IBD Flashcards
Patho of IBD
Exact mechanism unknown but thought the be a combination of factors including:
- damage to epithelial mucin proteins and tight junctions
- breakdown of homeostatic balance between host’s mucosal immunity and enteric microflora
- genetic polymorphisms in toll-like receptors
- disrupted homeostatic balance between regulatory and effector T cells
- Host immune response to own gut flora
- imbalance and deregulation between regulatory and effector T cells
Where is IBD prevalent and why?
W. world due to diet and environment
Two types of IBD
ulcerative colitis and Crohn’s disease
Which IBD disease has a higher incidence
ulcerative colitis
Age for Ulcerative colitis
15-30 and 50-70 (bimodal)
What is most important in ulcerative colitis
family history
Who has the highest risk factor of ulcerative colitis
Ashkenazi jews
What environmental factors affect ulcerative colitis?
- smoking decreases risk of flares
- history of prior GI infections (shigella, salmonella, campylobacter) changes gut flora–> chronic inflammatory process
- weak association btw NSAID/OCP and UC
- stress is not a trigger
Clinical UC
- symptoms wax and wane
- rectal bleeding
- bloody diarrhea
- fecal urgency
- tenesmus
- abdominal pain LLQ and suprapubic pain
- abdominal tenderness
- aphthous oral ulcers
- iritis- severe eye pain and photophobia
- seronegative arthritis with flares
- erythema nodosum on lower extrem. and extensors
- autoimmune hemolytic anemia
- primary sclerosing cholangitis
Clinical Mild UC
- gradual onset of diarrhea less than 4 days and intermittent bloody mucoid stool
- urgency and tenesmus
- LLQ cramping relieved by bowel movement
- mild fever, anemia, hypoalbunemia
Clinical Moderate UC
- gradual onset of diarrhea less than 6 days and intermittent bloody mucoid stool
- urgency and tenesmus
- LLQ cramping relieved by bowel movement
- mild fever, anemia, hypoalbunemia
Clinical Severe UC
- more than 6 bloody diarrhea stools/day
- severe anemia, hypovolemia, hypoalbunemia with nutritional deficit
- abdominal pain and tenderness
- fulminant colitis
- pulse over 90
- fever over 37.5C
- ESR over 30
What is fulminant colitis
- subset of severe dz which is rapidly worsening symptoms with toxicity
- distended abdomen, tender leukocytosis, severe diarrhea, fever
Primary sclerosing cholangitis
- life long chronic disease or scarring anti-inflammation of the bile ducts
- bile ducts scar and narrow
Which UC extraintestinal symptoms improve after colectomy
- arthritis
- ankylosin spondylitis
- erythema nodosum
- pyoderma gangrenosum
Which UC extraintestinal symptoms do not improve after colectomy
primary sclerosing cholangitis
Who is more likely to develop primary sclerosing cholangitis
HLA-B8 or HLA-DR3
What is increased risk with primary sclerosing cholangitis? What is cure for primary sclerosing cholangitis?
colon cancer
liver transplant
Classification of UC
E= extent/location 1- inflammation of rectum (proctitis) 2- inflammation of splenic flexure (left side; distal) 3- inflammation extendes to proximal splenic flexture (pancolitis) S= severity 0- remision, no sx 1- mild 2- moderate 3- severe
UC and CD dx
- based on clinical symptoms and confirmed by sigmoidoscopic and colonoscopic and histologic examination
If severe pancolitis use what for dx?
flex sig
UC colonoscopy results
- diffuse confluent disease from dentate line proximal
- edema, friability of mucosa, mucous, erythema, erosions, ulcerations, and spontaneous bleed
- only found in the colon
Histology UC
distortion of crypt architecture crypt abscee infiltration of lamina propria with plasma cells eosinophils lymphocytes lymphoid aggregates mucin depletion
Tx Mild UC
- 5-ASA drugs (aminosalicylates)- release only in colon
(Mesalazine PR suppository or budesonide rectal foam if rectal proctitis) - Distal colon inflammation- rectal/oral 5-ASA (PO sulfasalazine and PR mesalazine)
- long term maintenance with 5-ASA
Tx Mild/Moderate UC
- Fail of 5-ASA
- PO Budesonide
- Prednisone
- Taper over 60 days
Tx Severe UC
- hospitalization and IV steroids with IVF (methylprednisone 60mg/d)
- Anti-biologics if fail steroid tx (TNF alpha- infliximab, adalimumab, golimumab) or (VGEF blocker if fail TNF- vedolizumab)
- cyclosporine is last resort
Maintenence TX UC
- once in remission
- 5-ASA
- Budesonide
- Immunosuppressant- golimumab or 6-MP
- Induct with infliximab, then continue use
- probiotics
Only curative tx for UC
colectomy
Surgery TX UC
Emergency- toxic megacolon
Urgent- severe dz and not responding to tx in hospital
Elective
- refractory: intolerant to long term maintenance tx
- colorectal dysplasia or adenocarcinoma found
- dz more than 7-10yrs
UC patients at increased risk of?
colorectal cancer
Screening UC
- colonoscopy begins 8yrs after dz onset
- if L. sided colitis/pancolitis: every 1-2 yrs
- UC with PSC: every yr from PSC dx
Def Crohn Dz
insidious variable presentation of lifelong idiopathic inflammatory dz that affects anywhere in GI system
What type of inflammation in crohn dz and what does it cause?
transmural inflammation in skip distribution that causes strictures, fistulas, ulcerations, abscess
MC area affected in Crohn dz
small bowel and colon (terminal ileum and ascending colon)
Strongest risk factor for CD
family hx
Environmental factors for CD
tobacco
sedentary lifestyle
exposure to air pollution
consumption of western diet
When does CD commonly begin?
after infectious gastroenteritis
Clinical CD
- RLQ, periumbilical pain
- watery diarrhea
- incontinence
- low grade fever
- weight loss/anorexia/ malnutrition
- weak, fatigue, malaise
- bone loss
- SBO presentation
- rectal abscess or anal fistula
- arthralgia
- iritis
- erythema nodosum
6 complication of CD
abscess obstruction fistula perianal dz colon cancer dysplasia/malignancy--> malabsorption
Treat fistulas in patient with CD
TPN/ oral elemental diet
Antibiologics for 10 weeks
Surgery is medication fails
Treat perianal dz in patient with CD
ABX (flagyl or cipro)
Mesalamine suppository or tacrolimus ointment if refractory fissure
Antibiologics
Classification of CD
L= extent 1- terminal ileum 2- colon 3- ileum and colon 4- upper GI L3+L4= upper GI and distal B= phenotype 1- no stricture and non-penetrating 2- stricture 3- penetrating 3p- perianal penetrating
Colonoscopy results for CD
aphthoid, stellate, linear ulcers
strictures
segmental involvement with skip lesions
General TX CD
- stop smoking
- diarrhea: loperamide, BAS (terminal ileal disease), low fat diet if short gut
Tx mild CD
Mesalamine (colon and small bowel)
Tx moderate to severe
- Steroid short term to control sx, use until remission and then a slow 60day taper
- immunosuppressants (azathioprine or methotrexate)
When to use TNF alpha in CD
- steroid dependent and no taper
- fistula tx no responding to ABX
refractory cases - can do an induction and maintenance
- infliximab, adalimumab, certolizumab pegol
When to use anti-integrins in CD
- no response to TNF
- vedolizumab (gut leukocyte trafficking)
Screen CD
- Regular screen TB, hepatitis, CMV, HIV, and C. diff
- more than 1/3 colon affected (L3) colonoscopy 8 yrs after onset and repeat every 1-2yrs and 1-3 once normal
- PSC= annual screening
PSC and CD have a risk of? Screen with?
cholangiocarcinoma (cancer of bile ducts)
screen with MRCP
