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533 Cards in this Set

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What are 8 signs/symptoms of GI disease?
dyspepsia
nausea and vomiting
hiccups
constipation
eructation
flatus
diarrhea
GI bleeding
How is dyspepsia defined?
pain or discomfort centered in the upper abdomen
What are 8 symptoms that may be associated with dyspepsia?
upper abdominal fullness
early satiety
burning
bloating
belching
nausea
retching
vomiting
What are 6 etiologies of dyspepsia?
self-limited indigestion
luminal GI tract dysfunction
H. pylori infections
pancreatic disease
biliary tract diseae
functional dyspepsia
What is indigestion?
related to eating too much or too quickly, eating high-fat foods, eating under stress, alcohol, too much caffeine, etc.
What are 3 conditions that may cause luminal GI tract dysfunction which may lead to dyspepsia?
gastroparesis
gastric cancer
lactose intolerance
What is the most common cause of dyspepsia?
functional dyspepsia
-arise from complex interaction of visceral afferent activity, delayed gastric emptying, psychosocial stressors
For dyspepsia, history has ___ diagnostic utility and physical examination is ___ helpful.
limited
rarely
What is the study of choice for dyspepsia?
upper endoscopy
Which patients should always have an upper endoscopy?
patients over age 45 with new symptoms or all patiets with weight loss, dysphagia, or recurrent vomiting
What type of testing should be done for H. pylori?
noninvasive testing
What type of testing should be done for pancreatic or biliary tract disease?
abdominal imaging (CT)
What is nausea?
vague intensely disagreeable sensation of queasiness, not necessarily associated with vomiting
What stimulates vomiting?
medullary vomiting center
-afferent vagal fibers from GI
-fibers of vestibular system
-high CNS centers (sights, smells, emotions)
-chemoreceptor trigger zone (chemotherapy)
What are 6 complications of vomiting?
dehydration
hypokalemia
metabolic alkalosis
aspiration
rupture of esophagus
bleeding
What are 4 conditions that acute N/V without pain may be do to?
food poisoning
infectious gastroenteritis
cholecystitis
drugs
What are 3 conditions that acute N/V with severe pain may be due to?
peritoneal irritation
acute obstruction
biliary disease
What are 5 conditions that may cause persistent vomiting?
pregnancy
gastric outlet obstruction
gastroparesis
psychogenic disorders
CNS disorders
What does vomiting after meals suggest?
bulimia
What are 2 conditions that vomiting undigested food 1-3 hours after meals suggests?
gastroparesis
gastric outlet obstruction
What are 7 special examinations that can be done for N/V?
-abdominal films (assess acute onset w/ severe pain)
-NG tube placement (symptom relief)
-upper endoscopy
-barium radiography
-nuclear scintigraphy
-abdominal CT scan
-head CT/MRI (CNS causes)
What is singultus?
hiccups
What are 7 benign causes of hiccups?
gastric distension
carbonated beverages
air swallowing
overeating
sudden temp. changes
alcohol ingestion
heightened emotion
What are 5 causes of recurrent/serious hiccups?
CNS
metabolic
irritation of vagus/phrenic nerve
surgical
psychogenic
idiopathic
What are some treatment options for benign hiccups? (5)
irritation of nasopharynx
interruption of breath cycle
vagus nerve stimulation
diaphragm irriation
gastric distension relief
What is the "normal" range of BM's per week?
3-12
How is constipation defined?
2 or fewer BMs per week or excessive straining with defacation
What are 4 common causes of constipation?
poor diet
structural abnormalities (colonic lesions)
systemic diseases
medications
What are 2 medicines that can cause constipation?
anticholinergics
opiods
How much fiber should an individual get per day?
10-12g
What are 3 causes of severe or refractory constipation?
slow colonic transit
pelvic floor dysfunction
irritable bowel syndrome
How should constipation be evaluated?
history
physical exam
occult blood in stool
labs
colonoscopy
What are 3 labs that can be done for constipation?
CBC
chem panel
serum TSH
What group of patients is colonoscopy indicated for involving constipation?
patients over 50 or patients who fail a trial of fiber
What is belching also known as?
eructation
-usually not tied w/ a disease
What is eructation?
involuntary or voluntary release of gas from the stomach or esophagus
What are 4 common causes of eructation?
rapid eating
gum chewing
smoking
ingestion of carbonated beverages
What is chronic excessive belching almost always caused by?
aerophagia
Are antacids and anti-gas medications useful for eructation?
no
What are the 2 sources that flatus is derived from?
swallowed air

bacterial fermentation of undigested carbohydrates
What is initial recommended for increased flatus?
lactose-free diet
Do complaints of abdominal distension correlate with increased gas volumes?
no
What may help with flatus?
beano :)
How is diarrhea defined?
stool weight >250g/24 hours

>2-3 BMs per day or increased liquidity of feces
How long does acute diarrhea usually last?
less than 3 weeks
What usually causes diarrhea? (3)
infectious agent
bacterial toxin
drugs
What are 2 types of acute diarrhea?
noninflammatory
inflammatory
What is noninflammatory acute diarrhea?
-watery, nonbloody, associated w/ periumbilical cramps, bloating, N/V
-usually a small bowel source
What does prominent vomiting with acute noninflammatory diarrhea suggest?
viral enteritis or S. aureus food poisoning
What is acute inflammatory diarrhea?
-presence of fever and bloody diarrhea indicates colonic tissue damage
-invasion (shigellosis, salmonellosis, campylobacter, yersinia)
-toxin (C difficile, E. coli)
What is tenesmus?
feeling that you have to move your bowels but you don't
What type of evaluation should be done if diarrhea is present for >7-10 days?
stool should be sent for culture, fecal leukocytes, and ova and parasites
What type of evaluation should be done for severe proctitis?
sigmoidoscopy
What are the 7 major pathophysiologic categories of chronic diarrhea?
osmotic
secretory
inflammatory
malabsorption
motility disorders
chronic infections
factitious diarrhea
What are the 3 most common causes of chronic osmotic diarrhea?
lactase deficiency
laxative abuse
malabsorption syndromes
When does chronic osmotic diarrhea resolve?
during fasting
How is chronic osmotic diarrhea characterized? (3)
abdominal distension
bloating
flatulence
What type of diarrhea may olestra cause?
chronic osmotic diarrhea
Does fasting help with secretory conditions of chronic diarrhea?
no
What are 3 causes of chronic diarrhea of secretory conditions?
endocrine tumors
bile salt malabsorption
laxative abuse
What is an inflammatory cause of chronic diarrhea?
IBD
What may also occur with inflammatory conditions of chronic diarrhea? (4)
abdominal pain
fever
weight loss
mematochezia
What is the most common cause of motility disorders of chronic diarrhea?
IBS

may be secondary to surgery or systemic disease
How can chronic diarrhea be evaluated?
stool analysis
routine labs
serologic testing for celiac sprue
colonoscopy (mucosal biopsy)
upper endoscopy (small intestine biopsy)
abdominal CT
endoscopic U/S (chronic pancreatitis
barium radiography
What may be analyzed in a stool analysis for chronic diarrhea? (5)
weight & fecal fat (24 hours)
osmolality
laxative screen
fecal leukocytosis
ova and parasites
What are the routine labs that may be performed for chronic diarrhea? (5)
CBC
chem panel
liver function tests
TSH
PT
What is the most common presentation of upper GI bleeding?
hematemesis (bright red or coffee grounds) or melena (black, tarry)
What are 6 etiologies of upper GI bleeding?
peptic ulcer disease (half of upper GI bleeds)
portal HTN
Mallory-Weiss tears
vascular anomalies
gastric neoplasms
erosive gastritis/esophagitis
What should be done for initial evaluation of upper GI bleeding?
*hemodynamic stabilization
large bore IVS (type/match blood)
NG tube
blood/fluid replacement
preliminary risk assessment
What is the first step in initial evaluation of upper GI bleeding?
hemodynamic stablilization (Airway, Breathing, Circulation)
What are 3 reasons an upper endoscopy should be done for upper GI bleeding?
identify source
determine re-bleeding risk
render therapy (cautery, injection, sclerosis/binding of varices)
Where does lower GI bleeding arise?
below the ligament of Treitz
Does upper or lower GI bleeding tend to have a more benign course?
lower GI bleeding
What are 6 etiologies of lower GI bleeding?
diverticulosis
vascular ectasias
neoplasms
IBD
anorectal disease
ischemic colitis
Describe vascular ectasias?
-painless bleeding
-flat, red lesions w/ ectatic peripheral vessels
-most common in patients > 70 years
What are neoplasms?
benign polyps and carcinoma
What are 2 "signs" that may occur with anorectal disease?
hemorrhoids
anal fissures
What is ischemic colitis?
-bowel ischemia
-most bleeding is mild & self-limited
-older patients with atherosclerotic disease
How is lower GI bleeding evaluated?
asses color of blood/stool
exclude upper GI source
anoscopy/sigmoidoscopy
colonoscopy
capsule imaging
nuclear bleeding scans
angiography
What are 2 reasons that a colonoscopy will be performed for lower GI bleeding?
-performed urgently in patients w/ ongoing bleeding and 6-24 hours for others
-colonic lavage to clear colon
What are 4 esophageal symptoms?
dysphagia
heartburn
odynophagia
atypical chest pain
What are 2 types of dyspagia associated with esophageal symptoms?
oropharyngeal
esophageal (solids vs. everything)
What is GERD characterized by?
recurrent heartburn
Do more men or more women have GERD?
men
Is whites or blacks more common for GERD?
whites
What is the pathophysiology of GERD?
gastric contents reflux into the esophagus and remain long enough to overcome the resistance of esophageal epithelium
What are 2 symptoms of GERD?
recurrent heartburn
dysphagia (red flag)
What may dysphagia with GERD indicate?
peptic stricture or adenocarcinoma
How is the damage of GERD best assessed?
endoscopy
What are 7 signs of GERD?
erythema
edema
friability (easily torn)
erosions
ulcers
strictures
Barrett's esophagus
What are 9 extraesophageal manifestations of GERD?
pharyngitis, earache, laryngitis, globus sensation, gingivitis, eroded tooth enamel, chronic cough, asthma, aspiration pneumonia
What determines the diagnosis of GERD?
Hx of recurrent heartburn + positive response to acid-suppressant medication
What is the gold standard for identifying reflux?
esophageal pH monitoring
What are 4 tests that can be done for reflux?
upper GI series (barium swallow)
esophageal pH monitoring
esophageal manometry
upper endoscopy
*reserved for "red flag" symptoms of dysphagis, weight loss, or GI bleeding
GERD usually remains stable for long periods of time with short periods of exacerbation and ___.
remission (usually comes back once you stop medication)
What are 2 major complications of GERD?
peptic stricture (lumen is narrowing)

Barrett's esophagus
What is Barrett's esophagus?
normal squamous epithelium is replaced by specialized columnar epithelium; no symptoms; increases risk of adenocarcinoma
How is GERD treated?
goal is to relieve symptoms and prevent complications (lifestyle modifications)
What are lifestyle modifications that can be done to help relieve
GERD?
elevate head of bed 6+ inches
stop smoking
decrease EtOH
decrease dietary fat
smaller meal size
avoid eating before bed
weight reduction as needed
avoidance of "fun foods" ;)
avoidance of drugs that relax LES
What type of drugs relax the LES, worsening GERD?
anticholinergics
diazepam (Valium)
narcotics
progesterone
beta blockers
CCB's
What type of "fun stuff" ;) should be avoided with GERD to help relieve symptoms?
chocolate
mints
coffee
tea
cola
acidic foods
What type of drug therapy can be done for GERD?
antacids (Tums, Maalox)
H2 blockers (Zantac, Pepcid)
Prokinetics (Reglan)
PPI (*Prilosec, Rrevacid, Nexium)
What is the surgical procedure of choice for GERD?
laparascopic Nissen fundoplication (take fundus and wrap it around the esophagus)
What are 3 indications for surgery with GERD?
-alternative to medical maint. in young pts.
-means of controlling regurg
-erosive disease not controlled by PPI's
What types of surgery can be performed on GERD patients?
laparascopic Nissen fundoplication
Stretta & EndoCinch (endoscopy)
dilation of strictures
What is the therapy plan for Barrett's esophagus?
smoking & EtOH cessation to reduce risk of cancer

endoscopic surveillance (every 2-3 years)

esophagectomy (w/ high-grade dysplasia)

Tx same as for GERD
What are the 3 most common agents of infectious esophagitis?
Candida albicans
HSV-1
CMV

*most commonly in immunocompromised pts
What are 4 clinical manifestations of infectious esophagitis?
odynophagia
dysphagia
weight loss
GI bleeding
How can infectious esophagitis be diagnosed?
barium swallow

viral cultures or biopsy required for definitive diagnosis
What are 3 "clues" that show up with barium swallow for infectious esophagitis that may point to the particular causative agent?
candida-"shaggy" mucosa

HSV-numerous small, volcano-shaped ulcers

CMV-deep linear ulcers
How is candidal esophagitis treated?
non-Aids: oral nystatin or clotrimazole tablets

Aids: azole (oral/IV fluconazole or amphotericine IV)
How is HSV esophagitis treated?
oral acyclovir
How is CMV esophagitis treated?
IV ganciclovir
What are 5 other causes of esophagitis besides the common agents?
alkaline reflux (uncommon)
pill-induced
radiation
eosinophilic (topical food allergy)
caustic (accident/suicide)
What are 4 types of esophageal motor disorders?
achalasia
diffuse esophageal spasm
scleroderma
nutcracker esophagus
What is the most common primary esophageal motor disorder?
achalasia (etiology unknown)
What is achalasia?
an esophageal motor disorder that has degeneration of the nerves in Auerbach's plexus
-inc. LES pressure
-incomplete relaxation of LES w/out swallowing
-complete aperistalsis in the esophageal body
What is the primary complaint of achalasia?
dysphagia for liquids and solids

regurgitation is common
What does a barium swallw for achalasia show?
dilated esophagus and tapered "bird's beak" deformity at LES
How can achalasia be treated?
muscle relaxant before meals may help

Tx-endoscopic injection of botox onto LES, pneumatic dilator, or surgical Heller myotomy
On barium swallow, what does diffuse esophageal spasm show?
"corkscrew" esophagus
What are the symptoms of diffuse esophageal spasm?
chest pain and/or dyspagiea (pt may come in complaining of a heart attack)

uncommon motor disorder
How is diffuse esophageal spasm treated?
supportive
-assure pt that it is benign
-smooth muscle relaxants
What is the most commonly involved GI organ of scleroderma?
esophagus
What are the 3 symptoms of scleroderma (esophageal motor disorder)?
dysphagia
regurgitation
heartburn
How should esophageal scleroderma pts be treated?
prophylactically for GERD
What is nutcracker esophagus?
normal peristalsis but with contractions of very high amplitude; relatively common pattern in pts w/ noncardiac chest pain
What do pts with nutcracker esophagus commonly exhibit signs/symptoms of?
depression and anxiety
How is nutcracker esophagus treated?
treating depression/anxiety:
Amitriptyline
Imipramine
Trazodone
Clonazepam
What are some factors that increase the risk of esophageal squamous cell carcinoma? (7)
heavy tobacco/EtOH use, papillomavirus, lye ingestion, achalasia, celiac disease, radiation exposure
What is the clinical presentation of esophageal squamous cell carcinoma? (3)
rapidly progressive dysphagia, anorexia, weight loss
How is the diagnosis of esophageal squamous cell carcinoma made?
barium swallow

confirmed by biopsy
How is esophageal squamous cell carcinoma treated?
chemoradiation w/ or w/out surgery

low survival rate
What part of the esophagus is adenocarcinoma?
usually distal esophagus
What is the predominant risk of esophageal adenocarcinoma?
Barrett's esophagus
What may improve the survival of esophageal adenocarcinoma?
chemo & surgery
What are 4 symptoms that may occur with esophageal foreign bodies?
neck pain
chest pain
dysphagia
odynophagia
What may occur with delayed removal of esophageal foreign bodies?
ulceration
perforation
stricture
How is esophageal foreign bodies diagnosed and removed?
endoscopy (airway protection is essential during removal)
What is gastritis?
inflammation of the gastric mucosa
What are 3 types of gastritis?
H. pylori
hemorrhagic
infectious
What are 5 conditions of the GI that H. pylori is associated with?
gastritis
duodenal ulcer
gastric ulcer
gastric adenocarcinoma
primary gastric B-cell lymphoma
When is H. pylori typically acquired?
childhood
-chronic, serious infection with long latent period
-more common in less developed countries
What are the symptoms of H. pylori gastritis?
epigastric pain, N/V lasting a few weeks
H. pylori gastritis causes progressive damage starting in the ___, then possibly explain to the entire ___ (pangastritis).
antrum
stomach
What is it called if H. pylori expands to the entire stomach?
pangastritis
-highest risk for gastric adenocarcinoma
How is H. pylori gastritis detected?
noninvasive modalities (serology, C-urea breath test, stool antigen testing)

endoscopy w/ biopsy
How is H. pylori gastritis treated?
cure of infection
-reduces risk of PUD and gastric cancer
What may H. pylori gastritis lead to?
atrophic gastritis
What occurs with atrophic gastritis?
stomach becomes less acidic, leading to overgrowth of other bacteria and possible disappearance of H. pylori
What are the 3 types of pts that erosive hemorrgagic gastritis is seen with?
-alkaline reflux after gastrectomy
-duodenogastric bile reflux
-pts who take NSAIDs
Where is the pain with hemorrhagic gastritis and what other symptoms may be included?
midepigastric burning pain unresponsive to antacids

may include bilious vomiting, anemia and weight loss
How may hemorrhagic gastritis be partially prevented?
by simultaneous use of prostaglandin analogues (misoprostol) or suppression of gastric acid (like H2 blocker or PPI)
Patients who abuse alcohol may have intramuscular hemorrhages that appear like what?
"blood under a plastic wrap"
What has been implicated as a cause of gastric ulcers in normal hosts?
HSV-1
What are 3 types of infectious gastritis that immunocompromised pts may have?
gastric TB
secondary syphilis
CMV
What are the 2 most common causes of peptic ulcer disease?
NSAID use
H. pylori infection
What are gastric and duodenal ulcers associated with?
gastric-pangastritis

duodenal-antral predominant gastritis
What ages do duodenal and gastric ulcers commonly occur?
duodenal- 25-55 years old
gastric - 40-70 years old

men>women
What seems to play a role in ulcerogenesis?
genetic factors
What causes superficial mucosal damage (petechiae and erosions) in peptic ulcer disease?
stress
What are 6 factors that increase stress ulcer risk?
mechanical ventilation > 5 days, coagulopathy, hepatic or renal failure, sepsis and shock
*greatly increased mortality
Is gastrinoma a common form of peptic ulcer disease?
no
What are the symptoms of peptic ulcer disease?
may have no symptoms

burning epigastric abdominal pain after meals or at night and relieved with food or antacids
Is the physical exam useful for peptic ulcer disease?
not really

Unless:
-perforated ulcer-shows signs of peritonitis (rebound tenderness/involuntary gaurding)
-succession splash-retained gastric contents (pyloric stenosis)
How can peptic ulcer disease be differentiated from pancreatitis?
pancreatitis is more constant
What is included in the differential for peptic ulcer disease?
nonulcer dyspepsia
GERD
biliary tract disease
pancreatitis
intraabdominal neoplasms
IBD
IBS
What tests are used to make a definitive diagnosis for peptic ulcer disease?
upper endoscopy (more accurate, but costs more) or barium contrast radiography
Duodenal ulcers are almost never ___ and gastric ulcers should be ___.
malignant
biopsied
How is peptic ulcer disease treated?
acid suppression help accelerate ulcer healing, but do not cure the cause
What are the 3 goals of peptic ulcer disease?
relieve symptoms
heal the ulcer
cure the disease and/or prevent recurrence
What helps with neutralizing the acid to acclerate healing of peptic ulcer disease?
PPIs (most effective)
H2 blockers
Misoprostol
What type of antimicrobial therapy is given for H. pylori peptic ulcer disease?
*best results with combo. therapy
-BID: PPI + 2 of the following (amoxicilin, metroniadazole, or clarithromycin)
-QID: Bismuth + tetracycline + metronidazole OR clarithromycin OR amoxicillin
-Quadruple therapy: PPI BID + bismuth + tetracycline QID + metronidazole TID (yowsers!)

14 days better than 7-10 days
What type of medication can be used for peptic ulcer disease pts who require an anti-inflammatory?
prednisone
What are 4 complications of peptic ulcer disease?
intractability (failure of an ulcer to heal despite successful Tx)-->Zollinger-Ellison

hemorrhage

perforation

obstruction
What is the most common cause of major UGI bleed?
hemorrhage from peptic ulcer disease
What happens with perforation of peptic ulcer disease?
abrupt onset of severe abdominal pain followed rapidly by signs of peritoneal inflammation; leukocytosis appears rapidly
How is perforation with peptic ulcer disease confirmed?
free air on upright CXR or lateral decubitus film

surgery to close the perforation
What are the symptoms/signs of obstruction with peptic ulcer disease?
inflammatory swelling and fibrosis
What type of procedure needs to be done for obstruction of peptic ulcer disease?
endoscopic balloon dilation
surgery
What are 3 operative procedure that can be done for peptic ulcer disease to decrease acid secretion?
open or laparoscopic:
highly selective vagotomy
truncal vagotomy
pyloroplasty
What is Zollinger-Ellison syndrome also know as?
gastrinoma

(rare)
What is Zollinger-Ellison syndrome caused by?
gastrin-secreting tumors (gastrinomas)
-hypergastrinemia
-acid hypersecretion
Why is Zollinger-Ellison syndrome significant?
b/c ulcers don't heal
-over 2/3 are malignant
What are 4 signs/symptoms of Zollinger-Ellison syndrome?
peptic ulcers
GERD symptoms
diarrhea
weight loss
How is the diagnosis of Zollinger-Ellison syndrome made?
demonstration of increased fasting serum gastrin level
What type of imaging can be done for Zollinger-Ellison syndrome?
CT and MRI (only up to 70% sensitive)

newer:
somatostatin receptor scintigraphy
endoscopic ultrasonography
How is metastatic disease for Zollinger-Ellison syndrome treated?
-most important predictor of survival is presence of hepatic matastases
-initial therapy directed at controlling hypersecretion w/ PPIs
May may prolong survial of metastatic disease from Zollinger-Ellison syndrome?
surgical resection of isolated hepatic metastases
What is the treatment of localized disease from Zollinger-Ellison syndrome?
resection of gastrinoma before hepatic spread
Does lymph node metastases adversely affect the prognosis of localized disease from Zollinger-Ellison syndrome?
no
What are the 2 types of diseases for Zollinger-Ellison syndrome?
metastatic disease
localized disease
How is upper GI bleeding defined?
bleeding that occurs proximal to the ligament of Treitz
What are the 2 most common causes of upper GI bleeding?
peptic ulcers
esophageal varices
What is the method of choice for establishing the site of upper GI bleeding?
endoscopy
What type of equipment is useful to estimate the rapidity of upper GI bleeding?
NG
After hemodynamic stabilization with upper GI bleeding, what is indicated for nonvariceal bleeds?
endoscopy
If blood obscures with upper GI bleeding, what can be used prior to endoscopy?
gastric lavage
Why is barium radiography contraindicated in GI bleeding?
it interferes w/ endoscopy, angiography, and surgery
What are 3 conditions that increase the risk of upper GI bleeding?
age
shock
comorbidity
Endoscopy can identify patients at low risk for upper GI rebleeding and morbidity, allowing them to be treated as __ and ___ costs.
OP

decreasing
What is the least expensive method of endoscopy for upper GI bleeding?
injection
-may not be as effective for long-term hemostasis
What can reduce upper GI rebleeding in high-risk patients?
profound acid suppression
-PPP better than H2 blockers
What is the most common presenting symptom of lower GI bleeding?
hematochezia
-bloody diarrhea
-blood & clots per rectum
-maroon colored stool
Lower GI bleeding is commonly a disorder of the ___.
elderly
-increasing prevalence w/ age
What are the 3 most common causes of lower GI bleeding?
diverticula
vascular ectasis
tumors
What are 3 ways that vascular lower GI lesions may be treated?
injection
thermal methods
endoscopic laser therapy
If colonoscopy is not effective w/ lower GI bleeding, then what 2 tests may help?
angiography
scintigraphy
How is occult GI bleeding defined?
detection of asymptomatic GI bleeding
-routine FOBT
-iron deficiency anemia
What is the initial approach to occult bleeding?
endoscopy
-upper endoscopy & colonoscopy
What are potential causative agents of occult GI bleeding?
NSAIDs & aspirin
What type of testing can be done for occult GI bleeding to exclude a hepatic or pancreatic source of bleeding?
abdominal CT
What are the 4 functions of intestinal epithelium?
-nutrient digestion & absorption
-barrier & immune defense
-fluid & electrolyte balance
-production of proteins, amines, and peptides
What are the 3 phases of digestion?
intraluminal phase
mucosal phase
absorptive phase
What occurs in the intraluminal phase of digestion?
dietary fats, proteins, and carbohydrates are hydrolyzed and solubilized
Where does the mucosal phase occur and happens during the mucosal phase?
small intestine
-nutrient balance & absorption
What can dysfunction during the absorptive phase lead to?
significant protein losses
What is malabsorption?
disruption of digestion and nutrient absorption
What are 11 signs/symtpoms of malabsorption?
steatorrhea
diarrhea
weight loss, malnutrition
iron deficiency/megaloblastic anemia
bone pain/fractures
paresthesia/tetany
bleeding problems
edema
milk intolerance
nocturia
abdominal distension
What defines acute diarrhea?
lasts less than 2 weeks
What are 3 common causes of acute diarrhea?
infectious agents
bacterial toxin
drugs
What are 2 types of acute diarrhea?
noninflammatory
inflammatory
How is noninflammatory diarrhea defined?
-watery, nonbloody
-associated w/ periumbilical cramps, bloating, N/V
-usually a small bowel source
How is inflammatory diarrhea defined?
-presence of fever & bloody diarrhea
-associated w/ LLQ pain, urgency, tenesmus
What does inflammatroy diarrhea need to be distinguished from?
acute ulcerative colitis
What does the presence of fever and bloody diarrhea indicate?
inflammatory diarrhea
-colonic tissue damage caused by invasion or a toxin
What are 4 situations that prompt medical evaluation is required for acute diarrhea?
IBD signs
*profuse diarrhea w/ dehydration
frail eldery & infants
immunocompromised pts
What is the treatment plan for acute diarrhea?
bowel rest
rehydration
antidiarrheal agents (Loperamide, Pepto-Bismol)
empiric antibiotics (not all pts)
When should antidiarrheal agents not be given for acute diarrhea?
not w/ high fever or bloody diarrhea (sometimes need to get rid of it)
What are the 7 major pathophysiological categories of chronic diarrhea?
osmotic diarrhea
secretory conditions
inflammatory conditions
malabsorptive conditions
motility disorders
chronic infections
factitious diarrhea
What are 2 ways that chronic diarrhea can be evaluated?
stool analysis
colonoscopy w/ mucosal biopsy
What are 6 medications that can be used to treat chronic diarrhea?
Loperamide
Diphenoxylate w/ atropine
Codeine (dec. peristalisis)
Clonidine
Octreotide
Cholestyramine
What are 4 signs/symptoms of celiac disease?
weight loss
chronic diarrhea
abdominal distention
growth retardation

usually seent in infancy, but can occur in adults
What are 3 atypical symtpoms of celiac disease?
dermatitis herpetiformis (10%)
iron deficiency anemia
osteoporosis
What can improve celiac disease?
gluten-free diet
What is celiac disese also known as?
celiac sprue
What shows up on labs for celiac disease?
microcytic/megaloblastic anemia
low calcium or high alk phos
increased prothrombin time
What are 2 specific tests that can be done for celiac disease?
stool for fecal fat (24hr collection)
serologic tests (should be confirmed w/ biopsy)
What are 3 differentials for celiac disease?
IBS
bacterial overgrowth
lactose intolerance
What is Whipple's disese caused by?
infection w/ bacillus Tropheryma whippelii
-unknown source of infection
-will not spread human-to-human
Who does Whipple's disease commonly affect?
whit men 30-50 years old
What are the signs/symptoms of Whipple's disease?
arthalgias/migratory arthritis, abdominal pain, chronic diarrhea, malabsorption, flatulence, steatorrhea, weight loss, fever, lymphadenopathy, uveitis/retinitis, CHF or valvular regurg, enteric protein loss w/ edema/hypoalbuminemia
How is the diagnosis for Whipple's disease made?
endoscopic biopsy of the duodenum showing the Whipple bacillus
-PAS-positive macrophages
How is Whipple's disease treated?
antibiotic therapy at least 1 year
-IV Rocephin
-TMP-SMX
-Cepahlosporins (if allergic to sulfa)
What is the prognosis for Whipple's disease?
fatal if untreated

pts must be followed closedly for recurrence
What does bacterial overgrowth due to the GI system?
damages mucosa of small intenstine & interfers w/ absorption
What are 6 causes of bacterial overgrowth in the GI?
gastric achlorhydria
anatomic abnormalities w/ stagnation
motility disorders
gastrocolic/coloenteric fistula
AIDS
chronic pancreatitis
What are the S/S of bacterial overgrowth in the GI?
most pts asymptomatic

S/S of malabsorption
How can bacterial overgrowth be tested?
aspiration & culture of proximal jejunum secretions

14C xylose breath test
How is bacterial overgrowth in the GI treated?
-correction of anatomic defect if needed
-broad spectrum antibiotics 1-2 weeks (Cipro, Amoxicillin)
-may need cyclic antibiotic therapy
What is short bowel syndrome due to? (4)
removal of significant segments of small intestine
-Crohn's disease
-mesenteric infarction
-trauma
-radiation enteritis
What happens with terminal ileum resection?
malabsorption of bile salts/B12
What is the Tx for short bowel syndrome from terminal ileum resection?
low-fat diet
cholestyramine
vitamins
What happens with extensive bowel resection?
weight loss
diarrhea
What is the Tx for short bowel syndrome form extensive small bowel resection?
vitamin/mineral supplements
TPN (total parenteral nutrition) in severe cases
What are the signs/symptoms of lactase deficinecy?
bloating
abdominal cramps
flatulence
diarrhea
no weight loss
*after lactose ingestion
What type of lab can be done for lactase deficiency?
hydrogen breath test
What are 3 differentials for lactase deficiency?
IBD
malabsorptive disorders
IBS
What is the Tx plan for lactase deiciency?
patient comfort
limit lactose foods
lactase enzyme replacement
What are 2 types of IBD?
ulcerative colitis
Crohn's disease
Can ulcerative colitis or Crohn's disease go through the entire wall of bowel?
Crohn's
Which type of IBD has diffuse mucosal inflammation of the colon?
ulcerative colitis
Which type of IBD has patchy transmural inflammation of the GI tract?
Crohn's disease
Which type of IBD always involves the rectum?
ulcerative colitis
Which type of IBD may involve any part from the mouth to the anus?
Crohn's disease
Which type of IBD may smoking decrease the severity of the disease?
ulcerative colitis
Which type of IBD does smoking worsen the severity of the disease?
Crohn's disease
Which type of IBD is p-ANCA>ASCA?
ulcerative colitis
Which type of IBD is ASCA>p-ANCA?
Crohn's disease
What are 7 extraintestinal symtpoms of IBD?
arthritis
erythema nodosum
pyoderma gangrenosum
ocular problems (uveitis/retinitis)
cholestatic liver disease
oral aphthous lesions
nephrolithiasis
Which type of test is the key to diagnosis for ulcerative colitis?
sigmoidoscopy
What are the signs/symptoms of mild/moderate ulcerative colitis?
gradual onset of diarrhea
diarrhea
fecal urgency/tenesmus
LLQ cramps
What are the signs/symptoms of severe ulcerative colitis?
6+ bloody stools per day (severe anemia, hypovolemia, impaired nutrition)

abdominal pain
What do the labs for ulcerative colitis show? (3)
low H/H
increased sed. rate
low serum albumin
What are the general measures of Tx of ulcerative colitis?
limit caffeine
limit gas-producing veggies
fiber supplements
anti-diarrheals
How should distal ulcerative colitis be treated?
topical mesalamine
topical corticosteroids
oral 5-ASA
How should mild/moderate ulcerative colitis be treated?
oral agents (5-ASA, corticosteroids)
How should severe colitis be treated?
NPO 24-48 hrs
D/C opiods/anticholinergics
restore fluids/elctrolytes
corticosteroids 7-10 days
IV cyclosporine (if steroids don't work)
surgery (if no improvement)

oral fluids can be restarted once symptoms improve
What is fulminant colitis?
rapid progression of ulcerative colitis; very severe; small subset of pts
What are the signs/symptoms of fulminant colitis?
fever
prominent hypovolemia
hemorrhage requiring transfusion
abdominal distension
tenderness
What are 2 conditions that fulminant colitis is at high risk for?
perforation
development of toxic megacolon
How is fulminant colitis treated?
same as severe colitis + broad spectrum antibiotics
How is toxic megacolon defined?
colonic dilation of more than 6cm on plain films
How is toxic megacolon treated?
-same as severe fulminant colitis + NG tube
-decompression of distended colon
-maintenance of remission w/ 5-ASA daily
-surgery to prevent perforation if no improvement w/ 48-72 hrs
What type of treatment can be done for refractory ulcerative colitis?
-surgical resection
-immunosuppressive therapy (azathioprine or 6-MP)
-transdermal nicotine
-Infliximab/anti-TNF drug
What can be done to help with the risk of cancer w/ ulcerative colitis proximal to the sigmoid colon?
folic acic

colonoscopies q 1-2 years starting 8-10 years after diagnosis
What are 6 indications for surgery w/ ulcerative colitis?
severe hemorrhage
perforation
carcinoma
dysplasia on colonoscopy
refractory disease
no improvement w/ fulminant colitis/toxic megacolon
What are 3 things the can ge done with complete colectomy?
standard ileostomy w/ external appliance

continent ileostomy

internal ileal pouch anastomosed to anal canal
What is the prognosis for ulcerative colitis?
lifelong disease w/ exacerbations/remissions

surgery provides complete cure
What are the essential of diagnosis for Crohn's disease?
-insidious onset
-intermittent bouts of low-grade fever, diarrhea, and RLQ pain
-RLQ mass/tenderness
-perianal disease
-radiographic evidence of ulceration/stricturing/fistulas of small intestine/colon
What is the most common place in the GI tract for Crohn's disease?
ileo-cecal valve
What are the signs/symptoms of chronic inflammatory disease (most common presentation) associated w/ Crohn's disease?
low-grade fever
malaise
weight loss
decreased energy
nonbloody diarrhea
crampy
steady RLQ/periumbilical pain
focal RLQ tenderenss
What are the sign/symptoms of intestinal obstruction associated w/ Crohn's disease?
posprandial bloatin
cramping pains
loud borborygmi
What are the signs/symptoms of fistulization +/- infection associated with Crohn's disease?
development of sinus tracts
may lead to intra-abdominal abscesses
What are the signs/symptoms of perianal disease associated w/ Crohn's disease?
anal fissures
perianal abscesses
fistulas
What are 5 sign/symptoms of Crohn's disease?
chronic inflammatory disease
intestinal obstruction
fistulization +/- infection
perianal disease
extraintestinal manifestations
What special diagnostic studies can be done for Crohn's disease?
upper GI series w/ small bowel follow through
capsule imaging
barium enema
colonoscopy
What are 7 complications of Crohn's disease?
abscess
obstruction
fistulas
perianal disease
carcinoma
hemorrhage
malabsorption
What happens w/ abscess w/ Crohn's disease?
-presence of tender abdominal mass w/ fever & leukocytosis
-emergent CT required
-broad spectrum antibiotics
-percutaneous drainage or surgery is usually required
What happens w/ obstruction w/ Crohn's disease?
secondary to active inflammation or chronic fibrotic stricturing

-IV fluids & NG tube
-corticosteroids if inflammation acitve
What happens w/ fistulas w/ Crohn's disease?
majority are asymptomatic

6-MP or azathioprine
Infliximab

surgical therapy if no improvement
What happens w/ perianal disease w/ Crohn's disease?
severe perianal pain suggests an abscess --> I&D

Flagyl or Cipro
Is severe bleeding usual with Crohn's disease?
no it is rare
Patients w/ extensive colonic involvement w/ Crohn's disease are at increased risk for ___ cancer; screening colonoscopy ___ years after diagnosis.
colon

8
What is the Tx plan for Crohn's disease?
not curative
directed at improving symptoms
nutrition
symptomatic meds.
surgery
How can nutrition be maintained in Crohn's disease?
well-balanced diet
fiber supplement if no obstruction
TPN
supplemental enteral therapy via NG tube if poor growth
What is the specific drug therapy for Crohn's disease?
5-ASA
antibiotics (Flagyl or Cipro)
corticosteroids (Entocort)
immunomodulating drugs (Azathiprine, 6-MP)
Infliximab (anti-TNF)
What are 5 indications of surgery w/ Crohn's disease?
intractability to medical therapy
intra-abdominal abscess
massive bleeding
refractory fistulas
intestinal obstruction
What are 4 essentials of diagnosis for IBS?
chronic functional disorder
abdominal pain
alterations in bowel habits
symptoms start in late teens/early 20s
organic causes must be excluded
To be considered IBS, it must last more than ___ months.
3
What is the consensus defintion for IBS?
abdominal pain that 2 of the following 3 features:
-relieved w/ defecation
-onset of pain assocaited w/ change in freq. of stool
-onset of pain associated w/ change in stool form
What are 3 psychosocial abnormalities that can be associated with IBS?
depression
anxiety
somatization

-consider Hx of childhood sexual/physical abuse
What are the signs/symptoms of IBS?
lower abdominal pain that is usually intermittent and crampy

mucus is commonly seen
What are the 3 predominant types of IBS?
mostly diarrhea
mostly constipation
alternating
What are 7 "red flags" that may indicate organic disease associated w/ IBS?
acute onset of symptoms
nocturnal diarrhea
severe diarrhea/constipation
hematochezia
weight loss
fever
family Hx (cancer, IBD, celiac disease)
Is physical exam helpful for IBS?
no
What labs can be performed for IBS?
CBC
serum albumin
sed rate
thryroid function tests
serology for celiac disease
stool studies
*over age 45 --> colonoscopy
What are 6 differentials for IBS?
colon cancer
IBD
hyperthyroidism
hypothyroidism
celiac disease
endometriosis
What is the most important treatment plan for IBS?
reassurance
education
support
What type of dietary therapy can be done for IBS patients?
avoidance of fatty foods, caffeine, flatulogenic foods
Are high-fiber diets a good idea for IBS?
of little value and may increase gas & distension
What type of drugs can be given for IBS?
antispasmodics (anticholinergics)
antidiarrheal agents (Loperamide)
anticonstipation agents (osmotic laxatives)
TCAs/SSRIs (for pain/bloating)
partial serotonin agonist (Tegaserod)
Seotonin antagonist (Aloestron)
What is Tegaserod (partial serotonin agonist) with IBS?
constipation
-efficacy not proven in men
What is Aloestron (serotonin antagonist) used for with IBS?
diarrhea
-reduces pain, cramps, urgency, & diarrhea
-efficacy not proven in men
-*potential side effect of severe constipation and ischemic colitis
What are 3 types of psychological therapy that can be done for IBS pts?
cognitive behavioral therapy (CBT)
relaxation techniques
hypnotherapy
What is the prognosis for IBS?
not curable

most pts learn to cope
What structure of the anal canal distinguishes between external and internal hemorrhoids?
pectinate/dentate line
What are internal hemorrhoids?
-normal antatomic structures
-subepithelial vascular cushions made of CT, smooth muscle fibers and arteriovenous communications b/t terminal branches of the superior rectal artery and rectal veins
Are internal or external hemorrhoids painful?
external (innervated by cutaneous nerves)
What are external hemorrhoids covered with?
squamous epithelium of the anal canal or perianal region
What are 6 activities that increase venous pressure, causing distension and engorgement of hemorrhoids?
straining at stool
constipation
prolonged sitting
pregnancy
obesity
low fiber diets
What are the signs/symptoms of internal hemorrhoids?
bleeding
prolapse
mucoid discharge
bright red blood per rectum (BRBPR)
protrusion
discomfort
typically painless
What type of hemorrhoids have protuberant purple nodules covered by mucosa?
prolapse internal hemorrhoids
On digital rectal exam, uncomplicated ___ hemorroids are not painful and cannot be ___.
internal
palpated
What are the 4 degrees of prolapse for internal hemorrhoids?
I-confined to anal canal

II-prolapsed during straining & spontaneously reduce

III-require manual reduction after bowel movements

IV-remain chronically protruding
How are stage I and II internal hemorrhoids treated?
high fiber diet
increase fluids w/ meals
psyllium bulk laxatives (Metamucil)
How are edematous, prolapse internal hemorrhoids treated?
manual reduction
suppositories
Tucks pads
sitz baths
How are stage I, II, and III w/ recurrent bleeding internal hemorrhoids treated?
rubber band ligation (easiest)
electrocoagulation
injections sclerotherapy
When is surgery needed for hemorrhoids?
chronic severe bleeding w/ stage III-IV or acute thrombosed stage IV
What are anal fissures?
linear or rocket-shaped ulcers; usually <5mm in length
What is the cause of anal fissures?
trauma to anal canal during defecation (straining, constipation, high internal sphincter tone)
Where are most anal fissures located?
posterior midline
What are the signs/symptoms of anal fissures?
-severe, tearing pain during defecation followed by throbbing discomfort
-pain may lead to constipation due to fear of recurrent pain (catch 22)
How are anal fissures treated? (5)
Goal: effortless, painless BM's! (usually heal on their own)

-fiber supplements
-sitz baths
-topical nitroglycerin (for chronic cases)
-injection of botox into internal anal sphincter
-lateral internal sphincterotomy (chronic/recurrent problems)
What is the cause of an anorectal abscess?
anal glands at base of anal crypts at dentate line become infected and form an abscess

Other causes:
anal fissure
Crohn's
What are the signs/symptoms of an anorectal abscess?
-throbbing, continuous perianal pain
-erythema, fluctuance, & swelling in perianal region on external exam or in the ischiorectal fossa on digital rectal exam
How are anorectal abscesses treated?
perianal - local I&D

ischiorectal - drainage in the OR
What is the etiology of anorectal fistulas?
arises in the anal crypt; usually preceded by anal abscess
What 4 conditions should be considered if an anorectal fistula connects to the rectum?
Crohn's
lymphogranuloma venereum
rectal tuberculosis
cancer
What are the signs/symptoms of an anorectal fistula?
purulent discharge
+/- itching
tenderness
pain
How are anorectal fistulas treated?
idiopathic fistula in ano: surgical incision or excision under anesthesia

Crohn's related: different managment (going to treat disease over fistula)
What are the signs/symptoms of pruritus ani?
perianal itching/discomfort

on exam: erythema, excoriations, lichenified, eczematous skin
What are the causes of pruritus ani?
too dirty or too clean
What needs to be ruled out with pruritus ani?
skin infecitons/conditions
How is pruritus ani treated?
education:
-avoid spicy food, coffee, chocolate, tomatoes
-clean perianal area after BM's
-tuck cotton ball next to anal opening (absorb perspiration/fecal seepage)

+/- topical corticosteroids or diluted capsaicin cream
What are 5 things that bowel continence requires?
1. solid/semisolid stool
2. distensible rectal reservoir
3. sensation of rectal fullness
4. intact pelvis nerves/muscles
5. ability to reach a toilet in a timely fashion :)

*if those aren't met-->pt has incontinence
What are the signs/symptoms of minor fecal incontinence?
inability to control flatus
slight soilage of undergarments after BM's/straining/coughing
How is minor fecal incontinence treated?
fiber supplements
D/C caffeine
cleanse perianal skin
cotton ball near opening
Loperamide
What are elderly considerations/treatment for minor fecal incontinence?
scheduled toileting
bedside commode
What are the signs/symptoms of major fecal incontinence?
complete uncontrolled loss of stool
severe sphincteric injury
intact anocutaneous reflex
What is the etiology of major fecal incontinence?
problem w/ central perception or neuromuscular function
What diagnostic techniques can be used to exam major fecal incontinence?
anoscopy
proctosigmoidoscopy
anal U/S
pelvic MRI
anal manometry
What is the Tx plan for major fecal incontinence?
-bulking agents, antidiarrheal drugs
-scheduled toileting after glycerin suppositories or tap water enemas
-biofeedback training
-surgery (rare)
What is rectal prolapse?
protrusion through the anus of some or all of the layers of the rectum; most common in elderly
What are the causes of rectal prolapse?
-chronic, excessive straining at stool in conjunction w/ weakening of pelvic support structures
-surgical/traumatic injury
What are the signs/symptoms of rectal prolapse?
intially-reduces spontaneously after defecation

eventually-chronic prolapse caused mucous discharge, bleeding, incontinence, sphincter damage
What type of Tx should be done for rectal prolapse?
surgical correction of complete prolapse
What are 3 risk factors of adenocarcinoma of the stomach?
chronic H. pylori gastritis (inc. risk of distal stomach cancer)

pernicious anemia

Hx of partial gastric resection <15 yrs
What is the 2nd most common cancer worldwide?
adenocarcinoma of the stomach (skin is 1st)
What are the signs/symptoms of adenocarcinoma of the stomach?
asymptomatic until advanced
depends on tumor location
dyspepsia
vague epigastric pain
anorexia
early satiety
weight loss
GI bleeding (w/ ulcers)
postprandial vomiting (w/ pyloric obstruction)
-progressive dysphagia
Why is adenocarcinoma of the stomach delayed?
pts get initial symptomatic relief from OTC meds

physical exam is rarely helpful
Are are 4 signs of metastatic spread of adenocarcinoma of the stomach?
-Virchow's node (L supraclavicular)
-Sister May Josephy nodule (umbilical)
-Blumer's shelf (rigid rectal shelf)
-Krukenberg tumor (ovarian metastases)
What may be lab findings for adenocarcinoma of the stomach show?
iron deficiency anemia
anemia of chronic disease
elevated LFT's if liver metastases
+/- guaiac positive stool
When should endoscopy be done in suspection of adenocarcinoma of the stomach?
all pts >50yr w/ new onset epigastric sxs or persistent dyspepsia
What type of diagnostic test is highly sensitive for gastric carcinoma?
endoscopy w/ cytologic brushings & biopsy of suspicious lesions
What type of imaging can be done for adenocarcinoma of the stomach?
barium upper GI series (not as good as endoscopy)
After Dx of adenocarcinoma of the stomach, what is preop evaluation done with?
abdominal CT and esophageal U/S shows local extent of the primary tumor and nodal or distant metastases
What is the staging for adenocarcinoma of the stomach?
T-tumor
N-node
M-metastasis

4 stages

higher the stage, the worse the prognosis and the more difficult to treat
What stage of adenocarcinoma of the stomach has metastases?
stage IV
What is the treatment for adenocarcinoma of the stomach?
surgical resection (effective if localized)
lymph node dissection
chemo/radiation??
What are palliative measures that can be done for adenocarcinoma of the stomach?
resection of the tumor
gastrojejunostomy
chemo
What is the prognosis for adenocarcinoma of the stomach?
not very good
-proximal tumore have worse prognosis than distal tumors)
What reduces the mortality form colorectal cancer?
screening (CAN BE PREVENTED!)
-all pts >50yrs should be screened
-high-risk individuals should begin screening earlier
What are the colorectal cancer risk factors?
age > 45 yrs
family Hx
IBD
race (>in blacks)
Where does the vast majority of colorectal cancers arise from?
benign adenomas that progress over many years to cancer
-removal of adenomas prevents the majority of cancers
What is familial adenomatous polyposis (FAP)?
autosomal dominant development of 100s-1000s of colonic polyps

polyps average age 15
cancer average age 40
Unless prophylactic ____ for FAP, cancer is inevitable by age ___.
colectomy
50
What are the possible extraintestinal manifestations of FAP?
skin
thyroid
liver
CNS tumors
What is the Tx/prevention plan for FAP?
genetic counseling

complete proctocolectomy/colectomy w/ ileoanal/rectal anastomosis

upper endoscopy q 1-3 years thereafter
What are 2 inheritable factors/syndromes for colorectal cancer?
familial adenomatous polyposis (FAP)

juvenile polyposis (rare)
What are 5 techniques to screen for colorectal cancer?
average risk >/= 50yrs

annual FOBT
flexible sigmoidoscopy q 5yrs
annual FOBT & flex sig
*colonscopy q 10yrs
barium enema 1 5yrs
If the pt has a family Hx of 1st degree relative w/ colorectal cancer then when should screening be done?
1 relative dx'ed >/=60yrs:
-begin at 40yrs then q 10 yrs

1 relative dx'ed <60yrs OR > 1 relative:
-begin at 40yrs or 10 yrs younger than age at dx of youngest affected relative
-colonscopy q 5yrs
What happens w/ FOBT?
-get 2 samples from 3 consecutive stools
-should be done annually
What are the negatives of FOBT?
often misses polyps, may miss cancers

pos. results need colonoscopy

high false pos. rate = many unnecesary colonoscopies
What is the downfall of flexible sigmoidoscopy?
only goes up to splenic flexure (still missing 2/3 of colon)
What are the advantages of colonoscopy over other screening techniques for colorectal cancer?
evaluates entire colon

diagnostic AND therapeutic
-polyp detection & removal
When are 2 techniques for colorectal cancer screening that can be done if pt unwilling/unable to undergo colonoscopy?
double contrast barium enema

CT colonscopy (still need colonoscopy if abnormalities)
What suggestion can be made if the liver is enlarged with colorectal cancer?
metastatic spread
What type of S/S occur with right-sided colorectal cancer?
-iron deficiency anemia (fatigue, weakness)

-obstruction rare b/c of lg. diameter of R colon & liquid consistency of fecal material
What type of S/S occur with left-sided colorectal cancer?
-often involves the bowel cirumferentially

-smaller diameter of the colon

-solid fecal matter=obstructive s/s
What type of S/S occur with rectal colorectal cancer?
tenesmus
urgency
recurrent hematochezia
What type of labs can be done for colorectal cancer?
CBC (anemia)

carcinoembryonic antigen (CEA)
After complete surgical resection of the colon due to colorectal cancer, ___ levels should normalize.
CEA
What are the S/S of small bowel tumors?
rare
often no S/S
acute GI bleeding
chronic GI bleeding
obstruction
What type of imaging techniques can be done for small bowel tumors?
barium radiograph
upper endoscopy (visualization/biopsy)
What is the most common benign mucosal tumor?
adenomatous polyps
Why is resection warranted with adenomatous polyps?
b/c malignant transformations DO occur
What are benign stromal tumors?
leiomyomas
Where are leiomyomas found?
all levels of the intestine; intraluminal, intramural, or extraluminal
Leiomyomas require ___ to distinguish b/t benign and malignant stromal tumors.
excision
What are carcinoid tumors?
slow-growing neuroendocrine tumors; anywhere in the GI tract
What are 2 complications of carcinoid tumors?
metastasis to heart

carcinoid syndrome (tumor secrets hormonal mediators that cause cramps, flushing, diarrhea, cyanosis, or bronchospasm)
Zollinger-Ellison syndrome are a type of ___ tumors.
carcinoid
What are 6 types of hepatic disease?
HAV
HBV
HCV
HDV
HEV
HGV
What is fulminant hepatic disease?
severe development of hepatic encephalopathy w/in 8 weeks
What is sub-fulminant hepatic disease?
severe development of hepatic encephalopathy at 8 weeks-2 months
What does the liver do? (4)
energy metabolism, protein synthetic functions, solubilization/transport/storage, protective/clearance functions
What are 7 causes of hepatic disease? (7)
cholelithiasis
excessive alcohol intake
inherited disorders
viruses/bacterial infection
medications
cirrhosis
cancer
What are 4 causes of jaundice?
diminished hepatocyte function
inability to conjugate
transfer/excretion problems
biliary obstruction
How is HAV transmitted?
fecal/oral
Does HAV have a high or low mortality?
low
Is HAV chronic?
no-never
What is the Tx for HAV?
supportive care
What are the symptoms for the prodromal phase of viral hepatitis? (4)
malaise
mayalgia
arthralgia
fatigue
anorexia
N/V
malaise
aversion to smoking
fever (low-grade)
mild RUQ pain
serum sickness in HBV
How is HBV transmitted?
blood/blood products
sexual
maternal-fetal
homosexuals
IV drug users
What is the incubation period for HBV?
6 weeks to 6 months
Is HBV chronic?
in 1-2% of cases
Is there a vaccination for HBV?
yes
How is acute HBV treated?
supportive care
What do pts w/ chronic HBV have substantial risk of? (2)
cirrhoiss
hepatocellular carcinoma
What measure shows the first evidence of HBV infection?
HBsAG
What measure signals recovery from HBV infection and immunity?
anti-HBs
How is HCV transmitted? (4)
*IV drug use
intranasal cocaine
body piercings
blood transfusion
Is there vaccination for HCV?
no
What are 2 low risks of transmission for HCV?
sexual
maternal/fetal
Is HCV a chronic infection?
80% will become chronic
What is the incubation period for HCV?
6-7 weeks
What is HDV?
delta agent
-defective RNA virus that causes hepatitis ONLY in association w/ HBV
HDV is usually ___ exposure, occurs mainly in IV ___ users, has __x risk of hepatocellular disease, and may cuase ___ hepatitis or severe chronic hepatitis.
percutaneous
drug
3
fulminant
Is HEV common in the US?
no it is rare
How is HEV transmitted?
waterborne
Is HEV chronic?
no
-illness is self-limited
How is HGV transmitted?
percutaneously (blood borne)
HGV does not cause important ___ disease and HGV coinfection may improve survival in pts w/ ___.
liver
HIV
What are the 3 phases of viral hepatitis?
prodromal
icteric
convalescent
What are 3 signs of viral hepatitis?
hepatomegaly
liver tenderness
splenomegaly in 15% of cases

(these signs go away in convalescent phase)
How can viral hepatitis be prevented?
handwashing
universal precautions
blood supply screening
vaccination (HAV, HBV)
How is chronic hepatitis defined?
chronic inflammatory rxn of the liver of more than 3-6 months
What are 4 types of chronic hepatitis?
HBV +/- HDV
HCV
autoimmune hepatitis
Wilson's disease
Chronic HBV coninfection w/ HIV is associated w/ increased frequency of ___.
cirrhosis
How is chronic HBV treated?
Interferon (4 months)
Lamivudine (better tolerated)
How is chronic HCV detected?
HCV RNA in the blood
What increases the risk of cirrhosis with chronic HCV?
EtOH use more than 50g/day
How is chronic HCV treated?
pegylated interferon and ribavirin po (48 weeks)

may reduce the risk of hepatocellular carcinoma
What general features may pts with autoimmune hepatitis have besides signs of liver disease?
multiple spider nevi, striae, acne, hirsutism, hepatomegaly

usually a disease of young women
How is autoimmune hepatitis treated?
prednisone +/- azathiprine
What direct hepatic toxins can cause hepatic injury? (8)
acetominophen
EtOH
carbon tetrachloride
chloroform
heavy metals
mercaptopurine (6-MP)
tetracycline
vitamin A
What are 2 types of hepatic injury?
hepatic toxins
drug induced syncratic rxns
What drug induced syncratic rxns can cause hepatic injury? (9)
Amiodarone
ASA
carbamepine
chloramphenicol
diclofenac
halothane
isoniazid
ketoconazole
phenytoin

-not dose associated; sporadic; suggest allergic rxn (fever/eosinophilia)
What are the 3 stages of the liver w/ alcoholic hepatitis?
fatty liver

liver fibrosis (scar tissue remains)

cirrhosis (irreversible)
What is alcoholic hepatitis?
acute or chronic inflammation and parenchymal necrosis of the liver induced by EtOH
-often reversible
What is the most common cause of cirrhosis and 4-5x more common cause of death as HCV in the US?
alcoholic hepatitis
Does alcoholic hepatitis affect more men or women?
women>men
How many drinks is 50g?
4 (4 oz. 100 proof whiskey, 15 oz. wine, or 48 oz. beer)
What are the signs/symptoms of alcoholic hepatitis?
anorexia
nausea
hepatomegaly
jaundice
abdominal pain
splenomegaly
ascites
fever
encephalopathy :(
What is the Tx plan for alcoholic hepatitis?
EtOH abstinence!!!
caloric supplement
vitamins
folic acid
thaimine
prednisone (1 month)
pentoxifylline? (experimental-may reduce hepatorenal syndrome)
liver transplant
With alcoholic hepatitis, what needs to be conadministerd w/ glucose administration to prevent Wernicke-Korsakoffy syndrome?
thiamine
What are the absolute contraindications of liver transplant for alcholic hepatitis?
malignancy
advanced cardiomyopulmonary disease
sepsis
active substance abuse (relative?)
What happens w/ portal HTN?
blood not going through as well b/c of scar tissue --> pressure increases --> get dilated veins (varicosities in abdomen)
What are 4 major complications of portal HTN?
ascites
spontaneous bacterial peritonitis
hepatorenal syndrome
hepatic encephalopathy
How is ascited treated?
paracentesis
restriction of dietary Na & fluid
diuretics (spironolactone +/- Lasix)
TIPS
What are the most common bacteria for spontaneous bacterial peritonitis associated w/ portal HTN?
E. coli
pneumococci
What are the signs of spontaneous bacterial peritonitis associated w/ portal HTN?
abdominal pain
increasing ascited
fever
progressive encephalopathy
How is spontaneous bacterial peritonitis associated w/ portal HTN treated?
IV cefotaxime (5 days)
What is hepatorenal syndrome?
azotemia in the absence of shock or significant proteinuria in a pt w/ end-stage liver disease
The mortality of hepatorenal syndrome is ___ w/out liver transplant.
high
Hepatorenal syndrome associated w/ portal HTN does not improve w/ IV ___ saline.
isotonic
What happens w/ hepatic encephalopathy?
disordered CNS function due to failure of teh liver to detoxify noxious agents originating in the gut
What is withheld during acute hepatic encephalopathy episodes?
dietary protein
-lactulose to acidify colon contents (want to skew equation towards NH4+)
What should be avoided with hepatic encephalopathy?
opiods & sedatives that are metabolized or excreted by the liver
What are the essentials of diagnosis for Wilson's disease?
-excessive deposition of copper in the liver/brain
-rare autosomal recessive
-urinary excretion of copper/hepatic copper concentration high
What is a phlegmon?
inflammatory mass in and around the pancreas formed by edema and continued leakage of activated pancreatic enzymes
What is a pseudocyst?
a collection of tissue, fluid, debris, pancreatic enzymes, and blood that can develop after acute pancreatitis
What is a pseudoaneurysm?
occurs when a permanent communication occurs b/t an artery and a pancreatic pseudocyst (fistula b/t pseudocyst & artery)
What is acute pancreatitis?
discrete episode of abdominal pain and elevated serum amylase and lipase levels
What are the 2 distinct classifications of acute pancreatitis?
acute interstitial pancreatitis
acute hemorrhagic pancreatitis
What are the causes of acute pancreatitis? (7)
alcoholism (35%)
biliary tract disease (35%)
obstrution of pancreatic secretions
drugs/toxins
hypertriglyceridemia
familial (autosomal dominant)
trauma (blunt/penetrating)
What are the drugs/toxins that can cause acute pancreatitis?
insecticides, methanol, scorpion venom

immunosuppressants (azathiprine), Lasix, ACE inhibitors
What is the fundamental mechanism of acute pancreatitis?
injury causing activation of digestive enzymes leading to autodigestion; inflammation may lead to inflammatory response syndrome (SIRS)
What are the 2 major causes of death from acute pancreatitis?
SIRS
pancreatic infection
What are the typical symptoms of acute pancreatitis? (3)
pain
nausea
vomiting
How is the pain of acute pancreatitis characterized?
constant
epigastrium
may radiate to midback
lasts hours to days
not relieved by vomiting
What may the abdominal exam of acute pancreatitis show?
rebound tenderness
guarding
decreased/absent bowel sounds
What may severe attacks of acute pancreatitis include? (4)
hypotension
tachypnea
tachycardia
fever
What are 2 signs of acute pancreatitis?
Grey Turner's signs (ecchymosis of the flank)

Cullen's sign (periumbilical ecchymosis)
What may the labs for acute pancreatitis show?
elevated amylase
elevate lipase (elevated longer)
leukocytosis
hypocalcemia
elevated LFT's
triglycerides >1000 may cause attacks
What type of diagnostic imaging is used for acute pancreatitis?
U/S (gallstones)
CT/MRI (pancreatitis)
Is ERCP useful for diagnosing acute pancreatitis?
no
How is acute pancreatitis treated?
NPO (complete bowel rest)
*pain meds.
remove gallstones if needed
hydration
70-80% of chronic pancreatitis is related to ___.
alcoholism
What are the signs/symptoms of chronic pancreatitis?
persistent/recurren epigastric/LUQ pain
anorexia, weight loss
N/V
constipation/flatulence
attacks last 2hrs-2wks
steatorrhea (late finding)
What may the labs for chronic pancreatitis show?
elevated amylase/lipase
elevated alk phos/bilirubin
excess fecal fat
glycosuria
What type of imaging can be done for chronic pancreatitis?
plain films (calcifications)
CT
ERCP (most sensitive)
What are 5 complications of chronic pancreatitis?
opiod addiction
brittle diabetes
pancreatic pseudocyst/abscess
malnutrition
pancreatic CA
How is chronic pancreatitis treated?
surgery (biliary disease)
low fat diet
no EtOH
Creon/Pancrease/Ultrase
H2 blockers/PPIs
pancreatectomy (last resort)
What are 4 indications for surgical/endoscopic treatment of chronic pancreatitis?
persistent pseudocysts
biliary obstruction
intractible pain
concern of pancreatic CA
What is the prognosis for chronic pancreatitis?
-often leads to chronic disabilty
-best prognosis for pts w/ recurrent acute attacks related to biliary disease
-narcotic addiction common
What percentage of carcinomas of the pancreas are in the head of the pancreas?
75%
What are 5 risk factors of carcinoma of the pancreas?
age
obesity
tobacco use
chronic pancreatitis
family Hx
What are the signs/symptoms of carcinoma of the pancreas?
obstructive jaundice
enlarged gallbladder
diarrhea
weight loss
hard, fixed mass
migratory thrombophlebitis (rare)
*Sister Mary Joseph's nodule
vague, diffuse epigastric pain w/ radiation to the back
What may the labs for carcinoma of the pancreas show?
mild anemia
glycosuria/hyperglycemia
LFTs (obstructive jaundice)
occult blood in stool
What type of imaging can be used for carcinoma of the pancreas?
spiral CT
MRI
*endoscopic U/S (more sensitive)
*abd. U/S not reliable
How is carcinoma of the pancreas treated?
lap resection
radical pancreaticoduodenal (Whipple) resection)
palliation: radiation/chemo
What is the prognosis of carcinoma of the pancreas?
not very good
-very poor prognosis if in body or tail of pancreas
What are the 2 essentials of diagnosis for cholelithiasis?
classic biliary pain
stones detected on U/S
What are the risk factors for cholelithiasis?
obesity
rapid weight loss
glucose intolerance/hyperinsulinemia
Crohn's disease
DM
cirrhosis
pregnancy/HRT

*female, fat, forty, flatulent*
What are the 2 main types of gallstones?
cholesterol (most common)
calcium bilirubinate
What are the signs/symptoms of cholelithiasis?
may be asymptomatic
biliary colic
How is cholelithiasis treated?
lap cholecystecomy
cheno-/ursodeoxycholic acids (dissolve stones)

lithotripsy no longer used
What is acute cholecystitis associated w/ 90% of the time?
gallstones
What are the signs/symptoms of acute cholecystitis?
steady, severe epigastric RUQ pain
N/V
fever
leukocytosis
Murphy's sign
guarding/rebound
jaundice
acute attack precipitated by large fatty meals
What may the labs for acute cholecystitis show?
elevated WBCs, bilirubin, alk phos
What type of imaging can be used for acute cholecystitis?
HIDA (nuclear scan)
RUQ U/S
What are the complications of acute cholecystitis?
gallbladder gangrene
perforation
emphysematous cholecystitis
cholangitis
chronic cholecysitis
porcelain gallbladder (inc. risk for CA)
How is acute cholecystitis treated?
NPO
analgesics
IV antibiotics (ceph +/- Flagyl)
Meperidine
lap cholecystecomy
With acute cholecystitis, whos is better for pain due to less spasm of the sphincter of Oddi?
Meperidine
What is the classic picture of cholangitis?
**Charcot's triad:
-recurring attacks of severe RUQ pain
-fever/chills
-associated jaundice
What is Reynold's pentad?
acute suppurative cholangitis-->endoscopic emergency:
-Charcot's triad
-altered sensorium
-hypotension
What are the essentials of diagnosis for choledocholithiasis & cholangitis?
-Hx of biliary pain/jaundice
-sudden severe RUQ pain radiating to R shoulder
-N/V
-fever, jaundice, leukocytosis
-stones in common bile duct
What are the signs/symptoms of choledocholithiasis & cholangitis?
Charcot's triad
Reynold's pentad
hepatomegaly
cirrhosis if obstruction >30 days
What may the labs for choledocholithiasis & cholangitis show?
AST/ALT > 1000
elevated bilirubin/alk phos
leukocytosis (cholangitis)
What type of imaging should be used for choledocholithiasis & cholangitis?
EUS, spiral CT
*ERCP
What is the Tx plan for choledocholithiasis & cholangitis?
endoscopic sphincterotomy
stone extraction
lap chole
antibiotics if indicated