Ileitis, Colitis, and DiverticulitisTintinalli Chap. 81

Nicholas Cardinal, DO

Crohn Disease

• Also called regional enteritis, terminal ileitis, and granulomatous ileocolitis

• Chronic granulomatous inflammatory disease of the the GI tract

• Can affect any part of the GI tract from mouth to anus– 20% confined to colon– 30% confined to small bowel– 50% both small and large bowel– Mouth, esophagus, or stomach affected in a small percentage

• Exact cause unknown– Environmental, genetic, infectious, autoimmune

Epidemiology

• Peak incidence at 15-22 years old• Secondary peak at 55-60• Women have a 20-30% increased risk• Common in those of European descent– 4 times more common in Jews

• Familial– Often have family hx of IBS or UC

Pathology

• Involves all layers of the bowel wall with extension into mesenteric lymph nodes

• Discontinuous “skip areas”• Longitudinal, deep ulcerations penetrating bowel

wall– Fissures– Fistulas– Abscess

• Cobblestone appearance is a late finding– d/t criss-crossing of longitudinal ulcers

Clinical Features

• Abdominal pain• Anorexia• Diarrhea• Weight loss• Fever• 1/3 develop perianal fissures, fistulas,

abscesses, or rectal prolapse

Extraintestinal Manifestations• Arthritic

– Peripheral arthritis– Ankylosing spondylitis– sacroiliitis

• Dermatologic– Erythema nodosum– Pyoderma gangrenosum

• Hepatobiliary– Pericholangitis– Chronic active hepatitis– Primary sclerosing cholangitis– Cholangiocarcinoma– Cholelithiasis– Fatty liver– pancreatitis

• Ocular– Episcleritis– Uveitis

• Vascular– Thromboembolic disease– Vasculitis– Arteritis

• Malnutrition• Chronic anemia• Nephrolithiasis• Myelodysplastic disease• Osteomyelitis• Osteonecrosis• Growth retardation in children

Complications

• 75% of patients will require surgery within 20 years of symptom onset

• Abscess– Occur in 30%– Abdominal pain/tenderness, fever– May have palpable mass– Retroperitoneal abscess may cause hip/back pain and difficulty

ambulating• Fistulas

– Result of extension of intestinal fissures into adjacent structures– Most are between the ileum and sigmoid, cecum, or skin– Enterovesical fistulas are rare

Complications

• Perianal– 1/3 of patients with Crohns– Fissures– Abscesses– Fistulas– Rectal prolapse

• GI bleeding– Only 1% develop life-threatening hemorrhage– Most are patients who develop toxic megacolon

Complications

• Obstruction– Caused by stricture formation and bowel wall edema– Distal small bowel is most common

• N/V• Crampy abdominal pain• Distention

• Malnutrition• Malabsorption• Hypocalcemia• Vitamin deficiency• Malignant neoplasm

Complications

• Medication side-effects (sulfasalazine, steroids, immunosuppressants)– Leukopenia– Thrombocytopenia– Fever– Infection– Profuse diarrhea– Pancreatitis– Renal insufficiency– Liver failure

Differential

General Population• Lymphoma• Ileocecal amebiasis• Sarcoidosis• Deep chronic mycotic

infections• GI tuberculosis• Kaposi’s sarcoma• Campylobacter enteritis• Yersinia ileocolitis

Elderly• Ischemic bowel disease• Pseudomembranous

enterocolitis• Ulcerative colitis

Diagnostics

• Diagnosis is usually made months-years after onset of symptoms

• Plain radiograph– Obstruction, perforation, or toxic megacolon

• Upper GI series• Air-contrast barium enema• Colonoscopy– Diagnostic or surveillance for colon cancer– Rectal sparing with involvement of proximal colon

Diagnostics

• CT– Acute symptoms in patients with known crohns

• Bowel wall thickening• Mesenteric edema• Abscess formation

– Extraintestinal manifestation• Gallstones• Renal calculi• Hydronephrosis• Sacroileitis• osteomyelitis

Treatment Goals

• Longterm– Symptom relief– Remission induction– Remission maintenance– Complications

prevention– Optimizing timing of

surgery– Nutrition maintenance

• ED– Evaluate severity of

attack– Identify significant

complications• Obstruction• Intraabdominal abscess• Life-threatening

hemorrhage• Toxic megacolon

Treatment

• Fluid resuscitation• Restoration of electrolyte balance• NG decompression– Obstruction, peritonitis, toxic megacolon

• Broad-spectrum antibiotics– Fulminant colitis or peritonitis– Ampicillin, aminoglycoside, and metronidazole

• IV steroids

Treatment

• Sulfasalazine (Azulfidine)– Used in mild-moderate active disease– Many intolerable side-effects

• N/V• Anorexia• Epigastric distress• Arthralgias• Headache• Diarrhea• Male infertility• Hypersensitivity reactions

– Pericarditis, pleuritis, pancreatitis, arthritis, rash

Treatment

• 5-aminosalicylic acid derivatives– Most effective in colonic disease• Pentasa• Asacol• Claversal• Salofalk• Olsalazine (Dipentum)• Balsalazide (Colazide)

• Oral glucocorticoids– Effective primarily in small bowel disease

Treatment

• Immunosuppressive agents• 6-mercaptopurine (6-MP)• Azathioprine• Cyclosporine• Methotrexate

• Side effects– Leukopenia– Fever– Hepatitis– pancreatitis

Treatment

• Infliximab (Remicade)– Anti-TNF antibody– Must screen for TB as can ppt active disease

• CDP571 (Cellcept)• Etanercept• Thalidomide• Interleukin

Treatment

• Diarrhea• Loperamide (Imodium)• Diphenoxylate (Lomotil)• Cholestyramine (Questran

• Consultation– Gastroenterology– Surgery

Ulcerative Colitis

• Chronic inflammatory disease of the colon• Tends to be progressively more severe from

proximal to distal colon• Rectum is involved in nearly 100% of cases• Usually present with bloody diarrhea• Unknown etiology

Epidemiology

• Higher prevalence in US and northern Europe• Peak incidence in 2nd and 3rd decades• Slight predominance in men• Familial– First-degree relatives have 15-fold increased risk of

ulcerative colitis and 3.5-fold increased risk of Crohn disease

Pathology

• Primarily involves the mucosa• Mucosal inflammation with crypt abscesses, epithelial

necrosis, and mucosal ulceration• Early findings

– Finely granular, friable• Severe disease

– Spongy with small ulcerations oozing blood and purulent exudate

• Very advanced disease– Large, oozing ulcerations– pseudopolyps

Clinical Features

• Mild (60%)– 80% are limited to rectum– Less than 4 bowel

movements per day– No systemic symptoms– Few extraintestinal

manifestations– Usually present with

constipation and rectal bleeding

– 10-15% progress to pancolitis

• Moderate (25%)– Colitis usually extends to

splenic flexure– Good response to therapy

• Severe (15%)– Frequent bowel movements– Frequent extraintestinal

manifestations– Clinical findings may include

anemia, fever, weight loss, tachycardia, and low serum albumin

Clinical Course

• Intermittent attacks of acute disease with complete remission between attacks

• Some have chronically active disease

Complications

• Hemorrhage• Perirectal fistulas/abscesses• Obstruction• Acute perforation• Carcinoma– 10-30- fold increase risk

• 5-10% at 20 years• 12-20% at 30 years

– Requires periodic colonoscopies and biopsies• Begin 8-10 years after onset

Complications

• Toxic Megacolon– Advanced cases when disease extends through all layers

of the colon– Results in loss of muscular tone, dilatation, and localized

peritonitis– Can perforate causing septicemia– Mortality rate ~10%

• 50% if perforation occurs

– Precipitating factors may include antidiarrheal agents, narcotics, cathartics, enemas, pregnancy, recent colonoscopy, and hypokalemia

Complicatons

• Toxic Megacolon– Clinical Features

• Patients appear severely ill• Distended, tender, tympanic abdomen• Severe diarrhea• Fever• Tachycardia• Hypovolemia

– Diagnostics• Plain radiographs

– Air filled segment of the colon > 6cm in diameter– Loss of haustra– “Thumbprinting”

Complications

• Toxic Megacolon– Treatment• NG suction• IV steroids• IV fluids• Broad-spectrum antibiotics• Early surgical consult

Diagnostics• CBC

– Leukocytosis, anemia, thrombocytosis• Hypoalbuminemia• Abnormal LFT’s• Negative stool culture/O&P• Sigmoidoscopy• Barium enema

– Differentiates UC from Crohn disease– Defines extent of involvement

• Colonoscopy– Most sensitive– Biopsy differentiates acute vs. chronic disease and underlying causes– Findings include granular, friable, ulcerated mucosa; pseudopolyps in advanced

disease

Differential

• Infectious colitis• Crohn colitis• Ischemic colitis• Radiation colitis• Toxic colitis

– Secondary to chemotherapy• Pseudomembranous colitis• Gay bowel disease

– Limited to rectum• Rectal syphilis• Gonococcal proctitis• Lymphogranuloma venereum

Treatment

• Severe– IV steroids– IV fluids– Correction of electrolyte

imbalance– Broad-spectrum

antibiotics• Ampicillin plus clindamycin

or metronidazole

– Hyperalimentation– NG suction

• Toxic megacolon

• Mild/Moderate– Oral glucocorticoids– 5-aminosalicylic acid

enema• Rowasa

– Topical steroid preparations

Treatment

• Other agents– Sulfasalazine• Maintenance of remission

– 5-aminosalicylic acid derivatives• Induction and maintenance of remission

– Immunomodulators• 6-mercaptopurine (6-MP)• Azathioprine

Treatment

• Supportive therapy– Iron supplementation– Lactose-free diet– Psyllium (Metamucil)– Rest– Antidiarrheals can precipitate toxic megacolon and

are generally ineffective

Disposition

• Mild/Moderate– May be discharged with close follow-up

• Severe– Admit– Consultation• Gastroenterology• Surgery

Pseudomembranous Colitis

• Inflammatory bowel disorder• Membrane-like yellowish plaques of exudate

overlie and replace necrotic mucosa• Caused by Clostridium difficile• 3 syndromes– Neonatal– Postoperative– Antibiotic-associated

Clostridium difficile

• Spore-forming obligate anaerobic bacillus• Produces two toxins– Toxin A: enterotoxin– Toxin B: cytotoxin

• Transmission via direct human contact or contact with inanimate objects

Pathophysiology

• Inpatients are colonized in 10-25% of cases• Antibiotics– Usually begins 7-10 days after initiation but may

begin within a few days or several weeks• Clindamycin• Cephalosporins• Ampicillin/amoxicillin

• Contributing factors may include recent bowel surgery, bowel ischemia, shock, malnutrition, uremia, and Hirschsprung disease

Clinical Features

• Vary from frequent, mucoid, water stools to toxic picture including profuse diarrhea, crampy abdominal pain, fever, leukocytosis, dehydration, and hypovolemia

Complications

• Severe electrolyte imbalance

• Hypotension• Anasarca• Toxic megacolon• Perforation

• Extraintestinal– Arthritis– Visceral abscesses– Cellulitis– Necrotizing fasciitis– Osteomyelitis– Prosthesis infection

Diagnosis

• History• C. difficile toxin• Colonoscopy– Yellowish plaques– Typically limited to right colon

Treatment

• Discontinue antibiotic• IV fluids• Correction of electrolyte imbalance• Antidiarrheals may prolong or worsen symptoms• Antibiotics– Metronidazole 250mg QID– Vancomycin 125-250 QID

• Alternative therapy for resistant cases, pregnant women, and children

Disposition

• Admit– Severe diarrhea– Systemic response• Fever• Severe abdominal pain• leukocytosis

• Consult surgery– Toxic megacolon– Perforation

Diverticulitis

• Acute inflammation of the wall of a diverticulum and surrounding tissue

• Caused by micro- or macroperforation

Epidemiology

• Rare under age 20• Incidence increases with age– 1/3 have diverticular disease by age 50– 2/3 by age 85

• Diverticulitis occurs in 10-25% of patients with diverticular disease

• Higher incidence in men but increasing in women

Diverticular Disease

• False diverticula– most colonic diverticula– Do not include all layers of the bowel wall– Consist of mucosa and submucosa with a peritoneal

covering that has herniated through a defect in the muscular layer

– Occur between the mesenteric and antimesenteric taenia

• True diverticula– Occur in the cecum

Pathophysiology

• Cause is unknown– Lowe residue diets producing high intraluminal

pressures• Most occur in the sigmoid– Narrowist portion of the colon– Pressure is greatest where lumen is narrowist• Laplace’s law

Complications

• Inflammation• Bleeding• Perforation• Obstruction• Fistulas– Diverticula and bladder in males– Diverticula and vagina in females

Clinical Features

• May be indistinguishable from acute appendicitis

• Steady, deep LLQ pain• Change in bowel habits• Tenesmus• Urinary frequency, dysuria, pyuria• Recurrent UTI’s

– Suspect fistula

Clinical Features

• Low-grade fever• Localized tenderness• Guarding• Rebound tenderness• Palpation of a LLQ mass• Rectal tenderness• Perforation presents with diffuse abdominal

tenderness, guarding, rigidity, and rebound tenderness

Diagnostics• Acute abdominal series

– May be normal• Ileus• Partial SBO• Free air• Extraluminal collections of air

• Abdominal ultrasound• Abdominal CT

• Inflammation of pericolic fat• Presence of diverticula• Thickening of bowel wall• Peridiverticular abscess

• Barium contrast studies– Can precipitate perforation

• Sigmoidoscopy/colonoscopy– Performed after acute inflammation– r/o colon cancer

Treatment

• IV fluids• Correction of electrolyte abnormalities• NPO• NG suction

– Ileus or obstruction• Broad-spectrum antibiotics

– Inpatient• Aminoglycoside• Plus metronidazole or clindamycin

– Outpatient• Ampicillin, TMP/SMX, ciprofloxacin, or clindamycin• Plus metronidazole or clindamycin

Disposition

• Admit– Signs and symptoms of infection– Failed outpatient management– Signs of localized peritonitis

Questions?