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Medicine > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

UC definition + areas affected

A

relapsing + remitting inflammatory disorder of the colonic mucosa.

1- proctitis- can affect just the rectum 30%
2- left-sided colitis - or distal colitis extend to involve part of the colon40%- rectal bleeding, urge/tenesmus
3- pancolitis- or total/entire colon 30%- chornic >6m diarrhoea

never spreads proximal to ileocaecal valve except for backwash ileitis

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2
Q

what is the suspected cause of UC?

A

inappropriate immune respones against ?abnormal colonic flora in genetically susceptible individuals

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3
Q

what is the pathology of UC?

A

pathological hallmarks: inflammation always present in rectum, continuous, limited to mucosa of bowel/superficial

hyperaemic/haemorrhagic colonic mucosa +/- pseudopolyps formed by inflammation

punctate ulcers may extend deep into lamina propria- inflammation is normally not transmural

continuation inflammation limited to mucosa differentiates it from Crohns disease

prevalence 100-200/100 000

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4
Q

at what age does UC typically present?

A

20-40yrs

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5
Q

what are the symptoms of UC?

A

episodic or chornic diarrhoea +/- blood + mucus

malaise

crampy abdominal discomfort
bowel frequency relates to severity (4 mild, 5 mod, 6 severe)

urgency/tenesmus- proctitis

systemic symptoms in attacks: fever, malaise, anoreaxia, decreased weight

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6
Q

what are the signs of UC?

A

typically none
in acute severe UC may be fever, tachycardia, tender distended abdomen

extraintestinal signs: eyes, skin, joints, other
1- eyes: uveitis, conjunctivitis, episcerltis, iritis
2- skin: erythema nodosum, pyoderma gangrenous
3- joints: large joint arthritis, sacroiliitis, ankylosing spondylitis
4- other: clubbing, aphthous oral ulcers, nutrional deficits, hepatitis, gallstones, primary biliary cirrhosis

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7
Q

what investigations would you do for UC?

A

blood tests: FBC, ESR, CRP, UE, LFT, blood culture

stool MCS/CDT- to exclude campylobacter, c. difficile, salmonella, shigella, e coli, amoebae

faecal calprotectin- GI inflammaton, high sensitivity

AXR- to exclude toxic dilatation
lower gI endoscopy - limited flexible sigmoidoscopy if acute to assess and biopsy, full colonoscopy once controlled to define disease extent

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8
Q

what is shown on AXR for UC?

A

no faecal shadows
mucosal thickening/islands
colonic dilatation

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9
Q

what are the acute complications of UC?

A

toxic dilatation of colon (mucosal islands, colonic diameter >6cm) with risk of perforation

venous thromboembolism- give prophylaxis to all inpatients regardless of rectal bleeding

decreased K+

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10
Q

what are the chronic complications of UC?

A

colonic cancer- risk related to disease extent and activity about 5-10% with pancolitis for 20yrs

neoplasms may occur in flat, normal-looking mucosa

so to spot precursor areas of dysplasia surveillance colonoscopy 1-5yrs depdnign on risk with multiple random biopsies or biopsies guided by differential uptake by abnomral mucosa of dye spreayed endoscopically

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11
Q

what is the treatment for mild UC?

A

goals are to induce then maintain disease remission

F-ASA eg mesalazine

  • PR for distal disease 1g
  • PO extensive disease 2g
  • combined PR PO if flare

topical steroid foams PR eg hydrocortisone + prednisolone 20mg retention enemas added to PR 5-ASA if needed

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12
Q

what are the hallmarks of UC on rectal biopsy?

A

distortion of colonic crypts

depletion of goblet cell stores of mucus

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13
Q

what is the treatment for moderate UC?

A

induce remission with oral prednisolone 40mg/d for 1 week
taper by 5mg/week for next 7 weeks

then maintain on 5-ASA

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14
Q

what do you need to monitor when UC patient is on 5-ASA treatment?

A

FBC + U&Es at the beginning, then 3 months, then annually

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15
Q

what are the side effects of 5-ASA treatment?

A 
rash
haemolysis
hepatitis
pancreatitis 
paradoxical worsening of colitis
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16
Q

what is the treatment for severe UC?

A

if unwell + >6 motions/day admit

1- IV hydration/electrolyte replacement
2- IV steroids eg hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
3- rectal steroids eg hydrocortisone 100mg in 100ml 0.9 saline/12h PR
4- thromboembolism prophylaxis
5- multiple stool MC&S/CDT to exclude infection

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17
Q

what investigations will you do to monitor someone who is admitted with severe UC?

A

1- monitor obs- temp, pulse, bp + record stool frequency/character
2- BD exam- distension, bowel sounds, tenderness
3- daily FBC, ESR, CRP UE +/- AXR. consider blood transfusion hb<80g/L

18
Q

if someone is admitted with severe UC and on day 3-5 their CRP is >45 and stools >6/day what would you do? And what would you do if they worsen/improve?

A

rescue therapy with ciclosporin or infliximab

can avoid colectomy but involve surgeons early
if fails to improve by day 7-10 need urges colectomy

if improves- transfer to prednisolone pO 40mg/24h. schedule maintenace infliximab if used for rescue, or azathioprine if ciclosporin rescue

19
Q

when would you move on to immunomodulation treatment in UC patients?

A

patient flare on steroid tapering or require >2 courses of steroids/year eg azathioprine 2-2.5mg/kg/d PO

30% pts develop SE requiring treatment cessation eg abdo pain, nausea, pancreatitis, leucopenia, abnormal LFTs

20
Q

if UC patient is on immunomodulation therapy, what investigations would you do to monitor?

A

monitor FBC, UE, LFT weekly for 4 weeks

then every 4 weeks for 3 months

then at least 3-monthly

21
Q

when would you put UC patients on biologic therapy?

A

if intolerant of immunomodulation or developing symptoms despite an immunomodulator

22
Q

when does a UC patient need surgery? What type of surgery?

A

subtotal colectomy + terminal ileostomy for failure of medical therapy or fulminant colitis with toxic dilatation/perforation

subsequently completion proctectomy- permanent stoma

or ileo-anal pouch- but may get pouchitis- give abx metronidazole + ciprofloxacin for 2 weeks

23
Q

What is the definition of Crohn’s disease?

A

a chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus

especially terminal ileum in 70%
unaffected bowel between areas of active disease- skip lesions

24
Q

what is the cause of CD?

A

inappropriate immune response against ?abnormal gut flora in genetically suspectible individuals

smoking increases risk x3-4, NSAIDs exacerbates

prevalence 100-200/100 000

25
Q

at what age does CD typically present?

A

20-40yrs

26
Q

what are the symptoms of CD?

A

diarrhoea
abdominal pain
weight loss/failure to thrive

systemic symptoms: fatigue, fever, malaise, anorexia

27
Q

what are the signs of CD?

A

bowel ulceration
abdominal tenderness/mass
perianal abscess/fistulae/skin tags
anal strictures

beyond te gut: clubbing, skin, join and eye problems

28
Q

what are the complications of CD?

A

small bowel obstruction
toxic dilatation- colonic diamter>6cm, rarer than in UC

abscess formation- abdominal, pelvic, perianal
fistulae eg enters-enteric, colovesical, colovaginal, perianal, enterocutaneous

perforation
colon cancer
PSC
malnutrition

29
Q

what investigatons would you do for CD?

A

blood- FBC, ESR, CRP, UE, LFT, INR, ferritin, TIBC, B12, folate

stool- MC&S + CDT to exclude c difficile, campylobacter, e coli
faecal calprotectin

colonsocpy + biopsy- even if mucosa looks normal

small bowel- to detect isolated proximal disease by eg capsule endoscopy

MRI- assess pelvic disease + fistulae, small bowel disease activity + strictures

30
Q

how do you treat mild-moderate CD?

A

symptomatic but systemically well
prednisolone 40mg/d PO for 1 week, taper by 5mg every week for next 7 weeks
plan maintenance therapy

31
Q

how do you treat severe CD?

A

admit:
1- IV hydration/electrolyte replacement
2- IV steroids hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
3- thromboembolism prophylaxis
4- multiple stool MCS/CDT to exclude infx
5- consider blood tranfusion if hb<80g/L + nutritional support

32
Q

what would you monitor for someone with severe CD who was admitted?

A

1- obs T, HR, BP, stool frequency/character
2- daily physical exam
3- bloods daily- FBC, ESR, CRP, UE, plain AXR

33
Q

once someone with severe CD who was admitted improves, what would you do?

A

switch to oral prednisolone 40mg/d

34
Q

what do you do if someone who was admitted with severe CD does not improve with treatment?

A

consider biologics

surgical advice needed- consider abdominal sepsis complicating CD if abdominal pain - need USS, CT, MRI

35
Q

what investigation results would make you consider admitting someone with CD?

A

high temp
high HR, ESR, WCC, CRP
low albumin

admission for IV steroids

36
Q

what are the indications for surgical treatment in CD?

A 
drug failure (most common)
GI obstruction from stricture
perforation 
fistulae 
abscess

it never cures

37
Q

what are the surgical aims for surgical treatment of CD?

A

1- resection of affected areas- but beware short bowel syndrome
2- to control perianal or fistulising disease
3- definition (rest) distal disease eg with temporary ileostomy

pouch surgery is avoided in crohn’s because increase risk of recurrence

38
Q

what factors suggest poor prognosis in a patient with CD?

A 
<40yo
steroids needed at 1st presentation 
perianal disease
isolated terminal ileitis
smoking
39
Q

what is the Truelove-Witts criteria for severe colitis?

A

stool frequency>6/day PLUS one of:

1- temp>37.8
2- pulse>90
3- hb<10.5g/dL
4- ESR>30mm/h

40
Q

what are the pharmacological/surgical options for UC treatment?

A

1- steroids- severe acute colitis IV. less severe attacks oral/topical depending on disease extent

2- ciclosporin- severe acute colitis that fails to respond to inital tx

3- 5-ASA- mild attacks, reduce risk of subsequent episodes

4- azathioprine- for frequent relapses

5- infliximab TNF-a antibodies

6- surgery- for life threatening or life limiting cases only

41
Q

what are the pharmacological/surgical management options for CD?

A

1- steroids
2- 5-asa eg sulfasalazine, mesalazine for maintenance
3- azathioprine, 6-mercaptopurine, methotrexate for maintenance in frequent or severe relapses
4- biologicals eg TNF-a antibodies - for steroid resistant disease + perianal fitulae
5- surgery
6- nutrition- liquid diets good. elemental diet- nitrogen source from amino acids. polymeric diet- short peptides.

Medicine (3 decks)

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