Lower GI disorders- Paulson (exam 3) Flashcards
Inflammatory Bowel Disease (IBD)= consists of which 2 disease conditions
Crohn’s disease & Ulcerative colitis make up IBD
Risk factors for IBD:
- Age of onset: 15-40 years old
- More common in those of Jewish descent
- First degree relative with IBD
- Smoking: Increases risk of Crohn’s disease
- “Western diet” ↑ risk
What is a protective factor against Ulcerative colitis?
smoking
Ulcerative Colitis (UC)= an inflammatory condition involving the ______
mucosal surface of the colon
UC= diffuse ____ areas and erosions of bleeding
friable
T/F: UC usually starts distally and progresses proximally
True! starts distally at rectum and progresses proximally
–>*Disease is continuous (no skipped areas)
UC Clinical Manifestations
Bloody diarrhea
BMs often frequent and small volume
-**Tenesmus
-Those with mainly distal disease may have constipation + frequent blood and mucus discharge
-Incontinence
-Colicky abdominal pain
-Onset of symptoms usually gradual & progressive
-Systemic symptoms (fever, weight loss, fatigue) possible
Tenesmus=
the urge to deficate
Colicky pain=
comes and goes
UC: PE findings
-Often normal Possibly: Abdominal pain with palpation Fever Hypotension Tachycardia Pallor Blood on rectal exam
UC: Extraintestinal Manifestations
Arthritis Nondestructive peripheral arthritis of large joints Ankylosing spondylitis Uveitis/episcleritis Erythema nodosum Pyoderma gangrenosum VTE Arterial thromboembolism Autoimmune hemolytic anemia Primary sclerosing cholangitis
UC: Labs
Anemia
↑ ESR/CRP
Electrolyte abnormalities from diarrhea/dehydration
***↑ Fecal calprotectin
What lab can be used to differentiate IBS from IBD?
increased Fecal calprotectin in IBD, NOT IBS
Imaging: UC
- -Not required for diagnosis
- Xray findings:
- Proximal constipation
- Mucosal thickening or **“thumbprinting” from edema
- Colonic dilation if severe
- Double contrast barium enema:
- -**Diffusely reticulated pattern with punctate collections of barium in microulcerations
- -**Collar button ulcers
- Shortening of colon
- -Loss of haustra
- -Polyps or pseudopolyps
Avoid double contrast barium enema in which Pts?
Avoid in those severely ill –>can cause toxic megacolon
Other imaging studies for UC
- CT or MRI
- -have Lower sensitivity than barium enema at detecting subtle early disease
- they show Thickening of bowel wall
Dx: UC (4 things)
- **Chronic diarrhea ≥4 weeks
- Evidence of active inflammation on endoscopy
- **Chronic changes on biopsy
-Exclusion of other causes of colitis
Endoscopy findings for Ulcerative Colitis (2)
- Loss of vascular markings from swelling of mucosa–> looks erythematous
- Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
Ulcerative colitis: biopsy findings
-Crypt abscesses
Crypt branching
Shortening & disarray
Crypt atrophy
- Epithelial cell abnormalities: mucin depletion, Paneth cell metaplasia
- Inflammatory features: ↑ lamina propria cellularity, basal plasmacytosis, basal lymphoid aggregates, lamina propria eosinophils
Ulcerative colitis: patterns
- Involves rectum
- Extends proximally in a continuous, circumferential manner
- No normal areas of mucosa
UC: Severity of Disease (3)
- mild
- moderate
- severe
UC: mild disease (criteria)
- ≤ 4 stools/day (with or without blood)
- Normal ESR
- No severe abdominal pain, fever, weight loss, or profuse bleeding
UC: moderate disease
- > 4 loose, bloody stools/day
- Mild anemia (not requiring transfusions)
- Moderate abdominal pain
- Minimal signs of systemic toxicity ie: low-grade fever.
- No weight loss
UC: Severe disease (criteria)
- Frequent loose bloody stools ≥6/day
- Severe abdominal pain
- Systemmic symptoms (fever, tachycardia, anemia, or ↑ESR)
- May have rapid weight loss
UC: tx
- for ulcerative proctitis or proctosigmoiditis?
- for distal part of rectum?
- **Topical 5-aminosalicylic acid (5-ASA) is first-line
- Suppositories and/or enemas
- -Use a Suppository if disease confined to distal part of rectum: Mesalamine 1 PR BID
UC tx:
-if disease extends farther than distal part of rectum?
- Enema + suppository if disease extends further
- -Enema BID + suppository BID
UC tx:
-how quickly does tx provide relief?
- Symptomatic relief and decreased bleeding in only a few days
- Complete healing takes ≥4-6 weeks –> continue for 8 weeks then taper
UC:
- who needs maintenance therapy?
- who doesnt
–Maintenance therapy not recommended for 1st episode of proctitis
–Maintenance therapy is recommended for:
Proctosigmoiditis patients
Those with ≥1 relapse/year
UC: alternative tx
Topical steroids
Oral 5-ASA
*not as effective
UC: tx
-For Left-sided colitis, extensive colitis, pancolitis?
Combo therapy with oral 5-ASA, 5-ASA or steroid suppositories, and 5-ASA or steroid enemas
–All should have maintenance therapy
UC: Tx of refractory dz
Refer!
Likely will use further oral immunosuppressants
UC: chronic complications
Strictures: MC in rectosigmoid colon
- Can cause obstruction
- Consider malignant until proven otherwise (by biopsy)
Colorectal Cancer:
- UC Pts are at ↑ risk for colorectal cancer
- ↑ Duration of illness and ↑ extent of disease ↑ risk
UC: prognosis
-With treatment:
Exacerbations/flares alternating with long periods of symptomatic remission
Some unable to achieve remission
-Disease extension may be seen
-Some may need colectomy
20-30%
For acute complications or intractable disease
-Mortality: Slightly higher than the general population
Crohn Disease= transmural inflammation of the ____
GI tract that can occur anywhere from the mouth to perianal area
Crohn disease:
-MC involved areas?
- Ileum & right colon most commonly involved
- Skip areas are classic**
Crohn disease:
- etiology
- peak incidence?
-Cause is unknown
Peak incidence between 15-35 years old
Crohn disease:
-Sx
- Crampy abdominal pain
- Strictures–> can have repeated obstruction
- Diarrhea: Fluctuating over time, Gross bleeding less common than in UC (may be microscopic)
- Fistulas
- malabsorption
- absecess formation
- apthous ulcers (in the mouth)
Crohn Disease:
-common sites for fistulas?
- Enterovesical (to bladder)
- Enterocutaneous (to skin)
- Enteroenteric (to bowel)
- Enterovaginal (to vagina)
Crohn disease:
-extra-intestinal manifestations
Fatigue very common
Weight loss
Arthritis
Eye involvement: Uveitis, iritis, episcleritis
Skin: Erythema nodosum, pyoderma gangrenosum
Primary sclerosing cholangitis
-VTE & arterial thromboembolism
-Nephrolithiasis (from steatorrhea & diarrhea)
-Vitamin B12 deficiency
-Pulmonary involvement
-Secondary amyloidosis
Crohn disease: Physical exam findings
- Often normal
- Perianal skin tags
- Sinus tracts
- Abdominal tenderness
- Weight loss
- Pallor
Crohn disease: Labs
- CBC
- CMP
- ESR/CRP–>CRP higher in CD than UC
- Serum iron
- Vitamin D level
- Vitamin B12 level
- **Fecal calprotectin may help differentiate from IBS
- Antibody tests: pANCA and ASCA may help diagnose IBD and distinguish CD from UC
pANCA and ASCA stand for?
perinuclear antineutrophil cytoplasmic (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA)–> positive in crohn’s dz
How can a colonoscopy be useful in Crohn’s Pts?
- Colonoscopy can be used To establish the diagnosis***
- Focal ulcerations adjacent to areas of normal appearing mucosa
- Polypoid mucosal changes that give a cobblestone appearance
- Skip areas typical
- Rectal sparing common
Wireless Capsule Endoscopy:
- Another way to visualize small bowel
- No radiation exposure
- Don’t perform in those with suspected stricture***
-helps to dz crohn’s disease
Crohn’s disease: imaging (endoscopy findings)
- Upper GI series with small bowel follow through
- Narrowing of lumen with nodularity & ulceration
- **“String sign”
- Cobblestone appearance
- Fistulas/abscess formation
- Bowel wall thickening
- Stricturing
“cobblestone appearance”–
think crohn’s!!! since the barium gets dispersed and settles into the inflamed areas
Crohn disease: CT scan
-when is a CT the best study?
CT (with ingestion of a neutral contrast agent to distend small bowel)
-Best study if abscess suspected**
Crohn disease: MRI
-findings?
-Mural thickening, high mural signal intensity (edema), and layered pattern of enhancement = acute small bowel inflammation
Crohn’s Disease Activity Index (CDAI)
Stool patterns, abdominal pain rating, general wellbeing, complications, abdominal mass, anemia, weight change
Harvery-Bradshaw Index (HBI)
-General wellbeing, abdominal pain, number of liquid stools, abdominal mass, complications
Crohn Disease:
-Clinical Remission
Asymptomatic, no sequelae. Achieved spontaneously or after medical or surgical intervention
Crohn Disease:
-Mild Crohn Disease
Ambulatory, tolerating oral diet. <10% weight loss, no systemic symptoms. No s/s of obstruction
Crohn Disease:
-Mod-severe Crohn disease
Have failed treatment for mild-mod disease, or have prominent symptoms like fever, weight loss, abdominal pain/tenderness, intermittent n/v, anemia
Crohn disease:
-Severe-fulminant disease
Persistent s/s despite steroids or biologic agents, or have high fever, persistent vomiting, intestinal obstruction, peritoneal signs, cachexia, or evidence of an abscess
Crohn disease:
-Treatment- general approaches
- step up therapy
- Top-down therapy
Describe Step-up therapy
- Start with less potent meds (but fewer side effects)
- Use more potent meds if initial therapies not effective
(use step up tx for MILD crohn’s disease)
Describe Top-down therapy
- USE for Pts with SEVERE crohn’s disease
- Start with more potent therapies early in the course of the disease before they become glucocorticoid-dependent
Goal of tx: Crohn’s disease
Goal: Achieve remission (endoscopic, histologic, and clinical) by demonstrating complete mucosal healing
Treatment of Mild-Mod Disease: Crohn Disease
- Ileum or Proximal Colon Involvement–> Budesonide 1st line for induction. Budesonide 9 mg daily x 4-8 weeks, then taper Q2-4 weeks for 8-12 weeks total
- Alternatives to budesonide: prednisone, oral 5-ASA (controversial)
- Diffuse Colitis or left colonic involvement: Oral prednisone 40 mg daily x 1 week, then taper. Sulfasalazine is alternative
-Tx of Oral lesions:
Topical steroid medications ie: triamcinolone acetonide
Budesonide (aka _______
enterocort
Budesonide: pharmocologic category
corticosteroid
Budesonide:
-adverse reactions
headache, acne, adrenal suppression, osteoporosis, immunosuppression, edema, psychiatric disturbances, exacerbation of CV disease, hyperglycemia
After induction therapy is complete (crohn disease):
- If prednisone used for induction:
- -Taper and discontinue
- -Then clinically observe, ileocolonoscopy in 6-12 months
- If 5-ASA or sulfasalazine used:
- -Continue the same med for long-term maintenance
- -Ileocolonoscopy in 6-12 months
-If budesonide used:
Goal is to stop the med, but can continue at lower dose (6 mg) for no more than 3-6 months
- Immunomodulator may be used
- -More common for those with mod-severe disease
- -Azathioprine, methotrexate, 6-mercaptopurine
For Relapse of Crohn disease- tx
-Begin a second course of a glucocorticoid
Tx of more severe disease- crohn’s disease
- Top-down approach
- Refer!
- Biologic + immunomodulatory for induction
- -TNF-inhibitor: infliximab (Remicade), adalimumab (Humira), or certolizumab (Cimzia)
- azathioprine, 6-mercaptopurine, or methotrexate
- Some patients may also get a glucorticoid (up to 8 weeks) for more immediate symptom relief
- Maintenance therapy
- -Continue long-term treatment with a biologic agent
Surgical Management: Crohn disease
Required for Pts with complications:
- Perforation
- Abscess
- Fistula
- Hemorrhage
- Stricture
- Neoplasm
- Or those who have persistent symptoms despite medical management
Prognosis: Crohn disease
- Intermittent exacerbation followed by periods of remission
- Over half develop structuring or penetrating disease
- Up to 80% require at least 1 hospitalization
- Many will require surgery
- Predictors of severe course:
- -Age < 40
- -Perianal or rectal disease
- -Smoking
- -Low education level
- -Initial need for glucocorticoids
Constipation: list the causes
-Inadequate fiber & water consumption
-Medications: Opiates, anticholinergic meds, CCBs, antacids, iron
-Neurologic conditions:
MS, Parkinson disease, dementia, stroke
-Prolonged immobility
SCI, complete bed rest
-Metabolic diseases:
DM, hypothyroidism, uremia, hypercalcemia, hypokalemia
-Functional fecal retention:
Chronic stool-withholding behavior. Most common in kids
- Anatomic abnormalities:
- -Neoplams
- -Anal fissures, lesions, proctitis, perirectal abscess
- -Anorectal stenosis
- Functional abnormalities:
- -Increased rectal compliance
- -Pelvic floor dysfunction (ie: rectocele, enterocele, ie pregnancy)
Clinical manifestations of constipation
- “Hard or lumpy stools”
- Feeling of incomplete voiding
- Straining
- Abdominal discomfort and bloating
- Manual maneuvers
- Fewer than 3 defecations per week
- Loose stools rare without laxative use
Constipation: tx
-Fiber--> Psyllium (Metamucil), methylcellulose (Citrucel), calcium polycarbophil (FiberCon)
-Hyperosmolar agent:
Sorbitol, lactulose, PEG (Miralax)
- Stimulant: Glycerin suppository, bisacodyl (Dulcolax), senna (Senakot), senna/Colace
- Enema: Mineral oil, tap water enema, sodium phosphate (Fleet)
-Opioid antagonist:
Methylnaltrexone (Relistor), naloxegol (Movantik)
Fecal impaction
- A mass of compacted feces in the large intestine that can’t be evacuated spontaneously
- ->Usually in rectum or distal sigmoid colon
-Common in chronic constipation–> Especially elderly
Fecal impaction: clinical presentation and imaging
- Rectal discomfort
- Abdominal pain & cramping
- Bloating
- Overflow fecal incontinence or paradoxical diarrhea
- Increased urinary frequency, incontinence, or obstruction
- May detect impacted feces on rectal examination
-Xray or CT shows location of impaction and any associated bowel obstruction
Fecal impaction: tx
- Manual disimpaction
- Enema administration
- Osmotic laxatives
- Address underlying cause of constipation
- ->Adequate fiber & water intake
- ->Bulking agents, stool softeners
Fecal impaction: complications
- Large bowel obstruction with colonic perforation
- High mortality
Celiac Disease: aka ________
-inflammation of?
- AKA gluten-sensitive enteropathy and nontropical sprue
- Inflammation of the small bowel secondary to ingesting gluten-containing foods
- ->Wheat, barley, rye, some oats
Celiac disease- pathogenecity
- Immune disorder triggered by an environmental agent (the gliaden in gluten) in people who are genetically predisposed
- Mostly in Caucasian patients with northern European ancestry
- Many undiagnosed
- More prevalent than recognized
-Usually presents between ages 10-40 (dx mostly in their 20’s)
Celiac disease: Sx
- Diarrhea with bulky, **foul-smelling, **floating stools
- -Steatorrhea, flatulence
- Weight loss
- Weakness
- Abdominal distension
- Infants & kids may present with FTT
- Iron deficiency anemia
- Osteopenia & osteoporosis
Conditions associated with Celiac disease:
-Dermatitis herpetiformis
-Diabetes Mellitus Type 1
Down Syndrome
Liver Disease
-Menstrual & reproductive issues
Steatorrhea=
fatty stools
Describe dermatitis Herpetiformis
=Grouped pruritic papules and vesicles. Commonly associated with Celiac disease
-on Elbows, dorsal forearms, knees, scalp, back, & buttocks common sites
Describe Menstrual and reproductive issues
Recurrent miscarriage, infertility, later menarche, earlier menopause, preterm delivery, low birth weight
Who should have serologic testing (for celiac dz)?
- Pts with Suggestive GI symptoms
- Extraintestinal S/S suggestive of Celiac disease
-All testing should ideally be done while patient is on a gluten-containing diet
Describe low probability Serologic testing vs high probability serologic testing
low probability–> serologic testing:
- No significant s/s of malabsorption
- No FH of celiac disease
- Chinese, Japanese, or Sub-Saharan African descent
High probability–> serologic testing and small bowel biopsy
- Classic presentation
- Risk factors: 1st or 2nd degree relative with confirmed CD, -Type 1 DM, autoimmune thyroiditis, Down syndrome, Turner syndrome
Serologic testing must be done while the Pt is ____
eating gluten
Serologic testing
-Tissue transglutaminase ***(tTG)-IgA antibody is **preferred test
90-98% sensitivity
-Anti-endomysial (EMA-IgA) levels also measured
IF serologic testing is (+), a _____ biopsy is needed to confirm dx of celiac
small bowel biopsy (with endoscopy)
T/F: negative serology doesnt 100% exclude celiac disease
True. Could be negative because of:
IgA deficiency
Low gluten/gluten free diet
-False negative more common in mild disease
Endoscopy with Small Bowel Biopsy: what is seen on endoscopy?
- Atrophic appearing mucosa with loss of folds
- **Visible fissures
- Nodularity
- Scalloping
- Prominent submucosal vascularity
Small bowel biopsy: findings associated with celiac
- Graded using Marsh-Oberhuber classification
- At least **4 biopsies are recommended to confirm dx:
- -Increased intraepithelial lymphocytes
- -**Atrophic mucosa with villi loss
- -Epithelial apoptosis
- -Crypt hyperplasia
Management of Celiac disease
- Gluten-Free diet
- Refer to a RD! (registered dietitian)
- Replete any nutritional deficiencies
- Evaluate for bone loss with DXA
- Pneumococcal vaccination
- Improvement of dermatitis herpetiformis may be more delayed than the response to intestinal manifestations
- Consider screening family members
Celiac disease: prognosis
-which cancers are they at higher risk for??*
- Increase in overall mortality
- -Mostly due to CV disease and malignancy
- Increase risk for malignancy–> Lymphoma most common**
- GI cancers also common
Colorectal cancer is the leading cause of..
deaths in the US
Risk factors that influence screening recommendations for colorectal cancer?
- Hereditory syndromes: Familial adenomatous polyposis (FAP) & Lynch syndrome (HNPCC)
- IBD
- Abdominal radiation
- Cystic fibrosis
Colorectal cancer: demographic (& risk factors that MAY influence screening recommendations)
- African Americans highest rates of CRC–> Mortality 20% higher than Caucasians
- Male gender–>25% higher mortality
- Acromegaly
- Renal transplantation + long-term immunosuppression
RISK factors for colorectal cancer that DONT influence screening recommendations:
- Obesity
- Diabetes
- Red & processed meat–>High cooking temperature also implicated
- Smoking
- Alcohol consumption
Colorectal cancer: s/sx
-Suspicious signs & symptoms: Change in bowel habits Unexplained IDA Rectal bleeding + change in bowel habits Rectal mass or abdominal mass Abdominal pain
Can Pts with colorectal cancer be asymptomatic?
yes. but discovered on routine screening
- -Most patients with early stage cancer don’t have symptoms
Some Colorectal cancer Pts may need an emergency admission due to..
intestinal obstruction, peritonitis, or an acute GI BLEED
Colorectal cancer dx:
-Colonoscopy
Colonoscopy findings:
-Endoluminal masses- arise from mucosa and protrude into lumen
-Friable, necrotic, or ulcerated lesions may bleed
-“Apple core” description may be seen with circumferential involvement
CT colonography= aka _____
“virtual colonoscopy” or CT colography
=Computer-simulated endoluminal perspective of the air-filled distended colon
–Still requires a bowel prep
—Stool can simulate polyps
-Abnormal results should be followed up by colonoscopy for excision & tissue dx
tumor markers for colorectal cancer:
=CEA–> **Low diagnostic ability to detect primary colorectal cancer
- has Significant overlap with benign disease: ie Gastritis, PUD, diverticulitis, liver disease, COPD, diabetes, any acute or chronic inflammatory state
- **Low sensitivity for early-stage disease
CEA is useful for..
follow-up of patients with diagnosed CRC
- -If levels >5 preoperatively–> worse prognosis
- -If levels don’t normalize after surgery–> look for persistent disease
Management of colorectal cancer: (3 things)
- Carcinoma in a polyp–>Endoscopic removal alone as long as margins are clear
- Larger tumors–>Surgical resection. Then adjuvant chemotherapy
-Radiation therapy: Most commonly used for rectal cancer. Not routine for completely resected colon cancer
Colonoscopy Screening guidelines:
-who is at increased risk?
Personal history of CRC or an adenomatous polyp
-Family member with CRC or a documented advanced polyp
-Personal or family history of genetic syndromes that cause CRC: Familial adenomatous polyposis Lynch syndrome Juvenile polyposis syndrome Peutz-Jeghers syndrome MUTYH-associated polyposis
- Inflammatory bowel disease
- Prior history of abdominal radiation for childhood malignancy
Other risk factors that may influence colorectal cancer screening (2)
HIV positive men
African American
Age to Initiate Screening in those at average risk of colorectal cancer
- 50 years old for average-risk adults
- Some will start at age 45 for African American adults
- ->Recommendations vary
When to Discontinue Screening in those of average risk for colorectal cancer
-Screen through age 75 in average risk patients, as long as they are expected to live ≥10 years
- Between ages 76-85, individualize decision based upon:
- Patient preferences
- Prior testing results
- Comorbidities
Choices of Screening Tests (3)
- colonoscopy
- Fecal immunochemical teting (FIT)
- CT colonogrpahy (aka virtual colonoscopy)
Colonoscopy:
- how often is it needed?
- sensitivity?
BEST TEST!!! diagnostic and allows you to remove lesions simultaneously.
- Every 10 years for those at average risk
- Highest sensitivity for CRC and adenomatous polyps of the screening methods
- Allows lesion removal
- Associated with reduced incidence and mortality from CRC
Fecal immunochemical testing (FIT)=
-what does it measure?
- Screen for occult blood yearly using 1 stool sample
- *Measures hemoglobin in the stool
- If positive, patient needs colonoscopy ASAP
CT colonography:
-how often is it needed?
- Every 5 years
- If polyps or findings suggestive of CRC, need colonoscopy ASAP
- Still need bowel prep
Other screening tests for colorectal cancer (list 4) (not preferred)
- Sigmoidoscopy + FIT: Recommendations regarding timing vary
- Sigmoidoscopy alone–> Every 5-10 years. Minimal patient prep and no sedation required
-Guaiac-based FOBT:
3 samples given yearly
-Stool DNA testing (aka Cologuard):
One stool sample, performed every 3 years
Choice of screening test in those with FH of CRC or advanced Polyp=
colonoscopy
-If patient refuses, FIT testing annually is the alternative
When to Start Screening (FH of CRC or advanced Polyp) (3 things)
- One first-degree relative (FDR) diagnosed at age <60 years:
- -Begin screening at age 40 or **10 years before FDR’s diagnosis (whichever is earlier)
- -Colonoscopy every 5 years
- ≥2 FDRs diagnosed at any age:
- -Begin screening at age 40 or 10 years before the youngest FDR’s diagnosis (whichever is earlier)
- -Colonoscopy every 5 years
- One FDR diagnosed at age ≥60 years:
- -Begin screening at age 40
- -Same screening options as average-risk patients
- -Same frequency as average-risk patients
PT with 1 FDR diagnosed at 45 and another relative diagnosed at 43, when should this Pt start getting screened for colorectal cancer?
33 yo (10 years prior to youngest relative’s dx)
High Risk Syndrome Screening for colorectal cancer: list Some Examples
- Lynch syndrome: 20-25 years old or 2-5 years prior to the earliest age of CRC diagnosis in the family
- Familial adenomatous polyposis (FAP): yearly colonoscopy starting at age **10-12 years old if classic FAP and colonoscopy every 1-2 years starting at age 25 for attenuated FAP
- Peutz-Jeghers syndrome: EGD, video capsule endoscopy, and colonoscopy starting at *age 8
When to discontinue screening in higher risk patients? with colorectal cancer
- No direct evidence but:
- 1 FDR diagnosed after age 50: end at 79
- ≥2 FDRs diagnosed before age 40: end at 85
- If the patient has a life expectancy of <10 years–> reassess this plan
Anal fissures= a tear, cut, or crack in the lining of the ____
distal half of the anal canal
Anal fissures MC affect?
infants and middle aged adults
Anal fissures: etiology
- Primary?
- Secondary?
Most are primary from local trauma:
- Constipation
- Anal sex
- Diarrhea
- Vaginal delivery
Secondary:
- IBD
- Malignancy
- STI
Anal fissures:
- clinical Sx?
- MC location?
- 2nd MC location?
- Anal pain
- Pain intensifies with defecation
- May feel like ripping/tearing
- Often lasts for hours afterwards
- May have associated anal bleeding (mild)
- MC location: posterior midline. -2nd most common: anterior midline
- ->Doesn’t usually extend above the dentate line
anal fissures:
-acute looks ____
vs
-chronic fissure appearance:
-Acute: looks fresh, superficial, like a papercut
Chronic fissure: raised edges, fibrotic appearance often accompanied by a skin tag (sentinel pile)
Anal fissures:
diagnosis
- History + physical exam
- Direct visualization (thinner patients) –or-
- Reproduce the pain with (gentle) digital palpation of the posterior anal verge
Anal fissure: tx
- Fiber + water and/or stool softeners: prevents hard BMs which can cause reinjury
- Sitz bath: anus is immersed in warm water for 10-15 minutes BID-TID–>Relaxes the anal sphincter & improves blood flow to mucosa
- Topical analgesics: for pain control–> Ie: 2% lidocaine jelly
-Topical vasodilators: promote healing by ↑ local blood flow & ↓ anal sphincter pressure: —Nifedipine gel BID-QID
—Topical nitroglycerin BID: Si/E HA & hypotension
Don’t use within 24 hours of Viagra, Cialis, or Levitra!
Anal fissure: Follow-up after?
-Reevaluate after 1 month.
If symptoms persist–> complete 1 more month of the same treatment
-If sx persist after 2 months–> refer for endoscopy to R/O Crohn disease
-If Crohn disease–> refer to GI
If no Crohn disease–> refer to colorectal surgeon
—Botox or lateral sphincterotomy recommended
Hemorrhoids are swollen veins in the rectum and anus that can lead to ______
discomfort, prolapse, and bleeding
Describe external hemorrhoids
- (located) distal to the dentate line
- Arise from the superior hemorrhoidal cushion
- Somatic innervation –> more sensitive to pain/irritation
Describe Internal hemorrhoids
- (located) proximal to the dentate line
- Arise from the inferior hemorrhoidal plexus
- Visceral innervation –> less sensitive to pain/irritation
Describe mixed hemorrhoids
both above and below the dentate line
Risk factors for developing symptomatic hemorrhoids
- Advancing age
- Chronic constipation, straining
- **Pregnancy (after pregnancy this is common)
- Pelvic tumors
- Diarrhea
- **Prolonged sitting
- Anal sex
- Anticoagulants and antiplatelet medications
- Obesity
- Low fiber diet
Hemorrhoids: clinical sx
-about ___% of Pts are asymptomatic
40%
Clinical Sx: hemorrhoidal bleeding
- Painless
- Associated with a BM
- Typically bright red & coats the stool at the end of defecation
Clinical Sx: hemorrhoids
- Pruritis or irritation of perineal area very common
- Mild fecal incontinence, mucus discharge, or wet sensation
- Acute onset of perianal pain possible with palpable “lump” from thrombosis
- Appear like protuberant purple nodules covered by mucosa
Diagnosis: Hemorrhoids
- Classic symptoms + visualization of hemorrhoids
- Anoscopy: allows visualization of internal hemorrhoids
How do we classify internal hemorrhoids? (list grades)
Grade I: No prolapse (aka below the dentate line)
Grade II: Prolapse with defecation, spontaneously reduces
Grade III: Prolapse with defecation or other times, needs manual reduction (aka you have to manually push the hemorrhoid back in)
Grade IV: Permanently prolapsed/irreducible, Visible externally, may strangulate.
Hemorrhoids: tx?
-Increase fiber & water intake to produce soft stools
- Topical steroids: may shrink hemorrhoids & relieve pruritis:
- -Hydrocortisone cream BID x 7 days
- -Hydrocortisone suppository BID x 7 days
- Topical analgesics:
- -Lidocaine gel
-Warm sitz baths: reduce inflammation & edema and relax sphincter muscles
BID-TID
- Antispasmodic agents: reduce anal sphincter spasm:
- -Nitroglycerin ointment
When to Refer to Colorectal or General Surgeon for a Pt with hemorrhoids:
- Symptomatic low grade (grade I or II) hemorrhoids refractory to 6-8 weeks of medical treatment
- Symptomatic high grade (III or IV) hemorrhoids
- Thrombosed hemorrhoids
Office-based procedures for hemorrhoids:
-Describe rubber band ligation
- MC procedure
- Rubber band rings are placed on the internal hemorrhoids (NOT FOR EXTERNAL hemorrhoids)
- Bleeding & pain MC complications
Office-based procedures for hemorrhoids:
-describe Sclerotherapy
- Injecting a solution that causes an inflammatory reaction, destroying tissue
- Can be used for those who have an elevated bleeding risk
Office-based procedures for hemorrhoids:
-describe Infrared coagulation
infrared light waves are applied to the hemorrhoid, causes necrosis
Surgical Procedures:
-List indications for external hemorrhoidectomy:
- Symptomatic & refractory to conservative measures
- Symptomatic and refractory to office-based procedures
- Large or severely symptomatic external hemorrhoids
- Patients with substantial external skin tags
- Combined internal and significant external hemorrhoids
Surgical procedures:
-indications for internal hemorrhoidectomy?
-Prolapsed internal hemorrhoids that can be manually reduced (Grade III)
- Prolapsed and incarcerated internal hemorrhoids (Grade IV)
- Symptomatic internal hemorrhoids refractory to conservative measures
- Symptomatic internal hemorrhoids refractory to office-based procedures
- Combined internal and external hemorrhoids
Diverticulosis:
- a diverticulum is a sac-like protrusion of the _____
- develops at points of _____
- diverticulosis is defined by the presence of a _____
- colonic wall
- weakness
- **diverticula–> may be symptomatic or asymptomatic
Diverticular Disease= clinically significant and ______
symptomatic diverticulosis
Paulson’s takeaway for hemorrhoids:
-outpatient setting?
- topical steroids + suppository
- if no relief refer to colorectal
Describe Diverticular disease:
-Diverticular bleeding=
- diverticulitis=
- diverticular colitis=
- Diverticular bleeding= Painless hematochezia (BRBPR that is painless)–>MC cause of brisk hematochezia
- Diverticulitis= Inflammation of a diverticulum–>4-15% develop diverticulitis
- Diverticular colitis= Inflammation in the interdiverticular mucosa, without involvement of the diverticular orifices
Describe Symptomatic uncomplicated diverticular disease
=persistent abdominal pain attributed to diverticula without overt colitis or diverticulitis.
–AKA smoldering diverticulitis
diverticulosis: risk factors?
- Increasing age
- Low fiber, high fat, red meat diet
- Nut, seeds, and corn diet are **NOT associated with increased risk in diverticulosis, diverticulitis, or diverticular bleeding
-Lack of physical activity:
Risk is inversely related to level of activity
- BMI ≥25
- Smoking ≥40 pack year hx
- Meds: NSAIDs, opiates, steroids
IBS= a functional disorder of the ____
GIT with chronic abdominal pain and altered bowel habits
IBS: epidemiology
- Women > men
- Prevalence about 10-15% in North America
-Associated with: Fibromyalgia Chronic fatigue syndrome Depression Anxiety
IBS: clinical Sx
- **Chronic abdominal pain
- Usually crampy
- Variable intensity
- Location and character can vary widely
- **Defecation often improves the pain
- **Stress can worsen the pain
- Altered bowel habits**
IBS:
-describe altered bowel movements
Altered bowel habits:
- Diarrhea
- Constipation
- Alternating diarrhea and constipation
- Normal bowel habits alternating with diarrhea and/or constipation
Describe Bristol Stool Form Scale:
- Type 1
- type 2
- type 3
- type 4
- type 5
- type 6
- type 7
type 1: separate hard lumps, like nuts (hard to pass)
Type 2: sausage-shaped but lumpy
type 3: like a sausage but w/ cracks on the surface
type 4: like a sausage or snake, smooth and soft
type 5: soft blobs with clear cut edges
6= fluffy pieces with ragged edges, mushy
7= watery, NO solid pieces, entirely liquid
dont memorize- general idea
IBS: diagnostic criteria
- Recurrent abdominal pain on average at least once a week in the past 3 months associated with ≥2 of the following:
- -Related to defecation
- -Associated with a change in stool frequency
- -Associated with a change in stool appearance
Alarm Symptoms (**Refer to GI):
- More than minimal rectal bleeding
- Weight loss
- Unexplained IDA
- Nocturnal symptoms
- FH of colorectal cancer, celiac disease, inflammatory bowel disease
IBS: tx
- Education & reassurance
- Dietary modification: some patients may benefit from excluding gas-producing foods- a diet low in **FODMAPs (fermentable oligo- di- and monosaccharides and polyols) and lactose and gluten avoidance
- Increased fiber (psyllium) for those with constipation-predominant IBS:
- -Miralax another option
- -Lubiprostone for constipation-predominant IBS despite miralax
- Antidiarrheals for those with diarrhea-predominant IBS:
- -Imodium (Loperamide)
- -Bile acid sequestrant if failed: cholestramine (Questran)
FODMAPS
- fermentable:
- Oligosaccharides: wheat/barely, artichokes, pasta
- Disaccharides: milk, custard, icecream yogurt
- Monosaccarides: appples, pears, mangos, asparagus
- and
-Polyols:
IBS: Treatment for Abdominal Pain
- Antispasmodics: inhibits gastrointestinal smooth muscle –> significant improvements to postprandial abdominal pain, bloating, and fecal urgency
- Dicyclomine (Bentyl)= #1
- Hyoscyamine (Levsin)
IBS: other tx options
-TCAs: slow intestinal time (because of their anticholinergic properties) and help with abdominal pain:
Amytriptyline, nortriptyline, imipramine
-Antibiotics: In mod-severe IBS without constipation if failed to respond to other therapies, can try rifaximin
