Crohn Dz - background
chronic INCURABLE transmural inflammatory dz that can affect ANY PART OF GI w/ SKIP lesions SPARING RECTUM!!!
chronic w/ flare-ups, progressively worse
crohn - pathology hallmarks
- terminal ileum most common site
- skip lesions
- transmural inflammation
- fistula, noncaseating granulomas, abscesses, strictures, mesenteric fat creeping, cobblestoning
crohn - pres
- gradual fatigue, fever, malaise with NONBLOODY DIARRHEA, weight loss d/t malabsorption
- crampy RLQ pain w/ n/v
- perianal disease
crohn - extraintestinal sx
ARTHRITIS - seronegative, migratory monoarticular, ankylosing spondylitis UVEITIS / EPISLCERITIS ERYTHEMA NEDOSUM, ORAL APTHOUS lesions gallstones, kidney stones
crohn - dx
- clinical picture + endoscopy
- colonoscopy w/ bx
- CT / MR enterography or barium upper GI for small bowel
treatment crohn
- mild-mod: sulfasalazine and mesalamine - oral, first choice
- antibiotics for active - oral flagyl 10 mg/kg/d or cipro 500 mg BID or rifaximin 800 mg BID x 6-12 weeks
- corticosteroids: NOT longterm
- Budesonide (entocort) 9 mg QD x 8-16 weeks w/ MILD-MOD dz- preferred b/c fewer SE- prednisone or methylprednisolone 40-60 mg/d for SEVERE x 8-16 weeks
- if require long-term steroids, use IMMUNOMODULATORS
- biologics if all else fails
- bile acid sequestrants for terminal ileum disease - cholestyramine or colestipol
- antidiarrheal: loperamide, diphenoxylate
immunomodulators for crohn
1st line: azathioprine, mercaptopurine, improve in 2-4 mo (not for exacerbations)
2nd / unresponsive: methotrexate x 12 weeks w/ folic acid
biologics for crohn
infliximab, adalimumab, certolizumab for mod-severe active crohn
*alays test for TB, HBV prior
mild and severe flare-ups for crohn
mild: sulfasalazine or oral mesalamine, reduce for maintenance dose
severe: hydrocortisone 100 mg, add cyclosporine if not responding then change to prednisone w/ response, then add back maintenance med and w/draw steroid in 1-2 mo
crohn - indications for surgery
- refractory dz
- intra-abdominal abscess
- massive bleed
- sx fistulas
- obstruction
ulcerative colitis - background
chronic CURABLE dz w/ CONTINUOUS SUBMUCOSAL / MUCOSAL INFLAMMATION OF COLON AND RECTUM!
UC - pathology
-continuous, submucosal ulcerations w/ erosions and friable tissue w/ crypt abscesses
UC - pres
BLOODY DIARRHEA, LLQ abominal pain w/ tenesmus and fecal urgency
- more severe have anemia, hypovolemia, malnourished
- arthritis, pyoderma gangrenosum - other sx same as crohn
UC - dx
- r/o infectious diarrhea w/ fecal leukocytes, ova/parasites, c. diff toxin
- sigmoidoscopy / colonoscopy (DO NOT DO COLONOSCOPY IN ACUTE D/T RISK OF PERF)
- KUB xray - for colonic dilation
UC - tx
- AVOID NSAIDS AND LACTOSE - can precipitate flare
- acute exacerbations: systemic corticosteroids - predinsone 40-60 mg/d
- drug of choice: topical mesalamine suppository 1000 mg qHS or enema 4g
- w/o response / w/ decline can do PO
- can combine w/ hydrocortisone suppository if no response in 4-8 weeks, add systemic w/o further response
- immunomodulators w/o response to above - mercaptopureine or azathioprine
- anti-tnf: infliximab and adalimumab for mod-severe
toxic megacolon / colitis tx in UC
add antibiotics - broad spectrum against anaerobes / gram neg
UC - indications for surgery
absolute: severe hemorrhage, perforation, documented carcinoma
- fulminant colitis / toxic megaolon not improving in 48-72 hr, flat dysplasai / nonresectable dysplasia, refractory dz
UC - cure
proctocolectormy, most choose colectomy
-se: pouchitis in 40% - inflamm of ileal pouch, tx w/ oral flagyl or cipro
prognosis
UC better controlled and curable than crohn
- increased risk colon cancer and suppurative cholangitis in UC
- *monitor w/ colonoscopy q 1-2 yrs in UC w/ dz >8 yrs
diarrhea - acute and chronic def
acute: less than 2-3 weeks
chronic > 4weeks
diarrhea - causes
acute: VIRAL infection, (rotavirus, norwalk virus), medications (antibiotics!)
chronic: IBS #1, IBD, meds, bacterial infection, colon cancer, diverticulitis, malabsorption, post-op, fecal impaction, lax, immunocompromised, meds (metformin)
diarrhea - key sx
- w/ assoc n/v - more like gastroenteritis or food poisoning
- w/ food poisoning- occurs w/in hours - fever and blood - more likely shigella, campylobater, salmonella, e. coli (no fever / blood, more likely viral)
- look for travel, family/friends sick, bloody / assoc sx, travel, new foods / new meds
diarrhea - labs
- CBC - check for anemia (get FOBT), leukocytosis
- w/ blood consider colonoscopy
- BMP - metabolic acidosis, hypokalemia, elevated BUN:crt (check vol status on exam)
- fecal leukocytes and FOBT
- w/ neg leukocytes - dont need stool culture!
- pos leukocytes common in salmonella, shigella, c diff, campylobacter and e. coli (not w/ staph / clostridial food poisoning or viral)
- w/ pos send for stool culture and C. diff!
- also get culture w/ fever and hospitalized
- if suspect giardia (cramping, pale greasy stool) get ELISA
- AXR if suspect obstruction / toxic megacolon!
acute diarrhea treatment
- rehydrate, fix electrolytes
- hospitalize w/: dehydrated elderly, cannot tolerate PO, bloody, high fever / toxic
- sx of bacterial: FQ or macrolide
* **avoid abx w/ E.coli 0157:H7 - increases toxin (HUS!) - antimotility agents: loperamide (imodium): 2 mg after loose stool (max 16 mg/d) OR diphenoxylate-atropine (lomotil) 5-20 mg/d
- probiotics w/ antibiotics
