Gi Lecture 4

Front 1

What is the most common FUNCTIONAL GI disorder?

Back 1

Irritable Bowel Syndrome

Front 2

Does IBS lead to cancer?

Back 2

No. Not infectious or organic.

Front 3

What demographics are most affected by IBS?

Back 3

Sx appearing late adolescence or early adulthood. 2x more common in women

Front 4

What are the characteristics of IBS pathophysiology?

Back 4

Altered GI motility (hyper or hypo), visceral hyperalgesia (enhanced perception of visceral pain), psychopathology (increased w/ depression, anxiety), abnormal communication btwn CNS and enteric nervous system mediated by serotonin, flora changes

Front 5

What are the clinical symptoms of IBS?

Back 5

Abdominal pain or discomfort, altered bowel habits in ABSENCE of organic pahology. Diarrhea or constipation or alternating. Bloating, straining, feelings of incomplete evacuation and urgency.

Front 6

What are 9 Alarm signs/ sx in IBS?**

Back 6

GI bleeding, weight loss, fever, jaundice, persistent diarrhea, nocturnal sx, severe constipation or fecal impaction, fam fx of GI cancer IBD or celiac, onset of sx after age 45-50

Front 7

What is the main trigger of IBS?

Back 7

**Post infectious: gastroenteritis, Campy and Salmonella

Front 8

What is the Rome III diagnostic criteria used for?

Back 8

Irritable Bowel Syndrome

Front 9

What is the Rome III diagnostic criteria?

Back 9

Recurrent abd pain or discomfort at least 3 days per mo during previous 3 mos that is assoc w/ 2 or more of the following:
Relieved by defecation, onset assoc w/ change in stool freq, onset assoc w/ change in stool appearance.
Supporting sx: altered stool passage, mucorrhea, abd bloating.
*Must meet the main criteria to reach dx of IBS. Supporting not req, just supportive.

Front 10

What is IBS-D, IBS-C, IBS-M, IBS-A?

Back 10

IBS-D: diarrhea predominant, IBS-C: constipation, IBS-M: mixed, IBS-A: alternating.

Front 11

What are the 3 steps in diagnosing IBS?

Back 11

Step 1: meets Rome III, Step2: exclude other causes. step 3: diag testing (cbc, fecal occult, chem panel, esr)

Front 12

What are some other diagnostic tests for IBS only used if indicated?

Back 12

TFTs and TSH, Stool (guaiac, culture, O&P), Gliadin and anti-endomysial ab (sprue), flex sigmoidoscopy, colonoscopy

Front 13

What are the treatments for IBS?

Back 13

Make a pos dx, educate and reassure, dietary and lifestyle mods, stressor avoidance, increase fiber***, pharmacotherapy, consultations.

Front 14

What kind of diet modifications can be made to treat IBS?

Back 14

Fiber supp or restriction, increase h20, avoid caffeine, avoid legumes, limit lactose/ fructose, supp calcium

Front 15

How might you adjust fiber intake in IBS -D?

Back 15

Decrease insoluble, increase soluble

Front 16

How might you adjust fiber intake in IBS - C?

Back 16

Increase both

Front 17

What are 5 meds that can be used to treat pain associated w/ IBS?

Back 17

Antispasmodics, anticholinergics, opioid-like agents, amitriptyline/ TCAs, librax (benzo + anticholinergic)

Front 18

What are 4 meds that can be used to treat diarrhea associated w/ IBS?

Back 18

Loperamide, diphenoxylate, cholestyramine, probiotics

Front 19

What are 3 meds that can be used to treat constipation associated w/ IBS?

Back 19

Fiber, osmotic laxative (MOM, lactulose), PEG solution (GoLytely)

Front 20

What are two antidepressants that can be used to treat IBS?

Back 20

TCAs, SSRIs

Front 21

What is an antianxiety med that can be used to treat IBS?

Back 21

benzodiazepines

Front 22

What is Tegaserod (can be used to treat IBS)?

Back 22

5-HT4 agonist (stimulates peristalsis), only available through IND protocol

Front 23

What is Lubiprostone (can be used to treat IBS)?

Back 23

Used for IBS-C. Select type-2 chloride channel activator, increases fluid secretion into SI, increases colonic motility

Front 24

What are some non-med alternative treatments of IBS?

Back 24

Probiotics, enteric coated peppermint oil capsule (se: nausea, gerd, perianal burning), Yoga, Acupuncture

Front 25

What is lactose intolerance?

Back 25

Inability to digest lactose into glucose and galactose. Decreased levels of lactase in brush border of duodenum. Common disorder that affects 50 mil americans. Can be congenital or acquired.

Front 26

What are 4 things that occur in the SI in lactose intolerance?

Back 26

Maldigestion, increased osmotic load attracts fluid, accelerated small bowel transit, fermented by colonic bacteria.

Front 27

What populations are most affected by lactose intolerance?

Back 27

Asian, South american, African

Front 28

What are 8 symptoms of lactose intolerance?

Back 28

Diarrhea, Constipation, Increased flatulence, Borborygmi (growling stomach), Abd bloating, abd pain, abd cramping, irritability

Front 29

How is a diagnosis of lactose intolerance made?

Back 29

Dietary elimination, hydrogen breath test, lactose tolerance test (measure blood glucose), intestinal brush border biopsy (reliable, invasive, expensive) - will show missing enzymes.

Front 30

What are the best management processes for lactose intolerance?

Back 30

Avoid large amts of milk and milk products, watch for hidden sources of lactose, substitute soy-based milk, lactase supps for some ppl, calcium and vit d supp, pre-hydrolyzed milk, better tolerance of yogurt and fermented products

Front 31

What are the two major forms of Inflammatory Bowel Disease?

Back 31

UC and Crohns

Front 32

What are the characteristics of Inflammatory Bowel Disease in general?

Back 32

Mucosal inflammation, ulceration, edema, bleeding and fluid & lyte losses. Autoimmune trigger possibly. Age 15-40. Genetic predispositon.

Front 33

What are the imiging studies used in dx of inflammatory bowel disease?

Back 33

Barium enema, colonoscopy and biopsy

Front 34

What should be included in your diff dx of Inflammatory Bowel Disease?

Back 34

Infection, ischemic bowel, diverticulitis, IBS, carcinoma

Front 35

What are the hx and PE findings in Crohn's?

Back 35

Abd pain (RLQ - mimics appy and colicky), diarrhea, fatigue, fever, weight loss, bloating

Front 36

What are the hx and PE findings in UC?

Back 36

Bloody diarrhea***, fatigue, fever, lower abd pain, urgency, tenesmus (feeling of needing to defacate, incomplete BM, relapsing course

Front 37

What are 7 local complications of Crohns?

Back 37

Obstruction, strictures, fistrula/ abscess, gallstones, kidney stones, bowel malignancy, perianal disease

Front 38

What are 3 local complications of UC?

Back 38

Toxic megacolon, perf, carinoma

Front 39

How do Crohns and UC effect the terminal ileum?

Back 39

Crohns commonly does, UC seldom does

Front 40

How do Crohns and UC compare in their involvement of the colon?

Back 40

Crohns usually involves the colon, UC always and only effects the colon

Front 41

How do Crohns and UC compare in their involvement of the rectum? Anus?

Back 41

Rectum: Crohns usually spares. UC usually involves.
Anus: Crohns commonly, UC seldom

Front 42

How do Crohns and UC compare in their distribution of the disease?

Back 42

Crohns can involve anywhere mouth to anus, usually with skip lesions or patchy inflammation.
UC is a continuous are of inflammation.

Front 43

How do Crohns and UC compare in their depth of inflammation?

Back 43

Crohns may be transmural, deep.
UC is usually shallow, involving just mucosa.

Front 44

How do Crohns and UC compare in causing fistulae, strictures, adhesions, fissures, cobblestoning?

Back 44

Common in Crohns, seldome in UC

Front 45

Are Granulomas seen in bx in crohns and UC?

Back 45

Seen in 60% of Crohns. Not observed in UC.

Front 46

Is there a surgical cure of Crohns and UC?

Back 46

Crohns usually returns following surgical resection. UC cured by sresection.

Front 47

How does smoking effect Crohns and UC?

Back 47

At higher risk of crohns in smokers.
At lower risk of UC in smokers.

Front 48

What are 5 extra-intestinal manifestations of inflammatory bowel disease?

Back 48

Joint disease, Skin disease, eye disease, oral lesions, hepatobiliary disease

Front 49

How often are extra-intestinal manifestations present in inflammatory bowel disease?

Back 49

25-36% of the time. Any organ system can be involved.

Front 50

What are 3 classifications of ulcerative colitis?

Back 50

Protitis (limited to rectum), left-sided colitis (rectum, sigmoid, descending colon), pancolitis (entire colon)

Front 51

What is the correlation between cancer and UC?

Back 51

UC has 20-30x higher risk of developing colorectal cancer. 5-10% after 20 yrs w/ disease. 30% after 35 yrs

Front 52

What is the correlation between cancer and crohns?

Back 52

Not as likely as UC. Colon and small bowel can be effected. Usually delayed dx. Risk increased if extensive inflammatory changes. Cancers: lymphoma, carcinoid tumors, colorectal cancer

Front 53

What should be in your differential dx for inflammatory bowel disease?

Back 53

INfectious enterocolitis, ischemic colitis, diversiculitis, diverticulosis, IBS

Front 54

What are diagnostic tests used in dx inflammatory bowel disease?

Back 54

Stool culture, O&P, c.diff, heme and chem labs, KUB xray and abd look for obstruction, UGISBFT, colonoscopy, abd CT if abscess suspected, BE

Front 55

How could an UGISBFT help to differentiate UC and crohns?

Back 55

In Crohns, could see strictures, fistula

Front 56

How could a BE help to differentiate UC and Crohns?

Back 56

In UC: loss of colonic haustral folds***,
In CD: skip lesions**

Front 57

What are some specific test findings in Crohns?

Back 57

Anti-Saccharomyces cerevisiae abs (ASCA), in histology: inflammation of entire intestinal wall (transmural), granulomas seen in 50%.

Front 58

What are specific test findings in UC?

Back 58

Perinuclear antineutrophil cytoplasmic abs (pANCA), in histology: inflammation limited to mucosa.

Front 59

What are two very sensitive tests that when used together can often differentiate UC and Crohns?

Back 59

Anti-saccaromyces cervisiae abs (ASCA) and Perinuclear antineutrophil cytoplasmic abs (pANCA)

Front 60

What is the step-wise approach to inducing and maintaining remission of Inflammatory Bowel Disease?

Back 60

Step I: aminosalicylates,
Step IA: antibiotics
Step II: corticosteroids,
Step III: Immune modifiers
Step IIIa: TNF inhibitors
Step IV: experimental agents

Front 61

What is the cornerstone of therapy for UC and Crohns?**

Back 61

Step I: sulfasalazine.
Best option for mild to mod UC.
Not effective in maintaining remission in crohns.
Effective in treating Crohns in lrg bowel but NOT in small bowel.

Front 62

What antibiotics are recommended for step IA treatment of IBD?

Back 62

Metronidazole, ciprofloxacin. Use w/ caution in UC, used mostly in crohns

Front 63

What are the characteristics of using corticosteroids (Step II) for treatment of IBD?

Back 63

Rapid-acting anti-inflammatory agents, acute flares only - not for maintenance, oral and topical preps, Hydrocortisone, prednisone, Budesonide

Front 64

What is the indication for the Step III treatment (immune modifiers) for IBD?

Back 64

Use when remission difficult w/ aminosalicylates. Steroid sparing in ppl w/ refractory disease.
Side effects: pancytopenia

Front 65

What are 2 immune modifiers (step III) used for treatment of IBD?

Back 65

Azathioprine and 6-Mercaptopurine

Front 66

What are the TNF inhibitors in Step IIIa for treatment of IBD?

Back 66

Adalimumab, Certolizumab, Infliximab.
Monoclonal ab inhibits TNF. IV treatment for moderate to severe Crohns. Promotes mucosal healing, steroids do not.

Front 67

What are 3 experimental agents in step IV for IBD treatment? And what disease is each for?

Back 67

Methotrexate: CD, Thalidomide: CD, Cyclosporine - sever, refractory: UC.

Mltpl contraindications, interactions and precautions w/ these meds.

Front 68

What are treatments for symptomatic relief of IBD?

Back 68

Antidiarrheals, Antispasmodics, Acid suppressants

Front 69

What are nutritional support therapies for treating Crohns?

Back 69

Low insoluble fiber; soluble fiber, lactose-free, calc supps, low fat, enteral nutrition w/ products to induce remission in acute crohns, calorie and protein supp, tpn.

Front 70

How many UC pts and CD pts need surgery/ colectomy?

Back 70

1/3 UC pts and 2/3 CD. Req in 70% of CD but typically palliative - recurrence at anastamoses.

Front 71

What are the indications for surgery in IBD?

Back 71

Failed max med mgmt, toxic megacolon, Severe med side effects, malignancy, obstructions, strictures, fistula

Front 72

What is colonic diverticula?

Back 72

Herniation; sac-like protrusions; out-pouching of a hollow structure. 65% have this by age 85.

Front 73

What are 3 types of colonic diverticula?

Back 73

Asymptomatic diverticulosis (80-85%),
Uncomplicated diverticulitis (5%),
Complicated diverticulitis

Front 74

What is true diverticula?

Back 74

Involves all layers

Front 75

What is the pathogenesis of diverticula?

Back 75

Defects in colon wall, raised intraluminar colonic pressure, openings in circular muscle layer for penetration of nutrient artery provide area of weakness

Front 76

What is the most common location of diverticula?

Back 76

Sigmoid. Smallest diameter and highest intraluminal pressure

Front 77

What is another factor that can lead to diverticula?

Back 77

Lack of fiber (chronic constipation)

Front 78

What can cause hemorrhage w/ diverticula?

Back 78

Erosion vessel by fecolith in diverticula. Artery more likely to erode, but venule can as well.

Front 79

What is the clinical presentation of hemorrhage w/ diverticula?

Back 79

Painless bleeding***, hx of diverticula

Front 80

How is a dx made of hemorrhage w/ diverticula?

Back 80

Imaging --> angiography --> diagnostic and therapeutic.

Front 81

What is the treatment for hemorrhage w/ diverticula?

Back 81

Surgery if catheterization w/ vasoactive drugs fails.

Front 82

What is diverticulitis?

Back 82

Obstruction by fecolith often, inflammation or infection of diverticula. usually have multiple diverticula.

Front 83

What are the clinical presentations of diverticulitis?

Back 83

Crampy pain worse w/ BM, fever, poss peritoneal irritation, somtimes bleeding.

Front 84

What are complications of diverticulitis?

Back 84

Perf, sepsis, abscess, obstruction, fistula formation

Front 85

What are the diagnostics for diverticulitis?

Back 85

Imaging: CT = test of choice.
No BE - can cause more irritation, NO flex sig if bleeding.

Front 86

What is the treatment of acute uncomplicated diverticulitis?

Back 86

Outpatient, clear liquid diet 7-10 days, oral broad-spec abx

Front 87

What is the treatment of complicated diverticulitis?

Back 87

Hospitalization (infection, peritonitis, inadeq oral intake), bowel rest, IV fluids, broad spec IV abx, cultures.

Front 88

What is Meckel's Diverticulum**?

Back 88

Congeinital remnant of vitelline duct. Blind-ending true diverticulum.

Front 89

What is the rule of 2's in regards to Meckel's Diverticulum?

Back 89

2% of pop, 2 feet from IC valve, 2 in in length, 2 yrs old, 2x in males

Front 90

What is the most common presentation of Meckel's? What is presentation in children? Adults?

Back 90

MC: GI bleed, intestinal obstruction, diverticulitis.
Children: painless rectal bleed
Adults: obstruction, inflammation

Front 91

What are complications of Meckel's?

Back 91

Diverticulitis, ulceration, bleeding, perf, obstruction, umbilical fistula.

Front 92

What can Meckel's be confused with?

Back 92

Appendicitis***

Front 93

How is dx made for Meckel's?

Back 93

Meckel scan

Front 94

What is the treatment for Meckel's?

Back 94

Surgery

Front 95

What is Hirschsprungs Disease?***

Back 95

Development disorder of enteric nervous system. Absence of ganglion cells in distal colon (75% recto-sigmoid), Causes a blockage of the large intestine due to improper muscle movement in the bowel.

Front 96

When is Hirschspring's Disease diagnosed? What is the male to female ratio?

Back 96

90% newborn. M:F 4:1

Front 97

What would you see in a hx and physical for Hirschsprung's disease?

Back 97

Delayed meconium (ileus), chronic severe constipation, bilious emesis, failure to thrive. No stool in rectum.

Front 98

What are the complications associated with Hirschsprung's Disease?

Back 98

Intestinal obstruction, perforation

Front 99

How would you make a diagnosis of Hirschsprung's Disease?

Back 99

Imaging: BE would show narrowing w/ proximal dilation.
Rectal biopsy would give a difinitive diagnosis

Front 100

What is the treatment for Hirschsprung's Disease?

Back 100

Resection and anastomosis

Front 101

What are colon polyps?

Back 101

Discrete mass lesions that protrude into the intestinal lumen from normally flat mucsoa. Usually asymptomatic.

Front 102

What are 4 complications associated w/ colon polyps?

Back 102

Ulceration, bleeding, tenesmus, obstruction

Front 103

What are 4 classifications of colon polyps?

Back 103

Nonneoplastic: no malignant potential.
Submucosal lesions: +/- neoplastic.
Neoplastic: adenomas, carcinomas.
Polyposis syndromes.

Front 104

What percentage of polyps removed at colonoscopy are adenomatous?

Back 104

70%

Front 105

What are 3 classifications of non-neoplastic colon polyps?

Back 105

Hyperplastic: MC non-neoplastic
Mucosal: usually small, normal mucsoa
Inflammatory psudopolyps: result of mucosal regeneration (IBD)

Front 106

What are the 3 classifications of submucosal colon polyps?

Back 106

Lipomas, lymphoid aggregates, leiomyoma

Front 107

What are 3 types of adenomatous polyps?

Back 107

Tubular, tubulovillous, villous

Front 108

What are some characterizations of adenomatous polyps?

Back 108

80% are rectosigmoid, can be pedunculated or sessile, 25% have > 1 polyp and the bigger the size, the worse they are

Front 109

Of the types of adenomatous polyps, what makes up the majority?

Back 109

Tubular. >80% of adenomas

Front 110

What determines the risk of progression of tubulovillous adenomas? What percentage of adenomas are these?

Back 110

Degree of villous component correlates w/ risk of progression.
5-15% of adenomas.

Front 111

What type of adenomas have the highest rate of malignancy?

Back 111

Villous adenomas

Front 112

What are the characteristics of villous adenomas?

Back 112

Sessile, cauliflower-like, usually larger than other types. Most commonly in the rectum. More likely to be symptomatic than other types. Can have rectal bleeding.

Front 113

What are three types of manifestations of villous adenomas?

Back 113

In situ (more likely to be curative - 10%)
Local invasion (30%)
Frank stalk invasion which requires surgery, staging nodes.

Front 114

What are 2 types of polyposis syndromes?

Back 114

Familial inherited (autosomal dominant), Nonfamilial

Front 115

What are the two types of familial inherited (autosomal dominant) polyposis syndromes?

Back 115

Adenomatous polyposis syndromes and Harmatomatous polyposis syndromes

Front 116

What are adenomatous polyps?

Back 116

Premalignant

Front 117

By age 50 what is the cancer risk for polyposis syndromes?

Back 117

100%

Front 118

What is the treatment for polyposis syndromes?

Back 118

Prophylactic colectomy

Front 119

What are two types of adenomatous polyposis syndromes?

Back 119

Gardner's Syndrome, Familial adenomatous polyposis

Front 120

What sets Garnder's syndrome apart from other polyposis syndromes?

Back 120

Patient presents w/ fibromas, cysts, osteomas, everywhere

Front 121

What is harmatomatous?

Back 121

Looks like cancer but is benign.

Front 122

What are two types of Hamartomatous Familial polyposis syndromes?

Back 122

Juvenile polyposis and Peutz-Jegher syndrome

Front 123

What should you know about juvenile polyposis?

Back 123

In juvenile polyposis, polyps don't become cancer, but have an increased risk of other cancer.

Front 124

What do you see in Peutz-Jeghers syndrome?

Back 124

Polyps beomce large. Bleeding, intussusception, obstruction.

Front 125

What are some associations you might see w/ Peutz-Jeghers syndrome?

Back 125

Melanotic spots on lips, skin and buccal mucosa

Front 126

What is the 4th most common cause of cancer and 2nd most common cause of cancer-related death in the US?

Back 126

Colorectal cancer

Front 127

Why should we screen for colorectal cancer?

Back 127

It is preventable! Screening can reduce mortality by 50%

Front 128

What type of cancer are almost all colorectal cancers?

Back 128

Adenocarinomas

Front 129

Where are most colorectal cancers located?

Back 129

>50% in rectosigmoid region

Front 130

How do most colorectal cancers develop?

Back 130

Arise from malignant transformation of a polyp

Front 131

What are two types of colorectal cancer?

Back 131

Fungating, annular

Front 132

Why is colorectal cancer often diagnosed in later stages unless screened for?

Back 132

ASYMPTOMATIC! early on.
Distant metastatic disease in 20% at presentation

Front 133

What are some symptoms of colorectal cancer? Usually seen in later progression of disease

Back 133

Crampy abd pain, change in BM, pos occult blood, melena, hematochezia, weakness, fatigue

Front 134

What are the different presentations of right-sided vs left-sided lesions in colorectal cancer?

Back 134

Righ-sided lesions: more likely to bleed.
Left-sided lesions: more likely to obstruct.

Front 135

Why is the Why is the Liver usually the first site of dissemination of colorectal cancer?

Back 135

Because intestinal blood flow goes through portal circulation.

Front 136

What are some risk factors for developing colorectal cancer?

Back 136

Personal for fam hx, IBD (espec UC), diabetes, alcohol, obesity**, smoking

Front 137

What are 6 protective factors for developing colorectal cancer?***

Back 137

Phys activity, high-fiber diet, low-fat diet, increased intake of fruits and veggies, calcium, aspirin and NSAIDS

Front 138

What are diagnostic tools used to dx colorectal cancer?

Back 138

Labs: liver, kidney fx.
CEA (70% elevated).
Imaging: chest/ abd.

*Dx: Colonoscopy w/ bx - histology

Front 139

What is an older system other than TNM that can be used to stage colorectal cancer?**

Back 139

Duke's classification

Front 140

In colorectal cancer, what might be an indication that mets are present?**

Back 140

Mucin-secreting "signet ring" cells

Front 141

What is the overall survival rate of colorectal cancer?**

Back 141

35%

Front 142

What are 3 treatments for colorectal cancer?

Back 142

Resection, chemo, radiation

Front 143

What followup care should be done for colorectal cancer?

Back 143

Surveilance, CEA every few months, CT chest abd annually for 3 yrs, colonoscopy at 3 yrs.

Front 144

How common is recurrence of colorectal cancer?

Back 144

85% w/in 3 yrs of resection

Front 145

How often should a screening colonoscopy be done?

Back 145

Every 10 years most clinically effective **
Only test for surveillance of high-risk ppl**

Front 146

Currently, what is considered the most accurate form of colonoscopy for screening for colorectal cancer? Virtual or actual?

Back 146

Actual colonoscopy still "test of choice" and considered more sensitive than virtual.

Front 147

What is lower GI bleeding?

Back 147

Bleeding DISTAL to Ligament of Treitz

Front 148

What is the most common form of lower GI bleed? 60%

Back 148

Diverticulosis***

Front 149

What are other causes of lower GI bleed?

Back 149

Anal hemorrhoids, fissure, neoplasms, angiodysplasia, aortoenteric fistula, inflammation, upper GI source, vascular disorder, coagulopathies

Front 150

What are clinical signs of a lower GI bleed?

Back 150

Bright red blood per rectum, bloody diarrhea, occult blood

Front 151

How would you diagnose lower GI bleed?

Back 151

Endo (r/o upper GI bleed), CBC, PT, PTT, Colonoscopy**, angiography, scintigraphy

Front 152

What is the test of choice for diagnosing lower GI bleed?

Back 152

Colonoscopy

Front 153

What are treatments for lower GI bleed?

Back 153

Blood replacement, treat cause, surgery, embolization

Front 154

What are hemorrhoids?

Back 154

Very common vascular cushions that are NOT varicosities. Part of normal anatomy, but when they are enlarged, inflamed or thrombosed or prolapsed, we CALL them hemorrhoids.

Front 155

What increases risk of developing hemorrhoids?

Back 155

IBD (UC, Crohns), pregnancy, straining, low fiber diet

Front 156

Which hemorrhoids are painful? Not painful?

Back 156

Internal hemorrhoids: painless bleeding.
External hemorrhoids: painful

Front 157

Where are internal hemorrhoids vs external hemorrhoids located?

Back 157

Internal: proximal to dentate line.
External: distal to dentate line.

Front 158

What are the clinical manifestations of hemorrhoids?

Back 158

Perianal pruritus, rectal bleeding, anal pain, palpable mass in anal region, mucoid discharge, skin tags

Front 159

How is diagnosis of hemorrohoids made?

Back 159

Anoscopy, sigmoidoscopy

Front 160

What are anal fissures?

Back 160

Common anorectal complaint - painful linear tear or crack of distal anal canal.

Front 161

What are clinical manifestations of anal fissures?

Back 161

Painful, bright red blood per rectum.

Front 162

What are initiating factors of anal fissures?

Back 162

Etiology of chronic fissure unclear.
Initiating factors: trauma, low-fiber diets, prior anal surgery.
Usually young-middle-aged but can occur at any age

Front 163

Where are anal fissures usually located?

Back 163

90% are in posterior midline of anal canal.

Front 164

What are 7 things you should have in your differential dx of anal fissures?

Back 164

AIDS, carcinoma, Crohns, Leukemia, Syphilis, TB, immunosuppressive disorders

Front 165

What does the term ACUTE abdomen usually refer to?

Back 165

Sudden, severe abdominal pain of unclear etiology, < 24 hrs duration. Usually a medical emergency requiring urgent and specific diagnosis. Many cases need surgical tx

Front 166

What kind of tests would you use to evaluate acute abdominal pain?

Back 166

CBC, chem panel, UA, HCG, test for STIs, abd xray, CT, US: ruq, gyn, appendix

Front 167

What are 4 "Don't miss" diagnoses when evaluating acute abdominal pain?

Back 167

Ruptured ectopic pregnancy, vascular dz, intestinal obstruction, CV, ischemic or arteriosclerotic dz.

Front 168

What are 4 causes of diffuse abd pain?

Back 168

Mesenteric ischemia, infarct, periotnitis, gastroenteritis

Front 169

What are the Big Five of acute abdomen pain?***

Back 169

Fever, Tachycardia, WBC count (elevated count, bands), Peritoneal signs, advanced age (>65)

Front 170

What are 5 peritoneal signs to look for in acute abdomen pain?

Back 170

Palpable tenderness, rebound tenderness, cough tenderness, muscle guarding, rigidity

Front 171

What are 3 causes of acute surgical illness?

Back 171

Hemorrhage, Obstruction, Perforation

Front 172

What is the hallmark of intestinal obstruction?**

Back 172

Abdominal distention

Front 173

What are 3 types of mechanical intestinal obstruction?

Back 173

Extrinsic: adhesions, hernia.
Intramural: structures, tumors.
Intraluminal: foreign bodies, intussusception.

Front 174

What are clinical signs of a mechanical intestinal obstruction?

Back 174

Crampy pain, high pitched BS, constipation, vomiting, distension

Front 175

How is dx made of a mechanical intestinal obstruction?

Back 175

Abd plain and upright xray. Would see air fluid level.

Front 176

What are the treatments for a mechanical intestinal obstruction?

Back 176

Fluid replacement, balance lytes, NG tube, abx if strangulated and surgery*

Front 177

What is adynamic or paralytic ileus?

Back 177

Non-obstructive paralytic portion of the bowel or decreased motility.

Front 178

What are the etiologies of adynamic or paralytic ileus?

Back 178

Common after surgery, lyte imbalance, peritonitis, severe abd inflammation, systemic illness

Front 179

What is treatment for adynamic or paralytic ileus?

Back 179

Bowel rest and NG tube; correct the underlying problem.

Front 180

What is McBurney's point?

Back 180

1/3 of the way between the umbilicus and asic. RLQ pain.

Front 181

What are cliinical signs of appendicitis?

Back 181

Dull periumbilical pain --> anorexia, n/v.
RLQ pain, fever, peritoneal signs, increased WBC, psoas and obturator sign. Atypical presentation in elderly and steroid users.

Front 182

What is primary vs secondary spontaneous bacterial peritonitis?

Back 182

Primary effects existing ascites. Secondary can come from a perforated viscus, appendicitis or intestinal infarction.

Front 183

What is the clinical presentation of spontaneous bacterial peritonitis?

Back 183

Abd pain, guarding, rebound, fever, elevated WBC, ileus

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What is used to diagnose spontaneous bacterial peritonitis?

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Paracentesis (culture), xray

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What is treatment for spontaneous bacterial peritonitis?

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Supportive, abx, surgery