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A - MSRA Gastrointestinal [7] > Crohn's Disease > Flashcards

Crohn's Disease Flashcards

1
Q

What is Crohn’s disease?

A

A chronic inflammatory disease

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2
Q

What is Crohn’s characterised by?

A

Transmural granulomatous inflammation affecting any part of the gut from mouth to anus, especially the terminal ileum or proximal colon

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3
Q

What % of Crohn’s patients have involvement of the terminal ileum?

A

70%

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4
Q

What are areas of unaffected bowel called in Crohn’s disease, and why are they significant?

A

Skip lesions

They differentiate from UC, which has continuous inflammation

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5
Q

How is the pathophysiology of Crohn’s similar to UC?

A

Like UC, it is caused by inappropriate immune response against the gut flora in a genetically susceptible individual

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6
Q

When does Crohn’s disease present?

A

Typically 20-40 years

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7
Q

What is produced by the transmural inflammation in Crohn’s?

A

Deep ulcers and fissures

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8
Q

What kind of appearance is produced by deep ulcers and fissures in Crohn’s?

A

Cobblestone appearance

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9
Q

Describe the microscopic appearance of Crohn’s?

A

Non-caseating granulomatous inflammation

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10
Q

What is the result of the transmural nature of the inflammation?

A

Fistulas can form from the affected bowel to adjacent structures, resulting in perianal fistulas, recto-vaginal fistulas, entero-cutaneous fistulas, or enterovescicular fistulas

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11
Q

What causes Crohn’s disease?

A

Exact cause is unknown, seems to be combination of environmental factors and genetic predisposition

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12
Q

What is it suggested that Crohn’s is due to?

A

Genetic malfunction in the innate immune system, causing adaptive immune system to compensate for it, thus causing chronic inflammation

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13
Q

What genes are implicated in Crohn’s disease?

A

NOD2/CARD15

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14
Q

What are the risk factors for Crohn’s?

A
  • Genetics
  • Smoking
  • Intercurrent infections, e.g. URTI, enteric infection
  • NSAID use
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15
Q

What are the symptoms of Crohn’s?

A
  • Diarrhoea, may be bloody and become chronic
  • Abdo pain
  • Weight loss/failure to thrive
  • Systemic symptoms
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16
Q

What are the systemic symptoms of Crohn’s?

A
  • Fatigue
  • Fever
  • Malaise
  • Anorexia
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17
Q

Describe the course of Crohn’s

A

There will typically be periods of acute exacerbation, interspersed with remissions or less active disease

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18
Q

How might oral involvement of Crohn’s present?

A

Apthous mouth ulcers, which can be painful and recurring

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19
Q

How might perianal Crohn’s present?

A
  • Skin tags
  • Perianal abcesses
  • Bowel stenosis
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20
Q

What are the signs of Crohn’s disease?

A
  • Bowel ulceration
  • Abdominal tenderness
  • Abdominal mass
  • Perianal abscess
  • Perianal fistulae
  • Anal strictures
  • Clubbing
  • Skin, joint, and eye problems
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21
Q

What investigations should be done in Crohn’s disease?

A
  • Bloods
  • Stool MC&S
  • Faecal calprotectin
  • Colonoscopy and biopsy
  • Imaging
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22
Q

What bloods should be done in Crohn’s disease?

A
  • FBC
  • ESR
  • CRP
  • U&E
  • LFT
  • INR
  • Ferritin
  • TIBC
  • B12
  • Folate
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23
Q

Why should stool MC&s be done in Crohn’s?

A

Rule out infectious causes

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24
Q

What is the gold standard for diagnosis in Crohn’s?

A

Colonoscopy with biopsy

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25
Q

What is the characteristic macroscopic finding for Crohn’s on colonoscopy?

A

Cobblestoning of the bowel

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26
Q

What is cobblestoning of the bowel?

A

Where fissures and ulcers seperate islands of healthy mucosa

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27
Q

When should colonoscopy be avoided in Crohn’s?

A

During active flares

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28
Q

Why should colonoscopy be avoided during active flares of Crohn’s?

A

Due to increased risk of peritoneal performation

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29
Q

What might be needed for investigation of Crohn’s during an active flare?

A

Flexible sigmoidoscopy

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30
Q

What other imaging can be done in Crohn’s?

A
  • Capsule endoscopy
  • MRI
  • Ultrasound
  • CT scan
  • Barium swallow
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31
Q

What can capsule endoscopy be used to detect in Crohn’s?

A

Isolated proximal disease

32
Q

What might MRI be used for in Crohn’s?

A

Assess pelvic disease and fistulae, small bowel disease activity, and strictures

33
Q

What can ultrasound be used for in Crohn’s?

A

Can sometimes provide small bowel imaging

34
Q

When is CT used in Crohn’s?

A

Severe disease

35
Q

What can CT show in Crohn’s?

A
  • Bowel obstruction
  • Perforation
  • Collection formation
  • Fistulae
36
Q

What can barium swallow show in Crohn’s?

A
  • Strictures
  • ‘Rose thorn’ ulcers
  • String sign of Kantor
37
Q

What will management of Crohn’s disease involve?

A

Induction of remission, and once this is achieved maintenance of remission

38
Q

What is first line in induction of remission of Crohn’s?

A

Monotherapy with conventional glucocorticoid steroid, e.g. prednisolone

39
Q

When can prednisolone be used for induction of remission in Crohn’s?

A
  • First presentation

- Single inflammatory exacerbation of Crohn’s disease in 12 month period

40
Q

What is second line for induction of remission in Crohn’s?

A
  • Budesonide in people with distal ileal, ileocaecal, or right-sided Crohn’s disease
  • Mesasalazine in others
41
Q

How does budesonide and mesasalazine compare to prednisolone in induction of remission of Crohn’s?

A

Budesonide is not as effective, but may have fewer side effects
Mesasalazine is less effective than both

42
Q

When should budesonide and mesasalazine not be used?

A

In people with a severe presentation or exacerbation

43
Q

What can you consider adding to conventional first line treatment for induction of remission in Crohn’s?

A

Azathioprine or mercaptopurine

44
Q

When may you consider adding azathioprine or mercaptopurine to conventional first line treatment for induction of remission in Crohn’s?

A

If there have been 2 or more inflammaotry exacerbations in a 12 month period, or the glucocorticosteroid dose cannot be tapered down without symptoms

45
Q

What can be used instead of azathioprine or mercaptopurine if these are not tolerated or contraindicated?

A

Methotrexate

46
Q

What should be done if first line therapy + metacaptopurine/azathioprine is still insufficient in induction of remission of Crohn’s?

A

Biological treatment such as infliximab or adalimumab, either as monotherapy or combined with immunosuppressant

47
Q

When are biological therapies recommended in induction of remission of Crohn’s?

A
  • Adults with severe active Crohn’s disease that has not responded to conventional therapy
  • Intolerant to these therapies
48
Q

How long should biological therapies be continued in induction of remission in Crohn’s?

A

12 months, unless not effective (then stop)

49
Q

What can be used as an alternative to medical treatment in early course of Crohn’s?

A

Surgery

50
Q

When can surgery be used as an alternative to medical treatment in the early course of Crohn’s

A

When disease is limited to distal ileum

51
Q

What are the first line drugs in maintenance of remission of Crohn’s?

A

Azathioprine or mercaptopurine

52
Q

When should methotrexate be considered as an option in maintenance of remission of Crohn’s?

A
  • Needed to induce remission
  • Tried but did not tolerate first line
  • Contraindications to these agents
53
Q

What is required with methotrexate, azathioprine, or mercaptopurine?

A

Monitoring

54
Q

What further management may be required with Crohn’s?

A
  • Referral to IBD nurse specialist and patient support groups
  • Enteral nutritional support
  • Antibiotics
55
Q

When might enteral nutritional support be considered?

A

In young patients with growth concerns

56
Q

When might antibiotics be used in Crohn’s?

A

Only in those with obvious concurrent infection or perianal disease

57
Q

What antibiotics are typically used in Crohn’s?

A
  • Ciprofloxacin

- Metronidazol

58
Q

What % of Crohn’s patients need surgery at some point in their lifetime?

A

70-80%

59
Q

Who is surgery indicated in with Crohn’s?

A
  • Failed medical managment
  • Severe complications, e.g. strictures and fistulae
  • Growth impairment in younger patients
60
Q

What is the most common surgical procedure in Crohn’s?

A

Ileocaecal resection

61
Q

What is an ileocaecal resection?

A

Removal of the terminal ileum and caecu, with primary anastomosis between ileum and ascending colon

62
Q

What approach needs to be taken during surgery for Crohn’s, and why?

A

Bowel sparing approach, to prevent short-gut syndrome in later years

63
Q

What are the complications of Crohn’s?

A
  • Stricture formation
  • Fistulas
  • Perianal complications
  • GI malignancy
64
Q

What can stricture formation in Crohn’s lead to?

A

Bowel obstruction and perforation

65
Q

What strictures might form in Crohn’s?

A
  • Enterovesical
  • Enterocutaneous
  • Rectovaginal
66
Q

What perianal complications may arise in Crohn’s?

A

Formation of perianal abcesses or fistulae

67
Q

What is the risk of GI malignancy in Crohn’s?

A

3% risk of developing colorectal cancer over 10 years

30x higher risk of developing small bowel cancer than general population

68
Q

How can fistulas be managed?

A
  • Fistulotomy (opening tract up)

- Seton technique

69
Q

What happens in Seton technique?

A

Cord is tied around fistula which keeps ot open, and over time it drains and heals over

70
Q

In what extra-intestinal systems might Crohn’s manifest?

A
  • MSK
  • Skin
  • Eyes
  • Hepatobiliary
  • Renal
71
Q

What are the MSK manifestations of Crohn’s?

A
  • Enteropathic arthritis

- Metabolic bone disease

72
Q

What causes metabolic bone disease in Crohn’s?

A

Malabsorption

73
Q

What are the skin manifestations of Crohn’s?

A
  • Erythema nodosum

- Pyoderma gangrenosum

74
Q

What are the eye manifestations of Crohn’s?

A
  • Episcleritis
  • Anterior uveitis
  • Iritis
75
Q

What are the hepatobiliary manifestations of Crohn’s?

A
  • Primary sclerosing cholangitis
  • Cholangiocarcinoma
  • Gallstones
76
Q

What are the renal manifestations of Crohn’s?

A

Renal stones

A - MSRA Gastrointestinal [7] (44 decks)

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