Download
1 / 71
710 likes | 844 Views
AFP Journal Review. Naima Cheema, MD Emory Family Medicine January 3, 2008. Agenda. Ulcerative Colitis Somatoform disorders 2 nd Trimester Pregnancy Loss Pet-Related Infections. Agenda. Ulcerative Colitis Somatoform disorders 2 nd Trimester Pregnancy Loss Pet-Related Infections.
E N D
AFP Journal Review Naima Cheema, MD Emory Family Medicine January 3, 2008
Agenda • Ulcerative Colitis • Somatoform disorders • 2nd Trimester Pregnancy Loss • Pet-Related Infections
Agenda • Ulcerative Colitis • Somatoform disorders • 2nd Trimester Pregnancy Loss • Pet-Related Infections
Ulcerative Colitis Definition • Chronic Disease Characterized by Diffuse Mucosal Inflammation of the Colon. • Always Involved Rectum and may extend to involve Sigmoid Colon, the descending Colon or Entire colon Incidence • Affects 250K-500K persons in USA, with annual incidence of two to seven per 100K persons • Most Common between 15-40 yrs of age, and second peak between 50-80yrs of age
Ulcerative Colitis Etiology • Exact Cause Unknown • Current Hypothesis Suggest that Primary Dysregulation of the Mucosal Immune System leads to an excessive immunologic response to normal Microflora. Clinical Presentation • Intermittent bloody Diarrhea • Rectal Urgency • Tenesmus
Extra Intestinal Manifestations Extraintenstinal Manifestations in patients with UC is 6 -47 percent
UC Severity Index • Extent of Colonic involvement can often be predicted by the degree of symptomatology exhibited by the patient. • More fulminant presentations are often associated with Pancolitis, Severe Inflammation or both
Differential Diagnosis of UC • In Pt. with established UC, the presence of constitutional symptoms & extraintestinal manifestations particularly arthritis & skin lesions may provide clues to severity of disease. • Physical exam should target GI, dermatologic and Ocular Systems
Diagnosis Testing of UC • Stool Examination for : • Ova and Parasites • Stool Culture • Testing for C.Diff toxin • ESR and CRP • CBC … Anemia from Chronic Blood Loss • BMP- Hypokalemia from Persistent Diarrhea • When Endoscopy is not Available OR When Colonic Strictures prevent thorough evaluation, a double contrast barium enema and small bowel barium follow-through can demonstrate fine mucosal detail
Diagnosis Testing of UC (Contd. • Colonoscopy or Proctosmoidoscopy and biopsy … tests of choice (99% Sensitive) • Include Loss of typical vascular pattern • Friability • Exudates • Ulcerations • Granularity in a continous circumferential pattern • Although flex sig. is efficient method, it may miss lesions in the asc. or transverse colon in pt. with Crohn’s Disease. • Pt. who are diagnosed with IBD based on sigmoidoscopy should then undergo Colonoscopy
Treatment of UC Medical Management • Acute Treatment • Maintenance of Remission • 66% pt. achieve clinical remission with medical therapy and 80% pt. maintain remission • First line therapy contain mesalamine which acts topically from the colonic lumen to suppress the production of numerous proinflammatory mediators • Response is dose-dependent • Proctitis responds better to suppositories ,response may take 3-4 weeks. • Proctosigmoiditis require delivery of 5-ASA via enema,response may take 4-6 wks.
Treatment of UC Medical Management • Maintenance of Remission (Contd.) • Pancolitis require combination of oral and topical 5-ASA compounds and corticosteroids • Pancolitis require combination of oral and topical 5-ASA compounds and corticosteroids • Oral steroid therapy is also considered for pt. who fail to respond with maximal dosage of 5-ASA or who cannot tolerate the side effects. • Prednisone is given in dosage of 40-60 mg/day
Treatment of UC Medical Management • Full dosage theray is continued until symptoms are completely controlled (10-14 days), the dosage is then tapered by 5mg per week. • Long term oral steroid use is not recommended for chronic maintenance because of significant side effects like osteoprosis. • Pt. who fail to respond to oral steroids should be admitted to the hospital for IV steroids,Solu-Medrol 40 mg daily.
Treatment of UC Medical Management • Highest failure rate with IV steroids is noted in pt. with symptoms for more than 6 weeks or with severe lesions on endoscopy. • Hospitalized pt. who fail to respond to IV steroids after 5-7 days are candidates for IV cyclosporine (long term results not available ) • Infliximab,a chimeric monoclonal antibody that neutralize proinflammatory cytokine TNF-a can be used in pt. who do not respond to IV sterods.
Treatment of UC Medical Management • Two recent trials show that 60 % of pt. who failed to response with IV steroids achieve remission with infliximab compared with 30 % in placebo group. • Pt. who fail to respond to medical therapy are candidates for surgical therapy.
Treatment of UC Medical Management • Maintenance Therapy • The level of therapy that induce remission dictates the selection of maintenance therapy. • Pt. who achieve remission with 5 ASA compounds remain on same medication at lower dosage. • If response is achieved with azathioprine or infliximab , these medications are continued to maintain remission .
Treatment of UC Medical Management • Maintenance Therapy • If steroids are required to induce remission, higher dosages of 5-ASA are often needed. • Because of side effects from long term use, steroids should be tapered to the lowest effective dosage and stopped altogether if possible.
Treatment of UC Medical Management • Maintenance Therapy • All patients on chronic steroid therapy should be counseled to participate in regular weight-bearing exercise; screened for osteoporosis with dual energy x-ray absorptiometry; and considered for prophylaxis with calcium, vitamin D, and bisphosphonates.
Treatment of UC Surgical Management • Colectomy for the treatment of ulcerative colitis is warranted in patients • who develop dysplasia or cancer; • who have disease resistant to maximal medical therapy; • who experience massive hemorrhage, perforation, or toxic megacolon. • Toxic megacolon, which is a presentation of fulminant ulcerative colitis, is characterized by dilation of the transverse colon to more than 5.5 cm on supine abdominal radiography and requires emergent surgical evaluation.
Treatment of UC Surgical Management • Surgical treatment of UC is curative and has been shown improve the quality of life. • Potential complications include bowel obstruction, pouchitis, stricture, pouch dysfunction, and decreased fertility in women.
Treatment of UC Complimentary Therapy • Results of one study suggested that Lactobacillus was as effective as 5-ASA in preventing recurrence of ulcerative colitis, although the study was unblinded. • Other studies have shown the comparative effectiveness of nonpathogenic Escherichia coli to 5-ASA products in the treatment of ulcerative colitis and the prevention of relapse.
Treatment of UC Cancer Screening • ACS recommends initial colonoscopy eight to 10 years after disease onset for patients with pancolitis and 15 to 20 years after the onset of left-sided disease, with follow-up colonoscopies every 1-2 years in the second decade of the disease.
Answer : B Answer : D
Agenda • Ulcerative Colitis • Somatoform disorders • 2nd Trimester Pregnancy Loss • Pet-Related Infections
Somatoform Disorders Definition • Group of psychiatric disorders in which patient presents with myriad of clinically significant but unexplained physical symptoms. Incidence • Up to 50% of patients in primary care present with physical symptoms cannot be explained by medical conditions.
Somatoform Disorders Classification • Somatization disorder • Undifferentiated Somatoform disorder • Conversion Disorder • Pain disorder • Hypochondriasis • Body dysmorphic disorder • Somatoform disorder NOS
Diagnosis • At least 3 physical symptoms unexplained by medical condition • Exclude medical causes for physical symptoms while considering a mental health diagnosis • Somatoform disorders should be considered early in the process of evaluating patient with unexplained physical symptoms. • Factitious disorder (physical symptoms for unconscious internal gains) and Malingering (purposeful feigning of physical symptoms for external gain) must be excluded . • Significant impairment in social, occupational or other functioning.
Screening 3 out of 13 Symptoms with out medical explanation consider the diagnosis of Somataform Disorder
Practice Management Strategies • Accept that patients can have distressing, real physical symptoms and medical conditions with coexisting psychiatric disturbance without malingering or feigning symptoms • Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric diagnosis only when all criteria are met • Once the diagnosis is confirmed, provide patient education on the individual disorder using empathy and avoiding confrontation • Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals
Practice Management Strategies • Focus treatment on function, not symptom, and on management of the disorder, not cure • Address lifestyle modifications and stress reduction, and include the patient's family if appropriate and possible • Treat comorbid psychiatric disorders with appropriate interventions • Use medications sparingly and always for an identified cause • Schedule regular, brief follow-up office visits with the patient (five minutes each month may be sufficient) to provide attention and reassurance while limiting frequent telephone calls and "urgent" visits • Collaborate with mental health professionals as necessary to assist with the initial diagnosis or to provide treatment
Answer : D Answer : B
Agenda • Ulcerative Colitis • Somatoform disorders • 2nd Trimester Pregnancy Loss • Pet-Related Infections
Second Trimester Pregnancy Loss • Pregnancy loss during 13 to 27 weeks • Pregnancy loss before 20 weeks ... Miscarriage • Pregnancy loss after 20 weeks …Stillbirth • Miscarriage at 13-14 wks usually reflect pregnancy loss that occurred 1-2 weeks earlier. • 1-5% pregnancies are lost at 13-19 wks ,whereas still birth occur in 0.3 % pregnancies at 20-27 wks gestation.
