Diarrhoea in a young man Flashcards
Compare the Px of Crohn’s disease to Ulcerative colitis
Crohn’s disease:
- any part of GI tract affected
- uncommon rectal bleeding
- less diarrhoea
- post-prandial/colicky abdo pain
- common fever
- uncommon urgency/tenesmus
- frequent palpable mass (RLQ)
- common recurrence after surgery
Ulcerative colitis:
- isolated to large bowel only
- very common rectal bleeding
- frequent small stools/diarrhoea
- less common abdo pain
- uncommon fever
- common urgency/tenesmus
- rare palpable mass
- no recurrence post colectomy
Compare Cx of Crohn’s vs. ulcerative colitis
Crohn’s: strictures, fistulae, perianal disease
UC: toxic megacolon
Compare endoscopic features of Crohn’s vs. UC
Crohn’s: ulcers (aphthous, stellate, linear), patchy lesions, pseudopolyps, cobblestoning
UC: continuous diffuse inflammation, erythema, friability, loss of normal vascular pattern, pseudopolyps
Compare histologic features of Crohn’s vs. UC
Crohn’s: transmural, skip lesions, focal inflammation, noncaseating granulomas, deep fissuring, strictures, intact glands
UC: mucosal, continuous, no granulomas, destruction of glands, crypt abscess
Compare radiologic features of Crohn’s vs. UC
Crohn’s: Cobblestone mucosa, frequent strictures & fistulae, “string sign” on AXR due to bowel wall thickening
UC: lack of haustra, rare strictures (if present, suggests complicating cancer)
Compare colon cancer risk in Crohn’s vs. UC
Crohn’s: increased if more than 30% colon involved
UC: increased except in proctitis (higher chance of cancer)
Discuss the extraintestinal manifestations of IBD
- dermatologic
- rheum
- ocular
- hepatobiliary
- urologic
- others
Dermatologic:
- erythema nodosum
- pyoderma gangrenosum
- perianal skin tags (common in Crohn’s)
- oral mucsao lesions
- psoriasis
Rheum:
- peripheral arthritis
- ankylosing spondylitis
- sacroilitis
Ocular:
- uveitis
- episcleritis
Hepatobiliary:
- Cholelithiasis
- primary sclerosing cholangitis (PSC)!!!
- fatty liver
Urologic:
- calculi (esp after ileal resection in Crohn’s)
- ureteric obstruction
- fistulae
Others:
- thromboembolism
- vasculitis
- osteoporosis
- vitamin deficiencies (B12, vit ADEK)
- cardiopulmonary disorders
- pancreatitis
Ix of Crohn’s
- colonoscopy
- CT/MR enterography to visualise small bowel
- CRP elevated
- baterial cultures, O&P, C difficile toxin to r/o other causes of inflammatory diarrhoea
Discuss the traditional graded approach to induction therapy in Crohn’s disease (Mx)
- nutrition, symptomatic therapy (loperamide, acetaminophen)
- 5-ASA (mesaamine), antibiotics
- Corticosteroids (budesonide, prednisone)
- Immunosuppression (azathioprine, 6-MP, methotrexate)
- Immunomodulators (TNF-antagonist: infliximab, adalimumab)
- Experimental therapy or surgery
Surveillance colonoscopy if more than 1/3 of colon involved
Ix of UC
- sigmoidoscopy with mucosal biopsy (to exclude self limited colitis)
- colonoscopy to determine extent of disease or CT colonography
- stool culture, microscopy, C. difficile toxin to r/o infection
Mx of UC
Mainstays: 5-ASA (mesalamine) derivaties & corticosteroids with azathioprine used in steroid-dependent on resistant cases
Antidiarrhoeal medications generally NOT indicated in UC
- 5-ASA: topical, oral
- Corticosteroids: to remit acute disease. limited role in maintenance therapy
- Immunosuppressants (Steroid sparing): if severe & refractory to steroids. E.g. infliximab, cyclosporine.
- Surgical treatment: early in severe UC esp fulminant cases & toxic megacolon if no response after 3-5d of corticosteroids or after 4-7d of immunosuppressants. Ileal pouch-anal anastomosis 6 months after ileaostomy. Indicated also in pre-cancerous changes detected in endoscopy/biopsy (dysplasia).
