Crohn's Disease

Question 1

What are the defining features of crohn’s

Answer 1

GALS
Granulomatous inflammation (granulomas)
All parts of the GI tract (mouth to anus)
Layers - Transmural
Skip lesions (discontinuous inflammation) and cobblestone mucosa (fissures and deep ulcers)

Question 2

Where does Crohn’s most commonly affect?

Answer 2

Distal ileum or proximal colon

Question 3

What is the microscopic appearance of Crohn’s?

Answer 3

Non-caeseating granulomatous inflammation

Question 4

What is the risk of transmural disease?

Answer 4

Fistula formation between adjacent structures:
Perianal
Entero-enteric
Rectovaginal
Enterocutaneous
Entero-vesicular

Question 5

What are risk factors of Crohn’s?

Answer 5

Family history
Smoking
White European descent
Appendicectomy

Question 6

What are symptoms of Crohn’s?

Answer 6

Diarrhoea (chronic and may contain blood)
Abdominal pain (Colicky)
Weight loss

Acute attacks

Systemic symptoms: malaise, anorexia, low-grade fever, fatigue

Question 7

What are signs of Crohn’s disease?

Answer 7

Bowel ulceration, abdominal tenderness, abdominal swelling perianal abscess/fistulae/skin tags, anal strictures
Oral aphthous ulcers (painful, recurring)

Signs of malabsorption or dehydration

Question 8

What are extra intestinal features of Crohn’s

Answer 8

Clubbing, metabolic bone disease due to malabsorption
Skin: erythema nodosum: tender red/purple subcutaneous nodules, found on patients shins
Pyoderma gangrenous - ulcers on shins

Eye: anterior uveitis

Hepatobiliary - primary sclerosis cholangitis, cholangiocarcinoma, gallstones

Renal: renal stones (reduced absorption of bile salts)

Question 9

What investigations for Crohn’s?

Answer 9

Bloods: FBC anaemia, albumin, WCC
CRP, ESR
LFT
U&E INR B12
Folate

Stool: MC&S (C.diff, campylobacter, E. coli)
Faecal calprotectin (raised in IBD, marker of GI inflammation)

Question 10

What imaging for Crohn’s?

Answer 10

Colonoscopy with biopsy - coblestone mucosa - fissures and ulcers, non-caeseating granulomatous inflammation

Barium swallow
Pelvic MRI for perianal disease

Question 11

How is mild Crohn’s managed?

Answer 11

Prednisolonge (oral corticosteroids) for 1 wk then taper for 7 wks

Question 12

How are acute attack’s of Crohn’s managed?

Answer 12

Admit for IV fluid resuscitation, electrolyte replacement, nutritional support,
IV corticosteroids hydrocortisone, VTE prophylaxis, immunosuppressive agent - mesalazine/azothioprine, exclude infection, consider sepsis!

Question 13

How do you maintain Crohn’s remission?

Answer 13

Azathioprine/mercaptopurine mono therapy to maintain remission.
Methotrexate in those who cannot tolerate others.

Biological agents - infliximab, adaluminab, tiruximab used as rescue therapy during acute flares in those who have not responded to first line remission agents.

Question 14

What advice would you give to someone with Crohn’s

Answer 14

Smoking cessation due to increased risk fo colorectal malignancy

Question 15

How would you assess severity of Crohn’s flare? What would you do?

Answer 15

Raised temperature
Raised HR
Raised ESR, CRP, WCC
Low albumin

Admit for IV steroids

Question 16

hat would you give to patient refractory to steroids but relapsing on steroid taper?

Answer 16

Azathioprine

Alternaticves: mercaptopurine, methotrexate

Question 17

What are the side effects of azathioprine?

Answer 17

Abdo pain, nausea, pancreatitis, leucopenia, abnormal LFTs

Monitor FBC, U&E, LFT weekly for 4wks then monthly for 3 months

Question 18

What type of drugs are infliximab and adalimumab? How do they work? CI? SE?

Answer 18

Anti-TNF alpha
Counter neutrophil accumulation and granuloma formation
Cause cytotoxicity to CD4+ T cells clearing cells driving immune response

CI - infection, sepsis, underlying malignancy, latent TB
SE: rash

Question 19

What nutrition for Crohn’s patient?

Answer 19

Enteral nutrition

Question 20

When/How are Crohn’s patients managed surgically?

Answer 20

Indications: drug failure, GI obstruction from stricture, perforation, fistulae, abscess

Resect affected areas or control perianal disease or deduction distal disease with temporary ileostomy

Most commonly ileocaecal resection and form primary anastomosis between ileum and ascending colon

Question 21

What are complications of Crohn’s?

Answer 21

Stricture(tightening of bowel) formation - bowel obstruction and perforation

Fistula

Perianal abscess or fistula

Malignancy

Malabsorption -growth delay in children, osteoporosis, gall stones due to reduced reabsorption of bile salts, renal stones - malabsorption of fats in small bowel causing calcium to remain in the lumen, oxalate is then absorbed freely as normally young to calcium and excreted –> hyperoxaluria and formation of oxalate stones