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GI > IBD, Colon Cancer and Rectum - Exam 3 > Flashcards

IBD, Colon Cancer and Rectum - Exam 3 Flashcards

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1
Q

What are the differences between Ulcerative Colitis and Crohn’s Disease? Which one is MC in males? females?

A

UC: diffuse disease of the TOP layer of the COLON ONLY- MC in MALES

CD: patchy transmural inflammation in any segment of the GI tract, can be ANYWHERE in the GI tract and effects ALL LAYERS of the intestine- MC in FEMALES, smoking is risk factor

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2
Q

What are the lesions seen in CD called? Where is the MC location in the GI tract? Where is that sight found on the body?What does the transmural inflammation lead to?

A

skip lesions

MC = terminal ileum and +/- anus

“mass” in the RLQ (terminal ileum)

Strictures
Obstruction
Fistulas
Perforation

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3
Q

______ is strongly associated with the development of Crohn disease, resistance to medical therapy, and early disease relapse

A

Cigarette smoking

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4
Q

Chronic history of recurrent episodes of RLQ
pain and diarrhea
Crampy abdominal pain (RLQ MC)
NON-BLOODY diarrhea
weight loss
S/Sx Small bowel obstruction, fistula formation, abscess
May feel mass in right colon

A

Crohn’s disease

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5
Q

What does feeling a “mass” in the right colon when a pt has CD represent?

A

This represents thickened or matted loops of inflamed intestines

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6
Q

What are Extraintestinal Manifestations of CD? ** What are the 2 highlighted ones? Which one is MC?

A

Arthralgia, arthritis- MC

Iritis, Uveitis

Kidney Stones

Skin Disorders:
**Pyoderma gangrenosum
**Erythema nodosum

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7
Q

______ are a serious common complication seen with Crohn’s disease. How will these manifest clinically?

A

fistulas!

Infection, abscesses, problems with personal hygiene, weight loss, malnutrition, diarrhea but depend on the type of fistula

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8
Q

What are these? What are they correlated with?

A

Erythema Nodosum

Attacks correlate with bowel activity; skin lesions develop after onset of bowel symptoms, 1-5 cm hot, tender lesions on the anterior surface of lower legs, ankles and calves

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9
Q

What is this? What is it associated with?

A

Pyoderma Gangrenosum

Associated with severe disease
Lesions commonly found on dorsal surface of feet and legs, but can occur arms, chest, stoma, even face
Begins as pustule, spreads to rapidly undermine healthy skin, ulcerate with central necrotic tissue-up to 30cm

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10
Q

** What is the gold standard to dx CD? What will it show?

A

the diagnosis is Colonoscopy with biopsy

The presence of “skip areas” with a “cobblestone” may also seen pseudopolyps & granulomas

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11
Q

What are 2 important pt education points for CD?

A

NOT CURATIVE

need to stop smoking and eat a clean diet

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12
Q

With regards to age, LESS severe s/s of CD is associated with above or below 30?

A

LESS severe s/s is associated with dx OLDER than 30

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13
Q

What is the tx approach for mild CD symptoms? What region is more involved? What is the tx?

A

“step up” method: gradually progress to more potent medications

ileum region most involved

Enteric coated Budesonide (corticosteroid) 9mg qd for 4 weeks, no more than 8, then tapered by 3mg increments every 2-4 weeks for a total of 8-12 weeks of therapy aka this medication needs to be TAPERED off

-> 5-ASA if the pt does not want steroids but controversial

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14
Q

When would you consider stepping up therapy in a pt with mild CD?

A

If no improvement with Budesonide after 3-6 months, treatment escalation to immunomodulator or biologic

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15
Q

What is the tx for mild/moderate CD? What qualifies it as mild/moderate?

A

Oral prednisone 40mg qd for one week, then tapering by 5-10 mg per week with goal of tapering off over 1-2 months
Can use 5-ASA as alternative option

diffuse colitis or LEFT colonic involvement

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16
Q

After remission has been achieved in CD, what do you do next? What happens if the pt relapses?

A

After tapering and d/c, an ileocolonoscopy in 6-12 months and clinical observation

Any relapse we begin second course of a glucocorticoid, a immunomodulator (azathioprine) or biologic ( infliximab) is acceptable

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17
Q

What is the high risk criteria for CD?

A
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18
Q

**What is the tx for high risk/ moderate to severe CD?

A

TNF blockers -> infliximab (Remicade) PLUS immunomodulator -> azathioprine (Azasan)

may also need to treat fistula if present

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19
Q

What do you once a pt is in remission for CD?

A

ileocolonoscopy is performed in 6-12 months

An alternative can be glucocorticoid until remission, then maintenance with biologic agent (TNF)

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20
Q

**Where are the MC places to find UC?

A

M/C involves rectum and sigmoid colon

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21
Q

Gradual Presentation
Crampy lower abdominal pain
Relieved with defecation
Diarrhea with pus/mucus
Fecal Urgency and tenesmus
Fever, fatigue, weight loss
Anemia

What am I?
**What is the hallmark s/s?

A

Ulcerative Colitis

Bloody Diarrhea is hallmark

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22
Q

Are Extraintestinal Manifestations more commonly seen with CD or UC?

A

more commonly seen with CD

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23
Q

How is UC classified?

A

mild, moderate or severe based on how much they poop

mild: up to 4 poops (with or without blood), normal labs, ESR less than 20

moderate: 5

severe: 6+ mostly bloody, weight loss greater than 10lbs, ESR over 30 and albumin less than 3

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24
Q

_______ is actually thought to help decrease s/s in UC?

A

smoking

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25
How do you dx UC? **What is the gold standard for dx? What will you see?
Diagnosis of UC is based on presence of chronic diarrhea for more than 4 weeks and evidence of active inflammation on sigmoidoscopy Gold Standard for Diagnosis: Sigmoidoscopy will see continuous friable mucosa, edematous, with pus, bleeding and erosions, erythema May contain pseudopolyps
26
When should you NOT perform colonoscopy with UC? why?
DO NOT perform colonoscopy in patients with severe active disease or fulminant colitis!! Risk of Perforation or Megacolon: Perform after for disease extent
27
_______ is a complication of UC due to chronic inflammation causes colon to expand, dilate, and distend
Toxic Megacolon
28
Patients with long-standing UC are at increased risk for developing ______ and _____. What increases the risk?
colonic epithelial dysplasia carcinoma The risk of neoplasia in chronic UC increases with duration and extent of disease
29
What is a UC pt education point with regards to diet?
need to decrease caffeine
30
**What is the tx for mild/moderate UC proctitis?
Topical mesalamine (5-ASA) in enema, suppository form
31
** What is the tx Mild-Moderate Ulcerative Colitis extending past Sigmoid Colon? What is that doesnt work?
Oral mesalamine in conjunction with topical mesalamine oral corticosteroids if unresponsive to mesalamine therapy in 4-8 weeks
32
**What is the tx for moderate/severe UC?
Oral corticosteroids: Prednisone 40mg, then taper by 5-10mg weekly
33
When should you consider TNF or immunomodulators in the tx for UC?
Immunomodulators (azathioprine,cyclosporine) + or - TNF (infliximab) if unresponsive to corticosteroids OR if flares occur while tapering off corticosteroids
34
What is the curative tx for UC?
Total proctocolectomy with placement of ileostomy is curative
35
When is maintenance therapy indicated in UC? **What is the tx?
more than one relapse in a year All patients with ulcerative proctosigmoiditis (involving rectum/anus/sigmoid) All patients with UC proximal to sigmoid colon (left-sided colitis) **Mesalamine (oral or topical) or other 5-ASA
36
What are the 2 aminosalicylates medications? immunomodulators?
sulfasalazine, mesalamine 6-mercaptopurine, Azathioprine, and Methotrexate
37
**When are Aminosalicylates (5-ASA) contraindicated? What is the MOA?
Contraindicated if Sulfa or ASA allergy MOA: not well understood but inhinbits prostaglandin production
38
When in IBD are Corticosteroids/glucocorticoids the most effective? _____ is used in severe flares but NOT used for maintenance. ______ can be used in moderate active CD up to 3 months
Most effective to induce remission in severe flares Prednisone budesonide
39
_____ MOA inhibits DNA/RNA synthesis. What are the SE?
Immunomodulators/Immunosuppressants: Azathioprine (Imuran) 6-Mercaptopurine (6-MP) (Purinethol) SE: Leukopenia, Thrombopenia, Anemia and need to monitor CBC
40
**What is the BBW for Immunomodulators/Immunosuppressants?
mutagenic potential, rapid growing, malignancy/lymphoma
41
______ is an immunomodulator that is used if pts fail azathioprine only in CD!!!
Methotrexate- only in Crohn's disease!!
42
________ is used in severe UC/CD refractory to steroids but has multiple serious adverse effects and drug interactions
cyclosporine
43
______ is the TOC for CD fistula. What drug class? **What is the BBW?
TNF antibodies TNF antibodies: Infliximab (Remicade), Adalimumab (Humira), Certolizumab (Cimzia) **BBW: risk of serious infections
44
What abx are preferred for IBD especially with fistulas and abscess in CD?
Metronidazole (Flagyl), Ciprofloxacin (Cipro)
45
What is the recommendation for live vaccines and pt starting tx for IBD?
Any live vaccines needed should be given > 4 wks prior to start of tx pt should be UTD on vaccination before starting immunosuppressive therapy
46
What are 5 causes of IBD flare ups?
missing remission medication dosing NSAIDs- Tylenol is preferred smoking stress trigger foods
47
How often should a pt follow up with their provider? What is the colonoscopy recommendation?
Every six months when IBD is in remission More often when there is an IBD flare American Cancer Society recommends that people with IBD get their first colonoscopy at least eight years after diagnosis, and then every one to two years.
48
Pt with IBD also need to have regular _____ and ______
eye exams: at diagnosis and q1-2 years skin exams: should get regular skin exams if on biologic/immunomodulators
49
What are the 4 pathologic groups for colon polyps? **Which one is MC?
**Mucosal adenomatous polyps- MC subtypes: tubular, tubulovillous, villous Mucosal serrated polyps Mucosal non-neoplastic polyps Submucosal lesions
50
What are the 3 subtypes of Mucosal adenomatous polyps? What are risk factors?
tubular, tubulovillous, villous risk factors: Age > 50, slightly more common in men Diet (high fat, red meat, low fiber) Obesity
51
What characteristic of adenomatous polyps is more likely to be cancerous?
flat- more likely to be cancerous sessile: looks button like pedunculated: looks like a mushroom with a stalk
52
Based on their grade, which type is most and least likely to be cancerous?
Tubular - m/c - Less likely to be cancerous Tubulovillous Villous - Most likely to be cancerous
53
What risk factors are the risk factors for high-grade dysplasia/cancer?
Polyps > 1cm Villous histology Number of polyps Flat polyps
54
What age should you start screening colonoscopies? How often should you get a colonoscopy if it is normal?
start screening at 45 10 years if normal
55
What are characteristics of Mucosal Non Neoplastic Polyps?
M/C non-neoplastic polyp Can develop into adenomatous polyps M/C located in rectosigmoid area M/C small
56
What are submucosal lesions?
Mesenchymal polyps that are benign tumors
57
anemia weakness fatigue melena positive FOB weight loss proximal or distal?
proximal colon
58
change in bowel habits obstruction hematochezia urgency/tenesmus proximal or distal?
distal colon
59
What is the dx tool of choice for colon cancer? ____ is used for staging?
colonoscopy CT/MRI is used for staging
60
______ is a lab NOT for screening but level can suggest prognosis
CEA (carcinoembryonic antigen) tumor marker
61
What are the post-op follow up recommendations after a colon cancer curative resection?
62
What is Familial Adenomatous Polyposis (FAP)? What gene specifically? What is it characterized by? What age do polyps develop by? What is the tx?
Inherited Genetic mutation (APC gene) Characterized by the development of hundreds to thousands of colonic adenomatous polyps +/- in duodenum and stomach In classic FAP, colorectal polyps develop by a mean age of 15 years and cancer often by age 40 prophylactic colectomy before age 20, if they do not will develop Colorectal cancer by 50 will connect ileum to rectum once colon is removed
63
What am I? What screening is needed after dx?
Familial Adenomatous Polyposis (FAP) genetic counseling and testing, upper EGD of stomach and duodenum is performed q 1-3 years for adenomas/cancer
64
What is Lynch syndrome? How is it inherited?
Hereditary nonpolyposis colon cancer Autosomal dominant condition
65
What genetic reason is behind Lynch Syndrome? What does it increase your risk for?
Caused by mutations in a gene that detects and repairs DNA base-pair mismatches increases risk of other cancers: Endometrial/ovarian renal/bladder hepatobiliary/gastric/small intestines
66
What is the difference between Lynch Syndrome and FAP?
Lynch: only a few FLAT adenomas that are more likely to be villous FAP: round and a shit ton of them
67
What are the 3 tools for identifying an increased risk and meriting a more detailed assessment that would make you suspicious for Lynch Syndrome?
1st degree relative with colorectal/lynch-related cancer before 50? Have you (the pt) had colorectal cancer/polyps before age 50? 3 or more relatives with colorectal cancer?
68
What if a pt's genetic test comes back positive for Lynch Syndrome, what is the screening recommendations for 1st degree relatives?
If genetic mutation found, affected relatives get colonoscopy q1-2 years beginning at age 25 Women screening for endometrial/ovarian cancer at 30-35
69
What is the tx for Lynch syndrome?
Subtotal colectomy with ileorectal anastomosis Prophylactic hysterectomy and oophorectomy are recommended to women at age 40 or when finished with childbirth upper EGD q2-3 years at 30 to screen for gastric cancers
70
What are the differences between internal and external hemorrhoids? **What is the underlying cause?
internal hemorrhoids are ABOVE the dentate line external hemorrhoids are BELOW the dentate line **increased venous pressure
71
What are the 3 common internal hemorrhoid locations?
72
external hemorrhoids arise from the _______ veins located below the dentate line and are covered with ______ of the anal canal or perianal region
inferior hemorrhoidal squamous epithelium
73
What is the presentation of internal hemorrhoids?
Bleeding (think bright red blood on toilet paper or in the stool), Prolapse, Mucoid Discharge
74
What are the 4 stages of internal hemorrhoid?
75
What is the tx of hemorrhoids based on the presentation?
76
What is the presentation of external hemorrhoids? What is the tx?
Very Painful, acute onset Tense and bluish perianal nodule covered with skin that can be up to several centimeters in size Pain most severe in first few hours, but eases over 2-3 days tx:
77
What is an anal fissure? What are they caused by? **Where do they occur specifically?
Linear tears/ulcerations around the anus Usually less than 5mm Due to trauma to anal canal during defecation POSTERIOR MIDLINE
78
If a pt has an anal fissure that is off the midline, what are you thinking?
Crohn, HIV/AIDs, TB, Anal carcinoma
79
What is the tx for anal fissures? What if chronic?
Proper toileting Sitz Baths Fiber Topical anesthetics sx!
80
½ of all Perianal Abscesses caused by ______
Fistulas
81
Throbbing Continuous perianal pain erythema/fluctuance swelling What am I? What is the tx?
perianal abscess tx: I & D + / - Abx Surgical Excision
82
How does a fistula present? What is the tx?
Associated with purulent discharge that may lead to itching, tenderness, and pain tx: Fistulotomy: aka cut the tract open and leave it open
83
What is a rectal prolapse? What is the tx for a complete prolapse?
Protrusion through anus of some or all layers of the rectum sx
84
What are some risk factors for rectal prolapse?
over 40 female multiple vaginal deliveries prior pelvic surgery chronic straining/diarrhea/constipation dementia stroke pelvic floor dysfunction/anatomic defects
85
What is the tx for rectal prolapse?
Manual reduction Adequate fluid and fiber intake Kegel exercises SURGICAL CONSULT- especially for total prolapse
86
What is Pilonidal disease?
midline skin pits in the natal cleft
87
If your pt is found to have + genetic screening for Lynch syndrome when should they have their first colonoscopy?
25 years old
88
What is the most common cause of anal fissures? What is the tx?
hard stools stool softeners and proper toileting techniques
89

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