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3: MED2 Y3 - Gastrointestinal [7] > Crohn's Disease > Flashcards

Crohn's Disease Flashcards

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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
What is the characteristic macroscopic finding for Crohn's on colonoscopy?
Cobblestoning of the bowel
26
What is cobblestoning of the bowel?
Where fissures and ulcers seperate islands of healthy mucosa
27
When should colonoscopy be avoided in Crohn's?
During active flares
28
Why should colonoscopy be avoided during active flares of Crohn's?
Due to increased risk of peritoneal performation
29
What might be needed for investigation of Crohn's during an active flare?
Flexible sigmoidoscopy
30
What other imaging can be done in Crohn's?
- Capsule endoscopy - MRI - Ultrasound - CT scan - Barium swallow
31
What can capsule endoscopy be used to detect in Crohn's?
Isolated proximal disease
32
What might MRI be used for in Crohn's?
Assess pelvic disease and fistulae, small bowel disease activity, and strictures
33
What can ultrasound be used for in Crohn's?
Can sometimes provide small bowel imaging
34
When is CT used in Crohn's?
Severe disease
35
What can CT show in Crohn's?
- Bowel obstruction - Perforation - Collection formation - Fistulae
36
What can barium swallow show in Crohn's?
- Strictures - 'Rose thorn' ulcers - String sign of Kantor
37
What will management of Crohn's disease involve?
Induction of remission, and once this is achieved maintenance of remission
38
What is first line in induction of remission of Crohn's?
Monotherapy with conventional glucocorticoid steroid, e.g. prednisolone
39
When can prednisolone be used for induction of remission in Crohn's?
- First presentation | - Single inflammatory exacerbation of Crohn's disease in 12 month period
40
What is second line for induction of remission in Crohn's?
- Budesonide in people with distal ileal, ileocaecal, or right-sided Crohn's disease - Mesasalazine in others
41
How does budesonide and mesasalazine compare to prednisolone in induction of remission of Crohn's?
Budesonide is not as effective, but may have fewer side effects Mesasalazine is less effective than both
42
When should budesonide and mesasalazine not be used?
In people with a severe presentation or exacerbation
43
What can you consider adding to conventional first line treatment for induction of remission in Crohn's?
Azathioprine or mercaptopurine
44
When may you consider adding azathioprine or mercaptopurine to conventional first line treatment for induction of remission in Crohn's?
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
What can be used instead of azathioprine or mercaptopurine if these are not tolerated or contraindicated?
Methotrexate
46
What should be done if first line therapy + metacaptopurine/azathioprine is still insufficient in induction of remission of Crohn's?
Biological treatment such as infliximab or adalimumab, either as monotherapy or combined with immunosuppressant
47
When are biological therapies recommended in induction of remission of Crohn's?
- Adults with severe active Crohn's disease that has not responded to conventional therapy - Intolerant to these therapies
48
How long should biological therapies be continued in induction of remission in Crohn's?
12 months, unless not effective (then stop)
49
What can be used as an alternative to medical treatment in early course of Crohn's?
Surgery
50
When can surgery be used as an alternative to medical treatment in the early course of Crohn's
When disease is limited to distal ileum
51
What are the first line drugs in maintenance of remission of Crohn's?
Azathioprine or mercaptopurine
52
When should methotrexate be considered as an option in maintenance of remission of Crohn's?
- Needed to induce remission - Tried but did not tolerate first line - Contraindications to these agents
53
What is required with methotrexate, azathioprine, or mercaptopurine?
Monitoring
54
What further management may be required with Crohn's?
- Referral to IBD nurse specialist and patient support groups - Enteral nutritional support - Antibiotics
55
When might enteral nutritional support be considered?
In young patients with growth concerns
56
When might antibiotics be used in Crohn's?
Only in those with obvious concurrent infection or perianal disease
57
What antibiotics are typically used in Crohn's?
- Ciprofloxacin | - Metronidazol
58
What % of Crohn's patients need surgery at some point in their lifetime?
70-80%
59
Who is surgery indicated in with Crohn's?
- Failed medical managment - Severe complications, e.g. strictures and fistulae - Growth impairment in younger patients
60
What is the most common surgical procedure in Crohn's?
Ileocaecal resection
61
What is an ileocaecal resection?
Removal of the terminal ileum and caecu, with primary anastomosis between ileum and ascending colon
62
What approach needs to be taken during surgery for Crohn's, and why?
Bowel sparing approach, to prevent short-gut syndrome in later years
63
What are the complications of Crohn's?
- Stricture formation - Fistulas - Perianal complications - GI malignancy
64
What can stricture formation in Crohn's lead to?
Bowel obstruction and perforation
65
What strictures might form in Crohn's?
- Enterovesical - Enterocutaneous - Rectovaginal
66
What perianal complications may arise in Crohn's?
Formation of perianal abcesses or fistulae
67
What is the risk of GI malignancy in Crohn's?
3% risk of developing colorectal cancer over 10 years | 30x higher risk of developing small bowel cancer than general population
68
How can fistulas be managed?
- Fistulotomy (opening tract up) | - Seton technique
69
What happens in Seton technique?
Cord is tied around fistula which keeps ot open, and over time it drains and heals over
70
In what extra-intestinal systems might Crohn's manifest?
- MSK - Skin - Eyes - Hepatobiliary - Renal
71
What are the MSK manifestations of Crohn's?
- Enteropathic arthritis | - Metabolic bone disease
72
What causes metabolic bone disease in Crohn's?
Malabsorption
73
What are the skin manifestations of Crohn's?
- Erythema nodosum | - Pyoderma gangrenosum
74
What are the eye manifestations of Crohn's?
- Episcleritis - Anterior uveitis - Iritis
75
What are the hepatobiliary manifestations of Crohn's?
- Primary sclerosing cholangitis - Cholangiocarcinoma - Gallstones
76
What are the renal manifestations of Crohn's?
Renal stones

3: MED2 Y3 - Gastrointestinal [7] (44 decks)

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