10 Feb 2024 Flashcards
Erythema Nodosum CF
👩🏻🦰Tender , indurated , erythematous nodules
👩🏻🦰
Most common anterior legs
Mirrors IBD activity , worsens during IBD flares and resolves as flares improve.
Pathogenesis of erythema Nodosum
🧠Delayed hypersensitivity reaction
🧠Septal panniculitis without Vasculitis
Erythema Nodosum Associated Dx
🫂Infections ( streptoccocus)
🫂Inflammatory disorders (IBD , sarcoidosis)
🫂Medications (eg AB , OCPs)
🫂Pregnancy
Management if EN
Evaluation ;
CBC , ESR , Streptococcus testing, chest radiograph , tuberculin skin test
Symptomatic Ttt:
NSAIDs , KI , Corticosteroids (if refractory)
Colon ischemia pathophys
👮🏻♀️ usually watershed non occlusive ischemia
👮🏻♀️ underlying atherosclerotic dx
👮🏻♀️ state of low blood flow (hypovolemia)
CF of colonic ischemia
Moderate abd pain and tenderness
Hematochezia and diarrhea
Leukocytosis and lactic acidosis
Dx of colonic ischemia
CT scan with IV contrast :
Colon wall thickening , fat stranding
Endoscopy :
Edematous and friable mucosa
Ttt of colonic ischemia
IV fluids and bowel rest
AB with enteric coverage
Colonic resection if necrosis develops.
Watershed areas of colon
Splenic flexure :
Btwn SMA and IMA territory
Rectosigmoid junction:
Between sigmoid artery and super rectal artery
RF for severe dx in Crohns
👐Young age <30 at dx
👐Extensive anatomical involvement
👐Perianal dx
👐Deep ulceration
👐Strictures
👐Fistulization
👐Prior intestinal surgery
👶🏾Smoking is only Major modifiable RF that can affect severity and progresssion
Strongly ass with need for hopitalization and surgery plus failure of biologic agents
Severe Crohn dx ttt
Smoking cessation
Biologic agents (TNF alpha inhibitors)
Immunomodulators (azathioprine, 6-MP)
Close endoscopic surveillance
Pathophys of Bile Acid diarrhea
Unresorbed bile acids spill in colon causing mucosal irritation
🤖 bile acid enters terminal ileum too rapidly and overwhelms resorptive capacity (post cholecystectomy) 🤖 ileal dx impairs bile absorption (crohn dx , abd radiation damage)
CF of Bile acid diarrhea
Secretory diarrhea
(Happens during fasting and at night)
Unremarkable blood and stool studies
Bloating and abd cramps
Ttt of Bile acid diarrhea
Bile acid binding resins
Cholestyramine
Cholestipol
Mechanism of bile acid diarrhea
Gall bladder act as reservoir for bile.
Cholecystectomy causes bile acid to enter intestines more rapidly overwhelming ileal resorptive capacity.
Unresorbed bile causes irritation in colon causing secretory diarrhea.
Pt with constipation and mild L Abd pain upto date on colonoscopy
No change in diet.
Do colonoscopy for CA despite being up to date on colonoscopy due to:
Unexplained new constipation
Persistent change in bowel habits >4M
Significant change in bowel habits
<1 bowelmovement per week
Age >50
Weight loss
Hematochezia
Fe def anemia
Severe/worsening abd pain in high risk
New concerning SS
Pt with crohn dx have SS of SBO
Fibrotic stricture
Crohn dx and fibrotic strictures
Indications of worsening inflammation in crohn
Age <30
Strictures
Smoking
Ttt :surgery
Fibrotic stricture CF
Those of SBO
Bilious emesis
Abd pain
N V
Partial obs (cant pass stool but can pas gas)
Complete obs (obstipation)
Abd distension
High ptched bowel sounds
19yo Pt with watery diarrhea , blood in stools , abd pain , anemia , elevated CRP
Neg for C.difficile
IBD
Do colonoscopy
(To diff btw UC and crohn)
Pt with prev bowel surgery now has peritonitis cause
SBO and Perforation due to adhesion formation.
Opioid induced constipation ttt
Non pharm :
Inc fluids
Inc dietary fibre
Inc exercise
Early ambulation (post op)
Pharm:
👿Osmotic laxatives (polyethylene glycol , lactulose )
😈Contact cathartics or stimulant laxatives (senna bisacodyl)
😈Hard stools ; softeners (docusate)
😈Refractory : Methylnaltrexone , lubiprostone
First line for opioid constipation
Osmotic and stimulant laxatives
(Mostly no testing required)
Abd pain , bloody diarrhea after AAA repair
Ischemic colitis
