IBD

Question 1

What are all the forms of IBD?

Answer 1

Crohn's disease
Ulcerative colitis
Microscopic ulcerative colitis
Microscopic lymphatic colitis
Microscopic collagenous colitis

Question 2

What factors affect likelihood of developing IBD?

Answer 2

Genetics
Environmental susceptibility
Immune response

Question 3

Which environmental factors are risk factors for IBD?

Answer 3

Smoking
NSAIDs
Good hygiene
Psychological stress

Question 4

In what way is intestinal microbiota different in IBD?

Answer 4

Reduced diversity of gut flora

Decreased mucosal and chemical barrier

Question 5

In what way is the immune response different in IBD?

Answer 5

Overactive mucosal immunological response

Leaky epithelium increases chance of immune response

Question 6

Where does CD most commonly affect?

Answer 6

Terminal ileum and ascending colon

Question 7

What is proctitis?

Answer 7

UC affecting the rectum alone

Question 8

What is extensive colitis?

Answer 8

UC affecting the whole colon

Question 9

What is backwash colitis?

Answer 9

UC with inflammation of the distal terminal ileum

Question 10

What are the macroscopic changes in CD?

Answer 10

Involved bowel is thickened and often narrowed
Cobblestone appearance
Intra-abdominal fistulae and abscesses may be seen

Question 11

What are the macroscopic changes in UC?

Answer 11

Mucosa is red, inflamed and friable

Severe disease may have extensive ulceration with pseudo-polyps

Question 12

What are the microscopic changes in CD?

Answer 12

Transmural inflammation
Increase in inflammatory cells
Lymphoid hyperplasia
Granulomas in over half

Question 13

What are the microscopic changes in UC?

Answer 13

Superficial inflammation
Chronic inflammatory cell infiltrate in the lamina propria
Crypt abscesses
Goblet cell depletion

Question 14

What is the term for when it is not possible to distinguish between CD or UC?

Answer 14

Indeterminate colitis

Question 15

What are the extraintestinal manifestations of IBD that can manifest in the eyes?

Answer 15

Uveitis
Episcleritis
Conjunctivitis

Question 16

What are the extraintestinal manifestations of IBD that can manifest in the skin?

Answer 16

Erythema nodosum

Pyoderma gangrenosum

Question 17

What are the extraintestinal manifestations of IBD that can manifest in the liver and biliary tree?

Answer 17

Sclerosing cholangitis
Fatty liver
Chronic hepatitis
Cirrhosis
Gallstones

Question 18

How does microscopic colitis present?

Answer 18

Chronic or fluctuating watery diarrhoea

Question 19

Describe microscopic ulcerative colitis

Answer 19

Chronic inflammatory cell infiltrate in the lamina propria
Deformed crypt architecture
Goblet cell depletion

Question 20

Describe microscopic lymphocytic colitis

Answer 20

Surface epithelial cell injury
Prominent lymphocytic infiltration in surface epithelium
Increase in lamina propria mononuclear cells

Question 21

Describe microscopic collagenous colitis

Answer 21

Thickened sub epithelial collagen later adjacent to basal membrane
Increased infiltration of the lamina propria with lymphocytes and plasma cells
Surface epithelium damage

Question 22

What are the symptoms of CD?

Answer 22

Diarrhoea (+/- blood)
Abdominal pain
Weight loss and anorexia
Malaise, lethargy
Nausea and vomiting
Low grade fever

Question 23

What signs of CD can be seen on examination?

Answer 23

Weight loss
Signs of malnutrition
Aphthous ulceration
Abdominal tenderness or iliac fossa mass occasionally
Anal fissures or abscesses

Question 24

What blood tests are done in suspected IBD?

Answer 24

FBC
CRP/ESR
LFTs
Blood culture if septicaemia suspected
Serology

Question 25

Which stool tests may be done in suspected IBD?

Answer 25

Stool culture, including C. diff if diarrhoea Stool microscopy if travel history Faecal calprotectin raised in active intestinal disease

Question 26

Which endoscopic and imaging tests are done in suspected CD?

Answer 26

``` Colonoscopy with biopsy Upper GI endoscopy Small bowel imaging Ultrasound scanning Capsule endoscopy if radiological examination is normal ```

Question 27

How is disease activity of CD assessed?

Answer 27

``` Hb White cell count Inflammatory markers Serum albumin Faecal calprotectin or lactoferrin ```

Question 28

What medication is used to induce remission in a flare up of CD?

Answer 28

Steroids Enteral nutrition TNF-alpha if resistant to steroids or if disease is more extensive, preferably in combination with immunosuppressants

Question 29

What medication is used to maintain remission of CD?

Answer 29

Long-term immunosuppressants, e.g. azathioprine, methotrexate Anti-TNF (infliximab) for patients who are resistant to immunosuppressants

Question 30

What are the symptoms of UC?

Answer 30

``` Diarrhoea with blood and mucus Abdominal discomfort Malaise, lethargy Anorexia and weight loss Aphthous ulceration may be seen ```

Question 31

How is a severe attack of UC defined?

Answer 31

``` Stool frequency >6 per day with blood Fever Tachycardia ESR >30 Anaemia - Hb<100 Albumin <30 ```

Question 32

What is the management for a severe attack of UC?

Answer 32

1. Admit to hospital 2. Exclude enteric infection 3. Confirm diagnosis with limited flexible sigmoidoscopy 4. Assess fluid status 5. Give prophylactic anti-coagulation 6. IV hydrocortisone 7. Monitor

Question 33

What is toxic megacolon?

Answer 33

AXR showing thin walled colon with diameter of >6cm Gas filled and containing mucosal islands Impending perforation and high mortality

Question 34

What signs of UC can be seen on examination?

Answer 34

Abdomen may be slightly distended and tender Tacycardia and pyrexia indicate severe disease PR exam reveals the presence of blood

Question 35

What medication is used by most UC patients?

Answer 35

Aminosalicyclate

Question 36

What is the order medication is tried in UC?

Answer 36

5-ASA (aminosalicyclate) Steroids Immunosuppressant Anti-TNF

Question 37

What are the indications for surgery in UC?

Answer 37

In an acute attack: failure of medical treatment, toxic megacolon, haemorrhage, imminent perforation In chronic disease: incomplete response to medical treatment Dysplasia on surveillance colonoscopy

Question 38

What is the operation of choice for UC in acute disease?

Answer 38

Subtotal colectomy with end ileostomy and preservation of rectum