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Section II General Surgery P203Surgical Recall Sixth > Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis, C51 P338-344 > Flashcards

Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis, C51 P338-344 Flashcards

1
Q

What is IBD?

P338

A

Inflammatory Bowel Disease,

inflammatory disease of the GI tract

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2
Q

What are the two
inflammatory bowel
diseases?
P338

A

Crohn’s disease and ulcerative colitis

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3
Q

What is another name for
Crohn’s disease?
P338

A

Regional enteritis

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4
Q

What is ulcerative colitis
often called?
P338

A

UC

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5
Q

What is the cause of IBD?

P338

A

No one knows, but probably an
autoimmune process with environmental
factors contributing

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6
Q

What is the differential
diagnosis?
P338

A

Crohn’s versus ulcerative colitis, infectious
colitis (e.g., C. difficile, amebiasis,
shigellosis), ischemic colitis, irritable bowel
syndrome, diverticulitis, Zollinger-Ellison
syndrome (ZES), colon cancer, carcinoid,
ischemic bowel

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7
Q

What are the extraintestinal
manifestations seen in both
types of IBD?
P338

A 
Ankylosing spondylitis, aphthous (oral)
ulcers, iritis, pyoderma gangrenosum,
erythema nodosum, clubbing of fingers,
sclerosing cholangitis, arthritis, kidney
disease (nephrotic syndrome, amyloid
deposits)
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8
Q

How can these
manifestations be
remembered?
P339

A

Think of the acronym “A PIE SACK”:
Aphthous ulcers

Pyoderma gangrenosum
Iritis
Erythema nodosum
    Sclerosing cholangitis
    Arthritis, Ankylosing spondylitis
    Clubbing of fingers
    Kidney (amyloid deposits, nephrotic
       syndrome)
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9
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Crohn’s disease:
Incidence
P339
A

3–6/100,000

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10
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Crohn’s disease:
At-risk population
P339
A

High in the Jewish population, low in the
African black population, similar rates
between African American and U.S.
white population

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11
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Crohn’s disease:
Sex?
P339
A

Female > male

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12
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Crohn’s disease:
Distribution?
P339
A

Bimodal distribution (i.e., two peaks in
incidence): peak incidence at 25 to 40
years of age; second bimodal distribution
peak at 50 to 65 years of age

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13
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Ulcerative colitis:
Incidence?
P339
A

10/100,000

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14
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Ulcerative colitis:
At-risk population
P339
A

High in the Jewish population, low in the
African American population
Positive family history in 20% of cases

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15
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Ulcerative colitis:
Sex?
P339
A

Male > female

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16
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Ulcerative colitis:
Distribution?
P339
A

Bimodal distribution at 20 to 35 and

50 to 65 years of age

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17
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INITIAL SYMPTOMS
Crohn’s disease?
P340
A

Abdominal pain, diarrhea, fever,

weight loss, anal disease

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18
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INITIAL SYMPTOMS
Ulcerative colitis?
P340
A 
Bloody diarrhea (hallmark), fever,
weight loss
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19
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANATOMIC DISTRIBUTION
Crohn’s disease?
P340
A

Classic phrasing “mouth to anus”
Small bowel only (20%)
Small bowel and colon (40%)
Colon only (30%)

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20
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANATOMIC DISTRIBUTION
Ulcerative colitis?
P340
A 
Colon only (Think: ulcerative COLitis
= COLon alone)
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21
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ROUTE OF SPREAD
Crohn’s disease?
P340
A

Small bowel, colon, or both with “skip
areas” of normal bowel; hence, the
name “regional enteritis”

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22
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ROUTE OF SPREAD
Ulcerative colitis?
P340
A

Almost always involves the rectum and
spreads proximally always in a continuous
route without “skip areas”

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23
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ROUTE OF SPREAD
What is “backwash” ileitis?
P340
A

Mild inflammation of the terminal ileum
in ulcerative colitis; thought to be
“backwash” of inflammatory mediators
from the colon into the terminal ileum

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24
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
BOWEL WALL INVOLVEMENT
Crohn’s disease?
P340
A

Full thickness (transmural involvement)

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25
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
BOWEL WALL INVOLVEMENT
Ulcerative colitis?
P340
A

Mucosa/submucosa only

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26
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANAL INVOLVEMENT
Crohn’s disease?
P340
A

Common (fistulae, abscesses, fissures,

ulcers)

27
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANAL INVOLVEMENT
Ulcerative colitis?
P340
A

Uncommon

28
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
RECTAL INVOLVEMENT
Crohn’s disease?
P341
A

Rare

29
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
RECTAL INVOLVEMENT
Ulcerative colitis?
P341
A

100%

30
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
Crohn’s disease (6)?
P341
A
  1. Aphthoid ulcers
  2. Granulomas
  3. Linear ulcers
  4. Transverse fissures
  5. Swollen mucosa
  6. Full-thickness wall involvement
31
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
Ulcerative colitis (5)?
P341
A
  1. Granular, flat mucosa
  2. Ulcers
  3. Crypt abscess
  4. Dilated mucosal vessels
  5. Pseudopolyps
32
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
How can ulcerative colitis
and Crohn’s anal and wall
involvement be remembered?
P341
A

“CAT URP”:
Crohn’s = Anal–Transmural
UC = Rectum–Partial wall thickness

33
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
DIAGNOSTIC TESTS
Crohn’s disease?
P341
A

Colonoscopy with biopsy, barium enema,
UGI with small bowel follow-through,
stool cultures

34
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
DIAGNOSTIC TESTS
Ulcerative colitis?
P341
A

Colonoscopy, barium enema, UGI with
small bowel follow-through (to look for
Crohn’s disease), stool cultures

35
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
COMPLICATIONS
Crohn’s disease?
P341
A

Anal fistula/abscess, fistula, stricture,
perforation, abscesses, toxic megacolon,
colovesical fistula, enterovaginal fistula,
hemorrhage, obstruction, cancer

36
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
COMPLICATIONS
Ulcerative colitis?
P341
A

Cancer, toxic megacolon, colonic
perforation, hemorrhage, strictures,
obstruction, complications of surgery

37
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
CANCER RISK
Crohn’s disease?
P342
A

Overall increased risk, but about half that

of ulcerative colitis

38
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
CANCER RISK
Ulcerative colitis?
P342
A

≈5% risk of developing colon cancer at
10 years; then, risk increases ≈1% per
year; thus, an incidence of ≈20% after
20 years of the disease (30% at 30 years)

39
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE OF TOXIC MEGACOLON
Crohn’s disease?
P342
A

≈5%

40
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE OF TOXIC MEGACOLON
Ulcerative colitis?
P342
A

≈10%

41
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Crohn’s disease?
P342
A 
Obstruction, massive bleeding, fistula,
perforation, suspicion of cancer, abscess
(refractory to medical treatment), toxic
megacolon (refractory to medical
treatment), strictures, dysplasia
42
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Ulcerative colitis?
P342
A 
Toxic megacolon (refractory to medical
treatment); cancer prophylaxis; massive
bleeding; failure of child to mature
because of disease and steroids;
perforation; suspicion of or documented
cancer; acute severe symptoms refractory
to medical treatment; inability to wean
off of chronic steroids; obstruction;
dysplasia; stricture
43
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the common
surgical options for
ulcerative colitis?
P342
A 
1. Total proctocolectomy, distal rectal
    mucosectomy, and ileoanal pull
    through
2. Total proctocolectomy and Brooke
    ileostomy
44
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is “toxic megacolon”?
P342
A

Toxic patient: sepsis, febrile, abdominal
pain
Megacolon: acutely and massively
distended colon

45
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the medication
options for treating IBD?
P343
A 
Sulfasalazine, mesalamine
    (5-aminosalicylic acid)
Steroids, metronidazole (Flagyl®),
    azathioprine, 6-mercaptopurine
   (6-mp), infliximab
46
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is infliximab?
P343
A

Antibody vs. TNF- (tumor necrosis

factor-alpha)

47
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is the active metabolite
of sulfasalazine?
P343
A

5’-aminosalicylate (5’-ASA), which is

released in the colon

48
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is the medical
treatment of choice for
perianal Crohn’s disease?
P343
A

PO metronidazole (Flagyl®)

49
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the treatment
options for long-term
remission of IBD?
P343
A

6-mercaptopurine (6-mp), azathioprine,

mesalamine

50
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What medication is used for
IBD “flare-ups”?
P343
A

Steroids

51
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is a unique medication
route option for ulcerative
colitis?
P343
A

Enemas (steroids, 5-ASA)

52
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Which disease has
“cobblestoning” more
often on endoscopic exam?
P343
A

Crohn’s disease

Think: Crohn’s = Cobblestoning

53
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Which disease has
pseudopolyps on
colonoscopic exam?
P343
A

Ulcerative colitis; pseudopolyps are
polyps of hypertrophied mucosa
surrounded by mucosal atrophy

54
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Which disease has a
“lead pipe” appearance on
barium enema?
P343
A

Chronic ulcerative colitis

55
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Rectal bleeding/bloody
diarrhea is a hallmark of
which disease?
P343
A

Ulcerative colitis (rare in Crohn’s disease)

56
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is the most common
indication for surgery in
patients with Crohn’s
disease?
P344
A

Small bowel obstruction (SBO)

57
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the intraoperative
findings of Crohn’s disease?
P344
A 
Mesenteric “fat creeping” onto the
    antimesenteric border of the small
    bowel
Shortened (and thick) mesentery
Thick bowel wall
Fistula(e)
Abscess(es)
58
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Why do you see fistulas and
abscesses with Crohn’s and
not ulcerative colitis?
P344
A

Crohn’s disease is transmural

59
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is the operation for
short strictures of the small
bowel in Crohn’s disease?
P344
A

Stricturoplasty; basically a Heineke-
Mikulicz pyloroplasty on the strictured
segment (i.e., opened longitudinally and
sewn closed in a transverse direction)

60
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Should the appendix
be removed during a
laparotomy for abdominal
pain if Crohn’s disease is
discovered?
P344
A

Yes, if the cecum is not involved with

active Crohn’s disease

61
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is pouchitis?
P344
A

Inflammation of the pouch of an ileoanal
pull through; treat with metronidazole
(Flagyl®)

62
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Do you need a frozen
section for margins during a
bowel resection for Crohn’s
disease?
P344
A

No, you need only grossly negative

margins

63
Q 
COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is it called when the
entire colon is involved?
P344
A

Pancolitis

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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