Gen Surg: Chrons and UC Flashcards
What investigations would you do for suspected IBD (Chrons, UC)?
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.
How is remission maintained in Chrons?
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.
How is UC managed presenting to hospital ?
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.
How is UC surgically managed?
Total proctocolectomy is curative. Initially, pt may have subtotal colectomy.
Name 2 complications of Chron’s
Fistula,
strictures,
recurrent perianal fistulas,
GI malignancy,
malabsorption - leading to growth delay.
Osteoporosis,
increased risk of gall stones and renal stones
What is a complication of UC?
Toxic megacolon, colorectal carcinoma, osteoporosis, pouchitis (inflame of ilea pouch).
Define Chron’s disease
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.
Epidiemiology of Chron’s
- 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
Associated infections with Chron’s
- Atypical mycobacteria
- Enteroadherent strains of E. Coli
- Yersinia
- Listeria
Define a fistula
Abnormal connection between two epithelial surfaces
Endoscopic appearance of Crohn’s disease
In Chron’s the inflammation is Transmural - what complications can this lead to?
- Longitudinal fissures - ‘cobblestone mucosa’
- deep aphthous ulcers
- stritures
Perinal anal disease: - Fistulae
- Anal Fissures
- Abscesses
What pattern on inflammation in chrons
- Skip lesions
- Anywhere from mouth to anus: but tends to skip the rectum
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’
- Failure to reabsorb bile acids leads to malabsorption of fat causing steatorrhoea
- excess bile acid excretion irriates the colonic mucosa contributing to diarrhoea
Why can terminal ileal disease lead to macrocytic anaemia?
Failure to reabsorb intrinsic factor leads to B12 deficiency
* Reduced absorption of folate
Presentation of Chron’s
Abdominal pain
* Diarrhoea
* Systemic illness: fever, weight loss
* Mouth and anus
* Extra-intestinal
Extraintestinal features of Chron’s
Skin:
Pyoderma gangrenosum
Erythema nodosum
Extraintestinal features of Chron’s
Eyes:
anterior uveitis, posterior uveitis
Extraintestinal features of Chron’s
joints:
- Enteropathic arthritis
(in medium sized joints e.g. knee, ankle)
typically asymmetrical and non-deforming - Sacrolieitis
similar to Ankylosis spondylitis
On examination of a pt with Crohn’s what to look for
- Clubbing
- Anaemia
- Mouth ulcers
- Abdominal tenderness
- Surgical scars
- Perianal disease
Differencials for Chron’s
- Irritable bowel syndrome
- Infective gastroenteritis
- Ulcerative colitis
- Coeliac disease
Initial investigations if you suspect chrons
- 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
What 3 types of anaemia can you get in Crohn’s
- 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)
Imaging and next investigations to diagnosis
- 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)
Complications of Crohn’s
- Fistula formation
- Obstruction due to a stricture
- Abscesses
- Toxic megacolon
FAST - mneumonic complications and key differences from UC
F- Fistuale
A - Anal disease + abcesses
S - Strictures and skip lesions
T - Transmural
Medical management of Crohn’s to reduce remission
- 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
Severe disease treatment for Crohn’s
Biological agents if severe / not responding:
* infliximab (IV) if fistulae present
* adalimumab (IM)
* monotherapy or combined
Medical management of Crohn’s post ileo-colonic resection (maybe dont stress about this one haha!)
Azathioprine plus metronidazole for 3/12
Reduces risk of recurrence
Maintenace therapy for Crohn’s
- no treatment is option
- azathioprine or mercaptopurine
- Methotrextae if intolerant / contraindicated
- Do not use steroids for maintenance of remission
Surgical management of chron’s
rarely curative due to skip lesions - conservative management maximised
* Resection
* Stricutroplasty
Definiton of UC?
Ulcerative colitis (UC) is a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel.
Epidiemiology of UC
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.
causes of UC
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.
GI symptoms of UC
- 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
Systemic symptoms of UC
Weight loss
Fever
Physical examination signs in UC
Inspection:
* pallor due to anemia
* clubbing
Abdominal examination:
* abdo distension or tenderness
PR examination:
* may show tenderness
* blood/mucus
Extraintestinal features of UC:
Dermatological
erythema nodosum pyoderma gangrenosum
Extra-intestinal features of UC:
Eyes
- anterior uveitis
- episcleritis
- conjunctivitis
Extra-intestinal features:
MSK
- clubbing
- non-deforming
- asymmetrical arthritis
- sacroiliitis
Extra-intestinal features of UC:
Hepatobiliary manifestations
primary sclerosing cholangitis
Truelove Witts severity index for UC
Differencial diagnosis for UC
- Crohn’s disease
- infectious colitis
- ischemic colitis
Differencial Diagnosis for UC whar are key signs and symptoms to differenciate between UC and :
- Crohn’s disease
- Infectious colitis
- Ischaemic colitis
Initial investigations for UC?
lab and bloods
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.
Imaging in UC
- 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).
Endoscopic investigations for UC
Note endoscopic investigations and barium enema used for diagnosis
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)
UC: how to manage mild / moderate disease
- topical aminosalicylate
- If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate.
- still not achieved add topical / oral corticosteroid
UC how to manage proctosigmoiditis and left-sided ulcerative colitis
- 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
UC management : Acute severe disease
- 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
Indications for emergency surgery in UC
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
Surgical options for UC:
- Panproctocolectomy (remove the entire large bowl and rectum) with permanent end ileostomy / J Pouch
see Zero 2 finals for easy explanation
Short term / acute complications of UC
- 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.
long term complcations of UC
- 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
