Crohn's Disease Flashcards
How is it different from UC?
Where is commonly affected?
How does it affect the bowel lining?
Forms skip lesions from mouth to anus
Terminal ileum
Transmural (through whole bowel wall) granulomatous inflammation
Who is it more common in?
Smokers
Younger people more affected compared to UC
Symptoms:
2 common symptoms
3 more obscure ones
How does it tend to present compared to UC?
Diarrhoea - bloody 25% of the time
Lower abdo pain especially RLQ
Weight loss
Fever
Fatigue
More acutely
Signs:
- Perianal - 3
- What might you find in the RIF?
Abscess
Fistula
Tags
Mass from inflammation on palpation
Non-GI signs:
- Mouth - 1
- Eyes - 23
- Nails - 1
- You also get erythema nodosum and pyoderma
gangrenosum. Define both of them?
SAME AS UC
Aphthous ulcers
Uveitis
Episcleritis
Conjunctivitis
Clubbing
A type of panniculitis, an inflammatory disorder affecting subcutaneous fat. It presents as tender red nodules on the anterior shins. Less commonly, they affect the thighs and forearms
A rare, inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow.
Non-GI signs:
You also get entero-colitis. Define it? - What is it also known as?
You also get sacroiliitis. Define it?
ONLY IN CROHNS
Enteropathic arthropathy or enteropathic arthritis refers to acute or subacute arthritis in association with, or as a reaction to, an enteric (usually colonic) inflammatory condition.
Reactive arthritis
Sacroiliitis is a painful condition where either one or both of the sacroiliac joints become inflamed.
Hepatobiliary signs?
1 - ONLY IN CROHNS
3 other hepatobiliary diseases that may present in conjunction with Crohn’s? - Same as UC
Gallstones
Chronic hepatitis
NAFLD
Cirrhosis
Risk factors:
Gene mutation
What ethnicity is it more common in?
NOD2 mutation
White ethnicity
Investigations - Bloods - Why do you do the following:
- FBC - 2
- 2 other things you look for in the blood that could indicate inflammation
- CRP/ESR
- U&E, Mg and Ca
- LFT
- Antibodies for Crohn’s only
FBC - Haemoglobin and haematinics (iron, folate and B12) - patients usually have anaemia
Raised platelets
Low albumin
CRP/ESR - raised in inflammation
Nutritional deficiencies
Hepatobiliary disease
Anti-saccharomyces cerevisiae antibodies (ASCA) - antibodies (70% accurate in Crohn’s)
Investigations - stool:
What can be done to the stool to rule out infection?
Marker for inflammation and why it is used?
One important bacteria that may cause inflammation or colon and diarrhoea?
Culture to rule out infection
Faecal calprotectin
C. diff toxin
Investigations:
What classical signs would you find on endoscopy? - 3
What would biopsy show?
Are crypt changes more common in Crohn’s or UC?
Skip lesions
Cobblestone appearance
Aphthous ulcers
Transmural disease with granulomas
It is more common in UC
Investigations - imaging
AXR:
- what might you find on colon? - 2
- what might you find on the hips? - 1
What is the use of a CT/MRI?
What will a barium enema reveal?
Dilation - toxic megacolon, obstruction
Abscesses
Sacroiliitis
Show the disease extent in more detail
Any strictures
Management - Medical - inducing remission in an attack:
What med do you give to induce remission? Route? How long?
What med is given for 2 wks after this? Route?
When is budesonide used?
Methylprednisolone IV 3 days
Prednisolone PO
If the disease is isolated to the ileocecal region
Management - Medical - inducing remission in an attack:
What should be added if the disease is refractory?
What tends to be done only to kids instead of drugs? Why?
Add azathioprine or Mercaptopurine
Add/switch to the biologic
Enteral nutrition therapy for 6-8 wks - either polymeric formula (drinkable) or elemental formula (via NG tube as too gross to drink).
Less effective than steroids in adult but in kids, it’s more effective and doesn’t affect growth
Management - Medical - maintaining remission:
What one lifestyle change can be done if it is mild?
In what situation would treatment be needed?
What is the first line?
2-second line options?
Smoking cessation
Frequent relapses <6 wks
>2 steroids courses per yr
Relapse <6 wks after stopping steroids
5-ASA - Azathioprine or mercaptopurine
Immunosuppressor - Methotrexate
Biologics
Biologics and Janus Kinase Inhibitors:
Why are they used?
Give some examples of Anti-TNFα?
For induction and maintenance in refractory moderate-severe disease.
Infliximab
Adalimumab
Golimumab
Management - other considerations:
What might provide symptomatic relief?
Rx for upper GI disease?
Meds used for perianal disease? - two ABs and one 5-ASA
Treatment for fistulae
Loperamide
Antispasmodic - slows down GI tract
PPI
Metronidazole PO
Ciprofloxacin PO
Topical mesalazine - 5-ASA
Seton insertion - a thin silicone string inserted into the tract - allows drainage and healing
Surgical:
% that need surgery for Crohn’s
Indications
What is common after surgery?
70%
Medically refractory
Obstruction or perforation from stricture, fistulae and abscesses
Growth failure in kids
Relapse
Surgical - Small bowel procedures include resection ad anastomoses.
If an extensive amount of the small bowel is resected, it may cause short gut syndrome. What are some of the symptoms?
What can be done to avoid having to do this for structures?
Diarrhoea (due to lack of absorption)
Steatorrhoea (due to lack of absorption)
Electrolyte abnormalities (due to lack of absorption)
Malnutrition - vitamin deficiencies, weight loss and fatigue (due to lack of absorption)
Strictureplasty
Surgical - Large bowel procedures:
What is done if in the rectum?
If affecting other parts of the large bowel, what is then done?
Panproctocolectomy with ileostomy
Subtotal colectomy with ileorectal anastomosis
Surgical:
What can be given post-op to maintain remission?
What deficiency may happen if >20cm is removed?
You can also get some bile salt malabsorption due to the loss of the terminal ileum. What can be given to treat this?
Azathioprine plus 3 months of metronidazole
Vitamin B12 deficiency so supplements need to be taken
Cholestyramine - Cholestyramine powder is also used to treat itching caused by a blockage in the bile ducts of the gallbladder.
Severe Crohn’s:
4 things to do?
IV hydration and electrolytes
IV steroids
Thromboembolism prophylaxis
MC&S/CDT to exclude infection
Complications
Small bowel obstruction due to bowel thickening and fibrosis leading to stricture
Abscess
Fistula
Cancer though less than in UC
Azathioprine
MOA
How long does it take to work?
Side effects
What about 5-ASA?
Affects lymphocytes
6-10 wks
Abdominal pain
Nausea
Pancreatitis
Abnormal LFT’s so need monitoring
Has no effect in Crohn’s
