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IBD and IBS Flashcards

1
Q

Diff b/t UC and crohn’s?

A
  • UC: mucosal ulceration in colon, starts distally and moves proximally up the colon, see more bright red blood
  • crohns: transmural inflammation, can present from mouth to anus, skip lesions, can easily perf, form fistulas
  • both diseases have wide spectrum of severity
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2
Q

What ethnic backgrounds are hit hardest by IBD? Geographic distribution?

A
  • jews

- IBD very common in North America, throughout Europe

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3
Q

Does UC or crohns have an earlier onset?

A
  • UC

- male:female equally affected

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4
Q

Epidemiology of IBD?

A
  • common in developed nations
  • infrequent in countries with poor sanitation
  • North America and Europe rates are 5/100,000 for each disease (scandanavians)
  • most common in 2nd and 3rd decades, but can affect any age
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5
Q

What are the etiologic theories behind IBD? Most likely?

A
  • infectious, immunologic, genetic, dietary, enviro, vascular, neuromotor, allergic, psychogenic
  • most likely: autoimmune and genetic
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6
Q

PP of IBD?

A
  • defect in the fxn of intestinal lumen
  • breakdown of defense barrier of gut
  • exposure of mucosa to microorganisms of their products
  • results in chronic inflammatory process mediated by T cells
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7
Q

What are systemic complications of IBD?

A
  • aphthous stomatitis
  • episcleritis and uveitis
  • arthritis
  • vascular complications
  • Erythema nodosum
  • P. gangrenosum
  • gallstones
  • malabsorption
  • renal: stones, fistulaie, hydronephrosis, amyloidosis
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8
Q

What parts of the bowel are involved in UC?

A
  • involves mucosal surface of colon with formation of crypt abscess. Always includes the rectum, and spreads proximally
    distal colitis: proctitis, proctosigmoiditis
  • extensive colitis (pancolitis): mild to moderate, severe
  • is uniformly continuous, there are no skip lesions
  • 50% of rectosigmoid
  • 30% splenic flexure (L sided colitis)
  • 20% extend proximally (pancolitis)
  • At much higher risk for cancer (want to use colonoscopy to screen)
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9
Q

Clinical course of UC?

A
  • flare ups and remissions
  • more common in nonsmokers
  • disease severity may be lower in active smokers and may worsen in pts who stop smoking: onset occasionally appears to coincide with smoking cessation
  • higher risk for development of cancer: related to extend and duration of disease and age at dx
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10
Q

Signs and sxs of mild to moderate UC?

A
  • bloody diarrhea (hallmark)
  • lower abdominal cramps - relieved with defecation
  • fecal urgency
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11
Q

Signs and sxs of severe UC?

A
  • rectal bleeding
  • LLQ cramps
  • severe diarrhea
  • fever (low grade)
  • anemia (microcytic)
  • hypoalbuminemia (malabsorption)
  • hypovolemia
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12
Q

Systemic associations with UC?

A
  • peripheral arthritis
  • central (axial) arthritis)
  • erythema nodosum (swollen red nodules)
  • uveitis
  • sclerosing cholangitis
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13
Q

Labs for UC?

A
  • CBC: anemia is common due to multiple factors, leukocytosis
  • sed rate and CRP: elev sed rate and CRP reflect acute phase (only elevated during flare ups)
  • CMP: electrolyte disturbances, decreased serum albumin, prolonged clotting time
  • perinuclear antineutrophil cytoplasmic abs (pANCA)
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14
Q

lab values in mild UC?

A
  • stools: less than 4 a day
  • pulse: less than 90
  • hematocrit: normal
  • wt loss: none
  • temp: normal
  • ESR: less than 20
  • albumin will be normal
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15
Q

Lab values in moderate UC?

A
  • stools: 4-6/day
  • pulse: 90-100
  • hematocrit: 30-40
  • wt loss: 1-10%
  • temp: 99-100
  • ESR: 20-30
  • albumin: 3-3.5
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16
Q

lab values in severe UC?

A
  • stools: more than 6 a day (mostly bloody)
  • pulse: over 100
  • hematocrit: less than 30
  • wt loss: greater than 10%
  • temp: above 100
  • ESR: above 30
  • albumin: less than 3
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17
Q

Dx for UC?

A
  • usually based on clinical presentation, sigmoidoscopic demonstration of inflammation and exclusion of bacterial and parasitic infection
  • dx:
    bloody diarrhea (diff it from crohns)
    plain abd. xrays
    sigmoidoscopy
    CT scan (complications)
  • dx: is best made with sigmoidoscopy but want to use colonoscopy to rule out other diseases
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18
Q

DDx of UC?

A
  • infectious colitis
  • CMV colitis
  • rectal carcinoma
  • crohns disease
  • GI bleed
  • mesenteric ischemia
  • diverticulitis (esp in older pts)
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19
Q

Intestinal complications in UC?

A
  • bleeding
  • toxic megacolon
  • perforation
  • benign stricture
  • malignant stricture
  • colorectal cancer
20
Q

Tx guidelines for UC?

A
  • reduce dietary fiber during an exacerbation
  • rx folic acid supplements with sulfasalazine
  • oral Fe may be needed with rectal bleeding and documented Fe def anemia
  • frequent f/u and close monitoring
  • short course of loperamide for troubesome diarrhea
  • periodic colonoscopy and bx in pts with pancolitis lasting more than 8 years (yearly screening)
21
Q

Tx for mild to moderate UC?

A
  • sulfasalzine
  • olsalazine (non sulfa)
  • mesalamine
  • may have to add on prednisone (taper to lowest therapeutic dose needed)
22
Q

Tx for moderate to severe UC?

A
  • sulfasalazine
  • olsalazine
  • prednisone: may need to consider immunosuppresive therapy for pts who need constant high doses of steroids

sulfasalzine and olsalazine: azospermia while on meds, severe depression in young males
- also watch for folate deficiency while on meds

23
Q

Tx for proctocolitis (limited to rectosigmoid)?

A
  • sulfasalazine: oral or topical (enema or supp)

- hydrocortisone: enema, supps, or foam

24
Q

Indications for surgery in UC?

A
  • exsanguinating hemorrhage
  • toxicity and/or perf
  • suspected cancer
  • significant dysplasia
  • growth retardation
  • systemic complications
  • intractability
25
Q

Surgical options for UC?

A
  • conventional ileostomy
  • continent ileiostomy
  • ileo-anal anastomosis with reservoir

(all depends on how much bowel is left to reconnect)

26
Q

Crohn’s disease - what is involved?

A
  • transmural involvement with formation of fistulas, narrowing of lumen, obstruction
  • can involve any segment of the GI tract: ileocolitis - 45%, ileitis: 28%, colitis: 15%, gastroduodenitis: 7%, jejunoileitis: 5%
  • usually rectal sparing
  • since it is transmural - more likely to perf and form fistulas
27
Q

Cigarette smoking and crohn’s?

A
  • strongly assoc with development of crohn’s, resistance ot medical therapy and early disease relapse
28
Q

Clinical manifestations of Crohns?

A
  • presentation depends upon site and severity
  • insidious onset usually
  • intermittent bouts of low grade fever, diarrhea, and RLQ pain
  • post prandial pain is common
  • RLQ mass
  • perianal disease: abscess or a fistula, fissures, hemorrhoids, skin tags
  • often nocturnal BMs, night sweats, wt loss
  • skin lesions, primarily erythema nodosum, may precede intestinal sxs
  • pts are often chronically ill: wt loss and pallor (B12 and folate def)
  • children and adolescents: presentation often insidious with wt loss, failure to grow or develop secondary sex characteristics, arthritis, or fever of unkown origin
29
Q

Distinguishing features of crohns?

A
  • small bowel involvement
  • rectal sparing
  • 25-30% w/o gross bleeding
  • perianal disease
  • focal lesions
  • segmental distribution: skip lesions
  • asymmetric involvement
  • fistulization
  • granulomas
  • endoscopic features
30
Q

PE findings in Crohn’s disease?

A
  • abdominal distension
  • abnormal bowel sounds
  • tenderness in area of involvement
  • perianal region: abscess, fistula, skin tag and anal stricture
31
Q

Lab findings in crohns?

A
  • CBC: anemia is common due to mult factors - B12, folate, maybe iron, leukocytosis
  • sed rate and CRP: elevated sed rate, and CRP reflect acute phase
  • CMP: electrolyte disturbances, decreased serum albumin, prolonged clotting time
  • ASCA: serum anti-saccharomyces cerevisase ab (ASCA) highly specific but sensitivity is only 30%,
32
Q

Imaging in crohn’s?

A
  • barium contrast sutdies most commonly used for upper and lower GI tract - better for finding complications - strictures and fistulas, granulomas
  • see: “cobble stoning”, “skip lesions”, pseudodiverticula, dilated bowel fistulas comunicating to adjacent bowel/mesentery/bladder/vagina, can see ileitis, an string sign (severe inflammation)
  • histology: from endoscopic bx
33
Q

Tx of Crohn’s disease?

A
  • 5-aminosalicylic acid agents: sulfasazine (need folate supplementation), mesalamine, pentasa
  • abx if infections (high risk pts!)
  • corticosteroids (burst packs)
  • anti-TNF therapy: infliximab (remicade)
  • immunomodulating drugs: azathioprine, mercaptopurine, methotrexate
34
Q

Irritable bowel sydrome AKA?

A
  • spastic colon
  • spastic colitis
  • mucous colitis
  • functional bowel disease
35
Q

What is IBS? How muc of our population is affected? What kind of dx is it?

A
  • fxnl GI disorder that is a variable combo of chronic or recureent gi sxs not explained by structural or biochem abnormalities
  • 20% of pop
  • 20-50% of referrals
  • 25% of pts post enteric infections and 7% go on to develop true IBS
  • a dx of exclusion, a + dx must be made
36
Q

Characteristic sxs of IBS?

A

continuous or recurrent sxs for at least 3 months of:

  • abdominal pain or discomfort
  • pain relieved by defecation
  • pain with change in frequency or form of stools

Varying pattern of defecation with 3 or more of the following:

  • altered stool frequency
  • altered stool form
  • altered stool passage (straining, urgency, incomplete evacuation/sensation of rectal fullness)
  • abdominal distension and bloating
  • passage of mucus
37
Q

Epidemiology of IBS?

A
  • up to 15% of pop
  • females more than males and younger more than old
  • 2/3 don’t seek health care
  • sociocultural factors affect MD visits
38
Q

Assoc sxs with IBS?

A
  • fatigue (96%)
  • back ache (75%)
  • early satiety (73%)
  • nausea (62%)
  • HA (61%)
  • irritable bladder (56%)
  • fxnl dyspepsia (51%)
39
Q

Dx of IBS based on Rome II criteria?

A
  • Rome - most commonly used:
    abdominal discomfort/pain with 2 of the following 3 features for at least 12 weeks, not necessarily consecutive, for the past 12 months:
    -relief with defecation
    -onset assoc with change in stool frequency
  • onset assoc with change in stool formation
40
Q

Dx of IBS based on Manning criteria?

A

manning criteria:

  • pain relieved by defecation
  • more frequent stools assoc with pain onset
  • looser stools assoc with onset of pain
  • abdominal distension
  • passage of mucus
  • feeling of incomplete evacuation
41
Q

DDx of IBS?

A
  • dietary: lactose, caffeine, alcohol, fat, gas producing foods
  • malabsorption: post gastrectomy, intestinal, pancreatic
  • infection: giardia, bacterial, ameoba
  • inflammatory bowel: UC, CD, microscopic colitis, mast cell disease
  • psych: anxiey, panic, depression, somatization
  • misc: endometriosis, endocrine tumors (carcinoid, VIP), AIDS
42
Q

Hx questions you should ask pt that has suspecting IBS?

A
  • dietary habits (sorbitol sweetner, caffeine, cruciferous veggies), carb malabsorption
  • travel hx
  • med use
  • recent gastro-enteritis or food born illness
  • lactose intolerance
  • gender, age
  • family hx
  • night time defecation
43
Q

PE for IBS pt?

A
  • complete physical: necessary to exclude organic disease
  • pt will not usually have abdominal guarding - should have guarding considering the pain the pt is having
  • EBM: no dx tests can be justified
44
Q

Labs and imaging used in IBS dx?

A
  • labs: CBC, ESR, serum electrolytes, liver enzymes, stool occult blood x3, stool O&P, UA
  • imaging: flex sig, upper GI series with small bowel follow through, plain abdominal radiograph, air contrast barium enema

( all labs and imaging will appear normal if IBS)
- after H&P and labs negative - can make a dx, don’t have to do imaging unless pt wants imaging - then refer to GI

45
Q

Warning signs and red flags on exam with pt with suspected IBS?

A
  • any abnormality on PE
  • anemia
  • clinical or biochemical evidence of malnutrition
  • family hx of GI cancer, IBD, or sprue
  • fever
  • hematochezia
  • nocturnal sxs
  • onset of sxs after 50 (high risk for cancer after 50)

alarm sxs:

  • constant abdominal pain
  • constant diarrhea
  • constant abdominal distension
  • nocturnal disturbance
  • passage of blood with stool
  • wt loss
46
Q

How can we make a positive dx of IBS w/o costing the pt a lot of money?

A
  • use Rome and Manning guidelines

-

47
Q

Management of IBS?

A
  1. make a positive dx: usually possible from hx alone -
    - sxs usually begin in late teens - twenties
    - pain is intermittent and crampy
    - full PE
    - in younger pts, normal Hgb and ESR may help reassure pt
    - in pts older than 45 with long hx and no recent hange - a sigmoidoscopy and/or barium enema may help to reassure
  2. Consider pts agenda: a full psych, social, and family hx inquiry is necessary, try to get answer to question - why has this pt presented at this particular time?
3. make a management classification:
to which category does the pt belong:
- bloating and pain predominant
- constipation predominant
- diarrhea predominant
- anxiety assoc
- depression assoc
  1. Plan a management strategy:
    est a therapeutic provier pt relationship
    - focus should be on sx relief and addressing pt’s concern
    - shift responsibility for tx decisions to pt by providing therapeutic options
    - demonstrate a commitment to the pt’s well being rather than to tx of disease

pt education:

  • validates pt’s illness and sets basis for therapeutic interventions
  • set realistic goals rather than a cure
  • teach sxs monitoring
  • reassure benign nature of IBS
  • address psychosocial issues
  • tell pt to f/u if they have wt loss, blood in stool, bm at night

GI (21 decks)

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