‘A Solicitor with Diarrhoea’ Dr. Clark / Pollok Medicine Firm Katie Barge Shamara Fonseka Sylvia Kwong

Case of Miss X 25 yr old F Caucasian Trainee solicitor

PC Diarrhoea PR bleeding Lower abdominal pain Vomiting

HPC June 02: PR bleeding, mucus in stools, abdominal cramps, increased bowel frequency – Rectal biopsy July 02: Diagnosed with Crohn’s – Drugs: Colifoam, Pentasa, Prednisolone Remission – drugs slowly decreased in dose Never had a colonoscopy

HPC (cont..) Sept 03: PR bleeding started - Drugs – Predsol suppository and Asacol Nov 03: Increased bowel frequency, lower abdominal pain - Drugs – Prednisolone, Calcichew D3 Forte, Pentasa

HPC (cont..) Presented in A & E on 23/11/03 with: - Diarrhoea (1/52); x20 a day - PR bleeding (5/7) - Nausea & vomiting (1/7) - Dizziness & weakness (1/7)

HPC (cont..) - Lower abdominal pain - 1/52 - ‘Wrenching’ - No radiation - Relieved by defaecation - Intermittent - Severity: 10/10

PMH No previous hospitalisations No previous surgery No THREADS No significant childhood illnesses

MH Pentasa Colifoam Predsol suppository Prednisolone NKDA Feminax OC pill Aspirin Multi-vitamins, aloe vera & peppermint

SH Full time trainee solicitor Lives locally in a flat with a friend No recent travel abroad Smoking: gave up after being diagnosed (July 02), now smokes socially Alcohol: units per week Rec. drug: occasionally smokes marijuana

FH Dad (57): diagnosed with prostate cancer Mum (53): had a hysterectomy at 40 (no malignancy detected) Has a brother of 22 No family history of Crohn’s

Systems review No JACCOL CVS: NAD Resp: NAD GI: anorexia, weight loss, dehydrated, weak GU: NAD CNS: NAD

Examination CVS: pulse – 135, BP – 104/54 Resp: rate – 18, sats – 100% on air, chest clear GI: Abdomen soft, tender on light palpation in RIF, no mass/guarding, bowel sounds active, no abdominal distension - PR: empty rectum, no mass/tenderness, fresh blood GCS: 15

Differential Diagnosis Flare up of Crohn’s Infective aetiology ie gastroenteritis Evidence of obstruction at terminal ileum

Investigations Blood tests: FBC and Film, ESR, CRP, LFT, ALB Stool cultures Biopsy: histology

Investigations (cont..) Radiology & imaging: Small bowel meal, Abdominal ultrasound, CT, Radionucleotide scans (WCC Scan), Plain abdominal x-ray

Management of Miss X 1L saline + dextrose stat I/v hydrocortisone, 100mg qds I/v antibiotic - metronidazole I/v cyclosporin, 35mg over 6hrs Oral cyclosporin consider Azathioprine prior to discharge

Crohn’s Disease

Definition  A chronic inflammatory condition  May affect any part of the GIT – from mouth  anus  Common sites: terminal ileum ascending colon

Epidemiology Affects ~ 5-6 / annually Prevalence / M : F = 1 : 1.2 Mean age = 26 Commoner in the West More prone to Jews than non-Jews

Aetiology (I)Familial (II)Genetic (III)Smoking (IV)Infective agent (V)Endogenous bacteria (VI)Immunopathogenesis

Pathology Macroscopic changes: Small bowel involved – thickened + narrowed – discontiuous involvement (ie skip lesion) – deep ulcers + fissures  cobblestone appearance in mucosa

Pathology (cont..) Macroscopic changes: Large bowel involved – fistulae + abscesses – early: aphthoid ulceration; later: larger & deeper ulcers in a patchy distribution  cobblestone appearance in mucosa

Pathology (cont..) Microscopic changes: Inflammation extends thr’ all layers of the bowel (transmural) Chronic inflammatory cells, esp elicit TH1 response Granulomas are present in 50-60% pt

Classification Severity is hard to assess Severe symptoms inc: pyrexia pulse ESR > x6 bowel movement CRP WCC albumin may need hospitalisation

Clinical Features Diarrhoea Abdominal pain – in R iliac fossa Weight loss, ie sign of malabsorbtion Present of abdo mass Perianal lesions Constitutional symptoms: malaise, lethargy, anorexia, vomiting, pyrexia

Clinical Features (cont..) Non-GI manifestations of Crohn’s: Eyes – uveitis, conjunctivities Joints – *arthritis, *AS Skin – erythema nodosum *Liver – fatty change, cirrhosis Venous thrombosis

Anal and perianal complications of Crohn’s disease Fissure (multiple and indolent) Haemorrhoids Skin tags Perianal abscess and ischiorectal abscess Fistula (maybe multiple) Anorectal fistulae

Disease activity This can be assessed using simple parameter, such as Hb, WCC, CRP, and serum albumin and daily abdo XR

Medical management Induction of remission: Aminosalicylates (asacol/pentasa) Oral or iv glucocorticoids Enteral nutrition

Medical management (cont..) Maintenance of remission: Aminosalicylates Azathioprine, 6MP, Mycophenolate mofetil

Medical management (cont..) Rx of glucocorticosteriod / immunosuppressive therapy-resistant disases: Infliximab (TNF  antibody) I/v cyclosporin Methotrexate

Medical management (cont..) Perianal disease: Ciprofloxacin and metronidazole

Surgical management Indications for surgery are: Failure of medical therapy, with acute or chronic symptoms producing ill-health Complications e.g. toxic dilatation, obstruction, perforation, abscesses, enterocutaneous fistula Failure to grow in children

Surgical options Stricturoplasty Subtotal colectomy and ileorectal anastomosis Panproctocolectomy with an end ileostomy

Problems associated with ileostomies Mechanical problems Dehydration Psychosexual issues Infertility in men Recurrence of Crohn’s disease