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53 Cards in this Set

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What are risk factors for ampullary adenocarcinoma
Familial Adenomatous Polyposis (FAP) and Peutz-Jeghers syndrome
Patients with FAP have a markedly higher frequency of ampullary adenomas...what is the incidence?
50% to 86%
How do patients with ampullary adenomas present?
most commonly with obstructive jaundice (80%), less commonly pancreatitis and SOD type symptoms
What type of arthritis correlates with IBD disease activity
Asymetric oligoarticular arthritis (Type 1) primarily affecting large joints such as the knees, ankles, wrists, and elbows
Do the axial arthritides such as sacroiliitis and ankylosing spondylitis correlate with disease activity?
No. Ankylosing spondylitis is more common in Crohn's disease. AS is associated with HLA-B27
What is the aminosalicylate of choice in IBD patients with arthritis?
Sulfasalazine
What is the prevalence of rheumatologic manifestations of IBD
30%
When should Entamoeba histolytica serologies be checked?
In the setting of suspected amebic liver abscess and negative stool O&P x 3
What is morphologically identical to E. histolytica?
E. dispar (non-pathogenic/commensal).

Serologies can also be helpful to determine pathogenicity of Entamoeba cysts found in stools.
What is the treatment for E. histolytica?
Metronidazole 500 tid x 10 days than paramomycin
What part of the intestine does E. histolytica infect?
The colon- causing amebic colitis
What can a amoeboma resemble?
Adenocarcinoma
When is appendectomy considered curative for an appendiceal carcinoid?
When the tumor is less than 2 cm in size. If it is larger or shows invasion than a right hemicolectomy is recomended.
What is a malignant polyp?
A polyp which contains cancer cells that have invaded into the submucosa. If poorly differentiated, vascular or lymphatic involvement or cancer cells present at the margin of excision then consider surgical resection.
What two infections may produce a biphasic diarrheal illness? ie. start out watery than progress to bloody
E. coli 0157:H7 and Shigella
Are rectal corticosteroids effective for maintenance in UC, specifically proctosigmoiditis?
No, only for inducing remission. Rectal mesalamine is effective for maintenance
Is mesalamine corticosteroid-sparing for patients with corticosteroid-dependent Crohn's disease?
No. Only thiopurines, methotrexate and TNFs have been shown to be steroid sparing.
Who develops IBS after an acute episode of gastroenteritis.
IBS occurs in 7 to 36% of patients after gastroenteritis.
Predictors:
1) Females
2) underlying psychopathology
3) severity of the acute infectious diarrhea

pattern of bowel dysfunction is typically diarrhea predominant.
In the Walkerton, Canada post-infectious IBS study, what was considered severe acute infectious diarrhea.
1) weight loss (10 pounds)
2) bloody stools
3) prolonged duration of diarrhea (> 7days)
In the Walkerton, Canada study, were stool cultures done?
Only 39% of the patients had stool cultures which were positve for C. jejuni (7.5%) and E. coli 0157:H7 (4.5%).
When does surveillance colonoscopy begin for IBD patients?
Pancolitis- 8 years after disease onset

Distal disease- 15 years

inadequate data is available to recommend optimal surveillance intervals, intervals of 1 to 3 years are suggested.
Should Colectomy Be Performed for Flat Dysplasia?
Yes. Grade A: There is high certainty that colectomy for
flat HGD treats undiagnosed synchronous cancer
and prevents metachronous cancer.
On surveillance colonoscpy, how many biopsies should be taken? What areas?
At least 33 random biopsy specimens from all portions of the colon in patients with pancolitis.

Because dysplasia and cancer are more common in the left colon, it is also recommended that more extensive sampling should be performed in the left colon and particularly the rectum.
What should patients with UC and PSC receive as chemoprevention?
Ursodeoxycholic acid, which has demonstrated a significant reduction in CRC in patients with UC who also have PSC.
Do patients with ulcerative proctitis, ulcerative proctosigmoiditis, or limited Crohn’s colitis require surveillance colonoscopy?
No
When do patients with PSC begin surveillance colonoscopy?
At the time of this diagnosis and then undergo yearly
colonoscopy thereafter.
What are the two mechanisms for disordered defecation?
1) inadequate rectal propulsion owing to a failure to increase intrarectal pressure during evacuation

2) paradoxical contraction or impaired ability to relax the pelvic floor muscles during defecation
What is the treatment for disordered defecation
Biofeedback- usually 5 sessions seperated by 2 weeks
What is levator ani syndrome?
A difficult to treat etiology of proctalgia. On exam, it should be suspected when posterior traction on the puborectalis muscle during digital examination produces tenderness
What is the etiology of ischemic colitis?
Most cases do not have a
recognizable cause. It has been associated with:
1) aortic surgery and bypass surgery
2) colon carcinoma, and other potentially obstructive lesions
3) Hypotensive episodes- sepsis, post MI
What infections are associated with ischemic colitis? What can ischemic colitis mimic? Should antibiotics be used?
CMV and E. coli 0157:H7. Ischemic colitis can often mimic IBD. In general, antibiotics should be used, althought there is limited data.
What is the prognosis of ischemic colitis?
Excellent prognosis; most
cases resolve spontaneously
In acute mesenteric ischemia, what are the CT findings?
Portal venous air and pneumatosis. Unfortunately, these usually occur after gangrene. Peritoneal signs- laparotomy
Should patients with acute mesenteric ischemia undergo mesenteric angiogram?
Yes, particularly if there are no peritoneal signs present. Vasodilators (papaverine) should be administered if there is an SMA embolus.
What drugs are associated with microscopic colitis?
NSAIDS
PPIs
What are the treatments for collagenous colitis?
Budesonide
Mesalamine
Pepto-Bismol- 2 tabs QID (525 mg po QID) x 8 weeks

The Bismuth dose is the one used in Fine's study
In patients with perianal Crohns disease, should skin tags, hemorhoids, or fissures be surgically treated?
No- they have poor healing and lead to high rates of proctectomy
Should a pregnant woman with perianal Crohns deliver vaginally?
No. C-section is recomended

AGA MPS- 2003
What is appropriate treatment for a simple fistula?
Antibiotics, AZA/IFX, fistulotomy,
What is the role of a Seton in patients with a fistula due to perianal Crohn's?
A non-cutting Seton is particularly useful in those with rectal inflammation, as it maintains drainage of the fistula, thereby reducing the risk of perianal abscess formation
When can surgical treatment of rectovaginal fistulas be attempted?
Only when there is endoscopic healing of the rectosigmoid mucosa
What is the most common extracolonic malignancy in Lynch syndrome?
Endometrial cancer
What are the Lynch syndrome (HNPCC)-associated cancers?
Ovary, stomach, small intestine, urinary tract/kidney, bile ducts, glioblastoma multiforme, sebaceousgland tumors, and pancreas
What are the most common malignancies in FAP?
Desmoid
Duodenum
What are desmoid tumors?
Fibromatous tumors in a collagen matrix. Although they do not metastasize, they can grow very aggressively and be life threatening. 10% of FAP patients develop desmoids
In FAP patients, at what age does screening start? What is the interval?
Begin at age 10, repeat annually.
When should screening be initiated in patients with Lynch syndrome?
Age 21, then every 1-2 years until the age of 40, when colonoscopy is done annually.
Lynch syndrome with associated sebaceous tumors, cutaneous keratoacanthomas, and visceral carcinomas
Muir-Torre syndrome
What is the response rate to IV cyclosporine in refractory UC?
The response rate to IV cyclosporine is 80%, but 50% go on to require colectomy within 1 year.

Low dose IV cyclosporine- 2 mg/kg with Azathioprine is the preferred strategy.
What is the management of flat low-grade and high-grade dysplasia in IBD? Why?
High Grade- colectomy

Low Grade- controversial. Studies show significant variability in the incidence of progression to HGD or synchronous CRC (generally estimated to be 20%).

From AGA medical position statement (2010)
In IBD patients, what is the management of raised, endoscopically visible lesions or dysplasia associated lesion or mass (DALM)?
Non-adenoma like DALM- colectomy

Adenoma like DALM- endoscopic removal
What do non-adenoma like DALMs include?
Non adenoma-like DALMs include velvety patches, plaques, irregular bumps and nodules, wart-like thickenings, stricturing lesions, and broad-based masses.
In IBD patients, do postinflammatory pseudo-polyps increase the risk of colorectal cancer?
Yes. Two studies show that it doubles the risk.