Glossary of IM GI CA, Bleeds, Diarrhea USMLE 2

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What type of precursor to colon cancer is the worst?
Villous Polyps

(Villous are the Villains)
Place of Colon CA:
signs of anemia: pallor, weakness; possible dull abdominal pain
Right Colon
Place of Colon CA:
pencil-thin stools, rectal bleeding, constipation, vomiting
Left Colon
What is the next step if you fecal occult blood test is positive?
At what age should annual rectal exams begin?

Fecal occult blood test?

Flexible sigmoidoscopy or colonoscopy?
What if there is a family member w/ a Hx of colon cancer?
Annual Rectals:
40 years-old

50 years-old

Sigmoidoscopy / Colonoscopy:beginning at 50 years-old, for every 3-5 years

Hx of Colon CA: at 40yo or 10 years earlier then the family member's Dx (whichever is earlier)
70-yo woman presents w/ microcytic anemia, weight loss, and a vague abdominal pain that is not related to food or time of day
Colorectal CA
Dx lab test findings for Colon CA
Anemia (iron deficiency);

elevated CEA;

Check LFTs (inc may indicate Mets)
What type of colon polyp is benign?

Which (2) have malignant potential?

Malignant potential:
What is done if a polyp is found on colonoscopy?
when is the colonoscopy repeated?
perform a polypectomy/Bx

repeat colonoscopy: 3 years
In Endocarditis, which two bugs are assoc w/ Colon CA?
Strep Bovis;

Clostridium Septicum
Duke's Classification of Staging and Prognosis for Colon CA
(A-D and 5-year survival percent)
A: Confined to Mucosa and Submucosa - >80%

B: Invasion of Muscularis propria - 60%

C: Local node involvement - 20%

D: Distant Mets - 3%
First step in Tx for Colon Cancer

What Dx would lead to Radiation therapy?
1. Surgical resection (cures 50% in stage A and B);

2. Chemotherapy;

Radiation only for Rectal involvement
Drug regimen for Colon Cancer
(2 plus one of 2 more)
5-FU and Levimasole
(stage B and higher)

Oxaliplatinum or Irinotecan
Hereditary Colon CA Syndromes

which is the only low-moderate risk (the rest being high risk)?
Family Has Growing Polyps:

Familial Polyposis Coli;

Hereditary Non-polyposis Colon CA;

Gardner's Syndrome;

Peutz-Jeghers Syndrome (low risk)
thousands of adenomatous polyps appear throughout the colon by age 25 and cancer hits by 40-yo.

What are the genetics?
Familial Polyposis Coli

Autosomal Dominant
condition in which 3 or more relatives of a patient and at least one first-degree relative, develops colon cancer at an early age

What are the genetics?

When and How often should a colonoscopy be performed on this i
Hereditary Non-Polyposis Colon CA

Autosomal Dominant

Start at age 25
repeat every 1 - 2 years
disorder characterized by polyposis coli, supernumerary teeth, osteomas and fibrous displasia of the skull and mandible

What are the genetics?
Gardner's syndrome

Autosomal Dominant
multiple polyposis of the small intestine w/ multiple pigmented melanin macules in the oral mucosa or presents w/ freckles on lips

What other cancer is it assoc with?
Puetz-Jeghers syndrome

assoc with:
GYN Cancer
Polyposis w/ medulloblastoma or glioma
Turcot's syndrome
MC complaint or presentation of Colon CA
Intermittent Rectal Bleeding
Order of steps for resuscitation in the general approach to GI bleeds
1. Establish IV w/ (2) large-bore IV caths
2. Evaluate for Hemodynamic instability (hypotension, tachycardia)
3. Type and cross, CBC, coag study
4. IV fluid and blood
5. Vasopressors if BP does not respond to aggressive fluid
6. GI and Surgical evaluation
*When do you answer: Capsule Endoscopy?
Procedure of choice for suspected small bowel bleeding not detected in upper or lower endoscopy
How may UGI bleeds present?

Coffee ground emesis;


Hematochezia (BRBPR)
How may a LGI bleed present?
Hematochezia (BRBPR);

Etiology of UGI bleed
Mallory's Vices Gave (her) An Ulcer:
Mallory-Weiss tear;
Arteriovenous Malformation;
Ulcer (peptic)
Dx tests for UGI or LGI (same tests)
Gastric Lavage;
Rectal exam;
Bleeding scan;
Test that detects active bleeding by infusing a radioactive colloid and watching it collect in the GI

When is this the correct answer?
Bleeding Scan

Next step in patient w/ severe GI bleeding in whom the lower endoscopy is unable to find the source.
Etiology of LGI bleed
Can U Cure Aunt Di's Hemorrhoids?
Cancer or Polyps;
Upper GI bleed (Rule-out);
What class (and drug example) of anti-diarrheal agents is contraindicated in diarrhea that is due to infectious agents?

b/c they promote longer contact time b/t bacteria and intestinal mucosa
By asking the Quantity of diarrhea, how can it help w/ the Diff Dx in relation to site of problem?
Small bowel:
Large-volume, Watery diarrhea

Large Bowel:
Small-volume diarrhea
Bugs that cause Bloody Diarrhea
Amoeba (E. Histolytica);
What is acute (<2 weeks) of diarrhea usually due to?
Infectious etiology
What should the stool be tested for if infectious diarrhea is suspected?

which must be done w/ 3 different bowel movements over 3 days?

Ova and Parasites (over 3 days);

C. Difficile;

Bug Dx:
patient vomits w/i 6 hours of eating something w/ mayonnaise
Bug Dx:
patient has vomiting/diarrhea after eating reheated rice from leftover Chinese food
Bacillus Cereus
Bug Dx:
patient has vomiting and severe watery diarrhea after eating shellfish
Vibrio Cholera
Bug Dx:
patient has flatulence and foul-smelling diarrhea after a camping trip

Giardia Lamblia

Tx: Metronidazole
Bug Dx:
patient has watery diarrhea following a recent course of Abx

Tx? (2)
C. Difficile

Oral Metronidazole or Vancomycin
Bug Dx:
causes diarrhea from contaminated water in third-world countries
Vibrio Cholera
Bug Dx:
causes diarrhea and is assoc w/ Guillian-Barre syndrome
Bug Dx:
causes diarrhea and is assoc w/ raw eggs
Bug Dx:
causes diarrhea and is common in AIDS patient
Basic Tx for all acute diarrhea.
If it is due to bacteria, what is added to Tx? (2 possible)
If it is Parasitic?
All Acute Diarrhea:
1. Rehydration and Electrolyte replacement;
2. Anti-motility agent
(AMA only if not infectious diarrhea)

1. Ciprofloxacin;
2. Bactrim (TMP-SMX)

Flagyl (Metronidazole)
(3) viral causes of Acute Diarrhea

Norwalk virus;

(5)* Classes for the etiology of Chronic Diarrhea
Something Old Died In Me:

Decreased transit;
If fecal pH is < 5.5, what does it suggest the cause of diarrhea is?
Carbohydrate Malabsorption
*What is a D-Xylose Test?

What (3) diseases make it abnormal?
Test for chronic diarrhea that helps distinguish b/t malabsorption and Chronic Pancreatitis.
Low levels in Urine = problem w/ small bowel mucosal transport.

Abnormal results in:
1. Celiac Disease
2. Tropical Sprue
3. Whipple's Disease
How is the Osmotic gap determined for diarrhea (equation)?

what do the results indicate?
OG = 290 - 2(Na + K)

> 50 mOsm = Osmotic component

< 50 mOsm = Secretory (or other cause)
What would a 24-hour fasting help distinguish b/t with regards to chronic diarrhea?
Osmotic Diarrhea - resolves w/ fasting

Secretory Diarrhea - does not resolve w/ fasting

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