NPLEX Combination ReviewGastroenterology

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Stool Analysis & Procedures

Collection of Specimen• Bacterial culture

– Rectal swab or fresh (random) stool in container; must be < 4 hours old before culture.

– Perform for bacterial dysentery: (salmonella, Shigella, campylobacter jejuni, yersinia enterocolitica, clostridium difficile).

• Ova & parasites– Stool analysis (microscopic) Investigating for presence of

ova / parasites.

• Comprehensive digestive stool analysis (CDSA)– Complete stool evaluation for O & P, Bacteria, Leukocytes,

electrolytes and Osmolality.

Analysis of Stool Sample• Frank and occult blood (> 2.8ml/d = pathologic)• Color• Culture: Symptoms include bloody diarrhea, tenesmus, travel, FUO and

stool leukocytes.• Electrolytes: Osmolality changes (Excess diarrhea).• Fat content: ABN = > 7g/d: Rule out pancreatic/biliary function.• Leukocytes: Increased=UC, Parasitosis. Decreased=cholera and viral

diarrhea.• Meat fibers: Monitor pancreatic function.• Nitrogen• Ova & parasites• Stool pH: Normal range: 6.0 –7.2;

– Alkaline may indicate antibiotic use, fungal overgrowth. – Acid indicates CHO or fat malabsorption or disaccharide def.

• Porphyrins: Component of hemolytic work-up when occult blood present.• Trypsin: Absence indicates pancreatic function.• Urobilinogen: (> 400 Ehrlich units – Evaluate for hemolytic anemia).

– Decreased levels indicate hepatobiliary disfunction• Mucous• Bile: Diminished digestive function when hepatobiliary compromise.

Clinical Considerations • Implications

– Dependent on results; use clinical presentation to diagnose.

• Interferring factors– Sample contamination– Improper patient preparation and/or handling– Mishandled specimen

• Patient preparation and post-procedural management– Ensure patient compliance by educating patient

about procedure.

Salivary Tests• Immunoglobulin – A

– Saliva used for s-Ig-A collection– Can detect general IgA production OR specific Ab’s for

pathogens. (Good marker of both disease presence and cure)

ALSO TESTED IN SALIVA:

• Anti-gliadin Antibodies• Hormone Evaluation

– Male and Female hormone panels

• 4 - Sample Cortisol Analysis (ASI)– Circadian Cortisol analysis

GI Imaging:

• Ultrasound– Good for cystic masses, Aortic aneurisms, ovarian

cysts etc… quick non-radiation study.• CT

– Generally the go-to study for visualization of solid organs, masses, extraintestinal pathologies.

• WHAT ARE you ordering?– Abdominal exams generally STOP at the ASIS line –

so no pelvic contents will be seen.– If you need to visualize the area below the ASIS order

Abdominal AND Pelvic U/s or CT.

Diagnostic Ultrasound

• GI / GU ultrasound– Performed for renal, hepatobiliary, spleen,

pancreas, abdominal aorta and IVC patterning and visualization.

– Consider in acute inflammatory and cystic lesions

• Endoscopy– General term given to the examination and

inspection of body organ cavities by means of endoscopes.

• Laparoscopy– Intra-abdominal cavities may be visualized

by this technique in order to diagnose cysts, adhesions, fibroids, inflammatory processes and malignancies.

Specific Endoscopy Procedures

• Anoscopy– Good for internal hemmorhoids

• Colonoscopy– “Gold Standard” for colon CA and Polyp Dx

• Sigmoidoscopy– Includes examination of the 25 cm recto-sigmoid

region using a flexible sigmoidoscope. Should be routine (3 – 5 yrs.) for individuals over 50. Study can be used to evaluate hemorrhoids, tumors, polyps, blood or mucous in stool and other bowel conditions. Used to screen for rectal CA.

Flouroscopy• Historically, a method of “motion” X-Ray

examination (Ie. Barium Studies in motion…)

• Used both diagnostically and as placement guide for invasive procedures (injection…)

• Can operate under live fluoroscopic guidance during procedures requiring highly sensitive placement of instrumentation.

GastrointestinalPharmacology

GI Pharmacology Overview:• Pain:

– GERD– Ulcers– Dysbiosis– Inflammatory disease– Infection– Hemorrhoids

• Diarrhea:– Inflammatory disease– Infection

• Constipation:– Dietary troubles / hydration– GI atony

H2 Blockers MOA Uses Adverse Effects Other

Cimetidine[Tagamet]

H-2 Blocade: Blockshistamine from activating cAMP pathway IN PARIETAL CELLS (and elsewhere).

PUD, GERD Small chemical so can cross the BBB, think of antihistamine side effectsAlso decreased libido, impotence and gynecomastia

Causes P450 system to accelerate THEN decelerate; Contraindicated with kidney or liver failure

Ranitidine[Zantac]Etc…

H-2 Blocade: Less CNS and sexual effects than Cimetidine

Less inhibition of P450 system

Proton Pump Inhibitors

MOA Uses Adverse Effects Other

Omeprazole (Prilosec)

Lansoprazole (Prevacid)

Rabeprazole (Aciphex)

Pantoprazole (Protonix)

Esomeprazole (Nexium)

Block proton pump to inhibit H+, K+ and ATPase and blocks the formation of gastric acid

PUD, GERD

Headache, diarrhea, abdominal pain, nausea, vomiting, constipation, flatulence, URI, rash

Interact with drugs that require low gastric pH for absorption

Miscellaneous MOA Uses Adverse Effects

Other

Metoclopramide [Reglan]

Stimulates motility of upper GI tract to increase rate of gastric emptying, works on the CNS

GERD, pre-op gastric emptying, nausea / vomiting with chemotherapy treatments

Diarrhea, restlessness, anxiety, fatigue, seizures, headache, drowsiness

Extrapyramidal side effects

Muscarinic Antagonist

MOA Uses Adverse Effects Other

“Belladonna Alkaloids”

Hyoscyamine Levsin

Belladonna alkaloid (hyoscyamus)

Diarrhea

Scopolamine Act upon Muscarinic Receptors, more potent at eyes, less potent on heart, lungs and GI

Motion Sickness prevention

CNS depression. Constipation, dry mouth, N/V, drowsiness, headache

Available in transdermal application Increases digoxin levels

AntidiarrhealOpiates

MOA Uses Adverse Effects Other

Opium Tincture [Paragoric]

Diphenoxlylate & Atropine[Lomotil]

Inhibits GI motility by binding opiate receptors and muscarinic receptors

Diarrhea Constipation, abdominal pain or distention, nausea

Many side effects and drug-drug interactions

Loperamide[Imodium]

Acts directly on intestinal muscles to inhibit peristalsis and prolong transit time

Diarrhea Constipation, dry mouth, abdominal pain, distention, skin rash

Hepatotoxic at high doses

MiscellaneousAntidiarrheal

MOA Uses Adverse Effects Other

Hyoscyamine[Levsin]

Belladonna alkaloid (hyoscyamus)

Diarrhea Decreased sweating, GI motility, salivary gastric and bronchial secretion. Pupillary diliation, vision changes

Digestive Aids

MOA Uses Adverse Effects Other

HCL Restore gastric acidity

Hypochlorhydria

OD will damage esophageal and stomach epithelium

Digestive Enzymes Pancrease…

Improve food digestion

Pancreatic insufficiency, maldigestion, inflammation

Bile Salts Ursodiol

Bile Acid that probably suppresses hepatic cholesterol release into the biliary tract, slowly solublizing NON Ca++ Bile Stones.

CholelithiasisSurgical alternative

Nausea, diarrhea, acute cholecystitis, colic

Anti Nausea

Prochlorperazine

[Compazine]

Chlorpromazine

[Thorazine]

Anti-DOPA Antiemetic Extrapyramidal Side Effects!

Ondansetron

[Zofran]

Dola / Alo / Granisetron

5-HT-3 Antagonist

Antiemetic CNS effect

Increase AST / ALT

Stool Softeners

MOA Uses Adverse Effects Other

Docusate[Colace]

Reduced surface tension of the oil-water interface of stool to soften it.

Constipation Electrolyte imbalance with excessive use, decreases coumadin effect

TOXIC with concomitant mineral oil use.

Saline[Milk of Magnesia]

Draws water into lumen

Constipation, pre-op

Abdominal cramps, nausea, vomiting, diarrhea

Short term treatment only

Bulk Forming Agents

MOA Uses Adverse Effects Other

Psyllium [Metamucil]

Guar Gum[BeneFiber]

Swells in water to form gel or viscous solution, softening the stool

Constipation Flatulence, may cause impaction

Slower acting 1-3 days

Cathartics MOA Uses Adverse Effects Other

Castor oil

Senna

Cascara

Prunes

Stimulate intestinal mucosa by irritating mucosal lining

Constipation Nausea, vomiting, cramps, anorexia

Bisacodyl[Ducolax]

Increases water and electrolytes to increase motility

Constipation Diarrhea Do not mix with milk or antacids because it can prematurely dilute the enteric coating of the tablet

Note:

The wise physician will own a copy of:

Diagnosis of the Acute Abdomen

By Sir Zachary Cope

Referred Pain Patterns• Stomach - 5th Rib (Left) - to - Mid Lumbar Region, Midline to Left Lateral

Border : Dorsal & Ventral Epigastric area

• Liver - Same position as Stomach on Right half of Body. Dorsal and Ventral. Right Scapula.

• Gallbladder - Murphy's Point, Right Upper Quadrant, Right Scapula

• Appendix – McBurney’s Point, Right Lower Quadrant, Right Dorsal Flank, Celiac area

• Colon, Small Intestine - Celiac, Local area of Large Intestine

• Rectum - Suprapubic area, Sacral area

• Kidneys - Costovertebral Area, Bilateral Dorsal Flanks, Right & Left Dorsal Iliac Crests

• Ureters - Left Inferior Iliac Crest, Left Inguinal Area, Left Labia/Testicle

Differential Diagnosis

Generalized Abdominal Pain

Initial pain is often remote!

• API (appendicitis) pain may start high

• Transverse colon pain may start low

Initial API pain

Initial Transverse Colon Pain

Central / Celiac pain

• Acute / Early API• Acute small bowel

obstruction• Acute gastritis• Acute pancreatitis

– May also be Epigastric

• Acute intestinal colic

RUQ / Right Hypochondrium

• Pleuritic pain• Acute API (high organ)• Acute cholecystitis• Leaking duodenal ulcer• Subphrenic abscess

LUQ / Left Hypochondrium

• Subphrenic abscess• Perforated gastric ulcer• Jejunal diverticulitis• Spleen

– Pain– Rupture– Artery aneurysm

Right iliac pain

• Major:– API– Crohn’s– Mesenteric Adenitis– Leaking duodenal ulcer

• Less Common:– Cholecystitis (low GB)– Biliary peritonitis– Acute pancreatitis– Inflammed Meckel’s

diverticulum

Left iliac pain

• DIVERTICULITIS• Peritonitis (spreading)• Pericolitis (around colon

cancer)

Flank & Left Inguinal / Iliac pain

• Black:– Ureteric pain– Can be either

side

• Grey:– Kidney pain

1

Posterior pain patterns

1. Perforated duodenal ulcer

2. Biliary colic

3. Acute Pancreatitis / Renal colic

4. Uterine / Rectal pain

5. Colon pain

Left Right1

2

3

4

5 5 5

Chest Pain• Esophageal spasm

• May mimic MI or angina; may respond to nitrates or calcium-channel blockers

• Gastritis/esophagitis• Burning chest pain

• Anxiety and hyperventilation• May have chest pain, SOB, feeling as though will die

• Acute MI• Substernal pressure with radiation to arms, neck, jaw,

dyspnea, diaphoresis; occurs with exertion• Musculoskeletal

• Usually tender over specific point that reproduces pain

Chest Pain• Pericarditis

• Pleuritic, radiates to shoulder, worse when lying down, better sitting up; may have a rub

• Pneumonia• Generally have associated cough, fever

• Pulmonary embolism• Sudden onset, respirophasic (pleuritic in

nature), dyspnea• Thoracic aortic aneurysm

• Sudden-onset tearing pain radiating to back, arms, jaw, neck

Esophageal Disorders

Achalasia

Motility disorder of the esophagus secondary to the loss of neurons from the mesenteric plexusLower esophageal sphincter (LES) fails to relax with swallowing, and LES pressures become elevated

Esophagus Spasm

Sometimes drinking very cold liquids or eating ice cream will make dysphagia worse. This is very suggestive of esophageal spasm, but it is not invariably present.

Esophagus Reflux

DiagnosisBy history

Esophagoscopy will show esophagitis. Barium swallow may show reflux from stomach to esophagus

Peptic Ulcer Disease • Gastric Ulcer

– 25% of all PUD– Male = Female– H.pylori ~ 75% of cases

• Blood type A / NSAIDS / Smoking / Bile reflux– Lesser curvature (Gr. Curvature Incr. CA risk)– Complications: Perforation / Bleeding.– Burning epigastric pain post-eating. Pain WORSE with food intake

better antacid/milk/fish

• Duodenal Ulcer– 75% of all PUD– Male/ Female 2:1– Burning epigastric pain, 1-3 hours after eating, better EATING,

Antacids.– H.pylori >90% of cases

• Blood group O / Multiple Endocrine Neoplasia

Pancreatitis

Etiology: many but two most commonAlcohol and gallstones (>90%)

Symptoms:Epigastric sharp to boring pain w/ ½ patients having radiation to backAlleviated by sitting up or fetal positionAggravated by movementAssoc w/ nausea, vomiting and anorexia

Diagnosis: confirmed byLab: elevated amylase and lipaseAbdominal x-ray vs CT scan

Cholelithiasis

SymptomsNausea, vomiting, abdominal pain, RUQ tendernessVariable fever, leukocytosis, mild elevation of bilirubin, elevated alkaline phosphatase

Physical Exam and LabMurphy’s sign may be presentInvoluntary guarding of right-sided abdominal musclesUltrasound

Cholecystitis

Acute inflammation of the gallbladder wall95% of those with cholecystitis will have cholelithiasisSymptoms

Similar to biliary colic (nausea, vomiting, abdominal pain, RUQ tenderness) Variable fever, leukocytosis, mild elevation of bilirubin, elevated alkaline phosphataseAmylase elevation suggests (but does not confirm) gallstone pancreatitis

Bilirubin • If total bili is elevated check direct - indirect• Indirect / Unconjugated

– “Pre-hepatic” elevated in hemolytic conditions, or Glbert’ syndrome.

– Think poor glucuronidation or excessive RBC lysis.– The glucuronidation patheay is also slowed by:

• Toxic mushrooms• Acute Hepatitis• Acetaminophen toxicity

• Direct / Conjugated– Hepatocellular disease (normally with increased

ALT)– Biliary obstruction (Often with increased Amylase)

HepatitisClassified into acute hepatitis (self-limited liver injury of <6 months) and chronic hepatitis (hepatic inflammation >6 months)Signs and Symptoms

Fever, nausea, vomiting, anorexia, vague RUQ abdominal pain, jaundice, headache, myalgia and/or arthralgiaSmokers may find tobacco tastes badPronounced elevation of liver enzymes in acute hepatitis and variable increase with chronic disease

HEPATITIS• Hepatitis A (RNA)

– Fecal-Oral transmission, abrupt onset. 15-50 day incubation. Low mortality, no carrier state.

• Hepatitis B (DNA, only one)– Parenteral / sexual transmission. – Insidious onset, primary mortality 1-2 %.

• Incubation 10-12 weks, followed by fever, fatigue, nausea,and jaundice with heptaomegaly – Associated with primary hepatocellular carcinoma, and cirrhosis.

• Hepatitis C (RNA)– Same profile as HepB– More of a slow, chronic course in most– Parenteral transmission, sexual transmission is questionable (for boards purpose)– Very high risk of hepatocellular carcinoma

• Hepatitis E (RNA)– Fecal – Oral transmission– Not found in US: Endemic to Mexico, Africa, Indochinese subcontinent– Incubation period: Average 40 days

• Range 15-60 days– Case-fatality rate: Overall, 1%-3%

• Pregnant women, 15%-25%– Illness severity Increased with age – Chronic sequelae: None identified

• Hepatitis D (RNA)– Parenteral / Sexual transmission. Co-infection with HepB ALWAYS. Deadly.

Feature Hepatitis A Hepatitis B Hepatitis C

SerologicDiagnosis

IgMAnti-HA

HBsAg Anti-HCV

Transmission

Fecal-Oral Blood Blood

ChronicProgressi

on

None Occasional (5% to 10%)

Frequent (65% to 85%)

Hepatitis C

Accounts for 20% to 40% of acute hepatitis in the United States75% of those infected develop chronic disease with chronically elevated ALT (2-8 fold normal)20% of patients eventually develop cirrhosisMany patients with hepatitis C have a history of intravenous drug abuseDiagnosis: based on elevated Anti-HCV Ig or PCR.

Cirrhosis

Signs and Symptoms• Weakness, anorexia, malaise, and weight loss• Jaundice and pruritus• Palpable, firm liver with a blunt edge is typical

DiagnosisDecreased serum albumin and a prolonged prothrombin time directly reflect impaired hepatic functionCT to evaluate liver size and textureUS for organomegaly

Ascites

Ascites is a pathologic accumulation of serous fluid within the abdomenThink: Intra-abdominal masses, Liver diseaseSigns and Symptoms

Percussion of the flanks helps reveals dullnessFluid will shift upon rotating the patient in the right or left lateral positionsShifting dullness indicates the presence of at least 1.5 liters of ascites

Anorectal Disorders

Hemorrhoids Dilated vein within the anal canal and distal rectum.

Internal hemorrhoids are derived from the internal hemorrhoidal plexus above the dentate line and are covered by rectal mucosa.

External hemorrhoids are derived from the external hemorrhoidal plexus below the dentate line and are covered by stratified squamous epithelium.

Abscess

Obstruction of the anal glands, leading to infection and abscess formation

In its early stage the infection is called cryptitis

Escherichia coli, Proteus vulgaris, streptococci, staphylococci

Fissure

Classical symptoms

Pain and bleeding with a bowel movement

Pain may persist for many hours after a bowel movement

The fissure is caused by a tear in the lining of the anal skinUsually heal in 2 to 4 weeks

Fistula

A tube like tract with one opening in the anal canal and the other usually in the perianal skin.(Merck)Etiology:

Drainage of a perirectal abscessmild infection burrowing to the skin and bursting like a pimpleUsually begin in the anal-rectal crypts but sometimes result from

trauma diverticulitis neoplasm

Gastric Cancer

Adenocarcinoma 95% of casesThe chance of getting stomach cancer is higher if the patient:

has had an infection of the stomach caused by Helicobacter pyloriis olderis malesmokes cigarettesfrequently eats a diet that includes lots of dry, salted foods

Gastric Cancer (Symptoms)

Unintended weight loss and lack of appetite Abdominal pain Vague discomfort in the abdomenA sense of fullness in the upper abdomenHeartburn, indigestion, or ulcer-type symptoms Nausea Vomiting, with or without blood Swelling of the abdomen due to accumulation of fluid and cancer cells

Liver Cancer

• The majority of malignant tumors prove to be metastatic rather than primary.

• Hepatocellular carcinoma is associated with cirrhosis in 50% to 80% of patients

• Hepatitis B infection and hepatitis C infection appear to be significant causes of hepatocellular carcinoma worldwide

Pancreatic CancerAdenocarcinomas of the exocrine pancreas arise from duct cells nine times more often than from acinar cells; 80% occur in the head of the glandWhen cancer of the pancreas spreads metastasizes outside the pancreas, cancer cells are often found in nearby lymph nodesIf the cancer has reached these nodes, it means that cancer cells may have spread to other lymph nodes or other tissues, such as the liver or lungsSometimes cancer of the pancreas spreads to the peritoneum, the tissue that lines the abdomen

Pancreatic CancerDiagnosis

Routine laboratory tests are often normal.,

Alkaline phosphatase and bilirubin may be increased if bile duct obstruction or liver metastases are present.

Hyperglycemia occurs in 25 to 50% of patients (secondary or DM)

CT more sensitive than MRI

Prognosis: Overall 5-yr survival is < 2%

Colon Cancer

Tumors can develop anywhere in the colon or rectumA benign growth, called a polyp, may start to grow on the wall of the colon or rectumColorectal polyps can become cancerous

Colon Cancer

Risk Factors Over 50 years of ageHistory of polyps in the colonUlcerative colitisCrohn's diseaseFamily history of colon cancer or familial polyposis syndromeA diet high in fat and low in fiberSmokingAlcoholic beveragesInactive lifestyle

ACS Guidelines 2007 - Colorectal

• Beginning at age 50, both men and women should follow 1 of these 5 testing schedules: – yearly fecal occult blood test (FOBT)* or fecal immunochemical test (FIT) – flexible sigmoidoscopy every 5 years – yearly FOBT* or FIT, plus flexible sigmoidoscopy every 5 years** – double-contrast barium enema every 5 years – colonoscopy every 10 years

• *For FOBT, the take-home multiple sample method should be used. **The combination of yearly FOBT or FIT flexible sigmoidoscopy every 5 years is preferred over either of these options alone.

• All positive tests should be followed up with colonoscopy. • People should talk to their doctor about starting colorectal cancer screening

earlier and/or undergoing screening more often if they have any of the following colorectal cancer risk factors: – a personal history of colorectal cancer or adenomatous polyps – a strong family history of colorectal cancer or polyps (cancer or polyps in a first-

degree relative [parent, sibling, or child] younger than 60 or in 2 first-degree relatives of any age)

– a personal history of chronic inflammatory bowel disease – a family history of an hereditary colorectal cancer syndrome (familial

adenomatous polyposis or hereditary non-polyposis colon cancer)

Colon Cancer

Screening Age 40

digital rectal exam at your annual check-up

Age 50annual fecal occult blood testsigmoidoscopy exam every 3 to 5 yearsIf polyps are found during a sigmoidoscopy, a colonoscopy examination should be performed

Colon Cancer

Signs and SymptomsWarning signs to watch for include: a change in usual bowel habits, (constipation, diarrhea or both) stools that are narrower than usual blood in or on the stool general stomach discomfort, such as bloating, fullness and/or cramps frequent gas pains a feeling that the bowel does not empty completely weight loss with no known reason, and constant tiredness

Bacterial Gastroenteritis

CholeraCausative organism, Vibrio choleraeStarts with vague abdominal fullness followed by cold hands and feet, light headedness, rapidly progressing effortless vomiting, massive painless watery purging, leg muscle cramps, and urine shutdown

Bacterial Gastroenteritis

Escherichia Coil EnteritisWater or fecal/oral spread24-72 hour incubation periodEnterotoxin causes diarrheaUsually non-bloody unless caused by enterohemorrhagic strain type O157:H7

DiagnosisCulture

Food Poisoning

• More Rapid onset (1 – 8 hours post-ingestion) think Staph

• Longer onset (12-24 hours) think Salmonella / Vibrio …

Food Poisoning

StaphylococcalCramps, vomiting, diarrhea mild, occasional feverOnset is 1-2 hours and symptoms last from 5-8 hours to daysSource: meat type foodsDiagnosis: stool microscopy for gram-positive cocci

Food PoisoningBotulism (Clostridium botulinum)

Symptoms: Nausea, vomiting, abdominal cramps, and diarrhea

Home canned foods, fish

Neurological symptoms in later phase

Neurologic symptoms: bilateral and symmetric, beginning with the cranial nerves and followed by descending weakness or paralysis

Bacterial GastroenteritisClostridium perfringens

Meat (Usually meats cooked and cooled)Duration: 24 hoursSymptoms: Watery diarrhea, nausea, crampsvomiting rareDiagnosis: history, toxin or organisms in the feces, or serology.

Bacterial GastroenteritisSource Symptoms

Salmonella

EggsPoultry

Diarrhea with blood, crampsOccasional sepsis

Shigella Poor hygiene, person to person

Nausea, vomiting, diarrhea with progression to invasive diarrhea (heme positive stool)Neurologic symptoms, including seizures in young patients

Modified from University of Iowa Virtual Hospital; Gastroenterology And Hepatology: Table 5-2, 2002

Protozoal GastroenteritisSource Symptoms

Giardiasis

Water from animal feces

diarrhea, foul, greasy stools, abdominal cramps, bloating, increased gas, weakness, and weight loss

Cryptosporidiosis

Contaminated water

profuse watery diarrhea, abdominal cramping, and, less commonly, nausea, anorexia, fever, and malaise

Inflammatory Bowel Disease

Crohn’s (Regional Enteritis)Primarily affects distal ileum and colon but can be present anywhere in GITransmural inflammatory process; may have areas of normal intestine with affected sections (skip lesions)Signs and Symptoms: diarrhea, RLQ abdominal pain, fever, fatigue and bowel obstruction

Inflammatory Bowel Disease

Irritable Bowel SyndromeLong history of chronic or intermittent diarrhea

which usually starts before age 50 and is exacerbated by anxiety or stressDiarrhea is often worse in the morning and after mealsPatients may complain of incomplete evacuation, distention, passage of mucus, or associated abdominal, pelvic, and back pain

Ulcerative Colitis

Used with permission from Michael P. Buetow, M.D., 2002

Ulcerative Colitis: is an inflammatory bowel disease similar to Crohn’s disease. However, it continuously involves the colon and does not demonstrate the same linear ulcerations and segmental involvement as seen with Crohn’s disease. It virtually always involves the rectum and presents with small ulcerations and a tubular appearance to the colon.

Ulcerative Colitis

Diagnosis:

ExclusionPhysical exam, stool occult blood and imaging may all be normalConsider food allergy panel

Treatment:Avoid trigger or allergic foodsAddress stress and educate patientAnti-inflammatory supplements

Lactose IntoleranceReaction to lactose ingestion caused by a deficiency of lactaseSigns and Symptoms:

abdominal distention and paingaseous bloating and borborygmiflatulence and diarrhea resulting from increased distension and decreased transit time of lactulose in the small bowelproduction SCFAs and gases in the colon

Celiac Sprue (Gluten-Sensitive Enteropathy)

Celiac sprue is caused by the interaction of gluten of particular grains (e.g. wheat) with the small intestinal mucosa. Gluten causes the intestinal mucosa to lose its villous structure and absorptive capacitySigns and Symptoms:

Patients may have diarrhea, steatorrhea, foul-smelling flatulence, and weaknessDermatitis herpetiformisAnemia may result from alterations in iron, folate and vitamin B12 absorption

Celiac Sprue (Gluten-Sensitive Enteropathy)

Diagnosis:Serum IgA antiendomysial and tissue transglutaminase are found in up to 95% of patients with gluten sensitivity

Labs have a 4 value serum test correlating these values.

Anti-gliadin levels are less specific for sprue but do indicate an intoleranceIntestinal biopsy is the most sensitive means of making the diagnosisTo make the diagnosis unequivocally, the patient’s symptoms must be relieved with an adequate trial (a few weeks to up to a year) of a gluten-free diet

Appendicitis

Appendicitis is a common cause of abdominal pain

most common in adolescence and young adult years

Signs and Symptoms:periumbilical or epigastric pain that migrates to right lower quadrantPain may be felt in flank (retrocecal appendix, pregnancy), testicle (retroileal appendix), or bladder

Appendicitis

Diagnosis:CBC with differentialUApregnancy test should be obtained on women with lower abdominal painMild to moderately elevated WBC with left shift is typical but WBC is normal in 10%.

Diverticulosis/Diverticuliti

sDiverticulum (plural, diverticula)

Outpouching of the bowel wall usually between 0.1 to 1 cm in diameterMost occur in the sigmoid and descending colon

DiverticulosisPresence of multiple diverticula. Does not imply a pathologic condition. In industrialized countries, up to half of the population older than 50 years of age has colonic diverticulosis

DiverticulitisInflammation and infection in one or more diverticula

Diverticulosis/Diverticuliti

sTHINK “Left-Sided Appendicitis”Signs and Symptoms (Diverticulitis):

Abdominal tenderness to palpation with possible rebound tendernessA palpable mass may be present, representing an abscess or inflammatory phlegmonBowel sounds may be active if there is partial obstruction; hypoactive or absent if peritonitis has developedCT scan is the imaging procedure of choice especially if the diagnosis is uncertainSigmoidoscopy may be performed cautiouslyColonoscopy is contraindicated in the case of acute diverticulitis