Academic Half Day A Rounds Disorders of the Lower GI Tract

1. Academic Half Day A RoundsDisorders of the Lower GI Tract Marianne Yeung MD, CCFP(EM), FCFP October 10, 2013

2. Objective During this session, we will develop an approach to disorders of the lower GI tract re: • Diagnosis • Investigation • Treatment and Disposition

3. What Symptoms lead you to consider a LGIT disorder?

4. What Symptoms lead you to consider a LGIT disorder? • Abdominal pain • Change in stools +/- blood • Nausea/emesis • Decreased appetite

5. List potential Lower GI tract Diagnoses…

6. What are potential LGIT diagnoses? • Diverticulitis • Lower GI bleed • Large bowel obstruction / volvulus • Inflammatory Bowel Disease • Pseudo-obstruction / Ogilvie’s syndrome • Mesenteric ischemia

7. What are potential LGIT diagnoses? Anorectal disorders: • Hemorrhoids • Anal fissure • Anorectal abscess • Rectal foreign body

8. Case • Patient presents to ED with: • Abdominal pain - location • Change in stools • Nausea/emesis • Decreased appetite • Age 24, age 54, age 84

9. This could be anything! 1. Distinguishing features - age - specific signs and symptoms - predisposing factors e.g. family history 2. Diagnostic Tests - none, labs, imaging (XR, U/S, CT, other) 3. Treatment in ED and Disposition

10. Lower GI Diagnoses

11. Lower GI Diagnoses

13. Diverticulitis Distinguishing Features? (age, diet, symptoms) • Middle age, low fibre diet • Pain – often LLQ, or RLQ, +/- referred to pelvis, penis/scrotum • Bloody stools Pathophysiology? • Inflammation/infection of diverticular tissue • Chronic constipation/hard stools

15. Diverticulitis – Complications?

16. Diverticulitis – Complications? • Perforation • Obstruction • Abscess +/- rupture • Fistula

17. Diverticulitis – Diagnostic Tests Labs • CBC, SMA-7 – not super-helpful Imaging – what are you looking for? Which test? • X-ray - if suspect perforation or obstruction • U/S - tenderness on probing, fluid collections, diverticulae, operator-dependent • CT – best of all, if available

18. Diverticulitis - Treatment Diet • Liquid diet, then high fibre diet • No evidence for avoiding seeds Analgesia • Short-term narcotics

19. Antibiotics for Diverticulitis Which Organisms? • Gm negatives and anaerobes Which Antibiotics? • TOH: Ceftriaxone 1g iv q24h + metronidazole 500 iv/po q8h Cipro 500-750 po BID + metronidazole 500 po/iv q6-8h Clavulin 875 po q12h + metronidazole 500 mg po q8h • Septrapo BID + Flagyl 500 po q6h • Clavulin 1000/62.5 ii po BID po (all for 7-10 days) Maybe no antibiotics at all?

20. Diverticulitis - Disposition D/C home with instructions – return if… • Increased pain, bleeding, vomiting • Can’t tolerate po fluids and meds Admit or consult General Surgery if… • Complications – abscess, perforation • Failed/cannot tolerate outpatient po treatment • Poor social supports, co-morbidities Prognosis & follow-up… • Outpatient colonoscopy to r/o Ca • 1st episode diverticulitis - 95% are symptom-free for 2 years, and 80-90% symptom-free permanently • 2nd episode diverticultis – refer to outpatient General Surgery for possible elective resection

21. LGIB Etiology • Angiodysplasia • Diverticulitis • Cancer Admit/Consult Surgery

24. Large Bowel Obstruction Less common than Small Bowel Obstruction Distinguishing features? (age, clinical presentation) • Often middle-aged or elderly • May be sick – tachycardia, dehydration, fever • Tenderness, abdo mass Etiology? • Cancer • Volvulus • Diverticulitis • Abscess • Fecal impaction • Adhesions/strictures

25. Large Bowel Obstruction Diagnostic tests? • Usual labs to rule out other diagnoses • XR, CT Treatment and disposition? • Symptom relief / supportive - NPO, NG - iv hydration - iv analgesia - Electrolyte replacement • Transfer / consult General Surgery for admission

27. Volvulus Distinguishing features… • Clinically the same as any BO Pathophysiology? • Redundancy of bowel, mesentery twists on itself • Congenital? aging?

33. Volvulus - Imaging Diagnostic tests? Expected radiologic findings? • X-ray • Large dilated bowel loop • Empty quadrant depends on sigmoid or cecal location - Look for perforation • CT - if X-ray non-diagnostic

34. Volvulus - Treatment Treatment and Disposition all need immediate General Surgery consultation and admission How does Treatment differ between sigmoid and cecalvolvulus? Sigmoid – endoscopy to decompress and then self-detort Cecal – too proximal for endoscopy, so surgery to detort

35. What is Pseudo-obstruction/Ogilvie’s Syndrome? No physical obstructive lesion When do you suspect Ogilvie’s Syndrome to occur? • Narcotics • Severe acute co-morbid conditions e.g. trauma to spine or retroperitoneum severe electrolyte abnormality Etiology? • Malfunction of autonomic control, with change to bowel motility

36. Ogilvie’s Syndrome/ Pseudo-obstruction Diagnostic tests? • XR, CT to distinguish from true BO Treatment / disposition? • Bowel rest, hydration • General Surgery for colonoscopy or neostigmine • Operative treatment only if these fail

38. Inflammatory Bowel Disease Distinguishing features (pt characteristics and associated symptoms) • Young at onset <30yo • +/- Family hx • May be diffuse, intermittent disease (Crohn’s) vscontinuous, large bowel only (Ulcerative Colitis) • Extraintestinal symptoms – skin, eyes, joints

39. Inflammatory Bowel Disease Increased pain, bleeding, fever may signal IBD complications such as… • Fistula • Abscess • Stricture • Toxic megacolon • Perforation

40. Inflammatory Bowel Disease Diagnostic tests? • Labs – WBC, Hb • XR to r/o complications • Almost always need CT to r/o complications Treatment and Disposition • Mostly medical management – 5-ASA, steroids, antibiotics, anti-metabolites, consult GI liberally • Consult General Surgery if obstruction, perforation, leaking anastamosis

41. Colonic Ischemia Distinguishing features (symptoms and signs) • May not have a lot of pain! • If peritonitis, fever, high WBC – likely has progressed to perforation and gangrene Predisposed patients? • Low flow state • Older patients - CHF, vasoactive drugs, atherosclerosis, renal failure, CV surgery • Younger patients - collagen vascular disease, hematological disorders, distance runners, cocaine users

42. Colonic Ischemia Diagnostic tests • Labs – not great utility – lactate, ALP, phosphate may be increased • XR – thumbprinting=submucosal hemorrhage and edema (DDx – IBD, infection, hemorrhage) • CT • Colonoscopy best

43. Colonic Ischemia Treatment and Disposition • Consult Gen Surgery – admit, bowel rest, rehydration, broad-spectrum Abx • Treat hypotension – avoid pressors and steroids due to increased risk of perforation • Most do not require operative management

44. What Symptoms lead you to consider a disorder of the Anorectum? • Pain with defecation • Change in stools +/- blood • Lack of systemic symptoms • Usually no special diagnostic tests

45. Common Anorectal Disorders • Hemorrhoids • Anal fissure • Anorectal abscess • Rectal foreign body

46. Anorectal Diagnoses

47. Anorectal Diagnoses

49. Hemorrhoids Distinguishing features • Anal mass, pain, bleeding Treatment • WASH regimen = Warm water,Analgesics, Stool softeners, High-fibre diet • Sitz baths, topical treatments • Consider referral for lower endoscopy to rule out Ca

50. Internal Hemorrhoids Disposition - when to refer to Gen Surgery? • If 3rd degree internal hemorrhoid (manual reduction) or 4th degree (irreducible)