Disorders of the Colon Flashcards
1
Q
Ulcerative Colitis: What is it?
A
Chronic inflammation of the colonic mucosa and submucosa. Inflammation is continuous, widespread, and superficial, and almost always involves the rectum.
- Hallmark finding is continuous, symmetric involvement of the colon
2
Q
Ulcerative Colitis: Etiology
A
- Unknown
- Multifactoral (family history, genetic mutation, environmental factors, autoimmunity)
3
Q
Ulcerative Colitis: Assessment Findings
A
- Bloody or mucus-like diarrhea, rectal bleeding, fecal incontinence
- Tenesmus (cramping pain of the anal or vesical sphincter)
- Abd pain/cramping with sense of urgency and incomplete evacuation
- Weight loss and decreased appetite
- Fever, tachycardia, anemia with toxicity (severe cases)
- Extracolonic disease features: uveitis, arthritis, dermatitis, sclerosing cholangitis
- Low energy, fatigue
- Aphthous oral mucosa ulcerations
- Clubbing of fingernails (chronic disease)
- Peripheral edema
4
Q
Ulcerative Colitis: Risk Factors
A
Positive Family History
5
Q
Ulcerative Colitis: Diagnostic Studies
A
- Colonoscopy or sigmoidoscopy with biopsy: establishes whether inflammation is present and defines extent of involvement
- Plan abdominal films or CT scan: identifies toxic megacolon and should be used in UC accompanied by fever, abd pain, leukocytosis
- Air contrast barium enema: often normal in early disease
- CBC to detect anemia and leukocytosis
- Sedimentation rate: elevated
- pANCA: elevated in 85% of patients
- Serum electrolytes: hypokalemia
- Stools for culture, ova and parasite, giardia, cryptosproridium, C. diff
6
Q
Ulcerative Colitis: Non-Pharmacologic Management
A
- Complete bowel rest indicated ONLY in acute fulminant disease
- UC diet that avoids common triggers: caffeine, alcohol, carbonated beverages, lactose (patient-specific)
- Stress management
- Lifestyle modifications (exercise, healthy dietary choices)
- Surgery is curative and should be considered for disease that is unresponsive to 2-3 weeks of medical therapy
7
Q
Ulcerative Colitis: Pharmacologic Management
A
- Oral aminosalicylates (5-ASA): treatment of choice for chronic treatment of mild to moderate disease
- 5-ASA without sulfapyridine (Mesalamine) or another first-line choice to achieve remission
- Rectal (topical) 5-ASA options only or with the oral 5-ASA as an enema or suppository
- Steroid enemas or suppositories for proctitis or proctosigmoiditis
- Oral and parenteral steroids to manage more severe exacerbations
- In patients unresponsive to steroids, immune modulators are used
- Biologic therapy when unresponsive to therapy
- Antidiarrheal should be used cautiously
8
Q
Crohn’s Disease: What is it?
A
Chronic, slowly progressive transmural inflammation of the GI tract, small intestine (most common site), and/or large intestine, often involving the terminal ileum. Disease presentation ranges from mild to severe.
- Categorized unde the umbrella of inflammatory bowel disease (IBD)
9
Q
Crohn’s Disease: Etiology
A
Idiopathic
10
Q
Crohn’s Disease: Risk Factors
A
- Family history
- Cigarette smoking
- Food allergies
- Stress
11
Q
Crohn’s Disease: Assessment Findings
A
- Diarrhea, including nocturnal
- Occasional blood in stool (subjective)
- Occult bleeding (positive occult fecal blood test or immunochemical testing)
- Hematochezia (less common than in UC)
- Fever
- Abd pain and tenderness, perianal pain
- Ulcers of the intestine or mouth
- Fatigue
- Weight loss
- Abdominal mass
- Fistulas
- Intestinal obstruction (uncommon)
- Megacolon
- Joint swelling, hepatosplenomegaly
- Bone age in children usually delayed by 2 years
12
Q
Crohn’s Disease: Diagnostic Studies
A
- EGD: lumen narrowing with ulceration and nodularity. Cobblestone appearance, abscess and fistulas may be present
- Flexible sigmoidoscopy/colonoscopy to assess for ileocolic Crohn’s disease: polypoid mucosa changes that give a “cobblestone appearance”
- CT or MRI
- Antiglycan antibody: elevated in 75% of cases
- Barium xrays
- Sed rate: elevated
- CBC: anemia
- Albumin: below normal if severe disease
- Electrolytes: imbalances
- B12, folate deficiency
- Stool studies, fecal occult
- CRP
- Genetic testing
13
Q
Crohn’s Disease: Non-Pharmacologic Treatment
A
- Maintain nutrition and weight
- Stress management
- Sitz baths helpful if perianal irritation present
- Drainage of perirectal abscess, if present
- Manage extracolonic manifestations
- Long-term sulfasalazine therapy is associated with reversible sterility in men
- Surgery when indicated
14
Q
Crohn’s Disease: Maintaining Nutrition and Weight
A
- Non-pharmacologic Management
1. Avoid trigger foods
2. Low-fat diet
3. Avoid lactose (can worsen diarrhea)
4. Low-fiber diet if strictures present
5. Avoid caffeine, alcohol, nuts, seeds
6. Exercise regularly
15
Q
Crohn’s Disease: When is surgery indicated?
A
- Abscess refractory to nonoperative management
- Intestinal obstruction
- Bowel perforation
- GI bleeding refractory to medical therapy
- Enteric fistula refractory to medical therapy
- Small bowel or colon cancer
- Persistent inflammation refractory to medical therapy
16
Q
Crohn’s Disease: Pharmacologic Therapy
A
- Goal of therapy is to stop autoimmune response and promote healing
- Standard dose mesalamine or diazo-bonded mesalamine, sulfasalazine, or no treatment
- Oral 5-ASA for acute disease and maintenance
- For acute flare or inability to tolerate 5-ASA: antibiotics (metronidazole, ciprofloxacin)
- Short-term corticosteroids for moderate to severe disease
- Immunosuppressants such as azathioprine or mercaptopurine, methotrexate for severe, progressive disease
- Biologics such as adalimumab or inflizimab alone or in conjunction with azathioprine
- Antispasmotics, antidiarrheals, probiotics may be helpful
17
Q
Crohn’s Disease: Expected Course
A
- Chronic illness with recurrences and exacerbations
- Surgery usually needed every 4-7 years
- Full activities
- Normal but often shortened lifespan
- Surgery is not curative
- 5 year and 10 year rates of re-operation 24% and 35% respectively
18
Q
Irritable Bowel Syndrome: What is it?
A
Common intestinal disorder that causes cramping, abd pain, bloating, and changes in bowel habits (constipation and/or diarrhea). IBS is classified according to the patient’s predominant symptoms: IBS-D for diarrhea, IBS-C for constipation, IBS-M for mixed, and unclassified IBS.
- For diagnosis, symptoms must be present for at least 3 days a month for at least 3 months.
19
Q
Irritable Bowel Syndrome: Etiology
A
- Unknown
- Stress believed to be a factor
- Postinfectious theory: small intestine bacterial overgrowth (SIBO)
- Connection with food allergy or intolerance
20
Q
Irritable Bowel Syndrome: Risk Factors
A
- Family history
- Depression, anxiety
- High levels of stress
21
Q
Irritable Bowel Syndrome: Assessment Findings
A
- Crampy abdominal pain in lower quadrants
- Pain relieved after defecation or passage of gas
- Feelings of incomplete passage of stool
- Constipation and/or diarrhea
- Mucus in stool
- Abdominal distention, bloating, gas
- No significant weight loss
- No bleeding, persistent severe pain, or fever
** ALARM symptoms are rectal bleeding, nocturnal pain, and weight loss
22
Q
Irritable Bowel Syndrome: Diagnostic Studies
A
- CBC, chemistries: normal
- Serum IgA antibody to tissue transglutaminase: positive with celiac disease
- Sed rate: normal
- Stool for ova and parasites, culture, C. diff, occult blood: negative
- Colonoscopy or flexible sigmoidoscopy to rule out other disorders: may show spasm or increased mucosal folds (low diagnostic yield, not cost-effective)
** If Crohn’s is suspected, a colonoscopy with biopsy if necessary to confirm diagnosis
23
Q
Irritable Bowel Syndrome: Non-Pharmacologic Management
A
- Consider trial of lactose-free diet
- Exclusion of gas-producing foods
- Diet low in fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAP)
- Stress management, stress-reducing therapies
- Biofeedback
- Heat to abdomen
- Education about illness
- Avoid stimulants known to cause difficulty
24
Q
Irritable Bowel Syndrome: Pharmacologic Management
A
- Bulk producing agents
- Stool softeners
- Stimulants/Irritants
- Antidiarrheals
- Antispasmodics/Anticholinergics
- Laxatives for IBS-C Predominant
- Treatment for IBS-D Predominant
25
Irritable Bowel Syndrome: Bulk Producing Agents
Psyllium
26
Irritable Bowel Syndrome: Stimulants/Irritants
1. Bisocodyl
2. Senna
27
Irritable Bowel Syndrome: Antidiarrheals
1. Loperamide
28
Irritable Bowel Syndrome: Antispasmodic/Anticholinergics
1. Dicyclomine
2. Hyoscyamine sulfate
3. Phenobarbital/hyoscamine/atropine/scopolamine
29
Irritable Bowel Syndrome: Laxatives for IBS-C
1. Lubiprostone
2. Linaclotide
30
Irritable Bowel Syndrome: Treatment for IBS-D
1. Rifaximin
2. Alosetron
31
Hemorrhoids: What is it?
Varicose veins of the hemorrhoidal venous plexus that cause anal discomfort. Classified as grade I-IV, ranging from visualization/bulging to irreducible and possibly strangulated
** Two types
32
Hemorrhoids: Internal hemorrhoids
Occur above the dentate line
33
Hemorrhoids: External hemorrhoids
Occur in the perianal skin folds and results from prior perianal swelling: symptomatic only when becoming thrombosed
34
Hemorrhoids: Etiology
Veins of the hemorrhoidal plexus become engorged as a result of:
- Passage of stool: shearing force, straining
- Increased venous pressure (ex: pregnancy, heart failure, and other risk factors)
35
Hemorrhoids: Risk Factors
1. Chronic constipation
2. Straining with defecation
3. Chronic diarrhea
4. Pregnancy (due to constipation and direct effect of gravid uterus)
5. HTN, heart failure
6. Prolonged sitting
7. Obesity
8. Colon malignancy
9. Low-fiber diet
10. Lifting heavy weights
11. Aging
36
Hemorrhoids: Assessment Findings for Internal Hemorroids
1. Painless bright red bleeding with defecation
2. Feeling of incomplete evacuation after bowel movements
37
Hemorrhoids: Assessment Findings for External Hemorrhoids
1. Anal itching
2. Pain with defecation
3. Anal protrusion of blue, shiny mass
4. Can be acutely painful
38
Hemorrhoids: Diagnostic Studies
1. Digital rectal exam to check for masses: Check stool for occult blood. If positive, refer for colonoscopy. Do not assume bleeding is due to hemorrhoids
2. Colonoscopy preferred because greater amount of colon can be visualized during exam
3. Sigmoidoscopy
4. Consider Hgb/Hct check if significant lower GI bleeding
5. Anoscopy
39
Hemorrhoids: Prevention
- Avoid constipation
- Refrain from prolonged sitting and straining with bowel movements
40
Hemorrhoids: Non-Pharmacologic Management
1. Sitz baths to alleviate pain
2. Education about prevention
3. High-fiber diet and liberal water intake
4. Cold packs
5. Rubber band ligation (internal hemorrhoids)
6. Infrared coagulation (external hemorrhoids)
7. Sclerotherapy
8. Incision/evacuation for acutely thrombosed hemorrhoids if presentation occurs within 72 hours of symptom onset (surgical consultation)
9. Hemorrhoidectomy for severe cases
10. Hemorrhoids that occur with pregnancy usually resolve after delivery without treatment
41
Hemorrhoids: Pharmacologic Management
1. Constipation medications
2. Fiber supplements
3. Stool softeners
4. Analgesic ointment: benzocaine, dibucaine
5. Corticosteroid preparations (to reduce itching and shrink swollen hemorrhoids): hydrocortisone
