Intestine 2 Flashcards

1
Q

Abdominal pain
– SBO = periumbilical, cramping, paroxysmal
– LBO = lower quadrants
nausea/vomiting, abdominal distention/bloating, constipation, diarrhea, obstipation, anorexia, fatigue, weakness

CAVO = Crampy abdominal pain, Abdominal distention, Vomiting, Obstipation

A

bowel obstruction

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2
Q

Prior abdominal/pelvic surgery, hernia, IBD, malignancy, diverticulitis, volvulus, intussusception, opioid use

A

bowel obstruction

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3
Q

75% of bowel obstructions are

A

small

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4
Q

Mechanical = physical object (surgical adhesions, hernia, foreign body, IBD, volvulus, fecal impaction, intussusception, diverticulitis, colorectal cancer)

Non-mechanical = absent or reduced peristalsis (narcotics, post-op, neuro, hypokalemia, infections)
MC small = surgical
MC large = fecal impaction, diverticulitis, cancer

A

bowel obstruction

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5
Q

PE:
Signs of dehydration (tachy, orthostatic HOTN, reduced urine output, dry mucous membranes)
Fever (perf)
Abdominal distention
Bowel sounds – high pitched “tinkling” early on → absent/late nothing, visible peristalsis
Percussion = hyperresonance, fluid-filled loops with dullness
Palpation = generalized tenderness
Check for hernias!! If ruptured, peritoneal signs

DRE → fecal impaction or mass possible
Gross or occult blood = tumor, ischemia

Labs:
CBC (leukocytosis, anemia)
BMP (electrolyte abnormalities, BUN/Cr)
Mag
ABG, serum lactate (high = bowel is dying), cultures
UA

A

bowel obstruction

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6
Q

Plain XR: dilated loops of bowel with air-fluid levels in a “step-ladder”

Look for pneumoperitoneum

CT w/ IV contrast distinguishes paralytic ileus from mechanical obstruction w/ transition zone
– diameter >10-12cm ass w/ risk of perforation

A

bowel obstruction

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7
Q

how do you treat bowel obstruction

A

Admit to hospital → strict NPO, no narcotics or NSAIDs
Antiemetics – watch for hypokalemia
IV fluids
Correct electrolyte issues (K>4, Mg>2)

Decompress bowel (NG tube with suction)

IV steroids if IBD

Consult surgery

If strangulated hernia or acute abdomen = surgery right away

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8
Q

Mild, diffuse continuous abdominal discomfort, N/V, distention with minimal abdominal tenderness

NO signs of peritoneal irritation

A

acute paralytic ileus

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9
Q

RF for:
Hospitalized patients with intra abdominal processes, severe medical illness, or medications that affect intestinal motility
Post-operative
Opioids
Hypokalemia
Hypercalcemia
Hypothyroidism

A

acute paralytic ileus

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10
Q

Neurogenic failure/loss of peristalsis in the absence of any mechanical obstruction

A

ileus

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11
Q

how is risk reduced for ileus

A

minimally invasive surgery, patient-controlled analgesia, avoidance of opioids, early ambulation, gum chewing, clear liquid diet

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12
Q

PE: bowel sounds diminished-absent

Abdominal distention and tympany

Labs attributable to underlying condition
→ obtain serum electrolytes, Mg, phosphorus, Ca

Plain film = distended gas-filled loops of small + large intestine (looks like small bowel obstruction) w/o transition zone

CT scan to differentiate

A

paralytic ileus

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13
Q

how do you treat paralytic ileus

A

Treat underlying cause
– restriction of oral intake w/ slow re-introduction

May require NG suction + IV fluids and electrolytes

Alvimopan – reverses opioid-induced inhibition of intestinal motility, when post-op opioid therapy is indicated

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14
Q

Extraintestinal manifestations = spondylitis, oral ulcers, uveitis, erythema nodosum, hepatitis

common in Adolescents and adults <40 years

15-35 onset
Ashkenazi Jews

A

IBD

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15
Q

Easily misdiagnosed–

Fever, chills, change in well-being, weight loss, abdominal pain, bloating, cramping, borborygmi, diarrhea, prior surgical resections, rectal bleeding, tender abdominal mass, fatigue

Fistulae, recurrent UTIs if between intestine and bladder

Perianal disease = large, painful skin tags, anal fissures, abscesses, fistulas

Extraintestinal: arthralgias, arthritis, oral aphthous ulcers, iritis/uveitis, erythema nodosum, pyoderma gangrenosum, gallstones and kidney stones

A

crohn’s disease

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16
Q

What are RFs for crohn’s disease

A

Smoking
15-35y

RF for aggressive disease:
Young age
Early need for steroids
Perianal disease, fistulizing or structuring disease, upper GI
Lab markers of severe inflammation
Endoscopic findings of deep ulceration

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17
Q

Transmural disease → anywhere in GI tract, MC in terminal ileum and proximal colon & skip areas of involvement

– can cause fistulas, bowel strictures, perianal disease, abscesses

Dx made based on clinical picture w/ supporting evidence

A

crohn’s disease

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18
Q

What are IBD medication classes?

A

5-ASA (sulfasalazine, mesalamine)

corticosteriods (budesonide, prednisone)

immunomodulators - thiopurines, methotrexate, janus kinase inhibitors (-mab), sphingosine 1 phosphate receptor modulators -mod)

biologic therapies - anti-TNF (infliximab, adalimumab, golimumab, certolizumab)
anti-integrins (vedolizumab)
anti-IL 12/23 (ustekinumab)

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19
Q

patients w/ IBD have an increased risk of vaccine-preventable infections so what should you do?

A

confirm vaccination status
inactivated vaccines - hep a, b, shingles, influenza, dTAP (safely administered with immunosuppression)
pneumococcal vaccine in >65

live virus should never be administered while taking immunosuppressive drugs

20
Q

CBC: anemia, B12 deficiency, possible leukocytosis
CMP: albumin
CRP/sed rate

Fecal calprotectin → active inflammation
Stool cultures

Endoscopy = “skip lesions” and cobblestone appearance with aphthous, linear or stellate ulcers, strictures, segmental involvement (large or deep = higher risk)

Upper GI: string sign

Granulomas on biopsy

CT, MR enterography, capsule imaging, upper GI w/ SBFT

A

crohn’s disease

21
Q

surgery indications for crohn’s disease

A

Poor response to medical therapy
Intraabdominal abscess
Massive bleeding
Internal or perianal fistulas
Intestinal obstruction

22
Q

admit a crohn’s disease patient if

A

Intestinal obstruction
Abscess is suspected
Serious infectious complication
Severe diarrhea, dehydration, weight loss, or abdominal pain
Severe or persistent symptoms despite steroids
High fever, persistent vomiting, severe abdominal tenderness

23
Q

How do you treat a mild/low risk crohn’s disease?

A

Nutrition
Well balanced diet, smaller, more frequent meals, fluids, avoid fried/greasy foods, trial off dairy
Loperamide for diarrhea PRN up to 4x
Drug therapy based on location of involvement
Terminal ileum or ascending colon disease = extended-release budesonide (steroid)
Left sided or diffuse = oral steroids (prednisone/prednisolone) and taper, sulfasalazine (5-ASA)

24
Q

what is considered mild/low risk crohn’s disease

A

mild symptoms, no significant weight loss, normal or only mildly elevated inflammatory markers, absence of intestinal complications, limited intestinal involvement:

25
What is severe/high risk crohn's disease?
frequent diarrhea, weight loss, daily abdominal pain, abdominal tenderness, perianal disease, with evidence of inflammation on labs:
26
how do you treat severe/high risk crohn's disease?
Outpatients = oral corticosteroid (methylprednisolone/prednisone) w/ tapering + initiation of biologic agent Early treatment with biologic agents (w or w/o immunomodulators) anti-TNF = infliximab, adalimumab + immunomodulating azathioprine, mercaptopurine, methotrexate Nutrition low-roughage diet, decreased processed foods, TPN, B12, Vitamin D Symptomatic therapy Diarrhea = cholestyramine, colestipol, colesevelam Steatorrhea = low-fat SIBO = abx Diarrhea = loperamide, diphenoxylate w/ atropine, tincture of opium (NOT in active severe disease) Steroids
27
How do you treat crohn's disease if biologic therapies fail?
Failure of biologic therapies = oral small molecules (upadacitinib)
28
Diffuse mucosal inflammation → friability, erosions, ulcers w/ bleeding Bloody diarrhea Diarrhea w/ mucus Fecal urgency, tenesmus, LLQ cramping pain relieved by defecation in LLQ Hematochezia
ulcerative colitis
29
What are RFs for ulcerative colitis
Risk of colon cancer – begin 8 years after diagnosis, remove all polyps when possible, repeat q1-5 years
30
Recurrent, chronic disease ONLY in the colon Classify into mild, moderate, severe: Mild-moderate - 4-6 BM/day - NO constitutional symptoms Severe - >6 bloody BM/day - Anemia, hypovolemia, hypoalbuminemia Fulminant colitis: fever, chills, worsening of symptoms
ulcerative colitis
31
PE: abdominal pain + tenderness, red blood on DRE, hypovolemia, arthralgia, iritis/uveitis, scleritis, sclerosing cholangitis, pyoderma gangrenosum/erythema nodosum CBC: anemia, possible leukocytosis ESR: elevated, determines severity Low albumin FOBT + Stool culture, c. diff assay Hct, albumin, inflammatory markers reflect disease severity Sigmoidoscopy is DOC “Mayo” scoring system with 1-2 = mild/mod and 2-3 = mod/severe Avoid colonoscopy w/ fulminant disease, delay until improvement Plain films or CT = colonic dilation in severe disease (“stove/lead pipe”, loss of haustral markings” Barium enemas
ulcerative colitis
32
CRP > 5 or fecal calprotectin >150 = disease relapse → endoscopy
ulcerative colitis
33
Systemic signs of inflammation or ulcerations with extensive disease = risk of hospitalization or surgery → early aggressive therapy Disease activity assessed by clinical symptoms, lab data, inflammatory markers, fecal calprotectin Admit if: frequent bloody stools, anemia, weight loss, fever, fulminant disease, when surgery is indicated Refer for colonoscopy if needed, f/u for hospitilization
ulcerative colitis
34
how do you treat mild-mod distal colitis?
Topical mesalamine 5-ASA suppository/enema Oral if not tolerated No result = combo of topical w/ oral, topical steroid, all three Maintenance = 5-ASA
35
How do you treat mild-mod colitis?
Combo oral + topical 5-ASA (mesalamine) + oral steroid (budesonide or prednisone) if no improvement within 4-8 weeks If requiring >1 course of steroids every 1-2 years, add thiopurine or biologic agent
36
How do you treat mod-severe colitis?
Oral steroid (prednisone/methylprednisolone) w/ slow tapering → oral mesalamine Biologics or small molecules (infliximab or vedolizumab - older or high risk) recommended when; Steroids can’t be completely withdrawn Those who require 1+ steroids every 1-2 years Preferred agent from severity, comorbidity, prior exposure, preferred mode, insurance
37
How do you treat severe + fulminant colitis?
NPO x 24-48 hours until improvement (may need TPN) d/c offending agents IV fluids, support IV steroids, enemas → infliximab if no improvement IV cyclosporine with steroid failure Surgery
38
Severe, bloody diarrhea Toxic/ill appearing Altered sensorium Fever Postural HOTN Lower abdomen distention + tenderness +/- peritonitis Tachycardia
toxic megacolon
39
RF for toxic megacolon
IBD (UC), c. diff, diverticulitis, colon cancer, loperamide, CMV
40
Mid-transverse colonic dilation >5.5-6cm and systemic toxicity
toxic megacolon
41
Labs: CBC, ESR/CRP, CMP, stool specimen XR initial imaging choice Diagnostic Criteria: Radiographic dilation of colon >5.5-6cm AND at least 3: Fever >38.6/101.5 HR >120 WBC >10,500 Anemia AND at least one: Dehydration AMS Electrolyte disturbance HOTN
toxic megacolon
42
how do you treat toxic megacolon
IBD caused: complete bowel rest (NPO), IV hydration, NG tube, no anti-motility, opioids, anticholinergics, broad spectrum abx, IV steroids Infliximab if no steroid response Surgery if Clinical deterioration Failure to improve with medical care after 24-72 hours Perforation Uncontrolled hemorrhage Worsening signs of toxicity and/or dilation
43
Mild-moderate greenish, foul-smelling watery diarrhea 3-15 stools/day with lower abdominal cramps
antibiotic associated colitis
44
RFs for antibiotic associated colitis
Older, debilitated, immunocompromised, receiving multiple antibiotics, prolonged antibiotic therapy, tube feedings, PPIs, chemo, IBD
45
Almost always from c difficile – fecal-oral transmission MC: ampicillin, clindamycin, 3rd gen cephs, fluoroquinolones
antibiotic-ass colitis
46
PE: normal or LLQ tenderness Labs: WBC >15000 Cr >1.5 Stool studies = PCR toxin gene test or GDH (glutamate dehydrogenase) protein assay Flexible sigmoidoscopy if not responsive to treatment, atypical symptoms Biopsy = epithelial ulceration with “volcano” exudate
abx-associated colitis
47
abx associated colitis tx
Contact precautions Discontinue agent Fidaxomicin or vancomycin Fulminant disease = oral vancomycin + IV metronidazole + surgical consult