6 IBD and Celiac Disease Flashcards
1
Q
Chronic relapsing/remitting inflammatory conditions of the GI tract
A
Inflammatory Bowel Disease
Includes both Crohn Disease and Ulcerative Colitis
2
Q
The pathophysiology of IBD is…
A
Multifactorial
Immunologic
Genetic
Environmental
3
Q
IBD primarily affects _____ y.o., but prevalence is bimodal with a second peak at _______ years
A
15-35 yo
50-80 yo
4
Q
_____ is more common in men, and _____ is more common in women
A
Men = UC Women = CD
5
Q
IBD is more common in patients of ______ ancestry
A
Caucasian and Jewish
6
Q
Smoking increases your risk in _____ but decreases your risk in _____
A
Increased in CD
Decreased in UC
7
Q
Crohn Disease or Ulcerative Colitis:
Mouth to anus involvement
A
CD
8
Q
Crohn Disease or Ulcerative Colitis:
Patchy/skip lesions
A
CD
9
Q
Crohn Disease or Ulcerative Colitis:
Transmural inflammation
A
CD
10
Q
Crohn Disease or Ulcerative Colitis:
Limited to colon, involves rectum
A
UC
11
Q
Crohn Disease or Ulcerative Colitis:
Extends proximally with continuous circumferential involvement
A
UC
12
Q
Crohn Disease or Ulcerative Colitis:
Mucosal layer inflammation
A
UC
13
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)
14
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
15
Q
Bowel to bowel fistula
A
Enteroenteric
16
Q
Bowel to bladder fistula
A
Enterovesical
17
Q
Bowel to vagina fistula
A
Enterovaginal
18
Q
Bowel to skin fistula
A
Enterocutaneous
19
Q
CD presentation is considered:
Mild if ________
Moderate if ________
Severe if ________
A
Mild = inflammation
Moderate = inflammation + strictures
Severe = inflammation, strictures + fistula
20
Q
Onset in CD is ______
A
Insidious, and the disease course is usually intermittent
May alternate between exacerbation and relative remission
21
Q
What is tenesmus?
A
Anal quivering
22
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*)
23
Q
Extra-intestinal manifestations of CD
A
Oral aphthous ulcers Episcleritis, iritis, uveitis Erythema nodosum Pyoderma gangrenous ARTHRALGIAS*****(most common)
24
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
25
In what patients should you NOT perform a capsule endoscopy?
Those with suspected intestinal stricture
26
Colonoscopy findings in CD
```
SKIP LESIONS
ULCERATIONS, COBBLESTONING
Possible fistulas
RECTAL SPARING in most patients
Biopsy shows GRANULOMAS (30% of pts) and chronic inflammation
```
27
If you do CT or MR enterography on a CD patient, what will you see?
Detects mucosal inflammation, strictures, abscesses, and fistulas
28
If you do an UGI with SBFT (small bowel follow through) on a CD patient, what will you see?
STRING SIGN*****
29
Complications of CD
COLON CANCER*****
Intestinal strictures, abdominal and perianal fistulas, abscesses
Small bowel obstruction and perforation***
Malabsorption*** (esp Fe, B12)
30
When should colonoscopy’s be performed on CD patients
At diagnosis and every 1-2 years beginning 8 years after disease/symptom onset
31
Extent and severity of UC
Affects the COLON ONLY, in a continuous, CIRCUMFERENTIAL pattern
32
UC affecting the rectum only
Ulcerative proctitis
33
UC affecting the rectum and sigmoid colon
Ulcerative proctosigmoiditis
34
UC extending to but not beyond the splenic flexure
Left-sided/distal UC
35
UC extending beyond splenic flexure but not to cecum
Extensive colitis
36
UC that extends all the way to the cecum
Pancolitis
37
UC affects the _______ only
Mucosal surface of the colon - can cause friability, erosions, and bleeding
38
UC is considered:
Mild if _______
Moderate if ______
Severe if _______
Mild = <4 stools daily, no systemic toxicity
Moderate = >4 stools daily, anemia, low grade fever
Severe = >6 stools daily, systemic toxicity
39
Onset of UC
Insidious, usually intermittent
May alternate between exacerbation and relative remission
40
Clinical presentation of UC
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
```
41
Extra-intestinal manifestations of UC
```
Episcleritis, iritis, uveitis
Erythema nodosum
Pyoderma gangrenous
SCLEROSING CHOLANGITIS (Alk phos)*****
ARTHRALGIAS********(most common)
```
42
Diagnosis of UC is via...
Flex sigmoidoscopy or COLONOSCOPY*******
Can also do CT A/P if abscess concerns
43
What will you see on colonoscopy in patients with UC?
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*****
44
Complications of UC
COLON CANCER*******
Hemorrhage
TOXIC MEGACOLON*** Rare but high mortality
• Colonic dilation >6 cm with signs of toxicity
45
When should a patient with UC get a colonoscopy?
At diagnosis and every 1-2 years beginning 8 years after disease/symptom onset
46
The goals of IBD therapy are to...
Achieve remission
Maintain remission
Improve QOL
Treatment is based on extent and severity of disease
47
What are the different medical therapy options for IBD?
Salicylates (5-ASA)
Corticosteroids
Immunomodulators (6 MP, Azathiopurine, Methotrexate)
Biological (Anti-TNFs, others)
Antibiotics for CD (b/c infected perianal disease)
48
______ therapy is appropriate for low-risk IBD patients with mild disease
Step-up
Start with 5-ASA (and abx if infection in CD), then steroids —> immunosuppressants —> biologics —> surgery
49
______ therapy is appropriate for high-risk IBD patients with moderate to severe disease
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
50
MOA and indications for 5-ASA
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
51
Side effects of 5-ASA
Nausea
Diarrhea
Kidney injury***
Pancreatitis
52
UC limited to the rectum can be treated with ...
Canasa suppository (topical 5-ASA)
53
Left-sided UC can be treated topically with...
Rowasa enema (5-ASA)
54
How do corticosteroids work in IBD?
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
55
Corticosteroid options in IBD
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
56
Side effects of oral prednisone
```
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
57
How do immunomodulators work in the treatment of IBD?
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
58
What are the different options for immunomodulators in treating IBD?
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
59
Pt ed for any male or female patient on methotrexate
If planning to become pregnant, must be off methotrexate for at least six months before conception - incredibly teratogenic
60
Systemic risks of 6MP/Azathiopurine
```
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
61
Why do patients on 6MP need to make sure they are up to date on cervical cancer screenings?
Risk of HPV-related cervical dysplasia
62
How do Biologics work in treating IBD?
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
63
Which biologic has a risk of infusion reaction?
Infliximab (Remicade) - because it’s the only one that is IV infusion
64
Biologics are effecting in treating IBD but...
Can be associated with decreased or lost response - therefore, you should utilize “therapeutic drug monitoring” to help guide decision making
65
______ can treat UC and CD but _____ is for UC only and _____ is for CD only
Adalimumab (Humira) = UC and CD
Golimumab (Simponi) = UC only
Certolizumab (Cimzia) = CD only
66
Systemic risks of biologics
Secondary infections
Risk of reactivation of TB or HBV ***** SCREEN YOUR PATIENTS
Malignancies
• Non-melanoma skin cancer
• Non-Hodgkin lymphoma
67
Biologics are contraindicated in ...
Those with active infection
History of CHF
MS/optic neuritis
68
Abx options for CD patients with acute disease (perianal fistulas, abscesses)
Ciprofloxacin or Metronidazole
69
Side effects of Cipro
Tendinitis (tendon rupture)
Photosensitivity
Prolongation of QT interval
70
Side effects of Metronidazole
Peripheral neuropathy
Metallic taste
Disulfiram rxn (avoid EtOH while on therapy and 3 days after)
71
Red flags for IBD patients
Severe bleeding or significant anemia
Severe abdominal pain (peritoneal signs)
Inability to tolerate PO
Signs of dehydration (inc Cr, tachycardia, hypotension)
Signs of obstruction
72
Indications for surgery in IBD patients
Severe hemorrhage
Perforation
Dysplasia/cancer
Medical refractory disease
73
As a primary care provider, what do you always want to check in IBD patients?
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
```
74
Celiac disease is classically a disease of _______, but now more frequently presents in ________.
Infancy
10-40 yo now more common
75
Immune-mediated disease triggered by the ingestion of gluten in genetically susceptible individuals
Celiac disease
Gluten acts as a toxin to the small intestine
76
What foods contain gluten?
Wheat, rye, barley
77
What happens when a patient with celiac disease is exposed to gluten?
Mucosal inflammation, crypt hyperplasia —> villous atrophy**** of small intestine —> loss of absorptive surface capacity and small bowel malabsorption
78
Genetic predisposition to celiac disease
HLA DQ2
HLA DQ8
Also those with autoimmune disease (DM, thyroid disease) and Down syndrome
79
Clinical manifestations of Celiac disease
“Classic” malabsorption symptoms
• Diarrhea, steatorrhea, flatulence/bloating, weight loss
“Atypical” GI Sx
• Abdominal pain, constipation, dyspepsia
Silent - may present with extra-intestinal manifestations
80
Extra-intestinal manifestations of celiac disease
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)
81
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
Dermatitis Herpetiformis
Associated with Celiac
82
How is Celiac Disease diagnosed?
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****
83
What will EGD show in patients with celiac disease
Intraepithelial lymphocytes
Crypt hyperplasia
VILLOUS ATROPY
Make sure to get duodenal biopsy with the EGD
84
What is the primary method of management in celiac disease?
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)
85
Complications of celiac disease
Disease associated malabsorption
• Fe deficiency anemia
• B vitamin deficiency
• Osteoporosis (screening DEXA)
Slight increased risk of malignancy (Non-Hodgkin lymphoma and GI malignancies)
