Lower GI Disorders - Paulson Exam 3 Flashcards
What two conditions make up the inflammatory bowel diseases?
Crohn’s and ulcerative colitis
Which IBD is continuous and which has skip areas?
UC - continuous
Crohn’s - Skip areas
Smoking increases risk of _____ and is protective against ______.
Crohn’s
UC
What are some risk factors for IBD?
Jewish descent, Western diet, first degree relative with IBD.
Which IBD involves just the surface mucosa?
UC
Symptoms of UC?
Bloody diarrhea, frequent small volume BM, Tenesmus, blood and mucous discharge, incontinence, colicky abd pain.
What systemic symptoms are possible from UC?
Fever, weight loss, fatigue
arthritis
erythema nodosum, pyoderma gangrenosum, VTE, Arterial thromboembolism
autoimmune hemolytic anemia
primary sclerosing cholangitis Uveitis/episcleritis.
Onset of symptoms for UC gradual or rapid?
gradual
What labs would be positive in a UC patient?
Anemia, ESR/CRP, electrolyte abnormalities from diarrhea/dehydration, Increased fecal calprotectin
What lab would help distinguish between UC and irritable bowel syndrome?
Fecal Calprotectin - increased with intestinal inflammation
Although imaging is not required for diagnosis, what might you see on an X ray for UC?
Proximal constipation, mucosal thickening or “thumbprinting from edema, colic dilation if severe.
What might you see in a barium enema in a UC patient?
Reticulated pattern with punctate collections of barium in microulcerations, collar button ulcers, shortening of colon, loss of haustra, polyps or pseudopolyps
What are the criteria to diagnose UC?
Chronic diarrhea >4 weeks, evidence of active inflammation on endoscopy, chronic changes on biopsy, and exclusion of other causes of colitis.
Describe some of the biopsy findings in UC.
Crypt abscesses, branching, and atrophy.
Epithelial cells show mucin depletion and Paneth cell metaplasia.
Increased lamina propria cellularity, basal plasmacytosis, basal lymphoid aggregates, lamina propria eosinophils.
Describe the pattern of areas affected by UC.
Involves rectum and extends proximally continuously and circumferential.
Mild UC is defined as:
Less than or equal to 4 stools/day +/- blood.
Normal ESR
Moderate UC defined as:
> 4 loose, bloody stools/day
Mild anemia
Moderate abd pain
minimal signs of systemic toxicity
Severe UC is defined as:
Greater than or equal to 6 loose bloody stools/day
Severe abd pain
Systemic symptoms (fever, tachycardia, anemia, or increased ESR)
May have rapid weight loss
First line treatment for UC?
Topical/suppositories/enemas of 5 aminosalicylic acid (5-ASA)
How long should patients be treated with 5-ASA?
8 weeks then taper
Who is maintenance therapy recommended for?
Patients with proctosigmoiditis or with 1 or more relapses per year
Patients with left sided colitis, extensive colitis, and pancolitis should receive what other therapy in addition to 5 ASA?
Steroid suppositories or steroid enemas
Chronic complications of UC?
Strictures in rectosigmoid colon
Colorectal cancer
Does Crohn’s cause surface mucosa inflammation or transmural inflammation?
Transmural inflammation (deeper than just surface)
Where can Crohn’s occur?
Anywhere from mouth to perianal area.
Intestinal manifestations of Crohn’s?
Crampy abd pain Strictures Diarrhea Fistulas Malabsorption Abscess formation Aphthous ulcers
Extraintestinal manifestations of Crohn’s?
Fatigue Weight loss Arthritis Uveitis, iritis, episcleritis Erythema nodosum, pyoderma gangrenosum Primary sclerosis cholangitis VTE and arterial embolism Nephrolithiasis B12 deficiency Pulmonary involvement Secondary amyloidosis
Which has a higher ESR/CRP, UC or Crohn’s?
Crohn’s
What tests diagnose Crohn’s, and differentiate it from UC?
Antibody tests
pANCA and ASCA are positive in Crohn’s
Findings of colonoscopy in patients with Crohn’s?
Focal ulcerations adjacent to areas of normal appearing mucosa.
Cobblestone appearance of mucosa
Rectal sparing is common
What signs seen on barium enema are suggestive of Crohn’s?
“String sign”
Cobblestone appearance
What can be used to determine the severity of Crohn’s?
The Crohn’s Disease Activity Index or the Harvey-Bradshaw index
Patients with mild Crohn’s have no _____ symptoms.
Systemic
What two factors puts patients in the mod-severe category?
Prominent symptoms
Failed treatment for mild-moderate disease
Severe-fulminant disease is characterized by:
Persistent s/s depsite steroids or biologics.
Or High fever, persistent vomiting, intestinal obstruction, peritoneal signs, cachexia, or abscess
First line treatment for mild-moderate Crohn’s?
Budesonide
Treatment for severe Crohn’s?
Refer
Biologic + immunomodulatory for induction such as infliximab and azathioprine
What are some causes of constipations?
Inadequate fiber and water consumption Medications Neurologic conditions Prolonged immobility Metabolic diseases Functional fecal retention Anatomic abnormalities Functional abnormalities
What meds can cause constipation.
Opiates, anticholinergics, CCBs, antacids, iron, calcium
What neurologic conditions can cause constipation?
MS, Parkinson’s, dementia, stroke
What metabolic diseases can cause constipation?
DM, hypothyroidism, uremia, hypercalcemia, hypokalemia
Constipation treatments?
Fiber supplements (psyllium, methylcellulose,)
Hyperosmolar agents (sorbitol, lactulose)
Stimulant (glycerin suppository, bisacodyl, senna)
Enema
Opioid antagonists (methylnaltrexone, naloxegol)
What is a fecal impaction?
Mass of compacted feces in large intestine that cannot be evacuated spontaneously
Signs and symptoms of fecal impaction?
Rectal discomfort, abd pain and cramping, bloating, overflow fecal incontinence or paradoxical diarrhea, increased urinary frequency, incontinence, or obstruction
Treatment for fecal impaction?
Manual disimpaction
Enema administration
Osmotic laxatives
Address underlying cause
Celiac disease causing inflammation of the small bowel secondary to ingesting _____.
Gluten containing foods
What foods contain gluten?
Wheat barely, rye, some oats
What patient population is more commonly affected by celiac disease?
Caucasian patients with northern European ancestry, typically between 10 and 40 years old.
Clinical manifestations of celiac disease?
Steatorrhea, flatulence, weight loss, weakness, abd distension, iron deficiency anemia, osteopenia and osteoporosis. FTT is infants and kids
What conditions are associated with celiac disease?
Dermatitis herpetiformis DM 1 Down syndrome Liver disease Menstrual and reproductive issues
Describe the rash produced by dermatitis herpeteformis?
Grouped pruritic papules and vesicles. Common sites are elbows, dorsal forearms, knees, scalp, back, and buttocks
T/F? Patients should be while their diet contains gluten.
True
What is the serologic test done for celiac disease?
Tissue transglutaminase (tTG) IgA antibody
What test is needed to confirm diagnosis of celiac disease?
Small bowel biopsy
What changes are seen on endoscopy in a patient with celiac disease?
Atrophic appearing mucosa with loss of folds Visible fissures Nodularity Scalloping Prominent submucosal vascularity
Treatment for celiac disease?
Gluten free diet
What vaccine should patients with celiac disease receive?
Why?
Pneumococcal vaccine
Celiac disease can cause decreased spleen function
Patients with celiac disease are at higher risk for what conditions?
CV disease and malignancy (Lymphoma and GI cancers most commonly)
What risk factors for colorectal cancer change the screening recommendations?
Hereditary syndromes (familial adenomatous polyposis (FAP) and Lynch syndrome (HNPCC))
IBD
Abdominal radiation
Cystic fibrosis
What patient population is at higher risk for mortality from colorectal cancer?
African Americans, male gender
What conditions increase colorectal cancer risk but do not change the screening recommendations?
Obesity Diabetes Red and processed meat Smoking Alcohol consumption
What is the most common presenting symptom of colorectal cancer?
Change in bowel habits
What sign seen on radiology is associated with colorectal cancer?
Apple core lesion
What is done to diagnose colorectal cancer?
Colonoscopy
What lab is useful in determining effectiveness of treatment for colorectal cancer?
CEA
Treatment for carcinoma in a polyp?
Endoscopic removal as long as margins are clear
Treatment for larger colorectal tumors?
Surgical resections, then chemotherapy OR radiation therapy in rectal cancer)
What age is colonoscopy screening recommended in patients at average risk for CRC?
Age 50 (some say 45 for African Americans)
Patients should have colonoscopies until what age?
75 as long as they are expected to live greater than 10 years.
Give patients 76-85 the option if they want to or not.
What is the screening test of choice for CRC?
Colonoscopy
How often should patients be screened with colonoscopy if they are at average risk?
Every 10 years, unless something is found on colonoscopy.
What other tests can be done for CRC screening, but are not as reliable?
Fecal immunochemical testing CT colonography Sigmoidoscopy + FIT test Sigmoidoscopy alone Guaiac based FOBT Stool DNA testing
How is FIT testing different from FOB testing?
FIT testing screens from hemoglobin, which is specific to lower gi bleeding
FOB testing tests for heme, which can be upper GI
A patient with family history of CRC denies colonoscopy. What is the next best option?
FIT testing annually
A patients brother was diagnosed with CRC at age 58. When should they be have their first colonoscopy? How long between colonoscopies?
How would it change if the relative was diagnosed at age 60?
Age 40 and every 5 years after
If the relative was diagnosed at age 60, it would still start at age 40, but only every 10 years.
A patient has two first degree relatives diagnosed with CRC. One at age 60 and one at age 45. When should they start screening for CRC?
At age 35.
If they have two FDRs with CRC, start screening 10 years before youngest FDR was diagnosed, or age 40, whichever is lower.
When should a patient with Lynch syndrome start CRC screening?
20-25 years old or 2-5 years prior to the earliest age of CRC diagnosis in the family
When should patients with FAP start CRC screening and how often should they be screened?
Age 10-12 and every 1-2 years for classic FAP
Age 25 for attenuated FAP
What should a patient with Peutz-Jeghers syndrome start screening for CRC?
How should they be screened?
Age 8
EGD, video capsule endoscopy, and colonoscopy
When can a patient with 1 FDR with CRC diagnosed after age 50 stop screening?
Age 79
When can a patient with 2 or more FDRs diagnosed with CRC stop screening?
Age 85
What is an anal fissure?
Tear, cut, or crack in the lining of the distal half of the anal canal
Who is most commonly affected by anal fissures?
Infants and middle aged adults
Patients with an anal fissure may present with what symptoms?
Anal pain- worse with defecation
Most common and 2nd most common location for an anal fissure?
Posterior midline
Anterior midline
Treatment for anal fissures?
Fiber, water, and or stool softeners
Sitz bath
Topical analgesics (2% lidocaine)
Topical vasodilators (nifedipine gel, topical nitroglycerin)
What should you do if a patients anal fissure does not heal after two months of treatment?
Endoscopy for Crohn’s eval.
Crohn’s = GI referral
No Crohn’s = Colorectal surgeon referral
What are hemorrhoids?
Swollen veins in the rectum and anus that can lead to discomfort, prolapse, and bleeding
What differentiates external hemorrhoids from internal hemorrhoids?
Proximal to dentate line = internal
Distal to dentate line = external
What type of hemorrhoids are very painful?
Why?
External hemorrhoids - they have somatic innervation that are sensitive to pain
Common symptoms for hemorrhoids?
Rectal bleeding, pruritis or irritation, fecal incontinence, mucus discharge, wet sensation, perianal pain.
Define the grades of hemorrhoids.
Grade I - no prolapse
Grade II - prolapse with defecation, spontaneously reduces
Grade III - prolapse with defecation or other times, needs manual reduction
Grade IV - Permanently prolapsed, visible externally, may strangulate.
Treatment for hemorrhoids?
Increase fiber and water intake. Topical steroids Topical analgesics Warm stiz baths Antispasmodic agents
What grades of hemorrhoids should be referred to a colorectal or general surgeon?
Grade III or IV
or thrombosed hemorrhoids
Rubber band ligation is acceptable treatment for what type of hemorrhoids?
Internal only! External would be super painful due to somatic innervation
What is sclerotherapy?
Who is it used for?
Injection of a solution that destroys the tissue. Used for patients with bleeding risk
What is one other way to treat hemorrhoids?
Infrared coagulation
What is a diverticulum?
A sac like protrusion of the colonic wall
What is diverticulosis?
Presence of diverticula
T/F? You can develop diverticulitis without diverticulosis
False - diverticulitis when diverticulum get infected
Can diverticulosis cause symptoms?
Yes
What is the most common cause of brisk hematochezia?
Diverticular bleeding
What is diverticular colitis?
Inflammation of the interdiverticular mucosa without involvement of the diverticular orifices
What is symptomatic uncomplicated diverticular disease(AKA smoldering diverticulitis)?
Persistent abd pain attributed to diverticula without over colitis or diverticulitis.
Risk factors for diverticulosis?
Increasing age, low fiber and high fat, red meat diet, lack of physical activity, BMI greater than 25, smoking, Meds (NSAIDs, opiates, steroids)
T/F? Nuts, seeds, and corn are associated with increased risk of diverticulosis?
false
What is irritable bowel syndrome?
Functional disorder of the GIT with chronic abd pain and altered bowel habits
IBS more common in women or men?
women
Conditions associated with IBS?
fibromyalgia, chronic fatigue syndrome, depression, anxiety
In IBS, will a fecal calprotectin be high or normal?
Normal
Does IBS present with diarrhea or constipation?
Can be either
Diagnosis for IBS?
Recurrent abd pain on average at least once a week in the past 3 months associated with at least 2 of the following:
Related to defecation
Associated with a change in stool frequency
Associated with a change in stool appearance.
What IBS symptoms should be referred to GI?
More than minimal rectal bleeding Weight loss Unexplained IDA Nocturnal symptoms Concerning FH
Treatment for IBS?
Education and reassurance
Dietary modification (diet low in FODMAPs)
Increased fiber for those with constipation
Anti-diarrheals in those with diarrhea
Antispasmodics for abd pain (dicyclomine, hyoscyamine)
TCAs
Antibiotics are indicated for IBS when?
mod-severe IBS without constipation if failed other treatments
