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X Gastroenterology > IBD > Flashcards

IBD Flashcards

1
Q

Epidemiology of IBD

A 
Rates are increasing especially for Crohns
Developed world more than developing
20-30yrs and 60-70yrs peaks of onset
M = F
Familial = 10-15%
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2
Q

Immunopathology of IBD

A

Pro inflammatory state
TNF Alpha
IL-1, 8 and 12
IFN Gamma

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3
Q

Allelic variations of what gene are associated with Crohns disease

A

NOD 2/CARD 15

2 mutations = 3% absolute risk of CD
More likely to require surgery - fast stricture formation
High rate of recurrence
Younger patients
More likely small bowel disease
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4
Q

Environmental factors and IBD

A

Cigarette smoking = 90% increased risk of Crohns. Appears protective for UC

? Infections
? Drugs - NSAIDs - mucosal disruption
? Stress
? Diet

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5
Q

Natural history of Crohns Disease

A

Inflammation –> Stricturing –> penetration and surgery

Rapidly severe disease
75% of patients require surgery
Nearly 50% of these patients will have a clinical relapse

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6
Q

Natural history of Ulcerative colitis

A

1/3rd proctitis, 1/3rd left sided and 1/3rd extensive disease

Limited disease may extend over time - 50%
At any time only 50% of patients are in remission

20% of patients require colectomy - usually patients with pancolitis

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7
Q

Colorectal cancer risk in UC (and crohns colitis)

A

Gradually reducing with better treatments

Increased risk with:

  • Increased duration of disease
  • Increased extent of disease
  • Severity of disease
  • PSC and risk occurs earlier in disease
  • Family history of CRC
  • Dysplasia
  • HISTOLOGICAL INFLAMMATION
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8
Q

How to preform IBD surveillance?

A

Chromoendoscopy for visualization

Can only perform endoscopic surveillance if dysplastic lesions are completely removed endoscopically otherwise –> colectomy

Start at 8yrs of disease duration for all UC extending above the rectum and Chron;s disease with more than 1/3rd of colon involved

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9
Q

After commencing surveillance how regularly to preform colonoscopy?

A

Annually if:

  • Active disease
  • PSC
  • Family history of CRC <50yrs
  • Colonic stricture or pseudopolyps
  • Previous dysplasia

3 yearly if:

  • Inactive Crohns
  • Crohns colitis
  • Family history of CRC >50yrs

5yrly if 2 previous normal colonoscopies

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10
Q

Predicting severe Crohns Disease

A 
Age <40 
Peri-anal disease 
Initial need for steroids
Loss of weight >5kgs
Fibro-stenosing disease
Upper GI disease
Depp ulcers in colon
ASCA positive
Anti OmpC, I2, CBir1 positive
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11
Q

Serologies to differentiate IBD types

A

ASCA + = Crohns

pANCA + = UC

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12
Q

Predicting severe Ulcerative colitis

A 
Age <40yrs 
Extensive disease
PSC
Deep ulcers
High titre pANCA
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13
Q

Simple approach to UC treatment

A

UC activity is generally reflected by symptoms
Treat by disease extent and severity

Drugs:

  • 5ASAs - combination rectal and oral best
  • Steroids - must taper
  • Azathiopurine and mycophenolate mofetil - if need for steriods >1x/yr
  • Anti-TNFs
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14
Q

Approach to Crhon’s treatment

A

Stop smoking

Assessment of disease activity difficult
CRP and Fecal calprotectin non invasive assessment tools. Endoscopy to assess for mucosal healing

Drugs:

  • Antibiotics - fistulising disease and post resection. Metronidazole and ciprofloxicin
  • Steroids
  • Azathiopurine and MMF
  • Methotrexate
  • Anti-TNFs - infliximab and adalimumab
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15
Q

Complications of 5-ASAa

A 
Infrequent
Interstitial nephritis
Pancreatitis
Blood dyscrasias
Diarrhoea

Sulfasalazine only:

  • Sulfur intolerance
  • SJS
  • Azospermia
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16
Q

Side effects of antibiotics used in Crohns

A

Metronidazole –> Peripheral neuropahty

Ciprofloxicin –> Archilles tendon rupture

17
Q

Side effects of Steroids

A

Effective induction agents only - must taper

Cushingoid weight gain
Bruising
Mood changes
Insomnia
Increased appetite
Osteopenia
DM
HTN
Glaucoma
Increased infections
Increased mortality
18
Q

Thiopurine MoA

A

AZA –> 6-MP –> 6-TIMP –> either 6-MMP OR 6-TGN

6-MMP –> side effects

6-TGN –> Rac-1 blockade –> T-cell apoptosis

1 in 300 don’t have TPMT –> side effects
MUST MEASURE TPMT prior to using Thiopurines

19
Q

Thiopurine metabolite monitoring

A

For non-responders or developing adverse effects

Absent 6TGN and absent 6MMP = non-compliance

Low 6TGN and low 6MMP = under-dosing

Low 6TGN and high 6MMP = thiopurine resistance

High 6TGN and high 6MMP = Thiopurine refractory

20
Q

How do you improve 6-TGN and 6-MMP in shunters?

A

Allopurinol

100mg allopurinol and dose reduction of AZA/6-MP to 25-50% of original dose

–> increased 6-TGN and reduced 6-MMP

21
Q

Side effects of Thiopurines

A

25% of patients stop due to side effects

Main side effects:

  • Hepatotoxicity
  • Myelo-suppression
  • Pancreatitis
  • N+V/flu like illness/hypersensitivity syndrome
  • Infection
  • Lymphoma and skin cancers

Must perform regular FBC and LFTs
Start low dose and increase

22
Q

When to use anti-TNFs

A

Inflammatory Crohns disease refractory to steroids and AZA/MMF and MTX

Fistulizing Crohns disease refractory to other medical therapies

Acute severe UC

UC refractory to other therapies

23
Q

Side effects of Anti-TNF alpha

A

Infection

  • TB reactivation
  • HBV reactivation
  • Invasive fungal infections
Lymphoma
Demylinating disorders
Drug induced lupus
Congestive heart failure
Abnormal LFTs
Dermatological rashes
24
Q

Monotherapy Vs Combination therapy

A

Combination therapy results in higher rates of mucosal healing and steroid free remission

May result in higher rates of side effects though

25
Q

Treatment of acute severe ulcerative colitis

A

Initial therapy =
IV hydrocortisone 100mg QID, clexane, IV fluids and Transfusion if necessary

Day 3-5 if no clinical response =

  • Cyclosporine or infliximab OR
  • Colectomy and J-pouch formation
26
Q

Side effects of pouch surgery

A

Pouchitis:

  • 50% of pouch recipients
  • Recurrent in 10-15%
  • Therapy = antibiotics
1% mortality
SBO 
Fistulae
Reduced fertility
Cancer
27
Q

Perianal fistulising Crohns disease

A

20-40% of patients during disease course

Aim of treatment is to drain sepsis and evaluate fistula –> treat Crohns with antibiotics and Anti-TNFs

Relapse in 30-50% of patients
Increased in smoking and proctitis

20-25% –> colectomy

28
Q

Vaccination for IBD

A 
HBV
HPV
Influenza
VZV
Pnuemococcus
29
Q

Extra-intestinal IBD manifestations dependent on disease activity?

A

Apthous ulcers
Erythema nodosum
Appendicular arthopathy
Episcleritis

30
Q

Extra-intestinal IBD manifestations independent of disease activity?

A

PSC
Uveitis
Pyroderma gangrenosum
Axial arthropathy

31
Q

Mechanism of action of vedolizumab?

A

α4β7 integrin inhibitor
–> stops interaction of α4β7 integrin with MAdCAM-1 –> stops lymphocyte binding to endothelial surface and its extravasation into the GIT

Takes 8 weeks to work
Similar to natilizumab - no PML risk

32
Q

Pregnancy and IBD?

A

Active disease = worse outcomes
Must maintain remission

Can’t use MMF or MTX
Complications with TNF inhibitors and live vaccines in infants

X Gastroenterology (10 decks)

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