DiarrheaDefinition Increased frequency or volume of stool (eg 3+ liquid/semisolid stools daily for at least 2-3 consecutive days) | Etiology Infections, toxic, dietary (laxative use), other GI disease | Pertinent Patient History All current meds, illnesses among others who may have shared meals with pt. | Clinical Features: Secretory Diarrhea Large volume w/o inflammation (pancreativ insufficiency, ingestion of preformed bacterial toxins, laxative use) | Clinical Features: Inflammatory Diarrhea Bloody diarrhea + fever (invasive organisms or IBD) | Clinical Features: Antibiotic-Associated Diarrhea Clostridium dificile (causes pseudomenbranous colitis in the most severe cases) | Lab Findings WBCs in the stool = inflammatory process, and get cultures | Treatment Supportive therapy, antibiotics for pts with severe diarrhea and systemic sx (C. diff, Shigella, Campylobacter) |
Celiac Disease (celiac sprue)Definition Inflammation of the small bowel with the ingestion of gluten-containing foods (wheat, rye, barley) leading to malabsorption | Multifactorial inheritance Among the most common genetic conditions in Europe and USA | Clinical Presentation Diarrhea, steatorrhea, flatulence, weight loss, weakness, abdominal distension (infants/kids - failure to thrive) (older pts - iron deficiency, coagulopathy, hypocalcemia) | Diagnosis Serologic screening tests: IgA antiendomysial and antitisuue transglutaminase antibodies | Treatment Gluten-free dieat, should see nutritionist possibly lactose-free diet, supplementation, prednisone |
IBS (Irritable Bowel Syndrome)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. | Most common cause of... chronic or recurrent abdominal pain the the US. Usually an intermittent/lifetime problem. | DDX Lactose intolerance, cholecystitis, chronic pancreatitis, intestinal obstruction, chronic peritonitis, carcinoma of pancreas/stomach | 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 | 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 | Treatment Avoid triggers, high-fiber diet, bulking agents, and symptom control (antispasmodics, antidiarrheals, prokinetics, antidepressants) |
Colonic PolypsDefinition Fleshy growth on lining of colon/rectum; common and can be benign or malignant. Removal can reduce the occurence of colon cancer | 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) | Clinical Features Asymptomatic, Can get contipation, flatulence, rectal bleeding, or iron deficiency anemia | Lab Findings Heme-positive stool, detected by colonoscopy, and must get histologic evaluation to determine dysplasia | Treatment Removal and FU |
| | ConstipationDefinition A decrease in stool volume and increase in stool firmness accompanied by straining (normal BM ranges 3/day-3/wk) | Red Flag Patients >50 yo with new-onset constipation --> evaluate for colon cancer! | Basic Treatment/Lifestyle modifications Increase fiber (10-20g/day), increase fluid intake (1.5-2L/day), increased exercise | Treatment if constipation lasts > 2wks or if refractory to lifestyle modifications Investigate and treat underlying cause |
Bowel ObstructionEtiology: small bowel obstruction (SBO) Adhesions or hernias, neoplasm, IBD, volvulus | Etiology: large bowel obstruction Neoplasm, strictures, hernias, volvulus, intussusception, fecal impaction | Complete strangulation of bowel tissue can lead to Infarction, necrosis, peritonitis, death | Clinical Features Andominal pain, distention, vomiting, obstipation, high-pitched/rushing bowel sounds, more severe cases pts can be febrile/tachycardic, in shock | Lab Findings Dehydration, electrolyte imbalance, upright radiographs showing air-fluid levels | Treatment NPO, NG suctioning, IV fluids, monitoring (surgery likely, esp. with large bowel obstruction) |
Crohn's Disease (aka regional enteritis)Definition An IBD for which there is some genetic predisposition, but the cause is unknown. Must be differentiated from ulcerative colitis (other IBD) | 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) | Complications Fistula, abscesses, aphthous ulcers, renal stones, predisposition to colonic cancer | Clinical Features Abdominal cramps and diarrhea in pts <40yo (can also get low-grade fever, polyarthralgia, anemia, fatigue, bloody stool) | Lab Findings Colonoscopy, bx to reveal involvement (will often see granulomas), blood tests (anemia, decreased ESR, electrolyte imbalances) | Treatment Acute tx: Prednisone +/e aminosalicylates (add metronidazole or cipro if perianal dz/fissures/fistula. Chronic management: Mesalamine, also smoking cessation |
IntussusceptionDefinition 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) | Clinical Features Severe colicky pain, stool will contain mucus/blod (currant jelly stools), and sausage-shaped mass felt on palpation | Lab Findings Barium or air enema - diagnostic and therapeutic (plain-films, CT, surgery for adults) | Treatment Hospitalization, and barium/air enema for kids (surgery if that doesn't help or for all adults) |
Toxic MegacolonDefinition Extreme dilatation and immobility of the colon, Emergency! | Etiology: Newborn Hirschsprung's Disease = Congenital aganglionosis of the colon, leading to functional obstruction in the neworn | Etiology: Adults Occurs as a complication of UC, Crohn's colitis, pseudomenbranous colitis, and specific infectious causes (Shigella, C. diff) | Clinical Features Fever, prostration, severe cramps, abdominal distension, and rigid abdomen and abdominal tenderness on exam | Lab Findings Abdominal plain films will show colonic dilatation | Treatment Decompression (sometimes colostomy or complete colonic resection may be necessary) |
| | VolvulosDefinition The twisting of any portion of bowel on itself (most commonly the sigmoid or cecal area)-->requires emergent decompression to avoid ischemic injury! | Clinical Features Cramping abdominal pai, distention, N/V, obstipation | Ischemia from volvulus can lead to Gangrene, peritonitis, sepsis | Signs/symptoms of Bowel Ischemia Abdominal tympany, tachycardia, fever, severe pain | Diagnosis confirmed by Abdominal plain film-->showing colonic distention | Treatment Endoscopic decompression, surgery if unresolved by non-surgical means |
MalabsorptionDefinition May involve a single nutrient (like Vit B12 in pernicious anemia) or lactase deficiency (lactose), or it may be global (celiac disease, AIDS) | Etiology Problems in digestion, absorption, impaired blood/lymph flow | Clinical Features Diarrhea +/- bloating and discomfort, weight loss, edema, steatorrhea (othersL bone demineralization, tetany, bleeding, anemia) | 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 | Therapeutic trials to help in dx/tx Lactose-free diet, gluten-free diet, pancreatic enzyme, antibiotics in certain cases |
Ulcerative ColitisDefinition An IBD with ulcerated lesions in the colon, starts distally at the rectum and progresses proximally, continuous (NO skip lesions) | Clinical Features - most common Tenesmus (feeling of constantly needing to pass BM despite empty colon) and bloody/pus-filled diarrhea | 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) | Lab Findings Anemia, increased ESR, decreased serum albumin, abdominal plain film-->colonic distension. Sigmoidoscopy or colonoscopy best to establish diagnosis | What to AVOID in pts with possible acute UC Colonoscopy and barium enema - risk of perforation and toxic megacolon! | Treatment Aminosalicyates + Corticosteroids (surgery can be curative, total protocolectomy most common type) |
Diverticular DiseaseDiverticulosis (def.) Large outpouchings of the mucosa of the colon | Diverticulitis (def.) Inflammation of the diverticula caused by obstructing matter | In pts. with diverticulosis, can prevent diverticulitis with... High-fiber diet and avoidance of obstructing/constipating foods (seeds, etc.) | Clinical Features (diverticulitis) Sudden-onset LLQ/suprapubic pain +/- fever, altered BM, N/V | Diverticular bleeding presentation Sudden-onset, large-volume hematochezia (resolves spontaneously) | 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, | Treatment Surgical revascularization (+ hydration) |
Colorectal CancerRisk Factors Hereditary nonpolyposis colorectal cancer | General 3rd leading cause of cancer death in USA, >50yo, good prognosis if caught early | 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. | Lab Findings Occult blood in stool, colonoscopy | Treatment Surgical resection + chemo (stage III and higher) |
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