IBD Flashcards
What is the age distribution of Crohn’s disease?
Bimodal peak age presentation - 15-30 and 60-80 yrs old
What course does Crohn’s disease usually follow?
Remitting and relapsing course
What can happen as a result of severe exacerbations of Crohn’s disease?
Life-threatening causing:
Systemic upset
Bowel perforation
rarely death
What is the pathophysiology of Crohn’s disease?
Can affect any part of GI tract - commonly distal ileum or proximal colon - much of aetiology unknown
Smoking increase risk of developing unlike UC
Transmural inflammation producing deep ulcers and fissures (cobblestone appearance)
Skip lesions
What are the macroscopic changes seen in Crohn’s disease?
Discontinuous inflammation (skip lesions)
Fissures and deep ulcers (cobblestone appearance)
Fistula formation
What are the different types of fistula that can form in Crohn’s disease?
Perianal fistula (54% of pts)
Entero-enteric fistula (24%)
Recto-vaginal (9%)
Entero-cutaneous fistula
Entero-vesicalar fistula
What is the microscopic change seen on Crohn’s disease?
Non-caseating granulomatous inflammation
What are the risk factors for Crohn’s disease?
Strong FH
Smoking (developing and relapse)
What are the typical symptoms of Crohn’s disease?
Episodic abdominal pain - colicky in nature and site varies depends on region affected
Diarrhoea - often chronic and may contain blood or mucus
What are some systemic symptoms of Crohn’s disease?
Malaise
Anorexia
Low grade fever
Malabsorption and malnourishment if severe - late presenting feature (children may intially present as failure to grow or thrive)
What is the oral involvement in Crohn’s disease?
Oral aphthous ulcers (can be painful and recurring)
What is the perianal involvement of Crohn’s disease?
Perianal disease, including with peri anal abscess
What are the different types of extra-intestinal manifestations of IBD?
Musculoskeletal
Skin
Eyes
Hepatobiliary
Renal
What are the musculoskeletal manifestations of IBD ?
Enteropathic arthritis (sacroiliac and other large joints)
Nail clubbing
Metabolic bone disease (secondary malabsorption)
What are the skin manifestations for IBD?
Erthyema nodosum
Pyoderma gangrenosum (erthyemstous papules/pustules that develop into deep ulcers)
What are the eye manifestations of IBD?
Episcleritis
Anterior uveititis
Iritis
What are the hepatobilary manifestations of IBD?
Primary sclerosing cholangitis (more associated with UC)
Cholangiocarcinoma (associated with PSC)
Gallstones
What is the renal manifestation of IBD?
Renal stones
What investigations should be order for suspected Crohn’s disease?
Routine bloods - CRP/WCC - check for anaemia
Faecal calprotectin test
Stool sample for potential infective cause
Colonoscopy is GOLD standard - biopsies are taken
When can colonoscopy not be used to make diagnosis of Crohn’s disease?
When disease more proximal to terminal ilium - presumed diagnosis on clinical features and imaging alone
What other investigations may be warranted in Crohn’s disease and wha are they looking for?
CT scan abdomen pelvis - severe Crohn’s disease, look for bowel obstruction or perforation or any intra-abdominal collections - useful in acute phase when colonoscopy contraindicated
MRI imaging - asses disease severity for any eneteric fistula or peri-anal disease.
Examination under anaesthesia (EUA) with proctosigmoidoscopy - examine and treat perianal fistula.
Where should pts with IBD be managed?
Referred to gastroenterologist
Acute severe disease should be admitted on an emergency basis
What is done to induce remission in Crohn’s disease?
Fluid resuscitation, nutritional support and prophylactic heparin and anti-embolic stocking (pro thrombotic state of IBD flares)
Corticosteroid therapy as first line.
Subsequent treatments including - immunosuppressive agents (mesalazine, azathioprine) or biological agents (infliximab or adalimumab)
What is the severity classification of Crohn’s disease?
Montreal score:
Age at diagnosis
Location
Behaviour - e.g. stricture or no stricture add a “p” if concurrent perianal disease
What is the managing remission treatment for Crohn’s disease?
Azathioprine - first line mono therapy
Smoking cessation
Colonoscopic surveillance is offered offered to those who have had the disease for >10years with>1 segment of bowel affected
What other support should be offered for IBD?
IBD-nurse specialist and pt support groups
Enteral nutritional support - young pts with growth concerns
What percentage of Crohn’s disease pts require surgical management in their lifetime?
70-80%
When is surgical management indicated in Crohn’s disease?
Failed medical management
Severe complications (strictures or perforation)
All operations bowel-sparing approach should be taken to avoid short gut syndrome in later years.
Which types of surgery are usually requires in Crohn’s disease?
- Ileocaecal resection (removal of terminal ileum and caecum with primary anastomosis)
- Small bowel resection or large bowel resection
- Surgery for peri-anal disease (e.g. abscess drainage, seton insertion, or laying open of fistulae)
- Stricturoplasty (division of a stricture that is causing bowel obstruction)
CD patients are typically high risk patients to operate on, therefore pre-operative optimisation (including treating any acute attack and managing nutrition) should be attempted where possible.
When should primary bowel anastomosis not be performed in Crohn’s disease?
Active severe flare up
Or not at least without defunctioning stoma
What are the complications of Crohn’s disease?
Fistula
Stricture formation
Recurrent perianal fistulae - difficult to treat
GI malignancy
What are the extraintestinal complications of Crohn’s disease?
Malabsorption - growth delay in children
Osteoporosis - due to malabsorption or long term steroid use
Increased risk of gallstones - reduced reabsorption of bile at terminal ilium
Increased risk of renal stones - malabsorption of fats in small bowel which causes calcium to remain in lumen but oxalate is absorbed. Results in hyperoxaluria and formation of oxalte stones in renal tract.
Which drugs should be avoided in IBD and why?
Anti-motility such as loperamide. Avoid in acute attacks as these can precipitate toxic mega colon.
What is the prevalence and incidence of UC?
More common in Caucasian population
Bimodal distribution - 15-25, 55-65 yrs old
What may occur in a severe fulminant exacerbation of UC?
Life threatening:
Severe systemic upset
Toxic megacolon
Colonic perforation
Death
What is a protective factor in UC?
Smoking
What is the pathophysiology of UC?
Diffuse continual mucosal inflammation of the large bowel. Beginning in the rectum and spreading proximally
Portion of terminal may be affected if ileocaecal valve is not competent - backwash ileitis
Hyperaemic/haemorrahigic colonic mucosa
What are the macroscopic changes seen in UC?
Continuous inflammation
Pseudo-polyps (raised areas du to repeated cycles of ulcerations and healing) and ulcers may form
What are the microscopic changes that may occur in UC?
Crypt abscess formation
Reduced (hypoplasia) goblet cells
Non-granulomatous inflammation
What are the symptoms of UC?
Insidious onset. Cardinal feature is bloody diarrhoea, with visible blood in stool in more then 90% of cases. More likely if widespread colonic involvement + features of dehydration and electrolyte imbalance.
Proctitis
PR bleeding and mucus discharge
Increased frequency and urgency of defecation and tenesmus
What are some systemic signs of UC?
Malaise
Anorexia
Low-grade pyrexia
What may be found on clinical examination of UC?
Unless severe exacerbation, generally unremarkable.
Fulminant colitis, toxic megacolon or colonic perforation should be suspected if pt complains of severe abdominal pain and if signs of peritonism are present.
Which criteria can be used to grade the severity of UC exacerbations?
True love and Witt criteria
What are the diffential diagnosis of UC?
Crohn’s disease
Chronic infections
Mesenteric ischemia
Radiation colitis
Malignancy, IBS or coeliac disease
What investigations should be order for UC?
Routine bloods - CRP/WCC
Faecal calprotectin - raised in IBD but normal in IBS.
Stool sample
Colonoscopy with biopsy
Which scores are used in UC?
Montreal score - quantify disease extent
Mayo score - disease severity
What imaging may be order in acute exacerbations of UC?
AXR
CT imaging
What may be seen on AXR of UC?
Mural thickening and thumb printing
Chronic cases - lead-pipe colon
What is the inducing remission management of UC?
Fluid resuscitation, nutritional support and prophylactic heparin
Corticosteroid therapy and immunosuppressive agents such as cyclosporin or 5-ASA suppositories. Biological agents such as infliximab can be trialled as rescue therapy.
Stepwise approach depending on clinical severity and location of exacerbation.
What is the maintaining remission management of UC?
Immunomodulators - typically 5-ASAa such as mesalazine or sulfaslazine or azathioprine
Colonoscopic surveillance
How much percentage of pts with UC will require surgery?
30%
What are the indications for surgery in UC?
Refractory to medical treatment
Toxic megacolon
Bowel perforation
What are the surgical options for UC?
Depends on patient and disease factors
Segmental bowel resection (subtotal colectomy) and defunctioning, as primary anastomosis during acute IBD flare is advised
Elective cases - total proctocolectomy is curative (requires end ileostomy) or
Can undergo subtotal colectomy with ileo-rectal anastomosis (IRA) or
Panprotoctocolectomy with Leo-pouch anal anastomosis (IPAA)
What are the complications of UC?
Toxic megacolon
Colorectal carcinoma
Osteoporosis
Pouchitis - inflammation of ideal pouch - IPAA
What are the symptoms of toxic megacolon and treatment?
Severe abdominal pain, abdominal distension, pyrexia and systemic toxicity
Decompression of the bowel asap due to increased risk of perforation
What are the symptoms of pouchitis and what is the treatment?
Abdominal pain
Bloody diarrhoea
Treated with metronidazole and ciprofloxacin
