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AIP: Diarrhoea > Crohn's disease > Flashcards

Crohn's disease Flashcards

1
Q

What is Crohn’s disease?

A

chronic relapsing inflammatory bowel disease characterised by a transmural granulomatous inflammation which cna affect any part of the GI tract

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2
Q

Which parts of the GI tract are most commonly affected by Crohn’s disease?

A

ileum, colon or both

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3
Q

What is the geographic location where Crohn’s disease is most common?

A

northern climates and developed countries e.g. Europe and North America

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4
Q

What is the typical age of onset of Crohn’s disease?

A

bimodal

15-40 years is most common

smaller secondary peak 60-80 years

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5
Q

Which ethnic/religious groups are at higher risk of CD?

A

Caucasian people > Asian and black people

Ashkenazi Jews have 2-4 fold higher risk

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6
Q

How significant is family history in Crohn’s disease?

A

FH is a risk factor

10-25% of patients have a first-degree relative who also suffers from Crohn’s disease

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7
Q

What are 6 symptoms of Crohn’s disease?

A
  1. Diarrhoea (may be bloody)
  2. Crampy abdominal pain
  3. Perianal disease: skin tags or ulcers
  4. Weight loss
  5. Lethargy
  6. Fever
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8
Q

What feature of Crohn’s disease makes extra-intestinal features more likely?

A

colitis + perianal disease

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9
Q

What are 5 clinical signs of Crohn’s disease?

A
  1. Cachectic + pale (anaemia)
  2. Digital clubbing
  3. Aphthous ulcers in mouth
  4. Abdominal/right lower quadrant tenderness, right iliac fossa mas
  5. PR may show skin tags, fistulae, or perianal abscess
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10
Q

What are 2 types of dermatological manifestations of Crohn’s disease?

A
  1. Erythema nodosum
  2. Pyoderma gangrenosum
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11
Q

What is erythema nodosum?

A

painful erythematous nodules/plaques on the shins

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12
Q

What is pyoderma gangrenosum?

A

well-defined ulcer with purple overhanging edge

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13
Q

What are 2 ocular manifestations of Crohn’s disease?

A
  1. Episceritis - painless red eye
  2. Anterior uveitis - painful red eye with blurred vision and photophobia (but more common in UC)
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14
Q

What are 2 musculoskeletal manifestations of Crohn’s disease?

A
  1. Arthritis: asymmetrical and non-deforming
  2. Sacro-iliitis: similar to ankylosing spondylitis
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15
Q

What is a hepatobiliary manifestation of CD?

A

gallstones (more common in CD than UC)

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16
Q

What is a haematological manifestation of CD?

A

AA amyloidosis (secondary to chronic inflammation)

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17
Q

What is a renal manifestation of CD?

A

renal stones - more common in CD than UC

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18
Q

What are 6 investigations to perform in Crohn’s disease?

A
  1. Blood tests
  2. Stool culture
  3. Faecal calprotectin
  4. Endoscopy
  5. MRI
  6. Upper GI series
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19
Q

What are 6 blood tests that might be performed when investigating Crohn’s disease and what would they show?

A
  1. WCC (raised)
  2. ESR/CRP (raised)
  3. Platelets (thrombocytosis)
  4. FBC (anaemia due to chronic inflammation)
  5. Albumin (low secondary to malabsorption)
  6. Iron, B12, folate
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20
Q

What is the purpose of stool culture in suspected Crohn’s disease?

A

to exclude infection

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21
Q

What is faecal calprotectin?

A

an antigen produced by neutrophils, used as biomarker. present in the faeces when inflammation occurs

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22
Q

What will happen to faecal calprotectin in Crohn’s disease?

A

this helps distinguish inflammatory bowel disease from irritable bowel syndrome

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23
Q

When is endoscopy indicated in suspected Crohn’s disease?

A

required for diagnosis

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24
Q

When is MRI performed in suspected Crohn’s disease?

A

required for suspected small bowel disease

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25
Q

What might an upper GI series show when investigating Crohn’s disease and what does this indicate?

A

string sign of Kantour - string-like appearance of contrast-filled narrowed terminal ileum, suggestive of Crohn’s disease

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26
Q

What will colonoscopy with biopsy show in Crohn’s disease? 4 key things

A
  1. Intermittent inflammation (‘skip lesions’)
  2. Cobblestone mucosa due to ulceration and mural oedema
  3. Rose-thorn ulcers due to transmural inflammation ± fistulae or abscesses
  4. Non-caseating granulomas
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27
Q

What are 5 aspects of the medical management of Crohn’s disease to induce remission?

A
  1. Monotherapy with glucocorticoids - prednisolone or IV hydrocortisone
  2. 5-ASA drugs e.g. mesalazine sometimes used second-line
  3. Azathioprine or mercaptopurine: may be added if 2 or more exacerbations in 12months or glucocorticoid annot be tapered
  4. Methotrexate: may be considered if don’t tolerate azathioprine or mercaptopruine, or TPMT deficient
  5. Biological agents such as infliximab or adalimumab: recommended in patients with severe Crohn’s disease who don’t respond to the above
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28
Q

What can be offered to children to avoid treating them with steroids for induction of remission of Crohn’s disease?

A

enteral nutrition

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29
Q

Why might steroids be avoided when inducing remission of CD in children?

A

they can cause growth suppression

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30
Q

When would azathioprine or mercaptopurine be used to induce remission of CD?

A

if there are 2 or more exacerbations in a 12-month period, or the glucocorticoid cannot be tapered

31
Q

What must be performed before offering a patient azathioprine or mercaptopurine?

A

assess for thiopurine merthyltransferase (TPMT) activity before starting

32
Q

When are biological agents (infliximab and adalimumab) offered to induce remission of CD?

A

in patients who don’t response to steroid/ azathioprine/mercaptopurine / methotrexate

33
Q

When is methotrexate used in the induction of remission of CD?

A

in patients who don’t tolerate azathioprine or mercaptopurine, or who are TPMT deficient

34
Q

What is the first line medical management to maintain remission of Crohn’s disease?

A

azathioprine or mercaptopurine

35
Q

If patients do not respond to azathioprine/mercaptopurine, or have a contrainidication or adverse reaction, what other drug can be used to maintain remission of CD?

A

methotrexate

36
Q

What does surgical management of Crohn’s disease involve?

A
  • rarely curative (unlike UC) so should be maximally conservative
  • surgical options depend on part of GI tract affected
37
Q

What are 3 options for the management of peri-anal fistulae?

A
  1. Drainage seton
  2. Fistulotomy
  3. ‘Sphincter saving’ methods: fibrin glue, fistula plug
38
Q

For which type of fistulae is a drainage seton the management of choice?

A

high (trans-sphincteric) fistulae

39
Q

What is a seton? How does it work to treat fistulae?

A
  • thread passed through the fistula tract, forming a ring beween the internal and external openings
  • prevents division of anal sphincter muscles and inontinence
    • closure of fistula occurs by formation of granulation tissue
40
Q

What is the management of choice for low (submucosal) fistulae?

A

fistulotomy

41
Q

What does fistulotomy involve?

A

dissecting the superficial tissue (above the fistula) and opening the fistula tract

then resew it all up

42
Q

Why is fistulotomy not a treatment option for high fistulae?

A

high risk of incontinence

43
Q

What are 2 examples of sphincter saving methods of peri-anal fistulae treatment?

A
  1. Fibrin glue
  2. Fistula plug
44
Q

Are sphincter saving methods used yet for treat peri-anal fistulae?

A

no, still under investigation as not yet approved in mainstream management

45
Q

What are the 2 key aspects of the management of peri-anal abscesses in CD?

A
  1. patient should be started on IV antibiotics e.g. ceftriaxone + metronidazole
  2. examination under anaesthetic and incision and drainage
46
Q

What does the incision and drainage of peri-anal abscesses involve in CD?

A

incision made in affected region, pus broken up and infected tissue material excised

anti-septic soaked packs inserted

47
Q

By what type of healing does wound closure occur following incision, drainage + packing of a peri-anal abscess?

A

secondary intention

48
Q

Why do patients with CD get strictures, fistulas and adhesions?

A

because inflammation occurs in all layers (transmural) down to the serosa

49
Q

What is the most prominent symptom of CD in children?

A

abdominal pain (rather than diarrhoea)

50
Q

What type of hepatobiliary complication is seen in UC more than in CD?

A

primary sclerosing cholangitis

51
Q

What is the omst common extra-intestinal feature in both CD and UC?

A

arthritis

52
Q

Which ocular manifestation is more common in CD than UC?

A

episcleritis (uveitis more common in UC)

53
Q

What are 4 extra-intestinal manifestations of CD/UC that are related to disease activity?

A
  1. Arthritis (pauciarticular, asymmetric)
  2. Erythema nodosum
  3. Episcleritis
  4. Osteoporosis
54
Q

What are 5 extra-intestinal manifestations of CD/UC that are unrelated to disease activity?

A
  1. Arthritis: polyarticular, symmetric
  2. Uveitis
  3. Pyoderma gangrenosum
  4. Clubbing
  5. PSC
55
Q

Following which type of IBD is colorectal cancer much more common?

A

Ulcerative colitis

56
Q

Which bloods correlate well with disease activity in CD?

A

CRP

57
Q

What type of endoscopy is the investigation of choice in CD?

A

colonoscopy

58
Q

What are 2 macroscopic changes on endoscopy suggestive of CD?

A
  1. Skip lesions
  2. Deep ulcers
59
Q

What are 3 features on histology suggestive of CD?

A
  1. Inflammation in all layers from mucosa to serosa
  2. Goblet cells
  3. Non-caseating granulomas
60
Q

What are 5 possible signs from a small bowel enema image of CD?

A
  1. Strictures: Kantour’s string sign
  2. Proximal bowel dilation
  3. Rose thorn ulcers
  4. Fistulae
61
Q

When is a small bowel enema barium study useful in CD?

A

high sensitivity and specifiity for examination of the terminal ileum

62
Q

What is a rose-thorn ulcer?

A

deep penetrating linear ulcer or fissure, typically seen within stenosed terminal ileum with a thick wall

appear as thorn-like extraluminal projections on barium studies

63
Q

What is a key lifestyle measure important to the management of CD?

A

stop smoking

64
Q

What are 2 drugs for which there is some evidence for increased risk of relapse of CD?

A
  1. NSAIDs
  2. COCP
65
Q

What is an alternative type of steroid sometimes using for inducing remission of CD in a subgroup of patients?

A

budesonide

66
Q

When should 5-ASA drugs (e.g. mesalazine) be considered for patients with CD for maintenance of remission?

A

if patient has had previous surgery

67
Q

What proportion of patients with CD will eventually have surgery?

A

80%

68
Q

What is the surgical management of stricturing terminal ileal disease in CD (the comonest disease pattern)?

A

ileocaecal resection

69
Q

What are 3 types of bowel surgery commonly offered in CD?

A
  1. Ileocaecal resection
  2. Segmental small bowel resections
  3. Stricturoplasty
70
Q

Why are segmental resections of the colon in CD not generally advocated?

A

recurrent rate in remaining colon extremely high

71
Q

What are 3 standard options of colonic surgery in CD?

A
  1. Subtotal colectomy
  2. Panproctocolectomy (whole rectum and colon)
  3. Staged subtotal colectomy and proctectomy
72
Q

What can fistulation between loops of bowel in CD lead to?

A

bacterial overgrowth and malabsorption

73
Q

What are 3 examples of complications of CD?

A
  1. Small bowel cancer
  2. Colorectal cancer (not as high as UC)
  3. Osteoporosis

AIP: Diarrhoea (8 decks)

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