Clostridium Difficile Diarrhea

Overview

Clostridium Difficile (CD) is a bacteria which may reside in the colon of a normal person. When that person receives broad-spectrum antibiotic therapy, the good bacteria in the colon are killed and CD can proliferate and cause colitis.

Symptoms

Symptoms of CD diarrhea typically include severe watery diarrhea and abdominal cramping. Fever, chills and weight loss may occur. In severe cases, the diarrhea may become bloody.
Testing
Diagnosis is made by detecting the bacteria or the toxin it produces in a stool specimen. The condition can also be diagnosed during a colonoscopy where the lining of the colon will be noted to be severely inflamed with a characteristic pseudomembranous appearance.
Treatment

This condition is treated by antibiotics which specifically kill the clostridium difficile bacteria. The first line agent is typically metronidazole. A more powerful antibiotic, vancomycin, may be necessary in patients who do not respond to metronidazole or develop recurrent infection after the medication is discontinued. It is often advised that patients take a probiotic or consume yogurt to repopulate the colon with normal bacteria to prevent recurrence of the infection.

Colon Cancer

Overview

Colon cancer is a malignant growth that arises from the lining of the colon or rectum. Most colon cancer arises slowly from the growth of a benign polyp. The majority of colon cancer occurs sporadically. However, colon cancer can also be hereditary and arise from genetic abnormalities, which are transmitted from a parent. The incidence of colon cancer increases with advancing age and most commonly is seen in people over age 50. Men and women are affected equally. Colorectal cancer is the third most commonly diagnosed cancer in the world. It is more common in developed countries.

Symptoms

Symptoms of colorectal cancer depend on the location of the tumor and whether it is confined to the colon or has penetrated through the bowel wall. Right sided colon cancers typically cause chronic blood loss, which may result in anemia. Left sided colon cancers may produce frank rectal bleeding or symptoms of bowel obstruction. Early stage colon cancer may cause no symptoms at all. Ideally, these early tumors should be detected by screening before symptoms arise.

Testing

Colon cancer is most commonly diagnosed by a colonoscopy. Alternatively, the tumor may be found by performing a barium enema x-ray or an imaging study of the abdomen such as a CT scan. Once colon cancer is diagnosed, additional testing is indicated to determine if the tumor has penetrated the bowel wall and metastasized to the lymph nodes or other organs such as the liver or lungs.

Treatment

For people with localized cancer, the optimal treatment is complete surgical removal of the affected section of colon. If the disease has spread beyond the wall of the colon, additional treatment such as chemotherapy or radiation therapy may be necessary.

Constipation

Overview

Constipation refers to infrequent bowel movements or difficulty passing stool. There are many causes of constipation. Most commonly, it is due to a slow transit of fecal material through the colon. This may be related to diet, inactivity, medication side effects or other underlying medical conditions. Constipation may also result from a physical blockage of the intestine, such as colorectal cancer. It may also arise from problems with evacuating the rectum due to disorders of the anal or rectal nerves and muscles.

Symptoms

Symptoms of constipation include abdominal bloating and distention, infrequent bowel movements, passage of hard stool and difficulty evacuating the rectum.

Testing

The diagnosis is typically made based on the patient’s symptoms and a description of their bowel habits. Laboratory tests are often ordered to rule out underlying medical conditions, such as hypothyroidism or electrolyte abnormalities. An x-ray examination of the colon or a colonoscopy may be necessary to prove that there is not a mechanical obstruction of the colon. Rarely, more sophisticated testing such as anorectal manometry is necessary to eliminate disorders of the nerves and muscles of the rectum and anus.

Treatment

Constipation can often be relieved simply by increasing fluid and fiber intake. Occasionally, laxatives are necessary to allow adequate elimination. Exercise and a healthy lifestyle will also contribute to more normal bowel function.

Crohn’s Disease

Overview

Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the gastrointestinal tract.  Inflammation, ulcers, and narrowing of the digestive tract occur because the body’s immune system is inappropriately attacking the lining of the digestive tract.  Crohn’s disease most commonly occurs in young people, but can also be seen later in life.

Symptoms

Many patients with Crohn’s disease will have symptoms present for many years prior to diagnosis.  The degree and nature of the symptoms is dependent upon the location of the disease in the gastrointestinal tract.  Typical symptoms can include nausea and vomiting, abdominal pain and diarrhea.  Symptoms outside of the digestive tract may occur as well and include eye pain, skin rash, mouth ulcers, and arthritis.  Patients with Crohn’s disease are also at an increased risk for developing gall stones and kidney stones.

Testing

Crohn’s disease is most commonly detected by performing a colonoscopy or x-ray imaging studies of the abdomen, such as an upper GI series, CT scan, or MRI scan.  Blood tests may also be used to detect evidence of inflammation, anemia and malnutrition, which may all be seen in patients with Crohn’s disease.

Treatment

There is no cure for Crohn’s disease, but medications can be used to achieve remission and relieve symptoms.  The specific medications used to treat Crohn’s disease are dependent upon the disease location and severity.  Dietary modification is often helpful in minimizing symptoms.  Patients with narrowing of the digestive tract or active inflammation generally feel better when they consume a diet low in fiber.  A variety of medications such as Mesalamine, corticosteroids, immunomodulator medications (Imuran or 6 Mercaptopurine) and biologic therapy (Remicade, Humira, Cimzia) can be used to achieve remission.  In patients who fail to respond to medical therapy, surgery may be required to remove a diseased portion of the digestive tract; however, surgery is not curative and the disease will frequently recur over time.

Diarrhea

Overview

Diarrhea is a condition of having multiple loose bowel movements or a change in the consistency of bowel movements from solid to loose. Acute diarrhea typically comes on suddenly and resolves in several days or weeks. Chronic diarrhea typically persists for a longer period of time. Most cases of acute diarrhea are due to either a viral or bacterial infection. The cause of chronic diarrhea is extensive and can include such conditions as irritable bowel syndrome, Crohn’s disease, ulcerative colitis, celiac disease and even colon cancer.

Symptoms

Symptoms of diarrhea include frequent loose bowel movements, abdominal pain or cramping and sometimes fever. Stools may be loose, watery, bloody or fatty, depending upon the specific underlying cause.

Testing

The diagnostic approach to diarrhea is based on the extent and severity of the symptoms. Acute diarrhea is often self-limited and may require no testing. Stool specimens may be necessary to look for evidence of a bacterial or parasitic infection. Prolonged unexplained diarrhea may require a colonoscopy with biopsies of the intestinal lining to look for evidence of inflammation.

Treatment

In most cases of diarrhea supportive care with fluid replacement and anti-diarrheal medications such as Imodium may be all that is necessary. Bacterial or parasitic infections may require antibiotic therapy. Specific conditions such as irritable bowel syndrome, Crohn’s disease and ulcerative colitis typically require specific therapy. Please see the reviews of those specific diseases for more information.

Diverticulosis

Overview

Diverticulosis is a condition in which pockets or out pouchings develop on the wall of the colon. These most commonly occur on the left side of the colon known as the sigmoid colon. The incidence of diverticulosis increases with age and the condition is more common in western society, such as the United States.
Symptoms

Most patients with diverticulosis have no symptoms and the condition is found, incidentally, when they undergo diagnostic testing, such as a colonoscopy. When a diverticular pocket becomes infected, the condition is known as diverticulitis. This will often cause pain in the left lower abdomen, fever and constipation. Diverticula can also occasionally bleed. This typically results in profuse, painless rectal bleeding.

Testing

Diverticulosis is typically diagnosed at colonoscopy, barium enema x-ray, or by CT scan. An infected diverticula, or diverticulitis, can be diagnosed by typical symptoms and physical findings. An elevated white blood cell count will often be present on a complete blood count. The diagnosis can be confirmed by a CT scan of the abdomen and pelvis.

Treatment

People with asymptomatic diverticulosis do not require any specific treatment. It is recommended that they consume a high fiber diet. It is no longer recommended that people with diverticulosis avoid specific foods such as seed or nuts. Diverticulitis is usually successfully treated by antibiotic therapy. Infection unresponsive to antibiotic therapy may require surgery. Bleeding from diverticulosis is usually self-limited and will subside with observation in the hospital. Persistent bleeding can often be controlled by performing a colonoscopy and injecting medication, or clipping the bleeding diverticulum. Severe bleeding uncontrolled by these measures may require surgery.

Colitis

Overview

Colitis refers to an inflammation of the colon or large intestine. This may be due to an acute process, such as a bacterial infection, or a chronic process such as ulcerative colitis or Crohn’s Disease. Inadequate blood supply to the colon may cause a condition called ischemic colitis, which most commonly involves the left side of the colon.

Symptoms

The most common symptom of colitis is diarrhea. The stool will often contain blood. Bloating, abdominal cramping, and even severe pain may accompany the diarrhea. Severe colitis may result in fever, chills and weight loss.

Testing

Colitis can often be diagnosed simply on the basis of a patient’s presenting symptoms and physical examination. Laboratory studies will often reveal an elevated white blood cell count. Appropriate stool studies should be obtained to rule out an infectious cause such as salmonella, shigella, campylobacter or clostridium difficile. Parasitic infections can also cause colitis and are diagnosed by obtaining appropriate stool specimens. Additional testing can include an imaging study of the abdomen, such as a CT scan. Definitive diagnosis may require a colonoscopy with biopsies of the inflamed tissue.
Treatment

The treatment of colitis is dependent on the cause determined by the diagnostic studies outlined above. Infectious colitis is often self-limited and may not require treatment other than supportive care with fluids and careful observation. Severe infection may require antibiotic therapy. Ischemic colitis is usually self-limited and responds to supportive measures. The treatment of colitis due to Crohn’s Disease or ulcerative colitis is reviewed in the sections outlining those specific conditions.

Irritable Bowel Syndrome (IBS)

Overview

Irritable Bowel Syndrome or IBS is the most common disorder affecting the gastrointestinal tract.

Symptoms

Patients with IBS frequently complain of abdominal pain and bloating in association with either diarrhea, constipation or a combination of both of these symptoms. These symptoms may be aggravated by stress or ingesting trigger foods such as caffeine, fatty foods or spicy foods. Patients with Irritable Bowel Syndrome typically do not have worrisome symptoms such as weight loss, rectal bleeding, fever or anemia.
Testing

The diagnosis of Irritable Bowel Syndrome is typically made on the basis of a patient’s symptoms and physical exam. Diagnostic testing such as stool studies, blood tests and even a colonoscopy may be necessary to exclude other conditions that can cause similar symptoms.
Treatment

The treatment of Irritable Bowel Syndrome typically involves dietary modification and medications to relieve symptoms such as intestinal spasm, constipation or diarrhea. Patients often benefit from regular exercise and measures to relieve underlying stress or depression. Symptoms are usually chronic and require ongoing therapy.

Lynch Syndrome

Lynch Syndrome is a hereditary disorder caused by a mutation in a mismatch repair gene in which affected individuals have a higher than normal chance of developing colorectal cancer, endometrial cancer, and various other types of aggressive cancers, often at a young age – also called hereditary nonpolyposis colon cancer (HNPCC).

Children of a Lynch syndrome parent possess a 50% risk of acquiring a mutation.  Those with Lynch syndrome carry up to an 85% risk of contracting colon cancer as well as a higher than average risk for endometrial cancer, stomach, pancreas, kidney/ureter tract, hepatobiliary tract, gastric tract, prostate, ovarian, gallbladder duct, brain, small intestine, common breast and skin cancers.  Lynch Syndrome is not a rare condition but rather an under-diagnosed one!

Our Open Access nurses at RGAL ask our patients specific questions to identify patients at risk and refer them to genetic counselors for further investigation to determine if the patient or their family requires genetic testing for Lynch Syndrome.

For information on Lynch Syndrome, visit  Lynch Syndrome International at   http://lynchcancers.com/

Ulcerative Colitis

Overview

Ulcerative colitis is a form of inflammatory bowel disease. It is characterized by ulceration and inflammation of the lining of the large intestine or colon. Its cause is unknown.

Symptoms

Patients with ulcerative colitis typically experience diarrhea. Stools will often contain blood and mucous. There may be associated abdominal pain and cramping. Fever, night sweats, eye pain, joint pain, skin rash and anemia may also occur.

Testing

Ulcerative colitis is most commonly diagnosed by colonoscopy and biopsy of the abnormal lining of the colon.

Treatment

The treatment for ulcerative colitis is dependent on the severity of the disease and the extent of involvement of the colon. Disease limited to the lower colon or rectum may be treated with medicated suppositories or enemas. Colitis involving the entire colon typically requires more aggressive treatment. Treatment is often initiated with an anti-inflammatory medication called Mesalamine. More severe cases may require corticosteroid therapy, such as Prednisone. Immunomodulatory drugs or newer medications called biologics may be required in more severe steroid refractory cases. Patients who fail to respond to medical therapy may require surgical removal of the colon.