Abdominal: Inflammatory bowel disease (IBD)

Question 1

what are the two major forms of IBD?

Answer 1

Crohn’s disease

Ulcerative Colitis

Question 2

which type of IBD affects only the colon?

Answer 2

Ulcerative Colitis

Question 3

which part of the bowel does Ulcerative Colitis affect?

Answer 3

only the colon

Question 4

which part of the bowel does Crohn’s disease affect?

Answer 4

can affect any part of the bowel

NB: can affect any part of the GI tract from mouth to anus

Question 5

“skip lesions” are a classical feature of which IBD?

Answer 5

Crohn’s disease

affected areas followed by normal areas of bowel

Question 6

which IBD starts in the rectum and spreads proximally?

Answer 6

Ulcerative Colitis

Question 7

which IBD affects only the. mucosal layer?

Answer 7

Ulcerative Colitis

Question 8

which IBD is deep ulcers and fissures a classical feature of?

Answer 8

Crohn’s disease

Question 9

what do Crohn’s disease and Ulcerative Colitis have in common?

Answer 9

They both involve inflammation of the walls of the GI tract and are associated with periods of remission + exacerbation.

Question 10

what is the largest independent risk factor of IBD?

Answer 10

family history

CD and UC are polygenic diseases

Question 11

what are risk factors of Ulcerative Colitis?

Answer 11

• Family history - HLA-B27 gene.
• Infection.
• NSAIDs use.
• NOT smoking

Question 12

which IBD has an increased risk in non-smokers?

Answer 12

Ulcerative Colitis

There is an increased risk of UC in non- or ex-smokers and nicotine has been shown to be an effective treatment in one small clinical trial.

Question 13

what are risk factors of Crohn’s disease?

Answer 13

• Genetic susceptibility/family history.
• Age; (15-40y or 60-80y) – there is a bimodal age distribution in Crohn’s.
• Smoking
• NSAID ingestion.
• Hygiene; Good domestic hygiene has been shown to be a risk factor for CD. A ‘clean’ environment may not expose the intestinal immune system to pathogenic/non-pathogenic microorganisms.
• Nutrition (high sugar, high fat).
• Chronic stress.
• Depression.

Question 14

which IBD has an increased risk in smokers?

Answer 14

Crohn’s disease

Question 15

which IBD has an increased risk in patients with good hygiene?

Answer 15

Crohn’s disease

Good domestic hygiene has been shown to be a risk factor for CD but not for UC. Poor and large families living in crowded conditions have a lower risk of developing CD. A ‘clean’ environment may not expose the intestinal immune system to pathogenic/non-pathogenic microorganisms such as helminths which seems to alter the balance between effector and regulatory immune responses.

Question 16

what is the general presentation of IBD?

Answer 16

• diarrhoea
• abdominal pain
• weight loss

Question 17

clinical features of ulcerative colitis?

Answer 17

• rectal bleeding
• diarrhoea (with or without blood)
• abdominal pain
• faecal urgency
• Tenesmus
• Fever
• Weight loss
• Constipation
• Skin rash – Patients may have erythema nodosum and pyoderma gangrenosum
• Uveitis/Episcleritis (inflammation of eyes)
• Pallor

Question 18

what is Tenesmus?

Answer 18

persistent, painful urge to pass stool even when the rectum is empty

Question 19

clinical features of Crohn’s disease?

Answer 19

• Chronic diarrhoea
• Right lower quadrant pain (mimicking acute appendicitis)
• Perianal lesions – Skin tags, fistulae, abscesses, scarring or sinuses
• Bowel obstruction – Bloating, distention, cramping abdominal pains, loud borborygmi (gurgling noise made by the stomach or intestines), vomiting, constipation and obstipation
• Fever
• Fatigue
• Abdominal tenderness
• Weight loss
• Oral lesions – Ulcers in the mouth and gums
• Abdominal mass – Terminal ileum inflammation may present as a tender mass in the right lower quadrant

Question 20

which IBD can feature Right lower quadrant pain - mimicking acute appendicitis?

Answer 20

Crohn’s disease

Question 21

Blood and mucus in the stool is a classical feature of which IBD?

Answer 21

ulcerative colitis

Question 22

which other conditions can present in a similar way to IBD?

Answer 22

• Diverticular disease/Diverticulitis.
• Colonic Cancer.
• Gastroenteritis.
• Coeliac disease.
• Infectious Colitis.
• Irritable bowel syndrome.
• Crohn’s disease can present as an emergency with acute right iliac fossa pain mimicking appendicitis.

NB: CD and UC can present as each other.

Question 23

What blood test results would you expect with a PT who has IBD?

Answer 23

Anaemia is common, raised ESR and CRP (iron deficiency in severe attacks).

Question 24

what investigations would you do for a pt with suspected IBD?

Answer 24

• blood test
• stool test
• endoscopy
• colonoscopy

Question 25

How do you induce remission in a patient with the first presentation Crohn’s disease?

Answer 25

Offer prednisolone, methylprednisolone or IV hydrocortisone to induce remission

Question 26

How do you induce remission in a patient with a single inflammatory exacerbation Crohn’s disease?

Answer 26

Offer prednisolone, methylprednisolone or IV hydrocortisone to induce remission

Question 27

How do you induce remission in a patient with a Crohn’s disease if steroids don’t work alone?

Answer 27

Offer prednisolone, methylprednisolone or IV hydrocortisone to induce remission and add an immunosuppressant e.g.

(Azathioprine, Mercaptopurine, Methotrexate, Infliximab, Adalimumab)

Question 28

how do you maintain remission with a pt with Crohn’s disease?

Answer 28

Offer azathioprine or mercaptopurine to maintain remission.

Question 29

how do you maintain remission with a pt with Crohn’s disease who. can not tolerate azathioprine or mercaptopurine?

Answer 29

Consider using methotrexate

Question 30

true or false, surgery cures Crohn’s disease.

Answer 30

false

The benefits of surgery for Crohn’s disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. The best approach is to follow surgery with medication - maintain with azathioprine and metronidazole.

Question 31

How do you induce remission in a patient with ulcerative colitis?

Answer 31

depends on severity:

mild to moderate - First-line – Aminosalycilate (Mesalazine), Second-line – Corticosteroids (Prednisolone).

severe - First-line – IV corticosteroids (Hydrocortisone), Second-line – IV Ciclosporin

Question 32

How do you induce remission in a patient with mild to moderate ulcerative colitis?

Answer 32

First-line – Aminosalycilate (Mesalazine), Second-line – Corticosteroids (Prednisolone).

Question 33

How do you induce remission in a patient with severe ulcerative colitis?

Answer 33

First-line – IV corticosteroids (Hydrocortisone), Second-line – IV Ciclosporin

Question 34

which surgery could be performed for a pt with ulcerative colitis?

Answer 34

Removing the colon + rectum (panproctocolectomy)

NB: curative

Question 35

what is the down side of performing a panproctocolectomy to cure ulcerative colitis?

Answer 35

The patient will then be left with either a permanent ileostomy or ileo-anal anastomosis (J-pouch).

Question 36

what other medications may you consider advising a pt with IBD?

Answer 36

• anti-diarrheal
• pain killers (paracetamol not ibuprofen/NSAIDs)
• calcium/vit D supplements (steroids used to treat it can inc risk of osteoporosis)
• iron supplements for anaemic patients

Question 37

what are some complications of IBD if left untreated?

Answer 37

• Colon cancer.
• Primary sclerosing cholangitis.
• Increased risk of blood clots.
• Bowel obstruction.
• Malnutrition.
• Ulcers.
• Fistulas.
• Anal fissure.
• Dehydration (due to severe diarrhoea).
• Perforated colon.
• Osteopenia.