Crohn’s disease
Chronic inflammatory bowel disease of the gut with distinct disease pattern of full thickness transmural inflammation, involving any portion of the GI tract
Ulcerative colitis
Chronic inflammatory condition characterized by relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon and rectum
Macroscopic features of Crohn’s disease
- Thickened bowel wall (full thickness inflammation)
- Creeping extension of mesenteric fat over serosa
- Inflamed/ fibrotic/ stenotic/ fistulation
- Patchy linear ulcers with cobblestone appearance
Macroscopic features of Ulcerative Colitis
- Involves only colon and rectum, may have backwash ileitis if involve caecum
- Continuous mucosa and submucosal inflammation
- Pseudopolyp formation
Microscopic features of Crohn’s disease
- Transmural inflammation
- Non-caseating granuloma
- Lymphovascular granuloma
Microscopic features of Ulcerative Colitis
- Active cryptitis and crypt abscess formation
- Lamina propria cellular infiltrate (plasma cells, eosinophils, lymphocytes),
- Mucin depletion, Lymphoid aggregates, Erosion or ulceration(shallow)
Endoscopic appearance of Crohn’s disease
- Deep ulcers
- Aphthoid ulcers
- Swollen mucosa
- Skip lesions
- Transverse fissure
- Cobblestone appearance
Endoscopic appearance in UC
- superficial ulcers
- mucosa erythema
- granularity
- continous inflammation
- pseudopolyps
Montreal classification of UC (Extent of disease)
- E1: ulcerative proctitis
- E2: left side UC / distal UC (involves colon distal to splenic flexure
- E3: pancolitis / extensive colitis (extends proximal to SF)
E = extent
Truelove and Witt classification of UC (severity of disease)
- Number of bloody stools / day
- Temperature
- Heart rate
- Hemoglobin
- ESR
Management of elective presentation of UC
- Multi-disciplinary approach
- Workup up extent and severity of disease
- Bloods
- Colonoscopy + biopsy x 2 in at least 5 segments including ileum
- Imaging (CT /MRI enteroclysis +/- MRI pelvis)
- Screen for CRC, stool culture for infective causes
- Induce and maintain remission by medical treatment
- Surgery in refractory cases
Medical management of UC
Aim induction and maintain remission
- 1st line: topical ASA (rectal enema/foam/suppository of Sulfasalazine/ Mesalamine)
- 2nd line: oral ASA
- Oral steroids can help induce remission then tail down
- For steroid refactory:
- Azathioprine
- Infliximab
- Cyclosporin A
Elective surgical options for UC
- Restorative proctocolectomy with IPAA 1st line
- Total colectomy + IRA or ileostomy
- Proctocolectomy + end- ileostomy (with or without Koch pouch)
Restorative proctocolectomy
excision of entire colon and rectum with ileal pouch anal anastomosis
Contraindications for IPAA in UC
- Crohn’s disease
- Prior extensive small bowel disease
- Active perineal disease
- Anal sphincter dysfunction
- Low rectal cancer
- Sclerosing cholangitis (high incidence of pouchitis)
- Young female relative CI, affects fertility
Indications for emergency surgery for UC
- Fulminant colitis
- Toxic megacolon
- Bleeding
Management for severe UC
- Bowel rest
- Parenteral nutrition
- Broad spectrum antibiotics
- IV steroids +/ topical steroids
- Biologics if steroids fail (Infliximab)
Management of fulminant UC
- Bowel rest
- Intravenous fluids
- Broad spectrum antibiotics
- IV and topical steroids
- if not responsive within 3 days → biologics (Infliximab)
- If not responsive to biologics within 3 days → colectomy
Definition of acute severe ulcerative colitis
- Bloody stool frequency >6/day +
- Evidence of systemic toxicity from one of the following:
- Fever
- Tachycardia
- Anemia
- Elevated inflammatory markers
Definition of fulminant ulcerative colitis
- Bloody stool frequency >10 times/ day with fecal urgency +
- Criteria for acute severe colitis
Indication for surgery in small bowel Crohn’s disease
- Complications:
- Stenosis leading to obstructive symptoms
- Fistulas to other organ
- Draining intra-abdominal abscess
- Controlling acute / chronic bleeding
- Free perforation
- Limited disease to terminal ileum
Medical management for Crohn’s disease
- Induction of remission
- mild-moderate disease: oral prednisolone
- right colon: budesonide
- colitis: salicyclate component
- perianal: Metronidazole 400mg TDS or Ciprofloxacin 500mg BD
- severe
- IV prednisolone
- Infliximab
- mild-moderate disease: oral prednisolone
- Maintenance of remission (immunomodulatory drugs)
- Infliximab
- Azathioprine
- Methotrexate
Treatment options for small bowel fibrostenotic Crohn’s disease
- Resection
- Stricturoplasty (H-M, Finney, side-side long segment stricturoplasty)
- Endoscopic dilation
