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General surgery + HPB - YR3 > Crohns Disease > Flashcards

Crohns Disease Flashcards

1
Q

Age peaks for Crohns

A

15-30 and then 60-80

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2
Q

Where does it affect?

A

Anywhere from mouth to anus - ANY PART of GI tract

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3
Q

Crohns inflammation

A
  • Transmural
  • Deep ulcers and fissures
  • Non-continious - skip lesions
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4
Q

Microscope of Crohns

A

Non-caseating granulomatous inflammation

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5
Q

Consequence of transmural inflammation of Crohns

A
  • Can get fistulas
  • Most common is peri-anal, but can also be entero-enteric, recto-vaginal, entero-cutaneous or entero-vesicular
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6
Q

RF for Crohns

A
  • Mainly familial link
  • Smoking increases risk and relapse risk
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7
Q

UC vs Crohns - site, macroscopic changes and inflammation

A
  • Site - UC just large bowel, Crohns entire GI tract
  • Inflammation - mucosal in UC, transmural Crohns
  • Macro - UC continious, psuedopolyps and ulceration. Crohns skip lesions, fissures and deep ulcers (cobblestone), fistulas
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8
Q

UC vs Crohns microscopic changes

A

UC:
* Crypt abscess formation
* Reduced goblet cells
* Non-granulomatous

Crohns:
* Granulomatous (non-caseating)

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9
Q

Symptoms of Crohns

A
  • Episodic abdominal pain - colicky, varies in site
  • Diarrhoea - chronic, may contain blood/mucus
  • Systemic - malaise, anorexia, low grade fever, malabsorption/malnourishment (children can be failure to thrive)
  • Oral aphthous ulcers
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10
Q

Extra-intestinal features of Crohns - MSK

A
  • Enteropathic arthiritis (esp sacroiliac and other large joints)
  • Nail clubbing
  • Metabolic bone disease (secondary to malabsorption
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11
Q

Extra-intestinal features Crohns - skin

A
  • Erythema nodosum - tender, purple SC nodules on shins
  • Pyoderma gangrenosum - erythematous papules or pustules that develop into deep ulcers
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12
Q

Crohns features - eyes

A
  • Episcleritis
  • Anterior uveitis
  • Iritis
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13
Q

Crohns extra-intestinal features - hepatobiliary

A
  • Primary sclerosing cholangitis (more associated with UC though)
  • Cholangiocarcinoma - due to association with PSC
  • Gallstone disease
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14
Q

Renal manifestations of Crohns

A

Renal stones

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15
Q

Blood tests for ?Crohns

A
  • FBC - anaemia
  • LFT - albumin low? secondary to systemic illness
  • CRP - inflammation
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16
Q

Stool tests for ?Crohns

A
  • Faecal calprotectin
  • Stool MC&S - exclude infective cause
17
Q

Gold standard investigation Crohns

A

Colonoscopy - show inflammation and take biopsies to diagnose

18
Q

How to classify severity of Crohns

A
  • Montreal score
  • Includes age, location, behaviour (eg stricturing, penetrating), perianal disease present?
19
Q

Imaging for Crohns disease

A
  • MRI small bowel - assess and monitor involvement and severity, inflam or fistulating disease can be assessed via MRI
20
Q

When is examination under anaesthesia done for Crohns?

A
  • MRI imaging assesses for fistulating perianal disease
  • Can then consider EUA to examine and treat any perianal fistula present
21
Q

Acute presentation of Crohns imaging

A
  • CT scan abdomen pelvis - check for evidence of bowel obstruction (from stricture) or bowel perforation (from full thickness penetrating disease)
22
Q

Management - overall Crohns

A
  • Refer for Gastroenterology if suspect to confirm and initiate treatment
  • Complex disease may need IBD MDT meeting - gastro, general surgery, radiology, IBD specialist nurse, dieticians
  • Acute flare = acute admission usually to treat
23
Q

Inducing remission of Crohns disease

A
  • Acute flare - corticosteroid therapy first line to induce remission
  • Fluids
  • Prophylactic heparin with antiembolic stockings - prothromotic state IBD
  • Low residue diet (low fibre)
  • Avoid anti-motility drugs (eg loperamide) - precipitate toxic megacolon
24
Q

What to use if corticosteroids do not work to induce remission Crohns?

A
  • Immunosupressive agents eg Mesalazine (aminosalicylate) or Azathioprine
  • OR biological agents eg Infliximab or Adalimumab
25
Q

Maintaining remission in Crohns

A
  • Azathioprine 1st line - methotrexate as alternative
  • Smoking cessation
  • IBD nurse specialist input
  • Low fibre diets can be beneficial
26
Q

Monitoring of Crohns disease complications?

A
  • Colonoscopic surveillance
  • Offered to people who have had disease for more than 10 years with more than 1 segment of bowel affected
  • Due to increased risk of colorectal malignancy
27
Q

When is surgical management offered for patients with Crohns?

A
  • Failed medical management
  • Severe complications eg stricture or perforation
  • Always a BOWEL SPARING approach to prevent short gut syndrome
28
Q

Common operations required for patients with Crohns disease

A
  • Ileocaecal resection - removal of terminal ileum and caecum with anastomosis
  • Small bowel resection
  • Surgery for peri-anal disease - eg abscess drainage, seton insertion or laying open fistula
  • Stricturoplasty - division of stricture that is causing obstruction - can also consider balloon dilation if short, straight single stricture
29
Q

Crohns disease - pre op importance

A
  • High risk patients to operate on
  • Optimise pre op - treat acute flares and manage nutrition
  • If active severe flare, primary bowel anastomosis should not be performed - or at least not without defunctioning stoma - due to risk of breakdown of anatomosis
30
Q

Complications of Crohns - GI

A
  • Fistula
  • Strictures
  • Recurrent perianal fistula –> perianal abscess and then sepsis
  • GI malignancy - 3% colorectal cancer risk and SB cancer 30x more common
31
Q

Complications Crohns - extraintestinal

A
  • Malabsorption - growth delay, osteoporosis (long term steroid or malabsorption)
  • Increase risk of gallstones - reduced reabsorption of bile salts at terminal ileum
  • Increase risk of renal stones - malabsorption of fats in small bowel = calcium stays in lumen, oxalate then absorbed freely = hyperoxaluria and formation of stones
32
Q
A

General surgery + HPB - YR3 (38 decks)

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