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PMY3304 > IBD > Flashcards

IBD Flashcards

1
Q

Types of IBD

A

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)

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2
Q

IBD: Terminology / sub-types

A

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

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3
Q

Ulcerative colitis

A

Affects colon and rectum
Inner lining of bowel inflamed
Continuous

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4
Q

Crohn’s disease

A

Affects whole GI tract, mouth to anus
Transmural: all layers of intestine wall affected
Discontinuous

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5
Q

Microscopic colitis

A

Colon and rectum
No ulceration, visibly normal
Changes seen in biopsy under microscope

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6
Q

Symptoms

A

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

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7
Q

Complications of IBD - intestinal

A

Fistula
Infection and abscesses
Perforation
Toxic megacolon
Stricture
Obstruction
Carcinoma
Anaemia
Malnutrition

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8
Q

Complications of IBD - extra-intestinal

A

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

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9
Q

Severity of UC – Truelove and Witts Criteria

A
  1. Remission - Asymptomatic
  2. Mild - <4 stools/day, little bleeding, normal pulse, Hb, ESR, temp
  3. moderate - 4-6 stools/day, moderate bleeding, normal pulse, Hb, ESR, temp
  4. severe/ acute severe - ≥6 stools/day, visible bleeding, pulse ≥90bpm, temp ≥37.8oC, Hb <10.5g/dL, ESR >30mm/h
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10
Q

Diagnosis

A

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

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11
Q

Diagnosis - Investigations

A

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

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12
Q

Diagnosis – Confirmation (specialist)

A

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

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13
Q

Management of IBD - Goals

A
  1. Induce remission
    Active treatment of acute disease
    Mucosal healing
  2. Maintain remission
    Preventing relapse
    Minimise symptoms and toxicity
    Improve quality of life
  3. Providing information and additional supportive therapy
    Psychological
    Lifestyle and nutrition
    Bone health
    Growth monitoring
    GI supportive medicines
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14
Q

Medications used

A

5-ASA (aminosalicylates)
Corticosteroids (prednisolone / budesonide)
Immunosuppressants
Thiopurines (azathioprine / mercaptopurine)
Methotrexate
Ciclosporin
Biologics

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15
Q

Inducing remission in ulcerative colitis mild-moderate

A

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

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16
Q

Inducing remission in ulcerative colitis ACUTE SEVERE UC

A

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)

17
Q

Maintaining remission in ulcerative colitis MILD TO MODERATE

A
  1. 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

  1. 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
18
Q

Maintaining remission in ulcerative colitis ACUTE SEVERE

A

Oral thiopurine (azathioprine / mercaptopurine) OR oral 5-ASA OR oral ciclosporin (if used as inpatient)
Continue biologic at maintenance dose if commenced as inpatient

19
Q

Inducing remission in Crohn’s

A

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

20
Q

Inducing remission in Crohn - Early addition of immunosuppressants

A

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

21
Q

Maintaining remission in Crohn’s

A

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

22
Q

Corticosteroids

A

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

23
Q

Corticosteroids SIDE EFFECTS

A

Dyspepsia / stomach ulcers
Acne
Increased blood sugar / diabetes
Thin bones / osteoporosis
Adrenal insufficiency
‘moon face’

24
Q

Reducing the risk of adverse effects of Corticosteroids

A

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

25
Q

Osteoporosis and IBD risk factors

A

IBD is a cause of secondary osteoporosis.
Risk factors:
Malabsorption
High corticosteroid use
Reduced physical activity
Weight loss
Uncontrolled inflammation

26
Q

Osteoporosis and IBD - Lifestyle measures to prevent

A

Encourage weight bearing exercise
Adequate calcium and vitamin D intake / compliance with bone protection
Stop smoking
Avoid alcohol excess

27
Q

Aminosalicylates e.g. mesalazine (Octasa, Pentasa, Salofalk, etc.)

A

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.)

28
Q

Immunosuppressants: Thiopurines, methotrexate does and monitoring

A

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

29
Q

Immunosuppressants: Thiopurines, methotrexate CAUTIONS / RISK

A

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

30
Q

Biologics, e.g. infliximab, vedolizumab, tofacitinib - red list hospital only Some important safety precautions

A

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

31
Q

Microscopic colitis - first step

A

try and stop causative drug if possible, e.g. NSAID, PPI, SSRI

32
Q

Microscopic colitis Pharmacological management:

A

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.

33
Q

Supportive therapies examples

A

Anti-diarrhoeals, e.g. loperamide
Analgesics
Vaccinations
Smoking cessation /NRT
Psychological
Cancer screening
ect

PMY3304 (11 decks)

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