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Case 11 Young Adult - Abdominal Pain – Lower GI Tract Terminology Inflammatory Bowel Disease (IBD) = term used to describe 2 conditions: ulcerative colitis and Crohn’s Ulcerative Colitis (UC) = IBD that causes long lasting inflammation and ulcers (sores) affecting rectum and colon Crohn’s Disease (CD) = IBD that causes inflammation affecting any part of GI tract from mouth to anus Irritable Bowel Syndrome (IBS) = disorder that affects the large intestine colon NOTE: Inflammatory bowel disease is NOT the same as irritable bowel syndrome. IBD causes inflammation, ulcers and other damage to bowel whereas IBD is a much less serious problem and is more of a functional disorder Colicky Pain = form of pain that starts and stops abruptly. Occurs due to muscular contractions of a hollow tube (eg. colon, ureter, gall bladder). Usually, functional and secondary to IBD. Diarrhoea = a condition in which faeces are discharged from the bowels frequently and in a liquid form Piles = Haemorrhoids = swellings containing enlarged blood vessels found in anus and rectum. Hemorrhoid = swollen vein or group of veins in the region of the anus. Caused by excess pressure from the straining during a bowel movement, persistent diarrhea or pregnancy. Mebeverine (Antispasmodic agent) = medication taken to relieve colicky-type pain associated with conditions like IBS. Relieve boating and crampy pain. Relief of symptoms caused by GI cramps. MOA: antimuscarinic. Acts directly on gut muscles to relax them relieving painful muscle spasms of gut, without affecting its normal motility. Sick Note = note given to an employer confirming that an absence was due to sickness Fit Note = note to an employer to provide evidence of the advice given to a patient about their fitness to work. Details the work an employee is able to perform, taking into account their health condition.

Anatomy Of Lower GI tract Lower GI tract includes most of the small intestine and all of the large intestine. 

Duodenojejunal (DJ) junction = border between the duodenum and the jejunum (Ligament of Treitz)

SI is divided into duodenum, jejunum and ileum.  Main function is to absorb products of digestion (carbs, proteins, lipids and vitamins) into blood  Duodenum – receives chyme from stomach, pancreatic juices containing digestive enzymes from pancreas and bile from gall bladder. Digestive enzymes break down proteins, and bile emulsifies fats. Brunner’s glands produce mucous-rich alkaline secretion containing bicarbonate which neutralizes stomach acid contained in chyme  Jejunum – contains circular folds = villi which increase SA for absorption of sugars, aa and fatty acids into bloodstream  Ileum – contains villi also, mainly absorbs vitamins B12, bile acids and any other remaining nutrients

LI is divided into cecum, colon, rectum and anal canal  Main function is to absorb water  Cecum – first portion of colon, located at junction of small and large intestines NOTE: Cecum connected to the ileum of SI and ascending colon and LI. Separated from ileum by ileocecal valve and separated from colon by cecocolic junction.  Appendix – blind ended tube connected to cecum  Ascending Colon –part of colon between cecum and transverse colon, ascending up right side of abdomen  Right Colic/Hepatic Flexure – flexed portion of ascending and transverse colon apparent to liver  Transverse Colon – part of colon between ascending and descending colon, crosses the abdomen passing below the diaphragm  Left Colic Flexure – flexed portion of transverse and descending colon apparent to spleen  Descending Colon – part of colon between transverse colon and sigmoid colon, descending down left side of abdomen  Sigmoid Colon – loop of the colon closest to the rectum and anus  Rectum – final straight part of LI, begins at rectosigmoid junction at 3rd sacral vertebrae (S3), connects sigmoid colon to anus. Temporary storage for faeces in rectal ampulla.  Anal Canal – terminal part of LI. Situated between rectum and anus.  Anus – function is to control expulsion of faeces

Foregut – oesophagus to first 2 sections of duodenum. Arterial supply = celiac trunk. Includes: oesophagus, stomach, duodenum (1st and 2nd parts), liver, gall bladder, pancreas Midgut - lower duodenum to first 2/3 of transverse colon. Arterial supply = branches of superior mesenteric artery. Includes: lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, and first 2/3 of transverse colon Hindgut - last 3rd of transverse colon to upper part of anal canal. Arterial supply = branches of inferior mesenteric artery. Includes: last 3rd of transverse colon, descending colon, rectum and upper part of anal canal.

9 Regions  

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Right Hypochondriac - contains right portion of liver, gallbladder, right kidney, and parts of small intestine. Left Hypochondriac - contains part of spleen, left kidney, part of stomach, pancreas, and parts of colon. Epigastric - contains majority of stomach, part of liver, part of pancreas, part of duodenum, part of spleen, and the adrenal glands. This region pushes out when diaphragm contracts during breathing. Right Lumbar - consists of gallbladder, left kidney, part of liver, and ascending colon. Left Lumbar - consists of descending colon, left kidney, and part of spleen. Umbilical - contains the umbilicus (navel), and many parts of small intestine, such as part of the duodenum, the jejunum, and the ileum. Also, contains transverse colon and bottom portions of both left and right kidney. Right Iliac (Inguinal) - contains appendix, cecum, and right iliac fossa (RIF).

NOTE: Pain in RIF is generally associated with appendicitis. 

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Left Iliac (Inguinal) - contains part of descending colon, sigmoid colon, and left iliac fossa (LIF). Hypogastric - contains organs around pubic bone. These include bladder, part of sigmoid colon, the anus, and many organs of the reproductive system, such as the uterus and ovaries in females and the prostate in males.

4 Quadrants 

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Right Upper Quadrant (RUQ) - contains the right portion of the liver, the gallbladder, right kidney , a small portion of the stomach, the duodenum, the head of the pancreas, portions of the ascending and transverse colon, and parts of small intestine. Pain in this region is associated with infection and inflammation in the gallbladder and liver or peptic ulcers in the stomach. Left Upper Quadrant (LUQ) - location of the left portion of the liver, part of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine. Pain in this region is associated with malrotation of the intestine and colon. Right Lower Quadrant (RLQ) - sits the cecum, appendix, part of the small intestines, the right half of the female reproductive system, and the right ureter. Pain in this region is most commonly associated with appendicitis. Left Lower Quadrant (LLQ) - houses the majority of the small intestine, some of the large intestine, the left half of the female reproductive system, and the left ureter. Pain in this region is generally associated with colitis (inflammation of the large intestine) as well as pelvic inflammatory disease and ovarian cysts in females.

Physiology Of The Lower GI See Jeff Allen Lecture on Physiology Of GI

Bristol Stool Chart & Stool Terminology The Bristol stool chart is a medical aid designed to classify the form of human faeces into 7 categories. Type 1: Separate hard lumps, like nuts (hard to pass) Type 2: Sausage-shaped, but lumpy Type 3: Like a sausage but with cracks on its surface Type 4: Like a sausage or snake, smooth and soft Type 5: Soft blobs with clear cut edges (pass easily) Type 6: Fluffy pieces w/ ragged edges, mushy stool Type 7: Watery, no solid pieces, entirely liquid Types 1 and 2 indicate constipation, with 3 and 4 being the ideal stools (especially the latter), as they are easy to defecate while not containing excess liquid, and 5, 6 and 7 tending towards diarrhoea. Rectal Bleeding = any blood passed rectally due haemorrhaging of digestive origin that is discharged through the anus Haematochezia = passage of fresh blood through the anus, usually in or with stools Rectorrhagia = expulsion of fresh blood through anus without stools NOTE: Haematochezia and rectorrhagia are both types of rectal bleeding, with haematochezia being associated with defecation whereas rectorrhagia is bleeding not associated with defecation. NOTE: phrase bright red blood per rectum (BRBPR) is associated with haematochezia and rectorrhagia Faecal Occult Blood = blood in the faeces that is not visibly apparent (unlike other types of blood in stool such as melena or haematochezia). NOTE: Faecal occult blood test (FOBT) checks for hidden (occult) blood in the stool (faeces). Hematopapyrus = blood on toilet paper noticed when wiping Melena = black ‘tarry’ faeces associated with upper GI bleeding Steatorrhoea = presence of excess fat in faeces due to reduction in absorption of fat leading to bulky, difficult to flush stools which are pale, oily & foul smelling. Conditions affecting pancreas, bile salts & SI. Keriorrhea = production of greasy, orange coloured stools due to indigestible wax ester found in oil fish Constipation = infrequent and hard to pass bowel movements, associated with hardened faeces. Other Terms: Anal Fissure = split or crack in the lining or the anal opening, usually caused by the passage of very hard or watery stools Adenoma = glandular lesion thought to be the precursor to colorectal cancer Diverticulitis: An inflammation or infection of small sacs or outpouchings (diverticula) of the inner lining of the intestine which protrude through the intestinal wall. Diverticulosis: Presence of small sacs or outpouchings (diverticula) of the inner lining of the intestine which protrude through the intestinal wall. These sacs form in weakened areas of the bowel Enema = injection of fluid into rectum and colon to induce bowel movement Fistula = abnormal connection that forms between two internal organs or between two different parts of the intestine. This is a common complication of Crohn's disease. Polyps = mall, non-cancerous growths on the inner colon lining that may develop into cancer. Colon polyps and the early stages of cancer can have no symptoms. Therefore, regular screening is important.

Red Flag Symptoms Red flags are symptoms and signs of more serious medical conditions which require immediate attention. Below are some of the red flag symptoms for lower GI cancers. 

Abdominal masses

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Rectal masses

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Anaemia

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Rectal Bleeding

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Unintentional + unexplained weight loss

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Change in bowel habit lasting >6 weeks

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Family history of cancer

GI Investigations  Blood test – FBC to look for anemia or inflammation/infection. If inflammation/infection raised CRP. For coeliac test for IgA Tissue transglutaminase antibody = tTG (See Workshop on Lower GI Problems for more detail),  Stool sample – look for mucous, blood, infection. Stool culture for bacterial infections. Fecal occult blood test for blood in feces that is not visibly apparent – cancer, polyps and inflammation.  Endoscopy – Upper GI Endoscopy, Colonoscopy (Colon), Sigmoidoscopy. View GI system using a thin, flexible, lighted tube with an attached camera. Can look for bleeding, inflammation, ulcers and polyps. Can also take samples of tissue (biopsy) for lab analysis. Polyps can also be removed via instruments attached to the endoscope. NOTE: To perform a colonoscopy, the colon must be free of solid matter, therefore laxatives are given. NOTE: If patient has Toxic Megacolon, colonoscopies should NOT be performed as it may rupture the dilated colon resulting in peritonitis and septic shock. 

X-ray – Barium x-ray outlines GI tract more clearly. Outlines mucosal lining showing any tumors, ulcers, polyps, hernias or strictures. MRI may be used in kids as avoid use of ionizing X-rays, good at showing fistulas and abscesses and distinguishing between active inflammation & scarring. Also can use ultrasounds for kidney and gallstones and abscesses and fistulas of bowel wall.

Differential Diagnosis Crohn’s Disease Type of inflammatory bowel disease (IBD). May affect any part of GI tract from mouth to anus.  Symptoms: abdominal pain, diarrhea, fever and weight loss  Chronic inflammatory disorder in which body’s immune system attacks the GI tract possibly directed at microbial antigens (NOTE: It’s NOT an autoimmune disease)  Treatment: See notes below for treatment options  Can affect both ileum of small intestine and the large intestine (ileocolic) or just one or the other  Colonoscopy: ‘cobblestone’ appearance, patchy distribution of disease, inflammation  X-ray: narrowing, strictures, colonic fistulae  Blood test: FBC – anemia caused by blood loss leading to iron deficiency (microcytic anemia) or by vitamin B12 deficiency (macrocytic anemia) caused by ileal disease impairing vitamin B12 absorption. Ferritin levels help to asses if iron deficiency is contributing to the anemia. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) help to assess degree of inflammation, which is also important as ferritin can be raised in inflammation.  May be transmural, deep into tissues. Patchy areas of inflammation.  Usually involves terminal ileum, colon and anus. Not rectum.

Ulcerative Colitis UC is a long term condition that results in inflammation and ulcers of the colon and rectum  Symptoms: abdominal pain, diarrhea with blood, weight loss, fever and anemia  Treatment: see notes below on treatment of UC  Colonoscopy: erythema (redness of mucosa), superficial ulceration, pseudopolpys  Stool Culture: to rule out parasites and infectious causes  Blood Test: FBC – anemia, ESR and CRP elevated in IBD  Only shallow inflammation, affecting the mucosal layer. Continuous area of inflammation.  Usually involves the colon and the rectum. But, not ileum or anus.

IBS Irritable bowel syndrome (IBS) is a long term condition that affects your digestive system  Symptoms: abdominal pain/ discomfort, diarrhea OR constipation and a change in bowel habits.  Cause: gut-brain axis affected  Diagnosis: no specific test for IBS therefore have to exclude conditions that produce IBS like symptoms such as infection, IBD, lactose intolerance and coeliac before diagnosing IBS. IBS is differentiated from inflammatory bowel disease (IBD) when there are inflammatory changes.

Infectious Diarrhoea

Infectious diarrhea (Gastroenteritis) is inflammation of the GI tract that involves stomach and SI.  Symptoms: diarrhea, vomiting, abdominal pain, fever, lack of energy and dehydration.  Caused by infections due to viruses, bacteria, parasites and fungus.  Most common cause is viruses: rotavirus (kids) there's a vaccine, norovirus (adults)  Most common bacterial causes – Escherichia coli (E.coli) and Campylobacter  Blood in stool is more symptomatic of bacterial infection.  Transmission: eating improperly prepared foods, drinking contaminated water, close contact with an individual who is infected  Stool Culture: parasitic diseases, toxins from Clostridium Difficile (C. diff) and viruses such as rotavirus can be examined under a microscope  Management: rehydration, dietary, antiemetic, antibiotics (if severe bacterial infection)

Bowel Cancer See notes below

Coeliac Disease Celiac disease = Digestive disease that damages the small intestine and prevents the proper absorption of nutrients from food. Celiac disease occurs when the body reacts abnormally to gluten, a protein found in wheat, rye, barley and oats. Gluten causes an inflammatory response in the small intestine. Celiac disease is an autoimmune disorder that primarily affects the small intestine Symptoms: chronic diarrhea, abdominal distension, malabsorption, loss of appetite, weight loss Pale, loose and greasy stool (steatorrhea) Caused by a reaction to gluten which are various proteins found in wheat, barley and rye. Upon exposure to gluten, an abnormal immune response may lead to production of autoantibodies which causes an inflammatory reaction in the SI and may produce shortening of villi lining – villous atrophy. Affects absorption of nutrients leading to anemia.  Diagnosis: combination of blood antibody testing, intestinal biopsies. Genetic testing.  Treatment: lifelong gluten-free diet which leads to recover of intestinal mucosa, improves symptoms and reduces risk of developing complications  Blood Test: IgA and anti-tTG. See workshop for more details on blood tests. NOTE: If IgA deficient, people with coeliac may be unable to produce the antibodies on which these tests depend leading to a ‘false negative’ result  Capsule Endoscopy: scalloping of small bowel folds, mosaic pattern in mucosa  Villous atrophy

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NOTE: Coeliac disease can be differentiated from IBD with testing for specific antibodies = anti – tTG (anti-tissue transglutaminase) which are involved in the destruction of intestinal villous epithelial cells.

Diverticulitis Diverticulitis is a digestive disease in which pouches within the large bowel wall become inflamed.  Symptoms: lower abdominal pain (left lower quadrant) of sudden onset, fever, nausea, diarrhea or constipation or blood in stool.  Diverticulosis = small defects in muscle wall of colon allow small pockets or pouches = diverticula to form. When these abnormal pouches become inflamed = diverticulitis  Diverticulosis is a condition in which diverticula are present in the intestine without signs of inflammation  Diagnosis: CT scan showing localized colon wall thickening, inflammation extending into fat surrounding colon. Abscesses. NOTE: Barium enema and colonoscopy are contraindicated due to risk of perforation  Treatment: diet and painkiller. Antibiotics if cause by bacterial infection.  Complications of diverticulitis may require surgery such as abscess, fistula, stricture, bowel obstruction and peritonitis. During emergency diverticulitis surgery, the ruptured section is removed and a colostomy or ileostomy is performed.

Bowel Obstruction Bowel obstruction is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel of large bowel may be affected.

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Symptoms: abdominal pain, vomiting, bloating and NOT passing gas Causes: adhesions, hernias, volvulus (loop of intestine twists around itself), IBD, appendicitis, tumours, diverticulitis, ischemic bowel and intussusception (intestine folds into another section of bowel – donut appearance on CT scan) Diagnosis: bloods, X-rays, CT scan and ultrasound. Bowel distension. Tinkling bowel sounds. Management: some resolve spontaneously but many require operative treatment.

Ileus Ileus is a disruption of the normal propulsive ability of the GI tract. Hypomotilty. Caused by failure of peristalsis.  Symptoms: abdominal pain, constipation, abdominal distention, nausea/ vomiting, lack of gas, excessive belching  Causes: bowel obstruction or intestinal paralysis  Intestinal paralysis can be due to acute pancreatitis and peritonitis NOTE: Temporary intestinal paralysis often occurs after abdominal surgery = postsurgical ileus  On auscultation, NO bowel sounds are heard as the bowel is inactive

Toxic Megacolon Toxic megacolon is an acute form of colonic distension. Very dilate colon.  Symptoms: abdominal pain, bloating, tenderness, fever, shock, tachycardia  Causes: IBD, infection (C.diff), Hirschsprung’s disease (congenital)  Diagnosis: X-ray shows colonic dilation. WBC elevated.  Treatment: decompress bowel. If decompression not achieved a colectomy is indicated  Complications: perforation of colon, sepsis, shock NOTE: Colonoscopy is contraindicated as it may rupture the dilated colon resulting in periton...