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General Surgery > IBD > Flashcards

IBD Flashcards

1
Q

What is the age distribution of Crohn’s disease?

A

Bimodal peak age presentation - 15-30 and 60-80 yrs old

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2
Q

What course does Crohn’s disease usually follow?

A

Remitting and relapsing course

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3
Q

What can happen as a result of severe exacerbations of Crohn’s disease?

A

Life-threatening causing:
Systemic upset
Bowel perforation
rarely death

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4
Q

What is the pathophysiology of Crohn’s disease?

A

Can affect any part of GI tract - commonly distal ileum or proximal colon - much of aetiology unknown

Smoking increase risk of developing unlike UC

Transmural inflammation producing deep ulcers and fissures (cobblestone appearance)
Skip lesions

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5
Q

What are the macroscopic changes seen in Crohn’s disease?

A

Discontinuous inflammation (skip lesions)

Fissures and deep ulcers (cobblestone appearance)

Fistula formation

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6
Q

What are the different types of fistula that can form in Crohn’s disease?

A

Perianal fistula (54% of pts)

Entero-enteric fistula (24%)

Recto-vaginal (9%)

Entero-cutaneous fistula

Entero-vesicalar fistula

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7
Q

What is the microscopic change seen on Crohn’s disease?

A

Non-caseating granulomatous inflammation

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8
Q

What are the risk factors for Crohn’s disease?

A

Strong FH

Smoking (developing and relapse)

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9
Q

What are the typical symptoms of Crohn’s disease?

A

Episodic abdominal pain - colicky in nature and site varies depends on region affected

Diarrhoea - often chronic and may contain blood or mucus

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10
Q

What are some systemic symptoms of Crohn’s disease?

A

Malaise

Anorexia

Low grade fever

Malabsorption and malnourishment if severe - late presenting feature (children may intially present as failure to grow or thrive)

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11
Q

What is the oral involvement in Crohn’s disease?

A

Oral aphthous ulcers (can be painful and recurring)

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12
Q

What is the perianal involvement of Crohn’s disease?

A

Perianal disease, including with peri anal abscess

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13
Q

What are the different types of extra-intestinal manifestations of IBD?

A

Musculoskeletal

Skin

Eyes

Hepatobiliary

Renal

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14
Q

What are the musculoskeletal manifestations of IBD ?

A

Enteropathic arthritis (sacroiliac and other large joints)

Nail clubbing

Metabolic bone disease (secondary malabsorption)

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15
Q

What are the skin manifestations for IBD?

A

Erthyema nodosum

Pyoderma gangrenosum (erthyemstous papules/pustules that develop into deep ulcers)

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16
Q

What are the eye manifestations of IBD?

A

Episcleritis
Anterior uveititis
Iritis

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17
Q

What are the hepatobilary manifestations of IBD?

A

Primary sclerosing cholangitis (more associated with UC)

Cholangiocarcinoma (associated with PSC)

Gallstones

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18
Q

What is the renal manifestation of IBD?

A

Renal stones

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19
Q

What investigations should be order for suspected Crohn’s disease?

A

Routine bloods - CRP/WCC - check for anaemia

Faecal calprotectin test

Stool sample for potential infective cause

Colonoscopy is GOLD standard - biopsies are taken

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20
Q

When can colonoscopy not be used to make diagnosis of Crohn’s disease?

A

When disease more proximal to terminal ilium - presumed diagnosis on clinical features and imaging alone

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21
Q

What other investigations may be warranted in Crohn’s disease and wha are they looking for?

A

CT scan abdomen pelvis - severe Crohn’s disease, look for bowel obstruction or perforation or any intra-abdominal collections - useful in acute phase when colonoscopy contraindicated

MRI imaging - asses disease severity for any eneteric fistula or peri-anal disease.
Examination under anaesthesia (EUA) with proctosigmoidoscopy - examine and treat perianal fistula.

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22
Q

Where should pts with IBD be managed?

A

Referred to gastroenterologist

Acute severe disease should be admitted on an emergency basis

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23
Q

What is done to induce remission in Crohn’s disease?

A

Fluid resuscitation, nutritional support and prophylactic heparin and anti-embolic stocking (pro thrombotic state of IBD flares)

Corticosteroid therapy as first line.

Subsequent treatments including - immunosuppressive agents (mesalazine, azathioprine) or biological agents (infliximab or adalimumab)

24
Q

What is the severity classification of Crohn’s disease?

A

Montreal score:

Age at diagnosis

Location

Behaviour - e.g. stricture or no stricture add a “p” if concurrent perianal disease

25
Q

What is the managing remission treatment for Crohn’s disease?

A

Azathioprine - first line mono therapy

Smoking cessation

Colonoscopic surveillance is offered offered to those who have had the disease for >10years with>1 segment of bowel affected

26
Q

What other support should be offered for IBD?

A

IBD-nurse specialist and pt support groups

Enteral nutritional support - young pts with growth concerns

27
Q

What percentage of Crohn’s disease pts require surgical management in their lifetime?

A

70-80%

28
Q

When is surgical management indicated in Crohn’s disease?

A

Failed medical management

Severe complications (strictures or perforation)

All operations bowel-sparing approach should be taken to avoid short gut syndrome in later years.

29
Q

Which types of surgery are usually requires in Crohn’s disease?

A
  • Ileocaecal resection (removal of terminal ileum and caecum with primary anastomosis)
  • Small bowel resection or large bowel resection
  • Surgery for peri-anal disease (e.g. abscess drainage, seton insertion, or laying open of fistulae)
  • Stricturoplasty (division of a stricture that is causing bowel obstruction)

CD patients are typically high risk patients to operate on, therefore pre-operative optimisation (including treating any acute attack and managing nutrition) should be attempted where possible.

30
Q

When should primary bowel anastomosis not be performed in Crohn’s disease?

A

Active severe flare up

Or not at least without defunctioning stoma

31
Q

What are the complications of Crohn’s disease?

A

Fistula

Stricture formation

Recurrent perianal fistulae - difficult to treat

GI malignancy

32
Q

What are the extraintestinal complications of Crohn’s disease?

A

Malabsorption - growth delay in children

Osteoporosis - due to malabsorption or long term steroid use

Increased risk of gallstones - reduced reabsorption of bile at terminal ilium

Increased risk of renal stones - malabsorption of fats in small bowel which causes calcium to remain in lumen but oxalate is absorbed. Results in hyperoxaluria and formation of oxalte stones in renal tract.

33
Q

Which drugs should be avoided in IBD and why?

A

Anti-motility such as loperamide. Avoid in acute attacks as these can precipitate toxic mega colon.

34
Q

What is the prevalence and incidence of UC?

A

More common in Caucasian population

Bimodal distribution - 15-25, 55-65 yrs old

35
Q

What may occur in a severe fulminant exacerbation of UC?

A

Life threatening:

Severe systemic upset
Toxic megacolon
Colonic perforation
Death

36
Q

What is a protective factor in UC?

A

Smoking

37
Q

What is the pathophysiology of UC?

A

Diffuse continual mucosal inflammation of the large bowel. Beginning in the rectum and spreading proximally

Portion of terminal may be affected if ileocaecal valve is not competent - backwash ileitis

Hyperaemic/haemorrahigic colonic mucosa

38
Q

What are the macroscopic changes seen in UC?

A

Continuous inflammation

Pseudo-polyps (raised areas du to repeated cycles of ulcerations and healing) and ulcers may form

39
Q

What are the microscopic changes that may occur in UC?

A

Crypt abscess formation
Reduced (hypoplasia) goblet cells
Non-granulomatous inflammation

40
Q

What are the symptoms of UC?

A

Insidious onset. Cardinal feature is bloody diarrhoea, with visible blood in stool in more then 90% of cases. More likely if widespread colonic involvement + features of dehydration and electrolyte imbalance.

Proctitis

PR bleeding and mucus discharge

Increased frequency and urgency of defecation and tenesmus

41
Q

What are some systemic signs of UC?

A

Malaise
Anorexia
Low-grade pyrexia

42
Q

What may be found on clinical examination of UC?

A

Unless severe exacerbation, generally unremarkable.

Fulminant colitis, toxic megacolon or colonic perforation should be suspected if pt complains of severe abdominal pain and if signs of peritonism are present.

43
Q

Which criteria can be used to grade the severity of UC exacerbations?

A

True love and Witt criteria

44
Q

What are the diffential diagnosis of UC?

A

Crohn’s disease

Chronic infections
Mesenteric ischemia
Radiation colitis

Malignancy, IBS or coeliac disease

45
Q

What investigations should be order for UC?

A

Routine bloods - CRP/WCC

Faecal calprotectin - raised in IBD but normal in IBS.

Stool sample

Colonoscopy with biopsy

46
Q

Which scores are used in UC?

A

Montreal score - quantify disease extent

Mayo score - disease severity

47
Q

What imaging may be order in acute exacerbations of UC?

A

AXR

CT imaging

48
Q

What may be seen on AXR of UC?

A

Mural thickening and thumb printing

Chronic cases - lead-pipe colon

49
Q

What is the inducing remission management of UC?

A

Fluid resuscitation, nutritional support and prophylactic heparin

Corticosteroid therapy and immunosuppressive agents such as cyclosporin or 5-ASA suppositories. Biological agents such as infliximab can be trialled as rescue therapy.

Stepwise approach depending on clinical severity and location of exacerbation.

50
Q

What is the maintaining remission management of UC?

A

Immunomodulators - typically 5-ASAa such as mesalazine or sulfaslazine or azathioprine

Colonoscopic surveillance

51
Q

How much percentage of pts with UC will require surgery?

A

30%

52
Q

What are the indications for surgery in UC?

A

Refractory to medical treatment
Toxic megacolon
Bowel perforation

53
Q

What are the surgical options for UC?

A

Depends on patient and disease factors

Segmental bowel resection (subtotal colectomy) and defunctioning, as primary anastomosis during acute IBD flare is advised

Elective cases - total proctocolectomy is curative (requires end ileostomy) or
Can undergo subtotal colectomy with ileo-rectal anastomosis (IRA) or
Panprotoctocolectomy with Leo-pouch anal anastomosis (IPAA)

54
Q

What are the complications of UC?

A

Toxic megacolon

Colorectal carcinoma

Osteoporosis

Pouchitis - inflammation of ideal pouch - IPAA

55
Q

What are the symptoms of toxic megacolon and treatment?

A

Severe abdominal pain, abdominal distension, pyrexia and systemic toxicity

Decompression of the bowel asap due to increased risk of perforation

56
Q

What are the symptoms of pouchitis and what is the treatment?

A

Abdominal pain
Bloody diarrhoea

Treated with metronidazole and ciprofloxacin

General Surgery (20 decks)

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