MDT Lower GI 2 Flashcards
(86 cards)
1
Q
What are anal fissures?
A
Linear or rocket-shaped ulcers that are < 5 mm in length
2
Q
Where do anal fissures most commonly occur?
A
- Most common in posterior midline
- 10% occur anteriorly
3
Q
What locations of fissures should raise suspicion and why?
A
- Fissures that occur off the midline
- Could be symptomatic of more serious disease or sexual assault
4
Q
Most anal fissures are believed to arise from what?
A
Trauma to the anal canal during defecation, caused by straining, constipation, or high sphincter tone
5
Q
What are symptoms of anal fissures?
A
- Severe tearing pain during defecation followed by throbbing discomfort
- May lead to constipation due to fear of pain during shitting
- Bright red blood may be seen on TP
6
Q
How are anal fissures confirmed?
A
- Visual inspection of the anal verge while gently separating buttocks
- Looks like cracks in epithelium
- Digital and anoscopic exam may cause severe pain and may not be possible
7
Q
What do chronic fissures result in?
A
Fibrosis and development of skin tag on the outermost edge
8
Q
What are some differential diagnosis for anal fissures?
A
- Perianal abscess
- Inflamed/thrombosed hemorrhoids
- Condyloma acuminate
- Skin tag
- Chron’s disease
9
Q
Lab/rad for anal fissure?
A
Unless a more serious disease is expected, Pt should be referred
10
Q
Treatment of anal fissures?
A
- Directed at promoting effortless, painless BM
- Fiber supplements and sitz baths
- Topical anesthetics (5% viscous lidocaine)
- Oral analgesics (Tylenol/NSAIDS)
11
Q
When does healing occur for anal fissures?
A
Within 2 months in up to 45% of Pt’s
12
Q
When should fissures be referred and how can they be treated?
A
- Chronic fissures
- Topical nitroglycerin (0.2-0.4%) or diltiazem (2%)
13
Q
What is a anorectal abscess?
A
Obstruction occurs blocking the gland orifice resulting in infection and abscess
14
Q
What spaces can an anorectal abscess happen in?
A
- Perianal space
- Intersphincteric space
- Ischiorectal space
- Deep postanal space
- Supralevator or pelvirectal space
15
Q
What is the most/least common anorectal abscess?
A
- Most: Perianal abscess
- Least: Supralevator
16
Q
Who are anorectal abscess more common in?
A
Young, middle-aged males
17
Q
Symptoms of anorectal abscess?
A
- Dull, aching, or throbbing pain that becomes worse before defecation, lessened after BM, persists between BM
- Pain aggravated by straining, coughing, sneezing
- Eventually interfere with sitting/walking
18
Q
What easily palpable abscess in not usually accompanied by fever, leukocytosis, and sepsis?
A
Perianal abscess
19
Q
Differential Diagnosis for anorectal abscess?
A
- Pilonidal cysts
- Hemorrhoid
- Anorectal fistula
20
Q
Rad for anorectal abscess?
A
Ultrasound for deep abscess
21
Q
What is the treatment for anorectal abscess?
A
- Surgical intervention
- I&D early and often
- Perirectal abscesses must be done in OR
- Simple and isolated perianal abscess can be done outside OR
22
Q
What are some post drainage considerations of an anorectal abscess?
A
- No packing required (if done, do lightly and remove within 24 hours)
- Cover with bulk dressing
- Begin Sitz bath (3x/day)
- Antibiotics ONLY needed for febrile, leukocytosis, valvular-heart disease, or cellulitis
23
Q
Initial care of anorectal abscess?
A
- I&D
- Refer to General Surgery for complicated case
24
Q
What do anal crypts allow for?
A
Secretion of excess mucus otherwise found in the rectum and anus
25
What is an anorectal fistula?
The chronic manifestation of the acute perirectal process that forms an anal abscess which when ruptured or is drained, an epithelial track forms connecting the abscess in anus/rectum with perirectal skin
- also referred to as "fistula-in-ano"
26
What are symptoms of anorectal fistula?
- "Nonhealing" anorectal abscess following drainage
- Chronic purulent drainage and pustule-like lesion in perianal/buttock area
- Intermittent rectal pain, particularly during defecation, but also sitting
- Intermittent and malodorous perianal drainage and pruritus
27
What is differential diagnosis for anorectal fistula?
- Perianal abscess
- Hemorrhoid
- Anal Fissure
- Pilonidal Cyst
- Colorectal Cancer
28
Treatment for anorectal fistula?
- MEDEVAC, require higher echelon care
| - Stabilize and prepare for transport
29
Initial care for anorectal fistula?
- Based on vital signs and patient stability
| - If Pt presents in pain, consider MEDEVAC and treat with pain medicationst
30
What is pilonidal disease?
Malfunction that describes a spectrum of clinical presentations, range from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region (some tendency to reocur)
31
Pilonidal cysts can occur in the presence of what?
- Staph Aureus
| - Can invade through openings caused by ingrown hair
32
Where do pilonidal cysts/sinuses occur?
Midline in the upper part of the anal cleft overlying the lower sacrum and coccyx
33
What type of disease is pilonidal disease and when does it most commonly occer?
- Acquired condition
| - Most commonly occur in 4th decade of life
34
An abscessed pilonidal cyst is always located where?
- Midline
| - Does not communicate with anorectum
35
What are symptoms of pilonidal disease?
- Swelling
- Pain
- Persistent discharge
36
What will be found on examination for pilonidal disease?
- Area of inflammation in the midline of the gluteal crease, with 1+ opening
- Most common finding is single opening with hair protruding
- Spontaneous and ongoing drainage is common indicator
37
When will a patient present for pilonidal disease?
When an abscess has formed that can no longer drain
38
Labs for pilonidal disease?
CBC for Pt's with systemic disease
39
Treatment for pilonidal disease?
- Surgical intervention
| - mostly simple I&D
40
Antibiotic therapy for pilonidal disease?
- Considered only temporizing and palliative
- If surrounding area has cellulitis
- Keflex then Doxy
41
Disposition for Pilonidal disease?
- Retain on board if uncomplicated
- MEDADVICE depending on Physician Sup
- MEDEVAC for more complicated cases (refer to gen surgery)
42
What is Inflammatory Bowel Disease?
- Immune response disrupts the intestinal mucosa and leads to chronic inflammatory process
- Lifelong illness
- Includes ulcerative colitis and Chron's disease
43
What is Ulcerative Colitis?
- Inflammation limited to the colonic mucosa
| - Can have Pseudo-polyp
44
What is an inflammatory pseudo-polyp?
Island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue
45
What is Chron's disease?
- Can affect ANY portion of the GI tract from mouth to anus
- "Skin lesions"
- Transmural inflammation
46
What are some extra-intestinal manifestations of Ulcerative Colitis AND Chron's?
- May be associated in 50% of Pts(esp. chron's)
- Erythema nodosum
- Pyoderma gangrenosum
- Thromboembolic events
47
What are some extra-intestinal manifestations of Ulcerative Colitis?
- Peripheral arthritis
- Spondylitis
- Uveitis/Episcleritis
- Hepatitis
48
What are some extra-intestinal manifestations of Chron's?
- Oral Ulcers
| - Anorectal disease
49
What mucosal inflammation is indicative of ulcerative colitis?
Inflammation involving only the mucosal layer of the bowel wall
50
What transmural inflammation is indicative of Chron's?
- "Complete" inflammation of all layers structure
| - Inflammatory changes/ulceration of all layers of bowel
51
What is the most common portion of the GI tract that Chron's affects?
Terminal ilium
| * can result in malabsorption of digested foods, B12, bile salts and sodium
52
What disease is chronic and recurrent that involves all of the GI tract and involves "skip lesions"?
Chron's Disease
53
Pertinent history of Chron's?
- Fevers
- Pt general sense of well-being
- Weight loss
- Presence of abdominal pain
- Number of liquid bowels in a day
- Surgical/hospitalization history
54
Physical exam signs for chron's?
- Ileitis or ileo-colitis
- Diarrhea (non-bloody and intermittent)
- Low grade fever
- Malaise
- Weight loss
- Cramping abdominal pain
55
Obstructive bowel signs and symptoms?
- Abdominal distension
- Nausea/vomiting
- Intermittent liquid stools and/or constipation
56
Pertinent pathophysiology of chron's?
- Diffuse abdominal pain/discomfort
- Radiographic evidence of ulceration, stricturing, or fistulas
- 1/3 of all cases involve small bowel
- 1/2 of all cases involve small bowel and colon
- Cigarette smoking
57
Imaging for Chron's disease?
- Endoscopy
- Colonoscopy
- CT Scan of abdomen
58
Labs for Chron's?
- Poor correlation for labs
| - CBC and serum albumin
59
Treatment of Chron's?
- 5-aminosalicylic acid derivatives (5-ASA)
- Corticosteroids
- Immuno-modulating and biologic agents
- Treatment directed toward symptomatic relief and controlling disease process
60
Management of Chron's?
- Acute flairs may require surgical intervention (bowel perforation)
- Discontinue tobacco
- Consult GI/Gen surg
- MEDEVAC (only for new onset case)
61
Complications of Chron's disease?
- Intra-abdominal abscess formation
- Small bowel obstruction
- Fistulas
- Anal fissures
62
What is Ulcerative colitis?
- Chronic, recurrent disease
- Limited to colonic mucosa (large intestine)
- More common in non-smokers and former smokers
63
Ulcerative Colitis causes?
- Ulceration
- Edema
- Bleeding (common, unlike Chron's)
- Fluid and electrolyte loss
64
Symptoms of Ulcerative Colitis?
- Bloody diarrhea (hallmark)
- Lower abdominal cramps and fecal urgency
- Anemia, low serum albumin
- Negative stool cultures
65
Mild ulcerative colitis?
- Gradual onset of infrequent diarrhea (<5 movements/day)
- Stools may be formed or loose consistency
- Fecal urgency and tenesmus
- Lower Left quadrant cramps
66
Moderate ulcerative colitis?
- Have more severe diarrhea with frequent bleeding
- Abdominal pain and tenderness (not severe)
- Mild fever, anemia, and hypoalbuminemia
67
Severe ulcerative colitis?
- More than 6-10 bloody BM/day
- Severe anemia, hypovolemia, and impaired nutrition
- Abdominal pain and tenderness
68
Labs for ulcerative colitis?
- CBC
- ESR
- CRP
- Stool bacterial culture
- C dif
- Ova and parasites
- Serum albumin
- Electrolytes
69
Imaging for ulcerative colitis?
- CT Scan in suspected fistula, perforation, abscess, acute flares
- Colonoscopy (screen for carcinoma)
- Colonoscopy 8 years after initial Dx
70
Two main treatment objectives of ulcerative colitis?
- Terminate the acute, symptomatic attack
| - to prevent recurrence of attacks
71
Medication options for ulcerative colitis?
- Mesalimine
- Corticosteroid
- 5-ASA
72
Mild to moderate treatment of ulcerative colitis?
- As recommended by GI
| - Limit intake of caffeine and gas-producing vegetables
73
Treatment of severe ulcerative colitis?
- Hospitalization generally required
- NPO for 24-48 hours
- Discontinue all opioid and anticholinergic agents
- Restore circulating volume with fluids
- Serial abdominal exams
74
What is the definitive way to diagnose Chron's and ulcerative colitis?
Biopsy
75
Disposition of Chron's and Ulcerative Colitis?
- MEDEVAC
| - Refer to GI/Gen Surg
76
What is Irritable Bowel Syndrome?
- Chronic disease (at least 3 months)
- Characterized by abdominal pain or discomfort that occurs in association with altered bowel habits
- Not completely understood
- Believed that mental health plays huge role
77
Possible causes/associations of IBS?
- Ovum and Parasite
- Food poisoning via
* Campylobacter
* Shagella
* Salmonella
* E. coli
* C. dif
- Stress
- Mental health
78
Hallmarks IBS?
Abdominal discomfort relieved immediately after defecation with an otherwise normal physical exam
79
Other symptoms IBS?
- Usually begins late teens to twenties
- Abnormal stool frequency
- May have other somatic or psychological complaints
80
Diagnosis of IBS?
At least two of the three features:
- Relieved with defecation
- Onsite associated with a change in frequency of stool
- Onsite associated with a change in form of stool
81
3 major categories of IBS?
- IBS-C or IBS-D ( IBS-Constipation/IBS-Diarrhea)
- Infrequent bowel movements (IBS-U)
- IBS with mixed constipation and diarrhea (IBS-M)
82
Alarm symptoms associated with IBS?
- Acute onset of Sx (Esp in >40-50 yrs)
- Nocturnal diarrhea
- Severe constipation
- Hematochezia/Unexplained IDA
- Weight loss
- Fever
- FamHx: Cancer, IBD or celiac disease
83
Physical exam IBS?
- Usually normal
- Should not have fever, rashes, blood in stool
- Can have very mild abdominal tenderness in lower abdomen
84
Labs for IBS?
```
- Consider:
CBC
Chem
Serum albumin
Thyroid function test
*Only if alternate diagnosis is suspected
```
85
Rad for IBS?
- Colonoscopy only recommended for Pt's >50yrs to check for malignancy
86
Treatment for IBS?
- Establish therapeutic relationship with patient
- Diet (avoid caffeine and trigger foods)
- Symptomatic treatment (loperamide, anticonstipation)
- Potential for TCA's (mental health Rx only)
