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IBD Flashcards

1
Q

Site of Crohns/UC

A

Crohns - Anywhere in GI + perianal/perineal skin

UC - colon & rectum

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2
Q

Crohns/UC - gender, age

A

Crohns - Slight female preponderance
- bimodal distribution peaks at 20-30 and 50-60

UC - M=F

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3
Q

Crohns/UC - incidence

A

Crohns - increasing

UC - stable

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4
Q

Crohns/UC - distribution

A

Crohns - patchy, skip lesions, transmural (affects full thickness of bowel wall - edematous and thickened)

UC - Diffuse, continuous, no skip lesions - except catcall patch +/- appendix.
Mucosa and submucosa

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5
Q

Crohns/UC - presentation

A

Crohns - Variable; Pain (usually right lower quadrant); Diarrhoea (usually no blood or mucus); Weight loss (avoid food as it causes pain; may be malabsorbed, vitamin deficiencies)

UC - bloody diarrhea

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6
Q

Crohns/UC - granulomas? Ulcers?

A

Crohns
Yes - may be transmural and in lymph nodes
Deep fissuring ulcers

UC - No granulomas.
Broad-based, shallow ulcers

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7
Q

Crohns/ UC - fistula? strictures?

A

Crohns - Yes for both

  • Enteroenteric - cause diarrhea and malabsorption due to blind loop syndrome
  • entervesical - recurrent UTI and pneumaturia
  • enterovaginal - faeculent discharge

UC - no for both

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8
Q

Crohns/ UC - inflammatory polyps?

A

Crohns - less common but may be larger than in UC

UC - yes

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9
Q

Features of crohns

A

Pyloric metaplasia in small intestine

“cobblestone” mucosa from intersecting linear ulcers

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10
Q

Features of UC

A

Paneth cell metaplasia

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11
Q

Effect of smoking in UC/ Crohns

A

Crohns - bad

UC - protective

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12
Q

Crohns typical histology features

A

patchy inflammation with lymphoid aggregates

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13
Q

UC typical histology features

A

cry-titis, crypt abscesses, crypt architectural distortion and crypt loss in chronic UC

Goblet cell depletion

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14
Q

What are extra-intestinal manifestations of IBD?

A

Musculoskeletal
- arthritis, ankylosing spondylitis CD +++ / UC +

Hepatobiliary

  • primary sclerosing cholangitis CD + / UC +++
  • bile duct carcinoma CD+ / UC +++

Skin disorders

  • erythema nodusum CD +++ / UC +++
  • pyoderma gangrenosum CD+ / UC +++

Other

  • oral ulceration CD +++/ UC +
  • eye lesions CD+++ / UC +++
  • amyloid (rare) CD+++ / UC +
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15
Q

DD of IBD

A

(1) Other forms of colitis
- crohns disease
- ischemic colitis
infective colitis (bacterial, parasitic) - salmonella, shigella, campylobacter jejuni, enteropathogen E coli, C. diff “pseudomembranous colitis”
- drug induced colitis
- microscopic colitis

(2) Colo-rectal neoplasm/ polyp
(3) Diverticular disease
(4) IBS

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16
Q

What is toxic megacolon?

A

Possible complication

Colon dilates and bacterial toxins pass freely across diseased mucosa into the portal and then systemic circulation

Most common during first attack of colitis

Abdo xray should be taken daily because when transverse or right colon is >6cm dilated, high risk of perforation - high associated mortality.

Loss of haustration in patients with severe UC

50% resolve with medical therapy alone but urgent colectomy required for those that do not improve.

17
Q

IBD investigations + possible results

A

FBC

  • May be anaemic due to malabsorption of (iron, folic acid, Vit B12) or bleeding
  • Platelet count can be high as a marker of chronic inflammation
  • Albumin falls due to protein-losing enteropathy, inflammatory disease, poor nutrition
  • ESR & CRP increased in exacerbations and in response to abscess formation

Faecal calprotectin

  • Detects GI inflammation – indicates migration of neutrophils to intestinal mucosa
  • May be high when CRP is normal
  • Good at distinguishing IBD from IBS

Bacteriology

  • Stool microscopy, culture – C. diff, ova, cysts
  • Blood cultures
  • Should still be done in established disease to exclude superimposed enteric infections

Endoscopy

  • Diarrhoea & raised inflammatory markers/alarm features
  • UC – loss of vascular pattern, granularity, friability, contact bleeding, with/without ulceration
  • Crohns – patchy inflammation, discrete deep ulcers, strictures, perianal disease (fissures, fistulae, skin tags) – often rectal sparing
  • CT / MRI
18
Q

Endoscopy findings in crohns / UC

A

UC

  • loss of vascular pattern
  • granularity
  • friability
  • contact bleeding
  • with/without ulceration

Crohns

  • patchy inflammation
  • discrete deep ulcers
  • strictures
  • perianal disease (fissures, fistulae, skin tags)
  • often rectal sparing
19
Q

Crohns - treatment

A

Resuscitation: correct metabolic and nutritional disturbances
Treat active disease – medical or surgical

Achieving remission
1st line = Corticosteroids
- Prednisolone, methylprednisolone, IV hydrocortisone

2nd line = Budesonide (for ileocaecal, distal ileal or right-sided colonic disease)

Primary nutritional therapy

  • Enteral nutrition – rests the gut & nutritional support, direct anti-inflammatory effect too
  • Only considered in children / young people

High dose 5-ASA (4g/day) - mesalazine

Metronidazole (perianal disease)

TNFalpha antibody

Do not offer budesonide or 5-ASA treatment for severe presentations

20
Q

Crohns - maintenance of remission treatment

A

Maintenance of remission
Stop smoking

(1) Azathioprine
•	Minor toxicity relatively common
•	Nausea, fever, skin rash & malaise
•	Pancreatitis 3-7%
•	Bone marrow depression 2%
•	Allergic reactions 2%
•	Drug-induced hepatitis 0.3%
•	TPMT testing = routine clinical practice

(2) Methotrexate
• Decreased rate of nausea with concomitant daily folic acid & metoclopramide/ ondansetron peri-injection
• SE: ulcerative stomatitis, leukopenia, nausea, malaise, fatigue, chills & fever, dizziness,

(3) Anti-TNF therapy
• Infliximab
• 755 human IgG1 molecule & 25% murine
• binds with high affinity to soluble and membrane bound TNFalpha
• SE: TB, other serious infections, post-operative complications, malignancy, lupus, immunogenicity and allergy
• More effective in early Crohns

ASA compounds >2g/day (post-operative)

(4) Vedolizumab
• Monoclonal antibody against anti-alpha4,beta7 integrin (expressed on specific subset of CD4+ leucocytes)

21
Q

Crohns - surgery

A

75% require intestinal operation

39-53% require a second operation

Indications
• Sepsis – fistulae, abscess, perforation
• Obstruction
• Failure of medical treatment
• Haemorrhage
• Growth retardation, haemorrhage, fulminant colitis
• Cancer

22
Q

Azathioprine SE

A

Azathioprine inhibit purine synthesis.

SE:
•	Minor toxicity relatively common
•	Nausea, fever, skin rash & malaise
•	Pancreatitis 3-7%
•	Bone marrow depression 2%
•	Allergic reactions 2%
•	Drug-induced hepatitis 0.3%
•	TPMT testing = routine clinical practice
23
Q

Methotrexate SE

A

Decreased rate of nausea with concomitant daily folic acid & metoclopramide/ ondansetron peri-injection

SE: ulcerative stomatitis, leukopenia, nausea, malaise, fatigue, chills & fever, dizziness

24
Q

Anti-TNF therapy side effects

A

Anti-TNF therapy
Infliximab
- 755 human IgG1 molecule & 25% murine
- binds with high affinity to soluble and membrane bound TNFalpha

SE: TB, other serious infections, post-operative complications, malignancy, lupus, immunogenicity and allergy

More effective in early Crohns

25
Q

What is Vedolizumab?

A

Monoclonal antibody against anti-alpha4,beta7 integrin (expressed on specific subset of CD4+ leucocytes)

26
Q

What may provoke a relapse?

A 
Emotional stress
intercurrent infection
gastroenteritis
antibiotics
NSAIDs
27
Q

UC - investigations

A

FBC
Sigmoidoscopy/colonoscopy & biopsies
- Histology

Abdominal X-rays - colonic distension in acute fulminant colitis

Chest xray - air under diaphragm in perforation

CT abdomen

28
Q

What is microscopic colitis?

A

Typically affects women, sometimes men
Middle age

Watery, explosive diarrhoea

Microscopic changes

  • Normal appearance of colonic and rectal mucosa at endoscopy
  • Increase in chronic inflammatory cells in lamina propria

Two patterns:
Collagenous colitis - Thickened basement membrane Lymphocytic colitis - Lots of lymphocytes in surface epithelium

Corticosteroid treatment -> budeniside

29
Q

Acute severe colitis

A

Medical emergency

15% patients with UC will present with severe attack during course of disease

25-40% will require urgent colectomy with appreciable peri-operative morbidity

> 6 stools daily with blood, and evidence of systemic disturbance
- Anaemia / fever / tachycardia (>90bpm) / ESR>30mm / Albumin <30g/l

Management
- Hospitalise
- Administer IV fluids and correct anaemia, electrolyte balance
- Bloods: FBC, U&E, LFT, Alb, Glu, CRP, G&S
- IV corticosteroids
Hydrocortisone 100mg qds OR
Methylprednisolone 60mg/ 24hrs by continuous IV

Failure to respond within 3 days -> consider infliximab or ciclosporin

  • Thromboprophylaxis - Prophylactic LMWH: enoxaparin 40mg sc od
  • Stool MC&S and C. Difficile toxin (THINK PREVIOUS ANTIBIOTIC USE)
  • Consider IV feeding, rectal steroids
  • Assess response daily

Outcome

  • 20-30% require urgent colectomy
  • 70-80% respond to medical therapy, with steroids ciclosporin
30
Q

UC - maintenance therapy

A

No role for corticosteroids

Compounds containing 5-aminosalicylic acid (immunosuppressive - exact mechanism unknown)

  • Sulphasalazine ( broken down to sulfapyridine and mesalazine, which remains in colon)
  • Mesalazine
  • Olsalazine

If relapse frequently then use immunosuppressants (azathioprine, cyclosporine)

Next consider biologics

31
Q

UC - indications for surgery

A

(1) emergency
- Complications of severe attack: toxic megacolon or perforation
- severe bleeding
- failure to respond to medical therapy

(2) Elective
- Severe attack which failed to respond to medical treatment
- malignant transformation/ dysplasia
- Chronic continuous disease with impaired quality of life

32
Q

UC - types of surgery

A

NO role for segmental resection.

  • Timely surgery
  • Cures colitis
  • Removes unpredictability & risk of cancer
  • 38% short term complications

(1) initial operation
- total colectomy, ileostomy and closure of rectal stumps
OR
- total colectomy, ileostomy and rectosigmoid mucous fistula

(2) Second procedure
- patient is left with permanent stoma and rectum is excised
OR
- formation of ileal pouch (ileum joined to anus)
OR
no second operation

Chronic UC surgery
- total proctocolectomy (colon and rectum removed) and permanent ileostomy
OR
- total proctocolectomy (colon and rectum removed) and formation of ileal pouch

33
Q

UC pathology

A

mucosa +/- submucosa
pseudopolyps
crypt abscesses
ulceration
begins in rectum and spreads proximally - does not skip areas
only involves colon & rectum - small bowel only involved in backwash ileitis

Anal canal is spared. If anal canal is involved think Crohns

34
Q

UC clinical presentation

A 
Diarrhoea
rectal bleeding
tenesmus
mucous 
abdominal pain
35
Q

Identify ileostomy vs colostomy

A

Ileostomy
- RIF, spouted, liquid contents

Colostomy
- LIF, flat, more solid contents

36
Q

Counseling before ileal pouch procedure

A

Patients must be counseled before ileal pouch procedure

frequency - bowel open 2-3 times a day and 1-2 times per night

stools are fluid which may cause incontinence

must be looked after

risk of sexual dysfunction and risk of infertility if a nerve is damaged during rectal dissection

Pouchitis

37
Q

Crohns - pathology

A

Any part of GI tract can be affected and it can skip areas
Strictures
Mesenteric fat wrapping
Transmural (whole thickness of bowel affected)
Granulomas (non-caseating)
Crypt abscesses (also found in UC)
Fistula (do not offer pouch in Crohns as it can affect small bowel and there is a risk of fistula formation)

38
Q

Crohns - clinical presentation

A

Acute abdomen
Intestinal obstruction
Peritonitis (due to perforation)
Chronic - abdominal pain, recurrent subacute obstruction, abdominal mass, malnutrition, fistula, abscesses

39
Q

Causes of acute severe colitis?

A

> 6 bloody stools per day + 1 feature of systemic toxicity (pulse >90, Hb <105, ESR/CRP>30, temp >37.8C)

Causes:
(1) Inflammatory
UC/ Crohns/ indeterminate colitis

(2) Infective colitis
- C. diff / campylobacter / E coli

(3) Ischaemic colitis

GI (7 decks)

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