IBD

Question 1

What do UC and Crohn’s have in common and where do they differ?

Answer 1

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

Question 2

What three things contributed to the aetiology of IBD?

Answer 2

1. Genetics - in particular the NOD2 protein on chromosome 16 which is an intracellular sensor of bacterial peptidoglycan
2. Environmental factors = smoking exacerbates Crohn’s, but helps UC; NSAIDs; hygiene; psychological factors
3. 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

Question 3

UC
What age group is mostly affected?
Symptoms?

Answer 3

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

Question 4

What is the Truelove and Witt criteria for determining the severity of an attach of IBD?

Answer 4

> 6 bloody stools/24 hour, and one or more of:

• Fever (>37.8)
• Anaemia (Hb90/min
• Elevated ESR (>30mm/h)

Question 5

What are some extraintestinal manifestations of UC?

Answer 5

Skin
Joints - axial, peripheral
Eyes
Deranged LFTs
Oxalate renal stones
*Primary sclerosing cholangitis*

Question 6

Crohn’s disease
What age does it typically present in?
Distribution?

Answer 6

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

Question 7

Symptoms and signs of Crohn’s disease

Answer 7

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

Question 8

What is seen on pathology of Crohn’s?

Answer 8

Large, non-caseating granulomas
Cobblestoning
Rose-thorn ulcers
Strictures
Transmural inflammation
Ulcers
Oxalate renal stones
Increased goblet cells

Question 9

What are some common complications of Crohn’s disease?

Answer 9

Small bowel obstruction
Toxic dilatation 
Abscess formation
Fistulae
Colon cancer
Malnutrition

Question 10

What is seen on pathology of UC?

Answer 10

Depletion of goblet cells
Crypt abscesses
Pseudopolyps
Loss of haustrations on barium enema
Drainpipe colon
Tenesmus
Primary sclerosing cholangitis
Crypt abscesses

Question 11

What sites are affected in UC?

Answer 11

Colon and rectum
Mucosal and submucosal inflammation (except in toxic megacolon)
Continuous and confluent

Question 12

What is the typical UC patient?

Answer 12

32 yo female
Bloody diarrhoea and mucus
Goes to toilet 25 times per day

Question 13

What is toxic mega colon and what is the treatment?

Answer 13

Acute or acute on chronic fulminant colitis, where the colon swells up to a massive size and will rupture unless removed
Requires emergency colectomy

Question 14

How can UC progress to carcinoma?

Answer 14

Chronic inflammation leads to epithelial dysplasia and then carcinoma

Question 15

What treatments are used for both UC and CD?

Answer 15

Steroids
Immunosuppressants
Anti-TNF therapy
5-ASA is only used in UC

Question 16

What treatment is used for mild UC and remission from this?

Answer 16

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

Question 17

What is the treatment for a moderate UC?

I.e. >6 motions/day

Answer 17

Oral prednisolone + 5-ASA + 2x daily budesonide enema

If no improvement after two weeks, treat as severe UC

Question 18

What is the treatment used for severe UC?

Answer 18

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

Question 19

What is the treatment for a mild attack of Crohn’s?

Answer 19

Prednisolone, then gradually decrease dose as patient recoveres

Question 20

What is the treatment for severe Crohns?

Answer 20

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

Question 21

Azathioprine
What is it?
When is it used?
Onset of action?

Answer 21

An immunosuppressive agent (steroid sparing)
Used if steroid SEs are intolerable, or there are multiple/rapid relapses
Long - 16 weeks

Question 22

Anti-TNF therapy
E.g.
How does it work?

Answer 22

Infliximab, adalimumab

Promotes apoptosis of activated T-lymphocytes

Question 23

What is the main surgical procedure used in UC?

What is a common complication of this and how is it treated?

Answer 23

Panproctocolectomy with pouch formation - involves subtotal colectomy with end ileostomy and preservation of the rectum
Pouchitis - treated with metronidazole +/- ciprofloxacin

Question 24

What is the most common surgical procedure for Crohn’s?

Answer 24

Right hemicolectomy for terminal ileal disease

Perianal disease is very common and requires separate treatment