Transcript ‘A Solicitor with Diarrhoea’ Dr. Clark / Pollok Medicine Firm Katie Barge

‘A Solicitor with Diarrhoea’
Dr. Clark / Pollok Medicine Firm
Katie Barge
Shamara Fonseka
Sylvia Kwong
Case of Miss X
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25 yr old
F
Caucasian
Trainee solicitor
PC
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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
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No previous hospitalisations
No previous surgery
No THREADS
No significant childhood illnesses
MH
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Pentasa
Colifoam
Predsol suppository
Prednisolone
NKDA
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Feminax
OC pill
Aspirin
Multi-vitamins, aloe
vera & peppermint
SH
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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
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
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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
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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
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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
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
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may need hospitalisation
CRP
WCC
albumin
Clinical Features
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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
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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
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Mechanical problems
Dehydration
Psychosexual issues
Infertility in men
Recurrence of Crohn’s disease