Gastroenterology: IBD Flashcards
1
Q
What is Crohn’s disease?
A
Chronic relapsing inflammatory bowel disease (IBD)
2
Q
What is the key feature of Crohn’s disease?
A
It is characterised by a transmural granulomatous inflammation which can affect any part of the GI tract
3
Q
Which parts of the GI tract are most commonly affect by Crohn’s disease?
A
Terminal ileum, colon or both
4
Q
Where is Crohn’s disease most common?
A
Northern climates and developed countries
5
Q
Which IBD is more common?
A
Equal incidence - Crohn’s has increased over past 60 years
6
Q
What is the age of onset for Crohn’s disease?
A
Bimodal
1) Most common = 15-40 years
2) Smaller secondary peak = 60-80 years
7
Q
In which ethnic group is Crohn’s disease more common?
A
Caucasian
8
Q
Which ethnic group has a specific higher risk of Crohn’s disease (2-4 fold)?
A
Ashkenazi Jews
9
Q
Is there a familial risk with Crohn’s disease?
A
Yes - family history is a risk factor (10-25% of patients have a first degree relative with Crohn’s disease)
10
Q
What are the symptoms of Crohn’s disease?
A
1) Crampy abdominal pain
2) Diarrhoea
3) Weight loss
4) Fever
11
Q
What are the signs of Crohn’s disease (general + GI)?
A
1) Cachexia
2) Pale (due to anaemia)
3) Clubbing
4) Aphthous ulcers (canker sores) in mouth
5) Abdominal/right lower quadrant tenderness
6) Right iliac fossa mass
7) Perianal skin tags, fistulas, abscess
12
Q
What are aphthous ulcers?
A
Small, shallow lesions that develop on the soft tissues in your mouth or at the base of your gums
13
Q
What can be found on PR examination in Crohn’s disease?
A
1) Perianal skin tags
2) Fistulae
3) Perianal (pilonidal) abscess
14
Q
What are the dermatological signs in IBD?
A
1) Erythema nodosum (painful erythematous nodules/plaques on the shins)
2) Pyoderma gangrenosum (well-defined ulcer with a purple overhanging edge)
15
Q
Painful erythematous nodules/plaques on the shins?
A
Erythema nodosum
16
Q
Well-defined ulcer with a purple overhanging edge?
A
Pyoderma gangrenosum
17
Q
What are ocular manifestations of Crohn’s disease and UC?
A
1) Anterior uveitis - painful red eye with blurred vision and photophobia
2) Episcleritis - painless red eye
18
Q
How does anterior uveitis present?
A
Painful red eye + blurred vision + photophobia
19
Q
How does episcleritis present?
A
Painless red eye
20
Q
What are the musculoskeletal manifestations in IBD?
A
1) Non-deforming and asymmetrical arthritis
2) Sacroiliitis - similar to Ankylosing Spondylitis
3) Clubbing
21
Q
How does sacroiliitis present?
A
Similar to ankylosing spondylitis
22
Q
What are the features of IBD-associated arthritis?
A
Asymmetrical + non-deforming
23
Q
What hepatobiliary condition is associated with Crohn’s disease?
A
Gallstones
24
Q
In which IBD are Gallstones more common?
A
Crohn’s
25
What is a renal manifestation of Crohn's disease?
Renal stones
26
In which IBD are renal stones more common?
Crohn's disease
27
What is a haematological manifestation of IBD?
AA amyloidosis (secondary to chronic inflammation)
28
What initial investigations are done for Crohn's disease?
1) Blood tests
2) Stool culture - necessary to exclude infection
3) Faecal calprotectin - raised (helps distinguish IBD from IBS)
29
What is faecal calprotectin?
Antigen produced by neutrophils
30
What does faecal calprotectin help to differentiate?
IBD from IBS
31
What blood test results will you find in Crohn's disease?
1) Raised WCC
2) Raised ESR/CRP
3) Thrombocytosis
4) Anaemia - secondary to chronic inflammation
5) Low albumin - secondary to malabsorption
6) Iron, B12, folate
32
What causes low albumin?
Malabsorption
33
How do you diagnose Crohn's disease?
Endoscopy
34
Which imaging investigation is required for suspected small bowel disease?
MRI
35
What is a sign suggestive of Crohn's disease on Upper GI series (barium)?
String sign of Kantour = string-like appearance of contrast-filled narrowed terminal ileum
36
What findings will be present on colonoscopy + biopsy in Crohn's disease?
1) Skip lesions - intermittent inflammation
2) Cobblestone mucosa - due to ulceration and mural oedema
3) Rose-thorn ulcers (due to transmural inflammation) ± fistulae or abscesses
4) Non-caseating granulomas
37
Which IBD does the presence of non-caseating granulomas indicate?
Crohn's disease
38
What is first-line management to induce remission in Crohn's disease?
Prednisolone or IV hydrocortisone (monotherapy with glucocorticoids)
39
What can be considered as an alternative first-line management in children to induce remission in Crohn's disease?
Exclusive enteral nutrition, formula based (as steroids suppress growth) - 6-12 weeks
40
What medication can be added on to induce remission in Crohn's disease if there are 2 or more exacerbations in a 12 month period or the glucocorticoid cannot be tapered?
Azathioprine or mercaptopurine
41
What must you assess before offering treatment with azathioprine or mercaptopurine?
Thiopurine methyltransferase (TPMT) activity - if patients are deficient they cannot take it
42
What is third line add on therapy in patients who do not tolerate azathioprine or mercaptopurine or who are TPMT deficient to induce Crohn's disease remission?
Methotrexate
43
What is fourth line treatment to induce remission in severe Crohn's disease who fail to respond to previous treatments?
Biological agents e.g. infliximab or adalimumab
44
What is first line treatment to maintain remission in Crohn's disease?
Azathioprine or mercaptopurine
45
What is second line treatment to maintain remission in Crohn's disease?
Methotrexate
46
What are the indications for methotrexate treatment to maintain remission in Crohn's disease?
1) Patients who are intolerant or have a contraindication to azathioprine or mercaptopurine
2) Patients who do not respond to azathioprine or mercaptopurine monotherapy
47
How is surgical management used in Crohn's disease?
1) Surgery is rarely curative in Crohn's disease (unlike in UC) - so should be maximally conservative
2) Surgical options depend on the part of the GI tract affected
48
How do you manage perianal fistulae?
1) High (trans-sphincteric) fistulae - drainage seton to prevent division of the anal sphincter muscles and incontinence
2) Low (submucosal) fistulae - fistulotomy
3) Sphincter saving = fibrin glue and fistula plug
49
How do you manage a perianal abscess?
1) IV abx e.g. ceftriaxone + metronidazole
2) EUA + incision and drainage
50
What is ulcerative colitis?
Chronic relapsing-remitting inflammatory disease affecting the large bowel
51
Which part of the bowel is affected by UC?
Large bowel
52
When can UC present?
Any age
53
Which is the most common type of IBD?
UC
54
Which age groups have the highest incidence of UC?
Bimodal
1) 15-25 years
2) 55-65 years
55
What are the symptoms of UC?
1) Diarrhoea containing blood or mucus
2) Tenesmus or urgency
3) Pain in the left iliac fossa
4) Weight loss
5) Fever
56
What side is the tenderness/mass in Crohn's disease?
Right
57
What side is the pain in UC?
Left
58
What are the general and abdominal signs in UC?
1) Pale (anaemia - caused by PR bleeding)
2) Clubbing
3) Abdominal distention
4) Abdominal tenderness on palpation
59
What causes anaemia in Crohn's disease?
Chronic inflammation
60
What causes anaemia in UC?
PR bleeding
61
What are findings in UC on PR examination?
Tenderness + blood/mucus
62
What % of UC patients have extra-intestinal features?
10-20%
63
What is the additional ocular manifestation in UC?
Conjunctivitis
64
What hepatobiliary condition is associated with UC?
Primary sclerosing cholangitis
65
Which IBD is primary sclerosing cholangitis associated with?
UC
66
What initial investigations do you do for UC?
1) Blood tests
2) Stool MC&S and stool C difficile toxin - to exclude infective colitis
3) Faecal calprotectin
67
What will blood tests show in UC?
1) FBC - anaemia, raised WCC
2) Raised ESR/CRP
3) LFTs - low albumin (secondary to malabsorption)
68
How do you diagnose UC?
Endoscopy
69
What will you see on colonoscopy in UC?
1) Continuous inflammation with an erythematous mucosa
2) Loss of haustral markings
3) Pseudopolyps
70
What would you see on biopsy in UC?
1) Loss of goblet cells
2) Crypt abscesses
3) Inflammatory cells - mainly lymphocytes
± inflammatory pseudopolyps
71
What further investigations can be done in UC?
1) Colonoscopy + biopsy
2) Barium enema
72
What will you see on Barium enema in UC?
1) Lead-piping inflammation - secondary to loss of haustral markings
2) Thumb-printing - marker of bowel wall inflammation
3) Pseudopolyps - due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa
73
What is the key difference between Crohn's and UC microscopically (as the inflammation can appear similar)?
Non-caseating granulomas ONLY in Crohn's
74
Which two investigations are contraindicated in the acute UC presentation and why?
1) Colonoscopy (flexible sigmoidoscopy has lower risks of perforation so may still be used)
2) Barium enema
Due to the risk of bowel perforation
75
Which is the first line imaging investigation in acute UC presentation and why?
AXR + erect CXR - to exclude toxic megacolon and perforation (colonoscopy and barium enema contraindicated)
76
Which criteria are used to assess the severe of an acute exacerbation/presentation of UC?
Trulove and Witt's Criteria/severity index
77
What are the features of a mild UC exacerbation (Trulove and Witt's criteria)?
1) < 4 bowel movements per day
2) No more than small amounts of blood in stools
3) No fever, tachycardia (> 90) or anaemia
4) ESR < 30
78
What are the features of a moderate UC exacerbation (Trulove and Witt's criteria)?
1) 4-6 bowel movements per day
2) Blood in stools between small amounts and visible blood
3) No fever, tachycardia (> 90) or anaemia
4) ESR < 30
79
What are the features of a severe UC exacerbation (Trulove and Witt's criteria)?
1) > 6 bowel movements + features of systemic upset
2) Visible blood in stools
3) Fever > 37.8
4) HR > 90
5) Anaemia
6) ESR > 30
80
What is first line treatment in a moderate first presentation of UC?
1) Topical aminosalicylate (ASA) - mesalazine or sulfasalazine
2) If remission not achieved within 4 weeks, consider adding an oral ASA
81
What are the 5-aminosalicylates (ASA)?
1) Mesalazine
2) Sulfasalazine
3) Olsalazine
4) Balsazide
82
What are the two main aminosalicylates (ASA)?
Mesalazine + sulfasalazine
83
How do you manage mild to moderate acute UC to induce remission?
1) Topical or oral ASA (proctitis or proctosigmoiditis)/high dose oral ASA (left sided or extensive disease)
2) If this does not work after 4 weeks, add oral prednisolone
3) If this does not help after 2-4 weeks or symptoms worsen, add oral tacrolimus
84
What is the first line treatment of mild to moderate acute UC?
ASA (topical or oral)
85
What is the first line treatment of severe acute UC?
IV corticosteroids
86
How do you manage severe acute UC?
1) IV corticosteroids (if CI/not tolerated - IV ciclosporin)
2) If no improvement in 72h or worsening symptoms, add IV ciclosporin or consider surgery (if IV ciclosporin CI/not tolerated - infliximab)
3) Emergency surgery
87
What are the indications for considering emergency surgery in severe acute UC?
1) Acute fulminant UC
2) Toxic megacolon who have little improvement after 48-72h of IV steroids
3) Symptoms worsening despite IV steroids
88
How do you maintain remission in UC (proctitis)?
Topical and/or oral ASA
89
How do you maintain remission in UC (left sided and extensive UC)?
Oral ASA ± azathioprine/mercaptopurine ± biologic therapy e.g. infliximab
90
What are surgical options for treating UC?
1) Panproctocolectomy with permanent end ileostomy
2) Colectomy with temporary end ileostomy (approximately 3 months later the ileostomy can be reversed by forming an ileorectal anastomosis, an alternative option is completion proctectomy with a permanent end ileostomy or ileal pouch anal anastomosis (IPAA)).
3) Total colectomy with ileorectal anastomosis (no stoma) - ileo-anal anastomosis = J pouch
91
What are indications for considering elective surgery for UC?
Failure to induce remission by medical means
92
What are the short-term/acute complications of UC?
1) Toxic megacolon (severe form of colitis) - 15%
2) Massive lower GI haemorrhage - 3%
93
What are the long term complications of UC?
1) Colorectal cancer - 3-5%
2) Cholangiocarcinoma - UC doubles the risk
3) Colonic strictures - cause large bowel obstruction
94
What are the variable term complications of UC?
1) Primary sclerosing cholangitis
2) Inflammatory pseudopolyps - areas of normal mucosa between areas of ulceration and regeneration
95
What is the relationship between primary sclerosing cholangitis and UC?
1) PSC = inflammation + fibrosis of the extra and intra hepatic biliary tree
2) Affects 3-7% of patients with UC
3) LFTs should be monitored yearly to check for the presence of PSC
96
In which IBD is smoking a risk factor?
Crohn's
97
In which IBD is smoking protective?
UC
98
What is the mnemonic to remember to features of Crohn's
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
99
What is the mnemonic to remember the features of UC?
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
100
What is first line for inducing remission in Crohn's?
Steroids - oral prednisolone or IV hydrocortisone
101
What is first line for inducing remission in UC?
1) Mild to moderate = oral or rectal ASA e.g. mesalazine
2) Severe - IV hydrocortisone
102
What is first line for maintaining remission in Crohn's?
Azathioprine/mercaptopurine
103
What is first line for maintaining remission in UC?
Oral or rectal ASA e.g. mesalazine
