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Lower GI Disease. Lori F Gentile. Lower GI Disease. Diverticular disease Bowel Obstruction Appendicitis Colon Cancer Inflammatory Bowel Disease Volvulus Olgilvie’s Syndrome Lower GI Bleed Ischemic Bowel Disease. Obstruction. LGI-distal to the Ligament of Trietz

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lower gi disease

Lower GI Disease

Lori F Gentile

lower gi disease1
Lower GI Disease
  • Diverticular disease
  • Bowel Obstruction
  • Appendicitis
  • Colon Cancer
  • Inflammatory Bowel Disease
  • Volvulus
  • Olgilvie’s Syndrome
  • Lower GI Bleed
  • Ischemic Bowel Disease
obstruction
Obstruction
  • LGI-distal to the Ligament of Trietz
  • Ileus = obstruction 2/2 dysfunctional motility of bowel
  • Mechanical obstruction = 85% SB, 15% large bowel
    • Simple obstruction, closed loop obstruction, Strangulation
  • Most Common Cause
  • Pt with previous surgery

Small bowel – Adhesions

Large Bowel – Cancer

  • Pt without previous surgery

Small bowel – Hernia

Large Bowel - Cancer

sbo etiology
SBO: Etiology
  • Adhesion
  • Hernia
  • Tumor
  • Abscess
  • Hematoma
  • Annular pancreas
  • SMA syndrome
  • Congenital lesions
  • Gallstone ileus
  • Intussusception
  • Foreign body (bezoars, worms, etc)
  • Meconium ileus
  • Malrotation
colonic obstruction etiology
Colonic Obstruction: Etiology
  • Cancer #1 (60%)
  • Volvulus (sigmoid > cecum)
  • Adhesions
  • Hernia
  • UC
  • Diverticulitis
  • Congenital lesions
  • Fecal impaction
  • Adynamic ileus
  • Hirschsprung’s
  • Meconium ileus
  • Foreign body
history ddx
History & DDx
  • Proximal obstruction: early bilious vomiting, +/- flatus/BM
  • Distal obstruction: obstipation, distension, vomiting feculent material (2/2 bacterial overgrowth of SB contents)
  • Pain w/obstruction: begins as cramping pain, changes to continuous severe pain w/strangulation & peritonitis
  • Bowel Movements- Cabliber, Blood, Pain
  • PMHx: remember to ask about cardiac history (arrhythmias, prior MI, Afib - think about intestinal ischemia), IBD, gallstones, cancer
  • PSHx: remember to ask about ostomy output
  • Meds: narcotics (ileus), antipsychotics (ileus), diuretics (hypoK a/w ileus)
  • ROS: recent weight loss (CA)
slide7
PE
  • Start with ABCs
  • Look for surgical scars
  • Bowel sounds
  • Distention-> tympany to percussion
  • Localized tenderness
  • Look for hernias/masses
  • Do a rectal exam
slide8
Labs
  • WBC (nml in uncomplicated SBO)
  • CBC (anemia w/CA)
  • BMP (hypoK)
  • Alkalosis (a/w proximal obstruction)
  • Acidosis (a/w bowel infarction)
  • Lactic acid- may be indication of bowel ischemia
studies
Studies
  • Upright CXR/KUB: look for free air
  • Flat and upright/left lateral decubitus: look for dilated bowel loops, air-fluid levels
  • Note: if cecal diameter >12cm, there is a risk of perforation. At 12-14cm, the wall tension > perfusion pressure, increasing risk of necrosis
  • Barium enema
  • UGI series w/SB follow-through
  • CT scan- with PO/IV contrast
sbo management
SBO: Management
  • “Bowel Rest” - NPO, NGT, Foley, IVF-Cures >80% SBOs
  • Electrolyte replacement
  • “Don’t let the sun set on a (complete) SBO”  Complete bowel obstruction w/concern for strangulation/perforation requires immediate operative intervention (resuscitate first)
  • Indications for Surgery -> Failure to resolve, progressing pain, peritoneal signs, fever, increasing WBCs
slide11

A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting

Dedouit F and Otal P. N Engl J Med 2008;358:1381

slide12

A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in the right lower quadrant

Liu K and Lin B. N Engl J Med 2007;356:1152

colon cancer
Colon Cancer
  • Asymptomatic – Screening Colonoscopy @ age 50
  • Adenoma->TVA (50% harbor cancer)
    • Sessile, high grade dysplasia increase cx risk
    • Polypectomy for pathology, adequate for T1 if margins clear
  • Symptoms – abdominal pain, anemia, constipation, bleeding, weight loss
  • Sigmoid colon-most common site of primary, constipation
  • Right colon cancer – anemia, asymptomatic
  • Work-up - staging
      • CT C/A/P, CEA
      • If rectal mass-> EUS
slide14
Case
  • 76 year old man, mass in LLQ, gradual growth, intermittent abdominal pain
    • Last BM 3 days ago, Nausea, Vomiting
    • Weight loss
    • Gradually narrowing caliber stools
slide15
Case
  • Imaging: air fluid levels (obstruction)
  • “Apple core” lesion in colon
  • Dx: colon CA
  • Tx: NPO, NGT, lytes
    • Staging/monitoring:
      • Colonoscopy
      • CEA
      • Chest CT
    • Neoadjuvant therapy, Resection
    • Diverting ostomy

http://allbleedingstops.blogspot.com

diverticular disease
Diverticular Disease
  • Herniation of mucosa through colon call at points where arteries enter, increased intra-luminal pressure
  • 80% Left side, sigmoid colon
    • Diverticulitis – left
    • Bleeding – right

Diverticulitis- infection/inflammation of colonic wall

    • Sx- LLQ pain, tenderness, fevers, leukocytosis, emesis, diarrheah
    • Work-up – CT scan

Hinchey Classification – Stage 1-4

diverticular disease1
Diverticular Disease

Treatment :

Uncomplicated – Bowel rest, Bactrim/Flagyl (PO or IV)

  • Increase fiber in diet, stool softeners
  • Consider elective surgery if second attack occurs (50% chance of recurrence)

Complicated – obstruction, fluctuant mass, abscess, peritonitis, fistula, sepsis, Hinchey 3,4

    • Abscess-percutaneous drainage, abx
    • Peritonitis – OR->Hartmann’s procedure

Needs colonoscopy in 6-8 weeks when sx resolve – r/o cancer, other diseases

slide18
Case
  • A previously healthy 45-year-old man presents with severe lower abdominal pain on the left side, which started 36 hours earlier. He has noticed mild, periodic discomfort in this region before but has not sought medical treatment. He reports nausea, anorexia, and vomiting associated with any oral intake. On physical examination, his temperature is 38.5°C and his heart rate is 110 beats per minute. He has abdominal tenderness on the left side without peritoneal signs. CT scan shows Hinchey 2 with 4 cm peri-rectal contained abscess. How should his case be managed?
slide19
Case
  • Complete H&P
  • Admit – pt unable to hydrate himself
    • NPO, IVFs, IV abx
    • Percutaneous Drainage of Abscess
    • As pt improves, ADAT, convert to PO abx
    • Colonoscopy 6 weeks after discharge
    • Surgery referral should pt have recurrent diverticulitis