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Flashcards in Bowel Diseases II Deck (82)
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1
Q
Diseases of the Colon and Rectum
A
-Irritable bowel syndrome
-Antibiotic-associated colitis
-Inflammatory Bowel Disease (Crohns and UC)
2
Q
IBS
A
An idiopathic clinical entity characterized by chronic (more than 6 months) abdominal pain or discomfort that occurs in association with altered bowel habits
-can be continuous or intermittent
-diagnosis of exclusion
-s/s usually start in late teens to 20s, more common in women
3
Q
Definition of irritable bowel syndrome is abdominal discomfort or pain that has 2 of the following:
A
1. Relieved with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance) of stool
4
Q
Other S/S of IBS
A
abnormal stool frequency; abnormal stool form (lumpy or hard; loose or watery); abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); passage of mucus; and bloating or a feeling of abdominal discomfort
5
Q
Non GI complaints associated with IBS
A
dyspepsia, heartburn, chest pain, headaches, fatigue, myalgias, urologic dysfunction, gynecologic symptoms, anxiety, or depression
6
Q
Possible causes of IBS
A
-Abnormal Motility
-Visceral Hypersensitivity
-Enteric Infection
-Psychosocial Abnormalities
7
Q
3 categories of IBS
A
1. Irritable bowel syndrome with diarrhea
2. Irritable bowel syndrome with constipation
3. Irritable bowel syndrome with mixed constipation and diarrhea
8
Q
"Alarm symptoms” that suggest a diagnosis other than irritable bowel syndrome and warrant further investigation
A
-Acute onset of symptoms
-Nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, and fever
-Family history of cancer, inflammatory bowel disease, or celiac disease
9
Q
Physical exam with IBS
A
-usually normal
-abdominal tenderness, esp in lower abdomen is common but not pronounced
10
Q
Testing for IBS
A
-dont need routine blood tests
-stool specimen for ova/parasites
-no colonoscopy necessary in young pts
-colonoscopy in pts 50+ who haven't had one to exclude malignancy (take biopsy during)
-if diarrhea is present test for celiacs
-no hydrogen breath test for overgrowth necessary
11
Q
IBS treatment
A
-Reassurance, education, and support
-Dietary Therapy (intolerances)
-Pharmacologic Measures:
– Antispasmodic agents
– Antidiarrheal agents
– Anticonstipation agents
– Psychotropic agents
– Nonabsorbable antibiotics
– Probiotics
-Psychological Therapies (Cognitive behavioral therapies, relaxation techniques, hypnosis)
12
Q
Antibiotic Associated Colitis
A
-Occurs during the period of antibiotic exposure, is dose related, and resolves spontaneously after discontinuation of the antibiotic
-In most cases, this diarrhea is mild, self-limited, and does not require any specific laboratory evaluation or treatment
-Stool examination usually reveals no fecal leukocytes, and stool cultures reveal no pathogens
13
Q
Most cases of antibiotic-associated diarrhea are due to
A
changes in colonic bacterial fermentation of carbohydrates and are not due to C diff
14
Q
C difficile colitis is the major cause of diarrhea in
A
patients hospitalized for more than 3 days (most of whom used antibiotics)
-symptoms usually begin during or shortly after antibiotic therapy but may be delayed for up 8 weeks
(prevent with hand washing and gloves)
15
Q
________ to people who are receiving antibiotics reduced the incidence of C difficile–associated diarrhea
A
Prophylactic administration of the probiotics
16
Q
S/S of antibiotic associated Colitis
A
-Most patients report mild to moderate greenish, foul-smelling watery diarrhea 5–15 times per day with lower abdominal cramps
-Normal abdominal exam or mild left lower quadrant tenderness
-Colitis is most severe in the distal colon and rectum
-Over half of hospitalized patients diagnosed with C difficile colitis have a white blood count greater than 15,000/mcL
-Severe or fulminant disease occurs in 10–15% of patients
17
Q
Treatment for Antibiotic associated colitis
A
-Antibiotic therapy should be discontinued
-Start metronidazole, PO vancomycin, or fidaxomicin
-For patients with severe disease, PO vancomycin and IV metronidazole
-Early surgical consultation is recommended for all patients with severe or fulminant disease
-Total abdominal colectomy or loop ileostomy with colonic lavage may be required in patients with toxic megacolon, perforation, sepsis, or hemorrhage
18
Q
With antibiotic associated colitis, imaging studies for sever disease may show
A
true pseudomembranous colitis (if sever, during flexible sigmoidoscopy)
19
Q
Up to 25% of patients have a relapse of diarrhea from C difficile within 1 or 2 weeks after stopping initial therapy
– Most relapses respond promptly to _________
A
a second course of the same regimen used for the initial episode

-Probiotic therapy is recommended as adjunctive therapy in patients with relapsing disease
20
Q
For patients with two relapses, use ________
A
a 7-week tapering regimen of vancomycin is recommended
21
Q
For patients with three or more relapses, updated 2013 guidelines recommend consideration of __________
A
“fecal transplantation” from healthy donor into the terminal ileum or proximal colon (by colonoscopy) or into the duodenum and jejunum (by nasoenteric tube)
22
Q
Submucosal stripe- UC or C?
A
UC
23
Q
Full thickness enhancement- UC or C?
A
C
24
Q
Skip lesions- UC or C?
A
C
25
Q
Abscesses- UC or C?
A
C
26
Q
Fistulas- UC or C?
A
C
27
Q
Involvement of terminal ileum- UC or C?
A
C, sometimes UC
28
Q
Fibrofatty proliferation- UC or C?
A
C
29
Q
Wall thickening/Increased wall enhancement- UC or C?
A
both
30
Q
Increased signal intensity of mucosa- UC or C?
A
C
31
Q
Increased signal intensity of pericolic fat- UC or C?
A
both
32
Q
Comb sign- UC or C?
A
both
33
Q
Enlarged lymph nodes- UC or C?
A
C, sometimes UC
34
Q
Loss of haustration- UC or C?
A
UC, sometimes C
35
Q
Extension from rectum to proximal- UC or C?
A
UC
36
Q
One-third of cases of Crohn disease involve _______

Half of all cases involve __________
A
the small bowel only, most commonly the terminal ileum (ileitis)

the small bowel and colon, most often the terminal ileum and adjacent proximal ascending colon (ileocolitis)
37
Q
Unlike ulcerative colitis, Crohn disease is a transmural process that can result in __________
A
mucosal inflammation and ulceration, stricturing, fistula development, and abscess formation
38
Q
_________ is strongly associated with the development of Crohn disease, resistance to medical therapy, and early disease relapse
A
Cigarette smoking
39
Q
S/S vary from:
A
History of fevers, general sense of well-being, weight loss, the presence of abdominal pain, the number of liquid bowel movements per day, and prior surgical resections
– Physical examination should focus on the patient’s temperature, weight, and nutritional status, the presence of abdominal tenderness or an abdominal mass, rectal exam and extra intestinal manifestations
40
Q
5 common presentations of Crohns
A
1. Chronic inflammatory disease
2. Intestinal obstruction
3. Penetrating disease and fistulae
4. Perianal disease
5. Extraintestinal disease
41
Q
Labs with Crohns
A
-Poor correlation between laboratory studies and the patient’s clinical picture
-Labs may reflect inflammatory activity or nutritional complications of
-CBC and serum albumin should be obtained in all pts
42
Q
Specific lab findings with Crohns
A
-Anemia (may reflect chronic inflammation, mucosal blood loss, iron deficiency, or vitamin B12 malabsorption secondary to terminal ileal inflammation
-Leukocytosis (may reflect inflammation or abscess formation or may be secondary to corticosteroid therapy)
-Hypoalbuminemia (may be due to intestinal protein loss/protein-losing enteropathy, malabsorption, bacterial overgrowth, or chronic inflammation)
-The sedimentation rate or C-reactive protein level is elevated in many patients during active inflammation
*Autoantibodies to P-ANCA as well as antibodies to the yeast Saccharomyces cerevisiae
43
Q
Test usually performed first with Crohns testing
A
colonoscopy
44
Q
During Crohns, typical endoscopic findings include
A
aphthoid, linear or stellate ulcers, strictures, fat stranding, and segmental involvement with areas of normal-appearing mucosa adjacent to inflamed mucosa
45
Q
Complications of Crohns
A
--Abscess
– Obstruction
– Abdominal and Rectovaginal Fistulas
– Perianal Disease
– Colon carcinoma
– Hemorrhage (unusual)
– Malabsorption
46
Q
General treatment for Crohns
A
-Nutrition/Diet
-Enteral Therapy
-Total parenteral nutrition
*Symptomatic Medications
-Antidiarrheal in non-severe cases
47
Q
Specific drug therapy for Crohns
A
-5-Aminosalicyclic acid (5-ASA) agents
■ Antibiotics
■ Corticosteroids
■ Immunomodulators: Azathioprine, mercaptopurine, or methotrexate
■ Anti-TNF therapies
■ Anti-intergrins
– Surgery
■ Over 50% of patients will require at least one surgical procedure
■ Main indications for surgery are intractability to medical therapy, intra-abdominal abscess, massive bleeding, symptomatic refractory internal or perianal fistulas, and intestinal obstruction
48
Q
Ulcerative colitis is
A
an idiopathic inflammatory condition that involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding
■ Approximately one-third of patients have disease confined to the rectosigmoid region (proctosigmoiditis)
■ One-third have disease that extends to the splenic flexure (left-sided colitis)
■ One-third have disease that extends more proximally (extensive colitis)
49
Q
UC is characterized by
A
periods of symptomatic flare-ups and remissions
50
Q
Ulcerative colitis is more common in
A
nonsmokers and former smokers
■ Disease severity may be lower in active smokers and may worsen in patients who stop smoking
51
Q
Hallmark of UC
A
*bloody diarrhea*

-Severe based on stool frequency, the presence and amount of rectal bleeding, cramps, abdominal pain, fecal urgency, and tenesmus
-vitals are key
-Look for tenderness and evidence of peritoneal inflammation
-Red blood may be present on digital rectal exam
52
Q
Moderate UC
A
-4-6 stools/day
-90-100 pulse
-30-40% hematocrit
-1-10% weight loss
-99-100 F temp
-20-30 ESR
-3-3.5 albumin

MORE than this=severe UC
less= mild UC
53
Q
Treatment for mild-moderate UC
A
– 5-ASA agents
– Corticosteroids
– Immunomodulating agents
– Anti-integrin therapy
– Probiotics
54
Q
Treatment for severe and fulminant colitis
A
– NPO
– Corticosteroid therapy
– Anti-TNF therapies
– Cyclosporine
– Surgical therapy
55
Q
Colonoscopies are recommended ________ in patients with colitis, beginning ________
A
every 1–2 years

8 years after diagnosis

-At colonoscopy, all adenoma-like polyps should be resected, when possible, and biopsies obtained of non-endoscopically resectable mass lesions
-risk of colon cancer if disease is proximal to the rectum
56
Q
Almost all patients with diverticulosis have involvement in the _________
A
sigmoid and descending colon

57
Q
Diverticulosis is
A
the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. These are more common in the sigmoid colon,
-become more common after age 40 and increase incidence with age
58
Q
Diverticulosis may develop more commonly in the sigmoid because
A
intraluminal pressures are highest in this region
59
Q
Who is predisposed to diverticulosis?
A
Patients with abnormal connective tissue are also disposed to development of diverticulosis, including Ehlers-Danlos syndrome, Marfan syndrome, and scleroderma

-low fiber diet?
60
Q
Physical examination for diverticulosis pts
A
usually normal but may reveal mild left lower quadrant tenderness with a thickened, palpable sigmoid and descending colon
61
Q
Patients in whom diverticulosis is discovered, especially patients with symptoms or a history of complicated disease, should be treated with
A
a high-fiber diet or fiber supplements
62
Q
Diverticulitis
A
Perforation of a colonic diverticulum results in an intra-abdominal infection that may vary from microperforation (most common) with localized paracolic inflammation to macroperforation with either abscess or generalized peritonitis
63
Q
Common S/S of Diverticulitis
A
-Constipation or loose stools may be present
-Nausea and vomiting are frequent
-Low-grade fever, left lower quadrant tenderness, and a palpable mass
64
Q
First step when the presumptive diagnosis is diverticulitis
A
1. Mild symptoms and a presumptive diagnosis of diverticulitis, empiric medical therapy is started without further imaging in the acute phase

2. Outpatients with clear liquid diets, improvement usually within 3 days, start high fiber diet

3. Patients who respond to acute medical management should undergo complete colonic evaluation with colonoscopy or radiologic imaging after resolution of clinical symptoms to corroborate the diagnosis or exclude other disorders such as colonic neoplasms
65
Q
Patients who do not improve rapidly after 2–4 days of empiric therapy and in those with severe disease ___________
A
CT scan of the abdomen is obtained to look for evidence of diverticulitis and determine its severity
66
Q
_______ are contraindicated during the initial stages of an acute attack because of the risk of free perforation
A
Endoscopy and colonography
67
Q
-Patients with increasing pain, fever, or inability to tolerate oral fluids require hospitalization
-Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and patients who are elderly or immunosuppressed or who have serious comorbid disease require hospitalization acutely
A
-Patients should be given nothing by mouth and should receive intravenous fluids. If ileus is present, a nasogastric tube should be placed
-Intravenous antibiotics should be given to cover anaerobic and gram-negative bacteria
68
Q
Patients with a localized abdominal abscess ____ or larger are usually treated urgently with a percutaneous catheter drain placed by an interventional radiologist
A
4 cm in size
69
Q
Polyps
A
discrete mass lesions that protrude into the intestinal lumen
-most commonly sporadic
70
Q
Polyps may be divided into 4 major pathologic groups
A
1. Mucosal adenomatous polyps (tubular, tubulovillous, and villous)
2. Mucosal serrated polyps (hyperplastic, sessile serrated polyps, and traditional serrated adenoma)
3. Mucosal nonneoplastic polyps (juvenile polyps, hamartomas, inflammatory polyps)
4. Submucosal lesions (lipomas, lymphoid aggregates, carcinoids, pneumatosis cystoides intestinalis)
71
Q
Familial Adenomatous Polyposis
A
-colorectal polyps develop by a mean age of 15 years and cancer at 40 years
-Unless prophylactic colectomy is performed, colorectal cancer is inevitable by age 50 years
72
Q
With FAP, you have a development of a variety of other benign extraintestinal manifestations, including
A
soft tissue tumors of the skin, desmoid tumors, osteomas, and congenital hypertrophy of the retinal pigment
73
Q
Treatment for FAP
A
complete proctocolectomy with ileoanal anastomosis or colectomy with ileorectal anastomosis is recommended, usually before age 20 years
74
Q
Peutz-Jeghers Syndrome
A
-harmatomatous polyposis syndrome
-Autosomal dominant condition characterized by hamartomatous polyps throughout the gastrointestinal tract as well as *mucocutaneous pigmented macules on the lips, buccal mucosa, and skin*
75
Q
Familial juvenile polyposis
A
-harmatomatous polyposis syndrome
-Autosomal dominant and is characterized by several juvenile hamartomatous polyps located most commonly in the colon
76
Q
PTEN multiple hamartoma syndrome (Cowden disease)
A
-harmatomatous polyposis syndrome
-Hamartomatous polyps and lipomas throughout the gastrointestinal tract, trichilemmomas, and cerebellar lesions *(CNS problems)*
77
Q
Lynch Syndrome
A
(also known as hereditary nonpolyposis colon cancer [HNPCC]) is an autosomal dominant condition in which there is a markedly increased risk of developing colorectal cancer as well as a host of other cancers, including endometrial, ovarian, renal or vesical, hepatobiliary, gastric, and small intestinal cancers
78
Q
If genetic testing documents a Lynch syndrome gene mutation, affected relatives should be screened with colonoscopy ______
A
every 1–2 years beginning at age 25 (or at age 5 years younger than the age at diagnosis of the youngest affected family member)
79
Q
If cancer is found with Lynch Syndrome, _________
A
subtotal colectomy with ileorectal anastomosis (followed by annual surveillance of the rectal stump) should be performed
80
Q
With Lynch Syndrome, women should undergo screening for endometrial and ovarian cancer beginning at age
A
30–35 years with pelvic examination, transvaginal ultrasound, and endometrial sampling
81
Q
Prophylactic hysterectomy and oophorectomy is recommended to women at age ________
A
40 or once they have finished childbearing
82
Q
With Lynch Syndrome, screening for gastric cancer with upper endoscopy should be considered every ________
A
2–3 years beginning at age 30–35 years