PANCE Blueprint GI and Nutrition (10%)

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:

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

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

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

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

"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

Air fluid levels in the abdomen

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
Pancreatic neoplasms (ReelDx) (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: The Bowel Part 2
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