Download Inflammatory Bowel Disease

Derek Johnson
Bleeding
Diarrhea/GI Infection
Constipation
Diverticular Disease
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Intestinal Ischemia
Cancer
Etiologies
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Diverticular Hemorrhage (33%)
Neoplastic Disease (19%) – usually occult
Colitis (18%)
Angiodysplasia (8%)
Anorectal (4%)
Other – (postpolypectomy, vasculitis, brisk UGIB)
Management
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Assess Severity
Volume Resuscitation
Transfusion
Reverse Coagulopathy
Lab Studies (H/H, PT/PTT, BUN/Creat,)
Nasogastric Tube
Endoscopy
Radiographic Studies (RBC Scan, arteriography)
Clinical Manifestations
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Diarrhea
Tenesmus
BRBPR
Hematochesia
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Treatment Goals
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Replace Lost Fluids
 Oral Rehydration Therapy
 Adults – Sports drinks, water, diluted fruit juice, broth
 Pediatrics – WHO recommends reduced osmolality oral rehydration solution
(Pedialyte, Infalyte, Rehydrolyte, Ceralyte)
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Eradicate the infectious agent
Diagnosis
 History (travel, antibiotic use, possible tainted food, sick contacts, HIV)
 Symptoms (blood in stool, vomiting, abdominal pain)
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Viruses
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Rotavirus – most common cause of viral diarrhea in children
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Similar rates of infection in developed and developing countries
Large volume diarrhea without leukocytes in stool
Fecal-Oral spread; common in daycares
Treatment – supportive only
Immunization (SOR A) – 3 doses; must be completed by 8 Months
Norovirus – leading cause of gastroenteritis in adults in U.S. (90% of outbreaks)
Adenovirus
Astrovirus
CMV
 Suspect in immunosuppressed or HIV
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Bacteria
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Campylobacter
 Tainted poultry and eggs; Most common cause in adults; Erythromycin if CX positive
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Shigella
 Inflammatory diarrhea; Fecal-Oral spread; Bactrim (Peds) Fluoroquinolones (adults)
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Salmonella
 Non-typhoid – self limiting; poultry and pet lizards; begins 6-48 hours after contact
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E coli O157:H7
 Contaminated meat; Shiga toxin; marked Abd pain no fever; HUS; Supportive Care
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Vibrio
 Contaminated Seafood; Doxycycline
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C difficile
 Previous ABX exposure (amoxicillin, clinda, fluoroquinolones; Oral vancomycin or flagyl
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Parasites
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Giardia
 Contaminated water; profuse watery diarrhea; flagyl
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Cryptosporidia
 Contaminated water; usually self limited;
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Cyclospora
 Contaminated produce; Bactrim or cipro
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E histolytica
 Contaminated food/water; liver abscesses; inflammatory, bloody diarrhea; flagyl
NON-INFLAMMATORY
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Disruption of the small intestine
absorption and secretion
Voluminous; Negative FOBT/WBC
Etiologies
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Preformed Toxins
 S Aureus (meats/dairy)
 B cereus (fried rice)
 C perfringens (rewarmed meat)
Viral
 Bacterial
 Parasitic
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INFLAMMATORY
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Colonic invastion
Small Volume; cramping, tenesmus,
fever; Positive FOBT/WBC
Etiologies
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Bacterial
Viral
Parasitic
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Medications
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PPI, Abx, H2 blocker, SSRI, ARB, NSAIDS, chemo, caffeine
Malabsorption
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Whipple’s disease
 Tropheryma whipplei; Tx – PCN + streptomycin, 3rd gen ceph, bactrim
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Small Intestinal Bacterial Overgrowth
 Increased SI bacteria due to ileocecal valve dysfunction/absence
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Pancreatic Insufficiency
 Chronic pancreatitis or pancreatic cancer
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Decreased Bile Acids
 Due to decreased synthesis (cirrhosis) or cholestasis (PBC)
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Celiac disease
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Celiac disease
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Intolerance to the gliadin portion of gluten (wheat protein)
Signs and symptoms
 No typical presentation; Steatorrhea, anemia, failure to thrive, various deficiencies,
bone loss, arthritis, neuropsychiatric disease
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Labs
 CBC, Iron studies, Vit D, folate level
 Confirmatory tests – endomysial ab, IgA anti-tissue transglutaminase Ab, deaminated
gliadin peptide Ab (IgG/IgA)
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Histologic Confirmation – multiple proximal small intestine biopsies showing
flattened jejunal mucosa with villous atrophy
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Osmotic
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Inflammatory
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Lactose Intolerance – dx with hydrogen breath test; avoid lactose or supplement
lactase
Infection
Inflammatory bowel disease
Secretory
Hormonal – VIPoma, carcinoid, medullary thyroid cancer, ZE, glucagonoma
 Laxative abuse
 Neoplasm
 Lymphocytic/Collagenous colitis (associated with NSAIDS)
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Characterized by altered bowel habits and abdominal pain in the
absence of structural abnormality
10-15% prevalence
Due to altered intestinal motility/secretion in response to luminal
stimulation; associated with enhanced pain sensation
Altered bowel habits
Alteration of diarrhea and constipation
 Constipation begins as episodic, becomes constant
 Evacuation feels incomplete
 Worsened with stress
 No nocturnal diarrhea
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Patterns
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Symptoms
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80% diarrhea + constipation + pain
20% painless diarrhea
Abdominal pain – episodic and crampy; does not usually interfere with sleep
Gas and flatulence
UGI symptoms – dyspepsia, heartburn, nausea, vomiting
Diagnosis
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Careful H&P
Labs – CBC, iron studies, OCP, Stool leukocytes
Endoscopy – if older than 40 to rule out cancer
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Treatment
Increase insoluble fiber; soluble fiber (psyllium) is ineffective
 Amitiza (lubiprostone) (SOR B) for constipation predominant; locally acting
chloride channel activator; increases intestinal fluid secretion
 Antispasmotics
 Antidiarrheals
 Antidepressants – TCS (SOR B)
 CBT (SOR B)
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2 or more of the following over the previous 3 months
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Straining, lumpy/hard stools, incomplete evacuation, sensation of obstruction,
manual maneuvers to facilitate defacation, < 3 stools per week
Etiology
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Functional – slow transit, pelvic floor dysfunction, IBS
Meds – Opiates; anticholinergics
Obstruction
Metabolic – DM, hypothyroidism, uremia, pregnancy, porphyria electrolyte
disturbance
Neuro – Parkinson’s, Hirschsprung’s, MS, amyloidosis, spinal injury
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Loss of intestinal peristalsis in absence of mechanical obstruction
Precipitants – surgery, pancreatitis, peritonitis, sepsis, intestinal
ischemia
Dx – Decreased/absent bowel sounds, discomfort, supine & upright
KUB, CT
Treatement
NPO
 Mobilization
 NGT decompression
 Meds - neostigmine (colonic); methylnaltrexone (small bowel)
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600,000 cases in the U.S
Highest rates in Caucasians and Jews
Pathogenesis
No known infectious role
 Some genetic role
 Immune role as mediator for tissue injury
 Disruption of intestinal barrier with changes in gut microbiota
 Acute inflammation without downregulation or tolerance
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Ulcerative Colitis
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Incidence 1/10000; affects males and females equally; affects young adults
Lower incidence in smokers
Clinical features
 Mild to severe at onset
 Aburpt onset
 Rectal bleeding, fever, pain, diarrhea, weight loss
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Pathology
 Confined to mucosa
 Begins in rectum and spreads proximally without skip lesion
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Ulcerative Colitis
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Diagnosis
 Colonoscopy – 95% involve rectum;
shows granular friable mucosa with
diffuse ulceration
 Microscopy – superficial chronic
inflammation; crypt abscesses
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Complications
 Toxic megacolon
 Correlation with colon cancer
 Colonoscopy recommended every 1-2
years begun 8-10 years after onset
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Treatment
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5 ASA Derivatives
 Sulfasalazine
 Mesalamine
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Steroids
 Rectal Hydrocortisone
 Prednisone
 Methylprednisolone
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Immune Modulators
 Infliximab (Remicade)
 Azatthioprine (Imuran)
Surgery
 Probiotics – promote remission
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Crohn’s Disease
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Clinical features
 Incidious onset
 Mild, mucous containing, non-bloody diarrhea
 Abdominal pain, fever, malaise, weight loss
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Pathology
 Full wall thickness
 Any part of the GI tract can be affected
 Small bowel (47%) Terminal ileum most common
 Ileocolonic (21%)
 Colonic (28%)
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Crohn’s Disease
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Diagnosis
 Colonoscopy/Small Bowel Imaging
 Nonfriable mucosa, cobblestoning
 Microscopy shows transmural
inflammation, mononuclear cell
infiltrate, noncaseating granuloma
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Complications
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Perianal disease
Strictures
Fistulas
Abscesses
Malabsorption
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Crohn’s Disease
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Treatment
 Antibiotics – fluoroquinolone/flagyl for perianal disease
 Sulfasalazine
 Steroids
 Infliximab
 Patient Education
 Surgery
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Acute Mesenteric Ischemia
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Clinical Manifestation
 Sudden abdominal pain out of proportion to exam
 Hematochesia
 Positive FOBT
 Intestinal Angina – early satiety, postparandial pain
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Diagnosis
 High level of suspicion
 KUB – thumbprinting
 CTA
 Angiography
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Acute Mesenteric Ischemia
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Etiology/Treatment
 SMA Embolism – 50% have atrial fibrillation; SMA most prone to occlusion; tx with
fibinolytic vs surgical embolectomy
 SMA Thrombosis – clot at site of artery; percutaneous or surgical revasculization
 Venous Thrombosis – hypercoagulable states, malignancy, portal hypertension, IBD,
pancreatitis
 Non-occlusive – transient hypoperfusion (sepsis); remove offending pathology
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Other treatments
 Anticoagulation
 Papaverine – local vasodilator infused by catheter directly in SMA
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Ischemic Colitis
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Nonoccluive disease secondary to changes in systemic circulation often with
unknown etiology; Watershed areas most susceptible (splenic flecture and
rectosigmoid)
Clinical manifestations
 LLQ pain with overtly bloody stool
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Diagnosis
 r/o infectious colitis; consider flex sig if symptoms persist and no etiology identified
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Treatment
 Bowel rest; IVF; broad spectrum Abx; surgery for infarction
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Diverticulosis
Acquired herniation of colonic mucosa and submucosa through the colonic wall
 90% asymptomatic
 Intermittent LLQ pain
 Left Sided (90% mostly sigmoid) except in Asia
 5-15 % develop diverticular hemorrhage
 Treatment – high fiber diet
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Diverticulitis
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Clinical Presentation
 Acute lower Abd pain; possible acute abdomen with peritoneal signs
 Fever
 Tachycardia
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Pathophysiology
 Retention of undigested food > fecalith formation > obstruction > compromise of blood
supply > infection > perforation (abscess, fistula, obstruction)
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Diagnosis
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Lab – CBC, CMP, CRP (>50 with abdominal pain highly suspicious)
Xray – plain films checking for free air
CT - >95% SP & SN
Avoid Endoscopy – Colonoscopy 4-6 weeks following resolution
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Diverticulitis
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Treatment
 Non-severe – Clear liquids with oral Abx (Cipro or flagyl)
 Severe – NPO, NGT, IV fluids, narcotic pain relief, IV Abx
 Ampicillin + Aminoglycoside + flagyl
 Primaxin
 Zosyn
 Surgery – for prolonged symptoms despite proper Rx
 Percutaneous drainage of abscesses >4 cm
 Prevention
 Low fiber diet after acute episode; resume high fiber 6 weeks after resolution of symptoms
 If recurrent consider mesalamine +/- rifaximin
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Small intestinal cancer
Rare
 Most common with Crohn’s disease
 Adenocarcinoma most common
 Diagnosis – CT
 Treatment – Surgical Resection
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Colon Polyps
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Presentation – usually asymptomatic; may bleed; obstruction possible
Diagnosis – endoscopy
Treatment – removal during colonoscopy; if visualized on flex sig reflex to
colonoscopy
Cancer correlation
 <1 cm - <1% chance of malignant conversion
 1-2 cm – 10-20% chance of malignant conversion
 >2cm – 30-50% chance of malignant conversion
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Tubular Adenoma
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Villous Adenoma
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Tubulovillous Adenoma
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Hyperplastic polyp
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Hamartoma
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Inflammatory polyp
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Colon Cancer
2nd most common cause of cancer death
 1/17 lifetime risk
 More common in Western nations
 Up to 25% of patients have positive family history
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 Familial adenomatous poluposis – mutation in APC gene; 100% lifetime risk
 Hereditary nonpolyposis colorectal cancer; mutation in DNA mismatch repair genes;
predominantly right sided tumors
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Equal distribution male/female, Caucasian/African American; higher mortality
rate in African Americans
95% Adenocarcinoma
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Colon Cancer
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Predisposing factors
 Age
 Family HX
 IBD
 Polyposis – FAP, HNPCC, Peutz-Jeugers
 Diabetes
 Cholecystectomy
 Streptococcus bovis endocarditis
 High fat low fiber diet
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Colon Cancer Screening
Start Age 50 or 10 years before sentinel event in family history
 Recommended age 50—75 (average risk)
 Screening rate currently 58.6% (goal is 70%)
 Methodology
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 Colonoscopy – repeat 10 years if negative
 Flexible Sigmoidoscopy – repeat 5 years
 FOBT – yearly
 Double Contrast Barium Enema – 5-10 years
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Repeat colonoscopy
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Colon Cancer Treatment
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Surgical excision – 5 cm margins
Clearing colonoscopy; repeat 3-5 years
Chemo
 5-FU
 Irinotecan
 Oxaliplatin
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Radiation for metastasis
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A 19-year-old man on vacation with his family drinks water from a stream in
Yellowstone National Park. Forty-eight hours later, the patient develops profuse
watery, malodorous diarrhea, severe abdominal cramps, vomiting, and fatigue.
The patient is clinically diagnosed with Giardia lamblia and treated empirically with
metronidazole. The patient improves initially, but over the next 4 weeks, he
develops a more chronic picture of intermittent bloating, gas, and watery diarrhea
after eating and returns for further management. What is the most likely cause of
this patient’s ongoing symptoms?
(A)Chronic Giardia infection
(B)Crohn’s disease
(C)Lactose intolerance
(D)Misdiagnosis with ongoing parasitic infection from a non-Giardiaorganism
(E)Ulcerative colitis
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(C) Lactose intolerance.
This patient’s initial diagnosis ofG. Lamblia infection is likely correct
given his history and clinical presentation. Chronic infection with
Giardia is uncommon, as metronidazole therapy is usually curative.
Lactose intolerance, which can be prolonged, frequently develops
following Giardia infection and has very similar symptoms. Ulcerative
colitis and Crohn’s disease would likely have a more severe symptom
profile and are not associated with
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A 22-year-old man presents to the emergency department with severe abdominal
cramping and bloody stools. He states that he initially had nonbloody diarrhea for
several days. He has mild, diffuse abdominal pain and a low-grade fever. He has
marked leukocytosis and is also found to be in acute renal failure, likely from
dehydration. He is admitted to the intensive care unit where aggressive supportive
therapy is instituted. Studies of stool specimens demonstrate infection with
enterohemorrhagic Escherichia coli0157:H7. Which of the following antibiotics
should be used to treat this organism?
(A)Ceftriaxone
(B)Ciprofloxacin
(C)Levofloxacin
(D)Trimethoprim-sulfamethoxazole
(E)No antibiotic therapy should be instituted
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(E) No antibiotic therapy should be instituted.
The patient is infected with E. coli0157:H7. In general, antibiotic
therapy has not been shown to be helpful in such cases. Antibiotic
therapy does not appear to shorten the clinical course of the infection
and also does not appear to reduce the incidence of hemolytic uremic
syndrome, which can develop in patients with this particular infection.
Thus, treatment of E. Coli 0157:H7 infection is largely supportive.