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

2. Case of Miss X 25 yr old F Caucasian Trainee solicitor

3. PC Diarrhoea PR bleeding Lower abdominal pain Vomiting

4. 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

5. 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

6. 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)

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

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

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

10. 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: 20-25 units per week Rec. drug: occasionally smokes marijuana

11. 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

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

13. 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

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

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

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

21. 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

22. Crohn’s Disease

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

24. Epidemiology Affects ~ 5-6 / 100 000 annually Prevalence 27-106 / 100 000 M : F = 1 : 1.2 Mean age = 26 Commoner in the West More prone to Jews than non-Jews

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

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

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

28. 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

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

30. 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

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

32. 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

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

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

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

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

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

38. 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

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

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