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Gastroenterology > IBD > Flashcards

IBD Flashcards

1
Q

IBD epidemiology
- peak incidence
- M:F

A

2nd to 4th decade
M=F

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2
Q

UC features
- mild
- severe

A

With mild inflammation, the mucosa is erythematous and has a fine granular surface that resembles sandpaper
In more severe disease the mucosa is haemorrhagic, oedematous, and ulcerated.

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3
Q

Ulcerative colitis disease extent

A
  1. Proctitis 28%
    1. Left sided 25%
    2. Extensive 50%
    3. Backwash ileitis 7%
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4
Q

Scoring system for UC disease severity and domains measured
Scoring system to guide management in acute severe colitis

A

Truelove and Witts Criteria - measures, stool frequency, blood, fever, tachycardia, anaemia, ESR
Travis criteria - performed on day 3 of those with acute severe colitis, predicts steroid failure and need for selvedge therapy

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5
Q

Microscopic features of UC

A
  1. Limited to mucosa and submucosa (deeper layers only affected in fulminant disease)
    1. Crypt distortion (bifid, reduced in number, crypt abscesses)
    2. Multiple basal lymphoid aggregates
    3. Mucosal vascular congestion with edema and focal haemorrhage
    4. Inflammatory cell infiltrate (neutrophils, lymphocytes, plasma cells, macrophages)
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6
Q

UC treatment approach

A

5-ASAs for induction and maintenance
Steroids for induction only
Azathioprine if failure of maintenance by 5-ASAs
Biologics

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7
Q

5-ASAs
- examples
- routes
- different uses

A

Mesalazine - better side effect profile
Sulfasalazine - effective against arthritis too
PO or PR

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8
Q

Azathioprine
- speed of action
- adverse events

A

a. Acts slowly
b. Metabolites: 6TGN - correlates with myelosuppression, 6MMP - correlated with liver injury
c. Causes pancreatitis usually at 3 weeks from commencement (absolute contraindication for further use)
d. Causes serum-like sickness: absolute contraindication for further Aza use or 6-mercaptopurine
e. Myelosuppression: dose dependent. Can be prevented by monitoring TPMT activity and routine monitoring
f. Hepatitis:
i. Idiosyncratic - acute, early and severe
ii. Dose dependent - related to 6MMP, prevented by monitoring LFTs
g. Risk for non-melanoma skin cancers - need annual skin check and sun safety advice
Lymphoma: increased risk especially in those >65 or those EBV seronegative

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9
Q

What classes of biologics are used

A

Anti-TNF
Anti-IL12 & 23
Integrin inhibitor
JAK3 inhibitors

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10
Q

Anti-TNF
- examples
- side effects
- precautions

A

i. Infliximab
ii. Adalimumab
iii. Golimumab
iv. Check TB and HBV before starting - can start 1 month after commencing treatment, don’t use if they have a history of melanoma
Psoriasis can be a side effect of these medications - if it doesn’t improve with their disease switch to different TNF

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11
Q

Anti-IL12 and IL23
- name of drug
- special considerations

A

Ustekinumab
Helps if psoriasis also present

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12
Q

Vedolizumab
- MOA
- special considerations
- safety profile

A

safest, gut specific (don’t use if extra-intestinal manifestations are present that are disease independent)
alpha4 - beta 7 integrin inhibitor
Use if patient elderly or have cancer

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13
Q

Tofacitinib
MOA

A

JAK3 inhibitor

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14
Q

CD
- macroscopic features (10)

A

Macroscopic:
1. Any part of GI tract from mouth to anus
2. Small bowel disease alone 30-40%
3. Small and large bowel involvement 40-55%
4. Colitis alone 15-25%
5. Rectum is often spared
6. Skip lesions
7. Perirectal fistulas, fissueres, abscesses occur in 1/3rd
8. Transmural process
9. Cobble-stone appearance
10. Fistula tracts, stricturing

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15
Q

CD
- microscopic manifestations

A
  1. Ulcerations and focal crypt abscesses
    1. Aggregations of macrophages forming non-caseating granulomas##
    2. Submucosal and subserosal lymphoid aggregates, particularly away from areas of ulceration
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16
Q

CD
- symptoms

A

Inflammation evolves towards one of two patterns: fibrostenotic / obstructive pattern vs. penetrating fistulous pattern
Location of disease activity determines the symptoms

1. RLQ pain and diarrhoea
2. Fever
3. Bowel obstruction
4. Malabsorption / steatorrhoea
5. Anaemia, hypocalcaemia, hypomagnasemia, coagulopathy
6. Gastroduodenal disease
17
Q

CD differentials

A
  • infectious
  • atypical colitis (collagenous colitis, microscopic colitis)
18
Q

What are features of collagenous colitis:
- gender
- onset
- associations
- biopsy findings

A

Female&raquo_space;> male
Onset 6th or 7th decade
Associated with: Associated with NSAIDs, PPI, B-blockers, smoking and history of autoimmune disease
Subepithelial collagen, colitis with intraepithelial lymphocytes

19
Q

Microscopic colitis
- demographics
- microscopic findings
- associations
- treatment

A

similar epidemiology to collagenous colitis
similar microscopic findings except no subepithelial collagen deposition
associated with sertraline
treatment with budesonide

20
Q

CD treatment
- induction
- maintenance
- fistulating disease

A

steroid - induction
Azathioprine or methotrexate - maintenance, biologics if these fail
Infliximab for fistulating disease

21
Q

Extraintestinal manifestations
- demographic most affected
- types

A

females with colonic disease most affected (UC or colonic CD)
Dermatologic
1. Erythema nodosum
2. Pyoderma gangrenosum **
3. Sweet syndrome “intense neutrophillic infiltrate without vasculitis”
4. Psoriasis - associated with IBD as well as TNF-MABs
Rheumatologic
1. Peripheral arthritis (asymmetric, polyarticular, migratory, inflammatory) **
2. Ankylosing spondylitis **
Ocular
1. Conjunctivitis
2. Episcleritis - red eye, no visual impairment, some burning sensation
3. Scleritis - red eye, and impairment of vision
4. Anterior uveitis - red, painful eye with photophobia
Hepatobiliary
1. Primary sclerosing cholangitis ** - check ALP, assess with MRCP 4-yearly, if negative do liver biopsy. Need annual colonoscopies as they are at high risk of colorectal cancer
2. Hepatic steatosis
Urologic
1. Renal calculi
Metabolic bone disease
1. Osteoporosis / osteopaenia
2. Osteonecrosis
Thromboembolism

22
Q

EIM not associated with disease activity

A
  1. Pyoderma gangrenosum
  2. Primary sclerosing cholangitis
  3. Small joint and axial arthritis
23
Q

Cancer surveillance in IBD
- who is at high risk
- how often to scope

A

Extensive colitis UC or >50% CD colitis and:
PSC
FH CRC<50
Dysplastic polyp
Colonic stricture
*** yearly scopes

24
Q

Cancer surveillance and IBD
- intermediate risk
- how often to scope

A

Extensive colitis UC or >50% CD colitis and:
inflammatory polyps
FH CRC>50
**Scope 2-3 yearly

25
Q

Cancer surveillance in IBD
- low risk
- how often to scope

A

Not meeting criteria of high or intermediate risk categories
Scope every 5 years

26
Q

Montreal classification of IBD
- parameters

A

age of onset
location of disease
disease behaviour (for Crohn’s disease: stricturing disease vs. perforating / fistulating disease)

27
Q

UC extent of disease at diagnosis

A

pancolitis 1/3rd
left sided 1/3rd
proctitis 1/3rd

28
Q

Risk of Colorectal Ca in IBD

A

proportional to degree and duration of inflammation
HIGH in primary sclerosing cholangitis!! start screening at diagnosis

29
Q

UC (or Crohns disease) colonoscope frequency

A

Commence at 8 years duration
- annually for persistent active disease, family history or PSC
- three yearly for inactive UC / crohns
- five yearly if two previous have been normal

30
Q

Toxicity of sulfasalazine

A

sulfur intolerance
azoospermia
SJS

31
Q

Time to onset of action of azathioprine

A

3-4 months

32
Q

Thiopurine metabolites associated with:
- 6-MMPR
- 6-TGN

A

6-MMPR - hepatotoxicity
6-TGN - efficacy plus bone marrow suppression

33
Q

When to measure thiopurine metabolites

A

prior to commencing
to assess reason for incomplete response / medication compliance

34
Q

Which patients should get ustekinumab?

A

crohn’s disease

35
Q

TNFi risks

A

TB reactivation
Melanoma risk doubled
Demyelinating disorders
Lupus - ANA conversion
CCF
Abnormal LFTs
Psoriaform reactions

36
Q

Tofacitinib
- side effects
- target

A

shingles
JAK1 and 3

37
Q

ASUC - travis score

A

Bowel motions 3-8
CRP >45
Bowel motions >8 / day

85% required colectomy, performed day 3-5

38
Q

Medical management of perianal fistulating disease

A

infliximab
ciprofloxacin / metro

Gastroenterology (12 decks)

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