Intestine 2 Flashcards
Abdominal pain
– SB = periumbilical, cramping, paroxysmal
– LB = lower quadrants
nausea/vomiting, abdominal distention/bloating, constipation, diarrhea, obstipation, anorexia, fatigue, weakness
CAVO = Crampy abdominal pain, Abdominal distention, Vomiting, Obstipation
bowel obstruction
Prior abdominal/pelvic surgery, hernia, IBD, malignancy, diverticulitis, volvulus, intussusception, opioid use
bowel obstruction
75% of bowel obstructions are
small
Mechanical = physical object (surgical adhesions, hernia, foreign body, IBD, volvulus, fecal impaction, intussusception, diverticulitis, colorectal cancer)
Non-mechanical = absent or reduced peristalsis (narcotics, post-op, neuro, hypokalemia, infections)
MC small = surgical
MC large = fecal impaction, diverticulitis, cancer
bowel obstruction
PE:
Signs of dehydration (tachy, orthostatic HOTN, reduced urine output, dry mucous membranes)
Fever (perf)
Abdominal distention
Bowel sounds – high pitched “tinkling” early on → absent/late nothing, visible peristalsis
Percussion = hyperresonance, fluid-filled loops with dullness
Palpation = generalized tenderness
Check for hernias!! If ruptured, peritoneal signs
DRE → fecal impaction or mass possible
Gross or occult blood = tumor, ischemia
Labs:
CBC (leukocytosis, anemia)
BMP (electrolyte abnormalities, BUN/Cr)
Mag
ABG, serum lactate (high = bowel is dying), cultures
UA
bowel obstruction
Plain XR: dilated loops of bowel with air-fluid levels in a “step-ladder”
Look for pneumoperitoneum
CT w/ IV contrast distinguishes paralytic ileus from mechanical obstruction w/ transition zone
– diameter >10-12cm ass w/ risk of perforation
bowel obstruction
how do you treat bowel obstruction
Admit to hospital → strict NPO, no narcotics or NSAIDs
Antiemetics – watch for hypokalemia
IV fluids
Correct electrolyte issues (K>4, Mg>2)
Decompress bowel (NG tube with suction)
IV steroids if IBD
Consult surgery
If strangulated hernia or acute abdomen = surgery right away
Mild, diffuse continuous abdominal discomfort, N/V, distention with minimal abdominal tenderness
NO signs of peritoneal irritation
acute paralytic ileus
RF for:
Hospitalized patients with intra abdominal processes, severe medical illness, or medications that affect intestinal motility
Post-operative
Opioids
Hypokalemia
Hypercalcemia
Hypothyroidism
acute paralytic ileus
Neurogenic failure/loss of peristalsis in the absence of any mechanical obstruction
ileus
how is risk reduced for ileus
minimally invasive surgery, patient-controlled analgesia, avoidance of opioids, early ambulation, gum chewing, clear liquid diet
PE: bowel sounds diminished-absent
Abdominal distention and tympany
Labs attributable to underlying condition
→ obtain serum electrolytes, Mg, phosphorus, Ca
Plain film = distended gas-filled loops of small + large intestine (looks like small bowel obstruction) w/o transition zone
CT scan to differentiate
paralytic ileus
how do you treat paralytic ileus
Treat underlying cause
– restriction of oral intake w/ slow re-introduction
May require NG suction + IV fluids and electrolytes
Alvimopan – reverses opioid-induced inhibition of intestinal motility, when post-op opioid therapy is indicated
Extraintestinal manifestations = spondylitis, oral ulcers, uveitis, erythema nodosum, hepatitis
common in Adolescents and adults <40 years
15-35 onset
Ashkenazi Jews
IBD
Easily misdiagnosed–
Fever, chills, change in well-being, weight loss, abdominal pain, bloating, cramping, borborygmi, diarrhea, prior surgical resections, rectal bleeding, tender abdominal mass, fatigue
Fistulae, recurrent UTIs if between intestine and bladder
Perianal disease = large, painful skin tags, anal fissures, abscesses, fistulas
Extraintestinal: arthralgias, arthritis, oral aphthous ulcers, iritis/uveitis, erythema nodosum, pyoderma gangrenosum, gallstones and kidney stones
crohn’s disease
What are RFs for crohn’s disease
Smoking
15-35y
RF for aggressive disease:
Young age
Early need for steroids
Perianal disease, fistulizing or structuring disease, upper GI
Lab markers of severe inflammation
Endoscopic findings of deep ulceration
Transmural disease → anywhere in GI tract, MC in terminal ileum and proximal colon & skip areas of involvement
– can cause fistulas, bowel strictures, perianal disease, abscesses
Dx made based on clinical picture w/ supporting evidence
crohn’s disease
What are IBD medication classes?
5-ASA (sulfasalazine, mesalamine)
corticosteriods (budesonide, prednisone)
immunomodulators - thiopurines, methotrexate, janus kinase inhibitors (-mab), sphingosine 1 phosphate receptor modulators -mod)
biologic therapies - anti-TNF (infliximab, adalimumab, golimumab, certolizumab)
anti-integrins (vedolizumab)
anti-IL 12/23 (ustekinumab)
patients w/ IBD have an increased risk of vaccine-preventable infections so what should you do?
confirm vaccination status
inactivated vaccines - hep a, b, shingles, influenza, dTAP (safely administered with immunosuppression)
pneumococcal vaccine in >65
live virus should never be administered while taking immunosuppressive drugs
CBC: anemia, B12 deficiency, possible leukocytosis
CMP: albumin
CRP/sed rate
Fecal calprotectin → active inflammation
Stool cultures
Endoscopy = “skip lesions” and cobblestone appearance with aphthous, linear or stellate ulcers, strictures, segmental involvement (large or deep = higher risk)
Upper GI: string sign
Granulomas on biopsy
CT, MR enterography, capsule imaging, upper GI w/ SBFT
crohn’s disease
surgery indications for crohn’s disease
Poor response to medical therapy
Intraabdominal abscess
Massive bleeding
Internal or perianal fistulas
Intestinal obstruction
admit a crohn’s disease patient if
Intestinal obstruction
Abscess is suspected
Serious infectious complication
Severe diarrhea, dehydration, weight loss, or abdominal pain
Severe or persistent symptoms despite steroids
High fever, persistent vomiting, severe abdominal tenderness
How do you treat a mild/low risk crohn’s disease?
Nutrition
Well balanced diet, smaller, more frequent meals, fluids, avoid fried/greasy foods, trial off dairy
Loperamide for diarrhea PRN up to 4x
Drug therapy based on location of involvement
Terminal ileum or ascending colon disease = extended-release budesonide (steroid)
Left sided or diffuse = oral steroids (prednisone/prednisolone) and taper, sulfasalazine (5-ASA)
what is considered mild/low risk crohn’s disease
mild symptoms, no significant weight loss, normal or only mildly elevated inflammatory markers, absence of intestinal complications, limited intestinal involvement:
What is severe/high risk crohn’s disease?
frequent diarrhea, weight loss, daily abdominal pain, abdominal tenderness, perianal disease, with evidence of inflammation on labs, findings of deep ulceration stricture or penetrating disease on endoscopy or imaging
how do you treat severe/high risk crohn’s disease?
oral corticosteroid (methylprednisolone/prednisone) w/ tapering + initiation of biologic agent
Early treatment with biologic agents (w or w/o immunomodulators)
anti-TNF = infliximab, adalimumab
+ immunomodulating azathioprine, mercaptopurine, methotrexate
If fail biologics, small molecules (jak inhibitor - upadacitinib)
Nutrition
low-roughage diet, decreased processed foods, TPN, B12, Vitamin D
Symptomatic therapy
Diarrhea = cholestyramine, colestipol, colesevelam
Steatorrhea = low-fat
SIBO = abx
Diarrhea = loperamide, diphenoxylate w/ atropine, tincture of opium (NOT in active severe disease)
How do you treat crohn’s disease if biologic therapies fail?
Failure of biologic therapies = oral small molecules (upadacitinib)
Diffuse mucosal inflammation → friability, erosions, ulcers w/ bleeding
Bloody diarrhea
Diarrhea w/ mucus
Fecal urgency, tenesmus, LLQ cramping pain relieved by defecation in LLQ
Hematochezia
ulcerative colitis
What are those with ulcerative colitis at inc risk of? How can you monitor for it?
Risk of colon cancer – colonoscopy begin 8 years after diagnosis, remove all polyps when possible, repeat q1-5 years
Recurrent, chronic disease ONLY in the colon. What classifies it as mild-moderate, severe, and fulminant?
ulcerative colitis
Mild-moderate
- 4-6 BM/day
- NO constitutional symptoms
Severe
- >6 bloody BM/day
- Anemia, hypovolemia, hypoalbuminemia
Fulminant colitis: fever, chills, worsening of symptoms
PE: abdominal pain + tenderness, red blood on DRE, hypovolemia, arthralgia, iritis/uveitis, scleritis, sclerosing cholangitis, pyoderma gangrenosum/erythema nodosum
CBC: anemia, possible leukocytosis
ESR: elevated, determines severity
Low albumin
FOBT +
Stool culture, c. diff assay
Hct, albumin, inflammatory markers reflect disease severity
Sigmoidoscopy is DOC
“Mayo” scoring system with 1-2 = mild/mod and 2-3 = mod/severe
Avoid colonoscopy w/ fulminant disease, delay until improvement
Plain films or CT = colonic dilation in severe disease (“stove/lead pipe”, loss of haustral markings”
Barium enemas
ulcerative colitis
CRP > 5 or fecal calprotectin >150 = disease relapse → endoscopy
ulcerative colitis
Systemic signs of inflammation or ulcerations with extensive disease = risk of hospitalization or surgery → early aggressive therapy
Disease activity assessed by clinical symptoms, lab data, inflammatory markers, fecal calprotectin
Admit if: frequent bloody stools, anemia, weight loss, fever, fulminant disease, when surgery is indicated
Refer for colonoscopy if needed, f/u for hospitilization
ulcerative colitis
how do you treat mild-mod distal ulcerative colitis?
Topical mesalamine 5-ASA suppository/enema
Oral if not tolerated
No result = combo of topical w/ oral, topical steroid, all three
Maintenance = 5-ASA
How do you treat mild-mod ulcerative colitis?
Combo oral + topical 5-ASA (mesalamine)
+ oral steroid (budesonide or prednisone) if no improvement within 4-8 weeks
If requiring >1 course of steroids every 1-2 years, add thiopurine or biologic agent
How do you treat mod-severe ulcerative colitis?
Oral steroid (prednisone/methylprednisolone) w/ slow tapering followed by oral mesalamine
Biologics or small molecules (infliximab or vedolizumab - older or high risk) with or without immunomodulator recommended when:
Steroids can’t be completely withdrawn
Those who require 2+ steroids every every 1-2 yrs
If don’t respond, IL Antibodies
How do you treat severe + fulminant ulcerative colitis?
NPO x 24-48 hours until improvement (may need TPN)
d/c offending agents
IV fluids, support
IV steroids, enemas → infliximab if no improvement
IV cyclosporine with steroid failure
Surgery
Severe, bloody diarrhea
Toxic/ill appearing
Altered sensorium
Fever
Postural HOTN
Lower abdomen distention + tenderness
+/- peritonitis
Tachycardia
toxic megacolon
RF for toxic megacolon
IBD (UC), c. diff, diverticulitis, colon cancer, loperamide, CMV
Mid-transverse colonic dilation >5.5-6cm and systemic toxicity
toxic megacolon
Labs: CBC, ESR/CRP, CMP, stool specimen
XR initial imaging choice
Diagnostic Criteria:
Radiographic dilation of colon >5.5-6cm AND at least 3:
Fever >38.6/101.5
HR >120
WBC >10,500
Anemia
AND at least one:
Dehydration
AMS
Electrolyte disturbance
HOTN
toxic megacolon
how do you treat toxic megacolon
complete bowel rest (NPO), IV hydration, NG tube, no anti-motility (opioids, anticholinergics), broad spectrum abx if c diff, IV steroids if ulcerative colitis
Infliximab if no steroid response
Surgery if
Clinical deterioration
Failure to improve with medical care after 24-72 hours
Perforation
Uncontrolled hemorrhage
Worsening signs of toxicity and/or dilation
Mild-moderate greenish, foul-smelling watery diarrhea
3-15 stools/day with lower abdominal cramps
antibiotic associated colitis
RFs for antibiotic associated colitis
Older, debilitated, immunocompromised, receiving multiple antibiotics, prolonged antibiotic therapy, tube feedings, PPIs, chemo, IBD
Almost always from c difficile
– fecal-oral transmission
MC: ampicillin, clindamycin, 3rd gen cephs, fluoroquinolones
antibiotic-ass colitis
PE: normal or LLQ tenderness
Labs:
WBC >15000
Cr >1.5
Stool studies = PCR toxin gene test or GDH (glutamate dehydrogenase) protein assay
Flexible sigmoidoscopy if not responsive to treatment, atypical symptoms
Biopsy = epithelial ulceration with “volcano” exudate
abx-associated colitis
abx associated colitis tx
Contact precautions
Discontinue agent
Fidaxomicin or vancomycin
Fulminant disease = oral vancomycin + IV metronidazole + surgical consult
