FN: Crohns disease: Management

Question 1

Investigations

Answer 1

Bloods
Stool
Imaging
Endoscopy

Question 2

Bloods

Answer 2

(top 3 are severity markers)

1. FBC: reduce Hb, raised WCC
2. LFT: reduced albumin
3. Raised CRP and ESR
4. Haematinics: Fe, B12, Folate
5. Blood cultures

Question 3

Stool

Answer 3

MCS: exclude Campy, Shigella, Salmonella
CDT: C. difff may complicate or mimic

Question 4

Imaging

Answer 4

AXR: obstructino, sacroileitis
CXR: perforation
MRI
1. Assess pelvic disease and fistula
2. ASsess disease severity

Small bowel follow-through or enteroclysis

1. skip lesions
2. Rose-thorn ulcers
3. Cobblestonin: ulcerating + mural oedema
4. String sign of kantorL narrow terminal ileum

Question 5

Endoscopy

Answer 5

Ileocolonoscopy + regional biopsy: x of choice
Wireless capsule endoscopy
Small bowel enteropscopy

Question 6

Sever attack symptoms

Answer 6

Raised temp
Raise dHR
Raised ESR
Raised CRP
Raised WCC
reduced albumin

Question 7

Management of severe attack

Answer 7

REsus: admit, NBM, IV hydration
2. Hydrocortisone: IV + PR if rectal disease
3. Abx: metronidazole PO or IV
4. Thromboprophylaxis: LMWH
5. dietician REview
6. Monitoring
Vitals + stool chart
Daily examination

Question 8

Dietician Review

Answer 8

Elemental diet - liquid prep of amino acids, f=glucose and fatty acids
Consider parenteral nutrition

Question 9

Improvement in therapy

Answer 9

Switch to oral pred (40mg/d) –> oral theraoy

Question 10

No improvement –> rescue therapy

Answer 10

1. Discussion between pt, physcian and surgeon
2. Medical: methotrexate ± infliximab
3. Surgical

Question 11

Inducing remission:
Supportive therapy
Oral therapy
Perianal disease

Answer 11

supportive therapy:

1. High fibre diet
2. Vitamin supplements

Question 12

Oral therapy

Answer 12

1st line: 
ileocaecal: budesonide]2. ColitisL sulfasalazine
2nd line: prednisolone (tapering)
3rd line: methotrexate
4th line: infliximab or adalimumab

Question 13

Perianal disease

Answer 13

1. Occurs in 50%
Ix: MRI + EUA
Rx:
1. ORal Abx: metronidazole
2. Immunosuppression ± infliximab
3. Local surgery ± seton insertion

Question 14

Maintaing remission

Answer 14

1st line: azathioprine or mercaptopurine
2nd line: methotrexate
3rd line: infliximab/adalimumab

Question 15

Perianal disease

Answer 15

1. Occurs in 50%
Ix: MRI + EUA
Rx:
1. Oral Abx: metronidazole
2. Immunosuppression ± infliximab
3. Local surgery ± seton insertion

Question 16

Maintaining remission

Answer 16

1st line: azathioprine or mercaptopurine
2nd line: methotrexate
3rd line: infliximab/adalimumab

Question 17

urgery

Answer 17

50-80% need >1 operation in life
Never curative
Should be s conservative as possible

Question 18

Indiciation sfor surgery emergency

Answer 18

Failure to respond to medical Rx
Intestinal obstruction or perforation
Massive haemorrhage

Question 19

Indication for elective

Answer 19

Abscess or fistula
Perianal disease
Chronic ill health
Carcinoma

Question 20

Procedures

Answer 20

1. Limited resection e.g. ileocaecal
2. Stricturoplasty
3. Defunction distal disease with temporary loop ileostomy

Question 21

Complications

Answer 21

Enterocutaneous fistulae
Stoma complications
Anastomotic leak or stricture

Question 22

Short gut

Question 23

Short gut features

Answer 23

Steatorrhoea
ADEK and B12 malabsorption
Bile acid depletion = gallstones
Hyperoxaluria - renal stones

Question 24

Treatment of short gut

Answer 24

Dietician
Supplements or TPN
Loperamide