IBD Flashcards
Name two IBDs
- Ulcerative Colitis (effects only the COLON)
2. Crohn’s disease (any part of GI tract mouth - anus)
What ethnic group are most vulnerable to IBD
Jewish people
When does IBD occur
- Mucosal immune system exerts an inappropriate response to luminal antigens such as bacteria which may enter the mucosa via leaky epithelium
What is Ulcerative Colitis
Relapsing and remitting inflammatory disorder of COLONIC MUCOSA
What is ulcerative colitis od the rectum called
Proctitis
What is left-sided colitis
Rectum AND left colon
What is pan colitis
Ulcerative colitis that effects the ENTIRE COLON (up to ileocaecal valve)
Does ulcerative colitis effect ileocaecal valve
Never effects proximal to the ileocaecal valve
Where is ulcerative colitis most common
N. Europe
UK
N. A
Is Crohn’s or Colitis more common
Coeliac’s
What gender do ulcerative colitis effect
Males + females equally
What kind of habits can increase chances of colitis
SMOKERS and EX SMOKERS
Chances of ulcerative colitis with first degree relative having the disease
1 in 6
What surgery seems to protect people from ulcerative colitis
Appendicectomy before age 20
Risk factors of ulcerative colitis
- Family History
- NSAIDs
- Chronic stress + depression triggers flares
What differentiates Ulcerative Colitis from Crohn’s
- Restricted mucosal disease
What part of the colon does ulcerative colitis effect
Begins in the rectum and extends (only up to the ileocaecal valve)
Circumferential and continuous inflammation (NO SKIP LESIONS)
Appearance of mucosa in ulcerative colitis
Reddened and inflamed + bleeds easily
What structures are seen in severe ulcerative colitis
Ulcers and pseudo-polyps
Extent of spread of inflammation in ulcerative colitis
- Inflammation stays in mucosal layer
- No Granulomata
- Increased crypt abscesses
What happens to goblet cells in colitis
Depleted goblet cells
Clinical presentations in severe ulcerative colitis
- Runs a course of remissions and exacerbations
- Restricted pain in lower left quadrant
- Episodic or chronic diarrhoea with blood or mucus
- Cramps
- Bowel frequency linked to severity
Symptoms seen in acute UC
Fever
Tachycardia
Tender distended abdomen
In acute attacks of UC what is seen
- Bloody diarrhoea at night
Incontinence
What are extra-intestinal signs of Ulcerative Colitis
- Clubbing
- Aphthous oral ulcers
- Erythema nodusum
- Amyloidosis
What is erythema nodusum
Red round lumps below skin surface
Complications of Ulcerative Colitis
LIVER:
- fatty change
- Chronic pericholangitis
- Sclerosing cholangitis
COLON:
- Blood loss
- Perforation
- Toxic dilatation
- Colorectal cancer
Skin:
Erythema nodusum
Pyoderma gangrenous (painful ulcers on the skin )
Joints:
Ankylosing spondylitis
Arthritis
EYES:
Iritis
Uveitis
Episcleritis
Differential diagnosis of UC
Other causes of diarrhoea (salmonella, giardia intestinal and rotavirus)
Blood tests in UC
- WCC and planets raise din severe attacks
- Iron deficiency anaemia
- ESR and CRP raised
- Liver biochemistry abnormal
- Hypoalbuminaemia
- pANCA (Anti-neutrophilic cytoplasmic antibody) = positive
NEGATIVE in crown’s
Other than blood tests, how else do we diagnose UC
- Stool samples
- Faecal cal protein
- Colonoscopy (GOLD STANDARD) with mucosal biopsy
- AXR
Why are stool samples taken for UC
Exclude C.diff and campylobacter
What does the presence of faecal cal protein suggest
IBD (not specific)
Role of colonoscopy with mucosal biopsy for UC
- Allows assessment of disease activity and extent
2. Can see inflammatory infiltrate, goblet cell depletion, crypt abscesses and mucosal ulcers
What would an AXR show for UC
- Exclude colonic dilatation in acute severe attacks
When is an AXR used for UC
If too severe for colonoscopy
How is UC treated
INDUCE REMISSION
1. Aminosalicylate (5-ASA)
Where is 5-ASA absorbed
Small intestines
What 5-ASA is prescribed for UC
Sulfasalazine
MESALAZINE
OLSALAZINE
What is given for proctitis (mild UC)
Rectal 5-ASA
What is the first line treatment for left-sided colitis
Oral 5-ASA
If someone with UC does not response to 5-ASA what is prescribed instead
ORAL PREDNISOLON (glucocorticoid)
What is given in severe UC
ORAL PREDNISOLONE
In severe systemic involvement of UC, what is given (liver, skin and eye involvement)
- HYDROCORTISONE
- CICLOSPORIN
- INFLIXIMAB
How do we maintain remission
5-ASA: most patients require maintenance treatment
AZATHIOPRINE - for those who relapse if 5-ASA does not work
When is surgery done for UC
- Indicated for severe colitis that fails to respond to treatment
What two surges are done for UC
- Colectomy (colon removed) or ileoanal anastomosis (rectum fused to ileum)
What is the terminal ileum used for following ileoanal anastomosis
Reservoir pouch to store faeces
What is panproctocolectomy with ileostomy
Whole colon and rectum are removed and ileum is brought out to abdominal wall as a stoma
What is Crohn’s disease
A chronic inflammatory GI disease characterised by transmural (goes deep into mucosa) granulomatous inflammation affecting any part of the gut from mouth to anus (especially in terminal ileum and proximal colon)
Difference between Crohn’s disease and UC
- Skip lesions found in CD (unaffected bowel between areas of active disease)
Where is prevalence for Crohn’s highest
- N. Europe
- UK
- North America
What gender does Crohn’s effect more
Females
What risk factors are there for corhn’s
- Smoking
- 1 in 5 chance if first-degree relative
- NSAIDs
- Family History
- Chronic stress and depression triggers flares
- Good hygiene (those who live in poor hygiene families have lower risk of developing CD)
- Appendicectomy may increase risk of CD development
Where does Crohn’s typically effect
Terminal ileum and proximal colon
What happens to the wall of the bowel in Corhn’s
Thickened and narrowed
Cobblestone appearance of mucosa due to ulcers and fissures
What layers of the bowel does inflammation extend into
ALL LAYERS of the bowel
What happens to cells in Crohn’s
- Increase in chronic inflammatory cells
- Lymphoid hyperplasia
- Granulomas (non-caseating epithelia cell aggregates with langerhand’ giant cells)
- Goblet cells present
- Less crypt abscesses than UC
Clinical presentation of Corhn’s
- Diarrhoea with urgency (need to go 5-6 times in 45 mins), bleeding and pain
- Abdo pain (mimicks appendicitis - right iliac fossa pain)
- Weight loss
- Malaise
- Lethargy
- Anorexia
- Abdo tenderness
- Perianal abscess
- Anal strictures
- Extra intestinal signs: aphthous oral ulcerations, clubbing, skin, joint and eye problems
Complications of Crohn’s
- Perforation and BLEEDING - major
- Fistula formation
- Anal: skin tags, fissures, fistula
- Malabsorption
- Small bowel obstruction
- Toxic dilatation of colon
- Colorectal cancer
- venous thrombosis
- Amyloidosis
Differential diagnosis of Crohn’s
- Alternative causes of diarrhoea should be excluded (Salmonella, Giardia intestinal and rotavirus)
- Chronic diarrhoea
Physical examination of Crohn’s
- Tenderness of right iliac fossa
2. Anal examination
Blood tests in Crohn’s
- Anaemia is common due to malabsorption and iron/folate deficiency
- B12 anaemia is unusual
- Raised ESR and CRP
- Raised WBC and platelets
- Hypoalbuminaemia present in severe disease as part of acute phase response to inflammation associated with raised CRp
- Liver biochemistry may be abnormal
- Negative pANCA
Other than blood tests what other diagnostic features of crohn’s are there
- Stool sample (exclude C.difficile and campylobacter)
- Faecal cal protein (indicates IBD not specific)
- Colonoscopy (confirms spot lesions and granulomatous transmural inflammation)
- Upper GI endoscopy (exclude oesophageal and gasproduodenal disease)
How is Crohn’s treated
- Smoking cessation
2. Anaemia due to iron/B12 or folate deficiency (replacement)
How is mild attacks of crown’s traded
Controlled-release corticosteroids (BUDESONIDE)
How is moderate to severe tacks of crohn’s treated
Glucocorticoids (ORAL PREDNISOLONE)
When do we reduce the dosage of ORAL PREDNISOLONE
Every 2-4 weeks if symptoms resolve
How is severe attacks of Crohn’s treated
- IV HYDROCORTISONE
- Treat rectal disease (HYDROCORTISONE per rectum)
- Antibiotics (IV METRONIDAZOLE) for perianal disease (inflammation at or near the anus) and abscesses
- ORAL PREDNISOLONE if IV METRONIDAZOLE is working
how do we treat Corhn’s disease if there is no improvement
Switch to anti-TNF antibodies (INFLIXIMAB or ADALIMUMAB)
How do INFLIXIMAB and ADALIMUMAB function
Reduce disease activity by countering neutrophil accumulation and granuloma formation and activating complement
Causes cytotoxicity to CD4 cells clearing cells which drive the immune response
Main drugs that keep crohn’s in remission
- AZATHIOPRINE
- METHOTREXATE (if intolerant to AZATHIOPRINE)
- Anti-TNF antibodies (reduces remission if resistant to corticosteroids, immunosuppression then maintains it)
Main surgical intervention for crohn’s
Temporary Ileostomy = Allows time for affected areas to rest
Worst case scenario surgical intervention for Crohn’s
- Resection (results in short bowel syndrome so diarrhoea and malabsorption)
Parts of the colon affect din Coeliac’s, UC and Crohn’s
- Duodenum
- Colon
- ASS to mouth
Wat condition has no skip lesions
UC
