IBD + Diverticular disease

Question 1

UC epidemiology
- Prevalence
- Age
- White
- Sex

Answer 1

Prevalence (/100K): 100-200 (more than Crohn’s)

Age: 30s, peak in late teens- adulthood

Ethnicity
- White

Sex: F>M

Question 2

UC pathology
- Macroscopic
- microscopic

Answer 2

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

Question 3

UC complications

Answer 3

• Toxic megacolon (>6cm)
• Bleeding
• Malignancy
• Cholangiocarcinoma
• Venous thrombus
• Strictures (less common than Chron’s)

Question 4

Symptoms of UC
- Proctitis
- Left-sided colitis
- Pancolitis
- General

Answer 4

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

Question 5

Signs of UC
- Abdominal
- Extra-abdominal

Answer 5

Abdominal
- Tender, distended abdomen.

Extra-abdominal
- Skin: Clubbing, erythema nodosum

• Eyes: Iritis/ conjuctivitis/ scleritis

Question 6

Surgical management of UC
- Indications
(elective, emergency)
- Procedures

Answer 6

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

Question 7

Crohn’s epidemiology
- Prevalence
- Age
- Sex

Answer 7

Prevalence (/100K): 5-100 (less common than UC)

Age: 20s

Sex: F>M

Question 8

Crohn’s pathology
- Macroscopic
- Microscopic

Answer 8

Macroscopic
- Mouth to anus, mainly terminal ileum and caecum.
- Skips lesions.
- Cobblestoning

Microscopic
- Transmural inflammation.
- Lymphoid hyperplasia/ aggregates
- Non-caseating Granuloma

Question 9

Crohn’s complications

Answer 9

Strictures

Fistulae
- Due to perforation

Abscess
- Malabsorption.

Colonic Crohn’s associated with colorectal cancer.

Question 10

Examples of fistulaes in crohn’s

Answer 10

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.

Question 11

Symptoms of Crohn’s
- Inflammatory
- Stenosing features
- Anal disease

Answer 11

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

Question 12

Signs of Crohn’s
- Abdominal
- Extra-abdominal

Answer 12

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.

Question 13

Surgical indications in Crohn’s
- Elective
- emergency

Answer 13

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.

Question 14

Diverticulitis
- Definition
- Pathophysiology
- Pathology

Answer 14

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

Question 15

Diverticulitis
- Epidemiology (race, age, sex)

Answer 15

Westerners >60.

• F>M

Question 16

Diverticulitis risk factors

Answer 16

Obese

Saint’s triad
- Haitus hernia
- Cholelithiasis

Question 17

Differentials for IBD

Answer 17

Infective
Coeliac
Malignancy
Diverticulitis

Question 18

Diverticulitis
- Symptoms

Answer 18

• 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.

Question 19

Diverticulitis
- Complications and their presentation

Answer 19

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.

Question 20

Diagnosis of diverticulitis

Answer 20

Bloods
- Raised WCC, CRP, ESR

Imaging
- Erect CXR to rule out perf
- AXR
- Contrast CT
- Flexi sigm, colonscopy

Question 21

Truelove and witts criteria
- Indication
- Features
- Interpretation

Answer 21

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

Question 22

Medical management of acute severe UC

Answer 22

1. IV steroids
2. Adcal D3, consider bisphosphonates
3. 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

Question 23

Pouch operation

Answer 23

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.

Question 24

Pouch operation complications

Answer 24

Pouchitis

Cuffitis

Poor pouch function

Dysplasia

Fertility/ fecundity

Question 25

Crohn’s diagnosis

Answer 25

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)

Question 26

Medical treatment of acute CD

Answer 26

1. Diet
   - Non diary, low fat

Inducing remission
- Glucocorticoid= prednisolone/ IV hydrocortisone
- 2nd line= budenoside
- 3rd line= 5-ASA
- Multiple episodes= aziathioprine/ mercaptopurine

Question 27

Uc investigations

Answer 27

Bloods
- Raised WCC
- Raised CRP
- Hb and albumin may be lower

Protosigmoidoscopy
- Biopsy

Stool tests
- Culture: rule out infective cause

Question 28

Crohn’s
- Investigations

Answer 28

Bloods
- Raised WCC and CRP
- Anaemia; low Hb

Imaging
- Abdominal CT
- Colitis: endoscopy and biopsy
- Gastric: OGD

Question 29

Inducing remission in Crohn’s

Answer 29

First line
- Azathioprine/ mercaptopurine

2nd line
- Methotrexate

Severe disease/ resistant= biologics
- Infliximab/ Adalimumab

Question 30

Examples of fistulae in complicated diverticulitis

Answer 30

Vaginorectal

Vesicalrectal

Question 31

Inducing remission in UC

Answer 31

1. 5ASA- mesalazine
   - Topical and oral in extensive disease

2nd line= Steroids