2) IBD

Question 1

Who is UC more common in?

Answer 1

M=F
15-30yo common age of presentation
More common in non smokers(3x)

Question 2

Pathology of UC?

Answer 2

Hyperaemic/hemorrhagic granular colonic mucosa, w/wo psudopolyp formation from inflammation
Ulcers may extend to lamina propria
inflammation is NOT transmural

Question 3

Where does UC affect?

Answer 3

Rectum- Proctitis
Colon- Left sided colitis
Up to ileocaecal valve- pan colitis
Doesnt go past this

Question 4

Symptoms of UC?

Answer 4

Chronic or episodic diarrhoea +/- blood and mucus
Abdo discomfort- bowel frequency relates to severity
Urgency/tenesmus in rectal UC
Malaise, annorexia, wt loss

Question 5

Signs of UC?

Answer 5

May be none, may be fever, tachycardia and distended abdo

Question 6

Extraintestinal features of UC?

Answer 6

Clubbing, erythema nodosum, pyoderma granulosum, apthous oral ulcers, episcleritis, uveitis, sacroilitis, ank spond, psc, cholangiocarcinoma

Question 7

Tests in UC?

Answer 7

Bloods
Stool MC S to exclude infective 
AXF- mucosal thickening, dilatation
CXR- Can show perforation, 
Colonoscopy- extent of disease, allows biopsy look for goblet cell depletion, glandular distortion, mucosal ulcers, crypt abscesses

Question 8

Complications of UC?

Answer 8

Perforation/bleeding
Toxic dilation (>6cm, mucosal islands)
Ca- survey every 2-4 yr
venous thrombosis- use propylaxis

Question 9

How to induce remission in UC?

Answer 9

Mild- 5ASA and pred 20mg with steroid foam PR

Mod- 5ASA and oral pred 40mg for a week, 30, then 20 for 4.

Severe: NBM and IV fluids
100mg hydro IV
Rectal steroids
Monitor regularly, 2x exam a day
Daily Bloods

If not responding after 2 weeks treat as the severity above

Question 10

How is severity determined?

Answer 10

Mild: <4 stools, little blood, apyrexial, low pulse, hb fine and low ESR

Severe: 8 stools, lots of blood, fever, tachy, Hb <105 and ESR>30

mod inbetween

Question 11

Which topical therpay works best?

Answer 11

5ASA over steroids

Question 12

Treatment for pouchitis?

Answer 12

Metronidozole+cipro+immune modulation for 2 weeks

Question 13

Criteria for further action in severe UC?

Answer 13

day 3 CRP> 43 or bowels opening 6-8x

colectomy or ciclosporin/infliximab can help avoid immediate

Question 14

Inidcations for surgery in uC?

Answer 14

Perforation
toxic dilation
haemorrhage
failed medical therapy

Question 15

If steroids do not induce remission in UC?

Answer 15

Azathioprine and other immunosupressants can help

Question 16

Long term remission in UC?

Answer 16

5ASA are good, sulfasalazine 500mg/6h

Question 17

Side effects of sulfasalazine?

Answer 17

headache, nausea, annorexia
rash, temp, haemolysis (check at 3 mo and annually)
oligospeermia, hepatitis, pancreatitis, can worsen

Question 18

Indications for use of newer 5asa? (osalazine, mesalazine)

Answer 18

Man with fertility concerns

allergy/intolerance to sulpha drugs

Question 19

Who gets crohns?

Answer 19

Male=female
smokers 3-4X risk
Not asian pop.

Question 20

Pathology in crohns?

Answer 20

Transmural granulomatous inflammation, anywhere mouth-anus, esp. terminal ileum. Unlike UC get skip lesions

Question 21

Symptoms of crohns?

Answer 21

diarrhoea, pain, wt loss, fever, malaise, annorexia

Question 22

Signs of crohns?

Answer 22

apthous ulceration, abdo tenderness/mass, perianal abscess, fistulae, skin tags, anal strictures

Question 23

Complications of crohns?

Answer 23

Small bowel obstruction, abscess, toxic dilation (rarer than UC) fistulae, perf, haemorrhage osteomalacia, fatty liver, malnutrition

Question 24

Tests in crohns?

Answer 24

Bloods: All, ferritin, folate, TIBC
Stool: exclude infection
colonoscopy and biopsy- even if mucosa loooks normal
20% have microscopic granuloma

Question 25

Rx of crohns?

Answer 25

Help quit smoking, optimise nutrition

Mild attack: pred 30mg 1wk, 20mg 4wk, then drop by 5 a week

Severe: admit and NBM and Fluids
-100mg IV hydro
-monitor daily w/bloods
consider transfusion need
if no improvement after 5 days try infliximab/adalimumab

Question 26

rx of perianal disease in crohns?

Answer 26

Abx and immunosuppression and surgery

Question 27

Additional therapy options in crohns?

Answer 27

Steroids are disappointing long term
azathioprine is steroid sparing but takes 6-10 weeks
TNFa inhib are promising, C/I in sepsis, concurrent ciclo/tac
TB may reactivate
MTX can be good (C/I in pregnancy)
50-80% will need an op, it is not curative

Question 28

Indications for surgery in crohns?

Answer 28

drug failure, gi obstruction, fistulae

Question 29

Poor prognostic factors in crohns?

Answer 29

<30
steroids needed first presentation
perianal disease
diffuse small bowel disease