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Clin Med III Exam 1 > IBD & Celiac's > Flashcards

IBD & Celiac's Flashcards

1
Q

IBD consists of

A 
Chrohn Disease (CD)
Ulcerative Colitis (UC)
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2
Q

Risk factors for IBD

A 
15-35 YO (bimodal w/ second peak 50-80)
Men- UC
Women: CD
Caucasian and Jewish
1st degree relative w/ IBD
Smoking (increases CD; decreases UC)
potential association w/ "western" diet
imbalance in gut microbiome
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3
Q

Crohns disease overview

A

GI tract from mouth to anus
patchy/skip lesions
Transmural inflammation

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4
Q

Ulcerative Colitis

A

limited to colon, involves rectum
extends proximally w/ continuous, circumferential involvement
mucosal layer inflammation

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5
Q

Severity of CD involvement

A

entire GI from mouth to anus w/ SKIP lesions
- mouth (apthous ulcers) or gastroduodenal area
- ileum –> ileitis (most common) **
- terminal ileum (TI) & proximal ascending colon –> ileocolitis
- colon –> colitis “chrohn colitis”
perianal disease (abscess, fistula)

transmural – entire thickness of mucosa
PENETRATING DISEASE- ulcer, stricture, fistula, abscess

FISTULA (Tunnel) between two epithelial lined organs

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6
Q

skip lesion

A

CD

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7
Q

mucosal inflammation

A

UC

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8
Q

transmural inflammation

A

CD

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9
Q

Types of fistulas

A

enteroenteric
enterovesical
enterovaginal
enterocutaneous

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10
Q

Presentation of CD

A

depends on severity:
mild - inflammation
moderation- inflammation, strictures
severe - inflammation, strictures, fistula

insidious onset, usually intermittent - alternate bw exacerbations and relative remission

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11
Q

Hx and PE for CD

A

+/- fever, chills, fatigue, weight loss
+/- n/v, diarrhea (nocturnal), fecal urgency, tenesmus, rectal bleeding, perianal pain, fissure, abscess, IDA, B12 deficiency (TI involvement)

ABDOMINAL PAIN: RLQ pain/tenderness; tender, palpable RLQ mass (if abscess)

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12
Q

Extra-intestinal manifestations of CD

A 
oral apthous ulcers
episcleritis, iritis, uveitis
erythema nodosum
pyoderma grangrenosum
ARTHRALGIAS **
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13
Q

Dx of CD

A

CBC, CMP, ESR/CRP (+/- IBD specific antibodies)

Stool study: culture, c.diff, O&P, fecal calprotectin or lactoferin

Scope: colonoscopy w/ TI intubation; +/- IBD **

Imaging:
+/- CT, MR enterography, UGI w/ SBFT, capsule endoscopy (not in intestinal stricture)

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14
Q

Contra of capsule endoscopy

A

patients w/ suspected intestinal stricture

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15
Q

Diagnostic findings in CD

A 
skip lesions
ulcerations, cobblestoning
possible fistulas
rectal sparing in most pts
bx = GRANULOMAS (30% PTS) and chronic inflammation

CT/MR enterograph - inflammation, stricture, abscess, fistula

UGI w/ SBFT - “string sign”

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16
Q

fecal calprotectin

A

shows inflammation in bowed (IBD)

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17
Q

Complications of colon cancer

A

Colon CA
strictures, abdominal and perianal fistulas, abscess - SMALL BOWEL OBSTRUCTION/PERFORATION
malabsorption* (Fe, B12)

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18
Q

How often should CD get colonoscopy

A

every 1-2 years beginning 8 years after disease/sx onset

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19
Q

UC severity/extent

A

colon only; continuous, circumferential; mucosal surface only – friability, erosions, bleeding

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20
Q

Presentation of UC

A

mild: <4 stools/day, no systemic
mod: >4 stools daily, anemia, low grade fever
severe: >6 stools, systemic toxicity

insidious, intermittent

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21
Q

Hx and PE for UC

A

• +/- Fever, chills, fatigue, weight loss
• +/- Nausea/vomiting
• Abdominal pain***
- Periumbilical/LLQ pain
• Bloody diarrhea
• Fecal urgency, tenesmus, rectal bleeding • Constipation (if proctitis)
• +/- iron deficiency anemia

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22
Q

Extra-intestinal manifestations of UC

A
  • Episcleritis, iritis, uveitis
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Sclerosing cholangitis – (Alk phos) **
  • Arthralgias*
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23
Q

Labs for UC

A

CBC, CMP, ESR, +/- IBD antibodies
Stool studies: fecal calprotectin or lactoferrin

Scope* - Flex Sigmoidoscopy or Colonoscopy

Imaging: CT A/P

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24
Q

Diagnostic findings for UC

A

• Inflammation begins distally, spreads proximally
• Continuous circumferential pattern, no skip lesions
• Loss of vascular markings
• Superficial inflammation: erythematous,
exudate, friability/erosions
• Strictures rare
• Biopsy shows – crypt abscesses

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25
Q

Complications

A

Colon CA
Hemorrhage
Toxic Megacolon** - chronic dilation >6 cm w/ signs of toxicity

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26
Q

Goal of IBD management

A

obtain and remain remission; healing mucosa

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27
Q

Medical therapies used

A

Salicylates (5-ASA)
corticosteroids
immunomodulators (6MP, Azathiopurine, Methotrexate)
Biologics (anti-TNFs)
Antibiotics (CD)*** - due to perianal disease (abscess/fistulas)
surgery

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28
Q

Step-up therapy

A

low risk patients w/ mild disease

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29
Q

Step-down

A

high-risk pts w/ moderate to severe disease

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30
Q

5-ASA MOA

A

anti-inflammatory effects

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31
Q

Indications for ASA

A

mild/mod UC (primarily) and CD (less efficacy)

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32
Q

Options for 5-ASA

A

Sulfasalazine (must take folic acid)
Mesalamine (generic name for):
- PO: Asacol, Apriso, Lialda, Pentasa – small bowel and colon
- Topical: Canasa suppository; Rowasa enema (left colon)

33
Q

SE of 5-ASA

A

nausea
diarrhea*
kidney injury*
pancreatitis

34
Q

MOA of cortciosteroids

A

anti-inflammatory

suppress immune system

35
Q

Indications of corticosteroids

A

FLARES in UC & CD

  • short term use
  • exit strategy to avoid dependence
  • requires slow taper
36
Q

Options for Corticosteroids

A

Oral Prednisone (caution systemic side effects)

• Oral Budesonide (modified steroid provides targeted therapy with less systemic side effects)

  • Entocort – (CD), ileocecal disease
  • Uceris (UC)

• Hydrocortisone suppositories, enemas, foams – distal colonic disease

37
Q

SE of Oral Prednisone

A
  • Mood changes
  • Insomnia
  • Weight gain
  • Worsening of Diabetes • Increased infection risk • Osteoporosis
  • Cataracts
  • Psychosis
  • Adrenal insufficiency
38
Q

Recommendations for oral prednisone

A

DEXA scan in those with lifetime use of steroids >3 months

Ca and Vit D supplementation

39
Q

MOA of immunomodulators

A

modifies immune system activity; decreases inflammatory response

40
Q

Indication of immunomodulators

A

moderate to severe UC & CD**; steroid sparing agent; can be used in
combination with biologics to prevent immunogenicity

41
Q

Options for immunomodulators

A

• 6- Mercaptopurine (6MP), Imuran (Azathioprine)

  • Optimal response takes 3-6 months
  • Genetic testing* necessary to determine patient metabolism of drug
  • Be aware of systemic risks

• Methotrexate

  • Requires folate supplementation
  • Tetratogenic
42
Q

SE of 6MP, Azathioprine

A
  • Bone marrow suppression • Secondary infection
  • Pancreatitis
  • Hepatotoxicity
  • Non-Hodgkin lymphoma
  • HPV-related cervical dysplasia • Non-melanoma skin cance
43
Q

Recommendations fo 6MP, Azatioprine

A

CBC, LFT
annual derm exams
up to date on cervical CA screening

44
Q

MOA of Anti-TNFs

A

Modulates immune response; prevents intestinal inflammation, improves mucosal healing

45
Q

Indications of Anti-TNFs

A

Moderate to severe IBD; steroid sparing

• May be given as monotherapy or in combination with thiopurines

46
Q

Options for anti-TNFs

A
  • Infliximab (Remicade) - (UC &CD) Risk of infusion reaction
  • Adalimumab (Humira) – (UC & CD)
  • Golimumab (Simponi) – (UC)
  • Certolizumab (Cimzia) – (CD)
47
Q

Cons of Anti-TNFs

A

Effective, but can be associated with decreased or lost response

Clinicians utilize “Therapeutic drug monitoring” to help guide decision making – are there antibodies? change dosage?

be aware of systemic risks

48
Q

SE of Anti-TNFs

A 
• Secondary infections
• Risk of reactivation of TB and
HBV
• Malignancies
• Non-melanoma skin cancer 
• Non-Hodgkin lymphoma
49
Q

Contraindications of Anti-TNFs

A
  • Active infection
  • History of CHF
  • MS/optic neuritis
50
Q

Condierations prior to anti-TNF therapy

A

TB, HBV testing

51
Q

monitoring in Anti-TNFs

A

CBC, CMP

annual derm exams

52
Q

Biologics MOA

A

Modulates immune response; prevents intestinal inflammation

53
Q

inidcations for biologics

A

Considered in patients with inadequate or loss response to

conventional therapies

54
Q

Options for biologics

A
  • Vedolizumab (Entyvio) - (UC & CD)
  • Natalizumab (Tysabri) - (CD)
  • Rarely used given gut selectivity and safety profile of Vedolizumab
  • Ustekinumab (Stelara) - (CD)
  • No demonstrated increase in severe infections or malignancy
55
Q

Abx indication

A

acute disease for CD - perianal disease * - fistulas, abscess

56
Q

Abx choices

A

Cipro

Flagyl

57
Q

Cipro SE

A

tendinitis (rupture)
photosensitivity
prolonged QT (arrhythmia)

58
Q

Flagyl SE

A

peripheral neuropathy
metallic taste
disulfiram rxn (avoid ETCH and 3 days after tx)

59
Q

Red flags for IBD

A 
• Severe bleeding
• Significant anemia
• Severe abdominal pain 
• Peritoneal signs
• Inability to tolerate PO 
• Signs of dehydration
• Increased creatinine, tachycardia, hypotension
-  Signs of obstruction
60
Q

Indications for surgery

A

severe hemorrhage
perforation
dysplasia/cancer
medical refractory disease

61
Q

Risk factors assoicated w/ aggressive disease (benefit from early step-down tx)

A

high risk anatomic locations (extensive disease, perianal)
penetrating/fistualizing disease
steroid resistance/dependence
severe disease activity (malabsorption as evidenced by weight loss, nutrient deficiency, hypoalbuminemia)
young age

62
Q

Change in BM and diarrea in IBD

A

check stool study (for infection)
NSAIDS exacerbate disease
ensure f/u compliance w/ GI
identify those w/ increased infection risk- steroids, immunomodulators, biologics

63
Q

Exacerbate IBD

A

NSAIDS

64
Q

Health Maintenance for IBD

A
  • Immunizations
  • Cancer screening (Colon, Skin, Cervical)
  • Osteoporosis screening with DEXA
  • Anxiety/Depression Screening
  • Smoking cessation
  • Routine laboratory monitoring (CBC/CMP)
65
Q

Epidemiology of celiac disease

A

whites of northern european ancestry

originally in infants, but now more frequently in 10-40 YO

66
Q

What is celiac’s disease

A

Immune-mediated disease triggered by the ingestion of gluten (wheat, rye, barley) in genetically susceptible individuals

67
Q

Triggers in gluten for celiacs

A

wheat
rye
barley

68
Q

Response of small intestine to gluten

A
  • mucosal inflammation, crypt hyperplasia & abnormal villous architecture
  • villous atrophy of small intestines –> loss of absorptive surface capcity and small bowel malabsorption
69
Q

Associated w/ celiacs

A

genetic- HLA DQ2, HLA DQ8

autoimmune disease (DM, thyroid disease)

Down syndrome

70
Q

Presentation of celiac

A

“classic” malabsorptive sx: diarrhea, steatorrhea, flatulence/bloating, weight loss

“atypical” GI sx: ab pain, constipation, dyspepsia

Silent: extra-intestinal manifestations

71
Q

Extra-intestinal manifestations in celiac disease

A
  • Nutrient deficiencies (Iron, B vitamins)*
  • Osteopenia/Osteoporosis (Vitamin D & Calcium deficiencies)
  • Transaminase elevation
  • Dermatitis Herpetiformis***
  • Neuropsychiatric symptoms
  • In kids, may see FTT
  • Reproductive disorders (infertility, miscarriages)
72
Q

Dermatitis herpetiformis

A

burning and itching lesions
erythematous and papular, pustular or vesicles

pathognomonic of celiac

73
Q

Dx of Celiacs

A

Serology AND Bx of small intestines while on gluten diet
(+) serologic antibody testing: IgA tissue transglutaminase (tTG Ab)***, IgA endomysial (EMA Ab titer), Deamidated GLiadin Peptide (DGP- IgA levels must be normal for test to be valid)

EGD w/ duodenal bx = GOLD STANDARD

  • intraepithelial lymphocytes
  • crypt hyperplasia
  • villous atrophy
74
Q

gold standar dx for celiac

A

villous atrophy on EGD bx

75
Q

Primary antibody in celiacs

A

IgA tissue transglutaminage (tTG Ab)

76
Q

Management of Celiac

A

gluten free diet - fresh fish, meat, poultry, milk, fruits/veggies

77
Q

Supplements in celiac

A 
Folate
Iron
Zinc
Calcium
B12
D
78
Q

Overall managment of celiac

A 
Consult w/ dietitian
Educate about disease
Lifelong gluten-free diet
I- identify/tx nutrtional deficiencies
Access advocacy groups/resources
Continuous long-term f/u
79
Q

Complications of celiac

A

malabsorption: Fe, B vitamin, Osteoporosis (Ca, vit D) - get DEXA at diagnosis

Slight increase of malignancy

  • non-hodgkin lymphoma
  • GI malignancies

Clin Med III Exam 1 (5 decks)

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