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S - Ch. 6 - Inflammatory Bowel Disease > Full Chapter > Flashcards

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1
Q

IBD is defined as a relapsing remitting autoimmune condition mainly affecting the bowel along with extraintestinal manifestations due to the inability to suppress normal immune-mediated responses.
Describe the inflammation in Crohn’s vs UC

A

Crohn’s: Skip lesions (1), transmural (2), granulomatous (3) inflammation affecting any part of the GIT

UC: Inflammation confined to the mucosa and submucosa from the rectum to the caecum

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2
Q

What type of granulomas are seen in Crohn’s and UC?

A

Crohn’s has Non-caseating granulomas
UC is not a granulomatous disease

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3
Q

Give 5 autoimmune diseases you need to ask about when taking a history from a patient with IBD

A

1) Hep: PSC, Autoimmune hepatitis
2) Rheum: Enteropathic arthritis, Ankylosing spondylitis, Psoriatic arthritis
3) CTD: SLE
4) Autoimmune thyroid disease (hashimoto, grave’s)
5) coeliac disease
6) T1DM

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4
Q

What % of IBD will develop enteropathic arthritis?
What % of patients with PSC will have UC?

A

20%
70%

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5
Q

What is the typical age of onset for IBD?

A

Crohn’s: 10s-20s
UC: Late 10s, early 20s + 55-65 (=> bimodal)

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6
Q

Most common area of crohn’s is….
Rank the rest? (extra)

A

Terminal ileum

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7
Q

List the layers of the bowel wall from inside to out

A

1) Lumen
2) Mucosa
3) Submucosa (containing Meissner’s plexus)
4) Muscularis propria: Inner circular -> Auerbach -> Outer longigtudinal
5) Serosa/adventitia

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8
Q

How would you describe the Ulcers in IBD?

A

CD: Deep fissuring ulcers
UC: Mucosal/shallow ulcers

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9
Q

Which IBD is more associated with Crypt abscesses?

A

UC

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10
Q

Which IBD is more associated with Proctitis?
What is proctitis and how does it manifest

A

UC
Proctitis is inflammation of the rectal mucosa
1) Bloody, mucous diarrhoea
2) Rectal +/- LIF pain
3) Bowel Urgency and Tenesmus
4) Anorexia and weight loss

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11
Q

What is backwash ileitis and which IBD is it associated with?

A

Backflow of colonic content into the terminal ileum in UC. 20% will rpesent with this

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12
Q

Which IBD is more associated with perianal pathologies/manifestations?

List them

A

CD
1) Ulcers (deep fissuring)
2) Strictures
3) Fistulas
4) Bowel Incontinence
5) Watering Can Perineum
6) Skin tags

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13
Q

Briefly discuss pregnancy to a patient with IBD including the drugs that may be used in pregnancy

A

There is normal fertility but there is an increased risk of premature delivery and abortions

Safe drugs: 5-ASA, Steroids, Azathioprine, Infliximab

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14
Q

5-ASA has a 40% success rate alone. What are the side effects of 5-ASA?

Give 2 examples and state which can be given as a suppository for first line management of Proctitis in UC?

A

Azoospermia/infertility (although ok in pregnancy)
Lymphopenia
Renal toxicity

Sulfasalazine
Mesalazine (suppository)

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15
Q

Polyposis seen on colonoscopy is associated with which IBD?
Are they normal polyps or pseudopolyps?

when doing the colonoscopy you notice some ulcers but cant remember how to differentiate ulcers between UC and CD. So, you decide to take a biopsy and the biopsy comes back with reduced goblet cells. Is that finding consistent with UC or CD?

Unlike you in the past, you know how to differentiate the ulcers of CD and UC. Differentiate them

A

Pseudopolyposis seen on colonoscopy in UC

Ulcers: Deep in CD, superficial in UC

Biopsy: Raised goblet cells in CD, reduced in UC

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16
Q

Toxic megacolon is a feature of which IBD?

A

Most commonly UC

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17
Q

What is the gold standard imaging for IBD?
What is the most common imaging used in IBD?
What findings on imaging are consistent with IBD? For each, state if more common in UC or Crohns or about equal. Give 5 and youre good,

A

Gold standard = MR Enterography (especially for crohn’s
Most common = CT abdomen/Pelvis with IV AND Oral/rectal contrast (esp for crohn’s)
1) Bowel wall thickening (CD)
2) Fat Stranding vs Fat sparing (CD vs UC))
3) Comb sign (Specific to CD)
4) Skip lesions vs. Continuous (CD vs UC)
5) Fistulas (oral contrast) (only CD)
6) Obstruction (CD)
7) Toxic megacolon (UC)
8) Lead Pipe Colon (UC)

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18
Q

What is Comb sign?

A

It is the hypervascular appearance of the mesentery in crohn’s disease

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19
Q

Why (specifically) is MRI better than CT for imaging especially in IBD?

A

Can differentiate between active inflammation and fibrosis (previous inflammation). Other than that its just very accurate and avoid radiation (esp since most patients are young)

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20
Q

Define fat encroachment

A

Creeping and proliferation of mesenteric fat that wraps around the surface of the intestine (from the outside)

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21
Q

What does Fat stranding indicate?
What does Fat encroachment indicate?
Which IBD are they common in?
How is each detected?

A

Fat stranding = imaging observation = indicates acute/subacute inflammation

Fat Encroachment = Surgical observation = indicates chronic inflammation and structural changes

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22
Q

Hypokalaemia and hypoalbuminaemia is more common in which IBD? Why?

A

UC as it is large volume, bloody and mucous diarrhoea

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23
Q

What is the management of a toxic megacolon

A

Stabilise (ABCD 10 steps) + Emergency Colectomy

24
Q

Pyoderma gangrenosum and erythema nodosum are extra-intestinal manifestations of IBD. Which type is each more common in

A

Pyoderma = cobblestone = CD
Erythema nodosum = red = bloody = UC

25
List the extra-intestinal manifestations of IBD
AAPICEESS Apthous ulcers Ankylosing spondylitis Pyoderma gangrenosum Iritis, Anterior uveitis, Corneal ulcers Clubbing Erythema Nodosum Enteropathic arthritis Sacroiliitis Sclerosing cholangitis
26
How is anterior uveitis diagnosed? a) Clinical b) Fundoscopy c) Slit lamp d) Opthalmology referral
C - Slit lamp
27
Vitamin deficiency is associated with what IBD? Any questions to ask if you were to take a history?
CD Vit. A - eye dryness Vit. D - fatigue, muscle weakness, bone pain Vit. E - Peripheral neuropathy Vit. K - Easy bruising? These can also be asked in CF and chronic pancreatitis
28
Malabsorption is a cardinal feature of which IBD? How do these manifest?
CD as it is inflammation of the terminal ileum most commonly so the following are absorbed there 1) Protein-calorie deficiency => weight loss 2) Anaemia: Fe, Folate and B12 and everything that comes with it 3) Bile salts => Excess in stool => colonic irritation => diarrhoea +!!! Gallstone formation (and all its sequelae) 4) Vit. ADEK deficiency (dry eyes, fatigue, muscle weakness, bone pain, peripheral neuropathy (also B12), easy bruising)
29
Vitamin deficiency is associated with what IBD? Any questions to ask if you were to take a history?
CD Vit. A - eye dryness Vit. D - fatigue, muscle weakness, bone pain Vit. E - Peripheral neuropathy Vit. K - Easy bruising? These can also be asked in CF and chronic pancreatitis
30
The hepatic system is heavily affected by IBD. We know that PSC is strongly a/w UC. What about Crohn's? How does that affect the hepatic system?
Excess bile salts are typically absorbed in the terminal ileum. In crohn's this is all inflamed => malabsorption just like with the vitamins
31
What are the 4 types of fistulas seen in CD? How does each manifest?
Ileoenteric fisula - Abscess formation + peritonitis Enterocutaneous - Cellulitis + cutaneous discharge Enterovaginal - PV faeculent discharge + Genital infections Enterovesical - Pneumaturia + Recurrent UTIs
32
You are asked to take a history from a patient with known IBD. What are the top 10 questions you must ask. This is the only question on history so while youre at it, add in everything else if the primary presenting complaint was that consistent with IBD
1) Establish Timeline of dx including sx prompting initial investigation 2) Blood/mucus in stool (quantify, colour...) 3) Bowel movements: Tenesmus, hard, pellet, diarrhoea, changes recently 4) Weight changes? Changes in appetite 5) Abdominal pain, pain when passing stool 6) Extra-intestinal: Eye irritation, mouth sores, skin rashes, joint pain 7) Medications for IBD (if immunosuppressants, ask about recent infections and admissions and !!flareups) 8) Previous hospitalizations, flareups, and any complications when receiving care 9) Any other autoimmune diseases? anyone in the family has IBD? 10) QoL (school, work, sleep etc...) Malabsorption: 1) Protein-calorie deficiency => weight loss 2) Anaemia: Fe, Folate and B12 and everything that comes with it 3) Bile salts => Excess in stool => colonic irritation => diarrhoea +!!! Gallstone formation (and all its sequelae) 4) Vit. ADEK deficiency Vit. A - eye dryness Vit. D - fatigue, muscle weakness, bone pain Vit. E - Peripheral neuropathy Vit. K - Easy bruising? Ileoenteric fisula - Abscess formation + peritonitis Enterocutaneous - Cellulitis + cutaneous discharge Enterovaginal - PV faeculent discharge + Genital infections Enterovesical - Pneumaturia + Recurrent UTIs
33
How is enterocutaneous fistulas diagnosed? How is it performed?
Fistulography => injecting contrast directly into fistula and then PFA
34
Gastric outlet obstruction is associated with which IBD? What about dysphagia?
CD for both
35
Renal stones are associated with IBD. Which type of renal stones? What medication may be given to help with that?
Calcium oxalate stones Allopurinol
36
Do you know of any classification systems used specifically for CD? Name it What is it used for? Go through it Any others you know? (just the name)
Other = Harvey Bradshaw Index
37
Do you know any classification systems used specifically for UC? (2) I want you to name the one adapted from the Montreal classification, give its use, and its components (without values) I want you to name the one that is used when working up the patient in hospital. What is it used for? What are the components?
True-Love and Witt adapted from the montreal classification and is used to determine if there is Acute Severe Colitis. It includes 1) Number of Bloody stools (>6) 2) Pulse >90 3) Temp >37.8 4) Hb <10.5 5) CRP Markedly raised MAYO classification is used to assess the severity on endoscopy. Takes into consideraton 1) Stool frequency 2) Rectal bleeding 3) Mucosal findings on endoscopy 4) Physician's global assessment
38
When going through your investigation, whats one test that is more specific for UC and one more specific for CD. There is one serology investigation for each and one more that is more specific to CD if that helps
CD: Faecal calprotectin - released due to infl. OR ASCA (30-50% of CD) UC: pANCA ASCA to spANCA
39
If you had to pick one investigation to perform on a patient with signs and symptoms of IBD, what would it be?
Colonoscopy (which will also take a biopsy)
40
You are performing a colonoscopy on a patient with suspected IBD and are trying to differentiate between CD and UC. What features are you looking for that will help you make this distinction?
CD: 1) Skip lesions 2) Cobblestone mucosa 3) Deep fissuring ulcers UC: 1) Hyperaemic bowel mucosa with contact bleeding 2) Proctitis (infl. of rectal mucosa) 3) Pseudopolyposis 4) Multiple superficial ulcers
41
You are performing a colonoscopy on a patient with suspected IBD and are trying to differentiate between CD and UC. You take a biopsy and send it to the pathology lab. What features is the pathologist looking for that will help them make this distinction?
CD: 1) Increased goblet cells 2) Intralymphatic Non-caseating granulomas 3) Granulomatous vasculitis UC: 1) Reduced Goblet cells 2) Crypt Abscesses with PMN infiltration 3) Mucin depletion 4) Dysplasia (adenocarcinoma)
42
List all the investigations you would like to perform for a patient presenting with signs and symptoms consistent with IBD. Actually do this one, very important and give reasoning etc..
43
What is the non-pharmacological management you would offer a patient with CD on first diagnosis?
44
Fulminant colitis is considered a direct indication for surgical management. What would constitute fulminant colitis?
It is severe sudden deterioration chatacterised by - >10 stools/day - Continuous bleeding - Abdominal pain - Abdominal distention - Toxic megacolon
45
List the monoclonal antibodies used in IBD along with their names for 5/5
Biologics/Monoclonal antibodies: Anti-TNF (Infliximab), Anti- interleukin 12/23 (Ustekinumab), Anti-integrin (Vedolizumab), JAK inhibitors (Tofacitinib)
46
Are JAK inhibitors better for CD or UC? Give the name
UC, Tofacitinib
47
Discuss the Full medical management of IBD for both UC and crohns
1) Acute - Po Pred (8x5mg tablets) -> IV hydrocortisone 2) Proctitis (UC only): 5-ASA suppository (mesalazine) or Foam/liquid enema 3) Systemic Non-immunological (UC only): Sulfasalazine or Mesalazine 4) Systemic Immunomodulators: Azathioprine, 6-mercaptopurine, Methotrexate 5) Biologics/Monoclonal antibodies: Anti-TNF (Infliximab), Anti- interleukin 12/23 (Ustekinumab), Anti-integrin (Vedolizumab), JAK inhibitors (Tofacitinib)
48
What type of drug is azathioprine? What does this drug class fall into? What other medication falls into this category and is used in the setting of transplant rejection prophylaxis?
Thiopurine along with 6-mercaptopurine These fall under anti-metabolites along with Mycophenolate mofetil
49
How would you determine whether to give a patient Azathioprine, 6-mercaptopurine, or Methotrexate as part of the systemic immunomodulators?
TPMT levels Azathioprine is metabolised in the liver into 6-mercaptopurine so theyre essentially the same thing. 6-Mercaptopurine would be used to bypass the liver in patients with more side effects (N+V) 6-Mercaptopurine is then metabolized by TPMT into the inactive compounds before being excreted. Some patients have congenitally low TPMT -> increased relative dose => these patients should take methotrexate instead
50
Is surgical management in IBD curative?
CD: Non-curative UC: Curative
51
Discuss the surgical management of a patient with CD. For each surgery mentioned, you need to include what is involved in it/why its done
1-3 normally 4 in emergency
52
Discuss the surgical management of a patient with UC. For each surgery mentioned, you need to include what is involved in it/why its done
Extra information included
53
A patient with more weight loss and more abdominal pain is more likely to be CD or UC?
CD
54
Knowing a lot about the manifestations of IBD, do an exam. (actually useful)
55
You are in a long case and the examiner is telling you a patient presents with >6 bloody stools per day for the past 2 days and a temperature of >37.8 with a pulse of >90. VBG shows Hb, 10.5 and CRP is markedly raised. PFA shows the following What is the most likely diagnosis? (not in the pic) What classification should be used here? What is the full management of this patient?
Acute Severe colitis as it satisfies all the conditions of True-Love and Witt
56
You are in a long case and your examiner asks you to tell them the "complications" of each CD and UC. What will you say?
57
A patient with CD and enthesitis will have what +ve gene? Very very briefly how would it be managed acutely?
HLA B27 +ve As for IBD but + IA steroid injection for monoarthropathy

S - Ch. 6 - Inflammatory Bowel Disease (2 decks)

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