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Acute Appendicitis

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					Acute Appendicitis
            Epidemiology
• The incidence of appendectomy appears
  to be declining due to more accurate
  preoperative diagnosis.
• Despite newer imaging techniques, acute
  appendicitis can be very difficult to
  diagnose.
           Pathophysiology
• Acute appendicitis is thought to begin with
  obstruction of the lumen
• Obstruction can result from food matter,
  adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
  intraluminal pressure
          Pathophysiology
• Eventually the pressure exceeds capillary
  perfusion pressure and venous and
  lymphatic drainage are obstructed.
• With vascular compromise, epithelial
  mucosa breaks down and bacterial
  invasion by bowel flora occurs.
           Pathophysiology
• Increased pressure also leads to arterial
  stasis and tissue infarction
• End result is perforation and spillage of
  infected appendiceal contents into the
  peritoneum
           Pathophysiology
• Initial luminal distention triggers visceral
  afferent pain fibers, which enter at the 10th
  thoracic vertebral level.
• This pain is generally vague and poorly
  localized.
• Pain is typically felt in the periumbilical or
  epigastric area.
          Pathophysiology
• As inflammation continues, the serosa and
  adjacent structures become inflamed
• This triggers somatic pain fibers,
  innervating the peritoneal structures.
• Typically causing pain in the RLQ
           Pathophysiology
• The change in stimulation form visceral to
  somatic pain fibers explains the classic
  migration of pain in the periumbilical area
  to the RLQ seen with acute appendicitis.
           Pathophysiology
• Exceptions exist in the classic
  presentation due to anatomic variability of
  the appendix
• Appendix can be retrocecal causing the
  pain to localize to the right flank
• In pregnancy, the appendix ca be shifted
  and patients can present with RUQ pain
           Pathophysiology
• In some males, retroileal appendicitis can
  irritate the ureter and cause testicular pain.
• Pelvic appendix may irritate the bladder or
  rectum causing suprapubic pain, pain with
  urination, or feeling the need to defecate
• Multiple anatomic variations explain the
  difficulty in diagnosing appendicitis
                 History
• Primary symptom: abdominal pain
• ½ to 2/3 of patients have the classical
  presentation
• Pain beginning in epigastrium or
  periumbilical area that is vague and hard
  to localize
                 History
• Associated symptoms: indigestion,
  discomfort, flatus, need to defecate,
  anorexia, nausea, vomiting
• As the illness progresses RLQ localization
  typically occurs
• RLQ pain was 81 % sensitive and 53%
  specific for diagnosis
                  History
• Migration of pain from initial periumbilical
  to RLQ was 64% sensitive and 82%
  specific
• Anorexia is the most common of
  associated symptoms
• Vomiting is more variable, occuring in
  about ½ of patients
            Physical Exam
• Findings depend on duration of illness
  prior to exam.
• Early on patients may not have localized
  tenderness
• With progression there is tenderness to
  deep palpation over McBurney’s point
            Physical Exam
• McBurney’s Point: just below the middle of
  a line connecting the umbilicus and the
  ASIS
• Rovsing’s: pain in RLQ with palpation to
  LLQ
• Rectal exam: pain can be most
  pronounced if the patient has pelvic
  appendix
           Physical Exam
• Additional components that may be helpful
  in diagnosis: rebound tenderness,
  voluntary guarding, muscular rigidity,
  tenderness on rectal
            Physical Exam
• Psoas sign: place patient in L lateral
  decubitus and extend R leg at the hip. If
  there is pain with this movement, then the
  sign is positive.
• Obturator sign: passively flex the R hip
  and knee and internally rotate the hip. If
  there is increased pain then the sign is
  positive
            Physical Exam
• Fever: another late finding.
• At the onset of pain fever is usually not
  found.
• Temperatures >39 C are uncommon in
  first 24 h, but not uncommon after rupture
                Diagnosis
• Acute appendicitis should be suspected in
  anyone with epigastric, periumbilical, right
  flank, or right sided abd pain who has not
  had an appendectomy
              Diagnosis
• Women of child bearing age need a pelvic
  exam and a pregnancy test.
• Additional studies: CBC, UA, imaging
  studies
               Diagnosis
• CBC: the WBC is of limited value.
• Sensitivity of an elevated WBC is 70-90%,
  but specificity is very low.
• But, +predictive value of high WBC is 92%
  and –predictive value is 50%
• CRP and ESR have been studied with
  mixed results
               Diagnosis
• UA: abnormal UA results are found in 19-
  40%
• Abnormalities include: pyuria, hematuria,
  bacteruria
• Presence of >20 wbc per field should
  increase consideration of Urinary tract
  pathology
                Diagnosis
• Imaging studies: include X-rays, US, CT
• Xrays of abd are abnormal in 24-95%
• Abnormal findings include: fecalith,
  appendiceal gas, localized paralytic ileus,
  blurred right psoas, and free air
• Abdominal xrays have limited use b/c the
  findings are seen in multiple other
  processes
              Diagnosis
• Graded Compression US: reported
  sensitivity 94.7% and specificity 88.9%
• Basis of this technique is that normal
  bowel and appendix can be compressed
  whereas an inflamed appendix can not be
  compressed
• DX: noncompressible >6mm appendix,
  appendicolith, periappendiceal abscess
               Diagnosis
• Limitations of US: retrocecal appendix
  may not be visualized, perforations may
  be missed due to return to normal
  diameter
               Diagnosis
• CT: best choice based on availability and
  alternative diagnoses.
• In one study, CT had greater sensitivity,
  accuracy, -predictive value
• Even if appendix is not visualized,
  diagnose can be made with localized fat
  stranding in RLQ.
               Diagnosis
• CT appears to change management
  decisions and decreases unnecessary
  appendectomies in women, but it is not as
  useful for changing management in men.
        Special Populations
• Very young, very old, pregnant, and HIV
  patients present atypically and often have
  delayed diagnosis
• High index of suspicion is needed in the
  these groups to get an accurate diagnosis
               Treatment
• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and
  preoperative antibiotics
• Antibiotics are most effective when given
  preoperatively and they decrease post-op
  infections and abscess formation
               Treatment
• There are multiple acceptable antibiotics
  to use as long there is anaerobic flora,
  enterococci and gram(-) intestinal flora
  coverage
• One sample monotherapy regimen is
  Zosyn 3.375g or Unasyn 3g
• Also, short acting narcotics should be
  used for pain management
               Disposition
• Abdominal pain patients can be put in 4
  groups
• Group 1: classic presentation for Acute
  appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed
  appendicitis- benefit from imaging and 4-
  6h observation with surgical consult if
  serial exam changes or imaging studies
  confirm
               Disposition
• Group 3: remote possibility of appendicitis-
  observe in ED for serial exams; if no
  change and course remains benign patient
  can D/C with dx of nonspecific abd pain
• Patients are given instructions to return if
  worsening of symptoms, and they should
  be seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
              Disposition
• Group 4: high risk population(including
  elderly, pediatric, pregnant and
  immunocomprimised)- require high index
  of suspicion and low threshold for imaging
  and surgical consultation
Ileitis, Colitis, and
    Diverticulitis
             Crohn Disease
• Chronic granulomatous inflammatory
  disease of the GI tract.
• Can involve any part of GI tract from
  mouth to anus
• Ileum is involved in majority of cases
• Confined to colon in 20%
• Terms:regional enteritis, terminal ileitis,
  granulomatous ileocolitis
            Crohn Disease
• Etiology and pathogenesis are unknown.
• Infectious, genetic, environmental factors
  have been implicated.
• Autoimmune destruction of mucosal cells
  as a result of cross-reactivity to antigens
  from enteric bacteria.
           Crohn Disease
• Cytokines,including IL and TNF have been
  implicated in perpetuating the
  inflammatory response.
• Anti-TNF(remicade) drugs have shown
  efficacy in treating Crohn disease
           Crohn Disease
• Epidemiology: peak incidence is 15-22
  years old with a second peak 55-66years
• 20-30% increase in women
• More common in European
• 4 times more common in Jews than non-
  Jews
• More common in whites vs blacks
• 10-15% have family hx
           Crohn Disease
• Pathology: most important is the
  involvement of all layers of the bowel and
  extension into mesenteric lymph nodes
• Disease has skip areas between involved
  areas
• Longitudinal deep ulcers and
  cobblestoning of mucosa are characteristic
• These result in fissures, fistulas, and
  abscesses
            Crohn Disease
• Clinical features: variable and
  unpredictable
• Abd pain, anorexia, diarrhea, and weight
  loss are present in most cases
• 1/3 of patients develop perianal fissures or
  fistulas, abscesses, or rectal prolapse
            Crohn Disease
• Patients may present with lat
  complications including:
• Obstruction, crampy abd pain, obstipation,
  intraabdominal abscess with fever
• 10-20% have extraabdominal features
  such as: arthritis, uveitis, or liver disease
• Crohn’s should also be considered when
  evaluating FUO
           Crohn Disease
• Clinical course and manifestation depends
  of anatomic distribution.
• 30% involves only small bowel, 30% only
  colon, and 50% involves both
           Crohn Disease
• Recurrence rate is as high as 50% for
  those responding to medical management
• Rate is even higher for those requiring
  surgery
• Incidence of hematochezia and perianal
  disease is higher when the colon is
  involved
            Crohn Disease
• Dermatologic complications: erythema
  nodosum and pyoderma gangrenosum
• Ocular: episcleritis and uveitis
• Hepatobiliary: pericholangitis, chronic
  hepatitis, primary sclerosing cholangitis,
  cholangiocarcinoma, pancreatitis,
  gallstones
            Crohn Disease
• Vascular: thromboembolic disease,
  vasculitis, arteritis
• Other: anemia, malnutrition, hyperoxaluria
  leading to nephrolithiasis, myeloplastic
  disease, osteomyelitis, osteonecrosis
            Crohn Disease
• Complications: >75% of patients will
  require surgery within the first 20 years
• Abscesses present with pain and
  tenderness, but may also have palpable
  masses or fever spikes
• Most common fistula sites are between
  ileum and sigmoid colon, cecum, another
  ileal segment, or the skin
           Crohn Disease
• Fistulas should be suspected when there
  is a change in bowel movement frequency,
  amount of pain or weight loss
• GI bleed is common, but only 1% develop
  life threatening hemorrhage.
• Toxic megacolon occurs in 6% of patients
  and results massive GI bleed 50% of the
  time
            Crohn Disease
• Complications can also arise from the
  treatment of the disease
• Sulfasalazine, steroids,
  immunosuppressive agents, and
  antibiotics can cause leukopenia,
  thrombocytopenia, fever, infection,
  diarrhea, pancreatitis, renal insufficiency,
  liver failure.
            Crohn Disease
• Incidence of malignancy is 3 times higher
  in Crohn disease than in general
  population
            Crohn Disease
• Diagnosis: history, Upper GI, air-contrast
  barium enema and colonoscopy
• Characteristic radiologic findings in small
  intestine include: segmental narrowing,
  destruction of normal mucosal pattern, and
  fistulas.
            Crohn Disease
• Colonoscopy is most sensitive for patients
  with colitis
• Useful for detecting mucosal lesions,
  defining extent of involvement, occurrence
  of colon ca.
• Abd CT is most useful for acute
  presentation
            Crohn Disease
• Findings of bowel wall thickening,
  mesenteric edema, local abscess
  formation suggest Crohn disease.
             Crohn Disease
• Differential Dx: lymphoma, ileocecal
  amebiasis, sarcoidosis, deep chronic
  mycotic infections involving GI tract, GI
  TB, Kaposi’s sarcoma, campylobacter,
  Yersinia, ulcerative colitis, C.diff, ischemic
  colitis.
            Crohn Disease
• Tx: relief of symptoms, induction of
  remission, maintenance of remission,
  prevention of complications, optimizing
  timing of surgery, and maintenance of
  nutrition
• Since the disease is virtually incurable,
  emphasis should be placed of relief of
  symptoms and preventing complications
            Crohn Disease
• Initial ED management: focus on severity
  of attack, identifying possible
  complications such as obstruction,
  hemorrhage, abscess, toxic megacolon.
• CBC, electrolytes, BUN/creatinine, and
  type and cross if appropriate
• Plain films may be useful for obstruction,
  perforation or toxic megacolon
           Crohn Disease
• Initial Tx: NPO, IVF resuscitation and
  correction of electrolytes
• NG decompression if indicated, broad
  spectrum atbx(ampicillin or a
  cephalosporin, aminoglycoside, and flagyl)
  should be used for suspected fulminant
  colitis or peritonitis
            Crohn Disease
• IV steroids: hydrocortisone 300mg qd,
  methylprednisone 48mg qd, or
  prednisolone 60mg qd should be used for
  severe disease
• Sulfasalazine 3-4g qd can be effective for
  mild-moderate cases, although it has
  many toxic side effects
             Crohn Disease
• Oral steroids are reserved for severe
  disease-prednisone 40-60mg qd
• Immunosuppressive drugs:
  6-MP or azathioprine are useful for steroid
  alternatives, healing fistulas, or in patients
  with contraindications to surgery
  Response to immunosuppressant agents
  takes 3-6 months
           Crohn Disease
• Flagyl and Cipro have been shown some
  improvement in perianal complications and
  fistulous disease.
• Medically resistant or moderate cases may
  benefit from anti-TNF(Remicade) 5 mg/kg
  IV
• Cellcept, etanercept, thalidomide, IL
  therapy may also be beneficial
           Crohn Disease
• Diarrhea can be controlled using imodium,
  lomotil, or questran
             Crohn Disease
• Disposition: patients with signs of
  fulminant colitis, peritonitis, obstruction,
  significant hemorrhage, dehydration,
  electrolyte/fluid imbalance should be
  hospitalized under the care of a surgeon
  or gastroenterologist
           Crohn Disease
• Patients with chronic disease can be
  discharged home as long as there are no
  serious complications.
• Alterations in maintenance therapy should
  be discussed with GI
• Close follow up should be secured.
          Ulcerative Colitis
• Chronic inflammatory disease of the colon.
• Inflammation is more severe from proximal
  to distal colon
• Rectum is involved in nearly 100%
• Characteristic symptom is bloody diarrhea
• Etiology remains unknown
          Ulcerative Colitis
• Epidemiology: similar to Crohn disease
• More prevalent in US and northern
  Europe.
• First degree relatives have 15 fold
  increase for UC and 3.5 fold increase for
  Crohn disease
          Ulcerative Colitis
• Pathology: involves mucosa and
  submucosa
• Mucosal inflammation and formation of
  crypt abscesses, epithelial necrosis, and
  mucosal ulceration
• Early stages mucosa membrane appears
  finely granular and friable
• Severe cases show large oozing
  ulcerations and pseudopolyps
            Ulcerative Colitis
• Clinical features:
• Mild: <4 bm per day, no systemic symptoms,
  and few extraintestinal manifestations. (account
  for 60% of all UC patients)
• Severe: frequent bm’s, anemia, fever, wt loss,
  tachycardia, low albumin, frequent
  extraintestinal manifestations. (accounts for 15%
  of all patients and 90% of mortality)
          Ulcerative Colitis
• Moderate: manifesations are less severe
  and respond well to treatment. Typically
  have left sided colitis, but can have
  pancolitis.
           Ulcerative Colitis
• Characterized by: intermittent attacks of
  acute disease with remission between
  attacks
• Unfavorable prognosis and increased
  mortality is seen with higher severity and
  extent of disease, short interval between
  attacks, and onset of disease after 60
           Ulcerative Colitis
• Extraintestinal complications: arthritis,
  ankylosing spondylitis, episcleritis, uveitis,
  pyoderma gangrenosum, erythema
  nodosum, liver disease(similar to that
  found in Crohn disease)
          Ulcerative Colitis
• Complications: hemorrhage, toxic
  megacolon, perirectal abscesses and
  fistulas, colon ca, perforation
           Ulcerative Colitis
• Dx: lab findings are nonspecific.
• Diagnosis is made by Hx of abd cramps
  and diarrhea, mucoid stools, stool
  negative for ova/parasites, negative stool
  cultures
• confirmation of disease by colonoscopy
  showing granular, friable, ulceration of the
  mucosa, and sometimes pseudopolyps
          Ulcerative Colitis
• Differential Dx: similar to that of Crohn
  disease.
• Also be aware of STD’s when confined to
  the rectum
          Ulcerative Colitis
• Treatment:
• Severe UC: IV steroids, fluid replacement,
  electrolyte correction, broad spectrum
  atbx(amp and clindamycin or flagyl)
• Cyclosporine has been advocated for
  steroid refractory cases
• NG for toxic megacolon just as in crohn
  disease
           Ulcerative Colitis
• Mild to moderate: majority of cases can be
  treated as outpatient with daily prednisone
  40-60mg
• Active proctitis, proctosigmoiditis, and left
  side colitis can be treated with 5-
  aminosalicylic acid enemas or topical
  steroid preparations
          Ulcerative Colitis
• Treatment is very similar to Crohn disease
• Other supportive measures include
  metamucil or other bulking agents
• Anti-diarrheals should be used with
  caution in case of toxic megacolon
          Ulcerative Colitis
• Disposition:Fulminant attacks should be
  hospitalized for aggressive IVF and
  elctrolyte correction.
• Complications should be managed with
  appropriate surgical or GI consult
• Mild-moderate: may be discharged with
  close follow up secured. Instructions on
  when to return should be given
   Pseudomembranous Colitis
• Inflammatory bowel disorder with
  membrane-like yellowish plaques of
  exudate overlie and replace necrotic
  intestinal mucosa
   Pseudomembranous Colitis
• Epidemiology:
• Clostridium Difficile- spore forming
  obligate anaerobic bacillus
• 3 types: neonatal, post-operative and
  antibiotic associated
• Risk factors: recent atbx, GI surgery,
  severe medical illness, advancing age
• Transmission: direct contact and objects
   Pseudomembranous Colitis
• Pathophysiology: 10-25% of hospital
  patients are colonized
• Diarrhea in recently hospitalized person
  should suggest C.difficile
• Broad spectrum atbx such as clindamycin,
  cephalosporins, amp/amox- alter gut flora
  and allow C.difficile to flourish
• However any atbx can lead to C.difficile
     Pseudomembranous Colitis
•   C. difficile produces
•   toxin A enterotoxin
•   toxin B cytotoxin
•   Toxins interact and produce the colitis and
    associated symptoms
   Pseudomembranous Colitis
• Clinical features: from frequent mucoid,
  watery stools to profuse toxic
  diarrhea(>20-30 stools/day), abdominal
  pain, fever, leukocytosis, dehydration,
  hypovolemia
• Stool exam may reveal fecal leukocytes
   Pseudomembranous Colitis
• Complications: severe electrolyte
  imbalance, hypotension, anasarca from
  low albumin, toxic megacolon, bowel
  perforation
• Onset is typically 7-10 days after starting
  atbx therapy
   Pseudomembranous Colitis
• Extraintestinal complications are rare, but
  include: arthritis, visceral abscesses,
  cellulitis, necrotizing fasciitis,
  osteomyelitis, prostheitc device infection
   Pseudomembranous Colitis
• Diagnosis: hx of diarrhea that develops
  during or within 2 weeks of atbx treatment.
• Confirmed by stool for C.difficile toxin and
  colonoscopy
• Most labs use ELISA to detect C.difficile
  toxins even though there are many other
  modes
• 5-20% of patients require more than one
  stool to diagnose
   Pseudomembranous Colitis
• Treatment: d/c atbx, supportive IVF,
  electrolyte correction, flagyl 250 mg qid, or
  vancomycin 125-250mg po qid(alternative
  regimen)
• 25% of patients will respond to supportive
  measures only
• Severely ill patients should hospitalized
   Pseudomembranous Colitis
• Relapses occur in 10-20% of patients
• Use of anti-diarrheals should be avoided
• Surgery or steroids are rarely needed
   Pseudomembranous Colitis
• Disposition:
• Severe diarrhea, symptoms that persist
  despite outpatient management, or those
  with systemic response(fever,
  leukocytosis, severe abdominal pain)
  should be hospitalized
• Suspected perforation, toxic megacolon or
  failure to respond to medical treatment
  need a surgical consult
   Pseudomembranous Colitis
• For patients who are discharged whom:
  good oral intake must be encouraged.
  Flagyl or vancomycin are equally effective
  for treatment.
             Diverticulitis
• Acute inflammation of the wall of a
  diverticulum and surrounding tissue
• Caused by either a micro- or
  macroperforation
             Diverticulitis
• Epidemiology:
• Acquire disease of the colon has become
  common in industrialized nations
• Approximately 1/3 of population will
  acquire diverticuli by age 50 and 2/3 by
  age 85
• Rare <20 years
              Diverticulitis
• Diverticulitis is estimated in 10-25% of
  people with known diverticulosis
• Incidence increases with age
• Only 2-4 % are < 40
• Diverticulitis in younger age is associated
  with more complications requiring surgical
  intervention
              Diverticulitis
• Frequency is slightly higher in men, the
  incidence is on the rise in women
               Diverticulitis
•   Pathophysiology:
•   Cause is not known
•   Low residue diets have been implicated
•   Acute complications: Inflammation(and
    associated complications) and Bleeding
              Diverticulitis
• Inflammation is the most common
  complication of diverticulosis
• Mechanism was thought to occur when
  fecal material was inspissated in the neck
  of a diverticulum, resulting in bacterial
  proliferation, mucous secretion, and
  distention
             Diverticulitis
• More commonly, it results from high
  pressure in the colon, erosion of
  diverticulum wall, microperforation, and
  inflammation.
• Free perforation can occur with
  generalized peritonitis, but is uncommon
             Diverticulitis
• Other complications: obstruction and
  fistula formation between the bladder and
  diverticulum
             Diverticulitis
• Clinical Features: most common symptom
  is pain.
• Described as steady, deep discomfort in
  the LLQ
• Other complaints: change in bowel habit,
  tenesmus, dysuria, frequency, UTI,
  distention, nausea, vomiting,
              Diverticulitis
• Presentation may be indistinguishable for
  acute appendicitis
• Diverticulitis should always be considered
  in patient >50 with abdominal pain
• Perforation is characterized by sudden
  lower abdominal pain progressing general
  abdominal pain
              Diverticulitis
• Physical exam: frequently fever of 38 C,
  localized abdominal tenderness, voluntary
  guarding, rebound, rectal tenderness on
  left side, possibly occult blood +,
• As always, Pelvic should be done with
  female
• Watch for signs of peritonitis or perforation
              Diverticulitis
• Diagnosis: typically suspected by Hx and
  physical
• Abdominal plain films can show partial
  SBO, free air, extraluminal air
• CT is procedure of choice. Demonstrates
  inflammation of pericolic fat, diverticula,
  thickening of bowel wall, peridiverticular
  abscess
             Diverticulitis
• Barium enema can be done, but are
  insensitive and may cause perforation due
  to the introduction of barium at high
  pressures
• Routine labs include: CBC, electrolytes,
  BUN/creatinine, UA
• Sigmoidoscopy and colonoscopy are
  performed only after inflammation has
  decreased
               Diverticulitis
• Differential Dx:
• Similar to that of appendicititis, Crohn
  disease, UC, and C.difficile colitis
               Diverticulitis
• Treatment:
• NPO, IVF, electrolyte correction, NG for
  obstruction, Broad spectrum atbx,
  observation for complications
• Outpatient management includes liquids
  only for 48 hours and oral
  antibiotics(Cipro, flagyl, bactrim, ampicillin)
             Diverticulitis
• Disposition:
• Patients without signs of peritonitis or
  systemic infection maybe treated as
  outpatients with careful follow up
  arranged. Should be instructed to return
  for fever, increasing pain, unable to
  tolerate po.
              Diverticulitis
• If patient shows signs of systemic
  infection, perforation or peritonitis then
  they should be hospitalized with a surgical
  consult
               Questions:
• 1. With a retrocecal appendix, the pain of
  acute appendicitis may localize to the right
  flank. (True or false)
• 2. Outpatient antibiotics is the standard
  treatment of acute appendicitis. (True or
  False)
                Questions:
• 3. Special populations of people that may have
  delayed diagnosis of acute appendicitis due to
  atypical presentation include:
• A.) very young patients
• B.) elderly patients
• C.) AIDS patients
• D.) Pregnant patients
• E.) all of the above
               Questions:
• 4. Crohn disease can involve:
• A.) any part of the GI tract(from mouth to
  anus
• B.) colon only
• C.) esophagus only
• D.) small intestine only
               Questions:
• 5. Ulcerative colitis and Crohn disease are
  both considered types of inflammatory
  bowel disease. (True or False)

• Answers: 1T, 2F, 3E, 4A, 5T

				
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