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POST MIDTERM Flashcards

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1
Q

MC antibiotics that cause diarrhea/colitis

A

-azithromycin- diarrhea
-colitis (c. diff) - clindamycin, ampicillin, 3rd generation of cephalosporins, Fluoroquinolones

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2
Q

what can put you at risk for C. diff

A

-Severely ill/malnourished
-Chemotherapy
-Multiple antibiotics
-Tube feeds
-PPI* - long term bc your raising pH of stomach
-Surgery
-IBD- flora is not as strong
-age
-health care

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3
Q

C. diff diagnostics

A

-stool sample- first choice for typical course
-toxin a- enterotoxic
-toxin b- cytotoxic
-GDH antigen test (carrier) and toxin A and B tests
-both + -> c. diff present
-one + and one - -> PCR for tcdB and tcdC

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4
Q

C. diff treatment

A

-fidaxomicin
-vancomycin
-metronidazole (not used anymore)
-1st reoccurrence- same antibiotics but longer with biologic -> TAPER
-3 CDI (2 reoccurrence) - FMT- fecal microbiota transplantation

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5
Q

Different severity of C. diff

A

-C. diff w/ diarrhea- stool sample, leukocytosis
-severe C. diff- thumbprinting, pseudomembranous colitis -> sigmoidoscopy/colonoscopy
-fulminant- toxic megacolon, perforation, paralytic ileus and colonic dilatation-> CT -> colectomy can be life saving
-Abdominal radiograph or CT**- fulminant dx -> looks for thickening of sigmoid colon in pseudomembrane colitis, toxic megacolon, thumbprinting

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6
Q

vitamin K

A

-controls formation of coagulation factors 2, 7, 9, 10 -> activate factors 10 and 2
-disseminated intravascular coagulation (DIC)- decreased platelet and fibrinogen

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7
Q

thiamine (B1)

A

-water soluble - cant produce
-absorbed in jejunum
-must administer B1 with dextrose
-whole grains, meat, fish, eggs, milk, vegetable’s, legumes, orange, tomato
-early- anorexia, cramps, paresthesia, irritability
-advanced- wet and dry beriberi
-dry beriberi- legs>arm, symmetric -> Wernicke-Korsakoff syndrome
-wernicke encephalopathy- acute, COAT (confusion, opth, ataxia, thiamine)
-korsakoff- RACK
-dx- Erythrocyte thiamine transketolase (ETKA)
-only half recover- parental thiamine

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8
Q

niacin (B3)

A

-synthesized from tryptophan
-NAD, NADP
-cereal, vegetable’s, dairy product, tuna, beef, liver, chicken
-metabolic disorders
-early- anorexia, weakness, irritability, glossitis, stomatitis, wt loss
-advanced- pellagra - dementia, dermatitis, dermatitis

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9
Q

vitamin C

A

-cannot synthesize
-water soluble
-fruits and vegetables
-chronic illness, old, poor, alc
-early- weakness
-advanced- scurvy -> perifollicular hyperkeratotic papules, hemarthroses, subperiosteal hemorrhages, poor wound healing
-late stages- edema, oliguria, intracerebral hemorrhage, death
-large amount of vit c -> gastritis, farting, diarrhea, stones, false neg hemocult

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10
Q

vitamin A

A

-mineral oil abuse, poor
-early- night blindness, xerosis, bitot spots
-late- ulceration and necrosis (keratomalacia), perforation, endophthalmitis (purulent inflammation of intraocular fluid), blindness, hyperkeratinization of skin, loss of taste

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11
Q

vitamin D

A

-anticonvulsants (phenytoin), cholestyramine
-rickets 1 and 2

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12
Q

E. coli

A

-fecal-oral, contaminated meats
-enterotoxigenic e coli - non-inflammatory watery diarrhea
-shiga toxin producing e coli (O157:H7)- inflammatory bloody diarrhea -> MC cause of bloody diarrhea
-travelers diarrhea

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13
Q

inflammatory diarrhea vs non-inflammtory

A

INFLAMMTORY
-bleeding
-colon
-fecal leukocytes
-campylobacter
-salmonella
-shiga toxin producing e coli
-shigella
-vibrio
NONINFLAMMTORY
-small bowel
-secretory, watery
-hypokalemia, metabolic acidosis, dehydration
-norovirus, rotovirus
-giardia, crytosporidum, cyclospora
-enterotoxin- s. aureus, costridium
-cholerae

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14
Q

when to obtain stool specimen and what to order

A

-fever, hypovolemia, ≥6 unformed stools per 24 hours, severe abdominal pain, hospitalization, hypotensive, high pulse
-bloody diarrhea
-age ≥ 70 years, cardiac disease, immunosuppression, inflammatory bowel disease, pregnancy
-Symptoms persisting >1 week
-Public health concerns
-* consider empiric therapy if sick enough

-fecal leuks* (chronic IBD), parasite, bacteria, c. diff, giardia, viruses

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15
Q

acute diarrhea treatment

A

-cipro, levofloxacin, azithromycin
-shigella- fluoroquinolone
-cholera- doxycyclin, azithromycin
-C. diff- vancomycin
-giardia- metronidazole, tinidazole
-travelers diarrhea- fluoroquinolone

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16
Q

causes of osmotic diarrhea

A

-disaccharidase deficiency (lactose intolerance)
-lactulose
-sorbitol
-olestra
-magnesium containing medication

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17
Q

secretory diarrhea causes

A

-occurs with fasting
-endocrine tumors
-bile salt malabsorption
-laxative abuse

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18
Q

alarm features in pts with chronic diarrhea*

A

-onset after 50
-rectal bleeding or melena
-nocturnal pain or diarrhea
-unexplained weight loss, fever, systemic symptoms
-lab abnormalities (iron deficiency anemia, elevated ESR/CRP, elevated fecal calprotectin, fecal occult blood present)
-first degree relative with inflammatory bowel disease or colorectal cancer or celiac

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19
Q

chronic diarrhea dx and tx

A

-consider abdominal CT (pancreas), small bowel series or MR enterography (Crohns), breath tests (lactose, SIBO)
-treat underlying condition***
-anticholinergics/antispasmodics - dicyclomine and hyoscyamine -> IBS
-bile salt binding resin- cholestyramine- tx for ileal resection

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20
Q

exocrine pancreatic insufficiency

A

-ddx- celiac, lactose intol, SIBO, giardia*
-stool and then MRI or CT
-giardia -> egd and colonoscopy

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21
Q

bacterial overgrowth

A

-bacterial deconjugation of bile salts
-gastric achlorhydria
-anatomical abnormality- ileocecal vale, SI diverticulum, obstruction, blind loop
-motility disorder- scleroderma, diabetic enteropathy
-fistula
-malabsorption in severe cases
-breath test
-correct anatomic defect
-rifaximin**

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22
Q

secondary lactase deficiency

Study These Flashcards
A

-disease washes away lactase on brush border
-once heals -> goes away
-crohns, celiac, short bowel syndrome, gastroenteritis
-breath test

23
Q

tumors of small bowel

Study These Flashcards
A

-rare
-intussusception- telescoping
-CT or small bowel series - bx
-most are single
-adenomatous - benign but can turn into Ca
-multiple polyps -> hereditary polyposis
-remove all bc they can turn into cancer except lipoma (just bx) -> lipoma MC on ileocecal valve
-gastrointestinal stromal tumors (GST)- anywhere, soft tissue, act like lead, ulcerate -> benign or malignant
-lymphoma- distal small intestine* -> non-hodgkin’s or high grade B cell (assoc with h pylori) or T cell lymphoma (assoc with celiac)
-carcinoid - ileum

24
Q

Celiac disease that is refractory to gluten and no T cell lymphoma

Study These Flashcards
A

-treat with Corticosteroids or
-Immunosuppression- Azathioprine or cyclosporine

25
why do we care about treating IBD
-increases risk of colon cancer and reoccurrence
26
IBD drug treatment
-5 ASA- mesalamine (colon) -> also pentasa (ileum and colon) -> oral, topical (high dose), enema (whole left side) -Azo compounds (colon) -Corticosteroids (flares) -> budesonides, methyl prednisone, prednisone, hydrocortisone -mercaptopurine and azothioprine (reduce withdrawl) -biologics- integrin, interleukin, TNF, JAK
27
biologics risks
-hepatic failure -> must monitor CBC and LFTs
28
IBD types and causes
-immunologic -genetic -environmental triggers
29
extraintestinal manifestations of IBD
oligoarticular or polyarticular peripheral arthritis -spondylitis or sacrolitis -episcleritis or uveitis -erythema nodosum -pyoderma gangrenosum- concentric pustules -> ulcers -sclerosing cholangitis- UC typically -thromboembolic events
30
serologic testing for IBD
-Antineutrophil cytoplasmic antibodies with perinuclear staining (p-ANCA): -5–10% of pts with Crohn’s disease -50–70% of patients with ulcerative colitis** -Antibodies to the yeast Saccharomyces cerevisiae (ASCA): -60–70% of patients with Crohn’s disease** -10–15% of patients with ulcerative colitis -sensitive not specific -not very helpful, not really done
31
ulcerative colitis - unique features, dx, follow up, mild+moderate, severe, relapse
-Post inflammatory pseudo-polyps -> increases cancer risk -Toxic megacolon -MC finding on colonoscopy - extensive ulceration of mucosa -8-10 years pancolitis -> 1-2 year colonoscopy with biopsy -12-15 year left sided colitis -> 1-2 year colonoscopy with biopsy -dx- colonoscopy with bx -surgery tx with hemorrhage, perf, cancer, toxic megacolon (>6cm) -mild-moderate tx- pharm -severe- IV steroids, abd x-ray* to check for toxic megacolon, surgical consult, biologic -remission/relapse is very common -> more than 2 relapses a year -> biologic
32
crohns disease- unique signs, symptoms
-ulceration, stricturing, fistula, abscess, perianal disease -ileal involvement- bile salt, b12, kidney stones -RLQ pain or periumbilical -string sign -cobblestoning -granulomas*** -malabsorption -MR enterography -colonoscopy/EGD for bx -8 years -> colonoscopy for dysplasia (NOT POLYPS) every 1-2 years -cholestyramine for bile salt malabsorption -rifaximin for bacterial overgrowth -pantasa- mesalamine -surgery- obstruction, bad fistula, massive bleed, not getting better
33
microscopic colitis
-chronic/intermittent -non bloody watery, voluminous -normal appearing mucosa -collagneous- >10 micrometers colonic subepithelial band -lymphocytic- (assoc with celiac)- intraepithelial >20 lymphocytes per 100 epithelial cells -colonoscopy with bx -budesonide for active disease**
34
IBS pathogenesis
-abnormal motility -post enteric infection -visceral hypersensitivity -psychosocial -altered gut flora
35
IBS treatment
-FODMAP -Antispasmotics- dicyclomine -Antidiarrheals- loperamide -> if this doesnt work.... -bile acid sequestrants -Serotonin receptor agonists- IBS-C -> sertraline, paroxetine, fluoxetine -serotonin receptor antagonists- IBS-D -Mu-opioid receptor agonist and delta-opioid receptor antagonist -Nonabsorbable antibiotics- rifaximin -Probiotics -Psychotropics- Tricyclic antidepressants -> Amitriptyline -> IBS-D -Psychological Therapies -Anticonstipation
36
anticonstipation agents
-osmotic laxative- polyethylene glycol, lactulose -bulk forming laxative- fiber -> psyllium -stool softeners (surfactants)- docusate -stimulant laxative- habit forming -> senna
37
diverticulitis labs and complications
-leukocytosis -occult blood (hematochezia rare) -abscess or phlegmon -bleeding -fistula -stricturing
38
colonoscopy follow up
-6-8 weeks after diverticulitis -> perforated colon cancer -family hx, genetic syndromes, personal hx of polyps, IBD -> more frequent -FAP- every year until colectomy -> sigmoidoscopy 6-12 months + EGD every 1-3 yrs -any bleed -24 hours after large volume bleed -within 6-12 hrs of large active bleed- urgent
39
diverticulitis tx and follow up
-reassess every three days -metronidazole 3x day, cipro or augmentin 2x day for 10 days -liquid -> low fiber at first -> then high -f/u with clinical exam -> 6-8 weeks colonoscopy for perforated colon cancer -if increasing pain, fever, inability to drink, old, immunosuppressed -> hospital -> fluids, NG tube for ileus, IV antibiotics -elective (fistula, stricture, not getting better) vs emergent surgery (peritonitis, abscess)
40
polyps of colon and small intestine
-3-4% of all colorectal cancers are caused by genetic mutations* -mucosal neoplasm- adenomatous -mucosal nonneoplastic- hamartomas, juvenile polyps, hyperplastics, inflammatory polyps -submucosal lesions- lipomas, lymphoid aggregates, carcinoids (these can be cancerous) -cancer is always sessile or pedunculated -< 1 cm low risk; >1cm advanced adenoma -dysplasia - advanced -asymptomatic until bleeding usually -> anemia
41
malignant poly excision
-(1) polyp is completely excised and submitted for pathologic examination -(2) well differentiated -(3) margin is not involved (clear margins) -(4) no tumor budding vascular invasion -recheck in 3 months
42
who to consider for hereditary colorectal cancer and polyposis syndromes
-family hx of colorectal cancer in >1 family member (first degree) -personal or family hx of colorectal cancer < 50yo -personal or family hx of multiple polyps (> 20) -personal or family hx of multiple extracolonic malignancies
43
hamartomatous polyposis syndromes
-Peutz-Jeghers syndrome -throughout GI -mucocutaneous pigmented macules* -intussusception -can become adenomatous -extracolonic malignancy HIGH -EGD, colon, MRE 2-3 years -Familial juvenile polyposis ->10 juvenile hamartomatous polyps -MC colon -synchronous adenomatous polyps -colonoscopy 1-2 years -PTEN multiple hamartoma syndrome (Cowden disease) -throughout GI -trichilemmomas*- facial papules -cerebellar lesions -thyroid, breast, urogenital tract cancer high
44
lynch syndrome
-3% of CRC -CRC with synchronic endometrial ca -larger, aggressive, sessile, dysplastic -right side -<50 usually -colonoscopy 1-2 years
45
colorectal cancer
-CBC, LFTs (metastases), carcinoembryonic antigen (CEA) -inspection- CT colonography or colonoscopy -once established- PET CT -rectal- endorectal US
46
follow up after colorectal cancer surgery
-History, PE, CEA every 3-6 months for 3-5 years -recheck excision after 3 months -colonoscopy after 1 year -> then every 3-5 years -annual CT for at least 3 years -rectal- sigmoidoscopy every 3-6 months for 3 years
47
anal cancer
-rare -squamous cancers -anal intercourse and hx STD common -HPV 80% -bleeding and pain -bx, MR and endoluminal rectal US
48
lower GI bleeds
-50%- diverticulosis bleeds- MC -> right MC -5-10%- vascular ectasis (angiodysplasias)- upper and lower GI, >70 with chronic renal failure, mucosal capillaries, cecum and ascending colon MC -10%- neoplasm/polyps- MC cause of occult -IBD -anorectal -ischemic colitis- older pts, AAA, ASHD, (young pts- vasculitis, coagulation, estrogen, long distance running) -> hematochezia, mild -small intestine or right colon- maroon stools
49
GI bleed dx and tx
-NG tube -active bleed- colonoscopy -> epinephrine, cautery, endoclips // intra-arterial vasopressin, angiography + embolization -unable to locate bleed with colonoscopy -> nuclear bleeding scan or angiography -ongoing excessive diverticular or vascular ectasia bleed -> resection -occult bleed (mc upper)- + FOBT/iron deficiency anemia -> colonoscopy and EGD -> cant find -> capsule or double balloon enteroscopy
50
massive bleed
->65 -hmg = 6 -diverticulosis or angiodysplasias
51
anal fissure tx
-posteriorly 90% -> lateral -> Crohn’s, HIV/AIDS, cancer, TB, syphilis -skin tag -treat underlying bowel pattern -cortisone -anesthetics -chronic: -nitroglycerin or diltiazem -botox -lateral interior sphincterotomy
52
anal fistula
-often in anal crypt -often from anorectal abscess -Crohn’s**, lymphogranuloma venereum, rectal TB, cancer -purulent discharge*, itching, pain -surgery unless crohns -seton
53
hemorrhoids
-subepithelial vascular cushions -> normal pressure and water tight -sinusoidal pattern of arteriovenous communication between superior and inferior arterial and superior, inferior middle veins -right anterior and posterior, left lateral -external- inferior hemorrhoidal vein -> squamous epithelium -thrombosed- self limited or surgery -> painful -cold water is better than hot
54
hemorrhoids treatment
-stage 1- enlargement with bleeding -Fiber supplementation Cortisone suppository Sclerotherapy Endolase Banding -stage 2- protrusion with spontaneous reduction -Fiber supplementation -Cortisone suppository -Sclerotherapy -Endolase*- for bleeding hemorrhoids -Banding -stage 3- protrusion requiring manual reduction -Fiber supplementation Cortisone suppository Banding* Operative hemorrhoidectomy (stapled or traditional) -stage 4- irreducible protrusion -Fiber supplementation -Cortisone suppository -Operative hemorrhoidectomy

Gastroenterology (20 decks)

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