this is a continuation of week 5 CPD II notes on intestinal disorders, focusing on inflammatory bowel diseases- specifically crohn's and ulcerative colitis. crohn's disease is inflammation that can occur anywhere along the GI tract (most commonly found in the small intestine) involving the whole thickness of the intestinal wall and surrounding mesentary and lymph nodes. it has a "cobblestone" appearance due to the longitudinal and transverse apthous ulcers and is "regional" as well- inflamed sections of the intestine are next to normal, healthy sections. crohn's etiology is idiopathic, although several risk factors have been identified; a positive family history, smoking, oral contraceptives, and jewish ethnicity. it has a bimodal age distribution; 15-25 year olds and 55-65 year olds.
typical symptoms of crohn's include abdominal pain, recurrent oral apthous ulcers, malabsorption issues such as fatigue, occult blood loss, and melena (less commonly, blood in the stools). complications can lead to perianal diseases such as fistulas and fissures. patients may present clinically with a RLQ tenderness and a fullness or mass. blood tests might show anemia, leukocytosis, and an increased ESR, while a GI panel might show increased lysozyme and AACT. imaging of a severe case might show the "string sign"- a portion of the intestine that has constricted to the width of a string due to inflammation, and a colonoscopy might show the cobblestone appearance, normal areas, ulcerations, narrowing, and fistulas.
ulcerative colitis is a more acute inflammatory bowel disease which often presents with multiple bloody stools per day. it affects people of a similar age and race to crohn's sufferer's: jewish or caucasian, 15-25 or 55-65. it might be attributed to an autoimmune reaction, or an elevated immune reaction against bacterial antigens, or be related to a genetic susceptibility (chromosomes 12 and 16 have been implicated).
unlike crohn's, it begins in the distal end of the GI tract and works its way upwards without any skip areas. patients might present with bloody diarrhea, frequent urgent stools, lower abdominal cramps, weight loss. their labs might show anemia, elevated platelet count, ESR and CRP, while a chem screen might show low levels of albumin, potassium, magnesium, and high alkaline phosphatase. complications might include hemorrhage from sloughing off of the intestinal lining, colon cancer, and toxic megacolon, which is a dilatation of the colon that might lead to perforation. UC can be diagnosed by radiography, barium enemas, colonoscopy, which would show a loss of haustrations and a narrow tubular colon.
one can differentiate crohn's from UC in several key areas: crohn's generally affects the small intestine while UC starts from the bottom and works its wasy up. crohn's has normal intestinal patches mixed in while UC has continuous inflammation. the pain from crohn's is a constant pain in the RLQ and is not relieved by bowel movements while UC's pain is a crampy lower abdominal pain that is relieved by bowel movements. UC's stool is generally bloody and crohn's is generally not. finally, only crohn's is often accompanied by recurrent apthous ulcers, and may lead to perianal complications such as fistulas and fissures.
questions
crohn's...
1. what is crohn's disease?
2. why does crohn's have a "cobblestone" appearance?
3. what are risk factors for crohn's?
4. which ethnicities are more prone to developing crohn's?
5. what age group does crohn's typically affect?
6. crohn's most commonly affects which part of the GI tract?
7. what are some typical signs and symptoms of crohn's?
8. 1/3 of crohn's patients have...
9. what would the PE of a patient with crohn's reveal?
10. what are some complications of crohn's?
11. the blood tests of a patient with crohn's would show...
12. what are two markers on a GI panel that would be elevated in crohn's?
13. what are the imaging tests used to diagnose crohn's?
14. what might be seen on an upper GI series for an advanced crohn's case?
15. what might a colonoscopy of a crohn's patient show?
16. what are some extra intestinal manifestations of crohn's that are not shared with ulcerative colitis?
ulcerative colitis...
17. where in the GI does ulcerative colitis affect?
18. what are some etiological factors in ulcerative colitis?
19. what are the risk factors for ulcerative colitis?
20. what are the signs and symptoms for ulcerative colitis?
21. what might a blood test for UC show?
22. what might a chem screen for UC show?
23. what are some potential complications for UC?
24. what is toxic megacolon?
25. what are some imaging tests that can diagnose UC?
26. what might a barium enema of UC show?
27. what might a radiograph of UC show?
differential diagnosis of crohn's and UC: describe the differences in the following symptoms...
28. quality of pain...
29. stool...
30. masses...
31. location...
32. type of intestinal wall pathology...
33. continuity...
answers
1. an inflammatory bowel disease that extends through all layers of intestinal wall and involves mesentery and lymph nodes.
2. longitudinal and transverse apthous ulcers.
3. family history
smoking
oral contraceptives
diet
ethnicity
4. jewish, caucasian, then african americans and asians.
5. bimodal distribution: 15-20, and 55-65 year olds.
6. small intestine.
7. cramps
recurrent apthous ulcers
malasorption issues
occult blood loss
melena or blood in stool
[cramps, ulcers, malabsorption, blood, blood]
8. perianal diseases such as fissures or fistulas.
9. RLQ tenderness with an associated fullness or mass.
10. obstruction
fistula/abscess
perforation/hemorrhage
11. mild anemia, leukocytosis, increased ESR
12. lysozyme and AACT.
13. radiography, double contrast barium, single contrast upper GI series, colonoscopy.
14. "string sign"-- portion of marked stricturing of the ileum.
15. cobblestone appearance, skip areas, ulceration, narrowing, fistulas.
16. gallstones, kidney stones
B12 deficiency
obstructive hydro-nephrosis
apthous ulcers.
[crohn's stones be apt to obstruct]
17. from the distal end upwards, with no skipped areas.
18. autoimmune reaction against intestinal epithelium
immune mediated enhanced reactivity against bacterial antigens
genetic susceptibility related to chromosomes 12 and 16
[autoimmune, reactivity, genes]
19. more frequent in caucasians and jewish people. affects 30% more females than males. same bimodal distribution as crohn's, although can occur in people of any age.
20. bloody diarrhea with insidious onset, frequent urgent stools, lower abdominal cramps, weight loss.
21. anemia (if long term), elevated platelet count, elevated ESR, CRP.
22. hypoalbuminemia, hypokalemia, hypomagnesemia, elevated alkaline phosphatase.
23. hemorrhage, toxic megacolon, colon cancer.
24. markedly distended / dilated colon that has high risk of perforation.
25. radiograph, barium enemas, sigmoidoscopy, colonoscopy with biopsy.
26. loss of haustrations, narrow tubular colon.
27. dilatation of the colon, might suggest toxic megacolon.
28. UC: crampy, lower abdomen, relieved by BM. crohn's: constant, RLQ, not relieved by BM.
29. UC: bloody. crohn's: usually not bloody.
30. no abdominal mass in UC, often RLQ mass in crohn's.
31. UC generally only colon, crohn's generally small intestine, large intestine, sometimes esophagus and stomach.
32. UC: mucosal disease. crohn's: transmural disease with granulomas in some parts.
33. UC: continuous. crohn's: "skip areas".
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