5 Feb 24

Question 1

RF C difficile colitis

Answer 1

🪴Recent antibiotic use or hospitalization
🪴Advanced age >65
🪴Gastric acid suppression (PPI , H2 blocker )
🪴Underlying IBD
🪴Chemotherapy

Question 2

CF of C difficile colitis

Answer 2

🍀Profuse watery diarrhea
🍀Leukocytosis (15,000)
🍀Fulminant colitis or toxic megacolon

Question 3

Dx of C difficile colitis

Answer 3

🪹Stool PCR for C difficile genes

🪹stool EIA for C difficile toxin and glutamate dehydrogenase antigen

Question 4

C difficile infection control

Answer 4

🌹hand hygiene with soap and water
🌹contact isolation
🌹sporicidal disinfectants (bleach)

Question 5

Most imp RF for C difficile

Answer 5

Antibiotic use

Others.
Recent hospitalization
IBD
(Increased susceptibility by altering gut microbiome)

Question 6

Signs of toxic megacolon in C difficile

Answer 6

Severe systemic toxicity
Abd distention
Cesaation of diarrhea
Perforation (rebound tenderness)

Confirmation : CTscan

Question 7

Whipple dx CF

Answer 7

Men
Age 40-60s
Weight loss
Abd pain
Diarrhea
Malabsorption with distention
Flatulence
Steatorrhea
Migratory polyarthropathy
Chronic cough
Myocardial or valvular involvement (causes CCF or valvukar regurg)

Question 8

Workup for IBS - constipation

Answer 8

Do CBC

If normal - Treat for IBS -C

If abnormal- colonoscopy

Question 9

Workup for IBS- diarrhea

Answer 9

CBC
Stool culture celiac dx serology
CRP or Fecal calprotectin/lactoferrin

If normal - treat for IBS-D

If abnormal- treat underlying cause
Do colonoscopy

Question 10

Alarm symptoms of IBS

Answer 10

Age >50
Rectal bleed /melena
Fasting diarrhea (nocturnal)
Worsening abd pain
Family history of IBD/CRC

Question 11

IBS def

Answer 11

Recurrent abd pain and changes in stool freq or form in the absence of an organic cause or red flags.

Question 12

Ttt of IBS

Answer 12

First line :
Lifestyle modification
(Dietary changes , exercise)
Soluble fibre (psyllium)
Avoid bran
Antidiarrheals (IBS-D)

Question 13

Secretory diarrhea CF

Answer 13

🪴Secretion of electrolyes and water into intestine
🪴Low osmolar gap <50 mOsm/kg
🪴Large volume diarrhea
🪴Persists while fasting and at night

Question 14

Cause of secretory diarrhea

Answer 14

Toxins (vibrio cholerae)
Hormones (VIPomas)
Cystic fibrosis
Bile acids (post surgical patients)

Question 15

Osmotic diarrhea CF

Answer 15

🪵High stool osmotic gap >125mOsm/kg
🪵Presence of non absorbed osmotically active solute (polyethylene glycol, sorbitol, lactose)

Question 16

Normal stool osmotic gap

Answer 16

290-2 x(stool Na + stool K)

<50. Secretory diarrhea
50-125. Indeterminate
> 125. Osmotic diarrhea

Question 17

Common cause of secretory diarrhea in post op patients

Answer 17

Bowel resection or post cholecystectomy pts
Unabsorbed bile acids reach colon and cause direct stimulation of luminal ion channels
Resection of ileocecal area reduces ability of intestines to actively absorb sodium ions against electrochemical gradient.

Question 18

Fecal incontinence in a constipated elderly mechanism

Answer 18

Overflow incontinece due to fecal impaction

Mechanism: obstruction of fecal flow in rectum can cause backup of stool proximal to impaction , passage of liquid stool around impaction leads to incontinence.

Urinary incontinence is also common due to pressure against bladder

Question 19

Fecal incontinence causes

Answer 19

Cause: Elderly
Impaired mobility
Inadequate fluid or dietary fibr
Chronic constipation
Decreased sensation of stool in rectal vault (sp cd injury, dementia)

Question 20

Ttt of fecal incontinence due to impaction

Answer 20

Manual disimpaction
Enemas
Laxatives (polyethylene glycol , lactulose)
Dietary alterations:
(Inc intake fluid and fibre)

Question 21

Proctalgia figax pathphys

Answer 21

Spastic contraction of anal sphincter

Pendundal nerve compression

Question 22

RF for proctalgia fugax

Answer 22

Female
IBS
Psychosocial stress , anxiety

Question 23

CF of proctalgia fugax

Answer 23

🌻Recurrent rectal pain unrelated to defecation
🌻Episodes last sec to minutes (<30mins)
🌻No pain between episodes.
🌻ppt by stress, intercourse or sitting but often occur with no obvious trigger

Question 24

Examination and ttt

Answer 24

PE: Normal
Normal labs

Ttt :
Reassuarance
Nitroglycerin cream +- biofeedback therapy for refractory symptoms.

Question 25

DX of carcinoid syndrome

Answer 25

🌵Elevated 24hr urinary 5-HIAA 🌵CT / MRI of abd and pelvis to localise tumor 🌵Octreoscan to detect mets 🌵Echo (if symptoms of carcinoid heart dx are present)

Question 26

Ttt of Carcinoid S

Answer 26

🪴Octreotide for symptomatic pts And prior to surgery / Anasthesia 🪴Surgery for Liver mets.

Question 27

Carcinoid etiology

Answer 27

🌸Well differentiated neuroendocrine tumors 🌸Location : distal intestine , prox small colon , lung , mets to liver. 🌸Secrete histamine , serotonin , VIP In pts with liver mets the hormones are directly released into systemic circulation causing carcinoid

Question 28

CF of carcinoid syndrome

Answer 28

🍁Episodic flushing (85%) 🍁Hypotension and tachycardia 🍁Secretory diarrhea (with abd cramping) 🍁Cutaneous telangiectasia 🍁Bronchospasm 🍁TR : Plaque like deposits of fibrous tissue on endocardium on Rt side of heart.

Question 29

Crohn dx CF

Answer 29

GIT : Abd pain Non bloody diarrhea Oral ulcers Malabsorption Weight loss Fistula /abscess formation Perianal dx Extraintestinal : Musculoskeletal : arthritis Ophthalmic : uveitis , scleritis , episcleritis Skin : Erythema nodosum, Pyoderma gangrenosum

Question 30

Dxof crohn

Answer 30

🌞Labs : Inc TLC Fe def Inc Inflammatory markers 🌞B12 def (if terminal ileum involved) 🌞Endoscopy: Focal ulceration next to normal mucosa (cobblestoning) Skip lesions, rectal sparing 🌞Radiography: Strictures , bowel wall thickening And luminal narrowing (terminal ileum on CT)

Question 31

Ttt of crohn

Answer 31

Corticosteroids Azthioprine Anti TNF (infliximab)

Question 32

What is infectious colitis

Answer 32

Mimics crohns Presents with ileitis Acute process Doesnt involve oral mucosa Causative : Yersinia , parasites , amoebae

Question 33

Factitious diarrhea labs

Answer 33

Stool osmolality: Hypoosmolar: added water Hyoerosmolar : Urine added Stool electrolytes : Mg and PO4 laxatives Stool osmolar gap: High SOG: lactulose , polyethylene glycol Low SOG : senna , bisacodyl

Question 34

Factitious disorder (imposed on self ) Features

Answer 34

Self induced illness Exacerbation on self induced illness Motivated by internal factors(making ppl take care of them -sick role) And not external gains(finacial compensation)

Question 35

Factitious Dx imposed on self

Answer 35

DX : Discovery of medical supplies Sulfonylurea screen, stool laxative screen Medical record review

Question 36

Gonococcal proctitis transmission

Answer 36

Receptive anal intercourse Direct spread from vagina

Question 37

CF of gonococcal proctitis and ttt

Answer 37

🌎 mucopurulent anal discharge , occasional rectal bleed 🌎 tenesmus(straining with minimal stool , constipation 🌎 pruritis , rectal pain , rectal fullness Dx : NAAT of rectal swab Ttt: Ceftriaxone + doxycycline (to cover chlamydia)

Question 38

DD crohn dx vs gonococcal proctitis

Answer 38

CD has rectal sparing so it doesnt cause tenesmus. CD has anal fistula and perirectal abscess (visible on exam)

Question 39

Clostridium septicum bacteremia association?

Answer 39

Colon cancer Do colonoscopy as screening Also ass with group D strept(bovis)

Question 40

Why is C septicum risk inc in cancer

Answer 40

Tumor cells undergo anaerobic glycolysis creating adequte env for germination of C septicum spores , tumor damages the colonic mucosa which allows sporulated bacteria to go to bloodstream.