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Stage 3 > Gastroenterology: IBD > Flashcards

Gastroenterology: IBD Flashcards

1
Q

What is Crohn’s disease?

A

Chronic relapsing inflammatory bowel disease (IBD)

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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

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3
Q

Which parts of the GI tract are most commonly affect by Crohn’s disease?

A

Terminal ileum, colon or both

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4
Q

Where is Crohn’s disease most common?

A

Northern climates and developed countries

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5
Q

Which IBD is more common?

A

Equal incidence - Crohn’s has increased over past 60 years

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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

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7
Q

In which ethnic group is Crohn’s disease more common?

A

Caucasian

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8
Q

Which ethnic group has a specific higher risk of Crohn’s disease (2-4 fold)?

A

Ashkenazi Jews

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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)

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10
Q

What are the symptoms of Crohn’s disease?

A

1) Crampy abdominal pain
2) Diarrhoea
3) Weight loss
4) Fever

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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

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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

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13
Q

What can be found on PR examination in Crohn’s disease?

A

1) Perianal skin tags
2) Fistulae
3) Perianal (pilonidal) abscess

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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)

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15
Q

Painful erythematous nodules/plaques on the shins?

A

Erythema nodosum

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16
Q

Well-defined ulcer with a purple overhanging edge?

A

Pyoderma gangrenosum

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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

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18
Q

How does anterior uveitis present?

A

Painful red eye + blurred vision + photophobia

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19
Q

How does episcleritis present?

A

Painless red eye

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20
Q

What are the musculoskeletal manifestations in IBD?

A

1) Non-deforming and asymmetrical arthritis
2) Sacroiliitis - similar to Ankylosing Spondylitis
3) Clubbing

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21
Q

How does sacroiliitis present?

A

Similar to ankylosing spondylitis

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22
Q

What are the features of IBD-associated arthritis?

A

Asymmetrical + non-deforming

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23
Q

What hepatobiliary condition is associated with Crohn’s disease?

A

Gallstones

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24
Q

In which IBD are Gallstones more common?

A

Crohn’s

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25
Q

What is a renal manifestation of Crohn’s disease?

A

Renal stones

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26
Q

In which IBD are renal stones more common?

A

Crohn’s disease

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27
Q

What is a haematological manifestation of IBD?

A

AA amyloidosis (secondary to chronic inflammation)

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28
Q

What initial investigations are done for Crohn’s disease?

A

1) Blood tests
2) Stool culture - necessary to exclude infection
3) Faecal calprotectin - raised (helps distinguish IBD from IBS)

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29
Q

What is faecal calprotectin?

A

Antigen produced by neutrophils

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30
Q

What does faecal calprotectin help to differentiate?

A

IBD from IBS

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31
Q

What blood test results will you find in Crohn’s disease?

A

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

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32
Q

What causes low albumin?

A

Malabsorption

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33
Q

How do you diagnose Crohn’s disease?

A

Endoscopy

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34
Q

Which imaging investigation is required for suspected small bowel disease?

A

MRI

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35
Q

What is a sign suggestive of Crohn’s disease on Upper GI series (barium)?

A

String sign of Kantour = string-like appearance of contrast-filled narrowed terminal ileum

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36
Q

What findings will be present on colonoscopy + biopsy in Crohn’s disease?

A

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

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37
Q

Which IBD does the presence of non-caseating granulomas indicate?

A

Crohn’s disease

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38
Q

What is first-line management to induce remission in Crohn’s disease?

A

Prednisolone or IV hydrocortisone (monotherapy with glucocorticoids)

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39
Q

What can be considered as an alternative first-line management in children to induce remission in Crohn’s disease?

A

Exclusive enteral nutrition, formula based (as steroids suppress growth) - 6-12 weeks

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40
Q

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?

A

Azathioprine or mercaptopurine

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41
Q

What must you assess before offering treatment with azathioprine or mercaptopurine?

A

Thiopurine methyltransferase (TPMT) activity - if patients are deficient they cannot take it

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42
Q

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?

A

Methotrexate

43
Q

What is fourth line treatment to induce remission in severe Crohn’s disease who fail to respond to previous treatments?

A

Biological agents e.g. infliximab or adalimumab

44
Q

What is first line treatment to maintain remission in Crohn’s disease?

A

Azathioprine or mercaptopurine

45
Q

What is second line treatment to maintain remission in Crohn’s disease?

A

Methotrexate

46
Q

What are the indications for methotrexate treatment to maintain remission in Crohn’s disease?

A

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
Q

How is surgical management used in Crohn’s disease?

A

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
Q

How do you manage perianal fistulae?

A

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
Q

How do you manage a perianal abscess?

A

1) IV abx e.g. ceftriaxone + metronidazole
2) EUA + incision and drainage

50
Q

What is ulcerative colitis?

A

Chronic relapsing-remitting inflammatory disease affecting the large bowel

51
Q

Which part of the bowel is affected by UC?

A

Large bowel

52
Q

When can UC present?

A

Any age

53
Q

Which is the most common type of IBD?

A

UC

54
Q

Which age groups have the highest incidence of UC?

A

Bimodal
1) 15-25 years
2) 55-65 years

55
Q

What are the symptoms of UC?

A

1) Diarrhoea containing blood or mucus
2) Tenesmus or urgency
3) Pain in the left iliac fossa
4) Weight loss
5) Fever

56
Q

What side is the tenderness/mass in Crohn’s disease?

A

Right

57
Q

What side is the pain in UC?

A

Left

58
Q

What are the general and abdominal signs in UC?

A

1) Pale (anaemia - caused by PR bleeding)
2) Clubbing
3) Abdominal distention
4) Abdominal tenderness on palpation

59
Q

What causes anaemia in Crohn’s disease?

A

Chronic inflammation

60
Q

What causes anaemia in UC?

A

PR bleeding

61
Q

What are findings in UC on PR examination?

A

Tenderness + blood/mucus

62
Q

What % of UC patients have extra-intestinal features?

A

10-20%

63
Q

What is the additional ocular manifestation in UC?

A

Conjunctivitis

64
Q

What hepatobiliary condition is associated with UC?

A

Primary sclerosing cholangitis

65
Q

Which IBD is primary sclerosing cholangitis associated with?

A

UC

66
Q

What initial investigations do you do for UC?

A

1) Blood tests
2) Stool MC&S and stool C difficile toxin - to exclude infective colitis
3) Faecal calprotectin

67
Q

What will blood tests show in UC?

A

1) FBC - anaemia, raised WCC
2) Raised ESR/CRP
3) LFTs - low albumin (secondary to malabsorption)

68
Q

How do you diagnose UC?

A

Endoscopy

69
Q

What will you see on colonoscopy in UC?

A

1) Continuous inflammation with an erythematous mucosa
2) Loss of haustral markings
3) Pseudopolyps

70
Q

What would you see on biopsy in UC?

A

1) Loss of goblet cells
2) Crypt abscesses
3) Inflammatory cells - mainly lymphocytes
± inflammatory pseudopolyps

71
Q

What further investigations can be done in UC?

A

1) Colonoscopy + biopsy
2) Barium enema

72
Q

What will you see on Barium enema in UC?

A

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
Q

What is the key difference between Crohn’s and UC microscopically (as the inflammation can appear similar)?

A

Non-caseating granulomas ONLY in Crohn’s

74
Q

Which two investigations are contraindicated in the acute UC presentation and why?

A

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
Q

Which is the first line imaging investigation in acute UC presentation and why?

A

AXR + erect CXR - to exclude toxic megacolon and perforation (colonoscopy and barium enema contraindicated)

76
Q

Which criteria are used to assess the severe of an acute exacerbation/presentation of UC?

A

Trulove and Witt’s Criteria/severity index

77
Q

What are the features of a mild UC exacerbation (Trulove and Witt’s criteria)?

A

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
Q

What are the features of a moderate UC exacerbation (Trulove and Witt’s criteria)?

A

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
Q

What are the features of a severe UC exacerbation (Trulove and Witt’s criteria)?

A

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
Q

What is first line treatment in a moderate first presentation of UC?

A

1) Topical aminosalicylate (ASA) - mesalazine or sulfasalazine
2) If remission not achieved within 4 weeks, consider adding an oral ASA

81
Q

What are the 5-aminosalicylates (ASA)?

A

1) Mesalazine
2) Sulfasalazine
3) Olsalazine
4) Balsazide

82
Q

What are the two main aminosalicylates (ASA)?

A

Mesalazine + sulfasalazine

83
Q

How do you manage mild to moderate acute UC to induce remission?

A

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
Q

What is the first line treatment of mild to moderate acute UC?

A

ASA (topical or oral)

85
Q

What is the first line treatment of severe acute UC?

A

IV corticosteroids

86
Q

How do you manage severe acute UC?

A

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
Q

What are the indications for considering emergency surgery in severe acute UC?

A

1) Acute fulminant UC
2) Toxic megacolon who have little improvement after 48-72h of IV steroids
3) Symptoms worsening despite IV steroids

88
Q

How do you maintain remission in UC (proctitis)?

A

Topical and/or oral ASA

89
Q

How do you maintain remission in UC (left sided and extensive UC)?

A

Oral ASA ± azathioprine/mercaptopurine ± biologic therapy e.g. infliximab

90
Q

What are surgical options for treating UC?

A

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
Q

What are indications for considering elective surgery for UC?

A

Failure to induce remission by medical means

92
Q

What are the short-term/acute complications of UC?

A

1) Toxic megacolon (severe form of colitis) - 15%
2) Massive lower GI haemorrhage - 3%

93
Q

What are the long term complications of UC?

A

1) Colorectal cancer - 3-5%
2) Cholangiocarcinoma - UC doubles the risk
3) Colonic strictures - cause large bowel obstruction

94
Q

What are the variable term complications of UC?

A

1) Primary sclerosing cholangitis
2) Inflammatory pseudopolyps - areas of normal mucosa between areas of ulceration and regeneration

95
Q

What is the relationship between primary sclerosing cholangitis and UC?

A

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
Q

In which IBD is smoking a risk factor?

A

Crohn’s

97
Q

In which IBD is smoking protective?

A

UC

98
Q

What is the mnemonic to remember to features of Crohn’s

A

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
Q

What is the mnemonic to remember the features of UC?

A

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
Q

What is first line for inducing remission in Crohn’s?

A

Steroids - oral prednisolone or IV hydrocortisone

101
Q

What is first line for inducing remission in UC?

A

1) Mild to moderate = oral or rectal ASA e.g. mesalazine
2) Severe - IV hydrocortisone

102
Q

What is first line for maintaining remission in Crohn’s?

A

Azathioprine/mercaptopurine

103
Q

What is first line for maintaining remission in UC?

A

Oral or rectal ASA e.g. mesalazine

Stage 3 (61 decks)

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