IBD, Celiac, Lactose Intolerance Flashcards
Etiology of IBD
dysregulated mucosal immune response to host gut flora in genetically susceptible individuals
Two major types of IBD
Ulcerative colitis
Crohns disease
What parts of the GI tract does UC affect?
mucosa/submucosa of the colon and rectum (diffuse lesions)
What parts of the GI tract does Crohns disease affect?
the entire GI tract, transmurally (skip lesions)
Damage to what can contribute to IBD
epithelial mucin proteins and tight junctions
The breakdown of homeostatic balance between what two things can contribute to IBD (2 groups)
host mucosal immunity and enteric microflora
regulatory and effector T cells
Polymorphisms is what things are a factor in IBD
toll like receptors
IBD is common in what geographic location
western world and industrialized countries
Which type if IBD is most common
UC
Incidence of UC
bimodal distribution
15-30 years and 50-70 years
What things put you at a higher risk for developing UC?
- being Jewish
- hx of GI infections
- weak association with OCP and NSAID use
What factors can lower your risk of getting UC or make the disease milder?
smoking
What are the most common presenting sx with UC?
- rectal bleeding
- bloody diarrhea
- abdominal pain
What elements classify UC as mild to moderate?
- <4 bloody BMs a day
- urgency and tenesmus
- LLQ cramping relieved by a BM
- possible fever, anemia, hypoalbunemia
What classifies UC as severe?
- > 6 bloody BM a day
- severe anemia, hypovolemia, hypoalbunemia with nutritional deficit
- abd pain
What is fulminant colitis?
subset of severe disease whichc is rapidly worsening sx’s with toxicity (pt present septic)
What is the clinical course of UC?
periods of remission and relapse
Common extraintestional manifestations of UC
- apthous ulcers
- iritis/uveitis/episcleritis
- erythema nodosum
- seronegative arthritis, ankylosing spondylitis, sacroilitis
- primary sclerosing cholanitis
Which extraintestional manifestations improve after a colectomy
- arthritis
- ankylosing spondylitis
- erythema nodosum
- pyoderma gangrenosum
Which extraintestional manifestations do not improve after a colectomy
primary sclerosing cholangitis
What needs to be ruled out before a diagnosis of UC can be made
infectious and non infectious causes of diarrhea
- infectious colitis
- radiation proctitis
- ischemic colitis
- CMV colitis
- STI proctitis
What labs are used to diagnose UC
ESR, CRP, H/H, albumin
What does a colonoscopy show in a patient with UC
- diffuse disease proximal to the dentate line
- friability of mucosa
- erythema, erosions, ulcerations, spontaneous bleeding
Histologic features of UC
- crypt abscess
- infiltration of lamina propia with plasma cells, eosinophils, lymphocytes
- lymphoid aggregates
- mucin depletion
Medical treatment for mild disease
aminosalicylates (5-ASA)
mesalazine or sulfasalazine
Medical treatment with failure of 5-ASA
budesonide (preferred)
prednisone
Medical treatment of serve disease
hospitalization and IV methylprenisolone with IVF
Medical treatment of severe disease with steroid resistance
TNF- alpha blocker
VGEF blocker
What is the last resort treatment for severe disease
cyclosporine
Maintenance therapy for UC
5-ASA (if responsive)
steroids
immunosuppresants
OR
continue with infliamab if induction therapy successful
Surgical therapy for UC
colectomy
When is a colectomy considered emergent? urgent? elective?
emergent: life threatening complications related to fulminant colitis or toxic megacolon that is unresponsive to medical treatment
urgent: severe disease admitted to hospital and not responding to medical treatment
elective: refractory disease, colorectal dysplasia or adenocarcinoma found on screening, long term disease (7-10 years)
When to pts begin to be screened for colorectal cancer w/ UC
8 years after diagnosis of disease
In patients with UC, when do you do a follow up colonoscopy if proctitis/proctosigmoiditis is found on initial screen? left-sided colitis/pancolitis? if patient hasPSC?
proctitis: follow specific age guidelines
left-sided colitis: every 1-2 years
UC w/ PSC: anually from time of diagnosis of PSC
In Crohns disease inflammation causes what in the GI tract
strictures, fistulas, ulcerations, abcesses
Extraintestinal manifestations of Crohns disease
- arthralgia
- iritis/uveitis
- pyoderma gangrenosum or erythema nodosum
Factors attributing to Crohns disease
- family history
- smoking
- sedentary lifestyle
- exposure to air pollution
- post infectious gastroenteritis
Presentation of Crohns disease
- RLQ intermittent abdominal pain
- diarrhea (watery/nonbloody)
- weithloss, anorexia
- weakness
Complications of Crohns disease
- abcess
- obstruction
- fistula
- perianal disease
- carcinoma
- malabsorption
Gold standard for diagnosis of Crohns
colonoscopy and mucosal biopsy
Labs for diagnosis of Crohns
CRP/ESR, fecal calprotectin, H/H, albumin, WBC
Treamtent of mild Crohns
colon and small bowel disease= mesalamine
Treatment of moderate to severe Crohns
Budesonide (short term)
immunosuppresants
TNF-alpha blockers (unable to taper from steroid)
anti-integrins (last line, not responsive to anything else)
Treatment of fistula disease in Crohns
ABX (flagyl and metronidazole)
immunosuppressants/ TNF-alpha
surgery
Is surgery curative in Crohns diseae
NO
When us surgery indicated in Crohns disease
- abscess
- intractable fistula
- toxic megacolon
- strictures with obstruction
- perforation
- cancer
When do you admit someone with Crohns to the hospital
- bowel obstruction
- intra abdominla or perirectal abscess
- sevre sx
- serious infections in immunocompromised population
What screenings should be done for pts with Crohns
- TB
- hepatits
- CMV
- HIV
- C diff
- colonscopy
What is celiac sprue disease
immunologic/inflammatory response to ingested gluten
What part of the GI tract does celiac sprue affect
mucosa of proximal small bowel
GI presentation of celiac
presenation
- diarrhea
- borborygmus
- weightloss
- weakness
- abd pain
Extraintestional sx of celiac
- anemia
- dermatitis herpetiformis
- hormonal disorders
- osteopenia and osteoperosis
Do older or younger people present with more GI sx at time of diagnosis
younger
Lab testing for celiac. What will it show?
CBC- anemia
CMP- malnutrition, electrolyte abnormality
Coags- PT prolonged (vit K def)
Stool- fat malabsorption
Serologic testing for celiac
IgA TTG
IgA level
if less than 2 do IgA TTG and IgG
Gold standard for dx of celiac
endoscopy and mucosal biopsy of proximal and distal duodenum
What will an endoscopy show in a pt with celiac
- atrophy or scalloping of duodenal folds
- absent villi or atrophic villi
- hypertrophy of crypts
Treatment of celiac
REMOVE ALL GLUTEN
-steroid if accidental ingestion of gluten
What causes lactose intolerance
inability to digest lactose, not enough lactose
Lactose intolerance can develop secondarily to what other diseases
- celiac
- crohns
- giardia
- viral gastrointeritis
- malnutrition
- short bowel syndrome
Clinical presentation of lactose intolerance
- abd bloating/cramping
- flatulence
- diarrhea
- nausea
- borborygmi
Labs for lactose intolerance
hydrogen breath test
Treatment for lactose intolerance
- remove lactose
- lactase enzyme replacement
- spread lactose intake throughout the day
