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SWG GI Exam 2: LG3 Lower GI - Dr. Vasdev (SL)

Terms in this set (82)

A 55 year old woman with a history of constipation sees you for a three day history of left sided abdominal pain. Her stools have become looser and there is blood on the toilet tissue when she wipes. She is urinating more frequently and has some burning. One day ago she started to experience fevers and chills. She has not felt like eating.

On examination she appears uncomfortable. T 101.6, BP 106/82, HR 88. Abdomen is soft but tender in the LLQ. She feels more pain when you abruptly removed your hand. BS are normal. There are no bruits.

Labs: a WC of 16000/μL, neutrophils 84%, Hb 11.7, platelets normal. Chemistry profile including LFT's is normal. UA- WC present but gram stain negative

Ddx?
Dx: Diverticulitis

Ddx to include: Ischemic colitis
What is diverticular disease? What are the subcategories?
A blind pouch protruding from the GI tract. Includes diverticulosis and diverticulitis (when the diverticulum is inflamed)
How common is diverticular disease and what is prevalence correlated with?
It is extremely common and generally age dependent. Increases from less than 5 percent at age 40, to 30 percent by age 60, to 65 percent by age 85.
What is diverticulosis?
Acquired condition resulting from herniation of the GI mucosa through defects in the muscle coat. These are usually false diverticulum.
What is the cause of diverticulosis?
Caused by increased intraluminal pressure and focal weakness in colonic walls. Associated with low fiber diets.
Where does diverticulosis generally occur? $
Sigmoid colon
How is diverticulosis usually diagnosed?
Incidental finding usually on CT, barium enema, or colonoscopy.
What are some common symptoms of diverticulosis?
Often asymptomatic or associated with vague discomfort. Patient can complain of cramping, bloating, flatulence, and irregular defecation.

Complications include diverticulitis and diverticular bleeding. A common cause of hematochezia.
What is diverticulitis? What are the types?
Inflammation of a diverticula.

Simple or uncomplicated diverticulitis includes just inflammation.

Complicated diverticulitis includes abscess formation, fistulas, obstruction, and/or perforation.
What is the most common complaint in patients with diverticulitis? What are other symptoms? $
LLQ pain is most common. Also fever and leukocytosis.
What is the diagnostic test of choice for diverticulitis? Be specific. $$$
CT scan of the abdomen ANDDDD pelvis w/ or w/o contrast is the diagnostic test

You want to include a pelvis CT because the sigmoid colon (where most diverticulosis occurs) runs lower than most abd scans can screen
What is the treatment for uncomplicated diverticulitis?
Bowel rest, Antibiotics for Gram - (Cipro, quinolones w/ metronidazole). Slow progression in diet from liquids.
What is the treatment for complicated diverticulitis? $
Treatment of choice is surgical removal of affected segment. Can also do percutaneous drainage + broad spectrum antibiotics.
When is surgery advised for diverticulitis? When is the best time for surgery?
2+ attacks of uncomplicated diverticulitis in past 12m
(or)
1 attack of complicated diverticulitis in past month

Best time to treat is when the diverticulum is not actively inflamed. During an acute case, best thing is to divert w/ colostomy and only do surgery when it settles down.
What can patients do to prevent future attacks of diverticulitis? $$
Fiber + lots of water
Also come back for colonoscopy after recovery.
What are the main differentials for left sided abd pain with fever? $$$
Diverticulitis
Ischemic colitis

Dr. Vasdev: Please remember that ischemic colitis mimics acute diverticulitis
What is ischemic colitis? Where do they generally occur?
Reduction in intestinal blood flow that causes ischemia. Due to alterations in systemic circulation and impaired blood supply.
Where does ischemic colitis generally occur?
Occurs at watershed areas. Most commonly at the splenic flexure (Griffith's point) and the rectosigmoid junction (Sudek's point).
What can ischemic colitis mimic? Why? $$$
Inflammatory bowel disease w/ crypt abscesses. Perhaps also because pain can begin after eating and can also result in weight loss.
What is the treatment for ischemic colitis?
Broad spectrum antibiotics + treat underlying abnormalities (cardiac failure etc.).
A 68 year old man presents with progressive abdominal pain, generalized initially and subsequently more in the LLQ for three months. He notes that he is more constipated, and the stools are thinner. On several occasions he saw blood streaking the side of his stool. He has been losing weight.Three weeks ago he noted his urine was dark and he felt bloated. One week ago his wife told him he looked 'pale and yellow'. He volunteered decreased appetite and his clothes felt baggy.

On examination he appears gaunt and pale. There is visible pallor. Temp 98.1 BP 120/84 HR 78. Abdomen is soft with mild diffuse tenderness without peritoneal signs. Rectal exam reveals no masses but the stool is Guaiac positive.

Labs: WC 7,200/μL, Hb 9.7, platelets 233,000/μL, AST 2x's normal, ALT 2x's normal, Alk P 380, albumin 2.8, bilirubin 4.6

Dx?
Colon CA that has metastasized (hence, jaundice)
- Also bc of cachexia and anemia
How common is colon CA? What are some risk factors?
3rd most common CA. 90% of cases in 50yo+, slight male predominance, African Americans. Runs in families.

Other risk factors: IBD, primary sclerosing cholangitis, obesity, EtOH, smoking, DM
What is the most important risk factor for colorectal CA? $
Family history is crucial. Just one 1st degree relative increases risk almost 3x. If two, goes up 4x.
What is the one condition that 100% guarantees colorectal CA? What is the pathophysiology? $$$
Familial adenomatous polyposis (1-2% of CRC). APC mutation on chrom 5.

NB: Other genetic conditions that inc. risk for colorectal CA include FAP & HNPCC
What is familial adenomatous polyposis?
An AD mutation of the APC tumor supressor gene on chrom 5q that results in thousands of polyps after puberty.
What is the pathophysiology of HNPCC? What does it increase the risk for? $$$
HNPCC = hereditary nonpolyposis colorectal cancer (now called Lynch syndrome).

AD mutation of DNA mismatch repair genes w/ subsequent microsatellite instability (MSH2, MLH1, MSH6)

Increases risk for colorectal CA (80%) as well as extracolonic neoplams (endometrium, stomach, bile ducts, urinary tract, ovary)
What is the Amsterdam criteria to dx Lynch syndrome?
HNPCC Amsterdam II Criteria
3-2-1 rule: 3 relatives with Lynch syndrome, cancers across 2 generations, 1 of whom must be dx by 50yo
What do the entire efforts behind colorectal CA prevention revolve around? $$
The identification and removal of colon polyps which are precursors of colon cancer. Generally adenomatous (90% of colorectal CA)
What is the most important molecular pathway in the development of colorectal CA? $$
Adenoma-Carcinoma Sequence (APC/β-catenin)

Normal → Loss of APC gene → K-ras mutation → p53 deletion → carcinoma
What is the presentation of colorectal CA? How is the survival rate?
Can be asymptomatic and incidental. Usually change in bowel habits, weight loss, rectal bleeding. Pain usually implies more advanced cancers.

Survival rate up to 90% when cancer caught at stage 1. Goes down significantly to 60%, 50%, and ~10% in respective subsequent stages.
What is the presentation of colon polyps?
None.

They only really show up with colonoscopies.
What is the test of choice for screening colorectal CA?
Colonoscopy

Also flexible sigmoidoscopy, stool occult blood test. New test includes Cologuard (picking up abnormal genes via stool).
What are the screening guidelines for colorectal CA? $$$
If personal hx of colon polyps, start screening 10y below age of youngest affected relative $$$

Otherwise, start screening at 50yo. Also test for HNPCC.
A 28 year old graduate student is seen for a two month history or diarrhea. It began initially after a trip to Kenya on a mission, but then seemed to get better, only to recur one month ago. He describes six to eight loose loose bowel movements which appeared mushy and gelatinous. He described them as 'strawberry jam'-like. He states to experience urgency but only gas would come out, and he felt that he never quite emptied his rectum. He became fatigued and developed abdominal cramps that at times would be relieved by a BM.

On exam T 99, BP 110/78, HR 70
Abdomen: diffusively tender, more so on the left side.
Rectal: mucus, blood tinged stool, some tenderness, no masses
Labs: WC 14000/μL, Hb 11, platelets 300, Alk phosphates 420, normal AST, ALT, bilirubin

Ddx?
Bacterial/viral food borne infection
Chronic Ulcerative Colitis (the infection may have revealed this)
What is chronic ulcerative colitis? What antibody is generally present in this condition? $
An immune mediated inflammation of the colon consisting of colonic lesions. 60-85% have the autoantibody P-ANCA.

Also associated with other autoimmune disorders - thyroid, DM, pernicious anemia
Where does chronic ulcerative colitis occur?
Most are continuous lesions from the anus to the rectosigmoid region

40% rectosigmoid
40% extension beyond rectosigmoid
20% pancolitis
What is an important radiological finding of chronic ulcerative colitis? $$
Loss of haustral folds in the sigmoid region leading to a "lead-pipe" appearance

Barium study
What immune cells will be seen in chronic ulcerative colitis? $
Lymphocytes (w/o granulomas)
What is the presentation of chronic ulcerative colitis? $
Diarrhea, rectal bleeding, mucus passage, abd pain, tenesmus (feeling like bowel is never truly emptied), fatigue, prior infectious diarrhea
What are some other important differentials for chronic ulcerative colitis?
See chart

Distinguishing factors:
1) Crohn - less bleeding, presence of perianal lesions
2) Collagenous colitis - older women w/o rectal bleeding
What are some extraintestinal manifestations of chronic ulcerative colitis? $
Liver
- Primary sclerosing cholangitis (5%) $

Anemia & Thromboembolism $

Skin
- Drug rashes (5-10%)
- Erythema Nodosum (2-4%)
- Pyoderma Gangrenosum (1%)

Mouth
- Aphthous ulcers (10%)
- Angular Stomatitis (iron deficiency) (cracking around lips)

Eyes
- Episcleritis/Uveitis (5%)

Joints
- Acute arthropathy, asymmetric, large (5-10%)
- Sacroilitis (12%)
- Ankylosis Spondylitis (HLA B27) (2%)

Pericarditis (rare)
What are some treatments for chronic ulcerative colitis?
Hydrocortisone suppositories (localized)
Aminosalicylates - sulfasalazine, asocol, lialda
Immune modulators - 6-mercap, methotrexate
Biologics (TNF inhibitors)
Diet and nutrition
Surgery
What are some possible complications of chronic ulcerative colitis?
Hemorrhages
Perforation
Acute dilation (toxic megacolon)
Strictures
Pseudopolyps
Colorectal cancer

Perianal
- Fissures
- Perianal abscess
Complications of perianal fissures and abscesses are more common in which case? $$$

A) Chronic ulcerative collitis
B) Crohn disease
Perianal fissures and abscesses are more common in:

B) Crohn Disease

Know this!
What surgical treatment is an option for chronic ulcerative colitis and when is it indicated?
Total colectomy and ileoanal pullthrough
- Indicated only if patient is refractory to medications or develop toxic megacolon
What is Crohn Disease? What antibody is generally present in this condition? $
Uncertain etiology, likely autoimmune condition of the GI tract. Associated with ASCA (anti-Saccharomyesis cervisaiae antibody). 15x more likely w/ 1st degree relative.
What GI conditions are the following antibodies present?

1) ASCA
2) P-ANCA

$
1) ASCA - Crohn disease
2) P-ANCA - Ulcerative colitis
What other GI condition does Crohn disease mimic? What is the typical presentation of Crohn disease? $
Crohn disease mimics appendicitis (acute RLQ pain)

Presentation: Abd pain, abscess, obstruction, loose stools, fever, malaise, nausea, bloating, weight loss, perianal disease
Where does Crohn disease generally occur in the GI tract?
Can occur anywhere but generally the terminal ileum and colon. These are non-continuous lesions and the rectum is spared unlike UC.
What kind of inflammation does Crohn disease present with? $

Image warning
Transmural inflammation (as opposed to UC which is more superficial).

It is more likely to fistulate and develop perianal abscesses.
What are other findings of Crohn disease?
Cobblestoning
Non-caseating granulomas
Apthous ulcers
Fibrosis and strictures
What are some extraarticular manifestations of Crohn disease?
Pauciarticular arthropathy
Polyarticular arthropathy
Ankylosis Spondylitis
Sacroileitis
Erythema nodosum
Uveitis/scleritis
Gallstones
Kidney stones (oxalic/uric acid)
Prothrombotic activity
What are some treatment options for Crohn disease?
Amino salicylates for colonic involvement
Antibiotics
Glucocorticoids (Prednisone, Budesonide)
Immune modulators
Biologics
Surgery
How is the treatment for Crohn disease different from Ulcerative colitis?
$$
Unlike UC,

1) There is evidence that show antibiotics can be useful in CD
2) Surgery is not curative in CD (it can come back)

$$
What GI condition do 25% of patients with celiac disease end up with?

$$
Microscopic Colitis
What is the typical presentation of Microscopic Colitis?

$$
Chronic watery diarrhea $$

- No endoscopic or radiologic findings
- Chronic mucosal inflammation on biopsy

Subtypes:
- Lymphocytic colitis
- Collagenous colitis
What are some treatments for microscopic colitis?
Antidiarrheals
Psyllium
Bismuth
Bile acid binders
Budesonide
Aminosalicylates
Glucocorticoids
Immune modulators
AntiTNF Agents
Surgery
What increases the risk of Clostridium difficile infection? Presentation & Tx?
Antibiotic use (Clindamycin historically but any can cause it, also IBD)

Pseudomembrane formation, fecal leukocytes, increased white count

Tx: Discontinue antibiotics, supportive measures, (Vanco, Rifampicin can be used), fecal transplants
A 35 year old woman comes to you for abdominal pain, bloating, and generalized cramping in her abdomen. She has 'always been constipated' but now she has urgent explosive diarrhea every six to eight days, sometimes being unable to reach the bathroom. She denies rectal bleeding, anorexia, or weight loss. She states that she has gains 30 lbs since having her first and only child 10 months earlier. She denies fever, nausea, and vomiting.

On exam— appears tired. T 99, BP 110/74, HR 62 ,Wt 285 lbs, CBC and CMP entirely normal.

Dx?
Irritable Bowel Syndrome (IBS)

Likely not UC because no alarm signs: no bleeding, no weight loss

Ask about travel hx too in case to rule out infectious causes
What is Irritable Bowel Syndrome and what is the etiology? How common is it?
A functional bowel disorder w/ recurrent Abd pain thought to be due to a disturbance of the autonomic and enteric nervous systems of the gut.

Results in abnormal motility and visceral hypersensitivity.

This is also a very common condition
What are the classic symptoms of Irritable Bowel Syndrome (IBS)? Any diagnostic tests?

$
Abdominal pain, Diarrhea AND Constipation.

Diagnostic tests have not been effective for IBS. A few guidelines:
- Pus is an indicator of anything but IBS
- Check for celiac disease
- CBC and CMP usually normal
What is the Rome III diagnostic criteria for Irritable Bowel Syndrome?

$$$$$
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months (with symptom onset at least 6 months prior) associated with 2 or more of the following:

1) Improvement with defecation
2) Change in frequency of stool
3) Change in form (appearance) of stool

Know this!
What are some alarm symptoms in IBS? Ddx?
Rectal bleeding, weight loss, nocturnal wakings, etc.

Ddx: UC, CD, MC
What is the treatment for IBS?

$
Most important component of the treatment is in the physician-patient relationship: need to be empathetic with patient and educate patient of the proposed mechanisms.

Also take a careful dietary hx

FODMAP diet is trendy but not really that useful (unless you really enjoy steak and potatoes jk). Fiber and water can help.
What are some associated symptoms of constipation?
Abd: bloating, cramping
Constitutional: Nausea, malaise, dysgeusia, headache
What is celiac disease? What immune factors is it associated with? $
A GI malabsorption syndrome due to the autoimmune-mediated intolerance of gliadin (gluten protein) resulting in steatorrhea.

Associated with HLA-DQ2 & HLA-DQ8
What pathological finding will you make with Celiac disease?

$$$
Intraepithelial lymphocyte inflammation w/ villous atrophy
What are some clinical signs of celiac disease? Tx?
Kids: cramping pain, steatorrhea, FTT, irritability, muscle wasting, short stature

Adult: diarrhea, flatulence, bloating, nausea, weight loss

Check for IGA, TTG antiboies

FA: Associated with northern European descent, dermatitis herpetiformis, decreased bone density

Tx: Gluten free diet
A 50 year old man with celiac disease has been on a gluten-free diet since diagnosis a year ago. He now presents with increasing flatulence and diarrhea.

What are your thoughts?
Lymphoma & carcinoma
An eighty five year old man is seen for progressive shortness of breath when he climbs the stairs to his bedroom. His wife states that he has to stop half way. She states that he 'sleeps all the time'. He denies chest pain but sometimes feels his heart pounding. He wife states that he is 'always eating ice'. He denies abdominal pain, nausea, vomiting, weight loss, change in bowels, blood in stools. His medical history is significant for atrial fibrillation, 2VCABG, radical prostatectomy, and arthritis. His medication list includes coumadin.

On examination - T 98.4, BP 110/50, HR 62. 2/6 SEM. Lungs clear. Abdomen unremarkable. Rectal - brown hemoccult positive stool.

Labs: Hb 9.4 g/dL, MCV 66, platelets normal, INR 2.1, CMP normal. Iron levels and serum ferritin diminished. Colonoscopy shows several small red arterial 'blisters with spider leg appearance'. in the cecum and rectum.

Dx?
Angiodysplasia
What is angiodysplasia?
Also known as arteriovenous malformation (AVM), it is the most common vascular abnormality of the GI tract. Results in tortuous dilation of vessels.
What is the presentation for angiodysplasia? Where is it found and how do you dx it?
Hematochezia. Most found in cecum, terminal ileum, ascending colon of older adults. Dx w/ angiography.
What is the treatment for angiodysplasia?
If not bleeding, leave alone

Endoscopic treatment:
- Epinephrine
- Cautery
- Clipping
- Argon plasma coagulation
Switch to definition mode
Diverticulitis

CT scan of Abd AND pelvis

w/o abscess, fistula, perforation: Antibiotics, bowel rest

w/ abscess, fistulas, perforation: surgical removal of segment, percutaneous drainage, broad spectrum antibiotics
LLQ abd pain, fever, leukocytosis. Hx of hematochezia.

Dx?
Best diagnostic test?
Tx?
Ischemic colitis

Broad spectrum antibiotics, treat underlying abnormalities
LLQ abd pain, fever, pain after eating, weight loss, elderly.

Dx?
Tx?
Colon CA

Colonoscopy, barium enema "Apple core lesion"
Abd pain, anemia, weight loss, hematochezia, change in bowel habits.

Dx?
Best diagnostic test?
Ulcerative colitis
p-ANCA

image shows primary sclerosing cholangitis
Diarrhea, rectal bleeding, mucus, abd pain, tenesmus, fatigue.

Dx?
Markers?
Crohn disease

ASCA
RLQ abd pain, loose stools, fever, malaise, nausea, bloating, weight loss, perianal fissures & abscesses

Dx?
Markers?
Appendicitis
RLQ abd pain, fever, abscess.

Dx?
IBS only if >2 of following Rome III criteria:

1) Improvement with defecation
2) Change in frequency of stool
3) Change in form (appearance) of stool
Abd pain, diarrhea, constipation.

Dx?
Celiac disease

Image shows dermatitis herpetiformis
Diarrhea, flatulence, bloating, nausea, weight loss, worse after eating sandwiches.

Dx?
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