6 IBD and Celiac Disease Flashcards by Hannah Frank | Brainscape

Q

Chronic relapsing/remitting inflammatory conditions of the GI tract

A

Inflammatory Bowel Disease

Includes both Crohn Disease and Ulcerative Colitis

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Q

The pathophysiology of IBD is…

A

Multifactorial

Immunologic
Genetic
Environmental

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Q

IBD primarily affects _____ y.o., but prevalence is bimodal with a second peak at _______ years

A

15-35 yo

50-80 yo

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Q

_____ is more common in men, and _____ is more common in women

A

Men = UC
Women = CD

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Q

IBD is more common in patients of ______ ancestry

A

Caucasian and Jewish

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Q

Smoking increases your risk in _____ but decreases your risk in _____

A

Increased in CD

Decreased in UC

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Q

Crohn Disease or Ulcerative Colitis:

Mouth to anus involvement

A

CD

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Q

Crohn Disease or Ulcerative Colitis:

Patchy/skip lesions

A

CD

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Q

Crohn Disease or Ulcerative Colitis:

Transmural inflammation

A

CD

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Q

Crohn Disease or Ulcerative Colitis:

Limited to colon, involves rectum

A

UC

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Q

Crohn Disease or Ulcerative Colitis:

Extends proximally with continuous circumferential involvement

A

UC

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Q

Crohn Disease or Ulcerative Colitis:

Mucosal layer inflammation

A

UC

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Q

Extent and severity of inflammation in CD

A

Can affect the entire GI tract from mouth to anus with skip lesions**

Apthous ulcers in mouth

Most common location = ileum (ileitis)

Terminal ileum + proximal ascending colon = ileocolitis

Colon = colitis

Perianal disease (abscess, fistula)

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Q

Crohn’s disease is _______, meaning it effects the entire thickness of the mucosa

A

Transmural

Owes to penetrating disease - can cause ulcers, strictures, fistulas, and abscesses

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Q

Bowel to bowel fistula

A

Enteroenteric

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Q

Bowel to bladder fistula

A

Enterovesical

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Q

Bowel to vagina fistula

A

Enterovaginal

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Q

Bowel to skin fistula

A

Enterocutaneous

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Q

CD presentation is considered:

Mild if ________
Moderate if ________
Severe if ________

A

Mild = inflammation

Moderate = inflammation + strictures

Severe = inflammation, strictures + fistula

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Q

Onset in CD is ______

A

Insidious, and the disease course is usually intermittent

May alternate between exacerbation and relative remission

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Q

What is tenesmus?

A

Anal quivering

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Q

Clinical presentation of CD

A

+/- fever, chills, fatigue, weight loss
+/- N/V
ABDOMINAL PAIN - RLQ**
Tender, palpable RLQ mass if abscess
+/- intermittent diarrhea (often nocturnal)
+/- fecal urgency, tenesmus, rectal bleeding
+/- perianal pain with evidence of fissure, abscess, or fistula
+/- iron deficiency anemia
+/- B12 deficiency (if TI involvement*)

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Q

Extra-intestinal manifestations of CD

A

Oral aphthous ulcers
Episcleritis, iritis, uveitis
Erythema nodosum
Pyoderma gangrenous
ARTHRALGIAS*****(most common)

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Q

What is the best way to diagnose CD?

A

Colonoscopy with TI intubation
+/- EGD

Other imaging options:
CT or MR enterography
UGI with SBFT
Capsule endoscopy

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Q

In what patients should you NOT perform a capsule endoscopy?

A

Those with suspected intestinal stricture

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Q

Colonoscopy findings in CD

A

SKIP LESIONS
ULCERATIONS, COBBLESTONING
Possible fistulas
RECTAL SPARING in most patients
Biopsy shows GRANULOMAS (30% of pts) and chronic inflammation

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Q

If you do CT or MR enterography on a CD patient, what will you see?

A

Detects mucosal inflammation, strictures, abscesses, and fistulas

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Q

If you do an UGI with SBFT (small bowel follow through) on a CD patient, what will you see?

A

STRING SIGN*****

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Q

Complications of CD

A

COLON CANCER*****

Intestinal strictures, abdominal and perianal fistulas, abscesses

Small bowel obstruction and perforation***

Malabsorption*** (esp Fe, B12)

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Q

When should colonoscopy’s be performed on CD patients

A

At diagnosis and every 1-2 years beginning 8 years after disease/symptom onset

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Q

Extent and severity of UC

A

Affects the COLON ONLY, in a continuous, CIRCUMFERENTIAL pattern

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Q

UC affecting the rectum only

A

Ulcerative proctitis

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Q

UC affecting the rectum and sigmoid colon

A

Ulcerative proctosigmoiditis

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Q

UC extending to but not beyond the splenic flexure

A

Left-sided/distal UC

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Q

UC extending beyond splenic flexure but not to cecum

A

Extensive colitis

Q

UC that extends all the way to the cecum

A

Pancolitis

Q

UC affects the _______ only

A

Mucosal surface of the colon - can cause friability, erosions, and bleeding

Q

UC is considered:

Mild if _______
Moderate if ______
Severe if _______

A

Mild = <4 stools daily, no systemic toxicity

Moderate = >4 stools daily, anemia, low grade fever

Severe = >6 stools daily, systemic toxicity

Q

Onset of UC

A

Insidious, usually intermittent

May alternate between exacerbation and relative remission

Q

Clinical presentation of UC

A

COLON ONLY, CONTINUOUS PATTERN, MUCOSAL LAYER

\+/- fever, chills, fatigue, weight loss
\+/- N/V
ABDOMINAL PAIN - PERIUMBILICAL/LLQ******
Blood diarrhea
Fecal urgency, tenesmus, rectal bleeding
Constipation (if proctitis)
\+/- iron deficiency anemia

Q

Extra-intestinal manifestations of UC

A

Episcleritis, iritis, uveitis
Erythema nodosum
Pyoderma gangrenous
SCLEROSING CHOLANGITIS (Alk phos)*****
ARTHRALGIAS********(most common)

Q

Diagnosis of UC is via…

A

Flex sigmoidoscopy or COLONOSCOPY***

Can also do CT A/P if abscess concerns

Q

What will you see on colonoscopy in patients with UC?

A

Inflammation that begins DISTALLY, spreads proximally

CONTINUOUS, CIRCUMFERENTIAL pattern, no skip lesions

Loss of vascular markings

Superficial inflammation: ERYTHEMATOUS, EXUDATE, FRIABILITY/EROSIONS

Strictures rare

Biopsy shows CRYPT ABSCESSES*****

Q

Complications of UC

A

COLON CANCER***

Hemorrhage

TOXIC MEGACOLON*** Rare but high mortality
• Colonic dilation >6 cm with signs of toxicity

Q

When should a patient with UC get a colonoscopy?

A

At diagnosis and every 1-2 years beginning 8 years after disease/symptom onset

Q

The goals of IBD therapy are to…

A

Achieve remission
Maintain remission
Improve QOL

Treatment is based on extent and severity of disease

Q

What are the different medical therapy options for IBD?

A

Salicylates (5-ASA)
Corticosteroids
Immunomodulators (6 MP, Azathiopurine, Methotrexate)
Biological (Anti-TNFs, others)
Antibiotics for CD (b/c infected perianal disease)

Q

______ therapy is appropriate for low-risk IBD patients with mild disease

A

Step-up

Start with 5-ASA (and abx if infection in CD), then steroids —> immunosuppressants —> biologics —> surgery

Q

______ therapy is appropriate for high-risk IBD patients with moderate to severe disease

A

Step-down therapy

Get on it early to prevent disease

Start with a biological or immunosuppressant and relax to steroids or 5-ASA once in remission

Q

MOA and indications for 5-ASA

A

Anti-inflammatory for mild to moderate UC (less efficacy in CD)

Examples:
Sulfasalazine (take with folic acid)
Mesalamine (Asacol, April’s, Lialda, Pentasa are all oral, there are also topical formulations

Q

Side effects of 5-ASA

A

Nausea
Diarrhea
Kidney injury***
Pancreatitis

Q

UC limited to the rectum can be treated with …

A

Canasa suppository (topical 5-ASA)

Q

Left-sided UC can be treated topically with…

A

Rowasa enema (5-ASA)

Q

How do corticosteroids work in IBD?

A

Anti-inflammatory effects and suppress immune system activity

Good for FLARES in IBD, for short-term use (NOT maintenance)

Should have an exit strategy, and slowly taper to prevent adrenal insufficiency

Q

Corticosteroid options in IBD

A

Oral prednisone (caution - systemic side effects)

Oral Budesonide (less systemic effects)
• Entocort for ileocecal CD
• Uceris for UC

Hydrocortisone suppositories, enemas, and foams for distal colonic disease

Q

Side effects of oral prednisone

A

MOOD CHANGES
INSOMNIA
WEIGHT GAIN
Worsening of DM
Increased infection risk
Osteoporosis
Cataracts
Psychosis
Adrenal insufficiency

Consider DEXA scan if ≥3 months of use

Consider Ca and Vit D supplements

Q

How do immunomodulators work in the treatment of IBD?

A

Modifies immune system activity —> decreased inflammatory response

Can be used in moderate to severe UC/CD

Is considered a steroid sparing agent, and can be combined with biologics to prevent immunogenicity

Q

What are the different options for immunomodulators in treating IBD?

A

6-Mercaptopurine (6-MP), Imuran (Azathiopurine)
• Optimal response takes 3-6 months
• Genetic testing necessary to determine pt metabolism of drug
• Systemic risks

Methotrexate
• REQUIRES FOLATE SUPPLEMENTATION
• TERATOGENIC

Q

Pt ed for any male or female patient on methotrexate

A

If planning to become pregnant, must be off methotrexate for at least six months before conception - incredibly teratogenic

Q

Systemic risks of 6MP/Azathiopurine

A

Bone marrow suppression
Secondary infection
Pancreatitis
Hepatotoxicity
Non-Hodgkin lymphoma
HPV related cervical dysplasia*****
Non-melanoma skin cancer****

Frequent monitoring of CBC and LFTs, annual derm exams and UTD cervical CA screening

Q

Why do patients on 6MP need to make sure they are up to date on cervical cancer screenings?

A

Risk of HPV-related cervical dysplasia

Q

How do Biologics work in treating IBD?

A

Modulates immune response —> prevents intestinal inflammation —> improved mucosal healing

Indicated for moderate to severe IBD - steroid sparing

May be given as monotherapy or in combo with thiopurines

Q

Which biologic has a risk of infusion reaction?

A

Infliximab (Remicade) - because it’s the only one that is IV infusion

Q

Biologics are effecting in treating IBD but…

A

Can be associated with decreased or lost response - therefore, you should utilize “therapeutic drug monitoring” to help guide decision making

Q

______ can treat UC and CD but _____ is for UC only and _____ is for CD only

A

Adalimumab (Humira) = UC and CD

Golimumab (Simponi) = UC only

Certolizumab (Cimzia) = CD only

Q

Systemic risks of biologics

A

Secondary infections

Risk of reactivation of TB or HBV ***** SCREEN YOUR PATIENTS

Malignancies
• Non-melanoma skin cancer
• Non-Hodgkin lymphoma

Q

Biologics are contraindicated in …

A

Those with active infection

History of CHF

MS/optic neuritis

Q

Abx options for CD patients with acute disease (perianal fistulas, abscesses)

A

Ciprofloxacin or Metronidazole

Q

Side effects of Cipro

A

Tendinitis (tendon rupture)

Photosensitivity

Prolongation of QT interval

Q

Side effects of Metronidazole

A

Peripheral neuropathy

Metallic taste

Disulfiram rxn (avoid EtOH while on therapy and 3 days after)

Q

Red flags for IBD patients

A

Severe bleeding or significant anemia

Severe abdominal pain (peritoneal signs)

Inability to tolerate PO

Signs of dehydration (inc Cr, tachycardia, hypotension)

Signs of obstruction

Q

Indications for surgery in IBD patients

A

Severe hemorrhage
Perforation
Dysplasia/cancer
Medical refractory disease

Q

As a primary care provider, what do you always want to check in IBD patients?

A

Stool studies for those with diarrhea (look for INFECTIONS)

Monitor NSAID use - can exacerbate disease activity

Also:
• Ensure follow-up compliance with GI
• ID pt at risk for infection
• Immunizations UTD
• Can screening
• Osteoporosis screening
• Anxiety/depression screening
• smoking cessation
• Routine lab monitoring

Q

Celiac disease is classically a disease of _______, but now more frequently presents in ________.

A

Infancy

10-40 yo now more common

Q

Immune-mediated disease triggered by the ingestion of gluten in genetically susceptible individuals

A

Celiac disease

Gluten acts as a toxin to the small intestine

Q

What foods contain gluten?

A

Wheat, rye, barley

Q

What happens when a patient with celiac disease is exposed to gluten?

A

Mucosal inflammation, crypt hyperplasia —> villous atrophy** of small intestine —> loss of absorptive surface capacity and small bowel malabsorption

Q

Genetic predisposition to celiac disease

A

HLA DQ2
HLA DQ8

Also those with autoimmune disease (DM, thyroid disease) and Down syndrome

Q

Clinical manifestations of Celiac disease

A

“Classic” malabsorption symptoms
• Diarrhea, steatorrhea, flatulence/bloating, weight loss

“Atypical” GI Sx
• Abdominal pain, constipation, dyspepsia

Silent - may present with extra-intestinal manifestations

Q

Extra-intestinal manifestations of celiac disease

A

Nutrient deficiencies (iron, B vitamins)
Osteopenia/osteoporosis (Vit D and Ca deficiencies)
Transaminase elevations
DERMATITIS HERPETIFORMIS**
Neuropsychiatric symptoms
In kids, FTT
Reproductive disorders (infertility, miscarriages)

Q

Chronic inflammatory disease that produces lesions that burn and itch intensely. Lesions are erythematous and may be slightly popular, form small pustules, or there may be vesicles

A

Dermatitis Herpetiformis

Associated with Celiac

Q

How is Celiac Disease diagnosed?

A

Serology AND biopsy of the small intestine WHILE ON A GLUTEN CONTAINING DIET

IgA tissue transglutaminase (tTG Ab) = primary test
IgA endomysial (EMA Ab titer)
Deamidated Gliadin Peptide (DGP)

EGD with duodenal biopsy is GOLD STANDARD**

Q

What will EGD show in patients with celiac disease

A

Intraepithelial lymphocytes
Crypt hyperplasia
VILLOUS ATROPY

Make sure to get duodenal biopsy with the EGD

Q

What is the primary method of management in celiac disease?

A

GLUTEN FREE DIET (removal of wheat, rye, barley)

Be cautious of additives, sauces, dressings, gravies, marinades

Also, hidden sources in cosmetics and medications

Supplement as needed (folate, iron, zinc, calcium, B12, D)

Q

Complications of celiac disease

A

Disease associated malabsorption
• Fe deficiency anemia
• B vitamin deficiency
• Osteoporosis (screening DEXA)

Slight increased risk of malignancy (Non-Hodgkin lymphoma and GI malignancies)