Crohn's complications Flashcards
What is Crohn’s disease?
Crohn’s disease is a long-term condition that causes inflammation of the lining of the digestive system.
Where in the digestive system does inflammation due to Crohn’s disease occur?
Can affect any part of the digestive tract, but most commonly occurs in the ileum or the colon
What are common symptoms of Crohn’s disease?
recurring diarrhoea
abdominal pain and cramping, which is usually worse after eating
extreme tiredness (fatigue)
unintended weight loss
blood and mucus in your faeces
What is the pattern of Crohn’s symptoms?
Remission and relapse
Less common Crohn’s symptoms?
a high temperature (fever) of 38C (100F) or above
nausea
vomiting
joint pain and swelling (arthritis)
inflammation and irritation of the eyes (uveitis)
areas of painful, red and swollen skin – most often the legs
mouth ulcers
Why may children with Crohn’s disease may grow at a slower rate than expected?
The inflammation can prevent the body absorbing nutrients from food
When should you seek medical advice with Crohn’s?
persistent diarrhoea
persistent abdominal pain
unexplained weight loss
blood in your stools
What are the causes of Crohn’s disease?
Exact causes are unknown, thought to be caused by a combination of:
genetics
the immune system
smoking
previous infection
environmental factors
What immune system factor leads to destruction of gut microbiota in Crohn’s?
TNF-alpha
How can previous infection lead to Crohn’s?
Can cause an abnormal immune response
Aside from family history and ethnic background, what is the most important risk factor for Crohn’s disease?
Smoking
Smokers are twice as likely to develop the condition than non-smokers.
Furthermore, people with Crohn’s disease who smoke usually experience more severe symptoms and are much more likely to require surgery.
What 2 unusual aspects of Crohn’s disease that have led many researchers to believe that environmental factors may play a role?
Crohn’s disease is a “disease of the rich”. The highest number of cases occurs in developed parts of the world, such as the UK and the US, and the lowest number occur in developing parts of the world, such as Africa and Asia.
Crohn’s disease became much more widespread from the 1950s onwards.
What two hypotheses suggest that there is something associated with modern Western lifestyles that increases a person’s risk of developing Crohn’s?
Hygiene hypothesis- suggests that as children grow up in increasingly germ-free environments, their immune system doesn’t fully develop because of a lack of exposure to childhood infections. However, there’s little in the way of hard scientific evidence to support this theory.
An alternative theory is the cold-chain hypothesis, which suggests that the increase in Crohn’s disease cases might be linked to the increased use of refrigerators after the Second World War.
What aspects of initial history are discussed if Crohn’s is suspected?
diet
recent travel – for example, you may have developed travellers’ diarrhoea while travelling abroad
whether you’re taking any medication, including any over-the-counter medicines
whether you have a family history of Crohn’s disease
What initial tests are carried out in Crohn’s?
check your pulse
check your blood pressure
measure your height and weight
measure your temperature
examine your abdomen
What can blood tests indicate in Crohn’s?
Inflammatory markers
Infection
Anaemia (can suggest malnutrition or blood loss from abdomen)
What do we look for in a stool sample for Crohn’s
Blood
Mucus
Infection (parasitic e.g. roundworm)
Fecal calprotectin- to distinguish between IBS and IBD
What happens after you provide a blood and stool sample for Crohn’s
You’ll be referred to a gastroenterologist They’ll discuss the results with you
May conduct one/ more of the following tests:
Colonoscopy
Wireless capsule endoscopy
MRE and CTE scans
Small bowel enema or small bowel follow-through
How can a colonoscopy aid diagnosis in Crohn’s?
Show the level and extent of inflammation inside your colon
Can be used for biopsy
What happens in wireless capsule endoscopy?
Involves swallowing a small capsule (about the size of a large vitamin tablet). The capsule works its way down to your small intestines, where it transmits images to a recording device worn on a belt or in a small shoulder bag.
A few days after the test, the capsule passes out of your body in the stool. The capsule is disposable, so you don’t have to worry about retrieving it from your stools.
As this is a relatively new test, availability may be limited. In some cases, MRE or CTE scans may be used instead of capsule endoscopy.
What is the difference between enterography and enteroclysis in magnetic resonance enterography/enteroclysis (MRE) or computerised tomography enterography/enteroclysis (CTE)?
In enterogrpahy, you drink a contrast agent where’s in enteroclysis contrast agent is placed through a tube in your nose that leads to your small intestine
Difference between MRE and CTE?
During an MRE scan, magnetic fields and radio waves are used to produce detailed images of your small intestines. During CTE scans, several X-rays are taken and assembled by computer to create a detailed image.
Why are MRE and CTE scans being used increasingly over small bowel enema or small bowel follow-through?
Allow more detailed examination of the small intestine.
MRE scans also avoid any exposure to X-ray radiation
How much of the small intestine is seen in a colonoscopy?
Usually last 20cm
How much of the small intestine is seen in a small bowel enema or small bowel follow-through?
Whole of the inside of the small intestine, usually at the point where it meets the colon
What happens during SBE/ SBFT?
A local anaesthetic spray is used to numb the inside of your nose and throat.
A tube is passed down your nose and into your throat before being threaded into your small intestine.
Barium is passed down the tube
A series of X-ray images will then be taken. The images can often highlight the areas of narrowing and inflammation caused by Crohn’s disease
After the test, you’ll be advised to drink plenty of fluid to help wash the barium out of your body.
You may notice that your stools look white for the first few days after having an SBE or SBFT
What are the aims of treatment for Crohn’s disease?
Reduce symptoms/ induce remission
Maintain remission
In children, treatment also aims to promote healthy growth and development
Who is involved in MDT for treating Crohn’s?
A range of healthcare professionals, including specialist doctors (such as gastroenterologists or surgeons), GPs and specialist nurses.
What is it called when your Crohn’s is causing moderate/ severe symptoms?
How is this treated?
“Active disease”.
Treatment for active Crohn’s disease usually involves medication, but surgery is sometimes the best option.
What is the initial treatment for Crohn’s?
Steroid medication (corticosteroids) e.g. prednisolone tablets or hydrocortisone injections to reduce inflammation
If you prefer, you may be able to choose to have a milder steroid called budesonide, or a type of medication called a 5-aminosalicylate (such as mesalazine), as an alternative initial treatment. These medications have fewer side effects, but they’re less effective.
Side effects of corticosteroids?
What does this mean for treatment?
weight gain
swelling of the face
increased vulnerability to infections
thinning and weakening of the bones (osteopenia and osteoporosis)
Because of these possible side effects, your dose will be gradually reduced when your symptoms start to improve.
In children or young people, where there are concerns about growth and development, what additional initial treatment for Crohn’s is considered?
a special liquid diet may be recommended as an initial treatment. This is known as an elemental or polymeric diet, and it can reduce inflammation by allowing your digestive system to recover while ensuring you get all the nutrients you need.
If your symptoms flare up twice or more during 12 months, or return when your steroid dose is reduced what further treatment is recommended?
Immunosuppressants- usually azathioprine/ mercatopurine
Blood test should be carried out to test if you can use these medications
If they’re not suitable, an alternative immunosuppressant medication called methotrexate may be used
Side effects of immunosuppressants
nausea and vomiting
increased vulnerability to infection
pancreatitis
feeling tired, breathless and weak, which is caused by anaemia
liver problems
During the course of medication, you’ll have regular blood tests to check for serious side effects
Can immunosuppressants be taken during pregnancy?
Azathioprine and mercaptopurine are considered safe in pregnancy and breastfeeding.
However, methotrexate must not be taken for at least 6 months before trying for a baby, as this drug is known to cause birth defects. This applies to both men and women. It must also be avoided while you’re breastfeeding.
It’s important to speak to your doctor if you’re planning a pregnancy or if you become pregnant during your course of treatment for Crohn’s disease.
What treatment is used in cases of severe Crohn’s where corticosteroids and immunosuppressants are unsuitable or ineffective?
Biological therapies (powerful immunosuppressant medication created using naturally occurring biological substances, such as antibodies and enzymes)
The 2 medicines used to treat Crohn’s disease in the UK are called infliximab and adalimumab. Target TNF-alpha, which is believed to be responsible for the inflammation associated with Crohn’s disease. Infliximab can be used for children over 6 years old and adults, but adalimumab should only be used by adults.
Infliximab is given as an infusion in hospital. Adalimumab is given as an injection, and it may be possible for you, a family member or a friend to be taught how to give it.
Treatment usually lasts at least 12 months, unless these drugs stop being effective sooner than this. After this time, your condition will be assessed to determine if further treatment is necessary.
Risks of biologic treatment?
There’s a risk of these medicines causing an allergic reaction, which can cause symptoms such as:
itchy skin
a high temperature
joint and muscle pain
swelling of the hands or lips
problems swallowing
You should seek immediate medical assistance if you experience these symptoms. Reactions can occur immediately after treatment, although they have been known to occur months later, even after treatment stops
What type of surgery is used to treat Crohn’s?
Resection
Ileostomy to temporarily divert digestive waste away from the inflamed colon (large intestine) to give it a chance to heal.
Ileum is re-routed through a hole made in the abdomen (stoma) An external bag is attached to the opening to collect waste products.
Once the colon has sufficiently recovered – usually after several months – a second operation will be needed to close the stoma and re-attach the small intestine to the colon.
What is remission and what treatment is used during remission?
Remission is a period when you don’t have any symptoms or your symptoms are mild. During these periods, you can choose whether or not to use medication to help maintain this.
If you decide not to have further treatment, you should be advised about attending regular follow-up appointments and which symptoms to look out for. These symptoms include unintended weight loss, abdominal pain and diarrhoea.
If you choose to have treatment, this will usually involve immunosuppressants. Corticosteroids aren’t recommended for maintaining remission.
Can diet and smoking aggravate Crohn’s?
No evidence
Some people find that certain food aggravates symptoms- can keep food diary to monitor
However, the total elimination of entire food types, such as grains or sugars, isn’t usually recommended.
Some people find that eating 6 smaller meals a day, rather than three larger meals, improves their symptoms.
If you smoke, stopping can also reduce your symptoms and maintain remission.
Two most common complications of Crohn’s
Intestinal stricture
Fistula
What happens in intestinal stricture
inflammation–>scarring–>narrowing/stricture–> bowel obstruction which causes
abdominal pain and cramping
being sick (vomiting)
bloating
an uncomfortable feeling of fullness in your abdomen
If untreated–>perforation
How is intestinal stricture treated?
Non- surgically with balloon dilation, which is performed during colonoscopy.
During balloon dilation, a colonoscope is passed rectum and a balloon is inserted through the colonoscope. This is then inflated to open up the affected area.
If this doesn’t work or is unsuitable, a surgical procedure known as a stricturoplasty may be needed to widen the affected area.
What are fistulas
If your digestive system becomes scarred as a result of excessive inflammation, ulcers can develop.
Over time, the ulcers develop into tunnels that run from one part of your digestive system to another or, in some cases, to the bladder, vagina, anus or skin. These passageways are known as fistulas.
Symptoms of fistulas
Small fistulas don’t usually cause symptoms. However, larger fistulas can become infected and cause symptoms, such as:
a constant, throbbing pain
a high temperature (fever) of 38C (100F) or above
blood or pus in your stools
leakage of stools or mucus into your underwear
If a fistula develops on your skin (usually on or near the anus) it may release a foul-smelling discharge.
Fistula treatment
Biological medication is usually used to treat fistulas. Surgery is usually required if these aren’t effective.
Which radiograph shows SBO and which shows LBO
A- SBO, B-LBO
Position of bowel loops- more central in A, more peripheral in B
Haustra in B (more pronounced finger-like projections into lumen than in A, also lines of connective tissue((valvulae conniventes)) in SB go all the way round but haustra don’t go all the way through in image)
Can occasionally see faeces in LB- mottled appearance in radiography
Look at this picture and learn please :)
Another picture to look at and learn kids :))
How much liquid enters and leaves small intestine daily?
(remaining 9.9L reabsorbed at small and large intestine)
What amounts of water are reabsorbed at small and large intestine?
Discuss the RAAS
Which of these is an end ileostomy and which is an end colostomy?
A- colostomy
B- ileostomy
