IBD Flashcards
What do UC and Crohn’s have in common and where do they differ?
They share - Epidemiology --> western countries - Clinical - Therapeutic characteristics They differ in - Clinical presentation - Crohn's shows abdo pain and peri-anal disease; UC shows diarrhoea + bleeding - Pathology
What three things contributed to the aetiology of IBD?
- Genetics - in particular the NOD2 protein on chromosome 16 which is an intracellular sensor of bacterial peptidoglycan
- Environmental factors = smoking exacerbates Crohn’s, but helps UC; NSAIDs; hygiene; psychological factors
- Mucosal immune system - Crohn’s is a Th1 mediated disease; UC is a Th1/Th2 mediated disease
When grown on blood agar, Crohn’s patients keep the bacteria under control, whereas UC patients kill the bacteria too much
UC
What age group is mostly affected?
Symptoms?
15-30 Diarrhoea + PR bleeding + mucous Increased bowel frequency Urgency Tenesmus Incontinence Normally shouldn't have to move bowels over night Lower abdo pain, especially LIF Rashes, eye and joint pain
What is the Truelove and Witt criteria for determining the severity of an attach of IBD?
> 6 bloody stools/24 hour, and one or more of:
- Fever (>37.8)
- Anaemia (Hb90/min
- Elevated ESR (>30mm/h)
What are some extraintestinal manifestations of UC?
Skin Joints - axial, peripheral Eyes Deranged LFTs Oxalate renal stones *Primary sclerosing cholangitis*
Crohn’s disease
What age does it typically present in?
Distribution?
Typically 20-40 yo male
Anywhere from mouth to anus, with areas of unaffected bowel between areas of active disease (skip lesions)
Transmural inflammation
Recurrent abscess formation, causing pain
Can lead to fistula with persistent leakage
Damaged sphincters - if you don’t catch this early on, patients can be rendered incontinent
Symptoms and signs of Crohn’s disease
Determined by the site of the disease
Small intestine - abdominal cramps, diarrhoea, weight loss, obstruction
Colon - abdominal cramps, diarrhoea with blood, weight loss
Mouth - painful ulcers, swollen lips, angular chelitis
Anus - peri-anal pain, abscess
What is seen on pathology of Crohn’s?
Large, non-caseating granulomas Cobblestoning Rose-thorn ulcers Strictures Transmural inflammation Ulcers Oxalate renal stones Increased goblet cells
What are some common complications of Crohn’s disease?
Small bowel obstruction Toxic dilatation Abscess formation Fistulae Colon cancer Malnutrition
What is seen on pathology of UC?
Depletion of goblet cells Crypt abscesses Pseudopolyps Loss of haustrations on barium enema Drainpipe colon Tenesmus Primary sclerosing cholangitis Crypt abscesses
What sites are affected in UC?
Colon and rectum
Mucosal and submucosal inflammation (except in toxic megacolon)
Continuous and confluent
What is the typical UC patient?
32 yo female
Bloody diarrhoea and mucus
Goes to toilet 25 times per day
What is toxic mega colon and what is the treatment?
Acute or acute on chronic fulminant colitis, where the colon swells up to a massive size and will rupture unless removed
Requires emergency colectomy
How can UC progress to carcinoma?
Chronic inflammation leads to epithelial dysplasia and then carcinoma
What treatments are used for both UC and CD?
Steroids
Immunosuppressants
Anti-TNF therapy
5-ASA is only used in UC
What treatment is used for mild UC and remission from this?
5-ASA, e.g. sulfasalazine - has anti-inflammatory properties and helps to protect against colorectal cancer
Corticosteroids act as a bridge to maintenance therapy e.g. prednisolone oral, or budesonide topical - should be given high dose initially, then reduce over 6-8 weeks
What is the treatment for a moderate UC?
I.e. >6 motions/day
Oral prednisolone + 5-ASA + 2x daily budesonide enema
If no improvement after two weeks, treat as severe UC
What is the treatment used for severe UC?
Admit - nil by mouth and IV hydration
Hydrocortisone
Monitoring
If improving in 5 days, transfer to prednisolone + 5-ASA
If still not improving, consider surgery or rescue therapy
What is the treatment for a mild attack of Crohn’s?
Prednisolone, then gradually decrease dose as patient recoveres
What is the treatment for severe Crohns?
Admit for nil by mouth and IVI
IV hydrocortisone
IV metronidazole
Monitoring
If improving after 5 days, change to prednisolone
If no improvement, think about TNFalpha inhibitors
Azathioprine
What is it?
When is it used?
Onset of action?
An immunosuppressive agent (steroid sparing)
Used if steroid SEs are intolerable, or there are multiple/rapid relapses
Long - 16 weeks
Anti-TNF therapy
E.g.
How does it work?
Infliximab, adalimumab
Promotes apoptosis of activated T-lymphocytes
What is the main surgical procedure used in UC?
What is a common complication of this and how is it treated?
Panproctocolectomy with pouch formation - involves subtotal colectomy with end ileostomy and preservation of the rectum
Pouchitis - treated with metronidazole +/- ciprofloxacin
What is the most common surgical procedure for Crohn’s?
Right hemicolectomy for terminal ileal disease
Perianal disease is very common and requires separate treatment
