CPD II: bowel disorders

polyps are fleshy outgrowths of the intestinal mucosa that can be categorized as hyperplastic, adenoma, or "polyposis" syndromes, each with their own unique etiologies and morphologies. hyperplastic polyps are most common, making up about 90% of epithelial polyps, and are less than 5mm in diameter. they are asymptomatic, found via endoscopy, and are generally considered benign. adenoma polyps are precancerous and make up 10% of epithelial polyps and are from 1.5-10mm (most are smaller and the larger ones have a greater potential to be cancerous). polyposis syndromes are inherited conditions that result in a multitude of intestinal polyps that have a high chance of progressing to adenocarcinoma. for example, nearly 100% of patients with familial polyposis syndrome have adenocarcinoma by age 40. gardner's syndrome is another polyposis syndrome with osteomas, soft tissue tumors, and sebaceous cysts. peutz-jeghers syndrome is yet another with mucocutaneous pigmentation and polyps in the form of harartomas in the GI tract.

adenocarcinoma is a cancer that can affect the GI tract that is the third most common cancer, after lung and breast / prostate. in males it more commonly affects the rectum and in females the colon. etiological factors include diet low in fiber and high in animal protein, prolonged transit time, rancid oils / fats, while protective factors can include selenium, vitamin C and E, carotene, antioxidants. most patients present asymptomatically, or have a positive occult blood test, but late stage adenocarcinoma can result in a variety of symptoms including weight loss, malaise, anorexia, jaundice, and ascites. if adenocarcinoma is in the right colon, the patient might be more prone to developing anemia symptoms, bleeding, and vague abdominal discomfort. if adenocarcinoma is in the left colon, patients might develop diarrhea / constipation, tenesmus, hematochezia / occult blood. finally, adenocarcinoma of the rectum will cause blood with each bowel movement. diagnosis is usually missed on PE, but aided by CBC, livery enzyme tests, carcinoembryonic antigen tests, as well as a colonoscopy and double contrast barium enema.

hemorrhoids are clusters of vascular, connective, or musclar tissue that affects the epithelium of the anal canal. they are precipitated by laxity of rectal muscles or pelvic congestion- not surprisingly, 1/3 of truck drivers suffer from hemorrhoids. if the hemorrhoid is in the anal canal, patients would likely present with painless rectal bleeding, but may also have perianal itching/irritation/pain, or more acute pain if the hemorrhoid is thrombosed. external hemorrhoids are more prone to thrombosis and thus more acute pain which is triggered by exertion, diarrhea, etc. and can last 1-2 weeks or until the thrombosis is resolved, after which a skin tag remains where the hemorrhoid once was.

anal fissures are acute tears in the anal mucosa most commonly from either constipation or diarrhea. fistulas are new tracts that open up from the anal canal to the perianal or ischiorectal area (recall that this was a complication of crohn's), associated with leukemia, diverticulitis, foreign body reactions, actinomycosis, and chlamydia. fissures and fistulas cause throbbing pain that occurs most of the day, worsened with pressure from sitting, or movement, and especially from bowel movements. the draining of a fistula, or the formation of a new fistula tract may spontaneously resolve the pain.

a couple more anorectal disorders: pruritis ani is intense itching of the perianal area, usually brought on by allergies, pinworms, or dermatological disorders. proctalgia fugax is episodes of intense rectal pain that lasts seconds to minutes, with no symptoms in between episodes. it is associated with MS, low fiber diets and IBS, and is treated with kegel exercises.

questions
polyps...
1. what are the types of polyps?
2. how big are hyperplastic polyps?
3. what percentage of epithelial polyps are hyperplastic vs. adenomatous polyps?
4. what is the symptom picture and prognosis for hyperplastic polyps?
5. how big are adenomatous polyps?
6. how long do adenomatous polyps take to develop?
7. 90% of adenomatous polyps are...
8. polyposis syndromes are classified as...
9. polyposis syndromes always end up in...
10. what is familial polyposis?
11. what is gardner's syndrome?
12. what is peutz-jeghers syndrome?
13. what are some etiological mechanisms of polyps?
14. what is a type of skin lesion that is associated with polyps and how closely is it associated?
15. what is a type of medical procedure that can increase risk of polyps?
16. what are the signs and symptoms of polyps?
17. how is the diagnosis of polyps made?

adenocarcinomas...
18. how common is adenocarcinoma of the GI tract?
19. which parts of the GI tract does adenocarcinoma affect in males and females?
20. what are some etiological factors for adenocarcinoma?
21. what are some factors that might prevent adenocarcinoma?
22. what are the risk factors for adenocarcinoma?
23. what are the early signs and symptoms for adenocarcinoma?
24. what are the signs and symptoms for adenocarcinoma that develops in the right colon?
25. what are the signs and symptoms for adenocarcinoma that develops in the left colon?
26. what are the signs and symptoms for adenocarcinoma that develops in the rectum?
27. what are the signs and symptoms for late stage adenocarcinoma?
28. what are the best lab tests to perform for adenocarcinoma?
29. what are the imaging tests that can aid in the diagnosis of adenocarcinoma?
30. what are the differential diagnoses for adenocarcinoma?

hemorrhoids...
31. what are hemorrhoids?
32. hemorrhoids result from...
33. hemorrhoids are common in what occupation?
34. what is the imaging technique used to diagnose hemorrhoids and what does it find?
35. what are the treatments for hemorrhoids?
36. what are the signs and symptoms of internal hemorrhoids?
37. what are the signs and symptoms of external hemorrhoids?
38. describe the progression and quality of the thrombotic pain in external hemorrhoids.

anal fissures/fistulas...
39. what is an anal fissure?
40. 87% of people with anal fissures are between what ages?
41. what is the etiology of anal fissures?
42. what are anal fistulas?
43. what are anal fistulas associated with?
44. what are the signs and symptoms of anal fissures/fistulas?
45. describe the quality of pain with an anal fistula.
46. what are some differential diagnoses for anal fissures/fistulas?

pruritis ani, proctalgia fugax...
47. what is pruritis ani?
48. what are the most common etiologies for pruritis ani?
49. what is proctalgia fugax?
50. what condition in particular has a high incidence of proctalgia fugax?
51. what are some risk factors for proctalgia fugax?
52. what age group does proctalgia fugax usually affect?
53. describe the quality of pain in proctalgia fugax.
54. what is the treatment for proctalgia fugax?

answers
1. hyperplastic, adenomas, polyposis syndromes.
2. less than 5mm in diameter.
3. about 90% are hyperplastic, 10% adematous.
4. asymptomatic, found on endoscopy, benign on pathology report.
5. more than 10mm.
6. 5-10 years.
7. less than 1.5mm and have small potential for malignancy.
8. familial inherited (autosomal dominant), non familial.
9. colon cancer.
10. a rare hereditary disease that manifests in childhood with a colon carpeted with polyps, diarrhea / bleeding, and generally leads to carcinoma by age 40.
11. similar to familial polyposis, with osteomas, benign soft tissue tumors, sebaceous cysts.
12. similar to familial polyposis with more distribution and accompanied by mucocutaneous pigmentation and harartomas in stomach, colon, small intestine.
13. adaptative response to cigarette smoke, alcohol intake, ulcerative colitis.
14. 10-70% of individuals with skin tags have polyps.
15. irradiation of the pelvis.
16. asymptomatic, or bleeding (occult blood possible)
abdominal pain due to obstruction
change in bowel habits
watery diarrhea with large villous adenomas
17. barium x-ray, colonoscopy after routine exam.

18. 3rd most common cancer after lung, prostate/breast.
19. females: colon. males: rectum.
20. low fiber diet
high animal protein (grain fed animals that don't exercise)
prolonged transit time
rancid oils / fats
[fiber, fat, animal, transit]
21. selenium, vitamin C, vitamin E, carotene, antioxidants. [sell the vitamins to the anti carrot people]
22. over 40 years old
familial polyposis
low cholesterol with standard american diet
crohn's / ulcerative colitis
septicemia from strep bovis infection
[AC 40 familial SAD inflammatory septicemia] [ack- 40 sad families with toilets on fire?!?]
23. asymptomatic, or positive occult blood.
24. microcytic / hypochromic anemia symptoms
vague abdominal discomfort or palpable mass (later)
bleeding
[anemia, vague pain, bleeding]
25. diarrhea / constipation
tenesmus with BM
pain due to obstruction
hematochezia or positive occult blood
[diarrhea, tenesmus, pain, blood]
26. blood with each bowel movement.
27. weight loss, malaise, anorexia, jaundice, ascites.
28. CBC, liver enzymes, CEA, occult blood.
29. sigmoidoscopy / colonoscopy, double contrast barium enema.
30. diverticula, ischemic colitis, IBD, benign polyps, hemorrhoids.

31. clusters of vascular tissue, connective tissue, and musclar tissue.
32. laxity of rectal musculature, pelvic congestion/stagnation
33. 1/3 truck drivers.
34. anoscope reveals bluish color from veins.
35. lancing or sclerosing via electrodes.
36. bleeding with BM
perianal itching / irritation / pain
acute pain from thrombosed hemorrhoid or spasm
37. pain from thrombsed hemorrhoid
skin tags
38. thrombosis results from exertion, straining, diarrhea, or other event, pain lasts 7-14 days and resolves when thrombosis resolves.

39. an acute tear in the mucosa of the anal canal.
40. 20-60.
41. hard stool
chronic diarrhea
constipation
childbirth
cathartics
intercourse or examination
STD's
[poop cccc sex]
42. opened perianal or ischiorectal absesses that drain spontaneously.
43. leukemia, diverticulitis, foreign body reactions, actinomycosis, chlamydia.
44. burning/cutting rectal pain
pain / blood / spasm with BM
mucoid discharge
pruritis
45. throbbing pain throughout most of the day that is made worse by sitting, moving, BM, coughing and might resolve spontaneously with draining of abscess or formation of new fistula.
46. diverticular disease
foreign bodies
herpes simplex
hidradentis suppuritiva
HIV
inflammatory bowel

47. intense perianal itching
48. allergies, pinworms, dermatologic disorders
49. benign anorectal pain, thought to be associated with spasm of anal sphincter.
50. MS.
51. low fiber
IBS
52. 50% are 30-60.
53. sudden onset pain localized to rectum that lasts seconds to minutes, asymptomatic between episodes.
54. kegel exercises.

CPD II: esophageal disorders part II

this lecture is a continuation of the esophageal disorder lecture, the second in the GI series by Dr. Thom. we finished up the obstructive esophageal disorders: extrinsic compression, esophageal cancers, barrett esophagus, schatzki ring, plummer vinson, inflammation, candida. extrinsic compression of the esophagus causes dysphagia and results from a number of sources such as abnormal subclavian artery, diverticulosis, mediastinal masses, enlarged heart, cervical spurs. cancer of the esophagus is divided into two main categories: 75% of cases are squamous cell carcinoma, which affects the non keratinizing stratified squamous epithelium and is from tobacco, alcohol, and other carcinogens. adenocarcinoma results from metaplasia of stratified squamous cells, which then turn into barrett's epithelium, which can then undergo more dysplasia and turn into adenocarcinoma. adenocarcinoma does not have a clear link to alcoholism but is connected with smoking, scleroderma/other motor disorders, obesity, drugs, diet. schatzki rings and plummer vinson both involve an extra esophageal growth of some sort; schatzki rings are lower esophageal rings that cause intermittent dysphagias while plummer vinson is an esophageal web, accompanied by fe deficiency anemia.

GERD is gastric reflux caused by relaxation of the LES for various reasons. normally the regurgitation of gastric contents is protected by the LES constriction, downward peristaltic motion, and alkaline saliva mixing. the LES tone can be decreased by a number of factors such as drugs, hormones, certain foods, and GERD symptoms can be worsened with smoking, obesity, and pregnancy. a patient with GERD often experiences heartburn symptoms in addition to possible respiratory complaints due to aspiration of gastric contents, dysphagia / odynophagia, and waterbrash, which is copious salivary secretions in response to GERD. diagnosis is made by endoscopy with biopsy, esophagram with barium swallow, EGD to detect esophagitis (associated in 50% of cases), barrett's esophagus, and to rule out peptic ulcer disease.

the last two esophageal disorders are related to bleeding: mallory weiss is upper GI bleeding caused by lacerations at the gastroesophageal junction and can result in hematemesis, vomiting, or in more severe cases, blood in the stool. it has been shown to be correlated to high consumption of alcohol and aspirin. esophageal varices are varicose veins in the esophagus caused by increased portal hypertension (hep B, C, cirrhosis, alcoholism, fatty liver can all cause), which might rupture and cause massive bleeding in the stomach and out of the mouth.


questions
obstructive esophageal disorders, cont'd...
1. what is esophageal extrinsic compression due to? †
2. what percentage of esophageal cancers are due to SCC vs. adenocarcinoma? √
3. what is the etiology of SCC of the esophagus and what tissue layer does it affect? †
4. what is the treatment of SCC in the esophagus? √
5. what part of the esophagus is adenocarcinoma likely to affect? √
6. describe the pathogenesis of adenocarcinoma of the esophagus. †√
7. what is barrett epithelium? √
8. patients with barrett esophagus are more likely to have... √
9. what are the risk factors for esophageal adenocarcinoma? XX
10. what is a schatzki ring? †√
11. how common is a schatzki ring and what is the prognosis? †√
12. what is plummer vinson syndrome? X√
13. what is the etiology of plummer vinson syndrome? √
14. plummer vinson is resolved by treatment of... √
15. what are some factors that cause inflammation of the esophagus? X√
16. ∂escribe the clinical picture of a patient that has esophageal inflammation due to candida. X†
17. describe the imaging findings of the above patient. X

GERD...
18. what is GERD? √
19. reflux of acid into the esophagus is normally protected by... √
20. what are the causes of GERD? †
21. what can decreased LES pressure be caused by? X
22. what are some typical symptoms of a patient with GERD?
23. what are some extra-esphageal symptoms of a patient with GERD? X
24. patients with GERD are often misdiagnosed with... √
25. what are the imaging techniques used to diagnose GERD? †
26. what is the EGD technique useful for in the diagnosis of GERD? √
27. what are the complications of GERD? X
28. what are the treatments for GERD? X

bleeding problems...
29. what is mallory weiss syndrome?
30. what are the symptoms of mallory weiss?
31. what are the less common symptoms of mallory weiss?
32. what are two substances that have been linked to mallory weiss?
33. what are esophageal varices due to?
34. esophageal varices might lead to...

answers
1. mediastinal masses, aberrant right subclavian artery, enlarged heart, cervical spurs, divertuculi.
2. 2/3 SCC 1/3 adenocarcinoma.
3. tobacco, alcohol, other carcinogens, affects non keratinizing stratified squamous cell epithelium.
4. if surgery, involves removing most of the neck because of the high lymph node concentration.
5. mid and distal esophagus.
6. gastric reflux causes metaplasia of normal stratified squamous cells, turning them into "barrett epithelium", then dysplasia, then adenocarcinoma.
7. specialized intestinal epithelial layer containing goblet cells.
8. lower LES pressure and worse esophageal peristalsis, therefore more acid reflux.
9. not alcohol (!), smoking, scleroderma/other motor disorders, obesity, drugs, diet.
10. a lower esophageal ring that causes intermittent dysphagias.
11. 6-14% of patients who undergo GI exams; usually asymptomatic.
12. dysphagia for solids, esophageal webs (thin mucosal membrane that grows across lumen), fe deficiency anemia.
13. excess smoking and drinking.
14. anemia.
15. chronic debilitating disease, steroids, antibiotics, immunosuppresants, chemo, estrogen. [chronic drugs drugs drugs rays boobs]
16. dysphagia with intense pain of short duration, often tolerate only liquids, oral thrush.
17. barium swallow would show shaggy mucosa or filling defects, endoscopy would show white mucosa and swelling.

18. gastric esophageal reflux disease, a common condition characterized by heartburn and acid regurgitation symptoms.
19. LES, downward peristaltic motion, alkaline saliva.
20. decrease of LES pressure, smoking, pregnancy, obesity.
21. drugs (morphine, diazepam, calcium channel blocker, nitrates, beta-blockers), hormones (secretin, cholecystokinin, glucagon), foods (alcohol, caffeine, lipids, chocolate).
22. heartburn felt usually after eating or bending over, respiratory complications from regurgitation, dysphagia, odynophagia, waterbrash. [heartburn, breathe, swallow, swallow, water]
23. coughing/wheezing, aspiration pneumonia, fatigue, chest pain. [cough, pneumonia, tired, pain]
24. asthma because of the cough which is caused by aspiration.
25. endoscopy with biopsy, barium esophagram, esophagogastroduodenoscopy.
26. identifying esophagitis, barrett esophagus, ruling out peptic ulcer.
27. esophagitis (50% of cases), barrett's esophagus, stricture of distal esophagus, respiratory complications.
28. improve diet, cut out alcohol, stay elevated, heel drops, avoid constricting clothing. [diet, elevation, dropping, clothing]

29. gastroesophageal junction lacerations and upper GI bleeding.
30. hematemesis, followed by wretching / vomiting.
31. hematochezia, melena, syncope, abdominal pain.
32. exceess alcohol and aspirin.
33. anything that increases portal hypertension: Hep B, Hep C, cirrhosis, alcoholism, fatty liver.
34. rupture, massive bleeding into the stomach and out of the mouth (a life threatening emergency).