Crohns

Question 1

What is crohns

Answer 1

Chronic inflammatory disease 
Transmural 
Granulomatous 
Mouth to anus
Unaffected bowel in between active lesions - skip lesions

Question 2

Symptoms of crohns

Answer 2

Diarrhoea 
Abdo pain
Weightloss
Failure to thrive
Systemic symptoms 
Fatigue, fever, malaise, anorexia
Extra intestinal: clubbing, erythema nodosum, pyoderma gangrinosum, uveitis, episcleritis, conjucntivits, large joint arthritis .

Question 3

Signs of crohns

Answer 3

Bowel ulceration
Abdo pain tender, mass
Skin tags
Anal structures

Question 4

Complications of crohns

Answer 4

Small bowel obstruction
Toxic dilation >6cm rarer than in UC
Abscess formation - abdo, pelvic, colovescial, colovaginal 
Colon cancer 
PSC
Malnutrion

Question 5

Tests for crohns

Answer 5

Blood FBC, U&E, CRP, ESR, LFT, INR, ferritin, TIBC, B12, folate
Inflammation, nutritional deficiencies
Stool: MC&S, CDT, Fecal calprotectin
Small bowel: capsule endoscopy, MRI pelvic disease and fistula,US skilled hand

Question 6

Indication of poor prognosis

Answer 6

Diagnosed <40 years
Steroids needed at 1st presentation 
Perinatal disease 
Smoking 
Isolated terminal ileitis

Question 7

Perinatal disease occurrence and treatment

Answer 7

Approx 50%
Assess with MRI and visually under anaesthetic
Treatment
Oral antibiotics
Immunosuppressant therapy +- anti TNF ALPHA
+- local surgery
+- seton insertion

Question 8

Treatment

Answer 8

Depends on the severity of the crohns and current episode
Conservative - optimise nutrition and stop smoking
Medical - depends on severity
If mild moderate PO prednisoslone 40mg and taper 5mg a weeks for 7 weeks
Severe same as UC need resus IV fluids and electrolytes and steroids
If get better change to oral
If not biological therapy
Surgical not curative symptoms and complication control

Question 9

What does not have a role in crohns medical management

Answer 9

5 ASAs

Role in UC not crohns

Question 10

When to give azathioprine

Answer 10

None response to steroids
Flare on tapering steroids
Steroids treatment more than 2 a year

Question 11

Types of biological therapy

Answer 11

Anti TNF alpha
Anti integrin
Anti IL12 IL23

Question 12

What does anti TNF ALPHA do

Answer 12

MAB counters neutrophil accumulation and granuloma formation
Cause cytotoxicity to CD4 T cells
Clearing the cells driving immune response
Infliximab

Question 13

Contraindication to TNF alpha therapy

Answer 13

Sepsis
Active or latent Tb
Underlying malignancy
LFT raised above 3x upper limit of normal

Question 14

SE of anti TNF alpha

Answer 14

Rash

Question 15

Combined aza and anti TNF alpha

Answer 15

Better efficacy

But risk of lymphoma

Question 16

What does anti integrin do

Answer 16

MAB to adhesion molecules in the gut that help with lymphicyte trafficking into the gut
Vesolizumab gut specific

Question 17

Anti IL 12/IL23

What does it do

Answer 17

It is a cytokines target

Ustekinumab

Question 18

Side effects of azathioprine and monitoring

Answer 18

Abdo pain
Nausea
Pancreatitis
Leukopenia
Abnormal LFT 

Bloods every week for 4 weeks every 4 weeks for 3 months and then every 3 months

Question 19

Surgery aims

Answer 19

Resection of affected areas + beware short bowel syndrome
Control perianal or fistualising disease
Defunction to rest distal disease with an ileostomy