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Theme 1: The Alimentary System > Coeliac disease and inflammatory bowel disease > Flashcards

Coeliac disease and inflammatory bowel disease Flashcards

1
Q

Coeliac disease

A

Gluten sensitive enteropathy or coeliac sprue

Auto- immune mediated disease of the small intestine triggered by ingestion of gluten

Malabsorption

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2
Q

Gluten

A

Protein compound of wheat, rye and barley left behind after washing off the starch

Consists of gliadin and glutenins

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3
Q

Genetic abnormalities od coeliac disease

A

Associated with HLA-DQ2 and HLA-DQ*

Genes located in Chr 6p21

Strong hereditary predisposition affecting ~ 10% first degree relatives

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4
Q

Who gets coeliac disease?

A

Most prevalent in western europe and united states

Down’s syndrome, type 1 diabetes mellitus, auto- immune hepatitis and thyroid gland abnormalities

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5
Q

How does gluten cause coeliac disease?

A

Gluten in wheat + small bowel mucosa
»>

Tissue transglutaminase
»>

Diamidates glutamine in gliadin
»>

Negatively charged protein
»>

IL-15
»>

Natural killer cells + intraepithelial T lymphocytes
»>

Tissue destruction + villous atrophy

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6
Q

How does coeliac disease present?

A

Short stature and failure to thrive in children

Diarrhoea: smelly and bulky stool, rich in fat

Weight loss and fatigue

Anaemia- folate and Fe deficiency

Ostopenia and osteoporosis- calcium and vitamin D deficiency

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7
Q

Classification of coeliac disease

A

Classical- malabsorption symptoms

Non- classical symptoms outside GI tract

  • constipation, bloating alternate bowel habits
  • heartburn, nausea, vomiting and dyspepsia
  • recurrent miscarriage/ infertility
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8
Q

Investigations for coeliac disease

A

General: FBC, U and Es, LFTs

Serology:

  • tissue transglutaminase
  • endomysial IgA- connective tissue covering smooth muscle fibres
  • deamidated gliadin peptide IgA and IgG
  • sero negative coeliac disease

HLA D2 and HLA DQ8 in children

Duodenal biopsies

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9
Q

Microscopic features of coeliac disease

A

At least four biopsies sampled from duodenum at upper GIT endoscopy

On microscopy:

  • villous atrophy
  • crypt hyperplasia
  • increase in lymphocytes in the lamina proporia
  • increase in intraepithelial lymphocytes
  • recovery of villous abnormality on gluten free diet
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10
Q

Complication of coeliac disease

A

Enteropathy associated T-cell lymphoma

High risk of adenocarcinoma of small bowel and other organs

Associated with dermatitis hepetiformis

Infertility and miscarriage

Refractory coeliac disease despite strict adherence to gluten free diet

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11
Q

What constitutes inflammatory bowel disease?

A

Crohn’s disease

Ulcerative colitis

Diverticular disease

Ischaemic colitis

Drug induced colitis

Infective colitis

CD and UC

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12
Q

Crohn’s disease

A

Idiopathic, chronic inflammatory bowel disease often complicated by fibrosis and obstructive symptoms and can affect any part of the GIT from mouth to anus

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13
Q

Epidemiology of Crohn’s disease

A

High prevalence in western world with increased incidence in patients of Jewish origin

Increasing incidence in Africa, South America and Asia

Bimodal presentation with peaks in the teens-20s and 60-70 year age groups

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14
Q

What causes CD?

A

Exact cause unknown

Genetic, infectious, immunological, environmental, dietary, vascular, smoking, NSAIDs and psychological factors

Defects in mucosal barriers

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15
Q

Genetics of Crohn’s disease

A

First degree relative have 13-18% increased risk

NOD2 known as IBD1 gene on Chr16 encodes protein that binds to intercellular bacteria peptoglycans

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16
Q

Possible infectious cause of Crohn’s

A

Granulomas present in 60-65% patients

Mycobacterium para-tuberculosis extensively investigated but never proven

Other infectious organisms- measles virus, pseudomonas, listeria- never proven

17
Q

Environmental factors implicated in Crohn’s disease

A

Improved hygiene hypothesis- reduces ability of GIT mucosa to develop regulatory process that would normally limit immune response to pathogens which cause self limiting infectiouns

Migration from low risk population to high risk population

Cigarette smoking doubles risk

18
Q

Clinical features of Crohn’s disease

A

Chronic, indolent course punctuated by periods of remission and relapses

Abdominal pain, relieved by opening bowels

Prolonged non-bloody diarrhoea

Blood may be present if colon involved

Loss of weight, low grade fever

19
Q

Morphological features of Crohn’s disease

A

Fat wrapping around serosa

Typically segmental morphology- normal bowel separated by abnormal bowel

Ulceration with a cobblestone pattern

Strictures due to fibrosis

20
Q

Microscopic appearances of Crohn’s disease

A

Transmural or full thickness inflammation of the bowel wall

Mixed acute and chronic inflammation i.e. polymorphs and lymphocytes

Preserved crypt architecture

Mucosal ulceration

Fissuring ulcers

Granulomas present in 60-65%

Fibrosis of the wall

21
Q

Complications of Crohn’s disease

A

Intra-abdominal abscesses

Deep ulcers lead to fistula

Sinus tract

Obstruction due to adhesions

Obstruction due to strictures caused by increased fibrosis

Perianal fistula and sinuses

Risk of adnemocarcinoa

22
Q

Ulcerative colitis

A

Chronic inflammatory bowel disease only affects large bowel from the rectum to the caecum

Confined to the mucosa and sub-mucosa except in severe cases

23
Q

Epidemiology of ulcerative colitis

A

More common in western countries with higher prevalence in patients of Jewish descent

Less frequent in Africa, Asia and South America

Can arise at any age but rare before age 10

Peaks between 20-25 with small peak in 55-65

24
Q

What causes ulcerative colitis?

A

Unknown

Genetic not as well defined as in CD

Smoking is protective

NSAIDs exacerbates it

Antioxidants vitamins A and E found in low levels

25
Q

Clinical features of ulcerative colitis

A

Intermittent attacks of bloody diarrhoea

Mucoid diarrhoea

Abdominal pain

Low grade fever

Loss of weight

26
Q

Macroscopic features of ulcerative colitis

A

Large bowel from rectum to caecum

Affect rectum only, left sided bowel only or whole large bowel

No ulcers on endoscopic examination in early disease

Mucosa becomes flat with shortening of the bowel

27
Q

Microscopic features of ulcerative colitis

A

Inflammation confined to mucosa

Diffuse mixed acute and chronic inflammation

Crypt architecture distortion

In quiescent, mucosa may be atrophic with little or few inflammatory cells in the lamina proporia

28
Q

Complications of ulcerative colitis

A

Toxic megacolon- bowel grossly dilated

  • patient very ill
  • bloody diarrhoea
  • abdominal distention
  • electrolyte imbalance with hypoproteinaemia

Refractory bleeding

Dysplasia or adenocarcinoma

  • UC at early age
  • total unremitting UC
  • after 8-10 years UC
  • requires annual screening colonoscopy
29
Q

Extra-intestinal manifestations of CD and UC

A

Ocular- uveitis, iritis, episcleritis

Cutaneous- erythema . nodosum, pyoderma gangrenosum

Arthropathies- ankylosing spondylitis and others

Hepatic- screlosing cholangitis

30
Q

Investigations in CD and UC

A

FBC

U and E’s

LFTs

Inflammatory markers- C reactive protein

Endoscopy and biopsies

Radiological imaging

  • barium studies
  • MRI
  • USS
  • CT scan

Theme 1: The Alimentary System (16 decks)

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