Ileitis, Colitis, and Diverticulitis Tintinalli Chap. 81
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Ileitis, Colitis, and Diverticulitis Tintinalli Chap. 81 Presentation Transcript

  • 1. Ileitis, Colitis, and DiverticulitisTintinalli Chap. 81
    Nicholas Cardinal, DO
  • 2. Crohn Disease
    Also called regional enteritis, terminal ileitis, and granulomatousileocolitis
    Chronic granulomatous inflammatory disease of the the GI tract
    Can affect any part of the GI tract from mouth to anus
    20% confined to colon
    30% confined to small bowel
    50% both small and large bowel
    Mouth, esophagus, or stomach affected in a small percentage
    Exact cause unknown
    Environmental, genetic, infectious, autoimmune
  • 3. Epidemiology
    Peak incidence at 15-22 years old
    Secondary peak at 55-60
    Women have a 20-30% increased risk
    Common in those of European descent
    4 times more common in Jews
    Familial
    Often have family hx of IBS or UC
  • 4. Pathology
    Involves all layers of the bowel wall with extension into mesenteric lymph nodes
    Discontinuous “skip areas”
    Longitudinal, deep ulcerations penetrating bowel wall
    Fissures
    Fistulas
    Abscess
    Cobblestone appearance is a late finding
    d/t criss-crossing of longitudinal ulcers
  • 5. Clinical Features
    Abdominal pain
    Anorexia
    Diarrhea
    Weight loss
    Fever
    1/3 develop perianal fissures, fistulas, abscesses, or rectal prolapse
  • 6. Extraintestinal Manifestations
    Arthritic
    Peripheral arthritis
    Ankylosingspondylitis
    sacroiliitis
    Dermatologic
    Erythemanodosum
    Pyodermagangrenosum
    Hepatobiliary
    Pericholangitis
    Chronic active hepatitis
    Primary sclerosingcholangitis
    Cholangiocarcinoma
    Cholelithiasis
    Fatty liver
    pancreatitis
    Ocular
    Episcleritis
    Uveitis
    Vascular
    Thromboembolic disease
    Vasculitis
    Arteritis
    Malnutrition
    Chronic anemia
    Nephrolithiasis
    Myelodysplastic disease
    Osteomyelitis
    Osteonecrosis
    Growth retardation in children
  • 7. Complications
    75% of patients will require surgery within 20 years of symptom onset
    Abscess
    Occur in 30%
    Abdominal pain/tenderness, fever
    May have palpable mass
    Retroperitoneal abscess may cause hip/back pain and difficulty ambulating
    Fistulas
    Result of extension of intestinal fissures into adjacent structures
    Most are between the ileum and sigmoid, cecum, or skin
    Enterovesical fistulas are rare
  • 8. Complications
    Perianal
    1/3 of patients with Crohns
    Fissures
    Abscesses
    Fistulas
    Rectal prolapse
    GI bleeding
    Only 1% develop life-threatening hemorrhage
    Most are patients who develop toxic megacolon
  • 9. Complications
    Obstruction
    Caused by stricture formation and bowel wall edema
    Distal small bowel is most common
    N/V
    Crampy abdominal pain
    Distention
    Malnutrition
    Malabsorption
    Hypocalcemia
    Vitamin deficiency
    Malignant neoplasm
  • 10. Complications
    Medication side-effects (sulfasalazine, steroids, immunosuppressants)
    Leukopenia
    Thrombocytopenia
    Fever
    Infection
    Profuse diarrhea
    Pancreatitis
    Renal insufficiency
    Liver failure
  • 11. Differential
    General Population
    Lymphoma
    Ileocecalamebiasis
    Sarcoidosis
    Deep chronic mycotic infections
    GI tuberculosis
    Kaposi’s sarcoma
    Campylobacter enteritis
    Yersiniaileocolitis
    Elderly
    Ischemic bowel disease
    Pseudomembranousenterocolitis
    Ulcerative colitis
  • 12. Diagnostics
    Diagnosis is usually made months-years after onset of symptoms
    Plain radiograph
    Obstruction, perforation, or toxic megacolon
    Upper GI series
    Air-contrast barium enema
    Colonoscopy
    Diagnostic or surveillance for colon cancer
    Rectal sparing with involvement of proximal colon
  • 13. Diagnostics
    CT
    Acute symptoms in patients with known crohns
    Bowel wall thickening
    Mesenteric edema
    Abscess formation
    Extraintestinal manifestation
    Gallstones
    Renal calculi
    Hydronephrosis
    Sacroileitis
    osteomyelitis
  • 14. Treatment Goals
    Longterm
    Symptom relief
    Remission induction
    Remission maintenance
    Complications prevention
    Optimizing timing of surgery
    Nutrition maintenance
    ED
    Evaluate severity of attack
    Identify significant complications
    Obstruction
    Intraabdominal abscess
    Life-threatening hemorrhage
    Toxic megacolon
  • 15. Treatment
    Fluid resuscitation
    Restoration of electrolyte balance
    NG decompression
    Obstruction, peritonitis, toxic megacolon
    Broad-spectrum antibiotics
    Fulminant colitis or peritonitis
    Ampicillin, aminoglycoside, and metronidazole
    IV steroids
  • 16. Treatment
    Sulfasalazine (Azulfidine)
    Used in mild-moderate active disease
    Many intolerable side-effects
    N/V
    Anorexia
    Epigastric distress
    Arthralgias
    Headache
    Diarrhea
    Male infertility
    Hypersensitivity reactions
    Pericarditis, pleuritis, pancreatitis, arthritis, rash
  • 17. Treatment
    5-aminosalicylic acid derivatives
    Most effective in colonic disease
    Pentasa
    Asacol
    Claversal
    Salofalk
    Olsalazine (Dipentum)
    Balsalazide (Colazide)
    Oral glucocorticoids
    Effective primarily in small bowel disease
  • 18. Treatment
    Immunosuppressive agents
    6-mercaptopurine (6-MP)
    Azathioprine
    Cyclosporine
    Methotrexate
    Side effects
    Leukopenia
    Fever
    Hepatitis
    pancreatitis
  • 19. Treatment
    Infliximab (Remicade)
    Anti-TNF antibody
    Must screen for TB as can ppt active disease
    CDP571 (Cellcept)
    Etanercept
    Thalidomide
    Interleukin
  • 20. Treatment
    Diarrhea
    Loperamide (Imodium)
    Diphenoxylate (Lomotil)
    Cholestyramine (Questran
    Consultation
    Gastroenterology
    Surgery
  • 21. Ulcerative Colitis
    Chronic inflammatory disease of the colon
    Tends to be progressively more severe from proximal to distal colon
    Rectum is involved in nearly 100% of cases
    Usually present with bloody diarrhea
    Unknown etiology
  • 22. Epidemiology
    Higher prevalence in US and northern Europe
    Peak incidence in 2nd and 3rd decades
    Slight predominance in men
    Familial
    First-degree relatives have 15-fold increased risk of ulcerative colitis and 3.5-fold increased risk of Crohn disease
  • 23. Pathology
    Primarily involves the mucosa
    Mucosal inflammation with crypt abscesses, epithelial necrosis, and mucosal ulceration
    Early findings
    Finely granular, friable
    Severe disease
    Spongy with small ulcerations oozing blood and purulent exudate
    Very advanced disease
    Large, oozing ulcerations
    pseudopolyps
  • 24. Clinical Features
    Mild (60%)
    80% are limited to rectum
    Less than 4 bowel movements per day
    No systemic symptoms
    Few extraintestinal manifestations
    Usually present with constipation and rectal bleeding
    10-15% progress to pancolitis
    Moderate (25%)
    Colitis usually extends to splenic flexure
    Good response to therapy
    Severe (15%)
    Frequent bowel movements
    Frequent extraintestinal manifestations
    Clinical findings may include anemia, fever, weight loss, tachycardia, and low serum albumin
  • 25. Clinical Course
    Intermittent attacks of acute disease with complete remission between attacks
    Some have chronically active disease
  • 26. Complications
    Hemorrhage
    Perirectal fistulas/abscesses
    Obstruction
    Acute perforation
    Carcinoma
    10-30- fold increase risk
    5-10% at 20 years
    12-20% at 30 years
    Requires periodic colonoscopies and biopsies
    Begin 8-10 years after onset
  • 27. Complications
    Toxic Megacolon
    Advanced cases when disease extends through all layers of the colon
    Results in loss of muscular tone, dilatation, and localized peritonitis
    Can perforate causing septicemia
    Mortality rate ~10%
    50% if perforation occurs
    Precipitating factors may include antidiarrheal agents, narcotics, cathartics, enemas, pregnancy, recent colonoscopy, and hypokalemia
  • 28. Complicatons
    Toxic Megacolon
    Clinical Features
    Patients appear severely ill
    Distended, tender, tympanic abdomen
    Severe diarrhea
    Fever
    Tachycardia
    Hypovolemia
    Diagnostics
    Plain radiographs
    Air filled segment of the colon > 6cm in diameter
    Loss of haustra
    “Thumbprinting”
  • 29. Complications
    Toxic Megacolon
    Treatment
    NG suction
    IV steroids
    IV fluids
    Broad-spectrum antibiotics
    Early surgical consult
  • 30. Diagnostics
    CBC
    Leukocytosis, anemia, thrombocytosis
    Hypoalbuminemia
    Abnormal LFT’s
    Negative stool culture/O&P
    Sigmoidoscopy
    Barium enema
    Differentiates UC from Crohn disease
    Defines extent of involvement
    Colonoscopy
    Most sensitive
    Biopsy differentiates acute vs. chronic disease and underlying causes
    Findings include granular, friable, ulcerated mucosa; pseudopolyps in advanced disease
  • 31. Differential
    Infectious colitis
    Crohn colitis
    Ischemic colitis
    Radiation colitis
    Toxic colitis
    Secondary to chemotherapy
    Pseudomembranous colitis
    Gay bowel disease
    Limited to rectum
    Rectal syphilis
    Gonococcalproctitis
    Lymphogranulomavenereum
  • 32. Treatment
    Severe
    IV steroids
    IV fluids
    Correction of electrolyte imbalance
    Broad-spectrum antibiotics
    Ampicillin plus clindamycin or metronidazole
    Hyperalimentation
    NG suction
    Toxic megacolon
    Mild/Moderate
    Oral glucocorticoids
    5-aminosalicylic acid enema
    Rowasa
    Topical steroid preparations
  • 33. Treatment
    Other agents
    Sulfasalazine
    Maintenance of remission
    5-aminosalicylic acid derivatives
    Induction and maintenance of remission
    Immunomodulators
    6-mercaptopurine (6-MP)
    Azathioprine
  • 34. Treatment
    Supportive therapy
    Iron supplementation
    Lactose-free diet
    Psyllium (Metamucil)
    Rest
    Antidiarrheals can precipitate toxic megacolon and are generally ineffective
  • 35. Disposition
    Mild/Moderate
    May be discharged with close follow-up
    Severe
    Admit
    Consultation
    Gastroenterology
    Surgery
  • 36. Pseudomembranous Colitis
    Inflammatory bowel disorder
    Membrane-like yellowish plaques of exudate overlie and replace necrotic mucosa
    Caused by Clostridium difficile
    3 syndromes
    Neonatal
    Postoperative
    Antibiotic-associated
  • 37. Clostridium difficile
    Spore-forming obligate anaerobic bacillus
    Produces two toxins
    Toxin A: enterotoxin
    Toxin B: cytotoxin
    Transmission via direct human contact or contact with inanimate objects
  • 38. Pathophysiology
    Inpatients are colonized in 10-25% of cases
    Antibiotics
    Usually begins 7-10 days after initiation but may begin within a few days or several weeks
    Clindamycin
    Cephalosporins
    Ampicillin/amoxicillin
    Contributing factors may include recent bowel surgery, bowel ischemia, shock, malnutrition, uremia, and Hirschsprung disease
  • 39. Clinical Features
    Vary from frequent, mucoid, water stools to toxic picture including profuse diarrhea, crampy abdominal pain, fever, leukocytosis, dehydration, and hypovolemia
  • 40. Complications
    Severe electrolyte imbalance
    Hypotension
    Anasarca
    Toxic megacolon
    Perforation
    Extraintestinal
    Arthritis
    Visceral abscesses
    Cellulitis
    Necrotizing fasciitis
    Osteomyelitis
    Prosthesis infection
  • 41. Diagnosis
    History
    C. difficile toxin
    Colonoscopy
    Yellowish plaques
    Typically limited to right colon
  • 42. Treatment
    Discontinue antibiotic
    IV fluids
    Correction of electrolyte imbalance
    Antidiarrheals may prolong or worsen symptoms
    Antibiotics
    Metronidazole 250mg QID
    Vancomycin 125-250 QID
    Alternative therapy for resistant cases, pregnant women, and children
  • 43. Disposition
    Admit
    Severe diarrhea
    Systemic response
    Fever
    Severe abdominal pain
    leukocytosis
    Consult surgery
    Toxic megacolon
    Perforation
  • 44. Diverticulitis
    Acute inflammation of the wall of a diverticulum and surrounding tissue
    Caused by micro- or macroperforation
  • 45. Epidemiology
    Rare under age 20
    Incidence increases with age
    1/3 have diverticular disease by age 50
    2/3 by age 85
    Diverticulitis occurs in 10-25% of patients with diverticular disease
    Higher incidence in men but increasing in women
  • 46. Diverticular Disease
    False diverticula
    most colonic diverticula
    Do not include all layers of the bowel wall
    Consist of mucosa and submucosa with a peritoneal covering that has herniated through a defect in the muscular layer
    Occur between the mesenteric and antimesenterictaenia
    True diverticula
    Occur in the cecum
  • 47. Pathophysiology
    Cause is unknown
    Lowe residue diets producing high intraluminal pressures
    Most occur in the sigmoid
    Narrowist portion of the colon
    Pressure is greatest where lumen is narrowist
    Laplace’s law
  • 48. Complications
    Inflammation
    Bleeding
    Perforation
    Obstruction
    Fistulas
    Diverticula and bladder in males
    Diverticula and vagina in females
  • 49. Clinical Features
    May be indistinguishable from acute appendicitis
    Steady, deep LLQ pain
    Change in bowel habits
    Tenesmus
    Urinary frequency, dysuria, pyuria
    Recurrent UTI’s
    Suspect fistula
  • 50. Clinical Features
    Low-grade fever
    Localized tenderness
    Guarding
    Rebound tenderness
    Palpation of a LLQ mass
    Rectal tenderness
    Perforation presents with diffuse abdominal tenderness, guarding, rigidity, and rebound tenderness
  • 51. Diagnostics
    Acute abdominal series
    May be normal
    Ileus
    Partial SBO
    Free air
    Extraluminal collections of air
    Abdominal ultrasound
    Abdominal CT
    Inflammation of pericolic fat
    Presence of diverticula
    Thickening of bowel wall
    Peridiverticular abscess
    Barium contrast studies
    Can precipitate perforation
    Sigmoidoscopy/colonoscopy
    Performed after acute inflammation
    r/o colon cancer
  • 52. Treatment
    IV fluids
    Correction of electrolyte abnormalities
    NPO
    NG suction
    Ileus or obstruction
    Broad-spectrum antibiotics
    Inpatient
    Aminoglycoside
    Plus metronidazole or clindamycin
    Outpatient
    Ampicillin, TMP/SMX, ciprofloxacin, or clindamycin
    Plus metronidazole or clindamycin
  • 53. Disposition
    Admit
    Signs and symptoms of infection
    Failed outpatient management
    Signs of localized peritonitis
  • 54. Questions?