Colon Disorders and GI Neoplasms

1. Tory Davis PA-C January 2010 Colon Disorders and GI Neoplasms

2. Colon Disorders Anorectal Disorders Fissure Fistula Hemorrhoid IBS- Irritable Bowel Syndrome Diverticular Disease IBD- Inflammatory Bowel Disease Crohn’s disease Ulcerative Colitis

3. GI Neoplasms Esophageal Stomach Colorectal / anorectal Pancreatic Hepatic

4. Anal Fissure Acute longitudinal tear or chronic ovoid ulcer in anal epithelium. Located posterior or anterior midline. Pain, severe with defecation Sometimes bleed Often result from laceration with secondary infection. Pain  internal sphincter spasm decreased blood supply perpetuating fissure

5. Anal Fissure Tx Reduce local trauma: stool softener, fiber Protect: zinc oxide, glycerin suppository Relieve pain: topical anaesthetic (benzocaine, lidocaine), warm sitz bath Surgical (last choice)‏ - internal sphincterotomy

6. Anorectal Fistula Tube-like tract with one opening in anal tract and other in perianal skin Usually a chronic condition arising from acute perirectal abscess Constant to intermittent drainage of purulent or serosanguinous fluid +/- pain, depends on if infected Exam 1+ openings, +/- palpable cordlike tract. Probe to see depth, direction Tx: Surgical- deroof or seal with fibrin glue

7. Hemorrhoids Aka “Piles” Dilated veins of hemorrhoidal plexus in lower rectum Dentate line divides internal from external hemorrhoids Locations: L lateral, R anterior, R posterior zones Often asymptomatic, sometimes itching or protrusion. External: can thrombose. Ow! Internal: often bleed after BM

8. Hemorrhoids Internal- graded I- IV I – remain internal II – prolapse with strain, reduce spontaneously III. Require manual reduction after BM IV. Won’t go back

9. Thrombosed Hemorrhoid Results in perianal hematoma Acute onset of exquisite pain Firm blue/purple perianal nodule Tx with sitz baths, analgesics If able in 1st 24-48h, excision gives immediate relief

10. Tx Non-thrombosed hemorrhoids Symptomatic Sitz baths Witch hazel compress phenylephrine 0.25% (Preparation H) Anesthetic oint Surgical: photocoag, rubber band ligation, hemorrhoidectomy

11. Irritable Bowel Syndrome

12. Irritable Bowel Syndrome Poorly understood, but real. Characterized by recurrent upper and lower GI sx, varying abd pain, constipation and/or diarrhea, abd bloating

13. IBS Pathophys No consistent motility abnormality Some pts demonstrate abnl gastrocolic reflex with  colonic activity Maybe  gastric emptying But even in demonstrated abnormality, sx don’t correlate Excess mucus production even in absence of mucosal injury

14. More pathophys Hypersensitivity to normal amounts of intraluminal stretch.  perception of pain with normal amounts of intestinal gas Can be exacerbated by hormonal fluctuations (incr prostaglandins with menses causes more pain)

15. IBS S & S Abdominal pain related to or relieved by defecation Change in stool frequency and/or consistency Mucus in stool Sensation of incomplete evacuation

16. S & S Onset teens or 20s Irregular, recurrent bouts Sx usually do NOT affect sleep Sx are triggered by stress, also by some foods Varies per patient

17. Extra-intestinal sx Fibromyalgia Headache Dyspareunia TMJ syndrome Anxiety Depression

18. Constipation predominant Constipation alternates with nl BMs Clear-white mucus Colicky or dull constant pain Often relieved by BM Eating may trigger sx Bloating, flatulence, eructation, nausea, dyspepsia, heartburn

19. Diarrhea predominant Diarrhea immediately after eating, especially after rapid eating Pain, bloating, rectal urgency Incontinence happens

20. Differential Diagnosis Lactose intolerance Diverticular dz Drug induced Drug abuse Biliary tract dz Bacterial enteritis Parasites Early IBD Ischemic colitis, esp if age > 60 Hypothyroid Malabsorption syndromes

21. Rome Criteria Standardized sx-based criteria for dx Three months of the following sx: Abdominal pain/discomfort relieved by defecation or assoc with change in freq/consistency of BM Disturbed defecation involving at least 2 of these: Altered stool frequency, form or passage Passage of mucus Bloating or feeling of abdominal distention

22. Red Flags Onset after age 50 Weight loss Progressive dysphagia S/S bleeding or dehydration Steatorrhea Recurrent vomiting Fever  ESR or CRP Anemia, leukocytosis Hypokalemia Strong FHx colon cancer Blood or pus in stool

23. Physical exam Patient appears healthy Abd +/- tender, esp LLQ Possibly palpable tender sigmoid Nl DRE- no occult blood Females: nl pelvic exam (r/o ovarian tumor/cyst, infection, endometriosis)‏

24. IBS testing ONLY if objective abnormalities: consider abd US or CT, barium enema Stool cx, O&P - ONLY if supporting travel hx or fever, hematochezia or acute onset of diarrhea

25. IBS tx Sympathetic understanding, patience, explain condition and address fears Diet: Normal, moderate sized meals eaten slowly.  gas-producing food. Consider  lactose Eliminate sorbitol, mannitol in pts with diarrhea Dietary fiber to bulk up and soften stool, but start low, go slow or you’ll worsen sx ID stressors, mood d/o, or anxiety and address them

26. IBS Drugs Anticholinergics to reduce spasm Serotonin receptor modulators

27. IBS Drugs Loperamide (Immodium) for diarrhea TCAs for bloating, constipation, abd pain Down-regulates spinal cord and cortical afferent pathways from intestine Peppermint- relaxes smooth muscle spasm. Significant improvement in clinical studies. Ginger- digestive aid Aloe vera for constipation Fennel – reduces bloating.

28. Crohn’s Disease Ulcerative Colitis Inflammatory Bowel Disease

29. IBD 2 distinct disease entities Only about 10% are “indeterminate colitis” Usually fairly easy to differentiate Both Cause bloody diarrhea Are characterized by chronic, relapsing and remitting inflammation of various sites of the GI tract Have inflammation from cell-mediated immune response in GI mucosa

30. IBD Epi Gender equal, all ages, but peak incidence ages 14-24 UC has 2nd peak 50-70 Most common in people of N. European or Anglo-Saxon origin. 1st degree relatives 4-20x increased risk Smoking increases Crohn’s risk, but decreases risk of ulcerative colitis

31. IBD Extra-Intestinal Manifestations Common to BOTH Crohn’s and UC 1. Disorders which parallel IBD flares Peripheral arthritis, episcleritis, aphthous stomatitis, erythema nodosum 2. Disorders probably resulting from IBD but appear independent of flares Ankylosing spondylitis, sacroiliitis, uveitis, primary sclerosing cholangitis. Can appear years before IBD sx, and should prompt eval for IBD!

32. IBD Extra-Intestinal Manifestations 3. Consequences of disrupted bowel physiology (primarily seen in severe Crohn’s of small bowel)‏ Malabsorption (causing B12 and mineral deficiencies), anemia, clotting disorders, bone demineralization, kidney stones, hydroureter & hydronephrosis (from ureteral compression by inflammatory process)‏ Factors in all 3 categories can increase risk of thromboembolic disease

33. Crohn’s Disease

34. Crohn’s Disease Chronic transmural inflammatory dz, usually effects distal ileum and RIGHT colon, but can occuranywhere along GI tract Segmental rather than continuous (UC) Not symmetric Can have significant perirectal lesions, but rare rectal bleeding

35. Crohn’s pathophys Inflammation of crypts small abscesses & aphthoid ulcers which deep longitudinal and transverse ulcers with mucosal edema Transmural spread of inflam lymphedema, bowel wall thickening Severe inflam muscle hypertrophy, fibrosis, strictures (can cause obstruction)

36. Crohn’s pathophys Abscesses common, and resulting fistulas can penetrate nearby structures Bowel loops, bladder (can pee poop), psoas muscle (peritonitis sx), enterocutaneous Granulomas- Pathognomonic. Found in liver, lymph nodes, all layers of bowel wall

37. Crohn’s pathophys Discontinuous affected segments of bowel sharply demarcated from normal areas (“skip areas”)‏ Where is it? 35% ileum alone 45% ileum + colon <20% colon alone, usually spares rectum Uncommon in esoph, stomach, duodenum (but can be there)

38. Crohn’s S&S Chronic diarrhea w/ abd pain, fever, anorexia, wt loss Tender abdomen with mass or fullness Gross rectal bleeding RARE One third with significant perianal disease: fissures, fistulas, abscesses

39. Crohn’s S&S Can present w/ acute abd- looks like appendicitis or obstruction Recurrent disease sx vary- Pain common with simple recurrence and with abscess Severe flare: pt is SICK: marked tenderness, guarding, rebound Segmental stenosis can bowel obstruction with colicky pain, abd distention, vomiting Perforation not uncommon. Enterovesicular perf causes pneumaturia. Draining cutaneous fistulas

40. Crohn’s Dx To diagnose, you must first suspect! Suspect in pt w/ inflam or obstructive sx pts w/ perianal fistulas pts w/ unexplained arthritis, fever, anemia, erythema nodosum, kiddos with growth retardation

41. Work-up and Dx Pt presents w/ acute abd: flat & upright plain films, abd CT to find obstruction, abscess, fistula, and to r/o other cause (ie appendicitis)‏ Consider pelvis U/S for female with predom lower abd/pelvic sx

42. Work-up and Dx Less acute pres: GI series with small bowel follow-thru and spot films of terminal ileum Considered diagnostic if shows stricture, fistulas or separation of bowel loops

43. Work-up and Dx If symptoms predominantly colonic (ie diarrhea) Order barium enema which may show: Barium reflux into terminal ileum Irregularity and nodularity of bowel wall Wall stiffness and thickening Narrowed lumen Or colonoscopy with bx, sampling for enteric pathogens and visualization of terminal lumen

44. Labs CBC to monitor for anemia, leukocytosis CMP to monitor liver function, check for hypoalbuminemia, electrolyte abnormalities ESR, CRP- nonspecific, but useful serially to monitor disease status

45. Crohn’s Prognosis Rare cure Intermittent exac/remit Severe dz can be debilitating, severe pain and dysfunction Dz related mortality low, with most caused by GI cancers (small bowel, colon)‏

46. Ulcerative Colitis

47. Ulcerative Colitis Chronic, inflammatory, ulcerative disease arising in colonic mucosa, most often characterized by bloody diarrhea Only in the colon. Continuous, not segmental Symmetric Not perirectal. No abscesses. No fistulas.

48. UC Pathophysiology Begins in rectum Can remain localized (ulcerative proctitis), or extend to involve entire colon Inflammation affects mucosa and submucosa only, with sharp border between healthy/diseased tissue

49. More UC patho Fulminant colitis: transmural extension of ulceration (NB this is the only time UC is transmural)ileus & peritonitis Colon loses muscular tone and dilatesTOXIC MEGACOLON

50. UC- S&S Bloody diarrhea of varied intensity & duration. Asymptomatic periods Insidious onset of attack  urge to defecate Mild low abd cramps Blood/mucus in stools Can start s/p infection (ie amebiasis)‏