[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This lady in her 30’s has presented to A&E with worsening abdominal discomfort.  Please examine her abdomen and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191572″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has a midline laparotomy scar and no other clinical signs.  The cause cannot be deduced but may relate to previous operations for cancer, perforated viscus or inflammatory bowel disease.  However, as the patient is described as young it would be reasonable to speculate that an inflammatory cause is most probable.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Crohn’s Disease

Clinical Features:

  • peri-oral aphthous ulcers;
  • possible right iliac fossa mass;
  • possible midline laparotomy scar from previous bowel obstruction;
  • possible erythema nodosum;

Common Symptoms:

  • pain (primary feature of ileocaecal disease)
  • diarrhoea
  • anal lesions (with associated fissures possible)
  • rectal bleeding (fresh)
  • malaise
  • weight loss
  • fever

Classification of Crohn’s Disease

Montreal classification (for Crohn’s disease phenotype):

Onset:

A1 < 16 years;

A2 17-40 years;

A3 > 40 years.

Localisation:

L1 ileal;

L2 colonic;

L3 ileocolonic;

L4 isolated upper disease.

Behaviour

B1 non-stricturing;

B2 stricturing;

B3 penetrating.

p – perianal disease modifier.

Extra-intestinal manifestations of Crohn’s Disease:

  • aphthous ulceration
  • gallstonrs
  • fatty liver change
  • amyloidosis
  • granulomata
  • oxalate renal calculi

Complications

  • toxic megacolon
  • colorectal cancer

Pathology

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.

Preventative treatment

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

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

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.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has had a previous laparotomy.  As she is young I would speculate that inflammatory bowel disease may be a cause for this, although of course I would confirm this with the patient directly.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]