IBD Flashcards
Histology in CD
Goal
Transmural
Asymmetrical
Granulomatous
- 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?
- 50%
- 25%
- 8%
- 16%
- 50%
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
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
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
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
Describe type 1 peripheral arthropathy
Affects <5 joints, acute, self-limiting
Occurs alongside intestinal inflammation
Describe type 2 peripheral arthropathy
> 5 joints
Prolonged course, independent of gut inflammation
Associated with uveitis only
Classically what is the B12 and folate in SBBO
B12 low
Folate HIGH
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
In what situations can’t you give ciclosporin
Uncontrolled HTN
Renal impairment
My <0.5
Cholesterol <3
What can we use VSL#3 for?
Proctitis
What is the General role of CT colonoscopy
Tumour or polyp detection
Describe the histology in UC
Severe crypt architecture distortion Reduced crypt density Collins surface appearance Severe mucin depletion Diffuse, transmural lamina propria cell increase
Describe histology in Crohn’s
Epithelial granuloma
Discontinuous inflammation
Crypt distortion
Focal cryptitis
Which medication used to treat UC reduces sperm count and motility?
Sulfasalazine
Reversible infertility
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
Which medications are safe in pregnancy and IBD
Sulfasalazine
Mesalazine
Azathiprine
Infliximab (undetectable)
Which antibiotics are not safe in pregnancy and IBD?
Metronidazole
Cilrofloxacin
After prednisolone hoe long should you delay breastfeeding for
4 hours
What strongly predicts the presence of a peri-anal abscess?
Peri-anal pain
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
Describe the different types of simple fistulas
Superficial perianal
Inter-sphincteric perianal or duo-vaginal
Describe the types of complex fistula
Trans-sphincteric = enterocutaneous Supra-sphincteric = enters-enteric Extra-sphincteric = entero-enteric, enterovesical, rectovaginal
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
8%
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:
- Crohn’s
- UC
- 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
<5
HBI score that defines severe disease
> 16
What percentage of those with positive FOB test are then identified to have CRC on investigation
8%
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
