IBD & IBS Flashcards

1
Q

What are IBS and IBD?

A

IBS (irritable bowel syndrome) is a benign relapsing functional bowel characterised abdominal pain or discomfort is associated with defecation or a change in bowel habit.

IBD (inflammatory bowel disease) is a range of inflammatory bowel disorders (Crohn’s disease and ulcerative colitis) of unknown aetiology although it is though to have an autoimmune element.

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2
Q

Describe the diagnostic criteria of IBS?

A

6 month history of:

  • Abdominal pain/discomfort (associated with defecation or altered bowel habits)
  • Bloating
  • Change in bowel habit.

AND at least 2 of the following are present:

  • Altered passage of stool (straining, urgency, incomplete evacuation).
  • Abdominal bloating/distension
  • Symptoms aggravated by eating.
  • Passage of mucus in stool.

Note it is a diagnosis of exclusion you must 1st rule out more sinister causes: aka IBD

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3
Q

Describe the factors which may predispose to IBS?

A

Female gender 3:1

Stress

Antibiotic therapy

Can be a post parasitic infection IBS.

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4
Q

Describe common presenting symptoms of Crohn’s disease and ulcerative colitis?

A

Chronic diahorrea aka >6 weeks which may be bloody or contain mucous.

May be associated with weight loss and abdominal pain.

Systemic symptoms include: malaise, anorexia and fever. Relapsing and remitting diseases.

Extra GI features

UC: blood, mucus, urgency, tenesmus

Crohns: weight loss, abdominal cramping

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5
Q

List the pathophysiological + histological differences between UC and Crohns?

A

UC

  • Starts in the rectum and goes proximally. Colon only.
  • Proctitis if affects rectum alone. Doesnt usually affect anus
  • Only affects mucosa - causes severe ulceration and pseudopolyps
  • Crypt abscesses and goblet cell depletion, can loose horstra

Crohns

  • May affect any part of the GI tract, skip lesions
  • Ulceration of the mucosa is transmural (extends through the whole to the serosa)
  • Terminal ileum and proximal colon are most commonly affected.
  • Bowel narrowed due to thickened wall, deep ulcers described as ‘rose thorn’ or ‘cobblestone’.
  • Fistula and stenosis common.
  • Can cause lymphoid hyperplasia
  • Granulomas are present in 2/3 of cases.
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6
Q

Describe the extra-intestinal features of IBD?

A

Eyes: conjunctivitis/ episcleritis/ uveitis

Joints: arthralgia

Skin: erythema nodosum, pyoderma gangrenosum

VTE

Liver: AI hepatitis, 1y sclerosing cholangitis + cholangiocarcinoma (UC), gallstones (crohns)

Amyloidosis

Kidney stones

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7
Q

Describe the complications of crohn’s and UC?

A

Crohn’s:

  • Strictures (may cause obstruction)
  • Fistulae (between bowel and: other loops of bowel,bladder, vagina, skin)
  • Perforation: generalised peritonitis.
  • Haemorrhage.
  • Abscess formation
  • In crohn’s colitis increased risk of colonic ca.
  • Absorptive: Iron, folate and B12 deficiency (ileal involvement).

Steroid related complications:

  • Immuno-compromised
  • Osteoporosis
  • Cushingoid
  • Hyperglycaemia

UC:

  • Toxic Megacolon
  • Twice the risk of colorectal ca
  • Haemorrahage
  • Complications post surgery: Pouchitis (ileal pouch used as a false rectum following removal.
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8
Q

Describe the investigations you would do for a patient suspected of having IBD?

A

Bloods:

  • FBC (anaemia). Also test serum iron/b12/folate if anaemic
  • CRP and ESR should be raised
  • LFT may be abnormal (albumin can be low in acute disease)
  • Can do pANCA (usually +ve in UC not CD)

Stool sample:

  • ​Culture (exclude other causes of colitis)
  • Faecal calproctein (detects inflammation the bowel)

Imaging:

  • UC: Sigmoidoscopy/Colonoscopy + biopsy
  • Crohns: CT with oral contrast, colonoscopy if colonic involvement
  • Acute: AXR key in acute UC disease, dont conoloscopy if severe acute
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9
Q

Which medications are used for inducing remission in Crohn’s disease? (1st, 2nd and 3rd line)

A

1st line corticosteroids: Prednisolone Po (mild) or Hydrocortisone IV (severe)

2nd line aminosalicylates: Sulfalsazaine, mesalazine (mild) , thioprines: Azothioprine (severe)

3rd line: Infliximab

4th line: Methotrexate

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10
Q

Which medications are used for inducing remission in Ulcerative Colitis? (1st, 2nd and 3rd line)

A

1st line Aminosalicylates: Sulfasalazine oral or Mesalazine oral or topical (enemas, liquids) and suppositories.

2nd line corticosteroids: Prednisolone or IV hydrocortisone.

3rd line Calineurin Inhibitors: Tacrolimus or Ciclosporin can be added in severe disease which is unresponsive.

4th line: Anti TNF

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11
Q

Which are the medications used for maintaining remission in Crohn’s disease? (1st, 2nd and 3rd line)

A

1st line Thiopurines: Azathioprine and Mecaptopurine

Take several months to work so not effective for acute flares. Need to check TPMT level before starting.

2nd line: Methotrexate given once weekly.

Take several months to start so also not suitable for acute flares.

3rd line Anti TNF drugs: Infliximab or Adalimumab

Immunosupressant and can increase Ca risk.

Note: can be used to induce remision in both UC and Crohn’s but reserved as a last resort.

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12
Q

Which are the medications used for maintaining remission in Ulcerative Colitis? (1st and 2nd line)

A

1st line Aminosalicylates: Mesalazine or balsalazide

2nd line Thiopurines: Azathioprine or Mecaptopurine.

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13
Q

When are antibiotics indicaed in IBD?

A

Never indicated for UC.

Can be used in fistulising Crohn’s

Oral metronidazole can be used in Crohn’s anal disease.

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14
Q

Which medication can be used to control diahorrea caused by reduced absorption of bile salts?

A

Cholestyramine

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15
Q

Categorise the following medication into whether they are used for Crohn’s, UC or both: aminosalicylates, steroids, methotrexate, anti TNF, thiopurines, calcineurin inhibitors and antibiotics?

A

UC:

Calineurin Inhibitors (tacrolimus and ciclosporin)

Crohn’s:

Methotrexate

Antibiotics

(Anti TNF)

Both:

Aminosalicylates

Steroids

Thiopurines (Mercaptopurine/azathioprine)

(Anti TNF) mostly used in Crohn’s

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16
Q

Describe the indication and type of surgery in UC?

A

Indication:

  • Progressing disease which is not well controlled by medication.
  • Toxic Megacolon (emergency).
  • Dysplasic changes.

Surgery: usually curative but extreme:

Emergengy: subtotal colectomy and end ileostomy (stoma can be reversed + pouch added), Pan proctocolectomy and end ileostomy (cant be reversed)

Elective: Pan proctocolectomy and stoma, or subtotal colectomy and ileoanal pouch formation

17
Q

Describe the indications and types of surgery in Crohn’s disease?

A

Indications:

  • Symptomatic crohn’s with failed medical treatment
  • Complications such as fistulae, strictures or perforations.

Medication may be given beforehand to reduce inflammation.

Surgery

  • Involve limited resection of affected bowel. Patients will often have a stoma when there is an increased risk of failed bowel anastomoses these are known as Hartmann’s procedures.
  • Hemicolectomy (partial removal of bowel)
  • Small bowel resection.
18
Q

Describe some of the theories regarding the pathophysiology of IBS?

A

GI motility: no predeominant pattern of motor activity but motor abnormalaties are present in some patients. Such as:

  • increased frequency of contractions
  • prolonged transit time in constipation predominant IBS
  • exagerated motor response to cholecystokinin in diaorhoea predominant IBS

Visceral hypersensitity:

  • Increased sensation in response to stimulus

Other theories such as food sensitivities and bowel flora are being investigated.

19
Q

What are the relationship between smoking and Crohns/UC?

A

In Crohns smoking is a risk factors whereas in UC it is protective.

20
Q

Describe the management for IBS

A

Relaxation advice, exercise and diet advice (lots of water, regular mealtimes, limit tea/ coffee and high insoluble fibre food)

FODMAP if this unseccesful

Antispasmodics e.g. mebeverine if painful

Laxatives if constipation (avoid laculose), Loperamide if diarrhoea

2nd line: TCA, 3rs line SSRI

If these unsuccesful after one year: CBT referral

21
Q

What investigations should be done in IBS

A

Coeliac disease: TTG/ anti=endomysial antibodies

IBD: CRP/ESR, faecal calprotectin, FBC (anaemic)

22
Q

How does a patient with toxic megacolon present?

A

Fever, tachycardia, dehydration, abdominal pain and tenderness, blood stained stool

Will have high WCC and electrolyte abnormalities (low potassium)