Crohn's disease Flashcards

1
Q

Characteristics and classic appearance

A
  • thickened areas of the GI wall with inflammation extending though all layers
  • deep ulceration and fissuring of mucosa
  • classic cobblestone appearance
  • presence of granulomas
  • can affect any part of the GIT, from mouth to anus
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2
Q

Symptoms include

A
  • abdominal pain
  • diarrhoea
  • rectal bleeding
  • fever
  • weight loss
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3
Q

complications

A
  • malnutrition
  • colorectal and small bowel cancers
  • growth failure and delayed puberty in children
  • intestinal strictures (narrowing)
  • anaemia
  • abscesses in walls of intestine or adjacent structures
  • fistulae
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4
Q

Extra intestinal manifestation

A

most commonly arthritis and abnormalities of the joints, eyes, liver, skin

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5
Q

Link with osteoporosis

A
  • cause of secondary osteoporosis
  • inflammation in the gut, taking steroids, low levels of calcium and vitamin D or removal of parts of the small bowel all increase risk of weaker bones
  • pt at greater risk should be monitored for osteopenia and assessed for fracture risk
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6
Q

what is fistulating Crohn’s disease

A

Complication that involves the formation of a fistula between the intestine and adjacent structures e.g. perianal skin, bladder, vagina

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7
Q

how common is fistulating crohns disease

A
  • Occurs in ~ 1/4 of pt, mostly when disease involves the ileocolonic area
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8
Q

treatment aims in fistulating Crohn’s

A

surgery and medical treatment aims to close and maintain closure of fistula

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9
Q

Treatment of acute disease - mono therapy

A
  • CCs (prednisolone, methylpred, HC IV) to induce remission in pt with first presentation or single inflammatory exacerbation in 12 month period
  • consider budesonide in pt with distal ilea, ileocecal or right sided colonic disease in whom conventional CC unsuitable or contraindicated
  • budesonide is less effective but may cause fewer SE than other CCs because systemic exposure limited
  • aminosalicylates (e.g. sulfasalazine, mesalazine) are alternative in these pt - less effective than CCs and budesonide but may be preferred due to fewer SE
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10
Q

Aminosalicylates and budesonide for severe presentations or exacerbations

A

not appropriate

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11
Q

treatment of acute disease - when is add on therapy prescribed

A

if 2 or more inflammatory exacerbations in 12 month period, or if CC dose cannot be reduced

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12
Q

treatment of acute disease - add on therapy to CC or budesonide to prescribe if there has been 2 or more inflammatory exacerbations in 12 months, or if CC dose cannot be reduced

A
  • azathioprine or metacaptopurine (unlicensed indications) can be added to CC or budesonide to induce remission
  • if not tolerated or if thiopurine methyltransferase (TMPM) activity is deficient, add MTX to a CC instead
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13
Q

When can TNF-A inhibitors be given for Crohn’s, and name some examples

A
  • under specialist supervision for severe, active Crohn’s
  • only if inadequate response to conventional therapies or intolerant of/contraindications to conventional therapy
  • e.g. adalimumab, infliximab
  • adalimumab and infliximab can be used as mono therapy or combined with immunosuppressive
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14
Q

When can vedolizumab or ustekinumab be offered

A
  • vedo: moderate to severely active Crohn’s when therapy with adalimumab or infliximab unsuccessful , contraindicated or not tolerated
  • ustekinumab: moderate to severely active Crohn’s when conventional therapy or therapy with adalimumab or infliximab unsuccessful , contraindicated or not tolerated
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15
Q

advice for patients who chose not to receive maintenance treatment during remission to maintain remission

A
  • be aware of symptoms that may suggest relapse e.g. unintended weight loss, abdominal pain, diarrhoea, general ill health
  • create a suitable follow up plan to be agreed upon, and provide info on how to access healthcare if relapse occurs
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16
Q

main 2 drugs that can be used to maintain remission

A
  • azathioprine or mercaptopurine (unlicensed indications) as mono therapy can be used to maintain remission the previously used with CC to induce remission
  • may also be used in pt who have not previously used this drugs, esp those with with adverse prognostic factors e.g. early onset age, perianal disease, CC use at presentation, severe presentation)
17
Q

when can MTX be used to maintain remission

A

only in pt who required it to induce remission, or who are intolerant of/not suitable for azathioprine or mercaptopurine maintenance treatment

18
Q

maintaining remission following surgery in pt with ileocolonic Crohn’s how have had complete microscopy resection within previous 3 months

A
  • azathioprine + up to 3 months post metronidazole (unlicensed) should be used to maintain remission in these pt
  • consider azathioprine alone in pt two cannot tolerate metro
19
Q

drugs NOT to use for maintaining remission following surgery in pt with ileocolonic Crohn’s how have had complete microscopy resection within previous 3 months

A
  • aminosalicylates not recommended - lack of clinical efficacy
  • mercaptopurine not cost-effective so not recommended
  • do not use biologic therapies to maintain remission after complete macroscopic resection due to limited evidence
  • also do not use budesonide
20
Q

3 drugs that can be used to manage diarrhoea associated with Crohn’s disease

A
  • loperamide or codeine (as long as pt does not have colitis!!)
  • cholestyramine
21
Q

What is the most common occurrence in pt with fistulating Crohn’s

A

perianal fistulae

22
Q

when is treatment for fistulating Crohn’s disease indicated

A
  • treatment may not nee necessary for simple, asymptomatic perianal fistulae
  • when they are symptomatic, local drainage and surgery may be required in conjunction with medical therapy
23
Q

abx for fistulating Crohn’s disease

A

metro or cipro (unlicensed indications), alone or in combo, can improve symptoms but complete healing occurs rarely
- metro usually given for 1 month, but max 3 months due to concerns about peripheral neuropathy
- give other abx if specially indicated e.g. in sepsis, and for managing bacterial overgrowth in small bowel

24
Q

treatment of inflammation and maintenance in fistulating Crohn’s

A
  • azathioprine or mercaptopurine
  • infliximab recommended for pt with active fistulating Crohn’s who have not responded to conventional therapy
  • only use infliximab after ensuring all sepsis is actively draining
  • abscess drainage fistulotomy and seton insertion may be appropriate, esp before infliximab treatment
25
Q

how long to continue azath/mercap/infliximab as maintenance for fistulating Crohn’s

A

at least 1 year

26
Q

management of non-perianal fistulating Crohn’s disease (including entero-gynaecological and enterovesical fistulae)

A

surgery is the only recommended approach