Inflammatory Bowel Disease (updated 2021) - CRASH! Medical Review Series

[@woloabel]

Wednesday, November 9, 2022. Gastroenterology: Inflammatory Bowel Disease ([IBS] Digestive System Pathology) is an Idiopathic Chronic Inflammation of The Digestive Tract; 1) SSx of IBD: 1) Diarrhea. 2) Fever, 3) Fatigue, 4) Hematochezia, 5) Hemorrhage (Ulcer Bleeding), 6) Stomach Pain (Epigastric Pain/Abdominal Pain), 7) Bloating and Cramping, 8) Anorexia (Loss of Appetite), 9) Unintentional Weight Loss (Cachexia), 10) Anemia (chronic Intestinal Hemorrhage), 11) Flatulence and 12) Extraintestinal Signs (1) Pyoderma Gangrenosum, 2) Erythema Nodosum [Painful Panniculitis], 3) Primary Sclerosing Cholangitis [PBC] is an Obstruction of the Bile Duct (Onion skin Obliteration of Ducts Morphology), 4) Ophthalmopathy [Uveitis, Scleritis/Episcleritis, Iritis], 5) Gallstones [Cholesterol Type] with CD due to Hyperbilirubinemia, 6) Kidney Stones [Oxalic Acid Type] only with CD due to Chronic Inflammatory Reaction, and 7) Aphthous Ulcers with CD due to the full Tract Involvement); The underlying Pathology follows: 1) Crohn's Disease (CD) is Transmural Inflammation/Infiltration (WBC Extravasation) of the Digestive Tract (Mouth to Anus Possible Involvement) with a Typical Terminal Ileum Involvement (Biopsy shows a Granulomatous Inflammation known as a Noncaseating Granuloma) in a Cobble Stone Pattern (Skip Lesions And Interaction with Unaffected Tissue). Ileum Involvement is Diagnostic of CD; SSx: 1) Right Lower Quadrant (RLQ), Chronic Abdominal Pain, 2) Diarrhea, 3) Anorexia, 4) Weight Loss, 5) Low Grade Fever, 6) Extraintestinal Manifestations; In Contrasted CT (Imaging Investigation), there will be the String Sign, Linear Hypolucency showing Areas of Stricture Pathologic Anatomy; Dx will be Via 1) Biopsy via Endoscopy); 2) Serology will have a Positive ASCA on Titers (High Specificity for CD); Cx are Strictures and 2) Fistulae; In Contrast Ulcerative Colitis (UC) is a Continuous Infiltration/Inflammation of the Mucosa/Submucosa of the Colon, most Commonly Affecting the Rectum; SSx: LLQ Cramping and Bloating with Abdominal Pain, Bloody Diarrhea, Urgency, Weight Loss, Fatigue); Dx: 1) Colonoscopy with Endoscopic Biopsy (Pathologic Diagnosis) will show characteristic Crypt Abscesses and a Dense Mixed Inflammatory Infiltrate segregated to the Mucosa/Submucosa (Macroscopic Specimens would Show the Continuous Inflammatory Pattern [unlike CD]) and Vascular Changes. Colonoscopy would show 1) Friable Tissue, 2) Ulceration of Mucosa, and 3) Pseudopolyps, manifestations of Chronic Inflammation (Reactive Changes to the Normal Anatomy/Histology); Imaging Studies (Contrast CT) show the 1) Lead Pipe Sign (Loss of Haustrations) and possibly a 2) Dilation of the Colon (Toxic Megacolon) and 3) Subdiaphragmatic Air if Perforation has occurred (Pneumoperitoneum). History will guide the Aetiology of these Possible Complications; 2) Laboratories are the Standard (CBC [Anemia , Leukocytosis, Thrombocytosis, CMP [PSC if Elevation otherwise Normal], Iron Levels [Normal in CD and Low in UC], B12/B9 [Normal in UC, Low in UC] and Stool Studies [Absence of Infectious Agents but Blood Positive]); 2) Serology will be Positive for Perinuclear Antineutrophil Cytoplasmic Antibodies (p-ANCA); Cx:1) Toxic Megacolon and 2) Colon Adenocarcinoma (Malignancy and Metastasis); DDx of IBD: 1) Irritable Bowel Syndrome (IBS) is a Pain Syndrome and a Diagnosis of Exclusion (No Laboratory Indication of Infection or Abnormality). The Signs and Symptoms are alleviated upon Bowel Movement, Passage of Stool; 2) Infectious Colitis is an Acute Onset of Symptoms and Has a History of Travel, Sick Contacts, or Laboratory Investigations Indicate Pathogenic Aetiology, namely via Stool Studies; 3) Pseudomembranous Colitis (PC) has a SP Antibiotics Therapy/Use; Stool Studies has a Positive C. Dificile Toxin; the Colonoscopy Visualization has the Gray Pseudomembranes which peel of upon scopic manipulation; 4) Ischemic Colitis (IC) will have Atherosclerosis Stigmata (Angina, Medical Treatment Thereof), Abdominal Pain due to Hypoxia and/or Ischemia of Mesenteric Vasculature (Perfusion Injury) especially the Splenic Flexure (Watershed Zone) due to its Susceptibility to Hypoperfusion (Therefore Friability of Tissue); and 5) Yersinia Enterocolitica Colitis (Infection) will be Culture Positive for this Agent of Aetiology; Tx of IBD: 1) Mild cases warrant Tapered PO Budesonide (Oral Corticosteroids) with Mesalamine Anti-inflammatory Agents (5-ASA); 2) Moderate Cases Corticosteroids with Antimetabolites (Azathioprine, 6-MP, or Methotrexate [MTX]) with TPMT Genotype/Phenotype Status Testing prior to AZA, 6-MP or MTX (High/Low Levels is a Contraindication of these Agents due to a Greater Risk of Life-Threatening Myelosuppression and Hematopoietic Toxicity if TPMT Deficiency (Hypoactivity of Gene) or Hepatotoxicity if Hyperactivity of TPMT Gene); 3) In Refractory/Relapsing (otherwise failure of previous Treatment or Ineffectivity therein) IBD, 1) Corticosteroids, 2) Cyclosporine (CYA) an Immunosuppressant, Second Line Therapy, A Calcineurin Inhibitor, and 3) Biologics, Anti-TNFa Anti-inflammatory Agent Infliximab (Monoclonal Antibody Infusion Therapy) along with other Biologics (Purified Protein Derivative Assay to Assess for Latent TB Reactivation Risk because of AntiTNFa Possible Effect of Active TB Infection; otherwise Monitoring for Signs and Symptoms of TB is Standard); Also, a more Recent Biologic Agent, Tofacitinib of the Janus Kinase (JAK) Inhibitors/Inflammatory Bowel Agent Drug Class; 4) Colonoscopy is Mandatory 8-10 Years Post IBD Diagnosis and Annually Thereafter; 5) A Colectomy (Surgical Removal of Chronically Inflamed, Refractory Colon) in UC implicates a Colostomy Bag SP Colon Resection, a highly Risky infective Condition requiring much attention and maintenance. Topical Corticosteroids for Rectal Involvement; 6) In CD, Surgical Referral as Needed for Stricture, Fistulae (Antimicrobials For Fistula) and Possible Fistulotomy. Side Effects of IBS Agents: 1) Corticosteroids can cause a Cushingoid Stigmata or Cushing's Syndrome (SSx: Weight Gain, Lipodystrophy [Buffalo Hump], Hypernatremia [Hypertension], Hypokalemia [Arrhythmia], Infection); 2) Antimetabolites 6-MP, AZA, can cause Drug-Induced Pancreatitis and Myelotoxicity; 3) Infliximab Biologic (Anti-TNFa Chimeric Monoclonal Antibody) can Reactivate Latent TB (as any immunosuppressant Drug Class Agent). Mx of IBS Complications: 1) Colon Cancer makes Surveillance via Colonoscopy Mandatory (Every 2 Years) especially if Polyps are Present (q 1 Year) for Adenocarcinoma Malignancy; SSx 1) Hematochezia, 2) Stool Caliber/Texture Changes, 3) Constitutional Symptoms and 4) Pallor (Anemia); 2) Toxic Megacolon is a Surgical Emergency (SSx: 1) Fever, 2) Severe Abdominal Pain, 3) Abdominal Distention, and 4) Sepsis. Dx is via Abdominal Plain Film (X-Ray) showing Colonic Dilatation; Tx will involve Colonic Resection (Colectomy) along with Antimicrobial Therapy (Prophylactic Antibiotics); 3) Strictures is the Segmental Narrowing of the Large Intestine. SSx will be Consistent with Bowel Obstruction. Dx is with Barium Studies. Tx can be via 1) Endoscopic Dilatation or 2) Surgery (Strictureplasty); and 4) Fistulae (with complications therein of Abscesses, which are localized Sites of Infection/Inflammation) are the Abnormal Communication of the Colon with another Organ. Tx will be 1) Surgical Procedures to Correct the Abnormality (Fistulotomy) along with 2) a vigorous Antibiotic Medical Treatment (Metronidazole/Ciprofloxacin), 3) Biologics (Infliximab et al), 4) Drainage of Abscess via Surgical Incision usually Perianal. Mx of IBS Flares (Acute Relapsing Aggravations of IBS): 1) ED Management entails 1) IV Fluids in the Form of NS Bolus (Fluid Resuscitation); 2) Routine Laboratories are CBC, CMP/Liver Function Tests; 3) C. Diff Toxin Test if Subject has been on Antibiotics Recently; 3) Pregnancy Test in A Symptomatic Female of Childbearing Age (Non menopausal Female) to Exclude the possibility of an Ectopic Pregnancy (Negative Pregnancy Test); and 4) NB Acute Complications of IBS (Obstruction, Perforation and Dilatation) and 5) Analyze Accordingly (Investigations Proportionate to Disease Manifestations [Assays must be justified by the Relevant Manifestations [SSx] of a Disease]). Admission is warranted thereafter. IV Corticosteroids as in Methylprednisolone and 2) Diet is as Tolerated; 3) Progress Assessment: 1) Remittance of Symptoms warrants Switching of Corticosteroid Regimen from IV to PO which entails Budesonide or Prednisone; 2) Relapsing, Aggravation, or Continuation of Symptoms warrants Surgical Consultation and/or Referral to a Gastroenterologist Specialist. Goodness, my first Perianal Fistulotomy was a complete Surgical Success. Just Kidding. The Subject actually had a rectovaginal Fistula as direct result of Parturition/Childbirth (Obstetric Fistula). She is Fine Fun. MD Paul W. Bolin, Es gut ist zu lernen und lehren aber besser zu heilen ist. Heil!

[@EnverZiel]

Thank you for your content. I discovered your channel only 1 week ago and I was flabbergasted this quality content for free. I really appreciate it sir!

[@chickenkaraage5458]

Your videos are giving me such a better understanding of the topics covered in nursing school. Thank you thank you thank you!

[@_drk_1774]

Glad to have you back sir . Good work

[@NFT2]

Dr. Paul: This is a gross specimen Me: Yes it is

[@umeshlahiru9435]

We have been told sometimes UC may invole terminal ileum also. 👉 "backwash ileitis". Isn't this true sir? You said UC will NEVER involve ileum.??

[@deemadodo1404]

Yes of course 😅

[@abdelgadireshaq3990]

Nice, Dr paul bolin ❤️

[@Zaharan]

Love your work all from my heart. Keep doing more videos

[@mathiassari6499]

Welcome back ❤️🥂🤗

[@mohamadabedali9759]

Thank you DR, we're waiting for next videos!))

[@josephlauren7001]

Hope you .have a blessed day..

[@medicineman786]

Thank you very much Sir! Love you sooooooooo much Sir!

[@josephlauren7001]

I'll try..to watch..all of video..

[@ellewestbury2993]

You are incredible.

[@deemadodo1404]

Ulcerative colitis will never ever affect terminal ileum .... is not precisely correct as in ulcerative colitis there may be something called (backwash ileitis ) Anyway thank for your hard working ❤

[@Kartik-ij2vy]

Nice video are these enough for Mrcp too ?

[@pwbmd]

I'm not familiar with MRCP. But this is pretty high yield for any medical licensing exam, I reckon.

[@Kartik-ij2vy]

@@pwbmd after watching full video I guess these will be enough 🙂

[@georgel279]

[@7ab3tha]

It looks like pomegranate.

[@Delhi111]

Ya u can eat it