IBD, celiac, lactose intolerance Flashcards
what diseases make up IBD
- ulcerative colitis- more common
- crohns disease
where is UC usually found
- diffuse inflammation
- colon and rectum
- likely to see extraintestinal manifestations
- periods of relapse and remission
risk factors for UC
- genetics
- hx of GI infections
- week assoc with NSAIDs and OCP
- no data to support psychologic stress as trigger
si/sx of UC
- rectal bleeding*
- bloody, mucousy diarrhea*
- LLQ/ suprapubic pain*
- tenesmus
- few constitutional sx
extraintestinal sx of UC
- aphthous oral ulcers
- iritis, uveitis, episcleritis
- seroneg arthritis, ankylosing spondylitis, sacroilitis
- erythema nodosum*, pyoderma gangrenosum
- autoimmune hemolytic anemia
- primary sclerosing cholangitis
what treatment is considered curative for UC
- colectomy
- usually extraintestinal manifestations will also clear
mild-mod UC
- gradual onset diarrhea < 4x/day
- intermittent bloody mucoid stool
- urgency, tenesmus, accidents
- no significant abd pain
- LLQ cramping
severe UC
- bloody diarrhea > 6x/day
- severe anemia, hypovolemia, hypoalbuminemia, nutritional deficits
- LLQ pain/ tenderness
- fulminant -> toxicity and sepsis
- tachycardia, fever
how is IBD classified
- montreal classification
what is included in the montreal classification for UC
- extent (e)
- severity (s)
E1 UC
- proctitis
E2 UC
- left sided
- distal
- inflammation limited to splenic flexure
E3 UC
- pancolitis
- extends into proximal splenic flexure
S0 UC
- remission, no sx
S1 UC
- mild
- 4 or less stools per day
- absence of systemic sx
- normal inflammatory markers
S2 UC
- moderate
- 4 stools per day
- minimal systemic sx
S3 UC
- severe
- 6+ bloody stools per day
- pulse > 90
- temp > 37.5
- ESR > 30
dx of UC
- always r/o infection and non-infectious causes first with stool sample
- H&P
- inflammatory markers are good indicator of disease severity
- colonoscopy with bx
colonoscopy findings for UC
- diffuse disease from dentate line proximally
- edema, friability of mucosa
- erythema, erosions, ulcerations
- spontaneous bleeding
- do NOT perform on fulminant disease- risk of perf
medical management for mild UC
- aminosalicylates (5-ASA)
- mesalazine PR suppository or budesonide rectal foam for proctitis
- rectal and PO sulfasalazine, PR mesalazine
- used for long term maintenance after remission
medical management for mild-mod UC
- used after failing 5-ASA
- budesonide PO- targets colon with minimal systemic ADRs
- prednisone
- taper over 60 days
medical management for severe UC
- induction thearpy
- admission + IV methylprenisolone
- if steroid resistant give antibiologics
- TNF inhibitors: infliximab, adalimumab, golimuab
- VEGF inhibitors: vedolizumab
- cyclosporine last line
maintenance therapy for UC
- 5-ASA
- budesonide
- immunosuppressants- azathioprine or 6-MP
- if infiximab or azathioprine induction the continue with maintenance dose
- probiotics
colonoscopy screening for UC
- 8 years after disease onset
- if proctitis/ proctosigmoiditis guidelines vary
- left sided colitis/ pancolitis q1-2 years
- UC + PSC- annually from time of dx
where is crohns disease usually found?
- transmural
- anywhere in GIT
- skip lesions
- assos with exacerbations and remissions
- 1/3 of pts- terminal ileum onlin
- half of pts- small bowel + colon
- 1/5 of pts- colon only
- 1/3 of pts- perianal disease
- extraintestinal manifestations not as commo
what are common complications of crohns
- abscesses
- fistulae
- sinus tracts
- strictures
- adhesions
risk factors for crohns
- genetics
- tobacco use
- sedentary lifestyle
- exposure to air pollution
- western diet
- infectious gastroenteritis
si/sx of crohns
- intermittent abdominal pain
- RLQ pain usually
- diarrhea- watery, nonbloody
- incontinence
- more constitutional sx
- weight loss, anorexia, malnutrition
- bone loss
- SBO
surgical intervention for crohns
- generally want to avoid for as long as possible
- bowel resection does not decrease likelihood that pt has relapses
- want to preserve as much bowel as possible
treatment for abscesses in crohns
- CT to dx
- broad spectrum abx
- percutaneous drainage
treatment for obstruction in crohns
- IVF, IV steroids
- NGT decompression
- refractory -> partial resection or stricturoplasty
treatment for fistulas in crohns
- abdominal and rectovaginal fistulas common
- TPN/ oral elemental diet may temporarily close fistula
- antibiologics X 10 weeks- best mgmt but half recurr
- surgical resection if all others fail
treatment for perianal disease in crohns
- cipro or flagyl
- mesalazine PR or tacrolimus ointment for fissures
- antibiologics
- recurrence common
what is included in the montreal classification for crohns
- extent (L)
- phenotype (B)
L1 crohns
- confined to terminal ileum
L2 crohns
- confined to colon
L3 crohns
- ileum + colon
L4 crohns
- involves upper GIT
L3 + L4 crohns
- upper GIT plus distal GIT
B1 crohns
- without strictures, non-penetrating
B2 crohns
- stricturing
B3 crohns
- penetrating
B4 crohns
- perianally penetrating
crohns dx
- must r/o infectious and noninfectious causes first
- colonoscopy + bx
- inflammatory markers are good for monitoring disease progression
what is fecal calprotectin
- specific colonic inflammatory marker
- used in monitoring crohns
crohns treatment for diarrhea
- loperamide
- if terminal ileal disease or resection give bile acid sequesterants
- if short cut have pt on low fat diet
treatment for mild crohns disease
- mesalazine
treatment for mod-severe crohns
- steroid therapy until remission then taper X 60 days
- immunosuppressants- azathioprine or methotrexate
- TNF- alpha blockers common with good success
- VEGF inhibitors if lose response to TNF
- surgery NOT curative
surgical indications for crohns
- abscess failing medical mgmt
- intractable fistula
- toxic megacolon
- fibrotic strictures with obstruction
- recalcitrant sx despite high dose steroids
- perforation
- intractable hemorrhage
- cancer
colonoscopy screenings for crohns
- 8 years after onset
- q 1-2 years
- crohns + PSC annually
what infections should you monitor for in pts on immunosuppressants
- TB
- hepatitis
- CMV
- HIV
- C diff
where does celiac affect the gut
- proximal small bowel- duodenum
- vili become atrophied/ damaged/ absent -> malabsorption issues
si/sx of celiac
- diarrhea, flatulence, borborygmus
- weight loss
- weakness and fatigue
- sever abd pain
- older onset usually have atypical sx
extraintestinal sx of celiac
- fatigue, depression, iron deficiency anemia
- osteopenia/porosis
- neurologic sx
- dermatitis herpetiformis*- extensor surfaces of extremities, trunk, buttocks, scalp, neck
- amenorrhea, delayed puberty, infertility
PE findings for celiac
- protuberant and tympanitic abdomen
- weight loss
- orthostatic hypotension- dehydration
- peripheral edema- malabsorption
- ecchymosis- vit K
- hyperkeratosis- vit A
- cheilosis and glossitis- Fe
- peripheral neuropathy or ataxia- B12, E
- chvostek or trousseau sign, tetany- Ca
what blood tests are used for dx of celiac
- IgA TTG- best
- IgA levels- some may be deficient
- IgA TTG combined testing for IgG deaminated gliadin peptides
- all Ab should return to normal after GF diet- monitor compliance
gold standard for celiac dx
- endoscopy and biopsy at proximal and distal duodenum
treatment for celiac
- GF diet**
- dietary consult
- supplement initially for vit def
- steroids X2+ weeks for flare
what is often associated with celiac
- lactose intolerance
lactose intolerance
- inability to digest lactose
- low levels of lactase
- born wit high levels of lactase and declines with aging
si/sx of lactose intolerance
- abd bloating/ cramping
- flatulence, diarrhea
- nausea
- borborygmi
what lab test can be used to dx lactose intolerance
- hydrogen breath test
- lactose is fermented in absence of lactase -> acid production (H-)
