GI Patho 2 Flashcards
Irritable Bowel Disease (IBD)
Incidence, prevalence, risk factors
*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
IBD
Etiology
*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
IBD
2 Diseases
- Crohn’s Disease
- Ulcerative Colitis
Ulcerative Colitis
Cellular pathophysiology
- 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)
Ulcerative Colitis
Clinical Signs and Symptoms
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
Ulcerative Colitis
incidence
- 20 to 40 year olds
- smoking is protective
- diet is not associated
- NSAID use
- family history
- pathogenic gastritis
Ulcerative Colitis
Complications
- Bleeding and anemia
- ulceration
- perforation
- hemorrhage
- toxic megacolon
- fibrosis
- cancer
Non- pharmacological Management
UC
- 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
Diagnostic Evaluation
UC
Endoscopy with biopsy (gold standard)
Crohn’s Disease
Incidnece and Risk factors
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
Crohns’ Disease
Pathophysiology
- 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)
Crohn’s Disease
Clinical Signs and Symptoms
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
Crohn’s disease
Complications
- Fissures
- abscesses
- fistulas
- perforations
- obstructions
Crohn’s disease
Non-Pharmacological Management
- 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
Celiac Disease
Definition and Risk Factors
“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
Celiac Disease
Pathophysiology
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
Celiac Disease
Clinical Signs and Symptoms
- 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)
Celiac Disease
Complications
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
Celiac Disease
Risk Factors
1% Western world
Type 1DM
Down Syndrome
Family history
Genetic predisposition x unknown trigger
Celiac Disease
Non-Pharmacological Management
- 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
Irritable Bowel Disease (IBD)
Definition
Chronic abdominal pain and altered bowel habits in the absence of organic cause/inflammation
- diarrheal IBS (men)
- constipation IBS (women)
Irritable Bowel Disease (IBD)
Risk Factors
Women > men
Diagnosed before 50s (common in 20s)
Early childhood trauma
Mood/anxiety disorders (anxiety, depresison, firbomyalgias)
Irritable Bowel Disease
Pathophysiology
Unknown
Spasms of bowel in absence of inflammation
- Viseral hypersensitivity, hyperalgesia
- post - infectious
- food allergy
- Dysbiosis of bacteria
- hypersensitivity, hypermotility, hypersecertion
Irritable Bowel Disease
Clinical Signs and Symptoms
- 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
