MOD6-IM2-T2-Diseases of the Colon and Rectum-2.pdf

IM2 INTERNAL MEDICINE 2 Diseases of the Colon and Rectum TRANS 2...

IM2 INTERNAL MEDICINE 2 Diseases of the Colon and Rectum TRANS 2 MODULE 6 Maria Teresita R. Andal-Gamutan MD, FPCP, FPSG, FPSDE September 10, 2024 LECTURE OUTLINE I Colonic Diverticular Disease A. Definition of Terms B. Risk Factors C. Spectrum D. Clinical Presentations E. Clinical Manifestations F. Differential Diagnosis G. Diagnostic Management H. Therapeutic Management I. Case Scenario J. Summary II Irritable Bowel Syndrome Figure 1. Colonic Diverticula Dr. Andal-Gamutan’s Video Lecture Part 1 A. Case 2 B. Risk Factors C. Common IBS Symptoms A. DEFINITION OF TERMS D. Features Against IBS Diverticulosis E. Physical Examination ○ Merely the presence of a colonic diverticula F. Differential Diagnosis Diverticular disease G. Diagnosis ○ Defined as clinically significant and symptomatic diverticulosis H. Severe Symptoms or Red Flags ○ Can range from symptomatic uncomplicated diverticular I. Treatment disease to symptomatic disease with complications such as: J. Summary Diverticulitis - inflammation of the diverticula Colonic diverticular bleeding - hemorrhage from the III Inflammatory Bowel Disease colonic diverticula A. Ulcerative Colitis B. Crohn’s Disease C. Risk Factors D. Symptoms E. Physical Examination F. Extraintestinal Manifestation G. Differential Diagnosis H. Diagnosis I. Treatment J. Case Scenario K. Summary LECTURE OBJECTIVES 1. To diagnose the common diseases of the colon and rectum 2. To formulate a management plan for these diseases Figure 2. Diverticulosis vs. Diverticulitis vs. Bleeding Diverticulum Dr. Andal-Gamutan’s Video Lecture Part 1 🧠 Must Know 📖 Book 📝 Previous Trans B. RISK FACTORS Diverticular disease is common among elderly patients (>60 y/o), I. COLONIC DIVERTICULAR DISEASE but younger patients may also be affected. Constipation, bloody stools, LBM, and abdominal pain are some of It is a result of complex interactions (multifactorial) among: the complaints of patients with colon and rectal disorders. 1 Age Above 60 years old COLONIC DIVERTICULUM 2 Genetic Factors ​A sac-like pouch, protrusion, or outpouching of the mucosa 3 Alteration of Colonic Motility through the muscularis propria of the colon The protrusion occurs at the point where the nutrient artery (vasa Smoking recta) penetrates through the muscularis propria, resulting in a Obesity break in the integrity of the colonic wall. Alcohol 4 Lifestyle Conditions These protrusions are pseudodiverticula as these contain only Consumption of mucosa and submucosa, covered by the serosa. low-fiber diet Diverticula commonly affect the sigmoid, but these may also High meat intake present in other parts of the colon. 5 Alteration in Colonic Microbiota Diabetes mellitus 6 Comorbidities Hypertension Atherosclerosis 7 Chronic Aspirin Intake 8 Obesity 9 Abnormal Neuromuscular Activity Group 2B | Diseases of the Colon and Rectum 1 of 10  E. CLINICAL MANIFESTATIONS 1. CHRONIC DIVERTICULAR BLEEDING It is usually a painless hematochezia, not associated with abdominal pain. Hemorrhage from diverticulosis is the most common cause of hematochezia among patients >60 y/o, particularly with hypertension, atherosclerosis, and NSAIDs intake. Figure 3. Risk Factors for Diverticulosis Dr. Andal-Gamutan’s Video Lecture Part 1 C. SPECTRUM The spectrum of diverticulosis (Figure 4) includes: ○ Asymptomatic diverticulosis ○ Symptomatic diverticulosis Composed of the following spectrum of diseases: 1 Symptomatic Uncomplicated A symptomatic disease with no Diverticular Disease (SUDD) obvious inflammation 2 Acute, chronic or recurrent Diverticulitis May be complicated or Figure 6. Chronic Diverticular Bleeding uncomplicated diverticulitis Dr. Andal-Gamutan’s Video Lecture Part 1 3 Diverticular hemorrhage 2. ACUTE UNCOMPLICATED DIVERTICULITIS 4 Inflammation within the segment Present in around 75% of cases. Segmental Colitis Associated of the colon bearing the Characteristically has: with Diverticulosis (SCAD) diverticula, which is present only ○ fever in 1% of diverticulosis ○ anorexia ○ obstipation (severe constipation) ○ left lower quadrant (LLQ) pain May present like a left-sided appendicitis, since the sigmoid is the most frequently affected segment. Figure 7. Chronic Diverticular Bleeding Dr. Andal-Gamutan’s Video Lecture Part 1 Figure 4. Spectrum of Diverticulosis 3. COMPLICATED DIVERTICULITIS Dr. Andal-Gamutan’s Video Lecture Part 1 Accounts for 25% of cases May have peritonitis, and is associated with abscess or D. CLINICAL PRESENTATIONS perforation, and less commonly with fistula Colonic diverticulosis remains asymptomatic in most individuals. It can be detected on screening colonoscopy as an incidental HINCHEY CLASSIFICATION finding. Perforated diverticular disease is staged using the Hinchey About 25% of these cases will develop symptomatic diverticulosis Classification System to predict outcomes after surgery. or diverticular disease. Diverticular disease can range in severity from mild GI symptoms Stage 1 Pericolic or mesenteric abscess to symptomatic uncomplicated diverticular disease (SUDD) to a life-threatening symptomatic disease with complications such as Stage 2 Walled-off pelvic abscess diverticulitis with perforation or bleeding. Stage 3 Generalized purulent peritonitis Stage 4 Generalized fecal peritonitis Figure 8. Hinchey Classification System Dr. Andal-Gamutan’s Video Lecture Part 1 Figure 5. Clinical Presentation Dr. Andal-Gamutan’s Video Lecture Part 1 Group 2B | Diseases of the Colon and Rectum 2 of 10 F. DIFFERENTIAL DIAGNOSIS From Synchronous Session List of differential diagnoses, which can be excluded after detailed Colonic Diverticular Bleeding history, physical examination, and other workups (required for COLONOSCOPY - is the best workup for Colonic Diverticular Bleeding exclusion of differentials): Angiography - If there is massive bleeding Blood transfusion - If there is significant bleeding that requires Presence of diverticulitis in the cecum or transfusion. ascending colon can mimic acute SCAD Acute 1 appendicitis. Since the segments bearing the diverticula are inflamed, antibiotics, Appendicitis rifaximin can be given and also it can be treated as IBD (we can give Further work ups are required like CT scan to exclude appendicitis. Can cause change in bowel habits and LLQ Diverticulitis 🧠 anti-inflammatory agents). CT-SCAN is a better option for diverticulitis Sigmoid pain Giving antibiotics is indicated for diverticulitis. 2 Surgery is recommended for COMPLICATIONS and failure of medical Malignancy Should also be differentiated from sigmoid management. diverticulitis ○ Uncomplicated: there is no fistula or abscess formation. Inflammatory Presents with chronic diarrhea and bloody ○ Complicated: There is fistula or abscess formation. 3 Bowel Disease stools Dr. Andal-Gamutan (IBD) H. THERAPEUTIC MANAGEMENT Irritable Bowel Can be considered if all the workups are 4 Table 1. Therapeutic Management Syndrome (IBS) normal Additional diagnostic workups may be CONDITION MANAGEMENT needed to exclude these diseases: Asymptomatic Fiber enriched diet ○ Intussusception, hernia, adhesion Diverticulosis ○ Ureterolithiasis 5 Others ○ PID, endometriosis, uterine neoplasia Symptomatic Fiber enriched diet ○ Ovarian tumor Uncomplicated Rifaximin or Probiotics ○ Ectopic pregnancy Diverticular Disease ○ Aneurysmal dissection Antibiotics; AND ○ Recommended: TMP-SMX; or G. DIAGNOSTIC MANAGEMENT Ciprofloxacin + Metronidazole ○ Penicillin may be added for Detailed While detailed history, physical non-responders. History & examination, and laboratory tests are of Uncomplicated ○ Alternatively, single agent therapy 1 Physical great importance when examining a patient Diverticulitis with a 3rd generation penicillin or Examination with diverticular disease, they are not oral penicillin clavulanic acid may be sufficient to diagnose nor stratify diverticulitis given for 7-10 days. Laboratory without computed tomography. 2 ○ Rifaximin may be given to prevent Tests recurrent symptoms. Findings include sigmoid diverticula, Bowel rest 3 CT Scan thickened colonic wall, and pericolic fat Antibiotics inflammation. Surgery Complicated Chest x-ray May be requested initially for acute abdominal ○ Recommended for diverticulitis Diverticulitis upright/ pain to look for perforation complicated with perforation, fistula, 4 or abscess formation Abdominal (pneumoperitoneum) or obstruction x-ray secondary to complicated diverticulitis. Dr. Andal-Gamutan’s Lecture Video If the patient is bleeding as manifested by hematochezia, colonoscopy is the appropriate I. CASE SCENARIO diagnostic examination. 5 Colonoscopy Not only diagnostic, but also a therapeutic CASE procedure 65-year-old hypertensive male Bleeding can be stopped by doing various 1 colonoscopic hemostasis techniques Review of History Option for massive diverticular bleeding Left lower quadrant pain of 4 hours duration Can localize and occlude bleeding vessels Fever with a coil in 80% of cases 6 Angiography CBC can determine the presence of infection Past Medical History and anemia. History of self-limiting painless hematochezia a year ago Significant bleeding and severe anemia requires blood transfusion. Physical Examination Tender LLQ abdomen What is the best diagnostic work-up? A. Colonoscopy B. Abdominal x-ray C. CT Scan D. Ultrasound Figure 9. Diagnostic Management. Dr. Andal-Gamutan’s Video Lecture Part 1 Answer Left: CT Scan; Right: Colonoscopy C. CT Scan since the main complaint of the patient is pain Colonoscopy if the patient is bleeding Group 2B | Diseases of the Colon and Rectum 3 of 10 J. SUMMARY We have discussed colonic diverticular disease which includes symptomatic colonic diverticulosis, colonic diverticular bleeding, and diverticulitis. Depending on the presentation, diagnostic and therapeutic management include: ○ CBC and colonoscopy for diverticulosis and bleeding diverticular disease ○ CT scan and antibiotics for diverticulitis ○ Surgery is recommended for complications and failure of medical management. II. IRRITABLE BOWEL SYNDROME A functional bowel disorder characterized by: Figure 10. Common IBS symptoms Dr. Andal-Gamutan’s Video Lecture Part 2 1 Abdominal pain (prerequisite) 2 Altered bowel habits (most consistent feature) 1. ABDOMINAL PAIN Prerequisite clinical feature of IBS 3 Absent detectable structural abnormalities May be highly variable in intensity and location Frequently episodic and crampy or may be superimposed on a Abdominal pain and altered bowel habits in the absence of background of constant ache detectable structural abnormalities Often exacerbated by eating or emotional stress ○ The patient will appear normal on colonoscopy, CT scan, and Improved by the passage of flatus or stool other series of tests 2. ALTERED BOWEL HABITS A. CASE SCENARIO Most consistent clinical feature of IBS Usual pattern: constipation alternating with diarrhea CASE Patient may present with either constipation or diarrhea as the 30 year-old anxious female 2 predominant symptom May be aggravated by stress or consumption of food Review of History The stool may be accompanied by large amounts of mucus. 4 months history of recurrent lower abdominal pain once a week ○ Bleeding is not a feature of IBS unless hemorrhoids are Frequent soft stools of 3–4 times a day present With improvement upon defecation Malabsorption or weight loss does not occur Past Medical History 3. ABDOMINAL DISTENTION Several consultations with different doctors Increased belching Normal colonoscopy Flatulence Normal results in blood and stool examinations Physical Examination 4. UPPER GI SYMPTOMS Between 25–50% of patients with IBS, complain of dyspepsia, Unremarkable heartburn, or nausea and vomiting which suggests involvement of What is the diagnosis? the other areas of the gut. Irritable Bowel Syndrome D. FEATURES AGAINST IBS How will you manage the patient? >50: onset of signs and symptoms Weight loss Important to give reassurance and careful explanation of the Rectal bleeding functional nature of the disease. Fever It should start with patient counseling and dietary alterations. Nausea or recurrent vomiting Identify the food that can aggravate the symptoms and try to Abdominal pain: avoid obvious food precipitants ○ Is not completely relieved by bowel movement OR Symptomatic relief ○ Occurs at night (nocturnal) Diarrhea that is persistent or awakens you from sleep B. RISK FACTORS Anemia Affects all ages although most patients E. PHYSICAL EXAMINATION 1 < 45 years old would have their first onset of The patient with IBS has an overall healthy appearance, but may symptoms before 45 be tense or anxious. Female 2 to 3 times more often than men May also present with sigmoid tenderness or a palpable 2 sigmoid cord. Predominance Otherwise, the patient will usually have an unremarkable There is an increased risk observed in physical examination. Mental health individuals with mental health problems 3 problems or history of traumatic events such as sexual abuse or violence. F. DIFFERENTIAL DIAGNOSIS Major symptoms of irritable bowel syndrome are common 4 Recent gastrointestinal infections or antibiotic use complaints of many gastrointestinal organic disorders: ○ Abdominal pain 5 History of smoking and alcohol intake ○ Bloating ○ Change in bowel habits C. COMMON IBS SYMPTOMS Helpful to suggest specific disorders: quality, location, and Recurrent abdominal pain on average of at least 1 day per week timing of pain in the last 3 months. ○ Related to defecation OR ○ Associated with change of frequency of stool AND/OR ○ Associated with change in the form/appearance of stool Group 2B | Diseases of the Colon and Rectum 4 of 10  Table 2. Important Differentials 2. BRISTOL STOOL CHART Bristol stool chart can classify the stool consistency into 7 groups. CATEGORY DIFFERENTIALS Pain in the epigastric Biliary tract disease or periumbilical area Peptic ulcer disease Intestinal ischemia Carcinoma of the stomach and pancreas Pain mainly in lower Colonic diverticular disease abdomen Inflammatory bowel disease (IBD) Colon cancer Postprandial pain Gastroparesis associated with Partial gut obstruction bloating, nausea, and Infestation with Giardia lamblia or other vomiting parasites Diarrhea is the major Laxative abuse Figure 11. Bristol Stool Chart symptom ○ Bisacodyl Dr. Andal-Gamutan’s Video Lecture Part 2 ○ Lactulose ○ Senna ○ Castor oil Table 3. Stool Types based on Consistency Malabsorption Type Description Hyperthyroidism Inflammatory bowel disease (IBD) Types 1 and 2 Indicates constipation Infectious diarrhea Types 3 and 4 Ideal or normal stool Constipation Side effect of various drugs (e.g. Type 5 Lacking fiber antihypertensives, antidepressants, and anticholinergics) Types 6 and 7 Indicates diarrhea and urgency Endocrinopathies Dr. Andal-Gamutan’s Lecture Video ○ Hypothyroidism ○ Hypoparathyroidism IBS SUBTYPES Source: Dr. Andal-Gamutan’s Lecture Video For the purpose of treatment, IBS can be divided into four subtypes based on stool consistency using Bristol stool form scale G. DIAGNOSIS Relies on: Table 4. IBS Stool Subtypes ○ Recognition of positive clinical features IBS Subtype Stool type 1 and 2 Stool Type 6 and 7 ○ Elimination of other organic diseases ○ No pathognomonic abnormalities identified IBS with Detailed history and physical examination are helpful in predominant More than 25% Less than 25% establishing the diagnosis. constipation Clinical features suggestive of IBS include: ○ Recurrence of lower abdominal pain with altered bowel habits IBS with without progressive deterioration. predominant Less than 25% More than 25% ○ Onset of symptoms during periods of stress diarrhea ○ Absence of other systemic symptoms such as fever and weight IBS with mixed loss More than 25% More than 25% bowel habits ○ Small volume of stool without any evidence of blood Patient who meets diagnostic criteria for IBS but REMEMBER: There is no test to definitively diagnose IBS. IBS unclassified whose bowel habits cannot be accurately Sometimes none or only few tests are required for IBS patients, categorized into one of the three subtypes specially with typical features and with no alarm symptoms. Dr. Andal-Gamutan’s Lecture Video 1. ROME IV CRITERIA H. SEVERE SYMPTOMS OR RED FLAGS Diagnostic criteria including: Recurrent abdominal pain, lasting on average of at least 1 day 1 Stool exam per week in the last 3 months, associated with at least two of these Can rule out infection causes 2 CBC factors: ○ Related to defecation 3 Abdominal ultrasound ○ Associated with a change in stool frequency ○ Associated with the change of stool consistency, 4 X-Ray Can exclude other possibilities form/appearance 5 CT scan of severe symptoms or with red Criteria should be fulfilled for the last 3 months with symptom flags onset over six months prior to diagnosis 6 EGD 7 Colonoscopy I. TREATMENT Treatment options for IBS aids to relieve the symptoms and improve quality of life. ○ Important to give reassurance and careful explanation of the functional nature of the disease. ○ It should start with patient counseling and dietary alterations. ○ Identify the food that can aggravate the symptoms and try to avoid obvious food precipitants Group 2B | Diseases of the Colon and Rectum 5 of 10 1. SYMPTOMATIC TREATMENT Treatment should be individualized Depending on the complaint of the patient, symptomatic treatment can be given. COMPLAINT TREATMENT Stool bulking ○ 📝 Laxatives 📝 Senna Constipation ○ ○ 📝 Bisacodyl Lactulose Prokinetics Figure 12. Ulcerative Colitis Dr. Andal-Gamutan’s Video Lecture Part 3 📝 Chloride channel activators High fiber diet B. CROHN’S DISEASE Can affect any part of the gastrointestinal tract, though it often Antispasmodics involves the ileum and the cecum. Anti-flatulence The rectum is often spared. Abdominal pain Serotonin receptor agonists/ antagonists It often appears in patches, not in continuous sections of the colon. and bloating Modulation of gut flora It can involve all 4 layers of the intestinal wall; because of its ○ Rifaximin transmural involvement: ○ Neomycin ○ Patients with Crohn's disease may develop fistula, intestinal obstruction, stricture and perianal abscess. Loperamide Clinically, the site of the disease will determine the clinical Diarrhea Racecadotril manifestations Rifaximin (antibacterial) Patients with mental disorders may be prescribed with antidepressant drugs. Mental Disorder Consultation with a psychiatrist may help this group of patients. Dr. Andal-Gamutan’s Lecture Video J. SUMMARY IBS is a chronic functional bowel disorder characterized by Figure 13. Crohn’s Disease abdominal pain, bloatedness, altered bowel habits in the absence Dr. Andal-Gamutan’s Video Lecture Part 3 of detectable structural abnormalities. There is NO pathognomonic symptom or specific test to diagnose IBS. C. RISK FACTORS Treatment usually involves: education, reassurance and dietary or lifestyle changes, symptomatic treatment, antidepressants and Most people who develop IBD are other psychological treatment. diagnosed before they are 30 years old. 1 Age But some don’t develop the disease until they are in their 50s or 60s. III. INFLAMMATORY BOWEL DISEASE Is an immune-mediated chronic intestinal condition Although Caucasians have the highest risk There are two major types of IBD: for the disease, it can occur in any race. 2 Race There are already some cases among 1 Ulcerative colitis (UC) Filipinos. 2 Crohn’s disease (CD) The presence of a close relative, such as a 3 Family history parent, sibling or child with the disease is a These two conditions share many symptoms and risk factors yet higher risk are quite different This is the most important controllable risk factor for developing Crohn’s disease. A. ULCERATIVE COLITIS Cigarette Although smoking may provide some Affects only the large intestines or the colon 4 smoking protection against ulcerative colitis, the It tends to affect a continuous section of the colon and usually overall health benefits of not smoking make involve the rectum and extends proximally to involve all or part of it important to try to quit the colon Occurs only in the inner lining or the mucosa of the colon NSAIDS like ibuprofen, naproxen, sodium, diclofenac sodium, and others may 5 NSAIDS increase the risk of developing IBD or MAJOR SYMPTOMS worsen disease in people who have IBD 1 Chronic diarrhea People living in an industrialized country 2 Rectal bleeding are more likely to develop IBD therefore, 7 Environment it may be the environmental factors 3 Tenesmus including a diet high in fat or refined foods that play a role 4 Crampy abdominal pain Geographic People living in northern climates also 8 location seem to be at greater risk. Evidence for genetic predisposition to IBD Genetic is associated with certain genetic 9 predisposition syndromes like Turner’s syndrome and other immunodeficiency disorders. Group 2B | Diseases of the Colon and Rectum 6 of 10  F. EXTRAINTESTINAL MANIFESTATION Up to 1/3 of IBD patients have at least 1 extraintestinal disease manifestation ○ It may be dermatologic, rheumatologic, ocular, hepatobiliary, neurologic, metabolic bone disorder, and almost all other systems. Figure 14. Risk factors for Inflammatory bowel disease Dr. Andal-Gamutan’s Video Lecture Part 3 D. SYMPTOMS Symptoms vary depending on the severity of inflammation and where it occurs May range from mild to severe Likely to have periods of active illness followed by periods of remission Common symptoms seen between ulcerative colitis and Crohn's disease include: Patients experience more than 3 stools Soft to watery Chronic 1 Chronic (more than 1 month) diarrhea Fever and fatigue due to chronic diarrhea and Figure 16. Extraintestinal manifestations of IBD possible dehydration and infection Dr. Andal-Gamutan’s Video Lecture Part 3 Bloody Caused by intestinal inflammation 2 G. DIFFERENTIAL DIAGNOSIS stools Ulcerative colitis and Crohn’s disease have similar features to any Abdominal Usually colicky and crampy other disease. 3 pain Location will depend on the site of inflammation In the absence of key diagnostic tests, a combination of features is 4 Anorexia used It can be infectious or noninfectious diseases Unintended Detailed history and PE are required to exclude some of the 5 Reduced appetite weight loss differential diagnosis 1. INFECTIOUS DISEASES Infection of the intestines or colon can mimic Crohn’s disease or ulcerative colitis. Bacterial 1 Common infections include Salmonella, Clostridium and E.coli 2 Fungal 3 Viral 4 Protozoal Diagnosis of bacterial colitis is made by sending stool specimens Figure 15. Symptoms of IBD for bacterial culture and toxin analysis. Dr. Andal-Gamutan’s Video Lecture Part 3 Gastrointestinal involvement with mycobacterial infection occurs predominantly in the distal ileum and cecal areas and can be E. PHYSICAL EXAMINATION diagnosed by doing colonoscopy with biopsy. Amoeba can cause diarrhea, tenesmus, and abdominal pain, 1 Low grade fever which can be detected by a stool exam. With more extensive disease, patients have 2. NON INFECTIOUS DISEASES tenderness to palpation directly over the colon Abdominal or the affected segments Detailed history and physical examination are required to exclude 2 some of the differential diagnosis tenderness For Crohn's disease: RLQ tenderness similar to appendicitis may be palpated because of the involvement of the ileocecal areas 1 Appendicitis (If with acute onset) 3 Palpable abdominal mass 2 Diverticulitis Some patients may have signs of peritonitis if 3 Eosinophilic gastroenteritis perforation has occurred. 4 Colonic malignancy 4 Peritonitis Patients may present with both direct and rebound abdominal tenderness. 5 Drug/chemical-induced colitis A tender anal canal and presence of blood Blood on may be noted on rectal examination H. DIAGNOSIS 5 rectal Perianal diseases affect about 1/3 of patients Diagnosis is likely only after ruling out other possible causes of examination with Crohn’s disease and are manifested by abdominal pain and other symptoms strictures, fistulas, and perirectal abscesses. Diagnosis by detailed history and PE, in combination with other diagnostic tests Group 2B | Diseases of the Colon and Rectum 7 of 10  CBC can detect anemia in the presence of 1. ACTIVE DISEASE 1 Blood Tests bacterial or viral infection Rise in acute phase reactants like C-reactive protein (CRP), platelet count, erythrocyte sedimentation rate (ESR) With fecal occult blood test (FOBT) It is important to know whether IBD is active to know if treatment 2 Stool Test Indicated to check intestinal infection and will be continued. occult GI blood loss Increased biomarkers of active intestinal inflammation include: Colonoscopy, flexible sigmoidoscopy 1 Fetal leukocytes Necessary if the complaint is chronic diarrhea, hematochezia, or bloody stools Iron binding glycoprotein present in 2 Fetal lactoferrin Can directly visualize the colon neutrophils Can facilitate/guide biopsy procedure for histopathological Ca-binding protein in the neutrophil examination, which can confirm diagnosis 3 Fecal calprotectin cytosol 3 2. IMAGING STUDIES Standard May be taken to rule out a perforated colon or 1 Abdominal obstruction X-ray Figure 17. Colonoscopic picture of patient with ulcerative colitis (L) and Can evaluate the entire bowel as well as other cobblestoning of Crohn's disease (R) 2 CT scan Dr. Andal-Gamutan’s Video Lecture Part 3 tissues outside the bowel Esophagogastroduodenoscopy (EGD) Particularly useful in evaluating a fistula 3 MRI around the anal area or the small intestine Can directly examine the upper GI tract Recommended if the patients are having upper GI symptoms like nausea, vomiting, dysphagia, or epigastric pain I. TREATMENT Ordinary GI endoscopes: EGD and colonoscopy can reach The goal of treatment for IBD is to reduce the inflammation that only up to duodenum and colon, respectively. triggers the signs and symptoms If the small intestine is affected, other special procedures such ○ In the best cases, this may lead not only to symptom relief but as enteroscopy and capsule endoscopy might be requested, also to long term remission and reduce risk of complications but these are not readily available in most institutions IBD treatment usually involve drug therapy or sometimes surgery 4 1. ANTI-INFLAMMATORY Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease This includes: ○ Aminosalicylates ○ Corticosteroids Mesalazine Balsalazide Olsalazine Figure 18. EGD Dr. Andal-Gamutan’s Video Lecture Part 3 2. IMMUNE SYSTEM SUPPRESSORS Capsule Endoscopy Work in a variety of ways to suppress the immune response that releases inflammation-inducing chemicals in the intestinal lining Sometimes used to help diagnosed Crohn’s disease involving In some patients, a combination of these drugs works better than small intestine one drug alone Done by swallowing a capsule that has a camera. The images ○ Azathioprine ○ Cyclosporine is then transmitted to a recorder ○ Mercaptopurine ○ Methotrexate The capsule exits in the stool 5 3. TUMOR NECROSIS FACTOR ALPHA INHIBITORS OR BIOLOGICS Works by neutralizing a Other biologic therapies protein produced by the ○ Vedolizumab immune system ○ Natalizumab ○ Infliximab ○ Ustekinumab Figure 19. Capsule Endoscopy ○ Adalimumab Dr. Andal-Gamutan’s Video Lecture Part 3 ○ Golimumab Balloon-assisted Enteroscopy 4. OTHERS Enables the examiner to look further into the small bowel where standard endoscope don’t reach Ciprofloxacin and Metronidazole may be Useful when a capsule endoscopy shows abnormalities but used in addition to other medications or the diagnosis is still uncertain when infection is a concern in cases of 1 Antibiotics perianal Crohn’s disease Depending on the severity of IBD, some patient need symptomatic treatment 6 Fiber supplement can help relieve mild to moderate diarrhea by adding bulk to your Anti-diarrheal 2 stool medications For more severe diarrhea, Racecadotril or Loperamide may be effective Acetaminophen for mild pain may be 3 Pain relievers Figure 20. Balloon-Assisted Endoscopy recommended Dr. Andal-Gamutan’s Video Lecture Part 3 Group 2B | Diseases of the Colon and Rectum 8 of 10  Iron supplements may be given for iron POST QUIZ/ACTIVITY deficiency anemia Part II. Matching Type Treatment with steroids can increase the 6. 70-year-old, male, complaining of left lower quadrant pain 4 Supplements risk of osteoporosis, so calcium due to inflamed sigmoid mucosal outpouching. supplements with added vitamin D may 7. 30-year-old, male, with chronic diarrhea due to erythematous help to prevent osteoporosis mucosa involving continuously the left side of the colon. 8. 35-year-old, female, with chronic diarrhea and perianal Nutritional support and bowel rest can abscesses. reduce inflammation in the short term 9. 40-year-old, female, with abdominal pain, but with Sometimes parenteral nutrition may be unremarkable physical examination and work-ups. Nutritional 5 needed 10. 70-year-old, male, with change in bowel habits, support Presence of complications like stenosis or hematochezia and weight loss. stricture in the bowel may require a low-residue diet to prevent obstruction A. Irritable Bowel Syndrome B. Crohn’s Disease C. Ulcerative Colitis 5. SURGERY D. Colonic Diverticular Disease Recommended for IBD complications like: E. Colonic Malignancy ○ Stricture ○ Obstruction FEEDBACK ○ Perforation 6. Answer: D. Colonic Diverticular Disease ○ Fistula 7. Answer: C. Ulcerative Colitis ○ Abscess formation 8. Answer: B. Crohn’s Disease ○ If drug therapy or other medical treatment fails 9. Answer: A. Irritable Bowel Syndrome 10. Answer: E. Colonic Malignancy J. CASE SCENARIO IV. APA REFERENCES CASE A 30-year-old male consulted because of frequent Andal-Gamutan, M. T. (2024). Lecture VIdeos on Diseases of the 3 bowel movement of 3–5 times a day of loose bloody Colon and Rectum. stool for the past 2 months (chronic diarrhea). He was given Metronidazole and Ciprofloxacin but there was no relief noted. V. REVIEW QUESTIONS What is the best diagnostic work up? No. QUESTIONS A. CT Scan 1 A 60y/o, male sought consult due to low hemoglobin B. Colonoscopy detected during his annual check-up. Patient is C. Ultrasound asymptomatic. Previous smoker. Non-alcoholic beverage D. Abdominal X Ray drinker. s/p Colonoscopy with polypectomy 2015. What is the next BEST course of action? Answer A. Treat with FeSo4 and repeat CBC after 30 days. B. Colonoscopy for patients with bloody stool B. Whole abdomen CT-scan C. Colonoscopy D. Barium enema K. SUMMARY Inflammatory bowel disease is an immune-mediated chronic 2 A 65-year-old male with a history of colonic diverticulosis intestinal condition came to the ER because of severe abdominal pain. An Ulcerative colitis and Crohn’s disease are the two major types upright chest x-ray revealed pneumoperitoneum. This is IBD symptoms vary depending on the severity of inflammation and best managed by? the site where it occurs A. Therapeutic endoscopy The major goal of management is to reduce the inflammation, to B. Radiologic intervention relieve symptoms, and prevent complications C. Medical management Medications include anti-inflammatory agents, immune system D. Surgery suppressors, tumor necrosis factor inhibitors, biologics, antibiotics, 3 What is the most likely diagnosis in a 30-year old male with pain relievers, and other supportive management intermittent diarrhea for 2 months and further work ups Surgery is indicated for complications like obstruction, stricture, revealed an elevated lactoferrin and calprotectin? fistula, and perforations A. Irritable bowel syndrome B. Bleeding diverticulosis POST QUIZ/ACTIVITY C. Inflammatory bowel disease Part I. Matching Type D. Colonic polyposis 1. 75-year-old, male, hypertensive, with painless hematochezia. 4 Multiple outpouchings of the sigmoid mucosa were 2. 50-year-old with sigmoid outpouching on colonoscopy. discovered upon screening colonoscopy in a 60-year-old 3. CT Scan is a better option than colonoscopy in a 65 year old asymptomatic male. This is best managed by male with left lower quadrant tenderness and fever. A. Antibiotics 4. 50-year-old, male, with sigmoid outpouchings and mucosal B. High fiber diet erythema in the sigmoid area. C. Probiotics 5. 60-year-old, male, with left sided abdominal pain with no D. Anti Inflammatory agents obvious systemic inflammation. 5 Mesalazine, an aminosalicylate agent, is best given to A. Colonic Diverticulosis which of the following cases? B. Acute Diverticulitis A. 30-year old female with abdominal pain because of C. Colonic Diverticular Bleeding irritable bowel syndrome D. Symptomatic Uncomplicated Diverticular Disease B. 30-year old female with left lower quadrant pain due to E. Segmental Colitis Associated with Diverticulosis acute diverticulitis C. 30-year old male with hematochezia secondary to sigmoid FEEDBACK diverticular bleeding 1. Answer: C. Colonic Diverticular Bleeding D. 30-year old male with chronic diarrhea secondary to 2. Answer: A. Colonic Diverticulitis inflammatory bowel disease 3. Answer: B. Colonic Diverticular Bleeding 4. Answer: E. Segmental Colitis Associated with Diverticulosis 5. Answer: D. Symptomatic Uncomplicated Diverticular Disease Group 2B | Diseases of the Colon and Rectum 9 of 10  VI. RATIONALIZATION No. RATIONALIZATION 1 CORRECT ANSWER: C. Colonoscopy Screening is recommended for ALL asymptomatic individuals age 50 years or older, high-risk individuals, and those with risk factors such as smoker, male, obese, and family history of colorectal cancer. Since the patient has low hemoglobin, it can be said that he has anemia. Unlike in females, anemia is uncommon in males and if present this requires further tests since it is suspicious for malignancy, especially in elderly. In this case, the patient is a high-risk individual due to his age, sex (male), previous smoker, and previous history of polyp. Repeat colonoscopy is recommended for high-risk individuals. A is incorrect because giving FeSO4 and repeating CBC after 30 days can be done for anemia BUT further tests are still needed to rule out malignancy since anemia is an alarm symptom. B is incorrect since whole abdomen CT scan is the best diagnostic workup for patients presenting with severe abdominal pain and direct and rebound tenderness, in which colonoscopy is contraindicated. D is incorrect since barium enema is not the next best step because if there is something suspicious found, the patient will still need to undergo colonoscopy. Batch 2025 Ratio 2 CORRECT ANSWER: D. Surgery The presence of pneumoperitoneum indicates perforated diverticulitis, thus surgery is the best management for this case. Batch 2025 Ratio 3 CORRECT ANSWER: C. Inflammatory bowel disease In diagnosing active inflammatory bowel disease, there is rise in C-reactive protein (CPR), platelet count, erythrocyte sedimentation rate (ESR). Biomarkers of active intestinal inflammation include elevated fecal leukocytes, fecal lactoferrin, and fecal calprotectin. A is incorrect because diagnosing irritable bowel syndrome (IBS) relies on clinical features such as recurrence of lower abdominal pain with altered bowel habits. There are no tests to definitely diagnose IBS. B is incorrect because diagnosing bleeding diverticulosis requires the use of the following: CT scan (can reveal sigmoid diverticula), colonoscopy (for patients who are bleeding that is manifested as hematochezia), and/or angiography (option for massive diverticular bleeding). C is incorrect because diagnosing colonic polyps requires the use of colonoscopy to examine the rectum and lower bowel to detect swollen, irritated tissues, or polyps. For average-risk individuals, stool-based tests such as Fecal Occult Blood Test (FOBT), and Fecal Immunochemical Test (FIT) are requested. Batch 2025 Ratio 4 CORRECT ANSWER: B. High fiber diet One risk factor for colonic diverticulosis is constipation or lack of fibers in the diet. High fiber diet is therefore a management for diverticulosis A is incorrect because Antibiotics are usually given to patients with Uncomplicated Diverticulitis and Complicated Diverticulitis. C is incorrect because Probiotics are used for treating Symptomatic Uncomplicated Diverticular Disease (SUDD). D is incorrect because Anti inflammatory agents are used for patients with Inflammatory Bowel Disease (IBD). Batch 2025 Ratio 5 CORRECT ANSWER: D. 30-year old male with chronic diarrhea secondary to inflammatory bowel disease Aminosalicylate agent like Mesalazine is a treatment for Inflammatory bowel disease. Batch 2025 Ratio Group 2B | Diseases of the Colon and Rectum 10 of 10