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411 > W13 lower GI > Flashcards

W13 lower GI Flashcards

1
Q

what 3 things contribute to the etiology of IBD?

A

genetic predisposition
mucosal immune system
environmental triggers

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2
Q

what are the Rome IV criteria for IBS ?

A

recurrent abdominal pain at least 1 day/week in the last 3 months associatedwith 2 or more:
- related to defecation
- onset associated with a change in frequency of stool
- onset associated with a change in form (apperance of stool)
symptom onset at least 6 months prior to diagnosis

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3
Q

red flags in history that point away from IBS

A

unintended weight loss
onset after 50
family history of: Colorectal cancer, IBD, celiac
joint pain, skin rashes

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4
Q

red flags in physical that point away from IBS

A

malnourished, anemic
mass, obstruction
FOBT (fetal occult blood test) positive

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5
Q

red flags in investigations that point away from IBS

A

abnormal CBC
elevated CRP/ESR
altered biochemistry
abnormal thyroid testing

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6
Q

match the following symptoms with either ulcerative colitis or Crohn disease:
crampy lower abdominal pain: relieved by bowel movement
vs
constant RLQ pain not relived by BM

A

UC

CD

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7
Q

match the following symptoms with either ulcerative colitis or Crohn disease:

not bloody stool
vs
bloody stool

A

CD

UC

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8
Q

match the following symptoms with either ulcerative colitis or Crohn disease:
mass in RLQ
vs.
no mass

A

CD

UC

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9
Q

match the following symptoms with either ulcerative colitis or Crohn disease:
mucosal
vs. transmural

A

UC

CD

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10
Q

match the following symptoms with either ulcerative colitis or Crohn disease:
continous from rectum with no granulomas
vs
skip lesions with granulomas

A

UC

CD

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11
Q

which extraintestinal manifestations are more common in Crohn disease than UC?

A

arthritis
uveitis
aphthous stomatitis

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12
Q

What is the most common phenotype of Crohn disease?

A

L1

in the terminal ileum

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13
Q

what is fecal calprotectin?

A

cytosolic protein derived from dead neutrophils
stable for 7 days
correlates with active IBD

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14
Q

what treatment is used for patients with mild Crohn disease ?

A

topical:
budesonide
aminosalicylates

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15
Q

what treatment is used for patients with moderate Crohn disease?

A

infliximab
systemic corticosteroids
oral steroids

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16
Q

what treatmentis used for patients with severe Crohn disease?

A

surgery
infliximab
other biologics
anti-TNFs

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17
Q

what is the most common biologic used to treat Crohn disease?

A

anti-TNF:

infliximab

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18
Q

what are the characteristics that place a Crohn disease patient in the high risk for progression category?

A
  • young age at onset <18
  • non-inflammatory disease behaviour
  • extensive disease
  • early steroid need
  • extra intestinal manifestations
  • active smoker
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19
Q

what is the first line treatment in patients with Crohn disease with high risk for progression?

A

steroids: budesonide/corticosteroids
+
immune suppresant: AZA or MTX

smoking cessation

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20
Q

what is often the first pharmacologic therapy used in CD?

A

5-aminosalicylic acid (5-ASA)

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21
Q

what are the two 5-ASA compounds that are avaliable?

A

sulfasalazine

mesalamine

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22
Q

what are some of the short term side effects of corticosteroids?

A

night sweats
increased appetite
adrenal insufficiency
impaired glucose metabolism

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23
Q

what are some of the long term effects of corticosteroids?

A 
abnormal fat deposition 
excessive hair growth 
cataracts
glaucoma
osteoporosis 
hypertension 
aseptic bone necrosis of the hip
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24
Q

what are some key actions attributed to TNF?

A

macrophages: increase proinflammatory cytokines, increased chemokines –> increased inflammation
endothelium: increased adhesion molecules –> increased cell infiltration

fibroblasts: increased acute phase response –> increased CRP
increased metalloproteinase synthesis and decreased collagen production –> tissue remodeling

epithelium: increased ion transport and permeability –> compromised barrier function

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25
Q

risks of anti-TNF-a

A 
drug induced lupus 
injection site reactions 
non-Hodgkin lymphoma 
serious infections
opportunistic infections 
demyelination (don't use with MS patients)
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26
Q

what is the goal of surgery in patients with Crohn disease?

A

relieve symptoms

reilieve complications

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27
Q

indications for surgery in patients with CD

A 
failure of medical therapy 
cancer risk 
perforation 
haemorrhage 
stricture
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28
Q

risks for colorectal cancer in patients with UC

A 
duration of colitis
extent of colitis
primary sclerosing cholangitis
family history of CRC 
development of dysplasia 
endoscopic apperance
severity of inflammation at surveillance colonoscopy
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29
Q

Where does lower GI bleed occur?

A

Colon or rectum

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30
Q

What is hematochezia?

A

Passage of red blood or maroon coloured stools

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31
Q

What is melena?

A

Dark tarry stools

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32
Q

Anatomic causes of lower GI bleeding?

A

Diverticulosis

Outlet bleeding

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33
Q

Vascular cause of lower GI bleeding?

A

Angiodysplasia

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34
Q

Inflammatory cause of lower GI bleeding

A

Colitis

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35
Q

C-HAND

A 
Colitis: ischemic, inflammatory infectious 
Haemorrhoids
Angiodysplasia 
Neoplastic 
Diverticulosis
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36
Q

What is the dentate line and what is its clinical significance?

A

Separates rectum and colon

Above this line haemorrhoids won’t hurt, but below this line they will

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37
Q

What is the most common cause of GI bleeding in patients under 50?

A

Hemorrhoid

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38
Q

How are haemorrhoids diagnosed?

A

History
Digital rectal exam
Endoscopy

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39
Q

Medications used to treat haemorrhoids/fissures

A

Hydrocortisone based ointments
Suppositories
Sitz baths

Fissures:
Topical nitroglycerin, nifedipine, or diltiazem ointments

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40
Q

What is diverticulosis?

A

Sac like protrusions of the colon wall

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41
Q

Where is diverticulosis most commonly found?

A

Sigmoid colon

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42
Q

What is the clinical presentation of diverticulosis?

A

Bleeding in large volumes
Painless
Majority of the time bleeding stops spontaneously

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43
Q

What is the clinical presentation of diverticulitis?

A

Pain
Fever
High WBC
Not typically bleeding

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44
Q

What is the course of management in diverticulosis?

A 
ABCs
Colonoscopy
Angiography 
Surgery: segmental resection 
- persistent, recurrent, unstable
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45
Q

What is the classic presentation of IBD?

A

Chronic diarrhea
Rectal bleeding
Weight loss
Pain

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46
Q

What are the possible causes of ischemic colitis?

A

Non-occlusive colonic ischemia
Embolic occlusion
Mesenteric vein thrombosis

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47
Q

Clinical manifestations of ischemic colitis

A

Acute abdominal pain followed by diarrhea and mild rectal bleeding

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48
Q

Diagnosis of ischemic colitis

A

Labs: anemia, high serum lactate, high WBC
CT scan
Colonoscopy

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49
Q

Treatment of ischemic colitis

A

Most improve spontaneously
Antibiotics in severe cases
Treat underlying cardiovascular risk factors

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50
Q

Common causes of infectious colitis in developed countries

A

Shigella
Campylobacter
Salmonella
Enterohemorrhagic E.coli

From contaminated food and water

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51
Q

Clinical manifestations of infectious colitis

A

Acute onset diarrhea
Nausea
Vomiting
Fever

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52
Q

Antibiotics that can be used to treat severe infectious colitis

A

Ciprofloxacin

Azithromycin

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53
Q

Where is angiodysplasia frequently located and what is it commonly associated with?

A

Cecum and right colon

End stage renal disease, aortic stenosis, old age

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54
Q

What type of bleeding is seen with angiodysplasia?

A

Occult

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55
Q

Treatment for angiodysplasia

A

Endoscopic with argon plasma coagulation therapy

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56
Q

Clinical presentation of colon cancer

A

Bright red blood and/or maroon stools/melena
Occult iron deficiency
Altered bowel movements
Possible bowel obstruction

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57
Q

Management of colon cancer

A

Surgery

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58
Q

What is the 30-20-10 rule used to assess orthostatic hypotension

A

Decrease of 30 in HR
Decrease of 20 in systolic BP
Decrease of 10 in diastolic BP

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59
Q

How much blood loss is typically seen with supine hypotension

A

> 40%

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60
Q

What are the high risk features of lower GI bleed?

A 
Hemodynamic instability 
Known diverticulosis 
Profound anemia 
Significant comorbid illness
Blood thinnners
Altered mental status 
Advanced age 
Persistent bleeding 
New bleeding in hospitalized patient
Elevated urea
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61
Q

Labs commonly ordered with lower GI bleed

A 
CBC
Electrolytes 
Creatinine
BUN 
INR
Liver enzymes
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62
Q

Imaging for assessing lower GI bleeding

A

CT angiogram
Angiogram
RBC scan

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63
Q

What patients could CT angiography negatively impact?

A

Patients with active kidney disease

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64
Q

What classifies as diarrhea on the Bristol stool chart?

A

6+7

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65
Q

What are the two main types of diarrhea that are due to there being more fluid secreted into the lumen than the gut can absorb ?

A

Secretory

Osmotic

66
Q

Characteristics of secretory diarrhea

A

Watery
Minimal fever
Continues with fasting or diet changes

67
Q

Characteristics of osmotic diarrhea?

A

Due to overingestion of osmotic agents

68
Q

Characteristics of malabsorptive diarrhea

A

Foul smell/gas

And/or greasy stools

69
Q

Characteristics of inflammatory diarrhea

A

Fever, bloody stool, WBCs in stool

70
Q

Characteristics of acute diarrhea

A

<14 days
Often underlying illness
Might be inflammatory

71
Q

Characteristics of chronic diarrhea

A

> 14 days
Often accompanied by weight loss
Secretory or malabsorptive
Often immune compromised

72
Q

What is secretory infectious diarrhea?

A

Caused by bacteria: adhere to small intestinal epithelium without causing damage
Secrete toxins —> fluid secretion
Ex. Choleratoxin
Trouble absorbing fluid

73
Q

What is the appropriate management of watery diarrhea?

A

Volume repletion !!
Antibiotics (with cholera will shorten duration)
All infections are self limited

74
Q

Pathology of malabsorptive diarrheal infections

A

Villus blunting
Inflammation
Damaged villi

75
Q

What is inflammatory enterocolitis?

A

Bacteria that attach to and invade the small and/or large intestinal epithelia

76
Q

Symptoms of inflammatory enterocolitis

A

Diarrhea with blood and/or pus
Fever
Cramps
Prostration

77
Q

What is dystentery ?

A

A disease characterized by severe diarrhea with passage of mucus and blood and usually caused by infection

78
Q

What are some common causes of dysentery?

A 
Non-typhoidal salmonella
Campylobacter jejuni 
Shigella spp. 
Entamoeba histolytica
C. Diff
79
Q

How is dysentery transmitted?

A

Food/water
Fomites
Direct person to person

80
Q

Characteristics of Shigella

A

Gram negative rod
4 subspecies
Invades epithelial cells directly
Causes bacillary dysentery

81
Q

Characteristics of non-typhoidal salmonella

A

Gram negative rod
One species (enterica)
Frequent colonizer of poultry and meats
Self limited

82
Q

Characteristics of campylobacter jejuni

A

Gram negative gull wing rod
Colonizer of poultry
Almost never fatal

83
Q

Characteristics of entamoeba histolytica

A

Very infectious —> protozoan epidemic in developing countries
Fever, bloody diarrhea, tenesmus but can be non specific

84
Q

How is dysentery diagnosed?

A 
Blood in stool 
Fever (>38) 
Mucus/pus in stool 
Fecal WBCs 
Fecal calprotectin and lactoferin 
Do Stool Culture!
85
Q

Differential diagnosis of dysentery

A

UC/CD
Infectious proctitis
Hemorrhagic colitis
C. Diff colitis

86
Q

Characteristics of infectious proctitis

A

Sexually transmitted
Itching, discharge
Generally treated like other STIs

87
Q

Characteristics of hemorrhagic colitis

A

Caused by EHEC or STEC
Afebrile, bloody diarrhea, severe abdominal pain
Hemolytic-uraemic syndrome is severe complication
Diarrhea self limited

88
Q

Hemolytic-uraemc syndrome

A 
Caused by systemic Stx2>Stx1 
Triad of: 
Intravascular hemolysis 
Acute kidney injury 
Thrombocytopenia 
Neurological sequela may occur 
Permanent renal damage common
89
Q

Treatment of hemorrhagic colitis

A

Avoid anti-peristaltic against
Supportive care
Monitoring for HUS

90
Q

C. Diff characteristics

A 
Gram+ 
Spore forming 
Anaerobe
Colonized in farm animals, survives in meat 
Leading cause of nosocomial infection
91
Q

Characteristics of C. Diff infections

A

After antibiotic exposure in hospital
Produces 2 large toxins: TcdA, TcdB
Mild diarrhea to fatal colitis with shock

92
Q

Treatment of C. Diff infection

A

Vancomycin
Mild: metronidazole
Usually resolves in 4-7
Relapse common

93
Q

Diagnostic tests for infectious diarrhea

A 
Stool culture: routine bacterial pathogens
Stool O&amp;P: 
- microscopic exam with special stains
- molecular testing available 
Don’t order on inpatients 
Stool for C diff
94
Q

What pathogen should you suspect with undercooked poultry

A

Campy or salmonella

95
Q

What pathogen should you expect with raw eggs

A

Salmonella

96
Q

What pathogen should you expect with recent hospitalization

A

C. Diff

97
Q

What pathogens are common in day care outbreaks, MSM and tropical travel?

A

Shigella

E. Histolytica

98
Q

What pathogen should you suspect with oysters/sushi?

A

Vibrio

99
Q

What pathogens should you suspect with drinking from lakes or streams?

A

Giardia

Cryptosporidium

100
Q

When is stool testing most valuable

A

Outbreaks
Immune compromised
Bloody stools
CDI suspected

101
Q

Which pathogens need to be treated?

A

Shigella - little evidence for
Campylobacter: immune compromised and severe cases
SAlmonella: immune compromised, can help others but increase relapse
E. Histolytica: beneficial but difficult

102
Q

What are the most common sites of enteric infection

A

Small and large intestine

103
Q

What are the 6 main steps in outbreak management?

A
  1. Confirm the existence of an outbreak
  2. Define and identify cases
  3. Formulate hypothesis & implement initial control measures
  4. Test hypothesis
  5. Readjust hypothesis and control measures
  6. Plan for long term prevention and control
104
Q

Outbreak definition

A

Disease in excess of what would normally be expected in a defined community, geographical region, or season

105
Q

Endemic definition

A

Constant presence of a disease within an area or population

106
Q

Epidemic definition

A

Increased occurrence of disease in excess of normal expectation (longer and larger than outbreak)

107
Q

Pandemic definition

A

Epidemic spread across a large region

108
Q

What is active surveillance ?

A

Case finding through proactive investigation, employing data from health care providers and centres, health records, lab data, public surveys
- detect cases that would otherwise be unreported

109
Q

What is passive surveillance?

A

Cases identified through routine reporting

110
Q

What is a vector ?

A

Animal carrying an infectious pathogen to a human host

111
Q

What is a fomite?

A

An object that can become contaminated with and transmit an infectious pathogen

112
Q

What is a reservoir?

A

Habitat where a pathogen lives and multiplies

113
Q

What is the incubation period?

A

Period after exposure to a pathogen and before the first clinical manifestation

114
Q

What is the latent period?

A

Period after exposure to a pathogen and before the onset of transmissibility to others

115
Q

What is the period of communicability?

A

Period during which a pathogen can be transmitted from an infected individual to an uninflected individual

116
Q

What is isolation?

A

Separation of an infected individual from others for the period of communicability

117
Q

What is quarantine?

A

Separation of an exposed individual for the latent period or incubation period

118
Q

Difference between a point source and a continuous source

A

Time limited vs ongoing

119
Q

What does it mean if a disease is spread through propagation?

A

Person to person spread

120
Q

Terms ~ equivalent to IBS

A

Mucous colitis
Spastic colitis
Nervous bowel
Functional bowel disease

121
Q

IBS definition from Rome IV criteria

A

Continuous or recurrent symptoms for more than 3 months of:

  1. Abdominal pain
  2. Disordered defecation
  3. Bloating and distension
122
Q

Gynaecological manifestations of IBS

A

Dysmenorrhea

Dyspareunia

123
Q

Urologic manifestations of IBS

A

Dysuria

124
Q

Musculoskeletal manifestations of IBS

A

Fibromyalgia

125
Q

Psychological manifestations of IBS

A

Depression
Anxiety
Abuse

126
Q

IBS pathophysiology

A

Motility disturbance
Or
Visceral hypersensitivity

127
Q

Describe IBS diagnosis

A 
Symptom assessment 
Physical exam 
Limited screen for organic disease 
Identify subgroup 
- constipation predominant 
- diarrhea predominant 
- pain, gas, bloating
128
Q

Rome IV criteria for IBS diagnosis

A

Recurrent abdominal pain at least 1 day/week in the last 3 months with >=2 of the following:
- defecation
- change in stool frequency
- change in form
Symptom on set >6 month prior to diagnosis, symptoms for >3 months

129
Q

What are some IBS alarm symptoms?

A 
New onset >50 
Weight loss
GI bleeding 
Fever 
Nocturnal bowel movements
130
Q

What are the diet guidelines for IBS?

A 
Regular meals
Taking time to eat 
Limit high fat foods
Fluid intake, avoid fizz and caffeine 
Limit sugar free sweets and sorbitol 
Limit fruit to 3 portions per day
131
Q

What are FODMAPs

A 
Fermentable 
Oligosaccharides 
Disaccharides 
Monosaccharides 
And 
Polyols
132
Q

IBS drug therapy options

A 
Fibre
Antidiarrheals 
Antispasmodic
Motility regulators
Peppermint oil 
Choleystyramine
Antidepressants 
Probiotics
133
Q

Drugs used to treat diarrhea in IBS

A

Absorbants

GI relaxants

134
Q

Drugs used to treat constipation in IBS

A 
Fibre supplements
Osmotic laxatives 
Prokinetics
GI stimulants 
Pro-secretory
135
Q

Drugs used to treat pain/bloating in IBS

A 
Anxiolytics
Antispasmodic 
Anti-gas 
SSRIs 
TCAs
136
Q

Muscle relaxants used in IBS

A 
Benzodiazepines
Librax
Pinaverium 
Trimebutine 
Hyoscine
137
Q

Antidiarrheal medications

A

Imodium

Choleystyramine

138
Q

Antispasmodic medications

A

Buscopan

Peppermint oil

139
Q

How does info about pain travel?

A

In the spinothalamic tract to reach the contra lateral cortex

140
Q

What is the sympathetic innevation of the foregut

A

Greater and lesser splanchnic nerves

T5-T12

141
Q

What is the sympathetic innervation of the midgut ?

A

Less splanchnic nerve t5-t12

142
Q

What is the sympathetic innervation of the kidneys?

A

Least splanchnic nerve T12

143
Q

What is the sympathetic innervation of the hindgut?

A

Splanchnic lumbar nerves

Sacral splanchnic nerves L1/2

144
Q

Function of sympathetic innervation of the abdomen

A

Controls arterial blood flow through vasoconstriction
Tonic inhibitory influence on mucosal secretion
Inhibitory on smooth muscle

145
Q

Where do pain fibres travel along to reach the spinal cord ?

A

Sympathetic fibres

146
Q

Referred pain definition

A

Pain is perceived in regions innervated by nerves other than those that innervate the site of noxious stimulation

147
Q

What is projected pain?

A

Stimulation of a sensory nerve along its path may induce pain that is projected to the tissue by the stimulated nerve

148
Q

How is somatic pain characterized?

A

By the activation of peripheral nociceptors without actual damage to nerves

149
Q

Inflammation of the gut causing pain of the dermatomes on the abdomen is an example of what referred pain?

A

Referred pain from visceral nerve to somatic area (dermatome)

150
Q

What type of referred pain is it when irritation of the diaphragm causes shoulder pain?

A

Somatic nerve to somatic area (dermatome)

151
Q

What causes visceral pain?

A

Stretching, distension, ischemia

152
Q

Problems with what are felt as upper abdominal to epigastric pain?

A

Stomach, duodenum, hepatobiliary, pancreas

153
Q

Problems with what are felt as mid abdominal or periumbilical pain?

A

Jejunum, ileum, appendix, proximal colon

154
Q

Problems with what are felt as pain in the lower abdomen or hypo gastric area?

A

Colon, bladder, uterus, adnexa

155
Q

How does pain in appendicitis change as it progresses?

A

Starts as visceral pain in mid abdomen, feels like gas —>

Migrates to RLQ and os appreciated as somatic pain (McBurney’s point)

156
Q

What is Rovsing’s sign?

A

Pain in RLQ during left sided pressure suggests appendicitis

157
Q

Physical exam signs of appendicitis ?

A 
Direct tenderness of RLQ parietal peritoneum and somatic pain sensation
Rebound tenderness 
Referred rebound tenderness 
Rovsing;s sign 
Psoas and obturator signs 
Cutaneous hyperesthesia 
Guarding 
Rigidity
158
Q

What is sympathetic innervation of appendix and where does pain initial localize to ?

A

Lesser splanchnic nerve (T10/11)

Dermatome T10/11

159
Q

What is Valentino’s syndrome?

A

Perforated ulcer masquerading clinically as appendicitis

160
Q

What is Murphy’s sign?

A

As gallbladder becomes inflamed somatic pain is perceived in the RUQ with tenderness on deep inspiration

161
Q

What is Kehr’s sign?

A

Left shoulder pain in splenic ruptures?

411 (16 decks)

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