IBD Flashcards by Deema Baks

What is crohn’s disease?

chronic transmural inflammatory disease of GI tract

- most common in TERMINAL ILEUM

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Who are more commonly affected by Crohn’s disease?

2nd & 3rd decade
6th to 7th decade
2 times the risk in smokers
strong family history of Crohn’s

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What are the risk factors of Crohn’s disease?

familial aggregation
genetic predisposition ( NOD2, HLA-B27)
tobacco

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What is the pathogenesis of Crohn’s disease?

increased permeability of mucus membranes + abnormal immune mediated response to normal gut flora
TH1 mediated response
ASCA autoantibodies

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What are the types of Crohn’s disease?

terminal ileum 60%
Colitis alone 1/3
perianal lesions 50-75%
stomach & duodenum 5%

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What will be seen GROSSLY on exploration of Crohn’s?

thickened grayish-pink or dull purple-red loops of bowel
thick gray-white exudate or fibrosis of serosa
skip lesions
fibrotic thickening of intestinal wall (fat wrapping if circumferential)
dilated bowel proximal to stricture
SNAKE-LIKE/ROSE-THORN (linear mucosal ulcers)
mesenteric abscesses & fistulae

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What is the microscopic picture of Crohn’s disease?

edema of mucosa & submucosa before any gross change
inflammatory infiltrate extends transmurally
NONCASEATING GRANULOMAS WITH LANGERHANS GIANT CELLS

early acute -> hyperemic & boggy
chronic -> fibrotic scarring and bowel wall thickened with leathery texture

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What are the characteristic findings of Crohn’s disease?

C cobblestone mucosa 
R rose-thorn ulcers 
O obstruction of bowel 
H hyerplasia of mesenteric lymph nodes 
N narrowing of lumen 
S skip lesions

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What are the clinical features of Crohn’s disease?

insidious onset with slow & protracted course
gradually becomes more frequent & severe & longer lasting attacks
intermittent colicky abdominal pain in lower abdomen (mimics appendicitis)
diarrhea
perianal disease (suspect in any patient with multiple chronic perianal fistulas)
systemic symptoms
low-grade fever
weight loss
loss of strength
malaise

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What are the extraintestinal manifestations of Crohn’s disease?

skin lesions -> erythema nodosum, pyoderma gangrenosum
arthritis & arthralgias
uveitis & iritis
amyloidosis
hepatitis pericholangitis
pancreatitis
renal or gallbladder calculi

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What are the complications of Crohn’s disease?

obstruction
perforation
fistulas
localized abscesses
toxic megacolon
cancer

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What is the DD of Crohn’s disease?

acute appendicitis
mesenteric lymphadenitis
ovarian pathology
salmonella & shigella
intestinal TB
acute distal ileitis

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How can we confirm a diagnosis of Crohn’s disease?

CLINICAL
- history & examination

BLOOD

CBC U&E, LFT, coagulation profile
CRP, ESR
ANCA & ASCA +ve
nutritional albumin, prealbumin

STOOL

culture & microscopy to rule out infectious colitis
C diff toxin to rule out pseudomembraneous colitis

UGI scope & COLONOSCOPY WITH BIOPSY

patchy inflammation
linear ulcers
cobble stone appearance
stricture

MR enterography

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How can Crohn’s disease be treated?

conserve by 
MEDICAL 
- steroids
- aminosalicylates 
- antibiotics 
- imminomodulatory agents 
- monoclonal antibodies -> for severe active disease 
- nutritional support

ENDOSCOPIC TREATMENT OF STRICTURE

balloon dilatation through enteroscope or colonoscope
contraindicated if there’s an inflamed or ulcerated stricture

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What are the indications for surgery in Crohn’s disease?

complications

intestinal obstruction
intestinal perforation with fistula formation or abscess
free perforation
GI bleeding
cancer
perianal disease
extraintestinal manifestations

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What are the principles of surgery in Crohn’s disease?

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preserve gut length & maintain adequate function
resection kept to a minimum
optimize patient before surgery
surgery shouldn’t be delayed if there is a clear indication
risk of short bowel syndrome -> stricturoplasty
stoma formation (colostomy) incase of -> abscess, fistula, low albumin, steroid use

What are the options for surgery in Crohn’s?

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ILEOCECAL RESECTION WITH ILEOCOLIC ANASTOMOSIS -> terminal ileal Crohn’s
SEGMENTAL RESECTION & ANASTOMOSIS -> short segment stricture with no risk of short bowel syndrome
COLECTOMY & ILEORECTAL ANASTOMOSIS -> colonic Crohn’s with normal rectum & anus
SUBTOTAL COLECTOMY & ILEOSTOMY -> acute Crohn’s colitis
TEMPORARY LOOP ILEOSTOMY -> acute distal CD to allow remission and later restoration (severe perianal or rectal disease)
PROCTOLECTOMY -> colic/anal disease failing to respond to medical treatment (permanent ileostomy)
STRICTURE PLASTY -> multiple areas of CD & danger of short bowel syndrome

What is ulcerative colitis?

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dynamic disease characterized by remissions & exacerbation

- peak incidence 15-35 years then >55 years

What are the risk factors of ulcerative colitis?

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genetic (HLA-B27)
ethnicity (white & Ashkenazy jews)
family history
previous intestinal infection
increased fat intake
OCPs & NSAIDS

What are the protective factors against ulcerative colitis?

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appendectomy before established UC

- smoking

What is the pathogenesis of ulcerative colitis?

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increased permeability of intestinal epithelium
TH2 differentiation
dysregulation of immune system
ANCA against epithelial cells
CONTINUOUS UNINTERRUPTED INFLAMMATION OF COLONIC MUCOSA beginning in distal rectum & extending proximally

What is the gross picture of ulcerative colitis?

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hyperemic mucosa
friable & granular mucosa -> in severe
ulcerations
pseudopolyps or inflammatory polyps

What is the microscopic picture of ulcerative colitis?

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inflammation of mucosa & submucosa

- CRYPT ABSCESS

What is the most common course of ulcerative colitis?

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CHRONIC INTERMITTENT
- exacerbation followed by complete remission

chronic continuous
- no complete remission

acute fulminant
- sudden onset of severe diarrhea, dehydration & shock

What are the symptoms of ulcerative colitis?

- bloody diarrhea with mucus - fecal urgency - abdominal pain & cramps on left side - tenesmus

what are the extra-intestinal manifestations of ulcerative colitis?

- osteoarthritis, ankylosing spondylitis, sacroiliitis -> skeletal (most common) - uveitis, episcleritis, iritis -> ocular - primary sclerosing cholangitis -> biliary - pyostomatitis vegetans, apthous stomatitis, erythema nodusom, pyoderma gangrenosum -> cutaneous - fatigue & fever - growth retardation & delayed puberty in children

What are the complications of ulcerative colitis?

- acute fulminant colitis - toxic megacolon - colonic cancer (greater risk with longer disease)

How should the diagnosis of ulcerative colitis be confirmed?

BLOOD - increase ESR & CRP - leukocytosis - anemia - thrombocytosis - increase pANCA STOOL - search for bacteria to rule out infectious causes COLONOSCOPY (definitive diagnosis) - contraindicated in acute RADIOGRAPHY plain - loss of colonic haustrata (LEAD PIPE APPEARANCE in severe) - massive distention in toxic megacolon - pneumoperitoneum if perforated BARIUM ENEMA - able to detect early changes - granular appearance of mucosa - deep ulcerations - loss of haustra - pseudopolyps appear as filling defects CT -> wall thickening if severe MRI -> extent of involvement ULTRASOUND -> bowel thickening (absent hyperechoic reflection from lumen)

What is the DD of ulcerative colitis?

- Crohn's disease - exudative-inflammatory diarrhea - diverticular disease - ischemic colitis - infectious colitis - radiation colitis - celiac disease

How should ulcerative colitis be managed?

- first -> conserve with drugs to induce & maintain remission - if medical fails -> curative proctocolectomy

What is the initial management of ulcerative colitis?

PROCTITIS - 5ASA + steroids - immunosuppressant + monoclonal antibodies ACUTE COLITIS - mild -> steroids + 5ASA - moderate -> oral steroid + steroid enema + 5 ASA - severe -> NPO, IVF, IV antibiotics, steroid -> not improving? -> emergency surgery

What are the indications for surgery in ulcerative colitis?

- fulminant colitis with toxic megacolon - massive bleeding - intractable disease - dysplasia or carcinoma - malnutrition & growth retardation - extraintestinal manifestations - failure of medical

What are the surgical treatment options for ulcerative colitis?

EMERGENCY -> in systemic upset, malnourished patient, or on steroids - total colectomy with end ileostomy - no dissection of rectum (mucus fistula) - restorative surgery later ELECTIVE -> sphincter problems, lower complication rate, no risk of rectal cancer - restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) -> pelvic sepsis - colectomy with ileorectal anastomosis -> if minimum rectal inflammation with rectal checkups

IBD Flashcards

(33 cards)