Approach To Patient With Lower GI Problems - Dr. McGowen Flashcards
1
Q
4 common conditions causing hemarochezia
A
- Diverticulosis bleed
- IBD
- Ischemic colitis
- Inteussusception
2
Q
hemarochezia and under 50yo
A
- Infectious colitis
- IBD
- Anorectal disease (hemorrhoids, anal fissures)
- Meckel Diverticulum
3
Q
hemarochezia and over 50yo
A
- Malignancy
- Diverticulosis
- Arterial problem (AVM, Angiodysplasia, Angioectasia)
- Ischemic Colitis
4
Q
LGIB DX and TX
A
- colonscopy, massive do EGD
2. NPO (nothing by mouth), IV , stabilize
5
Q
how many hematochezias are from UGIB
A
10%
6
Q
Diverticulosis
prevalence and where
A
most common cause of LGIB
most common in sigmoid colon
7
Q
Diverticulosis
sx
A
90% are asymptomatic and only see accidentally in colonoscopy, LGIB, PAINLESS**,
8
Q
Diverticulosis DX and TX
A
- colonoscopy if stable, labs until then
2. high fiber diet to prevent constipation (if asymptomatic), NPO and IV or surgery if symptomatic
9
Q
IBD (UC, CD) risks
A
- ABs in 1st year of life
- genetics and environment
- breastfeeding protects against it
- appendectomy before 20yo can protect against UC
10
Q
IBD (UC, CD) DX
A
1. serum ANCA = UC serum ASCA : CD 2. fecal lactoferrin, calpretectin 3. String sign : (narrowing from inflammation) CD 4. Lead pipe colon : X haustra in UC
11
Q
IBD (UC, CD) risks TX
A
NPO, surgery, screening for colonoscopy cancer as prevention
12
Q
CD looks like what
A
= acute ileitis (appendicitis)
13
Q
CD SX
A
D, Fatigue, Malaise, WL, smoking cigarettes is a huge risk
usually RLQ tenderness
14
Q
CD DX
A
ASCA serum
15
Q
CD TX
A
ABs, NGT if obstruction, drain abscesses, surgery only if needed
16
Q
UC SX
A
Bloody D, fecal urgency (Tenesmus)
Lower abd cramping, relieved when pooping, usually LLQ pain
17
Q
UC Risk and associated with
A
- recently stopped smoking (more incidents in non-smoking pts)
- Associations:
= erythema nodosum
= Pyoderma gangrenosum
= Primary sclerosing cholangitis
18
Q
UC DX
A
ANCA serum
19
Q
UC Tx
A
surgery can be curative only not first thing ro so
blood transfusion if needed
20
Q
UC complications
A
- Toxic Megacolon –> colonic perforation
- colon cancer
- Primary Sclerosing cholangitis —-> Cholangiocarcinoma
- DVT
21
Q
extraGI SX of UC
A
- Gallstones
2. Nephrolithiasis
22
Q
extraGI SX of CD
A
- Pyroderma Gangrenosum
- Toxic megacolon
- Ankylosing spondylitis
23
Q
Ischemic Colitis where and SX
A
- Watershed areas : splenic flexures and distal SC
2. Cramping LLQ/LUQ, Bloody D, atherosclerosis, estrogen therapy can cause it
24
Q
Ischemic Colitis DX
A
- Xray = thumb- printing image in colon,
2. Sigmoidoscopy = shows submucosal hemorrhage, friability : risk for perforation= free air under diaphragm
25
Intussusception risks
1. polyp or mass or Meckels in adults
| 2. infants common
26
Intussusception SX
1. Lower ABD pain
| 2. V, Bloody jelly like stool (currant jelly)
27
Intussusception Physical exam
Dance sign : emptiness feeling when palpating RLQ
28
Intussusception DX and Tx
1. CT abd + US abd = telescoping bowel (Bulls eye)
| 2. NPO, IV fluids, surgery
29
Hemorrhoids how does it happen
hydrostatic P increased in hemorrhoidal venous pleux
30
Hemorrhoids SX
Bright Red Blood per rectum (BRBPR) (drops on tissue or in toilet)
31
Hemorrhoids DX
DRE, colonoscopy to rule out other cancer or diseases
32
Hemorrhoids TX
1. bulk laxatives + stool softerners, sitz baths, witch hazel compresses,
2. severe bleeding : rubberband ligation, sclerotherapy injection, surgery
33
Hemorrhoids complications
Thrombosed external Hemorrhoids : very painful acute pain, tense blue nodule (pain goes away in 2-3 days) ,sitz baths and analgesics
34
Anal fissures what is it
ulcer less then 5mm in anal skin, usually from pooping, (constipation or straining)
35
Anal fissures SX
sever, tearing pain followed by throbbing pain
| can have hematochezia or drops on toilet paper
36
Anal fissures DX
DRE can be too painful
inspection by spreading cheeks
colonscopy to rule out other things
37
Anal fissures TX
fiber supplements, sitz baths, ointments to relax anal canal
38
Anal Cancer happens how
HPV, chronic hemorrhoids, irritations, perianal fissures, LI cancer
39
Anal Cancer SX
analrectal pain, bleeding, othcing, perianal mass, BM changes, DRE mass
= usually SCC or can by adenocarcinoma, melanoma)
40
Anal Cancer DX
Pap anal test, anoscopy, US, DRE
41
Anal Cancer TX
HPV vaccine
| chema radiation , surgery,
42
Perianal Pruritus (pruritus ani) happens how
1. Poor anal hyagine (fissular, hemorrhoids, skin tags)
| 2. pinworms, staph, strep, STIs, dermititis, soaps that irritate
43
Perianal Pruritus (pruritus ani) SX and DX
perianal itching, and discomfort
| DRE and inspection, tape teszt for pinworm, biposy
44
Occult GI bleed is what and usually from
1. bleeding not seen by pt or physician
- premenopausal Fm IDA
- pt with IDA over 45yo think colon cancer
45
Occult GI bleed DX
1. test for Celiac D if IDA, (IgA anti-Ttg)
2. + FOBT (fecal occult Blood test)
3. + FIT (fecal immunochemical test)
46
FOBT
| false + and false -
Guaiac-based test :
1. can be + if you eat red meats, Fe+3, asprin, UGIB
2. can be - if VITC ingesting, intermittent bleeding
47
FOBT
Heme and Hb detection, sensitive
48
FIT
for Hb, most sensitive for colorectal cancer and advanced adenomas (detects human globin)
49
Fecal DNA tests
stool hb, to look at DNA for mutated tumor cells
50
Colon Cancer : colorectal cancer, adenocarcinoma
| who and how
1. greater then 45yo think about it
2, from polyps
3. high risk in Strep bovis bacteremia (also called strep gallolyticus)
51
Colon Cancer : colorectal cancer, adenocarcinoma SX
1. Leser Trelat sign (seb K)
| 2. bloody stool
52
Colon Cancer : colorectal cancer, adenocarcinoma RIGTH SIDE SX
1. usually late dx
2. anemia,
3. WL, blood in stool
4. perforations, fistulas, volvulus, inguinal hernia
53
Colon Cancer : colorectal cancer, adenocarcinoma LEFT SIDE SX
1. rectal bleeding
2. C, D, narrowing
3. abd pain, back pain
54
Colon Cancer : colorectal cancer, adenocarcinoma DX
1. colonoscopy
| 2. Barium enema (apple core sign*)
55
Arteriovenous malformations (AVM), Angioectasia happens how and SX
1. occult GIB, painless bleeding
2. usually over 70yo
3. common in CRF or Aortic stenosis
4. IDA can happen with no clear cause
56
Arteriovenous malformations (AVM), Angioectasia you know it pt shows up and has
1. over 60yo
2. normal EGD, not WL, ABD pain, neoplasms)
3. occult bleeding
57
Unintentional WL is defined as and questions to ask
1. 5% -10% WL in 6mos
| 2. difficulty eating?, dysgeusia (distorted sense of taste), dysphagia, Anorexia, N, change in BM
58
Unintentional WL tests and causes
1. poor dentition, oral thrush
2. DRE, prostate and GI issues
3. Pelvic exam on females
4. stool occult blood test
5. depression
59
ABD Aortic Aneurism (AAA) risk and SX
1. atherosclerosis, males, FH, HTN, smoking, age
| 2. asymptomatic usually, non-tender mass felt, abd pulsations, (pain in lower back, chest, scrotum)
60
AAA that is painful means
about to rupture and Medical Emergency
61
ABD Aortic Aneurism (AAA) DX
Abd US dx and screening
62
ABD Aortic Aneurism (AAA) prevention
1. US for male over 65yo who have smoked or FH
63
ABD Aortic Aneurism (AAA) TX
1. yearly US for pt asymptomatic AAA
| 2. >5cm diameter AAA in risk of rupture, surgery
64
ABD Aortic Aneurism (AAA) complications
1. rupture is life threatening (Acute pain, HTN)
2. AAA leakage, no pain
3. Aortic dissection : creates a false lumen (CT needed to see) --> usually on right lateral wall
4. atypical "tearing" CP, widened mediastinum, EM
65
Appendicitis happens how
obstruction of Appendix by fecalith, inflammation, foreign body, neoplasm
66
Appendicitis SX
vague colicky periumbilical or epigastric pain ----> RLQ pain
= gets worse when coughing of walking
67
Appendicitis TX
surgery
| AB : gram - and anaerobics
68
Appendicitis unusual pains
```
RUQ pain (retrocecal appendix)
right subcostal /RLQ /periumbilical pain in pregnant due to uterus displacing the appendix
```
69
Ectopic pregnancy risks
1. PID, ruptured appendix, tubal surgery
| 2. most common death in 1st trimester of mother
70
Ectopic pregnancy SX
severe LQ pain (right or left)
= 6-8 weeks ofter first period, sudden onset stabbing pain, not radiate,
= blood can accumulate in peritoneum
= orthostatic hypotension, fever
71
Ectopic pregnancy DX
1. Pregnancy test : serum beta-hCG does not double every 48hrs ****
2. US X intrauterine pregnancy (transvaginal US) with elevated serum B-hCG****
72
Ectopic pregnancy TX / DX
surgery, pharmacological, shocks, in 10% often after pelvic examination
73
Ovarian Torsion happens how
```
ovarian enlargement (cysts or masses) = ovary twists crating a fulcrum
= 70% on right side* (longer utero-ovarian lig)
```
74
Ovarian Torsion SX
1. sudden severe unilateral L abd pain (can happen after exertion), N, V, fever
2. gaurding, lower abd tenderness
75
Ovarian Torsion DX
Transvaginal US + Doppler
76
Ovarian Torsion TX
Surgical EM
77
Acute Colonic Pseudo-obstruction
other name
what is it
1. Ogilvie syndrome
| 2. spontaneous dilation of cecum or right colon (usually in ICU)
78
Acute Colonic Pseudo-obstruction SX
absennt BM, abd distension
79
Acute Colonic Pseudo-obstruction DX
Xray, CT : dilation *
| over 10cm-12cm = colon perforation
80
Acute Colonic Pseudo-obstruction TX
1. radiographs every 12hrs for size of dilation
2. recal tube placed
3. stop all anti-diarrhea drugs
4. colonoscopic decompression, surgery
81
Meckel's Diverticulitis is what
remnant of Vitelline duct from ileum
82
Meckel's Diverticulitis looks like what and SX
1. acute appendicitis
| 2. RLQ pain, N,V, rectal bleeding, reboud/guarding
83
Meckel's Diverticulitis DX
1. Angiography : see vitelline artery*
2. Meckel's scan : technetium-99m scan**
3. rule of 2** (2ft from ileocecal valve, 2& pop, 2in long, 2 types tissue (gastric or pancreatic)
84
Meckel's Diverticulitis TX
surgery
| PPIs
85
Meckel's Diverticulitis complications
1. intestinal obstruction (intussusception / volvulus) /SBO,
2. perforation
3. diverticular inflammation
86
Diverticulitis vs diverticulosis
Diverticulitis = no bleeding or hemorrhage usually
87
Diverticulitis is what
inflammation of div, microperforation --> macroperforation, abscess
88
Diverticulitis SX
1. acute LLQ pain, fever, N, V, C, loose stools (only liquids can pass due to narrowing)
89
Diverticulitis DX
= WBC
= CT + Contrast
= DONT DO : EGD, colonoscopy, sigmoidoscopy, barium enema ---- > can cause perforation
90
Diverticulitis TX
IV, NPO, ABs, after recovery do colonoscopy or barium enema
| surgery
91
Acute mesenteric ischemia (AMI) is what
inadequate BF in mesenteric vessels --> ischemia and gangrene of bowel wall (SMA)
92
Acute mesenteric ischemia (AMI) SX
Periumbillical pain more then tanderness= gut attack*, red current jelly stools
93
Acute mesenteric ischemia (AMI) DX
1. thumbprinting (submucsal edema)
| 2. CT angiography + contrast **
94
Acute mesenteric ischemia (AMI) TX
surgery
95
Chronic mesenteric ischemia (CMI)
| is what
= atherosclerosis for long time (celiac A, SMA, IMA) = reduction of BF in GI
96
Chronic mesenteric ischemia (CMI) SX
1. And angina : dull cramping, periumbilical pain, 15-30min (up to 60min) after meals lasting several hours,
2. WL, D sometimes
97
Chronic mesenteric ischemia (CMI) DX
1. CT angiography abd and pelvis + IV contrast **** see vasculature
2. Mesenteric arteriography*
98
Chronic mesenteric ischemia (CMI) TX
bypass graft surgery
99
Acute SBO usually happens how and SX
1. adhesions*, many surgeries, Crohns disease, diverticulitis
2. N/V when eating + NO BM**
3. high pitched tinkling BS**
100
Acute SBO DX
Plain ABD radiography (KBU Xray, abd series Xray) **** or CT= dilated loops of SB, air fluid levels
101
Acute SBO TX
```
Nasogastric tube (NGT)**** to suction
surgery if that doesnt help
```
102
Toxic Megacolon is what happens how
1. IBD (UC) complication
| 2. C. Diff
103
Toxic Megacolon SX
1. tachy, fever, Hypotension, adb pain distension
| 2. PMH of C.diff or IBD
104
Toxic Megacolon DX
WBCs
CT + contrast *
ABD Xray**
= no invasive risk of perforation *
105
Toxic Megacolon TX + complications
1. IVF, ABs, decompression of colon
| 2. perforation + death
106
Volvulus happen how and where
1. twisting of LI/SI --> LBO --> infarction
2. sigmoid in preg or elderly constipation = most common
3. cecum : young adults
107
Volvulus SX
bloating, preg, severe abd pain, SBO sxs
108
Volvulus DX
Bent Coffee bean sign on Xray ****
| Birds Bea sing : barium enema
109
Diarrhea is defined as what and length
3 or more loose watery stools / day
- acute : less then 2 weeks
- subacute : 15days - 4 weeks
- chronic : 4 weeks
110
Diarrhea blood works
WBC : infection
Lose Bicarbonate + Potassium (hypokalemia)
Dehydration
111
AB Associate Diarrhea how does it usually happen and SX
1. adverse effect, not from C.Diff usually, can be ab associated colitis
2. non-inflammatory, watery
112
Chronic Diarrhea most common causes
1. medications
2. IBS
3. Lactose intolarant
113
Chronic Diarrhea 2 types
1. Secretory : normal stool osmotic gap, no change when fasting (high watery D)
2. Osmotic : increase stool osmotic gap, better when fasting
114
Pathogens causing Chronic Diarrhea
1. Giardia, E. Histolytica, Cryptosporidium = protozoans
2. Strongyloidiasis Stercoralis = intestinal nematodes
3. C. Diff, Mycobacterium avium complex = bacteria
4. CMV, HIV = virus
115
4 things you measure in IBD
1. C-reactive P
2. leukocytes
3. Calprotectin
4. Lactoferrin
116
2 osmotic D
1. lactose
| 2. IBS
117
IBS is what and happens how
Visceral Hyperalgesia to mechanoreceptors stimuli
1. altered colon and SI motility at res, to stress, and drugs
2. lower pain threshold
= can happen after gastroenteritis
118
IBS SX
1. C, D = alternating
2. abd pain (lower)
3. no pathology detected
- onset 30yo, more if F
- decrease pain with BM
119
IBS DX
1. ROME IV Clinical Dx Criteria *
2. exclude other diseases
3. may have psychological problems also (OCD, depression hysteria)
120
IBS TX
- Low FODMAP diet (avoid fat, fermented carbs, alcohol
| - tx psychologic problem is present also
121
ALARM SX of chronic osmotic D
1. acute onset, older then 40yo
2. Nocturnal D
3. severe D/C
4. Hematochezia /FOBT + ----> (no blood in IBS only IBD)
5. WL, F, FH of cancer, IBD
122
Lactase Deficiency happens how
1. lactase enzyme not function or present to make glucose and galactose
2. proximal SI mucosa LD is secondary LD
123
Lactase Deficiency (secondary diseases)
1. CD, Celiac Disease, Viral gasteroenteritis
124
Lactase Deficiency DX
no dairy diets improves sx
| hydrogen breath test**
125
C. Diff infection from AB associated Colitis
happen how
what type of bacteria
what ABS
1. Anaerobic gram +, spore forming bacillus making Cytotoxin A + B (fecal oral TR)
2. elderly, hosp, many ABs, PPI, IBD
3. ampicillin, Clindamycin, 3rd gen cephalosporins, Fluoroquinolones
126
C. Diff infection from AB associated Colitis SX
1. mild to moderate greenish, foul smelling WATERY D (5-15 times per day)
2. only bloody if IBD pt (UC)
3. lower ABD cramping
127
C. Diff infection from AB associated Colitis DX
1. stool for C. Diff Toxins PCR
2. WBC : > 15,000mcL
3. Flexible sigmoidoscopy + biopsy : pseudomembranous colitis : yellow adherent plaques (epithelial ulceration volcanic exudate of fibrin and N)
128
C. Diff infection from AB associated Colitis TX
1. monitor for complications
2. wash hands with SOAP and WATER (not germX)
3. stop ABs
129
C. Diff infection from AB associated Colitis complications
Toxic megacolon (hemodynamic instability ----> perforation ----> death (surgery eeded)
130
Malabsorption syndromes SX
1. D WITH WL
2. osmotic D
3. Steatorrhea
4. Nutritional Deficiency
131
Malabsorption syndromes where and who
1. damage to proximal SI with malabsorption
| 2. HLA DQ2 DQ8, AB to tTG of gluten
132
Malabsorption syndromes SX
1. Dermatitis herpetiformis
| 2. D, IDA, ABD dist, pain
133
Malabsorption syndromes DX
1. IgA to tTG (goes away after not eating gluten for 3-12 months)
2. EGD biopsy : atrophy or scalloping of duodenal folds, loss of intestinal villi
134
Exocrine Pancreatic insufficiency happens from and SX
1. Chronic pancreatitis, CF
| 2. steatorrhea**, (cant absorb TAGs)
135
Exocrine Pancreatic insufficiency DX
Sudan stain : stain for fat
sweat chloride test
abd plain film xray
136
Bile salt malabsorption where and how
1. X bile salts becuz they cant be reabsorbed in terminal ileum **
2. usually after resecting this part from CD
137
Bile salt malabsorption SX
1. mild steatorrhea
2. X vit A, D, E, K absorption
3. bleeding, osteoporosis, hypocalcemia
4. SECRATORY WATERY D
138
Bile salt malabsorption TX
cholestyremine (bile acid resin)
139
Whipple Disease happens how and is what
1. multi-system disease (TROPHERYMA WHIPPLEI)****
| 2. infection from gram + bacillus (not fast acid)
140
Whipple Disease SX
1. WL
2. Malabsorption (hypoalbuminemia) = peripheral edema
3. Chronic D
141
Whipple Disease DX
1. PAS = periodic acid schiff : + M and bacillus
142
Whipple Disease TX + prognosis
1. antibiotic therapy, 1 yr
| 2. fatal if not Tx
143
pseudo-diarrhea
1. IBS
| 2. proctits
144
Constipation complications
1. fecal impaction, stercoral ulcers
145
Fecal impaction is what
1. impaction of recal vault can obstruct of fecal flow
| 2. can be caused from constipation
146
Fecal impaction SX
1. N/V
2. decreased appetite
3. abd distention
4. Paradoxical D : OVERFLOW incontinence (leaks around the impaction)**
5. Firm feces palpable on DRE
147
Fecal impaction TX
enemas, soft stools maintanance, and regular BM
148
Fecal impaction complications
melanosis coli (benign hyperpigmentation of the colon)
