Crohns disease

Question 1

Describe Crohns disease?

Answer 1

• Bimodal peak: 15-30 and 60-80
• Relapsing and remitting

Question 2

Describe the pathophysiology of crohns disease?

Answer 2

• Any part of GIT
• Commonly distal ileum or proximal colon
• Familial link, smoking increases risk of developing crohns
• Transmural inflammation producing deep ulcers and fissures (cobblestone)
• Inflammation is discontinuous with skip lesions
• Non-caseating granulomatous inflammation

Question 3

What are the risk factors for developing crohns disease?

Answer 3

• Family history
• Smoking
• White european descent (Ashkenzi jews)
• Appendicetomy

Question 4

What are the clinical features of Crohns disease?

Answer 4

• Episodic abdominal pain and diarrhoea
  
  • Pain may be colicky and vary depending on the site affected
  • Diarrhoea may contain blood or mucus
• Systemic symptoms: malaise, anorexia, low-grade fever
• Oral aphthous ulcers
• Perianal disease: skin tags, abscesses, bowel stenosis

Question 5

Describe the extra-intestinal features of Corhns disease?

Answer 5

• MSK:
  
  • Enteropathic arthritis, nail clubbing, metabolic bone disease
• Skin:
  
  • Erythema nodosum, pyoderma gangrenosum
• Eyes:
  
  • Episcleritis, anterior uveitis, iritis
• Hepatobiliary:
  
  • PSC, cholangiocarcinoma, gallstones
• Renal:
  
  • Renal stones

Question 6

Describe the investigations which should be performed for someone with suspected corhns disease?

Answer 6

• FBC, CRP, low albumin secondary to malabsorption
• Faecal calprotectin
• Stool sample for microscopy and culture
• Colonscopy with biopsy: gold standard
• CT scan: demonstrating obstruction, perforation, fistulae
• MRI scan
• Proctosigmoidoscopy may also be used to examine and treat dsitulating per-anal disease

Question 7

What is the management approach for Crohns disease?

Answer 7

• Induce remission
• Maintain remission
• Surgical management

Question 8

Describe the induction of remission in crohns disease?

Answer 8

• Fluid resus, nutritional support, prophylactic heparin
• Corticosteroids
• Immunosuppressive agents:
  
  • Mesalazine, azathioprine
• Rescue therapy if required:
  
  • Biological agents: infliximab

Question 9

Describe the maintenance of remission in crohns disease?

Answer 9

• Azathioprine or mercaptopurine as monotherapy
• Methotrexate second line
• Biologic agents:
  
  • Infliximab, rituximab, adaluminab
• Smoking cessation

Question 10

Describe the possible surgical management of Crohns disease?

Answer 10

• Ileocaecal resection
• Surgery for peri-anal disease (eg abscess drainage)
• Stricuroplasty (division of a stricture causing bowel obstruction)
• Small or large bowel resections

Question 11

Indications for surgery in crohns disease?

Answer 11

• Failed medical management
• Severe complications: fistula and strictures
• Growth impairment in younger patients

Question 12

Name some GI complications of crohns disease?

Answer 12

• Fistula
• Stricture formation
• Recurrent perianal abscesses
• GI malignancy (30x more common)

Question 13

Name some extraintestinal complications of crohns disease?

Answer 13

• Malabsorption
• Osteoporosis (steroid use)
• Increased risk of gallstones
• Increased risk of renal stones (malabsorption)