Transcript disorders of the intestine

Disorders of the Intestines
Victor Politi, M.D., FACP
Medical Director, SVCMC School of Allied Health
Physician Assistant Program
Anatomy
• The intestine is the portion of the alimentary canal
extending from the stomach to the anus.
• It consists of two segments, the small intestine and the
large intestine (or colon) .
• The small intestine is further subdivided into the
duodenum,jejunum, and ileum.
• The large intestine is subdivided into the cecum, colon and
rectum.
Structure and function
• The intestine shares a general structure with the
whole gut and is composed of several layers.
• The lumen is the cavity where digested material
passes through and from where nutrients are
absorbed.
• Along the whole length of the gut in the glandular
epithelium are goblet cells
– These secrete mucus which lubricates the passage of
food along and protects it from digestive enzymes.
Structure and function
• The next layer is the muscualris mucosa
which is a layer of smooth muscle that aids
in the action of continued peristalsis along
the gut.
• The submucosa contains nerves, blood
vessels and elastic fiber with collagen that
stretches with increased capacity but
maintains the shape of the intestine.
Structure and function
• Surrounding this is the muscularis externa
which is comprised of longitudinal and
smooth muscle that again helps with
continued peristalsis and the movement of
digested material out of and along the gut.
Structure and function
• Lastly, there is the serosa which is made up of
loose connective tissue and coated in mucus so as
to prevent friction damage from the intestine
rubbing against other tissue.
• Holding all this in place are the mesenteries which
suspend the intestine in the abdominal cavity and
stop it being disturbed when a person is physically
active.
Structure and function
• The large intestine hosts several kinds of bacteria that deal
with molecules the human body is not able to breakdown
itself. This is an example of symbiosis.
• These bacteria also account for the production of gases
inside our intestine (this gas is released as flatulence when
removed through the anus).
• However the large intestine is mainly concerned with the
absorption of water from digested material (which is
regulated by the hypothalamus), as well as any nutrients
that may have escaped primary digestion in the Ileum.
Common Intestinal Disorders
• Common intestinal disorders such as
diarrhea, constipation and flatulence affect
most people at some point in their lives.
• Flatulence does not usually indicate a
problem with the intestines, and is usually a
normal side effect of the digestive process.
Common Intestinal Disorders
• Constipation often can be traced to a lack of
fiber in the diet.
• Severe constipation can cause rectal tears
and intestinal blockages.
Common Intestinal Disorders
• Diarrhea is not an intestinal disorder, but
rather a symptom of intestinal disorders.
Depending on the cause, diarrhea may be
short-term and self-resolving, or a chronic
intestinal condition requiring medical care.
Diarrhea
• Characterized byfrequent watery, loose bowel movements.
• This condition can occur as a symptom, disease, allergy,
food intolerance, foodborne illness and/or extreme
excesses of Vitamin C and/or magnesium and may be
accompanied by abdominal pain, nausea and vomiting.
• Diarrhea occurs when insufficient fluid is absorbed by the
colon.
• Malabsorption as a result of bariatric surgery
Diarrhea
• Diarrhea is most commonly caused by viral
infections or bacterial toxins.
• Diarrhea can also be a symptom of more serious
diseases, such as dysentery, cholera, or botulism,
and can also be indicative of a chronic syndrome
such as Crohn’s disease.
• Though appendicitis patients do not generally
have diarrhea, it is a common symptom of a
ruptured appendix.
Diarrhea
• Diarrhea can also be caused by dairy intake
in those who are lactose intolerant.
• Symptomatic treatment for diarrhea
involves the patient consuming adequate
amounts of water to replace that loss,
preferably mixed with electrolytes to
provide essential salts and some amount of
nutrients.
Acute Diarrhea
• Defined as diarrhea that lasts less than 4 weeks,
and is also called enteritis. Can nearly always be
presumed to be infective, although only in a
minority of cases is this formally proven.
• The most common organisms found are
Campylobacter, Salmonella , Cryptosporidium,
and Giardia lamblia.
Acute Diarrhea
• Toxins and food poisoning can cause
diarrhea. These include staphylococcal
toxin and Bacillus cereus.
• Often "food poisoning" is really Salmonella
infection.
• Diarrhea can also be caused by ingesting
foods that contain indigestible material, for
instance, escolar and olestra.
Chronic diarrhea
• Chronic diarrhea may be due to:
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infective diarrhea
Malabsorption
IBS
IBD
Surgery I.e. Ileal resection/post gastrectomy
Intestinal resection or bypass
Whipple’s Disease-Tropheryma whipplei
Chronic Diarrhea
• Other possible causes of chronic diarrhea
– Some (but not all) bowel cancers may have associated
diarrhea. Cancer of the large colon is most common.
– Hormone-secreting tumors: some hormones (e.g.
serotonin) can cause diarrhea if excreted in excess
(usually from a tumor).
– Bile salt diarrhea: excess bile salt entering the colon
rather than being absorbed at the end of the small
intestine can cause diarrhea, typically shortly after
eating. Bile salt diarrhea is a possible side-effect of
gallballder removal. It is usually treated with
cholestyramine, a bile acid sequestrant.
Lactose intolerance
• Lactose intolerance is an inability to digest
lactose, a sugar found in dairy products.
• Lactose intolerance affects the intestines by
causing intestinal gas, cramping, and
diarrhea
Intestinal Parasites
• Intestinal parasites include roundworms
and tape worms, which can grow to great
lengths in the intestines.
Intestinal Parasites
• E. vermicularis, commonly referred to as
the pinworm or seatworm, is a nematode, or
roundworm.
• It is the most prevalent nematode in the
United States.
• Humans are the only known host.
Intestinal Parasites
• The worms live primarily in the cecum of the large
intestine, from which the gravid female migrates
at night to lay up to 15,000 eggs on the perineum.
• The eggs can be spread by the fecal-oral route to
the original host and new hosts.
• Disease secondary to E. vermicularis is relatively
innocuous, with egg deposition causing perineal,
perianal, and vaginal irritation.
Intestinal Parasites
• In the absence of host autoinfection,
infestation usually lasts only four to six
weeks.
• Pinworm infection should be suspected in
children who exhibit perianal pruritus and
nocturnal restlessness.
Intestinal Parasites
• G. lamblia is a pear-shaped, flagellated
protozoan that causes a wide variety of
gastrointestinal complaints.
• Giardia is the most common parasite
infection of humans worldwide, and the
second most common in the United States
after pinworm.
Intestinal Parasites
• Giardiasis is spread by fecal-oral
contamination.
• The prevalence is higher in populations
with poor sanitation, close contact, and oralanal sexual practices.
Intestinal Parasites
• The disease is commonly water-borne because
Giardia is resistant to the chlorine levels in normal
tap water and survives well in cold mountain
streams.
• Because giardiasis frequently infects persons who
spend a lot of time camping, backpacking, or
hunting, it has gained the nicknames of
"backpacker's diarrhea" and "beaver fever.”
Intestinal Parasites
• Giardia growth in the small intestine is
stimulated by bile, carbohydrates, and low
oxygen tension.
• It can cause dyspepsia, malabsorption, and
diarrhea.
Intestinal Parasites
• Clinical presentations of giardiasis vary
greatly.
• After an incubation period of one to two
weeks, symptoms of gastrointestinal distress
may develop, including nausea, vomiting,
malaise, flatulence, cramping, diarrhea,
steatorrhea, and weight loss.
Intestinal Parasites
• A history of gradual onset of a mild diarrhea
helps differentiate giardiasis or other
parasite infections from bacterial etiologies.
• Symptoms lasting two to four weeks and
significant weight loss are key findings that
indicate giardiasis.
Intestinal Parasites
• Rarely, patients with giardiasis also present
with reactive arthritis or asymmetric
synovitis, usually of the lower extremities.
• Rashes and urticaria may be present as part
of a hypersensitivity reaction.
Gastroenteritis
• Gastroenteritis involves diarrhea or vomiting,
with non-inflammatory infection of the upper
small bowel, or inflammatory infection of the
colon, both part of the GI tract.
• Usually caused by an infection, acute in onset,
normally lasting less than 10 days and selflimiting.
• It is often called the stomach flu or gastric flu
even though it is not related to influenza.
Gastroenteritis
• Viral gastroenteritis is an intestinal infection
caused by several different viruses.
• Highly contagious, viral gastroenteritis is
the second most common illness in the
United States.
• It causes millions of cases of diarrhea each
year.
Gastroenteritis
• The main symptoms of viral gastroenteritis
are watery diarrhea and vomiting.
• Other symptoms are headache, fever, chills,
and abdominal pain.
• Symptoms usually appear within 4 to 48
hours after exposure to the virus and last for
1 to 2 days, though symptoms can last as
long as 10 days.
Gastroenteritis
• The viruses that cause viral gastroenteritis
damage the cells in the lining of the small
intestine.
• As a result, fluids leak from the cells into
the intestine and produce watery diarrhea.
Gastroenteritis
• Four types of viruses cause most viral
gastroenteritis:
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Rotavirus
Adenovirus
Caliciviruses
Astrovirus
Diverticular disease
• Can affect both the large and small
intestines, although the disease is more
common in the large intestine.
• Diverticular disease occurs when pouches
develop in the intestinal wall.
• Diverticular Disease will be covered in
detail in another lecture.
Appendicitis
• Appendicitis, or epityphlitis, is a condition
characterized by inflammation of the appendix.
• While mild cases may resolve without treatment,
most require removal of the inflamed appendix,
either by laparatomy or laparoscopy.
• Untreated, mortality is high, mainly due to
peritonitis and shock.
Appendicitis
• Appendicitis can be classified into two types,
typical and atypical.
• The pain of typical acute appendicitis usually
starts centrally (periumbilical) before localizing to
the right iliac fossa (the lower right side of the
abdomen). There is usually associated loss of
appetite (anorexia) and fever, nausea or vomiting
may or may not occur.
Appendicitis
• Rebound tenderness may be present
suggesting that there is some element of
peritoneal irritation.
• If the abdomen is involuntarily guarded,
there should be a strong suspicion of
peritonitis requiring urgent surgical
intervention.
Appendicitis
• Diagnosis is based on history and physical
examination backed by an elevation of
neutrophilic white cells, and other infection
markers on blood testing and imaging.
Appendicitis
• The classical history in appendicitis is diffuse pain in the periumbilical
region which then localizes as pain and tenderness at McBurney’s
point (associated with an inflamed appendix coming in contact with
the surrounding parietal peritoneum.
• This point is located on the right-hand side of the abdomen one-third
of the distance between the anterior superior iliac spine and the naval.
• Here, on gentle palpation, the abdominal muscles often feel firm to
rigid because of involuntary spasm, and a cough also produces a
localized soreness.
Appendicitis
• Other physical findings include right-side
tenderness on a digital rectal exam.
• Since the appendix normally lies on the
right, if a finger is inserted into the rectum
and there is tenderness when pressure is
applied toward the right
Appendicitis
• Other signs used in the diagnosis of
appendicitis are the psoas sign (useful in
retrocecal appendicitis), the obturator sign
(specifically the obturator internus muscle),
Blumberg’s sign and Rovsing’s sign.
• The psoas sign. Pain on passive extension
of the right thigh. Patient lies on left side.
Examiner extends patient's right thigh while
applying counter resistance to the right hip
(asterisk).
• The obturator sign. Pain on passive internal
rotation of the flexed thigh. Examiner
moves lower leg laterally while applying
resistance to the lateral side of the knee
(asterisk) resulting in internal rotation of the
femur.
Appendicitis
• Ultrasound and doppler provide useful means to
detect appendicitis, especially in children.
• CT has become the diagnostic test of choice,
especially in adults.
• Signs of appendicitis on CT scan include lack of
contrast (oral dye) in the appendix and direct
visualization of appendiceal enlargement (greater
than 6 mm in diameter on cross section).
Appendicitis
• The inflammation caused by appendicitis in the
surrounding peritoneal fat (so called "fat
stranding") can also be observed on CT, providing
a mechanism to detect early appendicitis and a
clue that appendicitis may be present even when
the appendix is not well seen.
• Thus, diagnosis of appendicitis by CT is made
more difficult in very thin patients and in children,
both of whom tend to lack significant fat within
the abdomen.
CT scan showing cross-section of
inflamed appendix (A) with
appendicolith (a).
CTscan showing enlarged and
inflamed appendix (A) extending
from the cecum (C).
celiac disease
• celiac disease is an immune system disorder that
targets the small intestine.
• The immune system mistakes gluten (a protein
found in wheat, rye, barley and oats) as a threat
and responds by causing inflammation in the small
intestine.
• It occurs in genetically predisposed individuals in
all age groups after early infancy.
• Symptoms may include diarrhea, failure to thrive
in children.
celiac disease
• Children between 9 and 24 months tend to present
with bowel symptoms and growth problems
shortly after first exposure to gluten-containing
products.
• Older children may have more malabsorptionrelated problems and psychosocial problems,
while adults generally have malabsorptive
problems.
• Many adults with subtle disease only have fatigue
or anemia
Colitis
• Colitis is a digestive disease characterized
by inflammation of the colon.
• There are several types of colitis, including
ulcerative colitis, Crohn’s colitis, diversion
colitis, ischemic colitis, infectious colitis,
chemical colitis, microscopic colitis and
atypical colitis.
Pseudomembranous colitis
• Pseudomembranous colitis is a
complication of antibiotic therapy that
causes severe inflammation in areas of the
colon (large intestine).
• The bacterium Clostridium difficile, which
is normally present in the intestine, may
overgrow when antibiotics are taken.
Pseudomembranous colitis
• The bacteria release a powerful toxin that
causes the symptoms.
• The lining of the colon becomes raw and
bleeds.
• In addition to antibiotic use, chemotherapy,
advanced age, recent surgery, and history of
previous pseudomembranous colitis are risk
factors for this condition.
Pseudomembranous colitis
• Ampicillin, clindamycin, and cephalosporins are
the most common antibiotics associated with this
disease in children.
• Pseudomembranous colitis is rare in infants less
than 12 months old because they have protective
antibodies from the mother and because the
toxin does not cause disease in most infants.
Pseudomembranous colitis
• Either or both of the following tests will
confirm the disorder:
• An immunoassay for C. difficile toxin
• A colonscopy or flexible sigmoidoscopy
showing pseudomembranous colitis (a
characteristic appearance of the colon)
C. difficile toxin
Pseudomembranous colitis
• The antibiotic causing the condition should
be stopped. Metronidazole is usually used to
treat the disorder, but vancomycin or
rifaximin may also be used.
Pseudomembranous colitis
• Symptoms:
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Watery diarrhea
Urge to defecate
Abdominal cramps
Low-grade fever
Bloody stools
Colitis
• Any colitis which has a rapid downhill clinical
course is known as fulminant colitis.
• In addition to the diarrhea, fever, and anemia seen
in colitis, the patient has severe abdominal pain
and a clinical picture similar to septicemia with
shock is present.
• Approximately half of those patients require
surgery.
Signs & Symptoms of Colitis
• Include pain, tenderness in the abdomen, fever,
swelling of the colon tissue, bleeding, erythema of
the surface of the colon, rectal bleeding, and
ulcerations of the colon.
• Tests that show these signs are plain X-rays of the
colon, testing the stool for blood and pus,
sigmoidoscopy and colonoscopy.
• Additional tests include stool cultures and blood
tests,and blood chemistry tests.
Colitis Tx
• Treatment of colitis may include; antibiotics
and general anti-inflammatory medications
such as Mesalamine or its derivatives;
steroids, or one of a number of other drugs
that ameliorate inflammation.
• Surgery is sometimes needed, especially in
cases of fulminant colitis.
IBD- Inflammatory Bowel
Disease
IBD- inflammatory Bowel
Disease
• IBD is term used to describe two disease
processes
– Crohn’s disease
• chronic, recurrent disease, patchy transmural
inflammation involving any segment of the GI tract
from the mouth to the anus
• Ulerative Colitis
• chronic, recurrent disease - diffuse mucosal
inflammation of the colon
IBD
• While Crohn's can affect the entire
gastrointestinal tract, ulcerative colitis is
limited to the large intestine.
• Crohn's disease is widely regarded as an
autoimmune disease.
• Although ulcerative colitis is often treated
as though it were an autoimmune disease,
there is no consensus that it actually is such.
Anatomic distribution of Crohn’s
disease and ulcerative colitis
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IBD
• The same pharmacologic agents are used to
treat both Crohn’s disease and ulcerative
colitis.
• Mainstay of therapy – 5-aminosalicylic acid derivatives
– corticosteroids
– mercaptopurine or azathioprine
IBD- TX
• 5-ASA (5-Aminosalicylic Acid)
– used in active tx and during disease inactivity to
retain remission
– anti-inflammatory effect
– oral compounds
• Sulfasalazine
• oral mesalamine - Asacol / Pentasa
• Azo compounds - Balsalazide / olsalazine
– Topical compounds
• topical mesalamine - suppositories and enemas
IBD Tx
• Corticosteroids
– Moderate to severe IBD
• Oral - prednisone or methylprednisolone
• IV- hydrocortisone/methylprednisolone
• topical-hydrocortisone suppositories, foam, enemas
– short term therapy
– long term use should be avoided due to
associated risk of serious side effects
IBD- Tx
• Mercaptopurine & Azathioprine
– used in 10-15% of patients with refractory
Crohn’s disease
– also used increasingly in ulcerative colitis
– side effects - serious - occur in 10% of patients
• pancreatitis, bone marrow suppression, infectons,
hepatitis, cholestatic jaundice, allergies, potential
higher risk of neoplasm
• therapy must be monitored w/routine blood countsweekly at onset of therapy - monthly thereafter
IBD- Crohn’s Disease
• The cause of Crohn's disease is not known.
• Inflammatory bowel diseases (ulcerative colitis
and Crohn's disease) seem to run in some families.
• Some researchers think that a virus or bacteria
causes the immune system to overreact and
damage the intestines.
IBD- Crohn’s Disease
• Unlike ulcerative colitis, Crohn’s disease is
a transmural process that can result in
mucosal inflammation and ulceration,
stricturing, fistula development and abscess
formation
Anatomic distribution of Crohn’s
disease
IBD- Crohn’s Disease
• Most common presentation - chronic
inflammatory disease
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low grade fever
malaise
weight loss
diarrhea (non-bloody & intermittent)
right lower quadrant or periumbilical pain
IBD- Crohn’s Disease
• May present with variety of symptoms and
signs depending on location of involvement
and severity of inflammation
– 1/3 of cases involve only small bowel
– 1/2 cases involve small bowel and colon ileocolitis
– 20% of cases only colon affected
The pathologic findings in Crohn's
disease
IBD- Crohn’s Disease
Physical Exam
– Fistulization with or w/o infection
• fistulas to the mesentery usually asymptomatic but
can result in intra-abdominal or retroperitoneal
abscesses (fever, chills, tender abdominal mass,
leukocytosis)
• fistulas from colon to small intestine or stomach can
result in bacterial overgrowth (diarrhea,
malnutrition)
• fistulas to vagina/bladder - recurrent infections
IBD- Crohn’s Disease
Diagnostic work-up
– Colonoscopy findings• aphthoid ulcers, linear or stellate
ulcers, strictures
• inflamed mucosa
IBD- Crohn’s Dx
• Complications
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Abscess - get CT of abdomen
Obstruction
Fistulas
Perianal Disease
increased risk of colon cancer
Malabsorption
IBD-Crohn’s Disease
Treatment- general
• Treatment directed toward symptoms
• Goal of Tx - control disease process
– Diet - ? Lactose intolerance, add fiber
• patients w/obstruction - low roughage diet
– Enteral therapy (4wks - less effective than
corticosteroids)
– TPN - short term
IBD-Crohn’s Disease
Treatment- Medications
• 5-Aminosalicylic acid agents– for mild - moderately active ileocolonic and
colonic Crohn's
• Antibiotics
– ciprofloxacin
– metronidazole
IBD-Crohn’s Disease
Treatment-Medications
• Corticosteroids- prednisone
– dramatically suppress acute clinical
symptoms/signs
IBD-Crohn’s Disease
Treatment-Medications
• Immunomodulatory drugs
– Azathioprine & mercaptopurine effective in
long term tx of Crohn’s disease
– infliximab, a chimeric IgG ant-TNF antibody
used for tx of active moderate to severe Crohn’s
cases that did not respond to corticosteroids or
other immunomodulatory
drug
IBD-Crohn’s Disease
Treatment-Medications
• Aminosalicylates – lower disease recurrence by 6%
• Corticosteroids
– (including budesonide) should only be used in
active disease - not as a means to maintain
remission
IBD-Crohn’s Disease
Treatment-Medications
• Maintenance Therapy
– Azathioprine, mercaptopurine and methotrexate
• used to maintain remission in patients with frequent
occurrences
– infliximab
• maintenance therapy only when other
immunosuppressive therapies fail
IBD - Ulcerative Colitis
IBD- Ulcerative Colitis
• Most cases controlled with medical therapy
without need for surgery
• Idiopathic inflammatory condition
involving mucosal surface of colon
– 50% cases proctosigmoiditis
– 30% cases left-sided colitis
– 20% cases extensive colitis-pancolitis
IBD- Ulcerative Colitis
• Hallmark symptom - bloody diarrhea
• Lifelong disease characterized by periods of
symptomatic flare-ups and remissions
• In majority of cases, the extent of colonic
involvement does not progress over time
IBD-Ulcerative Colitis
• Classification:Mild-Moderate-Severe
• Mild– gradual onset of symptoms (infrequent diarrhea
< 5 per/day, rectal bleeding, mucus)
– fecal urgency/ tenesmus
– left lower quadrant cramps usually relieved
with defecation
IBD-Ulcerative Colitis
• Moderate – more severe diarrhea, frequent bleeding,
abdominal pain and tenderness
• Severe–
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> 6-10 bloody bowel movements per day
severe anemia, hypovolemia
impaired nutrition, hypoalbuminemia
abdominal pain/tenderness
Fulminant colitis may develop
IBD- Ulcerative Colitis
• 25% of cases develop extraintestinal
manifestations
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erythema nodosum
pyoderma gangrenosum
episcleritis
thromboembolic events
oligoarticular, nondeforming arthritis
Systemic and Extra-Colonic
Manifestations
Systemic and Extra-Colonic
Manifestations
• Arthritic complications may occur in as many as 26% of
patients with ulcerative colitis.
– Spondolylitis - 3% of these patients.
• Arthritic symptoms may appear before the inflammatory
bowel disease and do not necessarily follow the course of
the intestinal disease.
• 12 to 23% of patients with ulcerative colitis have
peripheral arthritis, which affects large, weight-bearing
joints such as knees or ankles.
• Arthritis signs and symptoms usually accompany
exacerbations of ulcerative colitis.
IBD- Ulcerative Colitis
• Essentials of diagnosis
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bloody diarrhea
lower abdominal cramps and fecal urgency
anemia, low serum albumin
negative stool cultures
sigmoidoscopy - key to diagnosis
IBD- Ulcerative Colitis
Diagnostic work-up
• Blood work - hematocrit, sed rate , serum
albumin
• Plain abdominal films –
– check for significant
colonic dilation
• Sigmoidoscopy • mucosal appearance characterized
by edema, friability, mucopus, and erosions
• colonoscopy should be avoided in severe cases due
to increased risk of perforation
IBD- Ulcerative Colitis
Diagnostic Work-up
• Stool Sample
– Infectious colitis should be excluded by stool
bacterial culture (to exclude salmonella,
shigella, Campylobacter)
– ova and parasites (to exclude amebiasis)
– toxin assay for C.difficile
IBD- Ulcerative colitis
Diagnostic Work-Up
• Mucosal biopsy
– can distinguish amebic from ulcerative colitis
– E. coli -as it cannot be detected on routine
bacterial cultures
– CMV colitis
IBD-Ulcerative Colitis
Treatment
• Treatment dependent upon the extent of
colonic involvement and the severity of
illness
• Goals of tx
– stop the acute, symptomatic attack
– prevent recurrence
IBD- Ulcerative Colitis
• Treatment - Distal Colitis
– symptoms confined to rectum or rectosigmoid
region
– acute therapy - topical agents
– drug of choice - mesalamine (3-12 weeks)
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as suppository for proctitis (500mg 2x daily)
as enema for proctosigmoiditis (4g at bedtime)
also used - hydrocortisone suppository or enema
consider systemic steroids or immunosuppressives
in refractory cases
IBD- Ulcerative Colitis
• Treatment - Mild to Moderate colitis
– Disease extending above the sigmoid colon best
treated with oral agents
– 5-aminosalicylic acid agents (sulfasalazine,
mesalamine, balsalazide) - symptomatic
improvement in 50-75% of cases
– sulfasalazine commonly used first line agentlower cost (folic acid 1mg/d should be given to
all patients on sulfasalazine)
– Balsalazide 2.25 g TID, more effective than
other 5-ASA agents
IBD- Ulcerative Colitis
• Treatment - Mild to Moderate Colitis
– Patients who fail to respond after 2-3 weeks of
5-ASA therapy should begin corticosteroid
therapy
• commonly used - hydrocortisone foam or enema, if
fails, then systemic steroid therapy
• systemic therapy - Prednisone and
methylprednisolone
IBD- Ulcerative Colitis
• Treatment - Severe Colitis
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10-15% of patients
Hospitalization usually required
d/c oral intake - TPN
restore fluid volume/ correct electrolyte
abnormalities
– Plain abdominal xray - look for colonic dilation
– bacterial culture/ exam for ova/parasite
– surgical consult
IBD- Ulcerative Colitis
• Treatment - Severe Colitis
– Corticosteroid therapy• methylprednisolone, hydrocortisone enemas, followed
by oral prednisone
• 50-75% of severe cases achieve remission with
systemic steroid therapy within 7-10 days)
– Cyclosporine - IV • used in cases that do not respond to steroid therapy
after 7-10 days
– Surgery• reserved for patients who do respond to corticosteroid
or cyclosporine therapy after 7-10 days
IBD- Ulcerative Colitis
• Fulminant colitis
– rapid progression of symptoms over 1-2 weeks
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signs of severe toxicity
prominent hypovolemia
hemorrhage requiring transfusion
abdominal distention w/tenderness
– Broad spectrum antibiotics - to cover anerobes
and gram negative bacteria
IBD- Ulcerative Colitis
• Toxic megacolon
– develops in less than 2% of cases of ulcerative
colitis
– characterized by colonic dilation of more than
6cm on plain films
– Same therapy as fulminant colitis with addition
of nasogastric suction
– Pts should be told to roll from side to side and
onto the abdomen to help decompress the colon
IBD- Ulcerative Colitis
• Toxic megacolon
– serial x-rays to check for worsening dilation or
ischemia
• Toxic Megacolon or Fulminant colitis
– Surgery should be considered for patients
whose condition worsens or fails to improve
within 48-72 hours to prevent perforation
IBD- Ulcerative Colitis
• Chronic maintenance therapy with
– sulfasalazine
– olsalazine
– mesalamine
• chronic maintenance therapy is shown to reduce
relapse rates by 33%
IBS - Irritable Bowel Syndrome
IBS
• IBS is the most common functional disorder of the
intestines, and specifically the bowel.
• Functional constipation and chronic functional
abdominal pain are other disorders of the
intestines that have physiological causes, but do
not have identifiable structural, chemical, or
infectious pathologies.
• They are aberrations of normal bowel function but
not diseases.
IBS
• Irritable bowel syndrome (IBS) or spastic
colon is a functional bowel disorder
characterized by abdominal pain and
changes in bowel habits which are not
associated with any abnormalities seen on
routine clinical testing.
• It is fairly common and makes up 20–50%
of visits to gastroenterologists.
IBS - irritable bowel syndrome
• Functional, Chronic condition
– symptoms should be present > 3 months before
diagnosis established
– Organic disease processes must be ruled out
• Onset
– usually late teens to twenties
IBS
• Symptoms
– lower abdominal pain (cramps- intermittent)
– onset associated with change in stool frequency
or form, pain relieved by defecation
– usually pain is not nocturnal
– stool usually contains mucus
– visible distention/bloating common
IBS
• Three main classification groups
– constipation (< 3 stools week, hard/lumpy
stools, or straining)
– diarrhea (> 3 stools per day, loose/watery,
urgency or incontinence)
– alternating constipation and diarrhea (some
patients report firm stool in AM followed by
progressively looser stools throughout the day)
Is it IBS ?
• The following symptoms are not compatible
with IBS and organic disease processes
must be ruled out
– acute onset of symptoms in patients > 40yrs
– severe diarrhea or constipation or nocturnal
diarrhea
– hematochezia, weight loss, fever
IBS
• Other disorders may present with similar
symptoms - they include;
–
–
–
–
–
–
–
inflammatory bowel disease
hyper/hypothyroidism
colonic neoplasm
celiac disease
lactase deficiency
endometriosis
psychiatric disorders (depression/anxiety)
IBS- Diagnostic studies
– blood tests -CBC, serum albumin, SED rate, TSH
– serologic tests for celiac disease in diarrhea cases
– stool exam –
• occult blood
• ova/parasites
– barium enema
– sigmoidoscopy
– colonoscopy
IBS- Treatment
• Conservative tx
– > 2/3 of patients with IBS have mild symptoms
that respond well with dietary modifications &
education.
– Dietary triggers - avoidance of certain trigger
foods: fatty foods, caffeine, gassy foods or
lactose
– High fiber diet or fiber supplements may be of
use for constipation
IBS Tx
• Drug therapy
– moderate to severe cases of IBS
– therapy directed at dominant symptom
•
•
•
•
antispasmodics - anticholinergic agents
antidiarrheals- Loperamide - prophylactically
anti-constipation drugs
Psychotropic drugs - low dose tricyclic
antidepressants -anticholinergic effects - useful in
constipation cases
• Serotonin receptor agonists & antagoniststegaserod, alosetron
IBS- Treatment
• Hypnotherapy
• Symptom diary can be useful to link
time/severity of symptoms to food intake,
life events
• Reassurance, education, support
– mind-gut interaction - symptoms may increase
in times of stress
Colon Cancer
Colon Cancer
• Colorectal cancer is the second leading
cause of cancer deaths. In almost all cases,
however, this disease is entirely treatable if
caught early by colonoscopy.
• There are over 130,000 cases of colorectal
cancer diagnosed in the United States each
year, and over 50,000 deaths
Colon Cancer – Risk Factors
• There is no single cause for colon cancer.
However, almost all colon cancers begin as
benign polyps which, over a period of many
years, develop into cancers.
• Factors that increase the risk of colon
cancer are colorectal polyps, cancer
elsewhere in the body, a family history of
colon cancer, and ulcerative colitis.
Colon Cancer – Risk Factors
• Patients with a history of breast cancer have
a slightly increased risk of developing colon
cancer.
• Certain genetic syndromes increase the risk
of developing colon cancer in affected
families.
Colon Cancer – Risk Factors
• Dietary factors that have been associated
with colon cancer are a high-meat, high-fat,
low-fiber diet.
• However, some studies found that the risk is
not reduced when people switch to a highfiber diet, so the cause of the link is not yet
clear.
Colon Cancer Detection
• With proper screening, colon cancer should be
detected BEFORE the development of symptoms,
when it is most curable.
• Most cases of colon cancer have no symptoms.
• The following symptoms, however, may indicate
colon cancer:
– diarrhea, blood in stool, abdominal pain/tenderness,
intestinal obstruction, stools narrower than normal,
weight loss with no known reason, and unexplained
anemia
Colon Ca Detection
• A physical examination rarely shows any
abnormalities, although an abdominal mass may
be present.
• A rectal examination may reveal a mass in patients
with rectal cancer, but not colon cancer.
• A colonoscopy or sigmoidoscopy may reveal
evidence of cancer.
– However, only colonoscopy examines the entire colon.
Colon Cancer Detection
• A fecal occult blood test (FOBT) may detect small
amounts of blood in the stool, a possible indicator of colon
cancer.
• However, this test is often negative in patients with colon
cancer.
• Not all polyps bleed, and not all polyps bleed all the time.
• That is why a FOBT must be used with one of the other
more invasive screening measures, either colonoscopy or
sigmoidoscopy.
Colon Cancer Detection
• Fecal occult blood test, sigmoidoscopy, and
barium enema are screening tests that can
be used for early detection and prevention
of colon cancer, but colonoscopy remains
the gold standard.
• A new test, a virtual colonoscopy, uses CT
scan technology to visualize the colon.
Colon Cancer Tx
• Treatment depends partly on the stage of the
cancer. This means how far the tumor has
spread through the layers of the intestine,
from the innermost lining to outside the
intestinal wall and beyond:
Colon Cancer – Tx -Staging
• Stage 0:
– Very early cancer on the innermost layer (more accurately
considered a precursor to cancer)
• Stage I:
– Tumor in the inner layers of the colon
• Stage II:
– Tumor has spread through the muscle wall of the colon
• Stage III:
– Tumor that has spread to the lymph nodes
• Stage IV:
– Tumor that has spread to distant organs
Colon Cancer - Tx
• Stage 0 colon cancer
– may be treated by cutting out the lesion, often
via a colonoscopy.
• For stages I, II, and III cancer,
– more extensive surgery to remove a segment of
colon containing the tumor and reattachment of
the colon is necessary.
A barium enema in a patient with
cancer of the large bowel
Colon Cancer - Tx
• Almost all patients with stage III colon
cancer, after surgery, should receive
chemotherapy (adjuvant chemotherapy)
with a drug known as 5-fluorouracil given
for approximately 6 - 8 months.
• This drug has been shown to increase the
chance of a cure.
Colon Cancer - Tx
• Chemotherapy is also used for patients with stage
IV disease in order to shrink the tumor, lengthen
life, and improve the patient's quality of life.
• Irinotecan, oxaliplatin, and 5-fluorouracil are the 3
most commonly used drugs, given either
individually or in combination.
• There are oral chemotherapy drugs which are
similar to 5-fluroruracil, the most commonly used
being capecitabine (Xeloda).
Colon Cancer - Tx
• For patients with stage IV disease that is
localized to the liver, various treatments
directed specifically at the liver can be used.
• Tumors may be surgically removed, burned,
or frozen in some cases.
• Chemotherapy or radioactive substances
can sometimes be infused directly into the
liver.
Beating Colon Cancer
• Beginning at age 50, men and women who are at average
risk for developing colorectal cancer should have 1 of the 5
screening options below:
– a fecal occult blood test (FOBT) or fecal immunochemical test
(FIT) every year, OR
– flexible sigmoidoscopy every 5 years, OR
– an FOBT or FIT every year plus flexible sigmoidoscopy every 5
years, OR (Of these first 3 options, the combination of FOBT or
FIT every year plus flexible sigmoidoscopy every 5 years is
preferable.)
– double-contrast barium enema every 5 years, OR
– colonoscopy every 10 years
Questions