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Lecture 6: Disorders of the Colon & Rectum Flashcards

1
Q

What are the two autoimmune conditions that make up IBD?

A
  • Crohn’s
  • Ulcerative colitis
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2
Q

What is ulcerative colitis?

A

Diffuse inflammation involving only the COLON

Often extends proximally.

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3
Q

What is Crohn’s disease?

A

Patchy, transmural inflammation affecting the GI TRACT

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4
Q

Who is IBD MC in?

A

Caucasians and western diet

Females: Crohn’s (football club)
Males: UC

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5
Q

What lifestyle/risk factor is extremely associated with Crohn’s development?

A

Smoking

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6
Q

What is the most commonly affected part of the GI tract in Crohn’s?

A

Terminal ileum, characterized by transmural inflammation and skip lesions

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7
Q

How does Crohn’s present clinically?

A
  • Chronic RLQ pain
  • Crampy abd pain
  • Intermittent, non-bloody diarrhea
  • Wt loss, weakness, fatigue
  • Mass in RLQ = terminal ileum
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8
Q

What are the extraintestinal manifestations of Crohn’s?

A
  • Pyoderma gangrenosum
  • Erythema nodosum
  • Arthralgia
  • Apthous ulcers (mouth)
  • Fistulas, abscesses

Crohns is the creepy manifestations

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9
Q

What are the 4 types of fistulas that can occur due to transmural inflammation in Crohn’s?

A
  • Enterovesical
  • Enterocutaneous
  • Enteroenteric
  • Enterovaginal
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10
Q

What are the clinical manifestations of fistulas in Crohn’s?

A
  • Infection
  • Abscess
  • Personal hygiene issues
  • Wt loss
  • Malnutrition
  • Diarrhea
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11
Q

Where does erythema nodosum occur in Crohn’s and what does it correlate with?

A
  • Occurs on anterior lower legs
  • Correlate with bowel symptoms

Red, hot lesions

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12
Q

What is pyoderma gangrenosum?

A

Severe disease on dorsal surface of feet and legs usually, beginning as a pustule that spreads and turns necrotic

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13
Q

What is the gold standard to diagnose Crohn’s?

A

Colonoscopy with biopsy showing skip areas with a cobblestone appearance.

May also see focal ulceration adjacent to normal areas

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14
Q

What is the management goal in Crohn’s?

A

Symptomatic relief

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15
Q

What is considered low risk Crohn’s?

A
  • Normal/mild CRP
  • Dxd > 30yo
  • Limited inflammation
  • Little to no ulcerations
  • No perianal complications
  • No prior resections
  • No penetration or strictures.
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16
Q

How do we treat low-risk Crohn’s involving the ileum/cecum?

A

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

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17
Q

For mild-mod Crohn’s involving diffuse colitis or the left colon, what is the treatment?

A
  • 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.

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18
Q

If there is a remission in mild-mod Crohn’s, what is the new therapy we start?

A

Second course of glucocorticoid + azathioprine or biologic (infliximab)

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19
Q

What is the overall therapy methodology in high-risk Crohn’s?

A

Step-down/Top-down

AKA starting with the big boys first

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20
Q

What is the top-down therapy for high-risk Crohn’s?

A

Combination therapy of TNF blockers + immunomodulators

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21
Q

What drug is NOT preferred for maintenance in Crohn’s?

A

Steroids

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22
Q

Once remission is seen in Crohn’s, what is the next step?

A

Ileocolonoscopy in 6-12 months.

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23
Q

What does UC most commonly involve?

A

Rectum and sigmoid colon

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24
Q

What is the hallmark sign of UC?

A

Bloody diarrhea

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25
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
26
What are the complications of UC?
* Severe bleed * Lots of diarrhea * Toxic megacolon * Perfd colon
27
What are the extraintestinal manifestations of UC?
* Arthritis * Ankylosing spondylitis
28
Severity table for UC | Adkins said MUST KNOW!!!
29
Who is UC ironically not as bad in?
Smokers
30
What is the gold standard to diagnose UC?
Sigmoidoscopy showing a **continuous friable mucosa**, edematous, with pus, bleeding, erosions, and erythema
31
When should we NOT do a colonoscopy for suspected UC?
Severe or fulminant colitis due to risk of perf or megacolon.
32
What kind of cancer are patients with long-standing UC most at risk for?
* Colonic epithelial dysplasia * Colonic epithelial Carcinoma
33
What lifestyle change is recommended to help with UC?
Cessation of caffeine
34
What is the treatment for mild-mod UC limited to the distal colon? (not past sigmoid)
Topical mesalamine (5-ASA) or hydrocortisone suppository (worse)
35
What is the treatment for mild-mod UC that extends past the sigmoid colon?
1. Oral mesalamine + topical mesalamine 2. Add-on oral corticosteroids if unresponsive after 4-8 weeks
36
For mod-severe UC, what is the treatment?
Prednisone +/- immunomodulators/TNF blockers
37
What is the curative treatment for UC?
Total proctocolectomy with placement of ileostomy.
38
When do we do maintenance therapy for UC and what is it?
1. More than 1 relapse in a year 2. Anyone with ulcerative proctosigmoiditis 3. Anyone with UC proximal to sigmoid (left-sided) 4. **Mesalamine**
39
What do 5-ASA/aminosalicylates do and their main SEs?
1. Indication: Induction and maintenance therapy of UC and CD 2. MOA: Inhibition of prostaglandin production 3. SEs: N/V, HA, 4. CI: Allergy to aspirin or sulfa | Sulfasalazine and mesalamine
40
What are corticosteroids indicated for in IBD?
Induce remission in severe flares or for acute flares.
41
What are the two corticosteroids used in IBD?
* Prednisone: more potent * Budesonide: poor systemic absorption, fewer SEs
42
What are the indications/MOA/SEs/AEs/BBW for immunomodulators/immunosuppressants?
1. Indication: Steroid dependent IBD or remission maintenance in severe IBD 2. MOA: Inhibition of DNA/RNA synthesis 3. SEs: Leukopenia, thrombopenia, anemia, infection, N/V/D, Malaise, myalgia 4. AEs: Lymphoma and severe infection 5. BBW: Mutagenic potential for rapidly growing malignancies | Azathioprine or 6-mercaptopurine
43
When is methotrexate used for IBD?
Only in mild-mod CD for maintenance if azathioprine fails
44
When is cyclosporine used for IBD?
Severe refractory IBD that failed steroids
45
What are the indications/MOA/SEs/AEs/BBW for Anti-TNFs?
1. Indication: Mod-severe active IBD 2. **TOC for CD fistula (treatment of choice)** 3. MOA: MAB that binds to human TNF, interfering with cytokine inflammation 4. SEs: Fever, rigors, N/V, urticaria, hypotension 5. AEs: Severe infection/sepsis/Malignancy 6. BBW: Severe infection ## Footnote ends in -mab
46
What ABX are used in IBD and when?
* Presence of fistula or abscess that makes patient susceptible to infection. * Metronidazole or ciprofloxacin
47
If we want to give a live vaccine prior to IBD treatment, how early should it be?
4 weeks prior
48
Image of CD vs UC
49
What are the 5 common causes of IBD flare-ups?
1. Missing doses while in remission 2. NSAIDs (recommend tylenol) 3. Smoking (esp with CD) 4. Stress 5. Certain foods
50
What are the 4 pathologic colon polyp groups?
1. Mucosal adenomatous (MC) 2. Mucosal serrated 3. Mucosal non-neoplastic 4. Submucosal | Serrated are 2nd MC
51
What causes adenomatous polyps?
DNA changes in lining of the colon | 95% of colon adenocarcinomas are from these polyps
52
What are the risk factors of adenomatous polyps?
* Age > 50, MC in men * High fat diets * Obesity
53
What do adenomatous polyps look like?
* Flat, sessile, pedunculated * Slow growing
54
How do you diagnose and workup adenomatous polyps?
* Colonoscopy * Check all the polyp pathologies
55
What are the 3 types of adenomatous polyps and what is the most likely to be cancerous?
1. Tubular: least likely 2. Tubulovillous 3. Villous: Most likely (villain)
56
What general characteristics suggest that a polyp has a high likelihood of being cancerous?
1. > 1 cm 2. Villous histology 3. # of polyps 4. Flat polyps
57
How do we manage and screen for polyps?
1. Removal via colonoscopy w/ polypectomy 2. FOBT, fecal immunochemical and fecal DNA annually 3. Colonoscopy screenings 4. Diet and wt loss
58
What are the characteristics of a serrated polyp?
* Sessile, serrated polyps * Varied types (adenoma, hyperplastic) * Variable malignancy potential
59
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
60
What are the submucosal lesions?
Mesenchymal benign tumors. * Lipoma * Leiomyoma * Neurofibroma * Vascular lesions | Usually made of **multiple tissue types**
61
What is the MC etiology of colon cancer?
Adenomatous polyps
62
What are the risk factors for colon cancer?
1. >50 y/o 2. FMHx 3. Diet (red meat and high fat) 4. Smoking 5. Obesity
63
When is colonoscopy screening recommended?
45 years for average risk individuals
64
How does proximal colon cancer tend to present?
* Anemia * Weakness, fatigue * Melena * Positive FOBT * Wt loss
65
How does distal colon cancer tend to present?
* Change in bowel habits * Obstruction * Hematochezia * Tenesmus
66
How is colon cancer diagnosed and staged?
* Diagnose: Colonoscopy * Staging: CT/MRI
67
What is the treatment for colon cancer?
1. Stage 1 = resection 2. Stage 2-4 = Resection + chemo/radiation
68
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
69
What tests are used to screen for colon cancer?
1. FOBT or FIT test 2. Flexible sigmoidoscopy 3. Colonoscopy 4. CT Colonography
70
What is familial adenomatous polyposis? | FAP
Genetic predisposition to making thousands of little polyps, often **developing by age 15 and cancerous by age 40.** ## Footnote Can also make little growths everywhere like skin.
71
For someone with FAP, what surgery is needed to prevent cancer by age 50?
Prophylactic proctocolectomy with anastomosis is recommended by age 20!!
72
Who do we screen for FAP?
* Anyone with many polyps upon endoscopy * Any first-degree family members with FAP
73
For someone with FAP, how often do we screen them?
EGD every 1-3 years
74
What does lynch syndrome predispose someone to?
Colorectal cancer
75
What does lynch syndrome present as?
Few adenomas, but they are flat and more villous | Villous = highest likelihood to cause cancer
76
What is the three tool screening for Lynch syndrome?
1. 1st degree relative with colo-rectal cancer prior to age 50 2. Has the pt had colo-rectal cancer/polyps before 50 3. 3 or more relatives with colo-rectal cancer?
77
When is genetic counseling recommended for Lynch syndrome?
* Family/Personal Hx of CRC before 50 * Family history of multiple people with CRC
78
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
79
What defines internal vs external hemorrhoids?
Dentate line
80
What are the primary causes of hemorrhoids?
* Constipation, low fiber * Straining * Pregnancy * Obesity | Venous pressure increases
81
Where exactly do internal hemorrhoids occur?
* Right anterior * Right posterior * Left Lateral | RAPLL ## Footnote definitely seems like a test question
82
What veins do external hemorrhoids originate from?
Inferior hemorrhoidal veins below the dentate line.
83
How do internal hemorrhoids tend to present?
* Bleeding, prolapse, Mucoid discharge * Often not painful
84
How do we look for hemorrhoids?
* Perianal inspection * Anoscopic evaluation
85
Table of internal hemorrhoid staging
86
How do you conservatively treat stage 1-2 hemorrhoids?
* Proper toileting * High fiber, drink water, take laxatives
87
How do you treat stage 1-2 hemorrhoids that have recurrent bleeding or stage 3-4?
1. Rubber band ligation (preferred) 2. Injection sclerotherapy
88
For stage 4 or a severe stage 3 hemorrhoid, what is the surgery?
Hemorrhoidectomy
89
How do external hemorrhoids tend to present?
* Very painful * Bluish nodule that looks poppable
90
How do you treat external hemorrhoids?
* Sitz baths * Topical ointments * Evacuation of clot
91
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
92
If someone has chronic anal fissures, what could we recommend?
Surgical repair
93
What is the MCC of perianal abscesses?
Perianal fistulas
94
How does a perianal abscess present?
* Fluctuance * Continuous pain * Throbbing and swelling
95
How do you treat a perianal abscess?
* I&D * Maybe use ABX * Surgical excision
96
How do you treat a perianal fistula?
Fistulotomy under anesthesia
97
Is rectal prolapse normal?
It often reduces spontaneously once you are done defecating
98
If rectal prolapse is chronic/complete, what do we do?
Surgical correction | Emergent
99
What are the risk factors for rectal prolapse?
* Age > 40 * Female * Vaginal delivery * Big baby delivery * Anything that weakens your pelvic floor * Dementia
100
How do you treat a rectal prolapse?
* Manual reduction * Fluid/fiber * Kegel exercises * Surgical consult
101
What is pilondial disease?
An extra sinus opening?

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