Clinical Aspects of IBD and Irritable Bowel Syndrome - IBS

Question 1

What are the terms in ulcerative colitis when you have involvement of each of the following areas:

1. Rectum only
2. Rectum and sigmoid colon
3. Left colon entirely
4. Entire colon

Answer 1

1. Rectum only - proctitis
2. Rectum and sigmoid colon - proctosigmoiditis
3. Left colon entirely - left-sided colitis or subtotal colitis
4. Entire colon - pancolitis or universal colitis

Question 2

What type of IBD is more associated with tenesmus and bleeding?

Answer 2

Tenesmus - urgency / straining - more associated with ulcerative colitis due to rectal involvement

Bleeding - more common in ulcerative colitis due to rectal involvement, but occasionally massive bleeding occurs in Crohn disease

Question 3

Where in the GI tract wall does bleeding generally occur in ulcerative colitis?

Answer 3

Typically just mucosal involvement giving pseudopolyps, but may occasionally extend into lamina propria and submucosa (fulminant disease / toxic megacolon)

Question 4

Are stones more common in Crohn disease or ulcerative colitis?

Answer 4

Crohn disease - due to involvement of the distal ileum in failure to resorb bile acids -> increased fatty acids in later GI tract to mop up calcium -> increased oxalate resorption

Question 5

What are the skin manifestations of IBD? Describe them?

Answer 5

Erythema nodosum - red markings due to fat inflammation on extensor surfaces of skin, common on shins

Pyoderma gangrenosum - ulcerating lesion with heaped up edges

Question 6

What are the eye manifestations of IBD?

Answer 6

Episcleritis, uveitis, iritis

Question 7

What are the joint manifestations of IBD? Which ones are associated with active disease / which ones occur all the time?

Answer 7

Peripheral arthritis - occurs only during exacerbations

Central arthritis - sacroilitis / ankylosing spondylitis, not associated with IBD activity - HLA-B27

Question 8

How do ulcerative colitis and Crohn disease differ with respect to likelihood to find perianal lesions and abdominal masses and why?

Answer 8

Abdominal masses - more likely in Crohn disease in RLQ, due to transmural thickening of wall / edema

Perianal lesions - more likely in Crohn disease due to fistula formation from nearby bowel which burrows into skin (transmural inflammation required)

Question 9

How is ulcerative colitis often told apart from Crohn disease in clinical practice? What is it called when mucosa bleeds easily?

Answer 9

Aside from presenting symptoms, endoscopy / colonscopy will show skip regions and common rectal sparing in Crohn disease

Furthermore, ulcerative colitis will show granular, easily-bleeding mucosa (“friable”) while Crohn disease shows linear ulcerations and cobblestoning with normal intervening mucosa

Question 10

How is the pathology of ulcerative colitis told apart from common acute inflammatory bowel conditions?

Answer 10

Glandular distortion -> major component, indicates longstanding interference with glands
= chronic inflammation

Question 11

What radiological studies are commonly used to diagnose IBD? How do they work?

Answer 11

Barium enema - for lower GI X-ray

Upper GI / Barium meal exam - for small bowel series with inclusion of terminal ileum

Narrowing or barium deposition should be distinguishable in ulcerated / affected areas, often with loss of normal barium deposition in affected areas

Question 12

What aspects of ulcerative colitis increase your susceptibility to cancer, and what are the screening guidelines?

Answer 12

1. Extent of colonic involvement
2. Duration of disease
3. Age at symptom onset
4. Primary sclerosing cholangiitis - associated, and an indepedent risk factor

Colonoscopy with multiple biopsies every 2 years after 8-10 years with disease, with colectomy for at least low-grade dysplasia

Question 13

What are the surgical indications for IBD?

Answer 13

1. Intractable or fulminant disease
2. Perforation (could lead to peritonitis)
3. Cancer or dysplasia

Question 14

What is the surgical treatment for ulcerative colitis and is it effective? What is the alternative treatment for younger patients?

Answer 14

Treatment is total colectomy which is curative in UC because it only affects colon

Usually this is done via colostomy bag, but subtotal colectomy can be done via using terminal ileum as a sac to store stool and directly connecting this to rectum. Patients may only need to go 3-4 times per day with anti-diarrheals.

Question 15

What are the surgical treatments for Crohn’s and are they effective?

Answer 15

Usually resection of affected bowel. Can also do stricturoplasty, abscess drainage, and bypass procedures if need be.

Not curative in Crohn’s disease, as any part of GI tract may be involved.

Question 16

Is irritable bowel syndrome a mechanical or functional disorder? What are the diagnostic criteria?

Answer 16

Functional (no structural changes)

Recurrent pain or discomfort at least 3 days / month in last 3 months, associated with 2 or more of:

1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in appearance of stool

Question 17

What are the three types of irritable bowel syndrome, and is it common?

Answer 17

1. IBS-C - constipation
2. IBS-D - diarrhea
3. IBS-alternating

Very common, more common than hypertension

Question 18

What is the cause of IBS?

Answer 18

Problem of disordered motility and/or nociception

• > multifactorial, and often associated with altered microbiome following infectious enteritis.
• > Psychosocial factors also play a role

Question 19

What are the nonpharmacologic treatments of IBS? Is medication effective?

Answer 19

Changing diets to less fermentable sugars

Fiber supplementation for constipation type

Psychotherapy

A considerable placebo affect is incurred with medications

Question 20

What is the normal workup for a patient with IBS?

Answer 20

Typically the diagnosis is met based on history, and you may include celiac serology and general labs to rule out other diagnoses

Colonscopy and extensive workup is generally not required as patient and clinican reach mutual diagnosis