Absorption/inflammatory diseases - GI

Question 1

MALABSORPTION

Answer 1

• impaired absorption of nutrients
• Congenital
• Acquired defects
• Maldigestion

Question 2

Normal function -MALABSORPTION

Answer 2

3 steps in normal function

1. Luminal and brush border processing
2. Absorption into intestinal mucosa
3. Transport into circulation

Question 3

Defects -MALABSORPTION

Answer 3

-In each of 3 phases and also one or more can exist concurrently
3 most common
    --Celiac disease
    --Chronic pancreatitis
    --Lactase deficiency

Question 4

Typical presentation -MALABSORPTION

Answer 4

• Diarrhea
• Weight loss
• Anorexia
• Flatulence
• Abdominal distension
• Borborygmus (stomach rumbling)
• Asymptomatic

Question 5

Lab abnormalities - MALABSORPTION

Answer 5

• DECREASED hemoglobin, folate, iron, ferritin, vitamin B12, calcium, magnesium, cholesterol, carotene, albumin, 25-hydroxyvitamin D
• INCREASED oxalate, prothrombin time, total serum iron binding capacity

Question 6

INFLAMMATORY BOWEL DISEASE

Answer 6

• two major disorders-ulcerative colitis and Crohn’s disease
• In North America 2-20 cases per 100,000
• Lower incidence in Asia and Middle East
• Increased incidence in northern latitudes in USA and Europe
• autoimmune disease

Question 7

Risk factors

Answer 7

• Pathogen unclear
• Age of onset between 15-40 years
• Bimodal peaks second peak 50-80 years of age
• Slight female predominance of Crohn’s disease
• More common in Jewish background, less common in black and Hispanic population
• Family history-10-25% have a first degree relative with dx
• Smoking
• Diet
• Obesity
• Infections (measles, Mycobacterium paratuberculosis, paramyovirus)
• Lack of breastfeeding
• Antibiotics
• Isotretinoin: chemotherapy - bowel irritant
• NSAID
• Oral contraceptives, hormone therapy
• Appendectomy
• Psychosocial factors-stress response

Question 8

Ulcerative colitis

Answer 8

• Chronic inflammatory condition with relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon.
• Uniform and continuous-95% of cases involve the rectum
• Ulcerative proctitis, pancolitis
• In severe cases bowel wall can become extremely thin leading to dilation and possible perforation(at risk when diameter>12 cm)
• Recurrent inflammation leads to “lead pipe” look of colon on barium enema
• Regenerating islands of mucosa surrounded by areas of ulceration and denuded mucosa appear as pseudopolyps
• Longstanding surface epithelium shows features of dysplasia-?premalignant
• dont do a colonoscopy may cause perforation

Question 9

UC signs/sxs

Answer 9

• Abdominal pain and cramping
• Abdominal sounds (a gurgling or splashing sound heard over the intestine)
• Blood and pus in the stools
• Diarrhea, from only a few episodes to very often
• Fever
• Tenesmus (rectal pain)
• Weight loss
• Children’s growth may slow.
• Other symptoms that may occur with ulcerative colitis include the following:
• Gastrointestinal bleeding
• Joint pain and swelling
• Mouth sores (ulcers)
• Nausea and vomiting
• Skin lumps or ulcers

Question 10

Tx - uc

Answer 10

-Terminate acute attack
-Prevent recurrent attacks.
-Diet-low caffeine, low in gas producing veggies, no antidiarrheals in acute setting
-Sulfasalazine-dosage range 2-6 gm/day
-Steroid enemas or mescaline enemas
-Steroid usage-orally or parentally
(40-60 mg/d gradual taper over 2 mo)
(10% of pts require continuous low to moderate steroid doses)
NEWER AGENTS
1.Oral 5 ASA derivatives-Mesalamine 800 mg tid
2. Immunomodulators i.e. azaththiopurine, methotrexate, cyclosporin used in pts unresponsive to steroids and 5 ASA drugs or those who cannot be weaned from high dose steroids.
3. Budesonide less toxic steroid cleared by liver
4. Infliximiab (Remicade) injection

Question 11

Surgery UC

Answer 11

• Colectomy in 20-25% of cases
• Emergency for massive hemorrhage, toxic dilatation of colon, refractory to treatment, persistent multisite dysplasia
• Total colectomy with ileostomy pouch is curative.

Question 12

Colon cancer risks in UC

Answer 12

• Single most important risk factor affecting long term prognosis. Incidence increases over time and begins after 7-8 years of disease.
• Considerably less risk in left sided disease
• Surveillance-colonoscopy with biopsy of mucosa every 1-2 years, low grade dysplasia f/u every 3-6 mo.
• Annual liver tests

Question 13

Crohn’s disease

Answer 13

• Transmural inflammation –all layers including mesentery and regional lymph nodes
• Skip lesions-scattered distribution
• Can affect total GI tract-small bowel and colon
• Transmural inflammation can lead to fibrosis and obstructive symptoms, development of sinus tracts, cobblestone look.

Question 14

Classic Presentation - Crohn’s

Answer 14

Gradual onset cramping, abd pain, diarrhea

• Low grade fever, malaise, weight loss, decreased energy, RLQ or periumbilical pain,
• Palpable tender mass-inflamed/matted loop of small bowel, ?obstruction
• Arthalgias
• Arthritis
• Iritis
• Uveitis
• Pyoderma gangrenosum
• Erythema nodosum
• Apthous ulcers
• Gallstones/kidney stones
• 30 % involve terminal ileum only
• 30% involve only colon
• 40% ileocolic involvement, usually ileum and R colon

Question 15

Treatment Crohn’s disease

Answer 15

• Maintain weight.
• Adequate nutrition. If fat malabsorption limit fat. Cholestyramine 2-4g may help.
• Perirectal disease-Sitz baths. Drainage of tracts.
• If diarrhea present increase dietary fiber.
• Decrease stress.
• Antispasmodics, anti-diarrheals
• Prednisone 20-60 mg /d po
• Sulfasalazine and mesalamine (maintenance)
• Perirectal tracts use metronidazole 250 mg tid times 8 weeks
• Depends on anatomic location, severity of disease, goal of therapy( induction or maintenance of remission)
• Oral 5-aminosalicylates(sulfasalazine, meslamine)
• Antibiotics-Ciprofloxacin, metronidazole,
• Conventional glucocorticoids-prednisone
• Non-systemic glucocorticoids-budesonide
• Immunomodulators-azathioprine, 6-mercaptopurine, methotrexate
• Biologic therapies-infliximab, adalimumab

Question 16

CONSTIPATION

Answer 16

• Definition –different for everyone: hard to pass, small amt
• Medical definition=stool frequency of less than 3 per week
• May be first signs of metabolic disease such as diabetes, hypothyroidism, hypercalcemia, heavy metal intoxication
• Most common digestive complaint in the general population -2-27%
• Prevalence rises with age

Question 17

Secondary causes CONSTIPATION

Answer 17

• Neurologic disease-cauda equina, spinal cord damage
• Metabolic disease
• Drug side effect
• Anorexia
• Irritable bowel disease
• Hirschsprung disease
• Functional outlet disorder (pelvic floor dyssynergic disorder)

Question 18

Radiography

Answer 18

• Plain film to see what stool is present.

- Barium enema-to detect megacolon, Hirschsprung’s disease, colon transit studies

Question 19

Treatment

Answer 19

• Acute
• Patient education, high fiber diet (20-35 grams per day), increase fluid intake, bulk forming laxatives (metamucil, psyllium, citracel)enemas,
• Surfactants-colace-docusate
• Osmotic agents-ployethelene glycol PEG-Golytely,
• Stimulant laxatives-dulcolax-biscodyl, senna