DSA21 - Chronic Diarrheas and Inflammatory Bowel Disease

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4 Terms

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Inflammatory Bowel Disease (IBD)

Define Condition:

Crohn Disease (Ileum) + Ulcerative colitis (Rectum); Dx of Exclusion

-Hx:

> Bimodal Age Distribution

>> Age 15-30 y/o

>> Age 50-80 y/o

> More in White, Jewish Populations

>> Female = Crohn (hormones)

>> Male = UC

> Vit D Deficiency

-Sx/PE:

> Episodes/Flares

> Arthritis (peripheral joints, Ankylosing Spondylitis, Sacroiliitis, Migratory Polyarthritis)

> Erythema nodosum (painful)

> Pyoderma gangrenosum

>> MC in 50s to 60s

>> Deep, necrotic skin ulceration

>> Distinctive rolled edges and violaceous border, more common in Crohn

>> Need to treat main cause

> PSC (in UC)

> Uveitis

-Dx:

> Elevated CRP

> Elevated ESR

<p>Define Condition:</p><p>Crohn Disease (Ileum) + Ulcerative colitis (Rectum); Dx of Exclusion</p><p>-Hx:</p><p>> Bimodal Age Distribution</p><p>>> Age 15-30 y/o</p><p>>> Age 50-80 y/o</p><p>> More in White, Jewish Populations</p><p>>> Female = Crohn (hormones)</p><p>>> Male = UC</p><p>> Vit D Deficiency</p><p>-Sx/PE:</p><p>> Episodes/Flares</p><p>> Arthritis (peripheral joints, Ankylosing Spondylitis, Sacroiliitis, Migratory Polyarthritis)</p><p>> Erythema nodosum (painful)</p><p>> Pyoderma gangrenosum</p><p>>> MC in 50s to 60s</p><p>>> Deep, necrotic skin ulceration</p><p>>> Distinctive rolled edges and violaceous border, more common in Crohn</p><p>>> Need to treat main cause</p><p>> PSC (in UC)</p><p>> Uveitis</p><p>-Dx:</p><p>> Elevated CRP</p><p>> Elevated ESR</p>

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Crohn Disease (if only Colon = Crohn colitis)

Define Condition:

Transmural inflammation involving ileum, but may involve any area of GI tract

-Hx:

> FEMALES

> Smoking

> FHx

-Path:

> Genetics = D/t NOD2 gene (protein for defending against intestinal bacteria) mutation -> ↑intestinal bacteria to penetrate past epithelium -> trigger inflammatory reactions

> Immune Defect = Defect in Th1 T-Cells --> Cytokine mediated chronic inflammation

> Cell Defect - Defects in intestinal epithelial tight junction barrier function

-Sx/PE:

> Intermittent RUQ Pain

> Watery/Non-Bloody Diarrhea

> Weight Loss

> Deficiencies:

>> Vit Deficiency fat soluble vitamins (ADEK) = Duodenum, Jejunum, Ileum

>> Folate Deficiency = Jejunum

>> Iron Deficiency = Duodenum & Upper Jejunum

>> Vit B12 & Bile Acid Deficiency = Terminal Ileum (Impaired absorption --> Fat malabsorption ==> Steatorrhea)

-Dx:

> (+) ASCA (Anti-Saccharomyces cerevisiae Abs)

> Endoscopy:

>> "Cobblestone" Deep Ulcers: Ileal stricture w/ effaced folds, heaped-up nodular mucosa

>> Fat Wrapping/Creeping Fat: Transmural inflammation heals --> Condensed mesentery tissue pulls fat around bowel

>> Segmental "Skip" Lesions

>> Strictures: Marked thickening of bowel wall (transmural inflammation) --> Stenosis of Lumen (stricture)

>> Fistulas: Transmural inflammation --> Fissures --> Extends deep ==> Fistula tracts

>> Right-sided predominance:

>>> MC = Terminal ileum

>>> Only SI = 40%

>>> SI and Colon = 30%

>>> Only Colon = 30%

>> Rectum-sparing (1/3 of cases) - can have oral involvement (aphthous ulcers) and anal involvement (fistulae)

> Imaging: "String Sign"

>> D/t severe narrowing from edema + spasm + fibrosis

>> Frequently a/w Proximal Dilation

> Biopsy: Non-caseating granulomas + Crypt Abscesses

-Prog:

> Colon Cancer (need colonoscopy & Bx every 2-3 yrs after 8 yr Dx)

>> PSC --> HIGH RISK of Colon Cancer

> Small Bowel ACA

> Anal Cancer

<p>Define Condition:</p><p>Transmural inflammation involving ileum, but may involve any area of GI tract</p><p>-Hx:</p><p>> FEMALES</p><p>> Smoking</p><p>> FHx</p><p>-Path:</p><p>> Genetics = D/t NOD2 gene (protein for defending against intestinal bacteria) mutation -> ↑intestinal bacteria to penetrate past epithelium -> trigger inflammatory reactions</p><p>> Immune Defect = Defect in Th1 T-Cells --> Cytokine mediated chronic inflammation</p><p>> Cell Defect - Defects in intestinal epithelial tight junction barrier function</p><p>-Sx/PE:</p><p>> Intermittent RUQ Pain</p><p>> Watery/Non-Bloody Diarrhea</p><p>> Weight Loss</p><p>> Deficiencies:</p><p>>> Vit Deficiency fat soluble vitamins (ADEK) = Duodenum, Jejunum, Ileum</p><p>>> Folate Deficiency = Jejunum</p><p>>> Iron Deficiency = Duodenum & Upper Jejunum</p><p>>> Vit B12 & Bile Acid Deficiency = Terminal Ileum (Impaired absorption --> Fat malabsorption ==> Steatorrhea)</p><p>-Dx:</p><p>> (+) ASCA (Anti-Saccharomyces cerevisiae Abs)</p><p>> Endoscopy:</p><p>>> "Cobblestone" Deep Ulcers: Ileal stricture w/ effaced folds, heaped-up nodular mucosa</p><p>>> Fat Wrapping/Creeping Fat: Transmural inflammation heals --> Condensed mesentery tissue pulls fat around bowel</p><p>>> Segmental "Skip" Lesions</p><p>>> Strictures: Marked thickening of bowel wall (transmural inflammation) --> Stenosis of Lumen (stricture)</p><p>>> Fistulas: Transmural inflammation --> Fissures --> Extends deep ==> Fistula tracts</p><p>>> Right-sided predominance:</p><p>>>> MC = Terminal ileum</p><p>>>> Only SI = 40%</p><p>>>> SI and Colon = 30%</p><p>>>> Only Colon = 30%</p><p>>> Rectum-sparing (1/3 of cases) - can have oral involvement (aphthous ulcers) and anal involvement (fistulae)</p><p>> Imaging: "String Sign"</p><p>>> D/t severe narrowing from edema + spasm + fibrosis</p><p>>> Frequently a/w Proximal Dilation</p><p>> Biopsy: Non-caseating granulomas + Crypt Abscesses</p><p>-Prog:</p><p>> Colon Cancer (need colonoscopy & Bx every 2-3 yrs after 8 yr Dx)</p><p>>> PSC --> HIGH RISK of Colon Cancer</p><p>> Small Bowel ACA</p><p>> Anal Cancer</p>

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Ulcerative Colitis

Define Condition:

Inflammation limited to colon and rectum, and extends only into the mucosa and submucosa

-Hx:

> Smoking is protective

> A/w PSC

-Path:

> Immune Defect = Defect in Th2 T-Cells --> Elaborates IL-13 (key cytokine in initiating pro-inflammatory cascade)

> Categories (based on location): Rectum is almost always involved (95%)

>> Only Rectum = Proctitis

>> Rectum + Sigmoid = Proctosigmoiditis

>> Left side of LI = Left-sided

>> Entire Colon = Pancolitis

> Mucosa & Submucosa only

-Sx/PE: Episodic

> Bloody Diarrhea

> Lower Abdominal Cramping

> Fatty Stools

> Wt Loss

-Dx:

> Serum: (+) p-ANCA/MPO-ANCA

> Endoscopy: Backwash Ileitis

>> May involve terminal ileum d/t incompetent ileocecal valve --> reflux of inflammatory mediators from colon --> Superficial mucosal inflammation

> Imaging: "Lead-pipe appearance" d/t loss of haustra in diseased section of colon (smooth walled and cylindrical like)

> Gross:

>> Bloody & diffusely Ulcerated (no skip lesions) - extends proximally

>> Isolated islands of regenerating mucosa bulging into lumen (Lumpy, bumpy inflammatory pseudopolyps)

> Biopsy:

>> Superficial mucosal disease

>> Mild (erosions) to severe (ulcers penetrating mucosa to submucosa) +/- cryptitis and Crypt Abscesses

-Prog:

> IDA d/t blood loss

>> Bloody diarrhea w/ mucus

>> Rectal bleeding

> Risk of Colon ACA (more in pts w/ Pancolitis 10+ yrs)

>> Dysplasia of colonic mucosa (FLAT mucosa) = High risk

>> Usually infiltrative w/o obvious exophytic masses

> Toxic Megacolon

>> Cessation of colonic contractions d/t NO made by neutrophils & macrophages ==> inhibits smooth-muscle tone and disturb NM function ==> Intestinal dilation ==> Distension ==> PERFORATION

> PSC --> HIGH RISK of Colon Cancer