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“This 34 year old patient presented with bloody diarrhoea and abdominal discomfort. Please examine him and discuss your findings with the examiners.”
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Inflammatory Bowel Disease
Inflammatory Bowel Disease (IBD) can be divided into Crohn’s Disease (CD) and Ulcerative Colitis (UC). A patient with Crohn’s disease presents with abdominal pain that is recurrent along with diarrhoea and perioral aphthous ulcers. It might take months to years for IBD to be diagnosed because of its non specific symptoms. An IBD patient may complain of cramps, disturbed bowel movements, irritable bowel syndrome symptoms and mucus and/or blood in the stool. Systemic symptoms of IBD include weight loss, malaise, sweats, arthralgia, easy fatigability and fever.
In ulcerative colitis, tenesmus and blood tinged stool is typical. If the colon or the terminal ileum is involved then the stools have a loose consistency. Weight loss is more predominant characteristic of Crohn’s Disease.
• Full blood count (anaemia and infection)
• C-reactive protein (infection)
• Renal function (dehydration)
• Liver function tests (associated liver disease, for example primary biliary cirrhosis)
• Auto-immune screen (anti-nuclear antibody)
• Tissue transglumatinase – TTG (exclude Coeliac disease)
• Stool culture
• Clostridium difficile toxin
- Abdominal X-ray
- Flexible sigmoidoscopy if UC is primarily suspected plus biopsy (within 72 hours of an acute attack) and preferably within 24 hours
- Colonoscopy plus biopsy
- CT colonoscopy can be used for monitoring or if a colonoscopy is not possible
- Biopsy should also be used to exclude Cytomegalovirus infection.
Ulcerative Colitis Severity Scoring – Truelove and Witts criteria (1950’s):
- ≥ 6 bloody stools/day
- Heart rate > 90 bpm
- Temperature > 37.8°C
- Haemaglobin < 10.5 g/dl
- ESR > 30
Inflammatory Bowel Disease is basically an idiopathic disease that is due to abnormal autoimmune response to the normal intestinal organisms or due to genetic causes. Some environmental factors also play part in the pathogenesis of the disease.
Maintenance in quiescent disease of Ulcerative Colitis:
- Aminosalicylates (ASA) – reduce relapses to a third
- Sulfasalazine – ASA + sulfapuridine via an azo bond
Mild to Moderate colitis:
- ASA and steroids (either enemas or if moderate-severe attack, orally)
Acute Severe colitis:
- Intravenous steroids (either hydrocortisone 100mg f/day or methylprednisolone 60mg/day or 40mg 2/day)
- There is no benefit with increased doses
- Thromboprophylaxis with low molecular weight heparin as it reduced death from venous thromboembolism
- Intravenous fluids
- Intravenous antibiotics if any evidence of sepsis
Indications for surgery:
- Toxic dilatation of the colon 5.5cm or caecum at 9cm or more
- If there is clinical, radiological or laboratory deterioration, this mandates emergency colectomy
Day 3 Assessment – Travis criteria:
- Stool frequency (whether > 8/day)
- C-reactive protein (whether > 45)
Predicts need for surgery in 85% of patients. There is no benefit of steroid therapy in acute severe colitis beyond the 10th day.
Management options in refractory acute severe colitis:
Maintenance in quiescent disease of Crohn’s Disease:
Colonic Crohn’s disease is managed in much the same way that UC is managed, as above described. However, the medications in remission are of lesser efficacy. Oral metronidazole has been found, for prolonged periods, to be of benefit in Crohn’s colitis. In mild to moderate exacerbations of the disease affecting the ileocaecum, higher doses of drugs such as Asocol and Mesalazaine are required. In severe disease systemic steroids are required. Immunomodulators such as methotrexate and azothioprine are required for remission maintenance.
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While examining this patient you observe erythema nodosum. What is the likely unifying diagnosis?CorrectIncorrect
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