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Ileitis, Colitis, and DiverticulitisTintinalli Chap. 81
Nicholas Cardinal, DO
Crohn Disease
• Also called regional enteritis, terminal ileitis, and granulomatous ileocolitis
• Chronic granulomatous inflammatory disease of the the GI tract
• Can affect any part of the GI tract from mouth to anus– 20% confined to colon– 30% confined to small bowel– 50% both small and large bowel– Mouth, esophagus, or stomach affected in a small percentage
• Exact cause unknown– Environmental, genetic, infectious, autoimmune
Epidemiology
• Peak incidence at 15-22 years old• Secondary peak at 55-60• Women have a 20-30% increased risk• Common in those of European descent– 4 times more common in Jews
• Familial– Often have family hx of IBS or UC
Pathology
• Involves all layers of the bowel wall with extension into mesenteric lymph nodes
• Discontinuous “skip areas”• Longitudinal, deep ulcerations penetrating bowel
wall– Fissures– Fistulas– Abscess
• Cobblestone appearance is a late finding– d/t criss-crossing of longitudinal ulcers
Clinical Features
• Abdominal pain• Anorexia• Diarrhea• Weight loss• Fever• 1/3 develop perianal fissures, fistulas,
abscesses, or rectal prolapse
Extraintestinal Manifestations• Arthritic
– Peripheral arthritis– Ankylosing spondylitis– sacroiliitis
• Dermatologic– Erythema nodosum– Pyoderma gangrenosum
• Hepatobiliary– Pericholangitis– Chronic active hepatitis– Primary sclerosing cholangitis– Cholangiocarcinoma– Cholelithiasis– Fatty liver– pancreatitis
• Ocular– Episcleritis– Uveitis
• Vascular– Thromboembolic disease– Vasculitis– Arteritis
• Malnutrition• Chronic anemia• Nephrolithiasis• Myelodysplastic disease• Osteomyelitis• Osteonecrosis• Growth retardation in children
Complications
• 75% of patients will require surgery within 20 years of symptom onset
• Abscess– Occur in 30%– Abdominal pain/tenderness, fever– May have palpable mass– Retroperitoneal abscess may cause hip/back pain and difficulty
ambulating• Fistulas
– Result of extension of intestinal fissures into adjacent structures– Most are between the ileum and sigmoid, cecum, or skin– Enterovesical fistulas are rare
Complications
• Perianal– 1/3 of patients with Crohns– Fissures– Abscesses– Fistulas– Rectal prolapse
• GI bleeding– Only 1% develop life-threatening hemorrhage– Most are patients who develop toxic megacolon
Complications
• Obstruction– Caused by stricture formation and bowel wall edema– Distal small bowel is most common
• N/V• Crampy abdominal pain• Distention
• Malnutrition• Malabsorption• Hypocalcemia• Vitamin deficiency• Malignant neoplasm
Complications
• Medication side-effects (sulfasalazine, steroids, immunosuppressants)– Leukopenia– Thrombocytopenia– Fever– Infection– Profuse diarrhea– Pancreatitis– Renal insufficiency– Liver failure
Differential
General Population• Lymphoma• Ileocecal amebiasis• Sarcoidosis• Deep chronic mycotic
infections• GI tuberculosis• Kaposi’s sarcoma• Campylobacter enteritis• Yersinia ileocolitis
Elderly• Ischemic bowel disease• Pseudomembranous
enterocolitis• Ulcerative colitis
Diagnostics
• Diagnosis is usually made months-years after onset of symptoms
• Plain radiograph– Obstruction, perforation, or toxic megacolon
• Upper GI series• Air-contrast barium enema• Colonoscopy– Diagnostic or surveillance for colon cancer– Rectal sparing with involvement of proximal colon
Diagnostics
• CT– Acute symptoms in patients with known crohns
• Bowel wall thickening• Mesenteric edema• Abscess formation
– Extraintestinal manifestation• Gallstones• Renal calculi• Hydronephrosis• Sacroileitis• osteomyelitis
Treatment Goals
• Longterm– Symptom relief– Remission induction– Remission maintenance– Complications
prevention– Optimizing timing of
surgery– Nutrition maintenance
• ED– Evaluate severity of
attack– Identify significant
complications• Obstruction• Intraabdominal abscess• Life-threatening
hemorrhage• Toxic megacolon
Treatment
• Fluid resuscitation• Restoration of electrolyte balance• NG decompression– Obstruction, peritonitis, toxic megacolon
• Broad-spectrum antibiotics– Fulminant colitis or peritonitis– Ampicillin, aminoglycoside, and metronidazole
• IV steroids
Treatment
• Sulfasalazine (Azulfidine)– Used in mild-moderate active disease– Many intolerable side-effects
• N/V• Anorexia• Epigastric distress• Arthralgias• Headache• Diarrhea• Male infertility• Hypersensitivity reactions
– Pericarditis, pleuritis, pancreatitis, arthritis, rash
Treatment
• 5-aminosalicylic acid derivatives– Most effective in colonic disease• Pentasa• Asacol• Claversal• Salofalk• Olsalazine (Dipentum)• Balsalazide (Colazide)
• Oral glucocorticoids– Effective primarily in small bowel disease
Treatment
• Immunosuppressive agents• 6-mercaptopurine (6-MP)• Azathioprine• Cyclosporine• Methotrexate
• Side effects– Leukopenia– Fever– Hepatitis– pancreatitis
Treatment
• Infliximab (Remicade)– Anti-TNF antibody– Must screen for TB as can ppt active disease
• CDP571 (Cellcept)• Etanercept• Thalidomide• Interleukin
Treatment
• Diarrhea• Loperamide (Imodium)• Diphenoxylate (Lomotil)• Cholestyramine (Questran
• Consultation– Gastroenterology– Surgery
Ulcerative Colitis
• Chronic inflammatory disease of the colon• Tends to be progressively more severe from
proximal to distal colon• Rectum is involved in nearly 100% of cases• Usually present with bloody diarrhea• Unknown etiology
Epidemiology
• Higher prevalence in US and northern Europe• Peak incidence in 2nd and 3rd decades• Slight predominance in men• Familial– First-degree relatives have 15-fold increased risk of
ulcerative colitis and 3.5-fold increased risk of Crohn disease
Pathology
• Primarily involves the mucosa• Mucosal inflammation with crypt abscesses, epithelial
necrosis, and mucosal ulceration• Early findings
– Finely granular, friable• Severe disease
– Spongy with small ulcerations oozing blood and purulent exudate
• Very advanced disease– Large, oozing ulcerations– pseudopolyps
Clinical Features
• Mild (60%)– 80% are limited to rectum– Less than 4 bowel
movements per day– No systemic symptoms– Few extraintestinal
manifestations– Usually present with
constipation and rectal bleeding
– 10-15% progress to pancolitis
• Moderate (25%)– Colitis usually extends to
splenic flexure– Good response to therapy
• Severe (15%)– Frequent bowel movements– Frequent extraintestinal
manifestations– Clinical findings may include
anemia, fever, weight loss, tachycardia, and low serum albumin
Clinical Course
• Intermittent attacks of acute disease with complete remission between attacks
• Some have chronically active disease
Complications
• Hemorrhage• Perirectal fistulas/abscesses• Obstruction• Acute perforation• Carcinoma– 10-30- fold increase risk
• 5-10% at 20 years• 12-20% at 30 years
– Requires periodic colonoscopies and biopsies• Begin 8-10 years after onset
Complications
• Toxic Megacolon– Advanced cases when disease extends through all layers
of the colon– Results in loss of muscular tone, dilatation, and localized
peritonitis– Can perforate causing septicemia– Mortality rate ~10%
• 50% if perforation occurs
– Precipitating factors may include antidiarrheal agents, narcotics, cathartics, enemas, pregnancy, recent colonoscopy, and hypokalemia
Complicatons
• Toxic Megacolon– Clinical Features
• Patients appear severely ill• Distended, tender, tympanic abdomen• Severe diarrhea• Fever• Tachycardia• Hypovolemia
– Diagnostics• Plain radiographs
– Air filled segment of the colon > 6cm in diameter– Loss of haustra– “Thumbprinting”
Complications
• Toxic Megacolon– Treatment• NG suction• IV steroids• IV fluids• Broad-spectrum antibiotics• Early surgical consult
Diagnostics• CBC
– Leukocytosis, anemia, thrombocytosis• Hypoalbuminemia• Abnormal LFT’s• Negative stool culture/O&P• Sigmoidoscopy• Barium enema
– Differentiates UC from Crohn disease– Defines extent of involvement
• Colonoscopy– Most sensitive– Biopsy differentiates acute vs. chronic disease and underlying causes– Findings include granular, friable, ulcerated mucosa; pseudopolyps in advanced
disease
Differential
• Infectious colitis• Crohn colitis• Ischemic colitis• Radiation colitis• Toxic colitis
– Secondary to chemotherapy• Pseudomembranous colitis• Gay bowel disease
– Limited to rectum• Rectal syphilis• Gonococcal proctitis• Lymphogranuloma venereum
Treatment
• Severe– IV steroids– IV fluids– Correction of electrolyte
imbalance– Broad-spectrum
antibiotics• Ampicillin plus clindamycin
or metronidazole
– Hyperalimentation– NG suction
• Toxic megacolon
• Mild/Moderate– Oral glucocorticoids– 5-aminosalicylic acid
enema• Rowasa
– Topical steroid preparations
Treatment
• Other agents– Sulfasalazine• Maintenance of remission
– 5-aminosalicylic acid derivatives• Induction and maintenance of remission
– Immunomodulators• 6-mercaptopurine (6-MP)• Azathioprine
Treatment
• Supportive therapy– Iron supplementation– Lactose-free diet– Psyllium (Metamucil)– Rest– Antidiarrheals can precipitate toxic megacolon and
are generally ineffective
Disposition
• Mild/Moderate– May be discharged with close follow-up
• Severe– Admit– Consultation• Gastroenterology• Surgery
Pseudomembranous Colitis
• Inflammatory bowel disorder• Membrane-like yellowish plaques of exudate
overlie and replace necrotic mucosa• Caused by Clostridium difficile• 3 syndromes– Neonatal– Postoperative– Antibiotic-associated
Clostridium difficile
• Spore-forming obligate anaerobic bacillus• Produces two toxins– Toxin A: enterotoxin– Toxin B: cytotoxin
• Transmission via direct human contact or contact with inanimate objects
Pathophysiology
• Inpatients are colonized in 10-25% of cases• Antibiotics– Usually begins 7-10 days after initiation but may
begin within a few days or several weeks• Clindamycin• Cephalosporins• Ampicillin/amoxicillin
• Contributing factors may include recent bowel surgery, bowel ischemia, shock, malnutrition, uremia, and Hirschsprung disease
Clinical Features
• Vary from frequent, mucoid, water stools to toxic picture including profuse diarrhea, crampy abdominal pain, fever, leukocytosis, dehydration, and hypovolemia
Complications
• Severe electrolyte imbalance
• Hypotension• Anasarca• Toxic megacolon• Perforation
• Extraintestinal– Arthritis– Visceral abscesses– Cellulitis– Necrotizing fasciitis– Osteomyelitis– Prosthesis infection
Diagnosis
• History• C. difficile toxin• Colonoscopy– Yellowish plaques– Typically limited to right colon
Treatment
• Discontinue antibiotic• IV fluids• Correction of electrolyte imbalance• Antidiarrheals may prolong or worsen symptoms• Antibiotics– Metronidazole 250mg QID– Vancomycin 125-250 QID
• Alternative therapy for resistant cases, pregnant women, and children
Disposition
• Admit– Severe diarrhea– Systemic response• Fever• Severe abdominal pain• leukocytosis
• Consult surgery– Toxic megacolon– Perforation
Diverticulitis
• Acute inflammation of the wall of a diverticulum and surrounding tissue
• Caused by micro- or macroperforation
Epidemiology
• Rare under age 20• Incidence increases with age– 1/3 have diverticular disease by age 50– 2/3 by age 85
• Diverticulitis occurs in 10-25% of patients with diverticular disease
• Higher incidence in men but increasing in women
Diverticular Disease
• False diverticula– most colonic diverticula– Do not include all layers of the bowel wall– Consist of mucosa and submucosa with a peritoneal
covering that has herniated through a defect in the muscular layer
– Occur between the mesenteric and antimesenteric taenia
• True diverticula– Occur in the cecum
Pathophysiology
• Cause is unknown– Lowe residue diets producing high intraluminal
pressures• Most occur in the sigmoid– Narrowist portion of the colon– Pressure is greatest where lumen is narrowist• Laplace’s law
Complications
• Inflammation• Bleeding• Perforation• Obstruction• Fistulas– Diverticula and bladder in males– Diverticula and vagina in females
Clinical Features
• May be indistinguishable from acute appendicitis
• Steady, deep LLQ pain• Change in bowel habits• Tenesmus• Urinary frequency, dysuria, pyuria• Recurrent UTI’s
– Suspect fistula
Clinical Features
• Low-grade fever• Localized tenderness• Guarding• Rebound tenderness• Palpation of a LLQ mass• Rectal tenderness• Perforation presents with diffuse abdominal
tenderness, guarding, rigidity, and rebound tenderness
Diagnostics• Acute abdominal series
– May be normal• Ileus• Partial SBO• Free air• Extraluminal collections of air
• Abdominal ultrasound• Abdominal CT
• Inflammation of pericolic fat• Presence of diverticula• Thickening of bowel wall• Peridiverticular abscess
• Barium contrast studies– Can precipitate perforation
• Sigmoidoscopy/colonoscopy– Performed after acute inflammation– r/o colon cancer
Treatment
• IV fluids• Correction of electrolyte abnormalities• NPO• NG suction
– Ileus or obstruction• Broad-spectrum antibiotics
– Inpatient• Aminoglycoside• Plus metronidazole or clindamycin
– Outpatient• Ampicillin, TMP/SMX, ciprofloxacin, or clindamycin• Plus metronidazole or clindamycin
Disposition
• Admit– Signs and symptoms of infection– Failed outpatient management– Signs of localized peritonitis
Questions?