E1: IBD And Celiac Disease Flashcards
What parts of the body are involved in Crohn’s disease?
-Can affect the entire GI tract from mouth to anus with skip lesions
What is the most common place for Crohn’s disease?
Ileum (ileitis)
What is the severity of Crohn’s disease?
- The disease is transmural and effects the entire thickness of mucosa
- owes to penetrating disease and may cause ulcer, stricture, fistula, and abscess
What is it called when a fistula goes from bowel to bowel?
Enteroenteric
What is it called when a fistula goes from bowel to bladder?
Enterovesical
What is it called when a fistula goes from bowel o vagina?
Enterovaginal
What is it called when a fistula goes from bowel to skin?
Enterocutaneous
What is the difference between mild, moderate, and severe Crohns?
- Mild: inflammation
- Moderate: inflammation, strictures
- severe: inflammation, strictures, and fistula
If a patient has T1 involvement of Crohn’s disease, what deficiency are they at increased risk for?
B12
What are the extra-intestinal manifestations of Crohn’s disease? Which is most common?
Arthralgia (most common Oral aphthous ulcers Episcleritis Erythema nodosum Pyoderma gangrenosum
What labs can help diagnose CD?
- CBC, CMP, ESR/CRP, possible IBD specific antibodies
- stool cultures, C diff toxin, and fecal cal protection or lactoferrin
If a patient has evidence of CD on colonoscopy what should you do next?
EGD
What can you seen on colonoscopy that is indicative of CD?
- Skip lesions
- ulcerations, cobblestoning
- possible fistulas
- rectal sparing
- biopsy shows granulomas
What will you see on UGI with SBFT that is indicative of CD?
String sign
What are the possible complications associated with CD?
- Colon cancer (colonoscopy recommended very 1-2 years beginning 8 years after disease symptom onset)
- intestinal strictures, abdominal and perinatal fistula, abscess (may present with SBO and perforation)
- malabsorption
What areas are involved in UC?
Affects the colon only in a continuous circumferential pattern
What is the severity of UC?
Disease affects mucosal surface of colon only, can cause friability, erosions, and bleeding
What is the difference between mild, moderate, and severe UC?
Mild: 4 stools daily, no systemic toxicity
Moderate: >4 stools daily, anemia, low grade fever
Severe: >6 stools daily, systemic toxicity
What is the clinical presentation of UC?
- possible fever, chills, weight loss
- possible vomiting
- periumbilical/LLQ abdominal pain
What are the extra-intestinal manifestations of UC? What is the most common?
- Arthralgias (most common)
- sclerosing cholangitis
- episcleritis
- erythema nodosum
- pyoderma gangrenosum
What kind of scope is used to diagnose UC?
Flex sig or colonoscopy
What can you see on flex sig or colonoscopy that is suggestive of UC?
- Inflammation begins distally, spreads proximally
- continuos circumferential pattern, no skip lesions
- superficial inflammation
What will you see on biopsy that is suggestive of UC?
Crypt abscesses
What are the possible complications of UC?
- Colon cancer (colonoscopy recommended very 1-2 years beginning 8 years after disease/symptom onset)
- Hemorrhage
- toxic megacolon
What is toxic megacolon?
-Colonic dilation >6cm with signs of toxicity
What are the pharmacologic treatment options for IBD?
- Salicylates (5-ASA)
- corticosteroids
- immunomodulators
- Biologics
- Antibiotics (CD with perinatal disease)
What is the MOA of 5-ASA?
-Anti-inflammatory effects, used for mild to moderate UC and CD
What kind of drugs are sulfasalazine and mesalamine?
5-ASA
What are the side effects of 5-ASAs?
Nausea, diarrhea, kidney injury, and pancreatitis
What is the MOA of corticosteroids?
-anti inflammatory effects, suppress immune system activity. Flares in UC and CD
How are corticosteroids used for UD and CD?
Used for flares, appropriate for short-term use, NOT maintenance
-requires slow taper
What are the side effects of oral prednisone?
-mood changes, insomnia, weight gain, worsening of DM, increased infection risk, osteoporosis, psychosis, adrenal insuffiency
What kind of study is recommended for patient with IBD and lifetime use of steroids for ≥ 3 months?
DEXA scan
What kind of supplementation should be offered with long term prednisone therapy?
Calcium and vitamin D
What kind of drug is Entocort and what does it treat?
Corticosteroid ( Oral budesonide), treats CD ileocecal disease
What kind of drug is uceris and what is it used for?
Corticosteroid (oral budenoside), treats UC
What is the MOA of immunomodulators?
-Modifies the immune system activity, decreases inflammatory response
How are immunomodulators used in the treatment of UC and CD?
-used for moderate-severe UD and CD, steroid sparing agent, and can be used in combo with biologics to prevent immunogenicity
What kind of drugs are thiopurines (6MP and azathioprine) , and methotrexate?
Immunomodulators
What kind of supplementation does methotrexate require?
Folate
What are the side effects of 6MP and azathioprine?
Bone marrow suppression, secondary infection, pancreatitis, hepatotoxicity, non Hodgkin lymphoma, and non-melanoma skin cancer
What tests should you frequently test in someone taking 6MP or azathioprine?
- frequent monitoring of CBC and liver tests
- annual dermatologic exam
- UTD on cervical CA screening
What is the MOA of biologics (Anti-TNF)?
-Modulates immune response, prevents intestinal inflammation, improves mucosal healing
What kind of drugs are infliximab, adalimumab, golimumab, certolizumab and what are they used for?
- biologics (Anti-TNFs)
- infliximab (UC and CD)
- Adalimumab (UD and CD)
- Golimumab (UC)
- Certolizumab (CD)
What should you test for prior to starting someone on Anti-TNFs?
- PPD, quantierfon TB gold, CXR to assess for TB
- HepBsAg, HepBsAb, to assess for HBV
What are the associated risks with Anti-TNFs?
- Secondary infection
- Risk of reactivating of TB and HBV
- Malignancies (Non melanoma skin cancer and Non- Hodgkins)
What are the contraindications for Anti-TNFs?
- Active infection
- history of CHF
- MS/optic neuritis
What should you monitor in someone taking Anti-TNFs?
- Check a regular CBC, and CMP
- annual derm exams
What is the MOA of Vedolizumab and Ustekinumab?
Modulates immune response and prevents intestinal infections
What are the indications for Vedolizumab and ustekinumab?
Considered in patients with inadequate or loss response to conventional therapies
What antibiotics are used for CD in perianal disease?
Cipro and flagyl
What are the red flag symptoms for IBD?
-severe bleeding (anemia), severe abdominal pain (peritoneal signs), inability to tolerate PO, signs of dehydration, signs of obstruction
What are the indications for surgery with IBD?
-Severe hemorrhage, perforation, dysplasia, and medical refractory disease
What medications should people with IBD avoid?
NSAIDs, may exacerbate disease activity
What is celiac disease?
Immune mediated disease triggered by the ingestion of gluten in genetically susceptible individuals
What happens when people with celiacs ingest gluten?
- it may cause mucosal inflammation, crypt hyperplasia, and abnormal villus architecture
- villus atrophy of the small intestine and loss of absorptive surface capacity and small bowel malabsorption
What are the genes associated with celiac disease?
HLA DQ2 and HLA DQ8
What is the clinical presentation of celiac?
- Classic malabsorptive symptoms (diarrhea, flatulence, bloating)
- Atypical GI symptoms (abdominal pain, constipation, dyspepsia)
- Silent (may present with extra-intestinal manifestations)
What are some of the extra-intestinal manifestations associated with celiac disease?
- Dermatitis herpetiformis
- nutrient deficiency
- osteopenia/osteoporosis
- transaminase elevation
- FFT in kids
- reproductive disorders
What is dermatitis herpetiformis?
A chronic inflammatory diseases that produces lesions that burn and itch intensely.
The lesions are erythematous and slightly popular, form small pustules/vesicles
What is the gold standard for diagnosing celiac disease?
EDG with duodenal biopsy
What blood tests can be performed to test for celiac?
- IgA tissue transglutaminase (tTG Ab) (primary)
- IgA endomysial
- Deamidated Gliadin Peptide
- ** These must be performed while on a gluten containing diet
What might you see on EDG that is suggestive of celiac disease?
-Villous atrophy , enlarged hyperplastic crypts, and increased infiltration of lymphoid cells in the lamina proprietary and epithelium
What is the management of Celiac disease?
- Gluten free diet
- supplementation PRN (folate, Iron, zinc, calcium, B12)
What are some complications associated with celiac disease?
- Disease associated with malabsorption (IDA, osteoporsis)
- Slight increased risk of malignancy (non Hodgkins and GI malignancy)
