GI/nutritional part 3 Flashcards
(39 cards)
Pathophys and etiology of anal fissure
Initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement
Low-fiber diets are associated with their development
Prior anal surgery is a predisposing factor
Hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures
Hx of anal fissure
Severe pain during a BM, with the pain lasting several minutes to hours afterward
Pain recurs with every BM, and the pt commonly becomes afraid or unwilling to have a BM
This leads to a cycle of worsening constipation, harder stools, and more anal pain
BRB on the toilet paper or stool
Where do most anal fissures occur?
Posterior midline
Workup of anal fissure
If fissure is off the midline or irregular, or if underlying issues present: ESR Stool and viral cultures HIV testing Bx of the lesion or fissure For recurrent or no healing: Anoscopy and rigid proctoscopy
Tx of anal fissure
Failure of medical therapy or symptomatic chronic fissure: surgery
with stool-bulking agents
Mineral oil to facilitate easier passage of stool
Sitz baths after BMs
Second-line: intra-anal application of NTG
Pathophys and etiology of anal fistula
Most originate in anal crypts, which become infected, with ensuing abscess formation. When the abscess is opened or when it ruptures, a fistula is formed
Opened perianal or ischiorectal abscesses
4 general types:
Intersphincteric
Transsphincteric
Suprasphincteric
Extrasphincteric
Hx of anal fistula
Recurrent malodorous perianal drainage, pruritis, recurrent abscesses, fever, or perianal pain
Pain occurs with sitting, moving, defecating, and even coughing
Usually throbbing in quality and is constant throughout the day
PE of anal fistula
Can be ID-ed by small circles of granulation tissue, which exude pus when compressed if tissue is patent
Inguinal LNs may be enlarged and painful
If abscess is also present, erythema, pain, increased temperature, edema may be found
Workup of anal fistula
If concurrent abscess present, and location and size is not well characterized, advanced imaging may be needed
Blood work for clinical sings of sepsis or those who appear toxic
Tx of anal fistula
Surgery
Pathophys of anorectal abscess
Arises predominately from the obstruction of anal crypts, possibly involving increased sphincter tone
Infection of the now static glandular secretions results in suppuration and abscess within the anal gland
Etiology of anorectal abscess
Both anaerobic and aerobic bacteria Most common anaerobes: -B. fragilis -Peptostreptococcus -Prevotella -Fusobacterium -Porphyromonas -Clostridium Most common aerobes: -S. aureus -Streptococcus -E. coli
Hx of anorectal abscess
Classic locations, from highest to lowest:
-Perianal
-Ischiorectal
-Intersphincteric
-Supralevator
-Submucosal
Perirectal pain that is indolent in nature
Dull perianal discomfort and pruritis
Pain often exacerbated by movement and increased perineal pressure from sitting or defecation
Constipation
Hx of ischiorectal abscess
Systemic fevers
Chills
Severe perirectal pain and fullness consistent
Erythema, induration, or fluctuance
PE of anorectal abscess
Usually nl vitals
Small, erythematou, well-defined, fluctuant, subcutaneous mass near the oral orifice
For ischiorectal, may need to use anesthesia
Workup of anorectal abscess
Suspected perirectal abscess or systemic dz: CBC with diff
Collect wound cultures with all I and Ds
CT for intersphincteric or supralevator
Tx of anorectal abscess
Simple- can treat with I and D in ED More complex need surgeon Use abx with: -Systemic inflammatory response or sepsis -Extensive cellulitis -DM -Immunosuppression -Heart valve abnormalities or prostheses Use vanc or Bactrim
Pathophys of cirrhosis
A diffuse hepatic process characterized by fibrosis and the conversion of nl liver architecture to structurally abnormal nodules
Portal hypertension results from a combination of increased portal venous inflow and increased resistance to portal blood flow
Etiology of cirrhosis
Hep C in the US MCC, then alcoholic liver disease
Crytogenic cirrhosis: NAFLD in many cases
Presentation of cirrhosis
Portal hypertension Ascites: -Abdominal distention -Bulging flanks -Shifting dullness -Elicitation of a puddle sign with pts in the knee-elbow position Hepatorenal syndrome Hepatic encephalopathy - Marked by personality changes, intellectual impairment, and a depressed level of consciousness These and additional sx vary based on cause Fatigue Anorexia Wt loss Muscle wasting Jaundice Spider angiomata Skin telangiectasias Palmar erythema White nails Disapparance of lunulae Finger clubbing Anemia
Tx of cirrhosis
Hepatic encephalopathy- lactulose 1st line, abx second line
Ascites- sodium restriction first line, diuretcs second line
Hepatorenal syndrome: avoid nephrotoxic meds. Early- albumin and FFP, avoidance of diuretics
Zinc sulfate
Antihistamines and topical ammonium lactate for pruritis
Nutritional supplements
Exercise
Liver transplant for decompensated cirrhosis
Workup of cirrhosis
Hepatorenal syndrome:
Diagnosed when CrCl is <40 or when SCr is >1.5, urine volume of <500 mL/day, and a urine sodium level of <10 is present
Hepatic encephalopathy:
Elevated arterial or free venous serum ammonia level
EEG changes of high-amplitude low-frequency waves and triphasic waves. Only do this test to r/o seizure activity
Portal HTN: gold standard is HVPG measurement
Ascites: paracentesis
>250 PMNs/ mm cubed defines neutrocytic ascites and SBP
Lymphocyte-predominant acites raises concerns about the possibility of underlying malignancy or tuberculosis
CBC
Assessing severity of cirrhosis
MELD score:
Calculated by evaluating creatinine, bilirubin, INR, and whether pt has had hemodialysis twice in the prior week
Ranges from 6-40 pts
Pathophys of esophagitis
Reflux esophagitis Infectious esophagitis -Fungal -Viral -TB Pill esophagitis Eosinophilic esophagitis Radiation and chemoradiation esophagitis
