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

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

Flashcards in Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis, C51 P338-344 Deck (63):
1

What is IBD?
P338

Inflammatory Bowel Disease,
inflammatory disease of the GI tract

2

What are the two
inflammatory bowel
diseases?
P338

Crohn’s disease and ulcerative colitis

3

What is another name for
Crohn’s disease?
P338

Regional enteritis

4

What is ulcerative colitis
often called?
P338

UC

5

What is the cause of IBD?
P338

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

6

What is the differential
diagnosis?
P338

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

7

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

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

8

How can these
manifestations be
remembered?
P339

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)

9

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INCIDENCE
Crohn’s disease:
Incidence
P339

3–6/100,000

10

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

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

11

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

Female > male

12

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

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

13

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

10/100,000

14

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

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

15

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

Male > female

16

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

Bimodal distribution at 20 to 35 and
50 to 65 years of age

17

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

Abdominal pain, diarrhea, fever,
weight loss, anal disease

18

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INITIAL SYMPTOMS
Ulcerative colitis?
P340

Bloody diarrhea (hallmark), fever,
weight loss

19

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANATOMIC DISTRIBUTION
Crohn’s disease?
P340

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

20

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ANATOMIC DISTRIBUTION
Ulcerative colitis?
P340

Colon only (Think: ulcerative COLitis
= COLon alone)

21

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
ROUTE OF SPREAD
Crohn’s disease?
P340

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

22

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

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

23

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

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

24

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

Full thickness (transmural involvement)

25

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

Mucosa/submucosa only

26

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

Common (fistulae, abscesses, fissures,
ulcers)

27

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

Uncommon

28

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

Rare

29

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

100%

30

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
Crohn’s disease (6)?
P341

1. Aphthoid ulcers
2. Granulomas
3. Linear ulcers
4. Transverse fissures
5. Swollen mucosa
6. Full-thickness wall involvement

31

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
Ulcerative colitis (5)?
P341

1. Granular, flat mucosa
2. Ulcers
3. Crypt abscess
4. Dilated mucosal vessels
5. Pseudopolyps

32

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
MUCOSAL FINDINGS
How can ulcerative colitis
and Crohn’s anal and wall
involvement be remembered?
P341

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

33

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

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

34

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

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

35

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

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

36

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

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

37

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

Overall increased risk, but about half that
of ulcerative colitis

38

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

≈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

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

≈5%

40

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

≈10%

41

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Crohn’s disease?
P342

Obstruction, massive bleeding, fistula,
perforation, suspicion of cancer, abscess
(refractory to medical treatment), toxic
megacolon (refractory to medical
treatment), strictures, dysplasia

42

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
Ulcerative colitis?
P342

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

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the common
surgical options for
ulcerative colitis?
P342

1. Total proctocolectomy, distal rectal
mucosectomy, and ileoanal pull
through
2. Total proctocolectomy and Brooke
ileostomy

44

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is “toxic megacolon”?
P342

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

45

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the medication
options for treating IBD?
P343

Sulfasalazine, mesalamine
(5-aminosalicylic acid)
Steroids, metronidazole (Flagyl®),
azathioprine, 6-mercaptopurine
(6-mp), infliximab

46

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What is infliximab?
P343

Antibody vs. TNF- (tumor necrosis
factor-alpha)

47

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

5’-aminosalicylate (5’-ASA), which is
released in the colon

48

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

PO metronidazole (Flagyl®)

49

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

6-mercaptopurine (6-mp), azathioprine,
mesalamine

50

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

Steroids

51

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

Enemas (steroids, 5-ASA)

52

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

Crohn’s disease
(Think: Crohn’s = Cobblestoning)

53

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

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

54

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

Chronic ulcerative colitis

55

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

Ulcerative colitis (rare in Crohn’s disease)

56

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

Small bowel obstruction (SBO)

57

COMPARISON OF CROHN’S DISEASE
AND ULCERATIVE COLITIS
INDICATIONS FOR SURGERY
What are the intraoperative
findings of Crohn’s disease?
P344

Mesenteric “fat creeping” onto the
antimesenteric border of the small
bowel
Shortened (and thick) mesentery
Thick bowel wall
Fistula(e)
Abscess(es)

58

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

Crohn’s disease is transmural

59

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

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

60

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

Yes, if the cecum is not involved with
active Crohn’s disease

61

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

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

62

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

No, you need only grossly negative
margins

63

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

Pancolitis