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Year 1: Patho/Pharm > GI Patho 2 > Flashcards

GI Patho 2 Flashcards

1
Q

Irritable Bowel Disease (IBD)
Incidence, prevalence, risk factors

A

*Canada has highest prevalence in world

Irritable Bowel Disease (IBD)
1. Crohn’s Disease
2. Ulcerative Colitis

Risk Factors
- White
- Azkenazi jewish
- South asian
- family history 10x
- Genes x environment

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2
Q

IBD
Etiology

A

*Shared etiology CD and UC = Chronic inflammatory disorder

Genes x environment

  • Loss of mucosal barrier
  • Loss of immune tolerance for commensal bacteria
  • Dendrites (APC) present antigens to mesenteric lymph and immune system
  • TH1, TH2, TH17, Treg cell differentiation and recruitment
  • Pro-inflammatory cytokines IFN gamma, TNF alpha, ROS (direct damage); recruitment immune cells (macrophages, neutrophils, T cells)

Result
- Chronic inflammatory response against bowel

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3
Q

IBD
2 Diseases

A
  1. Crohn’s Disease
  2. Ulcerative Colitis
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4
Q

Ulcerative Colitis
Cellular pathophysiology

A
  • starts in rectum (proctitis)
  • extends continuously proximally through large intestine (pancolitis)
  • chronic inflammation of mucosa layer
  • starts in Crypt of Lieberkuhn
  • starts on left side (rectum)
  • erythema, edema (pain), mucous, ulceration, bleeding (hematchezia)
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5
Q

Ulcerative Colitis
Clinical Signs and Symptoms

A

Physical assessment

  • pain mild to severe
  • usually left side (rectum)
  • urge to defecate
  • relief of pain with defecation
  • hematchezia (bloody stools)
  • mucous in stools
  • diarrhea (inability to absorb water > 4 per day)
  • fatigue and anemia (loss of blood)

Extracolonic symptoms
- Eyes: sceleritis, uveitis
- Liver: cirrhosis
- Skin: erythema nodosum, psoriasis
- Blood: coagulation problems
- anxiety, depression
*also present in CD

Colonoscopy & biopsy

  • erythema, edema, mucous, bleeding
  • friability
  • ulcerations
  • continuous extension proximally
  • infiltration WBC
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6
Q

Ulcerative Colitis
incidence

A
  • 20 to 40 year olds
  • smoking is protective
  • diet is not associated
  • NSAID use
  • family history
  • pathogenic gastritis
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7
Q

Ulcerative Colitis
Complications

A
  • Bleeding and anemia
  • ulceration
  • perforation
  • hemorrhage
  • toxic megacolon
  • fibrosis
  • cancer
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8
Q

Non- pharmacological Management
UC

A
  • FODMAP diet (reduced dietary fermentable oligo/di, mono and polyols)
  • treatment anxiety and depression
  • Screen for cancer
  • maintain vaccinations
  • Pharmacological induction and maintenance of remission
  • medication adherence
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9
Q

Diagnostic Evaluation
UC

A

Endoscopy with biopsy (gold standard)

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10
Q

Crohn’s Disease
Incidnece and Risk factors

A

10- 30 year olds (earlier onset than UC)

  • smoking 2x
  • NSAIDS, antibiotic use in childhood
  • reduced fibre and fat intake
  • family history
  • physical inactivity
  • stress

Associated conditions
- asthma
- pericarditis
- psoriasis
- celiac disease
- RA
- MS
- anxiety, depression

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11
Q

Crohns’ Disease
Pathophysiology

A
  • Transmural lesion
  • fissures result in spasm and severe pain
  • skip lesions (not continuous)
  • any location mouth to anus
  • most common location distal ileum, proximal cecum (ileocolitis)
  • right sided pain
  • malabsorption vitamins, nutrients (small intestine)
  • hypoalbuminuria and macrocytic anemia
  • granulomas
  • string sign on barium enema (strictures)
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12
Q

Crohn’s Disease
Clinical Signs and Symptoms

A

Cardial symptoms:
- Chronic diarrhea
- abdominal pain
- fatigue

Laboratory diagnostics
- Signs of inflammation: Elevated ESR, CRP, fecal calprotectin, anti saccharomyces cerevisiae antibodies (ASCA)

Physical assessment
- Pain moderate to severe (right side usually)
- weight loss
- malabsorption and nutrient deficit (vitamin B12, folate)
- hypoalbuminuria

Stool
- +/- diarrhea
- not usually bloody

Endoscopy assessment
- skip lesions
- string sign
- granulomas “cobble stone appearance”

Extra-intestinal symptoms
- Mouth: ulcers* unique to CD
- Skin: erythema nodosum
- Liver: cirrhosis
- MSK: arthritis
- Eyes: uveitis, sceleritis
*same as UC

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13
Q

Crohn’s disease
Complications

A
  • Fissures
  • abscesses
  • fistulas
  • perforations
  • obstructions
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14
Q

Crohn’s disease
Non-Pharmacological Management

A
  • Correct nutritional deficiencies (vitamin B12, folate, Vitamin D, etc.)
  • increase protein intake (TNF alpha and IL6 promote cachexia)
  • elimination diet (food that exacerbate symptoms - high residue, nuts, citrus)
  • Stop smoking
  • Management stress, anxiety, depression (CBT, mindfulness)
  • Medication adherence
  • *limited evidence (Probiotics, omega, cannibis)
  • vaccinations up to date
  • screen opportunistic infections
  • colorectal cancer screening
  • DEXA bone density screening
  • Pharmacological induction and maintenance of remission
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15
Q

Celiac Disease
Definition and Risk Factors

A

“Celiac Sprue”

Autoimmune disorder, inflammatory immune response against gluten (protein component in wheat, barley, rye, malt, spelt, kamut)

T-cell mediated auto-immune injury and destruction of SI epithelial villus

Unable to absorb vitamins, protein, fat, carbohydrate

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16
Q

Celiac Disease
Pathophysiology

A

Gluten exposure
- wheat, barley, rye, malt

T-Cell auto-immune response
- formation of antibodies
- 1. TGG IgA (transglutaminase IgA)
- 2. Anti EMA IgA (anti-endomysial antibody)
- Presence of HLA
1. HLA DQ2
2. HLA DQ8

Chronic inflammation of the SI epithelial villi

Direct destruction of the small intestine epithelial villi
- Function: increased SA and 1 cell thick, rapid absorption vitamins and macronutrients (protein, fat, carbohydrates)
- unabsorbed nutrients pull water into intestines
- water, electrolytes excreted
- osmotic diarrhea

GI endocrine dysfunction = malabsorption
- decrease GI hormone production
- decreased pancreatic endocrine/exocrine function
- decreased absorption nutrients

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17
Q

Celiac Disease
Clinical Signs and Symptoms

A
  • diarrhea/constipation
  • nausea/vomitting
  • abdominal pain
  • abdominal distention
  • flatulence
  • malabsorption
  • weight loss
  • failure to thrive
  • atypical symptoms (extra-intestinal): delayed puberty, ammenorrhea, iron deficiency anemia, osteoporosis, elevated LFTs

Osmotic diarrhea +/- pain
- presence of protein, fat, carbohydrates in stool

Malnutrition, weight loss, bleeding
- Vitamin B12, folate deficiency (anemia, neuropathy, stomatitis)
- Vitamin D and calcium deficiency (secondary parathyroidism, osteoporosis)
- Vitamin K deficiency (clotting irregularities)

Skin
- Dermatitis herpetiformis (Duhring’s Disease)

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18
Q

Celiac Disease
Complications

A

Celiac Crisis
- dehydration, electrolyte abnormalities
- severe osmotic diarrhea
- hypoproteinuria

Intestinal lymphoma

Small bowel adenocarcinoma

Refractory celiac disease
- despite persistence gluten free diet for 12 months

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19
Q

Celiac Disease
Risk Factors

A

1% Western world
Type 1DM
Down Syndrome
Family history

Genetic predisposition x unknown trigger

20
Q

Celiac Disease
Non-Pharmacological Management

A
  • Gluten free diet (wheat, barley, rye, spelt, kamut)
  • Nutritionist referral
  • Correct nutritional deficiencies (Vitamin D, B12, copper, zinc, B6, iron, floate)

Follow Up
- monitor growth and development
- bone mineral density DEXA scanning
- lymphoma screening

21
Q

Irritable Bowel Disease (IBD)
Definition

A

Chronic abdominal pain and altered bowel habits in the absence of organic cause/inflammation

  1. diarrheal IBS (men)
  2. constipation IBS (women)
22
Q

Irritable Bowel Disease (IBD)
Risk Factors

A

Women > men
Diagnosed before 50s (common in 20s)
Early childhood trauma
Mood/anxiety disorders (anxiety, depresison, firbomyalgias)

23
Q

Irritable Bowel Disease
Pathophysiology

A

Unknown
Spasms of bowel in absence of inflammation

  1. Viseral hypersensitivity, hyperalgesia
  2. post - infectious
  3. food allergy
  • Dysbiosis of bacteria
  • hypersensitivity, hypermotility, hypersecertion
24
Q

Irritable Bowel Disease
Clinical Signs and Symptoms

A
  • abdominal pain
  • bloating, flatulence
  • Diarrhea or constipation
  • relief of pain with defecation
    -* doesn’t interfere with sleep (UC does)

Rome III Criteria
- change frequency stools
- change consistency of stools
- relief of pain with defecation
- present for 6 months
- 3 symptoms / month for at least 3 months

25
Q

Irritable Bowel Disease
Non-pharmacological treatment

A

Modification Diet:
- regular spaced meals
- decrease caffiene and alcohol
- increase soluble fibre and water intake
- bulk forming laxatives (psyillium)
- low FODMAP diet

Pharmacological treatments:
- TCA
- SSRIs
- bulk laxatives (psyllium fibre)
- loperamide
- anti-spasmotic (pepermint oil)

26
Q

Diverticuli
Definition

A

Outpouching of the mucosal / submucosa through the artery foramen in the tunica mucular layers of the large intestine

Most common site sigmoid colon (western world, left side)

27
Q

Diverticulosis

A

Asymptomatic disease
presence of outpouching diverticuli
no inflammation

28
Q

Diverticular Disease
Definition

A

also known as Diverticulitis

Inflammation of the diverticlui (outpouching) resulting in clinical signs and symptoms
- LLQ pain
- WBC
- fever

29
Q

Diverticulosis
Risk Factors

A
  • older age
  • obesity
  • increased red meat
  • NSAID use
  • Low dietary fibre
  • genetics
  • smoking
30
Q

Diverticular Disease
Pathphysiology

A
  1. increase in transluminal pressure
  • increased collagen and elastin deposition in circular and longitudinal muscles
  • shorten and thickening
  • decrease motility (neuromuscular, low fibre)
  1. Outpouching of mucosa/submucosa through the foramen in the tunica layers
  2. Perforation and inflammation
    - transition from asymptomatic diverticuli to symptomatic diverticulitis
31
Q

Diverticulitis
complications

A
  • abscesses
  • bleeding
  • obstruction
  • perforation
  • fistula
  • peritonitis
32
Q

Diverticulitis
Management

A
  • do not perform sigmoidoscopy until 6-8 weeks after flare (risk of perforation)
  • bowel rest
  • analgesia and anti-pyretics
  • higher fibre diet and water intake
  • surgical resection
  • *antibiotics are not usually indicated
33
Q

Appendicitis
Prevalence

A

Most common emergency surgery for individuals 10-19 years of age

34
Q

Appendicitis
Pathophysiology

A
  1. uncomplicated appendicitis

obstruction drainage of appendix (feces, foreign body, tumour) results in ischemia, inflammation

  1. Complicated appendicitis

Ischemia leads to abscess, necrosis, gangrene and perforation

35
Q

Appendicitis
Clinical signs and symptoms

A

Typical
- Peri-umbilical pain
- radiation to RLQ in 24 hours
- anorexia, nausea, vomiting, fever

Atypical
- flank pain, costovertebral angle tenderness, suprapubic pain, R testicular pain, urinary frequency

Physical assessment findings:

  • McBurney’s point RLQ
  • Psoas sign: pain extension hip
  • Oburator sign: pain right flexed hip rotation
  • Rovsing Sign: pain L iliac fossa
36
Q

Appendicitis
Treatment

A

Appendectomy
Antibiotic therapy

37
Q

Intestinal Obstructions
Classification

A

ONSET
1. Acute: sudden onset (torsion, hernia, intussusception)
2. Chronic: slow onset (cancer)

EXTENT
1. Partial: incomplete
2. Complete: complete obstruction

LOCATION
1. Intrinsic: inside lumen (tumour, hemorrhage, edema)
2. Extrinsic: outside lumen (hernia, intussuception, fibrosis, torsion, tumour)

EFFECT
1. Simple: no impairment blood flow
2. strangulated: impaired blood flow
3. Closed loop: both distal and proximal ends

CAUSE
1. mechanical obstruction
2. functional obstruction (paralytic ileus)

38
Q

Intestinal obstructions
Causes

A
  • hernias
  • tumours
  • fibrosis
  • torsion
  • divertiulosis
  • paralytic ileus (trauma, surgery, hypokalemia, peritonitis, pneumonia)
  • fecal mass
  • intussusception
39
Q

Intestinal obstruction
Pathophysiology

A

Accumulation gas, intestinal contents above the obstruction -> distention

  1. Pneumonia
  • decreased respiratory volume
  • atelectasis and pneumonia
  1. Nausea, vomiting, dehydration, electrolyte, and acid-base imbalances
  • decreased intake
  • decreased absorption
  • metabolic alkalosis - high obstruction, early onset
  • metabolic acidosis - low obstruction, late onset
  1. Ischemia, peritonitis, sepsis, perforations, shock and death
  • decreased venous drainage and arterial blood flow
  • ischemia, necrosis
  • leakage of GI bacteria -> sepsis
  • necrosis of GI tissue -> perforations
  • hypotensive shock
40
Q

Treatment
Intestinal obstructions

A
  1. Mechanical obstruction
    - surgical
  2. Functional obstruction (paralytic ileus)
    - decompression of stomach
    - bowel rest
    - surgical
41
Q

Intussusception
Define

A

Proximal bowel (intussusceptum) telescopes over the distal bowel (intussuscipien)

Mesenteric vessels compressed resulting in venous distention, ischemia, and inflammation

42
Q

Intussusception
Risk factors

A

Infants age 5-7 months
Rotavirus vaccination (2,4,6 months of age)
post operative
tumours, diverticulum, polyps, adhesions

43
Q

Intussusception
Clinical Signs and Symptoms

A
  • severe abdominal pain (colic)
  • vomiting
  • current jelly stools
44
Q

Complications
Intussusception

A

Bowel necrosis
surgery within 24 hours
4/100 recurrence rate

45
Q

Colorectal cancer screening
IBD

A

Increased risk at 30-35 years post diagnosis

Screening initiate at diagnosis and every 8 years

Mechanism: chronic inflammation

Normally progresses from low grade dysplasia -> high grade dysplasia -> cancer

Year 1: Patho/Pharm (39 decks)

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