Intestine 1

Question 1

Infrequent stools (<3/week), hard or lumpy stools, excessive straining, sense of abdominal fullness, sense of incomplete evacuation

Decreased appetite, N/V (feculent), diarrhea, palpable stool in colon

Answer 1

constipation

Question 2

what are alarm symptoms for constipation?

Answer 2

hematochezia, weight loss, anemia, FOBT or FIT, history of family colon cancer

Question 3

what are risk factors for constipation?

Answer 3

Comorbidities, medications, poor eating, decreased motility, inability to sit on a toilet

> 50 should be evaluated for colon cancer

Question 4

What causes constipation

Answer 4

MCC:
– inadequate fiber or fluid intake
– poor bowel habits
– irritable bowel syndrome

OR: systemic disease, medications, structural abnormalities, slow colonic transit, pelvic floor dyssynergia

Primary* (not related to disease) or secondary (disease, medications, lesions)

Question 5

Exclude lesions in colonoscopy if

Answer 5

> 50 years
Alarm symptoms → hematochezia, weight loss, anemia, + feces occult
Family history of colon cancer

Question 6

normal stool function

Answer 6

Normal function = 3 stools/day → 3 stools/week

Question 7

DRE – assess anatomic abnormalities + pelvic floor motion
Ask patient to “bear down” + assess muscle tone
Ask them to “strain” to assess pelvic floor and ability to defecate
Labs: CBC, electrolytes, calcium, glucose, TSH

Anorectal manometry w/ balloon expulsion test (defecatory disorders)
Imaging not required unless meeting criteria

Answer 7

constipation

Question 8

further diagnostics for constipation in

Answer 8

Patients 45-50 or older w/ no prior screening
“Alarm” symptoms
Family history

Question 9

What’s treatment for constipation?

Answer 9

Dietary + lifestyle measures – optimize toileting habits, adequate dietary fluid + fiber intake, regular exercise, discontinue meds, maybe probiotics

Fiber laxatives – psyllium, methylcellulose, calcium polycarbophil, guar gum

Laxatives –
intermittent or chronic for constipation not responding to lifestyle changes
→ osmotic (FL) - polyethylene glycol/Miralax or magnesium citrate, stimulant (rescue - bisacodyl), secretagogues (less optimal - lubiprostone), serotonin 5-HT4-receptor agonist (prucalopride), opioid-receptor antagonist (for those with opioid-induced constipation that have not responded to other medications)

Also: stool surfactants, enemas

Question 10

use laxatives for constipation if

Answer 10

not responding to lifestyle changes

Question 11

what are osmotic constipation treatments

Answer 11

polyethylene glycol/Miralax or magnesium citrate, stimulant (rescue - bisacodyl), secretagogues (less optimal - lubiprostone), serotonin 5-HT4-receptor agonist (prucalopride)

Question 12

Decreased appetite, abdominal pain/distention, N/V (f), possible diarrhea, bowel obstruction

Answer 12

fecal impaction

Question 13

fecal impaction is common in

Answer 13

institutionalized elderly patients

Question 14

how do you treat a fecal impaction

Answer 14

Digital disruption of impaction
Enema to allow digital disruption
– saline, mineral oil, soap suds

Question 15

Decreased appetite, pain in RLQ, fever
Starts with vague, periumbilical or epigastric pain → shifts to RLQ
Vomiting occurs after pain

Answer 15

appendecitis

Question 16

what are atypical appendcitis symptoms

Answer 16

Pelvic appendicitis with lower abdomen, and urge to urinate/defecate and no pain
Older patient diagnosis is often delayed
In pregnancy may have pain in RLQ, periumbilical area, or right subcostal area

Question 17

MC emergency surgery, initiated by obstruction of the appendix (Fecalith, inflammation, foreign body, neoplasm)

Answer 17

appendicitis

Question 18

PE: sickly/toxic, RLQ rebound tenderness and guarding, light percussion may elicit pain
Rovsing
Psoas
Obturator
McBurney’s point

Labs: moderate leukocytosis (10k-20k) w/ neutrophilia + microscopic hematuria/pyuria

Abdominal US + CT (more accurate)

Answer 18

appendictis

Question 19

perforation should be suspected with appendicits in

Answer 19

Pain persisting > 36 hours
High fever
Diffuse abdominal tenderness or peritoneal findings
Palpable abdominal mass
Marked leukocytosis

Question 20

what is indicated by high fever, chills, bacteremia, jaundice w/ appendictis

Answer 20

septic thrombophlebitis

Question 21

What’s treatment for appendicitis

Answer 21

Early, uncomplicated = surgical appendectomy with broad spectrum antibiotics
IV cefoxitin or cefotetan
IV amp/sulb
IV ertapenem
Conservative management w/ antibiotics alone may be considered with non-perforation + surgical CIS or strong preference

Perforation = emergency appendectomy

Contained abscess – Percutaneous CT-guided drainage of abscess w/ IV fluids + abx for inflammation to subside + interval appendectomy after 6 weeks

Question 22

Fever, abdominal pain, peritoneal signs, presence of a causative diagnosis or comorbidity (acute abdominal infection)
Rebound tenderness

Answer 22

peritonitis

Question 23

Inflammation of the peritoneum –
Primary (spontaneous) w/o another intra abdominal process
Secondary (from other inflammation)
Tertiary (persistent inflammation)

Answer 23

peritonitis

Question 24

What’s treatment for peritonitis

Answer 24

Surgical emergency → general or acute care surgery

Question 25

Fever, abdominal pain (mild), AMS, common in cirrhotic patients

Answer 25

spontaneous bacterial peritonitis

Question 26

Infection of ascitic fluid w/o intraabdominal source of infection Almost always monomicrobial: E.coli, klebsiella, strep pneumo, viridans strep, enterococcus

Answer 26

bacterial peritonitis

Question 27

Abdominal tenderness, signs of chronic liver disease, ascites Labs: hepatorenal syndrome → bedside paracentesis: albumin, protein, RBCs. WBCs, ALP, amylase, cytology, glucose, CDH Cell count: ascitic fluid PMN>250 = SBP Secondary = high LD, low glucose, high protein Culture fluid

Answer 27

bacterial peritonitis

Question 28

How do you treat bacterial peritonitis

Answer 28

3rd gen cephalosporin IV 5-10 days IV albumin for patients at high risk for hepatorenal failure - Cr >1 - BUN > 30 - Bilirubin > 4 Discontinue beta blockers permanently

Question 29

for bacterial peritonitis, consider antbiotic prophylaxis if

Answer 29

prior episode or at-risk patients with 1+: → low protein ascites, SCr>1.2, decomp. cirrhosis

Question 30

Chronic (3m+) abdominal pain (intermittent, crampy, lower abdomen) w/ altered bowel habits, continuous or intermittent (with symptoms at least 6 months prior to dx) Does not occur at night/interfere w/ sleep Supportive symptoms: Abnormal stool frequency, form, passage, abdominal bloating or feeling of abdominal distention Also may have: dyspepsia, heartburn, chest pain, fatigue, myalgias, urologic dysfunction, gynecological symptoms, anxiety, depression common in late teens-twenties

Answer 30

irritable bowel syndrome

Question 31

Functional GI disorder – idiopathic Constipation + diarrhea predominant w/ visceral hypersensitivity, intestinal inflammation, psychosocial abnormalities >50% of patients w/ IBS have underlying depression, anxiety, or somatization

Answer 31

IBS

Question 32

What are the 3 categories of IBS

Answer 32

IBS w/ diarrhea - Loose or watery - >3/day - Urgency or incontinence IBS w/ constipation - Infrequent <3/week -Hard or lumpy = straining IBS w/ mixed - Features of both - Non-subtype

Question 33

Screen for eating disorders PE: usually normal with mild abdominal tenderness Perform DRE in those with constipation to screen pelvic floor Pelvic exam in postmenopausal women w/ recent onset constipation and lower abdominal pain to screen for gynecologic malignancy Clinical dx! If chronic diarrhea: CBC, CRP, fecal calprotectin level (>50 → endoscopy) Celiac disease PCR

Answer 33

IBS

Question 34

routine colonoscopy is not recommended <45 years w/ IBS w/o alarm symptoms but can be considered with --

Answer 34

failure of conservative management all patients >45 = colonoscopy to exclude malignancy

Question 35

further investigation in IBS is needed in

Answer 35

→ acute onset of symptoms (>45y) → nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, fever → family history of cancer, IBD, or celiac disease

Question 36

psychological therapies can be used in IBS like

Answer 36

CBT, relaxation, yoga, hypnotherapy

Question 37

How do you treat IBS?

Answer 37

Reassurance, education, support Discuss importance of mind-gut interaction Pain, bloating, altered bowel habits → anxiety/distress → further exacerbation Exercise Dietary therapy – fatty foods, alcohol, caffeine, spicy, grains are poorly tolerated w/ diarrhea, bloating, or flatulence → lactose intolerance excluded, FODMAPs may exacerbate these symptoms (eliminate fructose, lactose, fructans, wheat, sorbitol, raffinose) “Beano” can help high galactoside content Poorly fermentable soluble fiber Fermentable or insoluble fiber can increase gas/bloating

Question 38

Utilize drug therapy for IBS with no response --> targeting specific ymptoms like

Answer 38

Antispasmodic = enteric-coated peppermint oil formulations, anticholinergics to treat pain/bloating (hyoscamine, dicyclomine) Antidiarrheal = loperamide, bile-binding agents (cole) Anticonstipation agents Psychotrophic = SSRIs (fluoxetine, paroxetine, citalopram), low TCAs (nortriptyline, desipramine, imipramine) Nonabsorbable antibiotics = rifaximin (refractory) Probiotics

Question 39

Chronic constipation, abdominal pain, fluctuating bowel habits

Answer 39

diverticulosis

Question 40

RF for diverticulosis

Answer 40

Low fiber Abnormal motility Hereditary factors Connective tissue diseases

Question 41

commonly, diverticulosis is in the

Answer 41

sigmoid colon

Question 42

PE normal – may have mild LLQ tenderness w/ thickened, palpable sigmoid + descending colon

Answer 42

diverticulosis

Question 43

tx of diverticulosis

Answer 43

Increase dietary fiber in diet or with supplements

Question 44

Mild-moderate aching abdominal pain in LLQ, constipation or loose stools, N/V

Answer 44

diverticulitis

Question 45

Inflammation of diverticulum

Answer 45

diverticulitis

Question 46

diverticulitis severity --

Answer 46

REFER IF: Failure to improve w/n 72 hours Presence of significant abscesses (>4) Generalized peritonitis/sepsis Recurrent Chronic complications ADMIT IF: Severe pain or inability to tolerate oral intake Signs of sepsis/peritonitis CT signs Failure to improve Immunocompromised

Question 47

PE: low grade fever, LLQ tenderness, palpable mass Labs = stool occult blood, leukocytosis Perforation → general abdominal pain + peritoneal signs Abdominal CT if: – first time with mild symptoms – exclusion needed for complicated disease with fever, leukocytosis, sepsis, peritonitis, immunocompromised Colonoscopy or CT colonography if: – 6-8 weeks after resolution of symptoms – exclusion of colorectal cancer DO NOT if in acute stage

Answer 47

diverticulitis

Question 48

How do you treat diverticulitis?

Answer 48

Mild + no peritoneal signs = clear liquid diet 2-3 days Antibiotics ONLY in: - Immunocompromised - Significant comorbid disease - Small pericolonic abscess For 7-10 days or until afebrile for 3-5 days – augmentin or metronidazole AND ciprofloxacin or bactrim Then high fiber diet

Question 49

If increasing fever, pain, inability to tolerate fluids, immunocompromised or significant comorbid illness, abscess, severe = hospitalization diverticulitis

Answer 49

IV fluids, NPO, NG tube if ileus, IV antibiotics Cefoxitin, pip/taz, ticarcillin/clav Metronidazole or clindamycin PLUS AG or 3rd gen ceph

Question 50

Severe diverticulitis tx

Answer 50

Surgical consult + repeat abdominal CT in all with severe disease + no improvement in severe disease, abdominal abscess Emergent surgical management = general peritonitis, large abscesses, deterioration

Question 51

Asymptomatic or GI bleeding - dark red or maroon stools, adults with black or tarry stools Painless Males Children most commonly have complications

Answer 51

meckel's diverticulum

Question 52

Remnant of fetal omphalomesenteric duct, outpouching of distal ileum MC congestive anomaly – can lead to intestinal obstruction

Answer 52

meckel's diverticulum

Question 53

PE is benign CT scan, Meckel’s scan

Answer 53

meckel's diverticulum

Question 54

how do you treat meckel's diverticulum

Answer 54

Monitor Other complications = surgery