Colonic and Rectal Disease Flashcards
Obj: Differentiate clinical signs of recto anal diseae from colonic disease and unique clinical signs of specific underlying etiologies
Obj: describe the association between proctitis, colonic disease and possible sequela
Obj: given PE and imaging findings, recommendd the best treatment for an individual patient with rectoanal disease
Obj: list broad differentials for constipation and
Obj:
Obj:
What are the clinical signs of Rectoanal disease?
- Often difficult to distinguish from clinical signs of colonic disease
- Tenesmus
- Mucoid or hemorrhagic discharge
- Dyschezia
- Ribbon-like appearance to stool with masses/stricture formation
- Location of blood
- blood coating outside of stool - concern for luminal lesions
- Intermixed - inflammatory disease
What are the different categories of Rectoanal disease?
- Rectal disease
- Anal sac disease
- Perineal disease
- Diseases of storage/defecation
Define dyschezia
difficult/painful defecation
What is Proctitis? etiologies?
- Rectal mucosal inflammation
- Etiologies:
- Colonic inflammation
- Foreign body
- Rectal prolapse
What are the clinical signs of Proctitis?
- Tenesmus
- hematochezia
- dyschezia
- concurrent diarrhea suggests colonic involvement
How is Proctitis diagnosed?
- Exclusion of other causes
- Histopathology
- most common - lymphoplasmacytic inflammation
- less common - neutrophilic, eosinophilic, granulomatous
What is the treatment for Proctitis?
- Similar to idiopathic IBD/colitis
What is a Rectal-anal stricture? etiologies?
- Narrowing of rectal or anal lumen
- usually secondary to circumferential disease
- Etiologies:
- Circumferential neoplasia
- Rectoanal foreign body
- Severe IBD
- Perianal fistula
- Complication of rectal resection-anastomosis surgery
What are the clinical signs of Rectal-anal stricture
- Dyschezia
- Tenesmus w/ narrow ribbon-like stool
- secondary constipation/obstruction
How are Recto-anal strictures diagnosed?
- Physical exam (rectal)
- Abdominal ultrasound to ID underlying conditions
- Proctoscopy or colonoscopy for visualization and biopsy
What is the treatment for Recto-anal strictures?
- Endoscopic or fluoroscopic-guided balloon dilation or bougienage
- for non-infiltrative disease
- multiple procedures usually needed
- intralesional triamcinolone can decrease re-stricture rate
- Surgery - Rectal pull through, resection and anastomosis
- Peri-procedural antibiotics
- Easy digestible diet and laxatives
What are the possible complications of Rectal pull-through, resection and anastomosis for Rectal-anal strictures?
- Fecal incontinence
- dehiscence
- re-stricture
- infection
What is a Perianal Fistula? etiologies?
- Perianal ulceration and formation of one or more ulcerated perianal sinuses
- secondary to chronic, progressive inflammation
- Etiology: incompletely understood
- Immune-mediated inflammation (T-cell)
- Associated with dietary intolerance in some cases (e.g. idiopathic IBD)
- +/- bacterial or anatomic factors
What are the clinical signs of a Perianal Fistula?
- Severe perianal pain and dyschezia
- Foul-smelling, mucopurulent discharge from fistulas
- Self-mutilation, tail chasing
- +/- history of chronic diarrhea
How are Perianal Fistulas diagnosed?
- PE:
- sedation often required
- Rectal exam to evaluate for secondary stricture formation, involvement of anal glands, progression into rectal lumen
- +/- Rectal/colonic biopsies to diagnose underlying GI disease
What is the treatment for Perianal Fistulas?
- Immunosuppression
- Cyclosporine
- Low-dose ketoconazole may allow dose reduction: Cytocochrom P450 inhibitor
- Topical Tacrolimus 0.1%
- similar response as cyclosporine
- difficult to apply if animal is painful
- Other drugs: Prednisone, azathioprine
- Cyclosporine
- Daily topical cleaning
- Pain management Stool softener
- Diet trial - novel protein or hydrolyzed
What is the prognosis for Perianal Fistulas?
- 60-80% improvement after 4wks cyclosporine
- avg complete resolution time of 10-16 in 70-90% of dogs
- Guarded for complete resolution: relapse common
What are the possible complications of Perianal Fistula treatment?
- Fecal incontinence
- anal stricture
What is Fecal incontinence? Etiologies?
- Inability to retain feces, resulting in involuntary leakage of fecal material
- Etiologies:
- Reservoir incontinence
- disease-related decreased rectal capacity to hold fecal material or decreased compliance
- subtotal colectomy
- Colonic/rectal fibrosis or severe thickening due to severe IBD
- disease-related decreased rectal capacity to hold fecal material or decreased compliance
- Sphincter Incontinence
- disease-related denervation
- damage to external anal sphincter
- Reservoir incontinence
What are the clinical signs of Fecal incontinence?
- Usually more severe with sphincter incontinence vs reservoir incontinence
- Reservoir:
- frequent, voluntary defecation of small fecal balls due to intact external anal sphinter
- awareness of fecal material presence
- Sphincter:
- involuntary expulsion of fecal material
How is Fecal Incontinence diagnosed?
-
Physical Examination
- Reservoir:
- frequent posturing to defecate with urgency
- +/- concurrent signs of colonic disease
- hematochezia, dyschezia
- Specific disease processes
- Colorectal: neoplasia, constipation, proctitis, colitis
- Sphincter: Neurologic
- Dribbling of feces from anus, especially with conditions resulting in increased pressure
- e.g. coughing, excitement, barking
- Decreased anal tone
- Specific disease processes:
- Cauda equina
- Congenital vertebral malformation, meningomyelocele, sacrococcygeal hypoplasia (Manx), vertebral fracture, lumbosacral instability or compression, vascular insult, neoplasia, diskospondylitis
- CNS
- Infectious (Distemper, FIP) Degenerative myelopathy, neoplasia, vascular insult, trauma
- Peripheral neuromuscular Disease
- Polyneuropathies, dysautonomia, myasthenia gravis, +.- hypothyroidism
- Cauda equina
- Dribbling of feces from anus, especially with conditions resulting in increased pressure
- Reservoir:
-
Complete Neurologic Exam:
- Bladder size, ease of expression, colonic distention, gait, postural reactions, tail tone/anal tone, perineal reflexes, lumbosacral pain, other signs of autonomic nervous system disease
- distended, flaccid, easily expressed bladder suggest lesion of the sacral spinal cord, sacral or pudendal nerves, or generalized LMN disease
- Usually Normal w/ reservoir incontinence
- Bladder size, ease of expression, colonic distention, gait, postural reactions, tail tone/anal tone, perineal reflexes, lumbosacral pain, other signs of autonomic nervous system disease
- Rule-out behavioral/altered mentation/lack of house-training
What is the treatment for fecal incontinence
treatment of underlying disease
What is Constipation? Etiologies?
- Prolongation of GI transit, typically associated with hardened feces +/- difficult defecation
- Etiologies:
- Dehydration from systemic disease
- Electorlyte abnormalities: hypokalemia, hypo-/hypercalcemia
- Endocrine disease: hypothyroidism
- Neurologic disease: Breed/anatomic related or acquired (dysautonomia)
- Orthopedic or obstructive disease
- Prostatomegaly
- Lack of exercise
- Obesity
- Drugs: Opioids
- Idiopathic constipation (cats)
What is Feline Idiopathic constipation? etiologies?
- Impaired colonic smooth muscle function
- abnormalities in colonic motility pacemaker cells
- Decreased response to neurotransmitters, membrane depolarization, and electrical field stimulation
- No histopathologic lesions of muscle cells/myenteric neurons
How does Feline Idiopathic constipation progress?
- Constipation: prolonged GI transit +/- difficult defecation
- Obstipation: dilation + loss of function
- Megacolon: End-stage
What are the clinical signs of Feline Idiopathic Constipation?
- Days to months of reduced to absent or painful defecation
- Dry, hard feces
- +/- Tenesmus
How is Feline Idiopathic Constipation diagnosed?
- Rule-out local or systemic predisposing causes
- Abdominal Radiographs
- Radiographic obstipation: colonic distention 1.5x the length of L7 vertebrae
- Clinical obstipation: degree of loss of function
What is the treatment for Feline Idiopathic Constipation?
- Hydration
- Diet
- High fiber if no persistent colonic dilation/loss of function
- easily digestible/low residue if persistent colonic dilation
- Promotility medication
- Cisapride 0.1-0.5 mg/kg q8-12h,
- given 30min prior to feeding
- Cisapride 0.1-0.5 mg/kg q8-12h,
- Laxatives
