Inflammatory Disease Flashcards
What is Crohn’s disease?
- Type of chronic inflammatory bowel disease.
- Typically follows remitting and relapsing course.
- Severe exacerbations may be life threatening from severe systemic upset, bowel perforation or obstruction and even death
What are risk factors of Crohn’s disease?
- Family history
- Smoking
- White European descent
- Appendicectomy
How does Crohn’s disease macroscopically present?
- Can affect any part of gastrointestinal tract but most commonly targets distal ileum or proximal colon however aetiology unknown.
- Forms skip lesions throughout the bowel.
- Transmural inflammation in the affected region of bowel
- Produces deep ulcers and fissures
- Cobblestone appearance.
What is the Microscopic Appearance of Crohn’s disease?
Non-caseating granulomatous inflammation
What are the fistulaes that can form in Crohn’s disease?
- Fistula can form from affected bowel to adjacent structures, resulting in:
- Perianal fistula
- Entero-enteric fistula
- Recto-vaginal
- Entero-cutaneous fistula
- Entero-vesicular fistula
What are clinical features of Crohn’s disease?
- Present with episodic abdominal pain and diarrhoea. Pain may be colicky in nature
- Chronic Diarrhoea and may contain blood.
- Episode often comes in acute attacks.
- Systemic symptoms include malaise, anorexia and low-grade fever.
- Malabsorption and malnourishment if severe.
- May initially present as failure thrive in children
- Both oral and perineal involvement are common
- Oral aphthous ulcer – painful and recurring
- Perineal disease – present as skin tag, perianal abscesses, fistulae or bowel stenosis
What are abdominal examination signs of Crohn’s disease?
- Abdominal Tenderness
- Distension
- Mouth or Perianal Lesions
- Signs of Malabsorption or Dehydration.
What are extra-intestinal features of Crohn’s disease?
- Musculoskeletal
- Enteropathic arthritis
- Metabolic bone disease
- Skin
- Erythema nodosum - tender red/purple subcutaneous nodules, typically found on patient’s shins
- Pyoderma gangrenosum – erythematous papule/pustules that develop into deep ulcers
- Eyes
- Episcleritis
- Anterior uveitis or iritis
- Hepatobiliary
- Primary sclerosing cholangitis, Cholangiocarcinoma and Gallstones
- Renal
- Renal stones (reduced absorption of bile salts which lead to increased free oxalate)
What are tests for Crohn’s disease?
- Routine bloods: anaemia, low albumin raised CRP and WCC
- LFTs: become deranged in patients on treatment
- Faecal calprotectin testing carried out in patient with recent onset lower gastrointestinal symptoms. Raised in inflammatory bowel disease but unchanged in irritable bowel syndrome
- Stool Sample sent for MC&S for any potential infective cause
What are imaging tests for Crohn’s disease?
- Abdominal X-Ray: useful to exclude any potential toxic megacolon or bowel obstruction that may have occurred
-
Colonoscopy with biopsy – gold standard.
- Characteristic macroscopic finding is cobblestoning of bowel, deep ulcers, skip lesions
- Should be avoided during an active flare due to increased risk to potential perforation and flexible sigmoidoscopy warranted instead
- Histology: inflammation in all layers from mucosa to serosa, goblet cells and granulomas
- Barium Swallow: Less commonly performed yet can show strictures (kantor’s string sign), proximal bowel dilation, fistulae, rose-thorn ulcers
- CT scan: usually warranted in severe Crohns disease and may demonstrate bowel obstruction, perforation, collection formation or fistulae
- 1st line for Perianal disease: Pelvic MRI is first line as it is both accurate and non-invasive.
What are conservative management principles of Crohn’s disease?
- Stop smoking and due to increased risk of colorectal malignancy, colonoscopic surveillance is offered to people who have had the disease >10 years with >1 segment of bowel affected
- Patient should be referred to IBD-nurse specialists and patient support groups. Enteral nutritional support should be considered in young patient with growth concerns with close support from nutritional teams
- Antibiotics offered to those with obvious concurrent infect or perianal disease (typically ciprofloxacin or metronidazole)
How do we induce remission in Crohn’s disease?
Acute attacks
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Supportive
- Aggressive fluid resuscitation
- Nutritional support
- Prophylactic heparin
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1st line: Glucocorticoids (oral, topical or intravenous). Budesonide is an alternative in a subgroup of patients
- Azathioprine or Mercaptopurine* may be used as an add-on medication but is not used as monotherapy.
- Methotrexate is an alternative to azathioprine
- Infliximab for Refractory disease and Fistulating Crohn’s Refractory Disease with patients typically continue on azathioprine or methotrexate
- Azathioprine or Mercaptopurine* may be used as an add-on medication but is not used as monotherapy.
-
2nd Line: 5-ASA drugs (e.g. mesalazine) used but are not as effective
- metronidazole is often used for isolated peri-anal disease
- Enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission.
How do we maintain remission in Crohn’s disease?
1st Line Monotherapy: Azathioprine or Mercaptopurine
- Methotrexate can be considered in those who have used it to induce their remission or cannot tolerate other maintenance therapies
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Patient started on infliximab, adalumimab or rituximab if there has been failure of treatment with other agents.
When is Surgical Management considered in Crohn’s Disease?
Offered to those who failed medical management, with severe complication (strictures or fistulaes) or growth impairment in younger patient
What is the surgical management of Crohn’s disease?
Commonest disease pattern in Crohn’s is stricturing terminal ileal disease.
- 1st line: In an Ileocaecal resection
- 2nd Line: Segmental small bowel resections or Stricturoplasty.
Colonic Procedures (segmental resection not recommend due to high recurrence rates)
- Subtotal colectomy, Panproctocolectomy and Staged subtotal colectomy and proctectom
Short Gut syndrome must be prevented as much as possible
