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Surgery M4 part 2 > IBD > Flashcards

IBD Flashcards

1
Q

What is crohn’s disease?

A

chronic transmural inflammatory disease of GI tract

- most common in TERMINAL ILEUM

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2
Q

Who are more commonly affected by Crohn’s disease?

A
  • 2nd & 3rd decade
  • 6th to 7th decade
  • 2 times the risk in smokers
  • strong family history of Crohn’s
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3
Q

What are the risk factors of Crohn’s disease?

A
  • familial aggregation
  • genetic predisposition ( NOD2, HLA-B27)
  • tobacco
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4
Q

What is the pathogenesis of Crohn’s disease?

A
  • increased permeability of mucus membranes + abnormal immune mediated response to normal gut flora
  • TH1 mediated response
  • ASCA autoantibodies
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5
Q

What are the types of Crohn’s disease?

A
  • terminal ileum 60%
  • Colitis alone 1/3
  • perianal lesions 50-75%
  • stomach & duodenum 5%
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6
Q

What will be seen GROSSLY on exploration of Crohn’s?

A
  • thickened grayish-pink or dull purple-red loops of bowel
  • thick gray-white exudate or fibrosis of serosa
  • skip lesions
  • fibrotic thickening of intestinal wall (fat wrapping if circumferential)
  • dilated bowel proximal to stricture
  • SNAKE-LIKE/ROSE-THORN (linear mucosal ulcers)
  • mesenteric abscesses & fistulae
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7
Q

What is the microscopic picture of Crohn’s disease?

A
  • edema of mucosa & submucosa before any gross change
  • inflammatory infiltrate extends transmurally
  • NONCASEATING GRANULOMAS WITH LANGERHANS GIANT CELLS

early acute -> hyperemic & boggy
chronic -> fibrotic scarring and bowel wall thickened with leathery texture

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8
Q

What are the characteristic findings of Crohn’s disease?

A 
C cobblestone mucosa 
R rose-thorn ulcers 
O obstruction of bowel 
H hyerplasia of mesenteric lymph nodes 
N narrowing of lumen 
S skip lesions
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9
Q

What are the clinical features of Crohn’s disease?

A
  • insidious onset with slow & protracted course
  • gradually becomes more frequent & severe & longer lasting attacks
  • intermittent colicky abdominal pain in lower abdomen (mimics appendicitis)
  • diarrhea
  • perianal disease (suspect in any patient with multiple chronic perianal fistulas)
    systemic symptoms
  • low-grade fever
  • weight loss
  • loss of strength
  • malaise
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10
Q

What are the extraintestinal manifestations of Crohn’s disease?

A
  • skin lesions -> erythema nodosum, pyoderma gangrenosum
  • arthritis & arthralgias
  • uveitis & iritis
  • amyloidosis
  • hepatitis pericholangitis
  • pancreatitis
  • renal or gallbladder calculi
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11
Q

What are the complications of Crohn’s disease?

A
  • obstruction
  • perforation
  • fistulas
  • localized abscesses
  • toxic megacolon
  • cancer
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12
Q

What is the DD of Crohn’s disease?

A
  • acute appendicitis
  • mesenteric lymphadenitis
  • ovarian pathology
  • salmonella & shigella
  • intestinal TB
  • acute distal ileitis
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13
Q

How can we confirm a diagnosis of Crohn’s disease?

A

CLINICAL
- history & examination

BLOOD

  • CBC U&E, LFT, coagulation profile
  • CRP, ESR
  • ANCA & ASCA +ve
  • nutritional albumin, prealbumin

STOOL

  • culture & microscopy to rule out infectious colitis
  • C diff toxin to rule out pseudomembraneous colitis

UGI scope & COLONOSCOPY WITH BIOPSY

  • patchy inflammation
  • linear ulcers
  • cobble stone appearance
  • stricture

MR enterography

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14
Q

How can Crohn’s disease be treated?

A 
conserve by 
MEDICAL 
- steroids
- aminosalicylates 
- antibiotics 
- imminomodulatory agents 
- monoclonal antibodies -> for severe active disease 
- nutritional support

ENDOSCOPIC TREATMENT OF STRICTURE

  • balloon dilatation through enteroscope or colonoscope
  • contraindicated if there’s an inflamed or ulcerated stricture
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15
Q

What are the indications for surgery in Crohn’s disease?

A

complications

  • intestinal obstruction
  • intestinal perforation with fistula formation or abscess
  • free perforation
  • GI bleeding
  • cancer
  • perianal disease
  • extraintestinal manifestations
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16
Q

What are the principles of surgery in Crohn’s disease?

A
  • preserve gut length & maintain adequate function
  • resection kept to a minimum
  • optimize patient before surgery
  • surgery shouldn’t be delayed if there is a clear indication
  • risk of short bowel syndrome -> stricturoplasty
  • stoma formation (colostomy) incase of -> abscess, fistula, low albumin, steroid use
17
Q

What are the options for surgery in Crohn’s?

A
  • ILEOCECAL RESECTION WITH ILEOCOLIC ANASTOMOSIS -> terminal ileal Crohn’s
  • SEGMENTAL RESECTION & ANASTOMOSIS -> short segment stricture with no risk of short bowel syndrome
  • COLECTOMY & ILEORECTAL ANASTOMOSIS -> colonic Crohn’s with normal rectum & anus
  • SUBTOTAL COLECTOMY & ILEOSTOMY -> acute Crohn’s colitis
  • TEMPORARY LOOP ILEOSTOMY -> acute distal CD to allow remission and later restoration (severe perianal or rectal disease)
  • PROCTOLECTOMY -> colic/anal disease failing to respond to medical treatment (permanent ileostomy)
  • STRICTURE PLASTY -> multiple areas of CD & danger of short bowel syndrome
18
Q

What is ulcerative colitis?

A
  • dynamic disease characterized by remissions & exacerbation

- peak incidence 15-35 years then >55 years

19
Q

What are the risk factors of ulcerative colitis?

A
  • genetic (HLA-B27)
  • ethnicity (white & Ashkenazy jews)
  • family history
  • previous intestinal infection
  • increased fat intake
  • OCPs & NSAIDS
20
Q

What are the protective factors against ulcerative colitis?

A
  • appendectomy before established UC

- smoking

21
Q

What is the pathogenesis of ulcerative colitis?

A
  • increased permeability of intestinal epithelium
  • TH2 differentiation
  • dysregulation of immune system
  • ANCA against epithelial cells
  • CONTINUOUS UNINTERRUPTED INFLAMMATION OF COLONIC MUCOSA beginning in distal rectum & extending proximally
22
Q

What is the gross picture of ulcerative colitis?

A
  • hyperemic mucosa
  • friable & granular mucosa -> in severe
  • ulcerations
  • pseudopolyps or inflammatory polyps
23
Q

What is the microscopic picture of ulcerative colitis?

A
  • inflammation of mucosa & submucosa

- CRYPT ABSCESS

24
Q

What is the most common course of ulcerative colitis?

A

CHRONIC INTERMITTENT
- exacerbation followed by complete remission

chronic continuous
- no complete remission

acute fulminant
- sudden onset of severe diarrhea, dehydration & shock

25
Q

What are the symptoms of ulcerative colitis?

A
  • bloody diarrhea with mucus
  • fecal urgency
  • abdominal pain & cramps on left side
  • tenesmus
26
Q

what are the extra-intestinal manifestations of ulcerative colitis?

A
  • osteoarthritis, ankylosing spondylitis, sacroiliitis -> skeletal (most common)
  • uveitis, episcleritis, iritis -> ocular
  • primary sclerosing cholangitis -> biliary
  • pyostomatitis vegetans, apthous stomatitis, erythema nodusom, pyoderma gangrenosum -> cutaneous
  • fatigue & fever
  • growth retardation & delayed puberty in children
27
Q

What are the complications of ulcerative colitis?

A
  • acute fulminant colitis
  • toxic megacolon
  • colonic cancer (greater risk with longer disease)
28
Q

How should the diagnosis of ulcerative colitis be confirmed?

A

BLOOD

  • increase ESR & CRP
  • leukocytosis
  • anemia
  • thrombocytosis
  • increase pANCA

STOOL
- search for bacteria to rule out infectious causes

COLONOSCOPY (definitive diagnosis)
- contraindicated in acute

RADIOGRAPHY plain

  • loss of colonic haustrata (LEAD PIPE APPEARANCE in severe)
  • massive distention in toxic megacolon
  • pneumoperitoneum if perforated

BARIUM ENEMA

  • able to detect early changes
  • granular appearance of mucosa
  • deep ulcerations
  • loss of haustra
  • pseudopolyps appear as filling defects

CT -> wall thickening if severe

MRI -> extent of involvement

ULTRASOUND -> bowel thickening (absent hyperechoic reflection from lumen)

29
Q

What is the DD of ulcerative colitis?

A
  • Crohn’s disease
  • exudative-inflammatory diarrhea
  • diverticular disease
  • ischemic colitis
  • infectious colitis
  • radiation colitis
  • celiac disease
30
Q

How should ulcerative colitis be managed?

A
  • first -> conserve with drugs to induce & maintain remission
  • if medical fails -> curative proctocolectomy
31
Q

What is the initial management of ulcerative colitis?

A

PROCTITIS

  • 5ASA + steroids
  • immunosuppressant + monoclonal antibodies

ACUTE COLITIS

  • mild -> steroids + 5ASA
  • moderate -> oral steroid + steroid enema + 5 ASA
  • severe -> NPO, IVF, IV antibiotics, steroid -> not improving? -> emergency surgery
32
Q

What are the indications for surgery in ulcerative colitis?

A
  • fulminant colitis with toxic megacolon
  • massive bleeding
  • intractable disease
  • dysplasia or carcinoma
  • malnutrition & growth retardation
  • extraintestinal manifestations
  • failure of medical
33
Q

What are the surgical treatment options for ulcerative colitis?

A

EMERGENCY -> in systemic upset, malnourished patient, or on steroids

  • total colectomy with end ileostomy
  • no dissection of rectum (mucus fistula)
  • restorative surgery later

ELECTIVE -> sphincter problems, lower complication rate, no risk of rectal cancer

  • restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) -> pelvic sepsis
  • colectomy with ileorectal anastomosis -> if minimum rectal inflammation with rectal checkups

Surgery M4 part 2 (36 decks)

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