SI/Colon

Question 1

A young female presents with generalized LLQ pain that is worsened with food and relieved with defecation, what diagnosis are you thinking?

Answer 1

IBS

Question 2

How do you diagnose IBS?

Answer 2

Diagnosis of exclusion

Question 3

What kind of lab work are you doing to lead you to IBS?

Answer 3

CBC, ESR, stool for blood, thyroid, and colonoscopy

Question 4

What type of treatment can you offer your patient with IBS?

Answer 4

Avoid triggers, emotional support, dietary therapy, tricyclic antidepressants, and probiotics

Question 5

Your patient presents with severe cramping and abdominal pain, they state that they have not been able to pass gas or stool over the past 2 days, what diagnosis are you thinking?

Answer 5

Bowel obstruction

Question 6

How would you describe the decrease or absence of intestinal peristalsis? (like after surgery)

Answer 6

Paralytic ileus

Question 7

How would you describe twisting of the intestine?

Answer 7

Volvulus

Question 8

How would you describe telescoping of the intestine?

Answer 8

Intussusception

Question 9

What would you look for on PE with bowel obstruction?

Answer 9

Change in bowel sounds. Or sounds above & none below. Percussion - dense

Question 10

How would you diagnose a bowel obstruction?

Answer 10

Abdominal x-ray (start) – upright to see air fluid levels or dilated loops of bowel

Could do an abdominal CT

Question 11

How would you treat someone with a bowel obstruction?

Answer 11

Relieve the pressure (suction with nasal cannula), relieve obstruction, surgery is possible

Question 12

What are some consequences of missing a bowel obstruction?

Answer 12

Tissue death, perforation, sepsis, and death

Question 13

A patient presents with sudden severe abdominal pain they describe as a 10/10 with diarrhea, vomiting, and fever. What diagnosis are you thinking?

Answer 13

Mesenteric Ischemia

Question 14

What typically causes mesenteric ischemia?

Answer 14

Narrowing of the mesenteric arteries (chronic) or a sudden blockage of artery by embolus. It’s in the SMALL INTESTINE, resulting in decreased oxygenated blood flow.

Question 15

What is happening in Ischemic colitis?

Answer 15

Inflammation or injury to the LARGE INTESTINE that results in decreased blood flow.

Question 16

How would you diagnose mesenteric ischemia?

Answer 16

CT of abdomen with contrast is GOLD STANDARD; mesenteric angiogram followed by x-ray to determine the blockage. A duplex US of the mesenteric arteries may be helpful initially as well.

Question 17

Wait, how would you know the bowel isn’t perforated?

Answer 17

Think about higher fever & peritonitis (sxs)

Question 18

How do you treat mesenteric ischemia?

Answer 18

Surgical – stent/removal of emboli

Question 19

What happens if we fail to detect mesenteric ischemia?

Answer 19

Necrosis of bowel, perforation, sepsis, and death (quickly)

Question 20

What does diverticulum mean?

Answer 20

Sac-like protrusion in the colonic wall

Question 21

What does diverticulosis mean?

Answer 21

The condition of having diverticula

Question 22

What does diverticulitis mean?

Answer 22

Inflammation/infection of the diverticula.

Question 23

How does diverticula present?

Answer 23

Often asymptomatic but may have BRB in stool

Question 24

If a patient has a diverticula, what do we need to educate them about?

Answer 24

Avoid seeds, strawberries, popcorn (anything that can “catch”)

Question 25

What type of patient is at risk for diverticulitis?

Answer 25

Connective tissue disorders with out-pouchings, low fiber diet, and too little exercise

Question 26

If a patient has severe abdominal pain in the LLQ, with a fever, what diagnosis might it be?

Answer 26

Diverticulitis

Question 27

What labs would help confirm diverticulitis?

Answer 27

Occult blood in stool – otherwise diagnosis of exclusion (UA, preg test, LFT’s, pelvic exam)

Question 28

What PE exam must you do on a female with abdominal pain?

Answer 28

pelvic exam!

Question 29

What would you see on PE with diverticulitis?

Answer 29

Normal

Question 30

Is there any imaging that can be done to diagnose diverticulitis?

Answer 30

CT scan is best

Question 31

Should you ever use barium if you suspect perforation?

Answer 31

Heck no!!

Question 32

How would you treat a patient with diverticulitis?

Answer 32

Fluids, bed rest, ABx, may need surgical

Question 33

How can we prevent diverticulitis?

Answer 33

High fiber diet!

Question 34

A young female patient presents with 3 day history of diarrhea and RLQ pain. She states it has been a large volume of diarrhea that has blood in it and also appears to have mucous, what diagnosis are you thinking?

Answer 34

Crohn’s

Question 35

Another young female patient presents with loose, bloody stools, and urgency for BM. She has some pain in the LLQ. What diagnosis might you be thinking?

Answer 35

Ulcerative colitis

Question 36

When does the pain increase in Crohn’s?

Answer 36

After eating

Question 37

What is occurring in Crohn’s disease?

Answer 37

Skip lesions – anywhere from mouth to anus.

Question 38

What is occurring in Ulcerative Colitis?

Answer 38

There is a CONTINUOUS lesion(s) only in the colon

Question 39

How can you confirm diagnosis of Crohn’s or UC?

Answer 39

Colonoscopy!

Question 40

If a colonoscopy shows a thin colon wall with continuous inflammation, mucous lining intact, and no granulomas, what diagnosis are you thinking?

Answer 40

UC

Question 41

If a colonoscopy shows cobblestones & granulomas, what diagnosis do you think?

Answer 41

Crohn’s

Question 42

What can develop in Crohn’s patients?

Answer 42

Fistulas! That can spread to other organs – even the skin!

Question 43

What labs might you need to check with Crohn’s & UC?

Answer 43

CBC (check anemia), ASCA,LFT’s, Vit B12 & D, stool studies for occult blood, leukocytosis, and culture to R/O infection.

Question 44

How do we treat UC?

Answer 44

Removal of colon = curative

Question 45

Between UC & Crohn’s which one typically has obstruction and weight loss as well?

Answer 45

Crohn’s

Question 46

What’s a protective factor for UC?

Answer 46

Smoking…

Question 47

Between UC & Crohn’s which one can lead to toxic megacolon & higher risk for colon cancer?

Answer 47

UC

Question 48

If your patient with UC presents now with severe cramping and distention, with rebound tenderness, what diagnosis might you be thinking?

Answer 48

Toxic megacolon

Question 49

What is occurring in toxic megacolon?

Answer 49

Acute toxic colitis with dilation and immobility of the colon.

Question 50

What causes toxic megacolon?

Answer 50

Occurs with inflammation, obstruction, infection (like c diff)

Question 51

How do you confirm diagnosis of toxic megacolon?

Answer 51

``` X-ray = transverse colon >6cm + (3 of 4) Temp >101.5; HR>120bpm; leukocytosis >10.5; and anemia. + (1 of these) dehydration, altered mental status, hypotension, and electrolyte abnormality. ```

Question 52

How do we treat toxic megacolon?

Answer 52

Reduce distention (NG tube), correct fluid/electrolytes, and treat toxemia (abx or steroids) May need surgery due to risk of perforation & sepsis (colectomy)

Question 53

What type of patient can we see toxic megacolon in?

Answer 53

Narcotic addicts

Question 54

A patient presents with sudden onset of RLQ pain, with a loss of appetite for the past 24 hours, what do you immediately think of?

Answer 54

Appendicitis

Question 55

What is the most common cause of appendicitis?

Answer 55

Fecalith – leakacge of cecum contents or blockage

Question 56

What is the most common abdominal surgery?

Answer 56

Appendicitis

Question 57

What PE findings do you have with appendicitis?

Answer 57

McBurney’s point, Rovsings sign, rebound tenderness, Psoas sign, and obturator

Question 58

What do we need to remember about how appendicitis may present initially vs 12 hours later?

Answer 58

Initial umbilicus, then McBurney’s, the rebound tenderness

Question 59

What imaging can we do for appendicitis?

Answer 59

CT (you don’t have to)

Question 60

How do we treat appendicitis?

Answer 60

Surgical intervention; when you suspect surgical consult if suspected!!

Question 61

A patient presents with bowel pattern changes, diarrhea, excessive gas/bloating with fatigue & weakness, what diagnosis are you thinking?

Answer 61

Celiac

Question 62

What is celiac disease?

Answer 62

Autoimmune disorder of small intestine – intolerance to gluten

Question 63

What other symptoms may a person with celiac have?

Answer 63

Dermatitis Herpetiformis (on buttocks & extensor surfaces that itches)

Question 64

How do we diagnose a patient with celiac disease?

Answer 64

Lab – anti-tTG antibodies or anti-endomysium antibodies (IgA)

Question 65

How do we treat celiac disease?

Answer 65

Gluten free diet (may need to stop dairy until inflammation resolves) Abx for dermatitis herpetiformis

Question 66

What is considered “normal” for bowel movements?

Answer 66

2/day – 3/week

Question 67

So what then is constipation?

Answer 67

Decrease in stool volume and an increase in stool firmness accompanied by straining x 3 months with no obstructive or peristalsis disorder

Question 68

How do we confirm diagnosis of constipation?

Answer 68

R/O obstruction, rectal exam R/O impaction, x-ray for bowel gas pattern, complete ROS, abdominal exam

Question 69

How do we treat constipation?

Answer 69

No evidence of serious disease = diet (increase fiber), fluid intake, activity, and medication evaluation

Question 70

Where in the GI tract is it least likely to have a cancer occur?

Answer 70

small intestine (only 2%)

Question 71

When do we often diagnose small intestine cancer?

Answer 71

Once it has metastasized = deadly

Question 72

How would we diagnose small intestine cancer?

Answer 72

CBC, electrolytes, LFT’s, CT, and endoscopy

Question 73

If a patient has jaundice and you have R/O liver, GB, and pancreas. What body part should you think of?

Answer 73

Small intestine - cancer

Question 74

Where in the GI tract is it most common for cancer to occur?

Answer 74

Colorectal

Question 75

If a patient presents with colic type abdominal pain, with bleeding, a change in bowel habits, and a thin appearance, what diagnosis are you thinking?

Answer 75

Colorectal cancer

Question 76

What are some risk factors to developing colorectal cancer?

Answer 76

Genetic predisposition, polyps, diet (high in fat & refined carbs)

Question 77

What might someone with colorectal cancer also have?

Answer 77

iron-deficiency anemia, hypoalbuminemia, occult blood in stool, elevated alk phosphatase

Question 78

If alkaline phosphatase is elevated, what do you need to think of?

Answer 78

Can indicate colonic cancer, liver, or bone

Question 79

How would you confirm diagnosis of colorectal cancer?

Answer 79

X-ray = “apple core” appearance!

Question 80

What are the screening guidelines for colorectal cancer?

Answer 80

Colonoscopy every 10 years age 50 – 75 FOBT = every year Flex sig = every 5 years

Question 81

If a patient presents with maroon colored stool, melena, and fatigue, what diagnosis are you thinking?

Answer 81

Angiodysplasia

Question 82

What is angiodysplasia?

Answer 82

Swollen, fragile blood vessels of the colon due to age and degeneration of blood vessels

Question 83

How do you diagnose angiodysplasia?

Answer 83

Colonoscopy or CT

Question 84

How do you treat angiodysplasia?

Answer 84

Most stop bleeding, if not – cautery via colonoscopy

Question 85

If a patient presents with diarrhea, bloating, gas, and pain after consuming dairy product, what diagnosis?

Answer 85

Lactose Intolerance