IBD Flashcards
Types of IBD
Ulcerative Colitis: Inflammation and ulcers in large bowel (colon to anus)
Crohn’s disease: affects any part of GI tract (mouth –anus)
Microscopic colitis: microscopic inflammation of the large bowel (colon to anus)
IBD: Terminology / sub-types
Pancolitis: affects the whole large colon
Protitis: Rectum only
Proctosigmoiditis: rectum and sigmoid colon
Left-sided colitis: descending, sigmoid and rectum
Crohn’s colitis: Crohn’s isolated to the colon
Ulcerative colitis
Affects colon and rectum
Inner lining of bowel inflamed
Continuous
Crohn’s disease
Affects whole GI tract, mouth to anus
Transmural: all layers of intestine wall affected
Discontinuous
Microscopic colitis
Colon and rectum
No ulceration, visibly normal
Changes seen in biopsy under microscope
Symptoms
Diarrhoea - sometimes mixed with blood, mucus and pus
Urgency & faecal incontinence
Abdominal cramping pains – often very severe and can occur before passing a stool
Tiredness and fatigue - due to the illness itself, anaemia,-side-effects of medicines or disturbed sleep
Feeling generally unwell - fever
Loss of appetite, weight
Malabsorption, nutritional deficiencies, delayed growth
Anaemia – e.g. due to blood loss or malnutrition
Mouth ulcers
Rectal bleeding
Complications of IBD - intestinal
Fistula
Infection and abscesses
Perforation
Toxic megacolon
Stricture
Obstruction
Carcinoma
Anaemia
Malnutrition
Complications of IBD - extra-intestinal
Joint disease, e.g. arthritis
Liver, e.g. steatosis
Growth delay
Skin, e.g. pyoderma gangrenosum
Eye, e.g. episcleritis, uveitis
Osteoporosis
Psychosocial
Apthous mouth ulcers
Blood circulation, e.g. VTE, phlebitis
Severity of UC – Truelove and Witts Criteria
- Remission - Asymptomatic
- Mild - <4 stools/day, little bleeding, normal pulse, Hb, ESR, temp
- moderate - 4-6 stools/day, moderate bleeding, normal pulse, Hb, ESR, temp
- severe/ acute severe - ≥6 stools/day, visible bleeding, pulse ≥90bpm, temp ≥37.8oC, Hb <10.5g/dL, ESR >30mm/h
Diagnosis
Suspect if persistent (>4-6 weeks) otherwise unexplained diarrhoea +/- any other clinical signs or suspected intestinal or extra-intestinal complications
Diagnosis and initiation of treatment is carried out by a secondary care specialist, but physical examination and investigations in primary care can be carried out in advance of the patient being seen
Diagnosis - Investigations
Full Blood Count (FBC)
Test for anaemia*Raised platelets, WCC may suggest active inflammation
Inflammatory markers, e.g.
*C-reactive protein (CRP)
*Erythrocyte Sedimentation Rate (ESR)
- May be raised if active inflammation
Urea and electrolytes (U&E)
*Diarrhoea can cause dehydration and electrolyte disturbance
Liver Function Test (LFT)
*Can co-exist, low albumin may indicate protein-losing intestinal disease
Coeliac serology
*exclude Coeliac disease
Serum iron studies, B12, folate, vitamin D levels
*May be nutritional deficiencies due to malabsorption or intestinal losses
Stool microscopy and culture
*Check for infection, e.g. C. difficile
Faecal calprotectin
*If raised may suggest active inflammation
Diagnosis – Confirmation (specialist)
Endoscopy
Long, thin, flexible tube called an endoscope with a small camera on the end looks closely at gut lining
Can look for inflammation and complications of Crohn’s or UC, e.g. strictures
Types of endoscopy used include
Gastroscopy (inserted via mouth)
Colonoscopy (via bowel / rectum)
Sigmoidoscopy (better view of rectum and sigmoid colon)
Histology
Biopsies taken by the endoscopist are analysed under microscopy to check for inflammation and other signs of Crohn’s or Colitis
Further specialised imaging
Imaging including ulstrasound, x-ray, CT or MRI can be used to visualise the bowel, e.g. for thickening of bowel wall
Management of IBD - Goals
- Induce remission
Active treatment of acute disease
Mucosal healing - Maintain remission
Preventing relapse
Minimise symptoms and toxicity
Improve quality of life - Providing information and additional supportive therapy
Psychological
Lifestyle and nutrition
Bone health
Growth monitoring
GI supportive medicines
Medications used
5-ASA (aminosalicylates)
Corticosteroids (prednisolone / budesonide)
Immunosuppressants
Thiopurines (azathioprine / mercaptopurine)
Methotrexate
Ciclosporin
Biologics
Inducing remission in ulcerative colitis mild-moderate
STEP 1 ( FOR 4-6 OR CANNOT TOLERATE 5 ASA GO TO STEP 2)
If no prescribed treatment: Combination of oral (2-3g/d) and enema* 5-ASA (or oral alone if rectal route not tolerated)
OR
If flaring on already-prescribed oral 5-ASA: escalate dose (4-4.8g/d) alongside 5-ASA enema
IF REMISSION ACHIEVED STEP DOWN
STEP 2 (NO RESPONSE AFTER 2 WEEKS GO TO STEP 3 )
Oral corticosteroids – prednisolone 40mg daily weaning over 6-8 weeks
STEP 3
Consider treatment escalation to biologics or hospital admission
Inducing remission in ulcerative colitis ACUTE SEVERE UC
Inpatient management which may involve:
Surgical intervention
IV corticosteroids (hydrocortisone) stepped-down to oral (prednisolone)
IV ciclosporin (immunosuppressant)
Biologics (infliximab)
Prophylactic LMWH (e.g. enoxaparin)
Maintaining remission in ulcerative colitis MILD TO MODERATE
- Once daily oral 5-ASA as maintenance (1g suppository 5-ASA OD or intermittently preferred for proctitis)
>2 flares requiring corticosteroids in last year OR become corticosteroid refractory
- Escalate to one of the following treatment options:
Thiopirine (azathioprine / mercaptopurine)
Biologic (ant-TNF, e.g. infliximab, vedolizumab, tofacitinib)
Choice of above based on clinical factors, patient choice, cost, infusion capacity
Maintaining remission in ulcerative colitis ACUTE SEVERE
Oral thiopurine (azathioprine / mercaptopurine) OR oral 5-ASA OR oral ciclosporin (if used as inpatient)
Continue biologic at maintenance dose if commenced as inpatient
Inducing remission in Crohn’s
Corticosteroid monotherapy, e.g. oral prednisolone 40mg OD tapered by 5mg weekly (8 week course)
OR
Colonic-release budesonide MMX 9mg daily for 8 weeks if ileocolonic disease. Taper off over 1-2 weeks
OR
Exclusive enteral nutrition for 8/52 in children or where avoidance of corticosteroids is desired
OR
Surgical resection if failing / relapsing with medical therapy or patient prefers surgery
OR
If extensive disease or poor prognostic indicators, consider early introduction of biologics
Inducing remission in Crohn - Early addition of immunosuppressants
Tapering of glucocorticosteroids can cause further flare of Crohn’s
If >2 flares in last 12 months or glucorticosteroid taper causes flare; add thiopurine (azathioprine / mercaptopurine) as a steroid-sparing agent. Methotrexate is 2nd line option
Next choice if still no response is biologics
Maintaining remission in Crohn’s
Maintenance therapy
Thiopurine (azathioprine / mercaptopurine) or methotrexate monotherapy depending on what was used as part of regimen to induce remission OR should commence one of these
Biologics (e.g. infliximab, vedolizumab, ustekinumab) are 2nd line option if needed or if ongoing symptoms
NB 5-ASA is not recommended for maintenance therapy in Crohn’s due to a lack of evidence of effectiveness
Corticosteroids
USE: Used for induction of remission only, not maintenance due to significant adverse effects
EXAMPLES:
Hydrocortisone IV (if inpatient & sebere) or Prednisolone 40mg OD tapered down over 8 weeks (↓5mg every 7 days)
Budesonide MMX (e.g. Cortiment, Entocort) is delivered directly to colon, less systemic absorption and side-effects, not as effective
Corticosteroids SIDE EFFECTS
Dyspepsia / stomach ulcers
Acne
Increased blood sugar / diabetes
Thin bones / osteoporosis
Adrenal insufficiency
‘moon face’
Reducing the risk of adverse effects of Corticosteroids
Warn patients of importance of gradual taper of steroids and provide steroid emergency card (needed if on dose > 5mg daily prednisolone for > 4 weeks)
Monitor blood sugar
IBD patients receiving corticosteroids should receive an intake of 800-1000mg/d calcium and 800 units/day vitamin D to support bone health (supplementation should be provided if insufficient from diet
Assess risk of osteoporosis when stating corticosteroids (e.g. via FRAX tool). Commence bisphosphonate, e.g. alendronic acid if high risk
PPI gastroprotection should be considered, especially in those at high risk, e.g. hx. of PUD
Osteoporosis and IBD risk factors
IBD is a cause of secondary osteoporosis.
Risk factors:
Malabsorption
High corticosteroid use
Reduced physical activity
Weight loss
Uncontrolled inflammation
Osteoporosis and IBD - Lifestyle measures to prevent
Encourage weight bearing exercise
Adequate calcium and vitamin D intake / compliance with bone protection
Stop smoking
Avoid alcohol excess
Aminosalicylates e.g. mesalazine (Octasa, Pentasa, Salofalk, etc.)
DOSE (oral)
Doses of >2g more effective for inducing remission (most respond to 2-3g)
Doses of 4-4.8g if flare while already prescribed aminosalicylate
1.2-2.4g usual maintenance dose
1-2g normal rectal dose
Monitoring: Renal function (can cause nephrotoxicity, need baseline, at 2-3 months then annual)
Important side effects: Nephrotoxicity (as above), can cause blood disorders (counsel to report bleeding, bruising, purpura, sore throat, fever or malaise, etc.)
Immunosuppressants: Thiopurines, methotrexate does and monitoring
Amber medicines – require shared care arrangements
DOSE
E.g. azathioprine PO 0.5-3mg/kg daily (reduced in renal / hepatic impairment)
E.g. methotrexate at least 15mg WEEKLY (subcut route has better bioavailability) & need folic acid 5mg weekly
MONITORING
FBC, LFT, U&E baseline, 2 weekly for 6 weeks, monthly for 3 months then 3 monthly
Assess thiopurine methyltransferase (TPMT) before starting thiopurine
Avoid if low TPMT activity, reduce dose by 50% if intermediate
Immunosuppressants: Thiopurines, methotrexate CAUTIONS / RISK
CAUTIONS / RISK
Teratogenic (effective contraception)
Blood disorders (report oral ulceration, sore throat, abnormal bruising, etc.)
Infection & malignancy risk
nephrotoxicity / hepatotoxicity risk
Require annual influenza vaccine and pneumococcal vaccine. No live vaccines
Biologics, e.g. infliximab, vedolizumab, tofacitinib - red list hospital only Some important safety precautions
Pre-monitoring for TB and hepatitis (risk reactivating)
Obtain and update (if needed) vaccination history prior to starting – no live vaccines for at least 4 weeks before, during and 3 months after treatment
Pneumococcal vaccine (with 5-year booster) and annual influenza vaccination needed
monitor for allergic reactions
Some carry carcinoma risk
Microscopic colitis - first step
try and stop causative drug if possible, e.g. NSAID, PPI, SSRI
Microscopic colitis Pharmacological management:
9mg budesonide once daily for 8 weeks
taper to the lowest possible budesonide maintenance dose, for example, 3mg alternate days.
prescribe calcium and vitamin D supplementation and have bone mineral density checked. One should remain vigilant for corticosteroid side effects and, after a year of therapy, assess whether ongoing treatment is required.
Supportive therapies examples
Anti-diarrhoeals, e.g. loperamide
Analgesics
Vaccinations
Smoking cessation /NRT
Psychological
Cancer screening
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