Clinical Topic 1: Inflammatory Bowel Disease

Question 1

What are the genetic, microbial and environment associations with the development of Crohn’s Disease?

Answer 1

Genetic: Frameshift mutation of NOD2/CARD15 gene, or mutation in ATF16L1

Microbial: Mycobacterium tuberculosis, Listeria, Pseudomonas

Environmental: Smoking, Roaccutane, increased animal protein intake, reduced vegetable intake

Question 2

What are the Gastrointestinal, Systemic and Extraintestinal Manifestations of Crohn’s Disease?

Answer 2

Gastrointestinal: Bloody and mucoid diarrhoea, RLQ abdominal (ileal) pain, perianal disease i.e. fistulas

Systemic: FTT, weight loss, loss of appetite

Extraintestinal: Iritis, uveitis, epischleritis, pyoderma gangrenosome, erythema nodosum, ankylosing spondylitis, clubbing, primary schlerosing cholangitis

Question 3

What might you see on histology of a Crohn’s Disease patient’s GI tract?

Answer 3

Discontinuous, cobblestone appearance or skip lesions of inflammation, granulomas of immune cells, infiltration from the mucosa to the serosa

Question 4

What is the epidemiology of Crohn’s Disease?

Answer 4

Affects males and females equally, more common in Caucasians, those of European descent, Ashkenazi Jews and black people. Uncommon in Asians. Bimodal age of incidence: Peak at 20 and 50 years old

Question 5

What steroid might be given orally to patients with Crohn’s Disease? What is it given with?

Answer 5

Budesonide: topically affects the distal ileum and right sided colon, administered with Calcium for bone protection

Question 6

What might you see on blood test results with a Crohn’s patient?

Answer 6

Raised WCC, CRP, ESR, Plts = inflammation

Reduced B12 = terminal ileum disease

Question 7

What is the stool marker for IBD?

Answer 7

Faecal Calprotectin

Question 8

What might you see on abdominal X-ray for a patient with Crohn’s Disease or Ulcerative Colitis?

Answer 8

“Thumb printing” - Mucosal Oedema

Question 9

What surgery can be offered to patients with Crohn’s?

Answer 9

Generally not a resection, due to <1 year recurrence of CD, however stricturoplasty may be offered to remove strictures

Question 10

What are Gastrointestinal Symptoms of Ulcerative Colitis?

Answer 10

LLQ abdominal pain, mucoid and bloody diarrhoea, tenesmus

Question 11

What are the general medication options for patients with IBD?

Answer 11

Steroids i.e. Prednisolone or Budenoside
5-ASA drugs i.e. Mesalazine
Thiopurines i.e. Azathiopurine or 6-Mercaptopurine
Antifolates i.e. Methotrexate
Ciclosporins
Biologics i.e. Infliximab, Adalimumab, Vedolizumab

Question 12

What is the genetic mutation associated with Ulcerative Colitis?

Answer 12

HLA-DR103

Question 13

An appendectomy is protective for which IBD?

Answer 13

Ulcerative Colitis

Question 14

What is p-ANCA?

Answer 14

Antibodies which are associated with Ulcerative Colitis

Question 15

What are the complications of Ulcerative Colitis?

Answer 15

• Thromboembolism
• Toxic megacolon (>6cm in diameter)
• Bowel perforation
• Colorectal bleeding
• Colorectal carcinoma

Question 16

Fistulas are common in which IBD?

Answer 16

Crohn’s

Question 17

Pseudopolyps are common in which IBD?

Answer 17

Ulcerative Colitis

Question 18

Why is colorectal carcinoma indicated in IBD? What are such patients then offered?

Answer 18

Increased risk of dysplasia in the colon, hence are offered 1-5 year colonoscopy surveillance

Question 19

What endoscopic surveillance is offered to IBD patients with an increased risk of colorectal carcinoma What is it?

Answer 19

Pancolonic Chromoendoscopy: Indigo Carmine dye is sprayed in the colon and dysplasia is highlighted. Better than biopsy

Question 20

What are the two types of Microscopic Colitis?

Answer 20

Lymphocytic colitis

Collagenous colitis

Question 21

What is Loperamide and what is the MoA?

Answer 21

Anti-diarrhoeal agent
u-Opiod receptor agonist, acting on the myenteric plexus of the large intestine, decreasing its activity. This increases transit time for water re-absorption

Question 22

What abnormalities might you find on LFTs in patients with IBD?

Answer 22

Raised GGT and ALP, suggestive of Primary Schlerosing Cholangitis

Question 23

What might you see on histology of an Ulcerative Colitis patient’s GI tract?

Answer 23

Originating from the rectum, continuously and proximally travelling up the colon, inflammation from mucosa to the submucosa. Pseudopolyps may be present

Question 24

Rose thorn ulcers are common in which IBD?

Answer 24

Crohn’s Disease

Question 25

Crypt abscesses are common in which IBD?

Answer 25

Ulcerative Colitis

Question 26

What is defined as mild, moderate and severe Ulcerative Colitis?

Answer 26

Mild: < 4 stools/day, little blood
Moderate: 4-6 stools/day, varied blood, no systemic upset
Severe: >6 bloody stools, systemic upset

Question 27

What is the first and second-line treatment to induce remission in Ulcerative Colitis patients?

Answer 27

First line: Rectal aminosalicyclates, rectal steroids, oral aminosalicylclates
Second line: Oral steroids

Question 28

What is the first and second-line treatment to induce remission in Crohn’s Disease patients?

Answer 28

First line: Oral, topical, IV steroids

Second line: Aminosalicyclates

Question 29

What is the first line treatment to maintain remission in Ulcerative Colitis patients?

Answer 29

Oral aminosalicyclates

Question 30

What is the first and second-line treatment to maintain remission in Crohn’s Disease patients?

Answer 30

First line: Azathiopurine / 6-Mercaptopurine

Second line: MTX