management of ulcerative colitis.
Discuss etiology, clinical features and management
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of ulcerative colitis.What are the ulcerative lesions of the colon. Discuss
the management of ulcerative colitis.
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4. A patient gives chronic history of diarrhoea andblood in stool presents with multiple fistulae in the
perineum and multiple stricture in smal intestine. The
diagnosis is ?
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a)
Crohn's disease
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b)Radiation enteritis
c)
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Ulcerative Colitis
d)
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Ischemic bowel disease5. Pt. with recurrent diarrhoea, pseudopolyp, lead
pipe appearance on Ba enema has ?
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a)
Ulcerative colitis
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b)Crohn's disease
c)
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Irritable bowel syndrome
d)
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Short bowel syndrome6. Pyoderma ? gangrenosum is most commonly
associated with ?
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a)Ulcerative colitis
b)
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Crohns disease
c)
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Amoebic colitisd)
Ischemic colitis
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7. Most common cause of death in Crohn's disease is
due to ?
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a)Sepsis
b)
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Thromboembolic complication
c)
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Electrolyte disturbanced)
Malignancy
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8. Two 34 year old men have a stoma ? one a colostomy in the left
iliac fossa after rectal surgery, and other an ileostomy in the right
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iliac fossa after a panproctocolectomy for ulcerative colitis. Contents
of the colostomy bag in the left iliac fossa are relatively small in
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volume and consist of well-formed stools. Contents of the ileostomybag in the right iliac fossa are relatively copious non-smelly fluid.
What is the best explanation for the difference?
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A.
More than 75% of fluid absorption from the entire gut takes place in
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the colonB.
Random variation
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C.
The caecum absorbs more fluid than the smal intestine
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D.There is net secretion of fluid in the left (descending) colon
E.
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The colon absorbs a smal but significant proportion of ingested plus
secreted fluid in the gut
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Ulcerative colitisUC is one of the 2 major types of IBD.
Characteristical y involves only the large bowel.
The exact etiology is unknown.
HLA?B27 is identified in most patients with ulcerative
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colitis.
It is a lifelong il ness that has a profound emotional and
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social impact on the affected patients.Spreads proximal y from the anal verge in an
uninterrupted pattern to involve part or the entire colon.
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UC occasional y involves the terminal ileum, as a result
of an incompetent ileocecal valve.
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ETIOLOGYUnknown.
Factors contributing to UC include:
genetic factors,
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immune system reactions,environmental factors,
NSAID use,
low levels of antioxidants,
psychological stress factors,
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a smoking history,and consumption of milk products.
Genetics
Genetical y susceptible individuals have
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abnormalities of humoral and cell-mediated
immunity.
Enhanced reactivity against commensal intestinal
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bacteria and this dysregulated mucosal immune
response predisposes to colonic inflammation.
A family history of ulcerative colitis (observed in 1 in
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6 relatives) is associated with a higher risk for
developing the disease.
Immune reactions
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Autoantibodies against intestinal epithelial cells may
be involved.
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The presence of antineutrophil cytoplasmicantibodies (ANCA) and anti? Saccharomyces
cerevisiae antibodies (ASCA) is a well-known feature
of inflammatory bowel disease.
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Other etiologic factors
Vitamins A and E are found in low levels in patients
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with ulcerative colitis .
Psychological and psychosocial stress can
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precipitate exacerbations.Smoking is negatively associated with ulcerative
colitis. This relationship is reversed in Crohn disease.
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Milk consumption may exacerbate the disease.
Pathology
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The rectum is involved in all circumstances.It is a diffuse inflammatory disease, primarily affecting the
mucosa and superficial submucosa.
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There are multiple minute ulcers.When the disease is chronic, inflammatory polyps
(pseudopolyps) occur.
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Microscopic ally, there is an increase in inflammatory cells inthe lamina propria, the walls of crypts are infiltrated by
inflammatory cells and there are crypt abscesses.
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There is depletion of goblet cell mucin.
With time precancerous changes can develop (= severe
dysplasia or carcinoma in situ).
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HistoryPatients predominantly complain of rectal bleeding.
Frequent stools and mucous discharge from the
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rectum.
Tenesmus.
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Severe dehydration, especial y in the elderlypopulation.
Extracolonic manifestations
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Uveitis, pyoderma gangrenosum, pleuritis, erythema
nodosum, ankylosing spondylitis, primary sclerosing
cholangitis and spondyloarthropathies.
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Uveitis is the most common.
Physical Examination
Physical findings are normal in patients with mild
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disease.
Patients with severe disease can have signs of
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volume depletion and toxicity, including thefollowing:
Fever
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Tachycardia
Significant abdominal tenderness
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Weight lossIn general, a poor prognosis is indicated by
(1) a severe initial attack,
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(2) disease involving the whole colon and
(3) increasing age, especial y after 60 years.
Grading
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mild ? rectal bleeding or diarrhoea with four or
fewer motions per day and the absence of systemic
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signs of disease;moderate ? more than four motions per day but no
systemic signs of il ness;
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severe ? more than four motions a day together
with one or more signs of systemic il ness: fever over
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37.5?C, tachycardia more than 90\ min,hypoalbuminaemia less than 30 g\ l, weight loss
more than 3 kg.
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Ulcerative Colitis
Crohn Disease
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Only colon involvedPanintestinal
Continuous inflammation extending
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Skip-lesions with intervening normal mucosa
proximal y from rectum
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Inflammation in mucosa and submucosa only Transmural inflammationNo granulomas
Noncaseating granulomas
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Perinuclear ANCA (pANCA) positive
ASCA positive
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Bleeding (common)Bleeding (uncommon)
Fistulae (rare)
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Fistulae (common)
WORKUP
Best made with endoscopy.
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Double-contrast barium enema examination.ANCA and ASCA.
Anemia.
Thrombocytosis.
Hypoalbuminemia.
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Hypokalemia.Hypomagnesemia.
Elevation of ESR and CRP.
Stool studies to exclude other causes.
Barium enema
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The principal signs are:
? loss of haustration, especial y in the distal colon;
? mucosal changes caused by granularity;
? pseudopolyps;
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? in chronic cases, a narrow contracted colon.Colonoscopy and biopsy
The mucosa is hyperaemic and bleeds on touch,
There may be a pus-like exudate.
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Pseudopolyps.Ulcers are seen that appear to coalesce.
Colonoscopic biopsy is done:
1. to establish the extent of inflammation;
2. to distinguish between UC and Crohn's colitis;
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3. to monitor response to treatment;4. to assess longstanding cases for malignant change.
Colonoscopy and biopsy
Extensive disease - Evidence of ulcerative colitis
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proximal to the splenic flexure
Left-sided disease - Ulcerative colitis present in the
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descending colon up to, but not proximal to, thesplenic flexure
Proctosigmoiditis - Disease limited to the rectum with
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or without sigmoid involvementComplications
ACUTE:
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Toxic megacolon
Perforation
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HaemorrhageCHRONIC:
Cancer
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Extra-intestinal manifestations
TREATMENT
Medical management with corticosteroids and anti-
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inflammatory agents.
Symptomatic treatment with antidiarrheal agents
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and rehydration.Surgery is contemplated when medical treatment
fails or when a surgical emergency (eg, perforation
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of the colon) occurs.5-aminosalicylic Acid Derivatives
:
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1.
Sulfasalazine is useful in treating mild-to-moderate ulcerative colitis and
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maintaining remission. Sulfasalazine is 5-aminosalicylate (5-ASA) coupledto a sulfapyridine. It is poorly absorbed in the proximal bowel, and the
bacteria in the colon uncouple the 5-ASA from the sulfa moiety, al owing
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5-ASA to exert its anti-inflammatory effect on the colonic mucosa by
inhibiting prostaglandin synthesis. It acts local y in the colon to reduce the
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inflammatory response and systemical y inhibits prostaglandin synthesis.2.
Balsalazide is a prodrug that is converted into 5-aminosalicylic acid
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through bacterial azo reduction. Metabolites of drug may decrease
inflammation by blocking the production of arachidonic acid metabolites
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in colon mucosa.3.
Mesalamine is the drug of choice for maintaining remission. It is useful for
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the treatment of mild-to-moderate ulcerative colitis. It is better tolerated
and has less adverse effects than sulfasalazine. Enema and suppository
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forms are typical y used in patients with distal colitis.Tumor Necrosis Factor Inhibitor
These agents prevent the endogenous cytokine from
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binding to the cell surface receptor and exertingbiological activity. These agents adversely affect
normal immune responses and al ow development of
superinfections; reactivation of latent TB has been
reported in patients with previous exposure to TB.
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Infliximab, Adalimumab, Golimumab.Immunosuppressant Agents
These agents regulate key factors of the immune
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system. Effective in bringing steroid-resistant
disease under control. Azathioprine, Cyclosporine, 6
-Mercaptopurine, Tacrolimus.
Corticosteroids
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Decrease inflammation by suppressing the migration
of polymorphonuclear leukocytes and reversing
increased capil ary permeability.
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They are used for induction of remission in moderate
-to-severe active ulcerative colitis.
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They have no role in maintaining remission; long-term use can cause adverse effects.
Alpha 4 Integrin Inhibitors
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Emerging as option for moderate-to-severe active
IBD in patients who have had an inadequate
response with, lost response to, or were intolerant to
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a TNF blocker or immunomodulator; or had aninadequate response with, were intolerant to, or
demonstrated dependence on corticosteroids.
Vedolizumab.
Antimicrobials
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They prolong GI transit time and decrease secretion
via peripheral mu-opioid receptors. Loperamide,
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Treatment of mild diseaseIn disease confined to the rectum, topical
mesalazine given by suppository is the preferred
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therapy.Left-sided colonic disease is best treated with a
combination of mesalazine suppository and an oral
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aminosalicylate.Treatment of Acute, Severe disease
Acute, severe ulcerative colitis
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ie, >6 bloody bowel movements/d, with one of thefollowing: fever >38?C, hemoglobin level < 10.5
g/dL, heart rate >90 bpm, erythrocyte
sedimentation rate >30 mm/h, or C-reactive protein
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level >30 requires hospitalization and treatmentwith intravenous high-dose corticosteroids
(hydrocortisone 400 mg/d or methylprednisolone
60 mg/d).
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Alternative induction medications like Cyclosporine,tacrolimus, infliximab, adalimumab, and golimumab
are used in steroid-resistant disease.
Maintenance therapy
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Once remission has been achieved, maintenance therapy is
recommended for all patients to prevent relapse.
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Oral aminosalicylates are indicated for disease thatresponded to ASA or steroids.
Patients who are unable to maintain remission or are
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intolerant to 5-ASA, Azathioprine and 6-mercaptopurine are
alternatives.
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Extended-release oral formulation of budesonide providesthe benefit of a powerful anti-inflammatory drug delivered
locally while avoiding many of the systemic side effects
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associated with systemic steroids.
Probiotics .
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Indications for surgeryIt is the definitive therapy for ulcerative colitis.
Failure of medical management is the most common
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indication for surgery.
Indications for urgent surgery in patients with ulcerative
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colitis include (1) toxic megacolon refractory to medicalmanagement, (2) fulminant attack refractory to medical
management, and (3) uncontrolled colonic bleeding.
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Indications for elective surgery in ulcerative colitis
include (1) long-term steroid dependence, (2) dysplasia
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or adenocarcinoma found on screening biopsy, (3) anddisease present for 7-10 years.
Types of Surgery
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Total abdominal colectomy with ileostomy: donein emergency setting as a "first aid procedure". The
only problem is that because the rectal stump is left
behind chances of haemorrhage are always there.
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Proctocolectomy and ileostomy: has the lowest
complication rate.Indicated in patients who are not
candidates for restoration. The patient is left with a
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permanent ileostomy.Restorative proctocolectomy with an ileoanal
pouch: In this operation, a pouch is made out of
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ileum as a substitute for the rectum and sewn orstapled to the anal canal.This avoids a permanent
stoma. Complications are pelvic sepsis , poor
function and pouchitis or inflammation of the pouch
,women may suffer from reduced fertility.
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Colectomy and ileorectal anastomosis: used ifthere is minimal rectal inflammation.
Annual rectal inspection is required
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Has the advantage of stoma avoidance and
minimal risk to sexual function.
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Ileostomy with a continent intra-abdominalpouch (Kock's procedure): rarely
used.Complications include early leak with
formation of fistulae and late subluxation of the
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valve.Pouch survival at 10 years was 87% in onestudy.
CROHN'S DISEASE
1.
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In Crohn's disease al are seen except:
a)
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Hyperplastic polypsb)
Diverticulosis
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c)
Fissuring ulcer
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d)Epitheloid granuloma
e)
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Crypt abscess
2. Crohn's disease is associated with following ?
a)
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Stomach not involved
b)
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No granulomatous + Transmucosal fissuresc)
Continuous involvement
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d)
Through and trough involvement of thickness of
bowel wal
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3. Transmural inflammation with skip lesions is colon
are characteristic of ?
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a)Regional ileitis (Crohn's disease)
b)
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Ischemic colitis
c)
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Ulcerative colitisd)
Non specific colitis
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Crohn disease is an idiopathic, chronic inflammatoryprocess that can affect any part of the gastrointestinal
tract from the mouth to the anus.
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Occurs as a result of an imbalance between
proinflammatory and anti-inflammatory mediators.
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Approximately 30% of Crohn disease cases involve thesmal bowel, particularly the terminal ileum, another
20% involve only the colon, and 45% involve both the
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smal bowel and colon.
The characteristic presentation is abdominal pain and
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diarrhea, which may be complicated by intestinalfistulization or obstruction.
Etiology
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Genetic,
Microbial,
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Immunologic,Environmental,
Dietary,
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Vascular,
Psychosocial factors
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Smoking and the use of OCPs and NSAIDs.PATHOPHYSIOLOGY
Chronic inflammation from T-cell activation leading to tissue
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injury is implicated in the pathogenesis of Crohn's disease.After activation by antigen presentation, unrestrained
responses of type 1 T helper (Th1) cells predominate as a
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consequence of defective regulation. Th1 cytokines such as
interleukin (IL)-12 and TNF- stimulate the inflammatory
--- Content provided by FirstRanker.com ---
response.Inflammatory cells recruited by these cytokines release
nonspecific inflammatory substances, including arachidonic
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acid metabolites, proteases, platelet activating factor, and
free radicals, which result in direct injury to the intestine.
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Microscopical y, the initial lesion starts as a focalinflammatory infiltrate around the crypts, followed
by ulceration of superficial mucosa. Later,
inflammatory cells invade the deep mucosal layers
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and, in that process, begin to organize intononcaseating granulomas .The granulomas extend
through al layers of the intestinal wal and into the
mesentery and the regional lymph nodes.
Macroscopical y, the initial abnormality consists of
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hyperemia and edema of the involved mucosa.
Later, discrete superficial ulcers form over lymphoid
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aggregates and are seen as red spots or mucosaldepressions (see the image below). These can
become deep, serpiginous ulcers located
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transversely and longitudinal y over an inflamed
mucosa, giving the mucosa a cobblestone
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appearance. The lesions are often segmental, beingseparated by healthy areas, and are referred to as
skip lesions
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HISTORY
Low-grade fever.
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Prolonged diarrhea with abdominal pain.Weight loss.
Generalized fatigability.
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Crampy or steady right lower quadrant or periumbilical pain.
The pain precedes and may be partially relieved by defecation.
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Diarrhea is not grossly bloody and is often intermittent.Colonic Crohn disease may be clinically indistinguishable from
ulcerative colitis, with symptoms of bloody mucopurulent diarrhea,
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cramping abdominal pain, and urgency to defecate.
Those with perianal disease may have debilitating perirectal pain,
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malodorous discharge from the fistula, and disfiguring scars fromactive disease or previous surgery.
H\o Recurrent attacks of SAIO\AIO.
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Enterovesical fistula may present as recurrenturinary tract infections and pneumaturia.
Enterovaginal fistulae may present as as feculent
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vaginal discharge.
Enterocutaneous fistulae may present as feculent
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soiling of the skin.Physical examination
Chronic intermittent fever
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Diffuse or localized abdominal tenderness.
Ful ness or a discrete mass may be appreciated,
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typical y in the right lower quadrant of the abdomen.Inspection of the perianal region can reveal skin tags,
fistulae, ulcers, abscesses, and scarring.
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Mucocutaneous or aphthous ulcers,erythema nodosum
and pyoderma gangrenosum.
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Eye examination may reveal episcleritis.Arthritis and arthralgia.
Complications
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Intra-abdominal abscesses.Fistulae\ sinus tracts .
Bowel strictures and adhesions.
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Perforation.
Colonic malignancy.
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Disease activity and scoring systemsMontreal classification system is based on the
following 3 variables:
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Age at diagnosis
Disease distribution/location
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Disease behaviorAge at diagnosis (A) has 3 categories, as follows :
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A1 ? 16 yearsA2 ? 17-40 years
A3 ? > 40 years
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Disease distribution/location (L) has the following 4 categories, 1 of which is a modifier for
upper GI involvement :
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L1 ? IlealL2 ? Colonic
L3 ? Ileocolonic
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L4 ? Isolated upper GI disease; L4 is a modifier that can be added to L1-L3 when there is
concomitant upper GI involvement
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Disease behavior (B) has 1 interim category (B1) and 2 specified categories, with anadditional modifier for perianal diseases (p), as follows :
B1 ? Nonstricturing, nonpenetrating; B1p: nonstricturing, nonpenetrating with perianal
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involvement
B2 ? Stricturing; B2p: stricturing with perianal involvement
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B3 ? Penetrating; B3p: penetrating with perianal involvementWORKUP
Complete blood cell count
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HypoalbuminemiaDeficiencies in iron and micronutrients
Liv
Acute inflammatory markers, such as CRP level or ESR,
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may correlate with disease activity.Stool samples should be tested for the presence of
WBCs, occult blood, routine pathogens, ova, parasites,
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and Clostridium difficile toxin.
Fecal calprotectin has been proposed as a noninvasive
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surrogate marker of intestinal inflammation in IBD.WORKUP
Plain radiography or CT of the abdomen can be
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used to assess for bowel obstruction or intra-abdominal abscesses.
Barium contrast studies.
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CT enterography or MR enterography.MRI of the pelvis or transrectal ultrasonography can
identify perianal fistulae and detect pelvic and
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perianal abscesses.Endoscopy and biopsy.
TREATMENT-Medical
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Steroids are the mainstay of treatment.
5-ASA compounds.
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Those who have symptoms and signs of a mass or anabscess are also treated with antibiotics.
Azathioprine is now standard maintenance therapy.
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Anti-TNF therapy.
Nutritional support.
TREATMENT-Surgical
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Indications for surgery
Surgical resection will not cure CD. Surgery is therefore
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focused on the complications of the disease.? recurrent intestinal obstruction;
? bleeding;
? perforation;
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? failure of medical therapy;? intestinal fistula;
? fulminant colitis;
? malignant change;
? perianal disease.
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1.Ileocaecal resection.
2. Segmental resection.
3. Colectomy and ileorectal anastomosis.
4. Emergency colectomy.
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5. Laparoscopic surgery6. Temporary loop ileostomy.
7. Proctocolectomy.
8. Strictureplasty.
9. Anal disease is usually treated conservatively.
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