Colorectal 3 (673-684)

Question 1

What is ulcerative colitis?;

Answer 1

Ulcerative colitis is a chronic inflammatory bowel disease characterised by diffuse inflammation of the mucosa of the colon and rectum. The disease typically follows a remitting and relapsing course.

Question 2

Name some risk factos for ulcerative colitis;

Answer 2

Age (2 peaks: 15-30 and >60). Family history. (Smoking is protective)

Question 3

Name three difference in the clinical presentation between ulcerative colitis and Crohn’s;

Answer 3

UC - proctitis common, bloody diarrhoea (cardinal feature), Primary Sclerosing cholangitis. Crohn’s- episodic abdominal pain (colicky), abdo pain varies in region of bowel involved, oral apthous ulcers

Question 4

What are the macroscopic and microscopic difference between ulcerative colitis and Crohn’s disease?;

Answer 4

UC microscopic- crypt abscess formation, Reduced goblet cells, Non-granulomatous. UC macroscopic- continuous inflammation (rectum proximally), Pseudopolyps and ulceration, mucosa only. Crohns microscopic- Granulomatous (non-caseating). Crohns macroscopic- Skip lesions, Fissures and deep ulcers (cobblestone appearance), fistula appearance, transmural involement (all layers).

Question 5

What radiological features would you expect in a patient with ulcerative colitis?; https://teachmesurgery.com/general/large-bowel/ulcerative-colitis/

Answer 5

Lead pipe. Thumb printing.

Question 6

What radiological features would you expect in a patient with Crohn’s?;

Answer 6

Hosepipe.

Question 7

What drugs can be considered in patients with ulcerative colitis?; https://gramproject.com/diagram/management-of-ulcerative-colitis-uc-flares/

Answer 7

Topical aminosalicylate, oral aminosalicylate, topical corticosteroid, oral corticosteroid, IV corticosteroid, IV ciclosporin (infliximab if ciclosporin contraindicated)

Question 8

What drugs can be considered in patients with Crohn’s disease?;

Answer 8

Multiple medications can be used and depends on severity. Immunosuppresive agents- azathioprine (5 ASA) or mesalazine or meracptopurine. Biological agents- infliximab or adalimumab. Other-methotrexate.

Question 9

What is the serious side effect of treatment with thiopurines and what test can be done pre-treatment?;

Answer 9

(Immunosuppresive drugs such as azathioprine) Myelosuppression (bone marrow suppression, Hepatoxicity, GI symptoms. TPMT test.

Question 10

What are the key management principles in patients with acute exacerbation inflammatory bowel disease?;

Answer 10

Inducing remission- corticosteroids. Nutritional support

Question 11

What are the indications for surgery in a patient with ulcerative colitis?;

Answer 11

Emergency setting- toxic megacolon, colonic perforation, uncontrolled bleeding. Elective setting- medically refractory disease, medication intolerance or colorectal cancer. Surgery in three staged approach- 1st subtotal colectomy with end ileostomy. 2nd stage completion proctectomy and ileal-pouch anal anastomosis formation with a temporary loop ileostomy. 3rd stage- ileostomy reversal.

Question 12

What are the indications for surgery in a patient with Crohn’s disease?;

Answer 12

Failed medical management or developed severe complications such as strictures or perforation. Bowel-sparring approach taken to prevent short gut syndrome.