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IM Gastrointestinal/Nutritional II
Terms in this set (87)
What is Gastroenteritis?
What is the MC cause of gastroenteritis?
Rotavirus and Norovirus
What is Diarrhea?
3+ liquid or semisolid stools daily for at least 2 days. Can be acute (<4 weeks) or chronic (>4 wks), inflammatory, noninflammatory, or secretory
What is inflammatory diarrhea? Noninflammatory diarrhea?
Inflammatory: Due to colonic invasion. There is small volume diarrhea, LLQ cramps, tenesmus, fever, +fecal WBC or occult blood
Noninflammatory: Due to disruption of small intestine absorption and secretion. There is large volume diarrhea, N/V, - fecal WBC or occult blood
What is secretory diarrhea?
Large volume without inflammation (no blood)
Causes of diarrhea?
Infectious (viral, bacterial, parasite)
Dietary (laxative use)
Other GI disease (Celiac, IBS, etc)
What are key parts of the history in a patient with diarrhea?
Duration of sx
Current meds/recent abx?
Illness among others who have shared meals with the patient
Clinical features of Gastroenteritis?
Treatment for diarrhea?
Antibiotics for severe infection and systemic symptoms (Shigella, Campylobacter, C.diff)
Diagnostic studies for diarrhea?
What is antibiotic-associated diarrhea caused by?
Antibiotics for C.diff?
Metronidazole <---for mild-mod
Vancomycin <---for complicated
What is Crohn disease?
Inflammatory bowel disease with a genetic component. Cause is unknown. Males = Females. Peak incidence between 15-35 years.
What are clinical features of Crohn disease?
Can affect any part of GI tract but most commonly terminal ileum and right colon.
SKIP LESIONS are characteristic
Low grade fever, malaise, wt loss
Mucus containing, nongrossly bloody diarrhea
Smoking makes it worse
What diagnostic studies are useful with Crohn disease? What is the study of choice?
EGD/Colonoscopy with biopsy and small bowel imaging - study of choice
Labs for Crohns and UC
CBC - anemia
CMP - decreased albumin
Fe, B12, Folate, Vit D
How will Crohn's disease appear with Colonoscopy? Microscopy?
Colonoscopy: Non-friable mucosa, cobblestoning, aphthous ulcers, deep and long fissures.
Microscopy: Transmural (full thickness) inflammation with mononuclear cell infiltrate; Noncaseating granulomas are common
Complications from Crohn disease?
Perianal disease (Fistulas, fissures, abscesses)
How do you treat acute Crohn disease?
Metronidazole or Cipro if there are fistulas
Immunomodulators (Anti-TNFa) for refractory cases
Surgery (not curative - treats complications)
How do you treat Crohn disease during maintenance phase?
What is Ulcerative colitis?
Inflammatory bowel disease which starts distally at the rectum and progresses proximally. Onset could be gradual or abrupt.
What are clinical features of UC?
Disease is continuous - No skip lesions
Onset is usually gradual
Tenesmus and BLOODY, pus filled diarrhea
Distended abdomen w/absent bowel sounds
Fever, Weight loss, Malaise
Smoking makes it better
What is the depth of lesions with UC?
Complications from UC?
What diagnostic studies are useful with UC? What is the study of choice?
Colonoscopy - Study of choice. Avoid in acute disease
CBC - anemia
Abdominal Xray - may show colonic dilation
How does UC appear on colonoscopy? Microscopy?
Colonoscopy: Continuous, granular, friable mucosa with diffuse ulceration; Psuedopolyps
Microscopy: Superficial chronic inflammation; crypt abscesses and architectural distortion
Treatment for acute UC?
Meslamine (for mild dz)
Steroids (for mod dz)
Anti-TNFa agents (mod-sev dz)
Surgery - proctocolectomy is curative
Treatment for UC during maintenance phase?
What is Diverticular disease?
What is the pathogenesis of diverticula?
Acquired herniations of colonic mucosa and submucosa through the colonic wall. Possible cause could be low fiber diet which increases stool transit time and decreased stool volume which leads to intraluminal pressures and herniation.
What part of the colon develops diverticula?
Risk factors for diverticular disease?
Age (80% of cases are 50+)
Low fiber diet
Complications of diverticulosis?
Possible cause of diverticulitis?
Fecolith which leads to bacterial overgrowth and local tissue ischemia
What bacteria is the most commonly isolated organism in diverticulitis?
Anaerobes (bacteroides, peptostretococcus, clostridium, fusobacterium)
Clinical features of diverticulitis?
LLQ abdominal pain
Obstipation (NO DIARRHEA!)
Perirectal fullness (mass effect)
Stool guiac +
What is complicated diverticulitis characterized by?
Ddx of diverticulitis?
IBD (especially Crohn's)
Advanced colorectal cancer
What is the initial imaging study of choice for Diverticulitis? What study is contraindicated?
CT of abdomen
Colonoscopy - contraindicated acutely due to risk of perforation
How do you treat diverticulitis?
Depends on severity...
Control pain, vomiting, comorbidities
Low residue diet/NPO
PO/IV Broad spectrum abx (Cipro + Flagyl)
Same as above PLUS
+/- NG tube
Prevention of Diverticulitis?
Low fiber diet is recommended until 6 weeks. Then high fiber diet
What is Celiac disease?
Gluten-sensitive enteropathy. AKA Celiac sprue - injury to the lining of the small intestine because the immune system responds abnormally to gliadin, a component of gluten.
Pathogenesis of Celiac disease?
There is crypt hyperplasia and villus atrophy which leads to impaired intestinal absorption.
What is Gluten?
A protein found in foods such as rye, wheat, barley
Clinical features of Celiac disease?
Constitutional: Weight loss, delayed puberty
ENT: Changes in dentition
GI: DIARRHEA which lasts for a few weeks, constipation, abdominal pain, vomiting, poor appetite, bloating
Heme: Iron deficiency anemia
How do you diagnose Celiac Disease?
Blood test for IgA anti-endomysial (EMA) and anti-transglutaminase (tTG) antibodies - will be increased
Small intestine biopsy - will show flattened villi
Trial of gluten free diet to see if it alleviates sx
How do you treat Celiac Disease?
Elimination of gluten from diet
What is Irritable bowel syndrome (IBS)?
Functional disorder without a known pathology. Thought to be a combination of altered MOTILITY/secretion, hypersensitivity, and psychological distress
What are symptoms of IBS?
Abdominal pain - may occur anywhere
Pain may be worsened with food intake, relieved with defecation
Tender, palpable sigmoid colon
Hyperresonance of bowel with percussion
Alteration of bowel movements (diarrhea, constipation)
Urinary urgency, frequency
What diagnostic studies are useful for IBS?
Diagnosis of exclusion!
All labs will be normal
Neg. stool cultures
Normal osmotic gap
Colonoscopy, barium enema, CT, U/S all negative
Diagnostic criteria for IBS?
Rome III: Recurrent abdominal pain for >3 days/month over the last 3 months plus >2 of the following:
Improvement of sx with defecation
Change in frequency of stool with onset of sx
Change in form of stool with onset of sx
How do you treat IBS?
Awareness of triggers
For pain: Antispasmodics, TCA, SSRI
For bloating: rifaximin, probiotics
For diarrhea: antidiarrheals, rifaximin
For constipation: high fiber diet
How common is Colorectal cancer?
4th MC cancer
2nd leading cause of cancer death in the US
90% occur in patients >50 yo
Prognosis is good if caught early
Risk factors for colon cancer?
What is a genetic condition that has almost 100% risk of getting colon cancer?
What genetic conditions increase the risk of colon cancer?
Familial adenomatous polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC)
Clinical features of colon cancer?
Slow growing; symptoms often appear late in disease
Right sided lesions (proximal) cause chronic blood loss. Obstruction is uncommon
Left sided lesions (distal) cause change in bowel habits and obstruction and hematochezia
Screening for colon cancer?
Colonoscopy starting at age 50 and repeated every 10 years is strongly recommended (earlier if +FHx)
Fecal occult blood - screen adults >40
Diagnostic studies for colon cancer? What is the test of choice?
Colonoscopy - Test of choice
CT colonography (CTC)
What is the marker followed for colon cancer?
Carcinoembryonic antigen (CEA)
Treatment for colon cancer?
Surgical resection (with chemo in patients with stage III - Dukes C)
Radiation for rectal tumors
What are hemorrhoids?
When the internal and external hemorrhoidal plexuses become excessively engorged, prolapsed, or thrombosed.
What are clinical features of hemorrhoids?
Internal hemorrhoids - painless, BRBPR (bright red bleeding per rectum)
External hemorrhoids - painful
Risk factors for for hemorrhoids?
What are Stage I, II, III, IV internal hemorrhoids?
1 - internal hemorrhoids which are confined to the anal canal and may bleed with defecation
2- internal hemorrhoids protrude from the anal opening but reduce spontaneously. Bleeding and mucoid discharge may occur
3 - internal hemorrhoids require manual reduction after bowel movements. Pain and discomfort.
4 - internal hemorrhoids that chronically protude and risk strangulation
Tx for hemorrhoids?
Stages I and II are managed with high-fiber diet, increased fluids, bulking laxatives, and sitz baths
Higher stages - suppositories
Surgical management for hemorrhoids that don't respond to treatment and all stage IV
Surgical tx for hemorrhoids?
Rubber band ligation
What is an anal fissure?
A superficial linear tear of the anal canal beginning at or below the dentate line and extending distally along the anal canal to the anal verge
In >90% of cases, anal fissures occur in the ________.
What are clinical features of anal fissures?
Acute sharp, cutting pain
Pain is most severe during a BM
How do you treat anal fissures?
Topical anesthetics - nitro, silver nitrate, gentian violet solution
What are indications for surgery for anal fissures?
Chronic fissure refractory to conservative management. Lateral internal sphincterotomy (LIS) is done
What causes anal abscesses?
Clinical features of anorectal abscesses?
Localized tenderness, erythema, swelling, fluctuance
Afebrile unless abscess is deep
Tx for anorectal abscess?
Warm water cleanse
High fiber diet
What causes anal fistulas?
Result of untreated anal abscess
Clinical features of anal fistulas?
Recurrent perirectal abscess
"Diaper rash" itching
Management of an anorectal fistula?
Fillet tract open
Wound care (routine Sitz baths and dressing changes)
Seton placement (thick suture) if fistula is through the sphincter muscle
General characteristics of anal cancer?
Caused by HPV
Common in those with HIV, particularly MSM
Clinical presentation of anal cancer?
Tx for anal cancer?
What defines a lower GI bleed?
Loss of blood from the GI tract distal to the ligament of Treitz
What is the most common cause of massive lower GI bleeding in adults?
What are causes of lower GI bleeds?
Diverticular hemorrhage- #1
(Note: the most common cause of blood found in the lower GI however is from an upper GI source)
Clinical features of a LGI bleed?
Hematochezia with or without abdominal pain
What diagnostic tests can be used to evaluate a lower GIB? Which is the most accurate?
Based on local availability and consultant preference:
Colonoscopy - most accurate
___% of lower GI bleeding will resolve spontaneously