Gastroenterology: Crohn's Disease Flashcards
Where is the most common place to suffer CD? [1]
Terminal ileum
Name a gene that increases likelyhood of Crohn’s Diease [1]
NOD2
Why is CD pain increased in if suffered in the terminal ileum? [1]
Describe the pain associated with CD in terminal ileum [1]
Explain why [1] and when [1] this pain occurs [1]
- Terminal ileum is narrow; food passes through and touches inflammed area
- Colicky pain: CD is transmural - so pain constant due to serosal irritation.|
- Normally occurs after eating
Define Crohn’s Disease [1]
Crohns disease is a form of inflammatory bowel disease characterised by patchy, transmural inflammation of intestinal mucosa. It can affect any part of the gastrointestinal tract from mouth to anus.
It is important to note CD may present as an emergency with acute RIF pain mimicking []
It is important to note CD may present as an emergency with acute RIF pain mimicking appendicitis
Describe the symptoms of CD? [8]
Pain
Altered bowel habit:
- Diarrhoea
- Obstruction
PR & Blood loss
Weight loss
Fistulae / Abscesses
Oral symptoms:
- aphthous ulcers can occur on the buccal mucosa, tongue, or lips
- Cobblestoning of the oral mucosa and pyostomatitis vegetans
EIM
Fatigue
State the name of this symptom of Crohn’s [1]
Pyostomatitis vegetans: an inflammatory stomatitis
Signs of CD? [6]
Mass
Aphthous ulceration of the mouth is often seen
Scars
Stoma
Angular stomatitis
Aphthous ulcers
Hypotension
Dehydration
Fistulae
Abscesses
Malnutrition
The anus should always be examined to assess for perianal involvement: anal tags, fissures, perianal abscesses.
Describe the natural history of Crohns Disease [4]
- It starts off largely inflammatory
- Yet because it is transmural it can behave in two ways:
i) scarring that causes stricture, fibrosis and permanent narrowing
ii) complete penetration - Continues: most people do not have simple inflammatory CD and at some point (i.e. 5 years into CD diagnosis) there will be a degree of stricturing / penetration in patients
What sign of Crohn’s Disease are the arrows pointing to? [1]
Rosehorn ulcer
Describe the blood tests used to investigate Crohns [5]
Anaemia:
- is common and may be normocytic, normochromic of chronic disease.
- However, deficiency of iron/folate may occur.
- Despite common terminal ileum involvement, megaloblastic anaemia due to B12 deficiency is unusual
Raised ESR and CRP; raised WCC and platelets
Hypoalbuminemia is present in severe disease
Liver biochemistry may be abnormal
Serological testing; p-ANCA would be negative (ANCAs are more commonly found in ulcerative colitis)
Extra-intestinal manifestations (EIM) refer to the collection of clinical features that occur outside the gastrointestinal tract within CD.
What is the most common EIM? [1]
Describe this EIM of CD [2]
Musculoskeletal disease:
Two forms of arthritis are seen, type 1 and type 2.
- Type 1 is a pauciarticular peripheral arthritis related to intestinal disease activity.
- Type 2 is a polyarticular peripheral arthritis independent of intestinal disease activity.
Extra-intestinal manifestations (EIM) refer to the collection of clinical features that occur outside the gastrointestinal tract within CD.
What are the MSK [2]; skin [2]; eyes & mouth [3] and hepatobiliary EIMs in CD?
Musculoskeletal:
- Arthritis
- Sacrilitis
Skin:
- Erythema nodosum
- pyoderma gangrenosum
Eyes & mouth:
- Episcleritis (most common)
- Uveitis and conjunctivitis
- Aphthous ulcers
Hepatobiliary:
- Primary sclerosing cholangitis
- gallstones
Name this EIM symptom of CD [1]
Aphthous ulcers
Name this EIM symptom of CD [1]
pyoderma gangrenosum
Describe the endoscopric investigations for CD [2]
Colonoscopy is performed if colonic involvement is suspected except in patients presenting with severe disease, in whom a limited unprepared sigmoidoscopy should be performed.
Upper GI endoscopy may be required to exclude oesophageal and gastroduodenal disease in patients with relevant symptoms and is increasingly being performed in all patient at diagnosis to accurately define the extent of the disease
Describe faecal investigations for CD [3]
MC&S: to look for typical pathogens: campylobacter, E.coli, C.diff, etc
Parasites: shigella, salmonella
Faecal calprotectin; screening for genuine GI inflammation
Describe the radiological investigations for CD [5]
Small bowel imaging is mandatory in patients with suspected Crohn’s disease:
- Plain AXR: look for loops of small bowell
- Barium follow through (rare)
- CT scan with oral contrast: to ID terminal ileum thickening
- MRI: good because less radiation
- Small bowel ultrasound
Describe the difference in ulcers between CD and UC [1]
CD: long, pleoimorphic, serpiginous ulcers
UC: smaller
Describe the histopathological features of CD [1]
Non-caseating granuloma (w/ Langhan giant cells)
Describe therapeutic management of CD:
Steroids [3]
5-ASAs [2]
Antibiotics [2]
Immunosuppressants [2]
Anti-TNF-a [1]
Anti-integrins [1]
Anti-IL12/13 [1]
Steroids:
- oral prednisolone
- IV hydrocortisone
- Budesonide
Enteral nutrition
5-ASA drugs:
- mesalazine;
- pentesaare used second-line to glucocorticoids but are not as effective
Antibiotics: reduce burden of invasive gut microbiota
- Cipro
- Metronidazole
Immunosuppressants:
- Aziothioprine
- Methotrexate
Anti-TNFa:
- Infliximab
- Adalimumab
Anti-integrins:
- Vedolizumab
Anti-IL12/13:
- Ustekinumab
State a primary liver complication of CD [1]
State three symptoms [3]
Primary sclerosing cholangitis: itching, jaundice, increased risk of cholangiocarcinoma}}
Name this symptom of CD [1]
Erythema Nodosum
Name this symptom of CD [1]
Pyoderma gangrenosum: large, painful sores (ulcers) to develop on your skin, most often on your legs.
What is this eye condition that arises as a complication of CD? [1]
Episcleritis
What is this eye condition that is a complication of CD? [1]
Uveitis
Describe the management plan to induce remisison in mild-moderate [2] and moderate-severe patients [3]
mild-to-moderate CD:
- a course of exclusive enteral nutrition (EEN) can be considered over an 8 week period
- oral prednisolone (40mg/d for 1 week, then 5mg every week for 7 weeks)
moderate-to-severe CD:
- IV steroids: IV hydrocortisone or methylprednisilone
- there should be consideration of early introduction of immunosuppressive therapy: azathioprine or methotrexate alongside budesonide, prednisilone or hydrocortisone (These medications help with long-term control, but are not useful at initially inducing remission, which is why they are combined with steroids)
- - Biologicals: inflximab, adalimubab (anti-TNF); Vedolizumab (anti-integrins); Ustekinumab (anti-IL12/13)
What is a perinal fistualae? [1]
an inflammatory tract or connection between the anal canal and the perianal skin
What does this image show? [1]
Perianal abscess
First line treatment for IBS? [1]
low FODMAP diet
Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols, or FODMAPs, are short-chain carbohydrates that are poorly absorbed in the gastrointestinal tract.
Describe how to best manage complex perianal fistula? [1]
long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence.
Terminal ileal Crohns remains the commonest disease site. How might patients be treated surgically? [1]
Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections.
