IBD Flashcards
Name the two types of inflammatory bowel disease
Crohn’s disease
Ulcerative Colitis
How does smoking relate to Inflammatory bowel disease?
In Crohn’s disease smoking Accelerates disease progression
Less likely to respond to treatment
Smoking cessation effective treatment
In ulcerative colitis smoking has a protective effect. Onset of UC commonly follows
smoking cessation
nicotine patches as effective
as 5 ASA
Which drugs are known to initiate IBD or cause a relapse?
NSAIDS
Oral contraceptives
Opioids (loperamide, codeine)
How does physical activity relate to IBD and the different types?
Regular exercise reduces the risk of developing crohn’s disease - not ulcerative colitis
Reduces the relapse of crohn’s disease and possibly ulcerative colitis
At what age group is ulcerative colitis likely to happen?
20-40
Which areas of the bowel does Ulcerative colitis effect?
Colon and rectum only
Almost always rectum plus various amounts of colon
Describe the nature of inflammation found in ulcerative colitis?
Continues inflammation limited to the lamina propria / Mucosa- inner most layer
When someone presents with ulcerative colitis, what may their presenting complains be?
Diarrhoea - urgency Blood in stool Fatigue Weight loss low grade pyrexia Cancer Extra- intestinal manifestations
If proctitis (confined to rectum only) PR bleeding and mucus discharge, increased frequency and urgency of defecation, and tenesmus
How does having an appendectomy relate to IBD?
It has a proactive effect with ulcerative colitis
Where in the abdomen is a patient likely to experience pain with IBD?
Crohns- lower right abdomen - right iliac/right lumbar
Ulcerative colitis- Umbilical region
The pain is cramping pain
What are the signs of ulcerative colitis?
Tender abdomen – LIF generally mild
Pallor
Tachycardia
Leuconychia - malnutrition- white discoloration on the nails
Hypotensive
Extra-intestinal manifestations
In IBD what are the extra intestinal symptoms people may present with? (13)
- Joint inflammation and pain (arthritis) usually effects large joint, elbows, wrists, knees and ankles
- small joints of hands and feet can also be effected. Pain tends to be longer lasting and persist even after IBD is in remeission
More common in crohns and UC
sacroiliitis; ankylosing spondylitis
-Skin conditions such as erythema nodosum - raised tender red or violet swellings 1.5 cm in diameter, usually on the front of legs bellow the knee
Sweet’s Syndrome- sudden tender/ painful red nodules on the upper limbs, face and neck, sometimes with a fever. Assocaited with IBD treated with steroids or immunosurpressants
Pyoderma gangrenosum
Painful mouth sores/ ulcers- may go on their own or with steroid treatment
episcleritis, which affects the layer of tissue covering the sclera. scleritis (inflammation of the sclera itself) and uveitis (inflammation of the iris). These conditions are a lot more serious and can lead to loss of vision if not treated
Kidney stones- due to due to inflammation in the small bowel causing fat malabsorption, so the fat binds to calcium, leaving a molecule called oxalate free to be absorbed and deposited in the kidneys where it can form stones. Another cause of kidney stones is dehydration, which can be caused by fluid loss from diarrhea
Liver- About one in three people with Crohn’s develop gallstones. Primary sclerosing cholangitis, fatty liver, Autoimmunehepatitis
People with IBD are more than twice as likely to develop blood clots, including DVT (deep vein thrombosis) in the legs, and pulmonary embolisms in the lungs
osteoporosis
Anaemia- Iron deficiency, vitamin deficiency (B12, folate)- block loss and lack of absorption
Clubbing
In the blood tests for someone with ulcerative colitis, what are you likely to find?
Anaemia – microcytic Low ferritin, low albumin Raised inflammatory markers Low magnesium (absorbed in the colon) Low potassium
Which imaging techniques are used in someone with suspected ulcerative colitis?
Plain AXR
Endoscopy
Under which circumstance will Ulcerative colitis spread beyond the ileocaecal valve?
backwash ileitis
What is the cause of ulcerative colitis?
Inappropriate immune response against (?abnormal) colonic flora in genetically susceptibile individuals
If you suspect someone may have ulcerative colitis, which tests/ investigations should your order?
FBC ESR CRP U&E LFT Blood cultures Stool MC&S/CDT Faecal calprotectin- for GI inflammation Abdominal X ray Lower GI endoscopy / biopsy: flexible sigmoidoscopy in acute cases to assess and biposy full colonoscopy once controlled to define disease extent
Which categories are used to assess the severity of ulcerative colitis?
Number of bowel movements Rectal bleeding Temperature Resting pulse Haemoglobin ESR- erythrocyte sedimentation rate (also fo CRP)
How is mild ulcerative colitis defined?
Bowel movements- <4 Rectal bleeding- small Temperature- Normal Resting pulse rate <70 beats/min Haemoglobin- >110g/L ESR- <30
How is moderate ulcerative colitis defined?
Bowel movements- 4-6 Rectal bleeding- moderate Temperature- 37.1-37.8 Resting pulse rate 70-90 beats/min Haemoglobin- 105- 110g/L ESR-
How is sever ulcerative colitis defined?
Bowel movements- >6 Rectal bleeding- Large Temperature- >37.8 Resting pulse rate- >90 beats/min Haemoglobin <105g/L ESR/CRP- >30 (CRP >45mg/L)
List 4 acute complications of ulcerative colitis?
Toxic dilation of the colon (mucosal islands, colonic diameter >6cm)
Risk of perforation
Venous thromboembolism: give prophylaxis to all in-
patients regardless of rectal bleeding
Low potassium
List 2 chronic complications of ulcerative colitis?
Colonic cancer
Neoplasms
What is the name of the condition used to describe when ulcerative colitis effects the whole of the colon?
Pancolitis
How is mild ulcerative colitis treated?
5-ASA e.g. mesalazine
Given PR (suppositories or enemas) for distal disease ( < 20 cm on flexible sigmoidoscopy) or PO for more extensive disease
PLUS-
Topical steroid foams PR (eg hydrocortisone as Colifoam®), or prednisolone 20mg retention enemas
How is moderate ulcerative colitis treated?
If there are 4-6 motions but otherwise well treat with -
oral prednisolone 40mg/d for 1wk, then taper by 5mg/week over following 7wks
Then maintain on 5-ASA
What are the side effects of mesalazine and how are patients monitored when using the drug?
(headache, abdominal pain, nausea, diarrhoea, hair loss)
Rash, haemolysis, hepatitis, pancreatitis, paradoxical (weird) worsening of colitis
Monitoring- FBC and U&E at start, then at 3 months, then annually
How is sever ulcerative colitis treated?
Unwell plus >6 motions daily-
- admit for: IV hydration/electrolyte replacement
- IV steroids, eg hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
- Rectal steroids
- Thromboembolism prophylaxis (low molecular weight hearin)
- antibiotics if infection is a threat
- If on day 3–5 CRP >45 or >6 stools/d- Rescue therapy with ciclosporin or infliximab, can avoid colectomy
- If improving, transfer to prednisolone PO (40mg/24h). Schedule maintenance inflixi-mab if used for rescue, or azathioprine if ciclosporin rescue
If fails to improve then urgent colectomy by d7–10—
What is the treatment options for patients who are intolerant of immunomodulation, or developing symptoms despite an immunomodulator?
Maintenance therapy
Thiopurines (azathioprine and mercaptopurine):
Biologics: monoclonal antibodies including -
Anti TNF-
Infliximab, Adalimumab, Golimumab
Anti-integrin-
vedolizumab
JAK inhibitors
Tofacitinib
What should be monitored in someone suffering from an acute ulcerative colitis attack?
Temperature, pulse, BP. stool frequency and character
Abdominal distention bowel sounds and tenderness
FBC, ESR, CRP, U&E ± AXR
Which immunomodulator drugs are used in treating ulcerative colitis?
Azathioprine & 6-Mercaptopurine, cyclosporine
What are the macroscopic pathological changes caused by ulcerative colitis?
- Red inflamed mucosa
- Continues inflammation
- Friable
- Inflammatory polyps
What are the microscopic pathological changes caused by ulcerative colitis?
- Goblet cell depletion
- Crypt abscesses
- Inflammatory cells infiltrate lamina propria
What is the age range for peak incidence of crohn’s disease?
15-30 years
second mini peak at 60- 80
What are the symptoms of Crohn’s disease?
Pain Altered bowel habit - Diarrhoea - Obstruction Blood in stool weight loss Fistulae / Abscesses oral symptoms- e.g lip swelling, recurrent ulcers Extraintestinal manifestation Fatigue low grade fever
What are the signs of Crohn’s disease?
Pyrexia Dehydration Angular stomatitis Aphthous ulcers Pallor Tachycardia Hypotension Abdominal pain, mass and distension malnutrition
Which tests / imaging techniques would you order in someone suspected to have Crohn’s disease and what would the tests show?
Blood tests - Full blood count Liver function tests Urea & electrolytes CRP Magnesium Haematinics Bone profile Clotting
FBC- microcytic anaemia
Low ferritin, folate B 12
raised inflammatory markers e.g CRP and ESR
Low albumin
Faeces-
MC&S
OC&P
Faecal calprotectin
Plain abdominal X ray- loops of small bowel, small bowel dilation, megacolon
Barium follow up with X ray- strictures
rose thorn ulcers
CT scan-
Terminal ileal thickening
Abscesses or fistulae
Bowel obstruction
MRI-
Small bowel assessment for extent of inflammation and strictures
Pelvic/perineal sepsis
Endoscopy/ Biopsy
How is mild to moderate Crohn’s disease treated?
Prednisolone 40mg/d PO for 1wk, then taper by 5mg every wk for next 7wks
Budesonide 9 mg once daily for 8 weeks
A course of exclusive enteral nutrition (EEN) can be considered over an 8 week period. Or an Enteric diet
How is Sever Crohn’s disease treated?
- IV hydration/electrolyte replacement
- IV steroids, eg hydrocorti-
sone 100mg/6h or methylprednisolone 40mg/12h - thromboembolism prophylaxis (LMWH)
- Immunosuppressants (azathioprine or methotrexate)
- If improving switch to oral prednisolone (40mg/d).
- If not improving use biologics
Anti-TNFα – ACCENT 1&2, CLASSIC
Anti-Integrin - GEMINI
Anti IL-12/23 - UNITY
How is Perianal disease treated?
oral antibiotics- Cipro / Metronidazole
immunosuppressant therapy (Thiopurines or Methotrexate) ± anti-TNF (infliximab)
local surgery ± seton insertion
What is the Maintenance therapy for Crohn’s disease?
Thiopurines (azathioprine and mercaptopurine)
Methotrexate
Biologics-
Anti-TNFα – ACCENT 1&2, CLASSIC (infliximab)
Anti-Integrin - GEMINI (vedolizumab)
Anti IL-12/23 - UNITY- ustekinumab
What are the macroscopic features of Crohn’s disease?
cobblestone appearance in endoscopy
Bowel wall thickening, lumen narrowing, deep ulcers, fistulae and fissures
What are the microscopic features of Crohn’s disease?
Inflammatory infiltration
lymphoid hyperplasia
non-caseating granulomas
Skip lesions and transmural (across all the layers of the bowel wall) ulceration
Which parts of the GI tract is affected by Crohn’s disease?
Mouth to anus
usually anus spearing
