Module 2: Crohn's, Ulcerative colitis, Juvenile Polyp, Neoplastic, FAP, HNPCC, Carcinoid Flashcards
Now moving onto the inflammatory bowel diseases. The first disease to discuss is Crohn’s Disease/Terminal ileitis/Regional enteritis/Granulomatous Colitis. What is the etiology?
Etiology: Diagnosis of exclusion
- -most common is Ashkenazi Jews (due to imbreding in the past and Young Adults
- -Pre-disposing factors: genetic predisposition, abnormal host reactivity (autoimmune destruction by CD4 T cells) and microbial infections
- more common in women and has a bimodal distribution in terms of age (young adults and older females)
What is the pathogenesis for Crohn’s?
Chronic, transmural inflammation with non-caseating granulomas which can affect anywhere from the mouth to the anus
- -Produces SKIP lesions (not continous therefore not able to be fixed by sx)
- –Most common location: terminal ileum and proximal colon (but can happen anywhere)
- -Typically spares the rectum
What is the presentation for Crohn’s?
Fever Abdominal Pain Bloody/watery diarrhea --blood = colon ---watery = small bowel Weight loss Malabsorption Steatorrhea
What is seen on gross, barium enema and biopsy for Crohn’s patients? (pic 15a&b)?
Gross: Linear and serpentine ulcers with cobblestoning and creeping fat (due to fibrosis and the mesenteric fat coming over the serosa), skip lesions, transmural
Biopsy: pic to left: transmural so there is mucosal ulceration and lots of CD4 T cells within lamina propria all the blue dotted cells, PMNs, submucosa (fibrosis and fibroblasts), muscularia propria (thickening and fibrosis) and in serosa = non caseating granulomas
pic to right: blue dotted cells higher mag are lymphocytes aggregates of CD4 T cells, swallow and then deep ulcers (Also called fissures), blood vessels (angiogenesis and type III collagen)
Barium: See a string sign (that is due to luminal narrowing due to fibrosis) (pencil stools)
–note do the colonoscopy during remission not during an acute on chronic flare
What extraintestinal manifestations are seen with Crohn’s patients?
Eyes (uveitis and iritis)
Skin (erythema nodusum and pyoderma gangrene)
Joints (Arthritis)
Kidney ( stones — oxilic)
Cholesterol gallstones ( bile salt absorption problems in terminal ileum)
What are the complications of Crohn’s?
Colon Cancer — Adenocarcinoma
Colon Obstruction — due to strictures (Seen in pic), perforation
Malabsorption of iron, bile salts, water and B12 aka everything
Toxic Megacolon – exposing meisners and auerbach’s plexus
Perianal Abscesses: sterile abscess
What is the treatment for Crohn’s Disease?
Immunosuppressive Therapy
–surgery does not work due to skipping and recurrence
Now onto Ulcerative Colitis. What is the etiology for this?
Etiology: Idiopathic
–most common in Ashkenazi Jews
Pre-Disposing factors: Genetic, microbial infection, abnormal post reactivity (autoimmune destruction by CD4 T cells)
–bimodal distribution and more common in females
–associated with HLA-DRB1
What is the pathogenesis for Ulcerative Colitis?
Starts in the rectum (proctitis) and moves proximally and goes to distal part of ileum (Backwash ilitis)
- –no skipped lesions (so curable)
- -spares the anus
- -not transmural just mural (First two layers)
What is the presentation for patients with Ulcerative Colitis?
Fever Abdominal Pain Bloody Diarrhea Weight Loss Acute on chronic inflammation
On histology and gross image slide 16a,b what is seen in Ulcerative Colitis ?
Gross: no skip lesions; pseudopolyps on gross (due to regenerating mucosa)
Colonoscopy with biopsy: Mucosa CD4 T cells, abnormal morphology of crypts, ulceration of mucosa, granulation tissue and fibrosis of submucosa. (no granulomas thats Crohns)
16b: crypt abscesses with neutrophil exudate in the lumen of the crypts
PSC: periductal onion skining fibrosis and beaded appearance of biliary tree
On barium enema what do you see in Ulcerative Colitis?
Lead pipe appearance
–loss of hostra
What are the extraintestinal manifestations of Ulcerative Colitis?
Crohn’s manifestions + Primary sclerosis cholangitis
- -in biliary tract they get PSC (fibrosis in the biliary tree of both the intra and extra hepatic bile ducts, so what backs up is conjugated bilirubin so you get jaundice)
- -only time you will see jaundice in Ulcerative Colitis
- -PSC also causes malabsorption and PANCA positive
What are additional complications of Ulcerative Colitis besides Primary Sclerosis Cholangitis?
Colon Cancer (After about 10 years with dysplastic crypts as the precursor lesion)
Toxic Megacolon (damages meisners plexus) — peritonitis
Vit A,D,E,K deficiency due to malabsorption during PSC
PCS – malabsorption – osteomalacia
Liver Cancer — hepatocellular carcinoma
Now moving onto GIT polyps, the most common in children is Juvenile Polyp or Retention Polyp. what is the etiology?
Seen in children under 5
- -Juvenile Polyposis syndrome (AD): leads to increased risk of malignancy in other areas
- -Single, sporadic poly however had no malignant potential (No dysplastic features): lobulated with stalk
What is seen on histology for Juvenile Polyp?
Lamina Propria forms the bulk and encloses abundant cystically dilated glands
(+ or - inflammatory cells)