Intestine 2 Flashcards
Abdominal pain
– SBO = periumbilical, cramping, paroxysmal
– LBO = lower quadrants
nausea/vomiting, abdominal distention/bloating, constipation, diarrhea, obstipation, anorexia, fatigue, weakness
CAVO = Crampy abdominal pain, Abdominal distention, Vomiting, Obstipation
bowel obstruction
Prior abdominal/pelvic surgery, hernia, IBD, malignancy, diverticulitis, volvulus, intussusception, opioid use
bowel obstruction
75% of bowel obstructions are
small
Mechanical = physical object (surgical adhesions, hernia, foreign body, IBD, volvulus, fecal impaction, intussusception, diverticulitis, colorectal cancer)
Non-mechanical = absent or reduced peristalsis (narcotics, post-op, neuro, hypokalemia, infections)
MC small = surgical
MC large = fecal impaction, diverticulitis, cancer
bowel obstruction
PE:
Signs of dehydration (tachy, orthostatic HOTN, reduced urine output, dry mucous membranes)
Fever (perf)
Abdominal distention
Bowel sounds – high pitched “tinkling” early on → absent/late nothing, visible peristalsis
Percussion = hyperresonance, fluid-filled loops with dullness
Palpation = generalized tenderness
Check for hernias!! If ruptured, peritoneal signs
DRE → fecal impaction or mass possible
Gross or occult blood = tumor, ischemia
Labs:
CBC (leukocytosis, anemia)
BMP (electrolyte abnormalities, BUN/Cr)
Mag
ABG, serum lactate (high = bowel is dying), cultures
UA
bowel obstruction
Plain XR: dilated loops of bowel with air-fluid levels in a “step-ladder”
Look for pneumoperitoneum
CT w/ IV contrast distinguishes paralytic ileus from mechanical obstruction w/ transition zone
– diameter >10-12cm ass w/ risk of perforation
bowel obstruction
how do you treat bowel obstruction
Admit to hospital → strict NPO, no narcotics or NSAIDs
Antiemetics – watch for hypokalemia
IV fluids
Correct electrolyte issues (K>4, Mg>2)
Decompress bowel (NG tube with suction)
IV steroids if IBD
Consult surgery
If strangulated hernia or acute abdomen = surgery right away
Mild, diffuse continuous abdominal discomfort, N/V, distention with minimal abdominal tenderness
NO signs of peritoneal irritation
acute paralytic ileus
RF for:
Hospitalized patients with intra abdominal processes, severe medical illness, or medications that affect intestinal motility
Post-operative
Opioids
Hypokalemia
Hypercalcemia
Hypothyroidism
acute paralytic ileus
Neurogenic failure/loss of peristalsis in the absence of any mechanical obstruction
ileus
how is risk reduced for ileus
minimally invasive surgery, patient-controlled analgesia, avoidance of opioids, early ambulation, gum chewing, clear liquid diet
PE: bowel sounds diminished-absent
Abdominal distention and tympany
Labs attributable to underlying condition
→ obtain serum electrolytes, Mg, phosphorus, Ca
Plain film = distended gas-filled loops of small + large intestine (looks like small bowel obstruction) w/o transition zone
CT scan to differentiate
paralytic ileus
how do you treat paralytic ileus
Treat underlying cause
– restriction of oral intake w/ slow re-introduction
May require NG suction + IV fluids and electrolytes
Alvimopan – reverses opioid-induced inhibition of intestinal motility, when post-op opioid therapy is indicated
Extraintestinal manifestations = spondylitis, oral ulcers, uveitis, erythema nodosum, hepatitis
common in Adolescents and adults <40 years
15-35 onset
Ashkenazi Jews
IBD
Easily misdiagnosed–
Fever, chills, change in well-being, weight loss, abdominal pain, bloating, cramping, borborygmi, diarrhea, prior surgical resections, rectal bleeding, tender abdominal mass, fatigue
Fistulae, recurrent UTIs if between intestine and bladder
Perianal disease = large, painful skin tags, anal fissures, abscesses, fistulas
Extraintestinal: arthralgias, arthritis, oral aphthous ulcers, iritis/uveitis, erythema nodosum, pyoderma gangrenosum, gallstones and kidney stones
crohn’s disease
What are RFs for crohn’s disease
Smoking
15-35y
RF for aggressive disease:
Young age
Early need for steroids
Perianal disease, fistulizing or structuring disease, upper GI
Lab markers of severe inflammation
Endoscopic findings of deep ulceration
Transmural disease → anywhere in GI tract, MC in terminal ileum and proximal colon & skip areas of involvement
– can cause fistulas, bowel strictures, perianal disease, abscesses
Dx made based on clinical picture w/ supporting evidence
crohn’s disease
What are IBD medication classes?
5-ASA (sulfasalazine, mesalamine)
corticosteriods (budesonide, prednisone)
immunomodulators - thiopurines, methotrexate, janus kinase inhibitors (-mab), sphingosine 1 phosphate receptor modulators -mod)
biologic therapies - anti-TNF (infliximab, adalimumab, golimumab, certolizumab)
anti-integrins (vedolizumab)
anti-IL 12/23 (ustekinumab)
patients w/ IBD have an increased risk of vaccine-preventable infections so what should you do?
confirm vaccination status
inactivated vaccines - hep a, b, shingles, influenza, dTAP (safely administered with immunosuppression)
pneumococcal vaccine in >65
live virus should never be administered while taking immunosuppressive drugs
CBC: anemia, B12 deficiency, possible leukocytosis
CMP: albumin
CRP/sed rate
Fecal calprotectin → active inflammation
Stool cultures
Endoscopy = “skip lesions” and cobblestone appearance with aphthous, linear or stellate ulcers, strictures, segmental involvement (large or deep = higher risk)
Upper GI: string sign
Granulomas on biopsy
CT, MR enterography, capsule imaging, upper GI w/ SBFT
crohn’s disease
surgery indications for crohn’s disease
Poor response to medical therapy
Intraabdominal abscess
Massive bleeding
Internal or perianal fistulas
Intestinal obstruction
admit a crohn’s disease patient if
Intestinal obstruction
Abscess is suspected
Serious infectious complication
Severe diarrhea, dehydration, weight loss, or abdominal pain
Severe or persistent symptoms despite steroids
High fever, persistent vomiting, severe abdominal tenderness
How do you treat a mild/low risk crohn’s disease?
Nutrition
Well balanced diet, smaller, more frequent meals, fluids, avoid fried/greasy foods, trial off dairy
Loperamide for diarrhea PRN up to 4x
Drug therapy based on location of involvement
Terminal ileum or ascending colon disease = extended-release budesonide (steroid)
Left sided or diffuse = oral steroids (prednisone/prednisolone) and taper, sulfasalazine (5-ASA)
what is considered mild/low risk crohn’s disease
mild symptoms, no significant weight loss, normal or only mildly elevated inflammatory markers, absence of intestinal complications, limited intestinal involvement:
