Crohn's VS Ulcerative Colitis Flashcards
I affect any part of the GI tract from mouth to rectum. Inflammation extends through all layers of the gut wall. This inflammation is patchy in distribution. What am I?
Crohn’s
I affect the colon and rectum only. I only affect the mucosa and submucosa. The inflammation is continuous. What am I?
Ulcerative colitis
I affect younger people with a mean onset of age 26, What am I?
Crohn’s
I affect older people with a mean age onset of 34, What am I?
Ulcerative Colitis
50% of people relapse each year, what am I?
Ulcerative colitis
I am more common in females with a ratio of: 1:1.2 What am I?
Crohn’s
I am more common in males with a ratio of: 1.2:1 What am I?
Ulcerative Colitis
Smoking makes me worse, oral CC increases the chance of getting me due to vascular changes. 40% of patients with me smoke. What am I?
Crohn’s
10% of patients are smokers, and smoking can help to prevent the onset of me, as the chemicals affect the colon smooth muscle. What am I?
Ulcerative Colitis
What are some common causes of symptoms for Crohn’s and Ulcerative Colitis?
*Environmental
*Genetic then triggered by infection
Having what high within your diet can make UC/C worse?
Fibre
Why can enteric microflora cause IBD?
As the loss of immunological tolerance to intestinal microflora an the body then rejects normal flora.
-Antibiotics can change enteric microflora
What drugs can exacerbate IBD?
NSAIDs
Why can stress trigger IBD?
As it activates the inflammatory mediators at the enteric nerve endings in the gut wall.
What procedure can have a protective effect, with no reason to why?
Appendectomy
I have issues with lymphocyte differentiation, lots of cells and this is hard for me to switch off.
Gene CARD15/NOD2 in chromosome 16
Gene OCTNI chromosome 5 and DLG5 on the chromosome 10. These can be altered in this condition, what am I?
Crohn’s
70% of people with me have p-ANCA (Anti-neutrophil cytoplasmic antibodies). What am I?
Ulcerative colitis
My T Cells are resistant to apoptosis after inactivation due to having too much inflammation, this usually affects the terminal ileum and ascending colon. What am I?
Crohn’s
My affected areas are thickened, oedematous and lumen of the gut is narrow. What am I?
Crohn’s
I can make deep ulcers appear, What am I?
Crohn’s
I make fissures in the mucous membrane and have a cobblestone appearance, what am I?
Crohn’s
I can progress to deep fissuring ulcers, fibrosis and strictures. What am I?
Crohn’s
I can cause bowel obstructions, abscesses and gut perforations, what am I?
Crohn’s
On first presentation
-40% in the rectum (proctitis)
-40% Sigmoid & descending colon (L side)
-20% whole colon
What am I?
Ulcerative colitis
I have purulent and granular with superficial ulceration, and in severe inflammation pseudo-polyps are formed. What am I?
Ulcerative colitis
I form crypt abscesses and mucosal ulceration, I can cause the mucosa to look red, inflamed and easily bleed. What am I?
Ulcerative colitis
What happens to lymphocytes and cytokines in Ulcerative colitis and Crohn’s?
-Increased activity of effector lymphocytes and proinflammatory cytokines that override normal control mechanisms
-Primary failure of regulatory lymphocytes and cytokines
The cells associated with me are Th1, What am I?
Crohn’s
The cells associated with me is Th2, IL-10, IL-4, IL-5, IL-6.
Inflammatory cells. What am I?
Ulcerative colitis
Dysplasia can be seen from biopsies which can then progress to carcinomas, what am I?
Ulcerative colitis
The chronic inflammation I cause, can cause cancer. What am I?
Crohn’s
You have a patient with the following symptoms:
*N&V
*Weight loss
*Acute/insidious onset
*Pain (LRQ)
*Anaemia
*Palpable masses
*Small bowel obstructions
*Abscesses
*Fistulas
*Gut perforations
What is this associated with?
Crohn’s
You have a patient with the following symptoms:
*Diarrhoea with/without blood/mucus, up to 10-20 loose stools OD
*Abdo cramps with fever
*Constipation
What is this associated with?
Ulcerative colitis
What IBD complications can happen to the skin and why?
Cytokine release in these areas which can cause:
-Erythema nodosum - tender hot nodules on the skin
-Pyoderma gangrenosum - ulcer formation
What IBD complications can happen to the eyes and why?
-Episcleritis - intense burning and itching of the blood vessels involved
-Uveitis - headache, burning red eye, blurred vision
What IBD complications can happen to the liver and why?
-Sclerosing cholangitis
-Chronic inflammation of the biliary tree
-This leads to progressive fibrosis and biliary strictures
Your patient is p-ANCA positive, what are they likely to have?
Ulcerative colitis
Your patient is p-ANCA negative, what are they likely to have?
Crohn’s
What procedure is used to diagnosis ulcerative colitis ?
Sigmoidoscopy
What can an ultrasound find for a patient with Crohn’s?
Identifies thickened small bowel loops
What blood tests will be requested for a patient initially?
Anaemia
Iron/folate deficiency
ESR and CRP and WCC (raised)
Hypoalbuminemia - shows protein loss in the gut, as mucosal wall is not working
LFT
You have a patient who is inducing remission with mild-moderate proctitis (UC), what is the treatment plan?
1) Topical aminosalicylate (mesalazine/sulfasalazine)
-If cannot tolerate go straight to step 3
No remission within 4 weeks
2) ADD oral amino salicylate
3) ADD topical or oral cortico-steroid
You have a patient who is inducing remission with mild-moderate proctosigmoiditis and left sided colitis (distal colitis), what is the treatment plan?
1) Topical aminosalicylate
-If cant tolerate -topical/oral steroid
2) High dose oral aminosalicylate or oral and topical steroid
3) Oral aminosalicyte and oral corticosteroid
You have a patient with mild-moderate, extensive spread of UC, what is the treatment plan?
1) Topical aminosalicylate + high dose oral aminosalicyte
-If first presentation/exacerbation
-If the patient cannot tolerate aminosalicylates –> Oral Steroids
2) Stop topical treatment and offer oral steroids
Inducing remission with ulcerative colitis which is moderate - severe what is the treatment plan?
1) Oral corticosteroids - pred 40-60mg
2) Biologics and JAK after failure of conventional therapy
Inducing remission with ulcerative colitis which is acute - severe requiring hospitalisation affecting all areas, what is the treatment plan?
1) IV corticosteroids, 60mg Methyl pred or 100mg Hydrocortisone TDS-QDS
2) 72 hours later - if worse/no improvement
-> ADD IV Ciclosporin
BUT in practice they will add IV Infliximab
We want to maintain remission in mild to moderate ulcerative colitis, whom has proctitis and proctosigmoiditis, what is the treatment plan?
1) Topical aminosalicylate
or Oral and topical aminosalicylate together
We want to maintain remission in mild to moderate ulcerative colitis, affecting left sided and is extensive, what is the treatment plan?
Low maintenance dose of oral aminosalicylate
We want to maintain remission in ulcerative colitis which affects all areas, the patient has had 2 + exacerbations in the past 12 months and has required steroids, remission is not maintained by aminosalicylate, what is the treatment plan?
Consider Mercaptopurine or Azathioprine
We want to maintain remission in someone with ulcerative colitis, which affects all areas, and the patient has has a single acutely severe episode of there UC, what is the treatment plan?
Azathioprine, Mercaptopurine or Oral Aminosalicylate
With a patient who is firstly presenting with Crohn’s disease or had a single exacerbation in a 12 month period, what is the treatment plan to induce remission?
1) Gluco-corticosteroid:
Pred 40mg / IV Methyl Pred / Hydrocortisone
Budesonide is beneficial for proximal disease
- If no steroids oral aminosalicylate - less effective but NICE recommend
ADD on therapy
*Azathioprine or Mercaptopurine
OR
Consider Methotrexate if can’t tolerate above or have low TPMT activity
If the patient had moderate to severe active disease how do we induce remission when they have had no response to conventional therapy? Crohn’s
1) Infliximab or Adalimumab
2) Ustekinumab or Vedolizumab
How do we maintain remission in Crohn’s?
1) Azathioprine or Mercaptopurine
*Consider methotrexate only in those who needed it at induction or cannot tolerate first option
How do we maintain treatment if a patient decide to have no treatment? Crohn’s
Follow up’s, education on what to do when they relapse, how to access healthcare, smoking cessation
How do we maintain remission after Crohn’s surgery?
Azathioprine with Metronidazole for 3/12 weeks post op.
Azathioprine ALONE if cannot tolerate Metronidazole.
What class of drug is Sulfasalazine and Mesalazine?
Aminosalicylates
Are Aminosalicylates brand specific?
YES
Where are Aminosalicylates absorbed?
By the colon and metabolised by the liver and excreted in the urine.
What monitoring does a patient need on aminosalicylates?
FBC, LFT, Creatine, eGFR
-Counselling on symptoms of myelosuppression
What drug group may colour urine and stain contact lenses yellow?
Aminosalicylates
Mercaptopurine and Azathioprine are what class of drug?
Thiopurines
What monitoring needs doing when a patient is on Thiopurines?
Prior - FBC, U&E, LFT, HCV, HIV, HBV, VZV,
-Check TMPT,
-Check cervical screening is up to date
Ongoing monitoring
*FBC *U&E *LFT
When does monitoring on thiopurines need doing?
At least week 2, 4, 8, 12, and then 3 monthly
-Counsel patient on myelosuppression
What class of drug is Infliximab?
Anti-TNF
What class of drug ends in ‘Nibs’
JAK inhibitors
In moderate to severe active UC what drugs can be used?
Upadacitnib, Ozanimod, Filgotinib, Ustekinumab, Tofacitinib, Vedolizumab, Infliximab, Adalimumab, Golimumab
In severe UC what IV ca be given?
Infliximab - given when ciclosporin is contraindicated or not appropriate
In moderately to severely active Crohn’s disease what drugs can be offered?
Upadacitinib, Risankizumab, Ustekinumab, Vedolizumab, Infliximab and Adalimumab
What enteric infections are IBD patients at a higher risk of getting?
Norovirus, Campylobacter, E.coli, C.Diff
When is IV Ganciclovir followed by oral valganciclovir treatment given to IBD patients?
When they have Cytomegalovirus (CMV).
What percentage of IBD patients are reliant on steroids?
14.9%
What are the issues with prolonged steroid use?
*infection risk
*Osteoporosis
*Adrenal suppression
*Diabetes
*Weight gain
*CVD
What is important to monitor in patients with long term steroid use?
FBC, Glucose/HbA1c, lipids, BP, eyes (cataracts and glaucoma), mood, sleep
What dose of calcium should someone on Corticosteroids be on?
800-1000mg
What dose of vitamin D should people on corticosteroids be on?
800 IU
What deficiencies can someone with IBD be susceptible to?
*Magnesium
*Calcium
*Vitamin D
*Potassium (Sando K)
*Anaemia
What must an IBD patient have annually
*FBC
*Ferritin
*CRP
How many years after symptoms of IBD does the cancer risk begin?
8-10 years
What is short gut syndrome?
Lack of functioning small bowel
-This may affect nutritional absorption
-May affect oral medication absorption
What is the max dose of loperamide with a stoma?
64mg - can cause QT prolongation
MOA of sulfasalazine
1) Mesalazine (5-ASA) bound to sulfapyridine via aza bond.
2) Colonic bacterial azo reductase breaks the bond
3) Sulfapyridine is absorbed by colon, metabolised by the liver and excreted in the urine
Where is mesalazine metabolised?
Liver
What monitoring needs to be done with someone on sulfasalazine?
Prior and every second week for the first 3 months, then monthly for three months then every three months.
FBC, LFT
Creatinine/eGFR - monthly for 3 months then as indicated.
Any sore throat, fever, myelosuppression
What are the pH dependent formulations of Aminosalicylate?
Asacol, Mesren, Salafalk/granules, Mesasal
What are the time dependent formulations of Aminosalicylates?
Pentasa/granules
What are the multi-matrix systems for aminosalicylates?
Mezavant
What is the purpose of having different delivery mechanisms to change the release of mesalazine in the GIT?
To attach to other carrier molecules!
What does an enteric coating do ?
With a specific agent to release at a specific pH to prevent early disintegration in the stomach and upper GIT
What pH does Eudragit S dissolve at?
7 - due to a methyl acrylate copolymer coating
What pH does Eudragit L dissolve at?
6 - due to methyl acrylate copolymer coating
What are the multi-matrix aminosalicylates have in them?
Mesalazine is incorporated into the lipophilic matrix and enterically coated, dissolves at pH 7.
How do the multi-matrix systems work?
Matrix swells to form a gel - (slow diffusion) - gets the terminal ileum and entire colon release.
What is Azathioprine converted to in the body?
Mercaptopurine
When on Thiopurines what should the patient be counselled?
*Myelosuppression symptoms
*Exposure to the sun as increased risk of skin cancers
*Take with meals to avoid risk of nausea
If a patient is on Allopurinol what should we do with the dose of Azathioprine?
Azathioprine dose should be 1/4 of prescribed dose. Example, pt is on 100mg initially - lower to 25mg
