Crohn’s

Question 1

What regions of the gi track are affected by crohn’s disease

Answer 1

Gum to bum but mainly ileum and colon with sparing of rectum

Question 2

Difference between ulcerative colitis and crohn’s

Answer 2

Cohn’s has:
‘ skip lesions’
Rectum sparing
Deep Linear /serpiginous ulcers
Granulomatous inflammation
Fistulae and strictures

Question 3

Rise factors for crohn’s

Answer 3

Smoking
Ashkenazi Jewish ancestry

Question 4

Exacerbating factors for crohn’s

Answer 4

Cigarette smoking
NSAIDs
Infection

Question 5

Symptoms of crohn’s

Answer 5

Abdominal pain ( RLQ, post prandial)
Chronic / nocturnal diarrhea
Weight loss / failure to thrive
Rectal bleeding, anemia
Fever, fatigue
Fissures, fistulae, abscess

Question 6

Natural hx of disease in Cohn’s

Answer 6

10% have chronic relapsing disease
10% become disabled
20-25% eventually undergo colectomy (1% per year)

Question 7

Investigations for crohn’s disease

Answer 7

-CBC, ESR, CRP, LFTs,
- serology for celiac
- stool culture + C. Difficile to r/o infection
- fecal calprotectin to distinguish b/w IBS and IBD
-Diagnosis → Endoscopy + biopsy
-Aids in dx → air contrast barium enema, small bowel follow through
-If high risk of CA → chromoendoscopy
- to assess for complications → u/s, MRI, CT
- Assess nutritional status →B12, albumin
-prep for biologies → hep screen +cxr for Tb

Question 8

Complications of IBD

Answer 8

( Ulcerative colitis)
Urinary calculi
Liver problems
Cholelithiasis
Epithelial problems
Retardation of growth/ sexual maturation
Arthralgia
Thrombophlebitis
Iatrogenic
Vitamin deficiencies
Eyes

Colorectal CA
Obstruction
Leakage (perforation)
Iron deficiency
Toxic megacolon
Inanition
Stricture/fistula

Question 9

How is disease activity quantified in crohns

Answer 9

Cohn’s disease activity index

Question 10

Management of crohn’s

Answer 10

Preventative→
- ensure standard vaccinations up to date (mmrv, tdap, polio, hep a+b, HIV, shingles, procumococcal, flu, hib and meningococcal ( if risk factors)
- smoking cessation
- dietary counselling (replacement of vitamins and minerals based on deficiency) . Fluids only during exacerbation
- osteoporosis prevention ( no moving, exercise, vitamin d 1000 iu/d, calcium 1200 mgld +/- bisphosphonates
- Ca screening
- monitor for Mental Health

Pharmacotherapy
Surgery

Question 11

What are the components of preventative healthcare that should be considered in new dx of crohn’s

Answer 11

• ensure standard vaccinations up to date (mmrv, tdap, polio, hep a+b, HIV, shingles, procumococcal, flu, hib and meningococcal ( if risk factors)
• smoking cessation
• dietary counselling (replacement of vitamins and minerals based on deficiency) . Fluids only during exacerbation
• osteoporosis prevention ( no moving, exercise, vitamin d 1000 iu/d, calcium 1200 mgld +/- bisphosphonates
• Ca screening: 8-10 yrs after onsetof dx, q 1-5 years (5 you if 2 or more consecutive normal c-scopes and continued disease remission.2-3 yr I mild disease, no fdr<50
• monitor for Mental Health

Question 12

What are the treatment targets for crohn’s

Answer 12

• Immediate treatment target → Clinical response ( 50% or more decrease in patient reported outcome of stool frequency And abdominal pain in the crohn’s disease activity index )
• intermediate target → normalized crp and fecal calprotectin
• long term goal → endoscopic healing (absences of ulcerations)
• remissions → pro2 ( abdo pain <_ 1, stool frequency<_ 3)

Question 13

Pharmacotherapy for crohn’s

Answer 13

1 - sulfasalazine → mild
2- budesonide 9mg/d → mild
3- prednisone 20-40 mg/d → mild, mod, severe, fulminant (IV). Does not achieve mucosal healing so only use short-term
4-thiopurines ( azathioprine, 6- mercaptopurine ) → mod, severe, fistula, maintenance. Consider thiopurine methyltransferase testing prior to initiating. Combination with infliximab more effective than menotherapy. Avoid monotherapy in peds and using as maintenance in female patients
5 - methotrexate → mod, severe, maintenance
6- Anti TNF (infliximab,adalimumab)→
Mod, severe. Refractory, fulminant, fistula. Used if refractory to steroids, Mtx and thiopurines. Risk of febrile
Neutropenia. Combine with Mtx in ped
7- Anti integrin (vedalirumab)→ mod, severe
8- natalizumab → mod, severe, maintenance. Ensure JC virus -ve prior to initiation and q6mo
9 - ustekinumab→ refractory, maintenance
10 - tacrolimus → fistula
1I- antibiotics → fistula

Question 14

Indication for surgical therapy of Crohn’s

Answer 14

Complications such as fistula, obstruction, abscess

Question 15

Rate of recurrence for crohn’s

Answer 15

50% in 5 yrs, 85% in 15 yrs