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GI Pathology > 14. Inflammatory Bowel Disease > Flashcards

14. Inflammatory Bowel Disease Flashcards

1
Q

Define Idiopathic Inflammatory Bowel Disease.

A

Chronic inflammatory conditions resulting from inappropriate and persistent activation of the mucosal immune system driven by the presence of normal intraluminal flora

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2
Q

Name some Idiopathic Inflammatory Bowel Disease.

A

Crohn’s disease

Ulcerative colitis

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3
Q

Compare Crohn’s disease and Ulcerative colitis.

A

CD can affect any part of the GIT from the mouth to the anus whereas UC is limited to colon. Both have extra-intestinal manifestations.
UC inflammation: continuous mucosal. CD inflammation: patchy transmural granulomatous.

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4
Q

Name other inflammatory bowel diseases.

A 
Microscopic Colitis (an Inflammatory Bowel Disease that affects the large bowel (colon and rectum)). There are two main forms of Microscopic Colitis: 
Lymphocytic Colitis and Collagenous Colitis.
  1. Lymphocytic colitis (LC) – where the inner lining has more white blood cells (lymphocytes) than usual.
  2. Collagenous colitis (CC) – where the inner lining has a thicker layer of a collagen than usual. There may also be more white blood cells present.

The distinction between this and IBD is the absence of macroscopic evidence of inflammation.

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5
Q

What is the aetiology of inflammatory bowel disease

A

Current theory = an abnormal immunological response and/or increased reaction to commensal bacteria with defects in the epithelial barrier function within a genetically susceptible individual. Theory based around 3 core aetiological factors: immunity, genetics and the environment.
IBD = polygenic disease (that is, multiple genetic loci increase the likelihood of developing it, but do not directly cause it). IBD is not Mendelian inherited

Genetics: There is an association between single nucleotide polymorphisms (SNP) in the NOD2 (CARD15) gene and CD. HLA associations in UC.

Familial trend: Offspring = 10% risk of developing IBD.

In IBD there is a dysbiosis in microbial communities (reduced diversity of microbial species). Specific microbe not yet identified (higher concentrations of Bacteroides and E. coli, and lower concentrations of bifidobacteria and Faecalibacterium prausnitzii have been reported). Defects in mucosal barrier could allow microbes access to mucosal lymphoid tissue triggering immune response.

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6
Q

Ulcerative colitis:

  1. Which age group does it affect?
  2. What are the symptoms of it?
  3. What are the signs of it?
A
  1. Can affect any age. Bimodal peak in incidence between 15-25 and 55-65 years of age.
  2. Bloody diarrhoea, Abdominal pain, Weight loss, Fatigue, rectal bleeding, Tenesmus (incomplete emptying), Urgency
  3. Febrile, Pale, Dehydrated, Abdominal tenderness, distension/mass, Tachycardia, hypotensive
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7
Q

How would you investigate ulcerative colitis?

A
  1. Bloods for markers of inflammation (normocytic anaemia, increased CRP/platelets, low albumin)
  2. Stool culture to rule out infection
  3. Faecal Calprotectin (0-50ug/g stool=normal, 50-200=equivocal, >200 elevated)
  4. Colonoscopy and colon mucosal biopsies (for histological assessment of the mucosa. Caution should be taken during acute flares due to the increased risk of perforation). Sigmoidoscopy may be used as an alternative endoscopic test.
  5. pANCA( perinuclear antineutrophilic cytoplasmic antibody) positive in 75% of UC patients BUT only 11% of CD patients.
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8
Q

Ulcerative colitis:

  1. T/F: Can be localised to the rectum (proctitis)
  2. How does it spread?
A
  1. True

2. Begins rectum and works proximally

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9
Q

Outline pathogenesis of ulcerative colitis.

A

Macroscopically (seen endoscopically): continuous inflammation that extends proximally along the colon. Mucosa looks reddened and inflamed, and bleeds easily (friability). In severe disease = extensive ulceration, with the adjacent mucosa appearing as post-inflammatory (pseudo-) polyps.

Histologically: Mucosa – inflammation, Cryptitis, Crypt abscesses, Architectural dissarray of crypts, Mucosal atrophy, Ulceration into submucosa- pseudopolyps, Limited mainly to mucosa and submucosa, NO granulomas, Submucosal fibrosis

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10
Q

Define pancolitis. What can pancolitis lead to?

A

Pancolitis refers to inflammation of the entire colon. Patients with pancolitis are at risk of developing backwash ileitis. This refers to reflux of colonic contents into the distal few centimetres of the ileum through the ileocaecal valve. Backwash ileitis can make distinction between UC and CD more difficult.

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11
Q

How is severity of ulcerative colitis determined?

A

Assessed using the Truelove & Witts’ scoring.

Mild: < 4 bowel motions per day. Small amount of blood.

Moderate: 4-6 bowel motions per day. Quantity of blood between mild and severe.

Severe: > 6 bowel motions per day. Visible blood. Systemic upset (Temp > 37.8C, tachycardia >90bpm, anaemia, ESR > 30mm/hr, CRP >30mg/L)

Fulminant: 10 stools/day, continuous bleeding, toxicity, abdo distension or tenderness.

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12
Q

Proctitis:

  1. Define it.
  2. What are the symptoms?
  3. How is it treated?
A
  1. Inflammation of the rectum only.
  2. Frequency, urgency, incontinence, tenesmus. Small volume mucus and blood. Proximal faecal stasis (constipation)
  3. Responds to topical therapy
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13
Q

Acute severe colitis:

  1. T/F: patients look well, self caring and mobilising around ward.
  2. What is the main differential?
A
  1. True. As these patient are young with physiological reserve.
  2. Infectious colitis (e.g. with C. difficile and cytomegalovirus).
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14
Q

How would you manage acute severe colitis in first 24hrs?

A

SPECIALIST GI ASSESSMENT within 24 hours
EARLY SURGICAL REVIEW
PSYCHOLOGICAL SUPPORT
1. IV glucocorticoids
2. !!stool chart!!
3. 3-4 serial stool cultures for C. difficile
4. IV hydration, careful correction of electrolytes as
low potassium or magnesium can precipitate toxic megacolon
5. Give LMWH as 3X increased risk of thromboembolism
6. AXR – toxic dilatation, extent of disease – mucosal oedema, lead pipe, proximal faecal loading
7. AVOID/stop non steroidal analgesics, opiates, anti-diarrhoeal, anti-cholinergic. ASK ABOUT OTT DRUGS

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15
Q

What are the complications of ulcerative colitis?

A
  1. Colonic carcinoma (risk depends on severity and duration of the disease). UC- reactive atypia/ dysplasia
    - Dysplasia classified either high or low grade
    - Flat epithelial atypia > adenomatous change > invasive cancer
  2. Haemorrhage
  3. Perforation
  4. Toxic megacolon (serious complication associated with acute severe colitis). X-ray shows >5.5cm dilation
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16
Q

Crohn’s disease:

  1. What age group does it affect?
  2. What areas does it affect?
  3. T/F: associated with the development of perianal fistulae and fissures.
A
  1. Any age including childhood. Peaks 20-30 years and also 60-70 years. Females > males.
  2. Mouth to anus. Can involve 1 small area of the gut, e.g. terminal ileum, or multiple areas with relatively normal bowel in between (skip lesions).
  3. True
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17
Q

What are the macroscopic changes seen in Crohn’s disease?

A
  • Involved bowel = thickened and narrowed.
  • Deep ulcers and fissures in the mucosa produce a cobblestone appearance.
  • Intra-abdominal fistulae and abscesses may be seen, which reflect penetrating disease.
  • An early feature is aphthoid ulceration in the colon, usually seen at colonoscopy
  • islands of oedematous mucosa (mucosal islands)
  • Granular serosa / dull grey
  • Wrapping mesenteric fat
  • Mesentry- thickened, oedematous and fibrotic
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18
Q

What are the microscopic (histological) changes seen in Crohn’s disease?

A
  • inflammation extends through all layers (transmural) of the bowel - chain of pearls
  • Cryptitis and crypt abscesses
  • Architectural distortion
  • Atrophy –crypt destruction
  • Ulceration-deep
  • Non-caseating granulomas
  • Fibrosis
  • Lymphangiectasia
  • Hypertrophy of mural nerves
  • Paneth cell metaplasia
19
Q

What are the long-term features of Crohn’s disease?

A 
SI – malabsorption 
Strictures
Fistulas and abscesses
Perforation
Increased risk of cancer -  5x increased risk over the same age matched population.
20
Q

What are the clinical features of Crohn’s disease?

A

The clinical presentation of CD is variable, depending on both extent of disease and location of pathology.

  • Diarrhoea
  • Abdominal pain
  • Weight loss.
  • Malaise, lethargy, anorexia, nausea and vomiting, low-grade fever
  • Malabsorption: Anaemia, vitamin deficiency
21
Q

What are the signs of Crohn’s disease?

A 
Pyrexia
Dehydration
Angular stomatitis
Aphthous ulcers
Pallor
Tachycardia 
Hypotension
Abdominal pain, mass and distension
22
Q

How would you investigate Crohn’s disease?

A
  • Bloods for markers of inflammation (ESR, CRP, WBC, platelets elevated)
  • Stool culture to rule out infection if diarrhoea
  • Faecal Calprotectin (0-50ug/g stool=normal, 50-200=equivocal, >200 elevated) – may not be high if just small bowel disease
  • Colonoscopy with terminal ileum intubation and colon/TI mucosal biopsies
  • MRI small bowel study
  • Capsule endoscopy if radiological exam = normal.
  • Occasionally CT scan if acutely unwell and want to rule out complication eg abscess
  • Serological tests may reveal negative perinuclear ANCA (pANCA) and positive ASCA
23
Q

Compare CD and UC histology.

A 
CD = granulomas
Goblet cells depleted in UC
Crypt abscesses: UC > CD
Transmural inflammation in CD
Mucosal in UC
24
Q

Perianal Crohn’s disease:

  1. What does this refer to?
  2. What are physical findings?
  3. What are the symptoms of it?
  4. How would you investigate it?
  5. How would you treat it?
A
  1. Refers to a collection of perianal pathology commonly associated with CD.
  2. Skin tags, fissures, fistulae, abscesses and anal canal stenosis may all be seen.
  3. Perianal pain, Pus secretion, unable to sit down
  4. MRI pelvis. Examination under anaesthetic
  5. Surgery to drain abscess. Medical – antibiotics and biologic therapy (anti-TNF)
25
Q

Name some differentials you want to rule out in a suspected IBD patient.

A
  1. Chronic diarrhoeas: Malabsorption, Malnutrition
  2. Ileo-caecal TB
  3. Colitis must be distinguished from infective, amoebic and ischaemic colitis
26
Q

Outline IBD management in general.

A
  • IBD pharmacist - Therapeutic drug monitoring
  • Nurse led infusion clinic 3/week
  • IBD specialist nurse telephone helpline
  • Shared care GP protocols drugs
  • Direct communication between GP-consultant for advice
  • Dedicated colonoscopy lists for surveillance with chromoendoscopy
  • Weekly IBD MDT – GI consultants/trainees/IBD specialist nurses, colorectal surgeons, radiologist, dietitian, pharmacist
  • Colorectal surgeon with IBD specialist interest
  • Sub-specialty OP clinics 4/week. Proven diagnosis Urgent IBD clinic.
  • 3 specialist IBD nurses
27
Q

What is the aim of management in IBD patients?

A

The aims of management are to induce and then maintain clinical remission and to achieve mucosal healing in order to prevent disease progression and complications.

28
Q

Aminosalicylates (5-ASA):

  1. How do they work?
  2. Name some drugs with 5-aminosalicylic acid (5-ASA)?
  3. Is it effective in Crohn’s?
A
  1. Work by blocking prostaglandins and leukotrienes. Acts topically in the colonic lumen.
  2. Mesalazine (acrylic resin or Ethylcellulose microgranules)
    Pro drugs - Balsalazide, Olzalazine, Sulfasalazine
  3. No - new guidelines
29
Q

What is the 1st line therapy for inducing and maintaining remission in mild to moderate UC?

A

Induction: Aminosalicylates (5-ASA).

  • > 3g per day: No significant improvement in remission rate. Greater and quicker clinical improvement. No increase in adverse events
  • Rectal 5ASA: For distal (proctitis) and left sided disease. Superior to rectal steroids

Maintenance: Aminosalicylates (5-ASA).

  • Reduced number and severity of relapses
  • Reduced UC-related colorectal cancer (CRC) risk (Lifelong therapy with >2g/day)
30
Q
  1. When are steroids indicated for UC?

2. When is Azathioprine (6-Mercaptopurine) indicated in UC?

A
  1. For inducing remissions in patients who don’t respond to 5-ASA or if there are contraindication for use of 5-ASA.
  2. For Maintaining remission in patients who don’t respond to 5-ASA or patients who have had >2 inflammatory exacerbations in 12 months that required steroid therapy.
31
Q

What is the 1st line therapy for inducing and maintaining remission in mild to moderate CD?

A

Inducing remission use steroids:
1. Prednisolone: Optimal dose is 40mg per day. Tapering reduction over 4-6 weeks. Calcium/vit D supplements.
2. Budenoside: Slightly less effective than Prednisolone. Better side effect profile. Ileal and ascending colon disease only
Steroids = many side effects so not suitable for maintenance.

Maintenance: Give Azathioprine (6-Mercaptopurine)

32
Q

What are side effects of immunomodulator Azathioprine (6-Mercaptopurine)?

A
  • Leucopenia
  • Hepatoxicity: Requires Blood Monitoring (Weekly for 8 weeks and then every 8 weeks. Patients must see GP if sore throat/infection)
  • Pancreatitis
  • Possible long term lymphoma risk and non melanoma skin cancers
  • Up to 28% intolerant
  • Can check TPMT to assess suitability/aid dose target
    Thiopurine methyltransferase (TPMT) deficiency is a condition in which patients treated with standard doses of the immunosuppressant azathioprine or the antineoplastic drug 6-mercaptopurine (6-MP) may develop life-threatening myelosuppression or severe hematopoietic toxicity.
33
Q

What is methotrexate used for in CD patients?

A

Unlicensed use for inducing and maintaining remission.
Steroid depended.
Require specialist follow up.

34
Q

Elemental feeding:

  1. T/F: Exclusive elemental feeding can be as effective as steroids.
  2. is more efficacious in which patients?
  3. What are the disadvantages?
A
  1. True
  2. More efficacious in children
  3. Compliance difficult
35
Q

What are the biological treatment strategies for IBD?

A

Target lymphocytes directly
Target single cytokines
Target migration of immune cells to GI mucosa
Target multiple cytokines
Target cytokine intracellular signalling pathways
Modulation of microbiota

36
Q

Which monoclonal antibody (biologics) target migration of immune cells to GI mucosa? How does it work? How is it used in IBD?

A

Vedolizumab:
- Monoclonal humanised antibody to selective GI integrin ‘gut homing’ motif α4β7.
- Blocks migration of leucocytes to intestinal mucosal
Integrins are transmembrane proteins – important in lymphocyte trafficking and cell adhesion.
Give 8 weeks of IV transfusion.

37
Q

Which monoclonal antibody (biologics) target results in multi-cytokine blockade? How does it work? How is it used in IBD?

A

Ustekinumab:
- can also be used for Psoriasis, psoriatic arthropathy
- Towards (blocks) p40 subunit of IL-12 and IL-23.
IL-12 = pro-inflammatory Th1 cytotoxic T cell response. IL-23 = pro-inflammatory Th17 axis, susceptibility gene-GWAS.
IV loading followed by SC 8-12 weekly.

38
Q

Name anti-TNF antibodies used as biologics in IBD.

A

Anti-TNF antibodies:
1. Infliximab (Remicade): 8 weekly IV infusion

  1. Adulimumab (Humira): 2 weekly SC injections
39
Q

Which biologic target results in multi-cytokine blockade through inhibition of intracellular signalling?

A

Tofacitinib:

  • Pan JAK inhibitor (JAK 1 & 3)
  • Inhibits IL-2, IL-7, IL-9, IL-12, IL-15, IL-21, IFN, IL-6, IL-12 and IL-23
40
Q

Is there any microbial targeted therapy for IBD?

A

Trials are on-going. Faecal Microbiota Transplantation was shown to induce clinical remission in ulcerative colitis. However, long term safety is unclear. Also, donor, method of installation and how often FMT should be done = unknown.

41
Q

When is elective and emergency surgery indicated in UC patients?

A

Approximately 25% of patients with UC will have surgery at some stage.
Elective:
- frequent relapses despite medical therapy
- not able to tolerate medical therapy (unacceptable side affects)
- steroid dependant
- patient choice

Emergency:

  • Acute severe colitis (e.g. toxic megacolon) not responding to 72 hours high dose IV steroids +/- anti-TNF biologic ‘rescue’ therapy
  • uncontrolled colonic bleeding, perforation, bowel obstruction secondary to suspected cancer or a fulminant attack refractory to medical therapy.
42
Q

What is the operation of choice in acute UC disease?

A

Total colectomy with end ileostomy and preservation of the rectum.
After total colectomy: perform proctectomy with a permanent ileostomy; to avoid a permanent ileostomy. Also perform an ileo-anal pouch procedure.

43
Q

When is surgery indicated in CD patients?

A

Surgery is common in Crohn’s disease, utilised in 50-80% of cases. Not curative. Indicated when:

  • Failure of medical management
  • Relief of obstructive symptoms (small bowel)
  • Management of fistulae - e.g. bowel to bladder
  • Management of intra-abdominal abscess
  • Management anal conditions
  • Failure to thrive

GI Pathology (20 decks)

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