Gastroenterology II: Ulcerative Colitis & Crohn's Disease Flashcards
Describe the anatomy of the lower GI tract.
The lower GI tract runs from the small intestine to the large intestine to the anus.
look at slide
What is coeliac disease?
Gluten sensitivity/intolerance associated with HLA B8 tissue type with a prevalence of ~1 in 1800 but it is under-diagnosed in most people
How does coeliac disease present?
Presents with change of bowel habit (COBH):
-Pale, bulky, offensive, greasy stool
-Abdominal colic:
Abdominal pain that comes and goes in waves
-Weakness; weight loss
-Short stature/failure to thrive
What are the classical GI symptoms of coeliac disease?
-Diarrhoea (45-85%)
-Flatulence (28%)
-Borborygmus (35-72%) a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.
-Weight loss (45%)
-Weakness; fatigue (80%)
-Abdominal pain (30-65%)
-Secondary lactose intolerance
-Steatorrhea
What are the classical extra-intestinal symptoms of coeliac disease
Anaemias (10-15%): especially Fe, B12
Neurological symptoms (8-14%)
Skin disorders (10-20%) e.g dermatitis herpetiformis-maculopapular pruritic.
Endocrine disturbances including infertility, impotence, amenorrhea, delayed menarche
What investigations should you undertake to diagnose coeliac disease?
Serology test check for the presence or level of specific antibodies in the blood look at slide 8.
How is coeliac disease treated?
Gluten restriction curative in 95%
Refractory in 5%- so use corticosteroids (poor outcome)
Involve dietician, support groups, on-line recipes
Read labels including medications, cosmetics, etc.
What is important to be aware of if someone has coeliac disease?
Although rare, remember there is increased risk of lymphoma and adenocarcinoma of the pancreas, oesophagus, small bowel, biliary tract, including T & B cell non-Hodgkin’s lymphoma.
What are some long-term effects of coeliac disease?
People with it are more likely to be affected with problems relating to malabsorption, including:
-Osteoporosis
-Tooth enamel defects
-Central & PNS disease
-Pancreatic disease
-Internal haemorrhaging
-Organ disorders
-Gynaecological disorders
What is the dental relevance of coeliac disease?
Problems related to malabsorption:
-B12, folate, ferritin: can orally manifest as glossitis, angular cheilits, anaemia, burning mouth, smooth tongue
-Vitamin K: bleeding tendency
-Vitamin D:osteomalacia and rickets in children
Enamel defects may occur in the permanent dentition if the onset is in childhood
Contrast the environmental aetiology between Crohn’s & UC.
Appendicectomy = removal of the appendix
look at slides
How does Crohn’s manifest?
Patchy distribution of ‘skip lesions’ is quite common.
Contrast the epidemiology of Crohn’s disease & ulcerative colitis (UC).
Crohn’s:
-Slightly less common (27-106/100,000)
-Females: 1.2:1
-Younger: 26
UC:
-Slightly more common (80-150/100,000)
-Males: 1.2:1
-Older: 34
Is the aetiology of Crohn’s & UC well known?
No, but there are concerns about genetic tissue types, polygenic inheritance patterns, & familial patterns, as well as host immunology.
slides 16
Contrast the pathology of Crohn’s with UC.
Backwash ileitis- inflammatory reaction in the distal ileum
look at slides 18
What is Crohn’s disease?
Chronic Inflammatory bowel disease, specifically chronic and recurring inflammation of the GI tract.
Aetiology unknown - inflammatory response to intestinal microbes + environmental factors + genetic factors.
How do patients commonly present with Crohn’s disease?
-Intermittent abdominal pain, diarrhoea, abdominal distension (90%)
-Decreased appetite- anaemia and weight loss (50%)
-Fresh blood or melaena (40%)
-Fistulae and perianal sepsis (20%)
-Episodes of flares with asymptomatic intervals
What are some symptoms of Crohn’s disease?
Fat wrapping, cobble-stoning and thickened wall of the vessels
What are the 3 phenotypes of Crohn’s disease?
Stricturing: gradual thickening of intestinal wall- leads to stenosis/ obstruction
Penetrating: intestinal fistulas (abnormal passage from one organ to another) between GI tract and other organs (can occasionally be external fistulas-skin)
Non-penetrating: anal fissures, abscesses
What characterises Crohn’s in terms of macroscopic changes?
-Bowel is thickened
-Lumen is narrowed
-Deep ulcers
-Mucosal fissures
-Cobblestone
-Fistulae
-Abscess
-Apthoid ulceration
Contrast the microscopic changes in Crohn’s disease against UC.
Crohn’s:
-Transmural
-Lymphoid hyperplasia
*Granulomas
UC:
-Mucosal (chronic inflammatory cells: lamina propria)
-Goblet cell depletion
-Crypt abscess
How do you diagnose Crohn’s disease?
Diagnosis:
-Barium enema: rose thorn, skip lesion, string sign
-Sigmoidoscopy and biopsy, colonoscopy
-Differential diagnosis includes TB and sarcoidosis
How do you treat Crohn’s disease?
Symptomatic relief; reduction of inflammation; increase Quality Of Life
Medical- glucocorticoids
immunomodulators
biologics
Surgical- intestinal resection
What are the specific lesions you get in Crohn’s disease?
-Diffuse labial and buccal swelling
-Cobblestones
-Mucosal tags
-Linear ulcers
-Mucogingivits
-Staghorning - enhancement of submandibular ducts
-Granulomatous Cheilitis - swollen lips
What are the non-specific lesions you get in Crohn’s disease?
-Aphthous ulcers
-Angular Cheilitis
-Glossitis
-Dental Caries
-Gingivitis/Periodontitis
What does orofacial granulomatosis (OFG) have similar signs & symptoms to?
Crohn’s disease (concurrent Crohn’s occurs in ~40% of children diagnosed with OFG).
Who is OFG more prevalent in?
Children & young adults
What benefits 70% of people with OFG?
Avoiding cinammon & benzoates
What is UC (ulcerative colitis)?
Chronic inflammatory bowel disease where there is diffuse mucosal inflammation of the colon with backwash involvement of the terminal ileum: rectum always involved.
What is the hypothesis behind the aetiology of UC?
Dysregulated interaction mucosal immunology & intestinal microflora, and genetic predisposition.
How do patients with UC commonly present?
Painless, bloody diarrhoea with mucus
Associated fevers and remission periods where the patient returns to near normal
Visually compare UC and Crohn’s disease:
UC = Ulceration, surviving mucosa (pseudo-polyps), loss of haustra.
Visually compare a normal colon and a colon affected by ulcerative colitis:
Absence of goblet cells
Crypt distortion and abscess
Affects mucosal layer only
What is the risk with UC?
Chronic inflammation leading to colorectal cancer
How do you diagnose UC?
Colonoscopy and biopsy- findings include exudates, ulcerations, loss of vascular pattern, friability , continuous granularity (very fragile, bleeding)
Superficial inflammation with loss of haustration
How do you treat UC?
High protein, high fibre diet
5-ASA (5- amino salicyclic acid), sulphasalazine & mesalazine, thioprines, corticosteroids
Surgery
What do extra GI manifestations of UC look like?
It can include these issues:
-Occular (uveitis, episcleririts, conjunctivitis)
-Renal (Gall stones, fat liver, hepatitis, sclerosing cholangitis)
-Dermatological (erythema nodosum, pyoderma gangrenosum)
ORAL
-Hepato-billiary
-Vascular
-Skeletal
What is the dental relevance of UC?
Oral manifestations:
Pyostomatitis vegetans (PV)- benign, multiple small white and yellow pustules, erythematous/oedematous background (‘snail track’ ulcers)
^Primary involved sites include labial attached gingivae, soft/hard palate, buccal mucosa, sulcus
The intestinal symptoms usually precede PV
What are some other common conditions to have alongside UC?
-Aphthous ulcers
-Tongue coating
-Gingivitis
-Periodontitis
-Halitosis
-Acidic taste
-Cutaneous manifestations
What investigations would you carry out for IBD?
look at sldes
How do you generally treat IBD (inflammatory bowel disease)?
+ imaging = lead pipe sign/string signing or thinning of parts of the bowel.
Chest x-rays looking for perforations
If concerned about UC or Crohn’s, what should you ask your patient about?
-Rashes
-Mouth ulcers
-Joint/back pain
-Eye problems
-Family history
-Smoking status
Which meds work better for Crohn’s & UC?
Crohn’s:
-Azathioprine
-Methotrexate
-Cyclosporin
-Humera (adalimumab/anti TNF)
-Steroids for flares
UC:
-Aminosalicylates (mesalazie)
-Steroids (foam/PR; oral; IV)
-Azathioprine
Does surgery work in IBD?
Surgery can be curative for UC but 80% of Crohn’s have resections and generally it helps very little.
What are some indications for surgery in UC?
Acute:
-Failure of medical treatment for 3 days
-Toxic dilatation
-Haemorrhage
-Perforation (hole)
Chronic:
-Poor response to medical treatment
-Excessive steroid use
-Non compliance with medication
-Risk of cancer
I CHOP = acronym for main indication for surgery
What are the prognoses for Crohn’s & UC?
UC:
-1/3 have single attack
-1/3 have relapsing attacks
-1/3 progressively worsen requiring colectomy within 20 years
Crohn’s:
-Varied prognosis, new biological agents improving
Cancer:
-Both have increased risk of colon cancer, though UC>Crohn’s Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease
What are some predisposing factors for carcinoma of the colon?
Neoplastic polyps, UC FH, familial polyposis coli, previous cancer.
How does carcinoma of the colon present
Depends on the site:
Left colon- bleeding per rectum, change in bowel habit, and tenesmus
Right colon- anaemia, weight loss & abdo pain
Both- obstruction, perforation, haemorrhage/fistulae
Troisier’s sign/Virchow’s node (enlargement of left-sided supraclavicular lymph node)
Difference between colostomy and ileostomy:
Colostomy : the surgical creation of an artificial excretory opening between the colon and the body surface
Ileostomy: creation of an artificial opening into the ileum
What are some examples of functional bowel disorders?
Diverticular disease
Irritable bowel syndrome
Herniation= tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles.
What are the potential differential diagnoses of IBD?
IBS is the most common first diagnosis of many GI disorders and therefore can mask other inflammatory conditions.
