F>M. sx beginning before they were aged 35. Mostly start during childhood. Rarely after 40
Rome criteria: recurrent ab pain for at least 3 day/mo, assoc w/ 2 or more of the following
Improvement w/ defecation
Onset assoc w/ change in frequency of stool
Onset assoc w/ change in form of stool
types of IBS
IBS-D (diarrhea predominant)
IBS-C (constipation predominant)
IBS-M (mixed diarrhea and constipation)
IBS-A (alternating diarrhea and constipation)
features/characteristics of IBS
altered stool passage, altered GI motility, visceral hyperalgesia (widened dermatomal distributions of referred pain. Sensitization of GI afferent nociceptive pathways). psycho disturbances (can be cause or outcome--axis I disorders like anxiety, panic, depression), Small bowel bacterial overgrowth and fecal microflora
IBS tends to show as urgency _________
microscopic inflammation in IBS
postinfectious IBS. Enteroendocrine cells secrete high serotonin levels. lymphocytic infiltration. Increased numbers of colonic mucosal lymphocytes and enteroendocrine cells
pain mostly in LLQ, Acute episodes of sharp pain are often superimposed on a more constant dull ache
Meals may precipitate pain. Defecation may or may not improve pain, Pain from presumed gas pockets in the splenic flexure, sigmoid tenderness or a palpable sigmoid cord
differential dx close to IBS
Lactose intolerance. Fructose intolerance
Celiac Disease (1/200, more of Irish descendent) or Gluten intolerance
alarming sx of IBS
onset middle age or older. ･Nocturnal symptoms. Anorexia or weight loss. Fever. ･Rectal bleeding. Painless diarrhea. Steatorrhea
Irritable bowel disorders
ulcerative colitis and crohn dz. highest incidence in developed countries, highest in Jewish populations, appear in late adolescent to 3rd decade
bloody diarrhea, limited to mucosa/submucosa, begin at rectum, spread to sigmoid and rest of colon. NO skip lesions. no newly formed granulomas, mural thickening does not occur, high risk of carcinoma developmt, more common than Crohn, more common in whites, colicky lower ab pain, RELAPSES
Features of ulcerative colitis
Pseudopolyps, ASCA - / p ANCA+, Neutrophilic Infiltrate, Crypt Abcesses, Crypt Distorsion, toxic megacolon (colon swells & becomes gangrenous), progressive mucosal atrophy leads to a flattened and attenuated mucosal surface, diffuse mononuclear infiltrate in lamina
ulcerative colitis are also assoc w/
migratory polyarthritis, sacroiliitis, ankylosing spondylitis, uveitis, erythema nodosum, and hepatic involvemt (pericholangitis and primary sclerosing cholangitis)
Extra-intestinal manifestations are more common w/
ulcerative colitis than w/ crohn dz
pain in lower ab or RLQ, pt fatique and anemic, ASCA + / p ANCA-, ileum frequently involved, rectum spared, formation of granulomas, frequent fistulae, frequent perineal dz, SKIP lesions, Prevalent in US, Great Britain, and Scandinavia. Occurs at any age, F>M. More often among Jews than among non-Jews
Crohn dz morphology
often mesenteric fat wraps around bowel surface ("creeping fat"). Intestinal wall is rubbery and thick, result of edema, inflammation, fibrosis, and hypertrophy of the muscularis propria. Lumen is narrowed; in small intestine this is seen on x-ray as "string sign." Sharp demarcation of diseased bowel segments. TRANSMURAL
complications of crohn dz
Dysplastic changes appearing in mucosal epithelial cells, after long standing Crohn dz --> carcinoma. Fistula formation, abscess, intestinal strictures, Massive intestinal bleeding, toxic dilation of colon, or carcinoma of colon (less than cancer risk of ulcerative colitis) or small intestine
crohn dz may be accompanied by...
uveitis, sacroiliitis, migratory polyarthritis, erythema nodosum, bile duct inflammatory disorders, and obstructive uropathy with attendant nephrolithiasis
Cholangiocarcinoma types and locations
Type I & II in perihilar region. Type III is perihilar and intrahepatic. Type IV can be perihilar and intrahepatic or can spread to distal extrahepatic.
If pt has one 2nd degree or 3rd degree relative w/ colorectal cancer, screen at...
over 50 yrs (like average risk)
One 1st degree relative w/ colorectal cancer at or after age 60 or two 2nd degree relatives w/ CRC, screen pt at..
2 or more 1st degree relatives w/ colorectal cancer or one 1st degree relative w/ CRC before age 60, screen pt at...
age 40 or 10 yrs younger than earliest dx in family. repeat every 5 yrs
women, overweight, antibodies to mitochondria
most common anomaly. Failure of involution of omphalomesenteric duct, leaving a blind-ended tubular protrusion. Usually in ileum, asymptomatic, except when they permit bacterial overgrowth that depletes vitamin B12 --> pernicious anemia. Peptic ulceration, intestinal bleeding
Obstructive causes of pancreatitis
tumor, cystic fibrosis, gallstone in common bile duct
gallstones: bile concentrated in gallbladder --> supersaturated --> microscopic crystals --> trapped in gallbladder mucus --> gallbladder sludge --> crystals grow, aggregate, and fuse to form macroscopic stones ---> occlusion of ducts
Tenderness to palpation rebound tenderness, guarding over the gallbladder +/- rigidity pericholecystic inflammation. Murphy sign – push posteriorly at border of costal margin, midclavicular line. Fever, tachycardia and hypotensive. jaundice.
Charcot triad in cholethiasis
RUQ tenderness, fever, jaundice. characteristic of ascending cholangitis
gallstone risk factors
OBESITY, insulin resistance, type II diabetes mellitus, hypertension, and hyperlipidemia. pregnancy (progesterone), gallbladder stasis (prolonged fasting with total parenteral nutrition), rapid wt loss, gastric bypass
stone in common bile duct. Elevated wbc, transaminases, followed by elevated alkaline phosphatase & bilirubin. If obstruction is at level of ampulla of Vater, may obstruct pancreatic duct & see elevation of lipase and amylase
vinyl chloride predisposes one to...
types of gallstones
cholesterol stones most common.
calcium, bilirubin, and pigmented gallstones.
calcium, bilirubin, pigmented stones
Due to oxidation the stones turn black: High heme turnover. Disorders of Hemolysis