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IBD Flashcards

1
Q

The incidence of Crohn’s disease is higher in the Western world (i.e. UK, Europe and America) than the rest of the world. TRUE/FALSE?

A

TRUE

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2
Q

What can be used to prove that there are genetic links in IBD?

A
  • Twin studies

- Affected 1st degree relatives

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3
Q

What genetic mutation is present in 10-20% of caucasians with Crohn’s disease? What does it cause?

A

NOD2/ CARD15 (IBD-1)

=> Encodes a protein involved in bacterial recognition

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4
Q

How can adaptive immunity of the mucosa be affected by abnormal T cell function?

A

Overactive effector T-cells → Inflammation/ Disease

Absence of regulatory T-cells → Uncontrolled Inflammation/ Aggressive Disease

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5
Q

What cells of the adaptive immune system cause Crohn’s disease, and which cause UC?

A 
Crohn's = Th1 mediated
UC = Mixed Th1/ Th2 or NKCs
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6
Q

Does smoking aggravate Crohn’s or UC?

A

Aggravates Crohn’s disease but protects against UC

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7
Q

Describe the typical clinical presentation of UC?

A
  • Female 20-30s
  • Relapsing course
  • Affects rectum extending proximally
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8
Q

How is UC referred to if it only affects a) the rectum? b) the rectum and left-side of the colon? c) the entire colon?

A

a) Proctitis
b) Left-sided colitis
c) pancolitis

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9
Q

What symptoms are usually present in UC?

A
  • Diarrhoea + bleeding
  • Increased bowel frequency
  • Urgency
  • Tenesmus (incomplete emptying)
  • Incontinence
  • Night rising
  • Lower abdo pain (esp. LIF)
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10
Q

What should you remember to check in patient’s history if you suspect UC?

A
  • Recent travel
  • Antibiotics
  • NSAID’s
  • Family history
  • Smoking
  • Skin, eyes, joints
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11
Q

What criteria is used to assess the severity of UC, and why is this scoring important?

A 
Truelove and Witt criteria:
>6 bloody stools/24 hour
\+
1 or more of:
-  Fever (>37.8°C)
- Tachycardia (>90/min)
- Anaemia (Haemoglobin <10.5g/dl)
- Elevated ESR (>30mm/hr)

Important as Severe UC = 30% risk of colectomy

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12
Q

What investigations can be used if you suspect UC?

A
  • C-reactive protein (CRP)
  • Albumin (a negative acute phase reactant)
  • Plain AXR
  • Endoscopy
  • Histology
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13
Q

What can an AXR show you that would point towards a diagnosis of UC?

A
  • Stool distribution = Absent in inflammed colon
  • Mucosal oedema / ‘thumb-printing’
  • Toxic megacolon:
    => Transverse >5.5cm
    => Caecum >9cm
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14
Q

What signs at endoscopy indicate UC is present?

A

Loss of vessel pattern
Granular mucosa
Contact bleeding

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15
Q

What signs on histology indicate UC is present rather than normal mucosa?

A
  • lack of goblet cells
  • crypt distortion
  • formation of abscesses (due to crypts closing at surface)
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16
Q

What complications can arise from UC?

A

Increased risk of colorectal cancer

- depends on severity and extent of disease

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17
Q

What extra-intestinal manifestations are common in UC?

A
  • Skin - erythema nodosum/ pyoderma gangrenosum
  • Joint arthritis
  • Eyes (uveitis)
  • Deranged LFTs, gallstones/ PSC
  • Oxalate renal stones
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18
Q

PSC is more commonly associated with UC than Crohn’s. TRUE/FALSE?

A

TRUE

- 80% of those with PSC have associated IBD

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19
Q

When does Crohn’s disease normally present?

A

90% onset before age 40

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20
Q

Describe the normal clinical appearance of Crohn’s which distinguishes it from UC?

A
  • Affects any region of GI tract from mouth to anus
    => Skip lesions
  • Transmural inflammation (all the way through wall)
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21
Q

What peri-anal disease is common in Crohn’s ?

A
  • Recurrent abscess formation
  • Pain
  • fistula with persistent leakage
  • Damaged sphincters
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22
Q

Resections to treat Crohn’s disease are minimised as they are NOT curative. TRUE/FALSE?

A

TRUE

- many patients require multiple surgeries

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23
Q

What symptoms can patients with Crohn’s disease experience?

A

Small intestine disease:

  • Abdominal cramps (peri-umbilical)
  • Diarrhoea
  • Weight loss

Colon:

  • Cramps (lower abdomen)
  • Diarrhoea with blood
  • Wt loss

Mouth:

  • Painful ulcers
  • swollen lips
  • angular chielitis

Anus:

  • peri-anal pain
  • abscess
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24
Q

What may you notice on examination of a patient with suspected Crohn’s disease?

A
  • Evidence of wt loss
  • RIF mass
  • peri-anal signs
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25
Q

What blood tests would you consider if you suspected Crohn’s disease in a patient?

A
  • CRP
  • albumin
  • platelets
  • B12 (absorbed in terminal ileum)
  • ferritin
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26
Q

What is usually visible on Crohn’s histology that distinguishes it from UC?

A
  • granuloma formation common
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27
Q

What investigations can be used to view the small and large bowel lumens in Crohn’s disease?

A

SMALL:

  • Barium follow-through
  • MRI
  • Technetium-labelled white cell scan

LARGE:
- colonoscopy

28
Q

What are the aims of treatment in IBD?

A
  • Control inflammation + heal mucosa
  • Restore normal bowel habit
  • Improve quality of life
  • Avoid long-term complications
29
Q

What lifestyle advice can be given to help treat patients with Crohn’s disease?

A
  • SMOKING aggravates Crohns
    => makes worse disease outcome
    => more rapid recurrence post-surgery
30
Q

What drug therapies are used in UC?

A

5ASA (mesalazine)
Steroids
Immunosuppressants (e.g. azathioprine)
Anti-TNF therapy

31
Q

What drug therapies are used to treat Crohn’s disease?

A

Steroids
Immunosuppressants (e.g. azathioprine)
Anti-TNF therapy

32
Q

How do 5ASA therapies (e.g. Mesalazine) work to treat IBD?

A
  • produces a Topical effect
  • Anti-inflammatory
  • Reduces risk of colon cancer
33
Q

What are the side effects of using 5ASA therapies?

A
  • diarrhoea

- idiosyncratic nephritis

34
Q

How are 5-aminosalicylic acid (5ASA) preparations delivered topically to the bowel mucosa?

A
  • suppositories

- enemas

35
Q

5ASA drugs can also be taken orally. TRUE/FALSE?

A

TRUE - these may come in granules/ sachets rather than a tablet/capsule form

They can be:

  • Prodrugs
  • pH dependent release (Asacol)
  • delayed release (Pentasa)
36
Q

Why are different preparations of oral 5ASA agents made?

A

They act on different areas of the GI Tract

e. g.
- Sulphasalazine only acts on colon
- Asacol acts on ileum and colon
- Pentasa acts on duodenum, jejunum, ileum and colon

37
Q

What arer the advantages and disavantages of using suppositories or enemas?

A
  • Suppositories coat <20cm BUT have better mucosal adherence than enemas
  • Reflex contraction aids proximal spread of enemas
  • <10% enemas actually remain in the rectum
38
Q

What corticosteroids are used to treat IBD and what is the aim of using this treatment?

A
  • Prednisolone: oral / topical

=> short course used to induce remission
- high dose initially, reducing over 6 - 8 weeks

39
Q

What are the potential side effects of using steroid treatments?

A

MSK:

  • Avascular necrosis
  • Osteoporosis

DERM:

  • Acne
  • Thinning of skin

Metabolic:

  • Weight gain
  • Diabetes
  • hypertension

Others:

  • Cataracts
  • Growth failure
40
Q

What immunosuppressants can be used as a more potent suppressor of inflammation in IBD?

A
  • azathioprine / mercaptopurine

- methotrexate

41
Q

Azathioprine has a slow onset of action. TRUE/FALSE?

A

TRUE

- 16 weeks

42
Q

Why should Allopurinol not be co-prescribed with azathioprine?

A

Allopurinol inhibits Xanthine oxidase

- XO enzyme is involved in the activation of azathioprine to its active product

43
Q

What are the main side effects of Azathioprine use?

A
  • Pancreatitis
  • Leucopaenia
  • Hepatitis
  • Small risk of lymphoma or skin cancer
44
Q

What is anti-TNF therapy and how does it work?

A

Tumour Necrosis Factor α = proinflammatory cytokine

=> this drug provides antibodies to TNF

=> Promote apoptosis of activated T- lymphocytes

45
Q

How can anti-TNF drugs be delivered?

A

infliximab; IV

adalimumab; S/C injection

46
Q

Anti-TNF drugs have a rapid onset of action. TRUE/FALSE?

A

TRUE

- 30-40% remission after single infusion

47
Q

When do the NICE guidelines indicate use of anti-TNF alpha in IBD?

A
  • part of long term strategy (inc. immunosuppression, surgery (Crohns), supportive therapy etc)
  • Used if refractory / fistulising disease
  • (make sure to exclude current infection / TB before use)
48
Q

What are the two main types of surgery used in IBD?

A

Emergency
- Failure to respond to medical therapy, small bowel obstruction, abscess, fistulae

Elective

  • Failure to respond to medical therapy
  • Dysplasia of colon mucosa
49
Q

Crohn’s surgery is NOT curative. TRUE/FALSE?

A

TRUE

- minimal resections each time

50
Q

Repetitive surgery for Crohn’s can result in what clinical outcome?

A

‘short gut syndrome’

=> May require lifelong total parenteral nutrition (reduced life expectancy)

51
Q

Surgery for UC is normally curative. TRUE/FALSE?

A

TRUE

52
Q

What surgeries can be offered to UC patients?

A
  • Permanent ileostomy
    OR
  • Restorative proctocoloectomy and pouch
53
Q

What emergency surgeries for IBD are considered “planned”?

A
  • Sub total colectomy for UC

- Resection of Crohn’s disease

54
Q

Why may a patient with Crohn’s disease undergo elective operations?

A
  • Resection
  • Stricturolplasty
  • Fistulas
  • Anal disease
55
Q

What elective operations can be done to help with UC?

A
  • Proctocolectomy with end ileostomy

- Proctocolectomy with ileorectal anastomosis

56
Q

What indications are there for elective surgery in UC?

A
  • Medically unresponsive disease
  • Dysplasia/malignancy
  • Growth retardation in children
  • Attempted resolution of extra-intestinal disease
57
Q

What different types of ileorectal anastomosis can be created after surgery for UC?

A

W pouch
J pouch
S pouch

58
Q

Pouches are usually more popular with younger patients. TRUE/FALSE?

A

TRUE

- means they don’t have colostomy/ ileostomy bag to change/ wear for the rest of their life

59
Q

What immediate local complications can occur during IBD surgery?

A
  • haemorrhage

- enterotomy

60
Q

What early complications can present due to IBD surgery?

A
  • urinary dysfunction
  • wound infection/ abscess
  • anastomotic leak
  • ileus
  • portal vein thrombosis
61
Q

WHat complications of IBD surgery present late?

A
  • impotence
  • infertility
  • pouchitis
  • DVT/PE
  • small bowel obstruction
62
Q

What criteria is used to assess the severity of a UC attack?

A

Truelove and Witt Criteria

  • ESR/PV
  • Haemoglobin
  • Bloody Stools
  • Temperature
  • Heart rate
63
Q

Removal of the colon in IBD tends to settle rectal disease (even though the rectum itself is not removed). TRUE/FALSE?

A

TRUE

- rectal problems can be managed medically with enemas/ medication

64
Q

What are the main indications for surgery in Crohn’s disease?

A
  • Stenosis causing obstruction
  • Fistulae
  • Abscesses
  • Bleeding (acute or chronic)
  • Free perforation
65
Q

What surgery can be completed if patients with Crohn’s experience gastro-duodenal disease?

A

Gastrojejunostomy

- allows to avoid duodenal or pyloric stenosis

66
Q

Pouches for Crohn’s disease patients is controversial. TRUE/FALSE?

A

TRUE

67
Q

Squamous cell carcinoma may occur after peri-anal Crohn’s disease. TRUE/FALSE?

A

TRUE

GI (33 decks)

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