Nycc Jarrett-Thelwell Gen Di Exam 2 Winter 2012

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abdominal angina/bowelgina

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 post prandial (15 min) abdominal pain due to insufficient blood flow to meet the visceral demands. Postprandial Angina

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most common cause of abdominal angina/bowelgina

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atherosclerotic vascular disease

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autonomic neuropathy

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damage to nerves affecting the GI tract leads to  ability to move food

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inflammation of the appendix in patient 10-30 yoa

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acute appendicitis

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3 signs of appendicits besides Rosving's and Blumberg's

P.O.D. burst

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Dunphys (coughing pain), Obturator (internal rotation pain), Psoas (extension of R thigh if appendix is pelvic)

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why use radionucleide scanning to dx acute appendicitis?

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WBC attach, shows inflammation

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Overarching term for inflammatory conditions of the large intestine and sometimes small intestine

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Inflammatory Bowel Disease (not IBS which is less severe)

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2 main types of IBD

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Ulcerative colitis & Crohn's dz

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Difference between Ulcerative colitis and Crohn's dz?

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Location and nature: Crohn's is ANYWHERE in GI w/ skip lesions, UC is restricted to colon and anus

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Crohn's buzzwords

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Ilieitus, transmural, skip lesions, small intestine, non-bloody diarrhea, ocular uveitis & episcleritis

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physical findings of Crohn's

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apthous uclers (cankers in mouth), clubbing of nails, ocular sx (uveitis/episcleritis) leading to blindness if untreated

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diagnostic imaging for Crohn's

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STRING sign, COBBLESTONE appearance

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Labs for Crohn's (2)

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anti-saccharomyces cerevesiae Ab (ASCA) in 70% of cases and p-ANCA Ab (ANCA) in 19% of cases

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Buzzwords for Ulcerative Colitis

Defecation Often mucus-like
and with blood[2]
Tenesmus More common[2]
Fever Indicates severe disease[2]
Fistulae Seldom
Weight loss More seldom

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Large intestine, transmural, Bloody diarrhea, 15-30 year olds, pseudopolyps, aSca, aNca Ab's (same as Crohn's)

Symptoms in Crohn's disease (versus UC):
Defecation Often porridge-like[2],
sometimes steatorrhea
Tenesmus Less common
Fever Common
Fistulae Common
Weight loss Often

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symptoms as a result of half or more of small bowel resection or loss of absorptive function

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Short/Small Bowel Syndrome

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Signs of Small/Short Bowel Syndrome

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signs of MALNUTRITION– pallor, bruising, alopecia, spoon nails, delayed growth, glossitis, cheilosis, dry skin,  DTR

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a functional, chronic GI disorder of unknown cause characterized by abdominal pain and altered bowel habits

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Irritable Bowel Syndrome = IBS

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2 CRITERIA for IBS (proper names)

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ROME II & MANNING criteria

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ROME II criteria for IBS

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12 weeks discomfort w/ one of either relief by defecation, change in frequency, change in appearance of stool

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MANNING criteria for IBS

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distinguishes from organic dz: frequent, loose bm's w/ remaining sense of incomplete evacuation, and mucorrhea (each 25%)

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Where is IBS pain usually?

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LLQ

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IBS RED FLAGS

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anemia, family hx colon cancer, fever, melena/hematochezia/rectal bleed, palpable abdominal mass, recent antibiotic use, weight loss, gluten intolerance

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aka's for Traveler's diarrhea (3)

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Montezuma's Revenge - Tut's Tummy -Tourista Tummy

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most common cause of traveler's diarrhea

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E. coli bacteria (contaminated food and water in foreign countries)

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IBS and Short Bowel Syndrome lead to malabsorption of ?

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Vitamin B12 malabsorption

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most common laxative abusers

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anorexics and bulimics

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melanosis coli

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black or dark brown discoloration of the mucosa of the colon, due to the presence of pigment-laden macrophages within the lamina propria. The pigment comes from anthraquinone in laxatives. The condition is benign and reversible (laxative abusers)

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Not only can regular laxative use cause dependence, but can damage the?

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muscular function of the bowel and/or mask a more serious cause of constipation

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Complications of laxative abuse:

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** Intestinal paralysis, IBS, gastritis, pancreatitis, melanosis coli**

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Laxative abuse physical findings

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Sx of malabsorption and dehydration

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antibiotic associated colitis is known more often by the name?

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PSEUDOMEMBRANOUS colitis

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Cause of pseudomembranous colitis (usually)

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ANTIBIOTICS- Clostridium difficile associated colitis and diarrhea which releases toxins and causes plaques

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Labs for pseudomembranous colitis

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Anemia, increased WBC, hypoalbuminemia (low albumin) - these people are very sick!!

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an alteration in the normal flora of the intestines due to the use of broad-spectrum antibiotics

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PSEUDOMEMBRANOUS colitis

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pseudomembranous colitis physical symptoms/complaint

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non-bloody, FOUL-SMELLING diarrhea

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physical signs of pseudomembranous colitis

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steattorhea (low albumin in blood due to overgrowth of bacteria that changes flora of intestine), tenesmus, pneumaturia

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straining, especially ineffectual and painful straining at defecation or urination

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tenesmus -found in pseudomembranous colitis early + late stages

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pneumaturia (opening from colon to vagina allows feces or air to pass)

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found in pseudomembranous colitis late stage

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dilation of the abdominal aorta due to weakening of the vessel wall

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Abdominal Aortic Aneurysm - asymptomatic until sig. enlargement or rupture. Males >50

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Most common cause of AAA

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atherosclerosis

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atheroemboli from small AAA produce livedo reticularis of the feet

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peripheral emboli

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livedio reticularis of AAA

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blue, net-like patches of the skin on the limbs, which becomes intense on exposure to cold

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risk factors of AAA

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"high blood pressure, hx of smoking, hereditary disease (Marfan’s, Ehler Danlos)

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Stable/intact AAA sx

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asymptomatic, possible livedo reticularis (blue toe syndrome) due to emboli

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Describe an EXPANDING AAA

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1. Abrupt abdominal or BACK pain, Unaffected by movement, 2. Feeling of fullness or NAUSEA, 3. LIVIDEO RETICULARIS, 4. PULSATION in abdomen

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RUPTURED AAA sx

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SEVERE abdominal pain that may radiate to GROIN/BACK/LEGS with a fast pulse (losing blood)

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preferred screening method for AAA

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ULTRASOUND

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blockage of the small intestines, hindering the transport of substances

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small bowel obstruction

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most commonly due to POST OPERATIVE ADHESIONs

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small bowel obstruction

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may be strangulated/complete or non-strangulated/incomplete

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small bowel obstruction (and either functional or mechanical obstruction)

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Small bowel obstruction = intestine _______ proximally and _______ distally

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dilated proximally, collapsed distally (there's nothing in it to keep it open)

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how would small bowel obstruction cause death?

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Prolonged > venous bld flow compromised, edema, local tissue anoxia w/ ischemia > necrosis > perforation > peritonitis > death

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blockage of the large intestines, hindering the transport of substances

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large bowel obstruction

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What causes small bowel obstruction that is different from large bowel obstruction?

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Small: post-operative adhesions, Crohn's disease, gallstones, foreign bodies Both: hernias, impacted feces, volvulous, malignancy Large: IBD

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Small bowel obstruction due to? Large bowel obstruction due to?

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Small = POST OPERATIVE ADHESIONS vs. Large = ACUTE OBSTRUCTION (cecal or sigmoid volvulus)*****

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Most common causes, in order, of large bowel obstruction:

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Carcinoma, Sigmoid diverticulitis, Volvulus = most common causes 90% of colonic obstruction

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What may occur with fistula of sigmoid colon to the bladd secondary to diverticulitis or cancer?

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Pneumaturia, mucinuria, or fecaluria

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Large bowel obstruction on radiograph

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FILLING DEFECTS on barium study. Endoscope: sessile or pedunculated polyps

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NON-obstructive severe colitis episode w/ total or segmental DILATION of the COLON w/ assoc. SYSTEMIC TOXICITY

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TOXIC MEGA-COLON …a common complication of Inflammatory Bowel Dz (IBC)

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my be complication of ANTIBIOTIC colitis, Crohn's, radiation colitis

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TOXIC MEGA-COLON …a common complication of Inflammatory Bowel Dz (IBC)

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Physical exam presentation of toxic megacolon

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abdominal DISTENTION/tenderness, pain, FEVER > 105*F, signs of toxicity, dehydration, peritonitis (perforation)

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Plain film of toxic megacolon IF bowel perforation

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free air under diaphragm indicates bowel perforation

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CONGENITAL megacolon

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HIRSCHPRUNG'S DISEASE

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A congenital disorder characterized by ABSENCE of ENTERIC n. (ganglion cells) of intestine

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HIRSCHPRUNG'S DISEASE

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Loss of Enteric innervation in Hirschprung's dz leads to

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FUNCTIONAL obstruction and intestinal DILATION PROXIMAL to affected segment (nothing gets by)

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What is ALWAYS affected in Hirschprung's congenital megacolon dz?

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RECTUM = most cases involve the rectum and sigmoid only

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OLGILVIE syndrome

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acute PSUEDO-obstruction causing dilationg of the CAECUM, right colon and perhaps rest of large intestine

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What causes OLGILVIE syndrome?

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FUNCTIONAL obstruction of caecum onward due to IMBALANCE of AUTONOMIC innervation.

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OLGILVIE syndrome patient commons

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Recent severe SURGICAL or MEDICAL stress [ MI, sepsis, respiratory fail]

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TRICHURIASIS is an infection of the? Caused by?

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LARGE intestine, caused by WHIPWORM = Trichuris triciura. Children worldwide eating feces-contaminated soil. Eggs in stool.

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ABNORMAL growth of cells in colon

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COLON CANCER/ADENOCARCINOMA

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Describe colon cancer patient

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>50, POLYPS (adenomatous), genetics/family hx, HIGH FAT/CHOLESTEROL and LOW FIBER diet, ALCOHOL, SMOKING

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Long term IBD w/ rectal bleeding, melena, mucus in stools, tenesmus, fatigue, abdominal pain

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COLON CANCER/ADENOCARCINOMA

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Finding on a DRE [digital rectal exam] of colon cancer patient

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rectal bleeding and/or mass. Patient may have no symptoms or significant ones: weight loss, pallor, ascites, liver mass

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Diagnostic imaging for colon cancer/adenocarcinoma

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APPLE CORE appearance in barium study

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Labs of colon cancer

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cancer antigen 19-9, Fecal occult blood test, CEA antigen

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term for small cut or tear in skin of anal mucosa due to stretching

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anal FISSURE

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enlarged VEINS of rectum

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HEMORRHOIDS

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Difference between EXTERNAL vs. INTERNAL hemorrhoids

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INTERNAL are usually PAINLESS b/c no receptors inside rectum

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Labs of hemorrhoid patient

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anemia

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name some hemorrhoid risk factors

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preggers, familial, constipation, colon malignancy, portal hypertension, prolonged sitting, obesity, loss of rectal tone, surgery, episiotomy, anal intercourse (nothing like E. coli on your penis)

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a feeling of weariness, tiredness or lack of energy

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chiropractic school. FATIGUE.

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a generalized feeling of discomfort, illness or lack of well being assoc. w/ disease state

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MALAISE - can be accompanied by a sensation exhaustion or inadequate energy to accomplish usual activities

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a REDUCTION IN STRENGTH of one or more MUSCLES

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WEAKNESS = may be subjective (patient complaint) or objective (MRS testing). May be general or localized.

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GIGANTISM is a hormonal disorder due to ?

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EXCESS HUMAN GROWTH HORMONE via anterior pituitary, most commonly from a BENIGN pituitary ADENOMA

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name the ANTERIOR pituitary gland hormones

G-FLAT EP

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TSH, LSH, FSH, ACTH, GH, Endorphins, Prolactin

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name the POSTERIOR pituitary gland secretions

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OXYTOCIN & VASOPRESSIN/ADH

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When does GIGANTISM occur?

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BEFORE the growth plates/epiphyses close, then the elevated GH (and IGF-1) result in gigantism

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How does gigantism produce the clinical manifestations?

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Persistent hypersecretion of Human GH from Anterior pituitary adenoma causes HEPATIC secretion of ILGF-1 (insulin-like growth factor)

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Patients w/ too much IGF-1 are prone to?

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(gigantism) LEFT VENTRICULAR HYPERTROPHY or ENLARGED THYROID

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Anterior pituitary adenomas are most common cause of gigantism but what else can?

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Hypothalamic dysregulation due to head trauma or radiation increases GHRH (gr hor regulatory hor), EXOGENOUS GH or IGF-1 or GHRH from a hormone -secreting tumor [pancreatic, lung]

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cause of ACROMEGALY

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benign pituitary adenoma

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Why do people develop acromegaly?

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AFTER EPIPHYSES CLOSE: Persistent hypersecretion of Human GH from Anterior pituitary adenoma causes HEPATIC secretion of ILGF-1 (insulin-like growth factor)

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AGE for acromegaly vs. gigantism

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Acromegaly: 30-50 y.o. w/ High risk of GASTRIC POLYPS Gigantism: children before epiphyses close

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Describe acromegaly patient

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hirsuitism, diaphoresis, frontal bossing, prognathism, coarsening facial features, swollen eyelids, nose, soft tissue of hands and feet, galactorrhea, polyuria, polydipsia

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Why galactorrhea in acromegaly?

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pituitary stalk affected so crashes prolactin release, causing galactorrhea

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Why sleep apnea in acromegaly?

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Soft tissues increasing, including tongue (macroglossia), which blocks airway

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Endocrine and organ problems of acromegaly

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hypertension, diabetes, cardiovascular dz, fatty liver

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Imaging of ACROMEGALY**

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Increased size of SELLA TURCICA, SPADE FINGERS, POSTERIOR VERTEBRAL SCALLOPING, INCREASED HEEL PAD SIZE, distal tufts are spade-like, increased vertebral BODY size then DISC SPACE increased

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What do CT/MRI/GI studies for acromegaly show?

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COLONIC polyps/tumors*

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Main lab of acromegaly

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Main one is GLUCOSE TOLERANCE TEST = very reliable!!!! Increased GHRH, Increased IGF-1, Increased Prolactin…..decreased TSH if hyperthyroid, LFT abnormal due to fatty liver

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What is the most reliable test for acromegaly and when?

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GLUCOSE TOLERANCE TEST - FIRST THING

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After the Glucose tolerance test, next test for acromegaly?

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IGF-1 - GH secretion from pituitary into blood leads to release of IGF-1 from liver. GH level high? Then so is IGF-1

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Pituitary function test for acromegaly

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after glucose tolerance test and IGF-1 and GH, check the non-tumor part of pituitary for proper hormone release

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Abnormally short stature with NORMAL body proportions caused by a hormone deficiency

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proportional dwarfism/GROWTH HORMONE deficiency due to ANTERIOR pituitary tumor from brain infection, trauma or radiation

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A child that grows less than 2 inches per year, or who is only as tall as children two or more years younger

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proportional dwarfism/GROWTH HORMONE deficiency due to ANTERIOR pituitary tumor from brain infection, trauma or radiation

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Growth hormone deficiency is also called?

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PROPORTIONAL DWARFISM = pt has diabetes INSIPIDUS due to posterior pituitary ADH, slow growth before 5 y.o.

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Post-partum necrosis of the anterior pituitary **

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SHEEHAN'S syndrome = most common cause of HYPOpituitarism. Must be due to HEMORRHAGE. ***

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a GH deficiency plus deficiency of at least one other ANTERIOR pituitary hormone

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HYPOpitutarism (most important one to know for test is SHEEHAN's syndrome due to hemorrhage)

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idiopathic, chronic, inflammatory autoimmune destruction of myelin in CNS (esp. cerebellum)

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Multiple sclerosis Females 20-40 MOST COMMON TYPE: SECONDARY progressive from relapse/remitting to neurological decline

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4subtypes of MS

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RELAPSING/REMITTING no new signs,
SECONDARY PROGRESSIVE most common,
PRIMARY PROGRESSIVE no remission w/ attacks NOT evident, PROGRESSIVE RELAPSING attacks ARE evident

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Why pain in one eye w/ MS

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20-30% patients have OPTIC NEURITIS and lose RED vision = dyschromatopsia

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Exacerbation of MS symptoms due to HEAT

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UHTHOFF'S phenomenon

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brainstem signs of MS

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ataxia, nystagmus, internuclear ophthalmoplegia w/ emotional liability, depression, memory loss

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Inflammation or demyelination of the optic n.

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optic neuritis (assoc. w/ MS = along w/ Marcus-Gunn pupil, Charcot's triad, Uhthoff's sign)

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L'Hermitte's sign, Charcot's triad (SIN), Marcus-Gunn pupil, Uhtohoff's phenomenon

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Multiple sclerosis Females 20-40 MOST COMMON TYPE: SECONDARY progressive from relapse/remitting to neurological decline

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CHARCOT'S TRIAD

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SIN: Scanning speech and Scotomas (blind spots), Intention tremor, Nystagmus - It's a SIN to have MS.

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MARCUS-GUNN PUPIL

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Pupil responds by constricting to INDIRECT light shone into other eye because opposite side of brain compensates. Shine it directly into abnormal eye produces no constriction. Due to crapped afferent pupillary pathway on ipsilateral/direct side. Can be both that constrict to a lesser degree than normal.

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L'Hermitte's sign, Charcot's triad (SIN), Marcus-Gunn pupil, Uhtohoff's phenomenon

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shock like dysthesia down an extremity upon neck flexion