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Session 3 CM- GI-9

CM- GI-9- Inflam Bowel Disease

QuestionAnswer
This is an exaggerated mucosal immune response in the G.I. tract can result in ulcerative colitis or Crohn's disease Inflammatory bowel disease
What GI problem is marked by chronic inflammation of colonic mucosa and submucosa with occasional backwash ileitis Ulcerative Colitis
This GI disorder is characterized by its inflammatory involvement of the 4 intestinal mucosal layers it is most common in the ileum and colon but can be found anywhere in the GI tract Crohn's Disease
what is the etiology of Crohn's disease affects men=women, Northern European countries, starts ages 16-40, heritable link, Jewish 6x more likely to develop Crohn's
What environmental factors may increase risk of developing Crohn's disease living in urban area, smoking, diet high in sugar and hydrogenated fat and low in fruits and veggies. Infectious agens such as bacteria or other toxins may trigger Crohn's
Both colitis and Crohn's have a distinctive epidemiology with regards to occurrence what is it both have bimodal incidence larger peak at 20 years of age and smaller at 50
How can you tell ulcerative colitis from Crohn's each present, clinically, endoscopically, pathologically and serologically different
How does Crohn's present clinically RLQ pain, inflammatory mass, fever, weight loss, patient may complain of diarrhea, fever, fatigue, rectal bleeding, weight loss, anorexia, nausea
What may you find on Physical Exam of Crohn's patient abdominal tenderness, palpable mass, guaiac positive stool
Crohn's can present in several different manners give the treatment for each of the following, Fibrostenotic Disease, Inflammatory disease, Fistulizing disease Fibrostenotic disease- surgery; Inflammatory disease- steroids, 5 ASA IV/oral mesalamine, 6 mercaptopurine, methotrexate, infliximab or surgery; Fistulizing disease- 6-mp, metronidazole, infliximab, surgery
If you see linear ulcerations with "skip lesions" that are mostly seen in the ileum or colon what are you most likely looking at Crohn's disease you may also see noncaseating granulomas in 30% of patients
you are looking at an x-ray of the abdomen with contrast in the bowels and you see "thumbprinting" and narrowing of the lumen in a bowel segment what would you like to check for Crohn's disease
your patient has Saccharomyces cerevisiae antibody and perinuclear antineutrophil cytoplasmic antibodies what may they have as well Crohn's disease- 60% have ASCA, 10% have p-ANCA
What are the mainstays of tx for Crohn's Corticosteroids, 5-ASA, Mesalamine; don't use corticosteroids as maintenace therapy for remission
If you start a patient on sulfasalazine (combo of 5-asa, mesalamine and sulfapyridine) what else do you need to give them because of s/e of this treatment for Crohn's folic acid because sulfasalazine inhibits absorption of it, also not useful in treating small bowel disease
What tx for Crohn's disease can induce and maintain remission Sulfasalazine and mesalamine, methotrexate; azathioprine is useful in maintaining remission but has s/e
if your Crohn's patient develops a fistula what do you need to add to tx antibiotics- metronidazole
What drug is contraindicated in Crohn's with stricture but ok in Crohn's w/ fistula formation Infliximab- antibody to tumor necrosis factor
Pt has Crohn's or ulcerative colitis that involves most of the colon and has had it for >8yrs what are they at increased risk for developing Colorectal cancer- surveillance colonoscopy every 1-2yrs. Proctocolectomy should be done if precancerous findings appear
What are the indications that surgery should be done on Crohn's severe active disease refractory to tx, toxic mega colon, fibrotic structures, perforations, fistulas, corticosteroid dependence
What are the s/sx of toxic mega colon extreme inflammation and distention of colon, w/ pain, distention of abdomen, fever, rapid heart rate, dehydration. Life threatening requires immediate medical tx
What is an ileostomy bypassing the colon or done after resecting the colon it connects the ileum to the abdomen where it is drained. Excrement is watery and contains salt and enzymes that are corrosive to skin
Some Crohn's patients present with extra-intestinal manifestations what are some of these manifestations joint 25%- arthralgia, arthritis; Skin 15%- erythema nodosum, pyoderma gangrenosum, aphthous ulcers of mouth; Ocular- episcleritis, uveitis, recurrent iritis
If patient is ambulatory and able to take oral alimentation, w/ no dehydration, high fever, abdominal tenderness, painful mass, obstruction or weight loss >10% how would you define their Crohn's disease mild to moderate
if patient has failed tx, and has fever, significant weight loss, abdominal pain, intermittent N/V, or significant anemia how would you classify their Crohn's disease moderate to severe
If pt has persistent s/sx despite steroid therapy w/ high fever, persistent N/V, evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of an abscess how would you classify their Crohn's disease Severe Fulminant Disease
what tx should be used or IBD in a mild case aminosalicylates, antibiotics, oral corticosteroids, elemental diets
If case of IBD is moderate what treatment should be used oral/parenteral corticosteroids, elemental diets and antimetabolites
If case of IBD is severe what should be added to tx infliximab, parenteral corticosteroids, bowel rest and surgery
What is remission of Crohn's disease described as patient is asymptomatic or pt has no inflammatory sequelae and is responding to acute medical intervention
what are the common lab and radiographic findings in Crohn's disease mild anemia, mild leukocytosis, elevated ESR rate, small bowel involvement, fistulas, strictures
if pt presents w/ complaints of diarrhea and hematochezia and on endoscopic exam you note crypt abscesses, superficial inflammation that extends from rectum proximally through colon what do they likely have ulcerative colitis
what is the tx for mild ulcerative colitis 5-ASA (Asacol, Pentasa, Rowasa) nicotine
What is the tx for moderate ulcerative colitis 5-ASA, oral steroids, 6-MP
what is tx for severe ulcerative colitis iv corticosteroids, iv cyclosporine, followed by oral cyclosporine; possible surgery
what is considered mild ulcerative colitis less than 4 BM per day, occasional blood in stool, labs normal
what is considered severe ulcerative colitis >6 bm per day with bleeding, fever, anemia, pulse>90
Which disease has increased in prevalence and which has remained steady in rate of incidence between ulcerative colitis and Crohn's Crohn's has increased 6x, Ulcerative colitis incidence has remained stable
Is there a genetic link in ulcerative colitis yes 10-20% of pts have family member who has disease as well. Crohn's has a higher genetic link
What is the major difference radiographically between Crohn's and ulcerative colitis ulcerative colitis has collar button ulcers while Crohn's has cobblestone appearance; Ulcerative colitis has pseudopolyps while Crohn's has thickening of mucosa
if the small bowel is involved is it Crohn's or ulcerative colitis Crohn's, ulcerative colitis is confined to colon
If patient has gross rectal bleeding is it more likely Crohn's or ulcerative colitis ulcerative colitis
What is the most common GI cancer in the US colorectal cancer
Who is at most risk for developing colorectal cancer Born in N. America, western Europe, Australia/new Zealand; AA> Caucasians, men little> women, diet of meat, fat, sucrose, long standing IBD, old age, excessive EtOH, tobacco, obesity. 1st degree relative w/ colorectal cancer
This is a autosomal dominant disease where hundreds to thousands of adenomatous colorectal polyps appear early in adolescence cancer develops at mean age of 39 and is inevitable if colon is not removed Familial Adenomatous polyposis
This is an autosomal dominant condition with benign gastroduodenal polyps and connective tissue polyps, risk of getting colorectal cancer is high mean age of dx is 44 also associated with GU, endometrial and stomach cancer Hereditary Nonpolyposis
what does colorectal cancer develop from adenomatous polyps, removing polyps reduces development of Cancer significantly
what is the screening strategy for colorectal cancer at 50 start screening for blood in stools every year. Double contrast barium every 5yrs, colonoscopy every 10yrs. If 1st degree relative had colorectal cancer start at 40
If patient is at risk for having familial adenomatous polyposis when should you start screening strategy for colorectal cancer at age 10-12
IF patient has hereditary nonpolyposis when should you start screening for colorectal cancer age 20-25 with colonoscopy every 1-2 yrs
What are the recommendations to avoid colorectal cancer increase dietary fiber, moderate alcohol, avoid tobacco, long term aspirin, NSAIDS, folic acid, calcium
what is the tx for colorectal cancer surgery, with adjuvant chemo and or radiation to treat invasion and nodal involvement. Most cancer will recur in 2-5 yrs
according to the CMDT what are the essnetial to dx Crohn's disease insidious onset, intermittent bouts of low grade fever, diarrhea, and RLQ pain, RLQ mass and tenderness, perianal disease w/ abscess, fisutlas; radiographic evidence of ulcerations, stricturing, or fistulas of the samll intestine or colon
Created by: Max Smith Max Smith on 2010-03-21



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