IBD, Diverticulitis Tieman CIS

Question 1

Differences between Crohn’s and Ulcerative Colitis

Answer 1

lower GI cramping, tenesmus, bloody/ mucousy stools more typical of ulcerative colitis. Starts in rectum and moves proximally. Usually found in the 20s and 30s. small ulcerated regions surrounded by inflammation, continuous, sometimes with pseudopolyps Superficial, ulcers, exudate.

Crohn’s- (midgut/ small intestine) - usually in distal ileum. abdominal pain, crampy, weight loss over time, sometimes associated with diarrhea. Found anywhere from throat to anus. Bimodal age distribution. Skip lesions (cobblestoning). Histology: transmural, usually granulomas. Fistulae. Creeping Fat.

Question 2

IBD epidemiology

Answer 2

disease of developed countries.

UC slightly more prevalent than Crohn’s Disease. Both distributed pretty equally between men and women

Question 3

positive family history of UC or Crohn’s

Answer 3

means higher risk of either one

Question 4

aphthous ulcers associated with

Answer 4

Crohn’s

Question 5

erythema nodosum and pyoderma nodosum

Answer 5

both associated with Crohn’s

Question 6

more common area to find Crohn’s

Answer 6

terminal ileum

Question 7

what does CRP indicate?

Answer 7

C-reactive protein indicates some inflammation

Question 8

ASCA is what?

Answer 8

an antibody to yeast

Question 9

IgA and IgG elevated, ASCA up, CRP up, normal pANCA means what?

Answer 9

90% chance of Crohn’s disease

Question 10

hyperemia of ascending colon means what?

Answer 10

inflammation of the terminal ileum would cause this because it lives right next door.

Question 11

how do we treat acute episode of Crohn’s?

Answer 11

bowel rest, IV corticosteroids

for outpatient– could use oral prednisone, or 5ASA (a topical anti-inflammatory)
biologics: anti-TNF drugs

Question 12

CT ENTEROGRAPHY on our Crohn’s disease patient

Answer 12

Three areas of thickened bowel wall, hyperemia and prominence of the vasa recti in the distal ileum. These areas show narrowing of the bowel lumen with areas of dilatation between each area of narrowing. Suggestive of moderately severe active Crohn’s Disease. No fistulae or abscesses are identified.

Surgery is a last resort; tends to come back.

Question 13

ESR, CRP elevated, p-ANCA elevated

Answer 13

more like ulcerative colitis

Question 14

arthralgias

Answer 14

go along with IBD of either kind

Question 15

Endoscopy of ulcerative colitis patient

Answer 15

Proctosigmoidoscopy: Edematous, friable mucosa in rectal vault extending continuously into the proximal left colon beyond the level of the scope
Colonoscopy: Edematous, friable mucosa which bleeds when touched. Scattered polypoid formations. This pattern extends beyond the splenic flexure into the distal transverse colon. Beyond that point the colon is normal. Polyps removed and numerous random biopsies taken throughout the diseased areas.

Question 16

toxic megacolon

Answer 16

ulcerative colitis patients are prone to it; be very careful when sticking stuff up their butts (-scopy)

Question 17

biopsy in ulcerative colitis

Answer 17

elongated mucosa, inflammation

Question 18

treatment modalities for ulcerative colitis

Answer 18

5ASA products via suppository or enema, rectal preparation of prednisone, Budesonid MMX for induction

more severe case- deliver drugs intravenously or steroids that are not released until you get to the colon
Immunomodulator
Anti-TNF therapy
Infliximab, adalimumab or golimumab, vedolizumab, cyclosporine for induction

Disease refractory to medical therapy, colonic dysplasia or cancer: Proctocolectomy

Question 19

associated disease with ulcerative colitis

Answer 19

primary sclerosing cholangitis

Question 20

what age group does volvulus usually happen in?

Answer 20

80s, 90s- nursing home, stool backing up, flips on mesentery

Question 21

dirty fat on radiography

Answer 21

edema and fat, signifies sigmoid diverticulitis

treat with bowel rest, IV fluids, IV imipenem

then good to follow up with colonoscopy

Question 22

when do we start doing yearly colonoscopies on U/C patients?

Answer 22

after 8 years or maybe earlier due to the risk of colon cancer.

Question 23

feeling of fullness in buttock suggests what?

Answer 23

rectal fistula
can arise from Crohn’s disease

Good-Sol’s line is from 3-9 o’clock across anus in supine position. If fistula is anterior to that line, it’s likely a direct fistula; posterior is much more likely to be complex.

If direct, a probe and fistulotomy will do the trick and heal it. (won’t damage anal sphincter and cause incontinence)

posterior can be all complex and just trying to open it up would –> cut sphincter, incontinence (treat with setons– heavy sutures to tighten down slowly over time)

Question 24

fistulae with Crohn’s disease, how to treat?

Answer 24

don’t operate!

Use an anti-metabolite.

Question 25

anal fissures don’t heal because why?

Answer 25

constant trauma of bowel movements PLUS spasm of the internal sphincter (autonomic control; pain –> involuntary contraction, increased pressures)

trick with these– treat internal sphincter

Sitz baths, etc.

If they come back no better, do surgery– lateral internal sphincterotomy (stretch out the anal canal, make a little incision at 3 or 9 o’clock). Incidence of incontinence is almost zero.

Question 26

4 grades of internal hemorrhoids

Answer 26

1- do not prolapse
2- prolapse and go back in spontaneously
3- prolapse and must be manually reduced
4- prolapse and don’t go in no matter what you do

internal tend to bleed. can usually treat with rubber bands.

external cause pain