IBD, Colon Cancer, Disorders of the Rectum Flashcards
1
Q
two causes of IBD
A
- ulcerative colitis
- crohns
2
Q
difference between ulcerative colitis vs crohns
A
- Ulcerative Colitis (UC)
- Chronic, recurrent disease characterized by diffuse mucosal inflammation involving colon only
- Involves rectum and may extend proximally in continuous fashion - Crohn’s Disease (CD)
- Chronic, recurrent disease characterized by patchy transmural inflammation involving any segment of the GI tract from mouth to anus
3
Q
risk factors for IBS
A
- Female - CD Male - UC
- M/C in Caucasians
- “Western Diet”
- Others - infection, obesity
- Smoking: CD
4
Q
pathophys of crohns
A
- Transmural inflammation & Skip lesions in GI tract
- Any part from mouth to anus
- MC = terminal ileum
— Some may present with terminal ileum AND cecum
— ~ ⅓ have perianal disease
- Transmural inflammation leads to: Strictures, Obstruction, fistulas, Perforation
5
Q
segments of normal appearing bowel interrupted by areas of disease
A
skip lesions
6
Q
Cigarette smoking is strongly associated with the development of what?
A
resistance to medical therapy
early disease relapse
7
Q
clinical manifestations of crohn’s
A
- Chronic hx of recurrent episodes of RLQ
pain and diarrhea - Crampy abd pain (RLQ MC)
- Can be steady
- Can be periumbilical - Diarrhea (Intermittent, mostly Non-bloody)
- Malabsorptive
- Steatorrhea - wt loss, Weakness, fatigue, focal tenderness RLQ
- S/Sx Small bowel obstruction, fistula formation, abscess
- May feel mass in right colon
- represents thickened or matted loops of inflamed intestines
May feel “mass” in RLQ = The MC site of pathology = terminal ileum
8
Q
other sx of crohn’s
A
- Stricture/narrowing of small bowel
- Perianal disease - Fistulas, Abscess
- Oral Disease - Aphthous ulcers
- Extraintestinal
- Arthralgia, arthritis
- Iritis, Uveitis
- Kidney Stones
- Skin Disorders - Pyoderma gangrenosum, Erythema nodosum - S/Sx from nutrient deficiencies
9
Q
name the different types of fistulas
A
Enterovesical - intestine to bladder
Enterocutaneous - intestine to skin
Enteroenteric - intestine to colon
Enterovaginal - intestine to vagina
10
Q
What are the clinical manifestations of fistulas?
A
Infection, abscesses, problems with personal hygiene, weight loss, malnutrition, diarrhea
11
Q
this skin disorder has attacks correlated with bowel activity; skin lesions develop after onset of bowel symptoms
Lesions are hot, red, tender in Crohns
A
Erythema Nodosum
12
Q
Associated with severe crohn’s 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
A
Pyoderma Gangrenosum
13
Q
diagnostic work-up for crohn’s
A
-
Colonoscopy w/ bx
- skip areas
- cobblestone
- pseudopolyps and granulomas possible - labs: CBC, serum albumin, CMP, ESR, CRP, Iron, Vit D and B-12, stool studies
14
Q
management for crohn’s
A
provide symptomatic relief, shorten duration of acute flares, and minimize complications - NOT CURATIVE
Diet
Stop smoking
Symptomatic Medications - (Antidiarrheals)
Maintenance Medications
Acute Flare Medications
Many require at least one surgical procedure: Resection, Abscess Drainage/Removal, Fistulectomy
15
Q
Low-risk - No or Mild Symptoms of crohn’s
A
Normal or mild elevation in C-reactive protein
Diagnosis at age >30
Limited distribution of bowel inflammation
Superficial or no ulceration on colonoscopy
Lack of perianal complications
No prior intestinal resections
Absence of penetrating or stricturing disease
16
Q
Tx for Low-risk - No or Mild Symptoms of crohn’s in Ileum/cecum?
A
ileum region most involved
- Enteric coated Budesonide
- 5-ASA controversial in inducing remission; those who don’t want steroid
- no improvement 3-6 mo = immunomodulator/ biologic
17
Q
Tx for Diffuse colitis or left colonic involvement, mild to moderate
crohn’s
A
- Oral prednisone 40mg qd; tapering off over 1-2 months
- 5-ASA as alternative option - Maintenance of Remission
- ileocolonoscopy in 6-12 mo and observation
- If remission achieved with 5-ASA, continue therapy until ileocolonoscopy in 6-12 mo - relapse = glucocorticoid, immunomodulator (azathioprine) or biologic ( infliximab)
18
Q
characteristics of high-risk crohn’s for tx
A
Diagnosis at an age < 30
Tobacco use
Elevated C-reactive protein
Deep ulcers on colonoscopy
Long segments of small and or large bowel involvement
Perianal disease
Extra-intestinal manifestations
History of bowel resections
Also include patients who have not responded to glucocorticoids or who relapse after achieving clinical remission following induction therapy
19
Q
Crohn’s tx for High-Risk - Moderate to Severe
A
- “Top down” strategy
-
infliximab + azathioprine
- to induce and maintain remission
- treat fistula formation
20
Q
management for crohn’s tx once remission is seen?
A
- ileocolonoscopy in 6-12 mo
- combo therapy continued x 1-2 yrs - alt: glucocorticoid until remission, then maintenance with biologic agent (TNF)
Can use prednisone for initial symptomatic relief
>50% will require surgical intervention: fistulas
21
Q
- Relapsing & Remitting Episodes of inflammation - Mucosal Layer of Colon ONLY
- Resulting in diffuse friability and erosions with bleeding
what is this dx?
A
IBD - Ulcerative Colitis
22
Q
Ulcerative Colitis MC involves what parts of the digestive tract?
A
rectum and sigmoid colon
- Ulcerative Proctitis
- Ulcerative Proctosigmoiditis
- Left or Distal UC
- Extensive colitis (Proximal to Splenic Flexure)
- Pancolitis (Cecum)
23
Q
presentation of Ulcerative Colitis
A
- Crampy lower abd pain - Relieved with defecation
- Bloody Diarrhea is hallmark
- Diarrhea with pus/mucus
- Fecal Urgency and tenesmus
- Fever, fatigue, wt loss
- Anemia
- Extraintestinal: Arthritis, ankylosing spondylitis
Skin, Eye, others…..MC with CD
24
Q
complications with Ulcerative Colitis
A
Severe bleed
Fulminant colitis - > 10 BM’s/day
Toxic megacolon
Perforation
25
Ulcerative Colitis is Mc in who?
nonsmokers and former smokers
Severity may be lower in active smokers
May worsen in patients who stop smoking
26
work-up for ulcerative colitis
chronic diarrhea >4 wks + evidence of active inflammation on sigmoidoscopy
1. H/H, ESR, CRP, stool studies
2. **DX: Sigmoidoscopy**
- Continuous friable mucosa, edematous, with pus, bleeding and erosions, erythema
- pseudopolyps
- Moderate-severe - Deep ulceration and spontaneous bleeding
3. CT/Xray for colonic dilatation
27
DO NOT perform colonscopy in pts with ?
severe active disease or fulminant colitis!!
Risk of Perforation or Megacolon
28
Chronic inflammation causes colon to expand, dilate, and distend
Colonic diameter > 7cm
what is this dx
Toxic Megacolon
unable to move gas, feces, now get buildup
Can lead to perforation/infection
Fever, Elevated WBC, ESR, HR > 120
Dehydration, Hypotension
dx: Abdominopelvic CT w/ contrast, serial radiographs to monitor progression
29
tx for toxic megacolon
1. Supportive; restoring normal motility and decrease likelihood of perforation.
2. Surgery if needed, TPN, Etiology specific therapy
30
Patients with long-standing UC are at increased risk for ?
colonic epithelial dysplasia and carcinoma
31
tx for Mild-Mod Ulcerative Proctitis/Distal Colitis
1. **Topical mesalamine (5-ASA) (enema, suppository)**
2. Hydrocortisone suppository - less effective (cheaper)
32
tx for Mild-Moderate Ulcerative Colitis extending past Sigmoid Colon
1. **Oral mesalamine + topical mesalamine**
2. Oral corticosteroids
- If unresponsive to therapy after 4-8 wks
33
tx for Moderate - Severe Ulcerative Colitis
1. **Oral Prednisone**, taper x 5-10mg wkly
2. Immunomodulators (azathioprine,cyclosporine) +/- TNF (infliximab) - if unresponsive to corticosteroids OR if flares occur while tapering off corticosteroids
34
what is curative for ulcerative colitis?
Total proctocolectomy with placement of ileostomy
35
maintenance for ulcerative colitis
1. Indicated if:
- more than one relapse in a year
- All with ulcerative proctosigmoiditis (involving rectum/anus/sigmoid)
- All with UC proximal to sigmoid colon (left-sided colitis)
2. Mesalamine (oral or topical) or other 5-ASA
36
tx for Severe Disease in Ulcerative Colitis & Crohns Disease
Hospitalized
Bowel Rest (TPN if prolonged withholding of feedings)
IV Corticosteroids
Infliximab/Remicade (TNF blocker)- if no improvement on corticosteroids within 4-7 days
37
indication for 5-ASA
Induction and Maintenance therapy of UC and CD
5-ASA: Sulfasalazine, Mesalamine
38
MOA of 5-ASA
Poorly understood; Inhibits prostaglandin production - producing anti-inflammatory effects
must exert effect directly to colon (EC tabs, pH dependant/chemical dependant tabs, suppositories, enemas)
39
SE of 5-ASA
N/V, HA, Hypersensitivity reaction
40
CI of 5-ASA
Sulfa or ASA allergy
41
indications for Corticosteroids/glucocorticoids
in IBD
Most effective to induce remission in severe flares
For acute flares – CD and UC
42
MOA of Immunomodulators/Immunosuppressants for IBD
inhibits DNA/RNA synthesis
In this case lymphocytes
43
indications for Immunomodulators/Immunosuppressants
for IBD
Steroid dependent CD and UC.
Remission maintenance in mild-severe ds.
44
SE of Immunomodulators/Immunosuppressants
Leukopenia, Thrombopenia, Anemia
Infection
N/V/D
Malaise, Myalgia
Adverse Events: Lymphoma, Severe infection
45
what IBD med has a BBW for
Mutagenic Potential
Rapid Growing Malignancy/Lymphoma
Immunomodulators/Immunosuppressants
Azathioprine (Imuran)
6-Mercaptopurine (6-MP) (Purinethol)
Methotrexate
Cyclosporine
46
indications for Methotrexate
if fail azathioprine
Mild – Mod active CD and maintenance
_Not effective in UC_
47
indications for Anti-tumor necrosis factor antibody (biologics)
Mod-Severe active CD and UC and maintenance
TOC for CD fistula
48
MOA of Anti-tumor necrosis factor antibody (biologics)
Monoclonal antibody that binds to human TNF factor, thereby interfering with the binding to TNF receptor sites and subsequent cytokine driven inflammatory processes
49
SE of biologics
Fever, rigors, N/V, Myalgia, urticaria, hypotension
Serious Adverse Effects: Severe infection/sepsis, Malignancy
50
what IBD med has a BBW of increasing risk of serious infections?
biologics
51
indication for abx in IBD
Severe disease with risk of secondary infection
Fistula and abscess in CD
Metronidazole, Ciprofloxacin
52
IBD - Possible Causes of Flare-Ups
Missing Medication Doses while in remission
NSAIDs - so encourage acetaminophen if needed
Smoking - esp. with Crohn’s
STRESS
Certain foods - can vary pt to pt
53
4 Pathologic Groups of colon polyps
1. **Mucosal adenomatous polyps (MC)**
- tubular, tubulovillous, villous
2. Mucosal serrated polyps
3. Mucosal non-neoplastic polyps
4. Submucosal lesions
54
cause of Adenomatous Polyps
DNA changes in the lining of the colon
1. Genetic predisposition
2. Other Risk Factors
- > 50, men
- Diet (high fat, red meat, low fiber)
- Obesity
3. 95% of all adenocarcinomas of the colon arise from adenomatous polyps
55
Adenomatous Polyps - Characteristics
1. Flat (more cancerous), Sessile, Pedunculated
2. Grow slowly
3. Pt asx
- sx with larger polyps: Bleeding, Change in Bowel Habits, Obstruction, abd Discomfort
56
dx for Adenomatous Polyps
1. **Colonoscopy w/ bx**
- “glandular” structure
- _Tubular (MC)_ - < cancerous
- Tubulovillous
- **Villous - MC cancerous**
57
Risk Factors for high-grade dysplasia/cancer for polyps
Polyps > 1cm
Villous histology
Number of polyps
Flat polyps
58
management/screening for colon polyps
1. Removal (Colonoscopy with Polypectomy)
2. FOB tests, Fecal Immunochemical tests, fecal DNA tests - Can be done yearly
3. Colonoscopy Screenings
4. Prevention - Diet, wt Loss
59
Sessile, serrated (saw tooth) polyps
Varied types (adenoma, hyperplastic)
Variable malignant potential
what type of polyp
Mucosal Serrated Polyps
60
M/C non-neoplastic polyp - Can develop into adenomatous polyps
M/C located in rectosigmoid area
M/C small
what type of polyp
Mucosal Nonneoplastic Polyps
61
what are submucosal lesions
Mesenchymal polyps that are benign tumors
1. Formed by more than one type of tissue
- Lipoma
- Leiomyoma
- Neurofibroma
- Vascular lesions
62
cause of colon cancer
Adenomatous (almost all)
Familial adenomatous polyposis
IBD
3rd MC cancer among men & women
2nd leading cause of death d/t cancer
63
risk factors for colon cancer
> 50 yrs/old (90%)
Family hx
Diet (Red Meat, fat)
Smoking
Obesity
64
presentation of colon cancer
Asx; S/Sx depend on location
1. proximal colon: anemia, weakness/fatigue, melena, postive FOBT, wt loss
2. distal colon: changes in bowel, obstruction, hematochezia, urgency/tenesmus
65
work-up for colon cancer
1. **DX: colonoscopy**
2. Other Labs:
- H/H
- LFT’s - elevation could indicate mets to liver
- CEA (carcinoembryonic antigen)tumor marker- not for screening. Level can suggest prognosis
CT/MRI for staging
66
tx for colon cancer
1. Surgical Resection
2. Chemotherapy/Radiation
- Esp. in Stage II-III (node/local tissue involvement) and Stage IV (metastatic ds)
When caught early - good prognosis
Stage I - 5 year survival rate > 90% with just surgery
Stage II - 5 year survival rate 80% with just surgery
67
Post-op follow up - curative resections for colon cancer
- q 3-6mths x 5 yrs with H&P, CEA level
- annual CT x 5 yrs in high risk patients
- Colonoscopy 1 yr after resection, if no polyps, then again in 3 yrs
- Rising CEA or new onset sx - colonoscopy/CT
68
screening for colon cancer
Fecal Occult Blood Test (FOBT), FIT test
Flexible Sigmoidoscopy
Colonoscopy
CT Colonography
69
Characterized by the development of hundreds to thousands of colonic adenomatous polyps
Familial Adenomatous Polyposis (FAP)
Inherited Genetic mutation (APC gene)
70
Familial Adenomatous Polyposis (FAP) is MC in who/when?
- colorectal polyps develop by age 15 and cancer by 40
- Unless prophylactic colectomy is performed, CRC is inevitable by age 50
71
in FAP a variety of other benign extraintestinal manifestations can develop, such as?
Soft tissue tumors of the skin, desmoid tumors (noncancerous growth in connective tissue), osteomas
72
screening/tx for FAP
- Genetic counseling and testing and to first degree family members of patients with FAP
- Upper endoscopic eval of stomach and duodenum performed q1-3 yrs for adenomas/carcinomas
- complete proctocolectomy w/ ileoanal anastomosis or ileorectal anastomosis before age 20
73
HNPCC
Autosomal dominant condition
Caused by mutations in a gene that detects and repairs DNA base-pair mismatches
what is this dx?
Lynch Syndrome
AKA: Hereditary nonpolyposis colon cancer
74
lynch syndrome has an Increased risk of colorectal cancer, as well as other cancers:
Endometrial/ovarian
renal/bladder
hepatobiliary/gastric/small intestines
75
difference between FAP and lynch syndrome?
lynch syndrome - only a few adenomas
- Flat
- more villous features/high grade dysplasia
- Undergo rapid transformation over 1-2 years
76
what is the “Three tool” for identifying increased risk and meriting a more detailed assessment for lynch syndrome
1st degree relative with colorectal/lynch-related cancer before 50?
Have you had colorectal cancer/polyps before age 50?
3 or more relatives with colorectal cancer?
77
Screening/Treatment for lynch syndrome
1. Genetic eval if personal/family hx of CRC under age 50, or a hx of multiple family members with cancer
2. If genetic testing positive, test other 1st degree relatives
- affected relatives get colonoscopy q1-2 yrs at age 25
- Women screening for endometrial/ovarian cancer at 30-35
78
tx for lynch syndrome
- Subtotal colectomy with ileorectal anastomosis
- Prophylactic hysterectomy and oophorectomy at age 40 or when finished with childbirth
- Screening for gastric cancer with upper endoscopy q2-3 yrs beginning at age 30-35
79
what type of hemorrhoids are above the dentate line?
internal hemorrhoids
external = below
80
causes of hemorrhoids
Increase venous pressure
Constipation, low fiber diet
Straining
Pregnancy
Obesity
81
internal hemorrhoids commonly occur in 3 locations
right anterior, right posterior, and left lateral
82
how do external hemorrhoids happen?
Arise from the inferior hemorrhoidal veins located below the dentate line and are covered with squamous epithelium of the anal canal or perianal region
83
How do hemorrhoids become symptomatic?
As a result of activities that increase venous pressure
- Resulting in distention and engorgment
- Straining at stool, diarrhea, constipation, prolonged sitting, pregnancy, obesity, low-fiber diets
- May eventually result in bleeding or protrusion
84
presentations of hemorrhoids
1. Asx (MC)
2. Internal - Bleeding, Prolapse, Mucoid Discharge
3. Bleeding manifested
4. PE: perianal inspection, anoscopic eval
85
external inspection seen on rectal exam
Anal fissures
Anal fistula
Genital warts
External hemorrhoids
Pilonidal sinus
Skin disease (seborrhoeic eczema, skin cancer, natal cleft dermatitis)
Skin tags
Skin discoloration with Crohn disease
Rectal prolapse
86
internal inspection seen on rectal exam
Internal hemorrhoids
Rectal carcinoma
Rectal polyps
Tenderness with prostatitis or acute appendicitis
Malignant or inflammatory conditions of the peritoneum with anterior palpation
87
tx for hemorrhoids
1. Conservative (Stage I & II)
- Proper Toileting (decreased straining, limit sitting on toilet for more than 5 minutes)
- High Fiber Diet, Fiber/Bulk Laxatives, increase fluid intake
2. Medical (Stage I & II with recurrent bleeding or failure of conservative, Stage III - IV)
- Rubber band ligation of hemorrhoid (preferred)
- Injection sclerotherapy - Chemical injected into hemorrhoid - Reduces blood flow, shrinks hemorrhoid
3. Stage IV or severe III: hemorrhoidectomy
88
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
what is this presentation
External Hemorrhoid
89
tx for External Hemorrhoid
1. Warm Sitz baths
2. Topical ointments
3. Evacuation of clot
If evaluated in first 24-48 hrs, removal of clot may hasten symptomatic relief (ellipse of skin excised, clot evacuated)
90
Linear tears/ulcerations around the anus
Usually less than 5mm
d/t trauma to anal canal during defecation
Constipation/Hard stool
Straining with defecation
what is this dx?
Anal Fissures
MC posterior midline
91
if Fissures off midline, look for ?
Crohn, HIV/AIDs, TB, Anal carcinoma
92
tx for anal fissures
Proper toileting
Sitz Baths
Fiber
Topical anesthetics
93
½ of all Perianal Abscesses caused by ?
fistulas
94
sx of perianal
Throbbing
Continuous perianal pain
erythema/fluctuance
swelling
95
tx for perianal abscesses
I & D
+ / - Abx
Surgical Excision
96
presentation and tx for anal fistulas
- purulent discharge that may lead to itching, tenderness, and pain
- Fistulotomy: Probe inserted in fistula, incision made over length, curetted; Absorbable suture marsupializes the tract
97
Protrusion through anus of some or all layers of the rectum
what is this dx?
Rectal Prolapse
- Initially reduces spontaneously after defecation
- Over time rectal mucosa becomes chronically prolapsed: Mucus discharge, bleeding/incontinence, Sphincter damage
98
risk factors for rectal prolapse
1. >40
2. Female
3. Multiparity
4. Vaginal delivery
5. Prior pelvic surgery
6. Chronic straining
7. Chronic diarrhea
8. Chronic constipation
9. Dementia
10. Stroke
11. Pelvic floor dysfunction
12. Pelvic floor anatomic defects (eg, rectocele, cystocele, enterocele, deep cul-de-sac)
99
tx for rectal prolapse
Manual reduction
Adequate fluid and fiber intake
Kegel exercises
SURGICAL CONSULT
100
what is Pilonidal Disease
opening or chronic infection of the skin in the area between the buttocks
