Sunday, December 2, 2007

Crohn's Disease

Introduction:
Crohn's disease (also known as regional enteritis) is a chronic, episodic, inflammatory condition of the gastrointestinal tract characterized by transmural inflammation (affecting the entire wall of the involved bowel) and skip lesions (areas of inflammation with areas of normal lining between). Crohn's disease is a type of inflammatory bowel disease (IBD) and can affect any part of the gastrointestinal tract from mouth to anus; as a result, the symptoms of Crohn's disease vary among afflicted individuals. The main gastrointestinal symptoms are abdominal pain, diarrhea (which may be bloody) or constipation, vomiting and weight loss. Crohn's disease can also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, and inflammation of the eye.



Symptoms:
Gastrointestinal symptoms:
Abdominal pain may be the initial symptom of Crohn's disease. The pain is commonly cramp-like and may be relieved by defecation. It is often accompanied by diarrhea, which may or may not be bloody, though constipation is not uncommon especially in those who have had surgery. The nature of the diarrhea in Crohn's disease depends on the part of the small intestine or colon that is involved. Ileitis typically results in large-volume watery feces. Colitis may result in a smaller volume of feces of higher frequency. Fecal consistency may range from solid to watery. In severe cases, an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate. Visible bleeding in the feces is less common in Crohn's disease than in ulcerative colitis, but may be seen in the setting of Crohn's colitis. Bloody bowel movements are typically intermittent, and may be bright or dark red in colour. In the setting of severe Crohn's colitis, bleeding may be copious. Flatus and bloating may also add to the intestinal discomfort.


Systemic symptoms:
Crohn's disease, like many other chronic, inflammatory diseases, can cause a variety of systemic symptoms. Among children, growth failure is common. Many children are first diagnosed with Crohn's disease based on inability to maintain growth. As Crohn's disease may manifest at the time of the growth spurt in puberty, up to 30% of children with Crohn's disease may have retardation of growth. Fever may also be present, though fevers greater than 38.5 ˚C (101.3 ˚F) are uncommon unless there is a complication such as an abscess. Among older individuals, Crohn's disease may manifest as weight loss. This is usually related to decreased food intake, since individuals with intestinal symptoms from Crohn's disease often feel better when they do not eat and might lose their appetite. People with extensive small intestine disease may also have malabsorption of carbohydrates or lipids, which can further exacerbate weight loss.

Treatment:

Treatment is only needed for people exhibiting symptoms. The therapeutic approach to Crohn's disease is sequential: to treat acute disease and then to maintain remission. Treatment initially involves the use of medications to treat any infection and to reduce inflammation. This usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids, and may include antibiotics.
Once remission is induced, the goal of treatment becomes maintaining remission and avoiding flares. Because of side-effects, the prolonged use of corticosteroids must be avoided. Although some people are able to maintain remission with aminosalicylates alone, many require immunosuppressive drugs.

Surgery may be required for complications such as obstructions, fistulas and/or abscesses, or if the disease does not respond to drugs within a reasonable time. For patients with an obstruction due to a stricture, two options for treatment are strictureplasty and resection of that portion of bowel. According to a retrospective review at the Cleveland Clinic, there is no statistical significance between strictureplasty alone versus strictureplasty and resection specifically in cases of duodenal involvement. In these cases, re-operation rates were 31% and 27%, respectively, indicating that strictureplasty is a safe and effective treatment for selected patients with duodenal involvement.


Source : Wikipedia

Saturday, December 1, 2007

Celiac Sprue

Introduction:
It is a malabsorption syndrome related to immune reaction to gluten in diet, also called nontropical sprue, celiac disease and gluten sensitive enteropathy (GSE).

Causes:
  • Toxic effect of gluten/gliadin (gliadin is a glycoprotein component of gluten)
  • immune reaction (antibody to gluten/gliadin)
  • adenovirus type 12
  • may be autosomal dominant with incomplete penetrance
Physical Findings:

In infants - growth retardation, failure to thrive and irritability. Most patients are thin, emaciated.
Microscopic Findings:

This is a micrograph of a typical celiac disease intestine.



Diagnosis:
There are several tests that can be used to assist in diagnosis. The level of symptoms may determine the order of the tests, but all tests lose their usefulness if the patient is already taking a gluten-free diet. Intestinal damage begins to heal within weeks of gluten being removed from the diet, and antibody levels decline over months. For those who have already started on a gluten-free diet, it may be necessary to perform a re-challenge with 10 g of gluten (four slices of bread) per day over 2–6 weeks before repeating the investigations. Those who experience severe symptoms (e.g. diarrhoea) earlier can be regarded as sufficiently challenged and can be tested earlier.


Prognosis:
Patient do recover and villi regenerate.
Celiac disease associated with increased mortality among patients with malabsorption symptoms.

Early Gastric Carcinoma

This is a gross specimen of an early gastric carcinoma (from Pathology Text).
It shows nodular mucosa, not very apparent from this surface view, but it is very much evident on cut section, showing involvement of mucosa and submucosa, but not the muscularis.

Hirschsprung's disease

Description:

Also called congenital megacolon. Its a disease in which there is congenital absence of parasympathetic innervation of distal intestine.


Pathogenesis:

Physical Findings:

Abdominal distention, occasionally loops of stool-filled bowel palpable, increased rectal sphincter tone, no stool in rectal vault or ampulla, classically explosion of watery stool on removal of finger.

Lab Diagnosis:

  • Abdominal x-ray
  • Barium enema
  • Rectal suction biopsy
  • No ganglion cells in submucosal plexus confirms diagnosis

Treatment:

Cured by surgical excision of affected segment.

Acute Gastritis

Description:
Focal damage to gastric mucosa. Also called acute erosive gastritis, gastric erosion, acute hemorrhagic gastritis, stress ulcers.

Causes:
  • Aspirin (NSAIDs)
  • Ethanol
  • Aalkali and acid
  • Ischemia
  • Steroids, cigarettes, pancreatic enzymes, bile acids
  • Severe stress such as sepsis, severe trauma and burns.

Physical Findings:

Often normal, GI bleeding, tachycardia, hypotension, pallor and upper abdominal tenderness.

Diagnosis:

  1. Endoscopy shows congestion, friability, superficial ulceration, petechiae, black hemorrhagic areas are superficial erosions
  2. Blood in gastric aspirate

Treatment:

  1. Antacids, H2 blockers, sucralfate, omeprazoleprochlorperazine for treating uncomplicated nausea and vomiting.
  2. For massive bleeding give vasopressin IV or intra-arteriorly to mesenteric artery; contraindicated in coronary artery disease; only temporary treatment.
  3. Near-total gastrectomy if uncontrolled bleeding