IBD Flashcards
Differences and similarities of UC vs Crohn’s
Features/presentation of Crohn’s
- Diarrhoea → usually non-bloody
- Weight loss more prominent
- Upper gastrointestinal symptoms, mouth ulcers, perianal disease
- Abdominal mass palpable in the right iliac fossa
Features of UC
- Bloody diarrhoea
- Abdominal pain in the left lower quadrant
- Tenesmus
Extra-intestinal diseases associated with Crohn’s and UC
Crohns:
- gallstones → secondary to reduced bile acid reabsorption
- Oxalate renal stones
UC:
- Primary sclerosing cholangitis
Complications of Crohn’s and UC
- Crohns: obstruction, fistula, colorectal cancer
- UC: colorectal cancer → higher risk than in Crohn’s
Inflammation in Crohn’s vs UC
- location
- lesion pattern
Crohns:
- Lesions may be seen anywhere from the mouth to anus
- Skip lesions
UC:
- Inflammation always starts at rectum and never spreads beyond ileocaecal valve
- continuous pattern of lesions
Histology in Crohn’s
- Inflammation in all layers from mucosa to serosa
- increased goblet cells
- granulomas
Histology in UC
- No inflammation beyond submucosa
- neutrophils migrate through the walls of glands to form crypt abscesses
- depletion of goblet cells and mucin from gland epithelium
- granulomas are infrequent
What’s seen on endoscopy of Crohn’s vs UC
Crohn’s:
Deep ulcers, skip lesions - ‘cobble-stone’ appearance
UC:
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Radiological signs of Crohn’s
Small bowel enema
- high sensitivity and specificity for examination of the terminal ileum
- strictures: ‘Kantor’s string sign’
- proximal bowel dilation
- ‘rose thorn’ ulcers
- fistulae
What’s that?
Stricture → Kantor’s Sign in Crohn’s disease
What’s that?
Rose thorn sign → Crohn’s
Radiological signs of UC
Barium enema
- loss of haustrations
- superficial ulceration, ‘pseudopolyps’
- long standing disease: colon is narrow and short -‘drainpipe colon’
What can cure UC?
Proctocolectomy
Indications for elective surgery in UC
disease that is requiring maximal therapy or prolonged courses of steroid
An absolute indication for surgery in UC
Dysplastic transformation of the colonic epithelium with associated mass lesions → proctocolectomy absolutely needed
Emergency surgery for UC
- indication
- procedure
- Emergency presentations of poorly controlled colitis that fails to respond to medical therapy → subtotal colectomy
- End ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.
Restorative surgical option for UC (1)
- name
- requirement
- complications
- Restorative options in UC→ ileoanal pouch
- this can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy
- Ileoanal pouch complications: anastomotic dehiscence, pouchitis and poor physiological function with seepage /przeciekanie/ and soiling
Indications for surgical resection in Crohn’s
Surgical resection in Crohn’s does not provide a cure but may give some symptomatic improvement
Indications:
- fistulae
- abscess formation
- strictures
What can extensive small bowel resections (in Crohn’s) lead to and how to prevent these complications?
Extensive small bowel resections may result in short bowel syndrome → localised stricturoplasty may allow preservation of intestinal length
How to manage complex perianal fistula in Crohn’s? Why?
Complex perianal fistulae → best managed with long term draining seton sutures
(complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence)
Is pouch reconstruction recommended in Crohn’s?
- Proctectomy → if severe perianal and / or rectal
- Ileoanal pouch reconstruction in Crohns → high risk of fistula formation and pouch failure → not recommended
The commonest affected site of Crohn’s disease
- possible treatment option
- possible complications related to this location
Terminal ileal Crohns → the commonest site
- patients may be treated with limited ileocaecal resections
- Terminal ileal Crohns → may affect enterohepatic bile salt recycling and increase the risk of gallstones
Is Arthritis and Episcleritis more common in UC or Crohn’s?
- Arthritis → in both CD and UC
- Episcleritis →more common in CD
Common extra-articular features in both, Crohns and UC (4)
- Arthritis: pauciarticular, asymmetric
- Erythema nodosum
- Episcleritis
- Osteoporosis
Is PSC more common in Crohn’s or UC?
Primary sclerosing cholangitis is much more common in UC
Is uveitis more common in Crohn’s or UC?
Uveitis is more common in UC
Classification of UC severity (3)
- mild: < 4 stools/day, only a small amount of blood
- moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Treatment for proctitis in UC (mild-moderate)
Proctitis in UC (mild-moderate)
(treatment to induce remission)
- topical (rectal) aminosalicylate: for distal colitis rectal mesalazine
- if remission is not achieved within 4
- weeks → add an oral aminosalicylate
- if remission still not achieved → add topical or oral corticosteroid
Management of Proctosigmoiditis and L - sided UC (mild-moderate)
Proctosigmoiditis and left-sided ulcerative colitis → Rx to induce remission (in mild-moderate)
- topical (rectal) aminosalicylate
- if remission is not achieved within 4 weeks →add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- if remission still not achieved → stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
Treatment to induce remission in extensive disease (inflammation) in UC
Extensive disease in UC
- topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
- if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Treatment of severe colitis in UC
Severe colitis in UC
- should be treated in hospital
- IV steroids are usually given first-line
- IV ciclosporin may be used if steroid are contraindicated
- if after 72 hours there has been no improvement → add intravenous ciclosporin to intravenous corticosteroids or consider surgery
How to maintain remission of mild-moderate UC
Following a mild-to-moderate ulcerative colitis flare
-
proctitis and proctosigmoiditis
- topical (rectal) aminosalicylate alone (daily or intermittent) or
- an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
- an oral aminosalicylate by itself: this may not be effective as the other two options
- left-sided and extensive ulcerative colitis
- low maintenance dose of an oral aminosalicylate
Treatment of UC following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
If: severe relapse of >=2 exacerbations per year
Is methotrexate prescribed in Crohn’s or UC?
- methotrexate is in Crohn’s
Are probiotics useful in the management of UC?
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease
Ix in Crohn’s disease
- raised inflammatory markers
- increased faecal calprotectin
- anaemia
- low vitamin B12 and vitamin D
Presentations of Crohn’s disease
Crohn’s disease typically presents in late adolescence or early adulthood. Features include:
- presentation may be non-specific symptoms such as weight loss and lethargy
- diarrhoea: the most prominent symptom in adults. Crohn’s colitis may cause bloody diarrhoea
- abdominal pain: the most prominent symptom in children
- perianal disease: e.g. Skin tags or ulcers
- extra-intestinal features are more common in patients with colitis or perianal disease
Peak age incidence of UC
The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years
Typical symptoms of UC
The initial presentation is usually following insidious and intermittent symptoms. Features include:
- bloody diarrhoea
- urgency
- tenesmus
- abdominal pain, particularly in the left lower quadrant
- extra-intestinal features (see below)
Management to induce remission in Crohn’s
Inducing remission in CD
- glucocorticoids (oral, topical or intravenous) *Budesonide is an alternative in a subgroup of patients
- enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
- 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
- azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
- infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
- metronidazole is often used for isolated peri-anal disease
Maintaining remission in Crohn’s - management
Maintaining remission in Crohn’s
- stopping smoking is a priority
- azathioprine or mercaptopurine is used first-line to maintain remission
- methotrexate is used second-line
- 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Smoking and IBD
Smoking makes Crohn’s worse, but may help ulcerative colitis
