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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Flares:
If a patient has an unexpected flare, a dietary review must be carried out to check for
accidentalglutenexposure
Consider testing for associated conditions, e.g. lactose intolerance, pancreatic exocrine
insufficiency Consequencesofnutrientdeficiencies Increasedriskofosteoporosisandbonefracture Hyposplenismandreducedimmunity Enteropathy-associatedT-celllymphoma(EATL) Infertilityandpoorfetaloutcome.
Monitoringandfollow-up
Patientsmustbefollowedupannually Allofthefollowingmustbedone:
Checkheightandweight
Discusssymptomcontrol
Reviewadherencetogluten-freediet,preferablywithdieticianinput
Bloods monitoring: FBC, ferritin, folate, vitamin B12, LFT, glucose, TFT, calcium, and
coeliacautoantibodies ConsiderDXAscanningandstartingboneprotection Duodenal biopsy does not need to be regularly repeated, but one repeat duodenal biopsy >6 months after starting gluten-free diet is often recommended in adults to confirm resolution of epithelialdamage.
Furtherreading
1. WilkinsonIB, Raine T, Wiles K, et al. (2017). Coeliac disease. In: Oxford Handbook of Clinical Medicine,10thed(p.266).Availableat:https://doi.org/10.1093/med/9780199689903.003.0006
2. Simon C, Everitt H, van Dorp S, et al. (2020). Coeliac disease. In: Oxford Handbook of General Practice,5thed(pp.382–3).Availableat:https://doi.org/10.1093/med/9780198808183.003.0012
3.BloomS,WebsterG,MarksD(2011). Coeliac disease.In: OxfordHandbook of Gastroenterology, 2nded(p.259).Availableat:https://doi.org/10.1093/med/9780199584079.003.0169
4.AmericanCollegeofGastroenterology(2013).ACGclinicalguidelines:diagnosisandmanagementof celiacdisease.Availableat:https://gi.org/guideline/diagnosis-and-management-of-celiac-disease/
5. NICE (2015). Coeliac disease: recognition, assessment and management (NG20). Available at:
https://www.nice.org.uk/guidance/ng20
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Chapter29
Crohn’sdisease
Guidelines: European Crohn’s and Colitis Organisation (3rd European
evidence-based consensus on the diagnosis and management of Crohn’s Disease 2016: part 1: diagnosis and medical management):
https://academic.oup.com/ecco-jcc/article/11/1/3/2456546
European Crohn’s and Colitis Organisation (3rd European evidence-based consensusonthediagnosisandmanagementofCrohn’sdisease2016:part2: surgicalmanagementandspecialsituations):https://academic.oup.com/ecco-
jcc/article/11/2/135/2456548
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Crohn’s disease (CD) is a lifelong, idiopathic, autoimmune disorder that can cause inflammationofanypartoftheGItract,althoughitmostfrequentlyaffectstheterminal ileum,colon,andperianalareas.Itisestimatedtoaffectatleast115,000peopleintheUK andtypicallyfollowsarelapsing–remittingpatternofdisease.
Diagnosis
Diagnosis is made through clinical history and examination, combined with evidence from biochemical,endoscopic,histological, and radiological investigations. CDmaybe classifiedasmild,moderate,orsevere(Box29.1)
Box29.1SeverityofCrohn’sdisease
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Classified into mild, moderate, or severe disease although these categories are not preciselydefined.
TheCrohn’sDiseaseActivityIndex(CDAI)1classifiesactivediseaseasascore>150,
withseveredisease>300.
NICE2 defines severe active CD as very poor general health with one or more of weight loss, fever, severe abdominal pain, and frequent (3–4/day) diarrhoeal stools present.
History
GIsymptoms:
Chronicdiarrhoea(presentin>80%patients) Abdominalpain(80%) Blood/mucusinstool(40–50%)
Perianalfistula(4–10%) Systemicsymptoms:weightloss(60%),fever Extraintestinalmanifestations:joints,skin,andeyes(seefollowingsection) RecenttravelhistoryfocusingonGIinfections Country oforigin(focusing onTBendemicregions)andfamilyhistoryofTB(intestinalTBcan mimicCDleadingtodiagnosticconfusionandsomeCDtreatments,e.g.anti-TNF,increasetherisk ofdevelopingactiveTB) RiskfactorsforCD:currentsmoker;familyhistoryofinflammatoryboweldisease(IBD) Medicationhistory,especiallyNSAIDs(Box29.2).
Box29.2NSAIDs
Excessive use may cause NSAID enteropathy or colopathy which can mimic CD, or exacerbateexistingCD.FrequentuseisalsoaminorriskfactorforCD.
ExtraintestinalmanifestationsofCrohn’sdisease
Upto 35%of patientshaveextraintestinalmanifestationsofCD(Table29.1),which can precedeGIsymptoms.
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Table29.1ExtraintestinalmanifestationsofCrohn’sdisease
Relatedtodiseaseactivity Notrelatedtodiseaseactivity
Peripherallargejointarthritis Pyodermagangrenosum
Erythemanodosum Uveitis
Oralaphthousulcers Axialarthropathy(sacroiliitisorspondylitis)
Episcleritis Smalljointperipheralarthritis
Primarysclerosingcholangitis(uncommoninCD)
Source:datafromEuropeanCrohn’sandColitisOrganisationPart2.
Examination
Generalhealthandappearance BMI Bloodpressure,heartrate,andtemperature Abdominaltendernessordistension Palpableabdominalmasses Inspectionoftheperianalarea(fistulas)andoralcavity(ulcers) DRE.
Investigations
Bedside
Faecalcalprotectin:
Notdiagnostic
Typicallyusedinprimarycareforitsgoodnegativepredictivevalue Stoolteststoexcludeinfectiousdiarrhoea(Clostridiumdifficile,MC&Sbasedontravelhistory).
Bloods
FBC(↑platelets,↓haemoglobin) CRP/ESR(↑) Lowalbuminisasignofsevereinflammation,sepsis,orNSAIDuse Ironstudies(includingtransferrinsaturation),vitaminB12,andfolate.
Imaging
Allows staging of disease and may detect possible complications (fistula, obstruction, abscess).Considerpatientageandlikelylocationofdiseasewhenrequesting.
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MRIsmallbowel:moresensitivethanCTatdiagnosinginflammation CTabdomen/pelvis:usuallyreadilyavailable,firstlineforsuspectedabscessorobstruction,but considerradiationexposure Abdominal ultrasound scan (USS): reasonable sensitivity in detecting bowel inflammation, but may give an incomplete picture of extent of disease. Needs an experienced operator and not availableineverycentre Smallbowelcapsuleendoscopy(SBCE):generallyreservedforhighclinicalsuspicionofCDbut MRI/CT/colonoscopynegative.HighnegativepredictivevalueforexcludingCDifnormal.
Endoscopyandhistology
Ileo-colonoscopywithbiopsiesistypicallythefirst-linediagnosticprocedure Flexible sigmoidoscopyispreferable ifsevereactive disease,asbowel preparation maynotbe toleratedandthereisahigherriskofperforationwithcolonoscopy Endoscopic signs of CD: patchy inflammation; ‘skip lesions’ (inflammation between normal mucosa);longitudinalulcers;cobblestoneappearanceofileum/colon;fistulasandstrictures ConsiderOGDinpatientswithsymptomssuchasvomitinganddyspepsia,toinvestigatetheupper GItract.
Management
Patienteducation
Information must be appropriate for the patient’s age, literacy level, and cultural background and should cover prognosis, likely treatment side-effects, cancer risk, nutrition,andcontactdetailsforsupportgroups.
Lifestyleandsimpleinterventions
Smoking increases CD activity. All patients should be strongly encouraged to stop smoking,withactivecessationprogrammesrecommended.
Pharmacologicalmanagement
TreatmentmustbeledbyagastroenterologistexperiencedinmanagingIBD.Basicprinciplesare highlightedinFig.29.1 SomeCDpatientswillhaveamild–moderatepatternofdisease,withlittleornorequirementfor steroids ReductionofsteroiduseisakeyaimofgoodCDmanagement.
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Fig.29.1BasicmanagementprinciplesofCD.
Surgicalmanagement
Upto75%ofCDpatientswillrequiresurgery.Indicationsforsurgeryinclude:
Obstructivesymptoms
Smallbowelstrictures:strictureplastyorbowelresection Colonic strictures: endoscopic dilatation (high risk for perforation particularly if active inflammation)orsegmental/totalcolonicresection.
Abscess
Urgentsurgicalorpercutaneousdrainageplusantibiotics.
Fistula
ExcludepresenceofconcurrentabscesswithpelvicMRI Management using examination under anaesthetic (EUA), abscess drainage ± seton placement. Antibioticsmaybeneededasanadjunctivemeasure.
Isolatedileocaecaldisease
Laparoscopicileocaecalresectionshouldalwaysbeconsideredinpatientswithisolatedterminal ileal disease. Current evidence suggests this compares favourably with medical therapy and thereforeacarefuldiscussionwiththepatientisimportant.
Psychosocialconsiderations
Offermultidisciplinarysupporttodealwithpsychological concernsaboutCD,including bodyimage,livingwithachronicillness,andeffectonschool/work.
Complications
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Colorectal cancer: the overall riskis low, butsurveillancecolonoscopyis required forpatients whohavebeensymptomaticforadecadeandhavecolitiswhichaffectsmorethanonesegmentof
colon.
3
Metabolic bone disease: give calcium and vitamin D supplementation if using steroids for >6 weeks ↑riskofvenousthromboemboliceventsinactiveCD:in-hospitalthromboprophylaxisessential Complicationsoftherapy:
Azathioprine:lymphoma,non-melanomaskincancers,immunosuppression
Anti-tumour necrosis factor (TNF): infusion reactions, reactivation of latent TB, infection,
possibleriskoflymphoproliferativedisordersormalignancy
Anti-interleukin(IL)-12p40(ustekinumab):injectionsitereactions,lowriskofinfection
Anti-α4β7(vedolizumab):gut-specificagentwithverylowfrequencyofsideeffects
Steroids:Cushing’ssyndrome.
Monitoringandfollow-up
CDpatientsmusthaveregularfollow-up,andassessmentofdiseaseactivity.Themodeof assessmentwilldependontheindividualpatient.
Specialconsiderations
Pregnancy
Fertilityistypicallyunaffectedbywell-controlledCD Patientsconceivingduringinactivediseasehaveasimilarriskofrelapsetonon-pregnantpatients For the majority of CD medications there is no evidence of harm during pregnancy and breastfeeding,althoughpregnancymustbeavoidedifthepatientistakingmethotrexate Investigation during pregnancy should always be considered carefully and discussed with the patient:
Colonoscopyisnotperformedduringpregnancy
Thereisnoevidenceofharmwithflexiblesigmoidoscopy,althoughthisshouldbeavoidedif
possible.
Furtherreading
1. Crohn’s Disease Activity Index (CDAI). Available at: https://www.mdcalc.com/crohns-disease-
activity-index-cdai
2.ColombelJ, SandbornW, ReinischW,etal.(2010).Infliximab,azathioprineor combinationtherapy forCrohn’sdisease.NEnglJMed.362:1383–95.
3. NICE (2011). Colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative
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colitis,Crohn’sdiseaseoradenomas(CG118).Availableat:https://www.nice.org.uk/guidance/cg118/
4. NICE (2019). Crohn’s disease management (NG129). Available at:
https://www.nice.org.uk/guidance/ng129/
5. FeuersteinJD, Cheifetz AS(2017). Crohn disease: epidemiology, diagnosis andmanagement.Mayo ClinProc.92:1088–103.
1https://www.mdcalc.com/crohns-disease-activity-index-cdai
2https://www.nice.org.uk/guidance/ng129/chapter/Recommendations
3NICECG118;https://www.nice.org.uk/guidance/cg118/
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Chapter30
Gastro-oesophagealrefluxdiseaseanddyspepsia
Guideline: NICE CG184 (Gastro-oesophageal reflux disease and dyspepsia
in adults: investigation and management):
https://www.nice.org.uk/guidance/cg184
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Dyspepsiaisan umbrellatermfor aclusterofnon-specificsymptoms(see‘History’).If presentforatleast4weeks,dyspepsiamaysignifyunderlyingupperGItractpathology, e.g. gastro-oesophageal reflux disease (GORD). Causes of dyspepsia are listed in Box
30.1.
Box30.1Causesofdyspepsia
Functional(mostcommon) GORDorgastritis Helicobacterpyloriinfectionandpepticulcerdisease Symptomofcardiacorbiliarydisease Drugs,e.g.calciumchannelblockers,nitrates,theophyllines,bisphosphonates,steroids,NSAIDs Cancer,e.g.oesophageal.
Source:datafromNICECG184.
Diagnosis
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