GI 2

Question 1

Ulcerative Colitis Overview (9)

Answer 1

1. Affects colon
2. Colectomy is curative
3. After 8 years, risk for colon cancer increases dramatically
4. Diffuse contiguous disease starts at rectum and progresses proximally
5. Biopsy shows: more evidence of chronic inflammation and repair in branching of glands and crypt abscess is more common
6. Bowel movement with urgency
7. Rectal bleeding and blood in stools is more common than in CD
8. Superficial inflammation
9. Fever only in the presence of severe disease

Question 2

Extra-intestinal Manifestations of IBD: Skin (2)

Answer 2

1. Erythema nodosum

2. Pyoderma gangrenosum

Question 3

Extra-intestinal Manifestations of IBD: Liver

Answer 3

Hepatobiliary disease

Question 4

Extra-intestinal Manifestations of IBD: Bone (3)

Answer 4

1. Osteopenia
2. Aseptic necrosis
3. Arthritis nonerosive and asymmetric-large joints

Question 5

Extra-intestinal Manifestations of IBD: Eye (3)

Answer 5

1. Uveitis
2. Episcleritis
3. Keratitis

Question 6

Extra-intestinal Manifestations of IBD: Vascular/Hematological (4)

Answer 6

1. Hypercoagulability; thrombosis; thrombophlebitis; portal vein thrombosis
2. Anemia
3. Thrmobocytosis
4. Thrombocytopenia

Question 7

Extra-intestinal Manifestations of IBD: Joints (4)

Answer 7

1. ARTHRITIS
   i. Most common extraintestinal manifestation 7-25%, mainly in lower extremities
   * Can occur years before any gastrointestinal symptoms
   * Large joints: related to active colonic disease
   * Can occur before GI symptoms
2. Arthralgias
3. Ankylosing spondylitis: rare
4. Sacroilitis: rare

Question 8

Extra-intestinal Manifestations of IBD: Other (7)

Answer 8

1. Pancreatitis
2. Erythema nodosum
3. Pyoderma gangrenosum
4. Tongue lesions
5. Gallstones
6. Autoimmune hepatitis
7. Primary sclerosing cholangitis [More in UC (4%) than CD]; Fatigue, pruritis, intermittent jaundice with mild colitis symptoms

Question 9

Symptoms of Inflammatory Damage of the GI Tract (6)

Answer 9

1. Diarrhea
   a. May contain mucus or blood
   b. Nocturnal diarrhea
   c. Incontinence.
2. Constipation
   a. Can be primary symptom in UC limited to rectum (proctitis)
3. Pain or rectal bleeding with bowel movement
4. Severe bowel movement urgency
5. Tenesmus: Abdominal cramps and pain
   * In the right lower quadrant of the abdomen common in CD or around the umbilicus, in the lower left quad- rant in moderate to severe UC.
6. Nausea and vomiting may occur, but more so in CD than UC.

Question 10

Stool examination with IBD (7)

Answer 10

1. O and P
2. Clostridium Difficile (even without a history of antibiotic use)
3. Fecal blood or fecal leukocytes
4. CMV
5. Fecal calprotectin*
6. Fecal Lactoferrin*
7. Α1 antitrypsin deficiency*

Question 11

Fecal Calprotectin with IBD (6)

Answer 11

1. A calcium binding protein, derived mostly from neutrophils, it has a higher specificity of gastrointestinal disease because levels are not raised in extra digestive processes
2. Other serological and biological markers available (ESR, CRP, ANCA, and anti-Saccharomyces cerevisiae antibodies) have low sensitivity and specificity for
   intestinal inflammation.
3. In a recent meta-analysis, von Roon et al. summarized data from 30 studies that included 5983 patients
4. Fecal calprotectin was 219 ug/g higher in IBD patients than in non-IBD patients
5. Pooled sensitivity and specificity in distinguishing between these two groups was 95% and 91%, respectively.
6. Can predict relapse before patient is clinically symptomatic

Question 12

IBD Management (3)

Answer 12

1. Gold standard is endoscopy with mucosal biopsy. endoscopy is an expensive and invasive procedure that is onerous to the patient.
2. Fecal calprotectin allows a non-invasive monitoring of disease activity, especially advantageous when the dynamics of repeated measurements are considered.
3. Symptom-based clinical activity indices for defining IBD remission have been challenged and, among both CD and UC patients.

Question 13

CRP

Answer 13

1. Serum or plasma stable for 7 days

2. Elevations begins at 4-6 hours, Peaks at 36-50 hours, Returns to normal for 3-7 days

Question 14

When does sed rate increase? (4)

Answer 14

i. Hypercholesterolemia
ii. Hypergammaglobulinemia
iii. Polycythemia cachexia
iv. Monoclonal gammopathy

Question 15

When does sed rate decrease? (3)

Answer 15

i. Anemia
ii. Agammaglobulinemia
iii. Hypofibrinogenemia

Question 16

When do you have to do sed rate?

Answer 16

day of collection

Question 17

Other IBD tests (2)

Answer 17

1. Perinuclear antineutrophil cytoplasmic antibody (p- ANCA)
   a. Positive p-ANCA antigen and negative ASCA test suggests UC.
   b. p-ANCA can be positive in Crohn’s colitis and hence may not be able to distinguish CD from UC in otherwise unclassified colitis
2. Anti-Saccharomyces cerevisiae antibodies (ASCA) for cases of IBD unclassified
   a. Negative p-ANCA antigen and positive ASCA test suggests CD.
   b. ASCA is more specific for CD.
   i. Not recommended to use as screener

Question 18

Gold Standard IBD Work-up (5)

Answer 18

1. Good history and physical
2. Upper GI imaging with small bowel follow-up
3. Endoscopy and biopsy provides definitive diagnosis
4. Upper and lower endoscopy shows granulomas
5. Stool Guiac (+), stool for fat

Question 19

IBD Screening (6)

Answer 19

1. Vision
   a. Referral for signs of iritis or uveitis
   b. Uveitis: Abnormal pupillary reaction
   c. Iritis
   i. Redness of the eye, eye pain, photophobia, blurred vision
   d. If on steroids needs ophthalmologists referral biannually
2. Hearing Routine
3. Dental
   a. Cyclosporine gingival hyperplasia
   b. Dental care twice a year
4. Blood pressure
   a. Cyclosporine: causes hypertension
5. Hematocrit: yearly if asymptomatic, more if symptomatic
6. PPD: Needed before starting biologic Remicade or Inflixmab

Question 20

Crohn’s Disease Overview (8)

Answer 20

1. Cyclical disease from mouth to anus
2. Chronic inflammation with periods of remission followed by relapse
3. Characterized by skip lesions/granulomatous inflammations occurring in any part of the intestine/GI tract
4. Most common location = ileum, followed by colon, small bowel and gastroduodenal
5. Often diagnosed in adolescence and rarely occurs less than 5 years
6. Height and weight are significantly reduced, with a low BMI
7. FOCAL AND ASYMMETRICAL
8. No hx bloody stools

Question 21

Crohn’s Disease History (6)

Answer 21

1. ABD PAIN!! (99%) - severe, occurring at any time during the day, wakes child up, mainly in RLQ or periumbilical
2. Weight loss (80%)
3. Diarrhea
4. Hematochezia (vomiting blood)
5. Growth failure; more than in UC
6. Micro and macronutrient deficiencies

Question 22

CD Physical Exam (4)

Answer 22

1. Apthous-like oral lesions
2. Abd mass
3. Peri-anal disease (fissures, tags, fistula, abcess)
   * Any pt. with recurrent perianal abscess needs to be checked for CD
4. Growth failure

Question 23

Blood work with IBD (10)

Answer 23

1. CBC
2. ESR and CRP (inflammation)
3. Electrolytes, albumin, ferritin
4. Ca, Mg, Vitamin B12
5. Serum ferritin may be elevated in active IBD
6. Transferrin saturation to evaluate anemia
7. Decreased serum cobalamin (indicate malabsorption)
8. LFTs, INR, bili
9. HIV
10. Celiac antibody test