IBD Flashcards
What are the main differences between UC and Crohn’s disease?
LOCATION:
- UC= starts at ileocaecal junction + extends continously through large bowel i.e. distal colon to rectum
- Crohns= “mouth to anus” i.e. can affect any part of GI tract
LESIONS:
- UC= uniform, diffuse and superficial i.e. mucosa and submucosa
- Crohns= transmural segmental, deep lesions i.e. up to subserosa
GROSS FEATURES: UC: -distended lumen -pseuodopolyps -irregular glandular architecture -crypt distortion (cryptitis) -ulceration -lesions bleed easily
Crohns:
- thickened bowel wall + narrow lumen
- cobble stone mucosa
- fat-wrapping= fat progresses onto anti-mesenteric border
- Fistulas or fissures= due to being TRANSMURAL DISEASE
HISTOLOGICAL FEATURES:
UC:
-basal plasmacytosis (disproportionate amount of cytoplasm in plasma cells)
-Absence of granulomas
Crohns:
- Epitheloid granulomas (diagnostic of Crohns)
- Lymphoid hyperplasia
AGE OF PRESENTATION:
- UC= 15-30 and 50-70 (bimodal)
- Crohns= 20-40
Where is the first sight of presentation of Crohns?
Ileocaecal junction (terminal ileum)
What condition can Crohn’s disease be misdiagnosed for?
Appendicitis= due to location of 1st presentation of Crohns causing similar pain pattern to appendicitis due to being anatomically close (central periumbilical pain which localises to RIF)
What is the pattern of disease progression in UC?
Starts in rectum and extends proximally
What causes IBD?
Inappropriate immune response against colonic flora in genetically susceptible individuals with compromised epithelium
What are the different factors influencing the development of IBD?
Family history Smoking Diet low in fibres and high in red meat NSAIDS Recent gastro infection= compromised microbiota Immunocompromised state
How would someone with ulcerative colitis typically present?
NOTE: symptoms tend to be relapsing-remitting i.e. acute worsening of symptoms leads to patient presenting with flares
Diarrhoea +/- blood and mucus Tenesmum (feeling of needing to empty bowels despite already being empty) Frequency Lower abdo pain and cramping Bloating Fever Malaise Weight loss
Systemic symptoms when experiencing an attack:
- Weight loss
- fever
- malaise
What signs would you be looking for on examination in patient with UC?
Abdominal distention
Tenderness
Anaemia symptoms i.e. pallor and fatigue
Large joint pain
Clubbing
Erythema nodosum= red/darker patches of skin due to swollen fat under surface
Pyoderma gangrenosum= painful skin ulcers
Episcleritis= inflammation between the conjunctiva and sclera of eye
What bio marker of IBD can be tested for in faeces? Why is it present?
Faecal calprotectin
Increased gut permeability leads to neutrophils being able to diffuse into gut lumen. Neutrophils contain calprotectin which results in calprotectin being present in faeces
What investigations are done for ulcerative colitis? What would you expect to find in UC?
Blood tests
- FBC= raised WCC or signs of anaemia
- U+Es
- CRP= raised
- LFTS= hypoalbuminaemia in severe disease
Stool tests
- faecal calprotectin = raised (differentiates from IBS)
- Miscropscopy and culturing= need to exclude Campylobacter, C diff, E. coli and salmonella
Lower GI endoscopy (gold standard)
-flexible sigmoidoscopy
NOTE: colonoscopy can be performed if unclear findings on sigmoidoscopy or once diagnosis established and wanting to determine the extent of the disease
What macroscopic findings would you expect to see during a sigmoidoscopy in a patient with UC?
Continuous uniformly inflamed mucosa
Erythematous friable mucosa
Ulceration
Pseudopolyps
What are the possible complications of UC?
Toxic mega colon
Perforations due to toxic dilation of colon
VTE= prophylaxis given to all in patients regardless of whether rectal bleeding present
Adenocarcinomas
Primary sclerosing cholangitis
Malnutrition
What are the 2 main aims of UC management?
Induction of remission
Maintenance of remission
How is mild-moderate UC managed medically?
MILD
5-ASA (aminosalicylates)= Mesalazine
I.e. PR for distal disease and oral for more expense disease
MOA= anti-inflammatory drug to act locally on colonic mucosa
MODERATE
Prednisolone can be used to induce remission when patient having 4-6 motions per day
How would severe UC be defined and how is it managed?
Patient unwell and >6 motions per day = patient admitted
IV hydration/electrolyte replacement
IV steroids i.e. hydrocortisone 100mg/6hrs
Thromboembolic prophylaxis
Monitor bloods
Multiple stool samples to rule out infection
When is rescue therapy required in UC and what medications are used?
When CRP >45 and no change in stool frequency after 3-5 days of medical intervention for severe UC
Ciclosporin or infliximab= aims to avoid the need to colectomy
When is surgery indicated in UC patients? What are the main types of surgery which can be done?
When UC cannot be adequately controlled with medication or severe complications such as toxic mega colon or bowel perforation occur
Subtotal colectomy + terminal ileostomy
-temporary ileostomy which is reversed later
Complete proctocolectomy= resection of entire colon and rectum
-have permenant ileostomy
Restorative proctolectomy
-temporary loop ileostomy which can be reversed by surgery to join the ileal pouch to anal canal= ileal pouch anal anastomoses (IPAA)
How would someone with Crohn’s disease present? What signs might you expect to see in this patient?
Chronic diarrhoea
Abdominal pain= RLQ (due to preferentially effecting the terminal ileum
Weight loss/failure to thrive
Fresh blood in stool= Hematochezia
Systemic symptoms = fatigue/ malaise/ fever (with more severe disease)
Bowel ulceration
Perianal abscess or skin tags
Fistulaes i.e. between loops of bowel or from bowel to bladder
Anal strictures
Finger clubbing
Joint problems
Anaemia i.e. anaemia of chronic disease/ anaemia due to B12 deficiency or iron deficiency or folate
What investigations can be done to diagnose patient with Crohn’s disease?
Blood tests:
- FBC
- CRP
- U+E
- LFT
- INR
- Ferritin
- B12
- folate
Stool culture to rule out Campylobacter, H pylori, Ecoli
Faecal calprotectin= sensitive for bowel inflammation
Colonoscopy to identify the key mucosal changes associate with Crohn’s disease
Biopsy
Contract radiography can determine the extent and severity of Crohns
AXR= need to rule out toxic megacolon
What signs would indicate that Crohn’s patient should be admitted for IV steroids?
Raised temperature Raised pulse Increased ESR (erythrocyte sedimentation rate)= indicative of inflammation Increased WCC Increased CRP Decreased albumin
How you would treat mild to moderate Crohn’s disease? What can be done for symptomatic relief?
Prednisolone 40mg/d for 1 week and then decrease by 5mg every week for 7 weeks
Need to help manage diarrhoea:
-Loperamide (anti-diarrhoea drugs)
When is Azathioprine (AZA) indicated for use in Crohns patients? What is its function?
Refractory Crohn’s disease= persistent acute symptomatic disease despite anti-inflammatory therapy
Relapse on steroid taper
When patient requires > 2 courses of steriods a year
Immunosuppressant
How is severe Crohn’s managed?
IV hydration + electrolyte balance
IV steriods= hydrocortisone 100mg/6hr
Thromboembolic prophylaxis
Stool samples taken to exclude infection
Consideration of anti-TNF alpha medications if not improving on IV steriods
What biologics can be used in Crohn’s disease? When are they indicated?
Anti-TNF alpha= Infliximab + Adalimumab
-counters neutrophil accumulation and granulomas formation and prevent CD4+ T cell action i.e. inhibit the action of immune cells involved in disease process
When severe Crohn’s flare not responding to IV steroids
When is surgery indicated in Crohn’s patients? What are the 3 main aims of surgery in Crohn’s disease?
(50-80% will require surgery) Indications: -failure of drug therapy -GI obstruction due to stricture -perforation -fistula -abscess
AIMS:
- Resect effected area without causing short bowel disease
- Control perianal or fistulizing disease
- Rest distal bowel with temporary ileostomy
What are examples of extra-intestinal manifestations of UC?
Erythema nodosum
Apthous ulcers
Episcleritis
Anterior uveitis
Acute arthropathy
