Inflammatory bowel disease Flashcards
Presentation of UC
Systemic:
• Fever, malaise, anorexia, wt. loss in active disease
Abdominal symptoms: • Diarrhoea • Blood ± mucus PR • Abdominal discomfort • Tenesmus, faecal urgency
Signs:
• Fever
• Tender, distended abdomen
- Clubbing
- Erythema nodosum
- Pyoderma gangrenosum
Eyes:
- Iritis
- Conjunctivitis
- Episcleritis
- Scleritis
Complications of UC
• Toxic megacolon
- Diameter >6cm
- Risk of perforation
• Bleeding • Malignancy - colorectal cancer •Cholangiocarcinoma • Strictures → obstruction • Venous thrombosis
• PSC + cholangiocarcinoma
Crohns presentation
Systemic features:
• fever, malaise, anorexia and wt loss in active disease
Abdominal features:
• diarrhoea
• abdominal pain
Signs: • Apthous ulcers • glossitis • RIF (terminal ileum) • Perinanal abscesses, fistulas and tags • Anal/rectal strictures
Joints:
• Enteropathic Arthritis (asymmetrical)
• Sacroiliitis
• Ankylosing spondylitis
HPB:
• Gallstones and Renal stones
• Fatty liver
Complications of Crohns
Fistulae
- Strictures → obstruction
- Abscesses
- Malabsorption
- Fat → Steatorrhoea, gallstones
- B12 → megaloblastic anaemia
- Vit D → osteomalacia
- Protein → oedema
• Toxic megacolon and Ca may occur (less common)
Investigations
• Bloods:
- FBC: ↓Hb, ↑WCC
- LFT: ↓albumin
- ↑CRP/ESR
- Blood cultures
• Stool
- FIT
- Faecal calprotectin
- MCS: exclude Campylobacter, Shigella, Salmonella
- C. Diff toxin - complicates /mimics
• Imaging
- AXR: megacolon (>6cm), wall thickening
- CXR: perforation
- CT
- Ba enema
- Ileocolonoscopy + regional biopsy: gold standard for crohns
- colonoscopy with biopsy - UC or flexible sigmoidoscopy
UC signs on AXR
- Lead-pipe: no haustra
- Thumbprinting: mucosal thickening
UC signs on endoscopy + microscopy
Pseudopolyps: regenerating mucosal island
Decreased goblet cells
Crypt abscesses
Continuous inflammation
Acute severe UC Mx
• Resus: Admit, IV hydration, NBM
• Hydrocortisone IV • Transfuse if required • Thromboprophylaxis: LMWH • Monitoring - Bloods: FBC, ESR, CRP, U+E - Vitals + stool chart - Twice daily examination - ± AXR
When acute severe UC improves and doesn’t improve
Improvement:
- oral therapy - aminosalicylates
- oral pred
• Taper pred after full remission
No Improvement: rescue therapy
• On day 3: stool freq >8 or CRP >45
- Medical: ciclosporin, infliximab
- Surgical
Inducing remission for UC
Oral Therapy
• 1st line: Aminosalicylate
• 2nd line: Prednisolone
Topical Therapy: mainly left-sided disease
• Proctitis: suppositories
• Proximal disease: enemas or foams
Additional Therapy: steroid sparing
• Azathioprine or mercaptopurine
• Infliximab: steroid-dependent pts
Maintaining Remission for UC
1st line: Aminosalicylate -sulfasalazine or mesalazine
2nd line: Azathioprine or mercaptopurine
- Relapsed on ASA or are steroid-dependent
- Give 6-mercaptopurine if azathioprine intolerant
3rd line: Infliximab
Indications for surgery
- Toxic megacolon
- Perforation
- Massive haemorrhage
- Failure to respond to medical Tx
Surgery procedures
• Total/subtotal colectomy with end ileostomy ± mucus
fistula
• Followed after ~3mo by either
- Total proctectomy + Ileal-pouch anal anastomosis (IPAA) or end ileostomy
• Panproctocolectomy + permanent end ileostomy
Indications for elective surgery
- Chronic symptoms despite medical therapy
- Carcinoma or high-grade dysplasia
Procedures
• Panproctocolectomy with end ileostomy or IPAA
• Total colectomy with IRA
Surgical complications
• Abdominal
- Small bowel obstruction
- Anastomotic stricture
- Pelvic abscess
• Stoma:
- retraction, stenosis, prolapse, dermatitis
• Pouch
- Pouchitis - metronidazole + cipro
- ↓ female fertility
- Faecal leakage
Crohns Ix
• Bloods:
- FBC: ↓Hb, ↑WCC
- LFT: ↓albumin
- ↑CRP/ESR
- Haematinics: Fe, B12, Folate
- Blood cultures
• Stool
- FIT
- Faecal calprotectin
- MCS: exclude Campy, Shigella, Salmonella
- C. difficile toxin
• Imaging
- AXR: obstruction, sacroileitis
- CXR: perforation
- MRI
- Assess pelvic disease and fistula
• Endoscopy
- Ileocolonoscopy + regional biopsy
Signs of Crohns on AXR
- Skip lesions
- String sign of Kantor: narrow terminal ileum
Signs of Crohns on endoscopy
- Rose-thorn ulcers
- Cobblestoning: ulceration + mural oedema
- Granulomatous (non-caseating
Mx of severe attack of Crohns
• Resus: Admit, NBM, IV hydration • Hydrocortisone: IV + PR if rectal disease • Abx: metronidazole • Thromboprophylaxis: LMWH • Dietician Review - Liquid prep amino acids, glucose and fatty acids - Consider parenteral nutrition • Monitoring - Vitals + stool chart - Daily examination
How to manage improvement and no improvement of severe Crohns attack
Improvement: oral therapy
• Oral prednisolone
No Improvement: rescue therapy
• Discussion between pt, physician and surgeon
• Medical: methotrexate ± infliximab
• Surgical
How to induce remission in Crohn’s disease
Supportive:
• High fibre diet
• Vitamin supplements
• Smoking cessation
Oral Therapy: • 1st line - Ileocaecal: budesonide - Colitis: sulfasalazine • 2nd line: prednisolone • 3rd line: methotrexate • 4th line: infliximab or adalimumab
How to treat perianal Crohn’s disease
- Ix: MRI + Examination under anaesthesia
- Tx
- Oral Abx: metronidazole
- Immunosuppression ± infliximab
- Local surgery ± seton insertion
Maintaining remission in Crohn’s disease
- 1st line: azathioprine or mercaptopurine
- 2nd line: methotrexate
- 3rd line: Infliximab
Indications for surgery in Crohn’s disease
Emergency:
- Failure to respond to medical Tx
- Intestinal obstruction or perforation
- Massive haemorrhage
• Elective
- Abscess or fistula
- Perianal disease
- Chronic ill health
- Carcinoma
