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Inflammatory Bowel Disease + Anal Disease + Stomas Flashcards

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1
Q

What is inflammatory bowel disease?

A

Group of condition characterised by idiopathic inflammation of the GI tract

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2
Q

What are the 2 common types of inflammatory bowel disease?

A

Crohn’s disease
Ulcerative colitis

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3
Q

Location of Crohn’s disease

A
  • Affects anywhere in GI tract: terminal ileum in most cases + rarely affects rectum
  • Skip lesions (multiple places)
  • transmural (full thickness)
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4
Q

Location of ulcerative colitis

A

Begins in rectum
Can extend to involve the entire colon
Continuous pattern

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5
Q

Presentation of Crohn’s disease

A
  • weight loss
  • right lower quadrant pain
  • low grade fever
  • mildly anaemic
  • perianal inflammation/ulceration/lesions e.g. skin tags, fistulae, abscesses, scarring
  • multiple non-bloody loose stools a day
  • 15-30 year olds
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6
Q

Presentation of ulcerative colitis

A
  • multiple blood stools per day
  • mild abdominal pain
  • no perianal disease
  • normal temperature
  • 20-30 year olds
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7
Q

Skin changes in inflammatory bowel disease

A

Erythema nodosum
Pyoderma gangrenosum
Psoriasis

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8
Q

What other symptoms can you get if you have inflammatory bowel disease other than the GI?

A
  • enteropathic arthritis
  • skin problems: erythema nodosum, pyoderma gangrenosum, psoriasis
  • primary sclerosing cholangitis (UC)
  • uveitis
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9
Q

Causes of inflammatory bowel disease

A
  • genetic pre-disposition
  • gut organisms
  • immune response
  • triggers: antibiotics, infection, diet
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10
Q

Affect of smoking on Crohn’s disease and ulcerative colitis

A
  • worsens Crohn’s disease
  • can be beneficial to ulcerative colitis
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11
Q

What is a fistula?

A

Abnormal connection between two epithelial lined things

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12
Q

Classic microscopic presentation of Crohn’s disease

A

Epitheloid granuloma formation

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13
Q

What are people with Crohn’s disease likely to have that those with UC don’t?

A

Perianal disease
e.g. skin tags, fistula, abscesses, scarring

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14
Q

Investigation of IBD

A
  • FBC: anaemic
  • U&Es: possibly deranged electrolytes or AKI due to GI losses
  • faecal calprotectin
  • anti tTG: to exclude coeliac disease
  • stool sample + culture: exclude infective colitis
  • MRI for monitoring
  • CT for acute flare
  • colonoscopy + intestinal biopsies
  • flexible sigmoidoscopy
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15
Q

What is the safest test in cases of bloody diarrhoea?

A

flexible sigmoidoscopy

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16
Q

What does Crohn’s disease look like?

A
  • skip lesions
  • red appearance
  • ulcers
  • mucosal oedema
  • transmural inflammation + thickening of bowel wall + narrowing lumen (strictures)
  • cobblestone appearance
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17
Q

Features of Crohn’s disease

A
  • C: obblestone appearance
  • R:ose thorn ulcers (deep penetrating linear ulcers)
  • O:bstruction of bowel (strictures)
  • H:yperplasia of mesenteric lymph nodes
  • N:arrowing of intestinal lumen
  • S:kip lesions

granuloma formation

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18
Q

What is pathognomonic to Crohn’s disease?

A

Epithelioid granuloma formation

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19
Q

Pathological changes in ulcerative colitis

A
  • chronic inflammatory infiltrate of lamina propria
  • crypt abscesses + distortion
  • reduced numbers of goblet cells
  • pseudopolyps after repeated episodes
  • loss of haustra (inflammation reduces appearance)
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20
Q

Compare Crohn’s disease + ulcerative colitis:
- location
- rectal involvement
- continuous
- gross bleeding
- perianal disease
- fistula formation
- malnutrition
- smoking affect
- transmural inflammation
- granulomas
- fibrosis
- crypt abscesses

A

_Crohn’s disease
- location: anywhere in GI tract, mainly terminal ileum
- rectal involvement: rarely
- continuous: no, skip lesions
- gross bleeding: 25%
- perianal disease: yes
- fistula formation: yes
- malnutrition: potential
- smoking affect: damaging
- transmural inflammation: yes
- granulomas: yes
- fibrosis: common
- crypt abscesses: rare

Ulcerative colitis
- location: from rectum to colon
- rectal involvement: yes
- continuous: yes
- gross bleeding: yes
- perianal disease: no
- fistula formation: no
- malnutrition: no
- smoking affect: potentially beneficial
- transmural inflammation: no
- granulomas: no
- fibrosis: no
- crypt abscesses: yes

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21
Q

What are haustra?

A

Small pouches of the colon wall between folds

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22
Q

Treatment of UC flare up

A
  • first line: oral or rectal mesalazine
  • second line: oral or rectal prednisolone
    .
    if severe:
  • first line: IV hydrocorisone
  • additional options: IV ciclosporin, infliximab or surgery
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23
Q

Maintenance drug treatment of ulcerative colitis

A

oral or rectal mesalazine first line
azathioprine if M doesn’t work

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24
Q

What type of drug is used first line in UC?

A

aminosalicylate
mesalazine

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25
Surgical options for ulcerative colitis
- **panprotocolectomy** - removal of the large bowel + rectum then: - **ileostomy**: ileum is brought onto the skin with a spout into stoma bag - **J-pouch**: ileum is folded back on itself + fashioned into a larger pouch which attaches to the anus (acting like a rectum)
26
What is pouchitis?
inflammation of ileal pouch
27
Presentation of pouchitis
- abdominal pain - bloody diahrroea
28
Treatment of pouchitis
metronidazole ciprofloxacin
29
Treatment of Crohn's flare up
- **first line**: oral *prednisolone* or IV *hydrocortisone* - **enteral nutrition** - addition of *azathioprine, infliximab, metocaptopurine* if needed
30
How does enteral nutrition induce remission in crohn's?
- treating nutritional deficiencies - improving gut microbiome - removing inflammatory foods
31
maintenance drug treatment of Crohn's
*azathioprine* or *mercaptopurine* or biologics (first line in perianal or fistulating crohn's)
32
Surgical options for Crohn's
- resecting distal ileum - treating strictures of fistulas
33
Types of stomas
- colostomy - ileostomy - gastrostomy - urostomy
34
What is a stoma?
Artificial openings of a hollow organ *e.g. bowel*
35
Outline a colostomy
- colon is brought onto the skin - drain solid stools - found in LIF
36
Outline an ileostomy
- ileum is brought onto the skin - drain liquid stools - have a spout that drains into stoma bag - located in RIF
37
Outline a gastrostomy
- artificial connection between stomach and abdominal wall - used to provide feeds directly into stomach for pt who cannot meet nutritional needs by mouth
38
Outline a urostomy
- used to drain urine from kidneys - bypasses ureters, bladder + urethra - typically in RIF
39
What is a J pouch colostomy?
- wher the ileum is folded back on itself + fashioned into a larger pouch that functions like the rectum - J pouch is attached to anus + collects stools before opening bowels - ileo-anal anastomosis
40
Outline loop colostomy/ileostomy
- temporary stoma used to allow distal portion of bowel to heal after surgery - allows for faeces to bypass distal healing portion of bowel - both ends of bowel are brought to the skin to allow for easy anastomosis - reversed 6-8 weeks later
41
What is an anal fissure?
tear in the mucosal lining of the anal canal Most commonly due to trauma from hard stool
42
Classification of anal fissures
- **acute**: <6 weeks - **chronic**: >6 weeks. . - **primary**: no underling disease - **secondary**: underling disease *e.g. Crohns*
43
Risk factors of anal fissures
- constipation - dehydration - Crohn’s disease
44
Presentation of anal fissures
- intense pain post defecation - feeling of passing glass - bright red blood on wiping - itching
45
Most common location of anal fissures
Posterior midline
46
Management of anal fissure
- treat underlying cause - analgesia - increase fibre + fluid intake - stool softening laxatives *e.g. movicol* - topical anaesthetics *e.g. lidocaine* - GTN cream - surgery for chronic fissures: Botox injection to anal sphincters then lateral spincterotomy
47
What is a perianal fistula?
Abnormal connection between anal canal and perianal skin
48
Risk factors of perianal fistulas
- anorectal abscess - Crohn’s disease - diabetes mellitus - trauma to anal region - previous radiation to anal region
49
Presentation of perianal fistulas
- recurrent perianal abscesses - intermittent or continuous discharge per rectum *e.g. mucus, blood, pus, faeces*
50
Classifications/locations of perianal fistulas
- inter-sphincteric (most commonly) - trans-sphincteric - supra-sphincteric - extra-sphincteric
51
What is the Goodsall rule of perianal fistulas?
used to predict the trajectory of the fistula tract, depending on the external opening location in comparison to the transverse anal line: - **anterior to line**: direct tract straight to the dentate line - **posterior to line**: tract follows curved course to posterior midline
52
First line imaging of perianal fistulas
MRI scan
53
Management of perianal fistula
- medical management of crohn’s if the cause - fistulotomy - placement of seton - allows fistula to drain
54
What are anorectal abscesses?
Collection of pus in anal or rectal region
55
Types of anorectal abscesses
- perianal abscess (most common) - ischiorectal abscess - supralevator abscess - intersphincteric abscess
56
Pathophysiology of anorectal abscesses
- plugging of anal ducts > fluid stasis > infection - most commonly E. Coli - most commonly located in perianal area
57
Presentation of anorectal abscesses
- severe pain in perianal region - worse when sat down - perianal discharge or bleeding - erythematous, fluctuant, tender swelling on examination
58
Investigations of anorectal abscess
- clinical diagnosis - inspection + DRE - colonoscopy + blood cultures if query underlying cause - MRI - transperineal USS
59
Management of anorectal abscesses
- antibiotics *e.g. Ciprofloxacin + metronidazole* - analgesia - **incision + drainage** (first line) under LA if simple or GA if complex - intra-operative proctoscopy to check for any perianal fistulas
60
Simple vs complex anorectal abscess
- **simple**: superficial + no involvement of sphincter complex - **complex**: involves anal sphincter, underlying condition, deeper
61
Why are colostomy flushed to the skin?
The enzymes in the colon are less alkaline than in the small intestine so less damaging to the skin + do not need a spout like in an ileus Tommy
62
What is a hartmann’s procedure?
Sigmoid Cole to my with end colostomy formation

Gastrointestinal (37 decks)

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