REVIEW

OF THE
SMALL
BOWEL AND
COLON

Cristina Wiese M.D.

April 29, 2010
QUESTION 1

A 65 y/o woman underwent initial colonoscopy 1 month ago for

colorectal cancer screening. A 6mm tubular adenoma of the
sigmoid colon was found and removed during the examination. The
patient has no family history of colorectal cancer.

Which of the following is the most appropriate recommendation

for colorectal cancer surveillance for this patient?

A) Repeat colonoscopy in 1 year

B) Repeat colonoscopy in 3 years
C) Repeat colonoscopy in 5 years
D) Flexible sigmoidoscopy in 5 years
E) Virtual colonoscopy (CT colonography) in 5 years
QUESTION 2

A 32 y/o man comes for an annual health maintenance visit. His

mother was diagnosed with colorectal cancer at 55 years of age.
The patient reports no rectal bleeding or other symptoms. Medical
history is noncontributory except for hypercholesterolemia.
Physical exam is normal.

When should this patient first undergo colorectal cancer

screening?

A) Now
B) At age 40 years
C) At age 45 years
D) At age 50 years
QUESTION 3
Three months ago, a 62 y/o man underwent segmental sigmoid colon
resection for a near-obstructing colorectal cancer found on flexible
sigmoidoscopy. Surgery was considered curative, and the patient did
not require postoperative chemotherapy or radiation therapy. He has
no family history of colorectal cancer or polyps. On a follow-up visit
today, he feels well. Physical exam is normal.

Which of the following is the most appropriate colorectal cancer

surveillance procedure for this patient?

A) Colonoscopy now
B) Colonoscopy in 1 year
C) Colonoscopy in 3 years
D) Ct scan of the abdomen now
E) Ct scan of the abdomen in 3 years
COLORECTAL NEOPLASIA
COLORECTAL NEOPLASIA

 Adenoma-to-carcinoma sequence
 50% US population will have adenomas, 1in 20 progress
to cancer
 Progression is result of accumulation of genetic
mutations
 Mutations in APC gene cause FAP and 85% of sporadic
colorectal cancers
 Abnormalities in DNA mismatch repair genes (leading to
microsatellite instability) account for HNPCC syndrome
and remaining 15% of sporadic tumors
COLORECTAL CANCER SCREENING
 Primary Prevention: exercise, fiber, eat fruits/veges, limit
meat/fat intake, avoid obesity/smoking/excessive ETOH
 Calcium, vitamin D, folate, NSAIDs have been associated
with decreased colorectal cancer
 Screening: those pts without prior polyps or tumors
(surveillance is term for those with prior history of
polyps or cancer)

 Screening tests: FOBT annually, flexible sigmoidoscopy

every 5 years, colonoscopy every 10 years, double
contrast barium enema every 5 years (average risk
patients, start at age 50)
COLORECTAL NEOPLASIA-VIRTUAL CT
COLORECTAL CANCER-HIGH RISK

 Colonoscopy (most sensitive test) recommended for patients with

increased risk of developing colorectal cancer
 HNPCC
 IBD
 Family history or personal history of adenomas or colorectal cancer

 If any first degree relative has adenoma or colorectal cancer prior to age
60, then patient should have colonoscopy at age 40 or 10 years earlier
than relative’s diagnosis
 FAP: annual flexible sigmoidoscopy starting at adolescence (age 10ish)
to determine if polyps present
 HNPCC: colonoscopy every 2 years starting from age 20, then yearly
after age 40
SURVEILLANCE
 Colonoscopy in patients with prior adenomas or colorectal
cancer
 If adenoma removed on flexible sigmoidoscopy, patient needs
full colonoscopy (20% risk of synchronous proximal adenoma)
 Piecemeal removal of adenoma, repeat colonoscopy in 3-6
months
 Repeat colonoscopy in 3 years for large adenoma (>or=1cm),
>3 adenomas removed, or polyps with villous histology or
high grade dysplasia
 Repeat colonoscopy in 5 years for 1-2 small adenomas
 After subsequent negative examination, repeat every 5 years
IBD SURVEILLANCE

 Colonoscopy every 1-2 years after pancolitis for 8-10

years
 Colonoscopy every 1-2 years after left sided colitis for
12-15 years
 IBD with PSC pts have 5X greater colon cancer risk
 Colonoscopy at time of PSC diagnosis, then annually

 Dysplasia on colonic biopsies—send for colectomy

POST COLON CANCER
 Prognosis is based on pathologic stage
 Most lesions occur within 2 years post-op

 Check CEA q3 months for 3 years post-op

 Annual abd CT for 3 years post-op

 Colonoscopy! (either before resection or immediately

after to eval for synchronous lesions)
 Repeat colonoscopy at 3 years, then if ok, q5 years
QUESTION 4
A 63 y/o man with polycythemia vera is hospitalized because of a 2
week history of increasing abdominal pain and distension. He has
not had fever, nausea, vomiting, or change in bowel habits. On
exam, the patient appears uncomfortable. Temperature is normal,
HR 100, BP 120/80. Abdomen is soft with diffuse tenderness and
splenomegaly. WBC 6.8, Hg 13.1, Plts 400, normal electrolytes.

Which of the following is the most likely diagnosis?

A) Mesenteric venous thrombosis

B) Ischemic colitis
C) Chronic mesenteric ischemia
D) Acute mesenteric arterial occlusion
QUESTION 5
An 80 y/o man comes to the emergency room because of new onset left-
sided abdominal pain. The patient has paroxysmal afib and required
cardioversion 3 days ago following an episode of hypotension. He has
been taking warfarin since cardioversion. He had a UTI last week that
was treated with cipro with no residual symptoms.
Exam shows only mild left-sided abdominal tenderness. Normal vital
signs. Normal labs. The patient remains in the hospital overnight and
develops hematochezia the next morning.

Which of the following is the most likely diagnosis?

A) Bleeding from a diverticulum

B) C diff colitis
C) Ischemic colitis
D) Ulcerative colitis
COLONIC ISCHEMIA

 Mesenteric Ischemia: pain out of proportion to exam findings

 Acute Mesenteric Ischemia

 Causes:emboli (arterial/venous), hypoperfusion, vasculitis

 Most common cause is mesenteric arterial embolus (from heart),
then mesenteric arterial thrombus from atherosclerosis, then
mesenteric venous thrombus
 Bowel infarction
 Mesenteric angiography is diagnostic study of choice
 Treatment: varies depending on symptoms (laparotomy,
embolectomy, intra-arterial thrombolysis)
COLONIC ISCHEMIA

 Chronic Mesenteric Ischemia

 Abdominal Vasculopaths
 Post-prandialabdominal pain, weight loss, and fear of eating
 Diagnosis: angiography
 Treatment: angioplasty, stenting, surgical reconstruction
ISCHEMIC COLITIS

 Causes: idiopathic, low flow states, certain drugs

 Bloody diarrhea +/- LLQ pain

 Watershed areas (splenic flexure, rectosigmoid junction,

right colon)
 Diagnosis: usually clinical, occasional angiography for
right sided ischemia
 Treatment: usually supportive
QUESTION 6
A 67 y/o woman comes to the ED because of a 3 day history of marked LLQ
abdominal pain and fever. She had a similar episode 1 year ago. Diverticulitis
was diagnosed at that time, and she responded well to antibiotic therapy.
Colonoscopy was normal except for sigmoid diverticulosis.
On exam, the pt appears ill. Temp 38.1, +orthostatic, dry mucus mebranes,
abdominal exam shows LLQ tenderness and some gurading but no rigidity. Hg
15.1, WBC 14, Plts 280 Cr 1.2
Ct scan shows LLQ stranding, no abscess. She responds to IV antibiotics and is
discharged.

In addition to scheduling a follow-up office visit in 4 weeks, which of the

following should be done?

A) Begin low residue diet

B) Avoid eating seeds, berries, and popcorn
C) Schedule colonoscopy
D) Schedule metal stent placement
E) Refer for surgical resection of involved intestine
DIVERTICULAR DISEASE
 Diverticulosis
 Herniation of intestinal wall where vasa recta enter the muscularis layer
 Most asymptomatic
 High fiber diet

 Diverticulitis
 Obstructed diverticulum= microperforation
 Occurs in up to 25% of pts with diverticulosis
 Complicated diverticulitis: abscess, frank perforation, colonic obstruction, or
fistula
 Colonoscopy after acute episode to rule out malignancy
 Diet: low residue during acute episode, then high fiber (seeds etc are OK!)
 20% of diverticulitis pts have 2nd attack, and after 2nd attack 50% will have the
third---after second attack refer to surgery
 Right sided diverticulitis or immunosuppressed pts: refer to surgery after 1st
episode
DIVERTICULAR BLEEDING

 Painless hematochezia, sometimes massive bleeding

 Diverticulitis is “uncommon”---per GI, diverticulitis and
diverticular bleeding NEVER occur together
 Bleeding usually stops spontaneously

 Colonoscopy—if ongoing bleeding, then

angiography/embolization
 Surgery after 2 or more episodes of bleeding
QUESTION 7

A 68 y/o woman has an 8 month history of watery diarrhea associated with 8-

10 BMs daily, urgency, and occasional fecal incontinence. No significant
abdominal pain, weight loss, or GI bleeding. Loperamide, up to 10 tabs
daily, has not improved her symptoms. Medical history is unremarkable
and she takes no other meds.
Exam and routine stool studies are normal. Colonoscopy including ileal
intubation is normal. Random biopsies from colon show collagenous
colitis.

Which of the following is the most appropriate therapy at this time?

A) Increase loperamide dose

B) Begin bismuth subsalicylate
C) Begin mesalamine
D) Begin prednisone
MICROSCOPIC COLITIS

 Chronic diarrhea, can have mild abdominal pain and weight loss
 Elderly (70 and older)

 Associated with NSAID use

 Coexisting celiac disease

 Diagnosis: Lower endoscopy WITH BIOPSIES

 Increased epithelial lymphocytes on histology

2 subtypes: collagenous colitis (thickened subepithelial collagen band)
and lymphocytic colitis (band is absent)
 Treatment: loperamide, diphenoxylate, bismuth
 If these fail, try 5ASA or cholestyramine
 If these fail, try steroids (budesonide perferred to oral prednisone)—
steroids are to induce remission, so need to continue initial drug for
maintenance therapy
QUESTION 8
A 26 y/o man has a 4 week history of increasingly severe bloody diarrhea,
urgency, tensesmus, and abdominal pain without fever, chills, or sweating.
He has an 8 year pack smoking history.
On exam, he appears well. Hg 12, WBC 11.3, ESR 38. Colonoscopy shows
areas of inflammation throughout the colon associated with friability,
granularity, and deep ulceration. The inflamed areas are separated by
relatively normal-appearing mucosa, including normal rectal mucosa.
Normal ileum. Biopsies show moderately chronic active colitis without
granulomas. Ileal biopsies are normal.

Which of the following is the most likely diagnosis?

A) Crohn’s disease
B) Ulcerative colitis
C) Microscopic colitis
D) Yersinia enterocolitis
E) Ischemic colitis
QUESTION 9
A 23 y/o woman has a 3 week history of rectal discomfort, tenesmus, and
mild bright red blood per rectum. 3-4 BMs daily, streaked with blood.
No significant abdominal pain, weight loss, nausea, or vomiting.
Normal exam except for some blood on rectal exam. Hg 11.2, otherwise
normal labs. Colonoscopy shows normal mucosa in the distal ileum
and throughout the colon down to the descending colon. The rectum
and sigmoid colon have changes consistent with active colitis, including
mucosal ulcerations, friability, and purulent exudate. Biopsies are
consistent with ulcerative colitis. Stool cultures are negative.

Which of the following is the most appropriate therapy at this time?

A) Mesalamine suppositories
B) Oral mesalamine (pentasa)
C) Mesalamine enemas
D) Hydrocortisone enemas
E) Oral prednisone
INFLAMMATORY BOWEL DISEASE
 Risk Factors
 2-4th decades of life, older pts (60-80s) as well
 Men and women equally
 Ashkenazi Jewish descent
 NSAIDs can cause flares
 Smoking increases risk of Crohns disease but not UC (smoking helps)
 5-10% of pts have + family history

 Extraintestinal Manifestations
 10% of pts with IBD
 Arthritis is most common (peripheral or axial---sacroiliitis and ankylosing
spondylitis)
 Derm (erythema nodosum and pyoderma gangrenosum)
 Ophtho (uveitis and episcleritis)

 Metabolic Bone Disease

 Growth retardation (esp in Crohns disease)
ULCERATIVE COLITIS

 Inflammation typically involves rectum and extends

proximally in contiguous fashion
 Mucosal inflammation

 5% of pts will also have PSC---these pts have an even

higher risk of colon cancer than with UC alone!
 Diagnosis: colonoscopy with terminal ileum intubation
(and biopsies)
CROHN’S DISEASE

 Inflammation may affect any GI segment, skip areas

 Transmural inflammation
 Fistulas
 Abscesses
 Bowel obstructions

 Granulomas (but these are not found that often)

 Diagnosis: Colonoscopy with ileal intubation (and biopsies)
 Stool studies
 CT enterography, capsule endoscopy, barium radiographs of
small bowel
 Ct abd if suspected abscess or fistula
TREATMENT OF ULCERATIVE COLITIS
 Active Disease
 Distal disease=topical therapy (mesalamine
suppositories/enemas or steroid suppositories/enemas)
 Oral 5ASA if topical agents fail in distal disease or for mild-
moderate pancolitis
 Oral prednisone
 Azathioprine/6MP---take many weeks to “kick in” so are
often started during prednisone use
 If severe UC, give IV steroids for 7-10 days
 If IV steroids don’t work, then try remicade (infliximab),
cyclosporine, or surgery
 Surgery: steroid dependence/refractory, complications
(perforation), dysplasia, colon cancer
 Total proctocolectomy with IPAA for young pts, and end ileostomy
for older pts
MAINTENANCE OF REMISSION IN UC
 Often use the same medication that was given to achieve remission (oral
5ASA etc)
 Cannot give topical or oral steroids longterm

 If pts responded to oral prednisone:

 If mild disease, cont oral 5ASA while tapering prednisone
 If disease flares while tapering the prednisone, then definitely use AZA/6MP
 If disease is more severe, use AZA/6MP while tapering the prednisone

 If pts required IV steroids:

 Change to oral prednisone, start AZA/6MP and then taper oral prednisone
slowly
TREATMENT OF ACTIVE CROHN’S
DISEASE

 Stop smoking!
 5ASAs pretty much don’t work for Crohns disease—if you try
them, make sure you know where the medication is delivered
(small bowel versus colon)
 Flagyl (in the textbooks, but UCSD GI MDs don’t use this for
induction therapy)
 Moderate-severe disease needs steroids
 Budesonide is good choice for distal ileal/right colon disease
 More diffuse disease=oral prednisone
 Use AZA/6MP/methotrexate for steroid dependent pts

 Severe Disease: may need IV steroids

 Iffail IV steroids, use remicade
 Some severe pts need surgery (esp for obstruction, fistula, abscess,
dysplasia, cancer)
MAINTENANCE OF REMISSION IN
CROHNS

 AZA/6MP/methotrexate
 Remicade (infliximab)

 If you started a 5ASA you would continue that, but not

very effective for maintaining remission
PERIANAL CROHN’S DISEASE
(FISTULAS)

 If small/mild, can do nothing

 If symptomatic, give cipro/flagyl

 Remicade (infliximab)

 Setons

 Surgerical diversion/proctectomy
QUESTION 10
A 78 y/o man has a 10 day history of low grade fever and diarrhea with as many as
six BMs daily. He also has nocturnal diarrhea and develops abdominal pain
before defecating. He has CHF. Current meds include enalapril, lasix, and
atenolol. He lives in Oklahoma and has not traveled since a trip to Mexico one
year ago.
On exam Temp 38.2. HR 90, BP 110/70. Diffuse abdominal tenderness is present.
Rectal exam is normal. No stool in the vault. Hg 17, WBC 12, Plts 380,
negative stool cultures, stool assay for Entamoeba histolytica antigen is negative.

In addition to volume resuscitation with IVF, which of the following is

the most appropriate next step in managing this patient?

A) Stool exam for fecal leukocytes

B) Stool exam for O&P
C) 48 hour fecal fat determination
D) Upper endoscopy with duodenal aspirates
E) Flexible sigmoidoscopy with biopsies
DIARRHEA
 Acute: 2 weeks or less; usually infectious
 Chronic: 4 or more weeks; usually noninfectious

 Frequent, high volume, watery stools: usually small bowel process

 Small quantity of stools with tenesmus/urgency: usually rectal
process
 Nocturnal diarrhea=not a functional diarrhea (eg irritable bowel
syndrome pts generally don’t wake up at night with diarrhea, but
inflammatory bowel disease pts can wake up at night with diarrhea)
 Invasive process: fever, bloody diarrhea
 Catch phrases: flushing with diarrhea (think carcinoid)
 Erythema nodosum/pyoderma gangrenosum (think IBD)
 Dermatitis herpetiformis (think celiac disease)
DIARRHEA MANAGEMENT
 Empiric therapy is appropriate for healthy pts with acute noninvasive
diarrhea
 Avoid lactose, sorbitol etc
 Oral hydration
 Anti-diarrheals
 Acute travelers’ diarrhea: empiric antibiotics

 Fecal Fat Study

 Fecal Leukocytes=inflammatory process (IBD, infection etc)—may need
endoscopy with biopsy if infection excluded on stool studies
 Stool electrolytes
 Osmotic versus secretory diarrhea (but you can always just see if diarrhea
continues while fasting!)
 Factitious diarrhea (low stool osmolarity due to added water etc)

 Neuroendocrine tumors (VIPoma, 5HIAA, gastrin etc)

QUESTION 11
A 39 y/o woman is hospitalized because of blunt abdominal trauma
and bowel infarction sustained in a MVA. Subtotal colectomy and
resection of most of her small intestine are required; she has 100 cm
of small bowel left after surgery.
One week post-op the pt’s enterostomy output is over 2 liters per day.
She is currently receiving TPN and requires IVF to compensate for
her increased stomal output.

Which of the following is most appropriate for managing the

patient’s nutritional and fluid requirements at this time?

A) Cautious introduction of enteral feedings

B) Cholestyramine
C) A PPI
D) Oral magnesium supplements
SHORT GUT SYNDROME

 <200 cm of intestine
 60cm of small bowel in continuity with colon, or 115 cm
of small intestine without the colon, can usually stay on
enteral feedings (may need TPN initially or
intermittently)
 Intestinal transplantation or chronic TPN for those with
shorter amounts than above
 PPI, anti-diarrheals (including octreotide), and avoid
hypo/hyper-osmolar liquids/foods if enterally fed
QUESTION 12
A 67 y/o woman has a 3 month history of loose, watery stools 4-5 per day
without bleeding, weight loss, urgency, or fecal incontinence. No recent
travel. She has a 45 year history of type I DM, managed with insulin, and a 2
year history of GERD, treated with a PPI. She recently received two courses
of antibiotics for cystitis, during which time her diarrhea improved. She has
been drinking milk her entire life without problems. Screening colonoscopy
one year ago was normal.
Exam is notable for peripheral neuropathy and Charcot’s joints. C diff and O&P
neg. Neg stool culture.

Which of the following dietary changes should be tried at this time?

A) Begin a gluten free diet

B) Begin a lactose free diet
C) Add lactobacillus acidophilus to the diet
D) Increase dietary fiber
SMALL INTESTINE BACTERIAL
OVERGROWTH (SIBO)
 Too many bacteria in small bowel
 Causes bloating, diarrhea
 Vitamin B12 deficiency (megaloblastic anemia), high folate
 Think of pts with motility disorders (Diabetes Mellitus is risk factor,
as is scleroderma)
 Think of pts with prior bowel surgery (strictures, afferent loop, absent
IC valve etc)

 Diagnosis: Duodenal aspiration (gold standard), breath test,

empiric trial of antibiotic
 Treatment: augmentin, quinolone---most pts recur as underlying
cause has not been cured (pts may require antibiotic rotations)
 Low carbohydrate diet (avoid lactose)
QUESTION 13

A 46 y/o man with diarrhea undergoes upper endoscopy with small

bowel biopsies. Biopsy results are consistent with celiac sprue.
Normal CBC. Fasting glucose 98. AST 20, ALT 18, AP 130, Tbil 0.6

Which of the following diagnostic studies should also be done at this

time?

A) Colonoscopy
B) Serologic studies for hepatitis B and C
C) Upper GI series with small bowel follow-through
D) Measurement of hemoglobin A1C
E) Measurement of serum vitamin D and calcium
CELIAC SPRUE
 Gluten sensitive enteropathy
 Inappropriate T cell response to wheat gluten, rye, barley (no oats
in US)
 Affects 1:300 people, usually Northern Europeans

 50% will have diarrhea (steatorrhea)

 Fat soluble vitamin deficiencies, iron deficiency

 Increased autoimmune diseases (DM I, autoimmune thyroiditis)

 Diagnosis: ON GLUTEN do gold standard=endoscopy with small

bowel biopsy, can also do serologic testing (check TTG and total
IgA antibodies)
 Treatment: gluten free diet (test adherence with IgA antigliadin
Ab titers)
 When failing treatment: first consider dietary indiscretions, then
do colonoscopy with biopsy to rule out microscopic colitis, try
steroids, and if all else fails consider lymphoma!
CELIAC SPRUE-DERMATITIS
HERPETIFORMIS
THE END
 Any questions? Comments?