IBD, Diverticular Disease, Colon and Anorectal Neoplasia CIS

pANCA

ulcerative colitis

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ASCA

crohns disease

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apthous ulcers

crohns

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IBD

disease of developed countries

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north america

ulcerative colitis more prevalent

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crohns disease

young women

bimodal

15-30yo and 7th decade

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ulcerative colitis

bimodal

equal men and women

20-40 yo and 7th decade

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inflammatory bowel disease

polygenic - multiple causes

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cigarette smoking

helps UC

makes crohns worse

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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

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

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ulcerative colitis

mucosal

rectum and progresses continuously proximally

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crohns

transmural

ileocecal region

can occur anywhere

skip lesions

terminal ileum** - 70%

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family history of UC or crohns

increased risk for both - doesn’t matter which one

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ASCA, IgA and IgG elevation

90% specific for crohns

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cobblestone

crohns

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localization of crohns

small bowel imaging

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

CT enterography

small bowel imaging

tx of crohns

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

surgery in crohns

no - will come back in other places**

except to treat complications

budesomide

corticosteroid for crohns

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

DDx - cancer, UC, crohns

work-up - CBC, Ab tests

proctosigmoidoscopy - edematous friable in rectal vault

colonoscopy - extends to distal transverse colon

arthralgias

with ulcerative colitis

fistula

crohns

complication of acute ulcerative colitits

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

ulcerative colitis risk

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

tx of ulcerative colitis

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

to keep UC in remission

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

surgery and UC

can be curative total proctocolectomy

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

DDx - diverticulitis, colorectal cancer, UC, crohns work up - CBC, CT WBC with bands - acute infection CT - sigmoid diverticulitis

CT for diverticulitis**

make sure they don't have complication** also helps with diagnosis perforation - to peritoneum perforation - to sidewall

tx of acute diverticulitis

antibiotics, bowel rest, IV fluids don't do scope until it is controlled** then do colonoscopy - 6 weeks later - to rule out cancer

LLQ tenderness and fever

think sigmoid diverticulitis

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

anal fistula often associated with crohns -30% but normally - infection and abscess in anal crypts** work up - CBC, pANCA, ASCA, Ig levels

normal anal fistula

infection and abscess in anal crypt -ischioanal space - perirectal abscess - works out to skin - can drain pus and stool

tx of anal fistula

anal fistulotomy - open - from inside to outside seton - if complex fistula

crohns anal fistulas

surgery not 1st step not going to cure the fistula - they come back - "waterpot perineum" first - treat medically - infliximab or 6-MP

anal fissure

sores - constipation association - pain with bowel movement if chronic - tx is surgery -lateral internal sphincterotomy

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