Disorders of the Small and Large Intestinal Disorders

Enteritis

inflammation of any part of the small intestinal tract

Colitis

inflammation of colon

Bowel inflammation

any part of intestinal tract

Small, large, or both

Inflammatory Bowel Disease: 2 types

Crohn’s disease: any area of GI

Chronic ulcerative colitis: colon and rectum

etiology of Inflammatory Bowel Disease

Unclear; multifactorial

Alterations in host interactions with intestinal micro biome

Intestinal epithelial dysfunction

Alteration in microbiome composition

Inappropriate immune response

Genetic predispostion

Crohn disease

Slowly progressive Recurrent Granulomatous inflammation that can affect any area of the GI tract

• Most common locale is terminal ileum and cecum, but can involve other areas of the small intestine

Granulomatous lesions may be scattered with normal intervening areas or “skip areas”

• Submucosal layer is mostly involved

• Over time the bowel wall becomes thickened and inflexible

Symptoms and Signs of Crohn Disease

Symptoms are periodic with diarrhea and cramping, weight loss, fever and fecal urgency

• May mimic appendicitis with lower right abdominal pain, fever and bloody diarrhea

Asymptomatic periods can last for weeks to month

Symptoms associated with physical or emotional stress, diet or smoking

May have joint, eye, and skin inflammation during periods of activity

Extraintestinal manifestations may develop before intestinal disease

Complications with Crohn Disease

thickening can lead to blockage

Fistula (tube like passages )form connections between different sites of intestinal tract or other organs

Abscess formation and perforations

Ulcerative colitis

large intestines and rectum

Inflammation is limited to mucosa

Inflammatory process tends to be continuous

• Leads to pinpoint mucosal hemorrhages, which may become necrotic and ulcerate

• Usually superficial , but extensive lesion and often develop projections called “pseudopolyps”

• Chronic and repeated episodes result in thickening of the bowel wall

• Frequently begins in rectal mucosa and spreads until entire colon is involved

Clinical manifestations of ulcerative colitis

Relapsing disorder with bloody mucoid diarrhea, lower abdominal pain, and cramps that are temporarily relieved by defecation

• Persist for weeks or months then subside

• May present with severe attacks that are medical emergencies

• Attacks can be triggered by stress, infections

• May have joint, eye, and skin inflammation during periods    of activity

Complications Ulcerative colitis

Bleeding; bloody diarrhea

Perforation: from extensive inflammation with leakage of intestinal contents into peritoneal cavity

Long-standing disease may develop cancer of colon and/or rectum

Treatment Ulcerative colitis

Colectomy cures intestinal disease, but extra intestinal manifestations may persist  

Treatment for both Crohn Disease and Ulcerative colitis

Colectomy cures intestinal disease

Nutritional support

Medication –antidiarrheals, anti-inflammatory

Antibiotic associated colitis

broad-spectrum antibiotics destroy normal intestinal flora

• C. difficile is non-invavasive and requires disruption of normal flora

• Allows growth of anaerobic spore-forming bacteria, Clostridium difficile not inhibited by antibiotic taken

  • commonly acquired in hospitals,nursing homes

• Organisms produce toxins causing inflammation and necrosis of colonic mucosa

Clinical manifestations Of Antibiotic associated colitis

Mild Diarrhea, abdominal pain, fever

Symptoms Of Antibiotic Associated Colitis

usually subside after antibiotics are discontinued severe with ulcerative lesions can form: life threatening; fever, tachycardia, abdominal distention ,dehydration

Diagnosis Of Antibiotic Associated Colitis

stool culture, toxin in stool

Treatment Antibiotic Associated Colitis

stop antibiotic treatment; give vancomycin or metronidazole (inhibits growth of organism)

Acute Appendicitis

Occur at any age, but most common abdominal surgery in children

Pathogenesis of Appendicitis

obstruction of narrow lumen (fecolith or tumor), establishes conditions favoring resident bacterial growth

Signs and Symptoms of Appendicitis

Right lower quadrant abdominal pain

Nausea, vomiting and low grade fever with increased wbc count-neutrophilia

Some can present with pelvic pain

Appendicitis

Mucous secretions continues behind obstruction causing increase pressure

• Mucosal veins collapse leading to blockage of outflow of blood

As inflammation develops, further collapse of larger vessels leads to decrease oxygen supply and favors growth of anaerobic bacteria

Gangrenous necrosis results

Diverticulosis

pouch like sacs of mucosa  that protrude through the wall of the large intestine

• Usually sigmoid colon

• Many are asymptomatic, but can have abdominal pain and constipation

• Related to low fiber diet, which produces a dryer smaller stool that requires more forceful colonic contractions.

  • This increase in colonic intraluminal pressure promotes diverticula formation

Diverticulitis

a gastrointestinal disease that occurs when small pouches, called diverticula, in the large intestine become inflamed or infected

inflammation incited by bits of fecal material trapped within outpouchings

Complications Of Diverticulitis

inflammation, perforation, bleeding (ulcer formation), scarring, abscess in pelvis

Celiac Disease

a chronic autoimmune disorder that damages the small intestine and prevents the body from absorbing nutrients from food

Gluten  triggers injury to the mucosa of the small intestine

• Immune mediated enteropathy to a component of gluten causing damage to the intestinal epithelium (villous atrophy)

Results in malabsorption

• Failure to digest and absorb food

1-2% of population

• Northern European descent

• Genetic predisposition

Signs and Symptoms Of Celiac Disease

abdominal pain, diarrhea, flatulence, and fatty, foul smelling stool, weight  loss, vitamin and mineral deficiency

Linked to development of lymphoma and adenocarcinoma

Diagnosis Of Celiac Disease

intestinal biopsy and anti-gluten antibodies in serum

Definitive diagnosis is by complete resolution of symptoms and resolution of intestinal changes after treatment

Treatment of celiac disease

avoidance of gluten

Irritable Bowel Syndrome

Also known as spastic colitis or mucous colitis

Episodes of cramping, abdominal discomfort, loud gurgling bowel sounds, and disturbed bowel function without structural or biochemical abnormalities

◦Hallmark is abdominal pain that is relieved by defecation

•Alternating diarrhea and constipation

•Excessive mucus secreted by colonic mucosal glands

Cause Irritable bowel syndrome

Thought to be a result of dysregulation of intestinal motor and sensory function

◦Associated with psychological and physiological stress

Diagnosis Irritable bowel syndrome

by exclusion

◦Rule out pathogenic infections, food intolerance, and inflammatory conditions

◦Thorough history of recurrence of symptoms

•12 week duration

Treatment of Irritable Bowel Syndrome

Reduce emotional tension

Improve intestinal motility

Volvulus

rotary twisting of bowel impairing blood supply

common site: sigmoid colon

Intussusception

telescoping of a segment of bowel into adjacent segment; from vigorous peristalsis or tumor

Hernia

Protrusion of loop of bowel through a small opening, usually in abdominal wall

Inguinal hernia

common in men; loop of small bowel protrudes through a weak area in inguinal ring and descends downward into scrotum

Umbilical hernia

loop of bowel protrudes into umbilicus through defect in the abdominal wall

common in both sexes

Reducible hernia

herniated loop of bowel can be pushed back into abdominal cavity

Incarcerated hernia

cannot be pushed back

Strangulated hernia

loop of bowel is tightly constricted obstructing the blood supply to the herniated bowel; requires prompt surgical intervention