GIS chronic bowel disorders Flashcards by X X

CHRONIC BOWEL DISORDERS

3 TYPES?

COELIAC DISEASE
CROHN’S
ULCERATIVE COLITIS

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CROHN’S DISEASE

What is it? what does it affect

Affects whole GI-tract- thickened wall, all layers, deep ulceration

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Symptoms of crohns depend on the site of disease but may include

abdominal pain, diarrhoea, fever, weight loss and rectal bleeding.

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CROHN’S DISEASE

Can lead to complications such as…?

INTESTINAL FISTULAE
ANAEMIA/MALNUTRITION
COLORECTAL/SMALL BOWEL CANCER
GROWTH FAILURE/DELAYED PUBERTY IN CHILDREN
EXTRA-INTESTINAL MANIFESTATION: arthritis/joints/eyes/liver/skin abnormalities

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FISTULATING CROHN’S DISEASE

WHAT IS IT?

When a fistula develops between intestine & perianal skin/bladder/vagina

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CROHN’S DISEASE TREATMENT- ACUTE

1 FLARE-UP IN 12 MONTH PERIOD
1st LINE?

Prednisolone/methylprednisolone/IV hydrocortisone (monotherapy)

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Crohns: Tx Patient has distal ilea/ileocaecal/right-sided disease?
-Alternative?

Budesonide
-Alternative? Aminosalicylates (sulfasalazine/mesalazine)-> less side-effects, less effective

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CROHN’S DISEASE- ACUTE

2+ FLARE UPs in 12 MONTH PERIOD
Add-on 1st LINE?

2nd LINE?

SEVERE?

Add-on 1st LINE? Azathioprine OR Mercaptopurine

2nd LINE? add-in Methotrexate

SEVERE? Monoclonal antibodies

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CROHN’S DISEASE- MAINTENANCE OF REMISSION

( STOP SMOKING+NUTRITION KEY

DO NOT USE CORTICOSTEROIDS/BUDESONIDE FOR MAINTENANCE!)

MONOTHERAPY?
-Alternative?

MONOTHERAPY? Azathioprine OR Mercaptopurine
-Alternative? Methotrexate

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CROHN’S DISEASE- MAINTENANCE OF REMISSION
post surgery tx?

Azathioprine+Metronidazole (3 months)
OR
Azathioprine alone

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CROHN’S DISEASE- DIARRHOEA TREATMENT?

LOPERAMIDE
CoDeine (CD) if no colitis
COLESTYRAMINE

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FISTULATING CROHN’S DISEASE

ASYMPTOMATIC, no tx.
TO IMPROVE SYMPTOMS what may be given?

Metronidazole AND/OR Ciprofloxacin
(Metronidazole- ~1 month, NOT >3 months due to peripheral neuropathy)

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FISTULATING CROHN’S DISEASE
MAINTENANCE tx?

Azathioprine OR Mercaptopurine (Infliximab if no response)
Treatment at least 1 yr

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ULCERATIVE COLITIS

What is it? what area can it affect

has a relapsing-remitting pattern

Can affect region from rectum-whole colon- blood diarrhoea/defecation urgency/abdominal pain

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ULCERATIVE COLITIS

MOST COMMON AGE?

15-25years

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UC COMPLICATIONS?

Colorectal cancer
Secondary osteoporosis
Venous thromboembolism
Toxic megacolon

ULCERATIVE COLITIS

INCREASING SEVERITY?

Proctitis
Proctosigmoiditis
Left-sided
Extensive colitis

ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT

DISTAL inflammation-RECTAL tx?

EXTENDED inflammation?

DISTAL? Suppositories/Enemas-> foam preps used if patient has difficulty retaining liquid enema

EXTENDED? Systemic medication

DIARRHOEA IN ULCERATIVE COLITIS tx?

AVOID LOPERAMIDE/CODEINE-> can cause toxic megacolon (as gastric emptying is slowed down, build-up)
Only use on advice of a specialist!

ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT

PROCTITIS
1st LINE?
2nd LINE?
3rd LINE?

1st LINE? Topical aminosalicylate (sulfasalazine, mesalazine…)

2nd LINE? Oral aminosalicylate (if no improvement after 4 weeks)

3rd LINE? add Topical/oral corticosteroid for 4-8 weeks

NOTE: Aminosalicylates contraindicated? Consider topical/oral corticosteroid 4-8 weeks.

ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT

PROCTOSIGMOIDTIS/LEFT-SIDED ULCERATIVE COLITIS
1st LINE?
2nd LINE?
3rd LINE?

1st LINE?
TOPICAL AMINOSALICYLATE

2nd LINE?
+ HIGH-DOSE ORAL AMINOSALICYLATE if no improvement after 4 weeks
OR
SWITCH TO HIGH-DOSE ORAL AMINOSALICYLATE+4-8 WEEKS OF TOPICAL CORTICOSTEROIDS

3rd LINE?
STOP TOPICAL TX, GIVE:
ORAL AMINOSALICYATE+4-8 WEEKS OF ORAL CORTICOSTEROIDS

NOTE: Aminosalicylates contraindicated? Consider topical/oral corticosteroid 4-8 weeks.

ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT

EXTENSIVE ULCERATIVE COLITIS
1st LINE?
2nd LINE?

1st LINE? TOPICAL AMINOSALICYLATE+HIGH-DOSE ORAL AMINOSALICYLATE

2nd LINE? NO CHANGE AFTER 4 WEEKS?
STOP TOPICAL AMINOSALICYLATE, GIVE:
HIGH-DOSE ORAL AMINOSALICYLATE+4-8 WEEKS ORAL CORTICOSTEROID

NOTE: Aminosalicylates contraindicated? Consider ORAL (ONLY) corticosteroid 4-8 weeks.

ULCERATIVE COLITIS- ACUTE SEVERE TREATMENT

1st LINE?
2nd LINE?

Symptoms not helped within 72hrs?

Alternative to Ciclosporin?

1st LINE? IV hydrocortisone/methylprednisolone-> need for surgery?

2nd LINE? IV ciclosporin/surgery

Symptoms not helped within 72hrs? IV steroid+IV ciclosporin OR surgery

Alternative to Ciclosporin? Infliximab

ULCERATIVE COLITIS- MAINTENANCE TREATMENT

WHY DO WE AVOID CORTICOSTEROIDS?

side-effects

AMINOSALICYLATES>CORTICOSTEROIDS

ULCERATIVE COLITIS- MAINTENANCE TREATMENT PROCTITIS/PROCTOSIGMOIDITIS? LEFT-SIDED/EXTENSIVE? 2+ FLARES IN 12 MONTHS?

PROCTITIS/PROCTOSIGMOIDITIS? RECTAL AND/OR ORAL AMINOSALICYLATE LEFT-SIDED/EXTENSIVE? LOW-DOSE ORAL AMINOSALICYLATE 2+ FLARES IN 12 MONTHS? ORAL AZATHIOPRINE/MERCAPTOPURINE (Give monoclonal antibodies if no effect)

AMINOSALICYLATES- SIDE-EFFECTS & MONITORING NHB NEPHROTOXIC? RENAL HEPATOTOXIC? BLOOD DISORDERS?

NEPHROTOXIC? Monitor before, at 3 months & /year HEPATOTOXIC? Monitor at monthly intervals for first 3 months BLOOD DISORDERS? Monitor at monthly intervals for first 3 months Perform blood count+stop drug ASAP if signs of blood dyscrasia

AMIONOSALICYLATES CONTRAINDINCATED IN.. SULFASLAZINE COLOURFUL SIDE-EFFECT?

AMIONOSALICYLATES CONTRAINDINCATED IN SALICYLATE HYPERSENSITIVITY. Obvs… SULFASLAZINE COLOURFUL SIDE-EFFECT? Stains contact lenses orangey-yellow

IRRITABLE BOWEL SYNDROME What is it?

Common/chronic/relapsing/life-long-> abdomina/ pain/diarrhoea/constipation/urgency/incomplete defaecation/passing mucus

IBS more common in what ages and gender?

women 20-30yo Symptoms are usually relieved by defaecation

IBS CAN BE EXACERBATED BY..?

COFFEE/ALCOHOL/MILK LARGE MEALS FRIED FOODS STRESS

IBS NON-DRUG TREATMENT?

Exercise Regular meals Reduce fresh fruit-3/day Reduce insoluble fibre Drink >/= 8 cups of water Reduce caffeine/alcohol/fizzy drinks Avoid sorbitol if you have diarrhoea Reduce stress

IBS TREATMENT x4 OTC? LALA

LAXATIVES: if constipated (X lactulose, can cause bloating) ANTISPASMODICS: alverine, mebeverine & peppermint oil LOPERAMIDE: if experiencing diarrhoea ANTIMUSCARINICS: hyoscine BUTYLbromide (avoid in cardiac disease) hyoscine BUTYLbromide- IBS, your BUTT hyoscine HYDRObromide- ship, water, motion sickness, HYDRO

IBS TREATMENT- OTC not helping for abdominal pain/discomfort 2nd LINE? Alternative?

2nd LINE? TCA: Amitriptyline Alternative? SSRIs [UNLICENSED]

Psychological intervention can be offered to patients who have no relief of IBS symptoms after X months of drug treatment.