Large Intestine And Anorectal Conditions Flashcards
Large Intestine: Common Symptoms
-Abdominal pain, discomfort, cramping
-Constipation
-Diarrhea
-Distension
-Incontinence
-Bleeding
-Gas
Large Intestine: Exam
Focused intestinal exam
Large Intestine: Common Diagnostic Tools
-Colonoscopy: Entire colon
-Sigmoidoscopy: Left side of colon
-Biopsy: Cancer
-Stool/Fecal Occult Blood Test (FOBT)
-Fecal immunochemical Test (FIT)*
Constipation: Definition
– Infrequent passing of stool
– Difficulty passing of stool
– Feeling of incomplete evacuation or impaction
Constipation in the elderly is common & often due to:
–Low fiber diets
-Lack of exercise
-Coexisting medical conditions
-Use of constipating drugs
Constipation: Complications
– hemorrhoids, anal fissure, prolapse
– Other: fecal impaction, syncope
Causes of Constipation: Acute
• Obstruction
• Ileus
• Fecal impaction
• Drugs-examples: NSAIDs, antihistamines, antidepressants, high blood pressure, antispasmodics
Causes of Constipation: Chronic (Functional)
– IBS
– Pelvic floor syndrome
– Slow transit constipation
Causes of Constipation: Chronic (Pathological)
– Diabetes mellitus
– Hypothyroidism
– Pregnancy
– CNS disorders: Parkinsons, stroke, MS, spinal cord lesions
– Tumors
– Peripheral nervous system disorders
– Low fiber diet
– Chronic laxative abuse
– Medication
Constipation: Functional Disorders
-Slow-transit constipation
-Irritable bowel syndrome
-Pelvic floor dysfunction
Constipation: Metabolic Disorders
-Diabetes mellitus
-Hypothyroidism
-Hypocalcemia
-Hypercalcemia
Causes of Constipation: CNS disorders
-Parkinson disease
-Multiple sclerosis
-Stroke
-Spinal cord lesions
Causes of Constipation: Dietary Factors
-Low-fiber diet
-Sugar-restricted Diet
-Chronic laxative abuse
Constipation: Red Flags
– Distended, tympanic abdomen (suggests mechanical obstruction)
– Vomiting
– Blood in stool
– Weight loss
– Recent onset of severe constipation or worsening in elderly
Constipation: Treatment
Lifestyle, diet
-Increase dietary fiber
-Increase water intake
-Exercise
-Treat underlying conditions
Fecal Impaction
Hard, dry stool mass becomes stuck in colon/ rectum, often due to long term constipation
Tenesmus
Cramping rectal feeling that gives sense of needing to have a bowel movement even if already had movement
Diarrhea is defined as:
-Stool weight > 200 g/ day
(Normal: 100 to 200 g/ day)
Diarrhea: Complications from fluid loss
Dehydration, electrolyte loss (sodium, potassium,
magnesium, chloride)
Causes of Diarrhea: Acute
• Infection: viral, bacterial, parasitic
• Food poisoning
• Drugs-examples: Laxatives, Magnesium-containing antacids, Antibiotics
• Dietary factors*
Causes of Diarrhea: Chronic (Functional)
IBS
Causes of Diarrhea: Chronic (Pathological)
– Colitis related conditions
– Malabsorption related conditions
– Hyperthyroidism: possible
– Diabetes mellitus
– Tumors
– Surgery
– Dietary factors* see slide
Dietary Factors that may worsen diarrhea
• Caffeine: coffee, tea, cola, OTC headache remedies (caffeine can stimulate bowel movements)
• Fructose: apple or pear juice, grapes, honey, dates, nuts, figs, prunes, soft drinks
• Sorbitol/mannitol: sugar free foods, mints
• Lactose: milk, ice cream, frozen yogurt, soft cheeses
Diarrhea: Red Flags
– Distended, tympanic abdomen (suggests mechanical obstruction)
– Vomiting
– Blood or pus in stool
– Weight loss
– Chronic diarrhea
– Signs of dehydration
Diarrhea: Acute Watery
-Likely to be infection person)
-Considerations: travel, tainted food, known outbreak
Diarrhea: Acute Bloody
Diverticular bleeding
Ischemic colitis
If recurrent: consider IBD
Diarrhea: Large volume (over 1 liter/day)
-Endocrine
-If oil droplets (w/ weight loss): malabsorption
Diarrhea: After Eating Certain Foods
Food intolerance
Diarrhea: Voluminous, watery or fatty
Consider small bowel disease
Diarrhea: Frequent, small volume, possible blood, mucus
Consider large bowel
Diarrhea: Treatment (Lifestyle, Diet, Supplement)
• Rehydration (may need IV if severe): Ice chips, ginger ale, fruit juices,…
• Electrolyte support: Gatorade, etc
• Diet: eat as tolerated (bananas, rice, apple sauce) Avoid fried, greasy foods
• Probiotics (foods, supplements)
• Fiber? (Depending on root cause)
Diarrhea: Treatment (Other)
• Refer to MD: may need antidiarrheals
• Identify and treat underlying conditions
– May include medication
• Acupuncture
Bowel Incontinence
Involuntary defecation
Bowel Incontinence: Possible Causes
-Fecal impaction, nerve damage, congenital, diabetes, dementia, trauma to rectum/anus, inflammatory process
GI Bleeding: Melena
– Older black tarry colored stool
– Represents upper GI bleed
GI Bleeding: Hematochezia
– Brighter blood
– Represents lower GI bleed
GI Bleeding: Hematochezia
– Brighter blood
– Represents lower GI bleed
Hematochezia: Causes
Tumor, polyps, IBD, hemorrhoids, anal fissure
GI Bleeding: Importance of Amount
– Bleeding from anal fissure/ hemorrhoid: spots on toilet paper
– UC: blood in toilet, in stool
Elderly: Minor vs. Major Bleeding
– Minor bleeding: hemorrhoids & colorectal cancer
– Major bleeding: diverticular disease (diverticulosis)
Large Intestine: Acute Issues
• Ileus (temporary arrest of peristalsis)
• Hernia
• Volvulus (twisting of intestines)
• Intussusception (intestines telescope)
• Perforation & peritonitis
• Obstruction
Large Intestine: Generic Symptoms
• Acute onset
• Severe pain
• May be signs of shock
• Requires immediate medical attention
Intestinal Obstruction: Structural/Mechanical Causes
– Surgical adhesions or scar tissue (MC-60-75%)
– Hernias
– Tumors
– Volvulus
– Intussusception
– Diverticulitis
– Fecal impaction
Symptoms related to the Large intestine
• Milder sx that develop gradually
• Pain in lower abdomen
• Increasing constipation w/ abdominal distention
• Colicky spams last longer
• Vomiting less prominent
Pathological Disease
-Physiological change to tissue or organ
-Gross abnormalities seen by endoscope or tissue biopsy (Blood, pus, scars, ulcers)
Functional Disease
-Physiological function with no known organic basis
-Absence of evidence of underlying organic cause
-Diagnosis primaryily based on subjective findings
Irritable Bowel Syndrome (IBS)
• Chronic functional disorder
• Recurrent abdominal pain with altered bowel habits
Irritable Bowel Syndrome (IBS): Epidemiology
– Tends to begin adolescence / 20’s
– More females
IBS: Causes
-Unclear
– Possible combination of psychological / physical factors
IBS: Diagnosing
-Clinical
– Rule out other differences
– Fulfills Rome Criteria
IBS: Rome IV Criteria
• Recurrent abdominal pain
– At least 1 day/ week in last 3 months
• Associated with 2 or more of the following:
– Related to defecation
– Associated with change in frequency of stool
– Associated with change in form of stool
• Onset of sx: at least 6 months before diagnosis
IBS: Red Flags
– Fever, weight loss, bleeding
– Changes in odor
IBS may develop into anorectal issues including:
Anal fissure, Hemorrhoids, Abscess
IBS: Co-morbidities
– Fibromyalgia
– Endometriosis
– Interstitial cystitis
IBS: Diagnostic Procedures
• Tests are to only rule out other DDx or to screen for organic causes
IBS: Medical/Psychological Treatment
• Support and understanding
• Education about disorder
• Counseling / therapy
• Stress management
IBS: Lifestyle, Diet, Supplements
• Exercise regularly at sx
• Water to remain hydrated
• Avoid food triggers*
• Fiber
• Probiotics, peppermint
• Acupuncture, massage
Colitis
Inflammation of the Colon
Inflammatory Bowel Disease
• Chronic inflammation of GI tract
– Relapsing diarrhea & abdominal pain
Inflammatory Bowel Disease: Subtypes
– Crohn’s disease
– Ulcerative Colitis
Inflammatory Bowel Disease: Epidemiology
– Usually begins before 30
– Affects both sexes equally
– Familial tendency, especially with Crohn’s
Crohn Disease: Description
– Chronic inflammatory disease
– Typically affects distal ileum & right sided colon
– But can occur in any part of GI
– Never the rectum
Crohn’s Disease: Symptoms
-Chronic diarrhea-episodic*
-Chronic abdominal pain
-Fever
-Anorexia
-Weight loss
-Symptoms related to malabsorption & nutritional deficiencies (peripheral neurology, fatigue)*
Crohn’s Disease: Other extra intestinal manifestations
-Inflammation: Eye, mouth/skin, joints, liver/bile
-Headaches
-Depression
Crohn Disease: Exams
• Hyperactive bowel sounds possible (diarrhea)
• Tender abdomen: Guarding, rebound
• Palpable mass or fullness may be present
• Perianal disease possible
Crohn Disease: Diagnostic Procedures
-Endo/colonoscopy: Can identify skip lesions
-Labs: Malabsorption (CBC, iron, ferritin, B12, folate)
Crohn’s Disease: Lifestyle
-Address emotional factors
-Acupuncture
-Stop smoking
Ulcertative Colitis: Descrption
-Chronic inflammation and ulcerations with intermittent bloody diarrhea
Ulcerative Colitis affects ____ and contains no ______ or _____
Left sided colon; No fistulas or abcesses
Skip lesions are possible with:
Crohn’s disease
Ulcertative Colitis: Symptoms
-Bloody diarrhea*
-Lower abdominal pain & cramps*
-Sense of urgency to defecate
-Fever
-Nausea
-Anorexia
-Weight Loss
- may be described as 10-20 liquid, bloody stools & variable abdominal pain
Ulcerative colitis
Ulcerative Colitis: Systemic Symptoms
-Fatigue
-Dehydration
-Anemias
-Joint Pain
-Rashes
Ulcerative Colitis: Exam
-Increased bowel sounds (diarrhea)
-Abdominal tenderness
-Distention
Ulcerative colitis may have findings related to other systemic sx including:
-Tenting of skin (dehydration)
-Anemias, rashes etc.
Ulcerative Colitis: Diagnostic procedures
-Sigmoidoscopy with biopsy (will see uniform inflammation)
Ulcerative Colitis: Prognosis
-Recurrent episodes “flair ups”
-Normal life expectancy
Crohn’s vs. Ulcerative Colitis: Location
-Crohn’s: 80% involve small bowel & right sided colon
-Ulcerative Colitis: In large intestine only
*Crohn’s vs. Ulcerative Colitis: Skip Lesions
-Crohn’s: Yes
-UC: No
*Crohn’s vs. Ulcerative Colitis: Skip Lesions
-Crohn’s: Yes
-UC: No
*Crohn’s vs. UC: Bleeding
-Crohn’s: Rare
-UC: Present
Crohn’s vs. UC: Fistulas
Crohn’s: Fistulas, mass, abcess common
-UC: No
Crohn’s vs. UC: Perianal lesions
Crohn’s: Significant
UC: Not significant
Microscopic colitis: 2 forms
-Collagenous (connective tissue)
-Lymphocytic (lymphocytes)
Microscopic Colitis: Epidemiology
– More common in women over 40
– Peak incidence: 60’s and 70’
Microscopic Colitis: Associations
– may have other autoimmune diseases: thyroiditis, celiac, etc
– Bacterial or virus may also play a role
– Medications
Microscopic Colitis: Risk Factors
– Smoking
– Medications: pain relievers, PPI, antidepressants/antianxiety
Microscopic Colitis: Complications/Prognosis
– About 15% have persistent symptoms
– Diarrhea may reoccur intermittently over years
– Most resolve within 3 years
– Does not appear to increase risk for colon cancer
– Possible nutritional deficiencies?
Microscopic Colitis: Symptoms
-Chronic watery non-bloody diarrhea
-Lasting from weeks to years (may have remission)
Microscopic Colitis: Other Common Symptoms
– Abdominal pain & bloating
– Mild weight loss
– Nausea, weakness
– Possible fecal incontinence
Microscopic Colitis: Exam
-Distention
-Increased bowel sounds
-May have tenderness
-If severe, may have signs of dehydration, malabsorption, weight loss
Microscopic Colitis: Diagnostic Procedures
Endoscopy & Biopsy
Microscopic Colitis: Lifestyle Treatment
• Low-fat, low-fiber diet.
• Discontinue dairy products, gluten or both.
• Avoid caffeine and sugar.
Diverticulosis: Description
Mucusal herniations commonly in the distal colon
Diverticulosis: Cause
• Cause: unsure
– May be result of increased bowel pressure
– Attributed to low fiber diet
-Typically asymptomatic
Diverticulosis: Epidemiology
-Common after age 40
Diverticulosis: Significant risk factor
Constipation
Diverticulosis: Other risk factors
– Increasing age over 40
– De-conditioning & lack of exercise
– Smoking
– Obesity
– Family history
Diverticulosis, if symptomatic will result in:
-LLQ pain, especially after a meal (spasm)
-Irregular bowel movement: Constipation or diarrhea
-May have bloating, gas, vomiting
-Some relief with bowel movement
Diverticulosis: Exam
-Some distention and tenderness in LLQ possible (not as severe as diverticulitis)
Diverticulosis: Diagnostic procedures
Scoping
Diverticulosis: Lifestyle
-If asymptomatic, treat constipation
-High fiber diet (20-35g daily)
Diverticulitis: Description
• Develops from diverticulosis.
-herniated mucosa has now become infected & inflamed
Diverticulitis: Complications
-Abscess
-Perforation
-Peritonitis
-Bowel obstruction
-Fistulas
Diverticulitis: Risk Factors
– Elderly
– Medications that might increase risk of infection
Diverticulitis: Symptoms
-Acute onset of severe pain in LLQ
-Fever
-Chills as severity increases
-Constipation or diarrhea
Diverticulitis: Exam
-Distended abdomen
-Tymapinic with percussion
-Palpation: muscle rigidity and guarding
-Rebound tenderness
-Palpable mass
Diverticulitis: Diagnostic Procedures
-CT initially
-Colonoscopy with resolution
Diverticulosis vs. Diverticulitis: Herniations
Diverticulosis: Herniations in colon
-Diverticulitis: Herniations now infect3ed
Diverticulosis vs. Diverticulitis: Symptoms
Diverticulosis: Asymptomatic mostly
Diverticulitis: LLQ pain, Fever
Colorectal Polyps: Description
• Fleshy growth in lining of colon or rectum
Colorectal polyps can lead to:
Colorectal cancer
Colorectal polyps is typically:
Asymptomatic
Colorectal Cancer: Diagnostic Screening
– Digital rectal exam & fecal occult blood test
– Sigmoidoscopy, colonoscopy, barium enema
Colorectal Cancer: Treatment
– Surgical through colonoscopy or sigmoidoscopy
Colorectal Cancer: Predisposing factors
– Older age, African American
– Personal history of colon polyps
– History of IBD, DM
– Family history
– Certain types of diets: low fiber, high protein, fat, refined carb diet
– Other: obesity, lack of physical activity, smoking, heavy alcohol use
Colorectal Cancer: Symptoms
– Persistent change in stool: consistency, diarrhea, constipation
– Blood: rectal bleeding or in stool
• For rectal cancer, bleeding with defecation
– Fatigue, weakness, severe anemia
– Unexplained weight loss
When would you screen for colorectal cancer?
-Age 50
-Earlier if family history
Colorectal Cancer: Diagnosis
– Early diagnosis through routine exam & screen through fecal occult blood testing
– Colonoscopy
Anal Fissures
• Painful tear or crack in lining of anal canal
Anal Fissures: Cause
– Trauma after passage of large, hard stool
– Or from frequent loose stools
Anal Fissues: Risk Factors
– Anything causing constipation: diet, medication
Anal Fissues: Risk Factors
– Anything causing constipation: diet, medication
Anal Fissure: Signs/Symptoms (Acute)
• Sharp, burning or tearing pain with or after bowel movement
• Bright red blood on toilet paper
• Pain may persist for minutes to hours
• Reoccurs with next movement
Anal Fissure: Signs/Symptoms (Chronic)
Intermittent bleeding
Anal Fissure exam is used to rule out
Thrombosed hemorrhoid
Anorectal Abscess
• Localized pus in perirectal space
Anorectal Abscess: Symptoms
– pain, perianal swelling, redness, tenderness
Anorectal Abscess: Exam
• Exam: DRE (tender, swelling)
– DDx: hemorrhoid
Anorectal Abscess: Exam
• Exam: DRE (tender, swelling)
– DDx: hemorrhoid
Anorectal Fistula
• Tubelike opening that extend from anal canal to perianal skin
Anorectal Fistula: Sign/Symptoms
– Discharge and possible pain
Ano Proctitis
• Inflammation of the rectal tissue
Ano Proctitis: Possible Causes
– Ulcerative colitis, Crohn’s, radiation, infections (including STD’s)
Ano Proctitis
– Rectal bleed (bright red and persistent)
– Changes in bowel
–mucus, mild diarrhea
– Urgency (tenesmus)
Pruritus Ani: Symptoms
• Itching of perianal skin
Pruritis Ani: Causes
– Crohn’s, hemorrhoids, skin disorders, infections (candida,
pinworms), hygiene
– Foods & dietary supplements: vitamin C
Hemorrhoids
• Dilated veins in lower rectum
Hemorrhoids: Epidemiology
– Prevalence increases with age
Hemorrhoids: Associations
– Straining and constipation
– Pregnancy, obesity, IBD, etc
Hemorrhoids: External
-can be thrombosed, painful, purplish
Hemorroids: Internal
-bleeding after defecation, possible mucus, less painful
Hemorrhoids: Symptoms (External)
-Protrusion
-Rarely bleed
-May become thrombosed
Hemorrhoids: Symptoms (Internal)
– Bleeding after movement
– Not as painful as external
– May have mucus discharge or sense of incomplete evacuation
Hemorrhoids: Treatment
– Stool softeners
– Sitz bath
– Anesthetic ointment
– Witch hazel
Levator Syndrome
• Episodic rectal pain caused by spasm of the levator ani muscle
Levator Syndrome: Symptoms
• Pain:
– Spasm lasting <20 min (brief and intense or vague ache )
– May be high in the rectum or in pelvic floor muscles
– May refer to thigh and buttock
– Can waken patient from sleep
– Can occur in clusters: occur for period of time then disappear for weeks or months
• Worsens: with sitting, bowel movements or intercourse
• Improves: with walking or standing
Levator Syndrome: Symptoms
• Pain:
– Spasm lasting <20 min (brief and intense or vague ache )
– May be high in the rectum or in pelvic floor muscles
– May refer to thigh and buttock
– Can waken patient from sleep
– Can occur in clusters: occur for period of time then disappear for weeks or months
• Worsens: with sitting, bowel movements or intercourse
• Improves: with walking or standing
Levator Ani Syndrome: Exam/Diagnosis
-Exclude other rectal conditions
-Levator muscle: hypertonic, tender (may be only on left)
-May have tests for infections, IBD, etc.
