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Gastroenterology: the COLON


OVERVIEW
lymph drainage of colon and anus
massive amount of lymph tissue here
70-80% of entire immune system

absorb: water, fat, vitamins
constipation is #1 problem of colon
flora makes vit K, B
normally food stays in SI 4-6 hours, LI 12-72 hours

diff btw transit time and retention time?
1st time food exits vs and last time same food exits
fast transit-->less absorption
long retention-->putrefaction, toxicity, re-absorption of waste products

mouth to anus 30 feet of tube
SI is largest surface area in body
4 layers: peritoneal, muscular, submucosal, mucosal

CONSTIPATION
mc digestive complaint in US
3 types: muscular, neurogenic, obstructive

neurogenic
ignore reflex to poop, stress
DM2, Multiple Sclerosis
Hirschprung's dz = congenital aganglionitic colon-->megacolon
Chagas dz: trypon
opiates: vicodin, percocet, demerol, post surgery pain meds

muscular
weakness dt constant laxative use
(irritant-->BM instead of CNS loop)
hypothyroid, emphysema, preg

mechanical
hernia, strangulation
volvulus
intusussception
perianal fistula-->mm spasm
CRC
pregnancy

SYMPTOMS OF CONSTIPATION
less than 3 BMs/week, severe less than 1/week
stool: pellets or lumpy
hard, dry, small, difficult
painful, straining
bloating, sensation of full bowel
skin problems

ROME CRITERIA:
straining, lump hard, incomplete, blockage, manual, under 3
2 or more of those in last 3 mo, starting 6+ mo ago
loose stool rare w/o laxative
insufficient criteria for IBS

EPIDEMIOLOGY
elderly, women>men, non-caucasian
lower income and education, depression, inactivity

ETIO
habit, diet (not enough fiber, not enough liquids), laxatives, hormonal disorder
dz, CNS, colonic inertia, pelvic floor dyxfx
travel, old age, hypothryoid, lead
chronic neurologic disorders, hyperparathyroidism
meds

MEDS THAT CAN CONSTIPATE
narcotics (tyloenol 3, oxycodone, hydromorphone), antidepress (amitryiptyline, imipramine), iron supp (sulfate 325 tid), anticonvulsants (phenytoin, carbamazepine), ca channel blockers (diltiazem, nifedipine), aluminum containing antacid (aluminum hydroxide), antiparkinson's, antispasmodics, diuretics

TREATMENT
fiber, water (1/2 body wt in oz)
prunes
abdominal massage
walking, rebounder (trampoline)
probiotics
constitutional w/ sine machine
**mechanics: squatting position or other elevation of feet at toilet
**bowel re-training: LI time is 5-7am in Chinese medicine
(must get up early enough)
bulk-forming laxatives: bananas, brocc, seeds, cherries
fiber in diet: beans, whole grains, bran, fresh fruit, veggies
water is critical, avoid caffeine or alcohol
**Magnesium, Vit C commonly used (Dr T doesn't like this)
Betaine HCl
metamucil, colace (se: rash), dulcolax, senna, exlax: commonly used
castor oil packs
alternating sitz bath
cool water enema for atonic bowel
warm water enema for spastic bowel
botanicals to improve digestion
long list of homeopathic remedies in notes

in elderly, order of tx, one approach:
Geriatrics 1996 Dec: 51(12):34
1 start with bulk
2 emmolient
3 saline
4 hyperosmolar
5 stimulant laxative

ATONIC COLON TX
how to tx atonic colon per dr T
need direct stim of bowel muscle and avoidance of laxatives
sitz baths
self massage in direction of digestion and castor oil on belly
colinum organotherapy, nervinum vagum
bowel training
sine wave
therapeutic fasting

BLEEDING FROM THE COLON
very distressing
1/3 of all GI pts ??
majority of bleeding stops spontaneously
hematemesis, melena, hematochezia
vast majority of bleeds are colonic (85%)
doesn't take much blood to create melena: 50-60 mL-->5-7 days of melena
ddx is huge, varies by age
neonates: dairy allergy, anal fissure, necortising enterocolitis, vial, midgut volvulus, intussusception
elder: diverticula, UC, CRC, radiation, ischemic colitis, proctitis, hemorrhoids
DX
CBC, chem
clotting factors
flex sig, xray, colonscope
barium enema

DIVERTICULOSIS
outpouching of muscular wall dt low fiber, constipation
65% in sigmoid area, sigmoid and another area in 30%
5% at 40, 330-50% over 50, 80% over 80
10-20% of pts with osis-->itis
world: osis in .2% of pop
risks: age, low fiber, obes, inactive, L sided CRC

SX
most are asymptomatic --70%
some are painful
if infected dt fecalith, obstrx, or erosion thru serosa-->perforation
usu presents with frank blood, copious
pain in LLQ, rebound tenderness, fever
LABS: leukocytosis, urinalysis, fecal leukocytes
xrays, CT: thickening of distal colon, inflam
barium enema: sinus formation, communicating sinuses?
DDX: ischemic colitis, enterocolitis

TX
he's never seen them resolve with diet change, but mucosa may regain health
goal: avoid infection
surgery rare and if done they take whole colon, not diverticulae
itis-->conventional tx: ABX, cipro is #1, no seeds/nuts, cukes, tomatoes, etc

naturopathic tx for acute:
(if pt has intact immune system)
1) vinegar pack for pain
2) bowel rest, liquid diet
3) probiotic
4) demulcent: herbal, Robert's formula
analgesic botanicals
homeopathic remedy (Dr T uses Undas)
hydrotherapy
same as with appendicitis

tx for prevention of recurrence;
fiber
bowel retraining
improve bowel health
ok to eat seeds but chew to liquid before swallowing (JAMA catching up in 2008)

COLONOSCOPY
why order? screening for CRC, polyps
over 50 years old, younger if FHx of CRC
repeat within 5 years if positive, if neg then 10 years ?? this is allo standard
if totally clear at age 50, maybe never need another (GUT 2006; 55:1145-1150, study done in England where social med pays for healthcare, no cost benefit-->don't give service)
virtual colonoscopy is being developed (can't BX, radiation)

POLYPS // COLORECTAL CANCER
hyperplastic growth
2/3 of all over 65 have at least 1 adenomatous polyp under 1cm
incr risk of malic longer time there
allo: 1-2 adenomas-->followup at 5 yrs, advanced/multiple-->followup in 3 years
3 types: hyperplastic (90%), adenomas (10%) may-->CRC, familial syndromes (100%-->CRC)
Gardner's, Peutz-Jegers: "we have to take your colon out; when would you like it removed?"
DrT recommends waiting until CRC begins to develop
etio: IBD esp UC, smoking, drinking, acromegaly

ADENOCARCINOMA
3rd mc CA in US (after lung, breast/prostate)
APC, K-ras, p53 are mutations in order
takes decades to develop cancer, 2-5 years to develop adenoma
DETECTION
high death rate dt late detection, distant spread
early detection & removal of precancerous polyps or early CA-->much better survival rate
40% detected at earliest stage
just over 50% of Americans over 50 have had screening
no health insurance-->prob won't get screening
screening: detect polyps, or detect cancer
fecal occult blood test (FOBT) do 3x samples on 3x days (false sense of security from 1 test)
flex sig, scope
new tests will become prevalent:
stool DNA (sDNA) and computerized tomographic colonography (CTC)
insurance won't pay for these yet, cost is too high for most pts
somebody has to look at the pictures and if there's something they must do scope anyway
mets to bone, liver

PREVENTION
DrT says if a person has a polyp, start treating for colon cancer
consider familiar polyposis
diet: reduce red meat and fat, increase fiber, fruit/veg
folic acid
increase HDL if low
if meat eater with low chol, this is a risk factor
wt loss if obese
tx dysbiosis
stop smoking/drinking

TREATMENT
not considered curable: managed with chemo/radiation
LABS: CEA to follow pts who've had colon ca

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