Exam 1 - IBD, Celiac Disease Flashcards
What is the definition of IBD?
Crohn Disease + Ulcerative Colitis
- Chronic relapsing/remitting inflammatory conditions of the GI tract
What age group is most commonly affected by IBD?
15-35 years old, but with bimodal with second peak at 50-80 years old
How does smoking affect the risk of CD versus UC?
CD: Increases risk
UC: Decreases risk
Does the following presentation match with CD or UC?
- Limited to colon, involves rectum
- Extends proximally with continuous, circumferential involvement
- Mucosal layer inflammation
UC
Does the following presentation match with CD or UC?
- GI tract from mouth to anus
- Patchy/skip lesions
- Transmural inflammation
CD
What is the most common extent of involvement in CD?
Ileitis (Ileum)
Due to CD being transmural, what can this lead to?
Penetrating disease causing ulcers, strictures, fistulas, and abscesses.
What are the different fistulas that can develop from CD?
- Enteroenteric: bowel to bowel
- Enterovesical: bowel to bladder
- Enterovaginal: bowel to vagina
- Enterocutaneous: bowel to skin
Differentiate mild CD from severe CD?
Mild: inflammation
Severe: inflammation, strictures, fistula
What is the common symptom associated with CD?
Abdominal pain
- RLQ pain/tenderness
- Tender, palpable RLQ mass if abscess
What nutritional deficiencies can CD be associated with?
- B12 deficiency (if terminal ileum involvement)
- Iron
What is the most common extra-intestinal manifestation of IBD?
What are some others that are related to CD?
- Arthralgias (most common)
- Oral aphthous ulcers
- Episcleritis, iritis, uveitis
- Erythema nodosum
- Pyoderma gangrenosum
What should always be ordered for diagnostic evaluation of CD?
- Colonoscopy with TI intubation
- (+/-) EGD
What will be found on colonoscopy to support the diagnosis of CD?
- Skip lesions
- Ulcerations, cobblestoning
- Biopsy shows granulomas
What is a hallmark finding on colonoscopy for CD?
Ulcerations, cobblestoning
What will be found on UGI with SBFT that is suggestive of CD?
String sign
What are some possible complications of CD?
- Colon cancer
- Intestinal strictures, abdominal and perianal fistulas, abscess
- Malabsorption (B12, iron)
What should be done in regards to monitoring in a patient with CD and UC?
Colonoscopy recommended every 1-2 years beginning 8 years after disease/symptom onset due to risk of colon cancer
Differentiate mild UC from severe UC.
Mild: < 4 stools daily, no systemic toxicity
Severe: > 6 stools daily, systemic toxicity
What are some common symptoms associated with UC?
- Abdominal pain (periumbilical/LLQ)
- Bloody diarrhea
- Fecal urgency, tenesmus, rectal bleeding
What is the most common extra-intestinal manifestation of IBD?
What are some others that are related to UC?
- Arthralgias (most common)
- Sclerosing cholangitis (Alk. phos)
- Episcleritis, iritis, uveitis
- Erythema nodosum
- Pyoderma gangrenosum
What should always be ordered for diagnostic evaluation of UC?
Flex sigmoidoscopy or colonoscopy
What will be found on Flex sigmoidoscopy or colonoscopy to support the diagnosis of UC?
- Inflammation that begins distally and spreads proximally
- Continuous circumferential pattern with no skip lesions
- Superficial inflammation: erythematous, exudate, friability/erosions
- Biopsy shows crypt abscesses
What are some possible complications of UC?
- Colon cancer
- Hemorrhage
- Toxic Megacolon (colonic dilation > 6 cm with signs of toxicity)
What are the medical therapies for IBD?
- Salicylates (5-ASA)
- Corticosteroids
- Immunomodulators
- Biologics
- Antibiotics (for CD)
Salicylates (5-ASA):
MOA?
Indications:
Side effects:
MOA: Anti-inflammatory effects
Indications: Mild to moderate UC (primarily) and CD (less efficacy)
SE: Nausea, diarrhea, kidney injury, pancreatitis
Corticosteroids:
MOA?
Indications:
Side effects:
MOA: Anti-inflammatory effects; suppress immune activity
Indications: Flares in UC and CD (appropriate for short-term use, not maintenance; require slow taper)
Side effects (specifically for Prednisone): weight gain, worsening of DM, increased infection risk, osteoporosis, adrenal insufficiency, psychosis, mood changes
If prescribing Prednisone for UC/CD flares, what are some recommendations?
- Consider bone density (DEXA scan) in patients with IBD with lifetime use of steroids for 3 months or more
- Calcium and Vitamin D supplementation should be administered to help offset concern for osteoporosis
Immunomodulators:
MOA?
Indications:
MOA: Modifies immune system activity; decreases inflammatory response
Indication: Moderate to severe UC and CD; steroid sparing agent; can be used in combination with biologics to prevent immunogenicity
What are the requirements/important notes for the specific immunomodulators?
What is the main side effect of Methotrexate?
Thiopurines, Imuran:
- Systemic risks
- Optimal response takes 3-6 months
- Genetic testing required to determine patient metabolism of drug
Methotrexate:
- Require folate supplementation
- Tetratogenic
What are the systemic risks associated with the immunomodulators: Thiopurines (6MP) and Imuran (Azathioprine)?
- Bone marrow suppression
- Pancreatitis
- Hepatotoxicity
- Non-Hodgkin lymphoma
- HPV-related cervical dysplasia
- Non-melanoma skin cancer
What are the recommendations associated with the immunomodulators: Thiopurines (6MP) and Imuran (Azathioprine)?
- Frequent monitoring of CBC and liver tests due to risk of bone marrow suppression and hepatotoxicity
- Annual dermatologic exams due to risk of skin cancer
- Up to date on cervical cancer screening due to possible cervical dysplasia
- Avoid live vaccines
Biologics (Anti-TNFs):
MOA?
Indications:
MOA: Modulates immune response; prevents intestinal inflammation, improves mucosal healing
Indications: Moderate to severe IBD; steroid sparing
What are the systemic risks associated with the Biologics (Anti-TNFs)?
- Reactivation of TB and HBV
- Non-melanoma skin cancer
- Non-Hodgkin lymphoma
- Secondary infections
What are contraindcations for using Biologics (Anti-TNFs)?
- Active infection
- History of CHF
- MS/optic neuritis
When are antibiotics indicated for treatment of CD?
Which abx are used?
Perianal disease (fistulas, abscess)
Cipro and Flagyl (Metronidazole)
What are side affects of Cipro?
- Tendinitis (tendon rupture)
- Photosensitivity
- Prolongation of QT interval
What are side affects of Flagyl (Metronidazole)?
- Peripheral neuropathy
- Metallic taste
- Disulfiram rxn (avoid alcohol while on therapy and 3 days thereafter)
What are some IBD red flags indicating a need for emergent evaluation?
- Severe bleeding
- Severe abdominal pain (peritoneal signs)
- Inability to tolerate PO
- Signs of dehydration (creatinine, tachycardia, hypotension)
- Signs of obstruction
What are some indications for surgery for IBD?
- Severe hemorrhage
- Perforation
- Dysplasia/Cancer
- Medical refractory disease
What are some important considerations when considering IBD?
- Always check stool studies for those developing diarrhea
- Avoid NSAIDs (can exacerbate disease activity)
Colonoscopy reveals ulcerations and cobblestoning. What is the likely diagnosis?
CD
Biopsy of the colon reveals crypt absccess. What is the likely diagnosis?
UC
What medication option should be used for flares of UC and CD?
Steroids
What is the 1st line treatment for mild/moderate UC?
Oral and topical 5-ASA
What is the treatment for moderate/severe UC and CD?
Immunomodulators alone or in combination with biologics
Are antibiotics used in CD or UC?
CD for intestinal and/or perianal abscess/fistula
Are the following complications associated with UC or CD?
- Toxic megacolon
- Colon cancer
UC
Biopsy of the colon revealed granulomas. What is the likely diagnosis?
CD
Are the following complications associated with UC or CD?
- Abscess
- Strictures
- Fistulas
- Perforation
- Obstruction
- Colon cancer
- Malabsorption
CD
What is Celiac disease?
Immune-mediate disease triggered by the ingestion of gluten (wheat, rye, barley)
Describe the pathophysiology behind Celiac disease.
Small intestine exposure to gluten leads to mucosal inflammation, crypt hyperplasia, and villous atrophy. This villous atrophy then leads to loss of absorptive surface capacity and small bowel malabsorption.
What are the “classic” symptoms associated with Celiac disease?
- Diarrhea
- Steatorrhea
- Flatulance/bloating
- Weight loss
What extra-intestinal manifestationi is pathognomonic of Celiac disease?
- Dermatitis Herpetiformis
What are some extra-intestinal manifestations associated with Celiac disease?
- Dermatitis Herpetiformis
- Nutrient deficiencies (Iron, B vitamins)
- Osteopenia/Osteoporosis (Vitamin D, Calcium deficiencies)
- Transaminase elevation
- Reproductive disorders
- May see FTT in kids
What does the diagnostic evaluation for Celiac disease consist of?
- Serology and Biopsy of the small intestine while on a gluten containing diet
- EGD with duodenal biopsy
What is the gold standard diagnostic study for Celiac disease?
EGD with duodenal biopsy
What will be seen on Serology and Biopsy of the small intestine which would support the diagnosis of Celiac disease?
- IgA tissue transglutaminase (tTG Ab) (primary)
- IgA endomysial (EMA Ab titer)
- Deamidated Gliadin Peptide (DGP)
What will be seen on EGD with duodenal biopsy which would support the diagnosis of Celiac disease?
- Villous atrophy
- Intraepithelial lymphocytes
- Crypt hyperplasia
What is the management of Celiac disease?
Gluten free diet (removal of wheat, rye, barley)
- Common foods: fresh fish, meat, poultry, milk, fruits/vegetables
Supplements as needed:
- Folate, iron, zinc, calcium, B12, vitamin D
What are some complications associated with Celiac disease?
Diseases associated with malabsorption:
- Iron deficiency anemia
- B vitamin deficiency
- Osteoporosis
Slight increased risk of malignancy:
- Non-Hodgkin lymphoma
- GI malignancies
EGD with duodenal biopsy revealed the following:
- Villous atrophy
- Intraepithelial lymphocytes
- Crypt hyperplasia
What is the likely diagnosis?
Celiac disease?
