Gastro - IBD

Question 1

What are the general presenting features for Crohn’s disease?

Answer 1

Often fever, lethargy, weight loss without abdo symptoms.

Growth failure. Delayed puberty.

Abdo Pain
Diarrhoea (with blood/mucus, urgency, tenesmus)
Weight Loss
Fever

Question 2

What are the extracolonic features of IBD?

Answer 2

Oral lesions
Perianal skin tags
Uveitis, episcleritis
Arthralgia
Ankylosing spondylitis
Clubbing
Erythema nodosum
Pyoderma gangrenosum
Renal stones

Question 3

What are clinical investigations suggestive of Crohn’s

Answer 3

Raised ESR, CRP
IDA
Low serum albumin

Question 4

What is the pathology of Crohn’s disease?

Answer 4

Transmural
Focal
Subacute or chronic

Acutely inflamed, thickened bowel. Strictures of bowel and fistulae may develop eventually (between bowel, other organs, skin).

May affect any part of GI, but terminal ileum and proximal colon are commonest

“Skip lesions”

Question 5

How is Crohn’s diagnosed

Answer 5

Endoscopy and histology of biopsy

Question 6

How are episodes of Crohn’s managed?

Answer 6

Nutritional Therapy
Whole protein modular feeds for 6-8 weeks.
Effective in 75%

If ineffective: systemic steroids

Relapse is common, thus immunosuppressants may be required (azathioprine, mercaptopurine, methotrexate)

Anti-TNF agents (infliximab, adalimumab) if conventional treatment failed

Surgery is necessary for the complications (obstruction, fistulae, abscess)

Question 7

What is the pathology of UC

Answer 7

Recurrent
Inflammatory and ulcerating disease of the mucosa of colon

In contrast to adults, 90% of children have pancolitis

Otherwise, rectum is commonest site of involvement

Question 8

What is the presentation of UC

Answer 8

Rectal bleeding
Diarrhoea
Colicky pain

There may be weight loss and growth failure, but less commonly than Crohn’s

Question 9

Extracolonic manifestations of UC

Answer 9

Erythema nodosum

Arthritis

Question 10

Management of UC

Answer 10

Mild: aminosalicylates (balsalazide and mesalazine) for induction and maintenance

Topical steroids if confined to sigmoid/rectum

Systemic steroids for acute exacerbations to induce remission (PO prednisolone or IV methylprednisolone) plus immunomodulators for maintenance (azathioprine, ciclosporin, tacrolimus, methotrexate)

Question 11

How is severe fulminating disease (UC) managed

Answer 11

Medical emergency

IV fluids + steroids

Ciclosporin if previous fails

Colectomy with ileostomy or ileorectal pouch is undertaken if complicated by toxic megacolon or chronic uncontrolled

Question 12

GI signs in IBD

Answer 12

Aphthous ulcers
Abdominal tenderness
Abdominal distension (UC>CD)
RIF mass (CD)
Peri-anal disease
(abscess, sinus, fistula, skin tags, fissure, stricture)

Question 13

Surgical treatment of UC

Answer 13

Total colectomy and ileostomy, later pouch creation and anal anastomosis. Cures UC, but there is 10-20% complications

Question 14

Surgical management of Crohns

Answer 14

Local surgical resection for severe localised disease. High re-operation rate because inflammation recurrence is universal

Question 15

Causes of gastritis

Answer 15

H. pylori infection
Stress ulcer - post trauma
Drug related - NSAIDs
Increased acid secretion (Zollinger Ellison syndrome, multiple endocrine neoplasia type I, hyperparathyroidism)
Crohn's disease
Autoimmune gastritis

Question 16

Symptoms of gastritis

Answer 16

Often asymptomatic
Chronic abdominal and epigastric pain
N+V
GI haemorrhage
FTT + anorexia
IDA

Perforation (very rare)
Indigestion, bloating, hiccups, loss of appetite

Question 17

Specific symptoms of peptic ulcer (duodenal)

Answer 17

Gnawing/burning feeling in the abdomen, below ribs and above umbilicus

Pain often reduced by eating food, drinking milk or taking antacids

Ulcers can bleed causing haematemesis or melena

Question 18

What is the role of H. pylori in gastritis

Answer 18

Usually it does not cause a problem in gastrits. But if left untreated, it can cause gastritis, peptic ulcer and stomach cancer in later life

Most infectiosn are silent and asymptomatic. Otherwise they cause gastritis and peptic ulcer disease

Question 19

Diagnosis and treatment of H pylori

Answer 19

urease 13C breath test

Stool antigen may be positive, but serological testing is unreliable in children

Treat with quadruple therapy discussed

Question 20

Lifestyle factors in gastritis

Answer 20

Eat smaller and more frequent meals

Avoid irritant foods - acidic, spicy, fried

Drink alcohol in moderation

Avoid NSAIDs
Manage stress
Reduce smoking

Question 21

Treatment of gastric duodenal ulcers

Answer 21

Treat underlying cause eg. H. pylori (quadruple therapy: 7-10 days oral amoxycillin (clarythromycin), bismuth, metronidazole ± omeprazole)

Decrease gastric acid production - PPI, H2, antagonist, sucralfate (cytoprotective)
Antacids (Aluminum hydroxide)

Question 22

Presentation of Mesenteric Adenitis

Answer 22

Fever
Malaise
Central abdominal pain

Nonspecific abdominal pain. Diagnosis can only be made definitely on seeing large mesenteric nodes at laparotomy/scopy (WITH NORMAL APPENDIX)

NSAP resolves 24-48hrs
Pain is less severe than appendicitis and RIF tenderness is variable. Often accompanied by URTI with cervical lymphadenopathy