Clin Med III: GI practice Q's (EXAM 1)

Anal Fissures:

"Feels like pooping shards of glass" -more prone to fissures if you have high sphincter tone -anterior & posterior midline common -lateral can be pathological: HIV, CA, syphilis, abscesses, Crohn's -exam is classic: inc. tone, extreme pain -tx acutely & early Fissure causes: -Crohn's, post surgical, trauma but.... Most common cause by far is constipating stool stretching & tearing anoderm -often not remembered by patient Pathophys: -anoderm tear -somatic nerve -> pain -pain -> spasm of internal sphincter -spasm -> pain & dec. blood flow -dec. blood flow -> less chance of healing -BM's = more pain -more pain -> reluctance to have BM -harder, larger stool - re-tear/irritate fissure Fissure Treatment: -prevention -break the cycle -stool bulking (fiber): no narcotics -warm sitz baths -TP anesthetic ointment (2% xylocaine jelly) -TP calcium channel blockers, NTG ointment -botox -surgery: partially cutting internal sphincter Surgical Tx: lateral internal sphincterotomy -cut small portion of internal sphincter muscle

Pruritis ani:

"itchy anus" -irritation of the skin near the anus, resulting in strong urge to scratch the area M:F 4:1 -usually in 4th-6th decade Causes: -moisture, stool leakage -over or under cleaning after bowel movement -pin worms -PSO -eczema -dermatitis -hemorrhoids -anal fissures -STD's Food: -caffeinated drinks -ETOH -milk products -peanuts -spices -citrus -grapes -tomato (histamine) -chocolate/milk products -beer

Irritable Bowel Syndrome (IBS):

-10-15% prevalence in US -4:1 female:male -Features: defecation tends to alleviate sxm's, onset of pain associated w/ change in frequency of stools, onset of pain associated w/ change in form of stool Frequency change: >3x day or <3x week IBS w/ constipation or IBS w/ diarrhea Work-up: -H&P: FH of IBS, IBD, colon cancers -medication usage including laxatives -associated lab abnormalities (CBC, thyroid fxn tests, stool cultures) -is pt candidate for colonoscopy, imaging, transient time studies, rectal manometry, etc -any new stressors

Hemorrhoid Treatment:

-Fiber and constipation/diarrhea Tx -Sitz baths: 10-15 mins, 2-3 x a day -TP tx (1-2 wks at max) -Epsom salt: mag sulfate -Anesthetic & steroid cream or suppository -Witch hazel pads -Tucks, Anusol, etc -Skin protectants -NSAIDs -Ice -Donut pillow Local destruction: -mostly office procedures -rubber band ligation (m/c)

Complicated Diverticulitis: Treatment

-Hospitalization often required; if peritonitis, sepsis noted - surgery -IV fluids, bowel rest, analgesics, nasogastric tube if vomiting -IV Abx (broad-spectrum) -Use CT scan to assess for possible IR drainage of abscess if >2-3cm's -Monitor clinically for deterioration (fevers, tachycardia, worsening peritoneal signs, etc) -Surgical eval is usually recommended -Expect to see improvement 36-48 hrs after Abx begun Surgical Mgmt of Diverticular Dz: Performed under 2 scenarios: -more common scenario is to treat the complications of diverticulitis -perforation w/ sepsis, fistulas, failure of medical mgmt, colonic stricture formation -less common: recurring episodes causing significant QOL issues. More of an "elective type" operation. -Emergency operations carry much higher chance of requiring a temporary colostomy -Goal is to obtain sepsis control by removing the affected segment of colon. Re-anastomosing under these circumstances carries high chance of "leak" -reversal of colostomy usually can be done 12 weeks postop but requires a second abdominal operation -Recurrent diverticulitis following surgical resection for diverticular dz occur in 10% of pt's

Toxic Megacolon:

-Rare but life-threatening condition resulting from any inflammatory process of the colon -colon begins to distend, no peristalsis; functional LBO -radiographic evidence of colonic dilation -> classic finding is more than 6cm in transverse colon -any 3 of the following: fever, tachy, leukocytosis, or anemia -any 1 of the following: dehydration, altered MS, electrolyte abnormality, or hypoTN Treatment: -left untreated, sepsis & colonic distension -> perforation -supportive therapy, NPO, NG tube, hold narcotics, anticholinergics -identify & tx underlying cause (steroids for US) -consider IV abs (vanco/metronidazole) -early surgical consult recommended -may require subtotal colectomy for source control

Gastroparesis Workup:

1. Exclude mechanical obstruction -upper endoscopy -CT/MR enterography -barium follow through if CT/MRI not available 2. Assess motility -Scintigraphic gastric emptying Scintigraphic gastric emptying: -isotope -binds to solid food (low-fat egg substitute) -gamma camera measures isotope and how well food moves through stomach and GI tract -delayed gastric emptying = gastric retention of >10% of the meal at 4 hours and/or >60% at 2 hours Classified based on the extent of gastric retention at four hours: -mild: 10-15% -moderate: 15-35% -severe: >35% Wireless motility capsule (smart pill): -quantifies luminal pH and pressure -gastric emptying is measured by the changes in pH as the capsule travels from the stomach to the proximal small intestine (inc. pH) -can also measure small bowel and colon transit times

Acute diarrhea is characterized by lasting <_____ days. It is most commonly viral causes: adenovirus, norovirus, and rotavirus. It is self-limited and will resolve within 24 hours.

14 days M/c bacteria causes: salmonella, shigella, e. coli, campylobacter Treatment: hydration & rest -BRAT diet (bananas, rice, applesauce, toast) -imodium/lomotil (only if not infectious) Minimal role of Abx: -GI SE's -disruption of gut bacteria -> predisposing to c. diff infection -cost -reserved for severe cases of suspected invasive infection (bloody, mucoid diarrhea) or those at high risk for complications (age >70, cardiac dz, immunocompromised)

Small Bowel Obstruction (SBO):

3 categories: 1. extraluminal etiologies: adhesions, hernias, carcinomas 2. intrinsic etiologies: primary SB tumors, infections 3. intraluminal obstructors: gallstones, foreign bodies, bezoars Adhesions account for 60% of SBO Neoplasms (mostly metastatic) account for 20% Hernias 10% Crohn's 5% Other 5% Clearly one of the most anatomical disorder, "clogged drain", GI contents "back-up" Pathophys: -initial increase in peristalsis/intraluminal pressure in effort to push content through obstruction -intestine fatigues, dilates w/ dec. peristalsis -no air can pass through site of obstruction, distal SB collapses at "transition" point -SB dilates proximal to obstruction, collapsed distal -as bowel dilates, water & electrolytes accumulate both in lumen & bowel wall itself -massive "third space" fluid loss can cause metabolic derangements & induce vomiting which can result in renal failure, hypoTN, shock (dehydration) -further inc. in intraluminal pressure can cause decrease in mucosal blood flow/ischemia -this promotes bacterial overgrowth & "translocation" of bacteria into blood stream -anything that causes "blockage" of SB can cause arterial occlusion & rapid necrosis of affected SB

For Barrett's esophagus WITHOUT dysplasia, patients should have an endoscopy every ____________ years.

3-5 years

Lymphomas of SB

5% of all lymphomas can present as GI tract as primary disease site -1/3 of these occur in SB -can also have SB involvement as manifestation of systematic dz -m/c intestinal neoplasm in children <10 -m/c location is TI (high concentration of lymphoid tissue) -Sxms: pain, N/V, weight loss, change in bowel habits -fever usually denotes systemic dz -usually grows large (>5cms) -up to 25% of pts present w/ perforation -Tx: surgical resection +/- chemo

SB Adenocarcinoma:

50% of all SB cancers are adenocarcinomas -usually DO prodocue sxm's: obstruction, diarrhea, pain, weight loss, mucous per rectum -peak incidence is 70's, location tends to be duodenum & prox jejunum -those associated w/ crohn's, younger, and location is TI -Tx: surgical resection -1/3 have distant mets on presentation 5-year survival rate only 15-20%

Which of the following is the best diagnostic test to confirm the diagnosis of Zenkers diverticulum? A. Barium swallow study B. Chest computed tomography C. Chest radiograph D. Esophageal manometry

A. Barium swallow study Zenkers diverticulum is an acquired sac-like outpouching of the mucosal and submucosal layers located dorsally at the pharyngoesophageal junction. Because true diverticula contain all three layers of intestinal wall, Zenkers diverticulum is considered a false diverticulum. Zenkers diverticulum is thought to be caused by motor abnormalities of the esophagus. It usually occurs in adults at least 60 years of age but can occur in younger individuals including children. The majority occur in men. Zenkers diverticulum may present with a history of symptoms that have been present for weeks to years. The most classic symptom is oropharyngeal dysphagia. Other symptoms include regurgitation of food into the mouth, neck mass, pulmonary aspiration, halitosis, weight loss, and malnourishment. Zenkers diverticulum is diagnosed with barium swallow studies with dynamic continuous fluoroscopy. Patients with symptomatic Zenkers diverticulum are usually treated surgically, however, flexible endoscopic treatment is becoming more common. Complications from Zenkers diverticulum include aspiration pneumonia, inadvertent perforation of the diverticulum during endoscopy, and squamous cell carcinoma (rare).

What are some reasons for B12 deficiency?

Ab's that interfere with intrinsic factor (helps B12 absorption) - Intrinsic factor is a protein, secreted from gastric body Other reasons for B12 deficiency: decreased intake, gastric surgery, drugs that interfere w/ absorption, Crohn's of ileum Measurement of B12 level: MULTI-FACTORIAL - Methylmalonic acid (b12) - Homocysteine (folate) - Intrinsic factor antibody - Endo check for gastric cancer - Eval of ileum if applicable (Crohn's) B12 deficiency can cause macrocytosis, peripheral neuropathy, and stomatitis Gastric surgery causes deficiency of intrinsic factor which helps absorption of B12

______________ is defined as the failure of the lower esophagus to relax. It results from the degeneration of ganglion cells.

Achalasia

___________________ is a "failure to relax", the lower sphincter is in a constant state of tone.

Achalasia Idiopathic LES fails to relax making passage of food into stomach difficult Dilation of body of esoph Triad sxm's: dysphagia, regurgitation, weight loss but can have chest pain, nocturnal coughing, post-prandial choking & heartburn as well "Birds beak" sign Treatment: progressive disorder which is "never really cured" -early disease, can use pharmacologic agents, NTG, nitrates, Ca-channel blockers, botox -endoscopic dilation -> effective but only short-term relief (months) often requiring repeating -surgery -> myotomy offers much better long term results -esophagectomy in end-stage associated w/ "mega-esoph"

__________________ typically presents as acute appendicitis (RLQ pain).

Acute Ileitis -CT scan helpful especially if normal appendix visualized -at surgery, appendix appears normal but terminal ileum is beefy red, swollen, inflamed, and associated w/ enlarged LNs -usually self-limited -remove appendix if where it attaches to cecum is uninvolved -may be first manifestation of Crohn's but most often unrelated

___________________ is acute dilation of the colon in the absence of an obstruction anatomic lesion.

Acute colonic pseudo-obstruction (ACPO) -"Ogilvie's syndrome" Usually involves the cecum or right ascending colon -thinner walled, larger diameter -> less pressure required to dilate further -inc. tension on colonic wall increases risk for ischemia & perforation Exact cause unknown -usually occurs in hospitalized or institutionalized patients -in association w/ a severe illness or after surgery -may be precipitated by a metabolic imbalance or certain medication administration -possibly due to impairment of ANS -> interruption of parasympathetic fibers from S2-S4 -may be caused by inc. sympathetic tone and a dec. in the parasympathetic tone -> inhibition and impairment of colonic motility Clinical presentation: -age >60; men > women -abdominal distension -> gradual over 3-7 days (m/c 3-5), can be acute over 24-48 hrs -abdominal pain -N/V -constipation or diarrhea -bowel sounds present in 90% of cases -tympany -mild abdominal tenderness -suspect perforation/ischemia w/ fever, marked abdominal tenderness, peritoneal signs (eg. guarding, rigidity, rebound tenderness) Dx: Labs -CBC, electrolytes, lactate, thyroid panel -stool for C. diff -suspected perforation/peritonitits -> LFTs, bilirubin, amylase, & lipase to r/o other causes Dx: Imaging -plain radiography to measure degree of initial dilation & for serial imaging during observation after diagnosis -cecal diameter >10-12 cm associated w/ inc. risk of perforation -free air CT abdomen/pelvis preferred study -> can confirm dx, eval for other possible pathology -Contrast enema if CT not available -> can possibly cause an osmotically driven evac of the colon & relieve the pseudo-obstruction -cal also cause perforation -> avoid in peritonitis -avoid colonoscopy! Conservative treatment is an appropriate first step in patients WITHOUT: -SIG. abdominal pain -extreme >12cm colonic distension -signs of peritonitis -NPO, IV fluids, NG suction -48-72 hours -Neostigmine 2mg IV Other mgmt: -treat underlying condition, correct electrolytes, d/c meds that dec. motility Colonoscopic decompression: technically difficult w/ risk of perforation, risk of recurrence -after age suctioned, tube placed w/ guidwire without air insufflation & left in place to drainage Surgery: tube cecostomy placed via small laparatomy or percutaneously with radiologic guidance can decompress the colon -colonic resection if perforating or ischemia COmplications: ischemia, perforation -occurs in 3-15% of those dx with ACPO Prognosis: -mortality 15% uncomplicated -mortality 2-40% complicated -duration >5-7 days accounted w/ 5 fold increase in mortality Chronic intestinal pseudo-obstruction (CIPO) -may involve small bowel or colon or both -sxm's can be acute, recurrent, chronic over >3 mo -acute episodes of intense, cramping pain, distention, N/V -sxm's resolve or continue chronically

_______________ is a type of esophageal cancer that is seen more commonly in whites, Barrett's esophagus, and is increasing in incidence. This type of cancer is seen in the lower 1/3 of the esophagus.

Adenocarcinoma SCC -> seen in upper 1/3 of esophagus, more common in african americans, related to smoking, ETOH, decreating in # Esophageal cancer has a poor prognosis, no sxm's until later stages Eval: endoscopy, endoscopic US, CT/MRI, PET/CT, bronchoscopy Barrett's esophagus is when squamous cells are replaced by columnar epithelium to better handle acidity -can be present in asymptomatic pt's -only 0.15% risk of turning into cancer Barrett's pt's more likely to die from cardiovascular dz rather than cancer Sxm's: dysphagia, odynophagia, pyrosis, vomiting, weight loss, coughing, dyspnea, hiccups Admission: aspiration, profound anemia, inability to swallow, nausea/vomiting Staged via TNM system

_____________________ is the most common type of gastric cancer.

Adenocarcinoma (columnar cells, 95% of gastric ca) Other types: lymphoma, carcinoid, leiomyosarcoma Decreasing incidence in gastric cancer Intestinal adenocarcinoma m/c -> caused by helicobacter pylori Trosseau syndrome, Virchow's node (very large LN), and Sister Mary Joseph's nodule (mets to umbilicus) RF's: smoking, fam hx, alcohol, obesity, increases with age, H pylori, male gender, type A blood, diet high in red meat Sxm's: dyspepsia, malaise, loss of appetite Dx: CT scan, endoscopic US Early MALT lymphomas can be reversed with Abx

_______________ is the most common type of pancreatic tumor.

Adenocarcinoma (head/neck of pancreas m/c) 5% of pancreatic tumors are acinar cells Exocrine glands cause 95% of tumors

Layers of the esophageal wall include: Mucosa, submucosa, muscularis externa, ________________.

Adventitia

What are the alarm symptoms of lower GI tract?

Anemia, rectal bleeding, weight loss, and fevers If NO alarm sxm's and less than 45 yo: workup for IBS -CBC -CRP (should not be positive in IBS) -tTG - test for celiac dz -Stool for Giardia - r/o infection -Fecal calprotectin - substance that your body releases when there is inflammation in your intestines. Higher levels of faecal calprotectin - which is a protein biomarker - are associated with active inflammatory bowel disease (IBD) such as Crohn's disease or ulcerative colitis.

Which of the following diseases is a risk factor for pancreatic cancer? A. Coronary artery disease B. Cystic fibrosis C. Nonalcoholic steatohepatitis D. Ulcerative colitis

B. Cystic fibrosis Pancreatic Cancer Risk factors: history of smoking Sx: abdominal or epigastric pain, painless jaundice, weight loss, anorexia Labs: CA 19-9 serum marker useful in monitoring Dx: U/S, ERCP or MRCP, CT, endoscopic ultrasound Management: Resectable disease: Whipple procedure (pancreaticodudenectomy) + adjuvant chemo Unresectable disease: FOLFIRINOX or gemcitabine-based chemo Most common type is adenocarcinoma Poor prognosis

Which of the following is the primary risk factor for the development of gastric adenocarcinoma? A. Consumption of alcohol B. Infection with Helicobacter pylori C. Pernicious anemia D. Smoking

B. Infection with Helicobacter pylori Gastric Carcinoma Risk factors: male sex, history of H. pylori infection Sx: loss of appetite, unintentional weight loss PE: supraclavicular node (Virchow node), left axillary node (Irish node), periumbilical node (Sister Mary Joseph node) Adenocarcinoma is most common

Which of the following is first-line treatment to induce remission in Crohn disease using top-down therapy? A. Azathioprine B. Infliximab C. Mercaptopurine D. Mesalamine

B. Infliximab Two approaches exist for management strategies: step-up therapy and top-down therapy. The former begins with low potency and less toxic formulations, such as glucocorticoids (e.g. budesonide, prednisone) and escalates treatment only after initial treatment failure. Top-down therapy, alternatively, uses high potency therapies, including infliximab, to induce remission more quickly and reduce the risk of glucocorticoid dependence in Crohn patients. In mild, low-risk patients, step-up therapy is generally more acceptable, as the high potency drugs and their respective adverse effects may not be needed. Patients with moderate to severe Crohn disease with a high risk of complications may be started on top-down therapy to decrease the risk of morbidity and mortality. Induction of remission uses enteric-coated budesonide in step-up therapy or tumor necrosis factor inhibitors (e.g. infliximab) in combination with azathioprine or mercaptopurine in top-down therapy. Traditionally used 5-aminosalicylates (e.g., mesalamine, sulfasalazine) have mixed data on efficacy but can be used for low-risk mild Crohn disease. Maintenance therapy includes observation with ileocolonoscopy after 6 months or indefinite use of biologic agents, such as tumor necrosis factor inhibitors, in step-up therapy and top-down therapy, respectively. Common complications of Crohn disease include abscesses, intestinal obstruction, fistulae, and perianal disease, such as anal fissures and skin tags. Crohn disease course is characterized by intermittent exacerbations and remission of symptoms. Prolonged remission after initial presentation is achieved in approximately 10-20% of patients, but more than half of patients have evidence of strictures or penetrating disease after 10 years. Many patients require surgery with intestinal resection to alleviate symptoms and treat complications, but surgery is not curative but rather palliative. Crohn disease patients have an increased risk of death and decreased life expectancy compared to the general population.

Which of the following clinical findings is most suggestive of a small bowel obstruction? A. Constant left lower quadrant abdominal pain B. Intermittent crampy abdominal pain with abdominal distention C. Loose nonbloody stools D. Right upper quadrant tenderness with deep inspiration

B. Intermittent crampy abdominal pain with abdominal distention Small Bowel Obstruction History of prior abdominal or pelvic surgery Bilious vomiting PE will show high-pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NGT, surgery

A young woman was recently diagnosed with celiac disease. She is unsure which foods contain gluten and which ones do not. Which of the following foods is safe for a patient with celiac disease? A. Barley B. Oats C. Rye D. Wheat

B. Oats Celiac Disease Sx: diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension PE: dermatitis herpetiformis (pruritic papules and vesicles on extensor surfaces), glossitis Labs: IgA antiendomysial (EMA) and anti-tissue transglutaminase (anti-tTG) antibodies Diagnosis is made by small bowel biopsy - duodenal villous atrophy seen on endoscopy Tx: gluten-free diet

Which of the following is the best way to follow cirrhotic patient's for hepatoma? A. MRI every 2 years B. US every 6 months C. Blood testing D. All of the above

B. US every 6 months

Crohn disease is an inflammatory bowel disease that is most commonly associated with vitamin _________ deficiency.

B12 Crohn disease is an inflammatory bowel disease associated with a Th1 mediated response while ulcerative colitis associated with Th2 mediated response

Lab Workup in Pt with Diarrhea:

BMP to eval renal fxn & electrolytes CBC non-specific -low platelets in HUS Stool tests -not needed if no co-morbidities, non-severe illness -perform in pt's more likely to have a bacterial infection or who would warrant treatment if a bacterial infection were identified Stool studies done in severe illness: -profuse watery diarrhea w/ signs of hypovolemia -passage >6 unformed stools per 24 hours -severe abdominal pain -need for hospitalization -other s/s concerning for inflammatory diarrhea (bloody, passage of many small volume stools containing blood & mucus) -temp > 101.3 F High risk host features for stool studies: -age > 70 years -comorbidities, such as cardiac dz, which may be exacerbated by hypovolemia or rapid infusion of fluid -immunocompromising condition (including advanced HIV infection) -inflammatory bowel disease -pregnancy -sxm's persisting for more than 1 week -public health concerns -> food handlers, health workers, day care centers, outbreak setting -men who have sex with men Testing for parasites: -typically NOT warranted & not cost effective -for pt's w/ persistent diarrhea and hx suggesting strong possibility of parasitic infection -> exposure to daycare, hiking in mountains, ingestion fresh water, MSM -stool microscopy for ova/parasites, 3 specimens on 3 separate days -shedding can be intermittent -cryptosporidium spores require specific staining Imaging: NOT usually necessary -use in pt's w/ peritoneal signs -eval for perforation, obstruction, abscess, toxic megacolon -> CT

______________________: chronic GERD precipitates a metaplastic change in the lower esophagus from the normal squamous epithelium to a more acid-resistant columnar epithelium (gastric mucosa).

Barrett's Esophagus Approx 10% of people w/ chronic GERD, >2 million people in US Most common in white males, ages 50-60 Sx's: usually have sxm's of GERD but can be asymptomatic Upper endoscopy with biopsy to diagnose Stage 1: Barrett's esophagus w/ NO dysplasia -90% remain here throughout course of Barrett's -EGD w/ bx at 1 year after dx, then every 3 years Stage 2: Barrett's esophagus w/ low-grade dysplasia -EGD w/ bx at 6 mo after diagnosis, then yearly thereafter Stage 3: Barrett's Esophagus w/ high-grade dysplasia -endoscopic ablative therapy -radiofrequency ablation - Barrx procedure -photodynamic therapy -endoscopic crytotherapy Stage 4: Esophageal Adenocarcinoma Once present, Barrett's does not spontaneously regress -without an intervention, people will have Barrett's for life -goal is for early detection & to prevent progression -risk of progression to cancer in untreated Barrett's: 0.12-0.5% per year Treatment: every patient w/ a diagnosis of Barrett's esophagus, with or w/o dysplasia, symptomatic or asymptomatic, needs gastric acid reduction tx, endoscopic surveillance

What are the complications of GERD?

Barrett's/malignancy, esophagitis, esophageal ulcers (acid exposure related), esophageal strictures, dysmotility, pulm complications (regurg related) Significant QOL issues for pt's

Colonoscopy in Diverticular Disease:

Benefit of colonoscopy in the eval of pt's w/ diverticular dz has been called into question, its use is still considered important in the exclusion of colorectal cancer but not during "active" episode of diverticulitis (but can be done for diverticular bleed) Parallel epidemiology of CRC and diverticular dz provides enough concern for endoscopic eval before operative mgmt, even if just to exclude other colonic findings (polyps) Colonoscopy should be performed NOT before 6 weeks after an attack of diverticulitis

___________________: benign narrowing or tightness of the esophagus, commonly in areas where esophagus passes from 1 body area to another.

Benign esophageal strictures Causes: hypertrophy of esophageal mucosa w/ submucosal fibrosis due to chronic reflux, irritation, caustic ingestion, etc -radiation therapy to chest/neck -structural abn's in the chest Esophageal rings -concentric, thin, smooth extension of normal esophageal tissue consisting of all 3 anatomic layers of mucosa, submucosa, and muscle -usually located in distal esophagus -M/c = Shatzki ring: common complication is food impaction! -GERD common etiology Esophageal web -eccentric, smooth, thin extension of normal esophageal tissue consisting of mucosa and submucosa -usually located in proximal esophagus -commonly seen in Plummer-Vinson Syndrome -rare disease characterized by dysphagia, iron deficiency anemia, glossitis, cheilosis, & esophageal webs Benign esophageal strictures clinical presentation: -difficulty swallowing foods and/or liquids, sensation that "something is stuck", dysphagia Dx: H&P: pt fairly accurately can locate by pointing -upper endoscopy Tx: endoscopy w/ esophageal dilation

__________________: full thickness esophageal perforation. Results from sudden increase intraesoph pressure combined w/ negative intrathoracic pressure.

Boerhaave's Syndrome Violent retching, coughing, vomiting Classic triad: vomiting, abd or chest pain, SubQ emphysema; but not present in 1/3 of pts Dx: CXR, CT, gastrograffin swallow Tx: depends on clinical status of pt, site of perforation, contained perf? Conservative (IV abx, etc), endo stent, surgery (repair, resect, drain)

What is the most common risk factor for hepatocellular carcinoma in the United States? A. Acute hepatitis B infection B. Age over 55 years C. Cirrhosis D. Male sex

C. Cirrhosis Hepatocellular Carcinoma Most common primary liver cancer Most common cause: chronic HBV or HCV cirrhosis Rapidly ↑ ascites Bloody ascitic fluid ↑ AFP

A 24-year-old woman presents to the office to discuss management of her abdominal pain and diarrhea. She has undergone testing to rule out organic causes and has been diagnosed with irritable bowel syndrome. Her symptoms are bothersome but do not interfere with her ability to carry out daily activities. Which of the following is the best recommendation for this patient? A. Antidepressant therapy B. Antispasmodic therapy C. Dietary and lifestyle modification D. Probiotic therapy

C. Dietary and lifestyle modification Irritable Bowel Syndrome Sx: crampy abdominal pain, can alternate between constipation or diarrhea or present predominantly as either one (IBS-C or IBS-D) Diagnosis is made by Rome IV criteria: Recurrent abdominal pain at least 1x/week for 3 months associated with 2 or more criteria: -related to defecation -associated with change in stool frequency -associated with change in stool form Tx: lifestyle and dietary modification (low FODMAP diet), can consider antispasmodics, antidepressants. Constipation predominant: psyllium, osmotic laxatives, lubiprostone Diarrhea predominant: loperamide, cholestyramine

Which of the following liver neoplasms DOES have malignancy potential? A. Hepatic hemangioma B. Focal nodular hyperplasia C. Hepatic adenoma

C. Hepatic adenoma Mostly benign, some malignant potential so do a biopsy 13% malignant transformation, usually in young women and related to OCPs

Which of the following is the most common presenting symptom of esophageal stricture? A. Chest pain B. Chronic cough C. Progressive dysphagia D. Weight loss

C. Progressive dysphagia Esophageal Stricture Most common cause: GERD Progressive solid food dysphagia Diagnostic studies include upper endoscopy History or symptoms of a proximal esophageal lesion (e.g., Zenker diverticulum, surgery for laryngeal or esophageal cancer) or known complex stricture: initial test should be preendoscopy barium esophagram Surgery, high-dose PPIs

Which of the following represents the most common risk factor for squamous cell carcinoma of the esophagus? A. Barrett esophagus B. Dietary factors C. Smoking and alcohol D. Tylosis

C. Smoking and alcohol The majority of esophageal cancer is either squamous cell carcinoma (SCC) or adenocarcinoma. Adenocarcinoma is the most common type of esophageal cancer in resource-rich countries and predominantly affects the distal third of the esophagus, while squamous cell carcinoma is the most common esophageal cancer worldwide and tends to occur in the proximal two-thirds of the esophagus. SCC arises from small polypoid excrescences, denuded epithelium, or plaques. These early lesions are subtle and are often missed on endoscopy, although staining with Lugol iodide during endoscopy may facilitate diagnosis. As the disease progresses, the early lesions become circumferential, infiltrating, and ulcerated, invading the submucosa and extending along the walls of the esophagus in a cephalad fashion. Most cases of adenocarcinoma are located at the gastroesophageal junction and are associated with Barrett esophagus. Early lesions may present as an ulcer, a nodule, or an altered mucosal pattern. Early lymph node metastasis is seen in both SCC and adenocarcinoma but spread to the celiac and perihepatic nodes is more common with adenocarcinoma. The most common risk factors for esophageal SCC are cigarette smoking and alcohol consumption. An increased risk of esophageal SCC has been associated with cigar and pipe smoking, although the magnitude appears to be less than with cigarettes. Hard liquor has a higher risk than wine or beer, but the cumulative amount of alcohol rather than the type is probably more important. Other risk factors include dietary factors (hot foods, food rich in nitrosamine), fungal toxins, tylosis, poor oral hygiene, and human papillomavirus (HPV). Men are more frequently affected and the most common age is between 50 to 70 years. Clinical manifestations of esophageal cancer include progressive dysphagia for solid food, weight loss, heartburn, vomiting, and hoarseness. Cough (tracheal involvement) may also be present. Initial esophageal lesions can be visualized using biphasic barium esophagram. Endoscopy with tissue biopsy is used for definitive diagnosis. For staging of esophageal cancer, endoscopic sonography and CT scan may be used. Treatment is generally surgical. Radiotherapy and adjunctive chemotherapy may be used depending on the extent of disease progression. Esophageal cancers are often diagnosed late and, hence, have a poor prognosis. Patients known to have Barrett esophagus should undergo screening endoscopy every 3 to 5 years.

_________________ bacteria is associated w/ reactive arthritis, Guillain-Barre 1-2 weeks after infection.

Campylobacter -undercooked, contaminated poultry or contaminated water Campy jejuni m/c in food-borne illness; also campy coli Watery or hemorrhagic diarrhea 2-5 days after exposure w/ cramping abdominal pain Diagnosed via stool culture Typically self-limited, resolving ~7 days Supportive treatment, AVOID loperamide -antimotility agents can prolong disease in such infections or lead to more severe illness Antibiotics: -not indicated in most cases -use in severe disease -> bloody stools, high fever, extraintestinal infection, worsening or relapsing sxm's, or sxm's lasting >1 week -high risk for severe disease -> pregnant, immunocompromised -Azithromycin, fluoroquinolones

Cecal vs. Sigmoid Volvulus X-rays

Cecum: -cecum twists on itself, usually only see 1 lumen -more often see associated SBO -"points" toward LUQ Sigmoid: -loop twists so 2 lumens -coffee-bean sign -points to RUQ

__________________ is characterized by loss of villi, allergic/immunologic process, mostly in small intestine.

Celiac disease Dx of Celiac Dz: Antigliadin Ab, anti-endomyciel Ab, TTG, endoscopy with biopsy -HLA DQ2 and 7 are genetic nets -> looking for negative results meaning pt will never get celiac dz Note that TTG does NOT work if patient is on gluten free diet, takes several weeks to turn positive if they start eating gluten Iron deficiency occurs in many people with celiac disease due to duodenum being affected causing anemia, B12 deficiency if affecting the ileum -Duodenum takes the most hit from celiac disease. Unfortunately, this is the region of the gastrointestinal tract that helps absorb folate from food and supplements you consume. When your small bowel is unable to absorb folate, this will create a shortage in the body, leading to anemia

________________ is a rare cancer in the bile duct system that is NOT seen on ultrasound.

Cholangiocarcinoma

(Persistent/chronic) ___________ diarrhea lasts more than 30 days in duration.

Chronic Persistent diarrhea is more than 14 days but fewer than 30 days Diarrhea is one of the m/c causes of mortality in developing countries -infants -1.8 mil deaths per year Mild diarrhea <3 stools per day Moderate diarrhea >4 stools per day w/ local sxm's (abdominal cramps, nausea, tenesmus) Severe diarrhea >4 stools per day w/ systemic sxm's (fever, chills, dehydration) Dysentery (AKA invasive diarrhea): diarrhea w/ visible blood or mucus vs. watery diarrhea; commonly associated w/ fever & abdominal pain Transmission via fecal-oral route RF's: -improper hand hygiene -improper food handling, cooking, storage -unpasteurized dairy products, undercooked meat/poultry/fish -exposure to animals (reptiles -> salmonella) -daycare centers -travel to resource limited settings

_______________ is the 2nd most common cause of food-borne illness behind salmonella.

Clostridium Perfringes Less freq. reported due to mild, self-limited disease Spores can survive normal cooking temp's & germinate & proliferate in improperly stored food Outbreaks are m/c associated w/ inadequately heated or reheated meats, poultry, or gravy Releases an enterotoxin in the GI tract resulting in watery diarrhea and abdominal cramping Incubation 6-24 hrs, sxm's resolve within 24-48 hours Stool culture & food culture Self-limited illness requiring supportive therapy only

________________ colonizes intestinal tract after the normal gut flora has been disrupted (freq. in association w/ Abx therapy).

Clostridoides Difficile -spore forming, toxin producing, gram positive anaerobic bacteria One of the most common health care associated infections; 41% community acquired May be present as part of normal flora, but use of broad-spectrum Abx can result in an overgrowth Toxin-producing strains can cause diarrhea, C. diff colitis and other serious complications such as toxic megacolon Diagnosis via stool testing for toxin (PCR, EIA) Toxic megacolon: colonic dilation w/ systemic toxicity -inflammation invades beyond mucosa to smooth muscles, paralyzing smooth muscle and causing dilation -fever, tachycardia, peritoneal signs if perforation Pseudomembranous colitis: yellowish plaques on mucosa -often mild, treated supportively w/ hydration, d/c Abx -can progress to toxic megacolon, perforation Treatment only indicated for pt's w/ clinical disease Asymptomatic carriage is common -treatment shown to be little benefit -colonization can be protective vs. active CDI -host immune response, strain not causing active disease preventing infection w/ more virulent strain Fidoxamicin, Vancomycin, Metronidazole

Crohn disease is an inflammatory bowel disease that causes a _____________ appearance in the mucosa.

Cobblestone appearance Associated with string sign or narrowing of bowel lumen on xray

___________________ is a portion of colon, that loops & twists on itself. It cuts off its own blood supply by twisting of its mesentery. At risk for quickly becoming ischemic -> necrotic -> perforation with sepsis.

Colonic Volvulus A&P: -twisting also causes large bowel obstruction (LBO) -15% of LBO in US; third leading cause world wide -sigmoid colon m/c, cecum next, transverse colon 3rd (areas where colon not "fixed" in location) -"Volvulus Belt": middle east, africa, indian subcontinent, turkey, parts of SA -rare, but can occur in children (malrotation, Hirschsprung's) In adults, causes are varied: -abdominal adhesions -hx abdominal/pelvic surgery or procedure -enlarged colon -pregnancy -intestinal malrotation (birth defect) -long term constipation -high fiber diet S&S: -regardless of cause volvulus causes sxm's by 2 mechanisms: 1. bowel obstruction manifestated as abdominal distension, obstipation, cramping, bilous vomiting 2. ischemia to affected portion of intestine causing severe pain -Depending on extent, timing, presentation can range from mild xm's to pt's in extremis Dx: H&P always important -plain abdominal X-rays can make dx often -CT scan

____________________ is defined as diverticulitis w/ associated abscess, phlegmon, fistula, obstruction, bleeding, or perforation.

Complicated Diverticular Disease -Abscess defined collection of pus -Phlegmon: inflammatory area containing swollen loops of bowel, small amounts of pus; not truly a "drainable" entity -Fistula: lined (abnormal) tract connecting two entities -Sinus tract: lined (abnormal) tract w/ 1 opening and blind "dead-end"

What are the possible complications of PUD?

Complications: UPPER GI BLEEDING -> melena & hematemesis, anemia, possible hemodynamic instability -always refer to GI for urgent endoscopy -Tx: endoscopic therapy -> epi injection, argon coagulation, heater probe, clips -if in hospital setting, always start pt on IVF and IV PPI Bleeding: usually posteriorly penetrating DU into gastroduodenal artery -Tx: endoscopy w/ "clipping", injections, coagulation -surgery if bleeding uncontrolled Perforation: have have posterior penetration into organs -presentation: sudden, severe abdominal pain, will quickly become unstable -duodenal ulcers can penetrate into pancreas & cause associated pancreatitis -gastric ulcers can penetrate into liver lobe (less common) Anterior perforation: can be DU or GU -Sxm's: sudden, severe abd pain, +/- N/V -likely will have pre-existing issues with HB -pt will have peritoneal signs on exam (guarding and rigidity) -will see free air on x-ray Tx: surgery often indicated especially in elderly Gastric outlet obstruction: not as common, results from chronic ulcers & duodenal scarring -scarring over time narrows lumen -Sxm's: abdominal distension, nausea/vomiting -emesis is usually non-bilious and contains partial/undigested food -often note weight loss, dehydration -Tx: since this is result of benign dz, definitive surgery recommended -resect or bypass + treat for hyperacidity -if non-operative candidate, can palliate w/ stent of jejunostomy tube placement

_______________ are "genital warts" caused by HPV.

Condyloma Accuminata -predisposes to anal canal cancer -local ablation/excision only 60-80% effective

____________ is characterized by a wide range of bowel habits that makes it difficult to define. It is generally less than 3 bowel movements/week.

Constipation -hard lumpy stools -excessive straining -sense of incomplete evacuation Primary constipation: -no structural abnormalities or systemic disease -often have normal transit time (40%) -slow transit time (20%) -dyssynergic defecation: abnormal coordination between relaxation of the anal sphincter and pelvic floor musculature when abdominal pressure is increased Secondary constipation: -systemic disorders: neurologic gut dysfxn, myopathies, endocrine disorders, electrolyte abn's (hypercalcemia, hypokalemia) -medications (anticholinergics, opioids) -obstructing colonic lesions (neoplasms, strictures) Patient presentation: -hard stools -feeling of incomplete evacuation -abd bloating/distention -excessive straining -sense of blockage during defecation -need for manual maneuvers during defecation, digital manipulation Rectal exam: hemorrhoids, fissures, impaired sphincter fxn, dysnnergic defecation (ask patient to strain during rectal exam, assess ability to evac exam finger) Alarm sxm's: hematochezia, weight loss, positive FOBT, or FIT Age >50 yo -> severe constipation Look for hx of fam hx of colon cancer, IBD CBC, serum electrolytes, calcium, glucose, TSH Colonoscopy or flexible sigmoidoscopy -identify occlusive lesions, perform Bx

The most common etiological agent of short bowel syndrome is (disorder) _______________.

Crohn Disease

_______________ is an inflammatory bowel disease that can affect any portion of the gastrointestinal tract, though often spares the rectum.

Crohn Disease Crohn disease most commonly affects the ileum & colon Crohn's is an inflammatory bowel disease involving noncaseating granulomas

_____________________ is an inflammatory bowel disease that is associated with cholelithiasis.

Crohn disease (Also kidney stones)

Pain, weight loss, fever, and a palpable RLQ mass are all clinical features of ____________.

Crohn's

(Crohn's/Ulcerative colitis) _______________ is more likely to cause fistulae, fissures, or strictures in the bowel.

Crohn's disease

___________________ is the most common primary surgical disease of the small bowel.

Crohn's disease -chronic, transmural inflammatory disease of entire GI tract -unknown cause -bimodal: yound adults 20's and 30's; smaller peak 60's -male = female -2x higher in smokers -strong familial association: 30-fold in siblings Presenting sxm's: -insidious: intermittent, colicky abd pain & diarrhea, malaise, weight loss, low grade fevers -symptomatic periods gradually become more frequent, more severe, long lasting -main SB complication is obstruction & perforation -often can develop SB to SB fistulas; perianal fistulas -longstanding Crohn's pt's have higher incidence of SB/colon cancer -extraintestinal manifestations occur in 30% of pts Hx/physical: -lab eval: CBC (anemia?), inflammatory markers, serology markers -barium contrast studies -endoscopy, CT -cobblestone appearance on colonoscopy Tx: NO cure -meds can tx flares, help maintain remisssion -include 5-ASAs, corticosteroids, Abx, immunosuppresive agents, biologics -nutritional supplementation when necessary -surgery: usually tx complications (perf, obstruction, fistulas, cancer, etc) -resect as little SB as needed to be preserve SB length

Ulcerative colitis is an inflammatory bowel disease with histological findings of ____________ abscesses with neutrophils, ulcers, and no granulomas.

Crypt Ulcerative colitis is an inflammatory bowel disease associated with a Th2 mediated response and hence no granulomas.

___________________ is a common parasitic cause of food-borne diarrhea and is endemic in cattle. It is transmitted via ingestion of cysts.

Cryptosporidium Parvum Spreads from infected animal or person, a fecally contaminated environment (water/food prep), person-person -> cyst ingestion Incubation avg 7-10 days, self-limited (7-14 days), can result in severe dehydration Diagnosed on stool examination -direct immunofluorescence, PCR Treatment not typically required in immunocompetent pt's -supportive, fluid repletion, loperamide -immunocompromised pt's -supportive therapy, ART, nitazoxanide

A 32-year-old man with a history of gastroesophageal reflux disease presents to his primary care physician with concerns for progressive dysphagia of both solids and liquids which is not improved with treatment. He reports he has been belching more and feels epigastric burning after meals. He undergoes an upper endoscopy which is negative, but a barium esophagram shows a dilated esophagus with a "bird beak" appearance at the lower esophageal sphincter concerning for achalasia. Which of the following elements of his history is most consistent with a diagnosis of achalasia? A. Belching B. History of gastroesophageal reflux disease C. Male sex D. Progressive dysphagia of both solids and liquids

D. Progressive dysphagia of both solids and liquids Achalasia Sx: dysphagia to solids and liquids PE: absent peristalsis in the lower esophagus Barium swallow shows bird-beak appearance Diagnosis is made by esophageal manometry: increased LES pressure

A 32-year-old woman presents to the office with a two-day history of bloody diarrhea and painful defecation. She has had about two to three bowel movements per day. She has experienced these symptoms in the past, and her old doctor prescribed suppositories. She does not remember the name of the medication. Upon physical exam, her abdomen is soft, and bowel sounds are normal. She has some mild tenderness to palpation of the lower left abdominal quadrant. Which of the following is the most likely diagnosis? A. Crohn disease B. Ischemic colitis C. Shigellosis D. Ulcerative colitis

D. Ulcerative colitis Ulcerative Colitis Sx: Bloody diarrhea, crampy abdominal pain, tenesmus PE: continuous mucosal inflammation, always involving the rectum, absence of perianal involvement (prevalent in Crohn) Extraintestinal findings: uveitis, erythema nodosum, sacroiliitis, ankylosing spondylitis Tx: options depend on severity and location of disease -Mild-moderate: mesalamine, topical or oral steroids, 5-ASA -Severe: IV steroids +/- topical steroids initially, then anti-TNF or anti-integrin, colectomy for refractory cases (curative) Complications: toxic megacolon, ↑ colon cancer risk

______________ is the treatment for celiac disease in 2022.

DIET - Actively creating peptide vaccinations and enzymes for people who want to cheat on celiac diet - Only 30% of people with celiac dz follow their diet Patient already on self-imposed gluten free diet, duodenal biopsies will NOT be useful to check for celiac dz because inflammation will be gone - Pts already diagnosed with celiac disease and doing well DO NOT need additional gluten challenge or bx Testing is NOT recommended to asymptomatic family members for celiac disease

Normal Anatomy of the Anorectal Area:

Dentate line: very important, nerve innervation to the mucosa turns from autonomic to somatic -squamous cell on outer area, then turns into columnar epithelia Anal verge: where buttocks turn into the anal canal Nerve supply of anal canal: Mucous membranes: -upper 1/2 is sensitive to stretch and is innervated by hypogastric plexuses -lower 1/2 is sensitive to pain, temp, touch, and pressure and is innervated by inferior rectal nerves Involuntary internal sphincter: supplied by sympathetic fibers from inferior hypogastric plexus Voluntary external sphincter: supplied by inferior rectal nerve, a branch of pudendal nerve, and perineal branch of 4th sacral nerve

Asymptomatic diverticular disease discovered on imaging studies or at time of colonoscopy is best managed by _____________

Diet alterations -> fiber enrinched diet that includes 30g of fiber each day -> supplementary fiber products such as metamucil, fibercon, or citrucel are useful The incidence of complicated diverticular dz appears to be increased in pt's who smoke. Therefore patients should eb encouraged to refrain from smoking The historical recommendation to avoid eating nuts/seeds is NOT based on more than anecdotal data. Medical mgmt of uncomplicated diverticulitis: -simple, uncomplicated diverticulitis can be managed expectantly, but Abx are still the mainstay -once dx obtained (clinically or CT scan), consider Cipro/metronidazole or IV equivalent -Bowel rest (NPO, clear liquids, low residue diet) -should not improvement in 2-3 days -?maybe colonoscopy 6-8 weeks later

Constipation Management:

Dietary fluid & fiber intake, patient education, exercise, d/c contributing medications Laxatives: -bulk forming laxatives (fiber supp's) -> Psyllium, methocellulose, polycarbophil Osmotic: -increase secretion of water into intestinal lumen, softening stools & promoting defecation -magnesium hydroxide, polyethylene glycol, sorbitol, lactulose Stimulant: -stimulate fluid secretion & colonic contraction -bowel movement within 6-12 hrs after PO; 15-60 min after PR -bisacodyl and senna When to refer: pt's w/ refractory constipation for anorectal testing, may benefit from biofeedback therapy -pt's w/ alarm sxm's or who are over 50 should be referred for colonoscopy -rarely, surgery is required for pt's w/ severe colonic inertia Long-term opioid use inhibits peristalsis & increases intestinal fluid absorption -> constipation Mu-opioid receptor antagonists that block peripheral opioid receptors (including in GI tract) without affecting central analgesia -methylnaltrexone -naloxegol -naldemedine

Gastroparesis Treatment:

Dietary modification: -frequent small meals -low fat -avoid insoluble fiber -small particle size, homogenized food (easy to mash/pureed food) -avoid carbonated beverages -avoid ETOH, smoking Correction of nutritional status: -hydration -correction of metabolic, electrolyte disturbances -correction of vitamin, nutrient deficiencies Optimize glycemic control: -acute hyperglycemia delays gastric emptying & lessens effectiveness of prokinetic medication -amylin analogues, GLP-1 agonists delay gastric emptying Prokinetics: metoclopromide -anti-emetic and pro-kinetic effects -short term use only (12 weeks) -ADR's: dystonia, tardive dyskinesia (neuro disorder causes involuntary, rapid muscle movements of face, tongue, mouth, and body) Macrolides: Erythromycin -prokinetic, motillin agonist -may provide short term sxm relief -ADR's: cramps, nausea, prolong QT (sudden death), w/ long term use -Azithromycin: longer half life, fewer GI side effects/drug interactions than erythromycin, also prolongs QT Antiemetic medications: aids in improvement of N/V, but does not improve gastric emptying -odansetron, diphenhydramine -caution medication interactions, prolonged QT, hypokalemia, hypomagnesemia, heart failure, bradyarrhythmias Refractory Cases: -venting gastrostomy tube or decompression w/ abdominal pain/nausea -enteral feeding via jejunostomy if oral feeding cannot meet nutritional needs -parenteral nutrition seldom required unless there is a diffuse gastric and intestinal motility disorder -gastric electrical stimulation: internally implanted neurostimulators reduce nausea & vomiting in severe cases -surgery rarely indicated -> pyloroplasty, gastrojejunostomy (surg procedure creating anastomosis between stomach and prox. loop of jejunum)

Chest pain and dysphagia are the most common sxm's of ________________, which is a poorly understood hypermotility disorder that presents similar to achalasia.

Diffuse esophageal spasm (DES) More common in women Muscular hypertrophy seen in lower esophageal wall w/ vagus nerve degeneration More pronounced in times of emotional distress Dx: barium swallow ("corkscrew") and manometry (spontaneous high amplitude, multipeaked contractions of long duration) Treatment: not great -psychiatric eval to r/o depression, anxiety, psychosomatic disorders -eliminate trigger foods that may cause dysphagia -acid suppression if HB is a sxm -pharmacologic agents in some cases -endo dilation if severe dysphagia -surgery as last resort

___________ is 1st line for acute exacerbations of chronic intestinal pseudo-obstruction (CIPO) but is NOT used for chronic use due to side effects (prolonged QTc) w/ prolonged use

E-mycin, then neostigmine -E-mycin for for chronic use due to side effects (prolong QT) Intractable sxm's: -decompression, enteral needed, parenteral nutritional -intestine transplant

A 52-year-old homeless man comes to the emergency department because of several episodes of severe bloody diarrhea. He is responsive only to painful stimuli and is unable to answer questions. His temperature is 39.2°C (102.6°F), pulse is 125/min, respirations are 8/min, and blood pressure is 86/54 mm Hg. Physical examination shows marked lower abdominal distension. A complete blood count shows a hemoglobin concentration of 6.5 g/dL, hematocrit of 25%, and a leukocyte count of 14,000/mm3. Despite aggressive antibiotic treatment and multiple blood transfusions, he passes away. An autopsy shows extensive, continuous inflammation and necrosis of the distal colon from the sigmoid colon to the rectum. Which of the following is the most appropriate diagnosis? A. Crohn disease B. Hirschsprung megacolon C. Intussusception D. Irritable bowel syndrome E. Ulcerative colitis

E. Ulcerative colitis Ulcerative colitis (UC) is a subtype of inflammatory bowel disease, a chronic relapsing inflammatory disorder that affects the gastrointestinal tract. UC is characterized by inflammatory ulceration and destruction of the mucosa that begins in the rectum and spreads proximally. The spread of inflammation is continuous, and skip lesions are not observed. Affected individuals experience attacks of bloody diarrhea that may persist for days to months, colicky lower abdominal pain, and cramps. In rare cases, the muscularis propria and neural plexuses can be exposed to fecal material. The subsequent inflammatory response can cause toxic megacolon, a potentially lethal complication consisting of colonic distension, gangrene, and perforation.

A 21-year-old woman comes to the office because of abdominal pain and bloody stools with intermittent diarrhea and constipation. Additionally, she complains of fatigue and unintentional weight loss over the past six months. A blood test shows an erythrocyte sedimentation rate (ESR) of 30 mm/hour and a platelet count of 510,000/mm3. A computed tomography scan of the abdomen shows a large lesion that is restricted to the distal colon. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Irritable bowel syndrome D. Radiation colitis E. Ulcerative colitis

E. Ulcerative colitis Ulcerative colitis is characterized by mucosal inflammation and is limited to the colon. Crohn disease will be characterized by transmural inflammation on biopsy and may be found throughout the GI tract.

______________ is a common cause of diarrhea in resource-limited settings, therefore a common cause of traveler's diarrhea.

Enterotoxigenic E. Coli Incubation 1-3 days, self limiting (1-5 days) Spread through contaminated food or water, person-person Supportive mgmt (hydration, BRAT diet)

___________________: defined as chronic, immune/antigen-mediated, esophageal disease characterized clinically by sxm's related to esophageal dysfxn & histologically be _________________.

Eosinophilic Esophagitis..... Eosinophil-predominant inflammation -AKA "feline esophagitis" Clinical presentation: Male: female ration 3:1 -usually during 3-4th decades of life -predominance in caucasians Complain of solid food dysphagia, food impaction, heartburn, chest pain/discomfort -typically unrelieved by PPIs Commonly associated w/ other atopic diseases: food allergy, eczema, chronic rhinitis Dx: upper endoscopy w/ esophageal bx -2-4 biopsies obtained from at least 2 different esophageal locations -pathology will show >15 eosinophils per high-power field Endoscopic features of EoE: -fixed esophageal rings -esophageal narrowing

_____________________ diverticulum is usually a dysmotility disorder increasing intraesoph lumen pressures (pulsion); false.

Epiphrenic diverticulum Located near diaphragm within 10cm of GE junction Should consider congenital, connective tissue disorders, trauma in those pt's who do not have dysmotility abnormalities More common on right side Asymptomatic to dysphagia, chest pain Tx: depends on size & sxm's (<2cms can be observed) Surgery options like resection/pexy usually include myotomy

Fistula-in-ano:

Epithelial lined tract from anal canal to skin Usually a result from perianal abscess Course/tract of fistula determines tx options Don't want to destroy sphincters in process of treating fistula Sxm's are usually intermittent drainage, pain, perianal skin irritation On exam, heaped up tissue at external opening -may see d/c from opening on DRE Goodsall's rule: tract depends on anterior or posterior to the transverse anal line -anterior -> spokes of wheel straight tracts -posterior -> curved tracts Occasionally may spontaneously close -surgery to "lay open" the tract & debride the epithelial & granulation tissue (fistulotomy) Fibrin "plug" Use of seton Clearly, surgical eval -Fistulotomy; surgically lay the tract open & scrape out epithelial tissue Treatment depends on tract's in relationship to sphincters

Erosive Gastritis (acute) vs. Non-Erosive Gastritis (chronic)

Erosive Gastritis (Acute): -Causes: ASA, NSAIDs, other meds -ETOH -Stress (burns, trauma, surgery, shock) Clinical presentation: many are asymptomatic, epigastric pain, nausea, hematemesis Dx: EGD w/ bx Tx: PPI therapy x 1 mo Non-erosive Gastritis (chronic); -Causes: ABCs -Autoimmune (pernicious anemia) -Bacterial/infectious (80% caused by H pylori) -Chemical (bile, drugs) Clinical presentation: epigastric discomfort, nausea, bloating Dx: EGD w/ biopsy Tx: H pylori eradication, PPI therapy x 1 mo -slightly inc. risk of Gastric Cancer

_____________________ is a neuromuscular disorder, mostly thought to be a primary motor distrubance or abnormality of the UES or LES.

Esophageal Diverticula 3 classic locations: upper, mid, and lower esophagus True vs. false diverticulum Pulsion vs. traction True diverticula are outpouchings that include all layers of the esophageal wall while false diverticula only include the mucosa or submucosa. 3 m/c: 1. Pharyngoesophageal (Zenker's) Diverticulum: upper, pulsion, false 2. Midesophageal: middle, traction, true 3. Epiphrenic: distal, pulsion, false

_____________________: abnormal dilation of veins in distal esophagus due to abnormally high pressures within the portal venous system.

Esophageal Varices Cause: -develop when normal blood flow to the liver is obstructed due to the formation of scar tissue, m/c seen in cirrhosis (ETOH m/c) -blood then flows to collateral vessels that are not designed to carry large volumes of blood -may leak or rupture, causing massive UGI bleed -approx 1/3 of pt's with cirrhosis have varices, and 1/3 of these pt's will develop bleeding Most often due to liver disease (cirrhosis) which force blood to the areas where the portal venous system and the normal nevous system communicate. This collateral circulation develops in the lower esophagus, abdominal wall, stomach, and rectum. Esophageal venous drainage: -upper 2/3 of the esophagus are drained via the esophageal veins, which carry deoxygenated blood from the esophagus to the azygos vein, which in turns drains directly into the SVC. These veins have no part in the development of esophageal varices -the lower 1/3 of the esophagus is drained into the superficial veins lining the esophageal mucosa, which drains into the left gastric vein, which in turns drains directly into the portal vein. Usually there are NO sxm's unless the veins bleed. Sxm's of bleeding esophageal varices include vomiting blood, tar-like or bloody stools, and in severe cases, shock Treatments include beta blockers, medical procedures to stop bleeding (EGD w/ banding, sclerosing, TIPS), and in rare cases, liver transplant

__________________ clinical presentation: progressive dysphagia (first solids, then liquids), weight loss, and anemia.

Esophageal carcinoma Dx: -endoscopy -endoscopic US (EUS) -> detects tumor invasion & allows for staging -CT/PET scan: detects regional/distant dz -> lung & liver mets m/c Treatment: multimodality but only surgery offers "cure" -radiation & chemo -palliative care w/ esophageal stent placement -> causes dilation of esophagus & allows pt to eat & drink -often need placement of PEG tube for nutrition Prognosis: 5 year survival rate -localized 40% -regional 21% -distant 4% Staging: TNM

An esophageal (ring/web) ____________ is an eccentric, smooth, thin extension of normal esophageal tissue consisting of mucosa & submucosa that is typically locatedin proximal esophagus.

Esophageal web -usually located in proximal esophagus -commonly seen in Plummer-Vinson Syndrome -rare disease characterized by dysphagia, iron deficiency anemia, glossitis, cheilosis, & esophageal webs

Treatment of SBO:

Etiology of SBO important -partial vs. complete (if air is getting through) -clinical assessment most important factor Operative vs. non-operative -non-operative: IV fluid & electrolyte repletion, gastric decompression (NG tube), monitor clinical status of pt -75% of pts with PSBO from adhesions (prior surgery) will resolve spontaneously, therefore, avoiding surgery -surgery to prevent SB from becoming ischemic or necrotic -> can be done laparoscopic

T or F: Fever is a manifestation of celiac disease.

FALSE Elevated transaminases, neuropsychiatric illness, autoimmune illness are all manifestations Classic celiac: diarrhea, weight loss Non-classic: chronic fatigue, elevated transaminases, peripheral neuropathy, reduced bone density, etc

T or F: ASA & Warfarin both need to be stopped prior to guaiac testing, FIT tests, and Cologuard tests.

FALSE Only needs to be stopped for guaiac tests FIT tests and Cologuard do NOT need to be stopped for this -do stop both in active bleeding

T or F: Stress is the cause of IBS.

FALSE Stress is an exacerbation, not the cause - along with food Viral gastroenteritis can be a cause of IBS - post-infectious IBS Food allergies: Consider sprue/celiac disease and lactose intolerance - foods play a role, but are not the specific cause necessarily

T or F: Does the intensity of pain help distinguish IBS from IBD?

False IBS & IBD can co-exist as well

_______________ common cause of lower GI tract obstruction lagging behind stricture for diverticulitis & colon cancer. It is the result of chronic or severe constipation & m/c found in elderly population.

Fecal impaction (FI) -defined as inability to evacuate large hard inspissated concreted stool or bezoar lodged in the lower GI tract -m/c found in rectum -FI is seen as acute complication or chronic & untreated constipation 3 of most important RFs are colonic hypomotility, inadequate dietary fiber, poor water intake -can also see in laxative abuse -Sxms: rectal seepage & fecal incontinence, constipation, abd and/or rectal pain, urinary incontinence, confusion, agitation, worsening psychosis, N/V Tx: disimpaction -soften stool from below (enemas) -soften stool from above (golytely) -combination therapy PLUS manual disimpaction

In evaluating chronic diarrhea, the first two steps are to check for ___________________.

Fecal incontinence & IBS

A common complication of the esophageal ring, Shatzki ring, is _____________.

Food impaction Esophageal rings -concentric, thin, smooth extension of normal esophageal tissue consisting of all 3 anatomic layers of mucosa, submucosa, and muscle -usually located in distal esophagus -M/c = Shatzki ring: common complication is food impaction! -GERD common etiology Esophageal web -eccentric, smooth, thin extension of normal esophageal tissue consisting of mucosa and submucosa -usually located in proximal esophagus -commonly seen in Plummer-Vinson Syndrome -rare disease characterized by dysphagia, iron deficiency anemia, glossitis, cheilosis, & esophageal webs

Intraluminal Obstructors:

GS Ileus -gallstones: can erode through GB wall into small bowel. Travels down SB, usually "gets stuck" in the terminal ileum (TI) Pt presents with SBO (all the s/s) Correct fluid & electrolyte abnormalities Surgery to relieve obstruction Probably leave GB alone until pt metabolically in better condition Foreign bodies & Bezoars: -bezoars: solid mass of undigestable materal that accumulates in SB & causes obstruction -fruit/veggie matter m/c type -can present as SBO, bleeding, perforation -Tx: chemical dissolution, endoscopic retrieval, or surgery -FB ingestion: common in children; adults: psych disorders

______________________ is most commonly located in the gastric antrum. There is an increased risk of cancer if not in pre-pyloric channel. It is not necessarily hyperacidity related.

Gastric ulcer -m/c between ages 55-70 Clinical presentation: -Classic Sxm's: burning, epigastric pain precipitated by food, weight loss -Common sxm's: epigastric abdominal pain, N/V, bloating, belching Treatment: PPI therapy x 3 months GU's in the prepyloric channel are considered Peptic Ulcers -all other gastric ulcers are NOT -not necessarily hyperacidity related -inc. risk of cancer if NOT in pre-pyloric channel Dx: made with EGD +/- biopsies Tx: pharmacological (PPIs) and tx H Pylori is present Consider re-endoscopy in 3 mo to assure complete resolution of ulcer If still present, must bx then & retreat if non-malignant

___________________ is delayed gastric emptying of in the absence of mechanical obstruction.

Gastroparesis Causes: idiopathic, diabetes is the systemic dz most often associated w/ gastroparesis, iatrogenic (med induced), post-op complication Diabetes: >5 yrs after diagnosis -associated w/ retinopathy, nephropathy, neuropathy, and poor glucose control -autonomic dysfxn or abnormal intrinsic nervous system fxn -more common in type I DM vs. type II DM The vagus nerve signals the muscles in stomach to contract and propel food into small intestine -> If damaged, the transit of food from stomach to duodenum is slowed and gastroparesis occurs Post-op gastroparesis: abdominal/thoracic surgery with injury to the Vagus nerve -resection of malignancy -bariatric surgery -fundoplication -whipple Meds associated w/ gastroparesis: narcotics, alpha-2-adrenergic agonists, TCAs, CCB's, dopamine agonists, muscarinic cholinergic receptor antagonists, ocreotide, GLP-1 agonists, phenothiazines, cyclosporine, immune checkpoint inhibitor therapy Sxm's: nausea, vomiting, abd pain, early satiety, postprandial fullness, bloating, weight loss -More early satiety, postprandial fullness, and abdominal pain w/ idiopathic -More severe retching & vomiting with diabetes Exam: epigastric distention, tenderness, no gaurding/rigidity, signs of an underlying disorder

_________________ is a protozoan parasite infection that spreads via waterborne, food-borne, fecal-oral transmission. It survives well in fresh, cold water (hikers).

Giardia Lamblia Ingestion of raw, undercooked meat/veggies Daycare centers Watery diarrhea, malaise, abdominal cramps, and weight loss Sxm's occur within 7-14 days; sxm's last 1-4 weeks Usually self-limiting Dx: -stool microscopy -stool antigen detection assays (DFAs, ELISAs) -stool PCR testing Treatment not needed for most asymptomatic individuals except: -individuals in group settings w/ risk for transmission to others -household contacts of immunocompromised individuals -household contacts of pregnant individuals -food handlers Tinidazole, nitazoxanide, metronidazole

____________________ of SB: benign disorganized tissue of SB which grows abnormallty.

Hamartomas of SB -usual sxm is recurrent SBO or bleeding -can be part of Peutz-Jeghers syndrome -autosomal dominant genetic disorder -hamartomas, mucosal melanin, deposits -inc risk: colon, breat, lung, SB, gastric cancers Benign disorganized tissue of SB which grows abnormally -usual symptom is recurrent SBO or bleeding -can be part of Jeutz-jeghers -automsominal dominant genetic disorder -Increased risk: colo, breat, lug, SB, cancer Tx: based on sxm's

_______________ and regurgitation are the m/c symptoms of GERD.

Heartburn and regurgitation less common sxm's: dysphagia, odynophagia, CP, belching, epigastric pain, nausea, bloating, hoarseness, laryngitis, asthma, globus Frequent cause of "non-cardiac" CP (est 30% of ER visits for CP) "Newly" Dx asthma or asthma like sxm's in an adult Dx: can trial PPIs, should see response within 3-4 days if HB is presenting sxm -ALARM sxm's: dysphagia, weight loss, anemia, no relief w/ PPIs -endoscopy: important! BUT it only notes sequelae of GERD (esophagitis, Barretts) -specificity is good but since only 30-40% of GERD pts have esophagitis, sensitivity is poor -barrium swallow: anatomical & fxnl but neither specific or sensitive -ambulatory 24 hr pH monitoring: extremely helpful but not essential ->24 hr transnasal pH catheter or wireless 96 hr capsule; measures lower esoph acid exposure -esoph acid exposure doesn't always correlate w/ sxms Manometry: very important. Helps cofirm LES pressures & rules out other dysmotility disorders -Impedence: also done w/ 24 hr transnasal catheter; measures directional flow in lower esophagus Tx: meds first line tx -antacids: tums, rolaids, etc -histamine-2 receptor antagonists (H2 blockers) -> inhibit secretion of gastric acid by competitively blocking H2 receptors on parietal cells in gastric antrium (randitidine, famotidine, cimetidine) -PPIs -> block proton H+ pumps to prevent release of gastric acid (omeprazole, lansoprazole, etc) -> associated w/ greatest sxm relief & highest rates of healing -lifestyle interventions: 2nd line tx (weight loss, head of bed elevation, avoidance of late evening meals, tobacco/ETOH cessation, cessation of acidic foods) -overall difficult to comply, mixed results

_______________________ is a spiral urease producing organism that thrives in gastric & duodenal environment (survives low pH).

Helicobacter Pylori Clinical presentation: abdominal pain, bleching, bloating, indigestion, N/V, weight loss Tests for detection of H pylori: Non-invasive: -Urea breath test -> simple rapid, false negative if PPI use within 7 days -Stool antigen -> Inexpensive, convenient Invasive: -Bx of gastric & duodenal mucosa -> most accurate Treatment: A MUST IN PUD -triple therapy x 14 days: options -lansoprazole + amoxicillin + clarithromycin (PREVPAC) -bismuth subsalicylate + metronidazole + tetracycline -ranitidine + tetracycline + clarithromycin -omeprazole + metronidazole + clarithromycin

______________________ is caused by enterohemorrhagic E. coli and is characterized by hemolytic anemia, thrombocytopenia, and acute kidney injury.

Hemolytic Uremic Syndrome (HUS) aka. E coli 0157:H7, shiga toxin (STEC), enterohemorrhagic E. Coli (EHEC) Ingestion of undercooked meat, produce, uncooked/unpasteurized products Onset of sxm's 3-4 days after exposure -abdominal pain, bloody diarrhea, +/- fever Diagnosed via stool sample, rectal swab -selective culture, shig-toxin EIA, molecular testing (NAAT) Supportive care Abx may increase HUS and have not been shown to be of benefit -> AVOID

________________ are a cluster of veins that lie just beneath the mucosa of the anal canal. It results from increased intraabdominal pressure.

Hemorrhoids -"varicose veins" of the anal canal -tends to be left lateral, right anterior, right posterior distribution -internal -external -"combined" complex Inferior rectal arteries/veins (internal iliac -> internal pudendal) Risks for developing hemorrhoids: -obesity -older age -sitting for long periods of tie -diarrhea -pregnancy -prolonged straining -constipation/diarrhea -genetics? Affect nearly 50% of population, M>F Internal hemorrhoids: -ABOVE (proximal) dentate line -no pain receptors: painless bleeding -severe form: prolapsed -> so distended they push outside the anus; strangulated -> blood supply cut off by anus -dilated veins ABOVE dentate line -usually "painless" BRB -"Grades" 1-4 -conservative (non-op) tx often effective -TREAT THE CUASE -can perform local destruction (rubber band ligation, infrared, cryotherapy) External hemorrhoids: -below (distal) dentate line -painful -can be thrombosed -blood clot in veins below the dentate line -gradual swelling, achy pain to severe pain (thrombosis) -can see blood when overlying skin excoriates -body will begin to absorb clot in 48-72 hrs so can be self-limiting -if not, or too painful, may require excision -reabsorbed ext. hem will often leave residual skin known as anal tag

_____________ may or may not contribute to GERD. For those pt's choosing surgical repair & who have an associated _______________, repair of the ________________ is an integral part of the surgery (along w/ restoring the LES).

Hiatal hernia

Perforated diverticular disease is staged using the ____________________.

Hinchey Classification System Perforation: -can be localized or diffuse Developed to predict outcomes following surgical mgmt of complicated diverticular dz Fistula formation: -common locations: bladder, vaginal or skin -present w/ either passage of stool through the skin or vagina or the presence of air in urinary stream (pneumaturia) -colovaginal fistulas are m/c in women who have undergone hysterectomy

__________________ is similar to achalasia (dysphagia, chest pain, manometry findings of elevated LES pressures), but LES pressures do relax somewhat (not seen in achalasia).

Hypersensitive LES Unclear etiology Sxm's w/ abnormal manometry findings make the Dx Tx: endoscopic dilation offer good long term relief Surgery for refractive cases; myotomy +/- partial fundoplication

(IBS/IBD) ____________ is a functional disorder of the GI tract which means that it impairs normal functioning, but no anatomical abnormalities are detected.

IBS Bowel movements are diarrhea, constipation, and majority are mixed Note that the diagnosis of IBS is made clinically and with a few, select tests

______________ is the most common site for Crohn's disease.

Ileum (80%)

What are the indications for MRCP?

Indications: detect biliary & pancreatic duct stones, strictures, or dilations within biliary system. MRCP is less operator dependent, cheaper, non-invasive, uses no radiation, requires no anesthesia ERCP is an endoscope + xray and creates images of the ducts, whereas MRCP is an MRI technique

_____________________: most often associated with GERD. Though to result from esoph injury due to increased exposure to gastric contents. Causes damped contractility of lower esoph which leads to poor clearing of lower esoph.

Ineffective Esoph Motility Once altered motility occurs, irreversible Dx: reflux/HB, dysphagia, CP Dx: sxm's w/ manometry findings Tx: prevention/Treat GERD Other motor disorders: nonspecific esoph disorders include "everything else"

__________________ is colonic infection by bacteria, viruses, or parasites results in an inflammatory-type of diarrhea.

Infectious Colitis -pts present w/ purulent, bloody, and mucoid loose bowel mvmts, fever, tenesmus, & abdominal pain Common bacteria causing bacterial colitis include: campy jejuni, salmonella, shigella, E. coli, yersinia enterocolitica, clostridium difficile, and mycobacterium TB Common causes of viral colitis: -norovirus, rotavirus, adenovirus, and CMV Parasitic infestation: entamoeba histolytica, protozoan parasite is capable of invading colonic mucosa and causing colitis Work-up: -50% of cases of acute diarrhea are bacterial in origin (contaminated food) -detailed med hx & ID of exposure risks helpful -previous exposure to Abx very important info (C. diff) -stool cultures for bacteria and parasites very helpful as initial testing -routine blood work including sed rate -CT scans also helpful to exclude other entities DDx: Inflammatory causes: UC and Crohn's Infectious: bacterial, viral, parasitic Other: ischemia, drugs, radiotherapy

___________________: SB enteritis is inflammation of the lining of the small bowel. It is most often caused by ingestion of contaminated food: bacterial, viral, or protozoal pathogens.

Infectious enteritis -diarrhea, cramps, nausea, vomiting Careful hx can help if DDx: CT sometimes helps & often rules-out other etiologies of pt's sxm's Tx: usually to address sxm's -> fluid, electrolyte replacement, antiemetics -pathogen specific tx can be used if known (usually by stool sample eval)

C Diff Colitis:

Inflammation of colon associated w/ overgrowth of bacterium C diff Overgrowth of C diff often related to recent hospital stay that included Abx tx C. diff infections are m/c in people over 65 yo S&S: -watery malodorous diarrhea -abdominal cramps, pain, tenderness -fever, leukocytosis -pus/mucus in stool -nausea -dehydration Sxm's can begin as soon as 1-2 days after starting Abx, or as long as several months or longer after finising Abx M/c Abx to cause C diff: Fluoroquinolones, such as Cipro and levofloxacin, PCNs such as amoxicillin & ampicillin, clindamycin, cephalosporins (cefixime), but ANY abx can cause -can occur w/o Abx exposure, just not as common C diff spores are resistant to many common disinfectans & can be transmitted from hands of health care professionals to pt's -contact precautions -soap & water hand-washing extremely effective in preventing spread Stool sample for C. diff toxin -CBC & chemistries -colonoscopy & sigmoidoscopy -> signs of pseudomembranous colitis -> raised, yellow plaques, edema -imaging tests: abdominal x-ray or an abdominal CT scan to look for complications such as toxic megacolon/colon rupture Tx: -d/c other Abx if possible -hydrate, correct electrolytes prn -PO/IV/PR vancomycin: 1st line tx; metronidazole PO/IV 2nd line -fecal microbial transplantation (FMT) For refractory or sepsis: surgery (total or subtotal colectomy, or newer surgery; diverting loop ileostomy & colonic lavage is less invasive & has had positive results) C diff complications: -dehydration & electrolyte disturbances -kidney failure -toxic megacolon -sepsis -death

___________________ diarrhea is caused by exudation of proteins, mucous, and inflammatory cells in the setting of active inflammation & ulceration.

Inflammatory -pain, fever -fecal leukocytes -typically caused by infections & IBD -exclude colorectal tumor -> chronic inflammatory-type diarrhea in middle aged/elderly, especially +blood

__________________ diarrhea is more commonly due to bacteria

Inflammatory -fever, bloody or mucoid stool, abdominal pain Campylobacter m/c (20%) Salmonella - 17.1% Shiga toxin-producing E. coli - 6.3% Shigella - 4.8%

Internal/External Complex:

Internal tissue crosses DL and joints w/ ext tissue Difficult to manage conservatively May require formal surgical hemorrhoidectomy Surgical hemorrhoidectomy: -must remove internal & external complex -requires surgical suite -sutures edges together -very painful initial recovery due to somatic nerves involved in anoderm

______________________ is a "telescoping" of the small bowel into itself. It is a potential life threatening condition, especially in children.

Intussesception -> m/c abodminal emergency in early childhood 60% occur between ages 6 mo and 1 year (not in newborns) -80% of cases occur before age 2; m/c abdominal emergency in early childhood -Adults have "leading-edge" -> polp, tumor, adhesion M:F 4:1 Sxm's: crampy, colicky pain = crying -may see vomiting -current jelly stools Tx: -children: contrast enemas highly effective in reducing the telescoping -adults: bc of high incidence of anatomical cuase, mugh higher need for surgery -Because of high incidence of anatomical cuase, much higher than need for surgery -with either population: failed non-surg mgmt or clinical evidence of peritonitis

The (jejunem/ileum) _____________ is somewhat larger circumference & thicker.

Jejunem Mesentery of jejunem: 1 or 2 arcades (blood supply) send out straight vasa recta to the mesenteric border Blood supply of ileum may have 4 or 5 separate arcades w/ shorter vasa recta SB fxn: multiple -remarkable efficient at "digestion" and absorption -pancreatic enzymes, brush border enzymes, bile all act to break down food particles -absorption of CHO, proteins, fats, vitamins, ions, and water (eg. iron absorbed in duodenum; vit B12, bile sa,ts in TI, water & lipids thru-out) -GI tract hormones: gastrin, somatostatin, secretin, CCK, motilin -Immune fxn: develop lymphoid tissue rich in T/B cell lymphocytes (Peyer patches), IgA etc

_____________________ is the "gold standard" surgical therapy for GERD.

Laparascopic Nissen Fundoplication -LES wrapped in sleeve of stomach, increasing LES pressure & prevents reflux; good long-term results by dysphagia post-op is "wrap" too tight Endoscopic procedure: -thermocoagulation: application of radiofrequency energy to LES; regenerates & has some "correct" fxn Sphincter Augmentation (magnetic band to restore LES) -still surgery, more recent procedure Radiofrequency Ablation: defined burn of mucosa of lower esophagus -"procedure" as opposed to "surgery" -also newer technique: burned lining regenerates w/ some sphincter fxn return -not effective with HH or later stage reflux

(Short/Long) ____________ reflexes: sensory neuron sends information to CNS.

Long -defecation reflex, etc

Benign Neoplasms: GIST -> Gastro Intestinal Stromal Tumors

M/c sxm-producing benign tumors of SB -may be asymptomatic as lesion can be present for many years & slowly growing -sxm's vague & non-specific: dyspepsia, malaise, early satiety, dull abd pain (usually from displacement) -can cause bleeding in GI tract Tx: almost always surgical GIST: -usually >90% express CD117, the c-kit protein proto-oncogene: transmembrane receptor for tumor growth factor -70-80% will express CD34, human progenitor cell antigen -tumors tend to growth from outside SB rather than intraluminal -resection (surgery) first line tx -possible adjuvant imatinib if kit (+): tyrosine kinase inhibitor which blocks tumor growth receptors

___________________ is a superficial mucosal tear at gastro-esophageal junction. It most commonly occurs during vomiting/retching.

Mallory-Weiss Tear Causes 5% of upper GI bleeds 90% stop bleeding without any therapy -vasopressin, endoscopic injection, electocautery if needed

________________ is extremely important in workup of functional, motor disorders.

Manometry Range from hypomotile to hypermotile dysfxn 5 major primary types: achalasia, diffuse esoph spasm (DES), nutcracker esophagus, hypersensitive LES, ineffective esoph motility Secondary motor disorders are result of non-esophageal neuromuscular disorders

The 3 phases of swallowing can be measured via ___________________.

Manometry 3 phases: oral, pharyngeal, esophageal Rapid series of events, lasts ~1/5 seconds Once initiated, completely reflexive Oral phase: initiated by tongue, saliva excreted, bolus pushed to pharynx Pharyngeal phase: elevation of soft palate, hyoid bone, larynx, tilting of epiglottis Esophageal phase: UES, peristalsis, LES. Contractility is organized. Motility disorders: coordinated peristalsis lost to varying degrees causing poor swallowing & a variety of disorders & sxm's -"the same but different": can have overlapping sxm's and presentations making difficult to diagnose -often require ancillary testing: EGD, barium swallow, manometry

Rectal Polpys:

May be asymptomatic, can bleed, and/or secrete mucous Dx & tx like colon polyps, colonoscopy Think cancer! -bleeding when they wipe or on underwear that is painless -anal cancer is NOT the same as rectal cancer = reason for exam & referral for BRBPR Rectal polyp removal: most often can be removed endoscopically -if large, may require transanal removal

__________________ is th emost common etiology SB anomoly.

Meckerl's Dirverticulum Symptomatic Meckle's requires surgical resection, can resect diverticulum or segment of SB

_________________________is diagnosed in children with a low GI bleed; consider Meckel's scan.

Meckle's Diveritculum -accurate in children becaue high likihilood of fastric mucosa present to nase in adults oso lession Dx: children with GI bleed -99mTC-pertechnetate scan: picked up by mucous secreting cells of gastric tissue -accurate in children bc high likelihood of gastric mucosa present -not case in adults, so less accurate

Diverticular Disease: Terminology

Mere presence of colonic diverticula = diverticulosis -diverticula that "infect" = diverticulitis -diverticula that "bleed" = diverticular bleed -most colonic diverticula are "false" diverticula; lack serosa Epidemiology: -US: diverticulosis affect 70% of the population above the age of 80 -80% of the time affects sigmoid colon -only 20% develop symptomatic disease -1-2% require hospitalization, and <1% will require surgery -diverticular dz 5th most costly GI disorder in US -M=F, but males present at younger age -59 mean age at presentation, shifting younger A&P: -diverticula occur where nutrient artery, or vasa recti, penetrate through muscularis propria, resulting in a break in the integrity of the colonic wall and "potential weak spot" -processed, low fiber content foods in Western diets causes high pressures within lumen of colon, which over time, cause herniation of mucosa & submucosa through serosa -evidence now suggests pathogenesis more complex & multifactorial: chronic low-grade inflammation, gut microbiota suggests dysbiosis is important aspect of disease

_______________ diverticulum usually results from inflamed mid esoph lymph nodes. Traction causes "true" diverticulum.

Midesophageal diverticulum May have some association with dysmotility disorders Many are asymptomatic & found incidentally in workup Barium swallow; manometry needed if found Can have sxm's similar to Zenker's Tx: size dependent (>2cm) Pexy can be performed

When there is an issue with ______________, function is altered resulting in distension, vomiting, diarrhea or constipation.

Motility Each part of GI tract has a unique fxn to perform in digestion with a distinct type of motility Peptide hormones facilitate motility: gastrin, motilin, CCK, secretin, and Glucagon-Like Peptide I Gastrin: -produced in gastric antrum and duodenum -stimulates acid secretion and motility Motilin: -hormone secreted by endocrine cells in the small intestine -stimulates migrating motor complex to inc. peristalsis -recurring motility pattern during fasting -> clears stomach/small intestine to make room for next meal Cholecystokinin (CCK): -hormone secreted by endocrine cells of small intestine and by neurons in brain and gut -stimulates gallbladder contraction for bile release -inhibits gastric emptying -promotes intestinal motility Secretin: -hormone secreted by endocrine cells of small intestine -inhibits gastric emptying GLP-1: -hormone secreted by endocrine cells in small intestine -controls post-prandial glucose levels -promotes insulin secretion -inhibits glycogen synthesis -delays gastric emptying

______________ is an unpleasant feeling of sickness or discomfort in epigastrium that may come with an urge to vomit.

Nausea -subjective Vomiting/emesis: expulsion of gastric contents through mouth -objective Retching: labored movement of abdominal & thoracic muscles just prior to emesis Vomiting physiologic benefit: expel toxins Triggers of vomiting: -noxious stimuli in gut (ie. infected food) -higher brain centers induce without noxious stimuli in gut (sight/smell, motion sickness) -chemicals in circulation -> act on chemoreceptor trigger zone in 4th ventricle (opioids, chemo agents, hormones in pregnancy)

__________________ is similar to DES. It causes chest pain, dysphagia, but also odynophagia; rarely regurgitation/reflux. The barium swallow MAY NOT be abnormal.

Nutcracker esophagus Dx: subjective c/o chest pain w/ objective manometry abnormalities Peristaltic contractions 2 standard deviations above normal with high amplitudes and normal LES pressures Tx: medication & avoidance of caffeine, very hot/cold foods

What are the indications for an ERCP?

Obstructive jaundice, biliary or pancreatic ductal system disease, pancreatic cancer, pancreatitis, (find & treat problems in the pancreatic and bile ducts) ERCP is used for both diagnosis and treatment whereas MRCP is not a therapeutic procedure & less invasive

A positive ______________ sign, pain on passive flexion and internal rotation of either hip, is indicative of acute appendicitis.

Obturator The McBurney sign, severe abdominal pain with deep tenderness in the right lower quadrant, is suggestive of acute appendicitis. -The McBurney point is an anatomical landmark located one-third of the distance from the right anterior superior iliac spine to the umbilicus. Acute appendicitis classically presents with N/V, fever, and diffuse periumbilical pain migrating to the McBurney point. A positive Rovsing sign is indicative of acute appendicitis, and occurs when a patient experiences severe lower right quadrant abdominal pain upon palpation of the lower left quadrant of the abdomen. In adults, appendicitis is caused by fecalith obstruction of the appendix. In children, appendictis is caused by lymphoid hyperplasia obstructing the appendix. The curative treatment of appendicitis is appendectomy. A ruptured appendix results in peritonitis that presents with guarding and rebound tenderness. In addition to clinical signs, the CT scan imaging study or ultrasound can help make the diagnosis of appendicitis.

Malignant neopasms of SB:

Order of frequency: -adenocarcinoma -carcinoid -malignant GISTs -lymphoma

(Secretory/Osmotic) ___________ diarrhea is ingestion or malabsorption of an osmotically active substance.

Osmotic -carbohydrate malabsorption -lactase deficiency -congenital defects in brush border disaccharides -excessive ingestion of poorly absorbed carbs -> sorbitol, fructose -magnesium ingestion -> food supp's, antacids, laxatimes

In a patient with GERD that has regurgitation sxm's, what medication will likely have NO effect?

PPI's -> block proton H+ pumps to prevent release of gastric acid (omeprazole, lansoprazole, etc) Recognized problems w/ PPI's: -mineral & vitamin deficiences (Fe, Ca, Mg, vit B12) -osteoporosis (?inc. risk of bone fx); add daily Ca2+ supplement -PNA -enteric infections (salmonella, campy, C. diff) -won't stop reflux, just neutralizes acid so less chance of damage to lower esophagus: if pt has regurgitation sxm's, PPI's will likely have no effect

_________________ are associated w/ the greatest sxm relief and highest rates of healing in GERD patients.

PPI's -> block proton H+ pumps to prevent release of gastric acid (omeprazole, lansoprazole, etc) Recognized problems w/ PPI's: -mineral & vitamin deficiences (Fe, Ca, Mg, vit B12) -osteoporosis (?inc. risk of bone fx); add daily Ca2+ supplement -PNA -enteric infections (salmonella, campy, C. diff) -won't stop reflux, just neutralizes acid so less chance of damage to lower esophagus: if pt has regurgitation sxm's, PPI's will likely have no effect

________________________: Erosion of mucosa, usually in the stomach or duodenum, when an inciting factor overwhelms the defense mechanism of normal mucosa (gastric mucous & bicarb) causing formation of an ulcer.

Peptic Ulcer Disease -Considered "hyperacidity" -> issue ulcers Causes: -H pylori -NSAIDs, ASA, steroids -Hypersecretory states (Zollinger-Ellison Syndrome) These ulcers can occur in 2 locations: duodenum and pre-pyloric channel of stomach Can occur separately or together Can have duodenal and/or gastric ulcers -duodenal ulcers 5x m/c than gastric ulcer; m/c location -m/c between ages 30-55 NO increased risk of cancer: usually acid related (hyperacidity) Clinical presentation: classic sxm's -burning, epigastric pain 90 min to 3 hrs after meals, often occurs in the middle of the night, relieved by food and/or antacids -common sxm's much more vague -> epigastric abdominal pain, N/V, bloating, belching Tx: Acid reduction (eg. PPI therapy x 3 mo) Complications: UPPER GI BLEEDING -> melena & hematemesis, anemia, possible hemodynamic instability -always refer to GI for urgent endoscopy -Tx: endoscopic therapy -> epi injection, argon coagulation, heater probe, clips -if in hospital setting, always start pt on IVF and IV PPI Bleeding: usually posteriorly penetrating DU into gastroduodenal artery -Tx: endoscopy w/ "clipping", injections, coagulation -surgery if bleeding uncontrolled Perforation: have have posterior penetration into organs -presentation: sudden, severe abdominal pain, will quickly become unstable -duodenal ulcers can penetrate into pancreas & cause associated pancreatitis -gastric ulcers can penetrate into liver lobe (less common) Anterior perforation: can be DU or GU -Sxm's: sudden, severe abd pain, +/- N/V -likely will have pre-existing issues with HB -pt will have peritoneal signs on exam (guarding and rigidity) -will see free air on x-ray Tx: surgery often indicated especially in elderly Gastric outlet obstruction: not as common, results from chronic ulcers & duodenal scarring -scarring over time narrows lumen -Sxm's: abdominal distension, nausea/vomiting -emesis is usually non-bilious and contains partial/undigested food -often note weight loss, dehydration -Tx: since this is result of benign dz, definitive surgery recommended -resect or bypass + treat for hyperacidity -if non-operative candidate, can palliate w/ stent of jejunostomy tube placement

Perianal abscess:

Perianal, supralevator (high fever), intersphincteric (IM or submucosal), or isciorectal Ischioanal & perianal can be drained in ER Classification: perianal, submucosal, ischiorectal, pelvirectal (supralevator), and fissure abscess Tx: I&D

A ___________________ diverticulum is found in the upper esophagus, caused by pulsion, and is a false diverticulum.

Pharyngoesophageal (Zenker's) -m/c esoph diverticulum found today -usually elderly (7th decade) -thought to be age related due to loss of tissue elasticity and muscle tone -Killian's triangle: herniates through oblique fibers of the thyropharyngeal muscle & horizontal fibers of the cricopharyngeus muscle -False; pulsion: out the "backside" of the muscle Sxm's range from none to serious lung infections Increasing size: halitosis, regurgitation of foul smelling, undigested material, nagging cough, retrosternal pain, resp. infections Dx: barium swallow (lateral views) Tx: endoscopic vs. open surgical Depends on pt factors & size of diverticulum

What is considered a positive hydrogen breath test for lactose intolerance?

Positive hydrogen breath test + symptoms = positive Some pt's will NOT have hydrogen on the breath test but will have sxm's = positive test Another way of diagnosing is an empiric trial of lactose free diet

_____________ is the most common type of ulcerative colitis.

Proctitis (20-50%) L sided colitis and extensive colitis also possible

Dentate Line:

Proximal (above) dentate line innervated by autonomic nerves, essentially insensate to touch Distal (below), nerves are somatic: very sensitive to touch, irritation, direct stimulation Pathology below: sharp, severe, intense pain often Pathoogy above: usually NOT sharp or agonizing type pain, more dull achy throbbing pain

A ______________ of the pancreas typically develops 4 weeks after acute pancreatitis, resolves over time, and does NOT have a cell wall.

Pseudocyst Cyst: detected in over 2% of pt's due to imaging, may be benign or malignant, and have a true cell wall Not all are benign -> majority of pt's w/ cysts under surveillance program rather than surgery Concerning features: CA19-9 elevated, pancreatic duct enlargement, over 3cm

______________________ is the m/c cause of intestinal obstruction in infancy.

Pyloric Stenosis -due to hypertrophy & hyperplasia of the muscular layers of the pylorus, causing a fxnl gastric outlet obstruction M/c in whites, male:female predominance of 4:1 -30% being first-born males Clinical presentation: -usually detected within first 3-12 weeks of life -infant will have non-bilious vomiting, often projectile Physical exam: firm, nontender, mobile, hard pylorus described as an "olive" in the RUQ -best palpated AFTER child has vomited -may see peristaltic waves on abd inspection Tx: fluid support, electrolyte replacement -Ramstedt pyloromyotomy: surgery -procedure of choice ^

The stomach empties contents into small intestine at a controlled rate via ______________.

Pyloric sphincter

Diarrhea RF's and Workup

RF's: -recent travel, exposure to children in daycare, hx of immunosuppression -> think of infectious cause Initial w/u: -CBC, electrolytes, BUN, Cr -eval stool for ova & parasites, culture, C. diff, fecal leukocytes -+fecal leukocytes -> salmonella, shigella, & campy If blood is present, and not infectious, refer to GI -flexible sigmoidoscopy/colonoscopy -DDx: IBD, ischemic colitis, malignancy

Evaluating IBS is based on ____________ criteria and clinical judgement.

ROME criteria Not exhaustive testing

_______________ is when the rectum protrudes out through the anus -> "telescopes".

Rectal prolapse - procidentia -usually caused by weakening of pelvic floor musculature -age, female, chronic constipation, diarrhea are RF's -bleeding & protrusion mucosa are m/c sxm's -can be confused w/ prolapsing hemorrhoids Tx: -transabdominal (usually resect colon & "pull-up") -locally excise (perineal approach) -depends on pt factors (age, comorbid conditions, etiology)

Anal canal cancer:

Rectal vs. Anal is based on cell type, and therefore, location Anal canal cancer (squamous cell) -1% of GI tract cancers -strong association with HPV (16, 18) -detected in >80% of specimens -higher incidence in immunocompromised (HIV, transplant) -presenting sxm's are sensation of a mass, bleeding -small localized lesions (<2cms) can be locally excised -standard tx is concurrent chemoradiation -"Nigro": Radiation + 5-FU + mitomycin Rectal cancer (adenocarcinoma) -clearly originates above dentate line -RF's are like colon cancer (h/o polyps, fam hx, IBD, etc) -ability to preserve the sphincters determines whether "permanent" colostomy needed -surgery alone or multimodality tx: pre-op chemoRads followed by surgery -staging based on TNM

Anatomy of LB: blood supply & fxn

Right side up to mid-transverse colon: superior mesenteric artery (SMA) Left side up to prox rectum: inferior mesenteric artery (IMA) Mid & distal rectum: rectal arteries Vessels contained within peritoneal folds known as mesentery Fxn: 1. water reabsorption; 80-90% of water absorbed out of stool in colon 2. electrolyte reabsorption 3. transport & storage of stool 4. fermentation & breakdown of material by bacteria

________________ bacteria is found in poultry, eggs, and milk.

Salmonella Usually presents 8-72 hours post exposure Diarrhea, n/v, and fever; diarrhea is not grossly bloody typically Diagnosed via routine stool cultures Mild or even asymptomatic in majority of cases, self limited -fever resolves within 2-3 days; diarrhea within 4-10 days Supportive mgmt: hydration Antibiotics: fluoroquinolones, bactrim, azithromycin -severe disease -severe diarrhea (more than 9-10 stools per day) -high or persistent fever -a need for hospitalization -High risk patients: immunocompromised, age > 50, <12 mo

(Secretory/Osmotic) ___________ diarrhea is derangement in fluid/electrolyte movement across mucosa. There is large-volume, watery, painless diarrhea.

Secretory Causes: Medications: Abx, NSAIDs, chemotherapeutic agents, laxatives Hormones: serotonin, gastrin, thyroid hormone -carcinoid syndromes, gastrinoma, hyperthyroidism Infectious agents: vibrio cholera, E. coli Bile salts malabsorption s/p resection of terminal ileum, ileitis -bile acids not absorbed in ileum, excessive amount to colon stimulates water secretion -> diarrhea

_________________ causes dysenteric diarrhea. It causes mucoid, bloody diarrhea within 1-7 days of exposure (avg. 3 days).

Shigella -diagnosed on stool culture -spreads person to person, from fecally contaminated food & water Antibiotics found to shorten duration of fever and viral shedding -not indicated if self limited -fluoroquinolones, 3rd gen cephalosporins, and azithromycin Reserve for: -severe sxm's -immunocompromised -severe disease (bactermia, intestinal or extraintestinal complications, need for hospitalization) -individuals that have potential to spread disease -> food handlers, childcare providers, residents of nursing homes

(Short/Long) ___________ reflexes: signals from gut to pre-vertebral sympathetic ganglia back to gut.

Short

________________ is resection of portion of the small intestine leaving insufficient small bowel absorptive surface area.

Short bowel syndrome Develop malabsorption, malnutrition, diarrhea, & electrolyte abnormalities Clinical presentation: -weight loss, fatigue, malaise, diarrhea/steatorrhea -vitamin deficiencies (A, D, E, K, B12, folic acid, iron, calcium, and magnesium) Hx of bowel resection

Volvulus - Treatment

Sigmoid volvulus: -sigmoidoscopy w/ decompression will often "untwist" colon -if mucosa of the sigmoid looks normal & pink, a rectal tube for decompression may be placed -fluid, electrolyte, cardiac, kidney or pulmonary abnormalities should be corrected -surgery if signs or peritonitis & sepsis are noted Cecal volvulus: -usually requires surgery -right hemicolectomy (w/o colostomy) -untwisting & tacking cecum in place carries very high risk of recurrence

(Small bowel/large bowel) ______________ diarrhea is typically watery, of large volume, and associated w/ abdominal cramping, bloating, and gas.

Small bowel -fever is rarely a significant sxm and occult blood or inflammatory cells in the stool are rarely identified Large bowel: -frequent, regular, small volume, and often painful bowel movements -fever and bloody or mucoid stools are common -RBC/WBC on stool microscopy

____________ is an independent risk factor for the development of acute and chronic pancreatitis.

Smoking -note smoking and ETOH work synergistically There is NO way to make a prediction if a person will develop pancreatic cancer Patients with acute pancreatitis have elevated amylase and lipase, but chronic pancreatitis does not have elevations

What are risk factors for pancreatic cancer?

Smoking, obesity, eating diet high in red meat, male gender, african american, over 65 years old, diabetes, chronic pancreatitis, liver cirrhosis, family hx Sxms: vague! -> nausea, vomiting, fatigue, weight loss, malabsorption, midepigastric pain raidiating to mid lower back that is worse when laying flat, gallbladder enlarged and nontender -Trousseau sign -> small blood clots felt under the skin -Location of tumor can cause jaundice, pruritus, yellow skin if obstructing Labs: inc amylase/lipase, Ca19-9, CEA, elevated bilirubin, transaminases, and alk phos Perform imaging and biopsy to confirm dx Tx: Whipple procedure, chemo as neoadjuvant or adjuvant, ERCP & stenting -only 15-20% of pancreatic ca is resectable, poor prognosis

"Z" - Line: Mucosa

Squamous cell from esophagus to columnar epithelium of stomach

_______________ diarrhea is caused by fat malabsorption.

Steatorrheal Pancreatic insufficiency & short bowel syndrome Increased fecal output is caused by the osmotic effects of fatty acids Typically causes chronic diarrhea, weight loss, steatorrhea

Clinical manifestations of SBO (from any cause):

Sxm's: -bloating, intermittent cramping, nausea, vomiting, inability to pass flatus or stool -depends on level of obstruction and partial vs. complete Exam: -abdominal distention, tympany, tenderness, +/- rebound tenderness -borborygmi or absent bowel sounds -vital sign abnormalities reflect dehydration, sepsis, electrolyte derangements -look for scars in abdominal wall or "masses" Hx & PE often makes Dx of SBO -plain x-rays accuracy approx. 60% -requires 3 films: KUB, upright abd, CXR -look for SB distention, air/fluid levels, free air -labs not helpful for dx but aid in assessing pt's condition CT scan becoming the likely test to be done in ED's -can see distended bowel, transition zone, hernia, other pathology

Treatments generally associated with anorectal complaints:

TP: -sitz baths, creams, aldara Pharm: -oral Abx if indicated, botox Biomechanical: -sphincter exercises Non-surgical: -relaxation/meditation, ?herbals Surgical: -I&D, excisions, laser tx, hemicolectomy Physical exam findings: -sphincter tone -hemorrhoids -fissures -skin lesions -polyps -abscess -fistula -prolapsed rectum DRE: -inspection -palpation -pain -sphincter tone -contour of prostate in male -presence of stool (blood) -consistency in recording findings Anal pain word associations: -acute pain (throbbing, constant) w/ palpable mass = external hemorrhoids (thrombosed) -bright red blood, painless w/ BM = internal hemorrhoids ? -pooping shards of glass, sharp, tearing pain = fissure -gradual onset of pain, now excruciating = abscess

T or F: Early MALT lymphomas caused by H. Pylori can be reversed with Abx.

True

Functional Colonic Issues:

Two main sxm's of colonic dysmotility: 1. altered bowel habits (Diarrhea/constipation) 2. Intermittent cramping Additional sxm's: straining, urgency, sense of incomplete evacuation -no real identifiable anatomic abnormalities

_____________________: typically caused by the pathogen Salmonella typhosa.

Typhoid Enteritis -typhoid fever still world wide problem in underdeveloped areas -usually contaminated water supply: oral ingestion absorbed through small bowel Sx: fever, abd pain, diarrhea Dx: blood/stool cultures, high titers of agglutinins against O&H antigens Tx: Abx

Smoking can be protective in (Crohn's/Ulcerative colitis) ____________.

Ulcerative colitis Smoking can exacerbate Crohn's disease

Diverticulitis - Presentation:

Uncomplicated (75%): -abdominal pain, commonly LLQ -fever -anorexia/obstipation Complicated (25%): -abscess -> abd distension/localized peritonitis (16%) -perforation -> peritoneal signs (10%) -stricture -> possible obstruction (5%) -fistula -> air/feces in bladder or vagina (2%) Diverticular bleeding - Presentation: -occult to overt -m/c cause of hematochezia in pt's >60 years -however, <20% of pt's with diverticulosis will have GI bleed -pt's at inc. risk for bleeding: hypertensive, atherosclerotic, and regularly use ASA & NSAIDs -most bleeds self-limited and stop spontaneously w/ bowel rest -lifetime risk of re-bleeding is 25% Eval & Tx: bleeding -life treatening lower GI bleed require aggressive resuscitation & transfusions as needed -localizing site of bleed if possible: colonoscopy, bleeding scans -fortunately most tend to spontaneously stop -less "aggressive" bleeding may require colonoscopy Eval: -H&P, bowel habit changes, fever -prev. diverticulitis hx, prev. colonoscopy hx -LLQ tenderness (sometimes suprapubic) +/- localized rebound tenderness -CBC: leukocytosis, possible anemia -consider CT scan -DDx: GYN (ovarian cyst, endometriosis, PID); acute appendicitis, cystitis

Esophageal varices are diagnosed via ______________.

Upper endoscopy Tx: stabilize pt, ABC's! -endoscopic intervention -1st line therapy -> endoscopic variceal ligation (EVL) is used to control bleeding in >90% of cases -vasoconstricting meds (somatostatin or ocreotide) Preventative therapy: -non-selective BB's -propranolol or nadolol -act as portal venous antihypertensives Sengstaken-Blakemore tube, Transjugular intrahepatic portosystematic shunt (TIPS)

In a patient with suspected Celiac Disease, you should perform a tTG and IGA and then confirm results by doing _______________.

Upper endoscopy with biopsy

Vomiting pathways, receptors, and mechanism:

Vagal afferent pathway: -abdominal vagal afferent pathways triggered by either mechanical or chemosensory sensations -overdistension, food poisoning, mucosal irritation, cytotoxic drugs, and radiation -5-HT3 receptors Area postrema (CTZ): -important site for M1, D2, 5-HT3, and NK1 receptors Vestibular system: -emetic response to motion especially when vestribular input is in conflict with visual input -irritation/inflammation or labyrinthine -H1 receptors CNS (cortex & limbic system) response to emotional/cognitive stimuli: -stress, anxiety -noxious smells, disturbing sights Duodenum, stomach produce retrograde peristalsis as body of stomach & esophagus reflux -> strong contraction of abdominal muscles force diaphragm high into thoracic cavity -> higher intrathoracic pressure forces upper esophageal sphincter open -> chyme expelled from mouth -> stomach relaxes & upper esophagus relaxes to force chyme back into stomach ***process repeats if volume of chyme remaining in stomach

(Bacteria/Viruses) _______________ are the most common cause of acute diarrhea in the US.

Viruses -<5% stool cultures performed are positive -bacteria more commonly found in cases of severe diarrhea -parasites are an uncommon cause in <1% of cases Noroviruses in adults -accounts for 1/3 of gastroenteritis outbreaks in US -watery diarrhea within 24-48 of exposure, resolving in 48-72 hours -RT-PCR if testing needs for public health reasons Rotovirus, enteric adenoviruses, astrovirus, and sapovirus predominantly cause infection in children

What is the classic triad of Boerhaave's Syndrome?

Vomiting, Abd pain/chest pain, SubQ emphysema Full thickness esophageal perforation. Results from sudden increase intraesoph pressure combined w/ negative intrathoracic pressure. Violent retching, coughing, vomiting Classic triad: vomiting, abd or chest pain, SubQ emphysema; but not present in 1/3 of pts Dx: CXR, CT, gastrograffin swallow (don't use barium in perforations!) Tx: depends on clinical status of pt, site of perforation, contained perf? Conservative (IV abx, etc), endo stent, surgery (repair, resect, drain)

_________________ is malabsorption caused by T whipplei (gram positive bacillus).

Whipple's disease Treated with Abx

____________________ is caused by a gastrin-secreting tumor of the pancreas that stimulates the acid-secreting cells of the stomach (parietal cells) to maximal activity w/ consequent GI mucosal ulceration.

Zollinger-Ellison Syndrome May occur sporadically or as part of an autosomal dominant familial syndrome -> multiple endocrine neoplasia type 1 (MEN1) Classic triad: -diffuse peptic ulcers -diarrhea -acid hypersecretion (serum gastrin >1000 ng/L) Tx: aggressive PPI therapy/surgery

Chronic ulcerative colitis is a potential risk factor for ________________ cancer.

colorectal Colectomy is the definitive surgical treatment of ulcerative colitis. The malignancy adenocarcinoma of the colon can be a complication of ulcerative colitis that is usually not a concern until after ten years of disease. The first line treatment of ulcerative colitis is 5-aminosalicylic preparations such as mesalamine.

Toxic megacolon is paralysis of smooth muscles, lethal dilation of colon, systemic toxicity, related to UC or C. diff -> treated with ____________________.

high dose steroids, hyperalimentation, colectomy

Ulcerative colitis is an inflammatory bowel disease associated with pseudopolyps, loss of haustra, and a resultant "____________" appearance on imaging.

lead pipe

Ulcerative colitis is an inflammatory bowel disease that involves only (layers of the GI tract) _____________________ inflammation.

submucosal and mucosal Ulcerative colitis is an inflammatory bowel disease that is limited to the colon, including the rectum. Ulcerative colitis is an inflammatory bowel disease associated with left lower quadrant pain and bloody diarrhea.

A complication of ulcerative colitis that may be a presenting symptom is ________________, which is severe dilation of the colon.

toxic megacolon

Crohn disease is an inflammatory bowel disease that is more commonly associated with (mucosal/transmural) _______________ inflammation and skip lesions.

transmural