Gastrointestinal System II – 13
Wednesday, February 25, 2004, 9am
Dr. Shahid Aziz, DO
Morvarid Bidgoli
Page 1 of 4
Inflammatory Bowel Diseases: Part I
Note: Since this lecture went over into the 10 o’clock hour, Damien and I have split the lecture. Dr. Aziz
has agreed to review the scribe, but he may not be able to return his corrections immediately since he is on
hospital service.
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Celiac disease—an inflammatory disease of upper GI tract (not on power points)
Proximal small bowel usually involved
No symptoms except diarrhea
May or may not have systemic symptoms: weight loss, adult failure to thrive, nausea, vomiting,
abdominal pain
May even have constipation
Anti-endomysial antibodies and anti-gliadin antibodies: two serologic markers for celiac
disease
Case presentation—51 Year Old Female (not on power points)
Mildly elevated liver enzymes (AST, ALT)
Patient was mildly overweight.
Her PCP performed viral tests for hepatitis A, B, and C.
Saw a gastroenterologist—performed iron, copper, 1-antitrypsin, and ANA studies
Was told that these findings were probably due to her being mildly overweight, so all she
needed to do was lose some weight.
Was then seen by Dr. Aziz two years later still with elevated liver enzymes (same level as
before); no liver biopsy, repeat ultrasound, or other work-up had been performed.
Thus, a complete connective tissue work-up was conducted:
1. Complete anti-mitochondrial antibody (AMA), anti-liver kidney microsomal antibody (ALKM)
Liver biopsy performed—grade 1 or 2 inflammation, stage 0 fibrosis/scarring
All markers and studies returned negative.
Chronic constipation that worsened
Anti-gliadin and anti-endomysial antibody studies returned positive in high titers.
Upper endoscopy with enteroscopy performed, obtaining a biopsy from proximal to mid
jejunum
Diagnosis: celiac disease—one of the most commonly missed reasons for increased
liver enzymes
Idiopathic IBD: Crohn’s disease and Chronic Ulcerative Colitis
Affect both sexes equally
Majority of cases between 20-50 years old
Both diseases show a bimodal distribution, the second (smaller) peak between 50-70 years
old.
1. Increased incidence of diarrhea in elderly
Mortality rates higher in whites because IBD occurs at a higher incidence in whites.
Ask: are any symptoms nocturnal? If so, the disease is due to organic pathology.
1. Irritable bowel syndrome (not a disease) does not cause nocturnal symptoms, fever, or
weight loss.
Chronic Ulcerative Colitis (CUC)
Rectal bleeding common; diarrhea can occur, but rare.
1. Rectal bleeding is the main clinical finding with CUC.
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Fever uncommon
Perineal and perianal diseases: uncommon
Pseudopolyps (a.k.a. inflammatory polyps)
1. Can look like adenomatous/tubulovillous polyps
Colon shortened due to chronic inflammatory changes and fibrosis; ahaustral—like a “lead
pipe”—the folds flatten out
Crypt abscess seen in 30-40% of biopsies; crypt distortion (more common), and atrophy
1. Along with rectal bleeding and right signs and symptoms, all of these are indicative of
CUC.
Non-transmural vs. Crohn’s disease—transmural (can go through entire colonic or small
bowel wall from one loop of bowel to another, leading to fistulization and strictures that can
worsen diarrhea and malabsorption)
Wash-back ileitis: distal terminal ileum involvement; verify with histology to rule out Crohn’s
disease
Curative treatment: colectomy with procto-mucosectomy and ileorectal anastomosis
1. This does not work in Crohn’s disease!
Crohn’s disease
Rectal bleeding uncommon; nocturnal diarrhea—predominant clinical presentation
Low grade fever
Perineal disease common
Pseudopolyps not common (unlike CUC)
Colon not shortened
Granulomas seen more commonly; crypt abscess not frequently seen
Transmural—can happen anywhere in GI tract, even in stomach and duodenum
No uniform involvement—skip pattern, patchy areas in small bowel and colon
Granulomas represent hallmark of disease, but…
1. Found in less than 15% of patients
2. Thus in a patient with nocturnal diarrhea, low grade fever, and who falls in the age range of
20-50, do a colonoscopy and random biopsies of inflamed areas.
3. If pathologist sees inflammatory bowel disease without crypt abscesses or granulomas,
make sure the rectum is biopsied! Crohn’s disease spares it while CUC does not.
Strictures and fistulae are common and are the most common indications for surgery.
Incidence
1. Highest in North America, tip of South Africa, Australia, northwestern Europe
2. 10-25% occurrence in first degree relatives of patients with IBD
Fistulae can lead to weight loss, malabsorption, diarrhea, decreased albumin, and microcytic
anemia.
1. Food bypasses entire loops of bowel.
Enterocutaneous fistulae can develop post-surgery.
Microscopic perforation not uncommon
Complications of CUC
Megacolon
1. Hypertympany on percussion
2. Abdominal x-ray: colon is huge
3. Devastating—abdominal bloating, rectal bleeding that improved but now suffer from loose
stools, nausea, low grade fever, weight loss (patient cannot eat due to bloating)
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Hospitalize this patient! Give IV antibiotics and steroids; take serial abdominal x-rays on
a daily basis.
5. If unresponsive and the cecum continues to increase in size—get surgery on board
because there is a possibility of perforation of the colon.
a.
Look at labs; perform a sepsis work-up with blood cultures.
b.
Decide if an endoscopic decompression is necessary.
Hemorrhage
1. Anemia; high erythrocyte sedimentation rate (ESR)
2. Hospitalize, and change medications if unresponsive!
Pseudopolyps
1. Can become large—obstruction
Strictures—frequency of CA approaches 10%
1. Perform cytology to rule out malignancy—colon CA is flat and inflamed, not
fungating.
Extra-intestinal manifestations (EIMs)
1. Sclerosing cholangitis, cholangiocarcinoma, biliary strictures, chronic active hepatitis
(CAH)
2. Episcleritis, uveitis—eyes
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Ask about changes in vision or eye pain.
3. Pyoderma gangrenosum, erythema nodosum—skin
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Ask about sores on skin that won’t heal.
4. Arthritis (seronegative)—can parallel disease activity; worsens when disease worsens
5. Also inquire about changes in urine color, pain in any other part of body, energy levels, diet
and nutrition, appetite, and sleeping patterns.
54 Year Old Caucasian Male—a case of inflammatory disease of the upper GI tract (not IBD)
History of dyspepsia requiring over-the-counter medication and history of diabetes mellitus
Decreased appetite for two months but no weight loss
No systemic signs/symptoms
Complete blood count normal
Chemistries show elevated fasting glucose, liver function test normal, blood urea nitrogen
normal, serum creatinine mildly elevated (worry about diabetic nephropathy)
Double contrast UGI shows “mild” esophagitis, possibly an ulcer.
What is the differential diagnosis?
1. Esophagitis: diabetes can affect the lower esophageal sphincter
a.
Diabetics have higher transient lower esophageal sphincter relaxations
(TLESRs), which leads to high exposure time of the esophagus to acid.
2. Barrett’s esophagus and adenocarcinoma
a.
Barrett’s esophagus is exhibited as a color change from whitish-pink to salmoncolored; this, of course, would not show up on and upper GI x-ray.
3. Ulcer
What is the significance of diabetes mellitus?
1. Candida occurs often in patients with diabetes due to impaired immunity.
a.
The patient denies dysphagia or odynophagia, but in diabetics, these symptoms
can be attenuated.
b.
The diabetic patient also may not exhibit fever or leukocytosis.
2. Diabetic autonomic neuropathy (DAN): gastroparesis—abnormal emptying of gastric acid
into the duodenum
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How significant is the UGI?
Should have an upper endoscopy; patient is >45yo with signs/symptoms and abnormal x-ray
1. A small ulcer was found; cytology showed esophageal adenocarcinoma with no Barrett’s
esophagus.
An esophagectomy was performed.
46 Year Old Caucasian Male
Age falls in the range of the first peak of incidence of IBD
History of “colitis” (this term has often been misused) diagnosed in 1980’s; has been on
different medications that he doesn’t remember
Thinks he had a colonoscopy but doesn’t remember a biopsy; last exacerbation in early 1990’s
Now has watery diarrhea 4-6 times per day; it wakes him up from sleep
No melena or rectal bleeding
Has not had any systemic signs/symptoms (e.g., weight loss, fever, chills, night sweats)
What questions do you want to ask?
1. First, what are you, the doctor, thinking? Crohn’s disease!
2. When and where was the procedure conducted?
3. Was sedation used?
a.
If patient was completely sedated, then a complete colonoscopy was performed.
4. Family history?
5. Previous biopsy, CAT scan, upper/lower GI x-rays, or bowel surgery?
Why are nocturnal signs/symptoms important?
1. Rules in organic pathology
Air contrast barium enema (ACBE) is normal.
What do we do next? And why?
1. The most common site of Crohn’s disease is the terminal ileum, an area that the
ACBE does not examine well.
2. Thus, order a detailed small bowel study (DSB) and not an upper GI x-ray because
there are no upper GI symptoms.
What kind of extra-intestinal signs/symptoms should we be concerned about?
1. Vision changes, eye pain
2. Any pain in abdomen
3. Urine color changes
4. Liver problems, jaundice, hepatits in past
UGI with DSB was done—shows inflammation and stricturing in terminal ileum. Now
what?
1. Could also be caused by NSAID/aspirin use/abuse, so ask the patient about it!
2. Serology to confirm the diagnosis of Crohn’s disease: anti-Saccharomyces cerevsiae
antibodies (ASCA)—more specific for Crohn’s disease
a.
Vs. p-ANCA: more specific for CUC
3. Stool studies: look for parasites, white blood cells, and inflammatory cells
What kind of medicine can he possibly use?
Pharmacology of these medicines
***Take it away, Damien. I’m out!  ***