Professional Documents
Culture Documents
Radiology:
A plain abdominal film may indicate the severity of disease in
the acute setting and is particularly valuable in demonstrating
the development of toxic megacolon
Extraintestinal manifestations
MEDICAL TREATMENT
Medical therapy is based on anti-inflammatory agents. The 5-aminosalicylic
acid (5-ASA) derivatives can be given topically (per rectum) or systemically.
They act as inhibitors of the cyclo-oxygenase enzyme system and are
formulated to protect the aspirin-related drug from degradation before
reaching the colon. They can be used long term as maintenance therapy.
Corticosteroids are the mainstay of treatment for ‘flareups’, either topically
or systemically, and have a widespread anti-inflammatory action. The
immunosuppressive drugs azathioprine and cyclosporin can be used to
maintain remission and as ‘steroid-sparing’ agents. The monoclonal
antibodies infliximab and adalimumab both act against antitumour necrosis
factor alpha, which has a central role in inflammatory cascades. Most
recently, vedolizumab, which blocks integrins, has been used as ‘rescue
therapy’ for severe colitis, to try and avoid emergency colectomy.
INDICATIONS FOR SURGERY
The greatest likelihood of a patient with UC requiring surgery is during the first
year after diagnosis. The overall risk of colectomy is 20%. Indications for surgery in
UC are:
●● severe or fulminating disease failing to respond to medical therapy;
●● chronic disease with anaemia, frequent stools, urgency and tenesmus;
●● steroid-dependent disease – here, the disease is not severe but remission
cannot be maintained without substantial doses of steroids;
●● inability of the patient to tolerate medical therapy required to control the
disease (steroid psychosis or other side effects, azathioprine-induced pancreatitis),
such that remission cannot be maintained;
●● neoplastic change: patients who have severe dysplasia or carcinoma on review
colonoscopy;
●● extraintestinal manifestations;
●● rarely, severe haemorrhage or stenosis causing obstruction.
CROHN’S DISEASE (REGIONAL
ENTERITIS)
publication by Burrill Crohn and colleagues in 1932.
CD is characterised by a chronic full thicknes
inflammatory process that can affect any part of the
gastrointestinal tract from the lips to the anal margin. It
is most common in North America and Northern Europe
with an incidence of 5 per 100 000. It is slightly more
common in women than in men, and is most commonly
diagnosed in young patients between the ages of 25 and
40 years. There does, however, seem to be a second
peak of incidence around the age of 70 years.
Clinical features
Presentation depends upon the pattern of
disease. Very infrequently, CD presents acutely
with acute ileal inflammation and symptoms
and signs resembling those of acute
appendicitis, or even free perforation of the
small intestine, resulting in a local or diffuse
peritonitis. CD may present with fulminant
colitis but this is considerably less common
than in UC.
Colonic involvement is found in 30% of patients with CD,
frequently in association with perianal disease and it may
coexist with small bowel pathology. Colonic CD presents with
symptoms of colitis and proctitis as described for UC, although
toxic megacolon is much less common. Colonic strictures may
form just as are seen in small bowel CD. Endoscopic dilatation
may be performed in expert hands as an alternative to surgical
resection. Distinguishing between CD and UC is often difficult
and requires clinical and pathological patterns to be combined.
The presence of skip lesions, rectal sparing, non-caseating
granulomas or perianal disease will point to CD.
Colonoscopic examination may be normal or show patchy
inflammation. There will be areas of normal colon or
rectum in between areas of inflamed mucosa that are
irregular and ulcerated, with a mucopurulent exudate. The
earliest appearances are aphthous ulcers surrounded by a
rim of erythematous mucosa. These become larger and
deeper with increasing severity of disease. There may be
stricturing, and it is important to exclude malignancy in
these sites. An irregular Crohn’s stricture with polypoid
mucosa may be almost indistinguishable from malignancy.
Treatment
Campylobacter
Infection with Campylobacter jejuni (a gram-negative
rod with a distinctive spiral shape) is the commonest
form of gastroenteritis in the UK, typically acquired
from eating infected poultry. It causes diarrhea and
abdominal pain. Severe cases may resemble UC. The
organism may take several days to isolate on stool
culture. Treatment is supportive as it usually resolves
without antibiotics, but severe colitis and even
perforation may occur. It is a notifiable disease.
Intestinal amoebiasis