IBD Flashcards

1
Q

what is IBD?

A

Inflammatory bowel disease (IBD) is an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract.

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2
Q

what are the different types of IBD?

A
  • crohn’s disease and ulcerative colitis
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3
Q

what is the definition of Chron’s Disease?

A

chronic inflammatory and ulcerating condition of the GI tract that can affect anywhere from the mouth to the anus
(most common in the terminal ileum and the colon)

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4
Q

who is more likely to get Crohn’s Disease?

A
  • young patients

- more common in males

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5
Q

what is the presentation of Crohn’s Disease?

A
  • abdominal pain
  • small bowel obstruction
  • diarrhoea
  • bleeding PR
  • anaemia
  • weight loss
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6
Q

what are changes in histology?

A

granuloma formation, lamina propria plasma cells and lymphocytes, neutrophillic inflammation

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7
Q

what is the pathology of Crohn’s Disease?

A
  • segmental disease
  • ileal and/or colonic chronic active mucosal inflammation
  • transmural inflammation
  • deep knife-like fissuring ulcers
  • granulomas, 50%, non-caseating
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8
Q

what are the malabsorption complications of Crohn’s Disease?

A
  • malabsorption
  • -iatrogenic (short bowel syndrome)
  • -hypoproteinemia, vitamin deficiency
  • -gallstones (interrupted enterohepatic ciruclation)
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9
Q

what are the fitula complications of Crohn’s Disease?

A
  • vesicocolic
  • enterocolic
  • gastrocolic
  • recto vaginal
  • tuboovarian abscess
  • bind loop syndrome
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10
Q

what are the anal disease complications of Crohn’s Disease?

A
  • sinuses
  • fissures
  • skin tags
  • abscesses
  • perineum fall apart
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11
Q

what intractable disease complications are of Crohn’s Disease?

A
  • failure to tolerate or respond to medial therapy
  • continuous diarhoea or pian
  • may require surgery
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12
Q

give examples of environmental triggers f Crohn’s Disease

A
  • smoking
  • NSAIDs
  • infectious agents
  • vasculitis
  • sterile environment theory
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13
Q

describe the immune response involved in Crohn’s disease?

A
  • persistent activation of T cells and macrophages

- excess proinflammatory cytokine production

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14
Q

what is the definition of ulcerative colitis?

A
  • chronic inflammatory disorder confined to colon and rectum

- mucosal and submucosal inflammation

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15
Q

who is more likely to get ulcerative colitis?

A
  • young patients

- males

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16
Q

where is ulcerative colitis?

A

colon and rectum

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17
Q

what is the clinical presentation of ulcerative colitis??

A

diarrhoea, mucus and blood PR

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18
Q

what are the changes in histology for ulcerative colitis

A
  • massive influx of inflammatory cells
  • basal lymphoplasmacytic infiltrate with irregular shaped branching crypts
  • acute cryptitis
  • absecesses
  • excess fibrin
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19
Q

management of ulcerative colitis/

A
  • does not respond to medical therapy

- subtotal colectomy

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20
Q

where is inflammation confined to in ulcerative colitis?

A

mucosa and submucosa

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21
Q

give a pathological summary of ulcerative colitis

A
  • continuous, diffuse disease
  • rectal involvement
  • superficial ulceration and inflammation
  • chronic active colitis
    • cryptitis
    • crypt abscess
  • no granulomas
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22
Q

intractable disease complications of ulcerative colitis

A
  • continuous diarrhoea
  • flares may be due to intercurrent infection by enteric bacteria or CMV
  • total colectomy
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23
Q

what are the toxic megacolon complications of ulcerative colitis?

A
  • acute or acute on chronic fulinmant colitis
  • colon swells up to massive size
  • will rupture unless removed
  • emergency colectomy
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24
Q

how can complications of ulcerative colitis lead to colorectal carcinoma?

A
  • chronic inflammation leads to epithelial dysplasia and the carcinoma
  • risk increased if
    • pancolitis
    • disease longer than 10 years
  • requires surveillance
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25
Q

give a summary of complications of ulcerative colitis

A
  • blood loss
  • electrolyte disturbance
  • anal fissures
  • eyes: uveitis
  • liver: primary sclerosing cholangitis
  • joints: arthritis
    skin, erythema ?
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26
Q

why do you get ulcerative colitis?

A
  • genetic defects
  • aberrant immune response
  • environmental factors
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27
Q

describe the immune response of ulcerative colitis

A
  • persistent activation of T-cells and macrophages
  • autoantibodies present
  • excess proinflammatory cytokine production
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28
Q

explain the pathogenesis of ID

A

the genetic predisposition + mucosal immune system + environmental triggers

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29
Q

what is the IBD gene?

A

NOD2/CARD15 (IBD-1)

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30
Q

what chromosome is the disease susceptibility gene located?

A

16q12

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31
Q

what does the gene encode?

A

a protein involved in bacterial recognition

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32
Q

describe the innate immunity involved in IBD

A
  • tight junctions regulate epithelial permeability
  • hydrophobic mucus protects the epithelial cell layer
  • defensins (catatonic anti-microbial peptides) can be activated
  • NOD2 contributes to normal mucosal defences
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33
Q

describe the adaptive immunity involved in IBD

A
  • T lymphocytes are critical to the orchestration of adaptive mucosal immunity
  • ## normal conditions are characterised by a balance between effector and regulatory T cell responses
34
Q

what happens if there is an overreactive effector T-cell response?

A

inflammation/disease

35
Q

what happens if there is an absence of regulatory T cells?

A

uncontrolled inflammation/aggressive disease

36
Q

what T helper cells mediate Crohn’s disease?

A

Th1

37
Q

what T helper cells mediate ulcerative colitis?

A

mixed Th1/Th2 and NKTC

38
Q

what are the main symptoms of UC?

A
  • diarrhoea and bleeding
  • increased bowel frequency
  • urgency
  • tenesmus
  • lower abdo pain (esp LIF)
39
Q

how would you determine the severity of UC?

A
- Truelove and Witt criteria 
>6 bloody stools/24 hours
\+ 1 or more of 
   fever 
   tachycardia
   anaemia
   elevated ESR
40
Q

what tests would you do for UC?

A
  • bloods (CRP, albumin)
  • plain AXR
  • endoscopy
  • histology
41
Q

why would you do a plain AXR in UC?

A
  • to see stool distribution, mucosal oedema/thumb printing or toxic megacolon
42
Q

why would you do an endoscopy in UC?

A
  • to define extent
  • confluent inflammation
  • loss of vessel pattern
  • granular mucosa
  • contact bleeding
43
Q

what are histological signs of UC?

A
  • crypt distortion

- absence of goblet cells

44
Q

what are some extra-intestinal manifestations of UC?

A
  • skin
  • joints
  • eyes
  • deranged LFTs
  • oxalate renal stones
45
Q

what is Primary Sclerosing Cholangitis (PSC)?

A

chronic inflammation of biliary tree

46
Q

what are signs of PSC?

A
  • most asymptomatic OR itch, rigors
  • cholestatic LFTs
  • 15% get cholangiocarcinoma
47
Q

what is cholestasis?

A

a decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile ducts

48
Q

describe the distribution of Crohn’s disease

A
  • can affect any region of GI tract
  • skip lesions
  • transmural inflammation
49
Q

what are signs and symptoms of peri-anal disease?

A
  • recurrent abscess formation
  • pain
  • fistula with persistent leakage
  • damaged sphincters
50
Q

what are the disease phenotypes of Crohn’s disease?

A
  • stenosis
  • inflammation
  • fistula
51
Q

what are symptoms of Crohn’s disease in the small intestine?

A
  • abdominal cramps (peri-umbilical)

- diarrhoea, weight loss

52
Q

what are symptoms of Crohn’s disease in the colon?

A
  • abdominal cramps (lower abdomen)
  • diarrhoea with blood
  • weight loss
53
Q

what are symptoms of Crohn’s disease in the mouth?

A
  • painful ulcers
  • swollen lips
  • angular chielitis
54
Q

what are symptoms of Crohn’s disease in the anus?

A
  • peri-anal pain

- absecess

55
Q

what blood tests would you do for Crohn’s disease?

A

CRP, albumin, platelets, B12, ferritin

56
Q

what are endoscopic signs of Crohn’s disease?

A

cobblestoning, thickened walls, fissures

57
Q

what are endoscopic signs of ulcerative colitis?

A
  • ulceration
  • loss of haustra
  • crypt distortion
  • pseudopolyps
58
Q

what are some of the aims of IBD therapy?

A
  • control inflammation and heal mucosa

- restore normal bowel movement

59
Q

what is the lifestyle advice for therapy?

A
  • smoking aggravates Crohn’s

- diet not implicated in pathoogenesis but can induce symptoms

60
Q

what drug types would you give to a patient with ulcerative colitis?

A
  • 5ASA (mesalazine)
  • steroids
  • immunosuppressants
  • anti-TNF therapy
61
Q

what drug types would you give a patient with Crohn’s disease?

A
  • steroids
  • immuosuppressants
  • anti-TNF therapy
62
Q

what is the mechanism of action of 5ASA?

A
  • anti-inflammatory

- reduces risk of colon cancer

63
Q

what are side effects of 5ASA?

A
  • diarrhoea

- idiosyncratic nephritis

64
Q

what are the pros and cons of oral 5ASA?

A
  • prodrugs
  • pH dependent release
  • dealyed release
65
Q

what are the pro and cons of topical 5ASA?

A
  • suppositories coat <20cm but have better mucosal adherence than enemas
  • enemas. reflex contraction aids proximal spread of foam or liquid enemas
  • <10% enemas remain in the rectum
66
Q

give some examples of 5ASA drugs

A
  • sulphasalazine
  • balsalazide
  • mezavant
  • asacol salofalk
  • pentasa
67
Q

describe mechanism of corticosteroids

A
  • systemic anti-inflammatory properties
  • eg prednisolone, budesonide
  • to induce remission
  • short course of high dose initially then reduce over 6-8 weeks
68
Q

what are the musculoskeletal side effects of steroids?

A

avascular necrosis

osteoporosis

69
Q

what are the cutaneous side effects of steroids?

A
  • acne

- thinning of skin

70
Q

what are the metabolic side effects of steroids?

A
  • weight gain
  • diabetes
  • hypertension
71
Q

give examples of immunosuppressive drugs used in the maintenance therapy of Crohn’s

A
  • azathioprine/mercaptopurine

- methotrexate

72
Q

what is the mechanism of action of Azathioprine?

A
  • slow onset
  • TPMT activity contributes to toxicity
  • avoid co-prescription of allopurinol
  • regular blood monitoring required
73
Q

what are side effects of Azathioprine?

A
  • pancreatitis
  • leucopaenia
  • hepatitis
74
Q

what is Tumour Necrosis Factor alpha?

A

proinflammatory cytokine

75
Q

name antibodies to TNF

A
  • chimeric (infliximab)

- humanised (adalimumab)

76
Q

how is infliximab administered?

A

IV infusion

77
Q

how is adalimumab administered?

A

S/C injection

78
Q

what is the mechanism of action of anti-TNF therapy?

A
  • promote apoptosis of activated T-lymphocytes
79
Q

when would you use ant-TNF therapy?

A

as part of long term strategy, including immune suppression, surgery (Crohn’s), supportive therapy

80
Q

why would you perform an elective operation for Crohn’s disease?

A
  • resection
  • strictuoplasty
  • fistulas
  • anal disease
81
Q

why would you perform an elective operation for UC?

A
  • proctocolectomy with end ileostomy

- proctocolectomy with ileorectal anastomosis