Diarrhea
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Definition Increased frequency or volume of stool (eg 3+ liquid/semisolid stools daily for at least 2-3 consecutive days)
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Etiology Infections, toxic, dietary (laxative use), other GI disease
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Pertinent Patient History All current meds, illnesses among others who may have shared meals with pt.
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Clinical Features: Secretory Diarrhea Large volume w/o inflammation (pancreativ insufficiency, ingestion of preformed bacterial toxins, laxative use)
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Clinical Features: Inflammatory Diarrhea Bloody diarrhea + fever (invasive organisms or IBD)
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Clinical Features: Antibiotic-Associated Diarrhea Clostridium dificile (causes pseudomenbranous colitis in the most severe cases)
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Lab Findings WBCs in the stool = inflammatory process, and get cultures
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Treatment Supportive therapy, antibiotics for pts with severe diarrhea and systemic sx (C. diff, Shigella, Campylobacter)
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Celiac Disease (celiac sprue)
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Definition Inflammation of the small bowel with the ingestion of gluten-containing foods (wheat, rye, barley) leading to malabsorption
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Multifactorial inheritance Among the most common genetic conditions in Europe and USA
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Clinical Presentation Diarrhea, steatorrhea, flatulence, weight loss, weakness, abdominal distension (infants/kids - failure to thrive) (older pts - iron deficiency, coagulopathy, hypocalcemia)
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Diagnosis Serologic screening tests: IgA antiendomysial and antitisuue transglutaminase antibodies
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Treatment Gluten-free dieat, should see nutritionist possibly lactose-free diet, supplementation, prednisone
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IBS (Irritable Bowel Syndrome)
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Definition A functional disorder without a known pathology - thought to be a combination of altered motility, hypersensitivity to intestinal distention, and psychological distress, W>>M and can occur with menses/stress. A dx of exclusion.
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Most common cause of... chronic or recurrent abdominal pain the the US. Usually an intermittent/lifetime problem.
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DDX Lactose intolerance, cholecystitis, chronic pancreatitis, intestinal obstruction, chronic peritonitis, carcinoma of pancreas/stomach
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Clinical features Abdominal pain (worsened with ingestion, relieved with defecation), pain may be associated with bowel distention from accumulation of gas and associated spasm of smooth muscle; postprandial urgency common, changes in stool frequency/character, dyspepsia, urinary frequency/urgency in women
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Lab Findings Generally normal - test stool for blood, bacteria, parasites, lactose intolerance. R/O other pathology with colonoscopy/barium enema/US.CT, and endoscopic studies in pts with persisten sx or weight loss/bleeding
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Treatment Avoid triggers, high-fiber diet, bulking agents, and symptom control (antispasmodics, antidiarrheals, prokinetics, antidepressants)
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Colonic Polyps
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Definition Fleshy growth on lining of colon/rectum; common and can be benign or malignant. Removal can reduce the occurence of colon cancer
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Familial Polyposis Syndrome Genetic predisposition to multiple colonic poolups with a near-100% risk of developing colon cancer (evaluate q1-2 yrs beginning at age 10)
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Clinical Features Asymptomatic, Can get contipation, flatulence, rectal bleeding, or iron deficiency anemia
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Lab Findings Heme-positive stool, detected by colonoscopy, and must get histologic evaluation to determine dysplasia
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Treatment Removal and FU
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Constipation
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Definition A decrease in stool volume and increase in stool firmness accompanied by straining (normal BM ranges 3/day-3/wk)
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Red Flag Patients >50 yo with new-onset constipation --> evaluate for colon cancer!
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Basic Treatment/Lifestyle modifications Increase fiber (10-20g/day), increase fluid intake (1.5-2L/day), increased exercise
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Treatment if constipation lasts > 2wks or if refractory to lifestyle modifications Investigate and treat underlying cause
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Bowel Obstruction
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Etiology: small bowel obstruction (SBO) Adhesions or hernias, neoplasm, IBD, volvulus
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Etiology: large bowel obstruction Neoplasm, strictures, hernias, volvulus, intussusception, fecal impaction
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Complete strangulation of bowel tissue can lead to Infarction, necrosis, peritonitis, death
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Clinical Features Andominal pain, distention, vomiting, obstipation, high-pitched/rushing bowel sounds, more severe cases pts can be febrile/tachycardic, in shock
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Lab Findings Dehydration, electrolyte imbalance, upright radiographs showing air-fluid levels
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Treatment NPO, NG suctioning, IV fluids, monitoring (surgery likely, esp. with large bowel obstruction)
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Crohn's Disease (aka regional enteritis)
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Definition An IBD for which there is some genetic predisposition, but the cause is unknown. Must be differentiated from ulcerative colitis (other IBD)
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Anatomical Involvement Skip lesions, Terminal ileum and right colon most common, can also be in small and large bowels, mouth, esophagus, stomach (rectum frequently spared)
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Complications Fistula, abscesses, aphthous ulcers, renal stones, predisposition to colonic cancer
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Clinical Features Abdominal cramps and diarrhea in pts <40yo (can also get low-grade fever, polyarthralgia, anemia, fatigue, bloody stool)
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Lab Findings Colonoscopy, bx to reveal involvement (will often see granulomas), blood tests (anemia, decreased ESR, electrolyte imbalances)
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Treatment Acute tx: Prednisone +/e aminosalicylates (add metronidazole or cipro if perianal dz/fissures/fistula. Chronic management: Mesalamine, also smoking cessation
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Intussusception
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Definition The invagination of a proximal segment of bowel into the portion just distal to it (95% of the time occurs in children, following a viral infx. If in adults d/t neoplasm)
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Clinical Features Severe colicky pain, stool will contain mucus/blod (currant jelly stools), and sausage-shaped mass felt on palpation
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Lab Findings Barium or air enema - diagnostic and therapeutic (plain-films, CT, surgery for adults)
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Treatment Hospitalization, and barium/air enema for kids (surgery if that doesn't help or for all adults)
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Toxic Megacolon
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Definition Extreme dilatation and immobility of the colon, Emergency!
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Etiology: Newborn Hirschsprung's Disease = Congenital aganglionosis of the colon, leading to functional obstruction in the neworn
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Etiology: Adults Occurs as a complication of UC, Crohn's colitis, pseudomenbranous colitis, and specific infectious causes (Shigella, C. diff)
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Clinical Features Fever, prostration, severe cramps, abdominal distension, and rigid abdomen and abdominal tenderness on exam
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Lab Findings Abdominal plain films will show colonic dilatation
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Treatment Decompression (sometimes colostomy or complete colonic resection may be necessary)
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Volvulos
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Definition The twisting of any portion of bowel on itself (most commonly the sigmoid or cecal area)-->requires emergent decompression to avoid ischemic injury!
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Clinical Features Cramping abdominal pai, distention, N/V, obstipation
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Ischemia from volvulus can lead to Gangrene, peritonitis, sepsis
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Signs/symptoms of Bowel Ischemia Abdominal tympany, tachycardia, fever, severe pain
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Diagnosis confirmed by Abdominal plain film-->showing colonic distention
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Treatment Endoscopic decompression, surgery if unresolved by non-surgical means
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Malabsorption
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Definition May involve a single nutrient (like Vit B12 in pernicious anemia) or lactase deficiency (lactose), or it may be global (celiac disease, AIDS)
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Etiology Problems in digestion, absorption, impaired blood/lymph flow
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Clinical Features Diarrhea +/- bloating and discomfort, weight loss, edema, steatorrhea (othersL bone demineralization, tetany, bleeding, anemia)
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Lab Findings If 72-hr fecal fat test is normal, consider specific defects (ie pancreatic insufficiency), and specific tests can detect deficiencies like B12/calciu/albumin
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Therapeutic trials to help in dx/tx Lactose-free diet, gluten-free diet, pancreatic enzyme, antibiotics in certain cases
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Ulcerative Colitis
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Definition An IBD with ulcerated lesions in the colon, starts distally at the rectum and progresses proximally, continuous (NO skip lesions)
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Clinical Features - most common Tenesmus (feeling of constantly needing to pass BM despite empty colon) and bloody/pus-filled diarrhea
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Less common features LLQ pain, weight loss, malaise, fevere, might see toxic megacolon and malignancy seen more in UC than Crohn's (smoking actually protective in UC)
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Lab Findings Anemia, increased ESR, decreased serum albumin, abdominal plain film-->colonic distension. Sigmoidoscopy or colonoscopy best to establish diagnosis
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What to AVOID in pts with possible acute UC Colonoscopy and barium enema - risk of perforation and toxic megacolon!
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Treatment Aminosalicyates + Corticosteroids (surgery can be curative, total protocolectomy most common type)
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Diverticular Disease
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Diverticulosis (def.) Large outpouchings of the mucosa of the colon
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Diverticulitis (def.) Inflammation of the diverticula caused by obstructing matter
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In pts. with diverticulosis, can prevent diverticulitis with... High-fiber diet and avoidance of obstructing/constipating foods (seeds, etc.)
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Clinical Features (diverticulitis) Sudden-onset LLQ/suprapubic pain +/- fever, altered BM, N/V
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Diverticular bleeding presentation Sudden-onset, large-volume hematochezia (resolves spontaneously)
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Lab Findings Plain films + Ct: to r/o other causes of abdominal pain or tos how areas of edema/dilatation. Colonoscopy: best to evaluate for ischemia,
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Treatment Surgical revascularization (+ hydration)
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Colorectal Cancer
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Risk Factors Hereditary nonpolyposis colorectal cancer
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General 3rd leading cause of cancer death in USA, >50yo, good prognosis if caught early
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Clinical Features Slow growing and no sx at first, Abdominal pain, change in bowel habits, occult bleeding, intestinal obstruction, anemia (fatigue, weakness), frank blood in stool, change in stool size/shape.
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Lab Findings Occult blood in stool, colonoscopy
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Treatment Surgical resection + chemo (stage III and higher)
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