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?
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•
•
•
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