CLIN MED: Disorders of the Small Intestine

4 types of fistulas formed in Crohn's disease:

Enterovesical -intestine to bladder Enterocutaneous-intestine to skin Enteroenteric- intestine to colon Enterovaginal-intestine to vagina

T/F: You should perform a colonoscopy in patients with severe active UC or fulminant colitis.

FALSE. DON'T DO IT. Do a stool study 1st and rule out infection.

ALARM symptoms not associated with IBS:

-Onset after age 50 -Severe progressive pain -Anorexia or weight loss -Severe constipation -severe diarrhea -Nocturnal symptoms -Rectal bleeding -Fever

What are the risk factors of a small bowel obstruction?

-Prior surgery (adhesions) -Abdominal wall hernia -Neoplasm/tumor -history of radiation -chronic intestinal inflammation (IBD)

T/F: Greater than 80% of patients w/ Crohn's disease will require surgical intervention- even with treatment.

False. greater than 50%!

T/F: IBD is an acute and rarely recurring autoimmune disease.

False: IBD is a chronic, recurrent inflammatory process. (is autoimmune, though)

A malabsorptive disorder that is caused by an abnormal response to gluten is:

Celiac disease

Diarrhea, steatorrhea, flatulence, dyspepsia, weight loss, abdominal distention, weakness & muscle wasting, growth retardation in children are all clinical presentations of what disease?

Celiac disease

For what disease would your diagnostic work-up consist of serologic antibody tests - IgA TTGA, IgG DGB *levels become undetectable after 6-12 months of gluten free diet* and Vitamin/nutrient defieciencies

Celiac disease

What disease triggers an immune response that damages proximal small intestine mucosa and results in malabsorption of nutrients?

Celiac disease (Decreases SA)

3 conditions that have malabsorptive "fatty" diarrhea:

Celiac disease Lactose intolerance Bacterial overgrowth

How is the diagnosis of celiac disease confirmed?

EGD with duodenal mucosal biopsy

Gluten is a protein that is found in many ______ such as wheat, rye, barley, and flour.

grains

Risk factors of IBD include

Female - CD Male - UC M/C in Caucasions "western diet" Others = infection, obesity

What vitamin deficiency can manifest into megaloblastic, macrocytic anemia, glossitis, depression and confusion?

Folate

This condition is idiopathic and Chronic GI symptoms are NOT explained by the presence of structual/biochemical abnormality. Some preceding event usually occurs. -abnormal motility -visceral hypersensitivity -enteric infection -psychosocial

IBS (irritable bowel syndrome)

What disorder of the colon presents as Recurrent abdominal pain, at least one day per week, in the last 3 months with 2 or more of the following: (Rome IV criteria) related to defecation change in stool frequency change in stool form

IBS

Differential diagnoses for this condition include: -IBD -Celiac ds/Malabsorptive syndromes -chronic enteric infection (parasitic) -carcinoma -systemic disorders (thyroid ds,DM) -psychiatric disorders

IBS (irritable bowel syndrome)

What condition's epidemiology is MC in women and has an initial onset in late teens, early twenties?

IBS (irritable bowel syndrome)

Antispasmodics, antidiarrheal agents, laxatives, psychotropic agents, *linaclotide (Linzess) and lubiprostone (Amitiza)* are pharmacologic therapies for this condition/disorder:

IBS irritable bowel syndrome

Ways to manage this disorder include: patient support & education food dairy & dietary modification -avoid gas producing foods -low FODMAP diet -fiber supplements Behavioral therapy/relaxation techniques physical activity pharmacologic therapy

IBS irritable bowel syndrome

Manning criteria for IBS

in photo

3 types of biologics (TNF) inhibitors for IBD are:

infliximab (Remicade) -IV every 8 wks adalimumab (Humira) - self inject every 2 wks certolizumab (Olmizia)- self inject every 2 wks

How do you manage lactose intolerance?

lactose free diet lactase supplementation

Factitious diarrhea is caused by:

laxative abuse

Whipple disease is most common in (M/F)?

males -middle aged

What are the 2 most common places UC involves?

rectum and sigmoid colon *Works from bottom-up*

What is the main difference in treatment between a mechanical obstruction and a POI?

Mechanical obstruction - TX is surgery POI - Tx is supportive measures

What kinds of things can cause a small bowel obstruction?

Mechanical obstruction - adhesions, tumors, strictures, and hernias

complications of ulcerative colitis

severe bleed fulminant colitis >10 BMs/day toxic megacolon perforation

3 differential diagnoses of crohn's disease:

ulcerative colitis, infectious colitis, trauma

What are the potential complications from a "massive" intestinal dilation?

Rupture

T/F: Corticosteroids are most effective to induce remission in severe acute flares. Use of this is for CD and UC.

True both CD and UC acute flares *prednisone* *budesonide (Entocort, Uceris)* MUST TAPER

Clinical manifestations of this disease are: Crampy lower abdominal pain bloody diarrhea diarrhea with pus/mucus fecal urgency and tenesmus fever, fatigue, weight loss anemia Arthritis, ankylosing spondylitis

Ulcerative colitis

The diagnostic workup for this disorder consists of H/H, ESR, albumin-to determine severity of ds. The gold standard for diagnosis is a colonoscopy- where you would see continuous friable mucosa, edemetous with pus, bleeding and erosions. It may also contain pseudopolyps. What is it?

Ulcerative colitis

What has relapsing and remitting episodes of inflammation and is in the mucosal layer of the colon ONLY?

Ulcerative colitis

5-ASA or Aminosalicylates are indicated for induction and maintenence therapy of what ds?

Ulcerative colitis only Drugs in class = Sulfasalazine, Mesalamine

What vitamin deficiency can manifest into night blindness, xerophthalmia, and Bitot spots, with scaling, thickened skin and mucous membranes?

Vitamin A

chronic diarrhea decision diagram (KNOW)

chronic diarrhea (>14-30 days)

The gold standard to establish the diagnosis of Crohn's disease is:

colonoscopy

The 3 subtypes of IBS are:

constipation dominant, diarrhea dominant, mixed; unclassified *Can use Bristol stool form scale to help classify*

What is the epidemiology and etiology of celiac disease?

genetic predisposition -MC caucasions presents in childhood, early adulthood

What vitamin deficiency can manifest into rickets, osteomalacia, and hypocalcemia?

vitamin D

How do you manage celiac disease?

-Dietary supplements within first few weeks of treatment. (multivitamin) -support groups -AVOID Gluten -improvement of symptoms within 1-2 weeks

What is the treatment for paralytic ileus?

-treat underlying cause -*complete bowel rest (IV fluids/TPN & NG tube)* -slowly advance diet -Activity (walking) -Remove drugs that reduce intestinal motility

Mild-moderate active crohn's disease treatment: (3)

1. antibiotics 2. oral corticosteroids 3. immunomodulators

Differential diagnoses for Celiac disease (7)

1. lactose intolerance 2. food allergies/intolerances 3. whipple disease (rare) 4. IBS 5. IBD - crohn's ds 6. Infectious gastroenteritis 7. Zollinger-ellison

Transmural inflammation in crohn's disease can lead to: (4 things)

1. strictures 2. obstruction 3. fistulas 4. perforation

How would you treat a small bowel obstruction?

Admit to hospital IV fluids NPO NG tube- GI compression Surgery consult

2 types of immunomodulators/immunosuppressants used for IBD are:

Azathioprine (Imuran) Methotrexate (not effective in UC)

Secretory "watery" chronic diarrhea is caused by what (3)?

Bile salts chronic infections tumors (gastrinoma)

Tx chron's ds pharmocologic agents:

Biologic therapy + immunosupressant

Moderate-severe disease or refractory crohn's disease treatment (1):

Biologics/Anti-TNF therapy *especially w/ fistula present*

For a small bowel obstruction, the x-ray would look like "a stack of _____?"

Coins

The degree of obstruction/dilation can cause complications, such as:

Compromised perfusion (necrosis of bowel); severe N/V (hypovolemia); perforation

Osmotic laxative (PEG), LInaclotide (Linzess) and Lubiprostone (Amitiza) are for what type of IBS?

Constipation predominant IBS

What type of IBS is Limaclotide (Linzess) indicated for? What is the black box warning?

Constipation predominant IBS Do not use for patients under 18

What is a transmural inflammation of the GI tract with skip lesions that occurs in any part from the mouth to the anus?

Crohn's Disease *fistulizing and burrowing ds* *penetrates through GI tract wall*

3 conditions that have inflammatory (bloody) diarrhea are:

Crohn's Ds Ulcerative colitis Chronic infections

The clinical manifestations of this disease are: Crampy abdominal pain (RLQ) Diarrhea (intermittent, non-bloody) Weight loss, fatigue Signs/symptoms of small bowel obstruction, fistula formation, abscess perianal disease-fistulas, abscesses *Oral ds-aphthous ulcers* *Erythema nodosum* Arthralgia, arthritis, iritis, uveitis

Crohn's disease

Perianal disease is most commonly seen with which IBD?

Crohn's ds

Loperamide and Alosetron (Lotronex) are for what type of IBS?

Diarrhea predominant

Osmotic "watery" chronic diarrhea is caused by what 3 things?

Diet (sorbitol, lactose) Laxative abuse malabsorption

What type of IBS is Lubiprostone (Amitiza) indicated for? What are the contraindications?

Indicated: -Constipation predominant IBS in WOMEN -Chronic constipation Contraindicated: Diarrhea, GI obstruction

Ulcerative Colitis (UC) and Crohn's disease are 2 distinct disorders of what disease?

Inflammatory bowel disease (IBD)

Functional chronic diarrhea is caused by what condition?

Irritable bowel syndrome (IBS)

This clinical presentation consists of diarrhea, bloating, flatulence, and abdominal pain.

Lactose intolerance (lactase deficiency)

This syndrome most commonly occurs in post operative, vent dependant patients with severe electrolyte abnormalities and presents as a severely distended abdomen. It typically presents without pain.

Ogilvie syndrome

What is a spontaneous dilation of the cecum and proximal colon called?

Ogilvie syndrome

Mild-severe ulcerative colitis treatment (3):

Oral corticosteroids Oral mesalamine Immunomodulators

Clinical Presentations of this disorder are: N/V/obstipation Abdominal distension w/ tympany to percussion Diminished/Absent bowel sounds

Paralytic Ileus

What motility disorder is defined by a loss of peristalsis of the intestine?

Paralytic Ileus

The common causes for this motility disorder are surgery (abdominal and pelvic), peritonitis, medications, severe medical illness, & post infection.

Paralytic ileus

What kind of workup would you do for paralytic ileus? What are the differential diagnoses?

Plain abdominal x-ray Small bowel obstruction acute appendicitis, acute gastroenteritis, acute pancreatitis

Diagnosis of this condition would be a plain x-ray (upright and supine abdomen) and a CT.

Small bowel obstruction

On the physical examination of this condition, you should expect to see: evidence of dehydration (tachycardia, orthostatic hypotension, reduced urine output, dry mucus membranes, loss of skin turgor), abdominal distention and generalized tenderness with high pitched tinkling bowel sounds. What condition is it?

Small bowel obstruction

What condition presents as Sudden onset abdominal pain, abdominal distention, N/v/obstiaption?

Small bowel obstruction

What leads to progressive dilation of the intestine proximal to blockage?

Small bowel obstruction

What confirms the diagnosis of Crohn's disease via colonoscopy?

The presence of "skip areas" with a "cobblestone" appearance. (transmural fistulizing ds) May also see pseudopolyps and granulomas.

Mild-moderate active ulcerative colitis treatment: (3)

Topical mesalamine (Rowasa enema) -most effective Hydrocortisone suppository -less effective- cheaper Oral corticosteroids -only if unresponsive to 1st 2 therapies

Severe abdominal distention, fever, elevated WBC & ESR, HR >120, dehydration, hypotension are all clinical presentations of what complication of UC?

Toxic megacolon

Treatment for ogilvie sydrome is:

Treat the underlying cause -Complete bowel rest --- IV fluids/TPN ----NG tube slowly advance diet Activity (walk) Remove drugs that reduce intestinal motility

What is whipple disease caused by?

Tropheryma whippeli (bacterial infection)

T/F: Crohn's ds may require at least one of these surgical procedures: Resection, abscess drainage/removal, fistulectomy

True

What vitamin deficiency can manifest into megaloblastic, macrocytic anemia, loss of vibration sense, confusion, delirium, paranoia?

Vitamin B12

Deficiency in this vitamin can manifest into peripheral neuropathy, depression, confusion, seizures, glossitis, and cheilosis.

Vitamin B6

What vitamin deficiency can manifest into scurvy, gingivitis, petchial rash, impaired wound healing, infections, fatigue, depression, arthralgias?

Vitamin C

What vitamin deficiency can manifest into hemolytic anemia and retinopathy?

Vitamin E

What vitamin deficiency can manifest into bleeding due to lack of clotting factors: prothrombin (II), VII, IX, X and prolonged PT, INR?

Vitamin K

This disease presents as: fever, arthralgias, LAN, weight loss, chronic diarrhea, steatorrhea, flatulance, and can progress to neurologic involvement.

Whipple disease

Treatment for this disease includes Ceftriaxone x 2 wks, then bactrim x 12 months. Without treatment, this disease can be fatal or cause permanent neurologic defects.

Whipple disease

You would diagnose this disease with an EGD and biopsy; on microscopy- macrophages containing gram-positive bacilli (PAS positive macrophages). A PCR would confirm the diagnosis. What disease is it?

Whipple disease

The most common symptoms of bacterial overgrowth are:

abdominal distention, flatulence, diarrhea, weight loss

When does celiac disease typically present?

childhood, early adulthood

Diagnostic workup for IBS:

don't really need tests - just relieve stress if thinking it may be another differential... If one or more ALARM symptoms present = Abdominal CT or colonoscopy

Skin disorders seen with Crohn's disease (2)

erythema nodosum pyoderma gangrenosum

ATYPICAL symptoms of celiac disease include:

fatigue, depression iron-deficiency anemia, vitamin B12 or folate deficiency, osteoporosis, bone pain, amenorrhea, infertility, easy bruising, peripheral neuropathy, ataxia, dermatitis herpetiformis

causes of bacterial overgrowth

gastric achlorhydria anatomic abnormalities with stagnation small intestine mobility disorder coloenteric fistulas immunologic or immune deficiency states

3 ways to manage UC:

monitor diet antidiarrheals PRN - chronic only; not acute flares Pharmacotherapy depends on location and stage of ds -may need surgery if severe and refractory

What is the cause of short bowel syndrome/small bowel resection?

removal of portion of small intestine due to crohn's ds, ischemia, tumor, or trauma

Treatment of this condition is with parenteral administration of vitamins and nutrients (IV)

short bowel syndrome/small bowel resection

The severity of Celiac disease depends on the amount of ________ intestine affected.

small intestine

The goal of treatment for UC is:

terminate acute flares prevent recurrences/complications

What is the goal of therapy in crohn's disease?

to provide symptomatic relief, shorten duration of acute flares, minimize complications -not curative