Disorders of the Colon Flashcards
Ulcerative Colitis: What is it?
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
Ulcerative Colitis: Etiology
- Unknown
- Multifactoral (family history, genetic mutation, environmental factors, autoimmunity)
Ulcerative Colitis: Assessment Findings
- 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
Ulcerative Colitis: Risk Factors
Positive Family History
Ulcerative Colitis: Diagnostic Studies
- 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
Ulcerative Colitis: Non-Pharmacologic Management
- 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
Ulcerative Colitis: Pharmacologic Management
- 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
Crohn’s Disease: What is it?
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)
Crohn’s Disease: Etiology
Idiopathic
Crohn’s Disease: Risk Factors
- Family history
- Cigarette smoking
- Food allergies
- Stress
Crohn’s Disease: Assessment Findings
- 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
Crohn’s Disease: Diagnostic Studies
- 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
Crohn’s Disease: Non-Pharmacologic Treatment
- 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
Crohn’s Disease: Maintaining Nutrition and Weight
- 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
Crohn’s Disease: When is surgery indicated?
- 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
Crohn’s Disease: Pharmacologic Therapy
- 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
Crohn’s Disease: Expected Course
- 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
Irritable Bowel Syndrome: What is it?
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.
Irritable Bowel Syndrome: Etiology
- Unknown
- Stress believed to be a factor
- Postinfectious theory: small intestine bacterial overgrowth (SIBO)
- Connection with food allergy or intolerance
Irritable Bowel Syndrome: Risk Factors
- Family history
- Depression, anxiety
- High levels of stress
Irritable Bowel Syndrome: Assessment Findings
- 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
Irritable Bowel Syndrome: Diagnostic Studies
- 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
Irritable Bowel Syndrome: Non-Pharmacologic Management
- 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
Irritable Bowel Syndrome: Pharmacologic Management
- Bulk producing agents
- Stool softeners
- Stimulants/Irritants
- Antidiarrheals
- Antispasmodics/Anticholinergics
- Laxatives for IBS-C Predominant
- Treatment for IBS-D Predominant
Irritable Bowel Syndrome: Bulk Producing Agents
Psyllium
Irritable Bowel Syndrome: Stimulants/Irritants
- Bisocodyl
- Senna
Irritable Bowel Syndrome: Antidiarrheals
- Loperamide
Irritable Bowel Syndrome: Antispasmodic/Anticholinergics
- Dicyclomine
- Hyoscyamine sulfate
- Phenobarbital/hyoscamine/atropine/scopolamine
Irritable Bowel Syndrome: Laxatives for IBS-C
- Lubiprostone
- Linaclotide
Irritable Bowel Syndrome: Treatment for IBS-D
- Rifaximin
- Alosetron
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
Hemorrhoids: Internal hemorrhoids
Occur above the dentate line
Hemorrhoids: External hemorrhoids
Occur in the perianal skin folds and results from prior perianal swelling: symptomatic only when becoming thrombosed
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)
Hemorrhoids: Risk Factors
- Chronic constipation
- Straining with defecation
- Chronic diarrhea
- Pregnancy (due to constipation and direct effect of gravid uterus)
- HTN, heart failure
- Prolonged sitting
- Obesity
- Colon malignancy
- Low-fiber diet
- Lifting heavy weights
- Aging
Hemorrhoids: Assessment Findings for Internal Hemorroids
- Painless bright red bleeding with defecation
- Feeling of incomplete evacuation after bowel movements
Hemorrhoids: Assessment Findings for External Hemorrhoids
- Anal itching
- Pain with defecation
- Anal protrusion of blue, shiny mass
- Can be acutely painful
Hemorrhoids: Diagnostic Studies
- 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
- Colonoscopy preferred because greater amount of colon can be visualized during exam
- Sigmoidoscopy
- Consider Hgb/Hct check if significant lower GI bleeding
- Anoscopy
Hemorrhoids: Prevention
- Avoid constipation
- Refrain from prolonged sitting and straining with bowel movements
Hemorrhoids: Non-Pharmacologic Management
- Sitz baths to alleviate pain
- Education about prevention
- High-fiber diet and liberal water intake
- Cold packs
- Rubber band ligation (internal hemorrhoids)
- Infrared coagulation (external hemorrhoids)
- Sclerotherapy
- Incision/evacuation for acutely thrombosed hemorrhoids if presentation occurs within 72 hours of symptom onset (surgical consultation)
- Hemorrhoidectomy for severe cases
- Hemorrhoids that occur with pregnancy usually resolve after delivery without treatment
Hemorrhoids: Pharmacologic Management
- Constipation medications
- Fiber supplements
- Stool softeners
- Analgesic ointment: benzocaine, dibucaine
- Corticosteroid preparations (to reduce itching and shrink swollen hemorrhoids): hydrocortisone
