Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis, C51 P338-344 Flashcards
What is IBD?
P338
Inflammatory Bowel Disease,
inflammatory disease of the GI tract
What are the two
inflammatory bowel
diseases?
P338
Crohn’s disease and ulcerative colitis
What is another name for
Crohn’s disease?
P338
Regional enteritis
What is ulcerative colitis
often called?
P338
UC
What is the cause of IBD?
P338
No one knows, but probably an
autoimmune process with environmental
factors contributing
What is the differential
diagnosis?
P338
Crohn’s versus ulcerative colitis, infectious
colitis (e.g., C. difficile, amebiasis,
shigellosis), ischemic colitis, irritable bowel
syndrome, diverticulitis, Zollinger-Ellison
syndrome (ZES), colon cancer, carcinoid,
ischemic bowel
What are the extraintestinal
manifestations seen in both
types of IBD?
P338
Ankylosing spondylitis, aphthous (oral) ulcers, iritis, pyoderma gangrenosum, erythema nodosum, clubbing of fingers, sclerosing cholangitis, arthritis, kidney disease (nephrotic syndrome, amyloid deposits)
How can these
manifestations be
remembered?
P339
Think of the acronym “A PIE SACK”:
Aphthous ulcers
Pyoderma gangrenosum Iritis Erythema nodosum
Sclerosing cholangitis
Arthritis, Ankylosing spondylitis
Clubbing of fingers
Kidney (amyloid deposits, nephrotic
syndrome)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Crohn’s disease: Incidence P339
3–6/100,000
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Crohn’s disease: At-risk population P339
High in the Jewish population, low in the
African black population, similar rates
between African American and U.S.
white population
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Crohn’s disease: Sex? P339
Female > male
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Crohn’s disease: Distribution? P339
Bimodal distribution (i.e., two peaks in
incidence): peak incidence at 25 to 40
years of age; second bimodal distribution
peak at 50 to 65 years of age
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Ulcerative colitis: Incidence? P339
10/100,000
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Ulcerative colitis: At-risk population P339
High in the Jewish population, low in the
African American population
Positive family history in 20% of cases
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Ulcerative colitis: Sex? P339
Male > female
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE Ulcerative colitis: Distribution? P339
Bimodal distribution at 20 to 35 and
50 to 65 years of age
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INITIAL SYMPTOMS Crohn’s disease? P340
Abdominal pain, diarrhea, fever,
weight loss, anal disease
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INITIAL SYMPTOMS Ulcerative colitis? P340
Bloody diarrhea (hallmark), fever, weight loss
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ANATOMIC DISTRIBUTION Crohn’s disease? P340
Classic phrasing “mouth to anus”
Small bowel only (20%)
Small bowel and colon (40%)
Colon only (30%)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ANATOMIC DISTRIBUTION Ulcerative colitis? P340
Colon only (Think: ulcerative COLitis = COLon alone)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ROUTE OF SPREAD Crohn’s disease? P340
Small bowel, colon, or both with “skip
areas” of normal bowel; hence, the
name “regional enteritis”
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ROUTE OF SPREAD Ulcerative colitis? P340
Almost always involves the rectum and
spreads proximally always in a continuous
route without “skip areas”
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ROUTE OF SPREAD What is “backwash” ileitis? P340
Mild inflammation of the terminal ileum
in ulcerative colitis; thought to be
“backwash” of inflammatory mediators
from the colon into the terminal ileum
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS BOWEL WALL INVOLVEMENT Crohn’s disease? P340
Full thickness (transmural involvement)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS BOWEL WALL INVOLVEMENT Ulcerative colitis? P340
Mucosa/submucosa only
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ANAL INVOLVEMENT Crohn’s disease? P340
Common (fistulae, abscesses, fissures,
ulcers)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS ANAL INVOLVEMENT Ulcerative colitis? P340
Uncommon
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS RECTAL INVOLVEMENT Crohn’s disease? P341
Rare
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS RECTAL INVOLVEMENT Ulcerative colitis? P341
100%
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS MUCOSAL FINDINGS Crohn’s disease (6)? P341
- Aphthoid ulcers
- Granulomas
- Linear ulcers
- Transverse fissures
- Swollen mucosa
- Full-thickness wall involvement
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS MUCOSAL FINDINGS Ulcerative colitis (5)? P341
- Granular, flat mucosa
- Ulcers
- Crypt abscess
- Dilated mucosal vessels
- Pseudopolyps
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS MUCOSAL FINDINGS How can ulcerative colitis and Crohn’s anal and wall involvement be remembered? P341
“CAT URP”:
Crohn’s = Anal–Transmural
UC = Rectum–Partial wall thickness
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS DIAGNOSTIC TESTS Crohn’s disease? P341
Colonoscopy with biopsy, barium enema,
UGI with small bowel follow-through,
stool cultures
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS DIAGNOSTIC TESTS Ulcerative colitis? P341
Colonoscopy, barium enema, UGI with
small bowel follow-through (to look for
Crohn’s disease), stool cultures
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS COMPLICATIONS Crohn’s disease? P341
Anal fistula/abscess, fistula, stricture,
perforation, abscesses, toxic megacolon,
colovesical fistula, enterovaginal fistula,
hemorrhage, obstruction, cancer
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS COMPLICATIONS Ulcerative colitis? P341
Cancer, toxic megacolon, colonic
perforation, hemorrhage, strictures,
obstruction, complications of surgery
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS CANCER RISK Crohn’s disease? P342
Overall increased risk, but about half that
of ulcerative colitis
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS CANCER RISK Ulcerative colitis? P342
≈5% risk of developing colon cancer at
10 years; then, risk increases ≈1% per
year; thus, an incidence of ≈20% after
20 years of the disease (30% at 30 years)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE OF TOXIC MEGACOLON Crohn’s disease? P342
≈5%
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INCIDENCE OF TOXIC MEGACOLON Ulcerative colitis? P342
≈10%
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Crohn’s disease? P342
Obstruction, massive bleeding, fistula, perforation, suspicion of cancer, abscess (refractory to medical treatment), toxic megacolon (refractory to medical treatment), strictures, dysplasia
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Ulcerative colitis? P342
Toxic megacolon (refractory to medical treatment); cancer prophylaxis; massive bleeding; failure of child to mature because of disease and steroids; perforation; suspicion of or documented cancer; acute severe symptoms refractory to medical treatment; inability to wean off of chronic steroids; obstruction; dysplasia; stricture
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What are the common surgical options for ulcerative colitis? P342
1. Total proctocolectomy, distal rectal
mucosectomy, and ileoanal pull
through
2. Total proctocolectomy and Brooke
ileostomyCOMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is “toxic megacolon”? P342
Toxic patient: sepsis, febrile, abdominal
pain
Megacolon: acutely and massively
distended colon
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What are the medication options for treating IBD? P343
Sulfasalazine, mesalamine
(5-aminosalicylic acid)
Steroids, metronidazole (Flagyl®),
azathioprine, 6-mercaptopurine
(6-mp), infliximabCOMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is infliximab? P343
Antibody vs. TNF- (tumor necrosis
factor-alpha)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is the active metabolite of sulfasalazine? P343
5’-aminosalicylate (5’-ASA), which is
released in the colon
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is the medical treatment of choice for perianal Crohn’s disease? P343
PO metronidazole (Flagyl®)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What are the treatment options for long-term remission of IBD? P343
6-mercaptopurine (6-mp), azathioprine,
mesalamine
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What medication is used for IBD “flare-ups”? P343
Steroids
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is a unique medication route option for ulcerative colitis? P343
Enemas (steroids, 5-ASA)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Which disease has “cobblestoning” more often on endoscopic exam? P343
Crohn’s disease
Think: Crohn’s = Cobblestoning
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Which disease has pseudopolyps on colonoscopic exam? P343
Ulcerative colitis; pseudopolyps are
polyps of hypertrophied mucosa
surrounded by mucosal atrophy
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Which disease has a “lead pipe” appearance on barium enema? P343
Chronic ulcerative colitis
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Rectal bleeding/bloody diarrhea is a hallmark of which disease? P343
Ulcerative colitis (rare in Crohn’s disease)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is the most common indication for surgery in patients with Crohn’s disease? P344
Small bowel obstruction (SBO)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What are the intraoperative findings of Crohn’s disease? P344
Mesenteric “fat creeping” onto the
antimesenteric border of the small
bowel
Shortened (and thick) mesentery
Thick bowel wall
Fistula(e)
Abscess(es)COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Why do you see fistulas and abscesses with Crohn’s and not ulcerative colitis? P344
Crohn’s disease is transmural
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is the operation for short strictures of the small bowel in Crohn’s disease? P344
Stricturoplasty; basically a Heineke-
Mikulicz pyloroplasty on the strictured
segment (i.e., opened longitudinally and
sewn closed in a transverse direction)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Should the appendix be removed during a laparotomy for abdominal pain if Crohn’s disease is discovered? P344
Yes, if the cecum is not involved with
active Crohn’s disease
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is pouchitis? P344
Inflammation of the pouch of an ileoanal
pull through; treat with metronidazole
(Flagyl®)
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY Do you need a frozen section for margins during a bowel resection for Crohn’s disease? P344
No, you need only grossly negative
margins
COMPARISON OF CROHN’S DISEASE AND ULCERATIVE COLITIS INDICATIONS FOR SURGERY What is it called when the entire colon is involved? P344
Pancolitis
