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Year 3 Lower GI Surgery > Inflammatory bowel disease > Flashcards

Inflammatory bowel disease Flashcards

1
Q

Presentation of UC

A

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
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2
Q

Complications of UC

A

• Toxic megacolon

  • Diameter >6cm
  • Risk of perforation
• Bleeding
• Malignancy
- colorectal cancer  
•Cholangiocarcinoma
• Strictures → obstruction
• Venous thrombosis

• PSC + cholangiocarcinoma

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3
Q

Crohns presentation

A

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

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4
Q

Complications of Crohns

A

Fistulae

  • Strictures → obstruction
  • Abscesses
  • Malabsorption
  • Fat → Steatorrhoea, gallstones
  • B12 → megaloblastic anaemia
  • Vit D → osteomalacia
  • Protein → oedema

• Toxic megacolon and Ca may occur (less common)

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5
Q

Investigations

A

• 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
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6
Q

UC signs on AXR

A
  • Lead-pipe: no haustra

- Thumbprinting: mucosal thickening

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7
Q

UC signs on endoscopy + microscopy

A

Pseudopolyps: regenerating mucosal island

Decreased goblet cells

Crypt abscesses

Continuous inflammation

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8
Q

Acute severe UC Mx

A

• 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
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9
Q

When acute severe UC improves and doesn’t improve

A

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
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10
Q

Inducing remission for UC

A

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

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11
Q

Maintaining Remission for UC

A

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

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12
Q

Indications for surgery

A
  • Toxic megacolon
  • Perforation
  • Massive haemorrhage
  • Failure to respond to medical Tx
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13
Q

Surgery procedures

A

• 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

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14
Q

Indications for elective surgery

A
  • Chronic symptoms despite medical therapy
  • Carcinoma or high-grade dysplasia

Procedures
• Panproctocolectomy with end ileostomy or IPAA
• Total colectomy with IRA

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15
Q

Surgical complications

A

• Abdominal

  • Small bowel obstruction
  • Anastomotic stricture
  • Pelvic abscess

• Stoma:
- retraction, stenosis, prolapse, dermatitis

• Pouch

  • Pouchitis - metronidazole + cipro
  • ↓ female fertility
  • Faecal leakage
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16
Q

Crohns Ix

A

• 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

17
Q

Signs of Crohns on AXR

A
  • Skip lesions

- String sign of Kantor: narrow terminal ileum

18
Q

Signs of Crohns on endoscopy

A
  • Rose-thorn ulcers
  • Cobblestoning: ulceration + mural oedema
  • Granulomatous (non-caseating
19
Q

Mx of severe attack of Crohns

A 
• 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
20
Q

How to manage improvement and no improvement of severe Crohns attack

A

Improvement: oral therapy
• Oral prednisolone

No Improvement: rescue therapy
• Discussion between pt, physician and surgeon
• Medical: methotrexate ± infliximab
• Surgical

21
Q

How to induce remission in Crohn’s disease

A

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
22
Q

How to treat perianal Crohn’s disease

A
  • Ix: MRI + Examination under anaesthesia
  • Tx
  • Oral Abx: metronidazole
  • Immunosuppression ± infliximab
  • Local surgery ± seton insertion
23
Q

Maintaining remission in Crohn’s disease

A
  • 1st line: azathioprine or mercaptopurine
  • 2nd line: methotrexate
  • 3rd line: Infliximab
24
Q

Indications for surgery in Crohn’s disease

A

Emergency:

  • Failure to respond to medical Tx
  • Intestinal obstruction or perforation
  • Massive haemorrhage

• Elective

  • Abscess or fistula
  • Perianal disease
  • Chronic ill health
  • Carcinoma
25
Q

Surgery

A

Resection

26
Q

Complications of surgery for Crohn’s disease

A
  • Stoma complications
  • Enterocutaneous fistulae
  • Anastomotic leak or stricture
27
Q

Side effects of short gut

A
  • Steatorrhoea
  • ADEK and B12 malabsorption
  • Bile acid depletion → gallstones
  • Hyperoxaluria → renal stones

• Tx:

  • Dietician - supplements or TPN
  • Loperamide
28
Q

Fistulae in Crohns

A
  • Enterocolic - diarrhoea
  • Enterovesical → frequency, UTI
  • Enterovaginal
  • Perianal → “pepperpot” anus
29
Q

Risk factors

A

FHx
Smoking - Crohns
Jewish
Appendicectomy

30
Q

Colonoscopic surveillance

A

offered to people who have had the disease for >10 years with >1 segment of bowel affected

Year 3 Lower GI Surgery (10 decks)

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