Diseases of the Small Intestine and Colon (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 13 topics under the category diseases of the small intestine and colon

Appendicitis (ReelDx)	Umbilical pain → then pain over McBurney’s point (RLQ) Most common etiology: Fecalith Signs: Rovsing – RLQ pain with palpation of LLQ Obturator sign – RLQ pain with internal rotation of hip Psoas sign - RLQ pain with hip extension Treatment: Appendectomy
Celiac disease	Small bowel inflammation from allergy to gluten Symptoms usually occur following ingestion of gluten-containing food. Also, has extraintestinal manifestations. Diagnosis: IgA anti-endomysial and anti-tissue transglutaminase antibodies Small bowel biopsy is gold standard Treatment: Lifelong gluten free diet
Constipation (ReelDx)	Defined as less than 2 bowel movements per week
Diverticular disease	LLQ pain, tenderness, abdominal distention, fever and leukocytosis in older patients Most common location: Sigmoid colon CT: Fat stranding and bowel wall thickening Treatment: Metronidazole and Ciprofloxacin + bowel rest
Inflammatory bowel disease	Ulcerative Colitis Isolated to the colon starts at rectum and moves proximally Continuous lesions Mucosal surface only Barium enema: Lead pipe appearance (loss of haustral markings) Treatment: Colectomy is curative Medications: Prednisone and mesalamine Crohn's disease From mouth to anus, transmural, skip lesions and cobblestoning! Mouth to anus Skip lesions Transmural Fistulas common Barium enema: Cobblestone appearance Treatment: Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin Maintenance: Mesalamine Surgery is not curative. Adjacent portion of bowel is affected post-op Cobblestone appearance seen in Crohn’s disease Lead pipe appearance sene in ulcerative colitis
Intussusception (ReelDx)	Sudden onset of significant, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. Affects children after viral infections or adults with cancer Currant jelly stools Sausage-like mass in the abdomen Abdominal x-ray will reveal a “Crescent sign” or a “Bull's eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen Barium enema is both diagnostic and therapeutic in children
Irritable bowel syndrome	According to the Rome IV criteria, IBS is defined as recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria: Related to defecation Associated with a change in stool frequency Associated with a change in stool form (appearance)
Ischemic bowel disease	Fifty-year-old with history of coronary artery disease experiencing recurrent cramping with postprandial abdominal pain Most common artery: Superior mesenteric artery Acute: Abdominal pain out of proportion to findings Chronic: pain 10-30 mins after eating, relieved by lying or squatting Imaging: Plain films/CT: Bowel edema, pneumatosis intestinalis, portal venous gas Mesenteric angiography is the gold standard Treatment: Supportive: Bowel rest, fluids, antibiotics Laparotomy with bowel resection for bowel infarction Revascularization is the gold standard
Lactose intolerance	Symptoms may include abdominal bloating and cramps, flatulence, diarrhea, nausea, borborygmi (rumbling stomach), or vomiting after consuming significant amounts of lactose Lactose hydrogen breath test - definitive diagnosis Treatment focuses on avoidance of dairy products, use of lactose-free products, or the use of lactase supplements
Colon cancer	Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age Apple core lesion on barium enema, adenoma most common type Screening with colonoscopy begins at 50 then every 10 years until 85 Fecal occult blood testing – annually after age 50 Flexible sigmoidoscopy – every 5 years with FOB testing Colonoscopy – every 10 years Sometimes CT colonography Tumor Marker: CEA More likely to be malignant: sessile, > 1 cm, villous Less likely to be malignant: Pedunculated, < 1 cm, tubular Treatment: Resect tumors and adjuvant chemotherapy "Apple core" lesion on barium enema
Small bowel obstruction	Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds. KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon Etiology: Adhesion, hernia, fecal impact, volvulus, neoplasm Treatment: Bowel rest, NG tube placement, surgery as directed by underlying cause Dilated loops of bowel and air-fluid levels in the abdomen
Polyps	Colonic polyps are common; the incidence ranges from 7% to 50% (depending on the diagnostic method used) The main concern is malignant transformation, which occurs at different rates depending on the size and type of polyp Distal colon are commonly benign if seen in the proximal colon they are more likely to be cancerous The larger the colonic polyp, the greater the risk of malignant transformation Villous adenomas have a 30-70% risk of malignant transformation The greater the number of concomitant colonic polyps, the greater the risk of malignant transformation Most common cause of painless rectal bleeding in the pediatric population Once identified follow-up colonoscopy in 3-5 years Familial adenomatous polyposis (FAP) - is characterized by the development of hundreds to thousands of colonic adenomatous polyps Colorectal polyps develop by mean age of 15 years and cancer at 40 years First-degree relatives of patients with FAP should undergo genetic screening after age 10 years The family should undergo yearly sigmoidoscopy beginning at 12 years of age
Toxic megacolon	Complication of Ulcerative colitis (most common), Crohn’s, Hirschsprung’s, pseudomembranous colitis, enteritis KUB shows dilated colon > 6 cm Presentation: Rigid abdomen Plain film: Colonic distention Treatment: Decompression of colon, fluids, antibiotics If no improvement in 24 hours, colectomy is indicated