Crohn’s Disease and Ulcerative Colitis Flashcards
significant diseases of GI
Oesophagus and upper GI
Malabsorption
- Pernicious anaemia
- Coeliac disease
- Crohn’s disease
Large bowel
- Inflammatory bowel disease (IBD)
- Cohn’s disease
- Ulcerative Colitis
Colonic Ca
Infections
incidence of inflammatory bowel disease
20 times more in Western Societies
- Increasing
White > Black
age: 15-25, 50-80
gender ratio for Crohn’s
male > female
gender ratio for Ulcerative Colitis
female > male
aetiology of inflammatory bowel diseases
Immunological
Psychological
- Chronically anxious more at risk
Smoking
- Less risk but benefit lost by increase CV disease risk
Genetic
Mystery
- Complex pattern of inherited and environmental and psychological changes
- Change in gut pathology
Likely more than one cause in population
- Clinical manifestation the same but aetiology of changes in mucosa are different
aetiology of Crohn’s disease
Granulomatous inflammation – varied aetiology
- Collection of multinucleated giant cells in clump and resistant to removal by phagocytosis (surrounded by immune cells)
Tissue causes immune stimulation body is unable to deal with (alike TB) and generalised chronic inflammation
cause of Crohn’s disease
unknown
Food intolerance
- Irritation to immune system caused by something passing through the gut
Persisting viral infection/immune activation
- Recurrent viral infection
- Infectious agent passed to people in right susceptibility causes problems
? Infection with Mycobacteria (paratuberculosis)
- Johne’s disease
- -Problem in cattle which is similar to Crohn’s
Hard to find and ID agents
M.paratuberculoisis cycle
Mycobacteria causes disease in cow Happen in farm Dairy passed into industry Treated incorrectly Passed to humans
Incidence of both diseases increased similarly
- Gap in time of 10 years
- Zoonotic infection from cow to people
Pasteurisation of milk
- Good at getting rid of pathogens
But not M.paratubercolosis
- Only way is by UHT milk
Crohn’s disease impact on bowel surface
Lumps (should be smooth)
- areas of oedema, caused by granulomas washed into lymphatics carried away into tissue fluid, preventing draining of lymphatics
- Cobble stoning of mucosa
how are the lumps formed in Crohn’s disease
Block lymphatics cause oedema and lump
crohn’s disease sites
can be ID anywhere
- can be in certain sections and skip lesions
(colitis in colon)
3 common Crohn’s disease sites
Mouth
Ileocecal region - small to large
rectal
ulcerative colitis sites
only colonic disease
- Ascending, sigmoid, descending
Starts at rectum and works way up
- Continuous inflammation up the way
what is ulcerative colitis
Ulcers in colon
- Like mouth ulcers
Change in bowel activity
features of ulcerative colitis
Disease continuous
Rectum always involved (bottom up)
Anal fissures 25%
Ileum involved 10%
- Small bowel involved in small number
Mucosa granulomas & Ulcers
Vascular
Serosa normal
- Superficial inflammation
- Only areas affected are top layers
- a featureless colon with complete loss of haustration, total blurring of the normal vascular pattern, and agranular-likemucosadevelops.
ulcerative colitis thereisa continuous, diffuse granular mucosal pattern, with or without superadded ulceration; i
features of Crohn’s disease
Discontinuous
Rectum involved 50%
Anal fissures 75%
Ileum involved 30%
Mucosa cobbled and fissures
- Due to lymphatic blockage
Non-vascular
Serosa inflamed
- Entire thickness of bowel wall inflamed
microscopic features of ulcerative colitis
Granular Mucosal
Vascular more blood vessels
Mucosal abscesses
microscopic features of Crohn’s disease
Transmural
- full thickness effected
Oedematous
- blocking lymphatics
granulomas
- Drainage is deep
Biopsy to show it is a challenge
Clinical features and signs of Crohn’s disease
Oedema
Perioral erythema
- red inflammatory changed
- Swollen lips (can just be one or both)
Inflammation
Swelling
Oedema of bowel wall
- narrower lumen so problem with passing bowel contents
All though bowel wall so abscesses can form
Outside or inside
End up with inflammation causing a fistula
- hole between two loops of bowel, connection,
- bacteria spread
full thickness inflammation, granuloma formation and oedema
Crohn’s colitis is characterised by discrete ulcers with intervening normal mucosa.
ulcerative colitis effect on mucosa
Normal tissue
– Secretory mucosa
– Thin layer of serosa tissue
In UC distorted picture but not extended to outside
- Bottom area largely normal
- superficial
ulcerative colitis there is a continuous, diffuse granular mucosal pattern, with or without superadded ulceration
a featureless colon with complete loss of haustration, total blurring of the normal vascular pattern, and agranular-likemucosadevelops.
when taking a biopsy of a UC site what can a perforation cause
peritonitis
ease of management of UC
Straightforward to manage
- Easy access
- Take away colon = remove symptoms as only site effected
Bottom up (limited disease)
ulcerative colitis symptoms (3)
Diarrhoea
Abdominal pain
PR Bleeding
crohn’s disease symptoms
Depend on site effected
– Tend not to be painful but mouth can be
Colonic disease – same as UC
Small bowel disease
- Pain - obstruction
- Narrower tube so easier to block
- Malabsorption – anal disease
Mouth
- Change in appearance
- Orofacial granulomatosis
- Gingivitis
colonic crohn’s disease symptoms
same as UC
Diarrhoea
Abdominal pain
PR Bleeding
small bowel Crohn’s disease symptoms
Pain - obstruction
- Narrower tube so easier to block
- Malabsorption – anal disease
mouth Crohn’s disease symptoms
Change in appearance
- Orofacial granulomatosis
- Gingivitis
orofacial granulomatosis
Not a single condition
- Granuloma formation blocks lymphatics
Lip and oral swelling then noted from other causes increased capillary leakage
triggers of orofacial granulomatosis
Food preservative and additives – benzoate/Sorbate/cinnamon
- Benefit to miss additives in some people – exclusion diet
- Responsive after 3 months then potential success
Some have no identifiable trigger
children and orofacial granulomatosis
common in 6-13 year olds
can be very localised or wider issue with Crohn’s disease
- need to investigate
- need GA in endoscopy higher risk of perforating bowel in children
so Assess how they grow
- normal function= grow normally
- malabsorption will not
Younger Get OFG more likely to get Crohn’s disease
5 clinical features of OFG
lip swelling
angular cheilitis
- inflamed at corners of mouth, mouth tissue sitting incorrectly
cobble stoning
ulceration
microscopic granulomas
6 investigation for inflammatory bowel disease
Inflammatory process happening in body raised in Crohn’s
Blood tests
- Anaemia, CRP (c reactive protein), ESR
Faecal Calprotectin
Endoscopy
Leukocyte Scan
Barium Studies
Bullet Endoscopy
bullet endoscopy for IBD investigations
- Swallow capsule
- Photo inside bowel
- Send to radio by receiver
- Picture whole bowel
But if miss area of interest cannot retake as works its way out
faecal calprotein for IBD investigation
- Released in inflammation
- Bowel mucosal cells released into bowel, whether bowel is inflammed or not
If small areas of disease – not a lot produced so hard to tell
Significant area – can see higher than normal
Stool sample analysed
- Bleeding into bowel then RBC in stool
complication of ulcertaive colitis
developing carcinoma
- Risk increases with time (not as big now due to awareness and screening)
- Depends on time rather than disease activity
Judgement as to whether Colectomy is justified
- Attitude to risk
- Carcinoma surveillance potential
2 treatment pathways for IBD
medical treatment
surgical treatment
medical treatments for IBD
immunosuppressive
- Get rid of inflammation (Suppress immune system)
Systemic Steroids(Prednisolone)
Local Steroids (rectal administered – colorectal disease) - Work topically on surface of bowel
Anti-inflammatory drugs
- 5-ASA based drugs – Pentasa, mesalazine, sulphasalazine
- topical
Non Steroid immunosuppressants
- Azathioprine
- Methotrexate
Anti TNFα therapy
- Infliximab, adalimumab (‘biological’ drugs)
Anti TNFα therapy
- Infliximab, adalimumab (‘biological’ drugs)
for IBD treatment
- Manufactured antibodies against specific antigens e.g. TNF α
- Immune response for disease not generated
- Disease better controlled (inflammation where shouldn’t be) but infection response effected
topical medical treatments for IBD
Local Steroids (rectal administered – colorectal disease)
Anti-inflammatory drugs
- 5-ASA based drugs – Pentasa, mesalazine, sulphasalazine
systemic medical treatment for IBD
Systemic Steroids(Prednisolone)
- Easy treatment but can cause problem in patients (children stop growing)
- Pass straight through
oral issues for IBD
Oral lesion in Crohn’s – Orofacial granulomatosis
Oral ulceration
- ulcers worse when ulcerative colitis worse
- Worse by low iron, b12 or folic acid
- Inflamed bowel traumatised by food - bleed, lower store and malabsorption in small bowel of iron or folic acid or surgical removal of part of small bowel so less able to absorb
- Not able to absorb enough nutrient to maintain life
Haematinic deficiency caused by malabsorption or intestinal bleeding
- B12 deficient - ileocecal area effected commonly in crohn’s, site of absorption so get pernicious anaemia
what can make oral ulcers worse
Worse by low iron, b12 or folic acid
- Inflamed bowel traumatised by food - bleed, lower store and malabsorption in small bowel of iron or folic acid or surgical removal of part of small bowel so less able to absorb
- Not able to absorb enough nutrient to maintain life
- ulcers worse when ulcerative colitis worse
