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Flashcards in IBD and IBS Deck (47):
1

Diff b/t UC and crohn's?

- UC: mucosal ulceration in colon, starts distally and moves proximally up the colon, see more bright red blood
- crohns: transmural inflammation, can present from mouth to anus, skip lesions, can easily perf, form fistulas

- both diseases have wide spectrum of severity

2

What ethnic backgrounds are hit hardest by IBD? Geographic distribution?

- jews
- IBD very common in North America, throughout Europe

3

Does UC or crohns have an earlier onset?

- UC
- male:female equally affected

4

Epidemiology of IBD?

- common in developed nations
- infrequent in countries with poor sanitation
- North America and Europe rates are 5/100,000 for each disease (scandanavians)
- most common in 2nd and 3rd decades, but can affect any age

5

What are the etiologic theories behind IBD? Most likely?

- infectious, immunologic, genetic, dietary, enviro, vascular, neuromotor, allergic, psychogenic
- most likely: autoimmune and genetic

6

PP of IBD?

- defect in the fxn of intestinal lumen
- breakdown of defense barrier of gut
- exposure of mucosa to microorganisms of their products
- results in chronic inflammatory process mediated by T cells

7

What are systemic complications of IBD?

- aphthous stomatitis
- episcleritis and uveitis
- arthritis
- vascular complications
- Erythema nodosum
- P. gangrenosum
- gallstones
- malabsorption
- renal: stones, fistulaie, hydronephrosis, amyloidosis

8

What parts of the bowel are involved in UC?

- involves mucosal surface of colon with formation of crypt abscess. Always includes the rectum, and spreads proximally
distal colitis: proctitis, proctosigmoiditis
- extensive colitis (pancolitis): mild to moderate, severe
- is uniformly continuous, there are no skip lesions
- 50% of rectosigmoid
- 30% splenic flexure (L sided colitis)
- 20% extend proximally (pancolitis)
- At much higher risk for cancer (want to use colonoscopy to screen)

9

Clinical course of UC?

- flare ups and remissions
- more common in nonsmokers
- disease severity may be lower in active smokers and may worsen in pts who stop smoking: onset occasionally appears to coincide with smoking cessation
- higher risk for development of cancer: related to extend and duration of disease and age at dx

10

Signs and sxs of mild to moderate UC?

- bloody diarrhea (hallmark)
- lower abdominal cramps - relieved with defecation
- fecal urgency

11

Signs and sxs of severe UC?

- rectal bleeding
- LLQ cramps
- severe diarrhea
- fever (low grade)
- anemia (microcytic)
- hypoalbuminemia (malabsorption)
- hypovolemia

12

Systemic associations with UC?

- peripheral arthritis
- central (axial) arthritis)
- erythema nodosum (swollen red nodules)
- uveitis
- sclerosing cholangitis

13

Labs for UC?

- CBC: anemia is common due to multiple factors, leukocytosis
- sed rate and CRP: elev sed rate and CRP reflect acute phase (only elevated during flare ups)
- CMP: electrolyte disturbances, decreased serum albumin, prolonged clotting time
- perinuclear antineutrophil cytoplasmic abs (pANCA)

14

lab values in mild UC?

- stools: less than 4 a day
- pulse: less than 90
- hematocrit: normal
- wt loss: none
- temp: normal
- ESR: less than 20
- albumin will be normal

15

Lab values in moderate UC?

- stools: 4-6/day
- pulse: 90-100
- hematocrit: 30-40
- wt loss: 1-10%
- temp: 99-100
- ESR: 20-30
- albumin: 3-3.5

16

lab values in severe UC?

- stools: more than 6 a day (mostly bloody)
- pulse: over 100
- hematocrit: less than 30
- wt loss: greater than 10%
- temp: above 100
- ESR: above 30
- albumin: less than 3

17

Dx for UC?

- usually based on clinical presentation, sigmoidoscopic demonstration of inflammation and exclusion of bacterial and parasitic infection
- dx:
bloody diarrhea (diff it from crohns)
plain abd. xrays
sigmoidoscopy
CT scan (complications)
- dx: is best made with sigmoidoscopy but want to use colonoscopy to rule out other diseases

18

DDx of UC?

- infectious colitis
- CMV colitis
- rectal carcinoma
- crohns disease
- GI bleed
- mesenteric ischemia
- diverticulitis (esp in older pts)

19

Intestinal complications in UC?

- bleeding
- toxic megacolon
- perforation
- benign stricture
- malignant stricture
- colorectal cancer

20

Tx guidelines for UC?

- reduce dietary fiber during an exacerbation
- rx folic acid supplements with sulfasalazine
- oral Fe may be needed with rectal bleeding and documented Fe def anemia
- frequent f/u and close monitoring
- short course of loperamide for troubesome diarrhea
- periodic colonoscopy and bx in pts with pancolitis lasting more than 8 years (yearly screening)

21

Tx for mild to moderate UC?

- sulfasalzine
- olsalazine (non sulfa)
- mesalamine
- may have to add on prednisone (taper to lowest therapeutic dose needed)

22

Tx for moderate to severe UC?

- sulfasalazine
- olsalazine
- prednisone: may need to consider immunosuppresive therapy for pts who need constant high doses of steroids

sulfasalzine and olsalazine: azospermia while on meds, severe depression in young males
- also watch for folate deficiency while on meds

23

Tx for proctocolitis (limited to rectosigmoid)?

- sulfasalazine: oral or topical (enema or supp)
- hydrocortisone: enema, supps, or foam

24

Indications for surgery in UC?

- exsanguinating hemorrhage
- toxicity and/or perf
- suspected cancer
- significant dysplasia
- growth retardation
- systemic complications
- intractability

25

Surgical options for UC?

- conventional ileostomy
- continent ileiostomy
- ileo-anal anastomosis with reservoir

(all depends on how much bowel is left to reconnect)

26

Crohn's disease - what is involved?

- transmural involvement with formation of fistulas, narrowing of lumen, obstruction
- can involve any segment of the GI tract: ileocolitis - 45%, ileitis: 28%, colitis: 15%, gastroduodenitis: 7%, jejunoileitis: 5%
- usually rectal sparing
- since it is transmural - more likely to perf and form fistulas

27

Cigarette smoking and crohn's?

- strongly assoc with development of crohn's, resistance ot medical therapy and early disease relapse

28

Clinical manifestations of Crohns?

- presentation depends upon site and severity
- insidious onset usually
- intermittent bouts of low grade fever, diarrhea, and RLQ pain
- post prandial pain is common
- RLQ mass
- perianal disease: abscess or a fistula, fissures, hemorrhoids, skin tags
- often nocturnal BMs, night sweats, wt loss
- skin lesions, primarily erythema nodosum, may precede intestinal sxs
- pts are often chronically ill: wt loss and pallor (B12 and folate def)
- children and adolescents: presentation often insidious with wt loss, failure to grow or develop secondary sex characteristics, arthritis, or fever of unkown origin

29

Distinguishing features of crohns?

- small bowel involvement
- rectal sparing
- 25-30% w/o gross bleeding
- perianal disease
- focal lesions
- segmental distribution: skip lesions
- asymmetric involvement
- fistulization
- granulomas
- endoscopic features

30

PE findings in Crohn's disease?

- abdominal distension
- abnormal bowel sounds
- tenderness in area of involvement
- perianal region: abscess, fistula, skin tag and anal stricture

31

Lab findings in crohns?

- CBC: anemia is common due to mult factors - B12, folate, maybe iron, leukocytosis
- sed rate and CRP: elevated sed rate, and CRP reflect acute phase
- CMP: electrolyte disturbances, decreased serum albumin, prolonged clotting time
- ASCA: serum anti-saccharomyces cerevisase ab (ASCA) highly specific but sensitivity is only 30%,

32

Imaging in crohn's?

- barium contrast sutdies most commonly used for upper and lower GI tract - better for finding complications - strictures and fistulas, granulomas
- see: "cobble stoning", "skip lesions", pseudodiverticula, dilated bowel fistulas comunicating to adjacent bowel/mesentery/bladder/vagina, can see ileitis, an string sign (severe inflammation)
- histology: from endoscopic bx

33

Tx of Crohn's disease?

- 5-aminosalicylic acid agents: sulfasazine (need folate supplementation), mesalamine, pentasa
- abx if infections (high risk pts!)
- corticosteroids (burst packs)
- anti-TNF therapy: infliximab (remicade)
- immunomodulating drugs: azathioprine, mercaptopurine, methotrexate

34

Irritable bowel sydrome AKA?

- spastic colon
- spastic colitis
- mucous colitis
- functional bowel disease

35

What is IBS? How muc of our population is affected? What kind of dx is it?

- fxnl GI disorder that is a variable combo of chronic or recureent gi sxs not explained by structural or biochem abnormalities
- 20% of pop
- 20-50% of referrals
- 25% of pts post enteric infections and 7% go on to develop true IBS
- a dx of exclusion, a + dx must be made

36

Characteristic sxs of IBS?

continuous or recurrent sxs for at least 3 months of:
-abdominal pain or discomfort
- pain relieved by defecation
- pain with change in frequency or form of stools

Varying pattern of defecation with 3 or more of the following:
- altered stool frequency
- altered stool form
- altered stool passage (straining, urgency, incomplete evacuation/sensation of rectal fullness)
- abdominal distension and bloating
- passage of mucus

37

Epidemiology of IBS?

- up to 15% of pop
- females more than males and younger more than old
- 2/3 don't seek health care
- sociocultural factors affect MD visits

38

Assoc sxs with IBS?

- fatigue (96%)
- back ache (75%)
- early satiety (73%)
- nausea (62%)
- HA (61%)
- irritable bladder (56%)
- fxnl dyspepsia (51%)

39

Dx of IBS based on Rome II criteria?

- Rome - most commonly used:
abdominal discomfort/pain with 2 of the following 3 features for at least 12 weeks, not necessarily consecutive, for the past 12 months:
-relief with defecation
-onset assoc with change in stool frequency
- onset assoc with change in stool formation

40

Dx of IBS based on Manning criteria?

manning criteria:
- pain relieved by defecation
- more frequent stools assoc with pain onset
- looser stools assoc with onset of pain
- abdominal distension
- passage of mucus
- feeling of incomplete evacuation

41

DDx of IBS?

- dietary: lactose, caffeine, alcohol, fat, gas producing foods
- malabsorption: post gastrectomy, intestinal, pancreatic
- infection: giardia, bacterial, ameoba
- inflammatory bowel: UC, CD, microscopic colitis, mast cell disease
- psych: anxiey, panic, depression, somatization
- misc: endometriosis, endocrine tumors (carcinoid, VIP), AIDS

42

Hx questions you should ask pt that has suspecting IBS?

- dietary habits (sorbitol sweetner, caffeine, cruciferous veggies), carb malabsorption
- travel hx
- med use
- recent gastro-enteritis or food born illness
- lactose intolerance
- gender, age
- family hx
- night time defecation

43

PE for IBS pt?

- complete physical: necessary to exclude organic disease
- pt will not usually have abdominal guarding - should have guarding considering the pain the pt is having

- EBM: no dx tests can be justified

44

Labs and imaging used in IBS dx?

- labs: CBC, ESR, serum electrolytes, liver enzymes, stool occult blood x3, stool O&P, UA
- imaging: flex sig, upper GI series with small bowel follow through, plain abdominal radiograph, air contrast barium enema

( all labs and imaging will appear normal if IBS)
- after H&P and labs negative - can make a dx, don't have to do imaging unless pt wants imaging - then refer to GI

45

Warning signs and red flags on exam with pt with suspected IBS?

- any abnormality on PE
- anemia
- clinical or biochemical evidence of malnutrition
- family hx of GI cancer, IBD, or sprue
- fever
- hematochezia
- nocturnal sxs
- onset of sxs after 50 (high risk for cancer after 50)

alarm sxs:
- constant abdominal pain
- constant diarrhea
- constant abdominal distension
- nocturnal disturbance
- passage of blood with stool
- wt loss

46

How can we make a positive dx of IBS w/o costing the pt a lot of money?

- use Rome and Manning guidelines
-

47

Management of IBS?

1. make a positive dx: usually possible from hx alone -
- sxs usually begin in late teens - twenties
- pain is intermittent and crampy
- full PE
- in younger pts, normal Hgb and ESR may help reassure pt
- in pts older than 45 with long hx and no recent hange - a sigmoidoscopy and/or barium enema may help to reassure

2. Consider pts agenda: a full psych, social, and family hx inquiry is necessary, try to get answer to question - why has this pt presented at this particular time?

3. make a management classification:
to which category does the pt belong:
- bloating and pain predominant
- constipation predominant
- diarrhea predominant
- anxiety assoc
- depression assoc

4. Plan a management strategy:
est a therapeutic provier pt relationship
- focus should be on sx relief and addressing pt's concern
- shift responsibility for tx decisions to pt by providing therapeutic options
- demonstrate a commitment to the pt's well being rather than to tx of disease

pt education:
- validates pt's illness and sets basis for therapeutic interventions
- set realistic goals rather than a cure
- teach sxs monitoring
- reassure benign nature of IBS
- address psychosocial issues
- tell pt to f/u if they have wt loss, blood in stool, bm at night