Lower GI Flashcards by Reintine Han

Irritable Bowel Syndrome

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Red Flags

– Unintentional and unexplained weight loss

– Rectal bleeding

– Family history of bowel or ovarian cancer

– Change in bowel habits persisting MORE than 6 weeks in a person > 60

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Irritable Bowel Syndrome Treatment

Fiber is ineffective in the treatment of adult IBS
Lubiprostone (Amitiza) and Linaclotide (Linzess) are effective for constipation-predominant IBS.

– Works by increasing the amount of fluid in intestine, making it easier for stool to pass

Antispasmodics – Dicyclomine, tincture of belladonna, hyoscyamine
Antidepressants (Citalopram, Fluoxetine, Paroxetine; tricyclic antidepressants have been studied)

– Low dose: Analgesia, mood, colonic transit slowing

• Antidiarrheal agents – Diphenoxylate, loperamide; no help with pain

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Celiac Disease Diagnosis

• Several serologic tests are readily available for diagnosis.

– IgA anti-tissue transglutaminase antibody*§ (sensitivity 79%-90%, specificity 98%, most senstive)

If positive confirm with biopsy.

Test while consuming a diet of gluten-containing foods.
Gold standard: Endoscopy biopsy of proximal small intestinal mucosa – villous atrophy

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A 19-year-old patient presents to your office for follow-up. She reports continued intermittent abdominal cramping and bloating, diarrhea, fatigue, and a 4.5-kg weight loss. She initially was diagnosed with irritable bowel syndrome, but you suspect celiac disease. What should be used to establish the diagnosis?

Serologic testing initially, followed by endoscopy if test results are positive

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Ulcerative Colitis Pathology

– CONFINED TO MUCOSA – Starts in rectum, moves proximally WITHOUT skips

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What is UC linked to?

Ulcerative Colitis Link With Colon Cancer

• 2.8-15x as likely to develop colon cancer if there is history of moderate or extensive involvement of the colon

• Colonoscopy q 2-5 years

– Initiated 10 years after UC is diagnosed

– Interval based on findings

Crohn’s has similar cancer risk as UC after long-standing disease – similar screening recommendation and controversy

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Crohn’s Disease Pathology

– FULL WALL THICKNESS

– Any part of GI tract may be affected.

– Terminal ileum most common site

– SKIPS

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UC versus Crohn’s

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Treatment for UC

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Treatment for chronh’s

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In considering the treatment of a patient with Crohn’s Disease, which of the following statements is true?

A. Budesonide is not effective in inducing remission

B. Azathioprine is effective for maintenance of remission

C. Methotrexate is effective in inducing but not maintaining remission

D. Sulfasalazine and 5-aminosalicylic acid are first line agents in the treatment of severe disease activity

B. Azathioprine is effective for maintenance of remission

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Summary of Serological tests

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(Viral) Gastroenteritis

Majority of Gastroenteritis Is Viral

Rotavirus is the most common cause in children and produces similar incidence rates in both the developed and developing world.
Norovirus is the leading cause of gastroenteritis among adults in America, causing greater than 90% of outbreaks.

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Complications of Rotavirus

Complications: Necrotizing enteritis, biliary atresia, intussusception, chronic diarrhea

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Rotavirus vaccination

2 months – First dose minimum 6 weeks, maximum < 15 weeks
4 months
6 months – Must complete by 8 months

A 52-year-old female with hypertension presents with a 2-day history of profuse bloody diarrhea, moderate to sever abdominal cramping, and fever. She has recently returned from a week-long trip to Singapore. Her stool culture is positive for Campylobacter. What is the treatment of choice?

Azithromycin (Zithromax)

Bacterial Gastroenteritis in children and adults

Campylobacter

• Animal reservoir – Most human cases are contaminated poultry (~50%)

Severe cramps, bloody diarrhea, anorexia, malaise; rarely, Guillain-Barre, reactive arthritis

Diagnosis: Culture
Treatment

– Spontaneous clearing without antibiotics or

– Azithromycin, Erythromycin if culture proven

Shigella treatment

• Bloody diarrhea • Fecal oral spread – Highly contagious • Principal effect on colon mucosa – Low-volume diarrhea – Blood – Mucus – Fever – Tenesmus • Diagnosis – Culture

– TMP-SMX (children)

– Quinolone adults

Salmonellosis

• Sources – Eggs and poultry – Pet reptiles

– Self-limited

• Typhoid via fecal-oral contamination, rare in US – Constipation and rash early, then diarrhea and pain – Diagnosis • Culture from blood or stool

– Treat • Fluoroquinolone • Vaccine available

E. coli 0157:H7 (EHEC)

Complication – Hemolytic uremic syndrome
Source – Contaminated meat
Treatment – Supportive – Antibiotic NOT indicated

Amebiasis

E. histolytica mostly – Fecal-oral spread – Abdominal cramps – Chills, fever – Liquid BMs with bloody mucus
Diagnosis – Sigmoidoscopy – O&P – Stool/serum antigen – Serology
Treatment – Metronidazole etc.

Giardiasis

Common – Mostly from contaminated water
Symptoms – Abdominal cramps – Malabsorption – Nausea and vomiting – Watery diarrhea
Diagnosis – O&P – Giardia antigen assay
Treatment – Metronidazole

Pseudomembranous Enterocolitis

* Common in “post-antibiotic” setting * **Etiology** – Toxin from Clostridium difficile * **Diagnosis** – Cytotoxin assays – Immunoassays to toxin **• Treatment** – Stop antibiotic – use metronidazole or vancomycin • No reported resistance – Fluids

Traveler's Diarrhea Prophylaxis

• Prophylaxis – NOT recommended by CDC – Routine prophylaxis increases the traveler’s risk for adverse reactions and for infections with resistant organisms.

Traveler’s Diarrhea (TD) If Treatment Is Needed …

* Travelers who develop **\> 3 loose stools in an 8-hour period** – especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools * Antibiotics\* – **Fluoroquinolones** (cipro) are drugs of choice when needed single dose or 1 day (increasing resistance) – Alternative: Azithromycin (500 mg q day for 1-3 days) * **Bismuth subsalicylate** may also be used for treatment. – One fluid oz or two 262 mg tablets q 30 minutes for up to eight doses in a 24-hour period

Vibrio Cholerae

* In US, generally associated with travel • Asia • China • South/Central America – OR consumption of contaminated seafood – OR recent consumption of contaminated imported foods * Treatment – Vigorous rehydration – **Doxycycline**

Key Learning Points: Diarrhea

* **Rotavirus** is the leading cause of infectious diarrhea in children in the US. * **Norovirus** is the leading cause of foodborne disease in US and the leading cause of gastroenteritis in US adults. * **Salmonalla** is the most common cause of bacterial diarrhea in adults in the US. * Antibiotics are not indicated for treatment of E. coli 0157:H7. * Amoxicillin is most common offending antibiotic for pseudomembranous enterocolitis. * Prophylaxis for traveler’s diarrhea is NOT recommended.

Diverticulosis

Diverticulitis Clinical presentation & physical findings

• Clinical presentation – Acute lower abdominal pain – Fever (usually below 102º F) – Tachycardia – Physical findings • Tender lower abdomen, possibly with rebound – Tenderness only in the LLQ significantly increases the likelihood of diagnosis ([+] LR = 10.4). • Acute abdomen is possible

Diverticulitis Diagnostic Studies

Diverticulitis Treatment

• General – Depends on severity – May require only clear liquids and oral antibiotics * Can be done outpatient with follow-up in 2-3 days * Ciprofloxacin and/or metronidazole – OR MAY NEED (hospitalization) • NPO • NG suction • IV fluids • IV antibiotics – Ampicillin + aminoglycoside + metronidazole OR – Imipenem/cilastatin OR – Piperacillin/tazobactam

Second most frequent cause of cancer death AFTER lung cancer

Cancer of Large Intestine

Recommendation of the USPSTF on Screening for CRC

The FIT is preferred over the gFOBT because it is better at detecting cancer and it doesn't require dietary restrictions before testing, according to the U.S. Multi-Society Task Force (MSTF) on Colorectal Cancer. A colonoscopy examines the entire colon, while a sigmoidoscopy covers only the lower part of the colon, also known as the rectum and sigmoid colon

Guidelines for Follow-up Surveillance Colonoscopy

Types of Polyps

One week after a complete and adequate baseline screening colonoscopy, a 51-year-old female with no history of previous health problems visits you to review the pathology report on the biopsy specimen obtained from the solitary 8-mm polyp discovered in her sigmoid colon. The report confirms that this was a hyperplastic polyp. Her family history is negative for colon cancer. Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient?

10 years