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S2 E086 The Colon & Getting to the Right Answer

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Important Definitions

Abscess – a painful collection of pus, usually caused by a bacterial infection
Fistula – An abnormal connection between two body part
Stricture – A narrowing

Study tip for today.

Differentiate diagnosis and disease stats

Alright now on the large intestine.

Diverticular disease

  • Having diverticula or pockets in the colon
  • Diverticulitis is an inflammation of the diverticula
  • Endoscopy and colonoscopy are contraindicated in the acute setting due to risk of perforation

Clinical Presentation

  • Acute abdominal pain
  • Fever
  • Nausea and vomiting

Labs, Studies & Physical Exam Findings

  • Left lower quadrant tenderness
  • Palpable left lower quadrant mass
  • CBC with elevated WBCs
  • Often a positive fecal occult blood test
  • CT
  • Colonoscopy once symptoms have resolved in order to determine the extent of the diverticulosis

Treatment

  • Mild to moderate disease can be treated conservatively
    • Clear liquid diet
    • Oral antibiotics may be used
      • Metronidazole, Cipro, Augmentin
  • Severe disease
  • NPO
  • IV fluids
  • IV antibiotics
  • Surgery - Removal of diseased colon with a temporary colostomy
  • Education
    – Diet high in fiber and low in red meat

Ulcerative Colitis

  • An inflammatory bowel disease that involves only the mucosal surface
  • The rectum is always involved. The more proximal colon may be involved but always in a continuous pattern.
  • Symptoms are relapsing and remitting

Clinical Presentation

  • Attacks of crampy, painful diarrhea
    • Bloody diarrhea with mucus
    • More than six per day equals severe disease
  • Abdominal pain
  • Fever

Labs, Studies & Physical Exam Findings

  • Blood on digital rectal exam
  • Abdominal tenderness
  • CBC
  • Sed rate
  • Labs for malnutrition
    • B12
    • Albumin
    • Folate
    • Iron
  • Stool cultures which are negative
  • Plain abdominal x-ray
  • Sigmoidoscopy
    • Continuous area of unhealthy tissue
  • Colonoscopy once acute phase has passed
    • Continuous area of unhealthy tissue

Treatment

  • Acute phase
    • NPO only in severe colitis
    • Topical or oral aminosalicylate agents – 5 ASA via enema
      • Mesalamine
  • Topical or oral corticosteroids via enema
  • Surgical removal of the colon
  • Maintenance
    • Dietary management
      • Increase fiber
      • Low dairy
      • Avoid raw fruits and vegetables
    • Topical or oral aminosalicylate agents – 5 ASA via enema

Crohn’s Disease

  • An inflammatory bowel disease that is transmural
  • Causes inflammation and ulceration of the tissues which can result in the formation of strictures, fistulas and abscesses.
  • The ileum and the colon are the two most commonly affected areas, but Crohn’s disease can affect any area of the digestive tract except the rectum.
  • The lesions are not continuous through the digestive tract.
  • There is a significant increased risk of developing Crohn’s disease in smokers
  • Symptoms come and go over time

Clinical Presentation

  • Low grade fever
  • Abdominal pain
  • Frequent liquid bowel movements
  • Weight loss
  • Diarrhea is usually non bloody

Labs, Studies and Physical Exam Findings

  • Lab for inflammatory markers
    • C-reactive protein
    • Elevated WBCs
  • Labs for malnutrition
    • B12
    • Albumin
    • Folate
    • Iron
  • CBC
  • Colonoscopy with biopsy
    • Cobblestone appearance
    • Skip lesions
  • Endoscopy with biopsy
  • CT/MR
  • Barium upper GI series with a small bowel follow through

Treatment

  • Quit smoking
  • Encourage fluids to prevent dehydration
  • Treat malnutrition
  • Anti diarrhea medication
  • Aminosalicylate agents
  • Antibiotics may be of value
    • Metronidazole
    • Ciprofloxacin
  • Steroids- Prednisone 40-60 mg/day
  • Surgery may be necessary but is not curative

Toxic Megacolon

  • The colon loses muscle tone which results in massive dilation

Causes

  • Colitis
  • Medications
    • Opioids
    • Anticholinergics antidiarrhea

Clinical Presentation

  • I have had colitis and now I am extremely sick
  • Severe abdominal pain
  • Rebound tenderness
  • Abdominal distention
  • Fever
  • Severe hypovolemia

Labs, Studies & Physical Exam Findings

  • Abdominal tenderness
  • Serial abdominal plain x-ray

Treatment

  • High dose IV steroids
  • NPO
  • IV Antibiotics covering gram positives and gram negatives due to fear of perforation.
  • Fluids
  • Blood transfusion if necessary
  • Stop all antidiuretic
  • Nasogastric suction
  • Patients should roll from side to side and onto the abdomen
  • Corticosteroids
  • Surgical resection of the bowel may be necessary

Irritable Bowel Syndrome

  • Recurrent symptoms
  • Two thirds of those diagnosed are female

Clinical Presentation

  • Symptoms for more than 6 months
  • Abdominal pain relieved with defecation
  • Change in frequency or form or appearance of stool

Labs, Studies & Physical Exam Findings

  • Normal physical
  • Tests only performed to rule out other issues
    • CBC, BMP
    • Fecal occult blood
    • Thyroid panel
    • C Reactive protein and sed rate

Treatment

  • Symptomatic treatment
  • Regular office visits reduce patient anxiety
  • Reassurance
  • Modified diet – high fiber
  • Exercise
  • Antispasmodics
  • Laxatives
  • SSRIs
  • Tricyclics
  • Probiotics

Ischemic bowel disease (Ischemic Colitis)

  • Blood has stopped flowing to a portion of the bowel

Risk factors

  • Advancing age typically > 60
    • Likely to atherosclerosis
  • History of atrial fibrillation
  • Vasculitis
  • Hypercoagulable states
  • Use of vasoconstrictors – vasopressin, cocaine

Clinical Presentation

  • Severe abdominal plain
  • Bloody stool
  • Diarrhea
  • Fever
  • Shock

Labs, Studies & Physical Exam Findings

  • Abdominal pain out of proportion to exam
  • Plain x-ray
  • Endoscopy
  • CT
  • Angiography is the gold standard

Treatment

  • Ischemic colitis
    • Supportive care including NPO and IV fluids
  • Mesenteric Ischemia
    • Surgical removal of ischemic bowel
    • Diagnosed within 24 hours patients have a survival rate of 50%

I hope that all make sense and you start to see how test questions are written and how we separate out different disease with words and descriptions

For PA week I’m going to ask you to me and a friend a big favor. Recommend the show to them. If you got something out of this and you think it might help a classmate please for tell them. I’m planning on helping a lot more people in 2022 and I’m going to need our help to get there.

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