DISEASES OF THE PANCREAS
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Pancreas has two types of tissue
o Exocrine
 Digestive enzymes-these enzymes are INACTIVE until they reach the
duodenum to break down carbs, fats and proteins
 Bicarbonate enzymes to neutralize stomach acids
o Endocrine
 Consists of islets of Langerhans secrete hormones into the blood stream
 Glucagon & Insulin: regulates the level of glucose in the blood
 Somatostatin: which prevents the release of the other 2
hormones
PANCREATITIS
o An inflammatory process which pancreatic enzymes autodigest the glandenzymes become active within the gland
 RUQ PAIN radiating to the back
 may get worse when food is eaten
 Fever, mild jaundice, left lung effusion
 Acute=can heal without any impairment of function or any morphologic
changes
 MCC: Biliary colic (stone dz) and binge alcoholic consumption
 Minor causes: meds, endoscopic retrograde, hypertriglyceridemia,
peptic ulcer disease, CMV, EBV, cocksackie, mycolplasma,
scorpion and snake bites
 Chronic= recur intermittently, contributing to the functional and
morphologic loss of the gland
 Severe cases may present with (caused by hemorrhage)
 Grey Turner sign: bluish coloration of flanks
 Cullen sign: bluish coloration of periumbilical
o Necrotizing pancreatitis
 Pseudocysts and pancreatic abscesses can result from necrotizing
pancreatitis bc of enzymes being walled off by granulation tissue or
bacterial seeding of pancreatic or peripancreatic tissue
o LABS: 3x more amylase and lipase in blood—chronic may have low or normal
enzymes
o DX: CT SCAN preferred, ultrasound
o TX: supportive, don’t eat PO, analgesics (Meperidine), Ceftriaxone
PANCREATIC CANCER
o More common in heavy smokers and pts w/ chronic pancreatitis
o 5 yr survival rate-initial s/s are subtle so by the time pt is dx = BAD prognosis
o Significant weight loss
o The MC characteristic sign of pancreatic carcinoma of the head of the pancreas is
painless obstructive jaundice
o PE: may have palpable gallbladder (Courvoisier sign)
o LABS: carb antigen 19-9 (tumor marker)
o TX: Whipple procedure- pancreaticoduodenectomy
 Insulinoma
o Rare, secretes insulin
o S/S: faintness, weakness nervousness, profound hunger (low level of sugar in
blood)-surgery and Drugs (streptozocin and octreotide)
 Gastrinoma
o Secretes above average levels of gastrin
o Causes Zollinger-Ellison syndrome
 A dz that causes tumors in the pancrease and duodenum and aggressive
peptic ulcers in stomach and duodenum
o Use PPIs-if fail may need complete gastrectomy (need B12 injection then)
 Glucagonoma
o Secretes glucagon
o S/S: like DM, weight loss, very DISTINCTIVE RASH-chronic reddish brown skin
rash (buttocks and groin) and a smooth, shiny bright red-orange tongue
o DX. Arteriography
TX: octreotide reduces glucagon but
DIVERTIC DISEASE
 Diverticulum
o A pouch or a pocket-like opening in the bowel wall, usually in the colon-bulging
out in weak spots
o Infected or inflamed=diverticulitis
 MC occurs in the colon but can happen anywhere
o Causes: colonic motility disorders, long term corticosteroid or NSAID use,
Genetics
o S/S: usually asymptomatic, MC symptom is abdominal pain, MC sign is
tenderness around the left side of the lower abdomen
o DX: CT, CT w/ contrast to make sure no perforation, flexible sigmoidoscopy and
barium enema only after symptoms have improved (if these 2 tests are done too
early they can cause perforation)
o TX: antibiotics, hospitalization is required if outpt fails, fever, need for analgesics
or if pt has other underlying chronic dz
 Long term- high fiber, low fat and low beef diet
o Can cause scaring which leads to obstruction and ultimately need emergency
surgery
 PERITONITIS
o A large abscess can become serious if infection leaks out and contaminates areas
outside the colon-infection spreads to the abdominal cavity (peritonitis)
o Requires immediate surgery
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FISTULA
o Abnormal connection of tissue between two organs or between an organ and
the skin
 When diverticulitis-related infection spreads outside the colon the solons
tissue may stick to nearby tissues and heal causing a fistula
 MC type occurs between the bladder and the colon
 Surgery
GALLBLADDER LECTURE
1. CHOLELITHIASIS
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Gallstone disease is also known as cholelithiasis
Gallstones are small, inorganic masses formed in the gallbladder but can also develop in
the common bile duct and hepatic duct
Frequent cause of abdominal pain and dyspepsia
There are 3 types of gallstones:
- Pure cholesterol
- Pure pigment
- Mixed
3 major compounds dissolved in bile:
- Conjugated bile salts
- Cholesterol
- Lecithin
Under NORMAL conditions  there’s a balance btwn bile acids, cholesterol and
phospholipids but when this balance is disrupted stones can develop
Gallstones can cause obstruction of the common bile duct, causing jaundice
Cholangitis, a potentially life-threatening infection, can follow biliary obstruction
Obstruction of the gallbladder can cause acute cholecysitis which can lead to gangrene
or abscess formation
Classically, gallstones occur in obese, middle-aged women, which leads to the popular
mnemonic, fat, fertile, forties, female flatulent. FEMALES > MALES (2:1)
HISTORY
 NAUSEA
 HIGH FAT CONTENT FOODS
 BILIARY COLIC
PHYSICAL
 Murphy sign- pain on palpation of the right upper quadrant when the patient
inhales might indicate acute cholecystitis
 Fever and tachycardia
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COMPLICATIONS OF CHOLELITHIASIS
 Jaundice – detected in all races by examination of the sclera
 Pancreatitis – more diffuse abdominal pain (pain in the epigastrium and left
upper quadrant of the abdomen.)
 Severe hemorrhagic pancreatitis – high mortality rate due to multi organ system
failure ; present with discoloration around the umbilicus (Cullen Sign) or flank
(Grey-Turner Sign)
 Charcot Triad - RUQ pain, fever and jaundice ; (associated with common bile
duct obstruction and cholangitis)
CAUSES OF CHOLELITHIASIS
 Prolonged fasting (5-10 days) can result in biliary sludge which can result by itself
when eating is re-established ; but biliary symptoms and gallstones can result.
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2. ACUTE CHOLECYSTITIS
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Acute attack often follows a large, fatty meal
sudden, steady pain in epigastrium or right hypochondrium - pain may steadily
subside over a period of 12-18 hours
vomiting - 75% Of cases
RUQ tenderness associated with muscle guarding and rebound pain
Palpable gallbladder 15% of cases
Jaundice 25% of cases
also suggestive of choledocholithiasis
Fever
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LABS
 WBC – elevated
 Serum bilirubin: 1-4 mg/dL
IMAGING STUDIES
 X-ray – gallstones can be radiopaque and can sometimes be visualized
 Ultrasound (US) is the most sensitive and specific test for the detection of
gallstones.
 Thickening of the gallbladder wall and the presence of pericholecystic fluid are
radiographic signs of acute cholecystitis
 CT scan can visualize gallstones but its highly invasive and expensive
 HIDA scan does not detect gallstones
 HIDA scan identifies an obstructed gallbladder
 HIDA scan is the most sensitive and specific test for acute cholecystitis.
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TREATMENTS
 Removal of the gallbladder laparoscopic cholecystectomy is the treatment of choice
for symptomatic gallbladder disease
 There is generally no reason for prophylactic cholecystectomy in an asymptomatic
person unless the gallbladder is calcified or gallstones are > 3cm in diameter
 Analgesics –(Meperidine preferred drug- less spasm of sphincter of Oddi)
 Due to high rate of recurrence -cholecystectomy advised
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3. CHOLEDOCHOLELITHIASIS
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 Choledocholithiasis - common bile duct stones
 Increases with age
HISTORY
 History suggestive of biliary colic or jaudice
 frequent/recurrent attacks of severe RUQ pain- duration of several hours
 severe colic - chills/fever
 Charcot’s Triad- classic picture of cholangitis
IMAGING
 The most direct and accurate way to determine the cause, location, and extent
of obstruction:
(1) ERCP
(2) percutaneoustranshepatic cholangiography
TREATMENT
 endoscopic papillotomy and stone extraction - followed by laparoscopic
cholecystectomy
 Ciprofloxacin, 250mg IV q 12 hours effective tx for cholangitis
 alternative tx - mezlocillin, 3g IV q 4 hours with either metronidazole or
gentamicin or both
 Aminoglycosides should not be used for more than several days due to increased
risk of aminoglycoside nephrotoxicity in cholestasis
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4. PRIMARY SCLEROSING CHOLELANGITIS
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Rare disorder
Characterized by diffuse inflammation of the biliary tract leading to fibrosis and
strictures of the biliary system
Most common - men aged 20-40
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suggestive of genetic etiologic role
Sclerosing cholangitis may occur in AIDs patients
progressive obstructive jaundice
elevated alkaline phosphatase levels
Diagnosis generally made by:ERCP and magnetic resonance cholangiography
Tx w/corticosteroids and broad spectrum antimicrobial agents yields inconsistent
and unpredictable results
Episodes of acute bacterial cholangitis may be treated with ciprofloxacin
For patients with cirrhosis and clinical decompensation, liver transplantation is
the procedure of choice
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5. CARCINOMA OF THE BILIARY TRACT
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Occurs in 2% of people surgically treated for biliary disease
Insidious onset - usually discovered during surgery
Cholelithiasis usually present
Signs/ Symptoms = pain RUQ w/ pain radiating to back present in gallbladder CA
but occurs later in course of bile duct carcinoma
TREATMENT
 Laparoscopic cholecystectomy
Acute Abdominal Pain: Slides 1-41
- MCC of hospital admission in US
- Gastroenteritis is MCC of acute abdominal pain (not requiring surgery)
- Pts >60y.o. biliary dz and intestinal obstruction are MCC of acute abdominal pain
(surgically correctable)
- Appendicitis is MCC of acute abdominal pain in pts <60yo (requires surgery); leading
cause in children
- Intussusception is most likely cause of intenstinal obstruction in children
- Adhesions are the most likely cause of intestinal obstruction in adults
- Pain is sudden in onset, awakens a pt from sleep
- Pain precedes vomiting = abdominal pain is surgically correctable
- Vomiting precedes pain = conditions like gastroenteritis
- RUQ pain – duodenal ulcers, acute pancreatitis, acute cholecystitis, acute hepatits
- RLQ pain – acute appendicitis
- LUQ pain – gastritis, gastric ulcer, acute pancreatitis, splenic infact/rupture
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LLQ pain – diverticulitis
Epigastric, periumbilical, suprapubic areas
Abdominal pain radiation:
o Perforated ulcer –shoulder
o Biliary colic –scapula
o Renal colic – small of back
o Dysmenorrhea/Labor – center of lower back
o Renal colic – groin
Colicky pain – rhythmic pain resulting from intermittent spasms; biliary dz,
nephrolithiasis, intestinal obstruction
Dull, poorly localized aching pain, progressing to constant, well localized sharp pain =
surgically correctable cause
PE of abdomen: INSPECT, AUSCULATATION, PERCUSSION, PALPATION
Pt writhing in agony – colicky abdominal pain from ureteral lithiasis
Pt lying very still – peritonitis
Pt leaning forward to relieve pain – pancreatitis
Hypoactive bowel sounds – ileus, intestinal obstruction, peritonitis
Hyperactive bowel sounds – intestinal obstruction
In ascites – dull percussion note; test for shifting dullness (supine pt has resonance over
periumbilical region, dullness over flanks)
In intestinal obstruction – hyperresonant note
Voluntary guarding – conscious elimination of muscle spasms
Involuntary guarding – reported when the spasm response cannot be eliminated,
usually indicates diffuse peritonitis
Rebound tenderness – elicited by pressing on the abdominal wall deeply with the
fingers and then suddenly releasing the pressure, pain on abrupt release of steady
pressure indicated presence of peritonitis
o can also ask patient to cough to elicit signs of peritonitis
Costovertebral Angle Tenderness- Ass w/ renal disease. heel of your closed fist to strike the
patient firmly over the costovertebral angles
MCC of acute abdominal pain in the upper abdomen include: acute cholecystitis, acute
pancreatitis, perforated ulcers
Acute Cholecystitis
Localized or diffuse RUQ pain, Radiation to right scapula, Vomiting and constipation,
Low grade fever Murphy’s sign (have patient take a deep breath while right subcostal area is
palpated) abrupt cessation of inspiration secondary to pain is considered a positive Murphy’s
sign Charcot’s triad --Right upper quadrant pain, Fever, Jaundice
Acute Pancreatitis
Retroperitoneal dissection of blood can result in bluish discoloration of the flanks
(Turner’s sign) or of the periumbilical region (Cullen’s sign)
Biliary pancreatitis 2nd to cholelithiasis is MC in women > age 50 in community
hospital setting
Alcoholic pancreatitis is MC in men ages 30-45 years in urban hospital setting
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Symptoms-epigastric pain, nausea, vomiting, pain is constant & boring in nature, Bowel
sounds decrease - lack of rigidity or rebound tenderness
Perforated Peptic Ulcer
Sudden onset - severe epigastric pain Pain becomes generalized after a few hours to
involve the entire abdomen, Perioperative mortality rate of 23%, Patient usually lying quietly
and breathing shallow, Abdomen rigid,board-like, guarding - maximal at site of perforation
Upright chest x-ray - detection of free intraperitoneal air
Midabdominal pain
MCC : intestinal obstruction, mesenteric ischemia and early appendicitis, dissecting aortic
aneurysm, myocardial infarction
Intestinal Obstruction
Mechanical - results from gallstones, adhesions, hernias, volvulus, intussuseption,
tumors
Non-mechanical- results from intestinal infarction or occurs after surgery as a paralytic
ileus, pain medication
Obstruction high in small intestine results in severe abdominal pain in epigastric or
umbilical region with bilious vomiting, distention of abdomen not an early feature
Obstruction located lower in small intestine results in less severe pain vomiting late
feature and may be feculent
Large Intestine Obstruction
Pain less severe than small intestine obstruction, Vomiting infrequent, Distention of
abdomen - common
MCC-Ca of colon (change bowel habits, wt loss, rectal bleeding),
diverticulitis (fixed,tender, LLQ mass), volvulus (sigmoid volvulus most common)
Mesenteric ischemia
Presents with acute, diffuse, midabdominal pain, vomiting, decreased bowel sounds and
distention resulting from intestinal obstruction. Abdominal pain is out of proportion to physical
examination findings. Abdominal distention is a late sign indicative of gangrene - signs of
peritoneal irritation also indicative of gangrene
Lower abdominal pain
MCC’s- Acute appendicitis (typically RLQ pain), Sigmoid diverticulitis (typically
LLQ pain), Gynecologic causes, Urologic causes
Diverticulitis Lower Left Quadrant Pain, Cramping sensation, Possible fever
Appendicitis
Patients seen in first few hours - report poorly defined constant pain in periumbilical
region
As disease progresses - pain shifts to RLQ in a region known as McBurney’s point
(located 2/3 of the distance along a line drawn from the umbilicus to the right anterior superior
iliac spine)
Pain relieved slightly when pt assumes a right lateral decubitus position with slight hip
flexion
Abdominal tenderness - most likely physical finding, Voluntary guarding in RLQ is
common
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Rovsing’s sign can be elicited by palpating deeply in the left iliac area and observing for
referred pain in the right iliac fossa ,When present, the psoas and obturator are helpful
Psoas sign - the psoas sign is pain elicited by extending the right hip while the patient is
in the left lateral decubitus position - Examiner extends patient's right thigh while applying
counter resistance to the right hip (asterisk).
alternatively, while in the supine position, the patient can lift the right thigh against the
examiners hand, which is placed above the knee
Obturator sign - the obturator sign is pain elicited by flexing the patient’s right thigh at
the hip with the knee flexed and then internally rotating the hip. Examiner moves lower leg
laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal
rotation of the femur.
Right sided rectal tenderness may also be elicited on rectal exam of patients with acute
appendicitis
Acute Appendicitis
Diffuse periumbilical pain and anorexia early, Pain localizes to RLQ as peritonitis
develops, Low grade fever, nausea and vomiting may not be present, Xrays and other tests are
often negative, Remember that the position of the appendix is highly variable!
Other causes of abdominal pain
Abdominal aortic aneurysm, abdominal pain/backache, hypotension, 71% perioperative
mortality rate, Physical exam of abdomen - detect pulsatile mass, unequal femoral pulses
Nephrolithiasis
ureteral colic 4% of patients w/acute abdominal pain
Colicky pain - Upper lumbar region radiates laterally to inguinal region
Patient writhing in pain
Acute Renal Colic
Severe flank pain, Radiation to groin, Vomiting and urinary symptoms, Blood in the urine
Other causes
Cardiac Origin, Gastritis, GERD, Esophageal disease, Hiatal hernia, Liver
abscess/subdiaphragmatic abscess, Pulmonary origin, Herpes Zoster, Hernia, Gynecologic,
Ovarian cyst, Ectopic pregnancy, PID
Gynecologic
In the absence of a positive pregnancy test result - fresh blood suggests a corpus luteum
hemorrhage, old blood suggests a ruptured endometrioma (chocolate cyst), purulent fluid
suggests acute pelvic inflammatory disease (PID) ,sebaceous fluid indicates a dermoid cyst.
Ectopic Pregnancy
Unruptured ectopic pregnancy - localized pain due to dilatation of the fallopian tube.
Ruptured ectopic - pain tends to be generalized due to peritoneal irritation
Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present
Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of
hypovolemia in these patients
Abdominal examination findings include tenderness and guarding in the lower
quadrants.
Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish
bowel sounds may develop.
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Ovarian Torsion
resolves spontaneously - only symptom -lower abdominal pain
Persistent torsion leads to congestion, ovarian enlargement, thickening of the ovarian
capsule, and subsequent infarction. Pain becomes severe -accompanied by nausea, vomiting,
and restlessness.Infarction also leads to fever and mild leukocytosis
PID
Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually.
Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with
PID, and both organisms often coexist in the same patient.
Gonococcal disease tends to have a rapid onset, while chlamydial infection has a more
insidious onset
Lower abdominal tenderness, Cervical motion tenderness,
Adnexal tenderness
Diagnosis may also be supported by any of the following criteria:
Temperature greater than 101°F (38.3°C) , Abnormal cervical or
vaginal discharge, Laboratory evidence of C trachomatis or N gonorrhoeae, Elevated
erythrocyte sedimentation rate or elevated C-reactive protein value
Tubo-ovarian absess
A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition
is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender
masses.
Patients often present with generalized abdominal pain and rebound tenderness caused
by peritoneal inflammation
Fibroids
A pedunculated subserous fibroid- twist and undergo necrosis, causing acute abdominal
pain
A pedunculated submucous fibroid - cramping pain and vaginal bleeding
Endometriosis
Pain associated with endometriosis may worsen before or during menses.
Patients experience generalized lower abdominal tenderness, and associated complaints
include dysmenorrhea, dyschezia, and dyspareunia
Things to remember
Inguinal/rectal examination in males., Pelvic/rectal examination in females.
Disorders in the chest will often manifest with abdominal symptoms. It is always wise to
examine the chest and cardiovascular system when evaluating an abdominal complaint.
Consider mesenteric ischemia in diabetic patients and patients with vascular disease and
vasculitis
Disorders of the Intestine:
- Large intestine – absorption of water from digested material (regulated by the
hypothalamus). Also absorbs any nutrients that were not absorbed in the Ileum.
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Common intestinal disorders – diarrhea, constipation, flatulence
o Constipation – commonly caused by a lack of fiber; can cause rectal tears and
intestinal blockages
o Diarrhea – a symptom of intestinal disorders; ranges from short-term and selfresolving to chronic and requiring medical care
 Occurs when insufficient fluid is absorbed by the colon
 MCC = viral infections or bacterial toxins
 Tx symptomatically with fluids, mixed with electrolytes
Acute Diarrhea (aka enteritis): lasts less than 4 weeks; almost always is infective
o MC organisms found are – Campylobacter, Salmonella, Crytosporidium, and
Giardia lamblia
o Toxins and food poisonings – Staphylococcal toxin, Bacillus cereus
o Also caused by ingesting indigestible material (escolar, olestra)
Chronic diarrhea – caused by infective diarrhea, malabsorption, IBS, IBD, surgery,
intestinal resection/bypass, Whipple’s Dz- Tropheryma whipplei, some bowel CA,
hormone-secreting tumors.
o Bile Salt Diarrhea – excess bile salt in colon b/c not absorbed in small intestine,
causing diarrhea after eating. Possible side effect of gallbladder removal, Tx with
cholestyramine (bile acid sequestrant).
Lactose intolerance – inability to digest lactose causing intestinal gas, cramping, and
diarrhea
Intestinal parasites – roundworms and tapeworms that can grow in the intestine
(primarily the cecum)
o E. vermicularis (aka pinworm) – MC nematode in US
o Female worms lay eggs on the perineum; eggs spread the fecal-oral route; egg
deposition causes perineal, perianal, and vaginal irritation
o With NO autoinfection, infestation lasts 4-6 weeks
o Suspect pinworm infx in children with perianal pruritus and nocturnal
restlessness
o Giardia lamblia – MC parasite infection worldwide, 2nd most common in US
(pinworm is MC in US)
 Commonly water-borne, infects persons who are camping, backpacking,
or hunting; aka “backpacker’s diarrhea” or “beaver fever”)
 Giardia growth is stimulated by bile, carbs, low oxygen levels
 Can cause dyspepsia, malabsorption, and diarrhea
 Incubation period, then GI distress (nausea, vomiting, malaise, flatulence,
cramping, gradual onset of diarrhea, steatorrhea, significant weight loss)
with symptoms for 2-4 weeks
Gastroenteritis – diarrhea or vomiting with non-inflammatory infection of upper small
bowel, or inflammatory infection of the colon.
o Caused by infx, acute onset, lasts <10 days, self-limiting
o Viral Gastroenteritis = watery diarrhea and vomiting, also H/A, fever, chills,
abdominal pain
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Virus damages cells in lining of small intestine, causing fluid to leak from
cells into the intestine, producing watery diarrhea
Diverticular disease – can affect large and small intestines; large is MC affected; occurs
when pouches develop in intestinal wall
Appendicitis – inflammation of the appendix; mild cases resolve w/o Tx; most cases
require removal by laparatomy or laparoscopy; Presents as typical or atypical
o Typical – pain starts periumbilical, then localizes to right iliac fossa.
 McBurney’s Point – right side of abdomen, 1/3 of the distance b/t
anterior superior iliac spine and the naval; palpation reveals firm to rigid
abdominal muscles from spasms.
o Sx – anexoria, fever, nausea, or vomiting
o PE – right side tenderness on DRE. + psoas sign, + obturator sign
 Psoas sign – pain on passive extension of right thigh
 Obturator sign – pain on passive internal rotation of flexed thigh
o Dx – based on H&P, elevated PMNs, Doppler and ultrasound (children), CT scan
(test of choice for adults)
o Rebound tenderness = peritoneal irritation
o Involuntary guarding = peritonitis, requires urgent surgery
Celiac disease – genetically predisposed immune disorder targeting small intestine;
immune system mistakes gluten as a threat, responds with an inflammation to the small
intestine
Colitis – digestive disease characterized by inflammation of the colon; several types
o General Sx of colitis – pain, tenderness, fever, bleeding, ulcerations and
erythema of colon.
 Dx – X-ray, test stool for blood/pus, colonoscopy
 Tx – abx, steroids, anti-inflammatory meds
o Pseudomembranous colitis – complication of abx therapy causing severe
inflammation in areas of colon (large intestine)
 Clostridium difficile (normal flora) may overgrow when taking abx;
release a toxin; lining of colon becomes raw/bleeds
 Not common in infants
 Sx – watery diarrhea, urge to defecate, abdominal cramps, low-grade
fever, bloody stools
 Confirmed by: immunoassay for C. difficile toxin or colonoscopy/flexible
sigmoidoscopy
 Tx with Metronidazole, vancomycin, or rifaximin
o Fulminant colitis – in addition to regular Sx, also have severe abdominal pain,
and Sx similar to septicemia with shock
 Tx with surgery
IBD – Inflammatory Bowel Disease – Chron’s disease and Ulcerative colitis – seem to
run in families, no known cause
o Chron’s Dz – chronic, recurrent, patchy transmural inflammation involving any
segment of the GI tract (mouth to anus); autoimmune?
 Fat-wrapping, “cobble-stoning”, fissures, thickened walls
o Ulcerative colitis – chronic, recurrent, diffuse mucosal inflammation of the colon
 Loss of haustra, ulceration, pseudopolyps
o Tx BOTH with: 5-aminosalicyclic acid derivatives, corticosteroids, and
mercaptopurine or azathioprine
 5-ASA – in active tx, during dz inactivity; anti-inflammatory; oral or topical
 Corticosteroids – moderate to severe IBD; avoid long-term therapy
 Mercaptopurine & Azathioprine – pt with refractory Chron’s and
ulcerative colitis; serious side effects in 10% of pts
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IBD- Crohn’s Disease
Unlike ulcerative colitis, Crohn’s disease is a transmural process that can result in
mucosal inflammation and ulceration, stricturing, fistula development and abscess formation
MC presentation - chronic inflammatory disease, low grade fever, malaise, weight loss,
diarrhea (non-bloody & intermittent), right lower quadrant or periumbilical pain
fistulas to the mesentery usually asymptomatic but can result in intraabdominal or retroperitoneal abscesses (fever, chills, tender abdominal mass, leukocytosis)
fistulas from colon to small intestine or stomach can result in bacterial
overgrowth (diarrhea, malnutrition), fistulas to vagina/bladder - recurrent infections
Colonoscopy findings- aphthoid ulcers, linear or stellate ulcers, strictures,
inflamed mucosa
Complications Abscess - get CT of abdomen, Obstruction, Fistulas, Perianal Disease,
increased risk of colon cancer, Malabsorption
Treatment directed toward symptomsGoal of Tx - control disease process, Diet - ?
Lactose intolerance, add fiber, patients w/obstruction - low roughage diet, Enteral therapy
(4wks - less effective than corticosteroids), TPN - short term, 5-Aminosalicylic acid agentsfor mild - moderately active ileocolonic and colonic Crohn's ,
Antibiotics,ciprofloxacin, metronidazole , Corticosteroids- prednisone, dramatically suppress
acute clinical symptoms/signs, Immunomodulatory drugs, Azathioprine & mercaptopurine
effective in long term tx of Crohn’s disease, infliximab, a chimeric IgG ant-TNF antibody used for
tx of active moderate to severe Crohn’s cases that did not respond to corticosteroids or
other immunomodulatory drug, Aminosalicylates , Corticosteroids , (including budesonide)
should only be used in active disease - not as a means to maintain remission
Maintenance Therapy Azathioprine, mercaptopurine and methotrexate ,used to
maintain remission in patients with frequent occurrences, infliximab , maintenance therapy
only when other immunosuppressive therapies fail
IBD- Ulcerative Colitis
Most cases controlled with medical therapy without need for surgery
Idiopathic inflammatory condition involving mucosal surface of colon
Hallmark symptom - bloody diarrhea
Lifelong disease ,symptomatic flare-ups and remissions ,extent of colonic involvement
does not progress over time
Classification: Mild-Moderate-Severe
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Mild- gradual onset of symptoms (infrequent diarrhea < 5 per/day, rectal bleeding,
mucus)
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fecal urgency/ tenesmus, left lower quadrant cramps usually relieved with
defecation
Moderate - more severe diarrhea, frequent bleeding, abdominal pain and tenderness
Severe-> 6-10 bloody bowel movements per day, severe anemia, hypovolemia ,impaired
nutrition, hypoalbuminemia, abdominal pain/tenderness, Fulminant colitis may develop
Systemic and Extra-Colonic Manifestations of UC
Arthritis signs and symptoms usually accompany exacerbations of ulcerative colitis.
Essentials of diagnosis, bloody diarrhea, lower abdominal cramps and fecal urgency,
anemia, low serum albumin, negative stool cultures, sigmoidoscopy - key to diagnosis
Blood work - hematocrit, sed rate , serum albumin
Plain abdominal films – check for significant colonic dilation
Sigmoidoscopy - mucosal appearance characterized by edema, friability, mucopus, and
erosions
colonoscopy should be avoided in severe cases due to increased risk of
perforation
Stool Sample, Infectious colitis should be excluded by stool bacterial culture (to exclude
salmonella, shigella, Campylobacter), ova and parasites (to exclude amebiasis), toxin assay for
C.difficile
Mucosal biopsy, can distinguish amebic from ulcerative colitis, E. coli -as it cannot be
detected on routine bacterial cultures
CMV colitis
Treatment dependent upon the extent severity of illness
Goals of tx stop the acute, symptomatic attack, prevent recurrence
Treatment - Distal Colitis
symptoms confined to rectum or rectosigmoid region
acute therapy - topical agents
drug of choice - mesalamine (3-12 weeks)
as suppository for proctitis (500mg 2x daily)
as enema for proctosigmoiditis (4g at bedtime)
also used - hydrocortisone suppository or enema
consider systemic steroids or immunosuppressives in refractory cases
Treatment - Mild to Moderate colitis
Disease extending above the sigmoid colon best treated with oral agents
5-aminosalicylic acid agents (sulfasalazine, mesalamine, balsalazide) symptomatic improvement in 50-75% of cases
sulfasalazine commonly used first line agent-lower cost (folic acid 1mg/d should
be given to all patients on sulfasalazine)
Balsalazide 2.25 g TID, more effective than other 5-ASA agents
Patients who fail to respond after 2-3 weeks of 5-ASA therapy should begin
corticosteroid therapy
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commonly used - hydrocortisone foam or enema, if fails, then systemic
steroid therapy
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systemic therapy - Prednisone and methylprednisolone
Treatment - Severe Colitis
Hospitalization usually required
d/c oral intake - TPN
restore fluid volume/ correct electrolyte abnormalities
Plain abdominal xray - look for colonic dilation
bacterial culture/ exam for ova/parasite
surgical consult
Corticosteroid therapy- methylprednisolone, hydrocortisone enemas, followed
by oral prednisone 50-75% of severe cases remission with systemic steroid therapy within 7-10
days)
Cyclosporine - IV - used in cases that do not respond to steroid therapy after 710 days
Surgery- reserved for pts who do respond to corticosteroid or cyclosporin after
7-10 days
Fulminant colitis
rapid progression of symptoms over 1-2 weeks signs of severe toxicity,
prominent hypovolemia , hemorrhage requiring transfusion, abdominal distention
w/tenderness
Broad spectrum antibiotics - to cover anerobes and gram negative bacteria
Toxic megacolon
characterized by colonic dilation of more than 6cm on plain films
Same therapy as fulminant colitis with addition of nasogastric suction
Pts should be told to roll from side to side and onto the abdomen to help
decompress the colon
Toxic megacolon serial x-rays to check for worsening dilation or ischemia
Toxic Megacolon or Fulminant colitis
Surgery should be considered for patients whose condition worsens or fails to
improve within 48-72 hours to prevent perforation
Chronic maintenance therapy with
sulfasalazine ,olsalazine ,mesalamine
IBS
IBS is the MC functional disorder of the intestines, and specifically the bowel. .
Irritable bowel syndrome (IBS) or spastic colon is a functional bowel disorder
characterized by abdominal pain and changes in bowel habits which are not associated with any
abnormalities seen on routine clinical testing.
It is fairly common and makes up 20–50% of visits to gastroenterologists.
symptoms should be present > 3 months before diagnosis established
Organic disease processes must be ruled out
Onset usually late teens to twenties
Symptoms
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lower abdominal pain (cramps- intermittent), onset associated with change in
stool frequency or form, pain relieved by defecation, usually pain is not nocturnal, stool usually
contains mucus
visible distention/bloating common
Three main classification groups
constipation (< 3 stools week, hard/lumpy stools, or straining)
diarrhea (> 3 stools per day, loose/watery, urgency or incontinence)
alternating constipation and diarrhea (some patients report firm stool in AM
followed by progressively looser stools throughout the day)
The following symptoms are not compatible with IBS and organic disease processes
must be ruled out
acute onset of symptoms in patients > 40yrs, severe diarrhea or constipation or
nocturnal diarrhea, hematochezia, weight loss, fever
Other disorders may present with similar symptoms - they include;
inflammatory bowel disease, hyper/hypothyroidism,colonic neoplasm, celiac
disease, lactase deficiency, endometriosis, psychiatric disorders (depression/anxiety)
Diagnosis
blood tests -CBC, serum albumin, SED rate, TSH ,serologic tests for celiac disease
in diarrhea cases stool exam – occult blood, ova/parasites, barium enema, sigmoidoscopy
,colonoscopy
Conservative tx
> 2/3 of patients with IBS have mild symptoms that respond well with dietary
modifications & education.
Dietary triggers - avoidance of certain trigger foods: fatty foods, caffeine, gassy
foods or lactose
High fiber diet or fiber supplements may be of use for constipation
Drug therapy
moderate to severe cases of IBS
antispasmodics - anticholinergic agents
antidiarrheals- Loperamide - prophylactically
anti-constipation drugs
Psychotropic drugs - low dose tricyclic antidepressants -anticholinergic
effects - useful in constipation cases
Serotonin receptor agonists & antagonists- tegaserod, alosetron
Hypnotherapy
Symptom diary can be useful to link time/severity of symptoms to food intake, life
events
Reassurance, education, support
mind-gut interaction - symptoms may increase in times of stress
Colon Cancer
Colorectal cancer is the second leading cause of cancer deaths. In almost all cases,
however, this disease is entirely treatable if caught early by colonoscopy.
There is no single cause for colon cancer. However, almost all colon cancers begin as benign
polyps which, over a period of many years, develop into cancers.
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Certain genetic syndromes increase the risk of developing colon cancer in affected families.
With proper screening, colon cancer should be detected BEFORE the development of
symptoms, when it is most curable. Most cases of colon cancer have no symptoms.
The following symptoms, however, may indicate colon cancer:
diarrhea, blood in stool, abdominal pain/tenderness, intestinal obstruction,
stools narrower than normal, weight loss with no known reason, and unexplained anemia
A physical examination rarely shows any abnormalities, although an abdominal mass
may be present.
A rectal examination may reveal a mass in patients with rectal cancer, but not colon
cancer.
colonoscopy or sigmoidoscopy may reveal cancer. only colonoscopy examines the entire
colon.
That is why a FOBT must be used with one of the other more invasive screening
measures, either colonoscopy or sigmoidoscopy.
Fecal occult blood test, sigmoidoscopy, and barium enema are screening tests that can
be used for early detection and prevention of colon cancer, but colonoscopy remains the gold
standard.
A new test, a virtual colonoscopy, uses CT scan technology to visualize the colon.
Treatment depends partly on the stage of the cancer. This means how far the tumor has
spread through the layers of the intestine, from the innermost lining to outside the intestinal
wall and beyond:
Stage 0: Very early cancer on the innermost layer (more accurately considered a
precursor to cancer)
Stage I: Tumor in the inner layers of the colon
Stage II: Tumor has spread through the muscle wall of the colon
Stage III: Tumor that has spread to the lymph nodes
Stage IV: Tumor that has spread to distant organs
Stage 0 colon cancer may be treated by cutting out the lesion, often via a colonoscopy.
For stages I, II, and III cancer, more extensive surgery to remove a segment of colon
containing the tumor and reattachment of the colon is necessary.
Almost all patients with stage III colon cancer, after surgery, should receive
chemotherapy) with a drug known as 5-fluorouracil given for approximately 6 - 8 months. This
drug has been shown to increase the chance of a cure.
Chemotherapy is also used for patients with stage IV disease in order to shrink the
tumor, lengthen life, and improve the patient's quality of life.
Irinotecan, oxaliplatin, and 5-fluorouracil are the 3 most commonly used drugs, given
either individually or in combination.
There are oral chemotherapy drugs which are similar to 5-fluroruracil, the most
commonly used being capecitabine (Xeloda).
Tumors may be surgically removed, burned, or frozen in some cases.
Chemotherapy or radioactive substances can sometimes be infused directly into the
liver.
Beginning at age 50, men and women who are at average risk for developing colorectal
cancer should have 1 of the 5 screening options below:
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a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year,
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flexible sigmoidoscopy every 5 years, OR
an FOBT or FIT every year plus flexible sigmoidoscopy every 5 years, OR (Of these
first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5
years is preferable.)
double-contrast barium enema every 5 years, OR
colonoscopy every 10 years
RECTAL DISORDERS
1. ANATOMY OF THE RECTUM
o Lower 10 -15 cm of the large intestine
o Its external opening is the anus, which is tightly shut except during stool
evacuation by two strong but sensitive rings of muscles: the internal sphincter
and external sphincter
o The dentate line delineates where nerve fibers end.
o Above this line, this area is relatively insensitive to pain.
o Below the dentate line, the anal canal and anus are extremely sensitive.
----------------------------------------------------------------------------------------------------------------------------------------2. HEMORRHOIDS
o Hemorrhoids are dilated, twisted (varicose) veins located in the wall of the
rectum and anus.
o They occur when the veins in the rectum or anus become enlarged; they may
eventually bleed.
o Hemorrhoids may also become inflamed or may develop a blood clot
(thrombus).
o Hemorrhoids that form above the boundary between the rectum and anus
(anorectal junction) are called internal hemorrhoids.
o Those that form below the anorectal junction are called external hemorrhoids.
o Both internal and external hemorrhoids may remain in the anus or protrude
outside the anus.
o Lack a muscular wall – characterizes them more as sinusoids than veins
o External – system veins
o Internal – portal veins
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Etiology of Hemorrhoids
o MCC – constipation
Generalized Symptoms of Hemorrhoids
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o Bleeding on stool or in toilet
o Mucosal protrusion
o Discharge
o Soiled underwear - due to internal
o Sensation of incomplete evacuation
o External = very painful, blue swelling and associated with spasms
Diagnosis of Hemorrhoids
o Prone, jack-knife position or lateral Sim’s position
o Location of the hemorrhoids should be described according to their anatomic
position
o Visual inspection
o DRE- digital rectal exam
Treatment of Hemorrhoids
o Sitz baths - probably most effective topical treatment for relief of symptoms
o other forms of moist heat, suppositories, stool softeners, and bed rest
o Stool bulking agent – Psyllium or Methylcellulose
o Surgical - Operative hemorrhoidectomy
----------------------------------------------------------------------------------------------------------------------------------------3. ANAL INFLAMMATION
o Anal fissures are superficial erosions of the anal canal which usually heal rapidly
with conservative therapy
o Anal ulcers are more chronic and deep and give symptoms largely as the result of
painful spasm of the external anal sphincter during and after defecation
o Bleeding may occur with either fissure or ulcer
 Medical treatment of Anal Inflammation
o Fiber
o Water
o Sitz bath
----------------------------------------------------------------------------------------------------------------------------------------4. ANORECTAL ABSCESS
o pus-filled cavity caused by bacteria invading a mucus-secreting gland in the anus
and rectum
o develops when bacteria invade a mucus-secreting gland in the anus or rectum,
where they multiply
o When no external swelling or redness is seen, diagnosis is made by DRE.
o Usually, treatment consists of if I/D after a local anesthetic has been given.
----------------------------------------------------------------------------------------------------------------------------------------5. ANAL CANCER
o Anal cancers occur most commonly in individuals with a prior history of chronic
anal irritation.
o F>M
o Most often associated with bleeding,pain, the sensation of a perianal mass, and
perianal pruritus at the time of diagnosis
o Increased risk - homosexual males
o TX: alternative therapeutic approach combining external beam radiation with
concomitant chemotherapy has resulted in biopsy-proven disappearance of all
tumor in more than 80% of patients
------------------------------------------------------------------------------------------------------------------------------6. PROCTITIS
o Proctitis is inflammation of the lining of the rectum (rectal mucosa).
o Causes: Crohn's disease or ulcerative colitis, STD’s, bacteria, antibiotics,
radiation therapy
o Proctitis typically causes painless bleeding or the passage of mucus from the
rectum.
o When the cause is gonorrhea, herpes simplex virus, or cytomegalovirus, the anus
and rectum may be intensely painful.
o Antibiotics are the best treatment for Proctitis caused by a specific bacterial
infection.
o Metronidazole (Flagyl) or vancomycin (Vancocin) when proctitis is caused by use
of an antibiotic that destroys normal intestinal bacteria
------------------------------------------------------------------------------------------------------------------------------7. PILONDIAL DISEASE
o An infection caused by a hair that injures the skin at the top of the cleft between
the buttocks.
o A pilonidal abscess is a collection of pus at the infection site; a pilonidal sinus is a
chronic draining wound at the site.
o *presence of pits - tiny holes in or next to the infected area.
o Treatment for a pilonidal abscess consists of I/D.
o Pilonidal sinus must be removed surgically.
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8. RECTAL PROLAPSE
o Rectal prolapse is protrusion of the rectum through the anus.
o Causes the rectum to turn inside out, so that the rectal lining is visible as a dark
red, moist fingerlike projection from the anus.
o Temporary prolapse seen in infants and is rarely serious
o In infants and children, a stool softener eliminates the urge to strain.
o Strapping the buttocks together between bowel movements usually helps the
prolapse heal on its own.
o Adults – need surgery
------------------------------------------------------------------------------------------------------------------------------9. FETAL INCONTINENCE
o Fecal incontinence is the accidental loss of stool.
o Treatments for incontinence include dietary modification, medicines,
biofeedback, and surgery.
o Avoidance of foods that promote production of gas, and foods containing
ingredients such as lactose, fructose, and sorbitol.
------------------------------------------------------------------------------------------------------------------------------10. FOREIGN OBJECTS
o Swallowed objects may become lodged at the junction between the rectum and
anus.
o Objects used for sexual stimulation can be lodged in the rectum
o If the object can be felt, a local anesthetic is usually injected under the skin and
lining of the anus to numb the area.
o The anus can then be spread wider with a rectal retractor, and the object can be
grasped and removed.
o Natural movements of the wall of the large intestine (peristalsis) generally bring
higher foreign objects down, making removal possible.
o If cannot be removed = surgery.