PANRE/PANCE – Gastroenterology part 6 – Diverticulosis/Diverticulitis, Ulcerative Colitis, Crohn’s Disease

by Isabella on June 21, 2012

Hi everyone, sorry for taking a few days to post this lecture.  I’ve had a crazy few days with the baby, he’s been kinda all over the place with his eating and sleeping :(  This lecture was written in parts over a 3 day course, and the topics are not even that long.  Anyways, I tried to focus this lecture on ailments that cause bloody stool or lower GI bleeding, as I think reading all the topics together may help you differentiate one from the other.  Unfortunately, I haven’t had time to draw out my funny recaps, so I guess I’ll owe you one extra recap on the next lecture :)  Happy Studying to all!

Diverticulosis:

  • Diverticula is outpouching (pocket) in the colon due to increase pressure
    • most occur in the descending and sigmoid colon
    • Risk factors:
      • low fiber diet – leading to chronic constipation which leads to outpouching in the colon
      • usually age over 40
  • Symptoms/Signs: 
    • painless bloody stool – pt will see blood in the toilet bowl – most common cause of lower GI bleed in elderly patients
    • occasionally patient will complain of fatigue
    • CBC – may show anemia – due to blood loss
    • on rectal exam – may note blood on finger or positive hemoccult card
  • Diagnosis:
    • CT scan is recommended to confirm
    • Colonoscopy – all patients with rectal bleeding especially over the age of 40 – r/o neoplasm
  • Treatment: high fiber diet to avoid constipation and prevent recurrent bleeding

Diverticulitis:

  • Diverticulitis: occurs when pockets get irritated/bloced by fecal matter and get inflamed, leading to pain
    • can get irritated by foods that are small and seedy: popcorn, tomatoes, nuts
  • Symptoms/Signs:
    • LLQ/suprapubic pain – acute and constant
    • pain with urination and frequent urination – inflamed pockets irritate the bladder
    • fever
    • nausea/vomiting
    • constipation or diarrhea – non-bloody
    • Tenderness LLQ
  • Diagnosis:
    • CBC – leukocytosis with left shift
    • UA – order to rule out UTI
    • Pregnancy test – in younger female
    • abd xray to make sure no free air – perforation
    • CT scan with PO and IV contrast – will show inflammation of diverticulae
    • NO barium enema or colonoscopy – risk of perforation and peritonitis
  • Treatment:
    • If mild  and patient is younger – can treat outpatient
      • bowel rest and fluids
      • Broad spectrum antibiotics
        • Metronidazole 500 mg tid x 10 days with Ciprofloxacin 500 mg bid x 10 days
        • Metronidazole 500 mg tid x 10 days with Trimethoprim Sulfamethaxazole DS bid x 10 days
        • SAugmentin 875/125 bid x 10 days
    • Complicated cases or elderly patients
      • Hospitatlization
      • IV fluids
      • NPO
      • IV abx
      • surgery may be required if there is an abscess or perforation
    • High fiber diet – I usually recommend daily fiber supplementation (metamucil, benefiber)
    • Avoidance of seeds, popcorn and nuts

Ulcerative Colitis:

  • Ulcerative colitis is a chronic inflammatory condition involving the colon
    • always involves the rectum and progresses proximally and continuously - can involve the whole colon
    • does not involve rest of GI tract
  • Symptoms/Signs:
    • Most common symptoms are bloody diarrhea, urgency and constant feeling of needing to pass stool (tenesmus)
    • Abdominal pain – usually LLQ if present
    • In more severe cases there will be fever and weight loss
    • more likely to cause colon malignancy than Crohn’s disease
    • smoking improved UC symptoms – pt’s have flare ups when they try to quit smoking
    • Associated with  - scleritis, arthritis, sclerosing cholangitis, erythema nodosum
  • Diagnosis: 
    • Labs:
      • Stool Culture, O&P, C diff A/B toxins – r/o infectious causes of bloody diarrhea
      • ESR – inflammatory marker – often elevated in UC – above 20
      • CBC – may show anemia or leukocytosis in more severe cases
      • Low Albumin
      • CMP – may show signs of dehydration
    • Studies:
      • Simoidoscopy/colonoscopy with biopsy are best study – will reveal that inflammation is only on superficial bowel wall
        • no invasive testing in acute disease flares
  • Treatment:
    • Topical (enema or suppository) or Oral Mesalamine (aminosalicylates)- depending on severity of disease
    • Oral/topical steroids
    • Immunomodulators – for non responsive disease
    • Complete Proctocolectomy – can be curative

Crohn’s Disease:

  • Crohn’s disease is an inflammatory condition of the gastrointestinal tract
    • Crohn’s disease rarely has rectum involvement (unlike UC which ALWAYS has rectal involvement)
    • It is not continuous and has what’s called a “skip lesion” appearance – it can skip parts of the GI tract
    • It is a Mouth to Anus condition – which means it can affect any area of the GI tract
    • smoking cessation improves symptoms (unlike UC)
  • Symptoms/Signs:
    • Abdominal pain, diarrhea, blood in stool
    • fever, joint aches, fatigue
  • Diagnosis:
    • CBC – anemia, elevated ESR
    • Colonoscopy/Endoscpy – best test – will reveal that lesions involve the whole wall of the bowel
      • cobblestone appearance and skip lesions
      •  avoid during acute flare for risk of perforation or toxic megacolon
  • Treatment:
    • Corticosteroids and aminosalicylates (Mesalamine)
    • Antibiotics for complications such as fistulas and fissures
    • Surgery is NOT curative – but resection of parts of the bowel are possible

 

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