IBD

Question 1

Definition of UC and Crohn’s Disease

Answer 1

UC: relapsing, remitting inflammatory disorder of the colonic mucosa which may involve just the rectum (proctitis 50%), extend toot he colon (left colitis 30%) or the entire colon (pancolitis 20%). Smoking is protective

Crohn’s Disease: chronic, transmural inflammatory disorder which can affect any part of the GI tract from mouth to anus, but favours the terminal ileum and proximal colon. NOD2/CARD15 increase risk. SMoking increases risk

Question 2

HPC

Answer 2

diarrhoea +/- blood, mucous
abdo pain
urgency
tenesmus with rectal disease
systemic symptoms = weight loss, anorexia, fever
extraintestinal = skin changes, eye problems, joint pain, renal stones, liver problems

Question 3

Examination:

Answer 3

Hands = clubbing 
Eyes = conjuctivitis, scleritis, iritis 
Mouth = angular stomatitis, aphthous ulcers 
Abdo = tenderness, distension in acute, enlarged fatty liver 
anus = perianal abscess/fistulae/skin tags, rectal strictures in Crohn's and rectal ulcers in UC
Joints = large joint arthritis, sacroiliitis, ank spond

Question 4

Differential Diagnosis

Answer 4

Infective proctitis
NSAID, OCP, retinoic acid use
Infections - C. Difficile, salmonella, shigella, e. coli
Ischaemic colitis

Question 5

Complications:

Answer 5

UC: 
local 
 - toxic megacolon
 - perforation
 - haemorrhage 
 - strictures, fistula 
 - carcinoma 

Exta-colonic
LIVER: fatty, PSC, cirrhosis, acholangiocarcinoma, amyloidosis
BLOOD: anaemia, thromboembolism
ARTHROPATHY: large joint, ank spon
SKIN: erythema nodosum, pyoderma gangrenosum, ulcers
OCULAR: conjunctivitis, episcleritis, uveitis

Crohn's Disease: 
local 
 - anorectal disease = fissures, fistulas, abscesses 
 - obstruction, Fistula, Toxic MC
 - Carcinoma 

extracolonic (similar to UC except)

• PSC rare
• Gallstones more common
• Renal stones
• malabsorption
• osteomalacia
• joint skin eye as above

Question 6

Investigations

Answer 6

FBC - ? anaemia of chronic disease, blood loss
- WCC ?leucopenia with azathioprine
ESR/CRP - active inflammation?
UEC - renal disease? hypoalbuminaemia
LFT - ?liver disease
Antibody - pANCA negative and ASCA positive more likely to have crohns
cultures

Imaging:
AXR - bowel wall thickening, gaseous distension, evidence of toxic megacolon, obstruction
erect CXR - evidence of perforation

barium enema - NOT if active disease
UC: rectum involved, contiguous lesions, loss of haustra
CD: skip lesions, luminal narrowing, fistula

Other:
stool micro
sigmoidoscopy/colonoscopy
rectal biopsy

Question 7

Management of UC

Answer 7

MILD ( <4 motions a day, well)

• 5-ASA (eg. mesalazine)
• steroids to induce remission (40mg po bd for 2/52 the taper)
• topical: hydrocortisone foam

MODERATE: (4-6 per day, well)

• oral prednisolone (initially 40mg po bd for 1/52 then taper for 6 weeks) + mesalazine
• topical: BD steroid enema

SEVERE: > 6 motions per day

• admit for NBM + IV maintenance fluids
• IV and rectal hydrocortisone
• if on day 3 CRP > 45 then consider ciclosporin/infliximab/surgery

Maintaining Remission:
1st - sulfasalazine
2nd - mesalazine/5-ASA/pentasa
SE: temp, rash, pancreatitis, reversible oligospermia
3rd - Azathioprine (immunomodulatory) indicated in those with steroid SE or who relapse quickly when steroids are withdrawn
SE: leucopenia

Topical therapies for remission
Surgery - indicated if perforation, massive haemorrhage, toxic dilatation, failure to respond to medical therapy

Question 8

Crohn’s Disease Management

Answer 8

MILD attacks (symptomatic but systemically well) 
= prednisolone 30mg PO DB tapering down 

SEVERE attacks (symptoms + unwell) 
= admit NBM + IV maintenance fluids
= IV hydrocortisone 
= rectal hydrocortisone 
= oral metronidazole 
= regular obs, stool chart, BD examination 
if no response CT abdo and ?surgery 

Perianal disease:

• MRI + EUA
• oral Abx, immunosuppressant +/- infliximab, local surgery +/- stent

SURGERY

Question 9

Other/extra management of Crohn’s Disease

Answer 9

Combined immunotherapy in initial management = azathioprine + infliximab + steroids

5-ASA (sulfazaline)
Elemental Diet
Monthly IM methotrexate
TNF-alpha inhibitors = infliximab and humira

SCREENING :
pancolitis > 7 years
left sided colitis > 15 years
- colonoscopy with biopsy every 1-2 years to look for high grade dysplasia in the absence of inflammation that indicates surgery