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Gwen - GI and General surgery > GI: Inflammatory Bowel Disease > Flashcards

GI: Inflammatory Bowel Disease Flashcards

1
Q

What are the two major forms of IBD?

A
  • Crohn’s Disease
  • Ulcerative colitis
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2
Q

What environmental factors are associated with the development of IBD?

A
  • Smoking
  • NSAID ingestion
  • Hygeine
  • Nutrition
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3
Q

What is thought to be the primary cause of IBDs?

A

Inappropriate immune response against the gut flora in a genetically susceptible individual

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4
Q

How much does smoking increase the risk of developing IBD?

A

3-4x the risk

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5
Q

List the mediactions used in IBD managament

A

5ASAs (Aminosalicyclates)

Corticosteroids

Immunomodulators

Biologics

Other - antibiotics

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6
Q

What is ulcerative colitis?

A

Relapsing/Remitting inflammaotyr disorder of the colonic mucosa. It may affect the rectum, or extend to involve part of the colon, or the entire colon. It never spreads proximal to the ileocaecal valve (except for backwash ileitis)

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7
Q

What are the main sites of crohns?

A

Most commonly targets distal ileum/proximal colon

Affects small bowel so think malabsorption

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8
Q

What are the main sites the ulcerative colitis occurs?

A
  • Proctitis - rectum
  • Left-sided colitis
  • Pancolitis - whole colon
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9
Q

What are the pathological features of UC?

A
  • Hyperaemic/Haemorrhagic colonic mucosa +/-pseudopolyps
  • Thin wall appearance (red mucosa, bleeds early)
  • Superficial ulcers
  • Punctate ulceration (crypt absess)- extends deep into lamina propria

No inflammation occurs beyond submucosa

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10
Q

What distinguishes UC from Crohn’s Pathologically?

A
  • Crohn’s is transmural, whereas UC is primarily mucosal
  • Granulomas are often present in Crohns
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11
Q

What are the pathological features of Crohn’s Disease?

A
  • Granulomas
  • Fissuring ulceration
  • Focal/Patchy mucosal involvement
  • Neuromuscular hypertrophy
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12
Q

Which IBD does skip lesions occur in?

A

Crohn’s - areas of unaffected bowel between areas of active disease

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13
Q

Which IBD does backwash ileitis occur in?

A

UC - usually in pancolitis

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14
Q

What is the difference in terms of the affected bowel between Crohn’s and UC?

A
  • Crohn’s - Thickened wall + strictures/narrowed lumen
  • UC - Ulcerated wall with dilated lumen
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15
Q

Which IBD produces granulomas?

A

Crohn’s

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16
Q

Which type of IBD tends to fistulate more commonly?

A

Crohn’s

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17
Q

Which type of IBD are more at risk of cancer?

A

UC

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18
Q

Why does the bowel wall thicken in Crohn’s?

A

Due to oedema and fibrosis

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19
Q

Typical presentation uclerative colitis

A

Could be one of:

  • Persistent diarrhoea
  • Chronic type (relapses and remission)
    • Initial attack of moderate severity followed by recurrent exacerbations
    • Patient can look wasted from severe diarrhoea and anaemia from chronic blood loss
  • Severe fulminant colitis
    • ​Bowel movements >10hours/24hours
    • Fever, tachycardia, continuous bleeding, anaemia, reduced albumin
    • Abdominal distension (toxic megacolon)
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20
Q

What are symptoms of UC?

A

Episodic attacks (typically follows a relapsing remitting course)

  • Diarrhoea (episode/chronic) +/- blood/mucus
  • Urgency +/- tenesmus
  • Crampy abdominal discomfort
  • Increased frequency
  • Systemic features in attacks - fever, malaise, anorexia, weight loss
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21
Q

What signs may be present in someone with UC?

A

May be none. If presenting during an attack:

  • Fever
  • Tachycardia
  • Tender, distended abdomen

Extraintestinal signs (chronic)

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22
Q

What extraintestinal signs may be seen in IBD?

A
  • Skin
    • Clubbing
    • Erythema nodosum
    • Pyoderma gangrenosum
  • Eyes
    • Conjunctivitis
    • Uveitis/Episcleritis/Iritis
  • Joints
    • Large joint arthritis (pauciarticular, asymmetric)
    • Sacroiliitis
    • Ankylosing spondylitis/inflammatory back pain
    • Osteoporosis
  • HPB
    • PSC and cholangiocarcinoma (esp in UC)
    • Gall stones (esp CD)
    • Fatty liver
  • Other
    • Nutritional defects
    • Venous thrombosis
    • Amyloidosis
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23
Q

What is the following seen in?

A

Pyoderma gangrenosum

  • Idiopathic: 25–50% of cases
  • Inflammatory bowel disease: up to 50% of cases
  • Rheumatological disease
  • Paraproteinaemia
  • Haematological malignancy
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24
Q

What is the following?

A

Erythema nosodum - A skin disorder of acute onset with eruption of red, tender nodules and plaques, predominantly over the lower extremities, especially the extensor surfaces. It is a form of panniculitis

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25
Q

What is the mechanism behind erythema nodosum?

A

In theory, immune complexes form after exposure to an antigen and are deposited in venules around areas of subcutaneous fat and connective tissue. The subsequent inflammation causes the lesions.

Why the lesions appear so frequently on the shins has not been explained - suggested that a combination of a relatively meagre arterial supply combined with gravitational effects on venous system gravitational favour deposition in that area

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26
Q

What are causes of the following?

A
  • Inflammatory bowel disease
  • Infections – streptococcal, tuberculosis, URTIs, yersiniosis
  • Sarcoidosis
  • Rheumatological disorders
  • Drug reactions – usually sulfonamides and the oral contraceptive pill
  • Malignancies
  • Pregnancy
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27
Q

What is the following?

A

Clubbing

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28
Q

What are causes of the following?

A
  • Cyanotic heart disease/Crohn’s
  • Lung disease - ABCDEF
    • Abscess
    • Bronchiectasis
    • CF
    • DON’T SAY COPD
    • Empyema
    • Fibrosis
  • Ulcerative colitis
  • Biliary cirrhosis
  • Birth defect
  • Infective endocarditis
  • Neoplasm
  • GI malabsorption syndrome (coeliac)
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29
Q

What is the following?

A

Episcleritis - benign, self-limiting inflammatory disease affecting part of the eye called the episclera.

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30
Q

What is the following?

A

Scleritis - a serious inflammatory disease that affects the white outer coating of the eye, known as the sclera

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31
Q

What are signs of anterior uveitis?

A
  • Circumcorneal redness - ciliary flush
  • Keratic precipitates on corneal epithelium
  • Cells/flare in anterior chamber
  • Miosis - due to sphincter spasm
  • Hypopyon
  • Posterior/Peripheral anterior Synechaie/Festooned pupil
  • Iris atrophy
  • Fibrinous membrane in the pupillary
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32
Q

What are symptoms of crohn’s disease?

A

Symptoms depend on region of bowel involved

  • SI
    • ​Abdominal pain
    • Weight loss
  • Terminal ileum
    • ​COMMONEST AT ILEO-CAECAL VALVE
    • Presents as acute abdo with RIF pain mimicking appendicitis
  • Colonic
    • ​Diarrhoea, bleeding and pain related to defecation (although doesnt usually contain blood - thats more UC)
  • Perianal
    • ​Anal tags
    • Fissures
    • Fistulas
    • Abscess

OTHER:

  • Failure to thrive
  • Fatigue
  • Fever
  • Malaise
  • Anorexia
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33
Q

What are signs of crohn’s disease?

A
  • Abdominal tenderness/mass esp RIF
  • Perianal abscess/fistulae/skin tags
  • Anal strictures
  • Apthous ulcers
  • Systemic features of IBD
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34
Q

Potential acute presentations of crohns

A
  • Acute abdomen
  • Intestinal obstruction
  • Peritonitis (due to perforation)
  • Fulminate colitis (less common than UC)
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35
Q

Complications of crohn’s

A
  • Fistulae
    • ​Most commonly fistulae come from anus to peri-anal region and then produce pus
    • Hence never do ileal pouch in crohns
    • Seton suture
  • Strictures
    • ​Can cause obstructions
  • Abscessess
  • Malabsorption
    • ​Fat causing renal and gallstones
    • B12
    • Vit D
    • Protein
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36
Q

What is the following?

A

Apthous ulcer - A painful open lesion anywhere within the oral cavity.

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37
Q

What are causes of the following?

A
  • Trauma
  • Stress
  • Toothpaste
  • Iron deficiency/Folate deficiency/Vitamin B12 deficiency
  • Food hypersensitivity
  • Humoural/immunological
  • Inflammatory bowel disease
  • Behçet’s disease
  • SLE
  • HIV/AIDS
  • Nicorandil
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38
Q

How would you approach investigating someone who you suspected had UC?

A
  • Bedside - NEWS score
  • Bloods - FBC, ESR, CRP, U+E’s, LFTs, Blood culture
    • ​Raised WCC
    • Reduced Hb
    • Raised platelets
    • LFTs: hypoalbuminaemia (and LFTs can become derranged in severe attack because large ammount of inflammation affects coag cascade)
  • pANCA psoive in 70%
  • Imaging
    • AXR
    • Flexible sigmoidoscopy - acute attack
    • Colonoscopy once controlled
  • Other -
    • stool culture,
    • faecal calprotectin (+ve in inflammatory bowel but not IBS)
    • biopsy
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39
Q

What might you find on stool studies in someone with UC?

A
  • Negative culture
  • WBC present
  • Elevated faecal calprotectin
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40
Q

What might you see on FBC in someone with UC?

A
  • Variable degree of anaemia
  • Leukocytosis
  • Thrombocytosis
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41
Q

What might you see on LFTs in someone with UC?

A

Looking for features of PSC:

  • Elevated ALP
  • Elevated Bilirubin
  • Elevated AST/ALT
  • Hypoalbuminaemia
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42
Q

What might you see on U+E’s in someone with UC?

A
  • Hypokalaemia metabolic acidosis
  • Hypernatraemia
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43
Q

What might you see on AXR in someone with UC?

A

(Indicated in acute severe colitis)

  • Dilated colonic loops - >6cm
  • Mucosal thickening
  • Shaggy outline of colon - widespread ulceration
  • Lead pipe sign (no haustra)
  • Pneumoperitoneum/Rigler’s Sign - If perforated
  • Toxic megacolon
44
Q

What can be seen in the following AXR?

A

Toxic megacolon - colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of ulcerative colitis.

There is evidence of bowel wall oedema with ‘thumbprinting’, and pseudopolyps or ‘mucosal islands

45
Q

What feature of UC can be seen in the following AXR?

A

Lead pipe sign - featureless segment of transverse colon with loss of the normal haustral markings. This ‘lead pipe’ appearance is associated with longstanding ulcerative colitis.

46
Q

What is the feature highlighted in the following AXR?

A

Mucosal thickening + ‘thumbprinting’ - The distance between loops of bowel is increased (arrows) due to thickening of the bowel wall. The haustral folds are very thick (arrowheads), leading to a sign known as ‘thumbprinting.’

47
Q

What investigations would you consider doing in someone you suspected had Crohn’s Disease?

A
  • Bedside - NEWS score
  • Bloods - FBC, U+E’s, LFTs, CRP, ESR, INR, Iron studies, B12, Folate
  • Imaging - AXR, Colonoscopy, Capsule endoscopy, CT/MRI, US, Barium meal
  • Other - stool culture
48
Q

When would you consider limited flexible sigmoidoscopy to investigate UC?

A

During attack

49
Q

When and why would you perform a full colonoscopy in UC?

A

Once symptoms under control - To determine extent of disease

50
Q

How would you assess the severity of a UC attack?

A

Truelove and Witts modified criteria

51
Q

What are the criteria for the truelove and Witts criteria for assessing UC severity?

A
  • Motions/day
  • Rectal bleeding
  • Temp
  • Resting pulse
  • Hb
  • ESR/CRP
52
Q

What is classified as Mild UC as per Truelove and Witts criteria?

A
  • Motions/day - =4
  • Rectal bleeding - small
  • Temp - Apyrexial
  • Resting pulse < 70bpm
  • Hb - > 110g/L
  • ESR - <30
53
Q

What is classified as moderate UC as per Truelove and Witts criteria?

A
  • Motions/day - 5
  • Rectal bleeding - Moderate
  • Temp - 37.1-37.8oC
  • Resting pulse -70-90bpm
  • Hb - 105-110g/L
54
Q

What is classified as severe UC as per Truelove and Witts criteria?

A
  • Motions/day - >/= 6
  • Rectal bleeding - Large
  • Temp - >37.8oC
  • Resting pulse - >90bpm
  • Hb - <105g/L
  • ESR > 30/CRP >45mg/L
55
Q

What are acute complications of UC?

A
  • Toxic megacolon + perforation
  • Venous thromboembolism
  • Hypokalaemia
  • Haemorrhoage - blood loss, protein loss, massive
56
Q

What can be seen in the following AXR?

A

Toxic megacolon of the transverse colon

57
Q

What are chronic complications of Ulcerative colitis?

A

Colorectal cancer (more liekly that in CD)

58
Q

How would you manage someone with Mild UC?

A

Induction/Maintenance of remission

  • Distal colitis
    • 1st line – topical* 5-ASA (mesalamine)
    • 2nd line – topical* corticosteroids/oral mesalamine
    • 3rd line – oral corticosteroid ± oral tacrolimus
  • Extensive disease
    • 1st line – oral mesalamine
    • 2nd line - oral corticosteroids +/- oral tactrolimus

*Suppository

59
Q

How would you manage someone with Moderate UC?

A
  • Induce remission - Prednisolone 40mg/day for 1 wk, then taper
  • Maintenance - 5-ASA
60
Q

How would you manage severe UC?

A

Admit

  • IV fluids
  • IV Steroids - hydrocortisone 100mg/6h
  • VTE prophylaxis
  • Monitoring - bloods, Stool chart, AXR
  • Consider transfusion
  • Consider rescue therapy - (anti-TNF) infliximab, ciclosporin
61
Q

Name the immunomodulators

A

Thiopurines eg Azathioprine, 6-Mercaptopurine, methotrexate, cyclosporin

62
Q

How do immunomodulators work?

A

Azathioprine - inhibitrs purine synthesis, decreasing turnover of cells

Methotrexate - inhibits metabolism of folic acid which decreases turnover of quickly changing cells

Cyclosporin - inhibits T cells

63
Q

Name anti-TNF antibodies

A

Infliximab

Adalimumab

64
Q

What are indications for surgery in ulcerative colitis?

A

Fulminant acute attack

  • Failure of medical treatment
  • Toxic dilatation - unless dramatic response within 48 hours, don’t risk perforation with immunocompromised
  • Haemorrhage
  • Imminent perforation

Chronic disease

  • Incomplete response to medical treatment/steroid dependant
  • Dysplasia on surveillance colonoscopy
65
Q

What would you consider if rescue therapy failed in someone with severe UC?

A

Colectomy - based on disease extent

66
Q

When would you consider rescue/salvage therapy in someone with UC?

A
  • CRP >45 mg/L
  • >8 bowel motions after 3 days IV hydrocortisone
67
Q

What surgery is done in acute management of UC?

A

Total colectomy, ileostomy and closure of the rectal stump
OR

Total colectomy, ileostomy and recto-sigmoid mucous fistula

Then after acute situation:
Exicison of the rectum and patient is left with permanent ileostomy or formation of ileal pouch

68
Q

What surgery is done in chronic UC?

A

WHOLE COLON IS TO BE REMOVED or disease will return to the part of the colon you didnt remove

Total protocolectomy + permanent ileostomy (rarer)
OR
Total protocolectomy + ileal pouch (more common)

69
Q

What is an ileal pouch?

A

Folding loops of SI back on themselves and stitching/stapling together so pouch becomes the rectum

Requires 2 operations: 1 that forms the pouch and 1 that connects it to the anus (doing in 1 increases chance of sepsis)

There are 3 types: J, S, W (J most common)

70
Q

Contraindications to ileal pouch

A

CD, significant anal incontenance

71
Q

Complications of ileal pouch

A

Early: splenic injury, anastomotic complications, intra-abdominal abscess

Late: poor function (frequency, incontinence, pouchitis)

Pouchitis: inflammation of ileal pouch - abdo pain, bloody diarrhoea, nausea

Impotence, adhesions and infertility

72
Q

What are complications of Crohn’s Disease?

A
  • Small bowel obstruction
  • Toxic megacolon
  • Abscess formation
  • Fistulae
  • Perforation
  • Colon cancer
  • PSC
  • Malnutrition
  • Anal disease - Fissure in ano, Haemorrhoids, SKin tags, Abscess, Anorectal fistula
73
Q

What are the different types of fistulae that can occur in Crohn’s disease?

A
  • Entero-enteric
  • Colovesical
  • Colovaginal
  • Perianal
  • Entercutaneous
74
Q

What are the common sites for Crohn’s disease to occur?

A
  • Duodenum/Ileum/Jejunum
  • Ileocaecal disease
  • Perianal disease/proctitis
  • Colon
75
Q

What might you see on CT/MRI in someone with Crohn’s Disease?

A
  • Skip lesions
  • Stricturing
  • Bowel wall thickening
  • Surrounding inflammation
  • Abscess
  • Fistulae
76
Q

What might you see on biopsy of someone with Crohn’s disease?

A

Transmural involvement with non-caseating granulomas

77
Q

What might you see on Colonosopy in someone with Crohn’s Disease?

A
  • Hyperaemia
  • Oedema
  • Cobblestoning
  • Skip lesions
  • Fissuring
  • Crypt abscess
  • Rose thorn ulcers
78
Q

What is string sign of kantor?

A

Marked narrowing of terminal ileum seen on barium enemal in crohns

79
Q

What might you see on oesophagogastroduodenoscopy in someone with crohn’s Disease?

A
  • Aphthous ulcers
  • Mucosal inflammation
80
Q

Why might you do iron studies in someone with Crohn’s?

A

Check for iron deficiecy 2o to GI bleeding

81
Q

Why might you check B12 and folate levels in someone with Crohn’s?

A

Deficiency may be secondary to malabsorption - particularly in ileocaecal CD and post-ileocaecal resection

82
Q

What might you see on AXR with barium meal in someone with crohn’s disease?

A
  • Asymmetrical alteration in the mucosal pattern with deep ulceration
  • Areas of narrowing or stricturing
  • Cobblestoning
83
Q

What are the three major endoscopic findings in crohn’s disease?

A
  • Aphthous ulcers
  • Cobblestoning - normal tissues in between the ulcers give the typical cobblestone appearance.
  • Discontinuous lesions - areas of inflammation are interspersed between normal bowel ‘skip areas’.
84
Q

How would you manage Mild/moderate Crohn’s Disease?

A
  • Dietary modification
  • Stop smoking
  • Prednisolone - 1 wk, then taper
  • Manage extraintestinal manifestations
  • Consider maintenance therapy
85
Q

Which type of IBD are 5-ASA’s not used in?

A

Crohn’s disease

86
Q

How would you manage severe Crohn’s?

A

Admit

  • IV fluids
  • IV Steroids - hydrocortisone 100mg/6h
    • Switch to oral if response
    • Consider biologics if no response
  • VTE prophylaxis
  • Stool screen - Culture etc.
  • Physical examination daily + Bloods
  • Monitor for abdominal sepsis
87
Q

What are the main methods for induction of remission in Crohn’s disease?

A
  • Oral/IV steroids
  • Enteral nutrition
  • ANti-TNF
88
Q

What are the main Medications use to maintain remission in Crohn’s Disease?

A
  • Azathioprine
  • 6MP
  • Methotrexate
  • Mycophenolate mofetil
  • Anti-TNF antibodies
89
Q

What are examples of 5-ASA drugs?

A
  • Mesalazine
  • Sulfasalazine
90
Q

What is the mechanism of action of 5-ASA drugs?

A

The precise mechanism of action of 5-ASA is unknown, but it has both anti-inflammatory and immunosuppressive effects, and appears to act topically on the gut rather than systemically

Something about trapping free radicals to reduce inflammation

91
Q

What are important adverse effects of 5-ASA drugs?

A
  • Gastrointestinal upset (e.g. nausea, dyspepsia)
  • Headache
  • Leucopenia
  • Thrombocytopenia
  • Renal impairment
  • Serious hypersensitivity reaction
92
Q

When is Azathioprine used in Crohn’s Disease?

A
  • Refractory to steroids/relapse on steroid taper
  • Requiring > 2 steroid courses per year
93
Q

What are side effects of Azathioprine?

A
  • Abdo pain
  • Nausea
  • Pancreatitis
  • Leucopenia
  • Abnormal LFTs
94
Q

What are indications for surgical intervention in Crohn’s Disease?

A
  • Drug failure
  • GI obstruction fromm stricture
  • Perforation
  • Fistulae
  • Abscess
95
Q

What are poor prognostic factors in Crohn’s Disease?

A
  • Age < 40 yrs
  • Steroids at first presentation
  • Perianal disease
  • Isolated terminal ileitis
  • Smoking
96
Q

How would you manage perianal disease in Crohn’s Disease?

A
  • Oral antibiotics
  • Immunosuppressant therapy - anti-TNF
  • Local surgery +/- seton insertion
97
Q

What mnemonic can you use to remember the extra-colonic features of IBD?

A

A PIE SACK

  • Aphthous ulcers
  • Pyoderma gangrenosum
  • Iritis (uveitis)
  • Erythema nodosum
  • Sclerosing cholangitis
  • Ankylosing spondylitis/arthritis
  • Clubbing
  • Kidney (nephrotic syndrome – unusual)
98
Q

Typical age of onset in ulcerative colitis

A

Peaks at

  • 15-25 years
  • 55-65 years

Mean

  • 34
99
Q

Presentation of toxic megacolon?

A

Severe abdo pain, distension, pyrexia

100
Q

Pathophysiology of toxic megacolon

A

Triggered by electrolye abnormalities and narcotics

There is acute toxic dilatation of colon (TC or RC) until perforation at caecum.

101
Q

Management of toxic megacolon

A

50% respond to medical therapy ?????

Urgent colectomy (decompression of bowel)

102
Q

Size tm

A

>6cm

103
Q

Why might you do a CXR in IBD?

A

Exclude silent perforation

Findings: pneumoperitoneum

104
Q

Where are biopsies taken from in ileo-colonscopy of UC?

A

At least 2 biopsies from 5 sites including rectuma and terminal ileum

105
Q

What investigations are never done in acute presentation of IBD?

A

Barium enema

Colonoscopy (flexible sigmoidoscopy done instead)

Gwen - GI and General surgery (44 decks)

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