Crohn's disease Flashcards Preview

General surgery > Crohn's disease > Flashcards

Flashcards in Crohn's disease Deck (16):
1

Defintion

Disorder of the GIT of unknown etiology associated with transmural inflammation

2

Epidemiology

Diagnosis generally 15-40, second peak in >60
Equal gender ratio
+Whites
?+Smokers

3

Pathophysiology

Inflammatory infiltrate around intestinal crypts->ulceration->non caseating granulomas->all layers.
Hyperemia, edema->bowel spasm, thickening, scarring, narrowing and strictures->fistulas, sinus, perforation, abscess. Deficient absorptive capacity.
Poor bile acid reabsorption when involvement of ileum->steatorrhea, Xfat soluble vitamin absorption, gall stones. ++Fat in stool binds to calcium, +Oxalate absorption and predisposing to oxalate kidney stone formation.

4

History

Abdominal pain
Prolonged diarrhea
Perianal lesions
Bowel obstruction
Blood in stool
Fever, fatigue, weight loss
Abdominal tenderness, mass
Oral lesions
Erythema nodosum, pyoderma gangrenosum

5

Risk factors

Age 15-40
Family history
White
Smoking
OCP
Not breastfed
NSAID

6

Invetsigations

FBC->anemia, leukocytosis, thrombocytosis
Iron studeies
Serum B12->normal or low
Serum folate->normal or low
CMP, UEC, albumin->low Ca, low albumin, low cholesterol
+CRP/ESR
Stool MCS
Plain AXR->dilitation, calcification, sacroilitis, abscesses
CT/MRI abdomen->skip lesions, bowel wall thickening, inflammation, abscess, fistula

Consider:
Colonoscopy
Small bowel follow through

7

Findings on endoscopy

Apthous ulcers
Cobblestining
Discontinuous lesions

8

Activity index

1. Liquid stools
2. Abdominal pain
3. General well being
4. Complications
->Apthous ulcers
->Iritis, uveitis
->Arthralgia, arthritis
->Erythema nodosum, pyoderma gangrenosum
->Fissures, fistula, abscess
->Fever
5. Antidiarrheal medications
6. Abdominal mass
7. Reduced hematocrit
8. Deviation of weight

9

Define mild disease

Ambulatory, eating and drinking without dehydration, toxicity, abdominal
tenderness, painful mass, obstruction or >10% weight loss

10

Define moderate disease

Failure of response to mild medical therapies or fevers, significant weight
loss, abdominal pain or tenderness, intermittent nausea and vomiting
(without obstructive findings) or significant anemia

11

Define severe to fulminant

Persistent symptoms despite use of corticosteroids as outpatient or high
fevers, persistent vomiting, evidence of intestinal obstruction, rebound
tenderness, cachexia, evidence of abscess

12

Induction therapy for mild disease

Prednisilone PO 40-60mg daily, until clinical response, taper over 8-12 weeks or Budesonide

13

Acute management of severe disease

Admission
IVF->NS + glucose + KCl
IV hydrocortisone->switch to oral prednisilone when response
Metronidazole IV
Monitor temperature, BP, pulse, Stool chart
Daily FBC, UEC, ESR/CRP
Consider need for transfusion/parenteral nutrition
If no response consider surgery

If refractory to steroids/side effects->
Infliximab
Azathioprine->steroid sparing
Mercaptopurine
Methotrexate + folic acid

For perianal:
MRI + EUA
Oral antibiotics
Immunosuppressants
Infliximab
Surgery + seton insertion

14

Medical therapy overview

1. Nutrition and lifestyle
2. Antimicrobials
3. Anti-inflammatory
4. Imunomodulators
5. Anti-TNF

15

Maintenence

1. Azathioprine or mercaptopurine, if X effective->methotrexate + folic acid
2. Fistulating/perianal->metronidazole + Azathioprine or infliximab
3. Cholestyramine
4. Loperamide
5. Fluids/low residue/elemental diet in flare up
6. Smoking cessation
7. Regular diet, may need supplementation

16

Surgical indications, options, complications

Indications:
1. Relieve symptoms refractory to medical therapy->pain, obstruction, weight loss
2. +QOL when SE from medical therapy

Bowel resection, stricturoplasty, abscess drainage

May develop short bowel