CSI 8 - Complications of Crohn's Flashcards
1
Q
What is Crohn’s disease?
A
A long-term condition that causes inflammation of the lining of the digestive system
2
Q
Where can the inflammation be in Crohn’s disease?
A
- inflammation can affect any part of the digestive system, from the mouth to the anus
- mostly occurs in the last section of the small intestine (ileum) or large intestine (colon)
3
Q
What ages can Crohn’s disease affect, and when is it usually diagnosed?
A
- Crohn’s disease can affect people of all ages
- usually diagnosed between 15-40y/o
4
Q
What do the symptoms of Crohn’s disease depend on?
A
Symptoms of Crohn’s vary - depend on which part of the digestive system is inflamed
5
Q
What are some common symptoms of Crohn’s disease? (5)
A
- recurring diarrhoea
- abdominal pain and cramping, which is usually worse after eating
- extreme tiredness (fatigue)
- unintended weight loss
- blood and mucus in poo
6
Q
What are some less common symptoms of Crohn’s disease? (8)
A
- high temperature (fever) of 38oC or above
- feeling sick (nausea)
- being sick (vomiting)
- joint pain and swelling (arthritis)
- inflammation and irritation of the eyes (uveitis)
- areas of painful, red and swollen skin - most often legs
- mouth ulcers
- anal pain and discharge (perianal Crohn’s)
7
Q
What are some terms used to describe different parts of the course of Crohn’s disease?
A
- remission - long periods without symptoms, or very mild symptoms
- flare-ups / relapses - these may be followed by periods where the symptoms are particularly troublesome
8
Q
What can Crohn’s disease cause in children?
A
Children may grow at a slower rate than expected
9
Q
When should you contact a GP regarding Crohn’s disease? (5)
A
- diarrhoea for more than 7 days
- persistent abdominal pain
- unexplained weight loss
- blood in poo
- concerned about child’s development
10
Q
What are the causes of Crohn’s disease? (1 + 4)
A
Exact cause is unknown - a combination of factors may be responsible, including:
- genetics
- problem with immune system (autoimmune) where it attacks healthy bacteria in the gut and causes inflammation
- environmental factors e.g. air pollution, medication, previous infections
- smoking - smokers 2x likely to develop Crohn’s disease, and usually have more severe symptoms
11
Q
What might a GP arrange to investigate Crohn’s disease? (2)
A
- arrange blood tests to check for inflammation, infection and anaemia
- ask for a stool sample to use a qFIT test to check for blood and mucus, infection or inflammation via a faecal calprotectin test
12
Q
What tests might a gastroenterologist recommend for Crohn’s disease? (6)
A
- gastroscopy (camera tube put in mouth to look at oesophagus and stomach)
- colonoscopy (camera tube put into bottom to look at whole of large bowel)
- sigmoidoscopy (camera tube put into bottom to look at end of large bowel)
- colon capsule endoscopy (pill camera)
- X-ray or barium enema
- MRI / CT scan
13
Q
Is there currently a cure for Crohn’s disease?
A
No cure, but treatment can improve the symptoms and keep the inflammation under control
14
Q
When might you choose to stop treatment for Crohn’s disease?
A
If your Crohn’s stays under control for a long time, you may choose to stop treatment (may need to restart if symptoms come back)
15
Q
What treatment options are there for Crohn’s disease? (4)
A
- steroids
- immunosuppressants
- biological therapies
- surgery
16
Q
What is the first treatment usually offered to patients with Crohn’s disease?
A
- first treatment offered is usually steroids e.g. prednisolone or budesonide to reduce inflammation quickly
- often effective in reducing symptoms
17
Q
What is the problem with using steroids for Crohn’s disease?
A
- they can have significant side effects = not suitable for long-term use
- dose slowly reduced as symptoms improve
18
Q
When might immunosuppressants be given for Crohn’s disease?
A
May be given alongside steroids if your symptoms flare up twice or more during 12 months, or return when your steroid dose is reduced
19
Q
What are some common types of immunosuppressants? (3)
A
- azathioprine
- mercaptopurine
- methotrexate
20
Q
When might biological therapies be used for Crohn’s disease?
A
If steroids and immunosuppressants do not help or are not right for you
21
Q
How do biological therapies for Crohn’s disease work?
A
- block particular chemicals involved in the immune response which helps reduce inflammation
- made using living cells in a lab
- can be given as drip or infection
- treatment usually lasts around 12 months
22
Q
What are some common types of biological therapies? (4)
A
- adalimumab
- infliximab
- ustekinumab
- vedolizumab
23
Q
What side effects can biological therapies for Crohn’s disease have? (5)
A
- itchy skin
- high temperature
- joint and muscle pain
- swelling of the hands or lips
- problems swallowing
24
Q
When might you have surgery for Crohn’s disease? (4)
A
- you choose to have surgery instead of taking medications that may cause side effects
- medications do not control your symptoms
- your QoL is severely affected by your condition
- you have serious complications of Crohn’s disease
25
What might surgery for Crohn's disease involve?
Widening narrow parts of bowel, or removing parts (resection - removing inflamed area of intestine)
26
If you have a bowel resection, what are the two outcomes?
- you might have healthy sections of bowel joined back together
- you might have the end of your small bowel to the skin of your tummy (ileostomy / stoma)
- poo comes out of the opening on your tummy and is collected in special bags that you wear
- ileostomy might be temporary to give bowel time to heal, or it might be permanent
27
What should you do regarding your diet if you have Crohn's disease? (3)
- eat 5-6 small meals rather than 3 main meals
- try to eat a healthy, varied diet that includes a wide variety of fruit, vegetables, nuts, seeds, proteins and wholegrain
- drink plenty of water
28
What complications can long-term inflammation of the digestive system in Crohn's disease lead to? (2)
- narrowing of the bowel (stricture)
- a channel developing between your bowel and your skin, another section of bowel or a body organ (fistula)
- these usually require surgical treatment
29
What is the site of pain in appendicitis?
Migratory - starts umbilical --> RLQ (can vary depending on the anatomical location)
30
What is the character of pain in appendicitis?
Usually consistent with intermittent cramps
31
What associated symptoms are seen in appendicitis? (4)
- anorexia (very common)
- nausea and vomiting
- failure to pass flatus or stool
- Rovsing's sign
32
What are some exacerbating factors of pain in appendicitis?
Movement and coughing
33
What is the severity of pain in appendicitis?
Severe
34
What is the site of pain in small bowel obstruction?
Umbilical
35
What is the character of pain in small bowel obstruction?
Colicky and severe
36
What are some associated symptoms in small bowel obstruction? (4)
- anorexia
- nausea/vomiting
- unable to pass stool/flatus
- abdominal distention/bloating
37
What is an exacerbating factor of pain in small bowel obstruction?
Oral intake
38
What is the severity of pain in small bowel obstruction?
Severe
39
What is the site of pain in pancreatitis?
Epigastric/left upper quadrant pain, radiating to the back
40
What is the character of pain in pancreatitis?
Constant and severe
41
What are some associated symptoms in pancreatitis? (3)
- anorexia
- nausea/vomiting
- dyspnoea
42
What is an exacerbating factor of pain in pancreatitis?
Worse on movement
43
What is the severity of pain in pancreatitis?
Severe
44
What is the site of pain in cholecystitis?
Constant RUQ pain, might get right shoulder pain
45
What is the character of pain in cholecystitis?
Constant and severe
46
What are some associated symptoms in cholecystitis? (2)
- nausea/vomiting
- Murphy's sign
47
What is an exacerbating factor of pain in cholecystitis?
Eating fatty foods
48
What is the severity of pain in cholecystitis?
Severe
49
What is small bowel obstruction?
Surgical emergency
50
How can Crohn's cause small bowel obstruction?
Crohn's disease can thicken the wall of your intestines - over time the thickened areas can narrow the lumen, which can block your intestines (recurrent inflammation and repair --> scar tissue)
51
What symptoms are associated with small bowel obstruction? (5)
- nausea and vomiting
- abdominal pain
- bowels not opened
- not passing wind
- bloated and burping
52
Why do we get nausea and vomiting in small bowel obstruction?
The proximal region to the obstruction is distended
53
Why do we get severe abdominal pain in small bowel obstruction?
Obstruction = restricted venous drainage --> oedema and inflammation --> pain that comes in waves
54
Why do we get bowels not opening (constipation) and inability to pass wind in small bowel obstruction?
Contents proximal to the obstruction cannot reach the distal region
55
Why do we get burping and bloating in small bowel obstruction?
Inflammation
56
What can cause small bowel obstruction? (3 + 1)
- incarcerated hernia
- post-surgical adhesions
- malignancies
- (Crohn's)
57
What can cause large bowel obstruction? (4 + 1)
- diverticulitis
- inflammatory disease
- malignancies
- volvulus (twisting)
- (Crohn's)
58
How does a radiograph of a small bowel obstruction differ to that of a large bowel obstruction?
- SBO - can see mucosal folds (valvulae comitantes) across whole width of intestine (no haustra)
- LBO - haustra only partially across the width of the intestines
- SBO - centrally located
- LBO - peripherally located
- both SBO and LBO have bowel dilation
59
What do faeces look like on a radiograph?
Mottled appearance - due to mix of solid and liquid
60
How can large bowel obstruction also cause small bowel dilation?
Obstruction of large bowel can cause loss of patency of ileo-caecal valve, and the back pressure can lead to dilation of the small bowel
61
What is the 3,6,9 rule of abdominal X-rays?
- SB <3cm diameter
- LB <6cm diameter
- caecum (widest part of intestines) <9cm diameter
62
Why should we do a chest X-ray for bowel obstruction?
If bowel perforates (can occur in untreated bowel obstruction), air gets trapped under the diaphragm
63
What antigens and antibodies are present in blood groups A, B, AB and O?
- A: A antigen, anti-B antibodies
- B: B antigen, anti-A antibodies
- AB: A and B antigen, no antibodies
- O: no antigen, anti-A and anti-B antibodies
64
What donors can each blood group receive blood from?
- AB - O, A, B, AB
- B - O, B
- A - O, A
- O - O
65
For women with RhD negative blood type, why can exposure to RhD antigen be problematic for future pregnancy?
- immune system exposed to RhD antigen and makes anti-RhD antibodies
- can get pregnant in future with RhD +ve baby (from father's genes)
- these anti-RhD antibodies can cross the placenta, enter the uterus and haemolyse the RBCs of the foetus
66
How does an ileostomy affect water reabsorption?
An ileostomy means that faeces is removed before it reaches the large bowel (where 1-1.5L of H2O is reabsorbed), meaning the colon no longer has the ability to reabsorb this water
67
How does the body adapt to less water reabsorption by the colon after an ileostomy? (3)
- mucosal hypertrophy and hyperplasia - e.g. villi elongated, increased SA of small intestine for even more water reabsorption here
- aldosterone level up-regulation (sodium retention and reabsorption, hence water follows) - via RAAS system, aldosterone stimulates Na+ reabsorption not only in kidney but in SB too, also increases ENaC inserted into SB and increased SGLT-2
- hypomotility - increases time for water reabsorption
68
What can happen to the large intestine post-stoma, due to lack of use? (3)
- villi degenerate and become more scattered
- loss of smooth muscle mass
- consequences to microbiota that reside there (poorly understood)
69
Compare ileostomy vs colostomy (site, appearance, content).
- site: RLQ vs LLQ
- appearance: raised spout coming out (contents of SB more alkaline and irritating so we do not want this flushed to the skin) vs intestinal wall is flushed to the skin
- contents (of bag): higher up therefore more H2O content and more liquid vs lower down, more water has been reabsorbed so contents less liquid
70
What might Lucy Benjamin talk about in her Crohn's support group? (3 + 5)
- diet and recovery
- adaptations to life
- self-confidence
- impact on lifestyle (hobbies, work)
- body image
- patients will have different journeys and deal with uncertainty
- coping strategies
- emotional support
71
What are some surgical complications of Crohn's disease? (4)
- bowel obstruction
- strictures
- fistulas
- abscesses
72
How can Crohn's disease lead to strictures, and what can these lead to?
Chronic inflammation in the intestines can cause the walls of the digestive tract to thicken or form scar tissue --> can narrow a section of the intestine (stricture) --> can lead to an intestinal blockage
73
What two surgical procedures can help repair a stricture?
- strictureplasty
- small bowel resection
74
What is a strictureplasty?
Surgical procedure to repair a stricture by widening the narrowed area without removing any portion of the intestine
75
What are symptoms of a stricture? (4)
- nausea
- vomiting
- severe cramping
- constipation
76
Which areas of the small intestine is strictureplasty most effective in?
Most effective in the lower sections of the small intestine - ileum and jejunum (less effective in duodenum)
77
Which option out of strictureplasty and small bowel resection is preferred and why?
Strictureplasty - because removing portions of your small intestine can sometimes cause other complications including short bowel syndrome (SBS) - occurs when large sections are removed due to surgery and the body is unable to absorb adequate amounts of nutrients and water
78
Describe the procedure of a strictureplasty.
- surgeon makes cuts lengthwise along the narrowed areas of your intestine, then sew up the intestine crosswise
- this type of incision and repair shortens and widens the affected part of the bowel, allowing food to pass through
79
Where can fistulising Crohn's disease occur?
Anywhere along the GIT, affecting portions such as the small intestine, colon, rectum or the anus
80
What is a fistula?
A fistula is an abnormal connection or tunneling between the intestines and a nearby organ or skin
81
How do fistulas form?
Inflammation causes sores/ulcers on the inside wall of the intestine/nearby organs --> these ulcers extend through the entire thickness of the bowel wall, creating a tunnel to drain the pus from the infected area
82
What else (apart from inflammation causing ulcers) can cause a fistula to form?
An abscess (collection of pus)
83
What different types of fistula are found in Crohn's disease? (6)
- perianal fistula - tunnel/connection between anal canal and/or rectum and the surface of skin in the anal area
- rectovaginal or colovaginal fistula - tunnel/connection between the intestines and the vagina
- enteroenteric fistula - tunnel/connection from one part of the intestines to another part of the intestines
- enterocutaneous or colonocutaneous fistula - tunnel/connection from intestines to surface of skin
- enterovesical or colovesical fistula - tunnel/connection from intestines to the bladder
- enterocolonic fistula - tunnel/connection from colon to another part of the intestines
84
What are the possible symptoms of a perianal fistula? (4)
- tender swelling or lump in area around the anus
- pain and irritation when sitting, moving, having a bowel movement, or coughing
- drainage/discharge
- bleeding
85
What are the possible symptoms of a rectovaginal/colovaginal fistula? (3)
- passing air, stool or pus through the vagina
- brown/foul-smelling discharge
- painful intercourse
86
What are the possible symptoms of an enteroenteric fistula? (3 + 1)
- diarrhoea (can feel like flare)
- poor absorption of nutrients
- dehydration
- no symptoms at all
87
What are the possible symptoms of an enterocutaneous/colonocutaneous fistula?
Leaking of stool, which may include a foul smell, brown discharge, redness, and/or pain
88
What are the possible symptoms of an enterovesical/colovesical fistula? (5)
- passing air, stool or pus when urinating
- foul-smelling urine
- urine leaking from anus
- frequent urination
- frequent UTIs
89
What are the possible symptoms of an enterocolonic fistula? (3 + 1)
- diarrhoea (can feel like flare)
- poor absorption of nutrients
- dehydration
- no symptoms at all
90
Which kind of fistula is most common in Crohn's?
Perianal fistula
91
What is a perianal fistula?
Abnormal tract/tunnel between the anal canal/rectum and an external opening in the skin near the anus
92
What can make a perianal fistula more painful?
Perianal fistulas can be painful, especially if there is an abscess or infection at the site
93
What can perianal fistulas cause?
Leakage of stool, pus or blood that you may see on your underwear
94
How are perianal fistulas diagnosed?
- often diagnosed by previous medical history and a physical examination looking at the skin around the anal area
- may suggest additional testing e.g. MRI pelvis, endoscopic ultrasound or an examination under anaesthesia to help determine the extent of the disease
95
What is the best way to avoid Crohn's complications like fistulas?
IBD medications which aim to treat underlying disease and infection - but there may be times where a fistula develops and you may need additional medications to treat the fistula and help with the discomfort
96
How do we treat perianal fistulas?
A combination of medical and surgical treatments is the best approach to treat perianal Crohn's disease
97
What medications can we use to treat perianal fistulas?
- antibiotics e.g. metronidazole and ciprofloxacin - help clear infections and decrease drainage (but not long-term therapy, use alongside long-term maintenance medications)
- biologic anti-TNF medications - shown to be effective in reducing drainage and promoting healing
- thiopurines e.g. azathioprine and 6-MP are commonly prescribed in combination with anti-TNF meds to improve overall response, decrease antibody formation and achieve remission
- newer biologics have been shown to be effective in treating perianal fistulas
98
What medication should be avoided when experiencing a perianal fistula?
Corticosteroids - shown to lead to more abscesses and worsening fistulas
99
What is the goal of surgery to treat perianal fistulas?
To heal the perianal fistula while avoiding damage to anal sphincter muscles as they surround the area and control the elimination of stool
100
What is a seton?
- seton placement is one option to help heal perianal fistulas
- thin, rubber surgical thread that is placed through the fistula tract and exits through the anus
- seton then tied to form a loop - allows the tract to stay open for the fistula to drain which helps avoid infectious complications
- seton left for several months then potentially removed once the fistula has drained
- after infection cleared, medical management to control inflammation is required to continue healing the fistula tract
101
When might surgical procedures be considered for perianal fistulas?
Once a combination of seton placement and medical management has controlled the infection and inflammation - when the patient is in remission
102
What three surgical procedures can be done for perianal fistulas?
- fistulotomy: divide the fistula tract - length of fistula cut open and flattened out, obliterating the communication between the skin and the rectum/anus (suitable for simple fistulas that do not cross the sphincter muscle/only pass through small amount)
- advancement flaps: after fistula tract cleaned, inside lining of rectum is lifted and pulled down inside the anal canal to cover the internal opening of the fistula (complex fistulas where sphincter muscles involved and not been controlled/healed with medical therapy)
- LIFT (ligation of intersphincteric fistula tract): cut outside entrance of anal canal to reach space between internal and external sphincter muscles, cut fistula tunnel in two and both ends stitched and closed (complex fistulas)
103
How do we treat rectovaginal fistulas?
- medications aim to treat the underlying active disease, though surgical procedures may still be considered
- flap and LIFT procedure - folding a flap of healthy tissue over the fistula opening (vaginal advancement flap), or using the skin of the vaginal lip to close the fistula
104
In Crohn's, where can abscesses (collections of pus) develop?
In the abdomen, pelvis or around the anal area
105
How can abscesses be treated?
- abscesses require antibiotics to treat the infection
- doctor may also recommend surgical drainage of the pus cavity to ensure the area heals completely
106
What are the symptoms of an abscess? (5)
- severe pain in the abdomen
- painful bowel movements
- discharge of pus from the anus
- lump at the edge of the anus that is swollen, red and tender
- fever
107
How is abscess drainage done?
- surgeon will make a small cut into the abscess and insert a thin tube to drain the pus
- the tube may be left in over a week or more to allow the abscess to completely drain and begin healing
- most people feel better within a few days of surgery
