Case Based Question & Answer Session on Colon Cancer, Colon Polyps, Anorectal Disorders, Constipation, Diarrhea, Ischemic Diseases, Clostridioides Difficile, GI Infections, GI Bleeding, GI Pathology, TPN and Nutrition, Epidemiology, Extraintestinal Manifestations, IBD Mimickers
Welcome to the eighth annual Mount Sinai Hospital Board Review in Gastroenterology and Hepatology. My name is Ari Greenspan, and thank you so much for joining us for our third webinar session. Again, this is a question and answer session. So we highly encourage all of our attendees to ask their burning questions about the topic of small bowel and way Have a panoply of Panelists. Uh, today I could go through all of their names, but that would take up just about half of the time that we have here. So what I want to direct your attention to is on the bottom of your zoom screen. If you're on a computer, it might be on the top if you are on your phone, but you should see a Q and A box. If you press that Q and a box, you can type in your questions that we will then read aloud on. Have our Panelists answer them. Uh, well, read the question aloud, and the Panelists will answer them and will engage in a conversation. So I highly encourage you to, uh, type your questions in, because that is the entire purpose of today's webinar. Uh, now while you guys are stretching your fingers and and thinking about your questions, perhaps we'll start things off on. We've we've come up with a couple of questions that can begin Thio, spark some conversation and some dialogue about again topics in small bowel and colon. So, Pascal, perhaps you can pull up the questions. Okay. Question. Number one. A 59 year old woman is evaluated for bloating and intermittent diarrhea that has been present for six months. This sounds like my entire office hours today. The bloating improves after a bowel movement. She has had a £10 weight loss during the past six months. She has no other symptoms. There is no history of travel, sick contacts or medication changes. Her medical history is remarkable for pernicious anemia, for which she received vitamin B 12 injections. Monthly laboratory studies are notable for iron deficiency anemia, normal level of vitamin B 12 and a serum level of folic acid greater than 20. The TSH level is normal, and tissue trans glutinous antibody is negative. Stool Micro biologic findings were negative. E G. D. Shows an a trophic appearing gastric mucosa. Small bowel biopsy specimens show increased cellular parity in the lamb inappropriate colonoscopy with random biopsies was negative. H l A testing shows D Q four and Q seven. Positivity. What is the most likely diagnosis? So of our Panelists? Is there anyone who would like Thio dive in? Or should I just pick and choose who? I want to answer this question? Don't everyone jump in all at once. We're going to go with Professor Row on this one. Can you please enlighten us? Or please take us through this question? Yeah, sure. I'm happy to, um so for both purposes, I think when we go through the questions, then we need toe pick up on the different clues that have been set out for us. So looking at this 59 year old so six months of bloating and diarrhea, I think some of the key factors mentioned there are the weight loss and the fact that she does have pernicious anemia on vitamin B 12 repression, other important lab features the inefficiency, the elevated folic acid, the negative celiac serology ease on the E G D. Findings off the traffic gastric mucosa. So, among all the options listed there, um, you know the most likely diagnosis that I would choose a small intestinal bacterial overgrowth. Andi here the reasons for it. So one with Cibo in the question stem they would always highlight. What is the predisposing factors for this patient? Tohave, bacterial overgrowth and one big predisposing factors that she has is the a clear a clear off podria, which is cost, which is associated with a traffic gastritis of pernicious anemia. So that's her risk factor than the other features that are consistent with Cibo are her symptoms of bloating and diarrhea. Then, additionally, on, the lab features off the elevated four late levels a zealous the low B 12, although you can argue that in her case, the low B 12 is also contributed by the pernicious anemia. But the composite finding off the elevated four late and the low B 12 again puts suggests to us a diagnosis of Cibo on de. So again, we don't have a you know, the diagnostic test of a breath test results available to us, but with all these factors alone, it leads me to a diagnosis of it leads me to the auction of Cibo, and then I can eliminate some of the other options based on so the negative celiac psychologies make celiac unlikely. Her stool microbiology was negative. So grs, this is ruled out for I b s. You know she does not have the abdominal pain and her symptoms Her about movements have not seen related to her. You know, again she doesn't have bloating. She doesn't have pain. I'm sorry. So she does not mean toe meet the room four criteria for I B s and again Given the all the other pathologic features that she had, this cannot be attributed to lactose intolerant. So with all of that reasoning, I would make a diagnosis of Cibo in this case Perfect. And then on the next slide, we have a a detailed discussion and the reason why we include this is that all of these discussion this entire Q and A is going to be recorded and for you that you can actually view it again. Uh, if you would like to view it again, but anyone can view it on the broadcast med website where all of our 48 lectures will be hosted. Eso Yeah, I think it was a very detailed answering discussion about something that we not only see commonly in practice, but it's also frequently question on the G. I boards any of our other Panelists have any comments or, um, insight into this question that they would like to share with everybody. Yeah, I might, uh, this is Dr It's cool. It's I might just point out, as it was in the discussion here, that the iron deficiency can be attributed to the A chloral hydrate because you need You need acid to release iron from the diet in order for it to be absorbed. And that Z something that a lot of people tend to forget about when they see iron deficiency anemia as gastroenterologist. They always think that somebody's bleeding, but you should always consider whether or not the person is making enough acid to release iron from ingested iron sources. Great. Is there anybody else would like to comment or chime in Okay again. For the attendees, there is the Q and A function usually on the bottom of your screen. Please feel free to ask any question that you may have about any topic in small bell or colon. Uh, it does not have had to do anything with the questions that I ask. I'm just trying toe. Try to stir up some some conversation and some dialogue here on, but there's, uh, again any questions. Please use that Q and a function on the bottom of your zoom screen. Okay. Question Number two. A 38 year old with a long segment structuring crones. Ili Itis had a Elio Kalanick reception six weeks ago and subsequently develops voluminous, non bloody diarrhea. He had 2 ft of small bowel removed. His postoperative course was complicated by an intra abdominal abscess, and this was treated successfully with I V. Antibiotics and bowel rest. In addition to diarrhea, the patient reports increasing gas and bloating while at home. Blood work shows a hemoglobin of 10.5 vitamin B 12 of 120. See the PCR is negative. Toxin E. A is negative. Cal protecting is less than 16. What is the next best step in management for this patient? A. Start. Banco be start off Axeman. See start coolest Ironman de start a low fat diet with medium chain triglycerides or e start Busta Kenema. Perhaps we can ask Dr Cohen or Dr Kyle toe comment about this question sure I'll be happy. Thio shot about it. Um, So I think this is, uh, you know, one of the questions where you know is the last Panelist did. The nice thing to do is kind of go through the answers and just think about what the No questions then told you. So, you know, starting Banco mice and would be somebody where you thought that they were seat of positive. Um, in this case, obviously, we have the testing, which is negative. We're fax woman. Might be if you thought perhaps this was a case kind of irritable bowel syndrome. Um, and again, you know, there's not much here. It's it's conceivable. You could also think about it. Some other scenarios Cola star mean would be for your bile, uh, as the diarrhea, Which is going to be the answer here, which I'll go through, um, your low fat diet, medium chain triglycerides, the interesting one. So this is something we see in patients who have had really extensive small Bauer sections where you're going to interrupt the ability to re absorb bile acids. And so you are going to get, um, al absorptive diarrhea due to the fat malabsorption. So this is sort of a treatment you can do. Um, but, you know, if you can look at the questions them what you're not seeing is the fact that perhaps the patients having greasy stools or other signs you might suggest for fat malabsorption Onda Final One, which would be used to kill a mob. So, you know, a patient with Crohn's disease who undergoes a reception? Um, you know, this is six weeks out. We know from extensive post surveillance studies about patients with inflammatory bowel disease after section or Cohen's after section. The recurrence of clinical symptoms is incredibly rare. Even after six months. The recurrence of even that aske OPIC disease is still unlikely. It six months ago is significant, which is why often will consider patients for postoperative treatment. So because this patient is only six weeks out, the idea this is a Crohn's recurrence that they're symptomatic from is highly unlikely. Um, where they've lost on Lee about 60 centimeters and not grated 100 centimeters. Small intestine. Plus, they're not complaining about fat malabsorption. It makes it also. Not that this is a bile acid deficiency, and, you know, if anything, in these patients post operatively. It's incredibly common that don't have a biologic, diarrhea and so starting co star me and makes sense typically for these patients. I'll start twice a day. Um, it's a little bit harder as you push into elderly patients where there on a lot of other medications. Now, this is where your pharmacist could be very helpful. Um, you know, we have a pharmacist start clinic. But even just going through with their PCP, tell the patient, Understand how best to stagger medications? Because, obviously the coolest arming combined. Um, and then after a few months, I usually have the patients start to try to taper down. What you'll get is that the neo terminally, um, it's hard to sort of take over, and oftentimes patients can come off the coolest army. So, you know, I give them a little bit of time. I let them come back. And then this is a patient. When thinking about you know, E for Mr Kim, a mob, all of my patients. After surgery, I will bring them back at six months to do an endoscopy toe Look to make sure catch those patients who may start to have an endoscopic recurrence before they get sick. Because again, even at six months clinical symptoms, Izhar is highly unusual. Can I interject for a second? Because, I mean, we see we see those patients a lot, right? Post op. I mean, usually those patients are managed by surgeons, and it's really interesting, because obviously, our first line is to control the diarrhea eso, You know, within the first couple weeks, we see this high volume diarrhea, everybody puts them on the model rim odium, right, once you roll out infectious ideology. So the question is, what's the timing of concerning Because usually that's not our first line, you know, pushed up. So when would you say it's time to trigger it after the model and, um odium or at the same time? Yeah. I mean, I think in the first few weeks after the surgery, um, you know, sometimes these patients were just sort of actual mating, and often times they still didn't have a little bit Milius. And so sometimes they kind of come in and they're doing okay. And then even we'll start to have that high volume diarrhea. Uh, you know, in terms of the benefit of one versus the other. I mean, it really comes down the symptom control. So, you know, if they're well controlled with them odium, there's often not gonna be a huge downside if they just have some model spilling into the court. Um, if they're not well controlled, then certainly we could do that. In general, I find patients prefer, you know, um, Odium dependents, especially. They have a lot of medication issues, But you know, we'll often see the patients that go to your office and get the EMH odium. And then they still are having diarrhea and come back. Andi Well, sort of get them at that point where we put them on coal. So I mean, so you know who the institute? When, um, I think again. It sort of just depends on the patient again. A lot of medication issues. I might just do some odium, and then oftentimes patients will end upon both. Um perfect. Thank you. Excellent. Any any other comments or concerns about this particular question or the conversation that we had? The only thing I might add is that the mechanism for this is that excess bile salts entering the colon, um, produces a secret. Torrey. Diarrhea of the colon. Um, when I teach the medical students about this, I tell them that you know, bile is a detergent. It's like an irritant. And if you get detergent in your eye, your eye tears. And if you get too much detergent in your colon, your colon tears. So if you wanna try to neutralize the detergent effect of the bile acids, the coolest IRA mean is the thing that can help neutralize that. Yes, Steve, I'd agree. We talk about it as an irritant all the time. That makes sense to patients. I hate those weepy. Cullen's always, um, remind the attendees that, please, um, ask your questions. This is exactly what we're here for. Eso use that Q and A. If it's anything any potential potential issue or question or comment, you have please share with us again. This is this is your opportunity for us toe. Have the direct access to us and direct access to you so we can have as much An interactive conversation is possible, so do not hesitate to use that Q and A on the bottom of your zoom. Um, anyone else from the Panelists have any comment or discussion about this question. Okay, let's move on to the next question. Okay. Question number three. Which patient should receive prophylaxis for a stress ulcer? Is it a The patient was sepsis and acute renal failure. Be patient with chronic renal failure and coronary heart disease on aspirin. Patient on day number three of mechanical ventilation for pneumonia, de patient on day number one After calls the SEC to me or e patient on day number two after appendectomy. Who was receiving low dose heparin therapy. I will ask Dr Greenwald if he can shed some light on this question. I would be happy to thank you very much. So don't have to do much with the stem in this one because it's a short question. So it's just a matter of sort of understanding the issues for prophylaxis, for stress ulcers. I think the key thing here is that profile access for stress ulcers are lay overdone. So, you know, if you go to the standard intensive care unit around most hospitals, everybody's on, um, an acid type medications. And the bad part about that, in addition to overuse there is that most of those medications seem to be continued on into the outpatient world, you know, maybe indefinitely. So understanding the indications for prophylaxis for stress ulcers. And this is really physiologic stress that we're talking about is really, really important. So the guiding principle here is that stress also prophylaxis is indicated. Yeah, for people who are gonna be on mechanical ventilation and for those who are anti coagulated, Um, with guidelines suggesting that and I and our greater than 1.5 or a platelet count less than 50,000 are gonna be the people who would benefit from stress also prophylaxis and in everybody else the studies have not shown significant benefits. So if you go through the choices, then, um, number C is gonna be the correct answer here. Patient on day number three of mechanical ventilation for pneumonia. The other choices. Although those patients are quite sick, don't meet the criteria that I just laid out for for appropriate use of stress. Also prophylaxis perfect. Thank you for that detailed answer. That was great. I think that's ah topic that shows up on the boards about which patients should we be using G I prophylaxis? Which patients should we be using PP I therapy on, um, any other questions or comments from the Panelists regarding this question? David thoughts about what agent to use. You know there's forever and ever. It was h two blockers and it's pp ice, and it sort of seems like a fluctuates regularly. Yeah, I don't I don't know. Maybe some of the other Panelists? No, but I'm not aware of specific data that suggests that a specific proton pump inhibitor is more effective than others. Most of us use proton pump inhibitors for this, um, purpose. But, um, but I'm not aware of anything that suggests that one is better than the other. Um, Proton pump inhibitors in general block acid more effectively than H two receptor antagonists. Each has different side effect profiles. So, you know, we usually use the proton pump inhibitor that the hospital formula areas recommending others have comments on that. Dave, I just had a question asked related to that. So if if the issue care team is utilizing the gut for nutrition can speak given earlier, Do you recommend being given I V Yeah, I think it could be given its It's absorbed quite well, so it could be given orally as well as intravenously. Good question that comes up a lot. You know, Cara, fate was when it was first introduced, was touted as being the best drug for stress ulcers. And any of us you know who grew up in that era realized that if somebody was on Cara Fate and then they bled and you had to do an e g d you couldn't see anything because it just coached the stomach and you couldn't find the also with the exact date that you were looking for. So, um, I think I usually try to avoid Cara fate. Even though it is useful in this setting. If I think that the patient may bleed and you may have to do ah, quick E g d. In the short term, I think one other aspect we need to be cognizant off also is the duration off the profile axes. Oftentimes these patients get started on it in the I C. U. And even after they recover and get transferred to the floor and are ready for discharge, the medications sometimes tends to remain on their list on. Then they get discharged on it, and again while knowing the long term side effects of some of these medications is called. It's important for us. Toe, uh, you know, try to a certain if they still need to be on that medicine Onda appropriately reconcile while they're being discharged. Yeah, no, that that's absolutely true. I said that right at the outset. People stay on these medications forever because they were put on them, you know? I see you. So, you know, making sure using them appropriately from the beginning is really important. I've certainly read countless resident Q I projects focused on getting rid of P P, I S and H two blockers. That air started like this. So, um, certainly good to be mindful of great discussion. Any questions from the audience? Perhaps anyone wanna ask any one of the experts that air right in front of you any of your burning desires? Questions about all things intestine excellent will move forward with question number four. Okay. A 26 year old medical student with no past medical history traveled to Africa for a two month rotation. He was treated for a skin infection with an unknown antibiotic while traveling within two weeks of his return he presents to the ER with low grade fevers, abdominal pain and diarrhea with blood and mucus. He has lower abdominal pain and tenderness. Labs are notable for a white blood cell count of 17 hemoglobin of 10 albumin, 3.4 a s t. 250 a lt 200. A total bill, a ribbon of to and a sigmoidoscopy is performed, which is on the bottom right of the screen. What is the next best step? I will ask Dr Kyle if she can answer this question for us. Hey, thanks. Dr Greenspan s So this is a great, very interesting question. Um, when approaching questions about infections, it's helpful to kind of delineate the pattern of symptoms Onda way the patient is presenting to give you an idea of whether this is perhaps a small intestine versus an Ilia Kalanick infection, because that can help narrow down thebe potential organism that's causing the infection in the next step. So, in this situation, um, we have a young gentleman who has an exposure as a recent, travel has also been exposed to recent antibiotic is presenting quite dramatically with significant symptoms that are suggestive of inflammatory disease with elevated white count anemia, Hypo Album anemia and elevated LFTs. And on sigmoidoscopy, you can see you know ulcers in the sigmoid colon. Um, when I approach these questions, I like to think of small intestine versus Elio Kalanick infection. Patients with small intestine infection typically present with large volume, non inflammatory diarrhea. Essentially not letting usually and viruses the most common cause of small intestinal infections. Alia. Chronic disease. Infectious disease. If it leaves invasive, bloody inflammatory present small volume and could cost tens. HMAS bacteria, usually the most common pathogens there. But parasites such as Antony Batista Lyrica are also, you know, can occur in the right patient exposure setting. So in this situation, it seems like our patient had the exposure. Um, with his recent travel, is presenting with an inflammatory like illness with fevers and pain and diarrhea that's both blood and mucus and with inflammatory lab studies. So best guess is with his sigmoidoscopy that if you squint looks like flask shaped ulcers, um, most likely culprit here is entity the histological. So the correct answer would be to give Parma missing and Metronet is all, um, you know, and to me. But can actually bore into the intestinal wall and cause lesions and intestinal symptoms and can then get into the bloodstream and from there can reach different organs like the liver. But it can also reach the lungs, brain and the spleen, etcetera. So it's a common outcome of this invasion can be a liver abscess and can be elevated LFTs. As we've seen in this patient situation, um, we typically diagnosed by both a combination of serology and antigen testing. Um, if you can identify the parasite in the stool, that's great or an extra intestinal sites that's also helpful. All patients should be treated, uh, even in the absence of symptoms, because of the risk of developing invasive disease as we discussed, like liver abscess or other extra intestinal sites. And also there's of spreading the disease to family members. Eso treatment for invasive collided, as in this case, given that he had, you know, elevated LFTs and clear ulcers in the in the colon eyes. Metronet is on an aluminum agents such as promicin so that you can get rid of the intra Luminal cysts. Uh, I'm not gonna go into the kind of like the life cycle of and to me, like politica. But it does have a significant patients who haven't stimulus that. Can I have a significant sister bird in there? Cold. So you want to make sure that you add on that Luminal agent, um, in asymptomatic patients who for other reasons it was picked up on just treating with prime of my sin is adequate. Thank you. My That was a very detailed answer about your favorite topic and to me, even histological. Um, I think one of my tape main take away from this questions them is that, um everything looks like it could be inflammatory bowel disease on DSO. It's important that especially for the boards, they will say, Look, this patient could have inflammatory bowel disease. But what else is in the differential diagnosis where somebody's coming up with, uh, ulcers in the colon on an elevated and then again inflammatory type picture. So, knowing what those possibilities are, it's very important not just for the boards, but obviously for your for your clinical practice and also for the inpatient setting where you see these these acute presentations? Um uh, Dr hurting are you Are you available toe at a follow up question perhaps. Um, yeah, I'm off course. Specifically wanted to sort of just, uh you know, there's a lot of meme occurs out there for inflammatory bowel disease on, brother does this questions them. Besides obviously thinking about infection. Is there anything else you'd be thinking about? That you wanna rule out in this patient or B or something along the lines of somebody's presenting with this acute inflammatory bowel process? And but it's not really What else should we be thinking about? You know when when you're looking at this this kind of question here, I think you put it in perspective about the person you're evaluating eso their aides what other medical problems they have. And then their exposure is to come up with a differential diagnosis stuff of what would be most likely. So in this case, you're having ah, young young kids. So right off the back, things like a leukemia and other things which could look like inflammatory bowel disease are much less likely. You have to think about other other kind of exposures he's had. So it's someone that's recently traveled to Africa. So right away, infection is jumping up on your list. But again, we do know in IBD, people often attribute different kinds of environmental factors is triggers to the information and whether that zits, true or not, it could be argued. But, you know, when someone like this really infection would be first on my list for the clear reasons of travel and and based on the endoscopic findings, I would want to be sure this doesn't represent IBD. And I think that's where your biopsies and your histology will be very important. Where are you seeing features of Crignis ity or some of the early histological changes consistent with IBD or other conditions? So I think those would be the top two in my differential for someone like this. I was gonna fall up based on what you're just saying Rob with No, um, I mean how such a with an infection like in Geneva, where people may have symptoms for a little while, how reliable is histology and either excluding IBD or being definitive on including or diagnosing into the valley? She okay no one could probably comment on the specifics would be the pathology, the histology thing. This is the good questions to teach in the way that sometimes when we're catching people who are very early in the diagnosis of IBD, it can be challenging because we don't see those classic chronic features having developed yet when we're very early in kind of the time course. And that could open, be a little bit challenging to kind of fully commit toe, one diagnosis or the other. But perhaps no one could comment specifically on that. I just want I just want to make sure I'm being heard being heard and seen. Yep, You're good, right? Um, well, in general, most of patients who present actually with classic IBD already have chronic changes in place. Eso It's not terribly difficult, whereas patients who present with infections, um, generally have, ah, or a cute picture without the Quran Isett e. In the case of these politica, usually when we see these patients, the disease is not terribly advanced histological, and it really depends on identifying the organisms in the on the Lumen. And that actually could be kind of tricky, especially if the pathologist not sort of clued in. It's very helpful to be aware that there's a suspicion of it. They can be tricky to to find. In any event, the initial changes air very difficult with. If you don't see the organisms, there are very few. All you see is little histological depressions, a little bit of loss of surface mucous. It's very, um, very subtle. But once the ulcers develop, they're very distinctive. When you mentioned flask shaped ulcers, that actually is the It's not something you see Endoscopic Lee and this couple you just see the narrow mouth of the Ulster. But in the biopsy, you see the organism sort of spreading in sideways your laterally to form the flag shape ulcer. Um, that's Ah, very distinctive appearance to some extent where the mercy of the amount of tissue that you provide, if you just get the ulcer for itself or just the joining because you may not see the entire picture. So in any event, the key point is, um, sort of a queuing the pathologist that this is a possibility on den histological e finding ulcers in the background. That is not generally not as chronic looking as what you see with IBD, meaning the regularity is somewhat different. Crypt distortion is not as obvious. Uh, in in that case, I kept by the way. Occasionally we've seen both. We've seen patients have both IBD and history, Erica, and that's a That's a real tricky one. Dr. Harper's can actually ask you a question as a follow up and just to pivot back to what Rob was saying about criticism. He, uh, in patients with IBD like histological ethnicity. So if you have a patient who has been having symptoms for a short period of time, you know, maybe one month or so and they're seeing you for an expedited visit and you scope them. If there is no Crignis ity on histology, let's say it's T I or Colon. How comfortable are you saying that this is not IBD from a histological perspective? Well, the question is, what is the pattern of information that's there? If it's a really acute looking pattern with a demon neutrophils and not much else, I think it's probably not IBD or its IBD with a super post infection by when patients present with IBD, there's a clear picture of Cronus ity that implies that the process has been going on much longer than the patient might be aware of. Uh, eso there's there's a there changes there that probably take a T least weeks or months to develop. And that's actually an important clues. So we are able to recognize IBD even in patients, to have an early presentation. At least most of the time, we think we can. She thank you ast, perhaps the panel member most fresh from the G airports. If I can offer one more guidance. Oftentimes the boat questions seemed to be very long. And as the exam goes on, you know there can be some amount of fatigue on DSO. You know, sometimes we may tend to jump to an answer without going through the entire questions to him. Andi, that's when you know we may make like Ali was pointing out that this this question might, you know, trigger the you know it might trigger the response of IBD. You know, young young boy with president with bloody diarrhea and that sort off sigma the scope of the appearance. You might get tempted to think that this is IBD. But going through the entire questions time, you'll notice that you know, there's a clue that he went to Africa. The abnormal LFTs have been snuck in there so all of those little pointers are always there for a reason. In a boat style question, they're there to read you down a particular path on DSO. That's why, importantly, reviewing all those pointers and taking them into account while making your choice an important toe help get you to the right answer. And our if I could chime in for a second. You know, in the center where there's a lot of inflammatory bowel disease and those people with the homework presentation of bloody diarrhea e think it's important. Remember, the bloody diarrhea always need to rule out infection first because it's, um, it's sometimes there, and it's not IBD absolutely agree. Thank you all. That was that was a great discussion. Um, any other attendees like toe ask a question. Perhaps remember that Q. And a box is tempting you on the bottom of your zoom. I can feel that you have questions that you want to ask. This is your moment. Or perhaps in a moment we'll be coming later on. We're going to question number five. Okay, A 25 year old woman has a four week history of rectal pain, and tin is Miss three or four bowel movements per day are of normal consistently, but usually are blood streaked. Also, she intermittently passes blood without a bowel movement. She said that she does not have any notable abdominal pain, nausea, vomiting or weight loss. Initial lab studies are unremarkable, except for a hemoglobin of 10.2. Physical exam findings are normal. Other than blood on the examining finger on rectal examination, colonoscopy shows normal mucosa anything and throughout the colon, down to sigmoid color rectum and sigmoid has active colitis with diffuse inflammation and mucosal ulceration. Biopsy findings are consistent with all strategical itis. Which of the following would be the most appropriate therapy so that we have masala means depositories, hydrocortisone, anima masala mean anima Orel masala means such as Penn, Tasca or Orel Who? Destiny. So this could be any one of our Panelists. Feel free to answer this, but perhaps we'll start with Dr Hurt nor Dr Cohen. Uh, this is a very common clinical scenario that we see in the office a lot. So you have a young woman who was recently diagnosed with all sort of colitis, and when we're approaching this patient to think about a couple of things. First, how severe is the disease that she's experiencing? Help us gauge which agents we should start on. Also, the extent of disease. How much of the Coghlan's involved So overall, their symptoms are fairly mild. When we look at this around three bloody bowel movements per day and the extent of the disease is is, um, to the sigmoid colon. Um, so when we look at what the guidelines that show so a great guideline to review, especially if you're trying toe look at how you should approach all sort of collide, it's sort of in a in a clinical way with relevant scenarios is the Toronto Consensus, which have been published Ah few years ago in gastroenterology, And it nicely summarizes some of the guidelines of how we should approach patients in this scenario. And we know from the evidence that anyone with more than Prock Titus so if more than your rectum is involved, um, you should be starting on a T least in aural Miss Salome, and we know from evidence from There's a random meta analysis published in 2012 that showed combination between oral and rectal therapy security either alone So in this scenario you have someone, a young girl who's got inflammation beyond director. So we should be including oral therapy. And we know that the combination therapy between oral and rectal with Taliban superior So we should add some form of rectal therapy to that, because the disease extending beyond the rectum into the stigma, I probably would rely on adding a masala me an enema to the oral masala means, um, we're thinking about missile, A means for steroids. It's been shown in a few studies that masala means are superior to hydrocortisone enemies for induction of remission. So, in this case, for someone who's on Lee having again mild disease around three bloody bowel movement today I would start Orel and rectal masala means together to induce remission. In this case, that's that's not an option here, but the that would be like most in line with guidelines. Thank you. I think that I think that's absolutely accurate, that the appropriate answer in the clinic would be, yes, combined Pio and rectal therapy. I think the sometimes that these questions you have to choose the best available answer on DSO. They gave you the choice of Penn tasca on any comment by why potassium may not be the best choice for this particular patient. So so fantastic is usually released in the small intestine. So you might want to rely on in the Salome that's released in the colon. So in the end, you're oremus. Salomon is often dictated by your insurance company in general, but you could still give it a try, So I usually pick whatever oremus Salome the insurance will cover. But in this strict sense, I guess in a in a board question, um, you would pick a masala mean animals being the best agent here. Yeah, rather, it's Dave. Well, the teaching point there was the You know, the masala mean animal is you don't want to use justice depository because you need to get further into the colon. Can tacit. Um, you know, it is released in the small bowel, Um, the other. The other five essay products Oh, they're now nicely listed on the screen are going toe, have their anti inflammatory released more distantly, so they would be more appropriate here. 11 practical point for the clinic is that you know which is not the answer. This question, though. Ah, lot of patients with severe to investments, we try to initiate them on an animal. They can't actually tolerate it. So you know it's very common. Patients will try to put in the animal, and it just comes very term. I'll actually give patients a suppository just to sort of improve some of the rectal compliance. Then I'll start them on the anima to get sort of a practical thing that often you'll see in the clinic and will make your patients like you a little bit more excellent. Any other commentary from the Panelists, or perhaps questions from the audience? Okay, let's move on to the next question. 83 year old Woman presents to the hospital with three days of worsening abdominal pain and one day of Hamadeh Keyshia. Her medical history is notable for coronary artery disease, hypertension, hyper lipid anemia and osteoarthritis. Her medications, including loaded pain, 10 mg per day, aspirin, 325 mg per day, simvastatin, 40 mg per day and a cinnamon. If NPR n colonoscopy revealed Ara thema sub mucosal hemorrhage and also really, the terminal ilium appeared normal and you diagnose isolated right sided ischemic colitis. Which of the following is the best? Next step in this patient's management? A obtain a CT angiography. Be proceed to interventional radiology for angiography. See, proceed to surgery for emergent, right? Collect, um, e or d supportive care with I v fluids and antibiotics. Let's ask Dr Larry Cohen about this question. Okay, good. Well, thank you, Ari. Um, everyone can hear me where audio's on. Okay, but thank you. So make a few comments about this, This interesting case. Um, you know, we typically think of a schema colitis as being a disease of the left side of the colon. We all learned about the about the watershed regions are likely to be involved in the watershed areas are either the splenic fleck, sh er or the recto sigmoid. And that's correct. About 70% of patients with this chemical latest will have involvement of the left colon. But there's significant minority of patients who will have involvement of the right column, either as a patient with pan colitis or patient with just isolated right Kalanick involvement. As as we see in this patient. So isolated right Kalanick involvement due to due to a scheme it change occurs in about 25% of patients, so it it does represent a minority. But it's a respectable minority of individuals that will develop right sided disease. Um, the put the teaching point in this case is the fact that uh, right side of the scheme IQ disease has a worse prognosis than patients with left side of the scheme IQ disease, so that the guidelines state that patients who present with classic history and clinical findings of a scheme IQ disease they present with cramping abdominal pain on bloody stools and a CAT scan shows changes in the left Colin that are consistent with ischemic disease that you then can initiate your management strategy. The recommendation is that those patients have a at least a sigmoidoscopy within 48 hours of entry into the hospital. On that C T angiography is not indicated for patients with ischemic colitis unless they have involvement of the right colon. So that's where this case represents sort of the exception to the rule that C T angiography is not require for a scheme IQ disease. So the reason for this is the fact that, as I mentioned earlier that patients with right side of disease or more likely to go on to complications. Uh, they are more likely to have thrombin sick or m bolic disease than patients with left sided disease Where the where the cause for ischemic change is generally non inclusive. In contrast, right side of disease is inclusive and 30% of patients So number one you're looking for something on C t angiogram that you could intervene, such as an embolus or an acute Trumbo M bolic Trumbo thrombin Anabolic event. Um, second, about 10% of patients with right sided scheme. You also have involvement off the small bowel. So they'll present for the picture that may be mixed between acute messenger Eric ischemia and a schema colonist. And it may be difficult clinically to differentiate uh, those two conditions and so C t angiogram may be helpful. So for for all the reasons that that I've just stated the correct answer to this would be multiphasic CT angiography Excellent. Thank you for that very in depth answer. I think that Kalanick ischemia something that we see frequently, especially in the inpatient setting. Obviously, she's a set up giving her her risk factors. Um, I guess My question for for you or for any of the Panelists is, um if you read the most recent guidelines and I know we actually in our grand rounds here last week, we had this discussion. Um, but it's something that we frequently see. The guidelines state that for chronic ischemia we should be performing a A colonoscopy to essentially clinch the diagnosis or rule out anything else that this could potentially be in this clinical setting. And let's say that it wasn't right side. Let's say that it had classic left sided watershed area. Would you proceed with a colonoscopy? Thio for the diet for thio, confirm your diagnosis of a scheme it colitis? Or would you just use your clinical judgment that this is indeed a skin Nikolaidis and treat her accordingly? Yeah, well, eso you're right on both accounts are you're right in saying that the guidelines certainly indicate that the vast majority of patients presenting with suspected chemical ideas should have sigmoidoscopy or colonoscopy to help confirm the diagnosis. It also helps in in sort of staging the disease severity. Because if you see someone that has, uh, dusty looking bow, if you see lots of sub D coastal hemorrhage with modularity or you see gangrene has changed. And obviously those were patients who you classify as more severe disease and whom you're going to prepare your surgeon for the possibility that they may have to go in. So there's both a therapeutic as well as a diagnostic role. Um, not all patients, however, that have represent with scheme IQ disease need to be Kanis scope. If you see a patient, for example, the patient that we just talked about and you do your message Eric angiogram on it shows no evidence of inclusive disease, I would argue that patient does not should not be kaleidoscope. I think it's rather risky, and I think it really offers very little to be learned from the colonoscopy. You made your diagnosis of askey mia from the CAT scan and the C T A. Will help to, uh, to rule at anything anything that could be, uh, therapeutically. You managed at that point, and you could have your diagnosis. And, uh, in my own personal view, colonoscopy would not be, would not be indicated. Uh, I was gonna be Oh, yes. So I mean, the reality is that we get called first, right? Um, the surgeons get called first in a clinical scenario of pain, and then a CAT scan usually has been done. And it's usually the concern for the severity of this Kimia because we obviously know that it's this chemical itis. The question is whether or not it's, you know, full thickness or not m. Bolic or just a little profusion scenario, which is the most common scenario? Um, you know, we there's usually some clinical futures that are alarming. So usually the black tape we know which we track the lactate level. The bicarb level is low. You know, there's a little elevation to creatinine. There's some concern about, you know, profusion and blood pressure and potentially a favor on top of things. So usually the request is rarely to do a colonoscopy to see other diagnosis because you already know it's this chemical itis, but you're right. The next step is usually a C T. A. There's any concern of a symbolic event or something that could be potentially actionable with the intervention. Um, you know, Per continues in front of intervention, the sigmoidoscopy or colonoscopy. It's rare that we asked for a colonoscopy to evaluate the right colon, but for for the left, it's really one. The patient is clinical deterioration, and we're weighing the risk versus benefits of continued observation and conservative treatment versus the risk of preparation. Um, and you know, full thickness ischemia. So it's really to sort of determined early or as early as possible. Um, you know the course, you know, Are we heading towards surgery? In which case we have to initiate those discussions of the family? Thes patients are typically very high risk, So going to the operating room and, you know, prepared to do a colonic resection in those usually very high risk patients is not, You know, it's not ideal. So we're trying to really confirm that there's been a significant injury, which can be, you know, you can obviously re stratify those patients based on your endoscopic findings. So I don't see this as a diagnostic more sort of like as a triage, you know, as early, um, you know, to determine then the next stage in treatment for that. But Ari, can I push back on that a little bit? Pat, I think you see a more severe spectrum. I mean, there's a lot of patients that we see that have relatively uncomplicated. Typical cramping, abdominal pain, bloody diarrhea in the right, setting a fib, elderly patients Who we clinically say, You know, you have sort of mild the schema, Clay. Just remember that by the time we see them there, blood flows typically gone back to normal. Mucosal disease is the thing that's going to bleed, and they're already on their way to recovery, and all we can do is leave them alone and let him get better on their own. So, you know, we may be seeing different patients on just clinical judgment gets gets to be very important here. I think that's a great point, David, that the injury that we see with ischemic colitis, it's really it's a Reaper fusion injury. The insult has already occurred, and we're seeing the aftermath of that. Um, we have about five minutes left. So one other question, Oh, yes, please. The Larry or others could answer, So I mean, I know that the with the guidelines state, I think, practically speaking, this gets very tricky, because by the time we're concept on these patients, there's already one CAT scan done. Um, then you would do, you know, in the way the stem is right. You have the colonoscopy and potentially asking to do a second, uh, cat scan with die. And, you know, in this case, an elderly patient. Um, any comments from from about how to manage the multiple imaging modalities, evaluate the isolated right sided disease. If you see them going on space that you played a die injury, well, I'll take. I'll take it. Said this, You know, this is a good point. I think the point you're raising is you know, the concern about how much style you're you're going to give a sick patient who may already have some reduction in renal function. And an elevated creatinine came up recently, came up actually last week on a patient with the crannies of 1.8 who we were trying to establish a diagnosis of ischemic disease with occupation, had chronic esoteric insufficiency. And we're talking about doing first C T ah c T vs C t A. Versus going directly to explain the game angiogram. And the decision was ultimately made in conjunction with vascular to do an angiogram. The feeling was we were we were sufficiently confident in the diagnosis off ischemia and realizing that you did a c t A. That showed, uh, chronic disease that you would then have to go to an angiogram to do something therapeutic. And so we went directly to an angiogram, feeling fairly confident that we knew the diagnosis and to try to preserve the amount of of contrast the patient will ultimately received. So I think you do have to make some choices. And there may be ways of short cutting your decision in terms of you don't necessarily have to do a c t nsc ta. You may go right to a c t. A. The patient has, um, has if you suspected miss enteric insufficiency, that is small bowel involvement. I would I would go directly to a c t a getting Thank you, Larry. I I agree. I think it's important, especially for your you're studying to know the difference between and the clinical presentation there difference between Kalanick ischemia and Mesen, Terek ischemia, two very different ideologies for the clinical presentation and two very different treatment regimens based on your what your diagnosis ends up being, you know, again, we don't have too much time to discuss. In fact, we only have two minutes left. So this is the time attendees to jump to the computer type with those fingers that are just itching to ask us a question, because I'm sorry. Were we run out of time, There's no I do. I actually do I have one. There's there's one question I wanna ask because I think it's important. Um, if you go to the last question, please, Pascal, there's some really great question, but here it is. Okay. A 58 year old healthy man is referred for colon cancer screening. He has no risk factors. You scope him and he has a four centimeter Padang related policy from the sigmoid. It is fully respected. Histology reveals a TV A with high grade dysplasia. The respected stock was free of adenomas tissue. When will you repeat the colonoscopy? I will. I will give this to Dr. It's quits and Dr Greenwald just to briefly, you have 30 seconds. What would you say here for this answer? Three years. It's an advanced adenoma. Four centimeters. It's high grade dysplasia, but it's been and it's tubular. Village has been completely resected, so the guidelines recommend three years and just to call everybody's attention to the fact that the guidelines for surveillance after polyp ectomy was just updated this year earlier this year by the U. S. Multi Society task force. And that paper describes the follow up for following up at an ominous polyps and also says Sasa rated polyps and last follow up. Steve, if this was a 20 year old patient, it was a four centimeter Palop. But it was a hammer toe Metis polyp. What do we do with that patient? A single ham. Artemus Paul up, even in a young patient is usually not a syndrome. Um, you have to take everything into account family history. Are there any polyps in the upper GI tract? But in isolated ham, martoma is usually not a syndrome. I usually don't recommend genetic testing or genetic counseling, but certainly multiple hematomas should warrant genetic testing and genetic counseling. Okay, um, there is There was so much to go over in this one. Our webinar. Unfortunately, we've reached the limit of this hour. Um, I highly encourage you to look at the lectures that are associate with this webinar, um, incredible amount of information, not just for your board studies, but also just for your clinical practice on again. All of those webinars. All those lectures are available through March or April of this year. So you can study for the boards in November as well as you're taking the spring course. I think it's in March or April. You can access these as well. Um, please, you're gonna get a email about CMI. You could get credit and mock credit for attending this webinar and being part of this course, so please take advantage of that. And if you have any questions or concerns, please let any of us know Contact the course directors or each individual presenter Aan den. Next week we have our liver meet our liver webinar, which will be a one hour discussion. All things liver. So please, uh, make sure the log in for that Thank you so much for your time and enjoy the rest of your co vid free evening. God willing, take care
