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GI > Mr Alay Tutorial 2 - Surgical Management of IBD > Flashcards

Mr Alay Tutorial 2 - Surgical Management of IBD Flashcards

1
Q

Describe what is meant by IBD

A

Idiopathic inflammation of the bowel

Spectrum of presentations ranging between CD and UC

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2
Q

What is it called if you have IBD and you are on the middle of the spectrum between CD and UC?

A

Indeterminate colitis

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3
Q

What is the aetiology of IBD?

A

Genetic predisposition
Environmental triggers
Unregulated intestinal immune response
Loss of tolerance against certain enteric flora

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4
Q

What kind of cells are seen in TB of the gut?

A

Ceasating granulomas

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5
Q

What kind of inflammatory cells do you see in CD?

A

Non-ceasating granulomas

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6
Q

It is proposed that perhaps CD is caused by a variant of the ______ bacteria.

A

TB

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7
Q

Define ulcerative colitis

A

Chronic inflammatory ulcerative disease affecting the mucosa of the rectum + colon

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8
Q

In what age group is there the major peak of UC?

A

15-30 yos

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9
Q

In what age group is there a smaller peak of UC?

A

50-70yo

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10
Q

What are protective factors for UC?

A

Smoking

Appendiectomy

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11
Q

What layers of the bowel does UC affect?

A

Mucosa only

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12
Q

What is the pathophysiology of UC?

A

Inflammatory infiltrates + oedema as mucosa is damaged
Crypt abscesses form + ulceration
Pseudopolyps

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13
Q

What causes pseudopolyps in UC?

A

Attempts at healing produce epithelial thickening between the ulcers

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14
Q

Where does the disease in UC start?

A

In rectum + moves proximally

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15
Q

Where is the disease in UC confined to?

A

Rectum and colon

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16
Q

What are the subtypes of UC?

A

Proctosigmoiditis
L sided colitis
Pancolitis
Backwash ileitis

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17
Q

What parts of the GI tube are affected in proctosigmoiditis UC?

A

Rectum and sigmoid

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18
Q

What parts of the GI tube are affected in L sided colitis UC?

A

L side of colon

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19
Q

What parts of the GI tube are affected in pancolitis UC?

A

Whole of large bowel and rectum

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20
Q

What parts of the GI tube are affected in backwash ileitis UC?

A

Whole of large bowel and rectum and terminal ileum

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21
Q

For which of UC and CD can surgery offer long lasting symptom control?

A

UC

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22
Q

Of which of UC and CD is the disease usually continuous?

A

UC

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23
Q

There is no place for what kind of surgery in UC?

A

Segmental resection as disease will recur in bowel not resected

Try to avoid surgery, but if have to, take out whole bowel + rectum

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24
Q

What are local complications of UC?

A 
Blood loss, anaemia
Protein loss
Acute toxic dilatation of the colon + perforation 
Stricture 
Massive haemorrhage
Carcinoma
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25
Q

Why do you get protein loss in UC?

A

In UC the gut makes a lot of mucous and mucous is rich in protein

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26
Q

Why can you get acute toxic dilatation of colon in UC?

A

Any severe inflammation of the colon may lead to the muscular layer of the colon failing –> dilation

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27
Q

Why do you get strictures in UC?

A

Chronic inflammation, BUT as inflammation is only in mucosa it is unlikely to be just a benign stricture and must treat as though malignant

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28
Q

What is the risk of developing colon cancer in UC related to?

A

Extent of disease

Duration of disease (>10y)

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29
Q

What are indications for surveillance colonoscopy in UC?

A

Total colitis >10 years

L sided colitis >15 years

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30
Q

What is involved in surveillance colonoscopy in UC?

A

Colonscopy + taking 4 random biopsies every 10cm

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31
Q

What are systemic complications of UC?

A

Large joint disease
Uveitis
Spondylitis
Skin - erythema nodosum, pyoderma gangrenosum
Liver - fatty liver disease, cirrhosis, cholangiocarcinoma

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32
Q

Inflammation for a long time in the gut can lead to what changes in the cells?

A

Dysplasia (which can progress to a malignancy)

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33
Q

What result from surveillance colonoscopy in UC would lead to you contacting surgeons to take the bowel out?

A

Dysplastic cells

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34
Q

Why do you not wait until a patient with UC and dysplastic cells in their colon develops cancer before removing the bowel?

A

Cancer ontop of IBD has poorer outcomes as treatment involves immunomodulation (so immune system less effective against cancer)

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35
Q

What are the symptoms of UC?

A 
Diarrhoea
Rectal bleeding
Tenesmus 
Passage of mucous
Crampy abdominal pain
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36
Q

What correlates with the extent of disease in UC?

A

Symptom severity

Diarrhoea, ab pain indicate colon involvement

If only tenesmus, rectal bleeding, mucous may indicate solely a rectal involvement

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37
Q 
In relation to 
Bloody stools/day
Pulse
Hb
ESR
CRP 
what figures would be expected for a mild presentation of UC?
A 
Bloody stools/day <4
Pulse <90
Hb >11.5g/dl
ESR <20
CRP normal
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38
Q 
In relation to 
Bloody stools/day
Pulse
Hb
ESR
CRP 
what figures would be expected for a moderate presentation of UC?
A 
Bloody stools/day 4+
Pulse 90 or less
Hb 10.5g/dl or more
ESR 30 or less
CRP 30 or less
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39
Q 
In relation to 
Bloody stools/day
Pulse
Hb
ESR
CRP 
what figures would be expected for a severe presentation of UC?
A 
Bloody stools/day 6+
Pulse >90
Hb <10.5g/dl 
ESR >30
CRP >30
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40
Q

What is the fulminating type of UC?

A

I.e. initial presentation with acute attack

Bowel movements >10/24h
Fever, tachycardia, continuous bleeding, anaemia, hypoalbuminaemia
May have toxic megacolon

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41
Q

What is chronic type of UC?

A

Initial attack of moderate severity followed by recurrent exacrbations
Pt has severe diarrhoea and anaemia from chronic blood loss

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42
Q

Define toxic megacolon

A

Transverse/right colon with diam >6cm with loss of haustrations in patients with severe UC

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43
Q

What can trigger attacks of toxic megacolon?

A

Electrolyte abnormalities, narcotics

44
Q

What may attacks of UC be related to?

A

Stresses in life, e.g. exams

45
Q

Why is the treatment of toxic megacolon so difficult?

A

50% resolve with medical therapy alone but do not know what 50%

46
Q

How should toxic megacolon be managed?

A

Medical treatment, failure of medical treatment within 48h –> urgent colectomy

47
Q

What is the most dangerous complication of toxic megacolon?

A

Perforation

48
Q

What is the mortality of toxic megacolon?

A

15%

49
Q

Why can’t you rely on physical signs of peritonitis in perforation?

A

They may not be obvious as these patients are on immunomodulators

50
Q

What is the main modality for diagnosis of UC?

A

Endoscopy

51
Q

What findings might you see on endoscopy in UC?

A

Loss of normal vascular pattern
Mucous, pus, blood in lumen
Mucosal reddening and contact bleeding
Ulceration, granulation tissue, pseudopolyps

52
Q

What is contact bleeding?

A

Gentle probing with endoscopy leads to mucosal bleeding

53
Q

What is the normal vascular pattern of the colon?

A

Brancing BVs

54
Q

Why do you get contact bleeding in UC?

A

As the mucosa is inflamed and the BVs are friable

55
Q

What investigations can you do for UC?

A

Plain AXR
Erect CXR
CT abdomen
Endoscopy

56
Q

What is an indication for doing a plain AXR?

A

Acute fulminating colitis

57
Q

What might you see on AXR in acute fulminating colitis?

A

Gross colonic distension
Loss of haustrations
Bowel wall thickened due to oedema of bowel wall

58
Q

Why might you do an erect CXR in UC?

A

To exclude a silent perforation by checking for air underneath the diaphragm

59
Q

What is the imaging modality of choice for acute presentations in someone with UC?

A

CT

60
Q

What are indications for surgical treatment of UC in an acute attack?

A

Failure to respond to treatment
Acute megacolon (if no medical response within 48h)
Perforation/massive hawemorrhage

61
Q

What two investigations should you rely on to rule out an acute perfation?

A

CT and erect CXR

62
Q

What are the two surgical options for an acute attack of UC?

A

Total colectomy, ileostomy + closure of rectal stump/rectosigmoid mucous fistula

63
Q

What is damage control surgery?

A

In emergency situations want to do as little as possible to get the pt better then later can do more surgery when pt better and outcomes will be better

64
Q

In an emergency situation in UC do you want to take the bowel out or the rectum?

A

Take bowel out as rectum less likely to perforate as it is thicker

65
Q

What is a rectosigmoid mucous fistula?

A

A second stoma that drains mucous from the remaining bowel and rectum

Prevents fluid seeping into abdomen/pelvis

66
Q

What are options for surgery following recovery from emergency surgery in UC?

A

Excision of rectum –> pt left with permanent ileostomy

Formation of ileal pouch

67
Q

Why do surgeons often in emergency situation in UC only take the colon out and not the rectum?

A

To avoid a very long operation in a sick patient who may not be able to cope with it

68
Q

How is an ileal pouch formed?

A

Pull down small bowel and fold on itself to form a new rectum which is joined to the anal canal (which remember is spared in UC)

69
Q

What are indications for surgery in chronic disease for UC?

A

Continuous disabling symptoms

Carcinoma, dysplasia or risk of developing carcinoma

70
Q

What are the options for surgery in chronic disease for UC?

A

Total proctocolectomy + permanent ileostomy
OR
Total proctocolectomy + formation of ileal pouch

71
Q

What is a proctocolectomy?

A

Removal of rectum and colon in 1 operation

72
Q

Why can you do a proctocolectomy in 1 operation in chronic disease but not in acute situations?

A

Patients are more well and able to tolerate longer operations

73
Q

What are indications for ileal pouch?

A

UC

FAP

74
Q

What are contraindications for ileal pouch surgery?

A

CD

Significant anal incontinence

75
Q

Why is anal incontinence a CI for ileal pouch surgery?

A

Pouch stools are too liquidy and are often difficult to control as it is

Remember function of large bowel is to absorb water

76
Q

What preoperative preparation should be done prior to a patient proctocolectomy undergoing ileal pouch surgery?

A

Bloods - Hb, proteins
Histology (to ensure UC and not CD)
Counselling
Consent

77
Q

What do patients undergoing ileal pouch surgery require counselling on?

A
  1. Stools will be very soft and liquidy and difficult to control, may have to defaecate 3-5x day and through the night
  2. Sexual dysfunction (may sever nerves during surgery –> impotence, retrograde ejaculation, loss of ability to orgasm, loss of vaginal lubrication etc.)
78
Q

Why can ileal pouch surgery lead to retrograde ejaculation?

A

Can damage nerve to internal sphincter of bladder which normally closes during ejaculation to prevent sperm entering bladder

‘dry orgasm’

79
Q

What are the different types of ileal pouches? What is most common?

A

J - most common
S
W

80
Q

What are complications of ileal pouches?

A 
Splenic injury
Anastomotic complications
Intra-abdominal abscesses
Poor function - frequency, incontinence, pouchitis
Pouch failure (req. stoma)
81
Q

Define CD

A

Non-specific transmural inflammatory disease that can affect any part of the GIT

82
Q

In what age group of patients does CD tend to present?

A

<30 year olds

Peak between 14 and 24

83
Q

How does smoking affect CD?

A

Contributes to development, exacerbation and recurrence of CD

84
Q

What part of the GIT can CD affect?

A

Anywhere from mouth to anus

85
Q

Where does CD affect the most?

A

Terminal ileum and caecum

86
Q

What are subtypes of CD?

A

Inflammatory
Stricturing
Fistulating

Inflammatory tends to develop into one of the other two

87
Q

What do you see macroscopically on endoscopy in CD?

A

Skip lesions
Strictures
Mesenteric fat wrapping/creeping

88
Q

What do you see microscopically in CD?

A

Transmural disease
Non-ceasating granulomas
Crypt abscesses, fistula formation

89
Q

How might CD present acutely?

A

Acute abdo mimicking appendicitis
Intestinal obstruction
Peritonitis due to bowel perforation
Fulminate colitis

90
Q

Are the strictures in CD usually malignant?

A

No - as it is transmural disease usually just inflammatory strictures

91
Q

Why can you not offer an ileal pouch to someone with CD?

A

As they are prone to forming fistulas and you don’t want fistulas in the pouch

92
Q

Where do patients with CD complain of pain?

A

Usually RIF

93
Q

What may cause intestinal obstruction in someone with CD?

A

Strictures

94
Q

How can chronic CD present?

A 
Recurrent abdominal pain
Recurrent subacute intestinal obstruction
Abdominal mass
Malnutrition 
Chronic debility
Abdominal/perineal fistulas/abscesses
95
Q

What is a seton?

A

A little tube put in perianal fistulas in people with CD that prevent the fistula becoming blocked and forming an asbcess

96
Q

Who should take setons out?

A

Only the surgeon who put them in

97
Q

What imaging techniques can be used to investigate CD?

A 
Barium studies
Small bowel MRI (MRE)
CT
Upper GI endoscopy
Colonoscopy
Wireless capsules endoscopy
98
Q

What can you see on barium studies in CD?

A

Mucosal ulceration + cobble stoning
Areas of narrowing + skip lesions
Internal fistulae
String sign of Kantor

99
Q

What is the string sign of Kantor?

A

Marked narrowing of the terminal ileum

100
Q

What imaging technique is used for acute presentations in CD and to diagnose complications?

A

CT

101
Q

What is the gold standard imaging technique used to diagnose CD?

A

Small bowel MRI/MRE

102
Q

What complications of CD may require surgery?

A

Strictures
Fistula
Abscess
Intestinal obstruction

103
Q

What is a complication of draining abscesses in CD?

A

May form distula

104
Q

How do you manage bad CD surgically?

A

Resection of affected segment of bowel with end to end anastomosis

105
Q

How are strictures managed in CD?

A

Strictureplasty

106
Q

What kind of surgery is performed for duodenal CD?

A

Bypass surgery

GI (8 decks)

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