IBD

Question 1

What is crohn’s disease?

Answer 1

chronic transmural inflammatory disease of GI tract

- most common in TERMINAL ILEUM

Question 2

Who are more commonly affected by Crohn’s disease?

Answer 2

• 2nd & 3rd decade
• 6th to 7th decade
• 2 times the risk in smokers
• strong family history of Crohn’s

Question 3

What are the risk factors of Crohn’s disease?

Answer 3

• familial aggregation
• genetic predisposition ( NOD2, HLA-B27)
• tobacco

Question 4

What is the pathogenesis of Crohn’s disease?

Answer 4

• increased permeability of mucus membranes + abnormal immune mediated response to normal gut flora
• TH1 mediated response
• ASCA autoantibodies

Question 5

What are the types of Crohn’s disease?

Answer 5

• terminal ileum 60%
• Colitis alone 1/3
• perianal lesions 50-75%
• stomach & duodenum 5%

Question 6

What will be seen GROSSLY on exploration of Crohn’s?

Answer 6

• thickened grayish-pink or dull purple-red loops of bowel
• thick gray-white exudate or fibrosis of serosa
• skip lesions
• fibrotic thickening of intestinal wall (fat wrapping if circumferential)
• dilated bowel proximal to stricture
• SNAKE-LIKE/ROSE-THORN (linear mucosal ulcers)
• mesenteric abscesses & fistulae

Question 7

What is the microscopic picture of Crohn’s disease?

Answer 7

• edema of mucosa & submucosa before any gross change
• inflammatory infiltrate extends transmurally
• NONCASEATING GRANULOMAS WITH LANGERHANS GIANT CELLS

early acute -> hyperemic & boggy
chronic -> fibrotic scarring and bowel wall thickened with leathery texture

Question 8

What are the characteristic findings of Crohn’s disease?

Answer 8

C cobblestone mucosa 
R rose-thorn ulcers 
O obstruction of bowel 
H hyerplasia of mesenteric lymph nodes 
N narrowing of lumen 
S skip lesions

Question 9

What are the clinical features of Crohn’s disease?

Answer 9

• insidious onset with slow & protracted course
• gradually becomes more frequent & severe & longer lasting attacks
• intermittent colicky abdominal pain in lower abdomen (mimics appendicitis)
• diarrhea
• perianal disease (suspect in any patient with multiple chronic perianal fistulas)
  systemic symptoms
• low-grade fever
• weight loss
• loss of strength
• malaise

Question 10

What are the extraintestinal manifestations of Crohn’s disease?

Answer 10

• skin lesions -> erythema nodosum, pyoderma gangrenosum
• arthritis & arthralgias
• uveitis & iritis
• amyloidosis
• hepatitis pericholangitis
• pancreatitis
• renal or gallbladder calculi

Question 11

What are the complications of Crohn’s disease?

Answer 11

• obstruction
• perforation
• fistulas
• localized abscesses
• toxic megacolon
• cancer

Question 12

What is the DD of Crohn’s disease?

Answer 12

• acute appendicitis
• mesenteric lymphadenitis
• ovarian pathology
• salmonella & shigella
• intestinal TB
• acute distal ileitis

Question 13

How can we confirm a diagnosis of Crohn’s disease?

Answer 13

CLINICAL
- history & examination

BLOOD

• CBC U&E, LFT, coagulation profile
• CRP, ESR
• ANCA & ASCA +ve
• nutritional albumin, prealbumin

STOOL

• culture & microscopy to rule out infectious colitis
• C diff toxin to rule out pseudomembraneous colitis

UGI scope & COLONOSCOPY WITH BIOPSY

• patchy inflammation
• linear ulcers
• cobble stone appearance
• stricture

MR enterography

Question 14

How can Crohn’s disease be treated?

Answer 14

conserve by 
MEDICAL 
- steroids
- aminosalicylates 
- antibiotics 
- imminomodulatory agents 
- monoclonal antibodies -> for severe active disease 
- nutritional support 

ENDOSCOPIC TREATMENT OF STRICTURE

• balloon dilatation through enteroscope or colonoscope
• contraindicated if there’s an inflamed or ulcerated stricture

Question 15

What are the indications for surgery in Crohn’s disease?

Answer 15

complications

• intestinal obstruction
• intestinal perforation with fistula formation or abscess
• free perforation
• GI bleeding
• cancer
• perianal disease
• extraintestinal manifestations

Question 16

What are the principles of surgery in Crohn’s disease?

Answer 16

• preserve gut length & maintain adequate function
• resection kept to a minimum
• optimize patient before surgery
• surgery shouldn’t be delayed if there is a clear indication
• risk of short bowel syndrome -> stricturoplasty
• stoma formation (colostomy) incase of -> abscess, fistula, low albumin, steroid use

Question 17

What are the options for surgery in Crohn’s?

Answer 17

• ILEOCECAL RESECTION WITH ILEOCOLIC ANASTOMOSIS -> terminal ileal Crohn’s
• SEGMENTAL RESECTION & ANASTOMOSIS -> short segment stricture with no risk of short bowel syndrome
• COLECTOMY & ILEORECTAL ANASTOMOSIS -> colonic Crohn’s with normal rectum & anus
• SUBTOTAL COLECTOMY & ILEOSTOMY -> acute Crohn’s colitis
• TEMPORARY LOOP ILEOSTOMY -> acute distal CD to allow remission and later restoration (severe perianal or rectal disease)
• PROCTOLECTOMY -> colic/anal disease failing to respond to medical treatment (permanent ileostomy)
• STRICTURE PLASTY -> multiple areas of CD & danger of short bowel syndrome

Question 18

What is ulcerative colitis?

Answer 18

• dynamic disease characterized by remissions & exacerbation

- peak incidence 15-35 years then >55 years

Question 19

What are the risk factors of ulcerative colitis?

Answer 19

• genetic (HLA-B27)
• ethnicity (white & Ashkenazy jews)
• family history
• previous intestinal infection
• increased fat intake
• OCPs & NSAIDS

Question 20

What are the protective factors against ulcerative colitis?

Answer 20

• appendectomy before established UC

- smoking

Question 21

What is the pathogenesis of ulcerative colitis?

Answer 21

• increased permeability of intestinal epithelium
• TH2 differentiation
• dysregulation of immune system
• ANCA against epithelial cells
• CONTINUOUS UNINTERRUPTED INFLAMMATION OF COLONIC MUCOSA beginning in distal rectum & extending proximally

Question 22

What is the gross picture of ulcerative colitis?

Answer 22

• hyperemic mucosa
• friable & granular mucosa -> in severe
• ulcerations
• pseudopolyps or inflammatory polyps

Question 23

What is the microscopic picture of ulcerative colitis?

Answer 23

• inflammation of mucosa & submucosa

- CRYPT ABSCESS

Question 24

What is the most common course of ulcerative colitis?

Answer 24

CHRONIC INTERMITTENT
- exacerbation followed by complete remission

chronic continuous
- no complete remission

acute fulminant
- sudden onset of severe diarrhea, dehydration & shock

Question 25

What are the symptoms of ulcerative colitis?

Answer 25

- bloody diarrhea with mucus - fecal urgency - abdominal pain & cramps on left side - tenesmus

Question 26

what are the extra-intestinal manifestations of ulcerative colitis?

Answer 26

- osteoarthritis, ankylosing spondylitis, sacroiliitis -> skeletal (most common) - uveitis, episcleritis, iritis -> ocular - primary sclerosing cholangitis -> biliary - pyostomatitis vegetans, apthous stomatitis, erythema nodusom, pyoderma gangrenosum -> cutaneous - fatigue & fever - growth retardation & delayed puberty in children

Question 27

What are the complications of ulcerative colitis?

Answer 27

- acute fulminant colitis - toxic megacolon - colonic cancer (greater risk with longer disease)

Question 28

How should the diagnosis of ulcerative colitis be confirmed?

Answer 28

BLOOD - increase ESR & CRP - leukocytosis - anemia - thrombocytosis - increase pANCA STOOL - search for bacteria to rule out infectious causes COLONOSCOPY (definitive diagnosis) - contraindicated in acute RADIOGRAPHY plain - loss of colonic haustrata (LEAD PIPE APPEARANCE in severe) - massive distention in toxic megacolon - pneumoperitoneum if perforated BARIUM ENEMA - able to detect early changes - granular appearance of mucosa - deep ulcerations - loss of haustra - pseudopolyps appear as filling defects CT -> wall thickening if severe MRI -> extent of involvement ULTRASOUND -> bowel thickening (absent hyperechoic reflection from lumen)

Question 29

What is the DD of ulcerative colitis?

Answer 29

- Crohn's disease - exudative-inflammatory diarrhea - diverticular disease - ischemic colitis - infectious colitis - radiation colitis - celiac disease

Question 30

How should ulcerative colitis be managed?

Answer 30

- first -> conserve with drugs to induce & maintain remission - if medical fails -> curative proctocolectomy

Question 31

What is the initial management of ulcerative colitis?

Answer 31

PROCTITIS - 5ASA + steroids - immunosuppressant + monoclonal antibodies ACUTE COLITIS - mild -> steroids + 5ASA - moderate -> oral steroid + steroid enema + 5 ASA - severe -> NPO, IVF, IV antibiotics, steroid -> not improving? -> emergency surgery

Question 32

What are the indications for surgery in ulcerative colitis?

Answer 32

- fulminant colitis with toxic megacolon - massive bleeding - intractable disease - dysplasia or carcinoma - malnutrition & growth retardation - extraintestinal manifestations - failure of medical

Question 33

What are the surgical treatment options for ulcerative colitis?

Answer 33

EMERGENCY -> in systemic upset, malnourished patient, or on steroids - total colectomy with end ileostomy - no dissection of rectum (mucus fistula) - restorative surgery later ELECTIVE -> sphincter problems, lower complication rate, no risk of rectal cancer - restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) -> pelvic sepsis - colectomy with ileorectal anastomosis -> if minimum rectal inflammation with rectal checkups