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), FCFP October 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 Diagnoses Diverticulitis Abdominal pain Abnormal stools Nausea/em esis Distinguishing features Lower Large Pseudo GI Bleed Bowel Obstruction Obstruction Mesenteric Ischemia Inflammatory Bowel Disease Lower GI Diagnoses Diverticulitis Lower Large Bowel GI Bleed Obstruction Pseudo Obstruction Mesenteric Ischemia Inflammatory Bowel Disease Abdominal pain LLQ, RLQ LLQ Yes Usually no Yes Yes Abnormal stools +/Bleeding BRBPR Constipation Constipation +/- Bloody Bloody diarrhea Nausea/em esis +/- +/- Yes Usually not +/- +/- Distinguishing features Middleage recurrent Older, +/- VS unstable Narcotics Trauma Severe electrolyte abnormality Low flow states Young Family 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 q6-8h Clavulin 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 - Disposition D/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 Obstruction Less common than Small Bowel Obstruction Distinguishing 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 conditions e.g. trauma to spine or retroperitoneum severe electrolyte abnormality Etiology? • Malfunction of autonomic control, with change to bowel motility Ogilvie’s Syndrome/ Pseudoobstruction 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 Disease Distinguishing 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 Diagnoses Hemorrhoids Pain with defecation Abnormal Stools Distinguishing Features Anal fissure Anorectal abscess Fistula Rectal Prolapse Foreign body Anorectal Diagnoses Hemorrhoids Anal fissure Anorectal abscess Fistula Rectal Prolapse Foreign body Pain with defecation Yes Yes Yes No No No Abnormal stools +/- blood Hard stools Scant blood Perianal discharge No Mucous discharge Bleeding No Physical exam Physical exam Distinguish- Physical exam ing Features Co-morbid Physical conditions 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, comorbidities – may need urgent referral / CT • Disposition decisions highly dependent on diagnosis, social factors, local resources
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