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GI block 2 > Lecture 2 - Large Intestine > Flashcards

Lecture 2 - Large Intestine Flashcards

1
Q

Types of IBD?

A

Crohn
Ulcerative Colitis
Microscopic Colitis

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2
Q

IBD characterized by transmural inflammation

May involve entire GI tract

May involve ulceration, stricturing, fistulization, abscess formation

Ranges from mild to severe/fulminant

A

Crohn

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3
Q

What would you expect to see on endoscopy of pt w/ Crohn

A

skip lesion

Areas of patchy inflammation

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4
Q

Crohn Dz

Highly variable presentation due to involvement of the entire GI tract

CHaracterized by remission/exacerbations

General ssx?

A

Fatigue

Prolonged intermittent diarrhea

Wt loss

Fever

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5
Q

Most common presentation of Crohn is the chronic inflammatory disease… which is an idiopathic predilection to attack the terminal ileum.

Pts complain of cramping RLQ pain or mass

Other ssx include?

A

Malaise

Wt loss

Fatigue

Non-bloody intermittent diarrhea

(ddx might be appendicitis)

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6
Q

Another presentation of Crohn is intestinal obstruction… ssx?

A

Postprandial bloating

Cramping abd pn

Loud borborygmi

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7
Q

Crohn can also present as penetrating dz and fistulization… meaning?

A

Transmural bowel inflammation associated w/ development of sinus tracts

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8
Q

Crohn that presents w/ penetrating dz and fistulization may present as?

A

Phlegmon (may eventually lead to abscess)

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9
Q

What’s a phlegmon?

A

(possibly seen in penetrating dz and fistulization)

Walled off inflammatory mass w/o bacterial infxn

May be palpable on PE

most present as indolent process

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10
Q

Crohn Dz

Penetrating dz/fistulization may also lead to?

A

Intraabdominal abscess (which might manifest as an acute presentation of localized peritonitis w/ fever, abd pn, tenderness)

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11
Q

Crohn dz…

Fistulization process?

A

Sinus tracts penetrate the serosa and give rise to fistulas, which are tracts/communications that connect two epithelial organs

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12
Q

Bladder (enterovesical)
Skin (enterocutaneous)
Small bowel (enteroenteric)
Vagina (enterovaginal)

A

Common sites for Corhn fistulas

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13
Q

Ssx=

Recurrent UTI
pneumaturia

A

Ssx of enterovesical fistulas (bladder) seen in Crohn

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14
Q

Bowel contents drain to surface of skin

A

Enterocutaneous fistula from Crohn

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15
Q

Can present asymptomatically, or as palpable mass

A

enteroenteric fistula in Crohn

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16
Q

Passage of gas/feces into vagina

A

entervaginal fistula in crohn

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17
Q

What might be (two) complications from a retroperitoneal fistula as a results of Crohn fistulization?

A

Psoas abscesses

Ureteral obstruction w/ hydronephrosis

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18
Q

Perianal disease is a common clinical constellation of Corhn… What are the ssx?

A

Large painful skin tags

Anal fissures (LATERAL location)

Perianal abscesses

Fistulas

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19
Q

What are some extraintestinal manifestations of Crohn?

A

Arthalgias/arthritis

Iritis/Uveitis

Cutaneous manifestations (pyoderma gangrenosum, erythema nodosum, oral apthous ulcers)

Increased prevalence of gallstones (due to malabsorption of bile salts)

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20
Q

There is no specific lab test for Crohn… But what are some lab tests you can perform?

And what mgiht you look for?

A

CBC - look for anemia or leukocytosis

CMP

Iron/B12

Albumin

ESR

CRP

Stool culture/OandP

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21
Q

What establishes the diagnosis of Crohn?

A

Endoscopy

Colonoscopy first to evaluate colon/terminal ileum (cobblestoning on mucosal surface)

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22
Q

Aside from colonoscopy, what other studies could be employed for Crohn work up?

A

Barium upper GI series for ulcerations, strictures, fistulas

Capsule endoscopy to evaluate for small bowel involvement

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23
Q

Crohn dz grading system…

  1. Asymptomatic remission?
  2. Mild-moderate?
  3. Moderate-severe?
  4. Severe-fulminant?
A
  1. CDAI < 150
  2. CDAI < 150-220
  3. CDAI < 221-450
  4. CDAI > 451
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24
Q

Treatment options for Crohn dz?

A

Extraintestinal manifestations (abscess, obstruction, fistulization) require surgical consult

General tx measures = symptomatic improvement and control (improve QOL, reduce progression/complications)

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25
Q

Crohn Dz symptomatic meds?

A

Antidiarrheals (e.g. loperamide, bile acid sequestrants if there is significant involvement of the terminal ileum)

Oral steroid (e.g., kenalog) for apthous ulcer

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26
Q

For tx of mild-moderate active Crohn (CDAI 150-220), we might use a non-systemic corticosteroid, such as?

What’s necessary when using this drug?

A

Budesonide, daily for 8-16 weeks

TAPER DOWN BY 3 mg over 2-4 weeks

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27
Q

Severe Crohn might require systemic corticosteroids, such as?

A

Prednisone 40-60 mg/day until ssx resolve and resumption of wt gain

DON’T USE LONG TERM

(patients who fail oral corticosteroid therapy should be considered for hospitalization)

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28
Q

Symptom relapse in more than 80% of pts in absence of maintenance therapy

A

Check

so maintenance therapy is important

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29
Q

In Crohn, to maintain remission, what are some options?

A

Immunomodulators may induce remission in pt w/ severe dz who fail oral steroids or those w/ refractory dz

(immunomodulaatrs = azathioprine, 6-mercaptopurine, methotrexate)

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30
Q

Biologic therapy is also an option for Crohn, such as Anti-tumor necrosis factor agents, like?

A

Infliximab
Adalimumab
Certolizumab

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31
Q

Surgical indication for Crohn?

A

Failure pf medical therapy is the primary indcation

But always warranted in intestinal obstruction or abscess formation, perianal/enterocutaneous fistula

32
Q

Crohn patients to admit?

A

Suspected intestinal obstruction

Suspected intra-abdominal or perirectal abscess

Serious infectious complication (esp those who are immunocompromised - corticosteroids, immunomodulatrs, antiTNF agents)

Sever symptoms of diarrhea, dehydration, wt loss, abd pn

Severe/persisting symptoms refractory to tx

33
Q

Consultation options for Corhn?

A

GI
Dietician
Corhn’s and Colitis Foundation of America
Surgery

34
Q

Idiopathic inflammatory condition LIMITED TO THE MUCOSAL layers of the colon, resulting in diffuse friability/erosions w/ bleeding?

A

Ulcerative colitis

35
Q

What are the “thirds” of Ulcerative colitis

A

1/3 confined to rectosigmoid region (proctosigmoiditis)

1/3 extends to splenic flexure (left-sided colitis)

1/3 extends more proximally (extensive colitis)

36
Q

Ulcerative colitis is also characterized by exacerbations and periods of remission…

Can also range from mild colits to fulminant colitis, which a signficiant risk for what?

A

risk of toxic megacolon

37
Q

Ulcerative colitis has extraintestinal manifestations similar to Crohn, but… what?

A

Significantly fewer UC patients develop fistula

38
Q

Interestingly, disease severity (Ulcerative colitis) is lower in whom?

A

Severity lower in active smokers and may actually worsen in pataients who quit smoking

39
Q

Ulcerative colitis characterized by what type of involvement of the mucosa?

A

Universal involvement of the rectum and sigmoid colon, with continuous erythema and ulceration of the mucosal surface

(NOTE: NOT SKIP LESIONS, right?)

40
Q

Hallmark symptom of Ulcerative colitis?

A

Bloody diarrhea

Mild = 4
Moderate = 4-6
Severe > 6 (bloody)

41
Q

Severe Ulcerative colitis metrics?

A

> 6 stools/day

Pulse > 100

hematocrit < 30

Wt loss > 10%

Temp > 100

ESR > 30

Albumin < 3

42
Q

Moderate UC metrics?

A

4-6 stools/day

Pulse is 90-100

Hematocrit is 30-40

Wt loss is 1-10%

Temp 99-100

ESR 20-30

Albumin 3-3.5

43
Q

Mild UC metrics?

A

< 4 stools/day

Pulse < 90

Normal hematocrit/temp/albumin, no wt loss

ESR < 20

44
Q

Gradual onset of diarrhea (w/ blood/mucus)

Fecal urgency

Tenesus

LLQ pain (RELIEVED BY DEFECATION)

A

mild-moderate UC

45
Q

> 6 stools/day

Hypovolemia

Anemia

Hypoalbuminemia

LLQ pain

TTP on exam

A

Severe UC

46
Q

in Ulcerative colitis, BMs are frequent/small in volume why?

A

A result of rectal inflammation

47
Q

Work up/labs for Ulcerative colitis

A 
CBC
CMP
Sreum Albumin
CRP/ESR
Stool culture/OandP
Testing for STI
48
Q

How do we establish the diagnosis in Ulcerative colitis

A

Endoscopy establishes the diagnosis (Flexible sigmoidoscopy in acute dz)

AVOID FULL COLONOSCOPY DUE TO PERF RISK AND POSSIBILITY OF INCITING TOXIC MEGACOLON (can perform after improvement to assess extent)

49
Q

What might Ulcerative colitis look like, in regards to histology?

A

Biopsy of Ulcerative colitis include crypt abscess, crypt branching, shortening and disarray, and crypt atrophy

50
Q

A work up UC might include plain films, to assess for?

A

Assess for colonic dilation or toxic megacolon

51
Q

Tx approach for UC is similar to Crohn which is?

A

Treat acute/active disease

Prevent recurrence/maintain remission

52
Q

Mainstay of tx for UC?

A

5-aminosalicylic acid agents (5-ASA)

53
Q

tx for mild-moderate DISTAL colitis

confined to rectosigmoid colon

A

Topical mesalamine = DRUG OF CHOICE

5-ASA (as suppository or enema)

4-12 weeks

54
Q

Aside from mesalamine/5ASA therapy, what are some other tx options for mild-moderate DISTAL UC?

A

Topical corticosteroids (hydrocortisone suppository/enema)

Oral mesalamine (for patients unwilling to use topical therapy)

55
Q

How might you approach refractory DISTAL colitis?

A

co-therapy w/ ORAL and TOPICAL 5-ASA

Can add oral prednisone if symptoms still persist

56
Q

For patients w/ frequent relapse of UC, what’s an approach we could take?

A

Maintenance dose of topical mesalamine nightly or every other night

(PO mesalamine if pt refuses topical therapy, though PO is likely less effective at preventing remission)

57
Q

Mild-moderate EXTENSIVE colitis tx?

extending proximal to sigmoid

A

Oral 5ASA (x5 weeks) [DOC = mesalamine]

Sulfasalazine is also a cheaper option, but higher SE profiel AND requires coadministration of folic acid

58
Q

If mild-moderate EXTENSIVE colitis does not improve w/ 5ASA regimen in FOUR weeks, what can you add to the regimen?

A

add oral corticosteroids (prednisone or methylprednisone)

59
Q

For refractory mild-moderate EXTENSIVE UC, what can we do?

A

For pats who experience flares despite 5ASA/corticosteroids, immunomodulators are an option

Anti-TNF agents: infliximab, adalimumab, golimumab

Anti-integrin therapy (Vedolizumab), for tx of unresponsive severe-moderate UC

60
Q

Severe/fulminant Colitis (pancolitis or fulminant disease) may require?

A

Inpatient care…

Surgical consultation early
NPO
Parenteral fluid/electrolyte replacement
IV corticosteroids

61
Q

Ulcerative colitis maintenance therapy?

A

Oral mesalamine or sulfasalazine (daily)

w/o long term therapy, 75% of patients will relapse w/ in 1 year

62
Q

For patients w/ more than 2 ulcerative colitis relapses/year, what is the recommended maintenance therapy?

A

mercaptopurine or azathioprine

63
Q

UC patients are at a significantly increased risk of developing colorectal cancer… so?

A

Screening is recommended… colonoscopy w/ biopsy every 1-2 years starting EIGHT years after diagnosis

64
Q

What are the ABSOLUTE surgical indications for ulcerative colitis?

A

SEVERE HEMORRHAGE
PERFORATION
CARCINOMA

65
Q

Relative surgical indications for ulcerative colitis?

A

Severe colitis unresponsive to maximal medical therapy

Less severe colitis but medically intractable symptoms or intolerable medication side effects

66
Q

Consultations for ulcerative colitis?

kinda obvious but…

A

GI

Surgery, as needed

67
Q

What patients should get admitted for ulcerative colitis?

A

Severe disease w/ bloody stools, anemia, weight loss, fever

OR

Fulminant disease w/ rapid progression of symptoms, worsening abd pn, distension, high fever, tachycardia

68
Q

Chronic, inflammatory disease of the colon

Chronic watery diarrhea

NORMAL APPEARING COLONIC MUCOSA ON BIOPSY

A

microscopic colitis

no ulcers, skip lesions, etc.

69
Q

How is the diagnosis of microscopic colitis established?

A

histopathologic examination of biospy specimen

70
Q

Two subtypes of microscopic colitis?

A

Lymphocytic colitis

Collagenous colitis

71
Q

Characterized by an intraepithelial lymphocytic infiltrate

A

Lymphocytic microscopic colitis

72
Q

characterized by colonic subepithelial collagen band > 10mm in thickness

A

Collagenous microscopic colitis

73
Q

Whom is microscopic colitis more common in?

A

women, 60-70

74
Q

Though the etiology is unknown, several meds have been implicated in microscopic colitis, such as?

A 
NSAIDs
Lisinopril
Lansoprasole
Paroxetine
Sertaline
Simvastatin
75
Q

Clinical presentation:

chronic, non-bloody diarrhea that is typically watery (4-9 stools/day)

Abd pn

May also have fatigue, dehydration, wt loss

A

microscopic colitis

76
Q

Diagnosis of microscopic colitis?

A

Routine lab testing to r/o other etiologies of chronic diarrhea (clinical suspicion -> colonoscopy w/ biopsy)

77
Q

Tx for microscopic colitis?

A

D/c offending meds, if possible

Symptomatic care (w/ antidiarrheals)

IF diarrhea persists -> budesonide x4 weeks

GI block 2 (10 decks)

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