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Inflammatory Bowel Disease

Approach

  • Expose abdomen
  • Start by examining the hands

 

  1. Inspect
    • General signs of malnutrition
    • Hands - digital clubbing, pale skin creases, anaemic
    • Eyes - pale conjunctiva if anaemic, uveitis, iritis, episcleritis
    • Mouth - aphthouse ulceration, severe deep ulcers
    • Abdomen - scars, stomas, enterocutaneous fistulas, drains, healed sites
  2. Palpate
    • May be distended and tense
    • May be a mass, most common in RIF
    • Note site of any tenderness
    • Patient may have hepatomegaly
  3. Percuss
  4. Auscultate
    • Bowel sounds may be increased in acute exacerbations

Completion

  1. Inspect perineum
  2. Perform DRE
  3. Examine for regional manifestations of Crohn's disease
    • Large joint mono-arthritis and sacroilitis
    • Pyoderma gangrenosum

    • Erythema nodosum

Investigations

  1. Stool tests
    • Stool culture ?infective element
  2. Blood tests
    • FBC - anaemia, leucocytosis
    • U/Es: dehydration, hypokalaemia
    • LFTS
    • CRP, ESR
  3. Endoscopy
    • Sigmoidoscopy+ biopsy
  4. Radiology
    • Barium enema / small bowel study

Defintion of disease severity

  1. Local symptoms
    • > 10 stools /day
    • PR bleeding
    • Urge to defecate
    • Abdominal pain and distension
  2. Systemic signs
    • Tachycardia
    • Pyrexia
    • Pallor
    • Wasting

Indications for Surgery

  1. Failure of medical therapy
  2. Intestinal failure
  3. Toxic megacolon

Ulcerative colitis Crohns 
  1. Pan proctocolectomy + permanent ileostomy
    • Rectum and anus excised with all of colon
    • Indicated for carcinoma / dysplasia, and failed medical management
  2. Subtotal colectomy, mucous fistula and permanent ileostomy
    • Rectum brought out as mucous fistula and ileostomy
    • Further rectal symptoms can occur in mucous fistula but these can usually be controlled with topical agents
    • Indicated for toxic megacolon
  3. Restorative proctocolectomy
    • 3-stage procedure which removes need for a permanent ileostomy
    • Neo-rectum created in pelvic reservoic
    • Stage I: subtotal colectomy and end ileostomy
    • Stage II: residual rectum has mucosa removed and pouch placed within a tube of rectal muscle, anastamosed to anus - covered with a defunctioning loop ileostomy
    • Stage III: contrast radiology demonstrated intact pouch, loop ileostomy reverseed
  1. As much small bowel should be left after the operation as possible
  2. Intra-abdominal abscesses should be drained
  3. Colonic dysfunctioning using a loop ileostomy may be needed for patients who have failed medical therapy
  4. Ocassional a subtotal colectomy and permament end ileostomy may be needed
  5. Pouch surgery is contraindicated in Crohn's disease

Hepatobiliary complications of inflammatory bowel disease

  1. Liver
    • Fatty change
    • Chronic active hepatitis
    • Cirrhosis
    • Amyloid deposition
  2. Biliary
    • Gallstones
    • Sclerosing cholangitis
    • Cholangiocarcinoma
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