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Y4 final checklist_ SURGERY > IBD > Flashcards

IBD Flashcards

1
Q

Differences and similarities of UC vs Crohn’s

A
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2
Q

Features/presentation of Crohn’s

A
  • Diarrhoea → usually non-bloody
  • Weight loss more prominent
  • Upper gastrointestinal symptoms, mouth ulcers, perianal disease
  • Abdominal mass palpable in the right iliac fossa
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3
Q

Features of UC

A
  • Bloody diarrhoea
  • Abdominal pain in the left lower quadrant
  • Tenesmus
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4
Q

Extra-intestinal diseases associated with Crohn’s and UC

A

Crohns:

  • gallstones → secondary to reduced bile acid reabsorption
  • Oxalate renal stones

UC:

  • Primary sclerosing cholangitis
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5
Q

Complications of Crohn’s and UC

A
  • Crohns: obstruction, fistula, colorectal cancer
  • UC: colorectal cancer → higher risk than in Crohn’s
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6
Q

Inflammation in Crohn’s vs UC

  • location
  • lesion pattern
A

Crohns:

  • Lesions may be seen anywhere from the mouth to anus
  • Skip lesions

UC:

  • Inflammation always starts at rectum and never spreads beyond ileocaecal valve
  • continuous pattern of lesions
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7
Q

Histology in Crohn’s

A
  • Inflammation in all layers from mucosa to serosa
  • increased goblet cells
  • granulomas
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8
Q

Histology in UC

A
  • No inflammation beyond submucosa
  • neutrophils migrate through the walls of glands to form crypt abscesses
  • depletion of goblet cells and mucin from gland epithelium
  • granulomas are infrequent
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9
Q

What’s seen on endoscopy of Crohn’s vs UC

A

Crohn’s:

Deep ulcers, skip lesions - ‘cobble-stone’ appearance

UC:

Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)

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10
Q

Radiological signs of Crohn’s

A

Small bowel enema

  • high sensitivity and specificity for examination of the terminal ileum
  • strictures: ‘Kantor’s string sign’
  • proximal bowel dilation
  • ‘rose thorn’ ulcers
  • fistulae
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11
Q

What’s that?

A

Stricture → Kantor’s Sign in Crohn’s disease

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12
Q

What’s that?

A

Rose thorn sign → Crohn’s

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13
Q

Radiological signs of UC

A

Barium enema

  • loss of haustrations
  • superficial ulceration, ‘pseudopolyps’
  • long standing disease: colon is narrow and short -‘drainpipe colon’
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14
Q

What can cure UC?

A

Proctocolectomy

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15
Q

Indications for elective surgery in UC

A

disease that is requiring maximal therapy or prolonged courses of steroid

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16
Q

An absolute indication for surgery in UC

A

Dysplastic transformation of the colonic epithelium with associated mass lesions → proctocolectomy absolutely needed

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17
Q

Emergency surgery for UC

  • indication
  • procedure
A
  • Emergency presentations of poorly controlled colitis that fails to respond to medical therapy → subtotal colectomy
  • End ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.
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18
Q

Restorative surgical option for UC (1)

  • name
  • requirement
  • complications
A
  • Restorative options in UC→ ileoanal pouch
  • this can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy
  • Ileoanal pouch complications: anastomotic dehiscence, pouchitis and poor physiological function with seepage /przeciekanie/ and soiling
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19
Q

Indications for surgical resection in Crohn’s

A

Surgical resection in Crohn’s does not provide a cure but may give some symptomatic improvement

Indications:

  • fistulae
  • abscess formation
  • strictures
20
Q

What can extensive small bowel resections (in Crohn’s) lead to and how to prevent these complications?

A

Extensive small bowel resections may result in short bowel syndrome → localised stricturoplasty may allow preservation of intestinal length

21
Q

How to manage complex perianal fistula in Crohn’s? Why?

A

Complex perianal fistulae → best managed with long term draining seton sutures

(complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence)

22
Q

Is pouch reconstruction recommended in Crohn’s?

A
  • Proctectomy → if severe perianal and / or rectal
  • Ileoanal pouch reconstruction in Crohns → high risk of fistula formation and pouch failure → not recommended
23
Q

The commonest affected site of Crohn’s disease

  • possible treatment option
  • possible complications related to this location
A

Terminal ileal Crohns → the commonest site

  • patients may be treated with limited ileocaecal resections
  • Terminal ileal Crohns → may affect enterohepatic bile salt recycling and increase the risk of gallstones
24
Q

Is Arthritis and Episcleritis more common in UC or Crohn’s?

A
  • Arthritis → in both CD and UC
  • Episcleritis →more common in CD
25
Q

Common extra-articular features in both, Crohns and UC (4)

A
  • Arthritis: pauciarticular, asymmetric
  • Erythema nodosum
  • Episcleritis
  • Osteoporosis
26
Q

Is PSC more common in Crohn’s or UC?

A

Primary sclerosing cholangitis is much more common in UC

27
Q

Is uveitis more common in Crohn’s or UC?

A

Uveitis is more common in UC

28
Q

Classification of UC severity (3)

A
  • mild: < 4 stools/day, only a small amount of blood
  • moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
  • severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
29
Q

Treatment for proctitis in UC (mild-moderate)

A

Proctitis in UC (mild-moderate)

(treatment to induce remission)

  • topical (rectal) aminosalicylate: for distal colitis rectal mesalazine
  • if remission is not achieved within 4
  • weeks → add an oral aminosalicylate
  • if remission still not achieved → add topical or oral corticosteroid
30
Q

Management of Proctosigmoiditis and L - sided UC (mild-moderate)

A

Proctosigmoiditis and left-sided ulcerative colitis → Rx to induce remission (in mild-moderate)

  • 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
31
Q

Treatment to induce remission in extensive disease (inflammation) in UC

A

Extensive disease in UC

  • topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
  • if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
32
Q

Treatment of severe colitis in UC

A

Severe colitis in UC

  • should be treated in hospital
  • IV steroids are usually given first-line
    • IV ciclosporin may be used if steroid are contraindicated
  • if after 72 hours there has been no improvement → add intravenous ciclosporin to intravenous corticosteroids or consider surgery
33
Q

How to maintain remission of mild-moderate UC

A

Following a mild-to-moderate ulcerative colitis flare

  • proctitis and proctosigmoiditis
    • topical (rectal) aminosalicylate alone (daily or intermittent) or
    • an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
    • an oral aminosalicylate by itself: this may not be effective as the other two options
  • left-sided and extensive ulcerative colitis
    • low maintenance dose of an oral aminosalicylate
34
Q

Treatment of UC following a severe relapse or >=2 exacerbations in the past year

A

oral azathioprine or oral mercaptopurine

If: severe relapse of >=2 exacerbations per year

35
Q

Is methotrexate prescribed in Crohn’s or UC?

A
  • methotrexate is in Crohn’s
36
Q

Are probiotics useful in the management of UC?

A

there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

37
Q
A
38
Q

Ix in Crohn’s disease

A
  • raised inflammatory markers
  • increased faecal calprotectin
  • anaemia
  • low vitamin B12 and vitamin D
39
Q

Presentations of Crohn’s disease

A

Crohn’s disease typically presents in late adolescence or early adulthood. Features include:

  • presentation may be non-specific symptoms such as weight loss and lethargy
  • diarrhoea: the most prominent symptom in adults. Crohn’s colitis may cause bloody diarrhoea
  • abdominal pain: the most prominent symptom in children
  • perianal disease: e.g. Skin tags or ulcers
  • extra-intestinal features are more common in patients with colitis or perianal disease
40
Q

Peak age incidence of UC

A

The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years

41
Q

Typical symptoms of UC

A

The initial presentation is usually following insidious and intermittent symptoms. Features include:

  • bloody diarrhoea
  • urgency
  • tenesmus
  • abdominal pain, particularly in the left lower quadrant
  • extra-intestinal features (see below)
42
Q

Management to induce remission in Crohn’s

A

Inducing remission in CD

  • glucocorticoids (oral, topical or intravenous) *Budesonide is an alternative in a subgroup of patients
  • enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
  • 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
  • azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
  • infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
  • metronidazole is often used for isolated peri-anal disease
43
Q

Maintaining remission in Crohn’s - management

A

Maintaining remission in Crohn’s

  • stopping smoking is a priority
  • azathioprine or mercaptopurine is used first-line to maintain remission
  • methotrexate is used second-line
  • 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
44
Q

Smoking and IBD

A

Smoking makes Crohn’s worse, but may help ulcerative colitis

45
Q
A

Y4 final checklist_ SURGERY (25 decks)

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