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Pance Re-Up > GI Re-Up #2 > Flashcards

GI Re-Up #2 Flashcards

1
Q

What is the criteria for toxic megacolon?

Name two common etiologies for this condition

A

Nonobstructive extreme colon dilation > 6 cm + signs of systemic toxicity

Complications of IBD (UC), Infectious Colitis (C. diff)

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2
Q

Symptoms of toxic megacolon

What is the initial imaging study of choice and what is seen?

A

-Profound bloody diarrhea, abdominal pain/distention, nausea, vomiting, tenesmus
-Lower abdominal tenderness and distention
-Signs of toxicity: AMS, fever, tachycardia, hypotension, dehydration. Rigidity, guarding, rebound tenderness.

-Initial: Abdominal radiographs show colon > 6 cm

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3
Q

You need 3 of the following 4 things to diagnose toxic megacolon.

Plus, 1 of the following…

A

-fever, pulse > 120, neutrophilic leukocytosis > 10,500, anemia PLUS 1 of the following

-hypotension, dehydration, lyte abnormalities, AMS

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4
Q

Treatment for toxic megacolon

A

-Supportive: bowel rest, NG decompression, Ceftriaxone + Metronidazole, fluid replacement, lyte replacement

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5
Q

What is Ogilvie Syndrome?

What are some etiologies (think about ileus)

A

Colonic pseudo-obstruction in absence of any mechanical obstruction

-Etiologies: postoperative state, meds (opiates), hypokalemia, hypercalcemia, hypothyroidism, DM

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6
Q

What is the main symptom of Ogilvie Syndrome?

What is the most accurate test for this and what is shown?

A

-Abdominal distention, tympanitic abdomen

-Abdominal CT scan: proximal right colonic dilation

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7
Q

Management for Ogilvie Syndrome

A

-IVF and electrolyte repletion if colon dilation < 12 cm
-Neostigmine if at risk for perforation or > 12 cm or if failed conservative therapy after 24-48 hours (medical decompression)
-Colonoscopic decompression is next option
-Surgical decompression if everything else fails

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8
Q

Name some risk factors for IBD (includes Crohn’s and Ulcerative Colitis)

A

-Ashkenazi Jews, Caucasians
-15-35 years old
-UC in Males, Crohn’s in Females
-Genetics, Family History
-Smoking (increased in Crohn’s, Decreased in UC)
-Western Style Diet
-Infections
-NSAIDs, OCPs, Hormone Replacement Therapy

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9
Q

Explain some extra-intestinal manifestations of IBD
-Dermatologic
-Ocular
-Hematologic
-Rheumatologic

A

-Derm: Erthema Nodosum
-Ocular: Conjunctivitis, Anterior Uveitis, Episcleritis
-Hematologic: B12 and Iron Deficiency
-Rheumatologic: MSK pain, ALS, osteoporosis

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10
Q

Regarding Ulcerative Colitis, explain the following findings, symptoms, or labs.
-Area affected
-Depth
-Symptoms
-Complications
-Colonoscopy Findings
-Barium Study Findings (Upper GI series)
-Labs
-Surgery

A

-Limited to colon (begins in rectum with contiguous spread proximally to colon). Rectum ALWAYS involved.
-Mucosa and Submucosa Only
-LLQ pain, Tenesmus, urgency, bloody diarrhea**
-Toxic Megacolon, Colon Cancer (complications)
-Uniform inflammation and pseudopolyps on colonoscopy
-Stovepipe sign: loss of haustral markings on barium’
- + P-ANCA
-Surgery is curative

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11
Q

Regarding Crohn’s Disease, explain the following findings, symptoms, or labs.
-Area affected
-Depth
-Symptoms
-Complications
-Colonoscopy Findings
-Barium Study Findings (Upper GI series)
-Labs
-Surgery

A

-Any segment of GI that from mouth to anus. MC in terminal ileum (RLQ pain)
-Transmural
-RLQ pain, weight loss, diarrhea without blood
-Perianal disease (fistulas, abscesses, strictures, granulomas, Iron and B12 deficiency) complications
-Skip lesions (normal between inflamed areas, cobblestone appearance on colonoscopy)
-String sign: barium flow through narrowed transmural stricture on barium study
- + ASCA
-Surgery is noncurative

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12
Q

For UC and Crohn’s, what is the first line treatment if mild to moderate disease?

A

5-ASA (Topical 5-aminosalicylic acid) Mesalamine

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13
Q

For Crohn’s, explain the treatments for…
-Limited ileocolonic disease:
-Ileal and proximal colon disease:
-Severe and refractory:

A

-Limited: 5-ASA and oral glucocorticoids
-Proximal: Glucocorticoids (Prednisone, Budesonide)
-Severe: Azathioprine, Methotrexate, anti-TNF agents

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14
Q

For UC, explain the treatments for…
-Mild to moderate distal:
-Severe:
-Surgery:

A

-Mild to moderate: Topical 5-ASA. Topical corticosteroids may be added in some.
-Severe: Oral glucocorticoids + high dose 5-ASA + topical 5-ASA or steroids
-Surgical resection in some cases

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15
Q

Hemorrhoids, which are engorgement of venous plexuses, have two types (internal and external). Internal hemorrhoids originate from the _________ vein and are proximal (above) the dentate line. What symptoms are unique to this type?

A

-Superior hemorrhoid vein

-Tend to bleed and are painless

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16
Q

There are four grades of internal hemorrhoids. Explain each one.

A

-Grade I: Does not prolapse. May bleed with defecation.
-Grade II: Prolapses with defecation or straining but spontaneously resolve.
-Grade III: Prolapses with defecation or straining, requires manual reduction.
-Grade IV: Irreducible and may strangulate.

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17
Q

On the other hand, external hemorrhoids originate from the ______ vein and are distal (below) the dentate line. What are symptoms associated with this type?

A

-Inferior hemorrhoid vein

-Tend to be painful and don’t usually bleed

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18
Q

Risk Factors for hemorrhoids

How do you diagnose these?

A

-Straining during defecation (constipation), pregnancy, obesity, prolonged sitting, cirrhosis with portal hypertension

-Visual inspection, DRE, fecal occult blood testing
-Anoscopy for internal allows for direct visualization

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19
Q

Symptoms of internal hemorrhoids:

Symptoms of external hemorrhoids:

A

Internal: intermittent rectal bleeding (painless BRBPR). Rectal itching, fullness, mucus discharge.

External: perianal pain aggravated with defecation. Tender palpable mass. +/- Skin tags.

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20
Q

Treatment for hemorrhoids

A

-Conservative: high fiber diet, increased fluids, warm sitz baths. Analgesics.

-Rubber band ligation (MC used), Sclerotherapy, infrared coagulation. Excision of thrombosed external may be performed.

-Hemorroidectomy for Stage IV not responsive to other therapies. Surgical treatment for external only.

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21
Q

What is constipation defined as?

What are some etiologies?

A

-Infrequent bowel movements (<2/week), straining, hard stools, feeling of incomplete evacuation.

-Hypothyroid, DM, Verapamil, Opioids, Hirschsprung’s Disease

22
Q

Medications used for constipation.
-Fiber
–MOA

A

Retains water and improves GI transit

23
Q

Osmotic Laxatives
-Names
-MOA
-Adverse Effects

A

-Polyethylene Glycol (PEG), Lactulose, Sorbitol, Milk of Magnesia, Magnesium Citrate
-H20 retention in stool
-Bloating, flatulence, hypermagnesemia

24
Q

Bisacodyl and Senna, which are stimulant laxatives, work how?

A

Increases acetylcholine-regulated GI motility (peristalsis) and alters electrolyte transport in the mucosa

Can cause diarrhea and abdominal pain though

25
Q

Management for fecal impaction

A

-Digital disimpaction followed by warm-water enema with mineral oil
-Polyethylene glycol either orally or via NG tube

26
Q

Explain the pathophysiology of Duodenal Ulcers vs Gastric Ulcers

A

-Duodenal Ulcers: increased aggressive factors (H. Pylori)

-Gastric Ulcers: decreased protective mechanisms (mucus, bicarb, etc.)

27
Q

Etiologies of PUD

Symptoms of both types of ulcers.
Symptoms of duodenal ulcers.
Symptoms of gastric ulcers

A

-H. Pylori (MCC), NSAIDs, Aspirin, Zollinger-Ellison Syndrome (gastrin producing tumor), ETOH, smoking, stress, males, elderly, steroids, gastric cancer

-Both: Dyspepsia (burning, gnawing, epigastric pain), nausea, vomiting
-Duodenal: dyspepsia relieved with food, worse before meals or 2-5 hours after meals, nocturnal symptoms
-Gastric: symptoms worse with food (especially 1-2 hours after meals), weight loss.

28
Q

True or False, PUD is the MCC of upper GI bleed?

What are some symptoms of a perforated ulcer?

A

-True!

-Sudden onset of severe abdominal pain, may radiate to the shoulder. Rebound tenderness, guarding, rigidity may be peritonitis.

29
Q

Diagnostic test of choice for PUD

A

Upper endoscopy with biopsy
–All gastric ulcers need repeat UE to document healing

30
Q

What diagnostics are done to test for H. Pylori?

What’s the gold standard one?

A

-Urea breath test: H. Pylori converts urea into carbon dioxide.
-H. Pylori Stool Antigen (HpSA): confirm eradication after therapy
-Serologic antibodies: only useful in confirming H. Pylori
-Endoscopy with biopsy: GOLD STANDARD

31
Q

Treatment for PUD if H. Pylori Positive (think 4 and 3)

A

-Quadruple Therapy: Bismuth + Tetracycline + Metro + PPI x 14 days
–or CAMP (Clarithromycin + Amoxicillin + Metro + PPI for 10-14 days)
-Triple Therapy (CAP): Clarithromycin + Amoxicillin + PPI for 10-14 days (Metronidazole if PCN allergic)

32
Q

If H. Pylori negative, what treatment should you give for PUD?

If refractory, what is the treatment?

A

-PPI, H2 blocker, Misoprostol, antacids

-Refractory: Bilroth II surgery (associated with Dumping Syndrome)

33
Q

Duodenal ulcers are MC in ______ whereas gastric ulcers are MC in ________

A

Duodenal: younger patients (30-55)

Gastric: older patients (55-70)

34
Q

A volvulus is _______ and it MC involves the _________.

What are some symptoms of this condition?

A

-Twisting of any part of the bowel at it’s mesenteric attachment site. MC involves the sigmoid colon and cecum.

Symptoms (obstruction): crampy pain, tympanitic abdomen with tenderness to palpation. Distention, nausea, vomiting, constipation. (Impaired vascular supply): fever, peritonitis, tachycardia.

35
Q

What is seen on the following diagnostics with a volvulus?
-Abdominal CT
-Abdominal Radiograph
-Contrast enema

A

-Abdominal CT: dilated sigmoid colon, bird beak appearance at site of volvulus
-Abdominal Radiograph: bent inner tube or coffee bean sign. U shaped appearance of the air-filled closed loop of distended colon with loss of haustral markings
-Contrast enema: Bird’s beak appearance

36
Q

Management for a volvulus

A

-Endoscopic decompression (proctosigmoidoscopy) and then elective surgery due to high rate of recurrence

37
Q

Which organ is the most common organ injured during trauma?

What are some symptoms?

A

-Spleen

-Abdominal pain, Hypotension, Shock.
-Kehr Sign: referred left shoulder pain due to irritation of diaphragm and phrenic nerve

38
Q

Management for a splenic rupture or laceration if:
-Incomplete rupture:
-Complete rupture or intractable bleeding:

A

-Endovascular embolization

-Splenectomy

39
Q

A small bowel obstruction is partial or complete mechanical blockage of the small intestine. What is the MC etiology and what are some others you should remember?

What are some symptoms?
-Think of early and late findings as well

A

-Post-surgical adhesions (MC)
-Others: Incarcerated hernias, Crohn’s, Malignancy, Intussusception.

-Symptoms (CAVO): Crampy abdominal pain, abdominal distention, vomiting, and obstipation (no flatus)
-High pitched tingles on auscultation and visible peristalsis (early findings). Hypoactive bowel sounds (late in obstruction)

40
Q

What is seen on abdominal radiographs for a small bowel obstruction?

What is seen on a CT scan?

A

-Abdominal radiographs: multiple air-fluid levels in a step ladder appearance, dilated bowel loops

-CT scan: transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast.

41
Q

Management for a SBO

A

-Nonstrangulated: NPO (bowel rest), IVF. Bowel decompression (NG suction) if severe vomiting
-Strangulated: Surgical intervention

42
Q

What is a paralytic (adynamic) ileus?

What are some etiologies of this?

Name some symptoms.

A

-Decreased peristalsis WITHOUT structural obstruction

-Postoperative state, Opiates, Hypokalemia, Hypercalcemia, Hypothyroidism, DM

-Symptoms: Abdominal distention, obstipation, vomiting, nausea, decreased or absent bowel sounds (unlike SBO). No peritoneal signs

43
Q

What is seen on plain radiographs in a paralytic ileus?

A

-Dilated loops of bowel with no transition zone

44
Q

Management for paralytic ileus

A

-Supportive care: NPO or dietary restriction (clear fluids) Electrolyte and fluid repletion.
-NG suction if needed

45
Q

One more time, explain the difference on abdominal radiographs of a SBO and a paralytic ileus?

A

SBO: multiple air fluid levels in a step ladder appearance, dilated bowel loops

Paralytic ileus: dilated loops of bowel with NO transition zone

46
Q

Duodenal atresia, which is __________, has risk factors such as _____ and _______

A

Complete absence or closure of a portion of the duodenum, leading to gastric outlet obstruction

-Polyhydramnios (increased amniotic fluid), Down Syndrome

47
Q

Symptoms of duodenal atresia

What is seen on abdominal radiographs?

A

-Neonatal intestinal obstruction: within the first 24-38 hours of life, bilious vomiting, abdominal distention

-Abdominal XR: double bubble sign (distended air-filled stomach + smaller distended duodenum separated by pyloric valve)

48
Q

Management for duodenal atresia

A

-Decompression of GI tract, electrolyte/fluid replacement
-Duodenoduodenostomy is definitive treatment

49
Q

A hiatal hernia is herniation of structures from the abdominal cavity through the esophageal hiatus of the diaphragm. There are two types. Which is the MC. Explain both types.

A

-Sliding (Type I): MC type: GE junction slides into the mediastinum.

-Paraesophageal (Type II): Rolling hernia. Fundus of stomach protrudes through diaphragm with the GE junction remaining in normal location.

50
Q

Symptoms of a hiatal hernia

What is the management for both types?

A

-Asymptomatic incidental finding most times. Intermittent epigastric pain, postprandial fullness, retching, nausea.

-Sliding: Manage GERD: PPI’s + weight loss
-Paraesophageal: surgical repair reserved for complications

Pance Re-Up (76 decks)

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