Goljan – IBD, IBDS, and Colorectal cancer – Flashcards
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Chronic relapsing ulceroinflammatory disease of undetermined etiology
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Ulcerative colitis
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Ulcerations are continuous and limited to the mucosa and submucosa of rectum and colon
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ulcerative colitis
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Chronic granulomatous, ulceroconstrictive disease with transmural inflammation
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Crohn's disease
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Noncaseating granulomas with discontinuous spread throughout entire GIT
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Crohn's diseae
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Features of ulcerative colitis and Crohn's disease
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indeterminate colitis
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More common in whites vs. blacks: lower incidence in smokers and other nicotine users
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ulcerative colitis (mucosa and submucosa of rectum and colon)
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Lower incidence if previous appendectomy <20 y/o
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ulcerative colitis (mucosa and submucosa of rectum and colon)
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Gross features: inflammatory pseudopolyps, ulceration and hemorrhage
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ulcerative colitis
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Micro: ulcers and crypt abscesses containing neutrophils, dysplasia or cancer may be present
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ulcerative colitis
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Recurrent left-sided abdominal cramping with bloody diarrhea and mucus
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ulcerative colitis
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A/w fever, weight loss, and tenesmus as well as toxic megacolon (10%)
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ulcerative colitis (mortality: 50%)
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Extra-gastrointestinal associations include primary sclerosisn cholangitis, erythema nodosum, iritis/uveitis, pyoderma gangrenosum
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ulcerative colitis (p-ANCA antibodies+ >45%)
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Associated with HLA-B27 positive arthritis
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ulcerative colitis (p-ANCA antibodies+ >45%)
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Radiograph: "lead pipe" appearance in chronic disease
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ulcerative colitis (p-ANCA antibodies+ >45%)
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Complications of ulcerative colitis
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Toxic megacolon (hypotonic and distended bowel) Adenocarcinoma: greatest risks are pancolitis, early onset, duration >10 years)
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Treatments for ulcerative colitis
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sulfasalzine or mesalamine corticosteroids (severe disease) nicotine patch immunosuppressants (azathiopurine or cyclosporine) Surgery: colectomy with ileostomy
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5-ASA active metablite that acts as ROS scavenger and inhibits lipoxygenase pathway in AA metabolism.
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mesalamine (used in ulcerative colitis treatment)
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Location of Crohn's disease in GIT
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terminal ileum alone (30%), terminal ileum and colon (50%), colon alone (20%)
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Gross features: thick bowel wall and narrow lumen with apthous ulcers in bowel (early sign)
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Crohn disease
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Skip lesions, strictures, fistulas, linear ulcers with cobblestone pattern, creeping fat
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Crohn disease
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Micro: noncaseating granulomas, lymphoid aggregates
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Crohn disease (dysplasia and cancer less likely)
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Recurrent RLQ colicky pain with diarrhea and weight loss
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Crohn disease (bleeding occurs only with colon or anal involvement)
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Associated with aphthous ulcers in mouth, erythema nodosum, sacroilitis (HLA-B27)
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Crohn disease
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Radiograph: "string sign" in terminal ileum from luminal narrowing, fistulas may also be present
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Crohn disease
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Higher incidence of calcium ocalate renal caculi (increased reabsorption of oxalate through inflamed mucosa)
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Crohn disease
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A/w malabsorption d/t bile salt deficiency
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Crohn disease
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Macrocytic anemia (d/t Vitamin B12 deficiency) if terminal ileum involved
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Crohn disease
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Metronidazole used for colonic fistulas
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Crohn disease
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TNF used for enterocutaneous fistulas
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Crohn disease
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Other treatments for Crohn disease
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sulfasalazine or mealamine, corticosteroids, steroid analogues, immunosuppressants (azathiopurine or cyclosporine)
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Intrinsic colonic motility disorder
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irritable bowel syndrome (IBS)->constipation (most common) and/or diarrhea
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Abdominal pain and bloating relieved by defecation
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irritable bowel syndrome (IBS)
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Abnormal defecation with straining and sense of incomplete evacuation
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irritable bowel syndrome (IBS)
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Rules out inflammation when investigating irritable bowel syndrome (IBS)
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normal c-reactive protein
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Nonpharmacologic treatment for irritable bowel syndrome (IBS)
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adequate fiber intake, eliminate foods that aggravate (coffee, fatty foods, dairy products
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Pharmacologic treatment for irritable bowel syndrome (IBS)
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antispasmodics-anticholinergics (dicyclomine) loperamide (for diarrhea)->5-HT3 receptor antagonist lubiprostone (chloride channel activator) for constipation rifaximin (for small bacterial overgrowth)
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Most common site of primary adenocarcinoma in GIT
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duodenum (small bowel is least common site)
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Most common small bowel malignancy
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carcinoid tumor->neurosecretory granules
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Carcinoid tumors in these locations invade but rarely metastasize
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foregut (stomach) and hindgut (rectum)
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Carcinoid tumors in these locations invade and metastasize
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midgut carcinoid tumors (terminal ileum, etc)->commonly metastasize to liver
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Most common site of carcinoid tumor
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vermiform appendix (usually <2 cm and too small to metastasize to liver)
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Carcinoid syndrome
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Occurs when carcinoid tumor metastasizes to liver->5-HT secreted by metastatic tumor nodules->5-HT bypasses liver MAO and enters hepatic vein->systemic circulation
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Flushing of the skin occurs d/t vasodilation (may be triggered by emotion, alcohol, etc)
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carcinoid syndrome
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Increased bowel motility from serotonin causes diarrhea
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carcinoid syndrome
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Intermittent wheezing and dyspnea d/t bronchospasm
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carcinoid syndrome
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Associated with facial telengiactasia, tricuspid regurgitation and pulmonic stenosis
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carcinoid syndrome
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Increased urine 5-HIAA
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carcinoid syndrome
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Treatment involves alcohol avoidance, somatostatin analogues (to control diarrhea and flushing)
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carcinoid syndrome
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Usually occurs in Peyer patches in terminal ileum and usually of B-cell origin (eg. Burkitt lymphoma)
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malignant lymphoma
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Polyps which histologically have "saw tooth appearance
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hyperplastic polyps (no malignant potential)
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Most common polyp in children
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Juvenile (retention) polyps (sometimes prolaps out of rectum and bleed)
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Solitary poly with smooth surface and enlarged cystic spaces on cut section
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juvenile (retention) polyps
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Juvenile polyposis
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autosomal dominant or nonhereditary
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Nonhereditary polyposis syndrome with polyps + ectodermal abnormalities of nails
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cronkhite-canada syndrome
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Hamartomatous polyps predominant in small bowel + mucosal pigmentation of buccal mucosa and lips
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Peutz-Jegher syndrome (autosomal dominant)->increased risk of colorectal, breast, and gynecological cancers.
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Associated with inactivation of serine/threonine kinase 11 (STK11) tumor suppressor gene along with interruption of other suppressor genes (eg. p53)
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Peutz-Jegher syndrome
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Most common polyp of bowel: stalked polyp (mushroom) with complex branching of glands on section.
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tubular adenoma (adenomatous polyp)->MC in sigmoid colon
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Usually stalked polyp with adenomatous and villous change (similar to small bowel villi)
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tubulovillous adenoma
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Sessile polyp (no stalk) with mostly villous component
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Villous adenoma (rectosigmoid location)->secrete protein and potassium-rich mucus (large tumors can produce hypoalbuminemia and hypokalemia)
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Large tumors can produce hypoalbuminemia and hypokalemia
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villous adenoma (rectosigmoid location)->secrete protein and potassium rich mucus
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RF for malignancy in adenomas
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adenoma >2 cm multiple polyps polyps with increased villous component (villous adenomas have 30-40% risk of malignancy)
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Autosomal dominant disorder where all patients develop tubular adenomas and cancer.
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Familial polyposis (AD)->d/t inactivation of adenomatous polyposis coli (APC) suppressor gene
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Malignant transformation usually occurs between 35-40 y/o: prophylactic colectomy recommended
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Familial polyposis (AD)->d/t inactivation of adenomatous polyposis coli (APC) suppressor gene
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Associated with congenital hypertrophy of retinal pigment epithelium and desmoid tumors.
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Familial polyposis (AD)->d/t inactivation of adenomatous polyposis coli (APC) suppressor gene
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AD polyposis syndrome with benign osteomas and desmoid tumors.
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Gardner syndrome (contains APC suppressor mutation of FAP)
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AR polyposis syndrome with malignant brain tumors (medulloblastomas or astrocytomas)
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Turcot syndrome (contains APC suppressor mutation of FAP)
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Dietary factors which increase the risk of colon cancer
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low-fiber diet, increased saturated fats, reduced vegatable intake (also obesity, physical inactivity, heavy alcohol intake, cigarette intake)
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Genes involved in adenoma-carcinoma sequence of colon cancer
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APC, KRAS, p53, BAX
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Cause familial adenomatous polyposis
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germline mutations in APC (80% of sporadic cases of colon cancer)
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Cause hereditary non-polyposis syndrome
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germline mutations in DNA mismatch-repair genes
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Locations for colon cancer in descending order
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descending colon>rectosigmoid and rectum>cecum and ascending colon>transverse colon
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FOBT
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fecal occult blood test (guaic)->low sensitivity screen for colon cancer
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Colon cancer screening which uses antiboides to detect globin
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fecal immunochemical test
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Colon cancers which tend to obstruct bowel and have annular "napkin ring" appearance.
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left-sided cancers (a/w Strep bovis endocarditis)
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Changes in bowel habits with left-sided colon cancers
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constipation and diarrhea with or without bleeding->bright red blood coats stool
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Colon cancer which tend to bleed and tumors are more polyploid in appearance.
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right-sided cancer (blood ins mixed in with stool)->iron deficiency is more likely > left-sided cancers
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Sites of metastasis of colon cancer
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liver (MC), lungs, bone, brain
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Drugs which decrease incidence of colorectal carcinoma
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aspirin and NSAIDs, statins (may inhibit growth of colon cancer lines)
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Hormones which may reduce risk of colorectal carcinoma
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estrogens and progestin
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Marker used to detect recurrence of colorectal carcinoma
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CEA (carinoembryonic antigen)
