TEST 4 GIGU – DR



TEST 4 GIGU – DR. KUHN

CLASSIC INFLAMMATORY BOWEL DISEASE – (IBD)

Do not confuse IBD w/ IBS. IBS is a temporary disorder that produces no abnormal tissue in the bowel. IBD on the other hand does create abnormal tissues such as ulcers and other lesions.

IBD can be a mouth ( anus problem, but most often, certain target areas are seen

1. CROHN’S DISEASE – (aka Regional Enteritis or Regional Ileitis)

▪ This dz is considered idiopathic and may be linked w/ a viral etiology.

▪ Seems to present w/ a familial tendency and both men and women (20’s and 30’s) are equally likely to acquire Crohn’s.

▪ M/C target site is the distal ileum…possible to see Crohn’s pass through ICV and set up shop in cecum too (40% of the time)

▪ Symptomatology:

- Young male/female w/ persistent or repeat episodes of diarrhea followed by constipation

- RLQ pain

- Mild flu-like symptoms that persist and become worse

- Weight loss and nutritional deficiencies

▪ Radiographically:

- Skip lesions – alternating areas of diseased and normal bowel

- Lead pipe sign – film w/ contrast will show narrow, rigid channels in bowel due to fibrotic repair…leads to inability to contract bowel = aperistalsis or adynamic ileus

▪ Treatment:

- Acupuncture is proven to be helpful

- Avoid dairy, raw veggies and fruits…these prevent uptake and increase the bulkiness of contents moving through the GI tract

- Supplementation of folate and B12 is a must along w/ fat soluble vitamins

- Increase dietary calories and proteins…cook w/ low heat to retain nutrients and combat any deficiencies

- Anti-inflammatory diets seem to be very beneficial

- Surgical intervention is of LAST RESORT and should only be considered in life-threatening situations (story about surgically removing diseased portion of bowel and reconnecting normal portions…later, more diseased tissue is seen at reconnection site)

- Only 40% of patients w/ Crohn’s are helped by the standard treatment protocols

▪ Crohn’s dz is the one that produces the most ulcerations of the IBD. Crohn’s dz is a deep bowel dz (affects submucosal and muscular layers of SI). Also causes full thickness perforations of bowel lining…this can lead to fistula formations and peritonitis

▪ Crohn’s dz has the ability to produce OXALATE STONES, which could lead to obstruction of the GI tract or enter urinary system. Must include “os-cal” (Calcium Gluconate) in diet to help bind up the materials that precipitate into the oxalate stones.

▪ Multiple areas of ulceration patterns is m/c seen in Crohn’s

2. ULCERATIVE COLITIS – (UC)

▪ This is a more continuous bowel disease w/ NO SKIP LESIONS.

▪ M/C target tissue is distal colon and rectum. UC is usually first seen in distal colon but it also likes to travel backwards through the colon to ICV.

▪ UC is a very systemic dz as well…it affects the eyes, skin, liver, gall bladder, heart, bowels and spinal joints…(Enteropathic arthropathies)

▪ UC is mostly a superficial bowel dz w/ no perforations

▪ 3 degrees of dz process:

- Mild Dz –

o Most common stage. Chief symptom/sign is rectal bleeding and bloody stool. May want to do rectal exam to rule out malignancies or possible hemorrhoids. May/may not have diarrhea.

- Moderate Dz –

o 2ND m/c stage characterized by significant diarrhea (4-6 loose, bloody BM per day). Abdominal cramps likely…often relieved after defecation. Low grade fever is possible

- Severe Dz –

o Least common stage (15% of all UC patients). High fevers (101-104), dehydration, pallor, low BP, tachycardia. Blood loss anemia (Normochromic – Normocytic) from increased bloody diarrhea (20-40 BM per day w/ one or more at night)…lab findings will indicate leukocytosis, hypoalbuminemia and elevated ESR.

▪ Complications of UC include:

- Toxic Megacolon –

o This is a surgical emergency! 40% of these patients die. As the colon enlarges and stretches, the lining and blood vessels become thinner and thinner. This allows for easier entry of normal bowel flora (e. coli and others) to enter the vasculature or leech out into peritoneum and cause septicemia…patient becomes extremely ill and could die w/in hours!

- Colon Strictures –

o This is less common (5% of patients) and can be caused during the ebb and flow pattern of fibrotic repair (fibrotic repair takes place during periods of remission)

- Hemorrhages –

o Only occurs in about 4% of patients and can become quite scary when they rupture a major vessel and add this blood loss to that in the 20-40 BM…this is a severely anemic person

- Perforations –

o Perforations are more common in Crohn’s than UC, but when they do occur in UC patients, it is usually in the Severe Stage of the disease…very uncommon.

▪ Now as the name implies, ulcers are present in the colon in UC. These are usually the small shallow ones.

▪ Summary Table Below of UC and Crohn’s

3. WHIPPLE’S DISEASE – (aka Lipodystrophy)

▪ This is the least common of the IBD

▪ This is an IBD that can produce alternating diarrhea and constipation along w/ polyarticular arthropathies (Enteropathic)

▪ Classic presentation…OLD WHITE MAN W/ DIARRHEA AND STEATORRHEA – Mr. Whipple and “don’t squeeze the Charmin” ad.

CELIAC DISEASE – (aka Non-Tropical Sprue)

▪ This is an autoimmune disease in context of an allergy to whole grain…specifically the gleadin portion of gluten.

▪ The body attacks the surface area of the bowel and reduces the surface area. The bowel lining becomes smooth and can lead to malabsorption of nutrients.

▪ Most common allergens are Wheat, Rye, Barley and Soy

▪ Commonly seen in young women mostly, but also seen in adolescents too. Multiple doctors may see patients for many years before the correct diagnosis is reached. Common in the US to take about 10 years before correct diagnosis is reached…in Italy, for example, it only takes about 3 weeks!

▪ Blood tests are often performed to look for antibodies for Antigliaden, Antiendomyceum and Antireticulin. The immune response attacks the villi in the small intestine, typically the jejunum, first.

▪ Symptoms include pain in abdomen related to eating, bouts of diarrhea, weight loss, acne, bloating, constipation, depression, aggressiveness, general GI complaints, pale and foul smelling greasy stools, anemia, bone pain, mushy muscles (loss of tone), fatigue, skin lesions, missed menstrual periods and loss of tooth enamel.

▪ Treatment for Celiac Disease includes…

- Elimination diet (get rid of gluten-containing foods), anti-inflammatory diet and supplementation to make up for any malabsorption or anemia that may have taken place.

▪ Complications of Celiac Disease…

- Decreased bone mass and higher risk of osteoporosis, lymphoma and adenocarcinoma, miscarriage and congenital malformation, short stature, seizures and convulsions.

- Associated conditions include dermatitis herpatiformis (zits), collagen vascular disease, RA and Sjogren’s.

▪ Endoscopy w/ biopsy is the best way to accurately diagnose Celiac Disease

MALABSORPTION SYNDROME

▪ Many things can cause a person to have malabsorption such as chemotherapy, radiation therapy, atrophic gastritis, and gastroenteritis…but, in the context of GI causes, both UC and Crohn’s can cause malabsorption, but it’s more prevalent in Crohn’s.

▪ Think malabsorption when we see disturbances of digestion (like in Menitrier’s Dz) or when we see frequent steatorrhea (fatty stool).

▪ Other causes of malabsorption include…Celiac Dz, post-abdominal surgeries w/ loops of bowel removed, ischemia to GI system, and lymphatic obstruction…

▪ Fecal analysis is a good indicator of malabsorption (look for steatorrhea) – this is when you ask the patient to not flush after their next BM for at least a half hour. After 30 minutes, normal crap will mostly sink. Abnormally fatty crap will still be floating and this is steatorrhea. Also commonly found on fecal exam are proteins and carbs in the stool (large proteins = stomach problem…small proteins = small intestine)

▪ Patients can treat this very easily w/ use of laxatives to keep stool soft and also they can supplement w/ vitamins and minerals until the causative agent is dealt with.

▪ 3 M/C causes of malabsorption are…Crohn’s, Celiac Dz and Chronic Pancreatitis. Whipple’s Dz is a more minor cause of malabsorption.

DISACCHARIDE DEFICIENCY

▪ Disaccharides are your paired sugars (maltose, lactose, sucrose)

▪ M/C cause is lactose intolerance. Will present w/ mild to severe cramping and flatulence.

▪ Some races and ethnicities have a congenital intolerance to lactose such as Native Americans (70-80%), people of Mediterranean descent, Asians (70-80%) and Europeans (10-15%)

▪ Disaccharide deficiency can also be secondary to Celiac or Crohn’s Dz

▪ The treatment for this deficiency is to eliminate the offending agent such as milk or dairy products in general.

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