Inflammatory Bowel Disease

Question 1

What is the definition of severe exacerbation of inflammatory bowel disease

Answer 1

Truelove classification

GI symptoms - passage of bloody stools more than 6x per day
Systemic signs - HR over 90 bpm, pyrexia over 37
Lab findings - anaemia Hb under 10.5, C-reactive protein over 30

Question 2

What are the indications for surgery in acute severe UC

Answer 2

Toxic megacolon - transverse colon diameter of at least 6cm on AXR (high risk of peforation and faecal peritonitis)
Perforation - rare in absence of toxic dilatation
Severe GI bleeding

Question 3

What are the indications for surgery in chronic UC

Answer 3

Medical management failure to control symptoms
Malignant transformation
Maturation failure in children

Question 4

What are the indications for surgery in Crohn’s disease

Answer 4

To treat complications not amenable to medical therapy:-
Intra-abdominal abscesses that cannot be drained radiologically
Entero-cutaneous fistulae
Stenosis causing obstructive symptoms
Control of acute/chronic bleeding

Question 5

What are the hepatobiliary complications of IBD

Answer 5

Liver:-
Fatty change
Chronic active hepatitis
Cirrhosis
Amyloid deposition

Gall bladder and bile ducts:-
Gallstones
Sclerosing cholangitis
Cholangiocarcinoma

Question 6

What are the surgical options for managing UC

Answer 6

Subtotal colectomy with ileostomy (+/- mucous fistula) - operation of choice for acute severe colitis
Panproctocolectomy and permanent ileostomy
Restorative proctocolectomy - avoids permanent stoma

Question 7

What are the surgical options for Crohn’s disease

Answer 7

For surgery on the small intestine - as much bowel should be conserved as possible
Limited ileocaecectomy - for distal ileal disease
Intra-abdominal abscesses should be drained
Colonic defunctioning using a loop ileostomy - for patients who have failed medical therapy
Subtotal colectomy and permanent end ileostomy - occasionally needed

*Pouch surgery generally contraindicated in Crohn’s disease

Question 8

What are the causes of colitis

Answer 8

UC
Crohn's
Antibiotic associated colitis - eg. pseudomembranous colitis due to C. diff
Infective colitis - eg. campylobacter
Ischaemic colitis

Question 9

What is the epidemiology of UC

Answer 9

F>M

Two age peaks - 15-30 and 50-70

Question 10

How do you clinically differentiate between UC and Crohn’s

Answer 10

Perianal disease is rare in UC - unlike Crohn’s
Often profuse haemorrhage in UC - uncommon in Crohn’s
Small bowel not affected in UC - unlike Crohn’s

Question 11

What are the pathology of UC

Answer 11

UC:-
Disease extends proximally from rectum
Mucosal involvement only
No fistulas
Pseudopolyps of regenerating mucosa
No thickening of bowel wall
Malignant change common in long-standing cases
No granulomas

Question 12

What is the pathology of Crohn’s

Answer 12

Any part of the colon can be involved (skip lesions)
Transmural involvement
Fistulas in adjacent viscera
No polyps
Thickened bowel wall - cobblestone appearance of mucous membrane
Malignant change rare
Granulomas present

Question 13

What is the epidemiology of Crohn’s

Answer 13

No sex difference

Peak age of onset = 20-40

Question 14

In what different ways can Crohn’s present

Answer 14

Acute Crohn’s disease - similar presentation to appendicitis but history of several days/weeks
Intestinal obstruction - due to wall thickening
Fistula formation
Malabsorption
Diarrhoea
Perianal disease - 10% (ranging from fissures to fistulas)

Question 15

How do you medically manage Crohn’s

Answer 15

Steroids and immunosuppressants (eg. azathioprine) for acute attacks
TNF-alpha (eg. infliximab) - for acute exacerbations and fistulating disease
Sulfasalazine - for mild symptoms