Academic Half Day A Rounds Disorders of the Lower GI Tract

Academic Half Day A Rounds

Disorders of the Lower GI Tract

Marianne Yeung MD, CCFP(EM), FCFPOctober 10, 2013

Objective

During this session, we will develop an approach to disorders of the lower GI tract re: • Diagnosis• Investigation• Treatment and Disposition

What Symptoms lead you to consider a LGIT disorder?

What Symptoms lead you to consider a LGIT disorder?

• Abdominal pain• Change in stools +/- blood• Nausea/emesis• Decreased appetite

List potential Lower GI tract Diagnoses…

What are potential LGIT diagnoses?

• Diverticulitis• Lower GI bleed• Large bowel obstruction / volvulus• Inflammatory Bowel Disease• Pseudo-obstruction / Ogilvie’s syndrome • Mesenteric ischemia

What are potential LGIT diagnoses?

Anorectal disorders:• Hemorrhoids• Anal fissure• Anorectal abscess• Rectal foreign body

Case

• Patient presents to ED with:- Abdominal pain - location- Change in stools- Nausea/emesis- Decreased appetite

- Age 24, age 54, age 84

This could be anything!

1. Distinguishing features - age - specific signs and symptoms - predisposing factors e.g. family history

2. Diagnostic Tests - none, labs, imaging (XR, U/S, CT, other)

3. Treatment in ED and Disposition

Lower GI DiagnosesDiverticul-itis

Lower GI Bleed

Large Bowel Obstruction

PseudoObstruction

Mesenteric Ischemia

Inflammatory BowelDisease

Abdominal painAbnormal stoolsNausea/emesis

Distinguish-ingfeatures

Lower GI DiagnosesDiverticul-itis

Lower GI Bleed

Large Bowel Obstruction

PseudoObstruction

Mesenteric Ischemia

Inflammatory BowelDisease

Abdominal pain

LLQ, RLQ LLQ Yes Usually no Yes Yes

Abnormalstools

+/- Bleeding

BRBPR Constipation Constipation +/- Bloody Bloody diarrhea

Nausea/emesis

+/- +/- Yes Usually not +/- +/-

Distinguish-ingfeatures

Middle-age

recurrent

Older,+/- VS

unstable

Narcotics TraumaSevere

electrolyte abnormality

Low flow states

YoungFamily hx

Associated symptoms Recurrent episodes

Diverticulitis

Distinguishing Features? (age, diet, symptoms)• Middle age, low fibre diet• Pain – often LLQ, or RLQ, +/- referred to pelvis, penis/scrotum• Bloody stools

Pathophysiology?• Inflammation/infection of diverticular tissue • Chronic constipation/hard stools

Diverticulitis – Complications?

Diverticulitis – Complications?

• Perforation• Obstruction• Abscess +/- rupture• Fistula

Diverticulitis – Diagnostic Tests

Labs• CBC, SMA-7 – not super-helpful

Imaging – what are you looking for? Which test?• X-ray - if suspect perforation or obstruction• U/S - tenderness on probing, fluid collections, diverticulae,

operator-dependent• CT – best of all, if available

Diverticulitis - Treatment

Diet• Liquid diet, then high fibre

diet• No evidence for avoiding

seeds

Analgesia • Short-term narcotics

Antibiotics for Diverticulitis

Which Organisms? • Gm negatives and anaerobes

Which Antibiotics?• TOH: Ceftriaxone 1g iv q24h + metronidazole 500 iv/po q8h

Cipro 500-750 po BID + metronidazole 500 po/iv q6-8hClavulin 875 po q12h + metronidazole 500 mg po q8h– Septrapo BID + Flagyl 500 po q6h– Clavulin 1000/62.5 ii po BID po(all for 7-10 days)

Maybe no antibiotics at all?

Diverticulitis - DispositionD/C home with instructions – return if…• Increased pain, bleeding, vomiting• Can’t tolerate po fluids and meds

Admit or consult General Surgery if…• Complications – abscess, perforation• Failed/cannot tolerate outpatient po treatment• Poor social supports, co-morbidities

Prognosis & follow-up…• Outpatient colonoscopy to r/o Ca • 1st episode diverticulitis - 95% are symptom-free for 2 years, and 80-90% symptom-free permanently• 2nd episode diverticultis – refer to outpatient General Surgery for possible

elective resection

LGIB

Etiology• Angiodysplasia• Diverticulitis• Cancer

Admit/Consult Surgery

Large Bowel ObstructionLess common than Small Bowel ObstructionDistinguishing features? (age, clinical presentation)• Often middle-aged or elderly• May be sick – tachycardia, dehydration, fever• Tenderness, abdo mass

Etiology?• Cancer• Volvulus• Diverticulitis• Abscess • Fecal impaction• Adhesions/strictures

Large Bowel Obstruction

Diagnostic tests?• Usual labs to rule out other diagnoses• XR, CT

Treatment and disposition?

• Symptom relief / supportive - NPO, NG - iv hydration - iv analgesia - Electrolyte replacement

• Transfer / consult General Surgery for admission

Volvulus

Distinguishing features… • Clinically the same as any BO

Pathophysiology? • Redundancy of bowel, mesentery twists on itself • Congenital? aging?

Volvulus - Imaging

Diagnostic tests? Expected radiologic findings?• X-ray– Large dilated bowel loop– Empty quadrant depends on sigmoid or cecal location

- Look for perforation• CT - if X-ray non-diagnostic

Volvulus - Treatment

Treatment and Disposition• all need immediate General Surgery consultation and

admission

How does Treatment differ between sigmoid and cecalvolvulus?

• Sigmoid – endoscopy to decompress and then self-detort

• Cecal – too proximal for endoscopy, so surgery to detort

What is Pseudo-obstruction/Ogilvie’s Syndrome?

No physical obstructive lesion

When do you suspect Ogilvie’s Syndrome to occur?• Narcotics• Severe acute co-morbid conditionse.g. trauma to spine or retroperitoneum severe electrolyte abnormality

Etiology?• Malfunction of autonomic control, with change to bowel

motility

Ogilvie’s Syndrome/ Pseudo-obstruction

Diagnostic tests?• XR, CT to distinguish from true BO

Treatment / disposition?• Bowel rest, hydration• General Surgery for colonoscopy or neostigmine• Operative treatment only if these fail

Inflammatory Bowel DiseaseDistinguishing features (pt characteristics and

associated symptoms)• Young at onset <30yo• +/- Family hx• May be diffuse, intermittent disease (Crohn’s)vscontinuous, large bowel only (Ulcerative Colitis)• Extraintestinal symptoms – skin, eyes, joints

Inflammatory Bowel Disease

Increased pain, bleeding, fever may signal IBD complications such as…

• Fistula• Abscess• Stricture• Toxic megacolon• Perforation

Inflammatory Bowel Disease

Diagnostic tests?• Labs – WBC, Hb• XR to r/o complications• Almost always need CT to r/o complications

Treatment and Disposition• Mostly medical management – 5-ASA, steroids, antibiotics,

anti-metabolites, consult GI liberally• Consult General Surgery if obstruction, perforation, leaking

anastamosis

Colonic Ischemia

Distinguishing features (symptoms and signs)• May not have a lot of pain!• If peritonitis, fever, high WBC – likely has progressed to

perforation and gangrene

Predisposed patients?• Low flow state • Older patients - CHF, vasoactive drugs, atherosclerosis, renal

failure, CV surgery• Younger patients - collagen vascular disease, hematological

disorders, distance runners, cocaine users

Colonic Ischemia

Diagnostic tests• Labs – not great utility – lactate, ALP,

phosphate may be increased• XR – thumbprinting=submucosal hemorrhage

and edema (DDx – IBD, infection, hemorrhage)• CT• Colonoscopy best

Colonic Ischemia

Treatment and Disposition

• Consult Gen Surgery – admit, bowel rest, rehydration, broad-spectrum Abx

• Treat hypotension – avoid pressors and steroids due to increased risk of perforation

• Most do not require operative management

What Symptoms lead you to consider a disorder of the Anorectum?

• Pain with defecation• Change in stools +/- blood

• Lack of systemic symptoms• Usually no special diagnostic tests

Common Anorectal Disorders

• Hemorrhoids• Anal fissure• Anorectal abscess• Rectal foreign body

Anorectal DiagnosesHemorrhoids Anal

fissureAnorectal abscess

Fistula RectalProlapse

Foreign body

Pain with defecationAbnormalStoolsDistinguish-ing Features

Anorectal DiagnosesHemorrhoids Anal

fissureAnorectal abscess

Fistula RectalProlapse

Foreign body

Pain with defecation

Yes Yes Yes No No No

Abnormal stools

+/- blood Hard stoolsScant blood

Perianal discharge

No Mucous dischargeBleeding

No

Distinguish-ing Features

Physical exam Physical exam

Physical exam

Co-morbid

conditions

Physical exam

History

Hemorrhoids

Distinguishing features• Anal mass, pain, bleeding

Treatment• WASH regimen = Warm water,Analgesics, Stool

softeners, High-fibre diet• Sitz baths, topical treatments• Consider referral for lower endoscopy to rule

out Ca

Internal Hemorrhoids

Disposition - when to refer to Gen Surgery?

• If 3rd degree internal hemorrhoid (manual reduction) or 4th degree (irreducible)

Thrombosed External Hemorrhoids

Treatment• If >72 hours, treatment is same as for internal

hemorrhoids• If <72 hours, may elect to excise both skin and

clot• Avoid simple I&D – risk of rebleeding,

rethrombosis, extension, skin tags

Anal Fissure

Distinguishing features? (symptoms, pt age)

• Acute, intense pain with defecation of hard feces

• Scant bright red blood• Children; 30-50yo

Anal Fissure

Treatment and Disposition?

Anal Fissure

Treatment and Disposition• WASH regimen• NTG ointment 0.4% BID• Nifedipine gel 0.2% with Lidocaine 1.5%• rare General Surgery referral for - Botox - Anal dilatation - Surgical excision

Fistula

Distinguishing features (signs and symptoms, predisposed patients/etiology)

• Perianal discharge, pain if 1 end is occluded• Ischiorectal abscess, diverticulitis, Crohn’s, trauma, FB,

Ca, TB

Treatment and disposition• Antibiotics – temporary resolution• General Surgery referral for investigation and treatment

Anorectal Abscess

Anorectal Abscess

Distinguishing features (symptoms, signs)• Fluctuant, tender area, rectal pressure and pain• Usually afebrile and well

Treatment and Disposition• I&D if healthy, with uncomplicated abscess• +/- Abx, surgical referral depending on location

Rectal Prolapse

Distinguishing features (signs and symptoms)• Prolapsing mass, mucous discharge, bleeding

Treatment and disposition• Manually reduce prolapse• Anti-constipation meds• Outpatient General Surgery referral

Rectal Foreign Bodies

Distinguishing features• Interesting story, pain, bleeding

Diagnostic tests• Plain XR can help

Treatment and disposition• Remove under procedural sedation and analgesia,

lithotomy position• General Surgery consultation if unsuccessful, concern re

mucosal trauma

Take Home Points

• Symptoms are similar for many disorders of the lower GI tract:

- look for distinguishing features on history (age, co-morbidities)

- physical exam for anorectal disorders (Use our Tables!)• Image liberally - especially if elderly, co-morbidities –

may need urgent referral / CT• Disposition decisions highly dependent on diagnosis,

social factors, local resources