IBD

Question 1

Where is effected (inflamed) in Crohn’s disease?

Answer 1

anywhere in GI tract (most commonly terminal ileum and colon)

each layer of GI tract

NOTE: this is what makes Crohn’s prone to strictures, fistulas and adhesions

Question 2

What clinical features are seen in Crohn’s?

Answer 2

• diarrhoea (bloody if Crohn’s colitis)
• abdominal pain
• non-specific: lethargy, weight loss
• perianal disease: skin tags or ulcers

Question 3

What can be seen on bloods in IBD?

Answer 3

raised faecal calprotectin and inflammatory markers

CRP correlates well with disease activity

Question 4

Extra-intestinal features of IBD

1. What features are seen relating to disease activity in:
   a) both
   b) Crohn’s
   c) UC
2. What features are seen unrelating to disease activity in:
   a) Crohn’s
   b) UC

Answer 4

1. a) arthritis
   NOTE: most common extra-intestinal feature in both UC + Crohn’s

b) erythema nodosum + osteoporosis
c) episcleritis more common

2. 
a)
- polyarticular, symmetrical arthritis 
- pyoderma gangrenosum 
- clubbing 
- gallstones (due to reduced bile-acid absorption)

b)
- PSC more common
- uveitis more common

Question 5

Crohn’s Investigation

What is seen on

1. histology
2. small bowel enema
   (highly sensitive + specific for terminal ileum Crohn’s)

Answer 5

1. • goblets cells
   • inflammation of all layers
   • granulomas

mnemonic: Crohn’s is a tough gig

2. • strictures: “Kantor’s string sign”
   • proximal dilated bowel
   • rose thorn ulcers
   • fistulae

THINK: if stricture bowel is going to be dilated before t and rose thorn ulcer if extended all the way becomes a fistula

Question 6

Crohn’s Management

What is done re:

1. lifestyle advice
2. inducing remission
3. refractory disease or fistula
4. perianal disease / fistula
5. maintaining remission

Answer 6

1. stop smoking +/- stop NSAIDs and COCP
2. 1st line: glucocorticoids
   2nd line: 5-ASA drugs

+/- azathioprine or mecaptopurine

3. infliximab
4. metronidazole
5. azathioprine or mecaptopruine

Question 7

1. What must you test before giving azathioprine or mecaptopurine?
2. What should be done if this is not acceptable?

Answer 7

1. measure TMPT level (thiopurine methyltransferase)

2. give methotrexate instead

Question 8

What clinical features are seen with ulcerative colitis?

Answer 8

• BLOODY diarrhoea
• abdominal pain
• urgency
• tenesmus

THINK: these are features more associated with the bottom of the GI tract

Question 9

UC Investigations

What is seen on

1. endoscopy
2. barium enema

Answer 9

1. red, raw, ulcerated mucoua which easily bleeds
   - adjacent preserved mucosa has appearance of polyps ‘pseudopolyps’
   - loss of goblets cells
   - inflammatory cells infiltrate lamina propria
   - neutrophils migrate through gland walls to form crypt abscesses
2. • loss of haustrations
   • superficial ulcerations - pseudo polyps
   • long standing disease: narrow + short colon “drainpipe colon”

Question 10

UC flares

1. What can sometimes cause them?
2. When are they classed as
   a) mild
   b) moderate
   c) severe
3. What should be done in severe disease?
4. What test should you consider?

Answer 10

1. • smoking cessation
   • NSAIDs or ABx
   • stress
2. a) <4 stools a day, no systemic disturbance

b) 4-6 stools a day, mild systemic disturbance

c) >6 stools a day containing blood
systemic disturbance: fever, tachycardia, reduced bowel sounds, any deranged bloods

3. admit to hospital
4. CXR for toxic megacolon (transverse colon >6cm)

Question 11

UC management

What is the management for

1.

a) proctitis
b) proctosigmoiditis + left-sided ulcerative disease
c) extensive disease

2. severe disease
3. maintaining remission

Answer 11

1. a)
2. topical 5-ASA (AKA aminosalicyte)
3. if not resolved within 4 weeks give oral 5-ASA
4. if still not achieved add oral or topical steroid

b)
1. topical 5-ASA
2. if not resolved within 4 weeks add oral 5-ASA and can change topical 5-ASA to topical steroid
3. Oral 5-ASA + steroid

(think can add in semi-stage 3 at stage 2)

c)
1. topical + oral 5-ASA
2. oral 5-ASA + steroid

(think skipping straight to step 2)

2. IV steroid (cyclosporin if contra-indicated)
   if after 72 hrs no improvement add cyclosporin or consider surgery
3. proctitis + proctosigmoiditis: either / combination of oral and topical 5-ASA

left-sided / extensive: oral 5-ASA

if following severe or >2 in last year: azathioprine / mercaptopurine

Question 12

What is the investigation of choice for perianal fistula in Crohn’s?

Answer 12

MRI - to see if simple or complex

If complex requires seton