this lecture is a continuation of intestinal disorders, specifically focusing on inflammatory bowel diseases. ischemic colitis is the first disorder we covered, and is an inflammation of the mucosa and submucosa of the intestine that results either from insufficient perfusion (CHF) or an occlusive event (atherosclerosis), and accordingly is associated with elderly, smokers, and those who live sedentary lifestyles. acute cases, generally from occlusive events, present with sudden onset lower left abdominal pain, rectal bleeding, fever / hypotension, and peritoneal signs. chronic cases of ischemic colitis present with rectal bleeding as well, but have longer periods of vague abdominal pain, diarrhea, and generally a spared rectum, similar to crohn's. IC might present similar to diverticulitis or CA if there is frank blood.
irritable bowel syndrome is an extremely common disorder that contributes to 50% of all gastroenterologist visits. patients can be any age, and are more typically female. IBS can be the result of many different factors, and the exact etiological mechanism is unclear and oftentimes heavily influenced by emotional factors such as stress. other potential etiologies are: food allergy, abnormal transit profile, local histamine sensitization, epigenetics. diagnosis of IBS is made by the "rome III" criteria: lower abdominal pain for 3 days for 3 months in a row which is relieved by defecation and was accompanied at the onset by a change in stool frequency or appearance. diagnosis is also made by excluding "alarm signs" which might indicate a more serious, acute condition: onset after 50, severe diarrhea, nocturnal symptoms, severe weight loss, hematochezia, and positive family history for organic GI disease. the physical exam might be unremarkable, or reveal tenderness over the course of the colon. lab tests are generally only useful for excluding other diagnoses.
appendicitis is an inflammation of the appendix, which can be caused by fecaliths, lymphoid hyperplasia, parasites, and presents as epigastric pain that migrates to the right lower quadrant accompanied by weight loss and vomiting (which generally occurs after the onset of pain, as opposed to intestinal obstruction). there are a number of physical exam tests which can diagnose appendicitis with varying success, such as mcburney's, rovsing, obturator, cough, markle signs. a CBC might show WBC levels above 10,000 and neutrophilia above 75%.
diverticula present similarly to appendicitis in that they both cause localized lower abdominal pain-- but on opposite sides. diverticula are relatively common outpouchings of the colon caused by any factor that increases the intraluminal pressure of the colon, such as a low fiber diet or constipation. the sigmoid colon is particularly vulnerable to diverticula and thus typically pain is in the lower left quadrant of the abdomen.
while diverticula by themselves can be asymptomatic, inflammation and infection can result in diverticulitis, a more acute and serious condition which might even lead to perforation. patients with diverticulitis might have had a recent history of recurrent UTI's or pneumaturia, and present with severe LLQ pain, fever, altered bowel habits, and nausea/vomiting. complications of diverticula are manifold and can be detected by the symptoms that result: a vaginal fistula would result in feculent vaginal discharge. diffuse peritonitis would result in severe generalized abdominal pain. perforation would cause back or lower extremity pain, absent bowel sounds, and a high grade fever. lower GI bleeding might appear suddenly, be accompanied by an urge to defecate, and stop spontaneously. hemorrhoids or anal fissures might result in pain with defecation. diverticulitis is diagnosed by history, PE, and sigmoidoscopy imaging-- take note that barium xray should not be used in acute cases due to the danger of perforation.
questions
ischemic colitis...
1. what is ischemic colitis?
2. the morphology of ischemic colitis is similar to...
3. what are the risk factors for ischemic colitis?
4. what are the two etiological mechanism for ischemic colitis?
5. what is the clinical presentation of an acute case of ischemic colitis?
6. what is the clinical presentation of a chronic case of ischemic colitis?
7. what are the ddx's of ischemic colitis?
8. what are the imaging techniques used to diagnose ischemic colitis?
irritable bowel syndrome...
9. how common is IBS?
10. what is the age and gender that most commonly suffers from IBS?
11. what are the postulated etiological mechanisms for IBS?
12. what are the the "alarm symptoms" diagnostic criteria for IBS and what are their significance??
13. what is the primary symptom for the rome III criteria for diagnosis of IBS?
14. what must the primary symptom of the rome III criteria be associated with?
15. what is the clinical picture of patients with IBS?
16. what are some PE findings for patients with IBS?
17. how useful are labs in diagnosing IBS?
18. IBS can be confidently diagnosed by...
19. what are some naturopathic treatment strategies for IBS?
appendicitis...
20. what is the most common age of appendicitis sufferers?
21. what are the different etiological mechanisms for appendicitis?
22. what are fecaliths?
23. what is the "classic" history / symptom picture of an appendicitis patient and how often does it actually occur?
24. if vomiting occurs in a case of appendicitis, is it more likely to occur before or after the onset of pain?
25. duration of symptoms is typically...
26. what symptoms can be caused by appendicitis near the bladder?
27. what PE finding may male infants and children present with and why?
28. what are the tests one can perform in a PE that can diagnose appendicitis?
29. what are the expected CBC findings for a patient with appendicitis?
30. what are the imaging studies that can diagnose appendicitis?
31. what are the possible differential diagnoses for appendicitis?
32. what are some differential diagnoses for appendicitis in children?
diverticula...
33a. what are diverticula?
33b. what percentage of 60 and 80 year olds have diverticula?
34. what percentage of people with diverticula are asymptomatic?
35. which part of the GI tract is most prone to diverticula?
36. what are some factors that can increase intraluminal pressure?
37. what are some possible symptoms for diverticula?
diverticulitis...
38. what is diverticulitis?
39. what are some risk factors for diverticulitis?
40. what are some main differences and similarities between diverticulitis and appendicitis?
41. what are some signs / symptoms of diverticulitis?
42. patients with diverticulitis might have a recent history of...
43. what is a complication of diverticulitis related to the female reproductive tract?
44. if diverticulitis is accompanied by diffuse peritonitis, it might present as...
45. if diverticulitis is accompanied by perforation, it might present as...
46. if diverticulitis is accompanied by lower GI bleeding, it might present as...
47. describe the characteristics of blood flow from diverticulitis with GI bleeding.
48. diverticulitis with discomfort / pain upon defecation suggests...
49. in a case of diverticulitis, what sign would indicate an inflammatory bowel disease?
50. what would be involved in the PE for diverticulitis?
51. what might be the PE findings for diverticulitis that has led to perforation?
52. what is the imaging test used to diagnose diverticulitis?
53. what is an imaging test that might be dangerous to perform during an acute case of diverticulitis and why?
54. what are the conventional and naturopathic treatments for diverticulitis?
answers
1. an inflammatory bowel disease that results from ischemia of the mucosa and submucosa.
2. crohn's.
3. over 60, smokers, sedentary.
4. either decreased perfusion from insufficient cardiac output or occlusive disease such as atherosclerosis.
5. sudden onset lower left abdominal pain
rectal bleeding
fever / hypotension / tachycardia
peritoneal signs
[lower left, blood, fever, peritoneum] [i see you left perry's blood in the lower left freezer]
6. vague abdominal pain / tenderness
rectal bleeding
diarrhea
sparing of rectum
[vague, blood, diarrhea, spare] [i see you vaguely spared the bloody diarrhea]
7. diverticulitis, CA.
8. abdominal plain film, CT.
9. up to 50% of gastroenterologist visits are because of IBS.
10. any age, 70% females.
11. abnormal transit profiles
local histamine sensitization
food sensitivities
epigenetic effect (3-5%)
underlying emotional component.
12. part of the diagnosis of IBD by identifying symptoms that would be indicative of a more acute disorder:
onset after 50
severe diarrhea
nocturnal symptoms
unintentional weight loss
hematochezia
positive family history for organic GI diseases
[50, diarrhea, night, weight loss, blood, family] [HBS 50th anniversary: i had diarrhea that night, lost a lot of weight and blood, and called my family]
13. recurrent abdominal pain at least 3 days a month for 3 months in a row.
14. relief with defecation, onset associated with change in stool frequency, form, or appearance.
15. crampy abdominal pain
constipation, diarrhea, or alternating
increased mucous production
flatulence, nausea, anorexia
anxiety / depression / stress
[cramp, alternating, mucous, various, emotional]
16. may be asymptomatic, or increased bowel sounds and tenderness
17. only useful in excluding other conditions.
18. identifying typical symptoms, doing a complete PE, and excluding alarm features.
19. food hygiene and diet, stress reduction, fiber, probiotics, cell salts.
20. late teens.
21. obstruction from fecaliths, lymphoid hyperplasia, parasites.
22. a hard mass of feces formed from fecal debris and calcium.
23. 50% of cases have anorexia / weight loss with epigastric pain that is followed by RLQ pain.
24. nearly always follows onset of pain.
25. 48 hours, longer in elderly.
26. "irritative voiding symptoms", hematuria, pyuria.
27. hemiscrotum from migration of inflamed appendix or pus through patent processus vaginalis.
28. mcburney's point, rovsing sign, obturator / psoas sign, cough sign, Markle sign, rectal/vaginal tenderness.
[mburney, rovsing, obturator/psoas, cough, Markle, ass] [mr. burns's remarkable cough obstructed my roving ass]
29. WBC above 10,000
neutrophilia above 75%
30. abdominal CT, ultrasound.
31. pelvic inflammatory disease, acute gastroenteritis, pancreatitis, crohn's, cholecystitis, pyelonephritis, IBS.
32. volvulus, intussusception, acute gastroenteritis.
33a. outpouchings of the colon.
33b. 30%, 80%.
34. 90%
35. sigmoid colon.
36. low fiber diet
refined carbs
constipation
dehydration
corticosteroids
[fiber, refined, constipation, water, steroids] [divert the refined fiber-water; i have constipation on steroids right now]
37. if not asymptomatic, then LLQ pain, constipation, rectal bleeding if erosion.
38. inflammation of one or more diverticuli, leading to complications such as abscess, obstruction, fistula.
39. same as diverticula.
40. looks almost identical to appendicitis, except doesn't generally appear in children, and appears on the LLQ instead of RLQ.
41. LLQ pain- steady, severe, deep
fever
altered bowel habits
nausea/vomiting
dysuria, pyuria
[LLQ, fever, altered, nausea, pyuria] [look- a fever altered my nausea of pies via diversion!]
42. pneumaturia / recurrent UTI's.
43. fistulas with the vagina might result in feculent vaginal discharge.
44. severe, generalized abdominal pain.
45. back or lower extremity pain.
46. bright red or wine colored stool.
47. sudden onset, urge to defecate, massive flow, stopping spontaneous.
48. hemorrhoids or anal fissures.
49. history of weight loss, mucous in the stools.
50. checking abdomen for localized tenderness / rebound tenderness / guarding
vitals for hemodynamic stability, low grade fever
51. diffuse tenderness, absent bowel sounds, high grade fever.
52. sigmoidoscopy shows narrowing and inflammation.
53. barium xray, might cause perforation.
54. conventional: Cipro. naturopathic: hot vinegar pack, then treat like infection (similar to appendicitis treatment)
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