IBD, Colon Cancer and Rectum - Exam 3 Flashcards
What are the differences between Ulcerative Colitis and Crohn’s Disease? Which one is MC in males? females?
UC: diffuse disease of the TOP layer of the COLON ONLY- MC in MALES
CD: patchy transmural inflammation in any segment of the GI tract, can be ANYWHERE in the GI tract and effects ALL LAYERS of the intestine- MC in FEMALES, smoking is risk factor
What are the lesions seen in CD called? Where is the MC location in the GI tract? Where is that sight found on the body?What does the transmural inflammation lead to?
skip lesions
MC = terminal ileum and +/- anus
“mass” in the RLQ (terminal ileum)
Strictures
Obstruction
Fistulas
Perforation
______ is strongly associated with the development of Crohn disease, resistance to medical therapy, and early disease relapse
Cigarette smoking
Chronic history of recurrent episodes of RLQ
pain and diarrhea
Crampy abdominal pain (RLQ MC)
NON-BLOODY diarrhea
weight loss
S/Sx Small bowel obstruction, fistula formation, abscess
May feel mass in right colon
Crohn’s disease
What does feeling a “mass” in the right colon when a pt has CD represent?
This represents thickened or matted loops of inflamed intestines
What are Extraintestinal Manifestations of CD? ** What are the 2 highlighted ones? Which one is MC?
Arthralgia, arthritis- MC
Iritis, Uveitis
Kidney Stones
Skin Disorders:
**Pyoderma gangrenosum
**Erythema nodosum
______ are a serious common complication seen with Crohn’s disease. How will these manifest clinically?
fistulas!
Infection, abscesses, problems with personal hygiene, weight loss, malnutrition, diarrhea but depend on the type of fistula
What are these? What are they correlated with?
Erythema Nodosum
Attacks correlate with bowel activity; skin lesions develop after onset of bowel symptoms, 1-5 cm hot, tender lesions on the anterior surface of lower legs, ankles and calves
What is this? What is it associated with?
Pyoderma Gangrenosum
Associated with severe disease
Lesions commonly found on dorsal surface of feet and legs, but can occur arms, chest, stoma, even face
Begins as pustule, spreads to rapidly undermine healthy skin, ulcerate with central necrotic tissue-up to 30cm
** What is the gold standard to dx CD? What will it show?
the diagnosis is Colonoscopy with biopsy
The presence of “skip areas” with a “cobblestone” may also seen pseudopolyps & granulomas
What are 2 important pt education points for CD?
NOT CURATIVE
need to stop smoking and eat a clean diet
With regards to age, LESS severe s/s of CD is associated with above or below 30?
LESS severe s/s is associated with dx OLDER than 30
What is the tx approach for mild CD symptoms? What region is more involved? What is the tx?
“step up” method: gradually progress to more potent medications
ileum region most involved
Enteric coated Budesonide (corticosteroid) 9mg qd for 4 weeks, no more than 8, then tapered by 3mg increments every 2-4 weeks for a total of 8-12 weeks of therapy aka this medication needs to be TAPERED off
-> 5-ASA if the pt does not want steroids but controversial
When would you consider stepping up therapy in a pt with mild CD?
If no improvement with Budesonide after 3-6 months, treatment escalation to immunomodulator or biologic
What is the tx for mild/moderate CD? What qualifies it as mild/moderate?
Oral prednisone 40mg qd for one week, then tapering by 5-10 mg per week with goal of tapering off over 1-2 months
Can use 5-ASA as alternative option
diffuse colitis or LEFT colonic involvement
After remission has been achieved in CD, what do you do next? What happens if the pt relapses?
After tapering and d/c, an ileocolonoscopy in 6-12 months and clinical observation
Any relapse we begin second course of a glucocorticoid, a immunomodulator (azathioprine) or biologic ( infliximab) is acceptable
What is the high risk criteria for CD?
**What is the tx for high risk/ moderate to severe CD?
TNF blockers -> infliximab (Remicade) PLUS immunomodulator -> azathioprine (Azasan)
may also need to treat fistula if present
What do you once a pt is in remission for CD?
ileocolonoscopy is performed in 6-12 months
An alternative can be glucocorticoid until remission, then maintenance with biologic agent (TNF)
**Where are the MC places to find UC?
M/C involves rectum and sigmoid colon
Gradual Presentation
Crampy lower abdominal pain
Relieved with defecation
Diarrhea with pus/mucus
Fecal Urgency and tenesmus
Fever, fatigue, weight loss
Anemia
What am I?
**What is the hallmark s/s?
Ulcerative Colitis
Bloody Diarrhea is hallmark
Are Extraintestinal Manifestations more commonly seen with CD or UC?
more commonly seen with CD
How is UC classified?
mild, moderate or severe based on how much they poop
mild: up to 4 poops (with or without blood), normal labs, ESR less than 20
moderate: 5
severe: 6+ mostly bloody, weight loss greater than 10lbs, ESR over 30 and albumin less than 3
_______ is actually thought to help decrease s/s in UC?
smoking
How do you dx UC? **What is the gold standard for dx? What will you see?
Diagnosis of UC is based on presence of chronic diarrhea for more than 4 weeks and evidence of active inflammation on sigmoidoscopy
Gold Standard for Diagnosis: Sigmoidoscopy
will see continuous friable mucosa, edematous, with pus, bleeding and erosions, erythema
May contain pseudopolyps
When should you NOT perform colonoscopy with UC? why?
DO NOT perform colonoscopy in patients with severe active disease or fulminant colitis!!
Risk of Perforation or Megacolon:
Perform after for disease extent
_______ is a complication of UC due to chronic inflammation causes colon to expand, dilate, and distend
Toxic Megacolon
Patients with long-standing UC are at increased risk for developing ______ and _____. What increases the risk?
colonic epithelial dysplasia
carcinoma
The risk of neoplasia in chronic UC increases with duration and extent of disease
What is a UC pt education point with regards to diet?
need to decrease caffeine
**What is the tx for mild/moderate UC proctitis?
Topical mesalamine (5-ASA) in enema, suppository form
** What is the tx Mild-Moderate Ulcerative Colitis extending past Sigmoid Colon? What is that doesnt work?
Oral mesalamine in conjunction with topical mesalamine
oral corticosteroids if unresponsive to mesalamine therapy in 4-8 weeks
**What is the tx for moderate/severe UC?
Oral corticosteroids: Prednisone 40mg, then taper by 5-10mg weekly
When should you consider TNF or immunomodulators in the tx for UC?
Immunomodulators (azathioprine,cyclosporine) + or - TNF (infliximab) if unresponsive to corticosteroids OR if flares occur while tapering off corticosteroids
What is the curative tx for UC?
Total proctocolectomy with placement of ileostomy is curative
When is maintenance therapy indicated in UC? **What is the tx?
more than one relapse in a year
All patients with ulcerative proctosigmoiditis (involving rectum/anus/sigmoid)
All patients with UC proximal to sigmoid colon (left-sided colitis)
**Mesalamine (oral or topical) or other 5-ASA
What are the 2 aminosalicylates medications? immunomodulators?
sulfasalazine, mesalamine
6-mercaptopurine, Azathioprine, and Methotrexate
**When are Aminosalicylates (5-ASA) contraindicated? What is the MOA?
Contraindicated if Sulfa or ASA allergy
MOA: not well understood but inhinbits prostaglandin production
When in IBD are Corticosteroids/glucocorticoids the most effective? _____ is used in severe flares but NOT used for maintenance. ______ can be used in moderate active CD up to 3 months
Most effective to induce remission in severe flares
Prednisone
budesonide
_____ MOA inhibits DNA/RNA synthesis. What are the SE?
Immunomodulators/Immunosuppressants:
Azathioprine (Imuran)
6-Mercaptopurine (6-MP) (Purinethol)
SE: Leukopenia, Thrombopenia, Anemia and need to monitor CBC
**What is the BBW for Immunomodulators/Immunosuppressants?
mutagenic potential, rapid growing, malignancy/lymphoma
______ is an immunomodulator that is used if pts fail azathioprine only in CD!!!
Methotrexate- only in Crohn’s disease!!
________ is used in severe UC/CD refractory to steroids but has multiple serious adverse effects and drug interactions
cyclosporine
______ is the TOC for CD fistula. What drug class? **What is the BBW?
TNF antibodies
TNF antibodies: Infliximab (Remicade),
Adalimumab (Humira), Certolizumab (Cimzia)
**BBW: risk of serious infections
What abx are preferred for IBD especially with fistulas and abscess in CD?
Metronidazole (Flagyl), Ciprofloxacin (Cipro)
What is the recommendation for live vaccines and pt starting tx for IBD?
Any live vaccines needed should be given > 4 wks prior to start of tx
pt should be UTD on vaccination before starting immunosuppressive therapy
What are 5 causes of IBD flare ups?
missing remission medication dosing
NSAIDs- Tylenol is preferred
smoking
stress
trigger foods
How often should a pt follow up with their provider? What is the colonoscopy recommendation?
Every six months when IBD is in remission
More often when there is an IBD flare
American Cancer Society recommends that people with IBD get their first colonoscopy at least eight years after diagnosis, and then every one to two years.
Pt with IBD also need to have regular _____ and ______
eye exams: at diagnosis and q1-2 years
skin exams: should get regular skin exams if on biologic/immunomodulators
What are the 4 pathologic groups for colon polyps? **Which one is MC?
**Mucosal adenomatous polyps- MC
subtypes: tubular, tubulovillous, villous
Mucosal serrated polyps
Mucosal non-neoplastic polyps
Submucosal lesions
What are the 3 subtypes of Mucosal adenomatous polyps? What are risk factors?
tubular, tubulovillous, villous
risk factors:
Age > 50, slightly more common in men
Diet (high fat, red meat, low fiber)
Obesity
What characteristic of adenomatous polyps is more likely to be cancerous?
flat- more likely to be cancerous
sessile: looks button like
pedunculated: looks like a mushroom with a stalk
Based on their grade, which type is most and least likely to be cancerous?
Tubular - m/c - Less likely to be cancerous
Tubulovillous
Villous - Most likely to be cancerous
What risk factors are the risk factors for high-grade dysplasia/cancer?
Polyps > 1cm
Villous histology
Number of polyps
Flat polyps
What age should you start screening colonoscopies? How often should you get a colonoscopy if it is normal?
start screening at 45
10 years if normal
What are characteristics of Mucosal Non Neoplastic Polyps?
M/C non-neoplastic polyp
Can develop into adenomatous polyps
M/C located in rectosigmoid area
M/C small
What are submucosal lesions?
Mesenchymal polyps that are benign tumors
anemia
weakness
fatigue
melena
positive FOB
weight loss
proximal or distal?
proximal colon
change in bowel habits
obstruction
hematochezia
urgency/tenesmus
proximal or distal?
distal colon
What is the dx tool of choice for colon cancer? ____ is used for staging?
colonoscopy
CT/MRI is used for staging
______ is a lab NOT for screening but level can suggest prognosis
CEA (carcinoembryonic antigen) tumor marker
What are the post-op follow up recommendations after a colon cancer curative resection?
What is Familial Adenomatous Polyposis (FAP)?
What gene specifically? What is it characterized by? What age do polyps develop by? What is the tx?
Inherited Genetic mutation (APC gene)
Characterized by the development of hundreds to thousands of colonic adenomatous polyps +/- in duodenum and stomach
In classic FAP, colorectal polyps develop by a mean age of 15 years and cancer often by age 40
prophylactic colectomy before age 20, if they do not will develop Colorectal cancer by 50
will connect ileum to rectum once colon is removed
What am I? What screening is needed after dx?
Familial Adenomatous Polyposis (FAP)
genetic counseling and testing, upper EGD of stomach and duodenum is performed q 1-3 years for adenomas/cancer
What is Lynch syndrome? How is it inherited?
Hereditary nonpolyposis colon cancer
Autosomal dominant condition
What genetic reason is behind Lynch Syndrome? What does it increase your risk for?
Caused by mutations in a gene that detects and repairs DNA base-pair mismatches
increases risk of other cancers:
Endometrial/ovarian
renal/bladder
hepatobiliary/gastric/small intestines
What is the difference between Lynch Syndrome and FAP?
Lynch: only a few FLAT adenomas that are more likely to be villous
FAP: round and a shit ton of them
What are the 3 tools for identifying an increased risk and meriting a more detailed assessment that would make you suspicious for Lynch Syndrome?
1st degree relative with colorectal/lynch-related cancer before 50?
Have you (the pt) had colorectal cancer/polyps before age 50?
3 or more relatives with colorectal cancer?
What if a pt’s genetic test comes back positive for Lynch Syndrome, what is the screening recommendations for 1st degree relatives?
If genetic mutation found, affected relatives get colonoscopy q1-2 years beginning at age 25
Women screening for endometrial/ovarian cancer at 30-35
What is the tx for Lynch syndrome?
Subtotal colectomy with ileorectal anastomosis
Prophylactic hysterectomy and oophorectomy are recommended to women at age 40 or when finished with childbirth
upper EGD q2-3 years at 30 to screen for gastric cancers
What are the differences between internal and external hemorrhoids? **What is the underlying cause?
internal hemorrhoids are ABOVE the dentate line
external hemorrhoids are BELOW the dentate line
**increased venous pressure
What are the 3 common internal hemorrhoid locations?
external hemorrhoids arise from the _______ veins located below the dentate line and are covered with ______ of the anal canal or perianal region
inferior hemorrhoidal
squamous epithelium
What is the presentation of internal hemorrhoids?
Bleeding (think bright red blood on toilet paper or in the stool), Prolapse, Mucoid Discharge
What are the 4 stages of internal hemorrhoid?
What is the tx of hemorrhoids based on the presentation?
What is the presentation of external hemorrhoids? What is the tx?
Very Painful, acute onset
Tense and bluish perianal nodule covered with skin that can be up to several centimeters in size
Pain most severe in first few hours, but eases over 2-3 days
tx:
What is an anal fissure? What are they caused by? **Where do they occur specifically?
Linear tears/ulcerations around the anus
Usually less than 5mm
Due to trauma to anal canal during defecation
POSTERIOR MIDLINE
If a pt has an anal fissure that is off the midline, what are you thinking?
Crohn, HIV/AIDs, TB,
Anal carcinoma
What is the tx for anal fissures? What if chronic?
Proper toileting
Sitz Baths
Fiber
Topical anesthetics
sx!
½ of all Perianal Abscesses caused by ______
Fistulas
Throbbing
Continuous perianal pain
erythema/fluctuance
swelling
What am I?
What is the tx?
perianal abscess
tx:
I & D
+ / - Abx
Surgical Excision
How does a fistula present? What is the tx?
Associated with purulent discharge that may lead to itching, tenderness, and pain
tx:
Fistulotomy: aka cut the tract open and leave it open
What is a rectal prolapse? What is the tx for a complete prolapse?
Protrusion through anus of some or all layers of the rectum
sx
What are some risk factors for rectal prolapse?
over 40
female
multiple vaginal deliveries
prior pelvic surgery
chronic straining/diarrhea/constipation
dementia
stroke
pelvic floor dysfunction/anatomic defects
What is the tx for rectal prolapse?
Manual reduction
Adequate fluid and fiber intake
Kegel exercises
SURGICAL CONSULT- especially for total prolapse
What is Pilonidal disease?
midline skin pits in the natal cleft
If your pt is found to have + genetic screening for Lynch syndrome when should they have their first colonoscopy?
25 years old
What is the most common cause of anal fissures? What is the tx?
hard stools
stool softeners and proper toileting techniques
