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Stage 2: Inflammation > Crohn's Disease > Flashcards

Crohn's Disease Flashcards

1
Q

What layer of the GI wall is affected in Crohn’s?

A

Trans-mural (whole wall) inflammation

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2
Q

What is the peak onset age of Crohn’s?

A

20-30

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3
Q

What are the symptoms of Crohn’s?

A
  • Diarrhoea ± blood
  • Rectal bleeding
  • Right ileac fossa pain (cramping)
  • Weight loss and anorexia
  • Perianal abscesses/anal fissure
  • Frequency and urgency
  • Malaise
  • Malnutrition
  • Oral ulceration
  • Fistula formation (can destroy sphincter muscles)
  • Systemic symptoms (10-15%)
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4
Q

What is Crohn’s often misdiagnosed as?

A

Anorexia or IBS

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5
Q

How many patients need surgery in their lifetime?

A

70-80% (50% in first 10 years)

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6
Q

What does the Montreal classification do?

A

Classify Crohn’s by age at diagnosis, location and behaviour

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7
Q

What cell drives the Crohn’s inflammatory response?

A

T cells

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8
Q

What genetic defect is associated with Crohn’s?

A

NOD2 (receptor on Paneth cells) defect - recognise good and bad bacteria, good bacteria get through lining and set up immune reactive response

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9
Q

What are the 5 types of disease distribution?

A

1) Ileo-colonic
2) Ileal (most have some form of ileal disease)
3) Colonic
4) Perianal
5) Upper GI

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10
Q

What are signs of Crohn’s?

A
  • Cachexia
  • Abdominal mass
  • Scars from previous operations
  • Stomas (often 2-3)
  • Parenteral nutrition
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11
Q

What investigations are done to diagnose Crohn’s?

A

1) Blood tests
2) Faecal calprotectin
3) Endoscopy
4) Histology
5) Imaging

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12
Q

What blood test results would you see in Crohn’s?

A

Anaemia and low B12, folate, ferritin and albumin

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13
Q

What would you see in endoscopy for Crohn’s?

A

Discrete ulcers

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14
Q

What would you see in histology and what does it help distinguish between?

A
  • Granulomas and white cells

- Distinguishes between UC and Crohn’s

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15
Q

What imaging would you do in Crohn’s?

A
  • MRI small bowel (would see inflammatory strictures)
  • MRI pelvis
  • Small bowel ultrasound
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16
Q

How do you treat Crohn’s short term?

A

1) Steroids

2) Antibiotics - ciprofloxacin, metronidazole

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17
Q

How do you treat Crohn’s long term?

A

1) Immunosuppressants
2) Biologics
3) Enteral modulen (nutrition)
4) Surgery

18
Q

Describe enteral modulen (nutrition)

A
  • Anti-inflammatory properties
  • Especially useful in paediatrics and pre-surgery
  • If live on this for a few months, can cure Crohn’s, get nutrition but give bowel a rest
  • Can give in combination with diet, dietician advice
19
Q

Describe surgery for Crohn’s

A
  • Can’t cure like UC
  • If remove bowel it will come back and there is a limited amount of bowel can remove (short bowel syndrome)
  • Lifetime risk 80%
  • Examination under anaesthetic (EUA) - perianal abscess/fistula
  • Stricturoplasty - removal of small bowel structure
  • Colectomy
  • Diverting colostomy/ileostomy (stomas) - temporary or permanent
20
Q

What are most of the surgeries for Crohn’s?

A

Operations for fistulas and abscesses

21
Q

What is a common way to do surgery for Crohn’s?

A
  • Not removing bowel, just opening up areas so that food can get through
  • Cut and stitch the other way
22
Q

What kind of surgery might be done for someone with ileo-colonic Crohn’s and a fibrotic stricture?

A

Right hemicolecotmy

23
Q

Why is it difficult to keep patients taking the medication?

A

Bc patients don’t feel any different on them, and worsens immune system

24
Q

How might someone with acute Crohn’s present?

A
  • 2 weeks of worsening abdominal pain
  • Feverish
  • Tender in RIF
  • Cachectic
  • Weight loss 50kg to 43kg
  • CRP 150
25
Q

What is a normal CRP?

A

< 10

26
Q

How would you initially manage someone with acute Crohn’s?

A
  • Antibiotics (good for Crohn’s and infection)
  • CT or MRI (not AXR)
  • Discuss with surgery
  • Avoid steroids
27
Q

What might you see on a scan of someone with acute Crohn’s?

A
  • Perforating Crohn’s with intra-abdominal abscess around ileo-colonic anastomosis
  • Light area = dense inflammation, phlegmon (should be air)
28
Q

How would you treat acute Crohn’s long term?

A
  • Antibiotics
  • Modulen for 6 weeks (increases nutrition)
  • Wean any steroids
  • Planned (not emergency) surgery
29
Q

What is the distribution of Crohn’s?

A

Mouth to anus (patchy, ileum)

30
Q

What are the key histological features of Crohn’s?

A

Granulomas and transmural inflammation

31
Q

What is the relationship between Crohn’s and smoking?

A
  • Increased risk of Crohn’s, ileocaecal disease, fibrostenosis, need for surgery
32
Q

What are key features present in Crohn’s that aren’t present in UC?

A

Fistulas and structures

33
Q

What are two key points when treating Crohn’s?

A

1) Antibiotics are a valid treatment initially

2) imaging is crucial

34
Q

What are possible complications of IBD/Crohn’s?

A
  • Fistulae
  • Malnutrition
  • Increased risk of colon cancer
  • Uncontrolled symptoms may need surgery (stoma)
  • Strictures and bowel obstruction
  • Osteoporosis due to steroids (need calcium)
  • Stones
35
Q

What are indications for Crohn’s surgery?

A
  • Stenosis causing obstruction
  • Enterocutaneous, anal, or intra-abdominal fistulae
  • Perforation
  • Bleeding
  • Draining abscesses
  • Rectovaginal fistulae
36
Q

What are the surgical options for colorectal Crohn’s?

A

1) Panproctocolectomy + ileostomy (gold standard for colorectal disease)
2) Emergency colectomy
3) Segmental colectomy/hemicolectomy
4) Total colectomy + ileorectal anastomosis

37
Q

What are the surgical options for small bowel Crohn’s?

A

1) Stricturoplasty in non-inflamed bowel
2) Resection of stricture
3) Ileocaecal resection

38
Q

Describe post-surgical management of IBD?

A
  • ERAS (enhanced recovery after surgery) - early mobility, fluids, eating straight away
  • Appropriate wound dressing follow up
  • District nurses
  • Crohn’s - medication to try and maintain remission
  • Surveillance for colorectal carcinoma in those whose symptoms started > 10 years ago if more than one segment of colon is affected (Crohn’s)
39
Q

What are possible post-surgical complications?

A
  • Wound infection
  • Pouchitis
  • Intra-abdominal sepsis
  • Anastomotic leak
  • Incontinence
  • Bleeding incl. haematoma
  • Strictures
  • Sphincter damage
  • Nerve damage (urinary and sexual dysfunction)
  • Short gut syndrome
40
Q

What is the effect of cortisol levels increasing in the early morning on IBD?

A

Patients may get nocturnal diarrhoea or be woken up at 4am with stomach cramps (if not infection)

Stage 2: Inflammation (39 decks)

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