GI 2

Question 1

PEPTIC ULCER DISEASE (PUD):
1) Define
2) What is the pathogenesis?
3) What is the etiology?
4) What is the epidemiology?

Answer 1

1) Gastric/duodenal mucosal disruption through muscularis mucosae, usually > 5 mm diameter
2) Occurs in setting of impaired or overwhelmed normal mucosal defensive factors
3) NSAIDs & chronic H. pylori infection, CMV, Crohn’s disease, lymphoma, medications, chronic medical illness, idiopathic
4) ~500K new cases/yr, 4 million recurrences. Life prevalence in adults ~10%. Duodenal m/c 30-55 y/o, gastric m/c 55-70 y/o

Question 2

PUD:
1) What are the risk factors?
2) What would their history show?
3) What are the Sx?

Answer 2

1) H. pylori, NSAIDs, smoking
2) dyspepsia (80-90%), +/- relation to meals
3) Epigastric pain, improvement with milk/food/antacids (duodenal), worse with food (gastric), nausea, avoidance of food/anorexia, weight loss

Question 3

PUD:
1) What are some alarm features for penetration/perforation?
2) What are some alarm features for obstruction?

Answer 3

1) Melena, hematemesis, guaiac-positive stools, unexplained anemia
2) Persistent vomiting (including liquids and saliva,) bloody emesis or melena, unexplained weight loss

Question 4

How should you eval PUD?

Answer 4

1) EGD preferred over barium contrast radiology (higher diagnostic yield)
a) Gastric biopsy to r/o H. pylori.
b) Biopsy ulcer or repeat EGD to document healing to r/o malignancy

Question 5

PUD complications:
1) Sx of GI hemorrhage (up to 15%)?
2) Sx of Perforation (up to 7%)?
3) Sx of Gastric outlet obstruction (< 2%)?

Answer 5

1) Hematemesis (coffee-ground emesis,) black tarry stool (melena)
2) Severe abdominal pain, rigid abdomen (peritonitis)
3) Nausea, vomiting, early satiety, unexplained weight loss, dehydration, electrolyte imbalances

Question 6

What are the 3 categories of PUD Tx?

Answer 6

Acid anti-secretory agents, mucosal protective agents, & H. pylori eradication agents

Question 7

PUD Tx
1) What 2 categories are included in acid-antisecretory agents?
2) List members of each

Answer 7

1) Proton pump inhibitors (PPI), H2-receptor antagonists
2) PPIs: OTC omeprazole, esomeprazole, lansoprazole. Rx dexlansoprazole, pantoprazole, rabeprazole
H2RA: famotidine, nizatidine, cimetidine

Question 8

PUD Tx:
1) Give examples of mucosal protective agents
2) Give examples of H. pylori eradication agents

Answer 8

1) Bismuth, sucralfate
2) Quadruple therapy regimen recommended (triple therapy no longer recommended) bismuth/TCN/PPI/metronidazole

Question 9

PUD Tx: What do you need to do for H. pylori-associated ulcers?

Answer 9

Treat with appropriate regimen to relieve dyspeptic symptoms, promote healing, and eradicate infection
**Confirm eradication 4 weeks after completion of therapy (urea breath test or fecal antigen test)
Determine need for continued PPI or H2RA (2-4 wks duodenal, 4-6 wks gastric)

Question 10

What should you know about treating H. pylori (PUD)?

Answer 10

Macrolide resistance
Strict alcohol avoidance with metronidazole
Initial & salvage treatment tables
Quadruple therapy (individual Rx or PPI + pylera $$$) $1K
Newest regimen - Talicia (omeprazole/amoxicillin/rifabutin) $700

Question 11

PUD: How should you Tx NSAID-induced ulcers?

Answer 11

1) D/c offending agent (if possible)
2) Test for H. pylori (not serum) and treat if positive
3) Treat with PPI or H2RA
4) Consider continued daily PPI therapy for prevention in high-risk patients (NSAIDs, antiplatelet therapy)

Question 12

List the 3 subtypes of gastritis and their etiologies

Answer 12

Erosive - NSAIDs
Hemorrhagic – NSAIDs, alcoholics
Infectious – same as esophagitis

Question 13

Gastritis:
1) What is it?
2) What are the Sx?

Answer 13

1) Inflammation of the lining of the stomach
2) May be aymptomatic, but symptoms can include anorexia, n/v, epigastric pain, possible UGIB

Question 14

Gastritis:
1) Who is at higher risk?
2) What do these pts need?
3) What should you give?
4) What should you prophylactically Tx with?

Answer 14

1) Critically ill and mechanically ventilated patients at higher risk.
2) Parenteral feedings when able
3) IV PPI
4) Should prophylactically treat with PPI

Question 15

Give the OLDCARTS for gastritis

Answer 15

O – acute
L – epigastrum
D- continual
C - burning
A – melena, UGIB, nausea, heartburn, GERD
R – PPIs, antacids, mylanta, pepto
T – anytime, especially after eating
S – moderate, may have big impact on ADLs

Question 16

Gastritis: What are some DDxs?

Answer 16

GERD, dyspepsia, gastroenteritis, biliary tract  disease, PUD, pancreatic disease

Question 17

How do you Tx gastritis?
What should be discontinued?

Answer 17

1) PPIs (esomeprazole 40 mg PO QD x 2-4 weeks,) sucralfate tabs or susp 1 gm or 1 gm/10 mL PO BID – QID with meals
2) d/c NSAIDs, anticoagulants, alcohol, spicy and greasy foods

Question 18

1) How long is the rectum?
2) Where is the anus?

Answer 18

1) Approx. 15 cm in length
2) 3-4 cm from dentate line to anal verge

Question 19

1) What should eval for gastritis include?
2) What may EGD results show?

Answer 19

1) CBC to check for anemia, if necessary; patients with alarm features, anemia, severe pain or treatment failures should undergo EGD
2) Erythema, superficial erosions or ulcerations

Question 20

What are the Sx of diseases of the anus and rectum?

Answer 20

Pain, protrusion, bleeding, discharge

Question 21

Disease of anus and rectum: Most everyone complains of ____________________

Answer 21

hemorrhoids

Question 22

What should anus and rectum disease exam include?

Answer 22

Must examine, but be gentle NO LONG FINGERNAILS
1) Visual inspection: fissures, skin tags, hemorrhoids, fistulae, tumors, dermatologic or infectious conditions
2) Digital exam: tumors, polyps, sphincter weakness

Question 23

Perirectal abscess:
1) What is it?
2) What are the S/Sx?
3) What will you see on exam?

Answer 23

1) Local infection of perirectal spaces secondary to obstruction of anal glands & ducts
2) Anal pain, possible swelling or fever
3) Tender mass adjacent to anal canal

Question 24

Perirectal abscess:
1) How do you Dx?
2) Tx?

Answer 24

1) CT or MRI helpful (esp in Crohns)
2) Incision & drainage for ALL abscesses, antibiotics for immunocompromised or cellulitis

Question 25

Anorectal fistula: 1) What is it? 2) What are other causes? 3) What imaging do you want to get?

Answer 25

1) Tract connecting anal canal to perianal skin 2) Crohn’s, obstetric injury, radiation proctitis, rectal FB, infectious disease, malignancy 3) MRI pelvis or EUS

Question 26

Anorectal fistula: 1) Sx? 2) What will you see on exam?

Answer 26

1) Intermittent rectal pain, intermittent & malodorous perianal drainage & pruritis 2) Excoriated or inflamed skin, external opening, palpable cord, DRE, probe, anoscope, sigmoidoscopy

Question 27

Anorectal fistula: 1) How are they classified? 2) What are some DDxs?

Answer 27

1) Defined by tissues traversed 1) Anal abscess or fissure, Hidradenitis, Pilonidal disease

Question 28

Hemorrhoids: 1) What are they? 2) What are they precipitated by?

Answer 28

1) Enlarged & inflamed vein in anus & rectum 2) Constipation, straining, pregnancy, increased pelvic pressure (ascites, tumor), portal hypertension

Question 29

Hemorrhoids: 1) What are the 3 positions they're found in? 2) What is the presentation? 3) Describe the bleeding

Answer 29

1) Left lateral, right anterior, right posterior 2) Protrusion, bleeding, pain, itching (Severe pain with thrombosis) 3) Bleeding usually minimal, coats stool, bright red

Question 30

Differentiate external and internal hemorrhoids

Answer 30

1) Above dentate line -Graded 1-4 -Produce painless BRBPR 2) Below dentate line -Painful and often associated with fissures

Question 31

For all patients with hemorrhoids, what should you recommend for: 1) Dietary & lifestyle modification 2) Medications for symptomatic relief

Answer 31

1) 20-30 g insoluble fiber/day (dietary +/- supplemental), -1.5-2L water/day, avoid straining/lingering, regular exercise (but not heavy weightlifting,) avoid meds causing constipation or diarrhea 2) Topical analgesics & steroids, antispasmodic agents (NTG), Sitz baths

Question 32

Hemorrhoids: 1) What is the medical Tx? 2) What is the surgical Tx?

Answer 32

1) Grades 1 & 2: Fiber & Sitz baths, rubber band ligation (RBL) 2) Grades 2-4 (failed conservative treatment): surgery Thrombosed external: excision within 48 hours

Question 33

Anal fissure: 1) Define this condition 2) What is common in a pt's Hx? 3) Sx? 4) How is it Dx'd?

Answer 33

1) Tear in anoderm distal to dentate line (acute & chronic) 2) History of constipation common; passage of hard stools 3) Symptoms: intense pain with defecation, rectal bleeding 4) Dx: PE

Question 34

Anal fissure: 1) Where do most occur? 2) What are concerns with lateral fissures? 3) What will you see with chronic anal fissures?

Answer 34

1) 90% at posterior midline 2) Crohn’s, infections (TB, HIV/AIDS, syphilis) 3) Heaped up epidermis (sentinel tag)

Question 35

Anal fissures: 1) What is the initial Tx? 2) What is the refractory Tx?

Answer 35

1) Fiber supplementation, Sitz baths, topical CCB or NTG 2) Surgery (sphincterotomy)

Question 36

1) What is the universal definition of constipation? 2) What are patient's definition of conspitation?

Answer 36

1) Less than 3 stools per week 2) Infrequent stools, hard or small stools, excessive straining, sense of incomplete evacuation

Question 37

Constipation: Who is it more common in?

Answer 37

15% kids, adults, ~1/3 elderly, F > M

Question 38

List some primary and secondary etiologies of constipation

Answer 38

1) No structural abnormalities or systemic disease Slow colonic transit time (women; depression, anxiety) 2) Systemic disorders, medications, obstructing colonic lesions (uncommon, investigate alarm features)

Question 39

Constipation: 1) Name some systemic diseases that can cause it 2) Name some medications 3) Name some structural abnormalities

Answer 39

1) Hypothyroidism, DM, MS 2) Opioids, diuretics, some CCB, iron 3) Anorectal, mass, stricture

Question 40

List some other causes of constipation

Answer 40

-Slow colonic transit -Pelvic floor dyssynergia -Irritable Bowel Syndrome (IBS) -Pregnancy

Question 41

Constipation: 1) What should Hx and PE include? 2) What should you distinguish?

Answer 41

1) History & physical exam: patient’s definition, Bristol stool type+ Digital rectal exam (DRE) 2) Distinguish type (slow colonic transit, medication-induced, opioid induced)

Question 42

Constipation: What are situations in which a pt will need further diagnostic testing?

Answer 42

If any of the following: 1) > 50 y/o 2) Severe constipation 3) Signs of organic disorder 4) Alarm symptoms 5) FHx colon cancer or IBD

Question 43

Chronic constipation: 1) What are some additional diagnostic tests that can be done? 2) What should you Tx with?

Answer 43

1) CBC, Sr electrolytes, calcium, glucose, TSH, +/- colonoscopy 2) Dietary and lifestyle measures

Question 44

What are some dietary and lifestyle measures for chronic constipation Tx?

Answer 44

1) Address adverse psychosocial issues 2) Education: defecatory function & optimal toileting 3) Adequate fluid & fiber intake (*trial of fiber supplement*) 4) Encourage regular exercise 5) Discontinue constipating medications when possible + probiotics (more studies needed)

Question 45

What are 4 categories of chronic constipation Tx? Give examples of each

Answer 45

1) Osmotic: lactulose, Miralax (PEG), magnesium citrate 2) Stimulant: bisacodyl (Dulcolax), senna 3) Secretagogues: lubiprostone (Amitiza), linaclotide (Linzess), plecanatide (Trulance) 4) Opioid-receptor antagonist: methylnaltrexone (Relistor), naloxegol (Movantik), naldemedine (Symproic)

Question 46

True or false: Treatment with laxatives can be used intermittently or chronically for chronic constipation

Answer 46

True

Question 47

Describe how to approach chronic constipation Tx

Answer 47

1) Start with dietary & lifestyle measures 2) Trial of laxatives if no response to dietary & lifestyle changes a) Start with osmotics (safe in most cases) b) Trial of stimulants for no response to osmotics c) Use secretagogues for IBS-C or suboptimal response and/or side effects to less expensive agents d) Use opioid-receptor antagonists for opioid induced constipation e) Combination therapy may be needed

Question 48

1) Define fecal impaction 2) What may it result in?

Answer 48

1) Severe impaction of stool in rectal vault 2) Partial or complete large bowel obstruction

Question 49

Fecal impaction: 1) What are some predisposing factors? 2) What are some features?

Answer 49

1) Elderly, medications, prolonged bed rest, neurogenic disorders of colon, spinal cord disorders 2) Decreased appetite, n/v, abdominal pain & distention, + firm feces in rectal vault

Question 50

How do you Tx fecal impaction?

Answer 50

1) Relieve impaction with enemas (saline, mineral oil, tap-water) or digital disruption 2) Long-term care: maintain soft stools & regular bowel movements

Question 51

What is the diverticulum? Define diverticulosis

Answer 51

1) sac-like mucosal protrusion of the colonic wall 2) presence of diverticula

Question 52

Diverticular disease can cause symptoms due to what 2 things?

Answer 52

Diverticular bleeding Diverticulitis

Question 53

Diverticular disease: Explain the epidemiology

Answer 53

1) Prevalence: 20% at age 40, 60% at age 60 95% located in sigmoid (U.S.); some diffuse 2) Predominantly right-sided in Asians 3) Diverticular bleeding 5-15%; massive in 1/3 of these 4) Diverticulitis 4-15% (increases with age)

Question 54

What are some risk factors for diverticular disease?

Answer 54

1) Diet: low fiber, high fat/red meat 2) Physical inactivity 3) Obesity 4) Smoking

Question 55

Diverticulosis: 1) What are the Sx? 2) What is seen on PE? 3) What is the Tx?

Answer 55

1) Uncomplicated & asymptomatic disease in > 90% (no imaging needed) 2) Usually normal exam 3) Encourage increased dietary or supplemental fiber, exercise, & avoidance of red meats & NSAIDs

Question 56

Diverticulitis: 1) Define it 2) Where is it most commonly managed? 3) What are the main categories?

Answer 56

1) Inflammation and/or infection of a diverticulum 2) Most commonly managed in ambulatory setting 3) Acute or chronic; Uncomplicated or complicated (abscess, fistula, stricture, bowel obstruction, perforation, or peritonitis)

Question 57

Diverticulitis: 1) What is the most common Sx? 2) What are some other Sxs?

Answer 57

1) LLQ pain most common (may have RLQ or suprapubic pain) 2) + fever, nausea, vomiting, constipation, or diarrhea

Question 58

Acute diverticulitis: 1) Who should you suspect it in? 2) What are 2 supportive Sx? 3) What is required? 4) What should be avoided?

Answer 58

1) Pt with lower abdominal pain with tenderness on exam 2) Leukocytosis, fevers are supportive 3) Abdominal imaging required (CT with oral & IV contrast) 4) No role for colonoscopy & should avoid due to risk of perforation *Delayed colonoscopy 6-8 weeks after recovery to rule out colorectal cancer (unless colonoscopy within the previous year)

Question 59

How do you manage acute diverticulitis outpatient?

Answer 59

Most can be managed without antibiotics: 1) Pain control (acetaminophen, ibuprofen, or oxycodone) 2) Liquid diet 3) Reassessment in 2-3 days with weekly evals until complete resolution 4) Repeat imaging only if failure to progress clinically 5) Admission for patients not improving

Question 60

Acute diverticulitis Tx: 1) When should you use abx? 2) What are the abx options?

Answer 60

1) Used selectively for uncomplicated disease (immunocompromised, significant comorbid disease, or small pericolonic abscesses < 3-4 cm) 2) Amoxicillin-clavulanate potassium 875/125 mg PO BID x 7-10 days -Metronidazole 500 mg TID + ciprofloxacin 500 mg PO BID or TMP/SMX 160/800 mg PO BID x 7-10 days

Question 61

What else should you do for pts w acute diverticulitis who you Rx abx to?

Answer 61

Pain control, liquid diet, & reassessment

Question 62

Describe inpatient mgmt of acute diverticulitis

Answer 62

1) IV antibiotics 2) IV hydration 3) IV pain medications 4) Complete bowel rest or liquid diet

Question 63

Describe surgical management of acute diverticulitis

Answer 63

1) Surgical consultation & repeat abdominal CT for severe disease or failure to improve after 72 hours of medical management 2) Emergent surgery for generalized peritonitis, large undrainable abscesses, & clinical deterioration despite medical management & percutaneous drainage 3) Percutaneous catheter for drainage of larger abscesses (IR)

Question 64

Diverticular bleeding: 1) What is it the most common cause of? 2) How does it typically present? 3) What are some other Sx?

Answer 64

1) Brisk hematochezia (maroon or bright red blood) 2) Painless, brisk hematochezia 3) May have bloating, cramping, or urge to defecate

Question 65

Diverticular bleeding: 1) What Sx are assoc with severe and ongoing bleeding? 2) What is the usual volume? Outpatient or inpatient?

Answer 65

1) Tachycardia & hypotension associated with severe & ongoing bleeding 2) Usually large-volume & usually requires hospitalization

Question 66

Diverticular bleeding: What usually happens to these pts?

Answer 66

1) Bleeding stops on its own in most cases (~1/3 require intervention) -Need for surgery is rare

Question 67

Diverticular bleeding: 1) How to Dx? 2) Mgmt?

Answer 67

1) Colonoscopy is test of choice for HD stable patients when bleeding abates CT angiography for patients with severe, ongoing bleeding resulting in HD instability 2) Resuscitation Treatment of bleeding site (endoscopic therapy, angiography & embolization, surgery)

Question 68

IBD 1) What 2 conditions does it include? 2) What can each involve? 3) What are the features and mgmt?

Answer 68

1) Includes Crohn disease (Crohn’s) & ulcerative colitis (UC) 2) Crohn’s can involve any part of GI tract from mouth to anus UC affects only the colon 3) Some different pathologic & clinical features Individualized approach to management

Question 69

What is the epidemiology of IBD?

Answer 69

1) Bimodal onset age 15-30 & 50-80 (can occur at any age) 2) Adult-onset UC: M>F, Crohn’s: F>M (in US) 3) Jewish > non-Jewish; caucasian > AA & Hispanic

Question 70

What is the pathophys of IBD?

Answer 70

1) Not well-understood 2) Current understanding: hyperreactivity or loss of tolerance of the mucosal immune system to one’s own mucosal microbiota

Question 71

List the findings with IBD

Answer 71

1) Transmural inflammation & skip areas (segments of normal-appearing bowel interrupted by areas of disease) 2) Possible fibrosis & strictures leading to obstruction (not seen in UC) 3) Possible sinus tracts leading to microperforations & fistula formation 4) Most commonly involves terminal ileum & proximal colon

Question 72

IBD: Crohn disease (Crohn’s): What are the clinical features?

Answer 72

1) Smoking increases risk for CD but may lower risk of developing UC 2) Crampy abdominal pain (most common presenting symptom) 3) Diarrhea + gross bleeding 4) Fatigue 5) Weight loss

Question 73

Describe the external manifestations of Crohn's disease (an IBD)

Answer 73

1) Arthritis or arthropathy: oligoarticular or polyarticular nondeforming peripheral arthritis (most frequent extraintestinal manifestation in IBD); ankylosing spondylitis 2) Eyes: uveitis, iritis, & episcleritis 3) Skin: pyoderma gangrenosum & erythema nodosum oral ulcers

Question 74

Ulcerative colitis (UC; an IBD): 1) What is it? 2) Where is it?

Answer 74

1) Chronic inflammatory condition of relapsing & remitting episodes of inflammation 2) Limited to mucosal layer of colon Almost always involves rectum Extends proximally continuous from rectum

Question 75

Ulcerative colitis (UC; an IBD) is described by extent of involvement, give some examples

Answer 75

1) Ulcerative proctitis (rectum only) 2) Ulcerative proctosigmoiditis (rectum & sigmoid) 3) Left-sided colitis (up to splenic flexure) 4) Extensive colitis (proximal to splenic flexure)

Question 76

What are some clinical features of UC?

Answer 76

1) Lower risk with smoking 2) Diarrhea + blood 3) Frequent, small-volume bowel movements 4) Colicky abdominal pain (usually left-sided) 5) Urgency, tenesmus, incontinence, fever, fatigue, weight loss

Question 77

Ulcerative colitis (UC; an IBD): List the external manifestations

Answer 77

1) Musculoskeletal: oligoarticular or polyarticular nondeforming peripheral arthritis (most frequent extraintestinal manifestations in IBD); spondylitis or sacroiliitis 2) Eyes: episcleritis & uveitis (burning, itching, redness) 3) Skin: erythema nodosum & pyoderma gangrenosum 4) Oral ulcers (aphthous; buccal mucosa & lips)

Question 78

What are some diagnostic tests for IBDs?

Answer 78

1) CBC, CMP, CRP, ESR, fecal calprotectin (or lactoferrin) 2) Rule out bacterial, parasitic & C. diff infections 3) CT scan with oral & IV contrast to assess for abscesses 4) *Colonoscopy with biopsies

Question 79

IBD: Give the histology for Crohn's and UC

Answer 79

1) Crohn’s disease: Focal ulcerations; Acute and chronic inflammation; Granulomas 2) UC: Crypt abscesses + crypt atrophy

Question 80

List the categories of drugs used to Tx IBDs and give examples

Answer 80

1) Glucocorticoids *short term* (prednisone, budesonide)(topicals for UC mesalamine: suppositories & enemas; glucocorticoids: suppository, foam, enema (hydrocortisone). 2) Oral 5-aminosalicylates (aka, 5-ASA)(sulfasalazine, mesalamine)(topical mesalamine for UC) Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate) 3) Biologic therapies (infliximab, adalimumab, certolizumab pegol, natalizumab, vedolizumab, ustekinumab)

Question 81

Describe IBD management

Answer 81

1) Individualized approach to management 2) Goal of therapy: achieve remission (endoscopic, histologic & clinical) by demonstrating complete mucosal healing