Surgery for inflammatory bowel disease Flashcards

1
Q

Important aetiological factors in inflammatory bowel disease

A
  • Genetic predisposition
  • Infection with unknown organisms
  • Hypersensitivity to antigens in the luminal contents
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2
Q

What part of the GIT does ulcerative colitis usually affect

A
  • Affects the colon
  • Continuous disease that usually affects the rectum
  • Extends for a variable distance proximally in the colon
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3
Q

Which part of the bowel does Crohns affect

A
  • Any part from mouth to anus
  • May be patchy with skip lesions
  • Most commonly affects the terminal ileum and proximal colon
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4
Q

Which layers of the bowel wall does ulcerative colitis and crohns affect

A
  • Ulcerative colitis: Involves mucosa

- Crohns: deep fissuring ulcers that penetrate through bowel wall to involve adjacent organs

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5
Q

Microscopic features of ulcerative colitis and Crohns disease

A
  • Ulcerative colitis: Crypt abscesses

- Crohns: non-caseating granulomas

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6
Q

What is the significance of smoking in inflammatory bowel disease

A

Smoking is a promoter in Crohns but is protective in ulcerative colitis

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7
Q

Clincal presentation of inflammatory bowel disease

A
  • Diarrhea with urgency with or without rectal bleeding associated with constitutional symptoms
  • Crohn’s disease may also present with many other symptoms depending on the site
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8
Q

What diseases may crohns mimic

A
  • Acute appendicitis
  • Small bowel obstruction
  • May present as perianal sepsis
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9
Q

Definition of acute severe attack of ulcerative colitis

A
  • More than six stools a day associated with 2 or more of the following:
  • Pyrexia
  • Anaemia
  • Tachycardia
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10
Q

Initial management of inflammatory bowel disease

A
  • Resuscitation
  • Confirm the diagnosis usually with gentle rigid or flexible sigmoidoscopy.
  • Exclude infective diarrhea in all patients with stool culture
  • Daily erect chest and abdominal xrays
  • at least twice daily assessment by both medical and surgical gastroenterologist
  • High dose IV steroids
  • If the patient has not settled within 3-5 days, consider surgery or rescue therapy with cyclosporine or anti TNF agents
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11
Q

Causes of toxic megacolon

A
  • Ulcerative colitis
  • Crohn’s disease
  • Amoebiasis
  • Pseudomembranous colitis
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12
Q

Treatment of toxic megacolon

A
  • On medical therapy: emergency colectomy
  • Not on therapy: Short trial of medical therapy (hours) with progression to colectomy if the condition does not rapidly improve
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13
Q

Treatment of massive haemorrhage secondary to inflammatory bowel disease

A
  • Medical management of the underlying disease
  • Occasionally can be indication for urgent surgery
  • Emergency situation: total colectomy and end ileostomy. The rectum is left in the patient with the proximal end closed off
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14
Q

What defines failed medical therapy of an acute severe attack of ulcerative colitis

A
  • Patient partially responded
  • The stool frequency may have decreased somewhat and they may or may not still have blood in their stools
  • Attack however has not completely settled
  • Considered to have failed if not responded at the end of 3-5 days of IV steroids
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15
Q

Operation of choice in patients with acute severe attack of colitis ho have failed medical therapy

A

colectomy and ileostomy. The rectum is not removed at this stage

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16
Q

Indications for emergency surgery

A
  • Toxic megacolon
  • Colonic perforation
  • Massive haemorrhage
17
Q

Indications for elective surgery?

A
  • Chronic ill health: Underweight, chronically anaemic, significant side-effects of steroid usage, multiple hospital admissions for acute flares on the background of incomplete recovery
  • Risk of malignancy
18
Q

two methods of managing risk in patients with inflammatory bowel disease

A
  • Proctolectomy
  • Endoscopic surveillance: repeated colonoscopies at annual intervals from about 10 years from the start of disease
  • Ignore the risk if first attack happens late in life
19
Q

Operation for ulcerative colitis

A
  • Proctocolectomy
  • Restorative proctocolectomy
  • Colectomy and ileostomy (acutely ill patient)
  • Colectomy with ileorectal anastomosis (rectum retained)
20
Q

Surgical management of crohns disease (anal disease)

A
  • Abscesses require drainage

- Perinanal fistulas managed with setons

21
Q

Surgical management of small bowel and colonic crohns disease

A
  • If the surgeon is experienced and the segment of the disease is less than 10 cm; can resect it
  • Not experienced; biopsy of a lymph node
  • management of complications: strictures, enterocutaneous, enterovaginal and enterovesical fistulas