‘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: 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

• 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 conditionMay affect any part of the GIT – from

mouth anusCommon sites: terminal ileum

ascending colon

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

Aetiology

• Familial

• Genetic

• Smoking

• Infective agent

• Endogenous bacteria

• 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