IBD, IBS and Coeliac disease [completed] Flashcards
Describe how IBS may present.
Abdominal pain
Bloating
Change in bowel habit
How long must someone have had symptoms for for IBS to be considered?
6 months
What are some symptoms of IBS related to defecation?
Altered stool passage : diarrhoea an constipation
Symptoms worsened by eating
Rectal mucus
FRESH blood on tissue after constipation
What must be ruled out when diagnosing IBS and how?
Other conditions through blood tests
FBC, ESR, CRP should be normal and negative antibodies
What should be done if a person presents with black tarry stools?
Refer
What other symptoms (not related to stool or defecation) may a person with IBS present with?
Lethargy, nausea, back, pain, headache and bladder issues
What causes IBS?
May have an inflammatory cause but usually difficult to identify - could be due to stress, lifestyle etc
What dietary advice should be given to people with IBS?
Have regular meals and do not eat too fast
Drink at least 8 cups of water per day (avoid caffeinated drinks)
Reduce alcohol and fizzy drinks
Do not have more than three cups of tea or coffee a day
Limit the intake of high fibre food such as wholemeal bread, cereals and wholegrains such as brown rice)
Only up to 3 portions of fresh fruit a day
Avoid sorbitol
Eating oats may help with wind and bloating
Should people with IBS be encouraged to have soluble or insoluble fibre?
Soluble fibre - ispaghula husk, oats etc
what is the aim of pharmacological treatment when treating IBS?
Managing symptoms to make patient more comfortable and improve quality of life.
NOT TREATING CAUSE
What is the first pharmacological treatment for IBS?
single or combination medication depending on symptoms
Antispasmodics if there is abdominal cramps
Bulkforming laxatives for constipation
Antimotility agent for diarrhoea
What are some antispasmodics that can be used to treat abdominal cramp in IBS?
Hyoscine (buscopan)
Peppermint oil (calms system afterwards)
Mebeverine
Alverine
What laxative may be offered in treated constipation due to IBS?
Bulk forming laxatives (Ispaghula husk)
Macrogols (osmotic)
Which laxative should not be offered in IBS and why?
Lactulose - can cause further flatulence and bloating as a side effect
What is the first choice of anti motility agent for diarrhoea in IBS?
loperamide
Why can bulk forming laxatives also be used to treat diarrhoea in IBS?
They add bulk and improve consistency of the stool
What is the aim of using laxatives and anti motility agents?
A soft, well formed stool
What is coeliac disease?
Autoimmune condition.
Immune response is in response to gluten.
Causes damage to lining of the small intestine - villous atrophy.
What is the prevalence of coeliac disease in the UK?
1 in 100
Who is coeliac disease more common in?
Females
People with a first degree relative who have coeliac disease
People with other autoimmune conditions such as diabetes or thyroid disease
What can happen if a person is not diagnosed with coeliac disease?
continuous exposure to gluten –> more inflammation and damage —> body constantly trying to repair –> risk of mutations –> cancer
What is villous atrophy?
reduction in surface area of the villi. cells are unhealthy and undiferrentiated. Can lead to malabsorption, weight loss and fatigue
What are signs and symptoms that someone may have coeliac disease?
Persisent unexplained GI symptoms : indigestion, diarrhoea, steatorrhoea, bloating, constipation, IBS
Fatigue
Unexplained weight loss
severe or persistant mouth ulcers
How can coeliac disease be diagnosed?
Patient can buy test or go to doctor?
Should maintain a NORMAL diet without cutting out gluten and do the blood test
What would be a positive test result for coeliac disease?
Elevated total IgA
Elevated IgATGA
What would a histological examination of a person with coeliac disease show?
villous atrophy
Why does the patient need to NOT cut out gluten when testing for coeliac disease?
No gluten = less/no IgA in blood and gut may recover
Gluten is cut out of diet AFTER diagnosis is confirmed.
What are some complications of coeliac disease?
Anaemia
Osteoporosis (malabsorption of calcium and vitamin D)
Dermatitis herpetiformis
Autoimmune thyroid and liver disorders
What is dermatitis herpetiformis?
Severe skin reaction where patient experiences red raised batches and blisters in the flexures (elbows, knees, buttocks) but can occur in other area
Which age group is dermatitis herpetiformis most common in?
Age 50-69
Is symmetry likely with dermatitis herpetiformis?
Yes as it is has an immunological cause
What is the only effective treatment for coeliac disease?
long term adherence to a gluten free diet
What are some foods that should be avoided by patients with coeliac disease?
Wheat based foods - bread, flour, cakes, pastries (also includes semolina, spelt flour etc)
Foods that could be contaminated with gluten (during packaging or cooking) such as chips fried in the same oil as battered fish
Items that contain malt such as beer
Can people with coeliac disease eat oats?
Yes if they are pure and uncontaminated but could contain trace amounts of gluten so be careful
What is some advice that can be given to people with coeliac disease?
Check food labels
Avoiding contamination in the home - e.g. using the same utensils
Are gluten free products available on the NHS?
Yes but not as much anymore because there is an increase of gluten free products available in supermarkets
What are the two types of IBD?
Ulcerative colitis and Crohn’s disease
What is ulcerative colitis?
Autoimmune condition of the MUCOSA OF COLON
Is inflammation in colitis continuous or patchy?
CONTINUOUS
What are the three main types of colitis?
Extensive colitis (also called total or pancolitis)
Distal colitis - affect left side of colon and rectum
Proctitis - affects the rectum
What would histological examination show in ulcerative colitis?
Inflammation of the MUCOSA IN THE COLON only - continuous inflammation NOT patchy
What would blood tests in ulcerative colitis show?
ELEVATED CRP AND ESR
IgA and IgAtTGA are NEGATIVE
Low Hb
What is Crohn’s Disease?
Autoimmune condition causing inflammation of the full thickness of the colon BUT can also affect the entire alimentary canal from mouth to anus
Is Crohn’s disease continuous or patchy?
Patchy
What is a fistula and which IBD is it common in?
An abnormal connection between two parts of the colon - common in Crohn’s disease
When does IBD usually present?
adolescent to late 20s
What are some risk factors for IBD?
Family history
Appendectomy
NSAID use
Oral contraception
Bad case of food poisoning could trigger symptoms
What effect does smoking have on the risk of developing ulcerative colitis?
Smokers are less likely to develop ulcerative colitis
What management may be needed in IBD?
Inducing remission - acute episode
Maintaining remission
Nutrition - supplement for malabsorption
Pain relief (paracetamol)
Constipation (lifestyle and laxatives)
Diarrhoea - antispasmodics/ anti-motility/ bulk-forming laxatives
Fatigue due to malabsorption
Dyspepsia
Fistulas - surgery
What drug should not be used in ulcerative colitis but CAN be used in Crohn’s?
Anti-motility drugs such a Loperamide - can cause toxic megacolon
What is the first line treatment for Crohn’s disease to induce remission?
Prednisolone, methylprednisolone or IV hydrocortisone
2nd line is budesonide or 5-ASA
What two medications contain 5-ASA and what is important when prescribing them?
Mesalazine and Sulfasalazine - need to be prescribed by brand
What is the first line ADD ON treatment for inducing remission in Crohn’s
Aziathioprine
What is the second line ADD ON therapy for inducing remission in Crohn’s
Methotrexate
What biological treatment may be used to treat Crohn’s?
Infliximab
Adalimumab
What is first line in maintaining remission in Crohn’s?
Azathioprine or mercaptopurine as monotherapy
What is second line in maintaining remission in Crohn’s?
methotrexate
What is ulcerative colitis treatment based on?
Severity and location
What is severity of first bout/exacerbations UC decided with?
Truelove and Witts’ severity index. Looks at:
Daily number of bowel movements
Amount of blood in stool
Pyrexia
Pulse over 90 bpm (severe)
Anaemia (severe)
ESR (above 30 - severe)
Acute treatment for mild to moderate proctitis?
Topical 5-ASA if no remission within 4 weeks add oral 5-ASA or oral/topical steroid.
2nd line: topical corticosteroid or oral prednisolone
Acute treatment for proctosigmoiditis and left sided ulcerative colitis: mild to moderate?
Topical 5-ASA if no remission within 4 weeks add high dose oral 5-ASA +/- topical/oral steroid
Second line: topical corticosteroid or oral prednisolone
Acute treatment for extensive ulcerative colitis: mild to moderate.
Topical 5-ASA AND HIGH DOSE oral 5-ASA. If remission not achieved with 4 weeks STOP topical 5-ASA and give ORAL steroid with HIGH DOSE ORAL 5-ASA
2nd line: Oral prednisolone
What further treatments may be needed in moderate to severe UC?
Immunotherapy and biologics: Tafcitnib, Vedolizumab, Infliximab, adalimumab, golimumab
What is the treatment for acute severe UC (after hospital admission)
First line: IV corticosteroids and assess if person needs surgery
Second line: IV ciclosporin OR surgery
If no improvement after 72 hours add IV ciclosporin to corticosteroids OR surgery
What is the maintenance treatment for proctitis or proctosigmoiditis?
Topical 5-ASA alone or with oral 5-ASA.
May give oral 5-ASA alone.
Daily or intermittent treatment
What is the maintenance treatment for left sided and extensive UC?
Low maintenance oral 5-ASA
What is the maintenance treatment for all extents of UC?
1st line: oral azathioprine or oral mercaptopurine
2nd line: oral 5-ASA
What should be assessed before offering azathioprine or mercaptopurine treatment?
TPMT activity - do not offer if TPMT deficient. If TPMT below normal but NOT deficient consider lowering dose
What topical preparation is used in proctitis?
Suppository
What topical preparation is used in proctosigmoiditis (sigmoid is where descending colon joins to rectum)?
Foam
What topical preparation is used in distal (left sided) colitis?
Enema
