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PMY 3177 Clinical Therapeutics > IBD > Flashcards

IBD Flashcards

1
Q

What organs make up the lower GI tract?

A

Appendix, Caecum, Acending colon, Transverse colon, Descending colon, Sigmoid colon, Rectum

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2
Q

Describe the movement of food from the mouth to egestion.

A

Saliva starts the process of digestion.
Food moves from mouth to oesophagus to stomach.
Food broken down into small pieces in the stomach and digestion begins.
The food particles mix with pancreatic juices which breaks down fats and proteins.
Undigested food is passed to the large intestine.
The colon stores waste material until expelled.

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3
Q

What is IBD?

A

Chronic, relapsing, life-long condition which causes inflammation and ulceration of the gastro-intestinal tract. It is an umbrella term for GI conditions such as ulcerative colitis, Crohn’s disease and Microscopic colitis.

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4
Q

What part of the GI tract is affected by ulcerative colitis?

A

Colon (LI) and rectum.
The inner lining of the bowel gets inflamed.
Continuous - one particular area of the bowel is affected and can be visualised on endoscopy.

(Inner lining = in contact with bowel contents)

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5
Q

What part of the GI tract is affected by Crohn’s disease?

A

Any part of the GI tract (mouth to anus) but usually the SI.
All layers of the intestinal wall is inflamed (transmural).
Discontinuous - some parts affected, some parts healthy.

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6
Q

What part of the GI tract is affected by microscopic colitis?

A

Colon and rectum.
No ulceration.
Changes seen in biopsy under a microscope.

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7
Q

Why is microscopic colitis known as microscopic?

A

Inflammation is only visible through a microscope whereas in Crohn’s and ulcerative it is seen through endoscopy.

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8
Q

Describe microscopic colitis.

A

Water diarrhoea occurs leading to dehydration. The diarrhoea does not contain blood as the lining is not ulcerated.

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9
Q

What is the best way to reduce overall IBD symptoms?

A

Surgery to remove part of intestine.

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10
Q

What is the word used to describe bad symptoms?

A

Flare up

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11
Q

What is the word used to describe a remission in symptoms?

A

Remission

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12
Q

What causes IBD?

A

Actual cause is not known.
But it is believed to be an inflammatory response in the GI tract to environmental triggers in genetically susceptible individuals.
It can be an abnormal immune response to natural bacteria living in the intestine. Or an autoimmune reaction caused by medication. Or eating too much processed foods.

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13
Q

What are some symptoms of ulcerative colitis?

A

Bloody diarrhoea, cramps, pain, unintended weight loss.

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14
Q

What is proctitis?

A

Inflammation which affects end of the colon.

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15
Q

What is pancolitis?

A

Affects whole of large intestine.

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16
Q

What is proctosigmoiditis?

A

Affects rectum and sigmoid.

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17
Q

What is used to define the severity of ulcerative colitis?

A

Truelove and Witts criteria
- this is used for adults, there is a separate scale for children.

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18
Q

Describe the Truelove and Witts criteria.

A

Severity increases with increasing symptoms.

Remission: Asymptomatic
Mild: <4 stools/day, little bleeding, normal pulse, Hb, ESR and temperature.
Moderate: 4-6 stools/day, moderate bleeding, normal pulse, Hb, ESR and temperature.
Severe: ≥6 stools/day, visible bleeding, pulse ≥90bpm, Hb <10.5/dL, ESR >30mm/hr and temperature ≥37.8 degrees celsius.

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19
Q

Describe acute severe UC.

A

This is a potentially life threatening condition.
Immediate hospitalisation required with intensive management (ICU).
High risk of VTE - prophylactic treatment with LMW heparin needed e.g. enoxaparin.

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20
Q

What are the main symptoms of IBD?

A
  1. Diarrhoea - blood, mucus, pus sometimes
  2. Abdominal cramps - very severe and often before passing stools
  3. Tiredness and fatigue - due to illness itself, anaemia, disturbed sleep, side effects from medicines used
  4. Feeling unwell - fever
  5. Loss of appetite and weightloss - due to decreased nutrient absorption due to inflammation in gut
  6. Anemia - reduced blood cells due to loss of blood through stools
  7. Mouth ulcers - can cause lack of desire to eat and leads to weight loss
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21
Q

What are the intestinal complications associated with IBD?

A

Fistula
Abscess
Perforation
Toxic megacolon
Stricture
Obstruction
Carcinoma - colonoscopy and screening to check
Peri-anal disease

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22
Q

Fistuala is an intestinal complication. What is it?

A

Fistula is an abnormal connection between an organ and the surface of the skin or between two internal organs. This could be a hollow tube through which bowel contents can’t flow. Fistula begins as an abscess.

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23
Q

Abscess is an intestinal complication. What is it?

A

Pocket of pus caused by an infection from bacteria and this can form in the intestinal wall, sometimes causing it to bulge out and burst. When it bursts, a fistula remains.

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24
Q

Toxic megacolon is an intestinal complication. What is it?

A

Inflammation spreads through muscle layers and get distension of the colon so a lot of inflammation. Potassium levels decrease and less bowel motility due to use of opioids to manage pain and can require emergency surgery.
Patients with this will present with fever, distension and severe pain.
15% mortality rate with toxic megacolon.

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25
Q

Stricture is an intestinal complication. What is it?

A

Narrowing of the gut- can cause bowel obstruction and perforation caused by scar tissue following inflammation.

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26
Q

Peri-anal disease is an intestinal complication. What is it?

A

Causes pain, itch and bleeding. Causes ulcers – all caused by chronic inflammation and open sores can develop around the anus.
Can get skin tags – small fleshy growths around the anus and fissures where there are tears in the anal canal.

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27
Q

What does it mean by extra-intestinal complications in relation to IBD?

A

These occur prior to or in conjunction with or following active bowel disease.

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28
Q

What are the extra-intestinal complications associated with IBD?

A

Joint disease
Liver
Growth retardation
Skin
Eye
Osteoporosis
Anaemia

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29
Q

Joint disease is an extra-intestinal complication. What is it?

A

Most common extra-intestinal manifestation. Inflammation of joints because fluid collects in joint space, causing painful arms and legs. There will be swelling at knees, elbows and wrists.
Some people with ulcerative colitis also develop alkalizing spondylitis, which is a condition in which the joints of the spine and pelvis become inflamed and stiff.

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30
Q

Liver problems is an extra-intestinal complication. What is it?

A

Hepatobiliary disease
- includes fatty liver, chronic active hepatitis, gall stones and abnormal LFTs

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31
Q

Growth retardation is an extra-intestinal complication. What is it?

A

More common in younger patients who are diagnosed and who are nutrient deficient (due to inflammation in gut).

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32
Q

Skin problems is an extra-intestinal complication. What is it?

A

Red tender nodules and which is quite rare, but it is difficult to treat.

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33
Q

Eye problems is an extra-intestinal complication. What is it?

A

Eye inflammation - most common eye condition affecting those with IBD.
This affects the layers of tissue covering the sclera of the eye and the white outer coating of the eye, making it red, sore and inflamed.

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34
Q

Osteoporosis is an extra-intestinal complication. What is it?

A

It is a metabolic bone disease associated with IBD and can be caused as a side effects of many medications used.

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35
Q

Anaemia is an extra-intestinal complication. What is it?

Symptoms: pallour, delayed healing of wounds, hairloss, sore tongue.

A

Common to have anemia or a low hemoglobin due to malabsorption, blood loss and inflammation.
Iron deficiency anemia can delay recovery from flare ups and contribute to the general fatigue that many patients with IBD have.

35
Q

Anaemia is an extra-intestinal complication. What is it?

Symptoms: pallour, delayed healing of wounds, hairloss, sore tongue.

A

Common to have anemia or a low hemoglobin due to malabsorption, blood loss and inflammation.
Iron deficiency anemia can delay recovery from flare ups and contribute to the general fatigue that many patients with IBD have.

36
Q

Describe the prognosis of IBD.

A

It is a relapsing condition.
Still can have a normal life expectancy due to advances in medicine.
Increased risk of colonic carcinoma and the risk increases with a higher duration of disease.
Patients are monitored with regular screening and colonoscopies.
Surgery required if perforation of colon, growth retardation, carcinoma, pre-malignant changes are visualized, if symptoms are poorly controlled.
Surgery may be curative in those that have UC but extra-intestinal symptoms will still remain.
Surgery may not be successful in CD as condition can appear at another part of bowel and may need a stoma bag for life.

37
Q

How is IBD diagnosed?

A
  1. Clinical interview - clinical questions and differential diagnosis.
  2. Clinical examination - abdominal examination.
  3. Stool culture - check infection to rule out possible cause/infection.
  4. Colonoscopy.
  5. Biopsy.
    6.Lab results - liver effects, check potassium levels, malabsorption etc.
38
Q

What clinical questions will you be asking the patient?

A

What symptoms do you have?
What is your diet like?
How often do you go to the toilet and how long do you spend?
Bowel movements? Bowel history
Blood, mucus, pus in diarrhoea?
Medication - NSAIDs
Family history
Travel - can cause diarrhoea or parasitic infections
What grade on stool chart?
Smoking - biggest environmental factor which affects outcome of IBD
Toilet at night?
Examination - weightloss, abdominal abnormalities

39
Q

What is differential diagnosis?

A

Diseases/conditions with similar symptoms to IBD will be diagnosed instead of IBD.

40
Q

What are some conditions to think of for differential diagnosis?

A

Anaemia
IBS
Traveller’s diarrhoea
Coeliac disease
Intestinal infection
Cow’s milk protein allergy
Carcinoma
Diverticulitis
Drug-induced colitis

41
Q

What lab tests will have to be carried out to confirm diagnosis?

Some used to check for abnormalities, extra-intestinal complications and some to rule out other diseases.

A

FBC
Magnesium
ESR
CRP
U&Es
Faecal calprotectin
Coeliac screening
LFTs
Stool culture
Vitamin B and Folate

42
Q

What LFT in particular is measured and was will be the result in IBS?

A

Albumen - levels will be decreased.
- due to decreased nutrient uptake and malnutrition.
- albumen is a sign of severity of disease and is a sign of inflammation.

43
Q

What are the Magnesium levels like in those with IBD?

A

Low Mg
- due to GI losses and lack of absorption.
- symptoms: fatigue, bone pain, abdominal cramps, impaired wound healing.

44
Q

When checking U&Es, what electrolyte is specifically going to be checked?

A

Potassium.
This will be decreased - hypokalaemia due to diarrhoea.
Must be monitored if patient is prescribed corticosteroids and enoxaparin for treatment of IBD.

45
Q

What is faecal calprotectin test?

A

This is a sensitive marker for inflammation in GIT.
Can differentiate between inflammatory and non-inflammatory conditions.

46
Q

Why is it necessary to test stool cultures?

A

To test for infectious bacteria such as C. diff.

47
Q

What specifically in FBC will be tested?

A

Hb and platelets.
Hb levels will be low due to anaemia due to blood loss via diarrhoea. Platelet levels high due to increased platelets released to cause coagulation to stop blood loss. High platelet level = sign of inflammation.

48
Q

What is the aim of IBD treatment?

A
  1. Induce remission by active treatment of acute disease and begin to heal the mucosa.
  2. Maintain remission by preventing relapse and keep condition under control.
  • reduce symptoms
    -improve quality of life
    -minimise toxicity of medications used
49
Q

Topical therapy is usually first line along or in combination with oral treatments. What 3 topical agents are used for treatment?

A

Suppositories
Fluid-based enemas
Foam enemas

Usually long term oral treatment and short term 2 week topical treatment (initial firstline).

50
Q

What treatment is used for proctitis?

A

Suppositories (more effective than oral treatment)
- reaches rectum and sigmoid flexure.

51
Q

Why is it advised that topical treatments for IBD should be taken at night?

A

Enemas and suppositories inserted into back passage and retain as long as possible hence inserted at night time.

52
Q

What practical tips should we give patients using enemas and foams for treatment?

A
  • use at night
  • place towels on bedsheets in case enema leaks out
  • keep a bin beside bed – throw products after use
  • counsel using PIL - step by step on how to insert
53
Q

What is used to induce remission in young people with Crohn’s disease? What is the benefit of this?

A

Enteral nutrition
- reduces the use of steroids, risk of growth issues and side effects

54
Q

What is enteral nutrition?

A

Enteral nutrition is a complete liquid diet, which is predigested, which means that all the nutrients can be absorbed early in the small bowel, leaving the remainder of the boil to rest, and is as effective as corticosteroids in inducing remission in children.

55
Q

What is the issue with enteral nutrition?

A

Compliance issues.
- no other food or drink except water can be taken and it has to be continued for about 6 to 8 weeks to induce mucosal healing.
- patients must be very motivated to continue.

56
Q

How long will it take to get symptomatic relief and mucosal healing from liquid diet?

A

Take liquid diet for 8 weeks.
Symptomatic relief in 10 days.
Mucosal healing will take up to 8 weeks.

57
Q

Can probiotics help with ulcerative colitis?

A

Probiotics in UC can help to induce remission and maintain remission as they are thought to align the intestinal tract and stop bacteria from triggering an immune response.
It enhances a thicker mucus layer, which may protect against bacteria, produce immunoglobulins and help the gut to become more anti-inflammatory.
- lack of evidence.

58
Q

List some supportive therapies used for IBD.

A

Anti-diarrhoeals – codeine, loperamide
Laxatives
Analgesics
Anti-spasmodics
Vaccinations
Enoxaparin (in hospital)
Dietician review

59
Q

Describe why anti-diarrhoeals are used as supportive therapy.

A

Loperamide – slows down transit time of contents moving along the gut and allows more water to be absorbed.
- Lower volume of diarrhoea being produced.
- Loperamide cannot be used during a UC flare up.

60
Q

Explain the use of laxatives as supporting therapy.

A

Laxatives if experiencing constipation e.g. in proctitis
– osmotic laxative e.g. Macrogols – increase amount of water in large bowel making stools softer and easier to pass.

61
Q

Explain the use of analgesics as supporting therapy.

A

Paracetamol can be given for joint pain.
- Must avoid NSAIDs - can flare up IBD
- Use opioids sparingly as in severe cases as it can precipitate toxic megacolon.

62
Q

Explain the use of anti-spasmodics as supporting therapy.

A

Mebeverine and Hycosine - used to reduce painful cramps by relaxing intestinal walls.

63
Q

What vaccinations are required for patients having IBD?

A

Flu vaccine
Pneumonia vaccine
Covid vaccine
Needed as they are immunosuppressed - must avoid live vaccines (on steroids/immunosuppressed.

64
Q

Why is enoxaparin needed for those with IBD?

A

Given in hospital
- needed as prophylaxis - higher risk of thromboembolism due to increased risk of blood clotting.

65
Q

What would a dietician recommend?

A

High fiber or low residue diets should be used as appropriate and recommended.

66
Q

What antibiotics are used in IBS?

A

Metronidazole and Ciprofloxacin.
- specifically used to treat CD - abscesses, fistulae, secondary infection.
- lack of evidence to treat UC.
- treatment can be up to 3 months.
- counsel patients on correct use of antibiotics.

67
Q

IBD is a cause of secondary osteoporosis. What are the risk factors associated with it?

A

It is a corticosteroid related bone disease caused by:
malabsorption
high corticosteroid use
reduce physical activity
weightloss
uncontrolled inflammation

68
Q

How can osteoporosis be prevented in patients with IBD?

A

Avoid steroids if possible - by using other immunosuppressants or thiopurines
Encourage weight bearing exercise
Nutritious diet
Give calcium (1000mg/day) and Vitamin D whilst on steroids and bisphosphonate if >70
Stop smoking
Avoid alcohol excess

69
Q

How is remission induced in mild to moderate ulcerative colitis?

A
  1. A topical 5-ASA is used and add oral 5-ASA if needed.
  2. If further treatment needed, use a topical or oral corticosteroid for a short course only.
  3. Remission can be maintained with a topical 5-ASA alone or with an oral 5-ASA.
70
Q

How is remission induced in extensive ulcerative colitis?

A
  1. A topical 5-ASA and a high dose oral 5-ASA used as first line treatment.
  2. Then add in a time-limited course of oral corticosteroid if there is no improvement after one month.
  3. If patient suffers from moderate-severe flare ups, prednisolone 40mg tablets should be taken - tapering the dose over 8 weeks.
  4. Maintain remission with 5-ASA.
71
Q

What happens if remission cannot be achieved or maintained with 5-ASA?

A

Consider using oral thiopurines or treatment with biologics
- these are second line treatment options if aminosalicylates and steroids don’t work.

72
Q

Describe aminosalicylates (5-ASA) e.g. Mesalazine

A

5-ASA - main treatment for mild to moderate flare ups and maintenance treatment for ulcerative colitis. These induce and maintain remission.
It is not recommended for Crohn’s disease.
During a flare up patients will have topical and oral 5-ASA. Higher oral doses are used during flare ups then are decreased to maintenance therapy doses.
5-ASA require regular monitoring for effectiveness and side effects.
Renal function must be monitored.
Patients should remain on the same brand of 5-ASA.

73
Q

What symptoms associated with 5-ASA should patients be encouraged to report?

A

Bleeding, bruising, purpura, sore throat, fever or malaise and any other symptoms e.g. nausea, breathing issues

74
Q

How is remission induced in Crohn’s disease?

A

Remission induced using corticosteroids.
For patients who do not respond to first line treatment of corticosteroids - need biologics.
Enteral nutrition used for children.

75
Q

What do corticosteroids do in general?

A

Corticosteroids - similar to hormone cortisol.
When steroids are taken, the adrenal gland reduce/stop production of cortisol.
If steroids are stopped, it’ll take time for adrenal glands to produce cortisol again. Must gradually taper the dose.
Can lead to acute adrenal insufficiency.

76
Q

Overuse of corticosteroids can cause acute adrenal insufficiency. What are the consequences of this?

A

Nausea, fatigue, lightheadedness, low blood pressure, and even death.
Affects fight or flight.

77
Q

What are the starting doses of corticosteroids to achieve remission in CD patients?

A
  • If admitted in hospital, hydrocortisone 100mg IV QID given.
  • Then changed to oral prednisolone 40mg once a day for 8 weeks.
  • In a community setting, start with 40mg OD oral prednisolone and dose tapered over 6-8 weeks - reduce by 5mg every 7 days.
78
Q

Why are patients given calcium, vitamin D and oral PPI when on steroids?

A

Calcium and Vitamin D will help maintain bone structure and prevent the risk of osteoporosis developing. Would stay on this after steroid is stopped.
If on steroid - at risk of developing GI ulcerations hence PPI given to protect stomach. PPI stopped once steroids stopped.

79
Q

What is a topical corticosteroid used in treatment of CD?

A

Topical budesonide - dose of 9mg each day for 8 weeks - inserted rectally. Taper the dose.

80
Q

What are some temporary side effects of corticosteroids?

A

Increased appetite
Weight gain
‘Mooning’ of face (puffy round face)
Acne
Increased blood sugar and salt retention
Mood changes
Increased infection risk
Stomach ulceration

81
Q

What are some long-term side effects of corticosteroids?

A

Thinning of bones, muscles and skin (increase fracture risk and death if they fall)
Bruising
Diabetes
Glaucoma or cataracts

82
Q

What is the maintenance therapy for CD and UC?

A
  • some patients with CD would choose not to have maintenance therapy in that case, it must be discussed on how to deal with relapse and symptoms.
  • patients who responded well to 5-ASA for UC can use it for maintenance therapy. They can also be on topical if needed.
  • thiopurines such as azathioprine and biologics are useful second line therapies
83
Q

The immunosuppressants are considered cortical steroid sparing therapy. (Not used to induce remission)
These will reduce the risk of flare ups once the steroids are withdrawn.
Describe the use of immunosuppressants.

A

e.g. methotrexate and thiopurines
May act slowly - 3 months
Sensitivity to sunlight - wear sunscreen
Susceptibility to infections - get vaccines
Contraception - both men and women during and 3 months after treatment
Increased likelihood of some cancers
Report symptoms
Monitoring and TPMT test for thiopurines

84
Q

What is the TPMT test for thiopurines?

A

Test used before commencing on thiopurines.
- tests the activity level of the enzyme thiopurine S-methyltransferase (TPMT) in a person’s red blood cells.
- if inactive - patient should not be on thiopurine as it can cause toxic side effects.

85
Q

Describe the use of biologics for IBD.

A

e.g. infliximab and adalimumab
First line for maintenance therapy.
Must conduct tests to ensure there are no contraindications:
TB
Infection
Hepatitis
Labs
BP, temp, pulse
Injected SC at home after training from HCP.
Review every 8 weeks.

PMY 3177 Clinical Therapeutics (3 decks)

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