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Paediatrics finals > Crohn's disease > Flashcards

Crohn's disease Flashcards

1
Q

Name the two types of inflammatory bowel disease (IBD)

A

Crohn’s disease

Ulcerative colitis

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2
Q

Describe the age of presentation of crohn’s disease

A

Bimodal peak

15-30yo and 60-80yo

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3
Q

What type of course does inflammatory bowel disease follow?

A

Relapsing-remitting

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4
Q

What part of the GI system does crohn’s disease affect?

A

Any part

Most commonly targets the distal ileum or proximal colon

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5
Q

What is crohn’s disease characterised by?

A

Transmural inflammation - affecting all layers of the bowel

Deep ulcers and fissures - cobblestone appearance

Skip lesions - the inflammation is not continuous

Fistula formation

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6
Q

Give the microscopic appearance of crohn’s disease

A

Non-caseating granulomatous inflammation

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7
Q

Describe fistula formation in crohn’s’ disease

A

Between affected bowel and adjacent structures

Peri-anal 54% 
Entero-enteric 24% 
Recto-vaginal 9% 
Entero-cutaneous
Entero-vesicalar
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8
Q

List the risk factors of crohn’s disease

A

Family history - 20% have 1st degree relative
Smoking - increases risk and relapse
White European descent (Ashkenazi jews)
Appendicectomy - risk increased directly after surgery

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9
Q

Give the symptoms of crohn’s disease

A

Episodic colicky abdo pain
Diarrhoea - chronic, may be mixed with blood or mucus
Systemic symptoms - malaise, anorexia, low-grade fever
Malabsorption and malnourishment
Oral aphthous ulcers - painful and recurring
Perianal disease

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10
Q

Describe the abdominal findings of crohn’s disease

A

Abdominal tenderness
Mouth or perianal lesions
Signs of malabsoprtion or dehydration
Extra-intestinal features

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11
Q

List the extra-intestinal features of crohn’s disease

A

MSK - enteropathic arthritis, metabolic bone disease, nail clubbing
Skin - erythema nodosum, pyoderma gangrenosum
Eyes - episcleritis, anterior uveitis, iritis
Hepatobiliary - primary sclerosing cholangitis, gallstones and cholangiocarcinoma
Renal - renal stones

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12
Q

Which bones joint does enteropathic arthritis commonly affect?

A

Sacroiliac

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13
Q

Describe erythema nodosum

A

Tender red/purple sc nodules typically on shins

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14
Q

Describe pyoderma gangrenosum

A

Erythematous papules/pustules that develop into deep ulcers

Occur anywhere - typically the shins

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15
Q

List the investigations done for crohn’s disease

A

Bloods - FBC, CRP - anaemia, low albumin (malabsorption), evidence of inflammation

AXR/CT - obstruction

Faecal calprotectin - inflammation

Stool sample - infection

Colonoscopy with biopsy

CT scan abdomen pelvis - bowel obstruction, perforation, collection or fistulae

MRI - enteric fistulae and perianal disease

Examination under anaesthesia with proctosigmoidoscopy - examine and treat perianal fistulae

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16
Q

Which drugs should be avoided in acute attacks of crohn’s disease

A

Anti-motility (loperamide)

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17
Q

How do you induce remission in crohn’s

A

Fluid resuscitation
Nutritional support
Prophylactic heparin
Anti-embolic stockings
Corticosteroid therapy
Immunosuppressive agents - mesalazine and azathioprine
Biological agents - infliximab can be trialled as a rescue therapy

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18
Q

How is crohn’s remission maintained?

A

Azathioprine
Mesalazine or methotrexate as alternatives can be trialled or added in

Biologics - infliximab, adalimumab, rituximab - rescue therapy during acute flares in those who have not responded to first line remission

Smoking cessation is advised

Colonoscopy surveillance - increased risk of colorectal malignancy

Enteral nutritional support

Antibiotics - concurrent infection or perianal disease - ciprofloxacin or metronidazole

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19
Q

Describe the surgical management of crohn’s disease

A 
Ileocecal resection 
Peri-anal disease
Stricturoplasty 
Small or large bowel resection 
Pre-operative optimisation and bowel sparing approach
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20
Q

List the complications of crohn’s disease

A

GI - Fistula, stricture formation, recurrent perianal abscess/fistulae, GI malignancy

Extra-intestinal - malabsorption, osteoporosis, increased risk of gallstones and renal stones

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21
Q

Describe the increased risk of renal stones in crohn’s disease

A

Due to malabsorption of fats in the small bowel which cause calcium to remain in the lumen, oxalate is then absorbed freely resulting in hyperoxaluria and formation of oxalate stones in the renal tract

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22
Q

Which investigation should be avoided in an acute flare of crohn’s

A

Coloscopy

23
Q

Which is the most common IBD?

A

Ulcerative colitis

24
Q

Which population is ulcerative colitis most prevalent among?

A

Caucasian

25
Q

Give the age of presentation of ulcerative colitis

A

15-25yo
55-65yo
Bimodal

26
Q

Describe the histological appearance of bowel in ulcerative colitis

A

Non-granulomatous inflammation with crypt abscess formation

Reduced goblet cells

27
Q

What is the aetiology of ulcerative colitis

A

Genetics + environment

28
Q

Describe the characterisation of ulcerative colitis

A

Diffuse continual mucosal inflammation of the large bowel

29
Q

Which parts of the large bowel are affected in ulcerative colitis

A

Begins in the rectum and spreads proximally potentially affecting the entire large bowel

Distal ileum - backwash ileitis (incompetent ileocecal valve)

30
Q

What is a protective factor in UC?

A

Smoking

31
Q

Describe the clinical features of ulcerative colitis

A 
Bloody diarrhoea 
Proctitis 
PR bleeding, mucus discharge, increased frequency, urgency and tenesmus 
Malaise
Anorexia
Low grade pyrexia
32
Q

Which grading criteria is used to grade the severity of an exacerbation?

A

Truelove and Witt

33
Q

Which criteria are included in the True love and Witt grading system?

A 
Bowel movement number per day
Blood in stool
Pyrexia
Pulse >90
Anaemia
ESR
34
Q

List the extra-intestinal manifestations of ulcerative colitis

A

MSK - enteropathic arthritis and nail clubbing
Skin - erythema nodosum
Eyes - episcleritis, anterior uveitis or iritis
Hepatobiliary - primary sclerosing cholangitis

35
Q

What is primary sclerosing cholangitis?

A

Chronic inflammation and fibrosis of the bile ducts

36
Q

What are the differentials for ulcerative colitis?

A 
Crohn's
Chronic infection - TB, schistosomiasis, giardiasis
Mesenteric ischaemia 
Radiation colitis 
Malignancy
IBS
Coeliac
37
Q

What investigations should be ordered when suspecting UC?

A

Bloods - FBC, U&Es, LFT, clotting, CRP - anaemia, low albumin, inflammation

Faecal calprotectin - inflammation

Stool sample - infection

Colonoscopy with biopsy

Flexible sigmoidoscopy

AXR - mural thickening and thumbprinting. In chronic cases then lead pipe colon

CT - toxic megacolon and bowel perforation

38
Q

What is seen on colonoscopy in UC?

A

Continuous inflammation - ulcers and pseudo polyps

39
Q

How is remission induced in ulcerative colitis

A 
Fluid resuscitation 
Nutritional support
Prophylactic heparin 
Corticosteroid therapy and immunosuppressive agents (mesalazine and azathioprine)
Step wise approach
40
Q

Describe the stepwise approach for inducing remission in ulcerative colitis

A

Mild/moderate - topical mesalazine or sulfasalazine - add oral prednisolone and oral tacrolimus. Higher doses for more extensive inflammation

Severe (all spread of disease) - IV corticosteroids and assess need for surgery. Add infliximab if no short term response

41
Q

How is remission maintained in ulcerative colitis

A

Immunomodulators - mesalazine and sulfasalazine
Infliximab
Colonoscopy surveillance for colorectal malignancy
Enteral nutritional support

42
Q

What percentage of UC patients require surgery?

A

30%

43
Q

List the indications for acute surgical treatment of UC?

A

Disease refractory to medical management, toxic megacolon or bowel perforation
Reduce risk of colonic carcinoma if dysplastic cells are seen on routine monitoring

44
Q

Which surgical procedure is curative in UC?

A

Total proctocolectomy - patient requires ileostomy

45
Q

Which surgical procedure is used for symptom control in UC?

A

Sub-total colectomy with preservation of the rectum

46
Q

List the complications of UC

A

Toxic megacolon
Colorectal carcinoma
Osteoporosis
Pouchitis

47
Q

Describe the symptoms of toxic megacolon

A

Severe abdominal pain
Abdominal distension
Pyrexia
Systemic toxicity

48
Q

What is the treatment of toxic megacolon

A

Decompression of the bowel or surgery

49
Q

What is the risk of toxic megacolon

A

Risk of perforation

50
Q

What is Pouchitis?

A

Inflammation of the ileal pouch with typical symptoms

51
Q

What are the symptoms of Pouchitis?

A

Abdominal pain
Bloody diarrhoea
Nausea

52
Q

How should Pouchitis be treated?

A

Metronidazole

Ciprofloxacin

53
Q

What is the mechanism of action of infliximab?

A

TNF alpha inhibitor

Paediatrics finals (37 decks)

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