IBD Flashcards

1
Q

What is IBD

how do you differentiate between UC and Crohn’s

A

Inflammatory Bowel Disease (IBD)
- an inflammatory disease (2 groups mainly, but can be two other small groups; total of 4)
- in this in flammatory disease; the body attacks its own intestinal system

Ulcerative Colitis (UC)
- involves ONLY the colon
- begins at the rectum; thus the rectum must be involved
- a continuous pattern of inflammation, without any breaks in the lesions
- involves only the mucosal and submucosal layers

Crohn’s Disease
- can occur at any portion of the digestive tract, from mouth to anus
- most commonly, it occurs at the terminal illeum, or illoceccal junction
- involves the full thickness; trasnmurual inflammation
- can have skip lesions; in which there are areas of inflammation and damange intermixed with normal

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2
Q

Briefly, what is microscopic colitis

A

Microscopic Colitis
- inflammation which is found on biopsy to have inflammatory patterns within the colon, does not appear damagned from gross observation
- can be lymophcytic or collagenous
- lymphocytic = increased number of lymphoctes found on biopsy
- collagenous = lymphocytes AND collagen band found on biopsy

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3
Q

Etiology of IBD

Risk Factors (modifiable and non-modifiable)

A

Etiology
- not well understood, but known to be a type of auto-immune disease
- heriditary componente: first degree relatives at an increased risk
- genetic: NOD2 gene, IBD5, IL23R, IP31
- Turner’s syndrome associated

it is understood that there is a genetic underlying predisposing in some pt., and then when an event occurs (viral, bacterial or otherwise) this triggers the autoimmune process to occur

Risk Factors
- ashkenazi jewish population
- possible protective effect of VIt D and sun expsoure
- ages: bi-modal distribution 15-35 & then 50-80
- female = crohns
- male = ulcerative colitis
- Exercise = decreased increases risk
- Western Diet = increased risk
- sleep duration
- infections: campylobacter and salmonella can increase risk
- NSAIDS is a IBD mimicer
- OCPS
- Stress
- smoking increases risk of Crohn’s but decreased risk of UC direclty ipacts the ability of the immune response to take place in the mucosal

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4
Q

Crohn’s Disease
- specifics
- subtypes (based on location)

A

Specifics
- a transmural inflammatory condition which can occur at any area of the digestive tract associated with skip lesions
- occurs: gradually/insidiously

Subtypes
- ilitis
- ileocolitis - most common presentation
- crohns coloitis
- gastroduodenal crohns or UGI crohns least common
- (some can have perianal invovlement)

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5
Q

Crohn’s Disease
Symptoms
Quality of Abd. Pain
Eating Habitis

A

Symptoms
1. Systemic
- fever
- general sense of off
- weight loss
- low energy

  1. GI symptoms
    - abdominal pain
    - eating habits altered
    - bowel movement altered
    - perianal symptoms

Abdominal Pain
- most commong RLQ because thats the localation of teh ileoceccal junction & MC area of involvment
- also seen at periumbilical, diffuse, lower abd. pain
- pain usually right before BM; may resolve with BM
- ** focal tenderness in ilocecal region; +/- a mass due to matted or looped intestines**

Eating Habits
- decreased appetite: causing weight loss
- if giving post-meal pain = think lower GI involvment
- if trouble swallowing = think upper GI invovement
- “food running through them”

Weight Loss
- can be due to lack of nutrition and absorbtion
- terminal ileum: impacts B12 absorbtion –> anemia ; impact ADEK absorbtion & bile acid
- proximal SI: impacts calcium and iron
- diffuse SB; zinc
- severe colonic: IDA due to blood loss

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6
Q

Crohn’s Disease
Symptoms of…
Diarrhea
Perianal Symptoms
Fistulas
Perianal Abscess

A

Diarrhea
- frequency
- consistency
- nocturnal stools possible
- urgency
- episodes of incontinence

Periana Disease Symptoms
- 1/3 of pts.
- skin tags
- anal fissures
- fistulas
- these are a result of the TRANSMURUAL involvement of the disease

Fistulas
- sinus tracking connecting organs which shouldnt be
- enteroenteric: bowel to bowel
- entrovesicular or rectovaginal: UTI risk & feces to vaginal
- entercutaneous: drainage

Abscess
- severe pain in the rectum/buttock
- tender, warm and red
- purulent discharge & fever
- abscess can forma anywhere where there might be full thickness, trasnmural inflammation
- find leukocytosis on labs and may need to give opioids

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7
Q

Extra-GI Manifestations of Chrons Disease
- what other organs (8)
- what are the key signs that the Crohn’s disease is worsening

A
  1. Eyes
    - anterior uveitis
    - episcleritis
  2. Mouth
    - apthous ulcers
  3. Arthritis
    - ankylosing spondylitis
    - peripherial arthritis
  4. Skin
    - erythema nodosum
    - pyoderma gangrenosum
    - vulvular involvement

signs the Crohn’s is getting worse
- episcleritits
- peripheral arthritis
- erythema nodosum

  1. Hepatobilliary Involvement
    - can be related to the medications
    - primary sclerosing cholangitis
    - gallstones due to back up because of poor absorpbtion
  2. Kidney Stones
    - calcium oxalate
    - uric acid
  3. Bone Loss (steroid use)
  4. Pulmonary
    - inflammation
    - ILD
    - Pneumonia
    - bronchitis, bronchectasis
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8
Q

Crohn’s Diseae
- Workup
- Diagnosis (test of choice)
- what do you see on endo? hsitology?

A

Labs and Stool Studies
- CBC, CMP, vit D, B12, zinc, ESR, CRP = see anemia of CD, inflammation
- FCP, infectious panel, O&P = stool sample
- celiac markers
- ASCA +

Imaging
- CT & MRI: good for seeing complications (fistual and abscess)
- can do capusle endoscopy: if not strictures or obstruction
- barium study: see + String sign of contrast = inital test of choice

according to dubes email….
- chrons disease: inital choice of study is colonscopy
- CTE/MRI for concerns of small bowl disease

On Endoscopy….
- see uclers
- skip lesions
- cobblestoning (nodular changes)

On Pathology
- noncaseating granulomas: but not necessary for a dx.

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9
Q

Complications of Crohn’s Disease

A
  • strictures (narrowing) due to inflammation or fiberosis
  • fistulas & abscesses
  • bowel obstrction
  • thromboic events; increased risk of DVT
  • refractory disease
  • increased risk for cancer- specifically colon
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10
Q

Ulcerative Colitis (UC)
- what is it
- subtypes

A

UC is an autoimmune inflammatory condition involving only the mucosa and begins within the rectum and is a pattern of continuous inflammation

Subtypes
- ulcerative Proctitis
- ulcearitive protosigmoidits
- left sided colitis
- extensive/pancolitis

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11
Q

UC
Symptoms

A

Symptoms
- hallmark is bloody diarrhea
- gradual; but more sudden than crohns is
- crampy, colicky LLQ pain
- increased stool frequency
- urgency & tenesmus
- incontinence
- fever, fatigue & weight loss
- Iron Deficiency anemia with DOE

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12
Q

UC
- Diagnosis
- Work-up
- what imaging
- what do you see on endo? on patho?

A

Diagnosis

labs
- CBC = anemia
- ESR, CRP = increase
- PANCA
- CMP: phosphatase
- low albumin
- elevated alkaline
- stools: + fecal calprotectien

Imaging
- colonoscopy
- Xray: wall thickening and thumb printing due to edema
- CT/MRI: to see disease and complications
- US: thickened mucosa
- Barium Enema: DO NOT DO IN SEVERELY ILL ; INCREASE RISK OF TOXICMEGACOLON ; see stove pipe/lead pipe sign - lots haustra

Dubes email…. do signmoidoscopy for UC

Endoscopy
- lost vascular
- eryhthema
- granualr, friability (bleeding)
- erosins, ulcers, bleeding!
- cecal paths: isolated patches of inflammation
- backwas illeitis

PAthology
- crypt absecesses, branching and atrophy at the rectum and throughout the colon

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13
Q

Complications of UC

A

pt. may need colectomy

  • strictures
  • increased risk of colorectal cancer (mostly in pancolitis & left sided dz.)
  • concom. primary sclerosis colitis = increase risk = colonscopy more freqeuntly
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14
Q

Treatment of IBD
- first line is what med; part of what class
- what must you rx. with it

A

first line treatment is 5-ASA = mesalamine therapy; specifically SULFASALAZINE
- good for UC because it works on the mucosal layer, can be used in mild crohn’s too
- ALWASY GIVE FOLIC ACID WITH THIS MED
- risk fo agranulocytosis, GI, CNS side effects

for UC
- other topical 5-ASAs

Dubes email
- sulfasalazine if mild disease and responsive to steroids – nonresponsive to steroids then move onto biologics

if severe disease: can use sulfasalazine but most jump to biologics

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15
Q

Treatment of IBD
- when is steroid use used
- when is abx. used

A

during acute flares, not long term management
- prednisone & taper
- can use budesonide

watch side effects of steroid use

abx. may be used in chron’s not common
- metonidazole
- cirpfloxicin

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16
Q

when are IMM’s used in IBD treatment

A

IMM = imunomodulators

used to be first line but no longer
- use as add-on to potential drug level of another drug
- reduce risk of antibody production to the biologics
- help in refractory perianal disease

17
Q

Treatment of IBD
when are biologics used (the anti-TNFs)

A

1st line = anti-TNFs
- infliximab = IV for UC/CD
- adalimumab = UC/CD
- Certolizumab = Crohns
- Golimumab = UC

others
- IL-12-23 : ustekinumab = UC/CD
- Anti-intergrins: vedolizumab = UC/CD (gut only)
- JAK-I: tofacitinib (UC) , updacitinib (UC)

18
Q

Side Effects of Bioloigcs

What to order prior to meds

A

SE of Biologics
- injection site and infusion rxn
- malignancy: risk of lymphoma (high)

Order…
- TB tests, Hep B/C , TPMT

monitor CBC/CMP Q6mo. & colonoscopy Q6mo.

if on 3+ immunosup. need bactrum to prevent PCP