GI Conditions: D/O of Small & Large Intestine - Porth, Chpt. 29 Flashcards
How many Layers are there in the walls of the Large & Small Intestine?
4
Conditions that Cause Altered Intestinal Function
- Irritable Bowel Syndrome
- Inflammatory Bowel Disease
- Infectious Enterocolitis
- Diverticulosis
- Appendicitis
- Bowel Motility D/Os
- Diarrhea, Constipation, Obstruction
- Peritonitis
- Malabsorption Syndrome
- Colon CA
- Rectal CA
Shit… there’s alot.
Irritable Bowel Syndrome

“Functional GI disorder w/ variable combo of chronic & recurrent intestinal symptoms not explained by structural or biochemical abnormalities”
10-20% of ppl in Western countries have this… most do not seek medical attention.
Irritable Bowel Syndrome
Characterized

- Persistent, recurrent symptoms:
- Abdominal Pain
- Altered Bowel Function
- C/O - Flatulence, Bloating, Nausea, Anorexia, Constipation, Diarrhea
- Anxiety or Depression
Irritable Bowel Syndrome
Hallmark!
-
Abdominal Pain relieved by defecation & associated w/ change in consistency or frequency of stools
- Abd pain = intermittent, crampy, lower abdomen
- Doesn’t interfere w/ sleep
Irritable Bowel Syndrome
Why does this happen?
- Dysregulation of intestinal motor & sensory functions modulated by CNS
- Occurance reacts to stress
- Exaggerated responses
- Psych. role is uncertain
- Occurance reacts to stress
Irritable Bowel Syndrome
+ Women
- Occurs more often in women
- Exacerbated around premenstrual period
- Hormonal component?!
Irritable Bowel Syndrome
Diagnosis

- Clinically
- Signs & Symptoms
- Common diagnostic:
- Continuous or Recurrent of at least 12 weeks’ duration (in past year)
- W/ 2 of the following features:
- Relief with defecation
- Onset assc. w/ change in bowel frequency
- Assc. w/ change in stool form
Irritable Bowel Syndrome
Other Diagnostic Criteria
- Abnormal stool frequency
- Abnormal form
- Abnormal Passage
- Passage of Mucus
- Feeling of abdominal distention/Bloating
- Consider a history of Lactose Intolerance
Irritable Bowel Syndrome
Acute onset of Symptoms
- Be suspicious…
- Raise likelihood of organic disease
- As do
- Weight loss
- Anemia
- Fever
- Occult Blood in Stool….
- As do
- Raise likelihood of organic disease
Irritable Bowel Syndrome
Treatment
- Stress Management!!!
- Esp. related to symptom production
- Reassurance.
- Fiber intake :-)
- Avoid offending foods: fatty, gas-producing
- Antispasmodics, Anticholinergics
-
Alosetron = 5-HT3
- FDA approved for IBS
- reduces intestinal secretions, decreases nerve activity, reduces motility
- Restricted prescribing program
Inflammatory Bowel Disease
Designates 2 related inflammatory d/os:
- Chron’s Disease
- ulcerative colitis

Inflammatory Bowel Disease
Chron’s & UC
What do they have in common?
- Produce bowel inflammation
- Lack evidence of causative agent
- Familial pattern of occurace
- & both can have Systemic Manifestations
Inflammatory Bowel Disease
Chron’s & UC
What do symptoms do they share?
- Remissions & Exacerbations of:
- Weight Loss
- Fecal urgency,
- Diarrhea
- Intestinal Obstructions may occur during flares
Inflammatory Bowel Disease
Chron’s & UC
Location Differences
- Chron’s
- Distal Small Intestine
- Proximal Colon
- & can affect any area of GI Tract
- Ulcerative Colitis, confined to:
- Colon
- Rectum

Inflammatory Bowel Disease
Chron’s & UC
What makes these guys act up?
- Result of activation of inflammatory cells w/ elaboration of inflammatory mediators
- causes non-specific tissue damage
Inflammatory Bowel Disease
Chron’s & UC
Systemic Manifestations
- Axial arthritis
- spine & sacroiliac joints
- Oligoarticular arthritis
- large joints of arms & legs
- Uveitis
- Skin lesions
- Erythema nodosum
- Stomatitis
- Blood D/Os
- Inflammation of Bile Duct
Inflammatory Bowel Disease
Table 29-1: Differentiating CD vs. UC
Chron’s

- Granulomatous inflammation
- Submucosal layer involved
- Skip lesions = extent of involvement
- Primarly ileum & colon involved
- Diarrhea common
- Rectal Bleeding rare
- Fistulas, Strictures, Perianal Absesses = common
- Cancer development? Rare
Inflammatory Bowel Disease
Table 29-1: Differentiating CD vs. UC
Ulcerative Colitis

- Ulcerative & Exudative inflammation
- Mucosal layer involved
- Continous involvement
- Rectum & Left Colon involved
- Diarrhea & Rectal Bleeding common
- Fistulas, Strictures, Perianal Absesses = rare
- Cancer development? Common!
Inflammatory Bowel Disease
Chron’s & UC
Etiology & Pathogenesis
- Causes = uncertain
- Growing evidence of:
- Genetic Factors predispose to an immune response
- Possible triggered by:
- Dietary antigen, or
- Microbial agent
- Evidence of intestinal microorganisms contribution…but still uncertain!
Inflammatory Bowel Disease
Chron’s & UC
Tobacco Smoking:
Good for one, Bad for the other…
Smoking Tobacco:
- Predisposes to Chron’s
- Reduced incidence of Ulcerative Colitis
Inflammatory Bowel Disease
Chron’s & UC
Genetic Basis
- Greater risk if affected family member
- Family hx more common in Chron’s vs. UC
- Linked to:
- Major Histocompatibility class II alleles
- Chomosome 16 and 5 in Chron’s
Inflammatory Bowel Disease
Chron’s Disease
- Recurrent, granulomatous type of inflammatory response
- Affects ANY area of GI Tract
- Slowly progressive, Relentless, Disabling!!
- Strikes around age 20-30’s; MC in women

Inflammatory Bowel Disease
Chron’s Disease
- Recurrent, granulomatous type of inflammatory response
- Affects ANY area of GI Tract
- Slowly progressive, Relentless, Disabling!!
- Strikes around age 20-30’s; MC in women
Inflammatory Bowel Disease
Chron’s Disease
Characteristic Features
- Sharply demarcated, granulomatous lesions
- Surrounded by normal-appearing tissue

Inflammatory Bowel Disease
Chron’s Disease
Skip Lesions
- Multiple Lesions
- Interspersed btwn Normal Bowel Segments
- All layers of the bowel are involved, w/ submucosal layer affected most

Inflammatory Bowel Disease
Chron’s Disease
Skip Lesions
- Multiple Lesions
- Interspersed btwn Normal Bowel Segments

Inflammatory Bowel Disease
Chron’s Disease
“Cobblestone Appearance”
- Surface of inflamed bowel
- Fissures & Crevices
- surround by regions of submucosal edema

Inflammatory Bowel Disease
Chron’s Disease
Appearance over time….
- Wall over time becomes thickened & inflexible
- “lead pipe”, “rubber hose”
- mesentery inflamed
- regional lymphs & channels enlarged
Inflammatory Bowel Disease
Chron’s Disease
Clinical Course
- Variable
- Periods of Exacerbations & Remissions
- Symptoms related to location of lesions
Inflammatory Bowel Disease
Chron’s Disease
Symptoms
- Symptoms:
- Intermittent Diarrhea
- Ulceration of perianal skin can occur
- Colicky Pain (LRQ)
- Weight Loss
- Fluid & Electrolyte D/Os
- Malaise
- Low Grade Fevers
- Intermittent Diarrhea

Inflammatory Bowel Disease
Chron’s Disease
Why is there less bloody diarrhea in Chron’s than UC?
- B/c Chron’s affects the submucosal layer more than the mucosal layer
Inflammatory Bowel Disease
Chron’s Disease
Disrupted Absorptive Surfaces
- Nutritional Deficiencies may occur
- In childhood:
- Retardation of growth & physical development
- Retardation of growth & physical development
Inflammatory Bowel Disease
Chron’s Disease
Complications
- Fistula Formation
- Abdominal abscess formation
- Intestinal obstruction
Inflammatory Bowel Disease
Chron’s Disease
Complications
- Nutritional Deficiencies may occur
- In childhood:
- Retardation of growth & physical development
- Retardation of growth & physical development
Inflammatory Bowel Disease
Chron’s Disease
Fistulas
- Tubelike passages forming connections btwn different sites in the GI Tract
- May develop in other sites
- Perineal fistulas originate in the ileum (common)
- Lead to:
- Malabsorption
- Syndromes of bacterial overgrowth
- Diarrhea
- can also get infected & form abscesses
Inflammatory Bowel Disease
Chron’s Disease
Diagnosis
- Hx and PE
- sigmoidoscopy for direct visualization of affected areas & Biopsy
- Stool cultures
- r/o infectious agents
- Radiographic contrast studies
- Determine extent of involvement & spot fistulas
Inflammatory Bowel Disease
Chron’s Disease
Treatment - Basics
- Terminating the inflammtory response, promote healing, maintain adequate nutrition, prevent complications
- Nutritious diet
- Elemental!
- Balanced, residue & bulk free
- Elemental!
- Medications (see next flashcard)
If necessary: Surgical resection, drainage of abscesses, fistula repair
Inflammatory Bowel Disease
Chron’s Disease
Treatment - Medications
- 5-aminosalicylic acid (5-ASA) agents
- Pentsa
- act locally
- first line
- Pentsa
- corticosteroids
- suppress acute clinical symptoms
- antibiotics
- Metronidazole - treats bacterial overgrowth
- immunosuppresent drugs
- Azithioprine
- Methotrexate
- used if no respose to other therapies
- anti-TNF
- infliximab
- adalimumab
Inflammatory Bowel Disease
Ulcerative Colitis
Non-specific Inflammatory Condition
More common in US & Western Countries
Occurs at any age; peak in 3rd decade

Inflammatory Bowel Disease
Ulcerative Colitis
Confined to:
Rectum & Colon
- Begins in Rectum & spreads proximally*
- affects mucosal layer (sometimes submucosal)*

Inflammatory Bowel Disease
Ulcerative Colitis
May involve

- Rectum alone: Ulcerative Proctitis
- Rectum & Sigmoid Colon: Proctosigmoiditis
- Entire Colon: Pancolitis
Inflammatory Bowel Disease
Ulcerative Colitis
Does it have Skip lesions?
Nope!!
Ulcerative Colitis confluent & continuous
vs. Skipping areas like Chron’s
Inflammatory Bowel Disease
Ulcerative Colitis
Characteristics
- Lesions that form in crypts of Lieberkühn (Bieber-kuhn?)
- Inflammatory process leads to:
- pinpoint mucosal hemorrhages
- turn into: crypt abscesses
- May become necrotic & ulcerate
- __ulcers can grow large!
- pinpoint mucosal hemorrhages
- Bowel wall thickens
Inflammatory Bowel Disease
Ulcerative Colitis
Characteristics - Mucosal Layer may develop _____
Pseudopolyps
- Due to inflammatory process
- ‘tounge-like projections’
Inflammatory Bowel Disease
Ulcerative Colitis
Presentation
- Relapsing Disorder
- w/ Diarrhea attacks
- May persist days-weeks-months!
- then subside…
- May persist days-weeks-months!
- w/ Diarrhea attacks
- Stools contain Blood & Mucus!
- b/c affects mucosal layer! vs. Chron’s
- Nocturnal diarrhea esp if day diarrhea
- Mild abdominal cramping
- Fecal incontinence
- Anorexia, weakness, fatigability = common
Inflammatory Bowel Disease
Ulcerative Colitis
Severity & Extent
- Severity:
- Mild =
- most common; <4 stools/day, +/- blood, no toxicity, normal ESR
- Moderate =
- >4 stools/day, minimal toxicity
- Severe =
- >6 stools/day, bloody, toxicity signs, elevated ESR
- Fulminant
- >10 stools/day, bloody, toxcitiy, dilatation, transfusions… (bad stuff)
- Mild =
Inflammatory Bowel Disease
Ulcerative Colitis
Severity: Fulminant
- Fulminant Disease:
- w/ all its horrible things (bleeding, fever, distention, need for transfusions) leads to
- Toxic Megacolon risk!
- Colon dilation & systemic toxicity
- Toxic Megacolon risk!
- w/ all its horrible things (bleeding, fever, distention, need for transfusions) leads to
Inflammatory Bowel Disease
Ulcerative Colitis
Feared Complications of Ulcerative Colitis
Cancer of the Colon
- Regular annual or biannual surveilence colonoscopies w/ multiple biopsies
- Beginning 8-10 years after diagnosis
Inflammatory Bowel Disease
Ulcerative Colitis
Diagnosis
- Hx and PE
- Confirmed by:
- Sigmoidoscopy
- Colonscopy
- Biopsy
- Negative Stool exams (for infectious)
Inflammatory Bowel Disease
Ulcerative Colitis
Who should you NOT perform a Colonscopy on?
- Ppl w/ SEVERE DISEASE
- b/c danger of perforation
Inflammatory Bowel Disease
Ulcerative Colitis
Treatment
- Extent of disease & severity of symptoms
- Control acute manifestations
- Prevent recurance
- May be as easy as avoiding:
- caffeine
- lactose
- spicy foods
- gas-forming foods
- FIber supplements
- Medications (see next card)
- Surgical Treatment (if unresponsive to conservative tmt)
- Take it all out & ileostomy or ileoanal anastomosis
Inflammatory Bowel Disease
Ulcerative Colitis
Medications
- 5-ASA compounds
- Salfasalazine
- Mesalamine
- Corticosteroids
- use selectively
- decrease acute inflammatory response
- Immunomodulating & anti-TNF therapies can also be used
- in severe cases
Infectious Enterocolitis