1. How many UC Pt flare each yr 2. How many patients with pancolitis eventually have a colectomy? 3. What is the CRC incidence at 20yrs in UC? 4. What is the colorectal cancer incidence at 40years 5. What is the relative risk reduction for CRC with 5ASA?

1. 50% 2. 25% 3. 8% 4. 16% 5. 50%

IBD and pregnancy: 1. do you continue maintenance medications? 2. Are congenital defects reported in infliximab? 3. Infliximab is found in breast milk? Y/N 4. 1st line management of N+V in pregnancy 5. Which antibiotic used in CD should be avoided in pregnancy 6. 1st line constipation treatment

1. Yes 2. No 3. No 4. Ginger and P6 acupuncture 5. Metronidazole 6. Fibre supplements

IBD Flashcards by Ben Hicken

Histology in CD

Goal
Transmural
Asymmetrical
Granulomatous

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How many UC Pt flare each yr
How many patients with pancolitis eventually have a colectomy?
What is the CRC incidence at 20yrs in UC?
What is the colorectal cancer incidence at 40years
What is the relative risk reduction for CRC with 5ASA?

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When is a 5 year screening colonoscopy required for UC screening?

Extensive colitis with no macro/microscopic activity
Left sided colitis
Crowns colitis affecting <50% colon
Pouch surveillance post-colectomy

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When is a 3 year screening colonoscopy required for UC screening?

Extensive colitis with mild micro and macroscopic activity
Pseudo-polyp
Post inflammatory polyp
CRC in 1st degrees relative >50yrs

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When is annual screening colonoscopy required for UC screening?

Extensive colitis and severe micro/macroscopic changes
Hx stricture/dysplasia declining surgery in last 5yrs
CRC in relative <50yrs
PSC
Pouch with dysplasia
Severely inflamed pouch

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Describe diversion colitis
What Rx is given
What is the definitive Rx

Deficiency of short chain fatty acids
Unabsorbed carbs enter colon are metabolised by bacteria to SCFA to provide nutrition for colonic mucosa
Rx - SCFA enema, steroid enema, mesalazine
Surgery to restore faecal flow

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Describe type 1 peripheral arthropathy

Affects <5 joints, acute, self-limiting

Occurs alongside intestinal inflammation

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Describe type 2 peripheral arthropathy

> 5 joints
Prolonged course, independent of gut inflammation
Associated with uveitis only

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Classically what is the B12 and folate in SBBO

B12 low

Folate HIGH

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What is the criteria for a severe attack based on True Love and Witt criteria

Tachycardia >90
Temperature >37.8
Hb <10.5
ESR>30

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In what situations can’t you give ciclosporin

Uncontrolled HTN
Renal impairment
My <0.5
Cholesterol <3

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What can we use VSL#3 for?

Proctitis

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What is the General role of CT colonoscopy

Tumour or polyp detection

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Describe the histology in UC

Severe crypt architecture distortion
Reduced crypt density
Collins surface appearance
Severe mucin depletion
Diffuse, transmural lamina propria cell increase

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Describe histology in Crohn’s

Epithelial granuloma
Discontinuous inflammation
Crypt distortion
Focal cryptitis

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Which medication used to treat UC reduces sperm count and motility?

Sulfasalazine

Reversible infertility

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IBD and pregnancy:

do you continue maintenance medications?
Are congenital defects reported in infliximab?
Infliximab is found in breast milk? Y/N
1st line management of N+V in pregnancy
Which antibiotic used in CD should be avoided in pregnancy
1st line constipation treatment

Yes
No
No
Ginger and P6 acupuncture
Metronidazole
Fibre supplements

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Which medications are safe in pregnancy and IBD

Sulfasalazine
Mesalazine
Azathiprine
Infliximab (undetectable)

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Which antibiotics are not safe in pregnancy and IBD?

Metronidazole

Cilrofloxacin

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After prednisolone hoe long should you delay breastfeeding for

4 hours

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What strongly predicts the presence of a peri-anal abscess?

Peri-anal pain

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Treating fistulating disease

Map fistula - MRI
Assess current disease activity
EUA is gold standard - can then give therapeutic treatment if required
(Equivalent is ano-rectal USS

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Describe the different types of simple fistulas

Superficial perianal

Inter-sphincteric perianal or duo-vaginal

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Describe the types of complex fistula

Trans-sphincteric = enterocutaneous
Supra-sphincteric = enters-enteric
Extra-sphincteric = entero-enteric, enterovesical, rectovaginal

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What is the benefit of colonic release budesonide

As effective as prednisolone in mild-moderate left sided disease (UC). But high first pass metabolism and fewer side effects

What to tell pt when counselling for thiopurines

``` Slow onset Avoid sun Risk of cancer (<1% at 10 yrs) Avoid allopurinol Rise in MCV Monitor bloods 2-4/52 for 2/22 then every 3months ```

Treatment of complex fistula

Drain abscess and seton suture ABX and thiopurine first line Anti-TNF 2nd line Emerging therapy - topical IFX, stem cells, fistula plug, hyperbaric O2

There is evidence for VSL#3 in pouchitis, what main bacteria does it contain?

Strep. Thermophilus Bifidobscterium species Lactobacillus

Which genes show the greatest association with CD

NDD2 | CARD15

What is the chance of offspring developing IBD if both parents have IBD

30% If only one parent = 9% CD and 6% UC

Which cytokines does Th1 produce?

IL1 and IL6 and TNG

Th17 produces...

IL-17 and IL22 | They are proinflammatory cytokines

What increases risk of immunogenicity in IFX

Mono therapy | Episodic IFX therapy

Describe IFX and antibody production and how we manage this

Low IFX and positive antibody = switch drug (92% clinical response) Low IFX and negative antibody = increase drug dose

What is considered gold standard for diagnosing small bowel IBD

Capsule endoscopy

Describe the Vienna classification

Age - A1<40, A2>40 Location - L1 TI, L2 colonic, L3 ileocolonic, L4 upper GI tract Behaviour - B1 non-structuring, non-penetrating, B2 structuring, B3 penetrating, intra-abdominal or peri-anal fistula/ulcer

Management of peristomal pyoderma gangrenosa

Topical corticosteroids Pustules and rapidly ulcerates Serpinginous painful, bluish ulcer

Describe sweets syndrome

Acute onset febrile illness Pathergy at immunisation site Skin Bx shows diffuse polynuclear neutrophilic infiltration in upper dermis Treat with topical/oral steroids

Is episcleritis painful

NO it is painless

What proportion of patients have a significantly low TPMT level

0.3% (1 in 300). | This increases the risk of leucopenia - can consider dose reduction

MOA of sulfasalazine

Depends on cleavage of 5ASA dinners by colonic bacteria. It is linked to 5ASA by an AZO bond. This bond is split by colonic bacteria to release 5ASA

What is FCP

Protein complex of s100 family Present in neutrophils and macrophages Biomarker of inflammation Correlates well with mucosal inflammation

HBI - what score indicates remission and severe flare

<5 remission >5 is a relapse >16 = severe disease

What test should be performed in asymptomatic iron deficiency in patients with quiescent UC

Possibly colon cancer | Do colonoscopy

What is the prevalence of colon cancer in patients with a positive FOB test

Antigen exposure leads to activation of CD4 cells which produce TH1 and TH2 cells. Which cytokines are produced by TH1 cells

IL1, IL2, IL6, IL12, IFN, TNF-alpha

Antigen exposure leads to activation of CD4 cells which produce TH1 and TH2 cells and TH17 Which cytokines are produced by TH2 cells

IL4, IL5, IL13

Antigen exposure leads to activation of CD4 cells which produce TH1 and TH2 cells and TH17 Which cytokines are produced by TH17

IL17, IL6, IL22

Which cytokines are anti-inflammatory

TGF IL4 IL10 - levels found to be low in IBD

Which EIM of IBD run a course alongside IBD flare

EN Episcleritis (painless) Type 1 peripheral arthritis Oral ulcers

Which EIM is associated with type 2 arthritis

Uveitis

What proportion of IBD patients are under hospital follow up

30%

What proportion of patients with IBD have UC

66%

What is the lifetime risk of surgery in: 1. Crohn's 2. UC

1. 70% | 2. 30%

What congenital defects are associated with infliximab

VACTERL

In pregnancy, increasing daily recommended dose of folic acid is required when taking which IBD medication

Sulfasalazine Increase by further 2mg

There is evidence for what treatment in pouchitis

VSL3

Which EIM of IBD has RCT evidence for infliximab use

Pyoderma gangrenosum

1st line treatment for perianal fistula

ABX Azathioprine Then consider anti-TNF if above doesn't work

In a patient with mild-moderate colonic disease, what treatment can be offered

Increase 5ASA Addition of enemas Prednisolone BUDESONIDE MR - as effective as prednisolone with less side effects and high first pass metabolism

What bacteria are present in VSL3

Strep thermophilus Bifidobacterium species Lactobacillus

If both parents have IBD what is the chance of offspring developing disease

30% by age 30years

If one parent has IBD what is the chance of developing the disease

9% CD 6% UC

IBD is more common in black people compared to white? T or F

false

What is the incidence of CD in UK population

5-10/100,000

What is the incidence of UC in the U.K population

10-20/100,000

Th17 produces which pro-inflammatory cytokines

IL17 | IL22

Th1 cells produce which pro-inflammatory cytokines

IL1, IL-2, IL-6, TNF-alpha

Th2 cells produce which proinflammatory cytokines

IL4, IL10, TGF

What percentage of patients with toxic colon perforate?

35%

Treatment of peristomal pyoderma gangrenosum

Topical steroids Po steroids Painful serpinginous ulcer, bluish

Treatment of erythema nodosum

Treat flare of underlying IBD - PO steroids Can also give PO K-iodine, NDAIDS

What proportion of those who are homozygous (wild type) for TPMT have high/normal levels

90%

Those who are heterozygous for TPMT have ............. levels of TPMT

LOW 10%

What does the mechanism of sulphasalazine depend on...

Cleavage of 5-ASA diners by colonic bacteria 5ASA bound by an AZO bond. This bond is split by colonic bacteria to release 5ASA

HBI score that defines remission

HBI score that defines severe disease

>16

What percentage of those with positive FOB test are then identified to have CRC on investigation

What is the most useful test for assessing/monitoring toxicity with azathioprine use

FBC - WBCs

Excess of what metabolite can cause toxicity in azathioprine use

6-TGN 6-thioguanine nucleotide

1st line treatment of aphthous ulcers

Topical steroid (hydrocortisone lozenges) But ensure there is no need to treat IBD flare e.g. With PO steroids