IBD

Question 1

UC
- antibody found in 45% (also common in PSC)
- colonoscopy findings

Answer 1

a) p-ANCA

b) Friable mucosa, loss of normal mucosa, uniform continuous inflammation, ulceration

Question 2

Truelove & Witts
- 2 symptoms
- 2 signs
- 2 lab findings

Answer 2

Frequency: <4, 4-6, >6
Bleeding: small, moderate, large
Temp: 37.8 (more or less)
Pulse: 90 (more or less)
ESR: 30 (more or less)
Hb: 110 (more or less)

Question 3

Crohn’s radiological findings

Answer 3

C: cobblestone appearance of mucosa
R: rose-thorn ulcers
O: obstruction of bowel
H: hyperplasia of mesenteric lymph nodes
N: narrowing of intestinal lumen
S: skip lesions

Question 4

Crohn’s patient with multiple previous small bowel resections presents with abdominal bloating and profuse watery diarrhoea from her ileostomy. CRP 11, apyrexial.
a) Investigations
b) Likely diagnosis
c) What would you expect the folate levels to be?
d) Management

Answer 4

a) Small bowel aspirate and culture

b) Short bowel syndrome with bacterial overgrowth
(differential would be acute Crohn’s flare, but unlikely given CRP only 11)

c) Folate often very high, due to bacterial folate synthesis

d) - Cholestyramine
- Loperamide, opiates

Question 5

Crohn’s management.
a) inducing remission
b) maintaining remission
c) tests before starting azathioprine and biologics
d) drug that interacts with azathioprine

Answer 5

Induction:
1st line: steroids
- If 2 or more exacerbations in 12 months, consider adding azathioprine or methotrexate

2nd line: infliximab/adalimumab*
- Given if steroids not effective or contraindicated and Crohn’s with severe active symptoms (weight loss, fever, severe abdominal pain and usually 3+ loose stools daily) or imaging (strictures, fistulae)
- Continue for 12 months, and review annually based on disease activity to determine need to continue

Maintenance:
1st line: azathioprine
(note: if MTX used in inducing remission, continue for maintenance. If biologic used to induce remission, continue as above)
- Generally attempt to withdraw azathioprine therapy after 5 years of remission, due to 4-fold increase risk of lymphoma, and other risks e.g. pancreatitis

2nd line: methotrexate
- If TPMT levels deficient, or azathioprine not tolerated or not effective

Tests prior to treatment initiation:
- Azathioprine - thiopurine methyltransferase (TPMT) levels - 10% population are deficient, increasing the risk of thiopurine toxicity and myelosuppression
- Biologics - screen for TB, Hep B and C, assess for any skin cancer, routine FBC, LFT, etc.

d) Allopurinol - inhibits xanthine oxidase, which is involved in 6-mercaptopurine metabolism. It therefore interacts with azathioprine to cause thiopurine toxicity and bone marrow suppression

Question 6

Colonoscopy surveillance in IBD
a) Low, intermediate and high risk criteria
b) Frequency of surveillance for each (based on rating at last scope)

Answer 6

a) - Low risk: quiescent UC or Crohn’s colitis with no FHx bowel Ca
- Intermediate risk: extensive UC or Crohn’s colitis with mild inflammation on colonoscopy or histology, FHx bowel Ca >50 years
- High risk: moderate-severe UC or Crohn’s colitis inflammation, FHx bowel Ca <50 years, stricture in past 5 years, dysplasia in past 5 years, PSC

b) - Low risk: offer colonoscopy at 5 years.
- Intermediate risk: offer colonoscopy at 3 years.
- High risk: offer colonoscopy at 1 year

Question 7

UC management:
a) Inducing remission
b) Maintenance
c) Indications for acute colectomy

Answer 7

a) Induction:
- 1st line: IV steroids
- 2nd line (steroids not effective in 72h/contraindicated/not tolerated): IV ciclosporin
- 3rd line (if ciclosporin contraindicated): infliximab
- May require surgery if > 8 stool/day, pyrexial, tachycardic, CRP >45, anaemic, albumin <30, and/or no response to ciclosporin/infliximab within 72 hours

b) Maintenance:
- Proctitis/proctosigmoiditis: topical or oral (or combined) aminosalicylate
- Extensive UC: oral aminosalicylate
- If aminosalicylates not effective: first azathioprine/mercaptopurine, then consider biologics

c) Day 3 of exacerbation: stool >8 per day, CRP >45

Question 8

Toxic colitis
a) Features
b) Toxic megacolon - diagnosis
c) Risk factors
c) Management

Answer 8

a) - Fever >38.5, tachycardia >120, hypotension
- Severe abdo pain and tenderness +/- distension, guarding
- Raised WCC/CRP, low Hb

b) Colonic dilatation >6cm

c) - UC, Crohn’s colitis
- C. diff, other acute infective colitis
- HIV/AIDs
- Use of antimotility agents e.g. loperamide, opiates

d) - Surgical review
- IV antibiotics, IV fluids

Question 9

Crohns investigations

Answer 9

Small bowel - barium meal and follow through

Large bowel - colonoscopy

Question 10

IBD mimics
a) Medications
b) Other

Answer 10

a) Mycophenolate
NSAID enteropathy
Isotretinoin
Nicorandil

b) - Behcets - look for ulceration in mouth/genitals and red eyes
- TB
- FMF
- HIV enteropathy
- Chronic infection

Question 11

Causes of villous atrophy

Answer 11

• Coeliac disease
• Crohn’s disease
• NSAID use
• HIV enteropathy
• Tropical sprue
• Whipples
• Lymphoma
• Giardia, infectious enteritis
• Lactose intolerance
• Hypogamaglobulinaemia

Question 12

Risk of IBD treatments like azathioprine and sulfasalazine

Answer 12

Drug induced pancreatitis

Question 13

Microscopic colitis
a) Risk factors
b) Presentation
c) Diagnosis
d) Treatment

Answer 13

a) Female, 40-60s, NSAID use, coeliac disease

b) - Chronic watery diarrhoea and abdominal cramps
- Usually normal bloods and colonoscopy

c) Normal colonoscopy but colitis on biopsy

d) - Loperamide
- Avoid NSAIDs
- Steroids, 5-ASA, etc.

Question 14

Short bowel syndrome
a) Length
b) Management

Answer 14

a) < 2m remaining small bowel (normal length 275 to 850 cm) leading to the need for nutritional and fluid supplements

b) - Nutritional management including home PN
- Surgery as required
- Teduglutide - promotes small bowel mucosal growth

Question 15

UC vs Crohn’s
a) Associated conditions
b)

Answer 15

a) UC - PSC, Cholangiocarcinoma
Crohn’s - renal stones, gallstones

b)