Shared etiology CD and UC = Chronic inflammatory disorder Genes x environment - Loss of mucosal barrier - Loss of immune tolerance for commensal bacteria - Dendrites (APC) present antigens to mesenteric lymph and immune system - TH1, TH2, TH17, Treg cell differentiation and recruitment - Pro-inflammatory cytokines IFN gamma, TNF alpha, ROS (direct damage); recruitment immune cells (macrophages, neutrophils, T cells) Result - Chronic inflammatory response against bowel

GI Patho 2 Flashcards by Katie Bowden

Irritable Bowel Disease (IBD)
Incidence, prevalence, risk factors

*Canada has highest prevalence in world

Irritable Bowel Disease (IBD)
1. Crohn’s Disease
2. Ulcerative Colitis

Risk Factors
- White
- Azkenazi jewish
- South asian
- family history 10x
- Genes x environment

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IBD
Etiology

*Shared etiology CD and UC = Chronic inflammatory disorder

Genes x environment

Loss of mucosal barrier
Loss of immune tolerance for commensal bacteria
Dendrites (APC) present antigens to mesenteric lymph and immune system
TH1, TH2, TH17, Treg cell differentiation and recruitment
Pro-inflammatory cytokines IFN gamma, TNF alpha, ROS (direct damage); recruitment immune cells (macrophages, neutrophils, T cells)

Result
- Chronic inflammatory response against bowel

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IBD
2 Diseases

Crohn’s Disease
Ulcerative Colitis

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Ulcerative Colitis
Cellular pathophysiology

starts in rectum (proctitis)
extends continuously proximally through large intestine (pancolitis)
chronic inflammation of mucosa layer
starts in Crypt of Lieberkuhn
starts on left side (rectum)
erythema, edema (pain), mucous, ulceration, bleeding (hematchezia)

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Ulcerative Colitis
Clinical Signs and Symptoms

Physical assessment

pain mild to severe
usually left side (rectum)
urge to defecate
relief of pain with defecation
hematchezia (bloody stools)
mucous in stools
diarrhea (inability to absorb water > 4 per day)
fatigue and anemia (loss of blood)

Extracolonic symptoms
- Eyes: sceleritis, uveitis
- Liver: cirrhosis
- Skin: erythema nodosum, psoriasis
- Blood: coagulation problems
- anxiety, depression
*also present in CD

Colonoscopy & biopsy

erythema, edema, mucous, bleeding
friability
ulcerations
continuous extension proximally
infiltration WBC

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Ulcerative Colitis
incidence

20 to 40 year olds
smoking is protective
diet is not associated
NSAID use
family history
pathogenic gastritis

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Ulcerative Colitis
Complications

Bleeding and anemia
ulceration
perforation
hemorrhage
toxic megacolon
fibrosis
cancer

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Non- pharmacological Management
UC

FODMAP diet (reduced dietary fermentable oligo/di, mono and polyols)
treatment anxiety and depression
Screen for cancer
maintain vaccinations
Pharmacological induction and maintenance of remission
medication adherence

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Diagnostic Evaluation
UC

Endoscopy with biopsy (gold standard)

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Crohn’s Disease
Incidnece and Risk factors

10- 30 year olds (earlier onset than UC)

smoking 2x
NSAIDS, antibiotic use in childhood
reduced fibre and fat intake
family history
physical inactivity
stress

Associated conditions
- asthma
- pericarditis
- psoriasis
- celiac disease
- RA
- MS
- anxiety, depression

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Crohns’ Disease
Pathophysiology

Transmural lesion
fissures result in spasm and severe pain
skip lesions (not continuous)
any location mouth to anus
most common location distal ileum, proximal cecum (ileocolitis)
right sided pain
malabsorption vitamins, nutrients (small intestine)
hypoalbuminuria and macrocytic anemia
granulomas
string sign on barium enema (strictures)

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Crohn’s Disease
Clinical Signs and Symptoms

Cardial symptoms:
- Chronic diarrhea
- abdominal pain
- fatigue

Laboratory diagnostics
- Signs of inflammation: Elevated ESR, CRP, fecal calprotectin, anti saccharomyces cerevisiae antibodies (ASCA)

Physical assessment
- Pain moderate to severe (right side usually)
- weight loss
- malabsorption and nutrient deficit (vitamin B12, folate)
- hypoalbuminuria

Stool
- +/- diarrhea
- not usually bloody

Endoscopy assessment
- skip lesions
- string sign
- granulomas “cobble stone appearance”

Extra-intestinal symptoms
- Mouth: ulcers* unique to CD
- Skin: erythema nodosum
- Liver: cirrhosis
- MSK: arthritis
- Eyes: uveitis, sceleritis
*same as UC

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Crohn’s disease
Complications

Fissures
abscesses
fistulas
perforations
obstructions

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Crohn’s disease
Non-Pharmacological Management

Correct nutritional deficiencies (vitamin B12, folate, Vitamin D, etc.)
increase protein intake (TNF alpha and IL6 promote cachexia)
elimination diet (food that exacerbate symptoms - high residue, nuts, citrus)
Stop smoking
Management stress, anxiety, depression (CBT, mindfulness)
Medication adherence
*limited evidence (Probiotics, omega, cannibis)
vaccinations up to date
screen opportunistic infections
colorectal cancer screening
DEXA bone density screening
Pharmacological induction and maintenance of remission

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Celiac Disease
Definition and Risk Factors

“Celiac Sprue”

Autoimmune disorder, inflammatory immune response against gluten (protein component in wheat, barley, rye, malt, spelt, kamut)

T-cell mediated auto-immune injury and destruction of SI epithelial villus

Unable to absorb vitamins, protein, fat, carbohydrate

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Celiac Disease
Pathophysiology

Gluten exposure
- wheat, barley, rye, malt

T-Cell auto-immune response
- formation of antibodies
- 1. TGG IgA (transglutaminase IgA)
- 2. Anti EMA IgA (anti-endomysial antibody)
- Presence of HLA
1. HLA DQ2
2. HLA DQ8

Chronic inflammation of the SI epithelial villi

Direct destruction of the small intestine epithelial villi
- Function: increased SA and 1 cell thick, rapid absorption vitamins and macronutrients (protein, fat, carbohydrates)
- unabsorbed nutrients pull water into intestines
- water, electrolytes excreted
- osmotic diarrhea

GI endocrine dysfunction = malabsorption
- decrease GI hormone production
- decreased pancreatic endocrine/exocrine function
- decreased absorption nutrients

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Celiac Disease
Clinical Signs and Symptoms

diarrhea/constipation
nausea/vomitting
abdominal pain
abdominal distention
flatulence
malabsorption
weight loss
failure to thrive
atypical symptoms (extra-intestinal): delayed puberty, ammenorrhea, iron deficiency anemia, osteoporosis, elevated LFTs

Osmotic diarrhea +/- pain
- presence of protein, fat, carbohydrates in stool

Malnutrition, weight loss, bleeding
- Vitamin B12, folate deficiency (anemia, neuropathy, stomatitis)
- Vitamin D and calcium deficiency (secondary parathyroidism, osteoporosis)
- Vitamin K deficiency (clotting irregularities)

Skin
- Dermatitis herpetiformis (Duhring’s Disease)

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Celiac Disease
Complications

Celiac Crisis
- dehydration, electrolyte abnormalities
- severe osmotic diarrhea
- hypoproteinuria

Intestinal lymphoma

Small bowel adenocarcinoma

Refractory celiac disease
- despite persistence gluten free diet for 12 months

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Celiac Disease
Risk Factors

Study These Flashcards

1% Western world
Type 1DM
Down Syndrome
Family history

Genetic predisposition x unknown trigger

Celiac Disease
Non-Pharmacological Management

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Gluten free diet (wheat, barley, rye, spelt, kamut)
Nutritionist referral
Correct nutritional deficiencies (Vitamin D, B12, copper, zinc, B6, iron, floate)

Follow Up
- monitor growth and development
- bone mineral density DEXA scanning
- lymphoma screening

Irritable Bowel Disease (IBD)
Definition

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Chronic abdominal pain and altered bowel habits in the absence of organic cause/inflammation

diarrheal IBS (men)
constipation IBS (women)

Irritable Bowel Disease (IBD)
Risk Factors

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Women > men
Diagnosed before 50s (common in 20s)
Early childhood trauma
Mood/anxiety disorders (anxiety, depresison, firbomyalgias)

Irritable Bowel Disease
Pathophysiology

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Unknown
Spasms of bowel in absence of inflammation

Viseral hypersensitivity, hyperalgesia
post - infectious
food allergy

Dysbiosis of bacteria
hypersensitivity, hypermotility, hypersecertion

Irritable Bowel Disease
Clinical Signs and Symptoms

Study These Flashcards

abdominal pain
bloating, flatulence
Diarrhea or constipation
relief of pain with defecation
-* doesn’t interfere with sleep (UC does)

Rome III Criteria
- change frequency stools
- change consistency of stools
- relief of pain with defecation
- present for 6 months
- 3 symptoms / month for at least 3 months

Irritable Bowel Disease Non-pharmacological treatment

Modification Diet: - regular spaced meals - decrease caffiene and alcohol - increase soluble fibre and water intake - bulk forming laxatives (psyillium) - low FODMAP diet Pharmacological treatments: - TCA - SSRIs - bulk laxatives (psyllium fibre) - loperamide - anti-spasmotic (pepermint oil)

Diverticuli Definition

Outpouching of the mucosal / submucosa through the artery foramen in the tunica mucular layers of the large intestine Most common site sigmoid colon (western world, left side)

Diverticulosis

Asymptomatic disease presence of outpouching diverticuli no inflammation

Diverticular Disease Definition

also known as Diverticulitis Inflammation of the diverticlui (outpouching) resulting in clinical signs and symptoms - LLQ pain - WBC - fever

Diverticulosis Risk Factors

- older age - obesity - increased red meat - NSAID use - Low dietary fibre - genetics - smoking

Diverticular Disease Pathphysiology

1. increase in transluminal pressure - increased collagen and elastin deposition in circular and longitudinal muscles - shorten and thickening - decrease motility (neuromuscular, low fibre) 2. Outpouching of mucosa/submucosa through the foramen in the tunica layers 3. Perforation and inflammation - transition from asymptomatic diverticuli to symptomatic diverticulitis

Diverticulitis complications

- abscesses - bleeding - obstruction - perforation - fistula - peritonitis

Diverticulitis Management

- do not perform sigmoidoscopy until 6-8 weeks after flare (risk of perforation) - bowel rest - analgesia and anti-pyretics - higher fibre diet and water intake - surgical resection - *antibiotics are not usually indicated

Appendicitis Prevalence

Most common emergency surgery for individuals 10-19 years of age

Appendicitis Pathophysiology

1. uncomplicated appendicitis obstruction drainage of appendix (feces, foreign body, tumour) results in ischemia, inflammation 2. Complicated appendicitis Ischemia leads to abscess, necrosis, gangrene and perforation

Appendicitis Clinical signs and symptoms

Typical - Peri-umbilical pain - radiation to RLQ in 24 hours - anorexia, nausea, vomiting, fever Atypical - flank pain, costovertebral angle tenderness, suprapubic pain, R testicular pain, urinary frequency Physical assessment findings: - McBurney's point RLQ - Psoas sign: pain extension hip - Oburator sign: pain right flexed hip rotation - Rovsing Sign: pain L iliac fossa

Appendicitis Treatment

Appendectomy Antibiotic therapy

Intestinal Obstructions Classification

ONSET 1. Acute: sudden onset (torsion, hernia, intussusception) 2. Chronic: slow onset (cancer) EXTENT 1. Partial: incomplete 2. Complete: complete obstruction LOCATION 1. Intrinsic: inside lumen (tumour, hemorrhage, edema) 2. Extrinsic: outside lumen (hernia, intussuception, fibrosis, torsion, tumour) EFFECT 1. Simple: no impairment blood flow 2. strangulated: impaired blood flow 3. Closed loop: both distal and proximal ends CAUSE 1. mechanical obstruction 2. functional obstruction (paralytic ileus)

Intestinal obstructions Causes

- hernias - tumours - fibrosis - torsion - divertiulosis - paralytic ileus (trauma, surgery, hypokalemia, peritonitis, pneumonia) - fecal mass - intussusception

Intestinal obstruction Pathophysiology

Accumulation gas, intestinal contents above the obstruction -> distention 1. Pneumonia - decreased respiratory volume - atelectasis and pneumonia 2. Nausea, vomiting, dehydration, electrolyte, and acid-base imbalances - decreased intake - decreased absorption - metabolic alkalosis - high obstruction, early onset - metabolic acidosis - low obstruction, late onset 3. Ischemia, peritonitis, sepsis, perforations, shock and death - decreased venous drainage and arterial blood flow - ischemia, necrosis - leakage of GI bacteria -> sepsis - necrosis of GI tissue -> perforations - hypotensive shock

Treatment Intestinal obstructions

1. Mechanical obstruction - surgical 2. Functional obstruction (paralytic ileus) - decompression of stomach - bowel rest - surgical

Intussusception Define

Proximal bowel (intussusceptum) telescopes over the distal bowel (intussuscipien) Mesenteric vessels compressed resulting in venous distention, ischemia, and inflammation

Intussusception Risk factors

Infants age 5-7 months Rotavirus vaccination (2,4,6 months of age) post operative tumours, diverticulum, polyps, adhesions

Intussusception Clinical Signs and Symptoms

- severe abdominal pain (colic) - vomiting - current jelly stools

Complications Intussusception

Bowel necrosis surgery within 24 hours 4/100 recurrence rate

Colorectal cancer screening IBD

Increased risk at 30-35 years post diagnosis Screening initiate at diagnosis and every 8 years Mechanism: chronic inflammation Normally progresses from low grade dysplasia -> high grade dysplasia -> cancer

GI Patho 2 Flashcards

(45 cards)