Disorders of the Small Intestine and Colon Flashcards
(38 cards)
1
Q
-What types of disorders occur in the small intestine?
A
-Malabsorptive, and motility disorders
2
Q
- Examples of malabsorptive disorder?
- Motility disorders?
- What is celiac disease?
- When does it present?
- Which population is it most common in?
- How common is it?
A
- Celiac disease, Whipple disease, short bowel syndrome, lactose intolerance
- Paralytic ileus, small bowel obstruction. Ogilvie syndrome, gastroparesis (can involve all of the upper GI tract)
- An abnormal response to gluten (found in wheat, rye, barley, flour)
- Childhood and early adulthood, and must have a genetic predisposition
- Caucasions
- 1/100 but most go undiagnosed
3
Q
- What is the pathophysiology behind celiac disease?
- Clinical presentation?
- What are the atypical symptoms?
- What is dermatitis herpetiformis?
A
- Gluten triggers an immune response that damages the proximal small intestine mucosa, resulting in malabsorption of nutrients
- Diarrhea, steatorrhea, flatulence; dyspepsia; weight loss; abdominal distention; weakness, muscle wastin; growth retardation in children (adults can present with minimal GI symptoms but many atypical symptoms)
- Fatigue, depression; iron-deficiency anemia; osteoporosis; amenorrhea, infertility; easy bruising; peripheral neuropathy, ataxia
- Pruritic papulovesicular rash that occurs in <10% of patients with celiac disease, however, most who have the rash have celiac disease
4
Q
- What would you do upon PE?
- What should be done for diagnostic work-up?
- What are the sensitivity and specificity of these tests?
- How long after beginning a gluten free diet does it take for these antibodies to become undetectable?
A
- Everything!
- Vitamin/nutrient deficiencies; Serologic antibody tests: IgA endomysial antibody and IgA tTG antibody
- 6-12 months
5
Q
- How do you confirm the diagnosis of celiac disease?
- What might be on your differential diagnosis?
- How is it managed, and what is the prognosis?
A
- EGD w/ duodenal mucosal biopsy
- Lactose intolerance; food allergies/intolerances; Whipple disease (rare); IBS; IBD; infectious gastroenteritis, ZES (PUD w/diarrhea)
- Symptoms improve within 1-2 weeks, dietary supplements within the first few weeks of treatment, support groups; excellent if diet is maintained
6
Q
- What is Whipple disease?
- How do you contract it?
- Most common in who?
- Clinical presentation?
- How do you make the diagnosis?
- Treatment?
A
- A multisystemic disease caused by bacterial infection with Tropheryma whippelii
- We don’t know
- Middle aged men
- Fever, arthralgias, LAN; weight loss, chronic diarrhea, steatorrhea, flatulence
- EGD with biopsy (microscopy reveals macrophages with gram-positive bacilli, and PCR confirms the diagnosis)
- Ceftriaxone x 2 weeks, then trimethoprim sulfamethoxazole x 12 months
7
Q
- How do you treat short bowel syndrome/small bowel resection and lactose intolerance?
- What is the difference between obstipation and constipation?
A
- Cholesteramine
- Obstipation: cannot poop no matter what; constipation: difficult to poop, infrequent/hard stools
8
Q
- What do you call a oss of paristalsis of the intestine?
- What types of obstructions can cause this?
- What are the true common causes?
- Clinical presentation?
A
- Paralytic ileus
- None, there is no mechanical obstruction
- Abdominal surgery, peritonitis, medications, severe medical illness
- N/V/obstipation, abdominal distention, diminished/absent bowel sounds
9
Q
- What should be included in the differential diagnosis for a paralytic ileus?
- What is the work-up?
- How can you distinguish betwen an ileus and an obstruction?
A
- Small bowel obstruction; acute appendicitis, acute gastroenteritis, acute pancreatitis (all three can present with ileus)
- Plain film x-rays will show distended gas-filled loops of bowel (if not sure, get a CT)
- No obstruction with ileus
10
Q
-How do you treat an ileus?
A
- Treat the underlying cause; bowel rest (IV fluis/TPN, NG tube); slowly advance diet; activity; remove drugs that reduce intestinal motility
- –May also try a stimulant laxative, if its an obstruction, must remove it
11
Q
- What is Ogilvie syndrome?
- Who gets this?
- Clinical signs?
- Treatment?
- Potential complications?
A
- Spontaneous massive dilation fo the cecum and proximal colon
- Severely ill, hospitalized patients (postoperative, vent dependent, severe electrolyte abnormalities)
- Severely distended right abdomen
- Same as for ileus (underlying cause, bowel rest)
- Peritonitis, ischemic colon
12
Q
-What are potential disorders of the colon?
A
-IBS; IBD (ulcerative colitis, Crohn disease); Pseudomembranous colitis (c. diff or antibiotic associated colitis); diverticular disease; polyps of the colon; cancer of the colon
13
Q
- What is IBS?
- What causes it?
- Who is it most common in?
- When is the initial onset?
A
- Chronic GI symptoms not explained by the presence of structural or biochemical abnomality
- Ideopathic: abnormal motility (usually hyper), visceral hypersensitivity, enteric infection, psychosocial
- Women, but 10% of adult population have symptoms compatible with IBS
- Late teens and early twenties
14
Q
- What is the clinical presentation of IBS?
- How long must the symptoms persist in order to qualify as IBS?
- What would be on your differential diagnosis?
- When would you need a colonoscopy?
- What are the alarm symptoms?
A
- Crampy, lower abdominal pain (often relieved with defecation); change in stool frequency/form, urgency (diarrhea, constipation, mixed); abdominal distention, bloating
- At least 3 months
- IBD; celiac disease/malabsorptive syndromes; chronic enteric infection (parasitic0; carcinoma; systemic disorders (thyroid, DM); psychiatric disorders
- When alarm symptoms are present
- Severe constipation, severe diarrhea, hematochezia, weight loss, fever
15
Q
- How do you manage IBS?
- What types of pharmacologic treatment are available
A
- Patient support and education; sumptom diary/diet diary; behavioral therapy/relaxation techniques; pharmacologic treatment
- Antispasmodics; antidiarrheal/anticonstipation agents/simethicone; selective chloride activator; psychotropic agens; 5 HT3 antagonists; probiotics
16
Q
- Which antispasmodics are used to treat IBS?
- What are the side effects?
A
- Dycyclomine; Hyscyamine
- Anticholinergic (can’t spit, crap, see, or pee)
17
Q
- Which drug is used for constipation prominent IBD in women and chronic constipation?
- MOA?
- Contraindications?
- Side effects?
A
- Lubiprostone, a selective chloride activator
- Activates ClC-2 chloride channels, increasing intestinal fluid secretion and motility and reducing intestinal permeability
- Diarrhea, GI obstruction
- Diarrhea, nausea, fatigue, dizziness
18
Q
- What is alosetron?
- Indications?
- MOA?
- Black box warning?
- What must a patient do prior to using this med?
- Why are psychotropics sometimes used to treat IBS?
A
- A 5HT3 receptor antagonist
- Diarrhea prominent IBS in women
- Inhibits serotonin from bing to 5HT3 receptors in the intestine, too much serotonin can cause hypermotility of the GI tract
- Severe constipation and ischemic colitis
- Sign a consent form
- To relieve the high stress factor of the disease
19
Q
- What is IBD?
- Which diseases fall under this category?
- What is the incidence of UC and CD in the US?
- Risk factors?
A
- Chronic, recurrent inflammatory process
- Ulcerative colitis (UC), Crohn’s disease (CD)
- No clear trends, UC and CD about even
- Female (CD); Male (UC); most common in whites, “western diet;” infection, obesity, certain drugs
20
Q
- What part of the GI tract does CD effect most?
- Pathophys of CD?
- What can transmural inflammation lead to?
A
- Any part from mouth to anus (1/3 ileum only, 1/2 ileum and cecum, 1/3 with perianal disease)
- Transmural inflammation and Skip lesions in GI tract
- Strictures, obstruction, fistulas, perforation
21
Q
- Pathophys of UC?
- Which part of the GI tract does UC effect most?
- Which diseases fall under ulcerative colitis?
A
- Relapsing and remitting episodes of inflammation of the mucosal layer of the colon only
- Left splenic flexure to anus (m/c involves rectum and sigmoid colon)
- Ulcerative proctitis; ulcerative proctosigmoiditis; left or distal UC; extensive colitis (proximal to splenic flexure); pancolitis (cecum)
22
Q
-What are the clinical manifestations of Crohn’s disease? (There are a ton!)
A
- Crampy abdominal pain (RLQ)
- Diarrhea (Intermittent, Non-bloody)
- –Malabsorptive
- –Steatorrhea
- Weight loss, fatigue
- S/Sx Small bowel obstruction, fistula formation, -abscess
- Perianal disease - Fistulas, Abscess
- Oral Disease - Aphthous ulcers
- Extraintestinal Manifestations
- –Arthralgia, arthritis
- –Iritis, Uveitis
- –Skin Disorders
- —–Pyoderma gangrenosum
- —–Erythema nodosum
- S/Sx from nutrient deficiencies
23
Q
- Where might fistulas form in a patient with Crohn’s disease?
- How might perianal disease manifest?
A
-Intestine to bladder (enterovesical) Intestine to skin (enterocutaneous) Intestine to colon (enteroenteric) Intestine to vagina (enterovaginal) -Anal fistulas
24
Q
- What should be on your differential diagnoses for Crohn’s disease?
- Diagnostic workup?
- The presence of what type of lesions confirms the diagnosis?
- What other lesions may be visible?
- How is CD managed?
- What is the goal of therapy?
A
- Celiac disease, malabsorptive disorders
- Colonoscopy is gold standard to establish the diagnosis
- Skip areas with a cobblestone appearance
- Pseudopolyps and granulomas
- Diet, stop smoking, symptomatic meds, maintenance meds, acute flare meds, surgery (resection, abscess drainage/removal, fitulectomy)
- Provide symptomatic relief, shorten duration of acute flares and minimize complications; NOT curative
25
- What are the clinical manifestations of ulcerative colitis? (Many!)
- How is UC classified?
- Crampy lower abdominal pain
- Bloody Diarrhea
- Diarrhea with pus/mucus
- Fecal Urgency and tenesmus
- Fever, fatigue, weight loss
- Anemia
- Complications
- --Severe bleed
- --Fulminant colitis: > 10 BM’s/day
- --Toxic megacolon
- --Perforation
- Extraintestinal Manifestations
- --Arthritis, ankylosing spondylitis
- --Skin, Eye, others…..more common with CD
- Mild, moderate or severe
26
- What is toxic megacolon?
| - What are the signs and symptoms?
- Colonic diamete greater than or equal to 6 cm
| - Severe abdominal distention; fever; elevated WBC/ESR; HR>20; dehydration, hypotension
27
- What should be on your differential for UC?
- Diagnostic work-up?
- What will be seen?
- How do you treat the patient initially?
- H/H; ESR; albumin (determine severity of disease); colonoscopy is gold standard
- Continuous friable mucosa, edematou, pus, bleeding and erosion; may contain pseudopolyps
- Empirically
28
- What are the treatment goals for UC?
| - How do you manage it?
- Terminate acute flares and prevent recurrences/complications (much easier to treat than Crohn's disease)
- Monitor diet (decrease caffeine); symptomatic meds like antidiarrheals (not to be used during acute flares); pharmacotherapy depends on location and stage of disease; severe refractory disease may require surgery
29
-What types of pharmacotherapeutic agents can be used in the treatment of IBD?
-Amino salicylates; immunomodulators; tumor necrosis factor blockers; corticosteroids; antibiotics
30
- What type of drug are Sulfasalazine and mesalamine?
- MOA?
- Indications?
- Side effects?
- Where do these drugs need to exert their effects?
- Aminosalicylates (5-ASA derivatives)
- Poorly understood; inhibits prostaglandin production producing anti-inflammatory effects
- Induction and maintenance therapy of UC and CD
- N/V, HA, hypersensitivity reaction, sulfa or ASA allergy
- They must exert their effect directly on the colon (enteric coated tabs, pH dependent/chemical tabs, suppositories, enemas)
31
- With regards to UC and CD, what are corticosteroids effective for?
- Dosing?
- Induction of remission of severe and acute flares
- Prednisone 40-60mg daily (not for maintenance therapy, taper upon improvement); budesonide is for mild-moderate active CD and maintenance for up to three months
32
- What type of drug are Azathiopurine, 6-Mercatopurine (6-MP), Methotrexate and cylosporine?
- Which ones are indicated for steroid dependent CD and UC, and remission maintenance in mild-severe disease?
- What are their side effects? (Azathioprine and 6-MP)
- Adverse events?
- What is their black box warning?
- Immunomodulators/immunosuppressants
- Azathiopurine and 6-Mercaptopurine
- Leukopenia, thrombopenia, anemia; infection; N/V/D; malaise, myalgia
- Lymphoma; severe infection
- Mutagenic potential; rapid growing malignancy; lymphoma
33
- Which immunomodulator is used when azathioprine therapy fails?
- What is it used for?
- What is cyclosporine used for?
- Methotrexate
- Mild to moderate CD and maintenance; not effective in UC
- Severe UC/CD refractory to steroids; has multiple adverse effects and drug interactions
34
- What class of drugs does infliximab belong to?
- Dosage form?
- Indications?
- MOA?
- Side effects?
- Serious adverse effects/black box warning?
- Anti-tumor necrosis factor antibody
- IV infusion only
- Moderate to severe active CD and UC and maintenance; TOC for CD fistula
- Promotes inflammation; inhibits TNF
- Fever, rigors, N/V, myalgia, urticaria, hypotension
- Severe infection/sepsis, malignancy
35
- When should antibiotics be used for IBD?
| - Which ones would you use?
- Severe disease with risk of secondary infection; fistula and abscess in CD
- Metronidazole, Ciprofloxacin
36
- What are the treatment guidelines for mild-moderate Crohn's disease?
- Moderate-severe disease?
- Mild-moderate:
- --Oral 5 ASA agent x 12-16 wks (if working should see improvement in 3-4 wks)
- --Antibiotics x 6-12 wks
- --Oral corticosteroids (budesonide, prednisone x 8-10 weeks)
- -----Mose effective
- -----ACG recommends budesonide as 1st line
- --Immunomodulators for patients who do not respond to corticosteroids (azathioprine, 6-mercaptopurine)
- Moderate-severe or refractory disease
- --Anti-TNF therapy (infliximab)
- --Especially with fistula and abscesses
37
- What should be used for maintenance of Crohn's disease?
| - Without maintenance therapy, how long will a patient last before having a relapse?
- 5 ASA, low dose daily; infliximab, infusion q 8 wks
| - Most will relapse within 1 year
38
- What are the treatment guidelines for treatment of mild-moderate UC/distal colitis?
- Moderate-severe?
-
