chronic bowel disorder

Question 1

coeliac disease management

Answer 1

autoimmune disease that causes an immune response in intestinal mucosa

associated with gluten, wheat, barley, rye

can cause malabsorption of nutrients

management:
symptoms - abdominal pain, bloating,
malnutrition - give vit D, calcium etc.
- gluten free diet to avoid complications such as osteoporosis, malnutrition, cancer

Question 2

diverticular disease and diverticulitis

Answer 2

conditions that affect large intestine, bowel - cause abdominal pain
- caused by small pouches in wall of intestine called diverticula

diverticulosis - small pouches but asymptomatic

diverticular disease - small pouches and symptomatic - constipation, diarrhoea, abdominal pain, rectal bleed

treat with fibre, bulk forming laxatives, paracetamol, anti-spasmodics if needed

diverticulitis - when pouches become inflamed/infected

complicated diverticulitis - abscess, fistula, perforation, obstruction, sepsis, haemorrhage

Question 3

crohn’s disease management

Answer 3

CD - affects whole GIT, associated with thickened walls extending through all layers + deep ulceration

complications:
intestinal stricture or fistulae
anaemia and malnutrition
colorectal or small bowel cancer

acute:
1 flare up in 12 month period
- pred, methylpred or IV hydrocortisone
- if distal ileal or right sided - budesonide can be used if others dont work

aminosalicylates can be used - less S.E but less effective

2+ flares within 12 month period
- add on azathioprine/mercaptopurine
- methotrexate if aza/merc c/i
- severe: monoclonal antibodies

maintenance:
- smoking cessation
- monotherapy with azathioprine/mercaptopurine
- methotrextate
after surgery: azathioprine + metronidazole

when diarrhoea associated:
loperamide, codeine, colestyramine
- can use loperamide + codeine in CD not UC

fistulating CD:
- when fistula develops b/w intestine and perianal skin, bladder or vagina

• for symptoms - not fully heal - metronidazole +/- ciprofloxacin
• metro usually given for 1 month (no more than 3 months due to peripheral neuropathy)
• maintenance with azathioprine/mercaptopurine (infliximab if not responding)
• treatment must last at least 1 year

Question 4

UC

Answer 4

UC - can affect rectum to whole of colon
- associated with bloody diarrhoea, defeaecation urgency, abdominal pain
- most common in 15-25 year olds
- complications such as colorectal cancer, secondary osteoporosis, VTE, toxic megacolon

types:
proctitis
proctosigmoiditis
distal/left sided
extensive colitis
pancolitis

UC follows a continuous pattern, whereas CD is patchy

Question 5

UC acute treatment (mild to moderate)

Answer 5

proctitis - distal - topical preparations

extensive - systemic needed

diarrhoea - avoid loperamide + codeine - can cause toxic megacolon

proctitis:
1 - topical aminosalicylate
2- if no improvement in 4 weeks - add oral aminosalicylate
3 - still no improvement - topical or oral corticosteroids for 4-8 weeks

Pt can use oral aminosalicylate as 1st line if preferred (less effective)

proctosigmoiditis/left sided UC:
1 - topical aminosalicylate
2 - add high dose oral aminosalicylate if no improvement in 4 weeks OR high dose oral aminosalicyate + topical corticosteroids for 4-8 weeks
3 - stop topical - high dose oral aminosalicylate + oral corticosteroid for 4-8 weeks

extensive colitis:
1 - topical aminosalicyate + high dose oral aminosalicylate
2 - if no improvement in 4 weeks - stop topical - high dose oral amino + oral corticosteroid for 4-8 weeks

severe:
life-threatening, medical emergency
- IV hydrocortisone or methylpred - assess need for surgery
- if steroids c/i - IV ciclosporin, Infliximab

Question 6

UC maintenance treatment

Answer 6

oral aminosalicylate recommended
- corticosteroid not suitable due to s.e

proctitis/proctosigmoiditis - topical +/- oral aminosal

left sided/extensive - low dose oral aminosal

2+ flare ups in 12 month period
- oral azathioprine or mercaptopurine
- monoclonal antibodies if no effect

Question 7

imp points for aminosalicylates

Answer 7

sulfasalazine, mesalazine, olsalazine, balsalazide

nephrotoxic - monitor at initiation, at 3 months, then annually
hepatotoxic - monthly for first 3 months
blood disorders - monthly for first 3 months

c/i in salicylate hypersensitivity
sulfasalazine stains contact lenses orangey-yellow