Crohn's disease Flashcards by Adele Atkins

Name the two types of inflammatory bowel disease (IBD)

Crohn’s disease

Ulcerative colitis

How well did you know this?

Not at all

Perfectly

Describe the age of presentation of crohn’s disease

Bimodal peak

15-30yo and 60-80yo

How well did you know this?

Not at all

Perfectly

What type of course does inflammatory bowel disease follow?

Relapsing-remitting

How well did you know this?

Not at all

Perfectly

What part of the GI system does crohn’s disease affect?

Any part

Most commonly targets the distal ileum or proximal colon

How well did you know this?

Not at all

Perfectly

What is crohn’s disease characterised by?

Transmural inflammation - affecting all layers of the bowel

Deep ulcers and fissures - cobblestone appearance

Skip lesions - the inflammation is not continuous

Fistula formation

How well did you know this?

Not at all

Perfectly

Give the microscopic appearance of crohn’s disease

Non-caseating granulomatous inflammation

How well did you know this?

Not at all

Perfectly

Describe fistula formation in crohn’s’ disease

Between affected bowel and adjacent structures

Peri-anal 54% 
Entero-enteric 24% 
Recto-vaginal 9% 
Entero-cutaneous
Entero-vesicalar

How well did you know this?

Not at all

Perfectly

List the risk factors of crohn’s disease

Family history - 20% have 1st degree relative
Smoking - increases risk and relapse
White European descent (Ashkenazi jews)
Appendicectomy - risk increased directly after surgery

How well did you know this?

Not at all

Perfectly

Give the symptoms of crohn’s disease

Episodic colicky abdo pain
Diarrhoea - chronic, may be mixed with blood or mucus
Systemic symptoms - malaise, anorexia, low-grade fever
Malabsorption and malnourishment
Oral aphthous ulcers - painful and recurring
Perianal disease

How well did you know this?

Not at all

Perfectly

Describe the abdominal findings of crohn’s disease

Abdominal tenderness
Mouth or perianal lesions
Signs of malabsoprtion or dehydration
Extra-intestinal features

How well did you know this?

Not at all

Perfectly

List the extra-intestinal features of crohn’s disease

MSK - enteropathic arthritis, metabolic bone disease, nail clubbing
Skin - erythema nodosum, pyoderma gangrenosum
Eyes - episcleritis, anterior uveitis, iritis
Hepatobiliary - primary sclerosing cholangitis, gallstones and cholangiocarcinoma
Renal - renal stones

How well did you know this?

Not at all

Perfectly

Which bones joint does enteropathic arthritis commonly affect?

Sacroiliac

How well did you know this?

Not at all

Perfectly

Describe erythema nodosum

Tender red/purple sc nodules typically on shins

How well did you know this?

Not at all

Perfectly

Describe pyoderma gangrenosum

Erythematous papules/pustules that develop into deep ulcers

Occur anywhere - typically the shins

How well did you know this?

Not at all

Perfectly

List the investigations done for crohn’s disease

Bloods - FBC, CRP - anaemia, low albumin (malabsorption), evidence of inflammation

AXR/CT - obstruction

Faecal calprotectin - inflammation

Stool sample - infection

Colonoscopy with biopsy

CT scan abdomen pelvis - bowel obstruction, perforation, collection or fistulae

MRI - enteric fistulae and perianal disease

Examination under anaesthesia with proctosigmoidoscopy - examine and treat perianal fistulae

How well did you know this?

Not at all

Perfectly

Which drugs should be avoided in acute attacks of crohn’s disease

Anti-motility (loperamide)

How well did you know this?

Not at all

Perfectly

How do you induce remission in crohn’s

Fluid resuscitation
Nutritional support
Prophylactic heparin
Anti-embolic stockings
Corticosteroid therapy
Immunosuppressive agents - mesalazine and azathioprine
Biological agents - infliximab can be trialled as a rescue therapy

How well did you know this?

Not at all

Perfectly

How is crohn’s remission maintained?

Azathioprine
Mesalazine or methotrexate as alternatives can be trialled or added in

Biologics - infliximab, adalimumab, rituximab - rescue therapy during acute flares in those who have not responded to first line remission

Smoking cessation is advised

Colonoscopy surveillance - increased risk of colorectal malignancy

Enteral nutritional support

Antibiotics - concurrent infection or perianal disease - ciprofloxacin or metronidazole

How well did you know this?

Not at all

Perfectly

Describe the surgical management of crohn’s disease

Ileocecal resection 
Peri-anal disease
Stricturoplasty 
Small or large bowel resection 
Pre-operative optimisation and bowel sparing approach

How well did you know this?

Not at all

Perfectly

List the complications of crohn’s disease

GI - Fistula, stricture formation, recurrent perianal abscess/fistulae, GI malignancy

Extra-intestinal - malabsorption, osteoporosis, increased risk of gallstones and renal stones

How well did you know this?

Not at all

Perfectly

Describe the increased risk of renal stones in crohn’s disease

Due to malabsorption of fats in the small bowel which cause calcium to remain in the lumen, oxalate is then absorbed freely resulting in hyperoxaluria and formation of oxalate stones in the renal tract

How well did you know this?

Not at all

Perfectly

Which investigation should be avoided in an acute flare of crohn’s

Coloscopy

Which is the most common IBD?

Ulcerative colitis

Which population is ulcerative colitis most prevalent among?

Caucasian

Give the age of presentation of ulcerative colitis

15-25yo 55-65yo Bimodal

Describe the histological appearance of bowel in ulcerative colitis

Non-granulomatous inflammation with crypt abscess formation | Reduced goblet cells

What is the aetiology of ulcerative colitis

Genetics + environment

Describe the characterisation of ulcerative colitis

Diffuse continual mucosal inflammation of the large bowel

Which parts of the large bowel are affected in ulcerative colitis

Begins in the rectum and spreads proximally potentially affecting the entire large bowel Distal ileum - backwash ileitis (incompetent ileocecal valve)

What is a protective factor in UC?

Smoking

Describe the clinical features of ulcerative colitis

``` Bloody diarrhoea Proctitis PR bleeding, mucus discharge, increased frequency, urgency and tenesmus Malaise Anorexia Low grade pyrexia ```

Which grading criteria is used to grade the severity of an exacerbation?

Truelove and Witt

Which criteria are included in the True love and Witt grading system?

``` Bowel movement number per day Blood in stool Pyrexia Pulse >90 Anaemia ESR ```

List the extra-intestinal manifestations of ulcerative colitis

MSK - enteropathic arthritis and nail clubbing Skin - erythema nodosum Eyes - episcleritis, anterior uveitis or iritis Hepatobiliary - primary sclerosing cholangitis

What is primary sclerosing cholangitis?

Chronic inflammation and fibrosis of the bile ducts

What are the differentials for ulcerative colitis?

``` Crohn's Chronic infection - TB, schistosomiasis, giardiasis Mesenteric ischaemia Radiation colitis Malignancy IBS Coeliac ```

What investigations should be ordered when suspecting UC?

Bloods - FBC, U&Es, LFT, clotting, CRP - anaemia, low albumin, inflammation Faecal calprotectin - inflammation Stool sample - infection Colonoscopy with biopsy Flexible sigmoidoscopy AXR - mural thickening and thumbprinting. In chronic cases then lead pipe colon CT - toxic megacolon and bowel perforation

What is seen on colonoscopy in UC?

Continuous inflammation - ulcers and pseudo polyps

How is remission induced in ulcerative colitis

``` Fluid resuscitation Nutritional support Prophylactic heparin Corticosteroid therapy and immunosuppressive agents (mesalazine and azathioprine) Step wise approach ```

Describe the stepwise approach for inducing remission in ulcerative colitis

Mild/moderate - topical mesalazine or sulfasalazine - add oral prednisolone and oral tacrolimus. Higher doses for more extensive inflammation Severe (all spread of disease) - IV corticosteroids and assess need for surgery. Add infliximab if no short term response

How is remission maintained in ulcerative colitis

Immunomodulators - mesalazine and sulfasalazine Infliximab Colonoscopy surveillance for colorectal malignancy Enteral nutritional support

What percentage of UC patients require surgery?

30%

List the indications for acute surgical treatment of UC?

Disease refractory to medical management, toxic megacolon or bowel perforation Reduce risk of colonic carcinoma if dysplastic cells are seen on routine monitoring

Which surgical procedure is curative in UC?

Total proctocolectomy - patient requires ileostomy

Which surgical procedure is used for symptom control in UC?

Sub-total colectomy with preservation of the rectum

List the complications of UC

Toxic megacolon Colorectal carcinoma Osteoporosis Pouchitis

Describe the symptoms of toxic megacolon

Severe abdominal pain Abdominal distension Pyrexia Systemic toxicity

What is the treatment of toxic megacolon

Decompression of the bowel or surgery

What is the risk of toxic megacolon

Risk of perforation

What is Pouchitis?

Inflammation of the ileal pouch with typical symptoms

What are the symptoms of Pouchitis?

Abdominal pain Bloody diarrhoea Nausea

How should Pouchitis be treated?

Metronidazole | Ciprofloxacin

What is the mechanism of action of infliximab?

TNF alpha inhibitor