Surgery - Inflammatory Bowel Disease

Front 1

What are the two major types of inflammatory bowel disease?

Back 1

Crohn's disease (CD) and Ulcerative colitis (UC)

Front 2

When is the peak age of onset for inflammatory bowel disease?

Back 2

15-30

Front 3

Who is more likely to get UC, men or women?

Back 3

Equal

Front 4

Who is is more likely to get CD, men or women?

Back 4

Men (1.8 :1 ratio)

Front 5

What is the etiology of inflammatory bowel disease?

Back 5

Inflammatory bowel disease is considered to represent an inapropriate response to the endogenous microbiota within the intestines, with or without a component of autoimmunity.

In other words, IBD is not necessarily an auto-immune disease, but rather an immune response to normal commensal flora.

IBD may also have an as-yet unidentified infectious etiology.

Front 6

What is the first part of the GI tract to be affected by UC?

Back 6

Rectum

The disease process then progresses proximally from there.

Approximately 50% of patients have disease limited to the rectum and sigmoid colon. 50% have involvement of more proximal regions of the colon.

Approximately 20% of patients have total colitis.

Front 7

On endoscopy you see a region of normal looking colonic mucosa in a patient with suspected UC. Should you biopsy it? Why or why not?

Back 7

Yes.

Though the region may appear normally macroscopically, microscopically almost always inflammatory changes are found.

Front 8

Name 4 features you may see on colonoscopy in a patient with ulcerative colitis.

Back 8

Inflammatory polyps (pseudopolyps)

Hemorrhage

Edema

Ulcerations

Front 9

What layers of the GI tract wall are affected by ulcerative colitis?

Back 9

UC is limited to the mucosa and superficial submucosa.

Front 10

Which two major histologic (microscopic) features help distinguish UC from infectious or acute self-contained colitis?

Back 10

Distortion of the normal crypt architecture of the colonic mucosa.

Presence of plasma cells along with other inflammatory cells.

Front 11

Which regions of the GI tract are affected by Crohn's?

Back 11

Crohn's can affect any region of the GI tract, from "gum to bum."

The region most commonly involved, however, is the small bowel, particularly the distal ileum.

For this reason Crohn's is also sometimes called ileitis.

Front 12

The region of the GI tract most commonly affected by Crohn's diseae is...

Back 12

Small bowel, especially the distal ileum.

Front 13

In ulcerative colitis, is the GI tract affected in a continuous or discontinuous fashion?

Back 13

Continuous

Though some regions between abnormal-looking areas may appear normal, they should be biopsied and almost always show microscopic characteristics of UC.

Front 14

In Crohn's disease, is the GI tract affected in a continuous or discontinuous fashion?

Back 14

Discontinous

There are affected regions separated by normal regions. For this reason, the lesions in Crohn's disease are sometimes called "skip lesions."

Front 15

What layers of the GI tract are affected by Crohn's disease?

Back 15

Crohn's is a transmural disease, affecting all the layers of the GI tract wall.

Front 16

What's another name for Crohn's disease?

Back 16

Ileitis

Front 17

What is ileitis?

Back 17

Crohn's disease

Front 18

Which inflammatory bowel disease is associated with the formation of fistula tracks with subsequent fibrosis and stricture?

Back 18

Crohn's disease

Front 19

Which inflammatory bowel disease is associated with strictures causing recurrent bowel obstructions?

Back 19

Mostly it's Crohn's disease, but UC can also present this way.

Front 20

What is tenesmus?

Back 20

Subjective sensation of having to defecate without actually having anything in the rectum.

Front 21

Name 3 acute complications that may develop in a patient with ulcerative colitis.

Back 21

Massive hemorrhage
Toxic megacolon +/- perforation
Stricture with bowel obstruction

Front 22

Name a potential long-term complication of ulcerative colitis.

Back 22

Colon CA

Front 23

Name 3 extraintestinal manifestations of ulcerative colitis.

Back 23

Inflammation of the eyes (uveitis, episcleritis)

Inflammation of the skin

Autoimmune hemolyis

Front 24

The symptomatology of ulcerative colitis is variable. Into which three broad categories do you divide the clinical manifestations of UC?

Back 24

Mild, moderate, and severe.

The severity of symptoms often correlates with anatomic extent of disease:

Mild -- limited to rectum and sigmoid

Moderate and severe - extending beyond the sigmoid.

Front 25

Describe the clinical manifestation of mild ulcerative colitis.

Back 25

1.Mild crampy abdominal pain

2. Occasional diarrhea (up to 4 times per day) with passage of mucus in the stool.

3. Intermittent rectal bleeding

4. Afebrile

Bonus: tenesmus

Front 26

Describe the clinical presentation of moderate ulcerative colitis.

Back 26

Crampy abdominal pain

Diarrhea (often more than 4 times per day)

Bloody stool

Low-grade fever

Front 27

Describe the clinical presentation of severe ulcerative colits.

Back 27

More severe abdominal pain

Diarrhea sometimes in excess of 10 per day

Massive hemorrhage

Fever

Anemia

Front 28

How is the definitive diagnosis of ulcerative colitis made?

Back 28

Flexible sigmoidoscopy with tissue biopsy

Front 29

Name 5 extraintestinal manifestations of Crohn's disease.

Back 29

Inflammation of the eyes:
-uveitis, episcleritis

Inflammation of the skin:
-erythema nodosum, pyoderma gangrenosum

Inflammation of the joints:
-arthritis

Autoimmune hemolysis

Venous/arterial thromboembolism

Front 30

Name 2 integumentary manifestations commonly associated with inflammatory bowel disease.

Back 30

Pyoderma gangrenosum
Erythema nodosum

Front 31

What is the most common extraintestinal manifestion of inflammatory bowel disease?

Back 31

Arthritis

Front 32

Describe the clinical presentation of Crohn's disease.

Back 32

Constitutional symptoms:
-fever, fatigue, weight loss

GI symptoms:
-crampy abdominal pain, chronic diarrhea

Extraintestinal symptoms:
-eyes, skin, joints, thromboembolism, hemolysis

Fibrostenotic pattern:
-recurrent bowel obstructions

Penetrating fistulous pattern:
-fistulas (UTI, perianal disease)

Malabsorption
-low B12, fat absorption

Front 33

Which inflammatory bowel disease is associated with penetrating fistulas?

Back 33

Crohn's disease

Front 34

What are the three most common fistulas that occur in Crohn's disease?

Back 34

Entero-vesicular
Entero-cutaneous
Entero-enteric

Front 35

Name three potential pathophysiologic sequelae/complications of Crohn's disease.

Back 35

1) Fistula formation
2) Stenosis and bowel obstruction
3) Malabsorption

Front 36

What laboratory investigations would you order to investigate inflammatory bowel disease?

Back 36

CBC (anemia)
BUN/creatinine, liver function, glucose
ESR/CRP
B12

Front 37

How is the diagnosis of Crohn's usually made?

Back 37

For lower GI tract, endoscopy.
-colonoscopy with intubation of the terminal ileum + tissue biopsy

For upper GI tract, imaging.
Upper GI series with small bowel follow through

Front 38

What diagnostic tests would you order to investigate inflammatory bowel disease?

Back 38

1) Laboratory investigations
-bloodwork: CBC
-chemistry: electrolytes, urea/creatinine, LFTs, glucose
-special: ESR/CRP, B12

2) Endoscopy + histology
-for UC--> flexible sigmoidoscopy
-for Crohn's --> colonoscopy with intubation of distal ileum

3) Imaging (for Crohn's)
-upper GI series with small bowel follow-through