Gastro - IBD Flashcards
What are the extra-intestinal manifestations of IBD?
Uveitis/episcleritis/iritis
Aphthous ulcers/gingival hyperplasia (ciclosporin)
Finger clubbing (extensive SB Crohn’s)
NASH, gallstone disease, pancreatitis
GU: urolithiasis, renal amyloidosis
Arthritis incl sacrolilitis (usually UL), AVN
Erythema nodosum/pyoderma gangrenosum
What operative scars might you see in an IBD patient?
Crohn’s: Right hemicolectomy, bowel resection or striculoplasties.
50-80% of CD will need 1 or more surgeries in lifetime.
UC: pancolectomy -> ileostomy
What are the differentials for a RIF mass?
Acute CD
Appendix mass/abscess
Ileocaecal mass (malignant)
Ileocaecal abscess (Yersinia)
Ileocaecal TB
Renal transplant
Histological features of CD
- Affects entire GI tract - may get aphthous ulcers in and around mouth
- Fistulating disease, can be peri-anal
- Skip lesions
- Transmural inflammation
- Granuloma formation
Histological features of UC
- Exclusively affects the colon
- Can get dilated terminal ileum also (backwash ileitis)
- Superficial inflammation of mucosa
- Crypt abscess formation
3 features more suggestive of CD than UC?
What are some of the discerning clinical features of CD?
- Fat malabsorption from small bowel disease: steattorhoea, deficient in Fat-soluble vitamins (ADEK)
- RIF pain (Terminal ileum disease 30%)
- Perianal disease (ulceration or fistula)
Risks associated with UC
- Increased risk of PSC
- Increased risk of CRC
What is severe on Truelove & Witts?
1) > 6 stools/day
2) Systemic upset: fever, tachycardia
3) Anaemia
4) Raised ESR/CRP
How would you investigate and manage acute colitis?
Immediate assessment:
ABCDE
Bloods: FBC, U&E, inflammatory makers incl ESR/CRP, LFT baseline
Stool for MC&S, OCP, C.diff, calprotectin (consider FIT)
Chest + Abdo XR ?TMC
Cross sectional: CT/MRI
IP OGD/Flexible sigmoidoscopy + biopsy
+/- Bowel contrast studies: examine strictures/fistulae in CD
VTE prophylaxis (pro-thrombotic)
Treatment strategy for IBD
Crohn’s mild-moderate: oral steroid (5-ASA)
UC mild-mod: oral/top steroid + 5-ASA
Severe UC/CD: IV steroid
+ UC - IV ciclosporin
+ CD - IV infliximab
Maintenance:
CD: PO steroid, AZA, MTX, TNFa inhibitor (infliximab, adalimumab)
UC: PO steroid, 5-ASA, AZA
*AZA and infliximab are safe in pregnancy. Infliximab increases risk of lymphoma.
Consider metronidazole if infection in CD
50-80% of CD will need 1 or more surgeries in lifetime.
What are some of the longer term complications of CD or UC?
CD: anaemia, malabsorption, fistulae, abscess, intestinal obstruction (stricutures)
UC: anaemia, toxic dilatation + perforation, CRC.
What is the MDT approach to longer term management of IBD including lifetime risks?
- Smoking cessation,
- Dietitian: high fibre, low residue diet
- IBD CNS
- Explanation EI manifestations
- Complications: strictures/fistulae
- Increased lifetime risk of intestinal adenocarcinoma and NH- lymphoma
- May need surgery
- Regular gastro and GP FU
- Psychological support including patient groups
Differential diagnosis for colitis
- IBD
- Coeliac; diarrhoea, non-bloody
- IBS; diarrhoea, non-bloody
- Infective colitis including Giardia, amoebiasis (presents similar to IBD), CMV colitis, c.diff or Pseudomembranous colitis (c.diff overgrowth)
- Microscopic/ indeterminate colitis
- Ischaemic colitis (abdominal pain, history of clot disorder/AF)
- Radiation colitis
When is surgery indicated in acute colitis?
TMC (>5.5 colon, >9cm caecum)
3 days of treatment with >8 stools/day or CRP >45
What is sclerosing cholangitis?
bile duct inflammation causing scarring and strictures. Associated with UC, or autoimmune disease.
Typically (+) p-Anti-Neutrophil cytoplasmic Ab, (+) anti-smooth muscle Ab, anti-nuclear antibody.
