Ileitis, Colitis, and Diverticulitis Tintinalli Chap. 81


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Ileitis, Colitis, and Diverticulitis Tintinalli Chap. 81

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