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Inflammatory Bowel Disease (Examination (Peripheral Inspection (General…

- - - - UC
      - Malabsorption: coeliac
      - Mid-line lap: FAP
      - Crohn’s
  - - - Often young female pt.
        Laparotomy scars
      - Malnutrition or wt. loss
      - Cushingoid
      - Pallor
    - - Clubbing
        Leukonychia
        Beau’s lines
    - - Pale conjunctivae
        Iritis, episcleritis
    - - Aphthous ulcers
        Gingival hypertrophy (ciclosporin)
    - - Erythema nodosum
        Pyoderma gangrenosum
  - - - Scars
        
        May be multiple and atypical in Crohn’s
        Healed stoma sites
        Healed drain sites
      - Stomas or healed stoma sites
      - Enterocutaneous fistulae
    - - Tenderness
      - RIF mass
      - ± hepatomegaly
  - - - Large joint monoarthritis
      - Sacroileitis
      - Bronchiectasis
- - - - UC Pathology
        
        Macroscopic
        
        Rectum + colon
        ± backwash ileitis
        
        Contiguous distribution
        
        Microscopic
        
        mucosal inflammation
        
        shallow broad ulceration
        
        marked psuedopolyps
      - 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
    - - UC
        
        Toxic megacolon
        
        Malignancy
        
        CRC
        
        Cholangiocarcinoma
        
        Haemorrhage
        
        VTE
      - Crohn’s
        
        Fistulae
        
        Perianal abscess
        
        Strictures
        
        Malabsorption
        
        Toxic dilatation
    - - Skin
        
        Clubbing
        
        Erythema nodosum
        
        PG (esp. UC)
      - Mouth
        
        Aphthous ulcers
      - Eyes
        
        Anterior uveitis
        
        Episcleritis
      - Joints
        
        Large joint arthritis
        
        Sacroileitis
      - Hepatic
        
        Fatty liver
        
        Chronic hepatitis → cirrhosis
        
        Gallstones (esp. CD)
        
        PSC + cholangiocarcinoma (esp. UC)
      - Other
        
        AA amyloidosis
        
        Oxalate renal stones
    - - Acute Severe Exacerbation
        Dx: True-Love 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
      - Mx
        
        General
        
        Resus: Admit, NBM, IV hydration
        
        Hydrocortisone: 100mg IV QDS + PR if rectal disease
        
        Thromboprophylaxis: LMWH
        
        Dietician review
        
        Monitoring
        
        Bloods: FBC, ESR, CRP, U+E
        
        Vitals + stool chart
        
        Daily examination
        
        Crohn’s
        
        Abx: metronidazole PO or IV
        
        Consider parenteral nutrition
        
        Improvement: → oral pred (40mg/d)
        
        Refractory: methotrexate ± infliximab
        
        UC
        
        Improvement: → oral pred + 5-ASA
        
        Refractory: ciclosporin or infliximab
        
        Indications for Surgery
        
        Obstruction
        
        Megacolon
        
        Perforation
        
        Severe GI bleeding
        
        Failure to respond to medical therapy
    - - Mx of Mild-Mod Disease
        
        MDT: GP, gastroenterologist, dietician, nurses, surgeon
        
        Nutrition: ADEK vitamins, high fibre diet (esp. CD)
      - Induction
        
        UC
        
        Oral
        
        1: 5-ASAs
        
        2: prednisolone
        
        3: ciclosporin / infliximab
        
        Topical: Enemas / foams
        
        5-ASA
        
        Pred
        
        CD
        
        Oral
        
        1:
        
        Ileocaecal: budesonide
        
        Colitis: sulfasalazine
        
        2: prednisolone (tapering)
        
        3: methotrexate
        
        4: infliximab / adalimumab
      - Maintenance
        
        UC
        
        1: 5-ASA
        
        2: axathioprine
        
        3: infliximab / adalimumab
        
        CD
        
        1: azathioprine
        
        2: methotrexate
        
        3: infliximab / adalimumab
  - - - FBC: ↓Hb, ↑WCC
      - U+E: dehydration, ↓K
      - LFTs: ↓ albumin, deranged LFTs
      - Clotting: ↑INR
      - ↑ ESR, ↑ CRP: used to monitor activity
      - Haematinics: Fe, B12, folate
    - - Culture + CDT: exclude infective causes
        Campy, Yersinia, Shigella, C. diff, TB
    - - AXR
        
        Toxic megacolon in UC
        Bowel obstruction 2O 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
    - - Ileocolonoscopy + regional biopsy
        
        Ix of choice
        
        Safe in acute disease
        
        Distinguish UC from Crohn’s
        
        Assess disease severity
      - Wireless capsule endoscopy
  - - - Wt. loss, fever, malaise
      - Abdominal pain
      - Diarrhoea, blood and/or mucus PR
    - - Admissions
      - Medical therapy
      - Operations