Inflammatory bowel disease Flashcards
Crohn’s vs UC
Crohn’s (crows NESTS)
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas.
UC - remember U – C – CLOSEUP)
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
Presentation of IBD
Diarrhoea
Abdominal pain
Passing blood
Weight loss
Crohn’s also presents with perianal disease (e.g. skin tags, ulcers) and can cause fistulae
Investigations for suspected IBD
Routine bloods - FBC and CRP (for infection and anaemia), TFTs, LFTs, U&Es
- CRP indicates inflammation and active disease
Stool culture to rule out other causes
Faecal calprotectin is a useful screening test
Endoscopy (OGD and colonoscopy) with biopsy is diagnostic
Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.
Treatment of Crohn’s - inducing remission
- Glucocorticoids - first line
- Enteral feeding may be used
- 5-ASA drugs (second line to glucocorticoids) e.g. sulfasalazine, mesalazine
- Azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy (also methotrexate)
- Infliximab useful in refractory disease
Maintaining remission of Crohn’s
Azathioprine or mercaptopurine is first line
TPMT activity should be assessed before starting
- Second line is methotrexate
Complications of Crohn’s - intestinal complications
Perianal fistulae
Strictures
Perianal abscess
Surgery in Crohn’s
When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease. (But it usually involves the entire GI tract)
Also can be used to treat strictures and fistuale secondary to Crohn’s
What is the presentation and treatment of perianal fistulae?
Presentation:
- Recurrent perianal abscesses
- Discharge onto the perineum
MRI is the investigation of choice
Oral metronidazole if symptomatic
Draining seton is used for complex fistulae
- a piece of surgical thread that’s left in the fistula for several weeks to keep it open.
- This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation
Or A fistulotomy (suitable for superficial disease) involves laying the tract open by cutting through skin and subcutaneous tissue, allowing it to heal by secondary intention
What rule can be used to predict the trajectory of anal fistula?
Goodsall rule
External opening posterior to the transverse anal line – fistula tract will follow a curved course to the posterior midline
External opening anterior to the transverse anal line – fistula tract will follow a straight radial course to the dentate line
How is perianal abscess treated?
Incision and drainage combined with antibiotic therapy
A draining seton may also be placed if a tract is identified
How can strictures be treated?
Resection of bowel
Stricturoplasty
What is the management for inducing remission of UC?
Mild or moderate disease -
- First line - aminosalicylate topical (rectal) plus oral if no remission within 4 weeks or extensive disease
- Second line - oral steroids
Severe disease:
- IV corticosteroids e.g. hydrocortisone, methylprednisolone
- Second line IV ciclosporin (if no improvement after 72h)
Maintaining remission in UC
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
Surgery in UC
Can do panproctocolectomy in severe disease
This will remove the disease
he patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch).
What is a J Pouch?
This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum.
This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
