A 25-year-old man has recurrent, indolent fistula in ano. He also complains of weight loss, recurrent attacks of diarrhea with blood mixed in the stool, and tenesmus. Proctoscopy revealed a healthy, normal-appearing rectum. What is the most likely diagnosis?
Correct Answer: Crohn's colitis
Description: Answer: a) Crohn's colitis (BAILEY 26TH ED, P-1151)INFLAMMATORY BOWEL DISEASEPeak age of presentation 15-30 years and 60-80 yearsFemales > malesCROHN'S DISEASE/ REGIONAL ENTERITIS GRANULOMATOUS COLITIS / TERMINAL ILEITISULCERATIVE COLITISCan affect any part of GIT, but me sites - terminal ileum, ileocecal valve, and cecumLimited to colon and rectumHLA-DR1/DQw5HLA-DR2, HLA DR103* Smoking is a strong risk factor* OCPs and Appendicectomy increase risk* Non-smokers, ex-smokers - higher risk* Appendicectomy before 20 years protects against UCMorphologySkip lesionsContinuous lesionsThick bowel wallThin bowel wallStrictures commonRareTransmural inflammationLimited to mucosaNon caseating granulomas (35%)No granulomasModerate pseudopolypsMarked number of Pseudopolyps (tips fuse to form mucosal bridges)Deep, knife-like ulcersSuperficial broad-based ulcersFibrosis, serositis - markedMild to nonePerianal disease - painful skin tags, anal fissures, perianalabscesses, fistulasAbsentRectum mostly sparedRectum always involved* Earliest lesions - aphthoid ulcers* Crypt abscesses* Mesenteric fat wraps bowel surface (creeping fat)* Paneth cell metaplasia in the left colon* Distortion of mucosal architecture* Cutaneous granulomas - metastatic Crohn disease* Rectum always involved and disease extends proximally (pancolitis and backwash ileitis)* Crypt abscessClinical featuresIntermittent mild diarrhea, fever, abdominal pain (MC)Right lower quadrant mass, weight loss, anemiaSometimes mimics appendicitis or bowel perforationRelapsing disorder with attacks of bloodydiarrhea (usually nocturnal/postprandial),cramps, fecal urgencyAnal complaints (fissure, fistula, abscess) - frequentInfrequentLess incidence of perforationIncreased incidence of perforationFat/vitamin malabsorption presentAbsentMalignant potential + with colon involvementMalignant potential (UC > CD)Recurrence after surgery commonRareToxic megacolon - not commonToxic megacolon seen (diameter > 6 cm)Investigations70% ASCA +ve (anti Saccharomyces cerevisiae Ab)10% pANCA positive75% pANCA positive10% ASCA +veBarium meal follow through or small bowel enema* Straightening of valvulae conniventes* Multiple defects (cobblestone appearance).* Cicatrisation & narrowing of ileum (string sign of Kantor)* Rose thorn appearance of the bowel wall.* Antibodies to E. coli outer membrane porin protein C (OmpC), Antibody to I2, Antiflagellin (anti-CBir1)* CT enterography - first-line test for the evaluation of suspected CD and its complicationsBarium enema* Loss of haustrations* Narrow contracted colon (hose pipe colon)* Mucosal changes caused by granularity* Chronic - narrow contracted colon* Fecal lactoferrin - marker for intestinal inflammation* Fecal calprotectin - correlate with, predict relapses, detect pouchitisTreatment* 5-ASA agents (mesalamine) not used now* Mild to moderate disease involving terminial ileum or ascending colon- Budesonide* Severe disease involving proximal small intestine or distal colon - Prednisone* Immunomodulators (Azathioprine, mercaptopurine, methotrexate) and for maintenance of remission or induction of remission along with steroids in severe disease* Anti-TNF therapy (Infliximab, adalimumab, certolizumab) - first-line agents to induce remission in moderate to severe disease and to maintain remission* Anti-integrins: Natalizumab (anti-a4 integrin) - if no response to anti-TNF agents* Mild to moderate distal colitis - topical mesalamine is the drug of choice* Mild to moderate disease extending above the sigmoid colon- Oral 5-ASA agents- No response - add prednisone- No response- immunomodulators* Severe colitis- IV Methylprednisolone- No response - Infliximab- No response - Cyclosporine- No response - Surgery* Fulminant colitis & Toxic megacolon not improving in 48-72 hours - surgery - Total proctocolectomyExtraintestinal manifestationsRheumatologicInflammatory arthropathy is the most common extraintestinal manifestationPeripheral arthritis (CD > UC) - asymmetric, polyarticular, migratory, mostly affects large joints of the upper and lower extremities, worsens with exacerbations of bowel activityAnkylosing spondylitis (CD > UC) - not related to bowel activity, does not remit with glucocorticoids or colectomy, most often affects the spine and pelvisSacroileitis (CD=UC) - does not correlate with bowel activity DermatologicErythema nodosum (CD > UC) - attacks correlate with bowel activity; skin lesions develop after the onset of bowel symptomsPyoderma gangrenosum (UC>CD) - may occur before the onset of bowel symptoms, course independent of the bowel disease, respond poorly toAphthous stomatitis and "cobblestone" lesions of the buccal mucosa (CD > UC)Pyoderma vegetans, pyostomatitis vegetans, Sweet syndrome (neutrophilic dermatosis)
Category:
Surgery
Get More
Subject Mock Tests
Practice with over 200,000 questions from various medical subjects and improve your knowledge.
Attempt a mock test nowMock Exam
Take an exam with 100 random questions selected from all subjects to test your knowledge.
Coming SoonGet More
Subject Mock Tests
Try practicing mock tests with over 200,000 questions from various medical subjects.
Attempt a mock test now