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Year 3 Surgery block > Gen Surg: Chrons and UC > Flashcards

Gen Surg: Chrons and UC Flashcards

1
Q

What investigations would you do for suspected IBD (Chrons, UC)?

A

FBC, CRP, faecal calprotein, LFTs, stool sample, colonoscopy, CT abdo and pelvis. For Chron’s - MRI, proctosigmoidoscopy. For UC - AXR or CT for toxic megacolon or bowel perforation and to see mural thickening, thumb printing or lead pipe colon.

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1
Q

How is remission maintained in Chrons?

A

Azathioproine - 1st line monotherapy. Smoking cessation. Colonoscopic surveillance if had disease for over 10yrs with more than 1 segment affected. Refer to specialist nurse and nutritional support.

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2
Q

How is UC managed presenting to hospital ?

A

Fluid resus, nutritonal support, prophylactic heparin. Induce remission with steroids and immunosuppressive agent.
Need to maintain remission too with immunomodulatord.
Colonoscopic surveillance.
Refer to specialist nurse.

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3
Q

How is UC surgically managed?

A

Total proctocolectomy is curative. Initially, pt may have subtotal colectomy.

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4
Q

Name 2 complications of Chron’s

A

Fistula,
strictures,
recurrent perianal fistulas,
GI malignancy,
malabsorption - leading to growth delay.
Osteoporosis,
increased risk of gall stones and renal stones

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5
Q

What is a complication of UC?

A

Toxic megacolon, colorectal carcinoma, osteoporosis, pouchitis (inflame of ilea pouch).

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6
Q

Define Chron’s disease

A

Crohn’s disease (CD) is a chronic relapsing inflammatory bowel disease (IBD). It is characterised by a transmural granulomatous inflammation which can affect any part of the gastrointestinal tract, most commonly the ileum, colon or both.

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7
Q

Epidiemiology of Chron’s

A
  • Chronic inflammatory disease: relapsing, remitting
  • Typical onset aged 15-35 years
  • As common in males as females
  • Genetic predisposition + environmental triggers
  • Twice as common in smokers
  • Increased risk of colonic cancer after 8 years
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8
Q

Associated infections with Chron’s

A
  • Atypical mycobacteria
  • Enteroadherent strains of E. Coli
  • Yersinia
  • Listeria
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9
Q

Define a fistula

A

Abnormal connection between two epithelial surfaces

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10
Q

Endoscopic appearance of Crohn’s disease

A
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11
Q

In Chron’s the inflammation is Transmural - what complications can this lead to?

A
  • Longitudinal fissures - ‘cobblestone mucosa’
  • deep aphthous ulcers
  • stritures
    Perinal anal disease:
  • Fistulae
  • Anal Fissures
  • Abscesses
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12
Q

What pattern on inflammation in chrons

A
  • Skip lesions
  • Anywhere from mouth to anus: but tends to skip the rectum
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13
Q

Why if chron’s is in the terminal ileum can you get Steatorrhoea?
pt might describe:
* white bulky greasy motions
* hard to flush away
* ‘like porridge’

A
  • Failure to reabsorb bile acids leads to malabsorption of fat causing steatorrhoea
  • excess bile acid excretion irriates the colonic mucosa contributing to diarrhoea
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14
Q

Why can terminal ileal disease lead to macrocytic anaemia?

A

Failure to reabsorb intrinsic factor leads to B12 deficiency
* Reduced absorption of folate

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15
Q

Presentation of Chron’s

A

Abdominal pain
* Diarrhoea
* Systemic illness: fever, weight loss
* Mouth and anus
* Extra-intestinal

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16
Q

Extraintestinal features of Chron’s

Skin:

A

Pyoderma gangrenosum
Erythema nodosum

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17
Q

Extraintestinal features of Chron’s

Eyes:

A

anterior uveitis, posterior uveitis

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18
Q

Extraintestinal features of Chron’s

joints:

A
  • Enteropathic arthritis
    (in medium sized joints e.g. knee, ankle)
    typically asymmetrical and non-deforming
  • Sacrolieitis
    similar to Ankylosis spondylitis
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19
Q

On examination of a pt with Crohn’s what to look for

A
  • Clubbing
  • Anaemia
  • Mouth ulcers
  • Abdominal tenderness
  • Surgical scars
  • Perianal disease
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20
Q

Differencials for Chron’s

A
  • Irritable bowel syndrome
  • Infective gastroenteritis
  • Ulcerative colitis
  • Coeliac disease
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21
Q

Initial investigations if you suspect chrons

A
  • FBC, ESR and CRP (Aanaemia, raised WCC, ESR/CRP, thrombocytosis)
  • LFT (low albumin -malabsorption)
  • B12 and folate
  • Stool microscopy and culture (exclude infection)
  • Faecal calprotectin (an antigen produced by neutrophils) will be raised (this helps distinguish from IBS).
  • Coeliac antibodies
22
Q

What 3 types of anaemia can you get in Crohn’s

A
  • Normochromic normocytic anaemia of chronic disease
  • Macrocytic anaemia due to B12 and/ or folate deficiency
  • Microcytic anaemia due to iron deficiency (due to blood loss)
23
Q

Imaging and next investigations to diagnosis

A
  • Colonoscopy (w/biopsies) get skip lesions, cobblestone, rose thron ulcers, non-caseating granulomas
  • Barium enema - find rose thorn uclers (image)
  • MRI for suspected small bowel disease
  • Upper GI series may show the ‘string sign of Kantour’. This is used to describe the string-like appearance of contrast-filled narrowed terminal ileum, and is suggestive of Crohn’s disease. (ques)
24
Q

Complications of Crohn’s

A
  • Fistula formation
  • Obstruction due to a stricture
  • Abscesses
  • Toxic megacolon
25
Q

FAST - mneumonic complications and key differences from UC

A

F- Fistuale
A - Anal disease + abcesses
S - Strictures and skip lesions
T - Transmural

26
Q

Medical management of Crohn’s to reduce remission

A
  • 1st line: monotherapy prednisolone / IV hydrocortisone (consider bisphosphonates)
  • Mesalazine has fewer side-effects but less effective
  • NB Enteral nutrition is an alternative in children

ADD ON THERAPY
* or to help reduce steroid dose Azathioprine or mercaptopurine
* Check for (TPMT) activity first +
Regular check of FBC for neutropenia (agranulocytosis)
* Can consider Methotrexate if dont tolerate above

27
Q

Severe disease treatment for Crohn’s

A

Biological agents if severe / not responding:
* infliximab (IV) if fistulae present
* adalimumab (IM)
* monotherapy or combined

28
Q

Medical management of Crohn’s post ileo-colonic resection (maybe dont stress about this one haha!)

A

Azathioprine plus metronidazole for 3/12
Reduces risk of recurrence

28
Q

Maintenace therapy for Crohn’s

A
  • no treatment is option
  • azathioprine or mercaptopurine
  • Methotrextae if intolerant / contraindicated
  • Do not use steroids for maintenance of remission
28
Q

Surgical management of chron’s

A

rarely curative due to skip lesions - conservative management maximised
* Resection
* Stricutroplasty

29
Q

Definiton of UC?

A

Ulcerative colitis (UC) is a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel.

30
Q

Epidiemiology of UC

A

UC is the most commonly diagnosed inflammatory bowel disease.

UC can develop at any age, it most frequently occurs in two peak age groups: 15 to 25 years and 55 to 65 years.

31
Q

causes of UC

A

The exact cause of UC is unknown, a combination of:

  • genetic predisposition
  • environmental factors
  • dysregulation of the immune system.
  • a higher incidence of UC among non-smokers and ex-smokers.
32
Q

GI symptoms of UC

A
  • Diarrhea often containing blood and/or mucus
  • Tenesmus or urgency
  • Pain in the left iliac fossa (as large colon affected in UC)

in chron’s small bowel can be affected and Right sided pain / central

33
Q

Systemic symptoms of UC

A

Weight loss
Fever

34
Q

Physical examination signs in UC

A

Inspection:
* pallor due to anemia
* clubbing

Abdominal examination:
* abdo distension or tenderness

PR examination:
* may show tenderness
* blood/mucus

35
Q

Extraintestinal features of UC:
Dermatological

A

erythema nodosum pyoderma gangrenosum

36
Q

Extra-intestinal features of UC:
Eyes

A
  • anterior uveitis
  • episcleritis
  • conjunctivitis
37
Q

Extra-intestinal features:

MSK

A
  • clubbing
  • non-deforming
  • asymmetrical arthritis
  • sacroiliitis
38
Q

Extra-intestinal features of UC:
Hepatobiliary manifestations

A

primary sclerosing cholangitis

39
Q

Truelove Witts severity index for UC

A
40
Q

Differencial diagnosis for UC

A
  • Crohn’s disease
  • infectious colitis
  • ischemic colitis
41
Q

Differencial Diagnosis for UC whar are key signs and symptoms to differenciate between UC and :

  • Crohn’s disease
  • Infectious colitis
  • Ischaemic colitis
A
42
Q

Initial investigations for UC?
lab and bloods

A

Blood tests:
* FBC may show anaemia and a raised white cell count, ESR/CRP is typically raised, LFTs may show a low albumin.

Microbiological investigations:
* Stool microscopy culture and sensitivity
* stool C. difficile toxin to exclude infective colitis.

Faecal calprotectin:
* Distinguishes between IBS and IBD Raised in IBD.

43
Q

Imaging in UC

A
  • Abdominal X-ray and erect chest x-ray in acute settings to exclude toxic megacolon and perforation.
  • Barium enema will reveal:
    lead-piping inflammation (secondary to loss of haustral markings)
    thumb-printing (a marker of bowel wall inflammation)
    pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa).
44
Q

Endoscopic investigations for UC

Note endoscopic investigations and barium enema used for diagnosis

A

Colonoscopy:
* continuous inflammation with an erythematous mucosa, loss of haustral markings, and pseudopolyps.

Biopsy
* loss of goblet cells, crypt abscess, and inflammatory cells (predominantly lymphocytes)

45
Q

UC: how to manage mild / moderate disease

A
  1. topical aminosalicylate
  2. If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate.
  3. still not achieved add topical / oral corticosteroid
46
Q

UC how to manage proctosigmoiditis and left-sided ulcerative colitis

A
  • topical (rectal) aminosalicylate
  • if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
  • if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
47
Q

UC management : Acute severe disease

A
  • should be treated in hospital
  • intravenous steroids are usually given first-line
  • intravenous ciclosporin /infliximab may be used if steroid are contraindicated
  • if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
48
Q

Indications for emergency surgery in UC

A

Surgery should be considered in patients with:

  • Acute fulminant ulcerative colitis
  • Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids
  • Symptoms worsening despite intravenous steroids
49
Q

Surgical options for UC:

A
  • Panproctocolectomy (remove the entire large bowl and rectum) with permanent end ileostomy / J Pouch

see Zero 2 finals for easy explanation

50
Q

Short term / acute complications of UC

A
  • Toxic megacolon: this describes a severe form of colitis, and is seen in around 15% of ulcerative colitis patients.
  • Massive lower gastrointestinal haemorrhage: this occurs in up to 3% of patients.
51
Q

long term complcations of UC

A
  • Colorectal cancer (higher risk if severe and have PSC)
  • Cholangiocarcinoma (2x risk)
  • Colonic strictures: these can cause large bowel obstruction.
  • (PSC) Primary Sclerosing Cholangitis: LFTs should be monitored yearly
  • Inflammatory pseudopolyps

Year 3 Surgery block (66 decks)

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