Large intestine

Question 0

Diverticulitis

Answer 0

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.

Question 1

Diverticulosis

Answer 1

the condition of having diverticula

Question 2

Ddx of diverticulitis

Answer 2

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!!

Question 3

tx of diverticulitis

Answer 3

• 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)

Question 4

tx of diverticulitis (peri-diverticular abscess)

Answer 4

-more than 5cm in diameter without perforation)

CT scan-guided percutaneous drainage

Question 5

Diverticulitis- surgical indications

Answer 5

• 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)

Question 6

Diverticulitis- surgery

Answer 6

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

Question 7

Colo-rectal cancer- CEA

Answer 7

• 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.

Question 8

Double-contrast barium enemas for cancer dx

Answer 8

-limitations; miss lesions in the region of the ileocecal valve or the distal rectum, or in pts with severe diverticulosis.

Question 9

Colonoscopy as dx of colon cancer

Answer 9

might be the most effective and cost-effective screening method.

Question 10

Colon cancer- surgery

Answer 10

classic surgical procedure is anterior resection that involves a “no touch” isolation technique

Question 11

Colon cancer- chemo

Answer 11

Combination of 5-fluorouracil, leucovorin, and irinotecan (CPT11).
also be referred for radiation oncology consultation.

Question 12

Colon cancer- radiation

Answer 12

useful in palliative care- reduce tumor growth.

improve the quality of life- by helping to control pain or spinal cord compression or SVC syndrome

Question 13

Ulcerative colitis

Answer 13

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.

Question 14

Crohn’s disease

Answer 14

Most common- Ileo-colonic
Perianal fistula.
Malignancy risk is high if the entire colon is involved.
Calcium oxalate stones.

Question 15

Skin disease with IBD

Answer 15

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.

Question 16

Diagnosis of IBD

Answer 16

1: Clinical features/ Presenting signs
2: Endoscopic
3: Histological
4: Radiographic finding
* Lab tests are non-specific.

Question 17

tx of IBD

Answer 17

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)

Question 18

Experimental drugs for UC

Answer 18

• Cyclosporine A
• Nicotine patch
• Butyrate enema
• Heparin

Question 19

Experimental drugs for Crohn’s

Answer 19

• Methotrexate
• Thalidomide
• Interleukin 11

Question 20

Symptomatic tx for IBD

Answer 20

antidiarrheal agents, bile acid-binding agents, antispasmodics, and acid suppressants.
Antidiarrheal meds can cause toxic colitis or megacolon so use with caution

Question 21

Nutritional support

Answer 21

as primary tx, works only in Crohn’s of the small bowel.

Question 22

Surgery for Crohn’s disease

Answer 22

Segmental resection- resect as little bowel as possible

Question 23

Surgery for UC

Answer 23

Total proctocolectomy with ileostomy creation is the simplest procedure with the lowest overall complication rate