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Coeliac, IBS, IBD Flashcards

1
Q

What are the two types of inflammatory bowel disease and what are the distinctions between them in regard to pathophysiology and symptoms? (Formative Q)

A

Crohn’s disease

  • Affects entire GI tract (mouth to anus)
  • Occurs in a discontinuous manner i.e. skip lesions
  • transmural inflammation
  • Common Sx = abdominal pain, N+V, diarrhoea and weight loss

Ulcerative colitis

  • starts at rectum and progresses continuously through the colon
  • inflammation in mucosa lining.
  • Crypt abscesses are a common finding on biopsy.
  • Common Sx = abdominal pain, bloody diarrhoea
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2
Q

Coeliac disease is a common autoimmune condition:

  • WHO should be screened?
  • What tests do we use for screening? (Formative Q)
A
  • Patients with unexplained indigestion, diarrhoea, abdominal bloating and constipation.
  • Faltering growth in children.
  • Prolonged fatigue.
  • Unexpected weight loss
  • Severe or persistent mouth ulcers
  • Unexplained iron, vitamin b12, or folate deficiency
  • Type 1 diabetes mellitus
  • Autoimmune thyroid disease
  • IBS in adults
  • A first degree relative with coeliac disease
  • First line bloods tests: IgA, tTGA
  • Endomysial antibody can also be used
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3
Q

What is Coeliac Disease? RF?

A

(1. ) It is common and affects 1% of population
(2. ) Chronic autoimmune mediated disorder. - T-cell response to gluten in the small bowel causes villous atrophy and malabsorption
(3. ) Suspect this if diarrhoea + weight loss or anaemia
(4. ) RF = Fx, 1st-degree relatives, HLA types HLA-DQ2, DQ8 [genetic predisposition]

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4
Q

Pathophysiology of Coeliac?

A

(1. ) Auto-antibodies are created in response to exposure to gluten, that target epithelial cells of small bowel, particularly the jejunum.
(2. ) Anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA) relate to disease activity and rise with more active disease and disappear with effective treatment.
(3. ) Inflammation causes villi atrophy and thus malabsorption

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5
Q

Signs and Sx of Coeliac (7)

A

(1. ) Asymptomatic
(2. ) Abdominal pain, bloating, N+V
(3. ) Malabsorption Sx: Anaemia, Diarrohoea, Steatorrhea, Weight loss [Failure to thrive in children], Osteoporosis, Chronic Fatigue
(4. ) Dermatitis herpetiformis
(5. ) Amernorrhoea
(6. ) Aphthous ulcers, angular stomatitis
(7. ) Auto-immune associated disorders

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6
Q

What is Dermatitis herpetiformis?

A

(1. ) Severely itchy blisters that commonly affects knees, elbows, scalp, buttocks.
(2. ) Associated with Coeliac.
(3. ) Red, raised patches papules
(4. ) Dx = skin biopsy

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7
Q

Investigation and Diagnosis of Coeliacs

A

Dx = Serology and biopsy/endoscopy while on gluten diet

(1. ) Bloods: anaemia, iron and folate deficiency
(2. ) Serology: IgA-tTG [1st choice], EMA

(3. ) Upper GI endoscopy + biopsy
- Graded using MARSH STAGE that looks at crypt and villi
- Villous atrophy
- Crypt hyperplasia
- Inc intraepithelial lymphocyte counts

(4.) Skin biopsy - if dermatitis herpetiformis

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8
Q

Tx and Mx

A

(1.) Lifelong gluten free diet. Relapse will occur on consuming gluten

(2. ) Consider arranging annual blood monitoring, including:
- Coeliac serology
- FBC, ferritin, Ca, Vit D, B12 folate - screen for anaemia, deficiency due to malabsorption and dietary changes
- TFTs and LFTs - screen for associated autoimmune disease.

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9
Q

Complications of Coeliacs

A
  1. Malabsorption: Anaemia, Osteopenia/porosis
  2. Dermitis herpetiformis
  3. Hyposplenism (Reduced spleen function), Offer flu and pneumococcal vaccines
  4. QoL: Fear of cross contamination, Missing out on social events
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10
Q

What is IBS? RF? Aetiology?

A

(1. ) A syndrome affecting bowels associated with:
- Recurrent abdominal pain
- Abnormal bowel motility (constipation or diarrhoea)
- Pain often relieved by defecation

(2. ) Multifactorial aetiology: inflammatory, genetic, psychological and dietary
(3. ) RF = <40y, female, Fx, PTSD, previous infection of gastroenteritis, stress

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11
Q

Pathophysiology of IBS

A
  • No clear cause or signs of abnormalities in the gut
  • In some there is altered gut motility and secretion in response to certain stimuli e.g. stress, certain foods, toxins or inflammation
  • Some patients show bacterial overgrowth
  • Evidence of hypersensitivity in the gut – enhanced perception of abdominal pain
  • Brain-gut axis has shown to be dysregulated and this may enhance visceral perception
  • Enteric nervous system then reacts greater to perceived stressors
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12
Q

Signs and Sx of IBS, including relieving and exacerbating factors

A

Symptoms are chronic, >6m

(1. ) Abdominal cramping
(2. ) Bowel movement: Diarrhoea, Constipation, Alternating
(3. ) Urgency, incomplete evacuation
(4. ) Bloating
(5. ) Improves with defecation
(6. ) Exacerbating factors = Worsen after food, stress, menstruation, gastroenteritis

Signs

(1. ) General abdominal tenderness
(2. ) Lower left & right quadrant when palpating
(3. ) Visceral hypersensitivity

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13
Q

Investigations for IBS

A

(1.) FBC, ESR, CRP

(2. ) Faecal calprotectin test
- rule out IBD

(3. ) Coeliac screen:
- exclude coeliac disease

(4. ) CA 125
- For women with Sx which could be ovarian cancer

Additional tests if required

  • Faecal occult blood
  • Faecal ova and parasite tests.
  • Colonoscopy/sigmoidoscopy/barium enema
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14
Q

How is IBS diagnosed

A

Recurrent abdo pain at least 1/week in last 3m and associated with two or more of the following:

  1. Related to defecation
  2. Change in stool frequency
  3. Change in stool form

NOTE: for diagnosis this criteria must be fulfilled for the last 3m with sx onset of symptoms at least 6m

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15
Q

Management of IBS (5).

A

(1.) Lifestyle changes = reduce stress, caffeine, keep Sx diary

(2. ) Constipation
- low fibre diet and water
- consider laxative
- If both fails - lubiprostone or linaclotide

(3. ) Diarrhoea
- Avoid sweeteners, caffeine, alcohol
- Identify trigger foods
- Bulking agent e.g. Isphaghula +/- loperamide after each loose stool

(4. ) Antispasmodics for bloating
(5. ) Psychological Sx - CBT

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16
Q

What is IBD and its RF?

A

(1.) Describes disorders that involve chronic inflammation of GI tract. Two main types: Ulcerative Colitis and Crohn’s Disease

(2. ) RF
- Typically presents in ~20-40years
- Fx
- NSAIDs (exacerbate the condition, risk of relapse)
- Caucasian ethnicity
- “Westernization” of lifestyle - changes in diet, smoking, exposure to sunlight, pollution, and industrial chemicals are also factors.

17
Q

Describe pathophysiology of UC and CD. What would be seen under endoscope?

A

UC

  1. Affects inner lining (mucosal)
  2. Typically begins in rectum and may extend continuously to involve entire colon
  3. Under endoscope = Ulceration, Pseudo-polyps, crypt abscess

CD

  1. Affect all layers (transmural)
  2. Commonly involves Ileum, right colon h/e can affect any part of GI tract
  3. Areas of inactive next to active disease (skip lesion), creates a ‘cobble-stone’ appearance
  4. Under endoscope = Cobblestone appearance, Thickened Wall, Fissure, Granuloma
18
Q

Complications of UC and CD? (7)

A
  1. Severe GI bleeding (UC)
  2. Fulminant colitis/Toxic megacolon/Dilation
  3. Obstruction
  4. Strictures
  5. Perforation with peritonitis
  6. Inc risk of CRC
  7. Fistula (more common in CD)
19
Q

Extra-intestinal Manifestations/complications of UC (6)

[Think: immune, malabsorption)

A

(1. ) Joints: arthritis, ankylosing spondylitis
(2. ) Skin: Erythema nodosum (red nodules on skin), Pyoderma gangrenosum
(3. ) Anaemia
(4. ) Bones: osteopenia/porosis/malacia
(5. ) Eyes: Uveitis, Keratopathy, Episcleritis. Dry eye
(6. ) Primary sclerosing cholangitis

20
Q

Signs and Sx of IBD (6)

A

Relapses and remissions

  1. Abdominal pain
  2. Diarrhoea (bloody in UC)
  3. Tenesmus
  4. Fever
  5. Weight loss/Loss of appetite
  6. Malaise
21
Q

4 Investigations for UC and CD

A

(1. ) Bloods
(a. ) CRP: indicates active disease.
(b. ) Iron, vit B12, folate: malabsorption in UC

(2. ) Faecal calprotectin: rule out IBS
(3. ) Colonoscopy and biopsy {diagnostic}

(4. ) Abdominal Imaging
- to exclude toxic dilatation and perforation.
- help to assess disease extent or identify proximal constipation

22
Q

Tx of UC

A

Maintenance of remission: 5-ASA

Relapse Mx
MILD
(1.) Topical 5-ASA (mesalazine) if fail try oral
- If not tolerated: topical predinisolone

MODERATE
(2.) Topical AND oral 5-ASA
- If not tolerated: oral predinisolone
- If no response: immunosuppresants 
(azathioprine, mercaptopurine)
- OR biological therapy (Infliximab, adalimumab)

SEVERE

(3. ) IV fluids, steriods, enteral feeding
(4. ) IV broad-spectrum abx if infection present
(5. ) Consider subtotal colectomy + terminal ileostomy

23
Q

Tx of CD

A

Inducing Remission:

  1. GLUCOCORTICOIDS, if CI: consider budesonide or 5-ASA
  2. Biological therapy: Infliximab, adalimumab for severe exacerbation, fistulas
  3. Consider Surgery if: CD limited to the distal ileum, failure of medical tx, impaired QoL, fulminant Colitis

For Maintenance:

  1. IMMUNOSUPPRESSANTS: Azathioprine or mercaptopurine
    - If CI: methotrexate

Other Mx

  1. Smoking Cessation
  2. Elemental and polymeric diet
24
Q

Other Tx and Mx of IBD

A
  1. Lifestyle = Smoking cessation, Managing stress
  2. Antidiarrhoeals (loperamide)
  3. Bile acid sequestrants
  4. Antispasmodics (dicycloverine, hyoscyamine)
  5. Medical therapy/MDT

GI (12 decks)

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