Age 10-12 sigmoidoscopy yearly
  • Colonoscopy yearly after polyp discovered genetic testing and counseling
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9
Q

CRC screening reccomendations

hx of CRC

hx of adenoma

IBD

A

Personal Hx of CRC

  • Total colon exam w/in 1 yr, repeat at 3 yrs
  • Repeat 5 yrs if normal

Personal Hx of Adenoma- Repeat colonoscopy every 3-5 yrs

IBD

  • Begin 8 yrs after diagnosis
  • Colonoscopy every 1-2 yrs
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10
Q

differnetiate b/w cancer prevention vs cancer detection tests

A
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11
Q

Fecal Occult Blood Test(Stool Guaiac)

A

Testing stool for the presence of blood – 3 separate stools

Lowest specificity / sensitivity

•Detects ANY blood – could be from nose bleed etc

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12
Q

Fecal Immunochemical test (FIT)

A

More sensitive for colonic blood loss -Higher CRC detection rates compared to FOBT

Detection of advanced adenomas is VERY low

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13
Q

Fecal DNA (FIT-DNA

A

Looks for evidence of mutations associated molecular changes leading to malignancies – KRAS mutations, methylation biomarkers associated with neoplasia, and hemoglobin

•Full stool sample in a special collection kit

Higher specificity for CRC –Still LOW detection od adenomas

Convenient, no sedation

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14
Q

The definitive test for detection of precancerous adenomas and CRC

A

colonoscopy

Avg risk – 10 yrs

May be shorter for higher risk (3-5 yrs)

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15
Q

Patients who cannot take colonoscopy or who are sick –

why BAD for AAs or younger population ??

A

Sigmoidoscopy

•BAD for AAs or younger population as they are most likely affected by Right sided colon cancer

41-45% of CRC are on the right side and will be missed

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16
Q

Most colorectal cancers, regardless of etiology, arise from ____ polyps polyps

A

adenomatous

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17
Q

Currently Influence CRC Screening

A
  • Personal or Family History of CRC or polyps
  • Age
  • Hereditary CRC Syndromes
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18
Q

Carcionembryonic antigen (CEA) level

A

but used to monitor progression pre-post surgery, of CRC

• indicator of Recurrence. Expect to normalize after surgery

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19
Q

si/sx of CRC

A

Change in bowel habits – 74%

Rectal bleeding/bloody stool/black stool – 51%

Anemia

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20
Q

tx of CRC

A

Surgery – Resection of primary colonic or rectal cancer is the treatment of choice in all stages (I+II ONLY surgery)

  • Poorly differentiated histology
  • Lymphovascular invasion
  • T2 lesion, cancer at stalk margin

Chemotherapy –Stages III&IV Colon cancer

Radiation + Chemotherapy – Rectal Cancer stages II-IV

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21
Q

differntiate b/w iron deficency pattern vs anemia of chronic dz

A

iron deficency

Transferrin/TIBC – Increased

  • Transferrin Sat% - low
  • Ferritin* - low

anemia of chronic dz

•Transferrin/TIBC – low

  • Transferrin Sat% - normal or low-normal
  • Ferritin* – normal or elevated
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22
Q

chemo for CRC is reccomended at what stage

A

III

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23
Q

Indications to Consider Hereditary Intestinal Polyposis Syndrome

A
  1. Patient with family history of CRC affecting more than one family member.
  2. Personal or family history of colorectal cancer developing early age <50 years
  3. Personal or Family History of multiple polyps >20 cumulative!)
  4. Personal or family history of multiple extracolonic malignancies.
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24
Q

Intestinal Polyposis Syndromes

A

Lynch Syndrome / HNPCC

Familial Adenomatous Polyposis (FAP)

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25
Q

Lynch Syndrome / HNPCC si/sx

A

Poorly differentiated tumors in the right colon

Presenting at young age **

History of rectal bleeding, bowel obstruction, perforation

Family history

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26
Q

Extra-colonic malignancies: Lynch Syndrome / HNPCC

A

Endometrial , uterine, ovarian, stomach, small bowel, hepatobiliary, urinary tract, brain and skin cancers

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27
Q

Familial Adenomatous Polyposis (FAP) Extracolonic Manifestations

A

Gardner Syndrome – FAP patient with extracolonic manifestations

•Desmoid tumors – most common

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28
Q

define FAP

A

characterized by the presence of multiple colorectal adenomatous polyps (typically more than 100)

•First polyp age 16

Germline mutation in the APC gene located on chromosome 5q21-q22

•AD

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29
Q

dx FAP

A

Diagnosis should be suspected in anyone with >10 cumulative colorectal adenomas

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30
Q

tx

Lynch Syndrome / HNPCC

Familial Adenomatous Polyposis (FAP)

A

Lynch Syndrome / HNPCC - colectomy

Familial Adenomatous Polyposis (FAP)

Prophylactic Colectomy

  • Remaining rectum or ileal pouch will need to be screen q6mo-2 yos
  • Age 20-25 EGD q1-3 years

Chemoprophylaxis NSAID and COX2

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31
Q

screening guidelines in

lynch

FAP

A

lynch - Yearly colonoscopy 1-2 years starting age 20-25 years of age

FAP -

Age 10-12 yearly flexible sigmoidoscopy

Yearly colonoscopy once polyps detected

CRC in 100% of pts by 39

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32
Q

small bowel cancer etiologies

A

Adenocarcinomas -

Lynch syndrome, FAP

CF

Crohn’s or UC

Neuro -endocrine Tumors (Carcinoid Tumors) -Assoc w/ multiple endocrine neoplasia type-1

Lymphoma -

Crohn’s disease

Celiac disease

Chronic immunodeficiency

Leiomyosarcoma- Assoc w/ Meckel’s Diverticulum

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33
Q

noninvasive imaging modality of choice** for small bowel Cancer

A

CT scan – IV/PO contrast

Angiography if active bleeding

Surgical exploration – most sensitive diagnostic modality

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34
Q

anal cancer is most commonly assoc w/

etiologies?

A

HPV, anal warts

Small Cell Carcinoma (SCC)- Most common*

Adenocarcinoma

Melanoma

Sarcoma

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35
Q

tx of anal cancer

A

Systemic chemo and radiation

•Cisplatin +mitomycin C

Biopsy-proven disappearance in >80% of patients

•lesions <3 cm

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36
Q

Post Treatment Surveillance: anal cancer

A

Every 3-6 months for five years:

  • Digital Rectal Examination (DRE)
  • Anoscopy
  • Inguinal node palpation
  • +/-CT chest/abdomen/pelvis annually for three years
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37
Q

staging anal cancer

O-II

III

IV

A

Stage O-II : Node negative

Stage III: Node positive

Stage IV: Metastatic disease

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38
Q

name 2 types of SCC anal cancers

A
  • Non Keratinizing SCC – above the Dentate line
  • Keratinizing SCC –distal to Dentate line
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39
Q

define surgical adbomen

A

•an acute intra-abdominal condition of abrupt onset, usually associated with pain due to inflammation, perforation, obstruction, infarction or rupture of abdominal organs, and usually requiring emergency intervention

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40
Q

Periumbilical pain -> right iliac fossa pain

Colicky -> dull, constant

dx?

A

apendicitis

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41
Q

si/sx of apendicitis in

elderly

children

preganant

A

Elderly: >65

  • Diminished inflammatory response → < findings H&P
  • Increased rate of perforation at presentation

Children:

  • Clinical exam before imaging
  • Classic presentation with > WBC, CRP → Surgical Consult before imaging
  • Atypical or equivocal presentation → Ultrasound 1ST
  • Possible need for contrast CT or MRI

Pregnant:

  • Many present ‘non-classically’→ heartburn, bowel irregularity, diarrhea, malaise
  • Elevated WBC’s can be normal in pregnancy
  • US is imaging of choice → non-compressible, > 6mm diameter
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42
Q

US findings in apendicitis

A

appendiceal diameter of >6 mm)

  • Non-compressible tubular structure in RLQ
  • Wall thickness >2 mm
  • Overall diameter >6 mm
  • Free fluid in the right lower quadrant
  • Thickening of the mesentery
  • Localized tenderness with graded compression
  • Presence of a calcified ‘appendicolith’
43
Q

Exceptions NO Appe

A

: Stable patients with perforated appendicitis who have symptoms localized to the RLQ

  • Treated initially with antibiotics, intravenous fluids, and bowel rest, rather than immediate surgery
  • These patients will often have a palpable mass; (CT) scan may reveal or abscess
44
Q

pre-op abx in apendicitis

A

Peri-op IV Abx – broad spectrum to cover aerobic and anaerobic bacteria

•3 rd generation Cephalosporin or Gentamycin + Metronidazole (Flagyl)

45
Q

tx of prolonges ileus

A

NGT

  • improves patient comfort
  • Minimizes/prevents recurrent vomiting
  • Serves as a means to monitor the progress or resolution of these conditions
46
Q

most common causs of SB obstruction

A

•Post-operative adhesions - most common 70%

47
Q

si/sx of SB obstruction

A

Dehydration *** (hallmark) - Tachycardia, orthostasis, decreased urine out

+/- Fever

High-pitched ‘tinkling’ sounds on auscultation (acute), tympanic on

48
Q

imaging of choice for SB oobstruction

A

abdominal CT - •Finding the transition point between dilated and non-dilated bowel can identify site and cause of obstruction

plain XRay - “string of pearls’

49
Q

Blood gas, lactate in SB obstruction

A

(marker for mesenteric ischemia), and blood cultures

50
Q

tx of SB obstruction

A

NPO - bowel rest

IVF – fluid resuscitation is integral to treatment

Bladder catheter – measure urine output

NGT – if emesis - Decreases nausea, vomiting, distention, aspiration

•Sx improver!!

51
Q

SB Obstruction 80% of cases w/ _____ intestinal obstruction

A

mechanical

52
Q

ileus vs SB obstruction

bowel sounds

pain

fever, tachy

A

bowel sounds

ileus - quiet

SB - high-pitched

pain

ileus - mild and diffuse

SB - moderate - severe, colicky

fever, tachy

ileus - absent

SB - should raise suspicion

53
Q

ischemia of the small bowel, usually secondary to an acute cause involving the SMA or SMV

A

Mesenteric Ischemia

54
Q

etiology of Mesenteric Ischemia

A

SMA Occlusion (~70% of cases)

  • Embolism: MI, Afib, Endocarditis, Valve disease
  • Thrombosis: Atherosclerosis – plaque rupture

Non-occlusive Mesenteric Ischemia (NOMI)

  • Hypoperfusion + vasoconstriction (Transient/partial)
  • ‘Watershed’ areas of colon with limited collateral circulation

Mesenteric Venous Thrombosis (MVT)

  • ***younger patients w/o CV disease
  • Primary clotting disorder
55
Q

si/sx of mesenteric ischemia

A

Rapid onset

Severe, unrelenting periumbilical pain

Pain out of proportion to clinical exam ****

56
Q

Mesenteric Ischemia test of choice

A

Mesenteric Angiography

57
Q

Plain X-ray non-specific (normal in 25%)

Distended loops of bowel, ‘Thumbprinting”

A

Mesenteric Ischemia

58
Q

ischemic bowel dz includes

A

Mesenteric Ischemia

Ischemic Colitis

59
Q

tx of ischemic bowel dz

A

Mild: supportive care , bowel rest, IV fluids, observation, ? NGT

Moderate: Empiric ABX-broad spectrum

Severe: Surgical exploration - Surgical Laparotomy with resection

60
Q

The presence of four or more risk factors: 100% predictive of colonic ischemia - ischemic colitis

A
  • > 60 years
  • Hemodialysis
  • Hypertension
  • Hypoalbuminemia
  • Diabetes mellitus
  • Constipation-inducing medications
61
Q

si/sx of ischemic colitis

A

Rapid onset of mild cramping and tenderness over affected bowel -> Associated with the urgent desire to defecate

62
Q

imaging for ischemic colitis

A

CT (oral/IV)

Colonoscopy -Confirmatory, Not in patients with peritonitis

(MRA) – individuals w/ compromised renal function

63
Q

ischemic bowel dz effects what areas of the colon

A
  • Effects are typically prominent at the “watershed” areas of the colon à Collateral blood flow is limited
  • Splenic flexure
  • Rectosigmoid junction
64
Q

Potentially lethal complication of inflammatory bowel disease (IBD) or infectious colitis

A

toxic megacolon

65
Q

define toxic megacolon

A

Characterized by total or segmental non-obstructive colonic dilatation + systemic toxicity

  • Marked dilatation of the colon
  • Thinning of the bowel wall
  • Deep ulcers
66
Q

imaging in toxic megacolon

A

X-Ray - Marked dilation

CT scan - Thinning of wall lining

67
Q

infectious causes of toxic megacolon

A

c. diff

Stool WBC and cultures including C. diff

68
Q

dx criteria for toxic megacolon

A

Radiographic evidence of colonic distension

With at least three of the following:

  • Fever >38ºC
  • Heart rate >120 beats/min
  • WBC >10,500/microL
  • Anemia

At least one of the following:

  • Dehydration
  • Altered sensorium
  • Electrolyte disturbances
  • Hypotension
69
Q

tx of toxic megacolon

A

Non operative therapy is the first line of treatment

  • Antibiotics broad spectrum for IBD (Vanco and Flagyl for C. Diff)
  • Intravenous corticosteroids (IBD)
  • Bowel decompression with a NGT if needed

Surgery reserved for patients who do not improve on non-op management

–> subtotal colectomy with end-ileostomy (up to 50% mortality)

70
Q

Peptic Ulcer Disease PUD RF

types

A

Risk Factors:

H. Pylori, NSAIDs, Etoh, Bile salts, etc

Gastric Ulcer -Pain shortly after or during eating

Duodenal Ulcer -Pain hours after eating

—Pain wakes pt @ night

71
Q

dx of PUD

A

H. Pylori testing - Urea breath test

Endoscopy – modality of choice*

72
Q

Helicobacter Pylori: triple therapy

A
  • Omeprazole, lansoprazole or Esomeprazole
  • AND Clarithromycin 500mg bid
  • AND Amoxicillin or Flagyl 10-14 days

Alternative (PPI, Bismuth, Tetracycline, Flagyl)

73
Q

Epigastric pain *- Gnawing/Burning s/p meals

Chest pain/Heartburn

Hematemesis

A

PUD

74
Q

Dysmotility Disorders etiology (4)

A

Achalasia - Relative obstruction and proximal dilation of esophagus w/ food bolus stasis d/t loss of ganglion cells from esophagus wall causing LES to fail to completely relax

•Botox

Diffuse Esophageal Spasm - Functional imbalance btwn excitatory and inhibitory pathway thus disrupted peristalsis and manometry w/ >20% simultaneous contraction

Nutcracker esophagus - Distal esophagus mmhg @ peristalsis >220mmhg

•

Hypertensive LES - Resting LES >45mmgh

Scleroderma esophagus - Smooth muscle atrophy and fibrosis

•Smooth muscle replaced by scar tissue thus lose peristalsis and LES tone

75
Q

Barium Esophagram* - Birdbeak or Corkscrew appearance

Manometry* -Esophageal motor pattern/intensity w/ LES mmhg & function

DX?

A

Dysmotility Disorders

76
Q

TX OF DYSMOTILIOTY DISORDERS

A

Nitrates & CCB – SMC relaxants

•Isosorbide dinitrate OR Nifedipine OR Diltiazem

TCA - Modify neuropathic pain pathway

•Imipramine OR Amitriptyline

Botox in LES- Esp achalasia and HTN LES

Endoscopy therapy - Dilation (pneumatic) 50-93% response rate LES pathology)

•No response s/p x2 dilations consider surgery

Surgery - Heller Myotomy

77
Q

name 2 types of esoph striuctures

A

Distal stricture - Peptic stricture, GERD. Adenocarcinoma

Proximal/Mid Stricture - Caustic ingestion, Malignancy, esophagitis

78
Q

si/sx of eso stricture

A

Dysphagia* - food impaction

79
Q

tx of eso stricture

A

Medication - PPI

Diet - GERD restrictions

  • Weight loss
  • Small meals & eat slowly and deliberately
  • Avoid meds that cause pill esophagitis

Esophageal dilation* - repeat at 1 yr , tx of choice!!

80
Q

dx eso strictures

A

Barium esophagram*Location, length, diameter of the stricture

Endoscopy*

CT - Stage malignancy

81
Q

White people w/ GERD THINK -

A

eso stricture

82
Q

si/sx of

Mallory Weiss Tears

Boerhaave syndrome

A

Mallory Weiss Tears - Hematemesis 85% - Vomit/wretch then hematemesis classic

Boerhaave syndrome -Repetitive wretching/vomiting then s_udden chest pain_

  • ?radiates to back/shoulder
  • no hematemesis
83
Q

dx

Mallory Weiss Tears -

Boerhaave syndrome -

A

Mallory Weiss Tears - EGD - Most have stopped bleeding and risk of rebleed low

Boerhaave syndrome - CT (imaging of choice +/- esophagram)

84
Q

tx of mallory weiss

A
  • PPI +/- Sucralfate 1-2 weeks
  • Anti-emetic
85
Q

tx of Boerhaave syndrome

A

IVF, antibiotics

Surgical consult w/ Thoracotomy w/ direct repair of rupture and mediastinal/pleural cavity drainage

86
Q

esophagitis etiology

A

reflux

infectious

medication induced

radiography

systemic dz

87
Q

Heartburn - Worst w/ large meal, tight clothes, supine or bending over

Dysphagia*

A

esophagitis

88
Q

dx of esopahagitis

A

EGD (esophagastroduodenoscopy)

89
Q

tx of reflux esophagitis

A

Pain- Narcotics , H2 blockade

•Liquid antacid therapy or magic mouthwash

PPI - Omeprazole, Lansoprazole Sucralfate - Esophageal coating agent

90
Q

2 types of gastritis

A

•Erosive (reactive gastritis d/t exposure & gravity usually @ greater curvature of stomach most often w/ NSAIDs - Superficial, deep, hemorrhagic

•Non-Erosive - _H. Pylor_i most common cause of gastritis

91
Q

si/sx of gastritis

A

Epigastric pain, burning, gnawing

Nausea/Vomiting +/- w/ eating

Melena/hematemesis/hematochezia/coffee ground emesis

92
Q

dx gastritis

A

. Pylori Tests (same as PUD)

EGD

•Appearance: Thick, edema, erosions, erythematous gastric folds

93
Q

tx gastritis

A

H. Pylori+ then tx w/ triple/quad therapy

D/C offending agents (NSAIDs, Etoh)

Antacid -Aluminum & magnesium hydroxide INC pH and neutralizes gastric acidity

Sucralfate/Carafate - Mucosal protectant

H2 blocker - Inhibits gastric acid secretion

PPI - Inhibit proton pump and INC pH

94
Q

common causes of GERD

A

LES transient relaxation*

  • Foods- Coffee, Etoh, chocolate, fatty meal, mint/peppermint
  • Medications -CCB, B-Blocker, Nitrates, Hormones, anti-cholinergics
  • Nicotine

Hiatal hernia

  • LES migrates into chest thus lose HPZ (high mmhg zone) à Length of HPZ may decrease
  • Gastric contents trapped in hernia sac and reflux during LES relaxation
95
Q

Heartburn* -Retrosternal sensation of burning esp s/p

•Eating, supine, bending over

Dysphagia*

Regurgitation*

A

GERD

96
Q

dx GERD

A

24 hour esophageal pH monitoring***

Gold standard for GERD dx as quantifies amt reflux w/ sxs

97
Q

tx of GERD

A

Minimize gastric acid secretion à

Antacid - S/P each meal and @ bedtime

H2 Blocker -Ranitidine, famotidine, cimetidine

•Before meal ie. 30 min

PPI* - Best for GERD

  • Omeprazole, esomeprazole, lansoprazole
  • Few side effects and good long term

Corrective anti-reflux surgery - Nissen Fundlopication

98
Q

complications of GERD

A

Stricture

Barrett Esophagus

99
Q

types of esophageal cancer

A

Small cell carcinoma (Eastern europe, Asia)

  • Upper half of esophagus
  • Smoking & Etoh

Adenocarcinoma (North America, Western europe)

  • Lower half esophagus
  • GERD/Barretts metaplasia
100
Q

definitive dx of esoph cancer

A

endoscopy and bx

101
Q

tx of esophageal cancer

A

Esophagectomy- Transthoracic OR Transhiatal

•Type of surgery does not influence survival but staging @ time surgery does

102
Q

strongest RF for gastric cancer

A

h. pylori

103
Q

gastri cancer labs and imaging

A

CEA : carcinoembryonic antigen INCREASED 45-50%

CA 19-9 INC 20%

EGD* - Definitive diagnosis w/ Bx

104
Q

tx gastric cancer

A

Surgery

  • Total gastrectomy
  • Esophagogastrectomy - Tumor @ GEJ and Cardia
  • Subtotal gastrectomy - Tumors of distal stomach

Neoadjuvant chemoradiotherapy

  • Preoperatively = std of care in US
  • First line = epirubicin/cisplatin/5-FU or docetaxel/cisplatin/5-FU

Clin Med III - GI (3 decks)

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