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  • A 23-year-old female presents to the clinic for bloody diarrhea and abdominal pain for the past week. The pain is reported as intermittent, 7/10, and concentrated at the lower left quadrant (LLQ). She denies any rectal pain, trauma, or abnormal ingestions. She endorses subjective fever. A physical examination is unremarkable. A colonoscopy reveals friable rectal mucosa that bleeds easily on contact.
Introduction
  • Clinical definition
    • chronic, autoimmune condition that results in the inflammation and ulceration of the colon and rectum
      • characterized by recurring episodes of inflammation limited to the mucosal layer of the colon
      • with treatment, the disease course typically consists of intermittent exacerbations alternating with long periods of complete symptomatic remission
    • commonly involves the rectum and may extend proximally and continuously to involve other parts of the colon
  • Epidemiology
    • demographics
      • more common in North American and Europe compared to other regions
      • bimodal distribution in patients aged 15-30 years and > 60 years of age
    • risk factors
      • positive family history of inflammatory bowel disease (IBD)
      • Ashkenazi Jewish descent
      • smoking may lower risk
  • Pathogenesis
    • no direct cause has been identified but is likely due to genetic susceptibility with environmental triggers
      • genetic susceptibility
        • familial aggregation of the disease
        • identification of multiple genetic loci linked to the disease
      • environmental factors
        • diets low in fiber and high in fat have been linked to the disease
        • stress may exacerbate condition
    • interactions of various factors ultimately lead to chronic, immune-mediated inflammation
      • activated innate (e.g., macrophage) and acquired (e.g., T and B cell) immune responses
        • associated with a Th2 cell response
      • loss of tolerance to enteric commensal bacteria
  • Associated conditions
    • extraintestinal manifestations
      • primary sclerosing cholangitis
      • musculoskeletal involvement
        • ankylosing spondylitis
        • arthritis
        • sacroiliitis
      • eye involvement
        • uveitis
        • episcleritis
      • cutaneous involvement
        • erythema nodosum
        • pyoderma gangrenosum 
      • venous and arterial thromboembolism
      • autoimmune hemolytic anemia
Presentation
  • Symptoms 
    • diarrhea  
      • often with blood and mucus
      • recurrent episodes
    • fatigue
    • tenesmus
    • joint pain
    • abdominal pain
  • Physical exam
    • fever
    • rectal bleeding
    • pallor
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical presentation (e.g., chronic diarrhea > 4 weeks) and is confirmed via endoscopic biopsy
    • imaging
      • abdominal radiograph 
        • not required for diagnosis but may be the best initial test for patients presenting with symptoms of colitis
        • may see proximal constipation, mucosal thickening or “thumbprinting” secondary to edema, and colonic dilation
      • barium enema 
        • may be normal in patients with mild disease
        • positive findings include shortening of the colon, loss of haustra (“leadpipe appearance”), narrowing of the luminal caliber, and pseudopolyps 
      • computed tomography (CT) or magnetic resonance imaging (MRI)
        • may demonstrate marked thickening of the bowel wall
      • colonoscopy with biopsy
        • biopsy is necessary to establish the diagnosis
        • endoscopic findings may include 
          • touch friability, erosions, edema, and granularity of the mucosa
          • non-neoplastic pseudopolyps 
          • inflammation of the rectum that extends proximally in a continuous and circumferential pattern
        • biopsy features may include 
          • crypt abscess
          • inflammatory cells (e.g., eosinophils) within the lamina propria
    • studies
      • stool studies
        • for rule out of other causes of bloody diarrhea
      • complete blood count, albumin, electrolytes, an markers of inflammation
        • for evaluation of disease severity
      • perinuclear antineutrophil cytoplasmic antibody (pANCA)
Differential
  • Crohn disease 
    • differentiating factors 
      • will often present with perianal disease with patchy inflammation on colonoscopy  
  • Infectious colitis 
    • differentiating factors
      • will present with positive stool and tissue cultures/studies
Treatment
  • Management of the disease is dependent on the disease severity and extent of involvement
  • First-line
    • 5-aminosalicylic (5-ASA) drugs (e.g., sulfasalazine or mesalazine)
      • enema is the best initial step 
    • corticosteroids (e.g., prednisone) 
      • used for acute attacks
      • IV steroids for severe colitis 
    • iron supplementation
      • used to management anemia secondary to gradual loss of blood
  • Second-line
    • immunosuppressive agents (e.g., azathioprine) and biological agents (e.g., infliximab or adalimumab)
      • indicated in patients who cannot achieve remission with 5-ASA and corticosteroids
  • Third-line
    • total colectomy
      • curative
      • indicated in the event of exsanguinating hemorrhage, perforation, suspected carcinoma, severe colitis, toxic megacolon, or disease unresponsive to medical management
Prognosis, Prevention, and Complications
  • Anemia
  • Bleeding/hemorrhage
  • Perforation
  • Toxic megacolon 
  • Colorectal cancer
    • patients should receive initial screening colonoscopy 8 years after pancolitis
  • Osteoporosis
  • Strictures
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.7) A 53 year-old woman with history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools, and has been febrile for two days. Vital signs are: T 101.9 HR 98 BP 121/86 RR 17 Sat 100%. Abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. KUB is shown in figure A. CT scan shows markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient? Review Topic

QID: 102761
FIGURES:
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Oral prednisone

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IV hydrocortisone

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Rectal 5-ASA

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IV Metoclopramide

0%

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5

IV Ondansetron

0%

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(M2.GI.5) A 42-year-old male with a history of ulcerative colitis presents to the emergency room with four-day history of nausea, bloody diarrhea, and abdominal pain. He is on medical management with 5-aminosalicylic acid (5 ASA). Examination shows an ill appearing man with a tense, tympanitic abdominal exam. He is unable to be fully examined due to the abdominal pain. Vitals are T 38.2 C, HR 102 bpm BP 133/92 mmHg,2 RR 20 bpm, and O2 Sat 100% on room air. In the ED an abdominal radiograph is shown in Figure A. Which of the following is the diagnosis? Review Topic

QID: 102759
FIGURES:
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Sigmoid volvulus

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Perforated diverticulitis

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Toxic megacolon

100%

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Small bowel obstruction

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Cecal volvulus

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