Colorectal Disorders Flashcards
Constipation is a functional d/o. Name the 3 subtypes
- slow colonic transit
- obstructive defication
- IBS-C
constipation ddx (etis)
- MC: low fiber, sed lifestyle, inadequate fluid intake
- systemic: ENDOCRINE (hypothyroid, hyperparathyroid, DM), METABOLIC (hypokalemia, hypercalcemia, uremia, porphyria), NEURO (Parkinson, MS, sacral nerve damage, paraplegia, autonomic neuropathy)
- meds: opioids, diuretics, CCB, anticholinergics, psychotorpics, Ca, Fe, NSAID, clonidine, cholestyramine)
- structural: anorectal, perineal descent, colonic mass/stricture, Hirschsprung
- slowed transit: idiopathic, psychogenic, eating d/o, chronic pseudoobstruction
- pelvic floor dyssynergia
- IBS-C
constipation wu
- rectal & abd exam
- if alarm sx: CBC, TSH, BMP, ref for EGD or flex sig
constipation mgmt
- inc fiber intake gradually
- inc # of daily meals
- laxatives prn/chronically if refractory to lifestyle mods
Fiber laxatives
- FIRST LINE
- bran powder (gassy), Metamucil, Citrucel, FiberCon (pill), Benefiber
osmotic laxatives
- onset w/in 24 hrs
- Mild of Mg, epsom salt, sorbitol/lactulose, Miralax,
- AVOID IN RENAL DYSFXN (for whatever eti)
stimulant laxatives
- onset in 6-12 hrs PO, 15-60 min rectal
- bisacodyl & senna (cramping, not daily)
opioid-receptor antagonists
- does NOT affect central analgesia (good for pain pts)
- methylnaltrexone
stool surfactants/emollients
- softens ONLY (avoid straining)
- mineral oil, docusate sodium (colace: marginal benefit)
definition of constipation (sx)
< 3 stools/wk, difficutl-to-pass stools, sense of incomplete evacuation, abd distension, bloating, pain
encopresis def
leaking of liquid stool around hard, impacted stool
pediatric constipation eti & s/s
- self-perpetuating (don’t want to go after initial episode b/c of pain) = chronic rectal distention = desensitized to urgency
- encopresis, UTIs, chronic abd pain, poor appetite, lethargy, rectal skin tags
pedi constipation ddx
- imperforate anus
- Hirschsprung
- Crohn’s
- tethered cord
- spina bifida
- anterior displacement of anus
- CF
- celiac
- lead intoxication
- botulism
- cow’s milk constipation
pedi constipation wu
- Rome III criteria: sx x 1 month in toddlers, 2 mos in older
- labs only if refractory
pedi constipation mgmt
- initially enema or Golytely, followed by Miralax (if > 2 yr)
- goal = 1 soft stool qd
- “rescue plan” = stimulant lax, enema, suppository if recurrence
- behavioral mod: sit on toilet x 5-10 min after q meal, keep logs
diverticulosis eti/epi, s/s, mgmt
- outpouching of sub/mucosa thru musc layer of wall
- 20th century dz assoc w/ Western diet (low fiber, red meat, obesity, inc age
- most asx/incidental, chronic C, abd pain, fluctuating bowel habits
- fiber supps may reduce comps
diverticulitis s/s
- LLQ or suprapubic pain +/- palpable mass
- acute GIB that’s painless & maroon
- F, malaise, C, D, cramps, bloating, N/V, dysuria/u freq
diverticulitis ddx
perf’d colonic CA, Crohn’s, appy, ischemic colitis, CDAD, ectopic preg, ovarian cyst/torsion
diverticulitis wu
- CBC: leukocytosis w/ left shift (inc prod due to inf/inflam)
- CT w/ contrast = IMG OF CHOICE to assess severity
- XR (free air, ileus, obstruction)
diverticulitis mgmt
- uncomplicated/simple: aerobic/anaerobic coverage (cipro + metro) x 7-10 days, clear liq diet until imp (2-3 d), surg consult if no imp/worsens in 3 d
- complicated (peritonitis, obstruction, perf, abscess, fistula): admit w/ IV abx (amp, gentamicin, metro), IVF, pain mgmt, antiemetics
when to follow up acute diverticulitis
ref for CSY, CT, colonography, or barium enema w/ flex sig 2-6 wks s/p recovery (eval extent of damages & exclude malignancy, time avoids risk of perf)
diverticulitis prognosis
- complications: lower GIB, intra-abdominal abscess/peritonitis (from perf), fistulas, obstruction
- 30% recurrence
- 30-40% will have episodic abd pain w/o inf
name both inflammatory bowel dz’s
- crohn’s dz
- ulcerative colitis
IBD overview
- autoimmune, runs in families
- incidence highest if 15-40, > 60 y.o.
- extraintestinal sx poss: eye, skin (erythema nodosum (tender subQ nodules), pyoderma gangrenosum (painful ulcers, lower legs)), liver, joints
- dx via combo of endoscopy, histology, radiography, labs, clinical data
- tx affected area (response 30-70%)
- use steroids sparingly (flares: WBC, H/H, f/u w/ endoscopy ref if no improvement)
Crohn’s dz eti
- ANY portion of GI tract (ileum = MC)
- transmural involvement
- skip lesions (skips parts of tracts)
- bouts of flares & remission
Crohn’s dz s/s
- prolonged D & abd pain, fatigue, wt loss
- obstructions, perianal dz, fistulas, abscesses
- worse w/ smoking
crohn’s wu
- 1st img = upper GI series w/ small bowel follow thru
- CSY shows cobblestoning & varying deg of ulceration
- labs NOT specific/reliable
crohn’s ddx
UC, IBS, appy, diverticulitis w/ abscess, enteritis, NSAID-induced colitis, perianal fistula (lymphogranuloma venereum, CA, rectal TB)
crohn’s mgmt
- flares: steroids (budesonide = less adr)
- pain (sitz, gentle, pads)
- low-roughage diet if obstructive
- ref to rheum for pts unresponsive to steroids/need chronic steroids (will Rx immunomodulators: methotrexate)
- CSY q yr (w/ 8+ yr h/o dz)
- mesalamine & abx use are NOT effective in flares
crohn’s comps
- small bowel strictures
- fistulae (bowel, bladder, vagina, skin)
- high oxalate from malabsorption of injested fat (binds to Ca = kidney/gall stones)
- surgery
ulcerative colitis eti, s/s
- begins in rectum, limited to colon, superficial penetration of mucosal wall, bouts of flares/remission
- proctitis, tenesmus (rectal cramp/urgency w/wo small BM, strain), low abd/pelvic pain/cramp, bloody D, mucus/pus per rectum, F
UC ddx
colitis (inf, ischemic, pseudomembranous/CDAD), crohn’s, diverticular dz, colon CA, inf proctitis (G/C, HSV, syphilis), s/p radiation
UC wu
- labs: low sAlbumin, anemia, high ESR
- neg stool cx
- dx via sigmoidoscopy w/ bx (crypt abscesses, chronic colitis)
- barium enema (“stovepipe” colon: loss of haustra)
UC mgmt
- distal: DOC = mesalamine, hydrocortisone (suppository) prn - 2nd = PO sulfasalazine
- mild/mod (above sigmoid): mesalamine PO +/- hydrocortisone foam, enema prn - ref to rheum for immunomod if no response
- sev flare: ED for admission
- CSY q 1-2 yrs for pts w/ h/o dz x 8+ yrs
UC comps
toxic megacolon, ext of colonic dz, perf, strictures
IBS eti, ddx
- chronic abd pain & alt bowel habits in ABSENCE of organic cz (FUNCTIONAL)
- dietary, inf, IBD, psychogenic, malabsorption, tumor, endometriosis
IBS s/s
- pain relieved w/ BM
- more freq BM at onset of pain
- mucus
- bloating
- sense of incomplete evacuation
- urgency
IBS wu
- need to r/o IBD, inf, CA
- FOBT
- CBC, CMP, ESR, sAlbumin, +/- TSH
- celiac panel if D
- Manning and Rome criteria for DX
Red flags for CSY (in IBS wu, aka, not IBS)
- abnml exam
- F
- +FOBT
- wt loss
- onset in elderly
- nocturnal awakening
- anemic
- high WBC and/or ESR
IBS mgmt
- elimination diet (gluten, lactose) if elevated IgG
- psych for anxiety/depression
- antispasmodic/depressant for abd pain
- loperamide (caution) for D
- bulking agents (fiber) for C
- NO CURE
ischemic bowel dz epi/eti/RF
- most = acute
- from low BP, clot, vasoconstriction, idiopathic
- RF: age, atherosclerosis, low CO, arrhythmias, sev valve dz, recent MI, intra-abd malignancy
ischemic bowel dz s/s
- D, F
- hyperactive phase: bloody BM, sev abd pain
- paralytic phase: diffuse abd pain, tender abd, bloating, no more bloody BM, absent BS
- shock phase: leaky colon = metabolic acidosis, dehydration, hypotension, tachycardia, confusion
ischemic bowel dz wu, prog
- mesenteric angiography = GS, consult surg
- most pts fully recover w/o sequelae
ischemic bowel dz mgmt
- restore blood flow
- supportive
- correct metabolic acidosis (bicarb, lytes)
- broad spec AB (if mod/sev: cipor/metro)
- NGT for gastric decompression
- bowel rest
anal fissure cz/prev
- C/D, inf (TB, syphilis, HIV, abscess), IBD, anal sex, childbirth
- high fiber/fluid to prev D, wipe w/ moist cloth
anal fissure s/s
- tearing pain w/ BM (less if chronic)
- BRB on TP
- MC at posterior midline
- perianal pruritis/irritation
- chronic lesions: raised edges w/ ext skin tags & hypertrophied villae
anal fissure ddx
perianal ulcer (IBD, TB, STI), anorectal fistula
anal fissure mgmt
- stop C
- sitz
- 1% hydrocortizone cream, 2% NTG cream (vasodil, inc blood flow, dec internal anal sphinter pressure = can heal)
- surg consult if not better in 6 wks (internal sphincterotomy)
B9 colorectal neoplasms
- non-neoplastic polyps: hyperplastic, hamartomatous, inflammatory, lymphoid = NO PRE-MAL
- Neoplastic epithelial polyps: tubular/tubulovillous/villous adenomas = PRE-MAL (screen more freq)
- leiomyoma: smooth muscle tumor in colon/rectum
- others: lipoma, neuroma, hemangioma, lymphangioma
Colorectal adenocarcinoma = MAL
eti/RF
- 95% of primary colon CA
- 30% rectum, 25% right colon
- RF: age, FHx (30%), T2DM, metobolic synd, AA, IBD, high red/processed meats, inactivity, obesity, smoking, heavy EtOH
Associated familial syndromes of colon CA
- FAP (Familial adenomatous polyposis): inc risk of thyroid, pancreas, duodenal, and gastric CA
- HNPCC (Hereditary Non-polyposis Colorectal Cancer): assoc w/ endometrial, ovarian, gastric, urinary, renal cell, biliary, and gallbladder CA
- most occur > 50 y.o.
colon CA screening
- Assess risk at 20 y.o.
- CSY q 10 yr starting at 45 (AA) or 50 OR 10 yrs sooner than age of dx of family member
- stop when life exp < 10 yrs or pt is 85 y.o.
- CT colonography or flex sig q 5 yrs
- FOBT q yr if img not poss
colon CA s/s
rectal bleeding, Fe def anemia, fatigue/wt loss, obstruction, change in stool quantity/caliber, abd mass/pain, weakness, met to liver/lung
colon CA wu
- CSY for bx
- abd/pelvis CT for staging (“apple core” lesions)
- CXR for mets
- labs (CBC, CMP, baseline CEA)
- PET
colon CA mgmt
- early stage tumors: endoscopic removal
- hemicolectomy w/ lymph resect
- local tx of mets
- chemo for micromets
- rad not typically used b/c of toxic effect in gut
bowel obstruction can be mechanical or fxnl
- mech: intrinsic, post-op
- fxnl: paralytic, lyte abnml, DM
cause of lg bowel obst
- MC = neoplasms
- tic dz, volvulus (sigmoid, cecal), adhesions
cause of small bowel obst
- MC = adhesions (prev surg)
- hernia, neoplasm, stricture, intussusception, Meckel’s tic, volvulus, intramural hematoma
s/s of bowel obst
crampy/generalized abd pain/distension w/ diffuse midabd TTP (r/o ischemia), NO signs of peritonitis, reduced urine output, no flatus (can pass up to 12-24 hr s/p onset)
bowel obst wu
- chk lytes
- lactate if concern for strangulation/ischemia
- KUB (distended small B, air-fluid levels, free air under diaphragm (if perf’d), “swirl sign” (bowel twist on mesentary), “bird’s beak” or “corkscrew” (if volvulus)
- CT for further localization
- SBO in absence of prior abd surg = malignancy wu
bowel obst mgmt
- IVF
- abx (cipro/metro?)
- NPO, NGT decompression
- volvulus: rectal tube decompression w/ surg repair
- ischemia/perf: surgery
Toxic megacolon def
potentially lethal. total/segmental nonobstructive colonic dilation + systemic toxicity
toxic megacolon eti
IBD, inf/ischemic colitis, volvulus, diverticulitis, obst colon CA
toxic megacolon s/s, wu
s/s: sev bloody D
wu: XR (R colon dil > 6 cm, dil of trans colon, abscence fo haustra)
toxic megacolon mgmt
IVF, fix lytes, IV vanc/metro, bowel rest & decompress (NGT), surg consult (colectomy w/ end-ileostomy for refractory pts)
rectal abscess eti, s/s, wu, mgmt
eti: inf anal glands
s/s: sev pain, F/malaise, +/- fistula
wu: pelvic MR if nonvisible/palpable (use Goodsall’s rull to asses tract location if suspect fistula)
mgmt: I&D w/ cx (for pain out of proportion on PE), OR for complex location, abx if valve dz/immunosupp’d/extensive cellulitis/DM, surgery for fistula
Hemorrhoids
- engorged venous plexus. classified based on relation to DENDRATE line (divides the upper two thirds and lower third of the anal canal).
- czs: C/strain, portal HTN, preg
external hems
- rarely bleed, very painful (esp if thrombosed = lance/remove clot), itch, visible
- sitz, 1% hydrocortisone, stool softener, surg if refractory
internal hems grading
I: bulge into lumen, not below denate line
II: prolapse but spontaneously reduce
III: patient can reduce
IV: nonreducible (may strangulate, surg)
internal hems s/s, mgmt
s/s: painless bleed s/p BM, visible w/ anoscopy, not palpable/painful on DRE
mgmt: 1% hydrocortisone, band lig (GI/surg) if prolapse
