IBD + Diverticular disease Flashcards
UC epidemiology
- Prevalence
- Age
- White
- Sex
Prevalence (/100K): 100-200 (more than Crohn’s)
Age: 30s, peak in late teens- adulthood
Ethnicity
- White
Sex: F>M
UC pathology
- Macroscopic
- microscopic
Macroscopic
- ONLY affects colonic mucosa/submucosa.
- Starts distally, spreds proximally with continuous inflammation.
- Granular, hypervascular, loss of vascular pattern.
Microscopic
- Neutrophilic infiltration
- Crypt abscesses
- Goblet cell depletion
UC complications
- Toxic megacolon (>6cm)
- Bleeding
- Malignancy
- Cholangiocarcinoma
- Venous thrombus
- Strictures (less common than Chron’s)
Symptoms of UC
- Proctitis
- Left-sided colitis
- Pancolitis
- General
Procitis
- Diarrhoea: fecal urgency and frequency
- Bloody mucus faeces
Left-side colitis (up to splenic flexure)
- extensive blood mucus stools
- Blood diarrhoea
Pancolitis
- Backwash ileitis: secondary inflammation off secondary ileum
- Systemic: fever, malaise, anorexia, tachycardia, anaemia
- Mucus loss= hypokalaemia
Signs of UC
- Abdominal
- Extra-abdominal
Abdominal
- Tender, distended abdomen.
Extra-abdominal
- Skin: Clubbing, erythema nodosum
- Eyes: Iritis/ conjuctivitis/ scleritis
Surgical management of UC
- Indications
(elective, emergency)
- Procedures
Elective surgery
- Chronic symptoms persist despite medical therapy/ Medical treatment with intolerable side effects
- Occurrence of cancer/ high-grade dysplasia.
Emergency surgery indications:
- Toxic megacolon
- Perforation
- Massive haemorrhage
- Failure to respond to medical treatment.
Procedures
- Protocolectomy
- Panproctocolectomy
- Total abdominal colectomy
Crohn’s epidemiology
- Prevalence
- Age
- Sex
Prevalence (/100K): 5-100 (less common than UC)
Age: 20s
Sex: F>M
Crohn’s pathology
- Macroscopic
- Microscopic
Macroscopic
- Mouth to anus, mainly terminal ileum and caecum.
- Skips lesions.
- Cobblestoning
Microscopic
- Transmural inflammation.
- Lymphoid hyperplasia/ aggregates
- Non-caseating Granuloma
Crohn’s complications
Strictures
Fistulae
- Due to perforation
Abscess
- Malabsorption.
Colonic Crohn’s associated with colorectal cancer.
Examples of fistulaes in crohn’s
Entero-enteric/ colonic (between upper GI, upper GI to colon)
- Presents with diarrhoea
Enterovesical
- Between bowel and bladder
- UTI, increased urinary frequency
Enterovaginal
- Bowel and vagina
- Passage of stool/gas from vagina, UTI, foul smelling.
Perianal
- Between anal canal and perianal skin
- Symptoms/ signs: skin maceration, pus, itching.
Symptoms of Crohn’s
- Inflammatory
- Stenosing features
- Anal disease
Inflammatory
- Fever, malaise
- Abdominal pain, especially RIF
- Diarrhoea, usually non-bloody
- Weight loss
Fistuliszing features
Stenosing
- Colicky abdominal pain
- Weight loss
- Distended/ palpable small bowel
Anal
- Anal fissures
Signs of Crohn’s
- Abdominal
- Extra-abdominal
Abdominal
- Glossitis, stomatitis
- RIF mass
- Perianal abscess/ fistulae/ tags
- Anal/rectal strictures
Extra-abdominal
- Joints: arthritis, sacrolitis, ankylosing spondylosis.
- Hepatobiliary: PSC, gallstones, Fatty liver, Cholangiocarcinoma (less than UC).
- Amylodosis, oxlate renal stones.
Surgical indications in Crohn’s
- Elective
- emergency
Elective surgery
- Abscess/ fistula
- Perianal disease
- Carcinoma.
- Procedures: Limited resection, stricturoplasty.
Emergency surgery
Indications:
- Massive haemorrhage
- Intestinal obstruction/perforation
- Failure to respond to medical treatment.
Diverticulitis
- Definition
- Pathophysiology
- Pathology
Symptomatic, inflamed out-pouching of tubular structure (diverticulum)
- True= complete wall outpouching
- False= mucosa only
Pathogenesis
- High pressure contractions in colon causing pressure on the colinc wall= formation of diverticula
Acute pathology
- Neutrophil infiltration around diverticum in subserosa
Diverticulitis
- Epidemiology (race, age, sex)
Westerners >60.
- F>M
Diverticulitis risk factors
Obese
Saint’s triad
- Haitus hernia
- Cholelithiasis
Differentials for IBD
Infective
Coeliac
Malignancy
Diverticulitis
Diverticulitis
- Symptoms
- Altered bowel habit
- Left sided colic, relieved by defecation
- Nausea, flatulence
If bleeding
- Large volume dark red, clotted blood
- Due to rupture of peridiverticular submucosal blood vessel.
Diverticulitis
- Complications and their presentation
Perforation + peritonitis
- Present with acute diverticulitis: high fever, severe pain, involuntary guarding and rigidity
Haemorrhage
Pericolic Abscess
- Persistent infection causes thickenng of surrounding tissue and pus formation: tachy, fever, LIF mass
Fistulae
- Perforation into adjacent areas= vaginal, bladder
- Presents with recurrent UTI, bubbles and debris in urine, faeculent discharge.
Strictures
- Fibrosis and narrowing of the colon due to chroni/ repeptition inflammation
- Presents with colicky pain, distention, bloating.
Diagnosis of diverticulitis
Bloods
- Raised WCC, CRP, ESR
Imaging
- Erect CXR to rule out perf
- AXR
- Contrast CT
- Flexi sigm, colonscopy
Truelove and witts criteria
- Indication
- Features
- Interpretation
Classifies severity of UC
Features
- Frequency of stool (=4,5, 6+)
- Bloody stool (much in severe)
- Fever (37.5 + in severe)
- Tachycardia (90 bpm+ severe)
- Anaemia (Hb 10 or
Medical management of acute severe UC
- IV steroids
- Adcal D3, consider bisphosphonates
- 5-ASA
Must show improvement withing 3 days, or escalate treatment
- Escalate medical first (biologics)
Escalate by day 7 if no improvement
- Subtotal colectomy, ileostomy
Pouch operation
J pouch created with ileum- Double backed
- allows rectum to be stimulated.
- Only curative option in UC, allows mucosa of distal rectum to be removed.
Pouch operation complications
Pouchitis
Cuffitis
Poor pouch function
Dysplasia
Fertility/ fecundity
Crohn’s diagnosis
Bloods
- FBC: WCC, Hb,
- CRP, ESR
- U+Es
- Celiac serology
Stool
- Fecal calprotectin
- Culture
Imaging
- Erect CXR
- AXR
- Contrast CT
Endoscopy
Further development
- MRI: especially for fistulae and strictures
- Capsule endoscopy (XC if stricture indicated)
Medical treatment of acute CD
- Diet
- Non diary, low fat
Inducing remission
- Glucocorticoid= prednisolone/ IV hydrocortisone
- 2nd line= budenoside
- 3rd line= 5-ASA
- Multiple episodes= aziathioprine/ mercaptopurine
Uc investigations
Bloods
- Raised WCC
- Raised CRP
- Hb and albumin may be lower
Protosigmoidoscopy
- Biopsy
Stool tests
- Culture: rule out infective cause
Crohn’s
- Investigations
Bloods
- Raised WCC and CRP
- Anaemia; low Hb
Imaging
- Abdominal CT
- Colitis: endoscopy and biopsy
- Gastric: OGD
Inducing remission in Crohn’s
First line
- Azathioprine/ mercaptopurine
2nd line
- Methotrexate
Severe disease/ resistant= biologics
- Infliximab/ Adalimumab
Examples of fistulae in complicated diverticulitis
Vaginorectal
Vesicalrectal
Inducing remission in UC
- 5ASA- mesalazine
- Topical and oral in extensive disease
2nd line= Steroids
