IBD, Diverticular Disease, Colon and Anorectal Neoplasia CIS - Tieman

Question 1

pANCA

Answer 1

ulcerative colitis

Question 2

ASCA

Answer 2

crohns disease

Question 3

apthous ulcers

Answer 3

crohns

Question 4

IBD

Answer 4

disease of developed countries

Question 5

north america

Answer 5

ulcerative colitis more prevalent

Question 6

crohns disease

Answer 6

young women

bimodal

15-30yo and 7th decade

Question 7

ulcerative colitis

Answer 7

bimodal

equal men and women

20-40 yo and 7th decade

Question 8

inflammatory bowel disease

Answer 8

polygenic - multiple causes

Question 9

cigarette smoking

Answer 9

helps UC

makes crohns worse

Question 10

29yo RLQ pain and diarrhea last 6 months

• fam hx UC
• smokes 1ppd x 10 years
• ulcers inside lower lip
• tender RLQ
• guaiac positive stool

WBC 12,000
ESR elevated
CRP elevated
ASCA elevated
IgA and IgG elevated

colonoscopy - hyperemia ascending colon fullness of medial aspect

biopsy - normal colonic mucosa

CT enterography - thick bowel wall, suggestive of crohns

Answer 10

DDx - crohns, UC, appendicitis, pregnancy

work up - CBC, pregnancy test, Ab studies - pANCA and ASCA,

ESR and CRP - inflammatory process

ASCA, IgA, and IgG - crohns

colonoscopy - fullness medial aspect - inflammation

terminal ileum - crohns

Question 11

ulcerative colitis

Answer 11

mucosal

rectum and progresses continuously proximally

Question 12

crohns

Answer 12

transmural

ileocecal region

can occur anywhere

skip lesions

terminal ileum** - 70%

Question 13

family history of UC or crohns

Answer 13

increased risk for both - doesn’t matter which one

Question 14

ASCA, IgA and IgG elevation

Answer 14

90% specific for crohns

Question 15

cobblestone

Answer 15

crohns

Question 16

localization of crohns

Answer 16

small bowel imaging

-best for crohns - MRI enterography or CT enterography - with contrast material

Question 17

CT enterography

Answer 17

small bowel imaging

Question 18

tx of crohns

Answer 18

5-ASA - topical - targeted to area you need

diet changes - liquids, no milk, no grains

corticosteroids - systemic oral
-budesomide

infliximab - monoclonal Ab

methotrexate

6-MP

Question 19

surgery in crohns

Answer 19

no - will come back in other places**

except to treat complications

Question 20

budesomide

Answer 20

corticosteroid for crohns

Question 21

Case 24yo M, 3 month abdominal pain, urgency and defecation

• bloody, mucous stools
• fam hx crohns
• weight loss
• aching hips, knee, shoulders
• hyperactive bowel sounds, tender abdomen
• guaiac positive
• swelling of knees

ESR elevated
CRP elevated
ASCA normal
IgA normal
IgG normal
p-ANCA elevated

Answer 21

DDx - cancer, UC, crohns

work-up - CBC, Ab tests

proctosigmoidoscopy - edematous friable in rectal vault

colonoscopy - extends to distal transverse colon

Question 22

arthralgias

Answer 22

with ulcerative colitis

Question 23

fistula

Answer 23

crohns

Question 24

complication of acute ulcerative colitits

Answer 24

toxic megacolon**

barium enema or colonoscopy can incite this

bowel dilates and loses blood supply and get necrosis and perforation

be careful of scopes with severe ulcerative colitis

Question 25

ulcerative colitis risk

Answer 25

adenocarcinoma of colon

from time of onset - risk goes way up at 8 years**

after 8 years - screen yearly
-cancers can be submucosal

take random biopsies

Question 26

tx of ulcerative colitis

Answer 26

5-ASA - oral or enema - determining of extent of UC

Question 27

to keep UC in remission

Answer 27

maintenance therapy - 5-ASA type - oral or enema admin

Question 28

surgery and UC

Answer 28

can be curative

total proctocolectomy

Question 29

Case 39yo M anorexia, LLQ pain, low grade fever and diarrhea, never before

• pain 6/10
• LLQ tender with guarding
• rectal - fullness on left and stool trace guaiac positive

WBC 16,000 w/ bands

CT - acute inflammation of sigmoid

Answer 29

DDx - diverticulitis, colorectal cancer, UC, crohns

work up - CBC, CT

WBC with bands - acute infection

CT - sigmoid diverticulitis

Question 30

CT for diverticulitis**

Answer 30

make sure they don’t have complication**

also helps with diagnosis

perforation - to peritoneum
perforation - to sidewall

Question 31

tx of acute diverticulitis

Answer 31

antibiotics, bowel rest, IV fluids

don’t do scope until it is controlled**

then do colonoscopy - 6 weeks later - to rule out cancer

Question 32

LLQ tenderness and fever

Answer 32

think sigmoid diverticulitis

Question 33

Case 33yo M, fullness left buttock when sits, soiling of underwear

• lower abdomen pain
• lost 10 pounds
• anorexia
• low grade fever
• tender deep palp LLQ
• dimple left buttock - pus and fecal matter
• erythematous pre-tibial nodules on left leg

Answer 33

anal fistula

often associated with crohns
-30%

but normally - infection and abscess in anal crypts**

work up - CBC, pANCA, ASCA, Ig levels

Question 34

normal anal fistula

Answer 34

infection and abscess in anal crypt
-ischioanal space - perirectal abscess

• works out to skin
• can drain pus and stool

Question 35

tx of anal fistula

Answer 35

anal fistulotomy - open - from inside to outside

seton - if complex fistula

Question 36

crohns anal fistulas

Answer 36

surgery not 1st step

not going to cure the fistula

• they come back
• “waterpot perineum”

first - treat medically - infliximab or 6-MP

Question 37

anal fissure

Answer 37

sores

• constipation association
• pain with bowel movement

if chronic - tx is surgery
-lateral internal sphincterotomy