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Gastroenterology > IBD > Flashcards

IBD Flashcards

1
Q

What can patients do whilst waiting for the dietitian?

A

Look online at the diet and orientate yourself around what you will and won’t be able to have

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2
Q

What is the name of the skin rash that comes with Crohns flare up?
What does it look like/characteristics?
How many people get it?

A

Erythema nodosum
1 in 20 people

Tender, red, circular, nodule

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3
Q

What are some skin manifestations commonly seen in IBD?

A

Erythema nodusum
Pyodermal gangrenosum
Stomatitis
Vesiculopustula eruption

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4
Q

What is the epidemiology of IBD?

A

1-2 in 1000

1 in 50 in Ashkenazi Jews

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5
Q

What is Ulcerative Colitis?

A

A relapsing and remitting inflammation of the colonic mucosa

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6
Q

Where does UC occur?

A

Proctitis (rectum) 30%
Left sided colitis 40%
Pancolitis (whole colon) 30%

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7
Q

What causes UC?

A

Inappropriate immune response to ab/normal flora of the gut (genetically susceptible individuals)

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8
Q

In which layer is the inflammation in UC?

A

Mucosa - this differentiates it from Crohn’s disease

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9
Q

How do you end up with blood in your stool in UC?

A

Polyps can form from the inflammation and these can become haemorrhagic

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10
Q

How does smoking relate to UC?

A

The incidence is 3x in non-smokers and stopping smoking can actually cause relapse of symptoms

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11
Q

What are the symptoms of chronic UC?

A 
Episodic or chronic diarrhoea
Abdominal crampy discomfort
Blood/mucus in stool
Frequency
Urgency
Tenesmus (proctitis)

Systemic during attacks - fever, weight loss, malaise, anorexia

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12
Q

What are the symptoms of an acute episode of UC?

A 
Fever
Weight loss
Malaise
Anorexia
Tender abdomen
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13
Q

What are the extraintestinal manifestations/signs of IBD?

A 
SKIN
Clubbing
Erythema nodosum
Pyoderma gangrenosum
FACE
Conjunctivits
Episcleritis
Irits
Oral ulcer
JOINTS
Large joint arthritis
Sacroilitis
Ankylosing spondylitis
OTHER
Primary Sclerosing Cholangitis
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14
Q

How common is UC?

A

1-2/1000

100-200 in 100,000

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15
Q

When does IBD typically present?

A

20-40year olds

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16
Q

What blood tests would you do in UC?

A

FBC - anaemia, leukocytosis, thrombocytosis
LFTs - signs of PSC
UEs - signs of PCS elevated Na urea
ESR/CRP - raised
Blood sample
Stool sample - C.diff, WBC, faecal calprotectin

AXR - air fluid level, thumb printing
Colonoscopy

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17
Q

What are the risk factors for UC?

A

Family history

Infection in those who have previous history of UC

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18
Q

What is faecal calprotectin?

A

This is a marker that is raised in inflammatory bowel disease. This is important in distinguishing between IBD and IBS

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19
Q

What are the criteria for the severity of UC?

A

SEE PHOTO

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20
Q

What are the complications of UC?

A

Toxic megacolon
Colonic cancer (more in pancolitis)
Polyps
Perforation

Venous thromboembolism
Hypokalaemia

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21
Q

How do we treat mild UC?

A

5-aminosalicylic acid (5-ACA)

Mesalazine
Can give PR as suppository or foam 1g OD for proctitis.
Up to 2.4g split per day (800mg tablets) PO for more extensive disease
These doses are combined if needed.

Loperamide to treat the diarrhoea

Hydrocortisone (1 unit) PR or prednisolone PO (20-40mg) or 1 unit PR can be added if no better in 2-4 weeks

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22
Q

How do we treat moderate UC?

A

Give prednisolone 40mg PO for 1 week then taper down 5g/week for 7 weeks.

Give up to 4.8g of mesalazine OD (800mg tablets)

Can add tacrolimus (unlicensed) if not better in 2-4 weeks

If mesalazine doesn’t work, can add budenaside multimatrix

Maintain on mesalazine 1.2-2.4g split over day PO

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23
Q

What are some side effects of 5-ASAs?

A 
Rash
Haemolysis
Hepatitis
Pancreatitis
Worsening of UC

Rare - pericarditis/nephritis

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24
Q

What monitoring is required for mesalazine?

A

At prescription
Post 3 months
Yearly

UEs
FBC

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25
Q

How do we treat severe UC?

A

Give IV fluids, IV hydrocortisone 100mg/6hours, thromboembolism prophylaxis

Rescue therapy can be used: IV ciclosporin OR IV inflixumab

Monitor twice daily

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26
Q

What if the severe UC doesn’t get better after 3-5 days?

A

Urgent action is needed - i.e. rescue therapy

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27
Q

What happens if the severe UC gets better after 3-5 days?

A

Switch to prednisolone oral 40mg/day then treat as moderate UC

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28
Q

What is rescue therapy?

A

Ciclosporin
or
Infliximab

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29
Q

What if nothing is helping the UC attack?

A

Urgent colectomy if not better by day 7-10

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30
Q

What is immunomodulation?

A

Using drugs to modulate the immune system

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31
Q

What immunomodulation would you use in severe UC?

A

Ciclosporin

32
Q

What if the patient can’t tolerate immunomodulation/ it doesn’t work for them?

A 
Use biologics (MABs)
Infliximab
33
Q

What surgeries are done for severe ulcerative colitis?

A

Subtotal colectomy
Terminal ileostomy
Anterior resection

34
Q

WHAT IS THE MAIN DRUG USED TO MAINTAIN REMISSION OF UC?

A

Mesalazine

Alternatives: olsalazine, balsalazide

35
Q

What can be a bonus of balsalazide?

A

It is a pro-drug and metabolised in the colon so is a specific target

36
Q

What is azathioprine?

A

This is a steroid which can be used (unlicensed) for maintaining remission if the patient has more than 2 flare ups a year.

37
Q

What are the side effects of ciclosporin?

A 
Abdo pain
Nausea
Pancreatitis
Leucopenia
Abnormal LFTs
38
Q

What monitoring is required with ciclosporin?

A

FBE, UE, LFT weekly for four weeks, then monthly for three months then 3-monthly

39
Q

How can we treat recurrent pouchitis for those with a stoma?

A

Metronidizole + ciprofloxin for 2 weeks

40
Q

What is IBD-U?

A

IBD that is not obviously crohns or UC.

This is most common in children and will tend to grow into an obvious classification

41
Q

What can tell you the chances of someone getting a colectomy upon this admission of UC?

A

If the day 3 stool frequency is >8 per day
OR
3-8 per day with CRP >45

= 85% chance of colectomy

42
Q

What is Crohn’s disease?

A

It is a chronic inflammatory condition of transmural inflammation of the entire gut in a skip-lesion pattern

43
Q

What is transmural inflammation?

A

Inflammation of the entire 5 layers of the wall

44
Q

What is skip lesion?

A

Breaks in the inflammation where there is unaffected bowel

45
Q

What causes Crohn’s?

A

Inappropriate immune response to the gut flora in genetically susceptible individuals

46
Q

Where is Crohn’s most commonly found?

A

Terminal ileum

47
Q

How prevalent is Crohn’s disease?

A

100-200 in 100,000 with an incidence of 10-20 per 100,000

48
Q

What are the risk factors of Crohn’s?

A

Smoking increases risk 3/4 fold
NSAIDS can exacerbate disease
FH

49
Q

What are symptoms of Crohn’s?

A 
Diarrhoea (sudden)
Abdo pain - most likely in RLQ
Weight loss
Haematoschizia
Systemic symptoms
50
Q

What are the signs of IBD?

A 
Bowel ulceration
Abdo tenderness
Perianal lesions (abscess, tags, fistula)
Anal strictures (anus doesn't relax properly)
51
Q

What are complications of Crohn’s?

A 
SBO
Colon cancer
Abscess
Fistulae e.g. colovaginal
Primary Sclerosing Cholangitis
Malnutrition
Toxic megacolon (less common than UC)
52
Q

Which blood tests are needed for Crohn’s?

A 
FBC - anaemia, infection
ESR - chronic infection
CRP - acute infection
UEs - electrolyte imbalance
Iron studies - anaemia
B12, folate - malabsorption (terminal ileum)

Stool - MCS (c.diff, e.coli, campylobacter), faecal calprotectin

CT abdomen
Colonoscopy and biopsy
Capsule endoscopy w/ pre dissolving one in case blockage.
MRI

53
Q

How do we manage Crohn’s non-pharmacologically?

A

Help quit smoking

Optimise nutrition

54
Q

What are the drug therapies for Crohn’s?

A

Steroids
Azathioprine
Anti-TNFalpha (mabs)

55
Q

What signs/results merit IV admission for steroids?

A 
Raised tempurature
Tachycardic
Raised ESR
Raised CRP
Raised WCC
Raised albumin
56
Q

How do we treat Crohn’s?

A

Prednisolone 40mg OD for 1 week the taper 5mg a week for 7 weeks. Consider budesonide as second option.
IV hydrocortisone if too severe
May offer mesalazine if mild and can’t tolerate corticosteroids.
The above induces remission. The below maintain it but can also be used to induce remission if necessary.
Additional treatments can include
Azathioprine
Mercaptopurine
Methotrexate

57
Q

What is TPMT?

A

Thiopurine S-methyltransfurase

58
Q

Why is measuring TPMT important?

A

TPMT catalyzes the S-methylation of thiopurine drugs.
If the TPMT gene isn’t working properly, the drug won’t be catalysed which can increase bone marrow toxicity, potentialy causing myelosuppression, anaemia, bleeding, leukopoenia and infection.

59
Q

What do we MAINLY USE TO MAINTAIN REMISSION OF CROHNS?

A

Azathioprine 2-2.5mg/kg/day
Mercaptopurine 1-1.5mg/kg/day
Methotrexate 10-25mg/week PO

60
Q

Which biologic agents are used in Crohns?

A

Inflixumab
Adalimumab
Vedolizumab

61
Q

What should be prescribed alongside methotrexate?

A

Folic acid

62
Q

How is methotrexate monitored?

A

Monitor LFTs and UEs every 1-2 weeks until stable then every 2-3 months.

63
Q

What are side effects of methotrexate?

A

Fever, headache, nausea, vomiting

64
Q

How many people with Crohn’s often need surgery?

A

50-80%

65
Q

What are the indications for Crohn’s surgery?

A 
Drug failure
Obstruction
Perforation
Fistulae
Abscess
66
Q

What sort of diet may those with Crohn’s be put on?

A

Enteric (liquid) diet to maximise absorption.

Dietitian will know more

67
Q

How do we monitor azathioprine?

A

Monitor LFTs, FBC and UEs Weekly for four weeks
Monthly for three months
Three monthly

68
Q

What are the side effects of azathioprine that we have to look out for bc it means we have to stop?

A 
Abdo pain
Nausea
Pancreatitis
Leucopenia
Abnormal LFTs
69
Q

What are the contraindications of methotrexate and mercaptopurine?

A

Beware in females of childbearing age

70
Q

Which IBD uses 5-ASAs?

A

UC uses mesalazine.

Can be used as final resort in Crohn’s if all else in intolerable (rare)

71
Q

What do monoclonal antibodies target?

A

TNF alpha

72
Q

How do MABs work?

A

Counter neutrophil accumulation and granuloma formation and also cause cytotoxicity to CD4 cells, clearing the immune response driving cells.

73
Q

What are the contraindications for MABs?

A

Sepsis
Latent/active TB
Raised LFTs

74
Q

What is vedolizumab?

A

Anti-integrin

Gut specific mechanism of action

75
Q

How do anti-integrins work?

A

They target molecules that move lymphocytes around.

76
Q

Which surgery do we avoid in Crohn’s?

A

Pouch surgery

Gastroenterology (18 decks)

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