Inflammatory Bowel Disease

Question 1

Inflammatory Bowel Disease

Answer 1

A group of chronic disorders that cause inflammation or ulceration in the small and large intestines
may also be referred to as colitis, enteritis, ileitis, and proctitis
Geographically incidence decreases in North and South direction
Seasonally, flares peak in Spring

Question 2

Crohn’s Disease

Answer 2

chronic inflammatory condition affecting the gastrointestinal tract at any point from the mouth to the rectum
an inflammation that extends into the deeper layers of the intestinal wall, and also may affect other parts of layers of the digestive tract

Question 3

Ulcerative Colitis (UC)

Answer 3

chronic disease with recurrent symptoms and significant morbidity
Etiology still unknown
25% of pts have extraintestinal manifestations
Causes ulceration and inflammation of the inner lining of the colon and rectum

Question 4

UC and Crohn’s Presentation

Answer 4

Similar presentation

Often resemble other conditions, like irritable bowel syndrome

Question 5

Symptoms UC and Crohn’s

Answer 5

Abdominal pain-may be only complaint cramping - intermittent 
Diarrhea
Spasms in the rectum
Fecal incontinence
Rectal bleeding – seen on toilet paper, blood in stool, clots
Fatigue
Weight loss
Anorexia
Fever
Chills
Nausea vomiting
Joint pain
Mouth sores

Question 6

Hx Taking - Crohn’s

Answer 6

address the onset, severity, and pattern of symptoms, especially frequency and consistency of bowel movements
History targeting risk factors and possible alternative diagnoses includes recent travel, exposure to antibiotics, food intolerance, medications, smoking, and family history of inflammatory bowel disease
Specific questions addressing extraintestinal manifestations include eye and joint problems and symptoms of anemia
Symptoms severe enough to miss school/work

Question 7

S&S Crohn’s

Answer 7

Vague complaints
Fatigue
Abdominal cramping
Intestinal obstruction
Vomiting 
Bloating
No stool
Perianal disease with fissures, perirectal abscess, fistula

Question 8

Hx Taking - UC

Answer 8

The hallmark symptoms: intermittent bloody diarrhea, rectal urgency, and tenesmus (spasmodic contraction of anal or vesicle sphincter with pain and urge to empty bowel or bladder with involuntary, ineffectual strain or efforts)

Question 9

S&S - UC
MIld
Moderate
Severe

Answer 9

Mild: Intermittent rectal 	
bleeding with passage of mucous
Mild diarrhea 10 stools/day
Severe cramps
Fever
Bleeding, requires transfusion

Question 10

DD - IBD

Answer 10

1. Infectious agent (bacterial, viral, parasitic)
2. Irritable Bowel Syndrome
3. Colitis or proctitis (inflammation of the colon/rectum).
4. Appendicitis
5. Diverticulitis
6. Carcinoid tumor, carcinoma, lymphoma
7. Foreign bodies, bleeding from hemorrhoids, fissures, polyps
8. Radiation enteritis; proctitis
9. Pelvic Inflammatory Disease or other gyn disorders.
10. Systemic vaculitis
11. Medications
    (especially those causing chronic diarrhea)

Question 11

Diagnositc Labs
Blood
Stool

Answer 11

CBC, ESR, CMP
CD:mild anemia,mild leukocytosis, elevated ESR, UC:Anemia, UC:leckocytosisleckocytosis, , hypokalemiahypokalemia, , hypoaluminemia hypoaluminemia, elevated ESR, elevated LFTs

Genetic Testing

Stool Tests: 
evaluate for infection 
O & P 
c-diff 
stool culture 
fecal leukocytes (+ with inflammation)

Question 12

Barium Enema

Answer 12

Limited use in dx IBD, but is useful in detecting colonic distention, obstruction, fistulas, strictures, or tumors

Avoid with moderate to severe colitis because of risk of perforation

Question 13

Flexible Sigmoidoscopy

Answer 13

Since tx is based on extent of dz, flex sig is used to document extent at initial presentation
Preferred over colonoscopy b/c this is usually not necessary and can induce magacolon or perf in severely ill pts
UC - vascular markings are lost d/t engorgement of mucosa, giving it an erythematous appearance.
Petechiae, exudates, touch friability, and frank hemorrhage may also be present.
More severe cases may be associated with macroulcerations, profuse bleeding, and copious exudates
Colonic involvement is continuous in ulcerative colitis, in contrast to the patchy nature of Crohn’s disease.

Question 14

Flex Sig Uses

Answer 14

1. Determine the cause of blood, mucus, or pus in the stool
2. Confirm findings of another test or X-rays
3. Take a biopsy of a growth

Question 15

Therapy Goals - IBD

Answer 15

Relieve symptoms
Correct nutritional deficiencies
Control inflammation
Prevent colon cancer

Question 16

Drug Tx - Crohn’s

Answer 16

Mild Symptoms: slow release oral 5-aminosalicylic acid (5-ASA) agent (Pentasa or Asacol)
Treatment is usually begun with either Pentasa or Asacol at a dose of 2 g/day with an increase to a maximum of 4.8 g/day, depending upon the clinical response
—For patients who do not respond to or do not tolerate 5-ASA drugs, it is common practice to initiate a trial of one of several antibiotics as primary therapy before beginning corticosteroids

Question 17

Drug Tx - UC

Answer 17

varies according to the severity of symptoms
Initial thx in mild to moderate symptoms: combination of oral 5-ASA or sulfasalazine and topical therapy with either 5-ASA or steroid enemas

Question 18

Surgical Tx - Crohn’s

Answer 18

Resection and anastomosis: removes the diseased part of the intestine, then rejoins the two ends
Strictureplasty: procedure used to relieve bowel obstructions by widening the intestines.
Balloon dilatation: method of widening the bowel.

Question 19

Surgical Tx - UC

Answer 19

Patients with toxic megacolon (ie, those with colonic dilation of 6 cm or greater who appear toxic) who do not respond to therapy within 72 hours should be considered candidates for colectomy.
Less severely ill patients usually respond to parenteral corticosteroids within 7 to 10 days. Despite advances in therapy, rates of colectomy for severe ulcerative colitis have not changed substantially in more than 30 years

Question 20

DD Chronic Diarrhea

Answer 20

Watery
Secretory (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg)
Alcoholism
Bacterial enterotoxins (e.g., cholera)
Bile acid malabsorption
Brainerd diarrhea (epidemic secretory diarrhea)
Congenital syndromes
Crohn disease (early ileocolitis)
Endocrine disorders (e.g., hyperthyroidism [increases motility])
Medications (see Table 3)
Microscopic colitis (lymphocytic and collagenous subtypes)
Neuroendocrine tumors (e.g., gastrinoma, vipoma, carcinoid tumors, mastocytosis)
Nonosmotic laxatives (e.g., senna, docusate sodium [Colace])
Postsurgical (e.g., cholecystectomy, gastrectomy, vagotomy, intestinal resection)
Vasculitis
Osmotic (fecal osmotic gap > 125 mOsm per kg)
Carbohydrate malabsorption syndromes (e.g., lactose, fructose)
Celiac disease
Osmotic laxatives and antacids (e.g., magnesium, phosphate, sulfate)
Sugar alcohols (e.g., mannitol, sorbitol, xylitol)
Functional (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting)
Irritable bowel syndrome

Fatty (bloating and steatorrhea in many, but not all cases)
Malabsorption syndrome (damage to or loss of absorptive ability)
Amyloidosis
Carbohydrate malabsorption (e.g., lactose intolerance)
Celiac sprue (gluten enteropathy)–various clinical presentations
Gastric bypass
Lymphatic damage (e.g., congestive heart failure, some lymphomas)
Medications (e.g., orlistat [Xenical; inhibits fat absorption], acarbose [Precose; inhibits carbohydrate absorption])
Mesenteric ischemia
Noninvasive small bowel parasite (e.g., Giardia)
Postresection diarrhea
Short bowel syndrome
Small bowel bacterial overgrowth (> 105 bacteria per mL)
Tropical sprue
Whipple disease (Tropheryma whippelii infection)
Maldigestion (loss of digestive function)
Hepatobiliary disorders
Inadequate luminal bile acid
Loss of regulated gastric emptying
Pancreatic exocrine insufficiency
Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)
Inflammatory bowel disease Crohn disease (ileal or early Crohn disease may be secretory)
Diverticulitis
Ulcerative colitis
Ulcerative jejunoileitis
Invasive infectious diseases
Clostridium difficile (pseudomembranous) colitis–antibiotic history
Invasive bacterial infections (e.g., tuberculosis, yersiniosis)
Invasive parasitic infections (e.g., Entamoeba)–travel history
Ulcerating viral infections (e.g., cytomegalovirus, herpes simplex virus)
Neoplasia
Colon carcinoma
Lymphoma
Villous adenocarcinoma
Radiation colitis

Question 21

Hemorrhoids Management Options

Answer 21

Diet modification
Office-based procedures: rubber band ligation, sclerotherapy, infrared coagulation
Surgical hemorrhoidectomy: surgical excision, stapled hemorrhoidopexy, doppler-guided ligation