Bowel Diseases II Flashcards
Diseases of the Colon and Rectum
- Irritable bowel syndrome
- Antibiotic-associated colitis
- Inflammatory Bowel Disease (Crohns and UC)
IBS
An idiopathic clinical entity characterized by chronic (more than 6 months) abdominal pain or discomfort that occurs in association with altered bowel habits
- can be continuous or intermittent
- diagnosis of exclusion
- s/s usually start in late teens to 20s, more common in women
Definition of irritable bowel syndrome is abdominal discomfort or pain that has 2 of the following:
- Relieved with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in form (appearance) of stool
Other S/S of IBS
abnormal stool frequency; abnormal stool form (lumpy or hard; loose or watery); abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); passage of mucus; and bloating or a feeling of abdominal discomfort
Non GI complaints associated with IBS
dyspepsia, heartburn, chest pain, headaches, fatigue, myalgias, urologic dysfunction, gynecologic symptoms, anxiety, or depression
Possible causes of IBS
- Abnormal Motility
- Visceral Hypersensitivity
- Enteric Infection
- Psychosocial Abnormalities
3 categories of IBS
- Irritable bowel syndrome with diarrhea
- Irritable bowel syndrome with constipation
- Irritable bowel syndrome with mixed constipation and diarrhea
“Alarm symptoms” that suggest a diagnosis other than irritable bowel syndrome and warrant further investigation
- Acute onset of symptoms
- Nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, and fever
- Family history of cancer, inflammatory bowel disease, or celiac disease
Physical exam with IBS
- usually normal
- abdominal tenderness, esp in lower abdomen is common but not pronounced
Testing for IBS
- dont need routine blood tests
- stool specimen for ova/parasites
- no colonoscopy necessary in young pts
- colonoscopy in pts 50+ who haven’t had one to exclude malignancy (take biopsy during)
- if diarrhea is present test for celiacs
- no hydrogen breath test for overgrowth necessary
IBS treatment
-Reassurance, education, and support
-Dietary Therapy (intolerances)
-Pharmacologic Measures:
– Antispasmodic agents
– Antidiarrheal agents
– Anticonstipation agents
– Psychotropic agents
– Nonabsorbable antibiotics
– Probiotics
-Psychological Therapies (Cognitive behavioral therapies, relaxation techniques, hypnosis)
Antibiotic Associated Colitis
- Occurs during the period of antibiotic exposure, is dose related, and resolves spontaneously after discontinuation of the antibiotic
- In most cases, this diarrhea is mild, self-limited, and does not require any specific laboratory evaluation or treatment
- Stool examination usually reveals no fecal leukocytes, and stool cultures reveal no pathogens
Most cases of antibiotic-associated diarrhea are due to
changes in colonic bacterial fermentation of carbohydrates and are not due to C diff
C difficile colitis is the major cause of diarrhea in
patients hospitalized for more than 3 days (most of whom used antibiotics)
-symptoms usually begin during or shortly after antibiotic therapy but may be delayed for up 8 weeks
(prevent with hand washing and gloves)
________ to people who are receiving antibiotics reduced the incidence of C difficile–associated diarrhea
Prophylactic administration of the probiotics
S/S of antibiotic associated Colitis
- Most patients report mild to moderate greenish, foul-smelling watery diarrhea 5–15 times per day with lower abdominal cramps
- Normal abdominal exam or mild left lower quadrant tenderness
- Colitis is most severe in the distal colon and rectum
- Over half of hospitalized patients diagnosed with C difficile colitis have a white blood count greater than 15,000/mcL
- Severe or fulminant disease occurs in 10–15% of patients
Treatment for Antibiotic associated colitis
- Antibiotic therapy should be discontinued
- Start metronidazole, PO vancomycin, or fidaxomicin
- For patients with severe disease, PO vancomycin and IV metronidazole
- Early surgical consultation is recommended for all patients with severe or fulminant disease
- Total abdominal colectomy or loop ileostomy with colonic lavage may be required in patients with toxic megacolon, perforation, sepsis, or hemorrhage
With antibiotic associated colitis, imaging studies for sever disease may show
true pseudomembranous colitis (if sever, during flexible sigmoidoscopy)
Up to 25% of patients have a relapse of diarrhea from C difficile within 1 or 2 weeks after stopping initial therapy
– Most relapses respond promptly to _________
a second course of the same regimen used for the initial episode
-Probiotic therapy is recommended as adjunctive therapy in patients with relapsing disease
For patients with two relapses, use ________
a 7-week tapering regimen of vancomycin is recommended
For patients with three or more relapses, updated 2013 guidelines recommend consideration of __________
“fecal transplantation” from healthy donor into the terminal ileum or proximal colon (by colonoscopy) or into the duodenum and jejunum (by nasoenteric tube)
Submucosal stripe- UC or C?
UC
Full thickness enhancement- UC or C?
C
Skip lesions- UC or C?
C
Abscesses- UC or C?
C
Fistulas- UC or C?
C
Involvement of terminal ileum- UC or C?
C, sometimes UC
Fibrofatty proliferation- UC or C?
C
Wall thickening/Increased wall enhancement- UC or C?
both
Increased signal intensity of mucosa- UC or C?
C
Increased signal intensity of pericolic fat- UC or C?
both
Comb sign- UC or C?
both
Enlarged lymph nodes- UC or C?
C, sometimes UC
Loss of haustration- UC or C?
UC, sometimes C
Extension from rectum to proximal- UC or C?
UC
One-third of cases of Crohn disease involve _______
Half of all cases involve __________
the small bowel only, most commonly the terminal ileum (ileitis)
the small bowel and colon, most often the terminal ileum and adjacent proximal ascending colon (ileocolitis)
Unlike ulcerative colitis, Crohn disease is a transmural process that can result in __________
mucosal inflammation and ulceration, stricturing, fistula development, and abscess formation
_________ is strongly associated with the development of Crohn disease, resistance to medical therapy, and early disease relapse
Cigarette smoking
S/S vary from:
History of fevers, general sense of well-being, weight loss, the presence of abdominal pain, the number of liquid bowel movements per day, and prior surgical resections
– Physical examination should focus on the patient’s temperature, weight, and nutritional status, the presence of abdominal tenderness or an abdominal mass, rectal exam and extra intestinal manifestations
5 common presentations of Crohns
- Chronic inflammatory disease
- Intestinal obstruction
- Penetrating disease and fistulae
- Perianal disease
- Extraintestinal disease
Labs with Crohns
- Poor correlation between laboratory studies and the patient’s clinical picture
- Labs may reflect inflammatory activity or nutritional complications of
- CBC and serum albumin should be obtained in all pts
Specific lab findings with Crohns
- Anemia (may reflect chronic inflammation, mucosal blood loss, iron deficiency, or vitamin B12 malabsorption secondary to terminal ileal inflammation
- Leukocytosis (may reflect inflammation or abscess formation or may be secondary to corticosteroid therapy)
- Hypoalbuminemia (may be due to intestinal protein loss/protein-losing enteropathy, malabsorption, bacterial overgrowth, or chronic inflammation)
- The sedimentation rate or C-reactive protein level is elevated in many patients during active inflammation
- Autoantibodies to P-ANCA as well as antibodies to the yeast Saccharomyces cerevisiae
Test usually performed first with Crohns testing
colonoscopy
During Crohns, typical endoscopic findings include
aphthoid, linear or stellate ulcers, strictures, fat stranding, and segmental involvement with areas of normal-appearing mucosa adjacent to inflamed mucosa
Complications of Crohns
--Abscess – Obstruction – Abdominal and Rectovaginal Fistulas – Perianal Disease – Colon carcinoma – Hemorrhage (unusual) – Malabsorption
General treatment for Crohns
- Nutrition/Diet
- Enteral Therapy
- Total parenteral nutrition
- Symptomatic Medications
- Antidiarrheal in non-severe cases
Specific drug therapy for Crohns
-5-Aminosalicyclic acid (5-ASA) agents
■ Antibiotics
■ Corticosteroids
■ Immunomodulators: Azathioprine, mercaptopurine, or methotrexate
■ Anti-TNF therapies
■ Anti-intergrins
– Surgery
■ Over 50% of patients will require at least one surgical procedure
■ Main indications for surgery are intractability to medical therapy, intra-abdominal abscess, massive bleeding, symptomatic refractory internal or perianal fistulas, and intestinal obstruction
Ulcerative colitis is
an idiopathic inflammatory condition that involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding
■ Approximately one-third of patients have disease confined to the rectosigmoid region (proctosigmoiditis)
■ One-third have disease that extends to the splenic flexure (left-sided colitis)
■ One-third have disease that extends more proximally (extensive colitis)
UC is characterized by
periods of symptomatic flare-ups and remissions
Ulcerative colitis is more common in
nonsmokers and former smokers
■ Disease severity may be lower in active smokers and may worsen in patients who stop smoking
Hallmark of UC
bloody diarrhea
- Severe based on stool frequency, the presence and amount of rectal bleeding, cramps, abdominal pain, fecal urgency, and tenesmus
- vitals are key
- Look for tenderness and evidence of peritoneal inflammation
- Red blood may be present on digital rectal exam
Moderate UC
- 4-6 stools/day
- 90-100 pulse
- 30-40% hematocrit
- 1-10% weight loss
- 99-100 F temp
- 20-30 ESR
- 3-3.5 albumin
MORE than this=severe UC
less= mild UC
Treatment for mild-moderate UC
– 5-ASA agents – Corticosteroids – Immunomodulating agents – Anti-integrin therapy – Probiotics
Treatment for severe and fulminant colitis
– NPO – Corticosteroid therapy – Anti-TNF therapies – Cyclosporine – Surgical therapy
Colonoscopies are recommended ________ in patients with colitis, beginning ________
every 1–2 years
8 years after diagnosis
- At colonoscopy, all adenoma-like polyps should be resected, when possible, and biopsies obtained of non-endoscopically resectable mass lesions
- risk of colon cancer if disease is proximal to the rectum
Almost all patients with diverticulosis have involvement in the _________
sigmoid and descending colon
Diverticulosis is
the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. These are more common in the sigmoid colon,
-become more common after age 40 and increase incidence with age
Diverticulosis may develop more commonly in the sigmoid because
intraluminal pressures are highest in this region
Who is predisposed to diverticulosis?
Patients with abnormal connective tissue are also disposed to development of diverticulosis, including Ehlers-Danlos syndrome, Marfan syndrome, and scleroderma
-low fiber diet?
Physical examination for diverticulosis pts
usually normal but may reveal mild left lower quadrant tenderness with a thickened, palpable sigmoid and descending colon
Patients in whom diverticulosis is discovered, especially patients with symptoms or a history of complicated disease, should be treated with
a high-fiber diet or fiber supplements
Diverticulitis
Perforation of a colonic diverticulum results in an intra-abdominal infection that may vary from microperforation (most common) with localized paracolic inflammation to macroperforation with either abscess or generalized peritonitis
Common S/S of Diverticulitis
- Constipation or loose stools may be present
- Nausea and vomiting are frequent
- Low-grade fever, left lower quadrant tenderness, and a palpable mass
First step when the presumptive diagnosis is diverticulitis
- Mild symptoms and a presumptive diagnosis of diverticulitis, empiric medical therapy is started without further imaging in the acute phase
- Outpatients with clear liquid diets, improvement usually within 3 days, start high fiber diet
- Patients who respond to acute medical management should undergo complete colonic evaluation with colonoscopy or radiologic imaging after resolution of clinical symptoms to corroborate the diagnosis or exclude other disorders such as colonic neoplasms
Patients who do not improve rapidly after 2–4 days of empiric therapy and in those with severe disease ___________
CT scan of the abdomen is obtained to look for evidence of diverticulitis and determine its severity
_______ are contraindicated during the initial stages of an acute attack because of the risk of free perforation
Endoscopy and colonography
- Patients with increasing pain, fever, or inability to tolerate oral fluids require hospitalization
- Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and patients who are elderly or immunosuppressed or who have serious comorbid disease require hospitalization acutely
- Patients should be given nothing by mouth and should receive intravenous fluids. If ileus is present, a nasogastric tube should be placed
- Intravenous antibiotics should be given to cover anaerobic and gram-negative bacteria
Patients with a localized abdominal abscess ____ or larger are usually treated urgently with a percutaneous catheter drain placed by an interventional radiologist
4 cm in size
Polyps
discrete mass lesions that protrude into the intestinal lumen
-most commonly sporadic
Polyps may be divided into 4 major pathologic groups
- Mucosal adenomatous polyps (tubular, tubulovillous, and villous)
- Mucosal serrated polyps (hyperplastic, sessile serrated polyps, and traditional serrated adenoma)
- Mucosal nonneoplastic polyps (juvenile polyps, hamartomas, inflammatory polyps)
- Submucosal lesions (lipomas, lymphoid aggregates, carcinoids, pneumatosis cystoides intestinalis)
Familial Adenomatous Polyposis
- colorectal polyps develop by a mean age of 15 years and cancer at 40 years
- Unless prophylactic colectomy is performed, colorectal cancer is inevitable by age 50 years
With FAP, you have a development of a variety of other benign extraintestinal manifestations, including
soft tissue tumors of the skin, desmoid tumors, osteomas, and congenital hypertrophy of the retinal pigment
Treatment for FAP
complete proctocolectomy with ileoanal anastomosis or colectomy with ileorectal anastomosis is recommended, usually before age 20 years
Peutz-Jeghers Syndrome
- harmatomatous polyposis syndrome
- Autosomal dominant condition characterized by hamartomatous polyps throughout the gastrointestinal tract as well as mucocutaneous pigmented macules on the lips, buccal mucosa, and skin
Familial juvenile polyposis
- harmatomatous polyposis syndrome
- Autosomal dominant and is characterized by several juvenile hamartomatous polyps located most commonly in the colon
PTEN multiple hamartoma syndrome (Cowden disease)
- harmatomatous polyposis syndrome
- Hamartomatous polyps and lipomas throughout the gastrointestinal tract, trichilemmomas, and cerebellar lesions (CNS problems)
Lynch Syndrome
(also known as hereditary nonpolyposis colon cancer [HNPCC]) is an autosomal dominant condition in which there is a markedly increased risk of developing colorectal cancer as well as a host of other cancers, including endometrial, ovarian, renal or vesical, hepatobiliary, gastric, and small intestinal cancers
If genetic testing documents a Lynch syndrome gene mutation, affected relatives should be screened with colonoscopy ______
every 1–2 years beginning at age 25 (or at age 5 years younger than the age at diagnosis of the youngest affected family member)
If cancer is found with Lynch Syndrome, _________
subtotal colectomy with ileorectal anastomosis (followed by annual surveillance of the rectal stump) should be performed
With Lynch Syndrome, women should undergo screening for endometrial and ovarian cancer beginning at age
30–35 years with pelvic examination, transvaginal ultrasound, and endometrial sampling
Prophylactic hysterectomy and oophorectomy is recommended to women at age ________
40 or once they have finished childbearing
With Lynch Syndrome, screening for gastric cancer with upper endoscopy should be considered every ________
2–3 years beginning at age 30–35 years
