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IBD Flashcards

1
Q

What are inflammatory bowel diseases (IBD)?

A

chronic
relapsing
immunologically mediated disorders

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2
Q

What 4 main processes are thought to contribute to IBD pathogenesis?

A
  • luminal microbial antigens and adjuvants
  • genetic susceptibility
  • immune response
  • environmental triggers
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3
Q

Of the 110 IBS loci that are common between UC and Crohn’s, what are the main pathways implicated?

A

leprosy
myobacterial susceptibility
other immune-mediated disease

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4
Q

Name 2 loci implicated in Crohn’s susceptibility

A

NOD2

PTPN22

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5
Q

Name a loci implicated in UC susceptibility

A

MHC

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6
Q

What are common triggers for IBD?

A

NSAIDs
antibiotics
infections (viral, bacterial, parasitic)

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7
Q

What causes the mucosal damage in IBD?

A

hyper activation of T cell adaptive immune responses to commensal enteric bacteria
in combo with genetic susceptibility and environmental factors

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8
Q

What does the mucosal damage in IBD result in?

A

translocation of luminal contents
abnormal immune responses
chronic inflammation

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9
Q

What is ulcerative colitis?

A 
chronic inflammatory disease 
unknown aetiology 
affects colon only 
diarrhoea with blood and mucus
systemic features if extensive/severe
flare ups and remission
15-20% attacks are severe
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10
Q

What proportion of the colon is affected in UC?

A

Proctitis and distal colitis (36%)
Left-sided colitis (37%)
Pancolitis (37%)

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11
Q

What treatments can be used for UC?

A

proctitis: 5-ASA suppository

distal colitis: 5-ASA foam enema

L-sided colitis: 5-ASA liquid enema

pancolitis: topical and oral treatment

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12
Q

What is Crohn’s disease?

A 
chronic 
granulomatous inflammatory disease
affects any part of GI tract
most common: ileo-colonic
Crohn's colitis behaved similarly to UC
small number of colitis cases are indeterminate
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13
Q

Which areas of GI tract are commonly affected in Crohn’s disease?

A 
gastroduodenual (5%)
small intestine alone (5%)
distal ileum (35%)
right colon (35%)
colon alone (20%)
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14
Q

What are the main features of UC?

A 
11:100,000
M=F incidence
risk: 15-30, 60-80 yr
smoking reduces risk of UC
pANCA +ve in 75% of cases
8% concordance in twins
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15
Q

What are the main features of Crohn’s?

A 
7:100,000
M>F
risk: 15-30 60-80 yr
smoking increased risk
pANCA -ve
ASCA +ve in 86% of cases
67% concordance in twins
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16
Q

What are the Sx of UC?

A 
bloody diarrhoea
mucus
mucosal and submucosal inflammation
continuous/confluent disease
association with PSC
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17
Q

What are the Sx of Crohn’s?

A 
systemic Sx (weight loss)
abdo mass
fistulae/strictures
perianal disease
rectal sparing
skip lesions
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18
Q

What is the histology of UC?

A 
granular, friable
pseudopolyps
acute + chronic inflammation
muscularis and serosa are normal 
crypt abscesses
diminished goblet cells
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19
Q

What is the histology of Crohn’s?

A 
transmural 
submucosal oedema
lymphoid aggregates
fibrosis 
aphthous ulcers
granulomas (e.g. sarcoid/TB)
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20
Q

What are the microscopic features of UC?

A

Architectural:
crypt distortion, decreased crypt density, villous surface

Inflammatory:
increased transmucosal laminal propria cells, diffuse basal plasmacytosis, mucin depletion, paneth cell metaplasia

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21
Q

What are the microscopic features of Crohn’s?

A

architecture: normal/irregular/villous, crypt atrophy, distorted/dilated crypts

inflammatory:
basal plasmacytosis, increased basal lamina propria cells (neutrophils, round cells)

specific: epithelioid granuloma, basal giant cells, histiocytes infiltration in lamina propria

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22
Q

What are basal giant cells?

A

basal cells are the lowest layer of the epidermis (outer layer of skin)
presence of basal giant cells can be indicative of a malignancy/neoplasm, named on their appearance not that have to be a primary basal cell tumour

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23
Q

What are some extra-intestinal symptoms of IBD?

A

many - can lead to deficiencies affect multiple systems

e. g. eye: episcleritis
skin: pyoderma gangrenosum
circulation: phlebitis

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24
Q

What musculoskeletal complications can develop with IBD?

A

arthritis - seronegative spondylo-arthropathies

type 1: pauciarticular (< 5 joints), associated with disease activity

type 2: polyarticular

Rx: NSAIDs/sulphasalazine

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25
Q

How often do IBD patients have musculoskeletal complications?

A

9-53% of patients

26
Q

In which forms of IBD are musculoskeletal complications more common?

A

more common in:

  • Crohn’s colitis than UC
  • pancolitis UC than left-sided UC
  • colonic than small bowel disease
27
Q

Why is there osteoporosis risk for patients with IBD?

A 
corticosteroid use - to reduce IBD inflammation
reduced physical activity 
inflammatory-mediated bone resorption 
Ca/Vitamin D malabsorption
poor intake (lactose intolerance)

Fracture risk is 40% higher than general population

28
Q

What dermatological manifestations can present in IBD?

A

affects 2-34% of IBD patients
1-10.5% UC patients
0.5-20% of Crohn’s patients

erythma nodusom (EN) and pyodema gangrenosum (PG) are most common

others: psoriasis, angular stomatitis, aphthous stomatitis, Sweet syndrome

29
Q

What is ertythema nodosum?

A

painful palpable nodes
F>M
Crohn’s > UC
mirror disease activity

30
Q

What is pyoderma gangrenosum?

A

affects shins usually
adjacent to stoma
pathergy (exaggerated skin injury)

31
Q

What is Sweet syndrome?

A

very rare inflammatory skin condition
causes sudden onset of fever and painful rash on skin of limbs
also called acute febrile dermatosis

32
Q

What hepatopancreatobiliary complications are associated with IBD?

A 
PSC
cholelithiasis 
portal vein thrombosis
drug-induced hepatotoxicity 
drug-induced pancreatitis
33
Q

What is PSC?

A

primary sclerosing cholangitis (PSC)

inflammation, stricturing and fibrosis of intra- and extra-hepatic bile ducts

5% of UC patients have PSC
2% of Crohn’s patients have PSC

pancolitis > left-sided UC

30-59 years

M > F (2:1)

raised ALP 
raised ANA (33%)
raised pANCA (80%)

12-15% of patients with PSC undergoing liver transplantation

increased risk of colorectal Ca

34
Q

What malignancies is PSC a risk factor for?

A

cholangiocarcinoma

also increases risk of colorectal cancer

35
Q

What is cholelithiasis in IBD?

A

gall stones
affects mostly Crohn’s patients with ileal disease
causes interruption of enterohepatic circulation of bile acids
-> bile acid malabsorption

36
Q

Why does pancreatitis present in IBD patients?

A

common side effect of azathioprine and 6-mercaptopurine

immunosuppressive medications used in IBD

37
Q

What ocular manifestations are common in IBD?

A

affects 0.3-5% of IBD patients
less common is isolated small bowel disease

episcleritis - can mimic intestinal inflammation, treat bowel disease to correct. Can also use topical steroids

Scleritis: can impair vision. More severe cases may require systemic steroids/immunosuppression

uvetis: associated with musculoskeletal and/or dermatological presentations

f > M (4:1)

38
Q

What renal compilations present with IBD?

A

affects 6-23% of IBD patients

nephrolithiasis (kidney stones)

obstructive uropathy (hindrance to normal urine flow, normally structural or functional)

renal fistulae

treated with NSAIDs/sulphasalazine

39
Q

What is the main pulmonary complication of IBD?

A

Pulmonary embolus (PE)

40
Q

What is acute colitis?

A

bloody diarrhoea

Sx of colonic inflammation irrespective of cause

41
Q

How is colitis assessed?

A

history

toxicity extent: pulse, temperature, abdo tenderness and distension, wellness of patient

bloods: ESR/CRP, Hb, WCC, Platelets, albumin

Abdo X-ray

42
Q

What is the Ddx for (acute) colitis?

A

Infective: campylobacter, shigella, salmonella, E coli, C. diff, CMV colitis

IBD

Ischaemic colitis

Behcet’s

Drug-related (in UC): NSAIDs, cocaine, amphetamines

Drugs: nicorandil

43
Q

What is nicroandil used for?

A

used to treat angina

causes vasodilation

44
Q

What is Behcet’s disease?

A

inflammatory disorder affect multiple systems

most common; painful mouth sores, genital sores, eye inflammation, arthritis

sores last a few days

cause is unknown, likely partly genetic

45
Q

What pharmacological treatment can be used for UC?

A 
5-ASA: amino salicyclates
azathioprine: immunosuppressive 
oral steroids
IV hydrocortisone
ciclosporin: immunosuppressive
infliximab (monoclonal Ab targeting TNFa)
46
Q

What are the Truelove and Witts criteria for severe colitis?

A 
- 6+ bloody stools daily
one or more of:
- temp > 37.8
- pulse > 90
- Hb < 10.5 g/dL
- ESR > 30mm/h
47
Q

What is the mortality for acute ulcerative colitis?

A

untreated 24%
steroids 7%
timely surgery <1%

48
Q

What are the reasons why mortality of acute ulcerative colitis is thought to be <24% in DGHs?

A
  • delays in surgery
  • delays in Dx
  • undue persistence with unsuccessful medical treatment
49
Q

What are the factors predicting colectomy in severe UC?

A

Day 1
stool frequency > 9/day
albumin <30
HR >90

Day 3
Stool frequency >8/day
CRP > 45
(colectomy 85%)

Any
colonic dilatation (>5.5cm)
mucosal islands on AXR (abdo x ray)
(colectomy 75%)

50
Q

What are the Travis criteria (in UC)?

A

CRP > 45
Stool frequency >= 8
after 3 days of IV hydrocortisone

85% colectomy rate unless treatment is escalated

51
Q

By day 3 of treatment (in severe UC), what management must be implemented?

A
  • stool culture results
  • corrected electrolytes (esp. Mg)
  • colonic biopsy results
  • decision on treatment escalation (gastroenterologists)
52
Q

What is the role of Mg in the intestine?

A

intestinal inflammation can be caused by Mg deficiency

53
Q

What is toxic megacolon?

A

acute form of colonic distension
with abdo distension, fever, abdo pain and shock
very dilated colon observed on AXR

bad sign - call surgeons

54
Q

What investigations are done to screen for toxic megacolon?

A

daily abdo X-ray (AXR)

55
Q

What does treatment escalation depend on

in (severe) colitis?

A
  • age
  • severity
  • “colitis history”
  • pre-flare up therapy
  • patients wishes

Rx options

  • cyclosporin
  • infliximab
  • surgery
56
Q

How is the treatment option decided for colitis?

A

cyclosporin/infliximab vs surgery

  • ongoing azathioprine/6-mercaptopurine therapy
  • co-morbidies
  • patient wishes
57
Q

What are the types of staged surgery available for UC?

A

colectomy + ileostomy

ileoanal pouch

58
Q

What is cyclosporin?

A

calcineurin inhibitor
blocks activation of pro-inflammatory mediators
rapid onset of action (IV route)
high oral bioavailability

59
Q

How effective is cyclosporin?

A

response rate 80-90%
colectomy rate reduced to 30-47% in patients who respond to cyclosporin (6-9 months after Rx)
colectomy avoided at 5 years for 55-70%

60
Q

What is infliximab?

A

monoclonal antibody
targeting TNFa
mainly used in Crohn’s
increasing evidence for use in UC

61
Q

How can C. difficile infection complicate IBD?

A

C. diff + IBD = colectomy rate 20%
C. diff can mimic/precipitate IBD flares

C.diff enteritis is more problematic in IBD patients

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