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Gold standard case presentation
- peri-oral aphthous ulcers;
- possible right iliac fossa mass;
- possible midline laparotomy scar from previous bowel obstruction;
- possible erythema nodosum;
- pain (primary feature of ileocaecal disease)
- anal lesions (with associated fissures possible)
- rectal bleeding (fresh)
- weight loss
Classification of Crohn’s Disease
Montreal classification (for Crohn’s disease phenotype):
A1 < 16 years;
A2 17-40 years;
A3 > 40 years.
L4 isolated upper disease.
p – perianal disease modifier.
Extra-intestinal manifestations of Crohn’s Disease:
- aphthous ulceration
- fatty liver change
- oxalate renal calculi
- toxic megacolon
- colorectal cancer
Crohn’s disease is a characterized by chronic inflammation of the bowel which is transmural and can involve any part of the body from mouth to anus. It is an idiopathic condition, which is both relapsing and remitting in nature.
Up to 20% of patients with Crohn’s disease have a relative with either Crohn’s disease or ulcerative colitis. Other environmental associations with Crohn’s disease include smoking, non-steroidal anti-inflammatory NSAIDs; antimicrobials and oral contraceptive pills. Also, low-fbire diets and/or lots of high-refined sugar diets are also associated with Crohn’s disease.
Crohn’s disease primarily affects the terminal ileum (up to 35% of patients) and the ileocaecal area (up to 40% of patients) with up to 20% of patients having disease confined to the colon.
pathological features include transmural inflammation, with associated deep ulceration, fissures and the development of abscesses.
Due to antimicrobials and NSAIDs use being associated with an increased risk of Crohn’s disease should be avoided to reduce the risks of relapses.
Management is multi-disciplinary:
Dieticians: High fat diets should be avoided. Elemental diets are good for active disease, but can be very difficult to take in by the patient due to unpalatability.
Medications: 5-Aminosalicylic acid based compounds are not as good for Crohn’s disease as they are for ulcerative colitis. They are used primarily in active disease, and are not particularly effective in maintaining remission. In mild disease, no maintenance therapy is recommended.
Corticosteroids: Are used for active disease, to induce remission, but are not used for maintenance therapy and due to associated side effects are not used long term.
Anti-microbials: Despite the fact that anti-microbials have been associated with an increased risk of Crohn’s disease, if there is bacterial overgrowth or perennial disease, antimicrobials such as metronidazole are potentially useful. If fistulae are present, then ciprofloxacin can also be used.
Immunomodulators: Medications such as azothioprine or methotrexate can be useful in remission maintenance. To induce maintenance, TNF-alpha inhibitors such as infliximab or adalimumab are effective.
Surgery is far more common in Crohn’s disease than ulcerative colitis. The most common operation is a right hemicolectomy. Less common are panproctocolectomies with ileostomy.
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Question 1 of 5
1. Question1 point(s)CorrectIncorrect
Question 2 of 5
2. Question1 point(s)
Which of the following are indications for an ileostomy? Select all that apply.CorrectIncorrect
Question 3 of 5
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You examine the ileostomy bag and notice large volumes of liquid stool. Which possible complication should you mention to the examiners?CorrectIncorrect
Question 4 of 5
4. Question1 point(s)
The examiners tell you that this patient has presented with gradually progressive weakness of the limbs, paraesthesia and visual changes. What one blood test would you like to order to confirm your suspected diagnosis?CorrectIncorrect
Question 5 of 5
5. Question1 point(s)
Which food types are most problematic for patients with an ileostomy?CorrectIncorrect