colorectal disorders

constipation

straining with BM, lumpy hard stools, sensation of incomplete evacuation, < 3 BMs/wk

constipation RF

decreased mobility, poor eating, comorbid medical conditions, meds

primary constipation

not attributable to structural abnormalities, slow transit time, defecatory disorder

normal colonic transit time

35 hours

slow colonic transit time

usually idiopathic d/t dysfunction of ENS, generalized GI dysmotility, often hx psychosocial problems

defecatory disorders and primary constipation

dyssynergic defecation results in either impaired relaxation or paradoxical contraction of anal sphincter/pelvic floor muscles that impedes BM

meds associated with constipation

iron, narcotics, CCB, anticholinergics

secondary constipation

d/t systemic disorders, meds, or obstructing colonic lesions

systemic disorders causing constipation

neurologic gut dysfunction, myopathies, endocrine disorders, electrolyte abnormalities

obstructing colonic lesions causing constipation

neoplasms, strictures, anorectal disorders like rectal prolapse, rectocele, hirschsprung disease

constipation CP

infrequent stools, difficulty passing stool, hard stool, abd fullness/discomfort, fecal impaction, overflow fecal incontinence, N/V

new onset constipation in 50+

must evaluate for colon cancer

constipation dx

rectal exam, KUB, CT abd/pelvis w/cx, colonoscopy

colon transit studies, motility studies

overflow fecal incontinence

so much stool in rectum it backs up and diarrhea leaks around it

males constipation exam

prostate hypertrophy

females constipation exam

posterior vaginal masses

colon transit studies

radiopaque marker study, wireless motility capsule

motility studies

anorectal manometry, colonic manometry, balloon expulsion

constipation management

increase fluids and fiber, exercise, regular schedule, position

constipation pharmacological tx

bulk forming, osmotic, stimulant laxatives

colonic secretagogues

stool softeners, suppositories, enemas

bulk forming laxatives

metamucil, citrucel, benefiber

osmotic laxatives

polyethylene glycol, lactulose, sorbitol, magnesium hydroxide

colonic secretagogues

lubiprostone, linaclotide, plecanatide guanylate cyclase agonists

fecal impaction

severe impaction of stool in rectum leading to obstruction

fecal impaction RF

meds, severe psychiatric disease, bed-ridden, neurogenic disorders of colon, spinal cord disorders, running

fecal impaction CP

anorexia, N/V, abdominal pain/distention, “diarrhea” from liquid stool leaking around impaction

fecal impaction PE

hard feces or significant amount of palpable stool on rectal exam

fecal impaction tx

digital disimpaction, enemas

bowel continence requirements

solid/semisolid stool, distensible rectal reservoir, sensation of rectal fullness, intact pelvic nerves and muscles, ability to reach a toilet in timely fashion

minor fecal incontinence

inability to control flatus or slight soilage of undergarments after BMs or straining

often d/t local anal problems like hemorrhoids, weakness of IAS

minor fecal incontinence tx

fiber supplements, eliminate caffeine, loose application of cotton ball

hemorrhoid surgery

kegels

loperamide to reduce urge incontinence

major fecal incontience

complete uncontrolled loss of stool with or without awareness

major fecal incontinence without awareness

loss of central awareness - dementia, CVA, MS

peripheral nerve injury - SCI, cauda equina, pudendal nerve damage, aging, DM

major fecal incontinence with awareness

damage to sphincter - traumatic childbirth (forceps), episiotomy, prolapse, prior anal surgery, physical trauma

major fecal incontinence tx

bulking agents, antidiarrheals, scheduled toilet use, biofeedback, vaginal/anal. inserts, sterile gel injected in submucosa to narrow canal, sacral nerve stimulation device

surgery rarely

encopresis

fecal incontinence typically d/t retentive constipation

primary encopresis

children not toilet trained

secondary encopresis

incontinence returns after successful toilet training

encopresis management

isolate and treat cause (usually constipation), educate parents if in children

prevent recurrence - diet, behavioral intervention, meds

large bowel obstruction (LBO)

normal flow of intraluminal contents of large bowel is blocked

large bowel obstruction (LBO) incidence

not as common as SBO, median age 73, presenting sx for some CRC

large bowel obstruction (LBO) causes

MCC malignancy, volvulus MC benign cause

diverticular disease, hernia, adhesion, stricture

volvulus

loop of intestine twists around itself and mesentery causing bowel obstruction

can result in ischemic bowel

volvulus CP

abdominal distension, pain, vomiting, blood in stool

large bowel obstruction (LBO) acute CP

presents after 5 days, bloating, crampy abdominal pain with paroxysms of pain every 20-30 mins, obstipation, maybe N/V

large bowel obstruction (LBO) subacute/chronic CP

weeks to months, progressive change in bowel habits, if associated with unintentional wt loss think malignancy

large bowel obstruction (LBO) dx

CT abd/pelvis preferred

plain films less sensitive/specific

large bowel obstruction (LBO) management

bowel rest, IV fluids, electrolytes, gastric decompression

75% need surgery

large bowel obstruction (LBO) prognosis

bad if malignancy, emergent surgery

MCC mortality is sepsis/multiple organ failure

irritable bowel syndrome (IBS)

chronic abdominal pain and altered bowel habits without organic cause

irritable bowel syndrome (IBS) pathophys

uncertain - abnormal motility, hypersensitivity of visceral afferent nerves, inflammation, pscyhosocial

irritable bowel syndrome (IBS) population

most dx before 40, more females

associated with fibromyalgia, chronic fatigue syndrome, GERD, anxiety/depression, HA, CP

irritable bowel syndrome (IBS) CP

chronic cramping abd pain

altered bowel habits - diarrhea, constipation (alternating)

irritable bowel syndrome (IBS) subtypes

IBS-C - constipation

IBS-D - diarrhea

IBS-M - mixed

IBS-U - undefined, varying sx

irritable bowel syndrome (IBS) dx

diagnosis of exclusion

CBC, CRP, fecal calprotein level, celiac markers, fecal parasites

irritable bowel syndrome (IBS) lifestyle mods

avoid triggers, low FODMAP diet, fiber if constipated

irritable bowel syndrome (IBS) tx for abd pain/bloating

dicyclomine, hyoscyamine, peppermint oil, TCAs/SSRIs, rifaximin

IBS-C management

polyethylene glycol (miralax), lubiprostone, linaclotide, plecantide, tenapanor

IBS-D management

loperamide, alosetron

low FODMAP diet excludes…?

garlic, beans, onion, blackberries, watermelon, peaches, sausage, fried foods, almonds, avocado, gluten

irritable bowel disease (IBD) types

crohn’s, ulcerative colitis

crohn’s disease

chronic, immune related disorder involving inflammation of any part of the GI tract, 80% small bowel, rectum spared

ulcerative colitis

idiopathic inflammatory condition involving colon/rectum leading to mucosal friability and erosions

irritable bowel disease (IBD) population

more common in northern areas, typically 15-30 y/o

crohn’s - more females

UC - more males

jewish more common, less common in Hispanic/Black populations

irritable bowel disease (IBD) RF

genetics, smoking (increases for crohn’s, decreases for UC), physical inactivity, low fiber, high fat, low vit D for crohn’s, lack of sleep, NSAIDs, OCPs, hormone replacement

crohn’s disease CP

gradual onset of RLQ abd pain, diarrhea (maybe blood), low fever, fatigue, wt loss, phlegmon/abscess, perianal disease

FISTULAS

malabsorption

sx in other GI locations

ulcerative colitis CP

gradual and progressive, diarrhea maybe with blood (urgency, tenesmus, incontinence), colicky abdominal pain, constipation with bloody mucus discharge, fever, fatigue, wt loss, iron deficiency

ulcerative colitis extraintestinal sx

MC arthritis/arthropothy

eyes - uveitis, iritis, episcleritis

skin - erythema nodosum, pyoderma gangrenosum

primary sclerosing cholangitis, bone loss

irritable bowel disease (IBD) dx

colonoscopy, biopsy, stool inflammatory markers (fecal calprotectin or lactoferrin)

crohn’s disease characteristic finding

skip lesions

irritable bowel disease (IBD) tx

oral or tapical 5-ASA (mesalamine, sulfasalazine)

oral, topical, IV steroids

immunomodulators - thiopurines, methotrexate, JAK inhibitors

biologics - anti TNF/integrins (infliximab, adalimumab/vedolizumab)

ulcerative colitis curative tx

surgery

crohn’s disease prognosis

risk for lymphoma and small bowel adenocarcinoma

ulcerative colitis prognosis

increased risk of CRC

anal fissure

tear to anoderm within distal half of anal canal

acute - <8wks

anal fissure cause

local trauma (constipation, diarrhea, anal intercourse, vaginal delivery) or secondary cause (IBD, malignancy)

anal fissure pathophys

MC location posterior midline then anterior

cycles of tears lead to recurring anal pain/bleeding, can become chronic, internal sphincter spasms

anal fissure CP

acute anal pain at rest and worsened with BM, anal bleeding

anal fissure dx

clinical with f/u anoscopy or colonoscopy w/rectal bleeding

anal fissure management

stool softener, sitz baths, fiber, topical analgesic or nifedipine/nitro

anal fissure management if initial failure

topical diltiazem, bethanechol

oral nifedipine, diltiazem

botox, surgery

perianal abscess

acute phase of infection from obstructed anal crypt gland

perianal fistula

chronic manifestation of acute perirectal process that forms an anal abscess

“fisula-in-ano”

perianal abscess/fistula population

males 2x likely, mean age 40 y/o

perianal abscess/fistula pathophys

most d/t anal crypt gland becoming infected, 70% associated with fistula

perianal abscess/fistula CP

severe, constant pain of anus/rectum, fever, malaise

perianal abscess/fistula dx

rectal exam - be GENTLE!

CT/MRI/US

perianal abscess/fistula management

surgical I&D with culture, augmentin or cipro + metro, surgery for fistula

hemorrhoids

highly vascular structures found w/in submucosa of anal canal

hemorrhoids RF

fhx, constipation, pregnancy, heavy lifting, prolonged sitting

hemorrhoids population

lots in western civilization, more common in white pts/higher SES, age

hemorrhoid CP

lots asymptomatic

hemorrhoidal bleeding (painless, bright red), thrombosed hemorrhoids painful, perianal pruritis, fecal incontinence

hemorrhoid dx

anoscopy/colonoscopy

grade I hemorrhoid

enlargement/bleeding

grade II hemorrhoid

protrusion with spontaneous reduction

grade III hemorrhoid

protrusion with manual reduction

grade IV hemorrhoid

nonreducible, maybe acute thrombosis/strangulation

hemorrhoids management

high fiber, more fluids, sitz baths, limit toilet time

hemorrhoids pharmacological tx

topical benzocaine, steroids, vasoconstrictors, protectants/astringents (zinc oxide/witch hazel)

hemorrhoids surgery

rubber band ligation, hemorrhoidectomy