Lecture 6: Disorders of the Colon & Rectum Flashcards
What are the two autoimmune conditions that make up IBD?
- Crohn’s
- Ulcerative colitis
What is ulcerative colitis?
Diffuse inflammation involving only the COLON
Often extends proximally.
What is Crohn’s disease?
Patchy, transmural inflammation affecting the GI TRACT
Who is IBD MC in?
Caucasians and western diet
Females: Crohn’s (football club)
Males: UC
What lifestyle/risk factor is extremely associated with Crohn’s development?
Smoking
What is the most commonly affected part of the GI tract in Crohn’s?
Terminal ileum, characterized by transmural inflammation and skip lesions
How does Crohn’s present clinically?
- Chronic RLQ pain
- Crampy abd pain
- Intermittent, non-bloody diarrhea
- Wt loss, weakness, fatigue
- Mass in RLQ = terminal ileum
What are the extraintestinal manifestations of Crohn’s?
- Pyoderma gangrenosum
- Erythema nodosum
- Arthralgia
- Apthous ulcers (mouth)
- Fistulas, abscesses
Crohns is the creepy manifestations
What are the 4 types of fistulas that can occur due to transmural inflammation in Crohn’s?
- Enterovesical
- Enterocutaneous
- Enteroenteric
- Enterovaginal
What are the clinical manifestations of fistulas in Crohn’s?
- Infection
- Abscess
- Personal hygiene issues
- Wt loss
- Malnutrition
- Diarrhea
Where does erythema nodosum occur in Crohn’s and what does it correlate with?
- Occurs on anterior lower legs
- Correlate with bowel symptoms
Red, hot lesions
What is pyoderma gangrenosum?
Severe disease on dorsal surface of feet and legs usually, beginning as a pustule that spreads and turns necrotic
What is the gold standard to diagnose Crohn’s?
Colonoscopy with biopsy showing skip areas with a cobblestone appearance.
May also see focal ulceration adjacent to normal areas
What is the management goal in Crohn’s?
Symptomatic relief
What is considered low risk Crohn’s?
- Normal/mild CRP
- Dxd > 30yo
- Limited inflammation
- Little to no ulcerations
- No perianal complications
- No prior resections
- No penetration or strictures.
How do we treat low-risk Crohn’s involving the ileum/cecum?
Step-up therapy with EC budesonide and slowly increase it.
No improvement in 3-6 months => immunomodulator or biologic.
Alternative to budesonide is 5-ASA
For mild-mod Crohn’s involving diffuse colitis or the left colon, what is the treatment?
- Oral prednisone with a tapering off
- Post tapering => ileocolonoscopy in 6-12 months
Alternative to prednisone will be 5-ASA. 5-ASA will be continued until scopy.
If there is a remission in mild-mod Crohn’s, what is the new therapy we start?
Second course of glucocorticoid + azathioprine or biologic (infliximab)
What is the overall therapy methodology in high-risk Crohn’s?
Step-down/Top-down
AKA starting with the big boys first
What is the top-down therapy for high-risk Crohn’s?
Combination therapy of TNF blockers + immunomodulators
What drug is NOT preferred for maintenance in Crohn’s?
Steroids
Once remission is seen in Crohn’s, what is the next step?
Ileocolonoscopy in 6-12 months.
What does UC most commonly involve?
Rectum and sigmoid colon
What is the hallmark sign of UC?
Bloody diarrhea
What are the common complications of UC?
- Gradual onset
- Crampy lower abd pain that relieves with defecation
- Diarrhea with pus
- Bloody Diarrhea
- Fecal urgency
- Anemia
What are the complications of UC?
- Severe bleed
- Lots of diarrhea
- Toxic megacolon
- Perfd colon
What are the extraintestinal manifestations of UC?
- Arthritis
- Ankylosing spondylitis
Severity table for UC
Adkins said MUST KNOW!!!
Who is UC ironically not as bad in?
Smokers
What is the gold standard to diagnose UC?
Sigmoidoscopy showing a continuous friable mucosa, edematous, with pus, bleeding, erosions, and erythema
When should we NOT do a colonoscopy for suspected UC?
Severe or fulminant colitis due to risk of perf or megacolon.
What kind of cancer are patients with long-standing UC most at risk for?
- Colonic epithelial dysplasia
- Colonic epithelial Carcinoma
What lifestyle change is recommended to help with UC?
Cessation of caffeine
What is the treatment for mild-mod UC limited to the distal colon? (not past sigmoid)
Topical mesalamine (5-ASA) or hydrocortisone suppository (worse)
What is the treatment for mild-mod UC that extends past the sigmoid colon?
- Oral mesalamine + topical mesalamine
- Add-on oral corticosteroids if unresponsive after 4-8 weeks
For mod-severe UC, what is the treatment?
Prednisone +/- immunomodulators/TNF blockers
What is the curative treatment for UC?
Total proctocolectomy with placement of ileostomy.
When do we do maintenance therapy for UC and what is it?
- More than 1 relapse in a year
- Anyone with ulcerative proctosigmoiditis
- Anyone with UC proximal to sigmoid (left-sided)
- Mesalamine
What do 5-ASA/aminosalicylates do and their main SEs?
- Indication: Induction and maintenance therapy of UC and CD
- MOA: Inhibition of prostaglandin production
- SEs: N/V, HA,
- CI: Allergy to aspirin or sulfa
Sulfasalazine and mesalamine
What are corticosteroids indicated for in IBD?
Induce remission in severe flares or for acute flares.
What are the two corticosteroids used in IBD?
- Prednisone: more potent
- Budesonide: poor systemic absorption, fewer SEs
What are the indications/MOA/SEs/AEs/BBW for immunomodulators/immunosuppressants?
- Indication: Steroid dependent IBD or remission maintenance in severe IBD
- MOA: Inhibition of DNA/RNA synthesis
- SEs: Leukopenia, thrombopenia, anemia, infection, N/V/D, Malaise, myalgia
- AEs: Lymphoma and severe infection
- BBW: Mutagenic potential for rapidly growing malignancies
Azathioprine or 6-mercaptopurine
When is methotrexate used for IBD?
Only in mild-mod CD for maintenance if azathioprine fails
When is cyclosporine used for IBD?
Severe refractory IBD that failed steroids
What are the indications/MOA/SEs/AEs/BBW for Anti-TNFs?
- Indication: Mod-severe active IBD
- TOC for CD fistula (treatment of choice)
- MOA: MAB that binds to human TNF, interfering with cytokine inflammation
- SEs: Fever, rigors, N/V, urticaria, hypotension
- AEs: Severe infection/sepsis/Malignancy
- BBW: Severe infection
ends in -mab
What ABX are used in IBD and when?
- Presence of fistula or abscess that makes patient susceptible to infection.
- Metronidazole or ciprofloxacin
If we want to give a live vaccine prior to IBD treatment, how early should it be?
4 weeks prior
Image of CD vs UC
What are the 5 common causes of IBD flare-ups?
- Missing doses while in remission
- NSAIDs (recommend tylenol)
- Smoking (esp with CD)
- Stress
- Certain foods
What are the 4 pathologic colon polyp groups?
- Mucosal adenomatous (MC)
- Mucosal serrated
- Mucosal non-neoplastic
- Submucosal
Serrated are 2nd MC
What causes adenomatous polyps?
DNA changes in lining of the colon
95% of colon adenocarcinomas are from these polyps
What are the risk factors of adenomatous polyps?
- Age > 50, MC in men
- High fat diets
- Obesity
What do adenomatous polyps look like?
- Flat, sessile, pedunculated
- Slow growing
How do you diagnose and workup adenomatous polyps?
- Colonoscopy
- Check all the polyp pathologies
What are the 3 types of adenomatous polyps and what is the most likely to be cancerous?
- Tubular: least likely
- Tubulovillous
- Villous: Most likely (villain)
What general characteristics suggest that a polyp has a high likelihood of being cancerous?
- > 1 cm
- Villous histology
- # of polyps
- Flat polyps
How do we manage and screen for polyps?
- Removal via colonoscopy w/ polypectomy
- FOBT, fecal immunochemical and fecal DNA annually
- Colonoscopy screenings
- Diet and wt loss
What are the characteristics of a serrated polyp?
- Sessile, serrated polyps
- Varied types (adenoma, hyperplastic)
- Variable malignancy potential
What are the characteristics of a non-neoplastic polyp?
- MC non-neoplastic polyp but can develop to adenomatous
- MC found in rectosigmoid area
- MC very smol
What are the submucosal lesions?
Mesenchymal benign tumors.
- Lipoma
- Leiomyoma
- Neurofibroma
- Vascular lesions
Usually made of multiple tissue types
What is the MC etiology of colon cancer?
Adenomatous polyps
What are the risk factors for colon cancer?
- > 50 y/o
- FMHx
- Diet (red meat and high fat)
- Smoking
- Obesity
When is colonoscopy screening recommended?
45 years for average risk individuals
How does proximal colon cancer tend to present?
- Anemia
- Weakness, fatigue
- Melena
- Positive FOBT
- Wt loss
How does distal colon cancer tend to present?
- Change in bowel habits
- Obstruction
- Hematochezia
- Tenesmus
How is colon cancer diagnosed and staged?
- Diagnose: Colonoscopy
- Staging: CT/MRI
What is the treatment for colon cancer?
- Stage 1 = resection
- Stage 2-4 = Resection + chemo/radiation
For curative resections of colon cancer, what is the follow-up screening/treatment protocol?
- H&P and CEA
- Annual CT if high-risk
- Colonoscopy 1 year post-op then 3 years if clean
- If CEA starts going up; colonoscopy
What tests are used to screen for colon cancer?
- FOBT or FIT test
- Flexible sigmoidoscopy
- Colonoscopy
- CT Colonography
What is familial adenomatous polyposis?
FAP
Genetic predisposition to making thousands of little polyps, often developing by age 15 and cancerous by age 40.
Can also make little growths everywhere like skin.
For someone with FAP, what surgery is needed to prevent cancer by age 50?
Prophylactic proctocolectomy with anastomosis is recommended by age 20!!
Who do we screen for FAP?
- Anyone with many polyps upon endoscopy
- Any first-degree family members with FAP
For someone with FAP, how often do we screen them?
EGD every 1-3 years
What does lynch syndrome predispose someone to?
Colorectal cancer
What does lynch syndrome present as?
Few adenomas, but they are flat and more villous
Villous = highest likelihood to cause cancer
What is the three tool screening for Lynch syndrome?
- 1st degree relative with colo-rectal cancer prior to age 50
- Has the pt had colo-rectal cancer/polyps before 50
- 3 or more relatives with colo-rectal cancer?
When is genetic counseling recommended for Lynch syndrome?
- Family/Personal Hx of CRC before 50
- Family history of multiple people with CRC
What is the treatment for Lynch syndrome?
- Subtotal colectomy with ileorectal anastomosis
- Prophylactic hysterectomy/oophorectomy by age 40
- Screening with EGD every 2-3 years starting at age 30
- Colonoscopies starting at age 25
What defines internal vs external hemorrhoids?
Dentate line
What are the primary causes of hemorrhoids?
- Constipation, low fiber
- Straining
- Pregnancy
- Obesity
Venous pressure increases
Where exactly do internal hemorrhoids occur?
- Right anterior
- Right posterior
- Left Lateral
RAPLL
definitely seems like a test question
What veins do external hemorrhoids originate from?
Inferior hemorrhoidal veins below the dentate line.
How do internal hemorrhoids tend to present?
- Bleeding, prolapse, Mucoid discharge
- Often not painful
How do we look for hemorrhoids?
- Perianal inspection
- Anoscopic evaluation
Table of internal hemorrhoid staging
How do you conservatively treat stage 1-2 hemorrhoids?
- Proper toileting
- High fiber, drink water, take laxatives
How do you treat stage 1-2 hemorrhoids that have recurrent bleeding or stage 3-4?
- Rubber band ligation (preferred)
- Injection sclerotherapy
For stage 4 or a severe stage 3 hemorrhoid, what is the surgery?
Hemorrhoidectomy
How do external hemorrhoids tend to present?
- Very painful
- Bluish nodule that looks poppable
How do you treat external hemorrhoids?
- Sitz baths
- Topical ointments
- Evacuation of clot
What are anal fissures and what usually causes them?
- Linear tears/ulcerations around the anus caused by hard stools.
- MC in posterior midline
- Any other lines might suggest IBD
If someone has chronic anal fissures, what could we recommend?
Surgical repair
What is the MCC of perianal abscesses?
Perianal fistulas
How does a perianal abscess present?
- Fluctuance
- Continuous pain
- Throbbing and swelling
How do you treat a perianal abscess?
- I&D
- Maybe use ABX
- Surgical excision
How do you treat a perianal fistula?
Fistulotomy under anesthesia
Is rectal prolapse normal?
It often reduces spontaneously once you are done defecating
If rectal prolapse is chronic/complete, what do we do?
Surgical correction
Emergent
What are the risk factors for rectal prolapse?
- Age > 40
- Female
- Vaginal delivery
- Big baby delivery
- Anything that weakens your pelvic floor
- Dementia
How do you treat a rectal prolapse?
- Manual reduction
- Fluid/fiber
- Kegel exercises
- Surgical consult
What is pilondial disease?
An extra sinus opening?
