IBD/Celiac Flashcards
What is IBD
multifactorial disorder comprised of crohns and CUC
Not well understood but thought to be caused by genetics, environmental (dietary trigger), or immunologic
Give basics about Crohn’s disease
Idiopathic- more severe than UC! less prevalent than UC Peak onset 15-30 (but any age really) MC in jews Smoking increases your risk
Give basics about UC
Idiopathic more prevalent than crohns Peak onset 15-30 (but really any age) More common in jews Smoking decreases your risk
What does crohn’s disease affect
the entire GI tract, mouth to anus
Transmural= affects entire thickness of mucosa! this means ulcers, abscesses, and fistulas!!
MC site of Crohn’s is
Distal ileum
only a small percent also have mouth or upper GI manifestations (aphthuos ulcers)
Crohn’s can cause a fistulas (tunnels) where
bowel to bowel- Enteroenteric
bowel to bladder- Enterovesicular
bowel to vagina- Enterovaginal
bowel to skin- Enterocutaneous
How does Crohn’s present
Gradual onset and intermittent Sx- patient alternates between exacerbations and relative remission
Mild= inflammation
Mod= inflammation and strictures
Severe= inflammation, strictures, and fistulae
Sx of Crohn’s are
Abdominal pain Ileum: colicky RLQ pain \+/- palpable RLQ mass/fullness *Chronic, intermittent diarrhea, often nocturnal* Low grade fever, weight loss \+/- hematochezia/rectal bleeding
Rectal exam of someone with Crohn’s may present with
abscess, fistula, or skin tag
What does perianal disease in Crohn’s comprise
anal fissures
abscess
fistula
Extra-intestinal manifestations of crohn’s are
*Aphthous ulcers
*Large joint arthralgias
Erythema nodosum
*Episcleritis, uveitis, iritis
*Gallstones
Sclerosing cholangitis
What lab finding is indicative of sclerosing cholangitis
elevated alk phos
What Sx points you to iritis rather than another eye manifestation
Iritis is painful with pupil constriction
DDx for crohn’s can be
Infection (C diff, giardia, salmonella, shigella, E. coli) UC Colon cancer IBS Diverticulitis Lactose intolerance Celiac disease Lymphoma Endometriosis Ischemia -it is very hard to diagnose this if it's the first exacerbation!
How do you diagnose Crohn’s
Colonoscopy* and you can establish the diagnosis with endoscopic findings
Helps rule out cancer and determine extent of disease
Popcorns for Crohn’s are
Skip lesions* Cobblestoning, ulcerations Fistulas* *Spares the rectum* *Granulomas on biopsy
Other tests to help diagnose Crohn’s are
CT A/P w/ contrast- shows inflammation, abscess, and fistulas
Small bowel follow through- String sign*
ESR/CRP will be elevated in active disease
IBD specific Abs (not the best)
Long term inflammation increases risk of
Colon cancer
Crohn’s need colonoscopy surveillance q1-2 years
Complications of Crohn’s are
Fistula, abscess Obstruction Perforation *Nutrient deficiencies (iron, B12) Colon cancer Smoking and NSAIDs worsen Sx**
Generally what kind of treatment do you put a Crohn’s patient on
Step up plan; start conservative and build up
What are different Tx for Crohn’s
Crohn's specific Salicylates (5-ASA) Antibiotics for fistula/abscess Corticosteroids for flares Immunosuppressants TNF blockers (Remicade) Surgery (not curative bc they can still develop lesions anywhere) Nutrition
Where does UC commonly present
The colon only, almost always involves the rectum
Starts distal, moves proximal
Affects Mucosal surface only= friability, erosions, bleeding. but not through the entire lining like crohn’s!
Give some UC terms
Proctitis: disease limited to rectum
Left sided colitis: extends proximally but stops before splenic flexure
Extensive: extends beyond splenic flexure
Pancolitis: extends into cecum
How does UC present
Rectal bleeding Diarrhea, usually bloody* and nocturnal Crampy abdominal pain Tenesmus* (rectal urgency) Constipation w/ proctitis (rectum only)
Severe UC may cause
Anemia Fever >6 stools per day weight loss hospitalization PE: anemia, abd ttp, positive guaiac *if you see blood, you don't need to do a guaiac test!
Extra-intestinal manifestations of UC are
*Large joint arthralgias
Erythema nodosum
Episcleritis, iritis, uveitis
Sclerosing cholangitis
Difference with IBS and IBD is
IBS diarrhea is not bloody. IBD it usually is, esp in UC
How do you diagnose UC
*Flex sigmoidoscopy or colonoscopy for definitive Dx
helps r/o cancer and determine extent of disease
Endoscopy with UC is associated with
risk of perforation and induction of toxic megacolon
Some popcorn for UC are
Inflammation starts distally and spreads proximally
Continuous area of involvement, NO skip lesions
Loss of haustral folds
rarely see strictures
What are signs of inflammation in UC
Petechiae
Exudates
Friability
Other UC diagnostic tests are
CT A/P w/ contrast- will show inflammation
ESR/CRP will be elevated in active disease
IBD specific antibodies (not Sn/Sp)
Complications of UC are
**Toxic megacolon
NSAIDs can worsen
Colon cancer (colonoscopy q1-2 years)
Hemorrhage
What is toxic megacolon
Colon dilation >6cm w/ signs of toxicity
Usually presents in early, severe disease
Generally, how do you treat UC
Step up therapy; start conservative and build up 1st line: Specific Salicylates (5-ASA) Corticosteroids for flares Immunomodulators TNF blockers (Remicade) Surgery
What are indications for surgery in UC
Perforation
Severe hemorrhage (anemia requiring Tx)
Dysplasia/cancer
Refractory to medical management
If needed, what surgery is usually done
Proctocolectomy
What is first line therapy for UC
Salicylates specific to colon
Sulfasalazine
Mesalamine (asacol, lialda) (Rowsa enema, Canasa suppository)
Colazol
ADE of colon salicylates are
Nephrotoxicity
GI upset
What corticosteroids can you use for flares in IBD
Budesonide (less ADE)
Prednisone (may cause osteoporosis, insomnia, wt gain, adrenal insufficiency, psychosis)
-must taper SLOWLY, dont use for maintenance, and avoid dependence
What antibiotics are for Crohn’s ONLY (not UC)
Cipro and Flagyl
These are good for fistulas and abscesses
What immunomodulators are used for IBD
Mercaptopurine
Imuran
What TNF blockers are used for IBD
Remicade (infliximab)
Red flags in IBD are
Severe bleeding (severe anemia) Severe abdominal pain (peritoneal signs) Weight loss (cant tolerate PO) Signs of dehydration )high creatinine, tachy, hypotensive(
What are primary care considerations for IBD
Ensure compliance and appropriately monitor labs
Smoking exacerbates Crohn’s Sx so encourage them to stop (smoking improves UC Sx, but don’t promote smoking)
NSAIDs can worsen Sx
Patients on steroids, immunomodulators, and biologics are at increased risk for infection
Always check stool studies in patients with diarrhea
How are Crohn’s and UC different
Crohn’s: mouth to anus, transmural, MC at terminal ileum, fistulas, skip lesions, smoking worsens Sx
UC: colon only, mucosal layer only, MC at rectum, toxic megacolon, smoking improves Sx
What is Celiac disease
Immune disorder triggered by environmental exposure
Gluten is toxic to the small intestine; exposure causes mucosal inflammation, crypt hyperplasia, and villous atrophy (villa become flat)
Celiac is MC in
White northern Europeans
it runs in famiies
Celiac is associated with
FHx Autoimmune diseases T1DM Thyroid disease Down's syndrome
How does celiac disease present clinically
Diarrhea* w/ bulky, foul smelling floating stools (steatorrhea) *Bloating and flatulence Any GI Sx basically! Lactose intolerance *Iron deficiency anemia, Osteopenia, Dermatitis herpetiformis, vitamin B deficiencies (neuro d/o)* Elevated LFT weight loss FTT
How do you diagnose celiac disease
Must test pt WHILE gluten is in their diet
Serology: IgA anti tissue transglutaminase antibody test -or- “Celiac panel”
Gold: Small bowel biopsy with EGD (will see villous atrophy)
In order to complete an IgA test..
IgA levels must be normal to begin with in that patient. If IgA is baseline low, you wont know if they really have :low” levels
Someone presents with an itchy rash.. you think
Celiac disease!!!
DDx for celiac disease are
Crohn's IBS GERD Lactose intolerance or malabsorption Chronic constipation or diarrhea
How do you treat celiac disease
Avoid gluten!
Supplement as needed
What diseases are associated with malabsorption 2/2 celiac disease
*Iron deficiency anemia
B deficiency
Osteoporosis
Other celiac complications are
Increased risk of malignancy (non-hodgkins lymphoma, GI cancer)
Treatment helps decrease complications associated with celiac disease
