Crohn’s disease involves chronic inflammation of the bowels. The cause is unknown, but there does seem to be links with genetics, environment, stress, and the immune system. The condition is most commonly found in white females.
Patients with Crohn’s disease present with the following clinical picture:
- Lower right quadrant abdominal pain
- Recurrent attacks of fever
In order to confirm that diagnosis of Crohn’s disease, a colonoscopy and biopsy are performed. This would reveal segmental non-caseous granulomatous inflammation, which just means that pockets of macrophage white blood cells have formed. The colonoscopy will show skip lesions, meaning that there is a patchy distribution of affected areas, and a cobblestone appearance (shown below).
If Crohn’s disease becomes severe enough, the patient may need surgical removal of a section of the bowel. This can result in vitamin B12 deficiency as the nutrient can no longer be absorbed properly with the reduced size of the terminal ileum.
Ulcerative colitis is a gastrointestinal disease that is caused by chronic inflammation of the bowel. The cause is unknown, but there seem to be links to almost everything, including genetics, stress, environment, and immune factors. UC is more common in white females.
A patient with UC will present with:
- recurrent bloody diarrhea
- left lower quadrant abdominal pain
- weight loss
- iron deficiency anemia
A colonoscopy and biopsy are used to confirm the diagnosis. The colonoscopy will show severe superficial ulceration of the mucosal lining of the bowel.
Complications of ulcerative colitis include increased chances of colon cancer and toxic megacolon. Toxic megacolon is a condition where a section of the colon becomes paralyzed, preventing any movement of bowel matter. Eventually, the bowel contents will leak into the bloodstream, including E. coli, causing sepsis. Severe gastrointestinal bleeding can result in an iron deficiency anemia.
There are many options for treating ulcerative colitis, depending on the severity of the case. Typically, individuals are prescribed a steroid to reduce the inflammation. Others find a lot of relief with anti-inflammatory diets and supplements.
Spondylolisthesis refers to the movement of a vertebral body in relation to the vertebral body below. Movement can be considered retrolisthesis (slipping backwards) or anterolisthesis (slipping forwards), but typically when we talk about spondylolisthesis, we are discussing an anterolisthesis of a lumbar vertebra. On a lateral lumbar radiograph, we look for a break in George’s line, an imaginary line drawn along the posterior vertebral bodies. It is possible to have a break in the pars interarticularlis (spondylolysis) without having the slippage (spondylolisthesis).
There are many types of spondylolisthesis.
- Type I is a congenital defect of the facet joints that allows slippage, also called dysplastic spondylolisthesis.
- Type II is often found on younger patients, and it is likely caused by stress fracture of the pars interarticularlis. This type is called isthmic spondylolisthesis and is the most common type. The vertebral body begins to slip, elongating the pars. Once the fractures heal, the spondylolisthesis is stable, but the elongation and slippage is permanent. This type most commonly occurs at L5-S1.
- Type III is called degenerative spondylolisthesis and is typically found in older people. The facet joints degenerate with age, allowing the slippage. This type is most common at L4-L5.
- Type IV is traumatic spondylolisthesis, caused by acute fracture. It is most common at L3-L4 due to the weight bearing stress of being at the apex of the lumbar lordosis.
- Type V is pathological secondary to a bone disease or tumor.
In many cases, spondylolisthesis is entirely asymptomatic and may just be an incidental finding on radiographs. Others present with low back pain, but no change in muscle strenght, sensation, or reflexes.
Spondylolisthesis is graded using the Meyerding Grading method on the lateral lumbar film, placing it in a category of 1 to 5, with 5 being a complete slippage off the vertebra below, also known as spondyloptosis.
This diagram shows how the sacral base is split into quadrants and displays a grade 3 spondylolisthesis.
A grade of 3 or higher, indicating a slippage of at least 50 percent, should be referred to an orthopedic surgeon for evaluation of instability.
AS is a chronic inflammatory arthritis that involves the sacroiliac joints and the axial skeleton. There seems to be a genetic predisposition to the disease, with about 90 percent of AS patients being positive for Human Leukocyte Antigen B27. Approximately 5-7% of the normal white population in the United States is positive for HLA-B27. Depending on the reference, AS is anywhere from 3 to 10 times more common in males than in females. Onset is generally between the ages of 15 and 35 years.
Clinical picture for ankylosing spondylitis:
- low back pain lasting longer than 3 months, typically gets better with exercise
- limited lumbar spine motion
- tender SI joints bilaterally
- decreased chest expansion on inspiration (normal is 1-3 cm when measured at the level of the nipple)
With early AS that is still mainly affecting the SI joints, any orthopedic test that puts stress on the SI joints will cause pain.
Radiographs will show varying results depending on the progression of the disease. Early on, the only radiographic signs may be subchondral erosions on the iliac side of the SI joint. Eventually, these joints will fuse. The disease progresses into the spine, first showing up as Romanus lesions, erosions of the corners of the vertebral bodies. Next, the shiny corner sign shows up as the vertebral body corners become sclerotic. Marginal syndesmophytes will form, looking like thin lines that run along the edges of the vertebral disc space. In severely progressed cases, bamboo spine, trolley track sign (fusion of the apophyseal joints), and the dagger sign (fusion and calcification of the supraspinous and interspinous ligaments) are present.
- Fusion of the SI joints (although this actually shows all of the signs…)
Because ankylosing spondylitis is an inflammatory disease affecting the spine, it can cause issues with upper cervical instability, putting a patient at a higher risk for neurological damage in cases of trauma. Trauma can also result in a carrot stick fracture, a snapping of the fused spine. Another complication associated with AS and trauma is neurotrophic arthropathy.
Important note: enteropathic arthritis has an identical presentation to AS, except that it does NOT affect the cervical spine and is associated with an inflammatory bowel disease. All other clinical, exam, radiographic, and lab findings are the same.
Lydia, here! Sorry for the delay in posting for today. I had two finals today and my last one is tomorrow. I will try to get it finished sometime tonight. :)
Lumbar sprain and strain are different diagnoses, but they present similarly and have the same prognosis. A sprain is a ligamentous problem and has varying grades depending on the severity of the injury. A strain is a muscle problem and is also graded.
There are many ligaments in the spine that help to stabilize and protect the spine during movement.
Any number of these ligaments may be torn. However, ALL and PLL tears are uncommon and usually only seen with severe trauma; they are extremely strong, broad ligaments. The posterior ligaments are often torn in flexion type of injuries.
In a lumbar muscle strain, the erector spinae group of muscles is damaged. The erector spinae is made up of the iliocostalis, longissimus, and spinalis. These muscles are frequently damaged while lifting objects improperly or performing certain movements repetitively or too suddenly.
An individual with a lumbar sprain or strain presents with:
- pain in the low back or buttocks
- lumbar muscle spasm
- pain with certain ranges of motion
- pain that is relieved by rest
Lumbar sprain/strain is an extremely common injury and can happen to anyone fairly easily. Obesity and deconditioning contribute to the risks for injury. Patients will benefit from core exercises and instruction in proper lifting techniques to prevent future injuries. In very severe cases, a lumbar brace may be helpful until the pain begins to subside. However, it is very important that you do not allow your patient to become dependent on the brace, as it will just make their musculature weaker in the long run and place them at an even higher risk for re-injury.
Another great treatment option for patients with lumbar sprain/strain is referral to a chiropractor. They get excellent results and can help the patient with the rehabilitation exercises and managing the pain until healing is complete.
PCOS, also known as Stein-Leventhal syndrome for the doctors who discovered it, is a benign condition in which numerous cysts develop in the ovaries due to incompletely developed follicles. PCOS is idiopathic, but there does seem to be a genetic link. For some reason, the epithelium around the ovaries becomes thickened and does not allow the follicle to rupture. In an effort to force ovulation, the pituitary gland releases more luteinizing hormone that gets converted to testosterone. PCOS is rather common, affecting about 5 percent of women of reproductive age.
Women with PCOS present with:
- Amenorrhea or oligomenorrhea (no or fewer than normal menstrual periods)
- In some individuals, PCOS is accompanied by Metabolic Syndrome, and they may suffer from diabetes mellitus and hypertension as a result.
Ultrasound is the diagnostic imaging of choice. It will reveal numerous 2-8 mm cysts in both ovaries. The sign is known as the “string of pearls” sign.
Lab tests will reveal decreased levels of follicle-stimulating hormone (FSH) and estradiol, but androgens will be elevated. If associated with Metabolic Syndrome, there may be hyperglycemis, glycosuria, and hyperlipidemia.