on 10-Aug-2017 (Thu)

The 2012 American College of Physicians Guidance Statement on colorectal cancer screening recommends initiation of screening in high- risk patients (a first-degree relative with colon cancer or advanced adenoma diagnosed at age <60 years, or two first-degree relatives diagnosed at any age) at age 40 years, or 10 years younger than the earliest colon cancer diagnosis in the family, whichever is earlier. Colonoscopy is repeated every 5 years.

in a healthy, immunocompetent patient with diverticulitis and mild symptoms, outpatient therapy is appropriate and should consist of a liquid diet, oral antimicrobial agents that cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole), and as-needed analgesia

For older, frail, sicker patients, and in those with potential complications of diverticulitis (such as peritonitis or fistula formation), hospitalization is recommended for administration of intravenous antimicrobial agents and observation.

Percutaneous drainage is typically indicated in patients with diverticulitis with larger abscesses (often considered to be >3 cm) that are procedurally amenable in those without evidence of peritonitis. Smaller abscesses are usually treated with antibiotics alone and close follow-up.

Colonoscopy is recommended after recovery because diverticulitis may be precipitated by a sigmoid cancer;

For patients with large (≥10 mm) or dysplastic sessile serrated polyps or traditional serrated adenomas, the recommended postpolypectomy surveillance colonoscopy interval is 3 years.

Hyperplastic polyps are believed to have no malignant potential, whereas sessile serrated polyps and traditional serrated adenomas are neoplastic.

A 1-year surveillance interval is recommended for patients with serrated polyposis syndrome. Serrated polyposis syndrome is a rare condition characterized by multiple or large serrated polyps, including hyperplastic polyps, sessile serrated polyps, traditional serrated adenomas, and possibly also adenomatous polyps. Patients with serrated polyposis syndrome are at increased risk of colorectal cancer.

The recommended postpolypectomy interval for patients with sessile serrated polyps smaller than 10 mm is 5 years

A 10-year average-risk interval is recommended for patients with small rectosigmoid hyperplastic polyps

Observation is recommended for adult patients with asymptomatic gallstones.

The usual presentation of biliary colic is episodic, severe abdominal pain typically in the epigastrium and/or right upper quadrant but occasionally in the right lower or mid- abdomen. The pain rapidly intensifies over a 15-minute interval to a steady plateau that lasts as long as 3 hours and resolves slowly. The pain is often associated with nausea or vomiting, and there is no jaundice.

Pyoderma gangrenosum (PG) is characterized by painful pustules that rapidly ulcerate and expand, with edematous, rolled, or undermined borders that may have a violaceous hue; PG may be an extraintestinal manifestation of Crohn disease.

extraintestinal manifistation like aphthous ulcer,arthralgia, inflammatory eye diseases, and pyoderma gangrenosum PG are seen in approximately 10% of patients with inflammatory bowel disease.

Acrodermatitis enteropathica (AE) is an inherited or acquired metabolic disorder characterized by perioral and acral (in the extremities) erythematous and vesiculobullous dermatitis and alopecia related to zinc deficiency. AE has been associated with Crohn disease

Erythema nodosum is the most common cutaneous manifestation of inflammatory bowel disease, occurring in up to 20% of patients, particularly women. The lesions of EN are tender, subcutaneous nodules presenting as barely appreciable convexities on the skin surface, with a reddish hue in the acute phase. EN is frequently bilateral and symmetrical, and it usually occurs on the distal lower extremities, but it may also appear on the trunk, thighs, or upper extremities

Squamous cell carcinoma (SCC) usually appears as a scaly, crusted, well- demarcated red papule, plaque, or nodule. SCC can develop in patients with Crohn disease, most commonly at sites of chronic, long-standing inflammation such as chronic fistulas.

Giardiasis should be considered in patients with chronic diarrhea and exposure to young children or potentially contaminated water such as lakes and streams.

symptoms of giardiasis typically occur 1 to 2 weeks after infection and include watery, foul-smelling diarrhea; bloating; flatulence; and belching. Significant weight loss is common because of anorexia and malabsorption, but fever is distinctly unusual

Glucocorticoids are the cornerstone of treatment for autoimmune pancreatitis.

Type I autoimmune pancreatitis (AIP) typically presents in older men, with a mean age of onset in the fifth decade of life. This patient has evidence of type 1 AIP based on the presence of three diagnostic criteria: imaging features (focal pancreatic enlargement with a featureless rim and a nondilated pancreatic duct), increased serum IgG4 level, and extrapancreatic organ involvement (sclerosing cholangitis or IgG4-associated cholangitis). Almost all patients (>90%) enter clinical remission in response to glucocorticoids, but relapse is common

A biliary metal stent is generally reserved for long-term palliation of malignant biliary strictures and is not required for IgG4-associated cholangitis.

Treat small-bowel bleeding with push enteroscopy.

Enteroscopy should be performed after a negative upper endoscopy and colonoscopy or after a positive capsule endoscopy.

Intraoperative endoscopy is reserved for patients with active bleeding from the small bowel in whom both endoscopy and angiography have failed to identify the small-bowel bleeding source

Linaclotide is FDA approved for the treatment of irritable bowel syndrome with constipation in adults; like lubiprostone, it is second-line therapy for patients whose symptoms have not responded to standard laxative therapy

The absorption of the fat-soluble vitamins A, D, E, and K can be severely impaired following malabsorptive bariatric surgery, including Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch.

Symptoms associated with vitamin A deficiency include decreased vision at night or in dim light, dry eyes, corneal and/or eyelid inflammation, and rough and/or dry skin

Copper deficiency causes a chronic syndrome similar to subacute combined degeneration and is also associated with macrocytic anemia and leukopenia. Therefore, this deficiency can be difficult to differentiate from vitamin B12 deficiency

In patients with Barrett esophagus and no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years.

endoscopic assessment for Barrett esophagus (BE) in patients with chronic reflux symptoms may be appropriate in specific patients. It is reasonable to consider screening men older than 50 years with gastroesophageal reflux disease (GERD) symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and BE.

Recommended surveillance of patients with newly diagnosed BE is based on the presence and degree of dysplasia on biopsy. In those with no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years. In patients with low-grade dysplasia, surveillance is more frequent, usually 6 to 12 months following confirmation by an expert pathologist. High-grade dysplasia requires either more aggressive surveillance or treatment to remove BE (such as with endoscopic ablation or esophagectomy)

Fundoplication is the appropriate treatment for GERD in patients who wish to stop taking medication or in those with a poor response to medical therapy.

The diagnosis of primary biliary cirrhosis is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive antimitochondrial antibody test.

symptoms of primary biliary cirrhosis PBC include fatigue, dry eyes, dry mouth, and pruritus. Hyperlipidemia is common, but jaundice, cutaneous hyperpigmentation, hepatosplenomegaly, and xanthelasmas are rarely observed at diagnosis.

PBC is diagnosed by serum alkaline phosphatase levels greater than 1.5 times the upper limit of normal and typically normal serum total bilirubin levels. Serum aspartate (AST) and alanine (ALT) aminotransferase levels are typically less than five times the upper limit of normal. Serum antimitochondrial antibody is present in 90% to 95% of patients. For patients with undetectable serum antimitochondrial antibody levels, a liver biopsy is required for diagnosis.

Autoimmune hepatitis is a chronic inflammatory liver disease that is usually seen in women. The disease presentation ranges from asymptomatic to acute liver failure. Autoimmune hepatitis typically causes a predominant elevation of the serum ALT level rather than the serum alkaline phosphatase level,

. A Cholangiocarcinoma is classified by location as intrahepatic and hilar/extrahepatic. Intrahepatic cholangiocarcinoma is typically asymptomatic until the tumor is advanced, at which time right upper quadrant discomfort, weight loss, and fever may be the only symptoms. An elevated serum alkaline phosphatase level may be noted. Risk factors for cholangiocarcinoma are primary sclerosing cholangitis, biliary atresia, chronic infection with liver flukes, and biliary cysts.

Capsule endoscopy has become the first-line test in evaluating the small bowel in patients with obscure gastrointestinal bleeding after a negative upper endoscopy and colonoscopy.

Angiography and technetium-labeled nuclear scans are used in patients with active bleeding (melena or hematochezia) who are transfusion dependent and hospitalized.

Enteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis.

this patient with sever acute pancreatitis also has several risk factors for severe disease based on the presence of three of four Systemic Inflammatory Response Syndrome (SIRS) criteria (pulse rate >90/min, leukocyte count >12,000/µL [12 × 109/L], and respiration rate >20/min) and a blood urea nitrogen level greater than 23 mg/dL (8.2 mmol/L).

The optimal time to start enteral nutrition remains under investigation, but it should commence no later than 72 hours after presentation. In mild acute pancreatitis, oral feeding may start when nausea and vomiting resolve