Large intestine Flashcards
Diverticulitis
inflammation of one diverticulum or more.
Elderly is more vulnerable.
more common is a colo-vesicular fistula (colon to urinary bladder).
colo-vaginal fistulas may present with a purulent vaginal discharge.
Diverticulosis
the condition of having diverticula
Ddx of diverticulitis
transverse colon: peptic ulcer disease, pancreatitis or cholecystitis.
right colon: appendicitis
lab: liver function tests and amylase/lipase. serum electrolyte.
Imaging: flat and upright abdominal films may show an obstruction, or free air.
Barium enema is not advised!!
tx of diverticulitis
- liquid diet
- 7-10 days of oral broad-spectrum anti-microbial therapy (ciprofloxacin and metronidazole)
- Hospitalization if; unable to tolerate oral hydration. if outpatient therapy fails. significant fever. peritoneal signs. narcotics are needed for pain control. With chronic underlying medical disease. Old age.
- in moderate to severe (IV hydration and IV antibiotic- triple regimen of ampicillin, gentamicin, metronidazole)
tx of diverticulitis (peri-diverticular abscess)
-more than 5cm in diameter without perforation)
CT scan-guided percutaneous drainage
Diverticulitis- surgical indications
- free air perforation with fecal peritonitis
- suppurative peritonitis secondary to a ruptured abscess
- abdominal or pelvic abcess
- fistula formation
- recurrent episodes of acute diverticulitis
- inability to rule out carcinoma
- intestinal obstruction
- failing medical therapy
- pts who are immunocompromised (extremes of age)
Diverticulitis- surgery
1st stage– segmental resection of affected colon and creating diverting colostomy
2nd stage– colostomy closure 3-6 months later
or
1 stage only- resection of affected segment of colon and performing a primary anastomosis of the two ends of the colon
Colo-rectal cancer- CEA
- CEA may be elevated for other reasons (pancreatic or hepatobiliary disease), and elevation does not always reflect cancer or disease recurrence.
- recurrence remains a possibility when CEA is not elevated, even if CEA was elevated preoperatively.
Double-contrast barium enemas for cancer dx
-limitations; miss lesions in the region of the ileocecal valve or the distal rectum, or in pts with severe diverticulosis.
Colonoscopy as dx of colon cancer
might be the most effective and cost-effective screening method.
Colon cancer- surgery
classic surgical procedure is anterior resection that involves a “no touch” isolation technique
Colon cancer- chemo
Combination of 5-fluorouracil, leucovorin, and irinotecan (CPT11).
also be referred for radiation oncology consultation.
Colon cancer- radiation
useful in palliative care- reduce tumor growth.
improve the quality of life- by helping to control pain or spinal cord compression or SVC syndrome
Ulcerative colitis
50% with proctitis or proctosgmoiditis.
Most common with bloody diarrhea.
No fistulas.
Toxic megacolon
Concomitant infectious colitis- with Clostridium difficile
Malignancy (surveillance colonoscoy every 2 years after the 8th year of disease is recommended)
Eye disease- Episcleritis or Uveitis (tx with high-dose systemic steroids or Infliximab)
Sclerosing cholangitis (fatigue and jaundice)
Colectomy is curative.
Crohn’s disease
Most common- Ileo-colonic
Perianal fistula.
Malignancy risk is high if the entire colon is involved.
Calcium oxalate stones.
Skin disease with IBD
1: Erythema nodosum (anterior surface of the tibia)
2: Pyoderma gangrenosum (not associated with disease activity. Inflammation to ulceration.)
- Tx for 2: Dapsone, Metronidazole, Cyclosporine, Infliximab
- surgical removal of the diseased bowel does not ameliorate pyoderma gangrenosum.
Diagnosis of IBD
1: Clinical features/ Presenting signs
2: Endoscopic
3: Histological
4: Radiographic finding
* Lab tests are non-specific.
tx of IBD
1: Aminosalicylates (useful for treating flares of IBD and for maintaining remission)
1a: Metronidazole & Ciprofloxacin (with UC)- perioperative setting to avoid pseudomembranous colitis. (with Crohns)- used for perianal disease/ fistulae and inflammatory masses in the abdomen/ ileitis.
2: Corticosteroids- if aminosalicylates fail. (no role in maintaining remission, just for induction)
3: 6-MP or Azathioprine (not used for acute flares), or Infliximab (once every 8 weeks has been demonstrated to be effective for maintaining remission. Promote mucosal healing. Great for fistula. thus for Crohns) (seek insurance approval for the administration since it is extremely expensive)
Experimental drugs for UC
- Cyclosporine A
- Nicotine patch
- Butyrate enema
- Heparin
Experimental drugs for Crohn’s
- Methotrexate
- Thalidomide
- Interleukin 11
Symptomatic tx for IBD
antidiarrheal agents, bile acid-binding agents, antispasmodics, and acid suppressants.
Antidiarrheal meds can cause toxic colitis or megacolon so use with caution
Nutritional support
as primary tx, works only in Crohn’s of the small bowel.
Surgery for Crohn’s disease
Segmental resection- resect as little bowel as possible
Surgery for UC
Total proctocolectomy with ileostomy creation is the simplest procedure with the lowest overall complication rate
