Irritable Bowel Disease

Question 1

Chron’s Disease

Clinical

Answer 1

•	Specific
        −	Mouth: apthous ulcers
        −	Abdominal
              ⎫	Abdominal pain
              ⎫	Diarrhoea: porridge like
              ⎫	Can have PR bleeding 

   −       Anus
          ⎫	Abscesses and fistula
          ⎫	Fissures + skin tags

• Non-specific
− General ill health
− Anorexia
− Weight loss

Question 2

Chron’s Disease

Epidemiology

Answer 2

Peaks: 3rd and 6th decade

M=F

Question 3

Chron’s Disease

Risk Factors

Answer 3

• Ethnicity
− Caucasians
− Ashkenazi Jews
− Risk in Asians increases with move to Western countries

• Behavioural
− Smoking

Question 4

Chron’s Disease

Pathology

Answer 4

• Whole bowel affected
− Ileum + ascending colon: most common sites
− Rectum sparing
• Full thickness (transmural); serositis
• Lesions patchy/discontinuous
• Macroscopic: cobblestones; microscopic granulomas

Question 5

Chron’s Disease

Complications

Answer 5

• Mouth
− Apthous ulcers

• Colon
− Strictures (colon) obstruction
− Perforations (not as common as UC)
− Haemorrhage (not as common as UC)
− Impaired absorption of minerals + vitamins

• Anus
− Abscesses and fistula
− Fissures + skin tags

Question 6

Chron’s Disease

Diagnosis

Answer 6

• Clinical: Chron’s disease clinical activity index Harvey-Bradshaw index?

• Bloods
− General: CRP, orosomucoid

• Special investigations
− Abdominal x-ray
− Barium enema/CT
⎫ Aphthoid ulcers (target sign)
⎫ Transmural ulcers (rose thorn appearance)
⎫ Strictures (string sign of Kantor)
− Colonoscopy + biopsy

Question 7

Chron’s Disease

Management

Answer 7

• Conservative
− Diet
⎫ Low fat food, smaller, more frequent meals
⎫ Fluids only during acute exacerbations
⎫ Avoid high undigestable fibre + refined sugar
⎫ Extensive: mineral + vitamin supplements
− Behaviour
⎫ No smoking
⎫ Exercising
⎫ Resting
⎫ Stress reduction

• Pharmacological
⎫ Anti-inflammatories
⎫ Antidiarrheals
⎫ Antibiotics: metronidazole, ciprofloxacin

• Surgery (NOT CURATIVE)
− Indications
♣ Failed medical therapy
♣ Complications: recurrent perianal disease
− Options
♣ Small bowel: localised resections + primary anastomosis; stricturoplasty/balloon dilation
♣ Colon
⎫ Localised: localised resection + primary anastomosis
⎫ Wide distribution and NO rectal involvement: colectomy + primary ileorectal anastomosis
⎫ Wide distribution WITH rectal involvement: panproctocolectomy

Question 8

Chron’s Disease

Follow Up

Answer 8

• Activity
− Chron’s disease clinical activity index Harvey-Bradshaw index
− Bloods
⎫ General: CRP, orosomucoid

Question 9

Ulcerative Colitis

Clinical

Answer 9

•	Specific
        −	Abdominal pain
        −	Diarrhoea (if more than rectum involved): mucinous 
        −	PR bleeding 
               ⎫	Anaemia
                        ♣	Tachycardia
                        ♣	Decreased Hb
                        ♣	Raised ESR

•	Non-specific
        −	Fever (common)
        −	Anorexia
        −	Weight loss
        −	Fatigue

Question 10

Ulcerative Colitis

Epidemiology

Answer 10

• Peaks: 3rd and 6th decade
• M=F
• Twice as common as Chron’s

Question 11

Ulcerative Colitis

Risk Factors

Answer 11

• Behavioural

- Smoking (DECREASES RISK)

Question 12

Ulcerative Colitis

Pathology

Answer 12

• Only colon affected however can get backwash (inflammation limited to rectum or left colon is more common than pancolitis)
− Distal rectum + sigmoid
⎫ Rectum always involved (30% confined to rectum 15% = more extensive over 10 years)
− Left-sided splenic flexure
− Extensive hepatic flexure
− Pancolitis

• Superficial layers affected: mucosa + submucosa; normal serosa
• Lesions continuous
• Macroscopic: ulceration; microscopic: crypt abscesses

Question 13

Ulcerative Colitis

Complications

Answer 13

•	Colon
        −	Haemorrhage (hallmark sign)
        −	Perforations 
        −	Toxic megacolon 
        −	Colon Ca: increased risk associated with:
               ⎫	Family history
               ⎫	Age of onset (younger)
               ⎫	Extent of lesions directly proportional to risk of Colon Ca
               ⎫	Duration

Question 14

Ulcerative Colitis

Diagnosis

Answer 14

• Clinical: ulcerative colitis clinical activity index

• Bloods
− General: CRP, orosomucoid
− Specific: ESR

• Special investigations
− Abdominal x-ray
− Barium enema/CT
⎫ Lead pipe colon (loss of haustral markings)
− Sigmoidoscopy/colonoscopy + biopsy

Question 15

Ulcerative Colitis

Management

Answer 15

• Conservative
− Diet: shown to be of no benefit

• Pharmacological
⎫ Anti-inflammatories
⎫ Anti-diarrheals CI

• Surgery (CURATIVE)
− Emergency: total colectomy + primary ileorectal anastomosis
⎫ Indications
♣ Complications: haemorrhage, perforation, toxic megacolon
♣ Failed medical treatment: severe symptoms
− Elective: restorative proctocolectomy
⎫ Indications
♣ Failed medical treatment: mild chronic symptoms
♣ Colon Ca
⎫ Contraindicated
♣ > 60: need good anal musculature
♣ Biopsy shows Chron’s disease
⎫ Procedure
♣ Colon resected
♣ Ileoanal anastomosis (j-pouch) = ‘new rectum’

Question 16

Ulcerative Colitis

Follow Up

Answer 16

• Activity
− Clinical: ulcerative colitis clinical activity index
− Bloods
⎫ General: CRP, orosomucoid
⎫ Specific: ESR

• Colon Ca screening
− From what age?
⎫ Left-sided: from 15 years
⎫ Pancolitis: from 8 years
− How often: colonoscopy
⎫ No dysplasia: 1-2 years
⎫ In definitive: 3 months
⎫ Low grade: yearly
⎫ High grade: colectomy