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107 Cards in this Set
- Front
- Back
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Diverticulosis
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Outpouching of mucosa and submucosa through muscle wall (false diverticula); sigmoid colon
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Presentation of diverticulosis
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Sudden, intermittent, painless bleeding; *most common cause of bleeds in >40yo*
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Presentation of diverticulitis
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LLQ pain, fever, nausea, vomiting
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Workup of diverticulitis
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CBC - leukocytosis, CT scan
Colonoscopy = definitive diagnosis; avoid in early diverticulitis |
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Management of diverticulosis
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Routine followup, recommend diet changes
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Tx of diverticular bleeds that won't stop
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Hemostasis by colonoscopy, angiography with embolization, surgery
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Diverticulitis tx
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Bowel rest, NG tube
Metronidazole + fluoroquinolone + 3rd gen cephalo |
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Small bowel obstruction presentation
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Acute abd pain, *VOMIT*, fever;
Abd distention, tinkly bowel sounds Look for surgical scars, hernias |
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Large bowel obstruction presentation
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Constipation, deep cramping, *feculent vomit*
Distention, tympany, tenderness Look fever, shock - perforation |
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Most common causes of SB obstruction
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Adhesions post surgery (adults), hernias (children), volvulus, intussusception
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Most common causes of LB obstruction
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*COLON CA*, diverticulitis, fecal impaction
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Differentials for SB and LB obstruction
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Paralytic ileus, gastroenteritis, IBD, Ogilvie's (for LBO)
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Workup for SBO/LBO
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CBC, electrolytes, lactic acid, AXR, CT
Colonoscopy, water contrast enema for LBO |
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Tx of SBO
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Partial: NPO, NG suction, hydration, Foley catheter
Complete: Exploratory lap - also for ischemia, necrosis, partial SBO >3 days |
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Prognostic sign for SBO
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Lactic acidosis - suggests necrosis
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Tx of LBO
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Gastrografin enema, colonoscopy, *rectal tube*, surgery
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Sx of rt sided colon cancer
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Occult fecal blood loss - anemia, weight loss, diarrhea, weakness
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Sx of lt sided colon cancer
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Obstruction (apple core lesions), change in bowel habits - constipation; blood-streaked stool
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Sx of rectal cancer
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Bright red blood PR, tenesmus, rectal pain
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Risk factors for colon cancer
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Age (70-80), FAP (100% risk by 40yo), HNPCC, +FHx, UC, adenomatous polyps
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Workup for colon cancer
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Definitive diagnosis: colonscopy with biopsy
CXR, LFTs, CT to check fo rmets |
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Tx of colon cancer
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Surgical resection with adjuvant chemo for lymphadenopathy
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Tumour marker for colon cancer
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CEA
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Colon cancer screening for pt with no relevant hx
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Starting at age 50:
FOBT, DRE every year Colonoscopy every *10 yrs* or sigmoidoscopy every *5 yrs* |
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Colon cancer screening for pt with 1st deg relative hx
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Colonoscopy every 10 yrs starting at age 40 -or- at 10 yrs prior to age of affected family member
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Colon cancer screening for pt with UC
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Colonoscopy every 1-2 yrs starting 8-10 yrs after diagnosis
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Ischemic colitis, and most common location
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Insufficient blood supply to colon leading to inflammation, ischemia, necrosis; watershed area - splenic flexure
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Presentation of ischemic colitis
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Crampy abd pain, bloody diarrhea; fever, peritoneal signs indicate necrosis
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Workup for ischemic colitis
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CT scan with contrast - thickened bowel wall
Colonoscopy - pale mucosa, petechial bleeding |
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Tx of ischemic colitis
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Bowel rest, IV fluids, analgeis, broad-spectrum antibiotics
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Sx of upper Gi bleeds
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Hematemesis, melena, hypovolemia
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Causes of upper GI bleeds
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PUD, gastritis, Mallory-Weiss tears, esophageal varices
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Sx of lower GI bleeds
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Hematochezia, melena
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Causes of lower GI bleeds
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Diverticulosis, angiodysplasia, IBD, hemorrhoids/fissures, cancer
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Workup for upper GI bleeds
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NG tube, lavage
Endoscopy if stable |
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Workup for lower GI bleeds
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Rule out upper GI bleed (NG lavage)
Anoscopy/sigmoidoscopy for pts <45yo Colonoscopy if stable Arteriography/exploratory laparotomy if unstable |
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Management of GI bleeds
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Intubation, IV fluids, packed RBCs
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Sites of involvement for UC
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*RECTUM*, extend in continuous fashion
Mucosa and submucosal involvement |
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Sites of involvement for Crohn's
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*Ileocecal region*, but anywhere in GI tract, in discontinuous fashion; transmural inflammation
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Sx of UC
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Bloody diarrhea, lower abd cramps, tenesmus, urgency
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Sx of Crohn's
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Abd pain, mass, low-grade fever, watery diarrhea, weight loss
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Extraintestinal conditions associated with IBD
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Stomatitis, uveitis, primary sclerosing cholangitis, erythema nodosum, pyoderma gangrenosum, arthritis + fistulas (Crohn's)
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Workup for IBD
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Colonoscopy with biopsy (definitive)
CBC, AXR, stool culture, C. diff stool assay, O&P |
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Rx management of IBD
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5-ASA (sulfasalazine, mesalamine); AZA, infliximab, steroids for refractory disease
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Surgical management of IBD
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UC: proctocolectomy for chronic, fulminent colitis, toxic megacolon
Crohn's: surgical resection for fistulas, performation, stricture, abscess |
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Complications of UC
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Fulminent colitis, toxic megacolon, colon cancer
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Direct hernia location
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Medial to inferior epigastric vessels, through Hesselbach's triangle
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Indirect hernia location
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Lateral to inferior epigastric vessels, through patent processus vaginalis
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Causes of acute bloody diarrhea
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Campylobacter
E. coli C. diff Entameba histolytica Shigella |
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Campylobacter colitis
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*Most common cause of bact. diarrhea*
Ingested contaminated food/water Children, young adults Bloody diarrhea lasting 7-10 days |
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Treatment for Campylobacter infection
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Erythromycin
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Common causes of C. diff
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Clindamycin, penicillin, quinolones
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Severe complication of C. diff
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Toxic megacolon
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Workup for C. diff
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Toxin in stool
Pseudomembranes in endoscopy |
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Tx of C. diff colitis
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Cessation of inciting antibiotic
PO Metronidazole or vancomycin |
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Workup for Campylobacter colitis
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Fecal RBCs, WBCs
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Entamoeba histolytica colitis
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Transmitted via food/water - look for travel hx
Incubation period up to 3 months Severe abd pain and fever |
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Workup for Entamoeba histolytica
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Fecal RBCs, WBCs
Endoscopy - flask shaped ulcers |
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Tx for Entamoeba histolytica colitis
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Metronidazole
Steroids contraindicated! |
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EHEC colitis
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Ingestion of contaminated raw meat
Children and elderly Severe abd pain, fever, vomiting lasting 5-10 days |
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Complication associated with EHEC colitis
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HUS in children
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Tx of EHEC colitis
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Supportive - *antibiotics and antidiarrheals contraindicated!*
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Salmonella colitis
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Ingestion of comtaminated eggs/diary
Children and elderly Prodromal headache, fever, abd pain lasting 2-5 days |
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Complications with Salmonella colitis
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Sepsis
Osteomyelitis in SCD pts |
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Tx of Salmonella colitis
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Only sepsis or SCD pts - fluoroquinolone or TMP-SMX
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Shigella colitis
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Fecal-oral transmission
Children, institutions Look for fecal RBCs, WBCs |
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Complications of Shigella colitis
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Febrile seizures in children
Dehydration |
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Tx of Shigella colitis
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TMP-SMX to decrease spread
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Organisms causing watery diarrhea
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Vibro cholera, rotavirus, ETEC, Cryptosporidium, Giardia
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Causes of malabsorption
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Celiac disease, Whipple's disease, tropical sprue
Bile salt deficiencies Pancreatic insufficiency, short bowel |
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Malabsorptive disorder following gastroenteritis
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Transient lactose intolerance
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Diagnostic test for lactose intolerance
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Hydrogen breath test - increased hydrogen following lactose
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Pellagra
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Niacin deficiency - diarrhea, dementia, dermatitis, death
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Carcinoid syndrome
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Metastasis of carcinoid tumours to liver (from ileum, appendix) producing seratonin
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Presentation of carcinoid syndrome
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Cutaneous flushing, diarrhea, abd cramps, wheezing, rt sided cardiac valve lesions
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Workup for carcinoid syndrome
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Urine 5-HIAA; CT, In-111 octreotide scans for localizing mets
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Tx of carcinoid syndrome
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Octreotide, surgical resection
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Complication of carcinoid syndrome
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Pellagra (dry skin lesions, diarrhea, psych changes)
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Presentation of IBS
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At least 3 months of abd pain/cramp relieved by defecation and change in stool frequency/habit
Examination is normal |
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AXR of SBO
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Stepladder pattern of dilated small bowel loops, air fluid levels
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Ileus and risk factors
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Loss of peristalsis without structural obstruction; risks: recent surgery/trauma, hypokalemia/lyte imbalance, hypothyroidism, DM, meds (antichol, opioids)
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Presentation of ileus
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Diffuse abd pain, nausea and vomit, absence of gas, bowel movements
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Workup for ileus
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DRE to rule out fecal impaction in elderly
ABX: distended loops with air throughout SB and LB |
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Management of ileus
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Discontinue opiods
Stop oral feeds: NG suction/parenteral feeds |
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Common causes of mesenteric ischemia
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1) Arterial thrombosis - atherosclerosis, proximal SMA
2) Emboli from heart - Afib, stasis (low EF) |
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Presentation of mesenteric ischemia
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Severe abd pain out of proportion to exam
Hx of intestinal angina after meals |
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Workup findings of mesenteric ischemia
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CBC - leukocytosis
Metabolic acidosis with high LDH, lactate, amylase, CK AXR/CT - bowel wall edema (thumbprinting), penumatosis intestinalis |
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Gold standard diagnosis of arterial occlusion in mesenteric ischemia
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Mesenteric angiography
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Tx of mesenteric ischemia
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Broad-spec antibiotics
Anticoagulation for arterial and venous thrombosis Fluid resus Surgical resection of infarcted bowel |
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Complications of mesenteric ischemia
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Sepsis, multiorgan failure, death
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Zollinger-Ellison syndrome
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Gastrin-producing tumours in duodenum, pancreas
Recurrent gastric ulcers Associated with MEN type 1 |
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Presentation of Zollinger-Ellison syndrome
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Recurrent burning abd pain with diarrhea, GI bleeding
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Workup for Zollinger-Ellison
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Fasting serum gastrin (increased) and increased gastrin with secretin injection
CT scan, octreotide scan (carcinoid tumours) |
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Tx of Zollinger-Ellison
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High-dose PPIs for sx relief
Surgical resection |
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PUD causes
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H. pylori (duodenal > gastric)
NSAIDS, steroids, alcohol, smoking |
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Presentation of PUD
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Dull, burning epigastric pain relating to meals, can radiate to back; hematemesis, + guaiac
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Risk associated with PUD and presentation
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Perforation - rigid abd, rebound tenderness, guarding
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Workup of suspected PUD
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Rule out perforation
Upper endoscopy with biopsy H. pylori test Serum gastrin if recurrent |
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How to detect gastric and duodenal ulcer perforation
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Gastric - AXR air under diaphragm
Duodenal - CT with contrast air in retroperitoneal space |
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Acute tx of PUD perforation
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CT with IV contrast to confirm - surgical laparotomy
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Acute management of PUD
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Rectal vault exam, NG lavage, serial hematocrit to rule out active bleeds; BP, IV fluids, transfusion, PPI
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Long term management of PUD
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Antacids, PPIs, H2 blockers
H. pylori infection - triple therapy |
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Intestinal type gastric ca. and associated risk factors
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Differentiated ca originating from gastric mucosal cells; risks - risks: diet (high nitrites, salt, low in fresh veggies) H. pylori, chronic gastritis
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Diffuse type gastric ca. and characteristic histology
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Undifferentiated ca. type; unknown risk factors; signet ring cells on biopsy
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Presentation of gastric ca.
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Early: asymptomatic; indigestion, anorexia
Late: abd pain, weight loss, GI bleeds Vrchow's node (LEFT supraclav. adenopathy) |
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Workup for gastric ca.
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Upper endoscopy with biopsy
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Tx and prognosis for gastric ca.
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Surgical resection; 5-yr survival <10%
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