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Mr Alay Tutorial 2 - Surgical Management of IBD Flashcards

(106 cards)

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1
Q

Describe what is meant by IBD

A

Idiopathic inflammation of the bowel

Spectrum of presentations ranging between CD and UC

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2
Q

What is it called if you have IBD and you are on the middle of the spectrum between CD and UC?

A

Indeterminate colitis

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3
Q

What is the aetiology of IBD?

A

Genetic predisposition
Environmental triggers
Unregulated intestinal immune response
Loss of tolerance against certain enteric flora

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4
Q

What kind of cells are seen in TB of the gut?

A

Ceasating granulomas

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5
Q

What kind of inflammatory cells do you see in CD?

A

Non-ceasating granulomas

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6
Q

It is proposed that perhaps CD is caused by a variant of the ______ bacteria.

A

TB

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7
Q

Define ulcerative colitis

A

Chronic inflammatory ulcerative disease affecting the mucosa of the rectum + colon

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8
Q

In what age group is there the major peak of UC?

A

15-30 yos

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9
Q

In what age group is there a smaller peak of UC?

A

50-70yo

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10
Q

What are protective factors for UC?

A

Smoking

Appendiectomy

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11
Q

What layers of the bowel does UC affect?

A

Mucosa only

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12
Q

What is the pathophysiology of UC?

A

Inflammatory infiltrates + oedema as mucosa is damaged
Crypt abscesses form + ulceration
Pseudopolyps

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13
Q

What causes pseudopolyps in UC?

A

Attempts at healing produce epithelial thickening between the ulcers

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14
Q

Where does the disease in UC start?

A

In rectum + moves proximally

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15
Q

Where is the disease in UC confined to?

A

Rectum and colon

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16
Q

What are the subtypes of UC?

A

Proctosigmoiditis
L sided colitis
Pancolitis
Backwash ileitis

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17
Q

What parts of the GI tube are affected in proctosigmoiditis UC?

A

Rectum and sigmoid

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18
Q

What parts of the GI tube are affected in L sided colitis UC?

A

L side of colon

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19
Q

What parts of the GI tube are affected in pancolitis UC?

A

Whole of large bowel and rectum

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20
Q

What parts of the GI tube are affected in backwash ileitis UC?

A

Whole of large bowel and rectum and terminal ileum

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21
Q

For which of UC and CD can surgery offer long lasting symptom control?

A

UC

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22
Q

Of which of UC and CD is the disease usually continuous?

A

UC

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23
Q

There is no place for what kind of surgery in UC?

A

Segmental resection as disease will recur in bowel not resected

Try to avoid surgery, but if have to, take out whole bowel + rectum

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24
Q

What are local complications of UC?

A 
Blood loss, anaemia
Protein loss
Acute toxic dilatation of the colon + perforation 
Stricture 
Massive haemorrhage
Carcinoma
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25
Why do you get protein loss in UC?
In UC the gut makes a lot of mucous and mucous is rich in protein
26
Why can you get acute toxic dilatation of colon in UC?
Any severe inflammation of the colon may lead to the muscular layer of the colon failing --> dilation
27
Why do you get strictures in UC?
Chronic inflammation, BUT as inflammation is only in mucosa it is unlikely to be just a benign stricture and must treat as though malignant
28
What is the risk of developing colon cancer in UC related to?
Extent of disease | Duration of disease (>10y)
29
What are indications for surveillance colonoscopy in UC?
Total colitis >10 years | L sided colitis >15 years
30
What is involved in surveillance colonoscopy in UC?
Colonscopy + taking 4 random biopsies every 10cm
31
What are systemic complications of UC?
Large joint disease Uveitis Spondylitis Skin - erythema nodosum, pyoderma gangrenosum Liver - fatty liver disease, cirrhosis, cholangiocarcinoma
32
Inflammation for a long time in the gut can lead to what changes in the cells?
Dysplasia (which can progress to a malignancy)
33
What result from surveillance colonoscopy in UC would lead to you contacting surgeons to take the bowel out?
Dysplastic cells
34
Why do you not wait until a patient with UC and dysplastic cells in their colon develops cancer before removing the bowel?
Cancer ontop of IBD has poorer outcomes as treatment involves immunomodulation (so immune system less effective against cancer)
35
What are the symptoms of UC?
``` Diarrhoea Rectal bleeding Tenesmus Passage of mucous Crampy abdominal pain ```
36
What correlates with the extent of disease in UC?
Symptom severity Diarrhoea, ab pain indicate colon involvement If only tenesmus, rectal bleeding, mucous may indicate solely a rectal involvement
37
``` In relation to Bloody stools/day Pulse Hb ESR CRP what figures would be expected for a mild presentation of UC? ```
``` Bloody stools/day <4 Pulse <90 Hb >11.5g/dl ESR <20 CRP normal ```
38
``` In relation to Bloody stools/day Pulse Hb ESR CRP what figures would be expected for a moderate presentation of UC? ```
``` Bloody stools/day 4+ Pulse 90 or less Hb 10.5g/dl or more ESR 30 or less CRP 30 or less ```
39
``` In relation to Bloody stools/day Pulse Hb ESR CRP what figures would be expected for a severe presentation of UC? ```
``` Bloody stools/day 6+ Pulse >90 Hb <10.5g/dl ESR >30 CRP >30 ```
40
What is the fulminating type of UC?
I.e. initial presentation with acute attack Bowel movements >10/24h Fever, tachycardia, continuous bleeding, anaemia, hypoalbuminaemia May have toxic megacolon
41
What is chronic type of UC?
Initial attack of moderate severity followed by recurrent exacrbations Pt has severe diarrhoea and anaemia from chronic blood loss
42
Define toxic megacolon
Transverse/right colon with diam >6cm with loss of haustrations in patients with severe UC
43
What can trigger attacks of toxic megacolon?
Electrolyte abnormalities, narcotics
44
What may attacks of UC be related to?
Stresses in life, e.g. exams
45
Why is the treatment of toxic megacolon so difficult?
50% resolve with medical therapy alone but do not know what 50%
46
How should toxic megacolon be managed?
Medical treatment, failure of medical treatment within 48h --> urgent colectomy
47
What is the most dangerous complication of toxic megacolon?
Perforation
48
What is the mortality of toxic megacolon?
15%
49
Why can't you rely on physical signs of peritonitis in perforation?
They may not be obvious as these patients are on immunomodulators
50
What is the main modality for diagnosis of UC?
Endoscopy
51
What findings might you see on endoscopy in UC?
Loss of normal vascular pattern Mucous, pus, blood in lumen Mucosal reddening and contact bleeding Ulceration, granulation tissue, pseudopolyps
52
What is contact bleeding?
Gentle probing with endoscopy leads to mucosal bleeding
53
What is the normal vascular pattern of the colon?
Brancing BVs
54
Why do you get contact bleeding in UC?
As the mucosa is inflamed and the BVs are friable
55
What investigations can you do for UC?
Plain AXR Erect CXR CT abdomen Endoscopy
56
What is an indication for doing a plain AXR?
Acute fulminating colitis
57
What might you see on AXR in acute fulminating colitis?
Gross colonic distension Loss of haustrations Bowel wall thickened due to oedema of bowel wall
58
Why might you do an erect CXR in UC?
To exclude a silent perforation by checking for air underneath the diaphragm
59
What is the imaging modality of choice for acute presentations in someone with UC?
CT
60
What are indications for surgical treatment of UC in an acute attack?
Failure to respond to treatment Acute megacolon (if no medical response within 48h) Perforation/massive hawemorrhage
61
What two investigations should you rely on to rule out an acute perfation?
CT and erect CXR
62
What are the two surgical options for an acute attack of UC?
Total colectomy, ileostomy + closure of rectal stump/rectosigmoid mucous fistula
63
What is damage control surgery?
In emergency situations want to do as little as possible to get the pt better then later can do more surgery when pt better and outcomes will be better
64
In an emergency situation in UC do you want to take the bowel out or the rectum?
Take bowel out as rectum less likely to perforate as it is thicker
65
What is a rectosigmoid mucous fistula?
A second stoma that drains mucous from the remaining bowel and rectum Prevents fluid seeping into abdomen/pelvis
66
What are options for surgery following recovery from emergency surgery in UC?
Excision of rectum --> pt left with permanent ileostomy Formation of ileal pouch
67
Why do surgeons often in emergency situation in UC only take the colon out and not the rectum?
To avoid a very long operation in a sick patient who may not be able to cope with it
68
How is an ileal pouch formed?
Pull down small bowel and fold on itself to form a new rectum which is joined to the anal canal (which remember is spared in UC)
69
What are indications for surgery in chronic disease for UC?
Continuous disabling symptoms | Carcinoma, dysplasia or risk of developing carcinoma
70
What are the options for surgery in chronic disease for UC?
Total proctocolectomy + permanent ileostomy OR Total proctocolectomy + formation of ileal pouch
71
What is a proctocolectomy?
Removal of rectum and colon in 1 operation
72
Why can you do a proctocolectomy in 1 operation in chronic disease but not in acute situations?
Patients are more well and able to tolerate longer operations
73
What are indications for ileal pouch?
UC | FAP
74
What are contraindications for ileal pouch surgery?
CD | Significant anal incontinence
75
Why is anal incontinence a CI for ileal pouch surgery?
Pouch stools are too liquidy and are often difficult to control as it is Remember function of large bowel is to absorb water
76
What preoperative preparation should be done prior to a patient proctocolectomy undergoing ileal pouch surgery?
Bloods - Hb, proteins Histology (to ensure UC and not CD) Counselling Consent
77
What do patients undergoing ileal pouch surgery require counselling on?
1. Stools will be very soft and liquidy and difficult to control, may have to defaecate 3-5x day and through the night 2. Sexual dysfunction (may sever nerves during surgery --> impotence, retrograde ejaculation, loss of ability to orgasm, loss of vaginal lubrication etc.)
78
Why can ileal pouch surgery lead to retrograde ejaculation?
Can damage nerve to internal sphincter of bladder which normally closes during ejaculation to prevent sperm entering bladder 'dry orgasm'
79
What are the different types of ileal pouches? What is most common?
J - most common S W
80
What are complications of ileal pouches?
``` Splenic injury Anastomotic complications Intra-abdominal abscesses Poor function - frequency, incontinence, pouchitis Pouch failure (req. stoma) ```
81
Define CD
Non-specific transmural inflammatory disease that can affect any part of the GIT
82
In what age group of patients does CD tend to present?
<30 year olds | Peak between 14 and 24
83
How does smoking affect CD?
Contributes to development, exacerbation and recurrence of CD
84
What part of the GIT can CD affect?
Anywhere from mouth to anus
85
Where does CD affect the most?
Terminal ileum and caecum
86
What are subtypes of CD?
Inflammatory Stricturing Fistulating Inflammatory tends to develop into one of the other two
87
What do you see macroscopically on endoscopy in CD?
Skip lesions Strictures Mesenteric fat wrapping/creeping
88
What do you see microscopically in CD?
Transmural disease Non-ceasating granulomas Crypt abscesses, fistula formation
89
How might CD present acutely?
Acute abdo mimicking appendicitis Intestinal obstruction Peritonitis due to bowel perforation Fulminate colitis
90
Are the strictures in CD usually malignant?
No - as it is transmural disease usually just inflammatory strictures
91
Why can you not offer an ileal pouch to someone with CD?
As they are prone to forming fistulas and you don't want fistulas in the pouch
92
Where do patients with CD complain of pain?
Usually RIF
93
What may cause intestinal obstruction in someone with CD?
Strictures
94
How can chronic CD present?
``` Recurrent abdominal pain Recurrent subacute intestinal obstruction Abdominal mass Malnutrition Chronic debility Abdominal/perineal fistulas/abscesses ```
95
What is a seton?
A little tube put in perianal fistulas in people with CD that prevent the fistula becoming blocked and forming an asbcess
96
Who should take setons out?
Only the surgeon who put them in
97
What imaging techniques can be used to investigate CD?
``` Barium studies Small bowel MRI (MRE) CT Upper GI endoscopy Colonoscopy Wireless capsules endoscopy ```
98
What can you see on barium studies in CD?
Mucosal ulceration + cobble stoning Areas of narrowing + skip lesions Internal fistulae String sign of Kantor
99
What is the string sign of Kantor?
Marked narrowing of the terminal ileum
100
What imaging technique is used for acute presentations in CD and to diagnose complications?
CT
101
What is the gold standard imaging technique used to diagnose CD?
Small bowel MRI/MRE
102
What complications of CD may require surgery?
Strictures Fistula Abscess Intestinal obstruction
103
What is a complication of draining abscesses in CD?
May form distula
104
How do you manage bad CD surgically?
Resection of affected segment of bowel with end to end anastomosis
105
How are strictures managed in CD?
Strictureplasty
106
What kind of surgery is performed for duodenal CD?
Bypass surgery

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