IBD - Crohns and Ulcerative colitis Flashcards
What is IBD?
Umbrella term encompassing UC and Crohn’s
Involves inflammation of the walls of the GI tract and are a/w with periods of remission and exacerbation
Features differentiating IBS vs IBD
IBD may have night time diarrhoea and/or weight loss and bleeding
IBS does not
Which areas of the bowel does Crohn’s affect?
Terminal ileum and colon
Can affect any part of GIT (from mouth to anus)
Which areas of the bowel does UC affect?
Starts at rectum (most common site for UC)
Never spreads beyond ileocaecal valve
When does Crohn’s present?
Typically in late adolescence or early adulthood
When does UC present?
Peak incidence is in people aged 15-25 years and in those aged 55-65 years
Clinical features of Crohn’s?
- Diarrhoea (usually non-bloody)
- Weight loss more prominent
- Crampy abdo pain
- Mouth ulcers
- Perianal disease
- Abdominal mass palpable in the right iliac fossa
- Extra-intestinal features (more common in colitis or perianal disease)
Clinical features of UC?
- Bloody diarrhoea
- Urgency
- Tenesmus
- Abdo pain, particularly in left lower quadrant
- Extra-intestinal features
List 2 Dermatological manifestations seen in both Crohn’s and UC
- Erythema nodosum (painful erythematous nodules/plaques on the shins)
- Pyoderma gangrenosum (a well-defined ulcer with a purple overhanging edge)
List 2 Ocular manifestations seen in both Crohn’s and UC
- Anterior uveitis (painful red eye with blurred vision and photophobia)
- Episcleritis (painless red eye)
- Conjunctivitis
List 2 MSK manifestations seen in both Crohn’s and UC
- Arthritis (asymmetrical and non-deforming)
- Sacro-iliitis (similar to Ankylosis spondylitis)
- Clubbing
List a Hepatobiliary manifestation more common in Crohn’s
Gallstones secondary to reduced bile acid reabsorption
Oxalate renal stones*
List a Hepatobiliary manifestation more common in UC
Primary sclerosing cholangitis
List 2 other extra-intestinal manifestations seen in both Crohn’s and UC
- AA amyloidosis (secondary to chronic inflammation)
- Renal stones (more common in Crohn’s)
Investigations for Crohn’s and UC?
- Blood tests
- Stool culture to exclude infection
- Faecal calprotectin
- Endoscopy + biopsy
- MRI
Gold standard investigation to diagnose Crohn’s?
Colonoscopy + biopsy
List 4 blood test findings seen in Crohn’s and UC?
- ↑ ESR/CRP
- ↑ WCC
- Anaemia
- ↓ B12 and Vit D
- ↓ Albumin
List 3 Endoscopy findings in Crohn’s
- Skip lesions
- Cobblestone mucosa
- Deep ulcers
List 2 biopsy (histology) findings in Crohn’s
Inflammation in all layers from mucosa to serosa
- ↑ goblet cells
- Non-caseating granulomas
List 4 Radiology findings in Crohn’s?
Small bowel enema
- Strictures: ‘Kantor’s string sign’
- Proximal bowel dilation
- ‘Rose thorn’ ulcers
- Fistulae
Gold standard investigation to diagnose UC?
Colonoscopy and biopsy (Sigmoidoscopy)
List 3 Endoscopy findings in UC
- Continuous inflammation with an erythematous mucosa
- Loss of haustral markings
- Pseudopolyps
List 3 biopsy (histology) findings in UC
No inflammation beyond submucosa (unless fulminant disease)
- Inflammatory cell infiltrate in lamina propria
- Crypt abscesses
- ↓ Goblet cells and mucin from gland epithelium
List 4 Radiology findings in UC
Barium enema
- loss of haustrations
- superficial ulceration
- ‘pseudopolyps’
- long standing disease: colon is narrow and short ‘drainpipe colon’
List 3 Complications of Crohn’s
- Obstruction
- Fistula
- Abscess
Note: there is a risk of colorectal cancer but this is much higher in UC
List 3 Complications of UC
- Bleeding
- Toxic megacolon
- Colorectal Cancer (↑ risk in UC)
How does toxic megacolon present?
Sever colitis + tachycardia, fever, abdo pain, distension and constipation
Management of toxic megacolon?
- NMB
- Call the supervising doctor
- IV fluids and antibiotics
- Surgical referral for urgent colectomy
What is the predominant inflammatory cell in Crohn’s vs UC?
???? RISH If you see this card plz help
What are the 3 types of UC?
In the acute setting, what imaging is used for an individual with UC?
Explain
CT, abdominal X-ray and erect chest x-ray (to exclude TMC and perforation)
Colonoscopy and barium enema are contraindicated due to the risk of bowel perforation
What criteria is used to assess an acute exacerbation of UC?
Truelove and Witt’s Criteria for Severity
Management to induce remission in Crohn’s
- First line: Steroids (oral prednisolone or IV hydrocortisone)
- Add on Azathioprine or Mercaptopurine (Methotrexate if not tolerated)
- Biological agents (eg. Infliximab or Adalimumab) in severe disease who fail to respond to the above
What must be assessed before offering azathioprine or mercaptopurine?
Thiopurine methyltransferase (TPMT) activity
Management to maintain remission in Crohn’s
- First line: Azathioprine or Mercaptopurine
- Second line: Methotrexate if above not tolerated
Surgical management for Crohn’s?
Rarely curative in Crohn’s (unlike in ulcerative colitis)
Options depend on the part of the GIT affected
Management to induce remission in mild-to-moderate UC?
First line: ASA (eg. mesalazine oral or rectal)
Second line: add corticosteroids (eg. prednisolone)
If no improvement after 2-4 weeks or worsening symptoms, add oral Tacrolimus
Management of Acute severe UC?
First line: IV corticosteroids (eg. hydrocortisone)
Second line: IV ciclosporin
Consider emergency surgery if no improvement with the above
Medical management to maintain remission following a mild-to-moderate UC flare?
- ASA (e.g. mesalazine oral or rectal)
- Azathioprine
- Mercaptopurine
Indications for emergency surgery in acute severe UC? (3)
- Acute fulminant UC
- Toxic megacolon with little improvement after 48-72 hours of IV steroids
- Symptoms worsening despite IV steroids
Surgical management for UC?
Can be curative
- Panproctocolectomy with permanent end ilesotomy
- Colectomy with temporary end ileostomy
When should elective surgery be considered in UC?
If there is failure to induce remission by medical means
