Crohn's complications Flashcards
1
Q
What is Crohn’s disease?
A
Crohn’s disease is a long-term condition that causes inflammation of the lining of the digestive system.
2
Q
Where in the digestive system does inflammation due to Crohn’s disease occur?
A
Can affect any part of the digestive tract, but most commonly occurs in the ileum or the colon
3
Q
What are common symptoms of Crohn’s disease?
A
recurring diarrhoea
abdominal pain and cramping, which is usually worse after eating
extreme tiredness (fatigue)
unintended weight loss
blood and mucus in your faeces
4
Q
What is the pattern of Crohn’s symptoms?
A
Remission and relapse
5
Q
Less common Crohn’s symptoms?
A
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
6
Q
Why may children with Crohn’s disease may grow at a slower rate than expected?
A
The inflammation can prevent the body absorbing nutrients from food
7
Q
When should you seek medical advice with Crohn’s?
A
persistent diarrhoea
persistent abdominal pain
unexplained weight loss
blood in your stools
8
Q
What are the causes of Crohn’s disease?
A
Exact causes are unknown, thought to be caused by a combination of:
genetics
the immune system
smoking
previous infection
environmental factors
9
Q
What immune system factor leads to destruction of gut microbiota in Crohn’s?
A
TNF-alpha
10
Q
How can previous infection lead to Crohn’s?
A
Can cause an abnormal immune response
11
Q
Aside from family history and ethnic background, what is the most important risk factor for Crohn’s disease?
A
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.
12
Q
What 2 unusual aspects of Crohn’s disease that have led many researchers to believe that environmental factors may play a role?
A
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.
13
Q
What two hypotheses suggest that there is something associated with modern Western lifestyles that increases a person’s risk of developing Crohn’s?
A
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.
14
Q
What aspects of initial history are discussed if Crohn’s is suspected?
A
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
15
Q
What initial tests are carried out in Crohn’s?
A
check your pulse
check your blood pressure
measure your height and weight
measure your temperature
examine your abdomen
16
Q
What can blood tests indicate in Crohn’s?
A
Inflammatory markers
Infection
Anaemia (can suggest malnutrition or blood loss from abdomen)
17
Q
What do we look for in a stool sample for Crohn’s
A
Blood
Mucus
Infection (parasitic e.g. roundworm)
Fecal calprotectin- to distinguish between IBS and IBD
18
Q
What happens after you provide a blood and stool sample for Crohn’s
A
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
19
Q
How can a colonoscopy aid diagnosis in Crohn’s?
A
Show the level and extent of inflammation inside your colon
Can be used for biopsy
20
Q
What happens in wireless capsule endoscopy?
A
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.
21
Q
What is the difference between enterography and enteroclysis in magnetic resonance enterography/enteroclysis (MRE) or computerised tomography enterography/enteroclysis (CTE)?
A
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
22
Q
Difference between MRE and CTE?
A
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.
23
Q
Why are MRE and CTE scans being used increasingly over small bowel enema or small bowel follow-through?
A
Allow more detailed examination of the small intestine.
MRE scans also avoid any exposure to X-ray radiation
24
Q
How much of the small intestine is seen in a colonoscopy?
A
Usually last 20cm
25
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
26
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
27
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
28
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.
29
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.
30
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.
31
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.
32
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.
33
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
34
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
35
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.
36
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.
37
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
38
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.
39
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.
40
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.
41
Two most common complications of Crohn's
Intestinal stricture
Fistula
42
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
43
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.
44
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.
45
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.
46
Fistula treatment
Biological medication is usually used to treat fistulas. Surgery is usually required if these aren't effective.
47
Other Crohn's complications
osteoporosis – weakening of the bones caused by the intestines not absorbing nutrients and the use of steroid medication to treat Crohn's disease
iron deficiency anaemia – a condition that can occur in people with Crohn's disease because of bleeding in the digestive tract; common symptoms include tiredness, shortness of breath and a pale complexion
vitamin B12 or folate deficiency anaemia – a condition caused by a lack of vitamin B12 or folate being absorbed by the body; common symptoms include tiredness and lack of energy
pyoderma gangrenosum – a rare skin reaction that causes painful skin ulcers
Children with Crohn's disease may also experience problems with their growth and development because their bodies aren't absorbing enough nutrients.
48
Can Crohn's increase cancer risk?
Some people with Crohn's disease have a slightly increased risk of developing colorectal cancer in later life.
You should be offered regular check-ups to look for colon cancer if your healthcare team feels you may be at an increased risk.
This usually involves a colonoscopy and a biopsy
49
Possible causes of abdominal pain
Bowel obstruction
Appendicits
Pancreatitis
Cholecystitis
Vascular causes- AAA
Urological causes- renal stones, renal colic
Gynecological causes, especially in women of childbearing age- ectopic pregnancy
Some chest pathology- lower lobe pneumonia
50
Site of pain in appendicitis
Migratory- starts umbilical, then RLQ (can vary depending on anatomical location)
51
Character of pain in appendicitis
Usually consistent with intermittent cramps
52
Associated symptoms of appendicitis
Anorexia- very common (highly sensitive sign in children)
Nausea and vomiting
Failure to pass flatus/ stool
Rovsing's sign
53
Exacerbating factors of appendicitis
Movement, coughing
54
Site of pain in SBO
Umbilical
55
Character of pain in SBO
Colicky and severe
56
Associated symptoms of SBO
Anorexia
Nausea and vomiting
Failure to pass flatus/ stool
Abdominal distension/ bloating
57
Exacerbating factors of SBO
Oral intake
58
Site of pain in pancreatitis
Epigastric/ LUQ pain, radiating to back
59
Character of pain in pancreatitis
Constant and severe
60
Associated symptoms of pancreatitis
Nausea and vomiting
Anorexia
Dyspnoea
61
Exacerbating factors of pancreatitis
Worse on movement
62
Site of pain in cholecystitis
Constant RUQ pain, might get shoulder pain
63
Character of pain in cholecystitis
Constant and severe
64
Associated symptoms of cholecystitis
Nausea and vomiting, Murphy's sign
65
Exacerbating factors of cholecystitis
Eating fatty foods
66
Is small bowel obstruction a surgical emergency?
Yes.
67
Why does the small bowel dilate proximal to site of SBO?
What can this lead to?
Blockage-->build up of food contents, GI secretions
Can leas to nausea and vomiting
68
What can cause abdominal pain in SBO?
Wall of small bowel is stretched and pressure within the wall rises due to dilatation
Reduced blood supply--> ischaemia
69
Why is pain of SBO initially colicky
Peristaltic wave propels food contents against obstruction
70
Why do patients with SBO have issues with opening bowels/ passing flatus?
Bowel contents can't pass distal to obstruction
71
What can cause bloating and burping in SBO?
Abdominal distension and gas build up
72
How can the location of obstruction affect symptoms of SBO?
If obstruction is more proximal i.e. in jejunum nausea and vomiting are more likely but if obstruction is in descending colon vomiting less likely, constipation/ lack of flatus more prominent
LBO may cause more peripheral distension of abdomen, SBO may cause more central distension of the abdomen (unreliable, need to confirm with imaging)
73
Causes of SBO
Adhesions (one of most common causes of SBO)- abdominal surgery-->scar tissue-->obstruction
Hernias- organs protruding through weakened abdominal wall (e.g. post operative hernia when scar tissue doesn't heal properly)
Most hernias are reducible (can be pushed back), but some can get strangulated causing inflammation, swelling and obstruction
Crohn's
Foreign bodies
malignancy
74
Causes of LBO
Colon cancer- more common in the elderly
Diverticulitis leading to formation of strictures
Volvulus
75
Risks of bowel surgery
Bleeding, infection, pain
DVT/ pulmonary embolism- use socks during operation to reduce risk
Risk of damage to bladder, bowels, ureters, spleen, liver
Won't be able to eat/ drink immediately after
Hernia
May need to perform more operations
76
What imaging can be used for acute abdomen?
Ultrasound
Abdominal Xray
CT
77
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
78
What is the 3/6/9 rule in abdominal radiography
SB should measure less than 3cm across
LB should measure less than 6cm across
Caecum should measure less than 9cm across
If not, could indicate obstruction.
79
Look at this picture and learn please :)
80
Another picture to look at and learn kids :))
81
Why should an RhD negative individual be cautious in accepting RhD positive blood for transfusion in the context of potential future pregnancy
RhD negative individuals will not have RhD antigen on RBC membrane.They WILL have anti-RhD B cells in plasma (central tolerance-every B cell that binds too strongly to a host antigen will be destroyed via negative selection. Since RhD negative individuals don't have the RhD antigen the anti-RhD B cells won't be negatively selected)
Only a few found in blood, will not do any damage to future baby on their own as they don't cross placenta (too big-even pentameric IgM can't cross, and these are CELLS, so much bigger).
However exposure to RhD antigen-->sensitisation-->clonal expansion-->large numbers of plasma B cells that can make anti-RhD IgG antibodies (small enough to pass placental barrier)
Results in haemolytic disease of the newborn
82
Does exposure to RhD antigen only occur during blood transfusion?
No- can occur during previous pregnancy (if previous baby was RhD positive)- occurs at point of delivery when a bit of baby's blood leaks into maternal circulation
83
How much liquid enters and leaves small intestine daily?
(remaining 9.9L reabsorbed at small and large intestine)
84
What amounts of water are reabsorbed at small and large intestine?
85
How does ileostomy affect water reabsorption?
The resected portion can't reabsorb water
Leads to loss of water and electrolytes
86
How does the body adapt to loss of reabsorption capacity due to bowel resection?
Mucosal layer hypertrophy (increase in cell size) and hyperplasia (increase in cell number)- enhances reabsorptive capacity
Aldosterone level up regulation
Hypomotility- reduce rate at which contents move through small intestine
87
Discuss the RAAS
88
Difference between sodium retention and sodium resorption
Retention happens at kidneys, resorption occurs in small intestine
Both stimulated by aldosterone
89
Which of these is an end ileostomy and which is an end colostomy?
A- colostomy
B- ileostomy
90
Define stoma
Therapeutic opening in the wall of a hollow viscus
Can be temporary or permanent
91
How could you differentiate between ileostomy and colostomy?
Site- can bring stomas to skin anywhere, but more common for ileostomies to be in RLQ and colostomies to be in LLQ)
Appearance- ileostomy is spouted and protruding, colostomy is flush to the skin (small bowel contents is quite liquid and has a lot of digestive enzymes which could irritate skin, but in colostomy more faecal material)
Contents
92
What parts of bowel do we remove in a bowel resection
Necrosing bowel
Ischemic bowel
Compromised blood supply
93
How would we decide whether to join ends of bowel together or form a stoma?
In emergency (where bowel is highly inflamed/ oedematous), an anastomosis would be at risk of breakdown because oedematous bowel doesn't heal very well. Inside of abdomen might also be contaminated/ septic so don't want to anastomose.
Later, if bowel is healthy enough, might reverse this. Some may have stoma for life.
94
Difference between single barrel and loop ileostomy/ colostomy
Single barrel is end of alimentary canal, single lumen.
Loop has 2 lumens- you bring a little bit of bowel to surface and more distal bowel is defunctioned. Easier to reverse and put back
95
Major concern in Crohn's?
Lack of predictability- don't know which patients respond to treatment, develop complications.
96
How do strictures form?
Chronic inflammation in the intestines can cause the walls of your digestive tract to thicken or form scar tissue. This can narrow a section of intestine, called a stricture, which may lead to an intestinal blockage.
97
What is strictureplasty?
A surgical procedure to repair a stricture by widening the narrowed area without removing any portion of your intestine.
98
How are strictures treated?
When strictures are caused by disease inflammation, initial treatment may typically include medication to help improve the narrowing of the intestines. Surgery may also be a necessary option. Strictureplasty and small bowel resection are two surgical procedures to repair a stricture.
99
Symptoms of a stricture
Nausea
Vomiting
Severe cramping
Constipation
100
Is strictureplasty generally a safe procedure? Is it effective?
Strictureplasty is a generally safe procedure. It is most effective in the ileum and the jejunum.
Strictureplasty is less effective in the duodenum.
101
Why is strictureplasty generally preferred to resection?
Strictureplasty avoids the need to remove a section of your small intestine. It is preferred when possible, because removing portions of your small intestine cause sometimes cause other complications, including a condition called short bowel syndrome (SBS) which occurs when large sections of the small intestine are removed due to surgery (or various surgeries) and the body is unable to absorb adequate amounts of nutrients and water.
102
What happens during strictureplasty?
Your surgeon will make cuts lengthwise along the narrowed areas of your intestine, then sew up the intestine crosswise.
This type of incision and repair shortens and widens the affected part of your bowel, allowing food to pass through.
Your surgeon may repair several strictures during the same surgery.
103
How do fistulas form
Fistulas form when inflammation causes sores, or ulcers, to form on the inside wall of the intestine or nearby organs. Those ulcers can extend through the entire thickness of the bowel wall, creating a tunnel to drain the pus from the infected area. An abcess, or a collection of pus, can also cause a fistula to form.
104
Types of fistulas
The most common types of fistulas in Crohn’s disease patients form between two parts of the intestine, between the intestine and another organ, such as the bladder or vagina, or through to the skin surface. Women with Crohn’s disease can also develop a fistula between the rectum and vagina, which may be difficult to treat. Surgical treatment depends on individual circumstances.
105
How common are fistulas in Crohn's
About 35 to 50 percent of adults with Crohn’s disease will develop a fistula at some point.
106
Fistula between the small and large intestine symptoms
Diarrhea
Passage of undigested food
107
Fistula between the intestine and the bladder symptoms
Urinary tract infection
Burning with urination
Cloudy urine or blood in the urine
108
Fistula between the intestine and the vagina symptoms
Passage of gas or stool through the vagina
109
Fistula from the intestine to the skin symptoms
Can initially present as a painful bump or boil
Skin abscess that is open and draining fluid or stool
110
Fistula treatment
While some fistulas can be treated with antibiotics and other medication, fistula removal surgery may be necessary if the infection doesn’t respond to medication or if the fistula is severe enough to require emergency surgery.
There are several surgical options to treat fistulas, including:
A medical plug to close the fistula and allow it to heal
A thin surgical cord, called a seton, placed into the fistula to help drain any infection and allow it to heal
Opening up the fistula with an incision along its length to allow it to heal
Medical glue to close the fistula
111
Anal Fistula Removal
An anal fistula is a tunnel that forms between the inside of the anus and the skin surrounding the anus. This is often repaired with a surgical procedure called a fistulotomy.
The primary goal is to repair the fistula without damaging the anal sphincter muscles, which are necessary for fecal continence, the ability to hold fecal material in your rectum.
Recurrence rates for anal fistulas are fairly low after surgery.
Complications are rare and there is typically little impact on fecal continence.
112
Ileostomy
Your stool will sometimes need to be diverted from the intestine while its healing from fistula surgery. This is done with an ileostomy, a procedure that brings the small intestine up through the abdominal wall so that waste can leave your body through a surgically created hole called a stoma.
Feces are collected outside your body in an ostomy pouching system.
An ileostomy is often used as a temporary solution to allow healing.
You may require additional surgery to ensure the intestine is closed at the fistula location
113
Where do abscesses form in Crohn's
Abdomen, pelvis, or around the anal area.
114
Treatment of abscesses
Abscesses require antibiotics to treat the infection, but your doctor may also recommend surgical drainage of the pus cavity to ensure the area heals completely.
115
Symptoms of abscesses
Severe pain in the abdomen
Painful bowel movements
Discharge of pus from the anus
Lump at the edge of the anus that is swollen, red, and tender
Fever
116
Abscess Drainage
The surgeon will make a small cut into the abscess and insert a thin tube to drain the pus.
The tube may be left in for a week or more to allow the abscess to completely drain and begin healing.
Most people feel better within a few days of surgery.
