Please enable JavaScript.
Coggle requires JavaScript to display documents.
Inflammatory Bowel Disease (Examination (Inspection (Peripheral (General …
Inflammatory Bowel Disease
Examination
Inspection
Peripheral
General
Malnutrition or wt. loss
Cushingoid, evidence of steroids
Hands
Clubbing
Leukonychia
Beau’s lines
Eyes
Pale conjunctivae
Iritis, episcleritis
Mouth
Aphthous ulcers
Gingival hypertrophy
Legs
Erythema nodosum
Pyoderma gangrenosum
Abdominal
Scars
May be multiple and atypical in Crohn’s
Healed stoma sites
Healed drain sites
Stomas or healed stoma sites
Enterocutaneous fistulae
Palpation
Tenderness
RIF mass
± hepatomegaly
Completion
Examine for extra-intestinal features
Large joint monoarthritis
Sacroileitis
Bronchiectasis
Inspect perineum for perianal disease
Viva
Discussion
Clinicopathological distinction between UC and CD
Main complications of IBD
Extra-intestinal manifestations
Definition of severe exacerbation
Indications for surgery in UC and CD
Surgical options for UC and CD
Hx
Symptoms
Wt. loss, fever, malaise
Abdominal pain
Diarrhoea, blood and/or mucus PR
Peri-anal disease: abscesses, fistulae
Extra-intestinal: EN, arthritis, iritis, gallstones, PSC
Therapy
Admissions
Medical therapy
Operations
Ix
Bloods
FBC: ↓Hb, ↑WCC
U+E: dehydration, ↓K
LFTs: ↓ albumin, deranged LFTs
Clotting: ↑INR
↑ ESR, ↑ CRP: used to monitor activity
Stool
Culture + CDT: exclude infective causes
Campy, Yersinia, Shigella, C. diff, TB
Imaging
AXR
Toxic megacolon in UC
Bowel obstruction secondary to strictures in Crohn’s
Contrast studies
Ba or Gastrograffin enema in UC
Small bowel follow–through in Crohn’s
MRI: perianal disease in Crohn’s
Endoscopy
Ileocolonoscopy + regional biopsy
Ix of choice
Safe in acute disease
Distinguish UC from Crohn’s
Assess disease severity
Wireless capsule endoscopy
IBD: Key Facts for Surgery
UC
Pathology
Macroscopic
Rectum + colon
± backwash ileitis
Contiguous distribution
Microscopic
mucosal inflammation
shallow broad ulceration
marked psuedopolyps
Complications
Toxic megacolon
Haemorrhage
Malignancy
CRC
Cholangiocarcinoma
VTE
Hepatobiliary
Fatty liver
PSC (3% of UC) and cholangiocarcinoma
Gallstones
Chronic hepatitis → cirrhosis
Surgical Options for UC
Principles
Curative intent
IPAA or IRA offer continence but suffer from ↑ BMs, pouchitis and risk of malignancy.
Restorative Proctocolectomy
Proctocolectomy or completion proctectomy
Construction of ileal reservoir which is anastomosed to anus
Ileal pouch anal anastomosis (IPAA)
Usually covered by a diverting loop ileostomy
May check pouch anastomosis w/ water soluble contrast
Proctocolectomy and permanent ileostomy
Rectum and anus excised w/ all of colon
Only performed for pt. choice or when pt. is not suitable for
restorative procedure
↑ age
Impaired sphincter function
Subtotal colectomy w/ end ileostomy ± mucus fistula
Operation of choice for acute severe colitis
All colon excised except distal sigmoid and rectum.
Rectosigmoid stump may be exteriorised as mucus fistula
Followed after ~3mo by either:
Completion proctectomy + IPAA or end ileostomy
Ileorectal anastomosis (IRA)
Indications for Surgery
Acute Severe
Megacolon: ≥6cm on AXR
Perforation: 30-40% mortality
Severe GI bleeding
Chronic
Medical Mx failure
Malignancy
Maturation failure in children
Crohn's
Pathology
macroscopic
Mouth to anus
esp. terminal ileum
Skip lesions
Strictures
microscopic
Transmural inflammation
Deep, thin, serpiginous
→ cobblestone mucosa
marked fibrosis
granulomas
fistulae
Complications
Hepatobiliary
Fatty liver
Chronic hepatitis → cirrhosis
Gallstones
PSC (3% of UC) and cholangiocarcinoma
Fistulae
esp. perianal
Perianal abscess
Strictures
Malabsorption
Toxic dilatation
Surgical Options for Crohn’s
Principles
80% need ≥1 operation in their life
Never curative
Must be as conservative as possible: avoid short gut syndrome
Procedures
Ileocaecectomy
Drainage of intra-abdominal abscesses
Stricturoplasty
Colonic defunctioning for failed medical therapy
Occasionally a subtotal colectomy + permanent end ileostomy
may be needed.
Indications for Surgery
Acute Severe
Obstruction 2O to stenosis
Perforation
Severe GI bleeding
Chronic
Peri-anal disease: fistulae and abscesses
Intra-abdominal abscesses
Medical Mx failure: temporary defunction
Entero-cutaneous fistulae
Definition of Severe Exacerbation
Truelove and Witts Criteria
Symptoms
BMs >6 x /d
Large PR bleed
Systemic Signs
↑ HR >90
Pyrexia >37.8
Laboratory Values
↓ Hb <10.5g/dL
ESR >30mm/Hr