Disorders of the Intestines

1
Disorders of the Intestines

• Victor Politi, M.D., FACP
• Medical Director, SVCMC School of Allied Health
• Physician Assistant Program

2
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.

3
(No Transcript)
4
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.

5
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.

6
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.

7
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.

8
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.

9
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.

10
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.

11
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.

12
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

13
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 Crohns disease.
• Though appendicitis patients do not generally
  have diarrhea, it is a common symptom of a
  ruptured appendix.

14
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.

15
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.

16
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.

17
Chronic diarrhea

• Chronic diarrhea may be due to
• infective diarrhea
• Malabsorption
• IBS
• IBD
• Surgery I.e. Ileal resection/post gastrectomy
• Intestinal resection or bypass
• Whipples Disease-Tropheryma whipplei

18
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.

19
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

20
Intestinal Parasites

• Intestinal parasites include roundworms and tape
  worms, which can grow to great lengths in the
  intestines.

21
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.

22
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.

23
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.

24
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.

25
Intestinal Parasites

• Giardiasis is spread by fecal-oral contamination.
  
• The prevalence is higher in populations with poor
  sanitation, close contact, and oral-anal sexual
  practices.

26
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.

27
Intestinal Parasites

• Giardia growth in the small intestine is
  stimulated by bile, carbohydrates, and low oxygen
  tension.
• It can cause dyspepsia, malabsorption, and
  diarrhea.

28
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.

29
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.

30
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.

31
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
  self-limiting.
• It is often called the stomach flu or gastric flu
  even though it is not related to influenza.

32
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.

33
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.

34
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.

35
Gastroenteritis

• Four types of viruses cause most viral
  gastroenteritis
• Rotavirus
• Adenovirus
• Caliciviruses
• Astrovirus

36
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.

37
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.

38
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.

39
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.

40
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.

41
Appendicitis

• The classical history in appendicitis is diffuse
  pain in the periumbilical region which then
  localizes as pain and tenderness at McBurneys
  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.

42
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

43
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), Blumbergs sign
  and Rovsings sign.

44

• 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).

45

• 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.

46
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).

47
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.

48
CT scan showing cross-section of inflamed
appendix (A) with appendicolith (a).
49
CTscan showing enlarged and inflamed appendix (A)
extending from the cecum (C).
50
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.

51
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 malabsorption-related
  problems and psychosocial problems, while adults
  generally have malabsorptive problems.
• Many adults with subtle disease only have fatigue
  or anemia

52
Colitis

• Colitis is a digestive disease characterized by
  inflammation of the colon.
• There are several types of colitis, including
  ulcerative colitis, Crohns colitis, diversion
  colitis, ischemic colitis, infectious colitis,
  chemical colitis, microscopic colitis and
  atypical colitis.

53
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.

54
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.

55
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.

56
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)

57
C. difficile toxin
58
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.

59
Pseudomembranous colitis

• Symptoms
• Watery diarrhea
• Urge to defecate
• Abdominal cramps
• Low-grade fever
• Bloody stools

60
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.

61
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.

62
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.

63
IBD- Inflammatory Bowel Disease
64
IBD- inflammatory Bowel Disease

• IBD is term used to describe two disease
  processes
• Crohns 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

65
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.

66
Anatomic distribution of Crohns disease and
ulcerative colitis
67

68
IBD

• The same pharmacologic agents are used to treat
  both Crohns disease and ulcerative colitis.
• Mainstay of therapy -
• 5-aminosalicylic acid derivatives
• corticosteroids
• mercaptopurine or azathioprine

69
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

70
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

71
IBD- Tx

• Mercaptopurine Azathioprine
• used in 10-15 of patients with refractory
  Crohns 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 counts-
  weekly at onset of therapy - monthly thereafter

72
IBD- Crohns Disease
73

• 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.

74
IBD- Crohns Disease

• Unlike ulcerative colitis, Crohns disease is a
  transmural process that can result in mucosal
  inflammation and ulceration, stricturing, fistula
  development and abscess formation

75
Anatomic distribution of Crohns disease
76
IBD- Crohns Disease

• Most common presentation - chronic inflammatory
  disease
• low grade fever
• malaise
• weight loss
• diarrhea (non-bloody intermittent)
• right lower quadrant or periumbilical pain

77
IBD- Crohns 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

78
The pathologic findings in Crohn's disease
79
IBD- Crohns DiseasePhysical 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

80
IBD- Crohns DiseaseDiagnostic work-up

• Colonoscopy findings-
• aphthoid ulcers, linear or stellate ulcers,
  strictures
• inflamed mucosa

81
IBD- Crohns Dx

• Complications
• Abscess - get CT of abdomen
• Obstruction
• Fistulas
• Perianal Disease
• increased risk of colon cancer
• Malabsorption

82
IBD-Crohns DiseaseTreatment- 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

83
IBD-Crohns DiseaseTreatment- Medications

• 5-Aminosalicylic acid agents-
• for mild - moderately active ileocolonic and
  colonic Crohn's
• Antibiotics
• ciprofloxacin
• metronidazole

84
IBD-Crohns DiseaseTreatment-Medications

• Corticosteroids- prednisone
• dramatically suppress acute clinical
  symptoms/signs

85
IBD-Crohns DiseaseTreatment-Medications

• Immunomodulatory drugs
• Azathioprine mercaptopurine effective in long
  term tx of Crohns disease
• infliximab, a chimeric IgG ant-TNF antibody used
  for tx of active moderate to severe Crohns cases
  that did not respond to corticosteroids or
  other
  immunomodulatory drug

86
IBD-Crohns DiseaseTreatment-Medications

• Aminosalicylates -
• lower disease recurrence by 6
• Corticosteroids
• (including budesonide) should only be used in
  active disease - not as a means to maintain
  remission

87
IBD-Crohns DiseaseTreatment-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

88
IBD - Ulcerative Colitis
89
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

90
(No Transcript)
91
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

92
(No Transcript)
93
IBD-Ulcerative Colitis

• ClassificationMild-Moderate-Severe
• Mild-
• gradual onset of symptoms (infrequent diarrhea lt
  5 per/day, rectal bleeding, mucus)
• fecal urgency/ tenesmus
• left lower quadrant cramps usually relieved with
  defecation

94
IBD-Ulcerative Colitis

• Moderate -
• more severe diarrhea, frequent bleeding,
  abdominal pain and tenderness
• Severe-
• gt 6-10 bloody bowel movements per day
• severe anemia, hypovolemia
• impaired nutrition, hypoalbuminemia
• abdominal pain/tenderness
• Fulminant colitis may develop

95
IBD- Ulcerative Colitis

• 25 of cases develop extraintestinal
  manifestations
• erythema nodosum
• pyoderma gangrenosum
• episcleritis
• thromboembolic events
• oligoarticular, nondeforming arthritis

96
Systemic and Extra-Colonic Manifestations
97
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.

98
IBD- Ulcerative Colitis

• Essentials of diagnosis
• bloody diarrhea
• lower abdominal cramps and fecal urgency
• anemia, low serum albumin
• negative stool cultures
• sigmoidoscopy - key to diagnosis

99
IBD- Ulcerative ColitisDiagnostic 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

100
IBD- Ulcerative ColitisDiagnostic 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

101
IBD- Ulcerative colitisDiagnostic Work-Up

• Mucosal biopsy
• can distinguish amebic from ulcerative colitis
• E. coli -as it cannot be detected on routine
  bacterial cultures
• CMV colitis

102
IBD-Ulcerative ColitisTreatment

• Treatment dependent upon the extent of colonic
  involvement and the severity of illness
• Goals of tx
• stop the acute, symptomatic attack
• prevent recurrence

103
IBD- Ulcerative Colitis

• Treatment - Distal Colitis
• symptoms confined to rectum or rectosigmoid
  region
• acute therapy - topical agents
• drug of choice - mesalamine (3-12 weeks)
• 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

104
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
  agent-lower 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

105
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

106
IBD- Ulcerative Colitis

• Treatment - Severe Colitis
• 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

107
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

108
IBD- Ulcerative Colitis

• Fulminant colitis
• rapid progression of symptoms over 1-2 weeks
• signs of severe toxicity
• prominent hypovolemia
• hemorrhage requiring transfusion
• abdominal distention w/tenderness
• Broad spectrum antibiotics - to cover anerobes
  and gram negative bacteria

109
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

110
(No Transcript)
111
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

112
IBD- Ulcerative Colitis

• Chronic maintenance therapy with
• sulfasalazine
• olsalazine
• mesalamine
• chronic maintenance therapy is shown to reduce
  relapse rates by 33

113
IBS - Irritable Bowel Syndrome
114
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.

115
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 2050 of visits
  to gastroenterologists.

116
IBS - irritable bowel syndrome

• Functional, Chronic condition
• symptoms should be present gt 3 months before
  diagnosis established
• Organic disease processes must be ruled out
• Onset
• usually late teens to twenties

117
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

118
IBS

• Three main classification groups
• constipation (lt 3 stools week, hard/lumpy stools,
  or straining)
• diarrhea (gt 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)

119
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 gt 40yrs
• severe diarrhea or constipation or nocturnal
  diarrhea
• hematochezia, weight loss, fever

120
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)

121
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

122
IBS- Treatment

• Conservative tx
• gt 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

123
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 antagonists-
  tegaserod, alosetron

124
(No Transcript)
125
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

126
Colon Cancer
127
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

128
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.

129
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.

130
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 high-fiber diet,
  so the cause of the link is not yet clear.

131
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

132
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.

133
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.

134
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.

135
(No Transcript)
136
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

137
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

138
(No Transcript)
139
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.

140
A barium enema in a patient with cancer of the
large bowel
141
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.

142
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).

143
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.

144
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

145
Questions