Gastroenterology Clinical Essentials: Bowel and Liver Pathology
Posted on Jun 11, 2026 in Medicine
Surgical Management of Colitis
- Ulcerative Colitis (UC): Refractory disease requires panproctocolectomy (removal of colon, rectum, and anus) with a permanent end ileostomy. UC is a continuous disease involving the rectum; leaving the rectum results in persistent active disease.
- Ileostomy vs. Colostomy:
- Ileostomy: Right iliac fossa, spouted, liquid output (due to lack of colonic water absorption). The spout protects skin from digestive proteases.
- Colostomy: Left-sided, semi-solid stool, less spouted.
- Hartmann’s Procedure: Sigmoid colectomy + upper rectum resection with end colostomy. Used in emergencies (e.g., perforated diverticulitis). Not curative for UC.
- Loop Ileostomy: Temporary diversion with two lumens; used to protect distal anastomosis.
Gallstones and Crohn’s Disease
- Pathophysiology: Gallstones form due to bile supersaturation. In Crohn’s disease (terminal ileitis), the terminal ileum—the primary site of bile salt reabsorption—is inflamed or resected. This reduces the bile salt pool, leading to cholesterol precipitation.
| Risk Factor | Mechanism |
|---|
| Crohn’s (terminal ileitis) | Decreased bile salt reabsorption |
| Ileal resection | Loss of bile salt recycling |
| Rapid weight loss | Increased cholesterol mobilization |
| Female sex / OCP | Estrogen increases biliary cholesterol |
Oesophageal Pathology
- Adenocarcinoma: Associated with GORD and Barrett’s oesophagus; typically lower 1/3rd.
- Squamous Cell Carcinoma: Associated with alcohol and smoking; typically upper/middle 2/3rds.
Crohn’s Disease Management
Induction of Remission
| Treatment | Key Role |
|---|
| Glucocorticoids | First-line induction |
| Budesonide | Mild/localised disease |
| Infliximab | Refractory/fistulating disease |
| Azathioprine | Add-on therapy (check TPMT) |
Maintenance of Remission
- Smoking Cessation: Essential, as smoking worsens Crohn’s.
- First-line: Azathioprine or Mercaptopurine (check TPMT activity first).
Hepatology and Liver Disease
- Hepatic Encephalopathy Grading: Grade I (Irritability), Grade II (Confusion), Grade III (Incoherent), Grade IV (Coma).
- Wilson’s Disease: Decreased ceruloplasmin and serum copper. Treat with Penicillamine.
- Haemochromatosis: Increased risk of Hepatocellular Carcinoma (HCC); requires 6-monthly liver ultrasound.
- TIPS Complications: Hepatic encephalopathy and right-sided heart failure.
- Variceal Bleeding: Terlipressin + IV antibiotics. Endoscopy within 72 hours if stable; immediate band ligation if unstable.
Clostridioides Difficile Management
- First episode: Vancomycin (1st line), Fidaxomicin (2nd line).
- Life-threatening: Oral Vancomycin + IV Metronidazole.
