IBD Flashcards
which diseases make up IBD
Crohn’s and ulcerative colitis
IBD epidemiology
- 10-40 y/o- 1/250 in UK - 40% CD smoke, 10% UC
IBD aetiology
- mostly unknown - diet - smoking - infection - drugs - enteric microflora- appendectomy - stress - genetics
how does smoking affect IBD aetiology
may worsen clinical course but may have prevented onset - nicotine affecting smooth muscle
how does infection affect IBD aetiology
- bacteria causing TB - UC can occur after infective diarrhoea - associated with measles and mumps
how do medications affect IBD aetiology
- NSAIDs can exacerbate - contraceptive pill can increase CD risk - isotretinoin
how do genetics affect IBD aetiology
- Mutations of CARD15/NOD2 on chromosome 16 - inappropriate response to immune system- Genes OCTNI on chromosome 5 and DLG5 on chromosome 10 have also been linked to Crohn’s - 70% of ulcerative colitis patients have anti-neutrophil cytoplasmic antibodies
pathophysiology of CD
- discontinuous- deep ulcer, fissures and strictures can appear - TH1 associated - transmural inflammation - through all layers of bowels
pathophysiology of UC
- continuous - starts at rectum and moves upwards - crypt abcesses and mucosal ulceration - TH2 associated - only mucosa and submucosa affected - inflammatory cells infiltrate lamina propria
which disease skips areas
CD
which disease has a cobblestone mucosa
CD
which disease has transmural movement
CD
which disease is rectal sparing
CD
which disease has perianal involvement
CD
which disease has fistulas, strictures and granulomas
CD
what are the 3 components that work together in the gut to maintain health
microbes epithelium immune cells
which immune cells are involved in maintaining gut health
- payers patches - lymphatic - dendritic cells - sample antigens to lymphocytes - tolerogenic activation - Treg cells - once activated by dendritic cells move to laminar propria (IL10 to suppress immune response)
how is inflammation caused by chemical, mechanical or pathogen invasion
- epithelium activated - immune cell influx - tregs stop il10 secretion- dendritic cells secrete il6/12/23- recruitment of neutrophils
symptoms present in all IBD
diarrhoea fever abdominal pain N&Vmalaise lethargy weight loss malabsorption
symptoms present in CD
lower right quadrant pain anaemia palpable masses small bowel obstruction abscesses fistulas gut perforation
symptoms present with UC
diarrhoea with blood/mucus abdominal pain with fever constipation
diagnosis of IBD
- clinical evaluation, history, symptoms - blood tests, abdominal radiography, sigmoidoscopy, colonoscopy, small bowel radiology, ultrasound and tomography
how to manage risk of infections in IBD patients
- assess at diagnosis - treat active HBV, TB, HCV, HIV - in acute severe disease - corticosteroids can remain
corticosteroid issues
- infection risk - osteoporosis - adrenal suppression - diabetes - weight gain - CVD
monitoring requirements for steroids
- fbc - hba1c - lipids - bp - eyes - mood- sleep - calcium! should be given 800-1000iu calcium and 800iu vit d daily
risk factors of bone health in IBD
- weight loss - steroids - inflammation - malabsorption - lack of exercise
common malnutrition’s in IBD and how to treat them
- magnesium : PO/IV - PO can worsen diarrhoea - iron : dietary improvements, IV in active IBD PO up to 100mg in inactive - monitor every 3 months for one year and then every 6-12 months after
NSAIDs and IBD
may lead to an increase in disease activity - CD * Short term, low dose, in patients with controlled disease in remission - is potentially safe - not recommended
risk of colorectal cancer with IBD
- 8-10 years post diagnosis - UC extensive > distal > proctitis - reduce risk by managing inflammation, reviews, colonoscopies, dietary improvement
other pharmaceutical care issues in patients with IBD
adherence stoma short gut syndrome mental health fatigue VTE prophylaxis
what is the Montreal classification for
remission in UC S0 - no symptoms - remission S1 - mild S2- moderate S3 - severe
how is remission induced in UC - mild/moderate proctitis
topical amino salicylates PLUS oral if remission not achieved within 4 weeks (+ steroids if C/I or further treatment required)
how is remission induced in UC - mild/moderate proctosigmoiditis and left sided colitis
topical amino salicylates PLUS high dose oral if remission not achieved within 4 weeks (+ steroids if C/I or further treatment required)
how is remission induced in UC - mild/moderate extensive colitis
topical AND oral amino salicylates, if remission not reached within 4 weeks stop topical and add steroids
how is remission induced in UC - moderate to severe colitis
corticosteroids 4-60mg a day (side effects >40mg)
how is remission induced in UC - moderate to severe active disease
biologics and JAK inhibitors - infliximab/adalimumab after conventional therapy failure - vedolizumab - inadequate/loss of response to others - including tnfa inhib- tofacitinib - if all else fails
how to maintain remission in UC - Mild to moderate proctitis AND proctosigmoiditis
- topical aminosalicylate (nightly or every 3 nights) - oral plus topical aminosalicylate - oral alone but not as effective - 2 + exacerbations in 12 months that require corticosteroids OR if remission is not maintained Azathioprine/mercaptopurine
how to maintain remission in UC - Mild to moderate left sided and extensive colitis
low dose oral aminosalicylate - □ If 2 + exacerbations in 12 months that require corticosteroids OR if remission is not maintained Azathioprine/mercaptopurine
how to induce remission in CD
- glucocorticoid monotherapy (if C/I - budesonide but less effective then aminosalicylate but less effective than both) 2. >2 exacerbations in 12 months, add- azathioprine/mercaptopurine - mtx if above c/i - tnf inhibitors - infliximab - il inhibitors - ustekinumab - lymphocyte inhibitors - vedolizumab
how to maintain remission in CD
- no treatment follow up plans actions if relapse how to access healthcare - treatmentazathioprine/mercaptopurine mtx - if above c/i
when would you use budesonide in CD
to induce remission in patients who cannot have steroids with distal ileal, ileocecal and right sided colonic disease
CD treatment after surgery
azathioprine with metronidazole (for up to 3 months post op)
