Large Intestine Disorders

Front 1

ROME Criteria for IBS

Back 1

Recurrent abdominal pain or discomfort at least 3 days per month in the previous 3 months associated with two or more of the following:

1. Improvement with defecation

2. Onset associated with a change in frequency of stool

3. Onset associated with a change in form (appearance) of stool

Front 2

Alarms symptoms prompting consideration of alternative Dx than IBS:

Back 2

onset of symptoms after age 50

unintentional weight loss

anorexia

bloody stools

nocturnal diarrhea

family history of significant colon disease

Front 3

Alternative DX to consider in patients with IBS patterns of symptoms

Back 3

Constipation—Predominant
Bowel obstruction
Cancer
Adult-onset Hirschsprung’s disease
Rectocele
Paradoxical closure of the anus during defecation

Diarrhea—Predominant
Bacterial or parasitic intestinal infection
Inflammatory bowel disease
Lactose intolerance
Malabsorption
Radiation proctocolitis

Painful
Inflammatory bowel disease
Ureteral colic
Bowel obstruction
Diverticular disease
Gastroesophageal reflux or ulcer
Liver or pancreatic disease
Lead toxicity
Porphyria

Other Emergency

Pancreatitis

Hepatitis

Biliary Colic

Urological Disorders - (e.g. urolithiasis)

Front 4

Diverticulosis

Back 4

Presence of diverticuli in the colon

Front 5

Diverticulitis

- Simple

- Complicated

Back 5

Simple/Uncomplicated: Inflammation of diverticular tissue restricted to the pericolonic fat

Complicated: More extensive disease characterized by:

- abscess

- peritonitis

- intestinal obstruction

- fistula formation

Front 6

Diverticula

Back 6

Herniation of the colonic mucosa through the insteninal wall at the the vasa recta

Front 7

Oral Antibiotic therapy for uncomplicated diverticulitis

Back 7

• Trimethoprim-sulfamethoxazole, one double-strength tablet bid, and metronidazole 500 mg q6h or

• Ciprofloxacin 750 mg bid and metronidazole 500 mg q6h or

• Amoxicillin-clavulanate extended-release, 1000/62.5 mg, two tablets bid

All oral regimens should be taken for 7 to 10 days

Front 8

IV Antibiotic coverage for complicated/severe diverticulitis

Back 8

Mild to Moderate Infection
• Ticarcillin-clavulanate 3.1 g IV q6h or
• Ciprofloxacin 400 mg IV q12h and metronidazole 1 g IV q12h

Severe Infection
• Ampicillin 2 g IV q6h and metronidazole 500 mg IV q6h and (gentamicin 7 mg/kg q24h or ciprofloxacin 400 mg IV q12h)
• Imipenem 500 mg IV q6h

Front 9

Indications for hospital admission in uncomplicated diverticulitis

Back 9

significant comorbid illness

including inability to tolerate oral liquids

poor social support

inability to comply with follow-up in a reasonable time frame (2 to 3 days)

Front 10

Causes of Large Bowel Obstruction

Back 10

Malignancy/Tumor

Volvulus

Diverticular disease

Fecal Impaction

Strictures (due to inflammation)

Adhesions

Hernia

Front 11

Olgive's Syndrome

Back 11

massive colonic distension in the absence of mechanical obstruction

Thought to be due to impaired auntonomic nervous system control of gut motility

Front 12

Coffee Bean Sign

Back 12

Sigmoid volvulus

Front 13

ED Priorities for patients with IBD

Back 13

(1) recognize new cases of IBD

(2) exclude complications in patients with IBD

(3) identify IBD patients who need admission

Front 14

Differentiating Features of Crohn's Disease versus Ulcerative Colitis

Back 14

Front 15

Extraintestinal Manifestations of IBD

Back 15

Front 16

Complications of IBD

Back 16

Common

-fistulae

-strictures

-abscesses

Life threatining

- fulminant colitis

- toxic megacolon

- intestinal perforation

Front 17

Toxic megacolon

Back 17

pathologic dilation of the colon resulting from inflammation of the smooth muscle layers of the intestine

Leads to paralysis, dilation, and eventually perforation if left untreated

Hallmark: colonic dilation in a patient with a known inflammatory condition of the colon who appears systemically toxic

Front 18

Potential pharmacological triggers for toxic megacolon in patients with underlying IBD/colitis

Back 18

anticholinergics

antimotility agents

narcotics

antidepressants

Front 19

Medications used in the treatment of IBD

Back 19

5-Aminosalicylic Acid Agents
Sulfasalazine
Mesalamine

Antibiotics
Metronidazole
Ciprofloxacin
Rifaximin
Tobramycin

Corticosteroids
Prednisone
Hydrocortisone
Methylprednisolone
Budesonide

Antimetabolites
Azathioprine
6-Mercaptopurine
Methotrexate

Immunosuppressant
Cyclosporine

Anti–Tumor Necrosis Factor Antibody
Infliximab

Front 20

Disease severity criteria in Ulcerative colitis

Back 20

Mild Disease
• Fewer than four stools per day
• Stools may contain some blood
• No systemic signs of toxicity (fever, tachycardia, anemia, elevated ESR)

Moderate Disease
• More than four stools per day
• Minimal signs of toxicity

Severe Disease
• More than six bloody stools per day
• Signs of systemic toxicity

Front 21

Disease severity criteria in Crohn's disease

Back 21

Mild to Moderate Disease
• Patient ambulatory and able to eat
• No dehydration
• No toxicity
• No significant abdominal pain or mass
• Weight loss of 10%

Moderate to Severe Disease
(Any of the Following)
• Mild disease that has failed to respond to treatment
• Patient may have some systemic toxicity, significant weight loss, anemia
• Fever, some abdominal pain or tenderness, intermittent nausea or vomiting

Severe Disease
• Persistence of symptoms during corticosteroid or biologic therapy
• High fever, persistent vomiting
• Intestinal obstruction
• Rebound tenderness
• Cachexia
• Abscess

Front 22

Pathophysiology of colonic ischemia

Back 22

Combination of non-occlusive microvacular disease and low flow states/vasoconstriction

Front 23

Imaging sign suggesting colonic ischemia

Back 23

Thumbprinting

Front 24

Management of colonic ischemia

Back 24

Primarily supportive

Bowel rest

IV hydration

Analgesics

+/- Antibiotics dependent on severeity

Correct Precipitants

Avoid vasopressors and corticosteroids

Decompression

Surgical consultation if signs perforation/necrosis

Front 25

Pathophysiology of acute and chronic radiation proctocolitis

Back 25

Acute: Ulceration and inlammation or radiation induced damage to colonic mucosa

Chronic: Endarteritis leading to ischemia and ulceration

Front 26

Mainfestations of acute radiation protocolitis

Back 26

Abdominal pain

Bleeding

Tenesmus

Incontinence

Arises during acute pelvic radiation

Front 27

Manifestations of chronic radiation proctocolitis

Back 27

Insidious onset with protean manifestations:

- ulcerative disease

- stricture with or without obstruction

- fistulae

- bowel perforation