Crohns disease

Question 1

Epidemiology of crohns

Prevalence? age? F:M?

Answer 1

50 to 100 /100,000
20s
F>M (just)

Question 2

Causes of crohns

Answer 2

• Concordance = 70%
• Smoking ↑ risk
• TH1/TH17-mediated

Question 3

Macroscopic changes of crohns

Answer 3

• Mouth to anus esp. terminal ileum ulcers
• Skip lesions
• strictures

Question 4

Microscopic changes in crohns

Answer 4

• Transmural inflammation
• cobblestone ulceration
• marked fibrosis

Question 5

Symptoms of crohns?

Answer 5

I. systemic: fever, malaise, anorexia, wt loss
II. Abdo:
- Diarrhoea (not usually bloody)
- Abdominal pain

Question 6

Abdominal Signs of crohns?

Answer 6

• Aphthous ulcers, glossitis
• Abdominal tenderness
• RIF mass
• Perianal abscesses, fistulae, tags
• Anal / rectal strictures

Question 7

Dermatological signs of crohns and ulcerative colitis?

Answer 7

• Clubbing
• Erythema nodosum(red lumps)
• Pyoderma gangrenous (esp. UC) (painful ulcers_

Question 8

Eyes signs of crohns and ulcerative colitis?

Answer 8

• Iritis
• Episcleritis
• Conjunctivitis

Question 9

Joints signs of crohns and ulcerative colitis?

Answer 9

• Arthritis (non-deforming, asymm)
• Sacroiliitis
• Ank spond

Question 10

Hepato-pancreato-biliary signs of crohns and ulcerative colitis?

Answer 10

• Primary Sclerosing Cholangitits + cholangiocarcinoma (esp. UC)
• Gallstones (esp. Crohn’s)
• Fatty liver

Question 11

Other signs of crohns and ulcerative colitis?

Answer 11

• Amyloidosis

- Oxalate renal stones (esp. Crohns)

Question 12

Complication of crohns?

Answer 12

1. fistula
2. stricture
3. abscess
4. toxic megacolon and cancer
5. Malabsorption
   - Fat (steatorrhea)
   - B12 (megablastic anaemia)
   - Vit D (osteomalacia)
   - Protein (oedema)

Question 13

Blood investigations for crohns?

Answer 13

• FBC: ↓Hb, ↑WCC
• LFT: ↓albumin
• ↑CRP/ESR
• Haematinics: Fe, B12, Folate
• Blood cultures

Question 14

Stool investigations for crohns?

Answer 14

• MCS: exclude Campy, Shigella, Salmonella…

- CDT: C. diff may complicate or mimic

Question 15

Imaging investigations for crohns?

Answer 15

I. AXR: obstruction, sacroileitis
II. CXR: perforation
III. MRI
- Assess pelvic disease and fistula
IV. Small bowel follow-through or enteroclysis
- Skip lesions
- Rose-thorn ulcers
- Cobblestoning: ulceration + mural oedema
- String sign of Kantor: narrow terminal ileum

Question 16

Endescopy investigations for crohns?

Answer 16

• Ileocolonoscopy + regional biopsy: Ix of choice
• Wireless capsule endoscopy
• Small bowel enteroscopy

Question 17

Management of Severe crohns attack

Answer 17

1. Resus: Nil by mouth, IV hydration
2. Hydrocortisone: IV + PR if rectal disease
3. Abx (metronidazole PO or IV)
4. Dietician
   I. Elemental diet
   II. Consider parenteral nutrition

Question 18

Elemental diet

Answer 18

Liquid prep of amino acids, glucose and fatty

acids

Question 19

If no improvement after the initial management of severe crohns attack, what is the treatment?

Answer 19

• Medical: methotrexate ± infliximab

- consider surgical

Question 20

Secondary management of severe crohns after improvement post-primary care?

Answer 20

• oral therapy

- Switch to oral pred (40mg/d)

Question 21

Overview of management of crohns

Answer 21

1. Inducing remission in mild/mod disease (outpatient)
2. Supportive
3. Oral therapy

Question 22

Oral therapy for crohns?

Answer 22

1st line
- Ileocaecal: budesonide
- Colitis: sulfasalazine
2nd line:
- prednisolone (tapering)
3rd line: 
- methotrexate
4th line: 
- infliximab or adalimumab

Question 23

Perianal disease in crohns: how common?

Answer 23

Occurs in ~50%

Question 24

Perianal disease in crohns: investigations?

Answer 24

Ix: MRI + Examination under anaesthesia Rx

Question 25

Perianal disease in crohns: managements?

Answer 25

- Oral Abx: metronidazole - Immunosuppression ± infliximab - Local surgery ± seton insertion

Question 26

Maintaining remission in crohns drugs?

Answer 26

1st line: azathioprine or mercaptopurine 2nd line: methotrexate 3rd line: Infliximab / adalimumab

Question 27

How many crohns patients get surgery?

Answer 27

- 50-80% need ≥1 operation in their life

Question 28

Indications for emergency surgery on crohns patients?

Answer 28

- Failure to respond to medical Rx - Intestinal obstruction or perforation - Massive haemorrhage

Question 29

Indications for Elective surgery on crohns patients?

Answer 29

- Abscess or fistula - Perianal disease - Chronic ill health - Carcinoma

Question 30

Surgical options available to crohns patients?

Answer 30

I. Limited resection: e.g. ileocaecal II. Stricturoplasty III. Defunction distal disease with temporary loop ileostomy

Question 31

Complications of surgery on crohns?

Answer 31

I. Stoma complications II. Enterocutaneous fistulae III. Anastomotic leak or stricture

Question 32

Short gut syndrome features?

Answer 32

- 1-2m small bowel - Steatorrhoea - ADEK and B12 malabsorption - Bile acid depletion → gallstones - Hyperoxaluria → renal stones

Question 33

Management of short gut syndrome?

Answer 33

- Dietician - Supplements or TPN - Loperamide

Question 34

Supportive management of crohns?

Answer 34

- High fibre diet | - Vitamin supplements