Advertisement Upgrade to remove ads

Step 2 GI

What is the difference between dysphagia and odynophagia?

dysphagia is difficulty swallowing
odynophagia is pain with swallowing
Both indicate abnormalities of the oropharynx or esophagus

How does oropharyngeal dysphagia present?

difficulty passing material from the oropharynx to the esophagus. Involves liquids more than solids. Can be neuro or muscular in origina.

What are some possible causes of oropharyngeal dysphagia?

stroke
Parkinson's disease
Myasthenia gravis
prolonged intubation
Zenker's diverticula

How does esophageal dysphagia present?

Obstructive causes: involves solids more than liquids and is generally progressive.
Motility disorders: BOTH liquid and solid dysphagia

What are some possible causes for esophageal dysphagia?

Obstructive:
- strictures
- Schatzki rings
- Webs
- carcinoma
Motility:
- achalasia
- scleroderma
- esophageal spasm

What other types of neck etiologies can cause orophragyneal/esophageal dysphagia?

Goiter
Tumor
Anatomic defects

What syndrome does esophageal webs suggest?

Plummer-Vinson Syndrome when present with iron deficiency anemia and glossitis

What diagnostic test can be used to diagnose esophageal dysphagia?

barium swallow followed by endoscopy, mamometry, and/or pH monitoring
If obstructive lesion is suspected, endoscopy with biopsy

What diagnostic test can be used to diagnose odynophagia?

upper endoscopy

What diagnostic test can be used to diagnose oropharyngeal dysphagia?

cine-esophagram

What infectious esophagitis occurs in AIDS-defining illness?

candidal esophagitis

What is diffuse esophageal spasm?

motility disorder in which normal peristalsis is periodically interrupted by high-amplitude nonperistaltic contractions of unknown etiology. AKA nutcracker esophagus

How does HSV esophagitis present?

oral ulcers.
On endoscopy will see small deep ulcerations
Bx: multinucleated giant cells w/ nuclear inclusions

How is HSV esophagitis treated?

IV Acyclovir

How does CMV esophagitis treated?

retinitis, colitis
Endoscopy: large, superficial ulcerations
Bx: intranuclear inclusions on biopsy

How is CMV esophagitis treated?

IV ganciclovir

How does esophageal spasm present?

chest pain, dysphagia, odynophagia
can be triggered by hot/cold liquids

What causes relief in esophageal spasm?

nitroglycerin

How is esophageal spasm diagnosed?

Barium swallow: corkscrew-shaped esophagus
Esophageal manometry: high-amplitude, simultaneous contractions

How is esophageal spasm treated?

nitrates and CCB for symptomatic relief
Surgery (esophageal myotomy) for severe, incapacitating symptoms

What type of muscle is the upper 1/3 of the esophagus?

skeletal

What type of muscle is the lower 2/3 of the esophagus?

smooth muscle

What is achalasia?

motor disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the distal 2/3 of the esophagus

What is the hypothesized mechanism of achalasia?

loss or absence of inhibitory ganglion cells in the myenteric (Auerbach's) plexus

How does achalasia present?

progressive dysphagia, chest pain, regurgitation of undigested food, weight loss, nocturnal cough

How is achalasia diagnosed?

Barium Swallow: esophageal dilation with a "bird's beak" tapering of the distal esophagus
Manometry: increased resting LES pressure, incomplete LES relaxation upon swallowing, decreased peristalsis in the body of the esophagus
Endoscopy: r/o mechanical obstruction

How is achalasia treated?

Nitrates, CCB
Endoscopic injection of botulinum toxin into the LES for short term relief
Pneumatic balloon dilation or surgical Heller (myotomy) for definitive treatment options

What is esophageal diverticula?

cervical outpouching through the cricopharyngeal muscle: Zenker's diverticulum. Diverticula cna also occur in the middle/distal third of the esophagus

What is the most common esophageal motility disorder?

achalasia
2nd most: esophageal diverticula

How does esophageal diverticula present?

chest pain, dysphagia, halitosis, regurgitation of undigested food

How is esophageal diverticula diagnosed?

Barium swallow: demonstrate outpouchings

How is esophageal diverticula treated?

Sx: treat w/ surgical excision of teh diverticulum
Zenker's diverticulum: myotomy of teh cricopharyngeus to relieve high pressure zone

What is the most common type of esophageal cancer worldwide?

SCC

What is the most common type of esophageal cancer in teh US/Europe/Australia?

adenocarcinoma

Which esophageal carcinoma is assoc w/ Barrett's esophagus?

adenocarcinoma

What is Barrett's esophagus related to?

chronic GERD

What are major risk factors for SCC?

alcohol use and smoking

How does esophageal cancer present?

progressive dysphagia (solids than liquids), weight loss, odynophagia, GERD, GI bleeding, vomiting

How is esophageal cancer diagnosed?

Barium swallow: narrowing of esophagus w/ an irregular border protruding into the lumen
Endoscopy and bx to confirm dx
CT and endoscopic U/S for staging

How is esophageal cancer treated?

Poor prognosis
Definitive tx: chemoradiation and surgical resection (for high grade Barrett's dysplasia)
Palliative tx: endoscopically placed esophageal stent

What is GERD?

sx reflux of gastric contents into the esophagus, most commonly a result of transient LES relaxation. 2/2 incompetent LES, gastroparesis, hiatal hernia

How does GERD present?

heartburn 30-90min after a meal, worsens w/ reclining, improves with antacids, sitting or standing. Substernal chest pain difficult to distinguish from other causes, sour taste, globus, unexplained cough, morning hoarseness
Exam: benign unless have systemic disease like scleroderma

How is GERD diagnosed?

Hx and clinical impression
Empiric trial of lifestyle modification and medical tx
Barium swallow: to look for hiatal hernia
Esophageal manometry
24hr pH monitoring

Why does esophageal cancer metastasize early?

esophagus lacks a serosa

What are the risk factors for GERD?

hiatal hernia and increased abdominal pressure (obesity, pregnancy)

What other condition is often confused with GERD?

cough-variant asthma

When should endoscopy be performed for GERD pts?

In pts w/ sx unresponsive to initial empiric tx, long-standing, or suggestive of complicated disease (anorexia, weight loss, dysphagia/odynophagia)
Rules out Barrett's esophagus and adenocarcinoma

How is GERD tx?

Lifestyle: weight loss, head of bed elevation, reduction of meal size, avoidance of nocturnal meals and substances that decrease LES tone
Pharma: antacids (mild), H2 receptor antagonists (cimetidine, ranitidine; for intermittent sx), PPIs (omeprazole, lansoprazole; chronic and frequent sx). PPIs are preferred for severe or erosive disease
Surgical: for refractor or severe disease. Nissen fundoplication

What are some complications of GERD?

esophagitis, esophageal stricture, aspirationof gastric contents, upper GI bleeding, Barrett's esophagus

What types of foods can exacerbate GERD?

caffeine, alcohol, chocolate, garlic, onions, mints, and nicotine

What is a hiatal hernia?

herniation of a portion of the stomach upward into the chest through a diaphragmatic opening

What are the two common types of hiatal hernias?

Sliding hiatal hernia (95%): GEJ and portion of stomach displaced above diaphragm
Paraesophageal hiatal hernia (5%): GEJ below diaphragm, neighboring portion of the fundus herniates into the mediastinum

How does hiatal hernia present?

ASx
GERD

How is hiatal hernia dx?

incidental finding on CXR
frequently dx by barium swallow of EGD

How are hiatal hernias tx?

Sliding: medical tx and lifestyle mod to decreased GERD sx
Paraesophageal: surgical gastropexy (attachment of stomach to the rectus sheath and closure of the hiatus) to prevent gastric volvulus

What is gastritis?

inflammation of stomach lining

What is acute gastritis?

rapidly developing, superficial lesions that are often due to NSAIDs, alcohol, H. pylori infxn, and stress from severe illness (burns, CNS injury)

What is Type A chronic gastritis?

occurs at fundus and is due to autoabs to parietal cells. causes pernicious anemia and is assoc w/ other autoimmune disorders, such as thyroiditis. increases the risk of gastric adenocarcinoma

How is Type A gastritis associated w/ pernicious anemia?

the lack of intrinsic factor that is necessary for vitamin B12 absorption due to lack of parietal cells

What is Type B gastritis?

occurs in antrum and may be caused by NSAID use or H. pylori infxn.

How does Type B gastritis present?

ASx, but associated w/ increased risk of PUD and gastric cancer

How do pts w/ gastritis present?

ASx
complain of epigastric pain, nausea, vomiting, hematemesis, melena

How is gastritis dx?

Endoscopy: visualize gastric lining
H. pylori infxn: detected by urease breath test, serum IgG abs (which indicate exposure, not current infxn). H. pylori stool antigen, endoscopic biopsy

How is gastritis tx?

Mild: decrease intake of offending agents, antacids, sucralfate, H2 blockers, and/or PPIs
H.pylori confirmed: triple therapy (amoxicillin, clarithromycin, omprazole)
Prophy: H2 blockers/PPIs to pts at risk for stress ulcers (ICU pts)

What is gastric cancer?

malignant tumor in stomach

In what countries is gastric cancer most prevalent?

Korea and Japan

What are the two types of gastric cancer?

1. Intestinal type: thought to arise from intestinal metaplasia of gastric mucosal cells
2. Diffuse type: tends to be poorly differentiated and not associated w/ H. pylori infxn or chronic gastritis

What are the risk factors for intestinal type gastric cancer?

Diet high in nitrites, salt and low in fresh vegetables (antioxidants), H. pylori colonization, chronic gastritis

What are the risk factors for diffuse type gastric cancer?

unknown
not assoc w/ H. pylori infxn or chronic gastritis

What unique characteristics are seen on biopsy for diffuse type gastric cancer?

signet ring cells

How do pts with gastric cancer present?

Early signs: indigestion and loss of appetite
Advanced signs: abd pain, weight loss, or upper GI bleeding

How do you dx gastric cancer?

Early: incidentally found on endoscopy
Late: found on endoscopy (high-risk individuals)

How is gastric cancer treated?

Surgery: early detection and removal
five yr survival is <10% for advanced disease

What kind of tumor is gastric adenocarcinoma that metastasizes to the ovary?

Krukenberg tumor

What is assoc with an enlarged left supraclavicular LN? (Virchow's node)

gastric cancer

What is peptic ulcer disease?

damage to gastric or duodenal mucosa caused by impaired mucosal defense and/or increased acidic gastric contents

What causes duodenal and gastric ulcers?

H. pylori

What are other risk factors for PUD?

corticosteroids, NSAID, alcohol, and tobacco use

How does PUD present?

chronic or periodic dull, burning epigastric pain and improves w/ meals (esp duodenal ulcers), worsens 2-3 hrs after eating and can radiate to the back
Other Sx: nausea, hematemesis ("coffee-ground" emesis), blood in the stool (melena or hematochezia)
Exam: epigastric tenderness, active bleeding, + stool guaic

How does acute PUD present?

acute perforation: rigid abdomen, rebound tenderness, guarding, other sx of peritoneal irritation

How is PUD dx?

- AXR to r/o perforation (free air under the diaphragm)
- CBC to assess for GI bleeding (low or decreased hematocrit)
- upper endoscopy: biopsy to confirm PUD and r/o active bleeding or gastric adenocarcinoma (10% of gastric ulcers); barium swallow as alternative
- H. pylori testing
- Recurrent/refractory cases: serum gastrin to screen for Zollinger-Ellison syndrome

After a meal, does pain increase or decrease for gastric ulcers?

increase
decrease for duodenal ulcers

How is acute PUD treated?

- r/o active bleeding w/ serial hct, a rectal exam w/ stool guaiac and NG lavage
- monitor pt's hct and BP and treat w/ IV hydration, transfusion, IV PPIs, endoscopy, and surgery as needed for complications
- if perforation: emergent surgery indicated

What pharma interventions can be used for PUD?

Goal: protect mucosa, decrease acid production, eradicating H. pylori infxn
Mild: antacids, sucralfate, bismuth, misoprostol (a prostaglandin analog) for mucosal protection. PPIs or H2 receptor antagonists may be used to decreased acid secretion
H. pylori infxn confirmed: triple therapy
If recurrent/severe: require chronic sx therapy

What surgical interventions can be used for PUD?

Indications: sx gastric ulcers for >2 months that are refractory to med tx
- r/o gastric adenocarcinoma via endoscopy/upper GI series/barium swallow
- Procedure: parietal cell vagotomy

What are complications of PUD?

hemorrhage (posterior ulcers that erode into gastroduodenal artery)
gastric outlet obstruction
perforation (usually anterior ulcers)
intractable pain

What is Zollinger-Ellison Syndrome?

rare condition characterized by gastrin-producing tumors in the duodenum and/or pancreas that lead to oversecretion of gastrin, which lead to gastric and duodenal ulcers

What syndrome is Zollinger-Ellison syndrome associated w/?

MEN 1 (pancreas, pituitary, and parathyroid tumors)

How does Zollinger-Ellison present?

unresponsive, recurrent gnawing, burning abd pain and diarrhea, nausea, vomiting, fatigue, weakness, weight loss, and GI bleeding

How is Zollinger-Ellison syndrome dx?

increased fasting serum gastrin levels, increased gastrin following a secretin stimulation test, octreotide scan can localize the tumor

How is Zollinger-Ellison syndrome tx?

Decrease acid production: mod to high dose of PPI
Surgery (avoid possible malignant potential of the tumor): surgical resection

How is diarrhea defined?

>200g feces /day along w/ increased frequency or decreased consistency of stool

What are the four categories of diarrhea?

1) increased motility
2) increased secretion
3) increased luminal osmolarity
4) inflammation

What are the possible causes of acute diarrhea?

Bacteria with preformed toxins
- Staph
- Bacillus
Noninvasive bacteria
- ETEC
- Cholera
- C. Diff
Invasive bacteria
- EHEC
- Salmonella
- Shigella
- Campylobacter
- Yersinia
Parasites
- Giardia
- Entamoeba histolytica
Opportunistic organisms
- Cryptosporidium
- Isospora
- Microsporidium
- CMV

What is the most common cause of pediatric diarrhea?

rotavirus (winter)

What are possible causes of chronic diarrhea?

Increased intestinal secretion
- carcinoid
- VIPomas
Malabsorption/osmotic diarrhea
- bacterial overgrowth
- pancreatic insufficiency
- mucosa abnormalities
- lactose intolerance
Inflammatory bowel disease
Altered motility
- IBS
Osmotic diarrhea
- increased stool osmotic gap and resolution of diarrhea w/ fasting

How is diarrhea diagnosed?

Acute diarrhea does not need lab tests unless have sx of high fever, bloody diarrhea, diarrhea lasting > 4-5 days
Potential labs: stool for fecal leukocytes, bacterial culture, C- diff toxin, and O&P
Procedure: sigmoidoscopy if have bloody diarrhea

How is diarrhea treated?

Acute:
- If not suspicious for bacteria: antidiarrheals (loperamide, bismuth salicylate) and oral rehydration
- suspicious of bacterial infxn: avoid antimotility agents and consider abx after stool studies have been sent
Chronic
- identify underlying cause and treat sx w/ loperamide, opioids, octreotide, or cholestyramine
Pediatric
- oral rehydration: if cannot take PO fluids, hospitalize and give IV fluids, replete electrolytes and treat underlying cause

What is the causative agent for diarrhea associated w/ ingestion of raw eggs or dairy?

Salmonella

If after stool electrolytes, osmolality, weight/24 hrs, quantitative fat and an increased osmotic gap is detected, what causes of diarrhea should be considered?

Increased fecal fat
- malabsorption syndromes
- pancreatic insufficiency
- bacterial overgrowth
Normal fecal fat
- lactose intolerance
- sorbitol
- lactulose
- laxative abuse

If normal osmotic gap is detected after diarrhea tests what causes should be considered?

Normal stool weight
- IBS
- factitious diarrhea
Increased stool weight
- >1000 g: secretory or laxative abuse

What clues indicate C. diff infxn?

- recent abx (penicillins, cephalosporins, clinda)
- recent hospitalization

What complications can result from C. diff infxn?

toxic megacolon

What is a possible complication of EHEC?

HUS
Abx and antidiarrheal tx must be avoided because can increase HUS risk

What is the causative organism of osteomyelitis in sickle cell pts?

salmonella

What is malabsorption?

inability to absorb nutrients as a result of an underlying condition

What are some underlying conditions that can cause malabsorption?

bile salt deficiency (bacterial overgrowth, ileal disease)
short bowel syndrome
mucosal abnormalities (celiac disease, Whipple's disease, tropical sprue)
pancreatic insufficiency

How do pts with malabsorption present?

frequent, loose, watery stools and/or pale foul-smelling, bulky stools assoc w/ abd pain, flatus, bloating, weight loss, nutritional deficiencies, and fatigue

How is malabsorption treated?

Etiology dependent
Celiac sprue: gluten-free diet

If severely affected, need TPN, immunosuppresants, and anti-inflammatory meds

What is lactose intolerance?

Deficiency of lactase (brush-border enzyme that hydrolyzes the disaccharide lactose into glu and galactose)

How does lactose intolerance present?

Abd bloating, flatulence, cramping, watery diarrhea following milk ingestion

How is lactose intolerance dx?

Empiric lactose-free diet
H2 breath test: reveals increased breath hydrogen following ingestion of lactose load (indicates metabolism of lactose by colonic bacteria)

How is lactose intolerance tx?

avoidance of dairy products
lactase enzyme replacement

What is carcinoid syndrome?

liver metastasis of carcinoid tumors (hormone-producing enterochromaffin cells) that most commonly arise from the ileum and appendix and produce vasoactive substances such as serotonin and substance P

How does carcinoid syndrome present?

cutaneous flushing, diarrhea, abd cramps, wheezing, right-sided cardiac valvular lesions
Sx usually occur after eating, exertion, or excitement

How is carcinoid syndrome dx?

High urine levels of serotonin metabolite 5-HIAA are diagnostic
Octreotide scan to localize

How is carcinoid syndrome tx?

Symptoms: octreotide
Surgery: debulking of tumor mass

What is IBS?

idiopathic functional disorder that is characterized by changes in bowel habits that increase w/ stress as well as by abdominal pain that is relieved by bowel mvts

What kind of condition is associated w/ IBS?

psychiatric disorders
half of IBS pts have comorbid psychiatric disorders

How does IBS present?

abd pain, change in bowel habits (diarrhea and/or constipation), abd distension, mucous stools, relief of pain w/ bowel movt
Systemic sx rare: doesn't awaken from sleep, no vomiting, no weight loss
Exam: mild abd tenderness

How is IBS dx?

Dx of exclusion
R/O other GI causes: CBC, TSH, electrolytes, stool cultures, abd films, barium contrast studies, manometry to assess sphincter fxn

How is IBS tx?

Psych: reassurance from MD. Sx not all in their head
Dietary: fiber supplements (psyllium) may help
Pharma: TCAs, antidiarrheals (loperamide), antispasmodics (anticholinergics, such as dicyclomine)

What is small bowel obstruction?

blocked passage of bowel contents through small bowel. Fluid and gas can build up proximal to obstruction, leading to fluid and electrolyte imbalances and significant abd discomfort

What are the causes of SBO?

adhesions from a prior abd surgery (60%), hernia (10-20%), neoplasms (10-20%), intussusception, gallstone ileus, stricture due to IBD, volvulus

How does SBO present?

cramping abd pain w/ a recurrent crescendo-decrescendo pattern at 5-10 min intervals
Vomiting follows pain, early emesis is bilious and nonfeculent if the obstruction is prox but feculent if it is distal
Exam: distention, tenderness, prior surgical scars/hernias, bowel sounds are high-pitched tinkles, peristaltic rushes

What is an emergent presentation of SBO?

Fever, hypotension, rebound tenderness, tachycardia, peritonitis, disappearance of peristalsis-->surgical EMERGENCY

How does partial obstruction present?

continued passage of flatus, but no stool
Complete obstruction: no flatus or stool (obstipation)

How is SBO dx?

Labs: CBC show leukocytosis, COMP show dehydration and metabolic alkalosis (vomiting). If see lactic acidosis, suggest bowel necrosis and need for emergent surgical intervention.
AXR: stepladder pattern of dilated small bowel loops, air-fluid levels, paucity of gas in the colon

If there is radiopaque material at the cecum on AXR along with sx of SBO, what does that suggest?

gallstone ileus

How is SBO treated?

Partial Obstruction: supportive care (NPO status, NG suction, IV hydration, correction of electrolyte abnormalities, Foley catheterization to monitor fluid status
Surgery indications: complete obstruction, vascular compromise, and/or sx lasting >3 days w/o resolution
- Ex Lap w/ lysis of adhesions, resection of necrotic bowel, evaluation for stricture, IBD, and hernias
- second look laparotomy or laparoscopy may be performed 18-36 hrs after initial surgical tx to reevaluate bowel viability if ischemia is a concern

What is an ileus?

loss of peristalsis w/o structural obstruction

What are risk factors for an ileus?

recent surgery/GI procedure
severe medical illness
immobility
hypokalemia
electrolyte imbalances
hypothyroidism
DM
medications that slow GI mobility (anticholinergics, opiods)

How does ileus present?

diffuse, constant, moderate abd discomfort; nausea vomiting (w/ eating); absence of flatulence or bowel mvts
DRE: to rule out fecal impaction in elderly pts

How is ileus dx?

AXR (supine): diffusely distended loops of small and large bowel
AXR (upright): air-fluid levels
Gastrografin study: r/o partial obstruction
CT: r/o neoplasm

How is ileus tx?

Discontinue/decrease narcotics and other drugs that reduce bowel motility
Temporarily decrease/discontinue oral feeds
Initiate NG suction/parenteral feeds, as necessary
Replete electrolytes as needed

What is mesenteric ischemia?

decrease mesenteric blood supply leading to insufficient perfusion to intestinal tissue and ischemic injury

What are some causes of mesenteric ischemia?

acute arterial occlusion (SMA)
thrombosis (due to atherosclerosis)
embolism (Afib or decreased ejection fraction)
nonocclusive arterial disease (low cardiac output, arteriolar vasospasm)
venous thrombosis (due to hypercoabulable states)

How does mesenteric ischemia present?

- sudden onset of severe abd pain out of proportion to exam
- h/o prior episodes of similar abd pain after eating "intestinal angina"
- nausea/vomiting, diarrhea, bloody stools
Early exam: unremarkable
Late exam: may show peritoneal signs (bowel infarction)

How is mesenteric ischemia dx?

Labs: leukocytosis, metabolic acidosis, increased lactate, increased amylase, increased LDH, increased CK
AXR/CT: bowel wall edema ("thumbprinting") and air w/in the bowel wall (pneumatosis intestinalis)
Mesenteric angiography: gold standard for arterial occlusive disease

How is mesenteric ischemia tx?

- volume resuscitation, broad-spectrum abx, optimization of hemodynamics and avoidance of vasoconstrictors
- anticoagulation for arterial or venous thrombosis or embolism
Surgery: early lap for acute arterial occlusive disease or if evidence of peritonitis or clinical deterioration
- angioplasty and thrombectomy +/- endovascular stenting for acute arterial thrombosis
- embolectomy for acute arterial embolism
- resection of infarcted bowel

What are the complications of mesenteric ischemia?

sepsis/septic shock, multisystem organ failure, death

What is diverticular disease?

outpouchings of mucosa and submucosa (false diverticula) that herniate through the colonic muscle layers in areas of high intraluminal pressure; most commonly found in sigmoid colon

What is the most common cause of acute lower GI bleeding (>40yo)?

diverticulosis

What are the risk factors for diverticular disease?

low-fiber and high-fat diet
advanced age (65% occur in those > 80yo)
connective tissue disorders

What is diverticulitis?

inflammation and potentially perforation of diverticulum secondary to fecalith impaction

How does diverticulosis present?

ASx
bleeding that is painless and sudden, hematochezia with sx of anemia (fatigue, lightheadedness, dyspnea on exertion)

How does diverticulitis present?

LLQ abd pain, fever, nausea, vomiting, constipation.
Perforation is a serious complication that leads to peritonitis and shock

How is diveritcular disease dx?

Labs: leukocytosis
AXR: r/o free air, ileus, obstruction
Colonoscopy/barium enema: see outpouchings
AVOID sigmoidoscopy/colonoscopy in diverticulitis b/c of possible perforation
CT: to look for abscess/free air if no improvement b/c of severe disease

How is diverticular disease treated?

Uncomplicated diverticulosis: high-fiber diet/fiber supplements
Diverticular bleeding: bleeding usually stops spontaneously, transfuse and hydrate as needed, if bleeding does not stop, angiography w/ embolization or surgery
Diverticulitis: bowel rest (NPO), NG tube placement, broad-spectrum abx (flagyl, fluoroquinolone or 2nd/3rd gen cephalosporin) if pt is stable. AVOID barium enema, flexible sigmoidoscopy if diverticulitis suspected
If perforated: perform immediate surgical resection of diseased bowel via a Hartmann's procedure w/ a temporary colostomy

See More

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set