IBD Flashcards
Inflammatory bowel disease (IBD) includes ______ and ________
Crohn’s disease
Ulcerative colitis
IBD is characterised by…
Inflammation of the gut mucosa with diarrhoea, rectal bleeding, abdominal pain, and weight loss.
What two features distinguishes Crohn’s from UC
The location and type of inflammation distinguishes CD from UC
UC - location and type of inflammation
Affects the colon only with continuous mucosal inflammation extending proximally from the anus
Crohn’s - location and type of inflammation
Can affect anywhere in the GI tract, including the stomach, jejunum, the terminal ileum and/or colon with transmural inflammation and is often discontinuous
Peak incidence of IBD is between ________ years but may occur at any age
15 and 35 years
Diagnosis of IBD is made by _________
Colonoscopy and biopsy
Consider either IBD or colorectal cancer if what symptoms?
Diarrhoea with urgency, PR bleeding, abdo pain, and weight loss.
Nocturnal symptoms, such as diarrhoea or abdominal pain, are waking the patient.
Functional diarrhoea, e.g. IBS, usually stops at night.
Smoking relationship to Crohn’s
Smoking increases the risk of developing Crohn’s disease.
Smoking relationship to UC
Smoking cessation can precipitate ulcerative colitis.
Extra-intestinal manifestations of IBD
Skin, e.g. erythema nodosum, pyoderma gangrenosum
Arthritis (axial and peripheral)
Eye, e.g. uveitis, episcleritis, iritis
Mouth ulcers
Night sweats
Abnormal liver enzymes, e.g. primary sclerosing cholangitis
Examination for suspected IBD
Check temperature, HR, BP
Abdomen, and rectum for PR bleeding and perianal disease, e.g. abscesses, fistula, fissures.
If fever, tachycardia, hypotension, or significant abdominal pain in a patient with IBD then suspect…
Megacolon, perforation, bowel obstruction, or an abscess
Initial investigations if suspected IBD
CBC, CRP, LFT, electrolytes
Coeliac markers
Faecal culture, including ova/parasites
Clostridium difficile (C. diff) toxin
Faecal calprotectin
Blood test findings suggestive of IBD
Anaemia
Leucocytosis
Thrombocytosis
Increased CRP
Does a normal faecal calprotectin rule out IBD?
A negative faecal calprotectin, i.e. less than 50 micrograms/L makes IBD extremely unlikely
If blood tests suggestive of IBD and first presentation what should you do?
Ref gastro + request colonoscopy
If acutely unwell –> ref acutely
Bloods that should be checked annually when patient is in remission
Iron stores
Vitamin B12
Folate
Zinc
CRP
4 groups of medications that are used for either acute episodes or as maintenance treatment of inflammatory bowel disease (IBD)
Aminosalicylates (ASA)
Steroids (prednisone)
Immunomodulators
Biologics
Consider the risk of immunosuppression in patients on _____________. Add an alert to patient notes. Recall patients for _________
Steroids, thiopurines, methotrexate and the biologics
Recall - annual influenza vaccinations and three yearly cervical screening
Examples of aminosalicylates
Mesalazine (e.g., Pentasa, Asacol)
Olsalazine sodium
Sulfasalazine
____________ are the core drugs for ulcerative colitis and are tried first-line for remission and maintenance
Aminosalicylates (ASA)
All ASAs can cause __________. Advise patients to look out for ________
Blood disorders
Advise patients to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment.
Which ASA is used more commonly
Mesalazine - effective and well tolerated
Why is sulfasalazine used less commonly now?
Due to side-effects (headache, nausea, diarrhoea) and intolerance
What route of administration do ASA’s come in?
Rectal therapies (e.g., suppositories and enemas) are effective for distal disease and are given in addition to oral ASA
When would you give ASA as an enema or suppository?
Suppositories - for rectal disease
Enemas - for disease distal to the splenic flexure
Are ASA’s effective in Crohn’s?
ASAs probably only have a very limited effect in active Crohn’s disease
For mesalazine and olsalazine when do adverse effects usually occur?
Within the first 3 months of therapy
Blood test monitoring for mesalazine and olsalazine
CBC, AST, and ALT, creatinine
Before initiation
After 3 months
Then annually if stable
Indications for steroids (prednisone) in IBD
Can be used to obtain remission either initially for more severe disease or in flare-ups for both UC and Crohn’s
Duration of course of steroids in IBD to achieve remission or flare ups
Usually 8 weeks and slowly reduce, otherwise an early relapse can occur.
Can you use steroids for maintenance therapy?
Note that steroids have no role in maintenance therapy.
Consider using what route of administration of steroids in patients with proctitis?
Topical treatment, such as enemas in those with proctitis (inflammation in the rectum)
What should you offer at the same time as the steroid course?
Offer bone protection with calcitriol (0.5 micrograms daily) and calcium carbonate (depending on dietary calcium intake) at the same time as the steroid course.
Examples of immunomodulators used in IBD
Azathioprine
Methotrexate (second-line), oral or subcutaneous
Examples of biologics used in IBD
Stelara
Infliximab (Remicade)
Adalimumab (Humira and Amgevita)
Special considerations re COCP in IBD
Absorption may be reduced if there is small bowel involvement in Crohn’s
In IBD, the main factor in fertility relates to___________
Good disease control
I.e. the better the disease control, the more likely to get pregnant
Which IBD medication needs to be stopped when planning a pregnancy / during a pregnancy
Methotrexate
ASA in pregnancy and breastfeeding
It is safe to continue aminosalicylates (ASA) in pregnancy and breastfeeding
Steroids in pregnancy
Steroids may be associated with cleft palate in first trimester but should be used if required to control disease. Discuss with a gastroenterologist if unsure.
In UC and Crohn’s disease, long-term use or recurrent courses of________ is not appropriate. Request non-acute gastroenterology assessment for _______ treatments.
Prednisone
Steroid-sparing treatments
Criteria for an acutely unwell patient with ulcerative colitis
> 6 bloody BM/day , plus
≥1 of the following:
Temperature > 37.8°C
Heart rate > 90
Hb < 105
CRP > 30
Investigations in flare ups
Faecal culture and C. diff toxin. Relapses are often associated with pathogens or due to C. diff after antibiotics.
Blood tests – CBC, CRP, LFT, electrolytes.
Medication for acute flare up in UC
Optimise 5-Aminosalicylate (5-ASA)
- Increase oral 5‑ASA
- Start rectal 5‑ASA (e.g. suppositories/enemas)
Flare up in UC - what to do if on max 5‑ASA or limited response after 1 week
Start prednisone and request non-acute gastroenterology assessment to consider starting an immunomodulator or changing the current medications.
Medication for acute flare up in Crohn’s
Start prednisone
Refer gastro to consider starting an immunomodulators or biologic
Can consider __________ as an alternative to steroids in the treatment of acute Crohn’s flare. This should be done with the support of a specialist dietitian.
Exclusive enteral nutrition
In acute IBD flare - it may be more appropriate to arrange an urgent gastroenterology assessment, especially if a patient is already on __________
An immunomodulator or biologic.
